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Copyright
1993
Symptomatic
BY
DAVID
P. JOHNSON.
Synovial
M.B.CH.B..
AND
of Bwu- ati1 Joust Surgery.
by The Journal
F.R.C.S..
PETER
Investigation
ten
knees
improved
after
the
performed
subsequent
at The
division
of the plicae
(p < 0.01). We concluded
that synovial
plicae of the knee may be a definite
cause of anterior
pain in children
and adolescents.
It has been
the
causes
suggested
of anterior
adolescents.
with anterior
that
pain
in the
of the
knee,
acute
internal
derangement
appearance
of the syndrome
lescence
or until symptoms
mation
symptoms
within
are
femoral
the plica
due to the
condyle
chronic
injury
or lateral
*No
from
article.
England.
in any
party
No
funds
Glen
Hospital,
Please
address
IBristol
8HW,
to nerves
meniscal
benefits
tThe
it may
and
even
secondary
to an
plica bow-stringing
in the lateral
patellar
Royal
syndrome49,
tears’7
form
have
related
were
present
been
received
Durdham
requests
Infirmary.
received
directly
in support
Down,
of this
for reprints
study.
BS6
7JJ,
Street,
Bristol
Hospital
8HW,
England.
VOL.
75-A,
NO.
for
10.
Sick
OCTOBER
Children,
1993
St.
Michaels
Hill,
the
plica
syndrome
may
be difficult
previous
plica
studies
syndrome
and have
of
have
often
the
operative
been uncontrolled
included
a variety
of pathological
pnoblemst#{176}.Anthrotomy
of the knee
excision
plica
by Hughston
of the
was
first
reported
al.’7569.
However,
sally superseded
anthrotomy
has
by the anthroscopic
which
has
reported
90 per
cent
We
has
been
rate
know
shown
to
them.
Unfortunately,
to be
and
et
been almost
univertreatment
of plicae,
associated
with
a 60 to
of success9’34243454792777992”.
of no controlled,
synovial
plicae
randomized
study
to be symptomatic
that
or division
of the plicae
to be of any more
benefit
to the patient
than
the natural
decrease
in anterior
pain in the knee
that
may occur
in an adolescent
with
the passage
of
time’’.
The aims of the present
study were to determine
if the synovial
plicae
of the knee were
the cause
of the
anterior
pain in a specific
group
of patients
who did not
respond
to
whether
anthroscopic
tients
had
non-operative
any
anthroscopy
ized control
the
knee.
short
the
fat pad
the
treatment,
division
division
of patients
purpose
to the
and
of the plicae
or long-term
without
group
For
the
benefit
ascertain
in these
compared
of this
study.
the
notch
cruciate
ligament
are referred
to as the supenomedial
plicae
(Fig. 2) or the suprapatellar
The plica to the medial
and lateral
from
the
in the
synovial
fat pad
coronal
shelf
(Fig.
pawith
of the plicae
in a randomwho had anterior
pain in
intercondylar
anterior
to
fold
running
of the
femur
is called
anterior
plica;
this is the most
common
plica
knee4t (Figs. 1 and 2). The medial
and lateral
bands
the proximal
border
of the patella
in a horizontal
Materials
the
in the
along
plane
or superolateral
membrane
(Fig. 3).
sides of the patella,
to the side of the patellar
plane,
is called
the medial
or
2).
Bristol
study
and
was prospective,
Methods
randomized,
and blindly
assessed.
It was undertaken
Health
Service
orthopaedic
department
hospital
where
the choice
of treatment
financial
the
BS2
committee,
BS2
tients
and
randomly
England.
§The
F.R.C.S4.
Bristol
from
treatment
of the
and non-randomized
On
to Mr. D. P. Johnson.
Marlborough
and
differentiate
Our
be received
Bristol
Children,
syn-
to the subject
Clifton,
complex.
symptom
or will
or indirectly
Sick
M.B.CH.B..
ENGLAND
syn-
Hoffa
a similar
Hospitalfor
lateral
retinaculum29,
M. EASTWOOD.
BRISTOL.
running
retinaculum
retinacular
compression
DEBORAH
overlying
The
the
of the Knee*
F.R.C.S.I.
from
mimic
injury.
across
lateral
hyperpressure
a commercial
of this
in children
of the knee’3’938429.
The
may be delayed
until adoare precipitated
by inflam-
subluxation’3,
and
and
patellae”92935,
patellofemoral
drome’,
knee
are one of
on flexion.
Chondromalacia
drome
plicae
The plica syndrome
has been
associated
pain as well as clicking,
catching,
locking,
or pseudolocking
pain,
synovial
M.D.t.
M.B.CH.B..
ABSTRACT:
Forty-five
knees
(thirty patients)
with
a specific
diagnosis
of synovial
plica syndrome,
and
without
any other known
lesion,
were randomized
to
be treated
with either diagnostic
arthroscopy
alone or
arthroscopy
and division
of all plicae.
The diagnosis
of synovial
plica syndrome
had been made on the basis
of intermittent
pain in the anterior
aspect of the knee,
painful
clicking
with activity,
giving-way,
and a palpable, tender plica. The patients
were selected
for arthroscopy only if the symptoms
had continued
unabated
after a course
of physical
therapy.
At the time of
follow-up,
improvement
had occurred
in only six (29
per cent) of the twenty-one
knees in which the plicae
had not been divided,
in contrast
with twenty
(83 per
cent) of the twenty-four
knees in which they had been
divided
(p < 0.001). Ten (48 per cent) of the knees in
which arthroscopic
division
had not been done were
treated
with another
arthroscopic
operation.
Seven of
these
Plicae
F.R.C.S.(ORTH).
J. WITHEROW.
Incorporated
consequences
basis
for
the
of a discussion
we
parents,
assigned
obtained
who
one
patient
with
verbal
agreed
of the
controlled,
in a National
in a pediatric
did not have any
on the
the
regional
consent
from
surgeon.
ethical
the
that the patient
could
two forms
of treatment
pabe
if
I 485
1486
D. P. JOHNSON.
D. M.
EASTWOOD.
AND
operative
therapy
or how many
were discharged
before
the study
began.
