The hypermobile lateral meniscus: a retrospective review of presentation, imaging, treatment, and results.

PURPOSE: Hypermobility of the posterior portion of the lateral meniscus has been reported in several recent case reports and small case series. Pathophysiology and optimal treatment have not been fully elucidated. Our purpose was to evaluate results following arthroscopic stabilization. METHODS: Over a 10-year period, 13 knees were diagnosed at the time of arthroscopy as having hypermobility of the posterior portion of the lateral meniscus in the absence of a discrete tear or discoid morphology. Clinical presentation, pre-operative MRI findings, arthroscopic findings, and repair technique were retrospectively reviewed. Most recent outcomes data were gathered via a telephone interview utilizing the IKDC-9 questionnaire. RESULTS: Eleven of 12 patients presented primarily with mechanical symptoms. Duration of symptoms ranged from 7 months to over 10 years. Eight of 12 patients did not recall any history of trauma. Twelve of 13 pre-operative MRIs did not identify a meniscal tear. Stabilization was obtained by fixation of the meniscus to the posterior capsule by various techniques. Average follow-up was 4 years (range 6 months to 10.7 years). Subjective current knee function averaged 8.0 (range 3.5-10) on a scale of 0-10. Knee pain severity averaged 2.2 (range 0-4) on a scale of 0-10. Pain frequency averaged 3.3 (range 0-9) on a scale of 0-10. Better results were seen in younger patients. CONCLUSION: Hypermobility of the posterior portion of the lateral meniscus can successfully be treated with arthroscopic repair to the posterior capsule. LEVEL OF EVIDENCE: IV.

Clinical assessment of the ulnar nerve at the elbow: reliability of instability testing and the association of hypermobility with clinical symptoms.

BACKGROUND: Ulnar nerve hypermobility has been reported to be present in 2% to 47% of asymptomatic individuals. To our knowledge, the physical examination technique for diagnosing ulnar nerve hypermobility has not been standardized. This study was designed to quantify the interobserver reliability of the physical examination for ulnar nerve hypermobility and to determine whether ulnar nerve hypermobility is associated with clinical symptoms. METHODS: Four hundred elbows in 200 volunteer participants were examined. Each participant was queried regarding symptoms attributable to the ulnar nerve. Three examiners, unaware of reported symptoms, independently performed a standardized examination of both elbows to assess ulnar nerve hypermobility. Ulnar nerves were categorized as stable or as hypermobile, which was further subclassified as perchable, perching, or dislocating. Provocative maneuvers, consisting of the Tinel test and flexion compression testing, were performed, and structural measurements were recorded. Kappa values quantified the examination's interobserver reliability. Unpaired t tests, chi-square tests, Wilcoxon tests, and Fisher exact tests were utilized to compare data between those with hypermobile nerves and those with stable nerves. RESULTS: Ulnar nerve hypermobility was identified in 37% (148) of the 400 elbows. Hypermobility was bilateral in 30% (fifty-nine) of the 200 subjects. For the three examiners, weighted kappa values on the right and left sides were 0.70 and 0.74, respectively. Elbows with nerve hypermobility did not experience a higher prevalence of subjective symptoms (snapping, pain, and tingling) than did elbows with stable nerves. Provocative physical examination testing for ulnar nerve irritability, however, showed consistent trends toward heightened irritability in hypermobile nerves (p = 0.04 to 0.16). Demographic data and anatomic measurements were similar between the subjects with stable nerves and those with hypermobile nerves. CONCLUSIONS: Ulnar nerve hypermobility occurs in over one-third of the adult population. Utilizing a standardized physical examination, a diagnosis of ulnar nerve hypermobility can be established with substantial interobserver reliability. In the general population, ulnar nerve hypermobility does not appear to be associated with an increased symptomatology attributable to the ulnar nerve.

Joint leveling for advanced Kienböck's disease.

PURPOSE: The use of joint leveling procedures to treat Kienböck's disease have been limited by the degree of disease advancement. This study was designed to compare clinical and radiographic outcomes of wrists with more advanced (stage IIIB) Kienböck's disease with those of wrists with less advanced (stage II/IIIA) disease following radius-shortening osteotomy. METHODS: This retrospective study enrolled 31 adult wrists (30 patients; mean age, 39 y), treated with radius-shortening osteotomy at 2 institutions for either stage IIIB (n = 14) or stage II/IIIA (n = 17) disease. Evaluation was performed at a mean of 74 months (IIIB, 77 mo; II/IIIA, 72 mo). Radiographic assessment determined disease progression. Clinical outcomes were determined by validated patient-based and objective measures. RESULTS: Patient-based outcome ratings of wrists treated for stage IIIB were similar to those with stage II/IIIA (shortened Disabilities of the Arm, Shoulder, and Hand score, 15 vs 12; modified Mayo wrist score, 84 vs 87; visual analog scale pain score, 1.2 vs 1.7; visual analog scale function score, 2.6 vs 2.1). The average flexion/extension arc was 102° for wrists with stage IIIB and 106° for wrists with stage II/IIIA Kienbock's. Grip strength was 77% of the opposite side for stage IIIB wrists versus 85% for stage II/IIIA. Postoperative carpal height ratio and radioscaphoid angle were worse for wrists treated for stage IIIB (0.46 and 65°, respectively) than stage II/IIIA (0.53 and 53°, respectively) disease. Radiographic disease progression occurred in 7 wrists (6 stage II/IIIA, 1 stage IIIB). The one stage IIIB wrist that progressed underwent wrist arthrodesis. CONCLUSIONS: In this limited series, clinical outcomes of radius shortening using validated, patient-based assessment instruments and objective measures failed to demonstrate predicted clinically relevant differences between stage II/IIIA and IIIB Kienböck's disease. Given the high percentage of successful clinical outcomes in this case series of 14 stage IIIB wrists, we believe that static carpal malalignment does not preclude radius-shortening osteotomy. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.