The trial was performed
on patients
who were first
seen because
of anterior
pain in the knee or who were
plica
being
gional
--
Anterior
-...
plica
A diagram
of the lateral
synovial
aspect
cruciate
showing
of
the position
plicae.
had
during
the
study.
in whom
present
All
patients
to determine
were
thought
of presentation
Supero-medial
to
was
in the knee,
and sudden,
knee
flexion,
Some
of the
the
synovial
plicae
The
was excluded
had symptoms
intervention
which
he
were
exact
the
only
a population
already
surgeon.
of patients
knee
study
was being
proceeded
were
referred
treated
and
specifically
therefore
been
selected
sible to determine
how
of the knee.
had
finding
resolution
of
was
symptoms
syndrome.
discerned;
it included
had
a habitual
painful
A
or painful
pattern
anterior
which
was intermittent
and often
painful
clicking
during
activities
crouching,
jumping,
or running
patients
with
the
de-
pain
episodic,
such
as
upstairs.
click
on
knee
plica
showing
at the
of all patients
Supra-patellar
chorda
Supero-medial
plica
Supero-lateral
plica
the position
arthroscopy.
who
and managed
When
the
who
in the
became
were
seen
at
had
anterior
follow-up
known,
referral.
patients
of those
Incomplete
supra-
patellar
membrane
appropriately
by
study
was started.
pain
in the
Complete
clinics.
As the
some
patients
for plica-related
before
many
had
plica
locking.
giving-way.
noted.
A characteristic
because
of anterior
pain
in the knee
Anterior
pain in the knee
had previously
non-operatively;
therefore.
many
patients
had been
seen
an orthopaedic
the
.
number
symptoms
from
the study.
that were
too
were
not in-
patients
from
plicae.
that
institution
is unknown.
been
treated
symptoms
aspect
the
2
FI;.
of the anterior
assessed
children
the years
before
study.
The remaining
patients
were
entrial and assessed
by one of us (D. P. J.),
discrete
history
of injury.
parapatellar
clicking
was
A diagram
knee
at a rebeginning
in
including
skyline
patellar
radiographs
flexed
to 30 degrees4.
were
made
knee.
Any knee
in which
a lesion
in the
into the
specifically
that
Anterior
in the
period
1988. Many
surgeons
pain in the knee
eluded
tered
1
of the knee.
anterior
pain
a six-month
tectable
radiographically
In addition,
patients
who
mild
to warrant
operative
ligament
the
for
during
September
with anterior
radiognaphs,
the knee
symptomatic
Anterior
Fi;
managed
center
had resolved
with non-operative
therapy
were excluded
from this study. Then,
anteropostenior
and lateral
plain
pad
Fat
P. J. WITIIEROW
pain.
and
after
membrane
had
It was not poswho had similar
symptoms
supra-
patellar
non-
FI;.
A diagram
of the five types
FIlE
JOURNAl.
3
of suprapatellar
OF
BONE
plicae
ANt)
of the knee.
JOINT
SURGERY
SYMPTOMATIC
SYNOVIAL
PLICAE
TABLE
DATA
(Plicae
THE
ON
PATIENTS
OF
THE
I
IN THE
Group
I
Divided)
TWO
GROUPS
Group
Not
(Plicae
II
Divided)
No.ofknees
24
Sex
1OM,14F
8M,13F
Side
17R,7L
9R,12L
Age*
(yrs.)
1487
KNEE
Significance
between
of Difference
Groups
21
p =0.95
14 (7-24)
14 (9-17)
p
=
0.68
Duration
of symptoms*
(nios)
23 (6-72)
24 (4-60)
p
=
0.59
Duration
of fo11owup*
(mos.)
29 (24-43)
29 (27-43)
p
=
0.98
21 (88%)
19 (90%)
p
=
0.87
3(13%)
2(10%)
Clickingt
24(100%)
18 (86%)
Giving-wayt
17 (71%)
12 (57%)
Paint
Severe
or moderate
Mild
5(21%)
Lockingt
*The
values
are
given
as means,
with
ranges
tThe
values
are
given
as means,
with
percentages
flexion,
which
could
patellan
region,
the
fat pad.
Giving-way
because
of
sudden
acute
instability
of something
Clinical
pable,
the
anterior
pain
in the
lateral
palpated
in the
of the
but
in the
knee
front
retinaculum,
of the patellar
and
fat pad
with
on
the
of an impingement
condyle
because
of
tients
and
feeling
of the
the
patellar
for
tissue,
and
region
tendon
A tender
the
any
pal-
especially
with
the
could
in
the
medial
tenderness
knee
in the
from
in flexion
fat
pad
tenderness
helped
subsequently
over
the
a medial
anterior
horn
The
patients
were
then
referred
for a minimum
three-month
course
of physiotherapy
consisting
of passive and active
range-of-motion
quadriceps
exercises
and
was
vastus
medialis
training.
used as appropriate,
but
rehabilitation
program
described
not undertaken.
relieved
after
Patients
physiotherapy
by
in whom
were
McConnell52
the symptoms
not entered
was
into
were
the
Once
the patient
or she was randomly
number
list,
I, all of the
to one
plicae
had been
assigned,
of two
were
entered
into the study, he
according
to a random-
treatment
subjected
groups.
to wide
Group
II, none
of the plicae
were
divided.
No other
concomitant
procedure
was done, and any impingement
lesion
that was present
was left untouched.
The anthroscopy
was done
by one of the two senior
ones
were
of us (D. P. J. or P. J. W.). If the anthroscopic
normal
except
for the presence
of synovial
the knee
was included
and degree
of fibrosis
VOL.
75.A,
NO.
10. OCTOBER
in the study.
The
on inflammation
1993
findings
plicae,
size, thickness,
of the plicae;
In
on
decision
to
(thirty-five
had been
because
one,
plicae;
the
or
femoral
include
remaining
patients)
pa-
other
forty-five
knees
duration
knees
in Group
instability
two
the
en-
depended
five knees
after
the
one, because
of
minor
menis-
patellofemoral
The
were
that the data
of the plicae,
from
the study
analyzed
of a coexisting
because
diagnosed.
male
patients.
were
involved.
The
was
(two
pa-
of follow-up
(twenty-four
II) in thirty
Twenty-six
mean
seven
night
age of the
to twenty-four
preoperative
symptoms
four to seventy-two
tiated
the
The
symptoms
anterior
in Group
patients
or severe
in Group
troublesome
two
in Group
knee
knees
I and nineteen
in five knees
II).
was
The
six knees
in the
in forty
nineteen
made
left
was
(89 per
(13
was
per
described
cent)
in Group
II)
(11 per cent)
There
knees
fourteen
years
mean
duration
was twenty-three
months).
An injury
in only
pain
and
patients
years).
of the
(range,
I and
In Group
division.
by the
lesion
up the study
group
(Table
I); fifteen
patients
had bilateral
symptoms
and anthroscopy
of the knee. Twentyseven
knees
were
in female
patients
and eighteen,
in
erate
study.
the
knees
twenty-one
( range,
Patellar
taping
on bracing
the formal
patellofemoral
influence
of fifty
and
The
of
condyle
tients)
were excluded
because
had been
less than two years.
I and
or
not
femoral
study.
notes
another,
cal tear;
or lat-
the
into the trial. To ensure
on the effect of the division
patients)
were
excluded
in
to differen-
overlying
tered
only
(five
be
or the fat pad to the medial
on lateral
tendon.
Palpation
of the netinaculum
the
did
in the
operative
synovitis;
knee
usually
presence
A total
lateral
patellar
to the medial
plica
pouch,
the
knee.
a search
synovial
suprapatellar
eral
side
lateral
shelf
the menisci.
in the
in flexion.
impingement
or the
not
to
knee
pouch,
the medial
the infrapatellar
sides
and
supra-
localized
included
bands
extension
tiate
of
examination
tender
be
in parentheses.
on lateral
retinaculum,
a common
complaint,
catching
the suprapatellar
retinaculum,
and
and
often
medial
was
5(24%)
in parentheses.
months
had micent).
as mod-
(twenty-one
and as mild but
(three
in Group
painful
clicking
in
forty-two
knees
(93 per cent)
(twenty-four
in Group
I
and eighteen
in Group
II) when
the knee was flexed
on
when
the patient
crouched,
jumped,
on ran upstairs.
Twenty-nine
and
and
palpable,
three
knees
(64 per
twelve
in Group
ten knees
(22 per
tender
(73
per
We could
synovial
cent)
detect
cent)
(seventeen
II) had symptoms
cent)
had symptoms
of the
band
was
in Group
I
of giving-way
of locking.
A
present
in thirty-
knees.
no significant
difference
in terms
of
1488
D. P. JOHNSON.
100_
D. M.
EASTWOOD,
AND
P. J. WITHEROW
.,..
90
(4)
80
70
(I)
60
c:
ci)
(ci
0
(4)
40
30
20
Non
divided
Divided
10
plicae
plicae
0
0
4
8
12
20
16
Time
FIG.
A graph
the age of the patients,
tients,
or the preoperative
between
the group
in
of the survivorship
the
proportion
duration
of
which
all plicae
analysis,
difference
between
The
in terms
of the severity
of preoperative
pain
the two groups
(Table
I).
average
duration
of follow
up was twenty-nine
months
duration
(range,
twenty-four
of follow-up
did
to forty-three
months).
not differ
between
the
Forty-two
and
(48
per
cent)
of the
eighty-eight
in the forty-five
knees
were in the
Twenty-one
(24 per cent)
(fourteen
any
seven
in Group
(22 per cent)
superolateral.
superomedial
(ten in Group
I and
In two knees
(2
superomedial
into
plete
II) were
and
and
I
superolateral
plicae
had
membrane.
identified.
coalesced
No comleast one
At
group);
(three
plica,
I and fourteen
present
in Group
being
cent)
(six
in each
a lateral
shelf,
in seven
knees
(16 pen cent)
in Group
I and four in Group
II); and an anterior
in twenty-seven
knees
(60 per cent)
(thirteen
in
Group
was
per
two
in Group
in thirty-one
I and
fourteen
plicae
for
The
distribution
groups
did not differ
was present
in four
knees
in Group
the
whole
II). More
than
(69 per
cent)
II),
with
one plica
(seventeen
the
average
series.
of the plicae
between
the
two
statistically.
Only an anterior
plica
knees
(9 per cent).
Although
an
in which
the plicae
of the
were
inclusion
of
varieties
in this
by chance,
asnot
divided,
of anterior
plicae
in which
those
only
abnormality
examination
patellae
was
in four
grade-1
in which
changes
the
the
study.
plicae
that
reduces
after
anthroscopic
resulting
from
this
to diminish
were
that
a small
knees
were
divided.
was
found
area
(four
thought
divided.
to
As
the
be
reports
associated
of a good
with
result
of the plicaeM77”,
occurrence
would
any bias
be ex-
of arthroscopic
division
were
with
success
all patients
rehabilitation
program.
A
managed
ban-
applied.
Oral analgesia
routinely,
and a single
(acetaminophen)
intramuscular
a narcotic
analgesic
was
Non-steroidal
Mobilization
with
(meperidine)
anti-inflammatory
was
the
help
begun
on the same
day
OF
was
of
not
used.
as the operaActive
quadni-
the first postoperative
the second
week.
assessed
clinically
years
postoperatively.
JOURNAL
dose
if necessary.
were
of a physiotherapist.
The patients
were
and at least two
THE
given
agents
ceps exercises
were begun
during
week
and active
flexion,
during
the
wool-and-crepe
dage was
prescribed
year,
insuffi-
study.
Postoperatively,
tion,
an-
were
not exin the group
previous
chondromalacia
the probability
division
chance
on
of mild chonpatients).
As
results,
these
knees
All four knees
were
were
have
suggested
synovial
plicae
pected
the plicae
other
cient
to influence
eluded
from the
same
(27
group
as a result
after
was
knees
to be a cause
than
in this
in twelve
considered
to improve
the results
after
the pronot involve
division
of the plicae
rather
of the types of suprapatellan
plicae was found in thirtytwo (71 per cent) of the forty-five
knees.
A medial
shelf
present
has not been
could
be expected
cedures
that did
these
nine in Group
II) were
per cent)
in Group
I,
an incomplete
suprapatellar
synovial
membranes
were
to the
bias
throscopic
dromalacia
nineteen
operation.
it was included
with the other
As these
four
knees
were,
The
plicae
suprapatellar
in Group
as no additional
plica
signed
groups.
found
pouch.
defined
anterior
The
two
36
(months)
symptoms,
study53-’.
of the plicae
no significant
32
28
4
with survival
of female
pathe symptoms
were
divided
(Group
I) and the group
in which none
were divided
(Group
II). There was also
24
BONE
AND
six months,
one
The examJOINT
SURGERY
SYMPTOMATIC
SYNOVIAL
PLICAE
OF
THE
1489
KNEE
100
90
80
(4)
70
(I)
60,
C
ci)
(ci
50.
a-
40.
30.
20.
.
10.
0.
-,.,.,.,,,,,
.
Non
divided
plicae
plicae
Divided
I.I.l.I,I,I.J.
0
.
4
8
12
16
20
Time
FI;.
A graph
ination
was performed
not been
associated
and
was
been
blinded
done
another
sessment.
regard
patient.
in whom
the
complained
plicae
of
toms.
They
done
at a second
requested
these
patients
the patients
which
and
regard
to the
they
outcome
time
of the
most
accurately
examination,
or
and
with
of the
were
the
also
recent
at
at the same
time
or excellent
A
with
4) and
result
clinical
the
result.
when
the patient
full
sports
(Fig.
A result
activity;
square
VOL.
test
75-A,
the
separately.
In
order
to
account
was
considered
good
when
there
were
assess
to be
and was able
was
sports
activity;
normal
daily
the operative
symptoms
to
worse
and
NO.
was
performed
a contingency-table
10. OCTOBER
1993
with
analysis
with
was used.
(Abacus
program
on a Macintosh
Cupertino,
California).
analysis,
This was
Concepts,
microcomputer
six
months,
the
anterior
pain
in the
knees
Thirteen
pen
per
cent)
painful
had
than
knees
failure
no pain,
and
eight
(33
knee
had
in which
knees
cent)
had
the
(54
only
ache. The pain had not decreased
in
(13 pen cent),
and none
were
more
before
the
procedure.
the most
recent
follow-up
examination,
of twenty-nine
months
(range,
twenty-four
months),
the
results
(13 per cent)
because
for one (4 pen cent)
during
to
intermittent,
use
For group
t test
decreased
in most of the twenty-four
plicae
had been divided
(p < 0.001).
the
four
good
was
had
continued
at
to
a
to
im-
activity.
The
a poor
of a chi-
sult
a con-
had
Thus,
twenty
of mild
because
(83 per
pain and it was a
of moderate
pain
cent)
of the
twenty-
knees
in this group
were
categorized
as having
a
or excellent
result
two years
postoperatively.
This
a significant
improvement
from
the preoperative
situation
tion
analysis
appropriate.
prove
slightly.
The result
for thirteen
knees
(54 per cent)
was described
as excellent,
and that for seven
(29 per
cent) was considered
good. The result
was poor for three
excellent
before
result.
I
forty-three
poor
when
the
activities
or had
procedure;
and a
than
where
California)
Computer,
At
mean
the
to return
36
Results
At
additional
operation
a survivonship
analy-
used
or excellent
correction
Berkeley,
(Apple
follow-up
into
as a good
a slight,
occasional
only
three
knees
anthroscopy
to take
was
no pain
mild
pain
only
during
patient
had pain during
derived
no benefit
from
failure
when
operation.
Statistical
for
5)44.7g.
system
had
data
latest
tinuity
Group
for the rest of
of the initial
second
defined
a single-group
or two-group
done with a Stat View 512+
was
survival
defined
as no additional
with survival
defined
as a good
grading
clinical
The
32
5
di-
which
follow-up.
results
as(ten
symp-
plicae,
considered
of the
had
initially
worsening
those
results
the seven
patients
who
had an
because
of an initially
poor result,
sis was performed,
operation
(Fig.
six-month
patients
procedure.
included
analysis
had
been
of the
anthroscopic
were
in the
not
continuing
arthroscopy,
analyze
had
had
patients
28
(months)
with survival
operation
of the
a division
with
at the
to
None
operative
procedure
before
the
Subsequently,
however,
seven
knees)
vided
analysis,
by one of us (D. M. E.) who had
with
the anthroscopic
procedure
with
on the
of the survivorship
24
(p < 0.001).
three
knees
result
at
the
(13 per
cent)
most
recent
in this
group
follow-up
that
had
examina-
had had an excellent
result
at six months.
The redeteriorated
to a poor
grade
because
the pain
recurred
before
the most recent
review.
A palpable.
1490
D.
P. JOHNSON.
D.
M.
EASTWOOD,
AND
TABLE
SURvIvoRsi-uP
No.
Interval
(Ivios.)
I
WITHOUT
REOPERATION
II
WITHEROW
II
Two
AT LEAST
YEARS
POSTOPERATIVELY*
Average
(No.)
Failure
Success
I
II
P. J.
I
Success
(Per cent)
I
II
II
I
Cumulative
Success
(Per cent)
Failure
(Per cent)
I
II
II
I
II
100
100
100
0-I
24
21
100
1-2
24
21
1(X)
2-3
3-4
24
21
1(X)
24
21
4-5
24
21
100
l()0
5-6
24
21
100
100
100
6-7
24
24
21
1
95
20
3
17
9-10
24
23
10-11
23
11-12
17
12-13
23
23
13-14
23
14
14-15
23
15-16
16-17
100
95.1
4.9
1(X)
83.8
16.2
100
80
96
80
17
96
80
17
96
80
96
64
96
64
12
96
96
54
54
23
12
96
54
23
12
96
54
17-18
23
54
23
12
12
96
18-19
96
54
19-20
23
23
96
50
20-21
96
50
21-22
23
11
11
22-23
23-24
23
11
96
96
50
50
23
11
24-25
23
11
96
96
50
50
25-26
22
11
96
50
26-27
22
96
50
27-28
28-29
96
96
50
50
96
50
96
50
7-8
8-9
20.5
18.5
1
95.7
23.5
3
4.3
80.6
15.5
19.4
17
2
12
13.0
I
84.6
5.4
91.3
11.5
8.7
1
22.5
11
3
20.5
19
Il
9
7
14.5
7.5
10
4
2
3
9.0
2.5
29-30
30-31
8
8
1
1
3
1
6.5
0.5
31-32
5
0
1
4.5
96
32-33
33-34
4
3
1
3.5
96
34-35
3
35-36
1
2
1
2.0
0.5
*1
the
=
tender
group
band
was
thought
have
96
in which
was
present
that
division
resulted
palpable
the
in scan
fibrous
plicae
were
in one
divided
and
of these
II
three
tissue,
which
and
plica
accumulated
reproduced
group
knees.
of a superomedial
band
the
=
It
may
into
the
Of the fifteen
symptoms,
patients
eight
in the study
(sixteen
cae in only one knee;
the
side. A good
or excellent
of the
eight
a poor
knee
result.
for
months
turned
the
knees
who
had bilateral
had
division
of the
other
result
knee
was
acted
as a control
obtained
in seven
the
phicae
in one.
which
The
the
result
but had deteriorated
because
of scarring
eight
knees
(the
control
four
remained
of the patients
that the knee
in which
knees)
had
unchanged.
poor
had
(as
the
divided
better
still
thought
were
knee.
Only
ph-
and
At
one
clicked
preoperatively
had
it at the
In three
of painful
clicking
at six
decreased,
and,
not
At the six-month
who had had bilateral
in which
the phicae had
been
divided
result
review,
other
and
all
symptoms
stated
been
divided
was
area
maining
knees
that
at
at six months;
that
giving-way
a mild,
because
had
changes.
six
four
a small
symptoms
resolved,
the
returned
to
subsequently
pain.
pain
ache
in all
full
sports
had an-
At
the
see-
the area of chondromalacia
to a two-square-centimeter
Since
concluded
JOURNAL
had
the
occasional
of persistent
procedure,
deteriorated
THE
click
follow-up.
patients
had
these
patients
it was
knees
to
chondromalacia,
and
of grade-36
lesion,
latest
despite
the
of
operation
ond anthroscopic
patehlae
had
giving-way
four
grade-1
three
knees,
activity.
One
seven
at the most
recent
examinaknees
that had had giving-
had
of the
of minor
examination,
continued
of the
in the
had
recent
of the twenty-four
clicked
seventeen
time
occurred
or excellent
most
(4 per cent)
excellent
neof
the
preoperatively
way
area
divided.
to be so.
been
the symptoms
described).
Four
not
this
result
when
just
phicae
a good
were
plicae
months.
No knee
tion. Three
of the
knees)
in which
the
the
had
symptoms.
96
in which
a
original
96
this
that
OF BONE
was
this
AND
the
was
JOINT
only
the
re-
cause
SURGERY
SYMPTOMATIC
SYNOVIAL
PLICAE
TABLE
SURVIVORSHIP
WITH
No.
Interval
(ftitos.)
A
GOOD
OR
Success
EXCELLENT
II
1491
KNEE
Two
AT LEAST
Average
(No.)
I
II
THE
III
RESULT
Failure
I
OF
YEARS
POSTOPERATIVELY*
Success
(Per cent)
I
II
I
Cumulative
Success
(Per cent)
Failure
(Per cent)
II
I
II
lOt)
1(X)
1(X)
1(X)
0. 1
1(X)
9()
5.4
1(X)
85
1(X)
85
79.3
1 1.8
20.7
96
96
75
60
12.5
92.0
8.0
96
96
60
55
I
II
0-1
24
21
1-2
24
21
2-3
24
21
2
20.0
9().O
3.4
24
19
1
18.5
94.6
4-5
5-6
24
24
18
18
6-7
16
3
14.5
7-8
23
23
8-9
23
13
13
1
I
II
24.0
1
2
23.5
17.0
95.7
88.2
4.3
9-10
23
12
96
55
10-11
23
12
3
10.5
71.4
28.6
96
39
11-12
12-13
23
23
9
9
1
8.5
88.2
11.8
96
35
96
40
13-14
23
8
96
35
14-15
23
8
96
35
15-16
8
16-17
23
23
17-18
23
7
7
96
96
96
30
30
30
18-19
23
7
96
30
19-20
23
7
20-21
23
6
96
96
25
25
21-22
22-23
23
22
6
6
92
25
92
25
23-24
22
6
87
25
24-25
20
6
87
25
25-26
20
6
2
87
25
26-27
18
6
6
81
25
27-28
11
6
5
4.5
81
25
28-29
6
3
2.0
81
25
29-30
6
1
2
81
25
30-31
31-32
4
2
1
0
2
81
25
32-33
33-34
1
81
1
81
34-35
1
35-36
1
*1
the
=
of the
1
7.5
86.7
13.3
1
6.5
84.6
15.4
1
1
22.5
21.0
1
continuing
95.2
1
14.5
3
8.5
plicae
1
3.0
0.5
81
1.5
81
81
1.0
were
divided
and
II
the
=
group
in which
the
knees
symptoms.
ii
In Group
II as a whole,
significantly
(p = 0.16).
twenty-one
five other
knees
knees
the severity
at the six-month
Only
three
(14
had no pain
(24 per cent)
and
had
of pain
had
not
follow-up
exper cent)
of the
an excellent
an occasional,
result;
mild
ache and were
knees
(57 per
classified
as having
a good result.
Twelve
cent)
still had moderate
or troublesome
pain
result),
(a
poor
and
one
anterior
pain that was severe
only eight
knees
(38 per cent)
provement,
worse.
The
better
vided
in the
(Group
six months
in Group
twelve
knees
were
result
at six
months
75-A,
was also significantly
II (p < 0.001).
NO.
knee
(5 per
recent
10. OCTOBER
follow-up
1993
cent)
and a failed
result.
had some
degree
unchanged,
and
in terms
patients
in whom
the plicae
I) (p < 0.001).
The clinical
At the most
VOL.
only
icantly
decreased
amination
better
had
one
had been
assessment
in Group
examination,
the
most
painless
walking.
those
during
These
sports
results
in Group
recent
group
did
deteriorated
review.
At
only three
significantly
I, in which
not
the
activity
were
painful
during
sports
activity
during
walking
(p < 0.01).
knees
in this
and two knees
signiftwenty
(p < 0.001)
improve
after
six
even further
before
most
knees
(14 per
fewer
than
recent
follow-up
cent)
had
in Group
an exI (p <
0.001).
Three
Group-Il
knees
(14 per cent)
had a good
result,
although
only one patient
was able to return
to
full sports
activity.
One
knee
was mildly
painful
when
the
Group
II had
before
the
four
divided.
from
knees
were not
and twenty-three,
was
diat
during
different
The
months,
not
II were
five,
was
I than
only
were
examination,
cellent
result,
Thus,
of im-
of pain
plicae
in Group
and
Group
6.9
5.0
1
the
4.8
93.1
2
in which
4.4
19.0
1
group
95.6
patient
walked.
Thus,
only
operation.
were
worse
could
six knees
be claimed
(29 pen cent)
in
or
excellent
result,
significantly
fewer
than in Group
I (p <
0.001).
Twelve
knees
(57 per cent) had a poor result,
with the same symptoms
and restriction
of activities
as
symptoms
what
In three
than
knees
before
to be a good
(14
the
pen
cent),
anthroscopy
the
and
1492
D.
the results
significantly
after
were considered
as failures.
more
poor
results
in this
arthroscopic
additional
was
tients),
the
in ten
EASTWOOD.
there
than
were
seen
AND
P. J. WITHEROW
p < 0.001,
p < 0.001)
and
and
(seven
severe
symptoms
division
of
patients)
in
symptoms,
months
(range,
six to
arthnoscopy.
In seven
preoperative
(Fig.
5, Table
III).
Discussion
knees
of unremitting
of eleven
the initial
Thus,
group
anthroscopy
necessary
II because
mean
after
D. M.
(p < 0.001).
division
Subsequent,
all phicae
Group
P. JOHNSON.
twelve
knees
were
at a
months)
(six paunchanged,
very
Anterior
pain
controversial
cae
as a cause
in the knee and its treatment
is still a
subject,
and the role of synovial
phi-
of such
pain
has
been
a need
for a study
whether
plicae
can be the
knee
and whether
division
been
disputed.
There
has
to demonstrate
conclusively
cause
of anterior
pain in the
of the symptomatic
phicae
relieves
pain.
Synovial
phicae represent
the
separate
cavities
in the synovial
remnants
of the three
mesenchyme
of the
trial.
At the most
recent
examination,
all symptoms
had resolved
in four of these
knees
(two patients)
and
the patient
had
returned
to sports
activity.
In three
developing
into
knees
(three
plica
(two
of these
sports
activity).
and
in three
become
tients
the
the
knees
more
formed
severe
their
after
the
own control
were
symptoms
achieved.
the
phica
and
was
an excellent
Of the eighteen
not
division
and
Thus,
repeat
an excellent
knees
with
done,
the
anterior
result
was
obtained.
knees
fifteen
continued
significantly
Twelve
Group-I!
more
knees
-
in a good
(p < 0.01).
plica
The
but
and
three
to
patients).
divided.
knees,
Group-Il
preoperatively,
).
was
mild
returned
(three
an anterior
in three
disappeared
In one of the
had
to
who
knees
in which
unchanged
anthroscopy
months
0.001
of the
knees
in isolation,
ing
decreased
were
unchanged
after
the
considered
to be a failure.
four
were
vided,
had
in patients
In three
symptoms
and division
of the phicae resulted
result
in seven
of the ten knees
In the
repeat
the
arthroscopy.
These
pagroup
as a crossover
pain
knees
anthroscopy
or excellent
toms
patients).
patients),
symptoms
result
was
found
(three
was
symp-
in one
the
result
was
a poor
result,
phica
that
had
to
was
degree
had
was
eradicated
in only three
at six months
and at the most
recent
review
significantly
fewer than in Group
I (p <
0.05).
-
with
suprapatellar
during
with
into
pouch
its size
an opening
the knee
Synovial
described
1916
and
Analysis
In order
to compensate
recent
review,
operation
Group
survival
in Group
II and one
I, a survivorship
analysis
defined
as no additional
with
survival
ten
for the fact that,
knees
defined
had
as a good
rates
of survival
without
100, 96, and 96 pen cent
and
phicae
two
years.
had
been
respectively
divided.
-
been
treated
These
with
a re-
had been
so treated
in
was performed,
with
operation
and also
on excellent
an additional
at six months,
-
at the most
for the
rates
result79.
operation
twelve
knees
in which
of survival
The
were
months,
were
the
80,
54, and 50 per cent in the knees
in which
the phicae had
not been
divided
(p < 0.08, p < 0.05, and p < 0.01) (Fig.
4. Table
II). With survival
defined
as a good or excellent
result
with
were
and
failure
defined
as no improvement
compared
the preoperative
condition,
the rates of survival
96, 96, and 87 per cent in Group
I. The comparative
results
in Group
II were 60, 35, and 25 per cent (p < 0.01,
3). There
the knee
may
a
on
may
joint
itself
be incomplete,
the suprapatellar
(Fig.
knee
in 1918.
have
1, 2, and
pouch
3).
apparently
were
by
Fullerton’9
dissections
plicae
was
by Patel
studies
depending
from
from
anatomical
The
arthroscopic
first
in
appear-
described
by Iino39 in 1939 and
and by Watanabe
et al.92. Postshown
phicae
in 20 to 50 per
cent
of knees’,
with the highest
prevalence
in individuals
of Japanese
descent43942’73.
A 40 to 80 per cent prevalence
of synovial
plicae
seen
in anthroscopic
examinations has been
reponted’4’’44’57’74.
There
is some controversy
regarding
of the phica syndrome,
and some
reports
that
it does
not
exist1564.
have
Survivorship
seen
proper63
of the
by MayedaTM
at the
extent
membrane
or a porta
in
cavity
membrane,
so that there
is
pouch
that does not communi(Fig. 3). In this situation,
the
at the proximal
margin
of the
The
joint
phicae
and
(Figs.
is not
anthroscopy.
one
growth32.
If the reabsorption
the cavities
is incomplete,
of reabsorption
mortem
most
recent
examination.
Twelve
Group-Il
knees
had giving-way
preoperatively,
and this symptom
coalesce
be a complete
suprapatellar
a separate
suprapatellar
cate with the knee joint
articulanis
genu
muscle
at
six
which
result,
ance of the
subsequently
Group
I (p <
to click at the
than
in
continued
the
may
click-
had
click
di-
knee,
twelve-week
stage
of fetal
of the divisions
between
Jackson
stated
cause symptoms
but that the
and many
normal
synovial
the prevalence
have suggested
et al.442,
that
phicae
Dandy6,
may
and
indeed
syndrome
is overdiagnosed
phicae
are removed.
Con-
versely,
other
authors
have
considered
the phica syndrome
to be a common
cause
of anterior
pain
in the
knee that is often
misdiagnosed
and have believed
that
a suprapatellar
membrane
is virtually
never
asymptomatic2’43669.
Attempts
have
been
of symptomatic
biopsy
specimens
phicae
of
Klein4t’
medial
reported
shelfshowed
that
mation,
sixteen
and Mital
and
biopsies
showed
Jackson77
symptomatic
ate clinical
treatment,
proposed
synovial
made
to quantify
through
histological
phica obtained
at
analysis
arthroscopies.
15 per cent of 186 biopsies
fibrosis
indicative
of chronic
Hayden56
reported
phica hemorrhage.
a set of criteria
phica:
JOURNAL
of
of the
inflam-
that nine of
Sherman
and
for the diagnosis
(1) a history
symptoms,
(2) the
(3) the arthroscopic
THE
the occurrence
of
of the appropni-
failure
of non-operative
finding
of a plica with
OF BONE
AND
JOINT
SURGERY
SYMPTOMATIC
an
avascular
fibrotic
femoral
condyle
no other
abnormality
symptoms.
the severity
the
of
on
the
thought
to be an association
in the
inferior
same
population33M.
results
after operative
of
the
It has
of the
synovial
also
been
that
plica,
would
and
explain
Richmond
between
the
of pathological
suggested
that
and
duration
changes
a localized
at the site of impingement
condyle
is evidence
that
of
in
area
by a plica
a phica is the
symptoms.
Detection
pain
in the
clinical
plica as the cause of anterior
on recognition
of the rele-
symptoms
in 64
per
pseudolocking,
are not well
contrast
plica
or
graph
and
cent;
in 45
seen
on
anthrognam
an anterior
may
the
absence
of
signs
ex-
giving-way,
a suprapatellan
a skyline
radio-
a synovial
been
92 pen cent
and
a specificity
otherwise
has proved
reported
of 73 per
femoral
normal’4.
to be
Thus,
helpful
bracing,
and an
the
findings
of
as well
ultrasound,
and
are
axial
tomography
chondromalacia.
and other
modalities
is in doubt,
plica
diagnosis
during
anthroscopy.
The non-operative
volves
stretching
gastnocnemius
otherapy,
may show some
with an impinge-
axial images
of a magnetic
to be a more
useful
mode
than
computerized
of synovial
plicae
a clinical
but
of
detec-
Computerized
axial
tomography
useful,
but a synovial
shelf
is easily
while
radiographic
when
a diagnosis
remains
abnormalities,
syndrome
exist.
The
that
can
treatment
of plica syndrome
the quadriceps,
hamstrings,
as isometric
microwave
strengthening,
diathermy,
are
inand
crypatellar
bicycle-riding,
anti-inflammatory
medication,
altered
sports-training
schedule227’#{176}’7.
In
patellae
the
lateral
in the
plica
facet
syndrome.
hyperpressure
and the conditions
an operation
may
release
was
done
or
same
be
may cofurther
for lateral
retinaeas
that
pnesent49’535.
Our
study
was
designed
with
a view
to the difficul-
ties that surround
the subject
ofsynovial
phicae. Initially.
all of the discernible
conditions
that
also might
have
been
the source
of the symptoms
were
excluded
with
the use of clinical
and radiographic
assessment.
Only
if
symptoms
continued
unabated
after
and if the clinical
of phica syndrome.
an initial
course
findings
led to the
was anthroscopy
considered,
and the patient
was included
in the study
only if the anthroscopic
findings
were otherwise
normal.
The trial design
included
a randomized
control
group
in
which
diagnostic
phicae
were
effect
reasons,
of
ting
had
arthroscopy
not
divided,
anthroscopy
the patients
symptoms
a second
The
only
conditions
present
between
and
is indistinct49’75,
situation
after
if a lateral
separate
Some
studies
have
shown
treatment
of phicae when
were
pain,
in
pain or for lateral
facet hyperpressure
syndrome.
procedure
may also divide
any lateral
plicae
uation
may be
syndrome
be confirmed
ular
this
found
it is generally
as chondromalacia
overlap
retinacular
but
of two
such
knee’9’’7#{176}’77’51.
The
lateral
is commonly
plica&’2,
subluxation,
of physical
therapy,
specific
diagnosis
Ultra-
in the
synovial
patellofemoral
the
a sensitivity
cent
scan
condyle,
missed’’76’75.
In one study,
the
resonance
scan were reported
of investigation
for the detection
shelt’925.
as having
A technetium
bone
uptake
in association
on the
and
may demonstrate
phica6’7’2’67’74 and
demonstrate
lesion
cent;
patients’3.
Plicae
but a double-
has
ment
in 59 per
per cent
of the
plain
nadiographs,
sonognaphy
tion of phicae2.
focal
increased
other
with
confused
of a synovial
knee
depends
cept, perhaps,
for a palpable,
tender
synovial
band.
In a
previous
study
of plicae
in the knee,
clicking
was reported
patehlae
the
knee
and
1493
KNEE
Chondromalacia
medial
knee,
THE
However,
Jackson
et al.42 commented
that
of symptoms
is not proportional
to the size
in the
the
OF
association
of chondromalacia
on the femoral
vant
impinges
found
no correlation
and the presence
phica.
cause
that
flexion
PLICAE
(4)
on breadth
McGinty7
symptoms
edge
during
SYNOVIAL
irrigation.
who still
at six months
arthroscopy
after
before
the initial
the most
at a minimum
average
age
but
of two
of the
years.
patients
the mean
duration
had been
twenty-three
had had chronic
that had proved
the
placebo
For ethical
had unremitarthroscopy
recent
eval-
in this
study
of symptoms
months.
symptoms,
resistant
was
beThus,
starting
to non-
therapy.
Since
all of the plicae
had been
present
wondered
why the onset
of symptoms
until
but
the
joint
group
most of the patients
in early
adolescence,
we
performed
neutralizing
and
in this
fourteen
years,
fore presentation
operative
was
thus
adolescence.
A discrete
injury
preceded
since birth.
was delayed
the onset
of pain
contrasts
trauma
in only
13 per cent of the knees.
This finding
with the 50 per cent
prevalence
of previous
reported
by Hansen
and Boe33. In many
of our
resulted
in an improvement
in 40 per cent of patients
over
a one-year
period.
Conversely,
Apnin
et al.7 neported
that.
in knees
in which
an anthrogram
dem-
patients,
tivities
the symptoms
and appeared
increase
in the
onstrated
condyle
sult in
dentaken
that the
that
the
during
early
adolescence.
It is also possible
elasticity
of the phicae
diminishes
with age or
adolescent
growth
spurt
may
in some
way
uncontrolled
study72,
these
types
impingement
of the
in flexion,
non-operative
long-term
improvement.
of treatment
phicae
on
treatment
Injection
an
methods
the femoral
did not reof the syn-
were
exacerbated
by sports
acto have
been
precipitated
by an
amount
of structured
sports
activity
un-
ovial
plicae
with
steroids
and
a local
anesthetic
in
another
uncontrolled
study7’
was reported
to have
an
excellent
result
in 73 per cent
of patients,
although
percutaneous
injection
of the thin intra-anticulan
band
of the plicae
is difficult
and reliable
placement
of the
change
the mechanical
relationship
between
the synovial tissue
and the movement
of the femoral
condyle
during
flexion
of the knee’3.
We speculate
that any of
these
factors
may have caused
the symptoms
by initiating bow-stringing
of the plicae
over the femoral
condyle
needle
and
VOL.
is impossible.
75-A,
NO.
10. OCFOBER
1993
impingement
of the
plicae
on the
condyle
as well
as
1494
D.
entrapment
of the
femoral
plicae
P. JOHNSON.
between
the
D.
M.
patella
EASTWOOD.
and
AND
P. J. WITHEROW
obtained
a good
or excellent
Although
only
one knee
the
condyle.
A characteristic
pattern
of presentation
was discerned:
the anterior
pain in the knee
was episodic
and
associated
with painful
clicking,
giving-way.
and the feeling of something
catching
in the knee.
Careful
palpa-
and
tion
of the
knee
extended
prevalence
of recurrent
symptoms
(17 per cent)
of twenty-four
knees,
detection
patellar
of
flexed
tender
tenderness
the
can
retinaculum
and
the
anterior
horn
of the
he difficult
to resect
anterolateral
the surgeon,
resection
of the
for
differentiation
from
tenderness
menisci.
through
the
for the
of
over
As the synovial
an anteromedial
shelf
or
can assist
portal for
that
the phica syndrome
originating
from
a medial
referred
is con-
for this
reason
it has
been
or the
medial
shelf
syndrome.
plicae
study
found clinically
and anthroscopically
in the present
suggests
that suprapatellar
and lateral
shelves
may
plica
similar
was
brane
symptoms.
distribution
there
knee
The
the suprapatellar
was present
in only
of plicae
convincing
and
After
improved
did not
arthroscopy
either
Thus,
knee
that
in our
anthroscopies
who
on
described
the knee
to be subjectively
Additional
support
by the
plicae
were
symptomatic
viously
had
improve
months
described3’
who
had
division
only
one
side.
in which
the
better
than
for the
results
for
plicae
but
of these
in the
division
patients
phicae had been
the contralateral
benefit
of the
procedure
the
knees
in which
Seven
of these
ten
knees
eventually
only
lesion
commonly
the
conversely,
the
ular
is
the
However,
cartilage
the
the
ward
to
for an excision
not
the
may
that
the
necessarily
symptoms;
lesion
loose
argument
medical
for
that
re-
does
from
division
alone
of the area
of impinge-
of any
open
a me-
phicae
lesion
believe
is a logical
plica is performed
patient’5.
There
as compared
arthroscopy.
the case for
we
is present
It is sometimes
with
of an impingement
private-insurance-based
was
of the lesion
in
not included
with
d#{233}bnidement
that
phica
of the femoral
lesion
does
the cause
of
result
after
divided
had varied
knees
in this group
Our policy
is to
who have the phica
with other
plicae.
in association
Therefore,
presence
results
division
of many
an impingement
with
symptoms.
persistent
an anterior
or a lateral
shelf.
Documentation
study
was poor and was therefore
Nonetheless.
associated
by
well
as Sherman
who
had major
on the edge
found
retro-
improved
arthroscopic
unpredictable
found
and in which
the phica was not
results.
However,
there
were too few
for any firm conclusions
to be drawn.
divide
the anterior
phica in patients
syndrome.
whether
or not it is found
ment.
divided
knee.
not divided
and that
were
still severely
at six months.
Although
this group
prehad physiotherapy,
a failed
anthroscopy,
and
anthroscopy.
had
of
patients
it demonstrated
of the phicae.
four knees
in which
the results.
were
not
return
three
still had a mild
Klein,
as
that
patients
not preclude
an excellent
without
a local chondroplasty
persistent,
severe
anterior
pain in the knee, there was
marked
improvement
after division
of the phicae at the
second
performed;
patellae.
reported
was
of our
did not pre-
or the
although
patellae
of chondromalacia
dial
this
is benefi-
of the
with
arthroscopic
knee
that was not
another
diagnostic
hieved
symptoms
ten
chondromalacia
was
result
activity,
presence
of an impingement
mean
that the phicae
are
findings
All
to full sports
An impingement
syndrome.
reported
Because
after
patellae
of a good
ache.
In one
of the phica,
condyle
two
shell”.
of chondromalacia
attainment
had
division
The
in the
was
excision
associated
phicae
in the present
study, we currently
to its capsular
attachment
with a motorshaver
rather
than only incising
it.
was not apparent
by the
phicae.
study was four
is comparable
that
symptoms
phica
of the
bilateral
pain
who
recurrent
areas
the
areas
over-all
of recurrence
of a medial
chondromalacia
and Jackson77,
at least
rate
in this
which
and McGinty7.
However,
capsular
base has also been
with
Minor
procedure
diagnostic
after
of anterior
is supported
had
after
or
of the
synovial
that
some
The
cent
excision
The
of a marked
alone,
division
wide
patellar
division
plicae
at both
(at least two-
deteriorated.
diminution
that
patients
provided
others
so often
contention
phicae
evidence
arthroscopy
of patients
patients
of the
diagnostic
the natural
in these
eight
for a
Fifty-four
per cent of the
after division
of the phicae and
on good result,
findings
that
at six
has been
5 per
the patient
mem-
suggests
after
and with persistent
pain’6. and
patella
has been reported
after
elude
one phica in a symptomatic
is commonly
bilateral.
significantly
population
The
cial
site
of the knees.
division
of the
and medium-term
while
assessment
years.
common
scar
an area of scar formation
lateral
subluxation
of the
of
with the 39 to 59 per cent rate of asympthat was previously
reported
in unconby Hansen
and Boe33 and by Andersen
Poulsen3.
knees
medial
distribution
A suprapatellar
statistical
year)
follow-up
evaluations.
knees
were asymptomatic
83 per cent had an excellent
are comparable
tomatic
knees
trolled
studies
most
4 per cent
at the
benefit
after
anthroscopic
short-term
(six-month)
to as the
The
pouch.
is usually
more
than
and that the syndrome
We found
the
by Richmond
phicae to the
division
of the
excise
the plica
ized arthroscopic
shelf’665’5”,
phica
produce
with
experience
reported
synovial
the symptoms
returned
after
an interval
in two other
knees;
this supports
the possibility
that division
of the
phicae
may be followed
by formation
of a scar3”5”6. The
shelf.
to symptoms
and
pad
with
to be useful
portal,
preoperative
diagnosis
who can expect to use a superior
It has been
fined
and
fat
fat pad
found
phicae
within
and
was
a palpable
(p < 0.01).
recurrent
symptoms
result
had
flap
of antic-
procedure42.
whether,
practice,
in a
release
of
the benefit
of the surgeon
be a considerable
financial
or
re-
of a phica or a partial
synovectomy
with
the compensation
for a diagnostic
This study
was not undertaken
to support
phicae
division
en masse,
but to attempt
to
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
SYMPTOMATIC
delineate,
population,
procedure.
SYNOVIAL
PLICAE
in a scientific
way, if, in a carefully
selected
there
is any clinical
benefit
from
such
a
We believe
that we have demonstrated
that
there
is a clinical
benefit.
Continued
treatment
and anthroscopy
alone
resulted
improvement
over
a period
of at least
non-operative
in no marked
two years.
We
OF
THE
I 495
KNEE
support
the current
trend
the financial
remuneration
of a phica as no greater
in some
countries
to classify
from
anthroscopic
division
than
that
from
a diagnostic
arthroscopy.
of a large
considerable
noted,
however,
that excision
requires
additional
time and
It should
be
shelf sometimes
expertise.
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