(Radiology. 1999;213:213-216.)
© RSNA, 1999
Oblique Meniscomeniscal Ligament: Another Potential Pitfall for a Meniscal Tear-Anatomic Description and Appearance at MR Imaging in Three Cases1
Timothy G. Sanders, MD,
Ricardo C. Linares, MD,
Keith W. Lawhorn, MD,
Phillip F. J. Tirman, MD and
Craig Houser, MD
1 From the Department of Radiology, Wilford Hall Medical Center, 759th MDTS/MTRD, 2200 Bergquist Dr, Ste 1, Lackland AFB, TX 78236-5300 (T.G.S.); the Departments of Radiology (R.C.L., C.H.) and Orthopaedics (K.W.L.), David Grant United States Air Force Medical Center, Travis AFB, Calif; and the San Francisco Magnetic Resonance Center, Calif (P.F.J.T.). Received November 19, 1998; revision requested December 29; revision received February 12, 1999; accepted March 26. Address reprint requests to T.G.S.
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Abstract
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Three patients with an arthroscopically proved normal variant, the oblique meniscomeniscal ligament, underwent prospective magnetic resonance (MR) imaging of the knee. In the first case, the ligament was misinterpreted as a displaced flap tear of the posterior horn of the lateral meniscus. In the two subsequent cases, the ligament was identified correctly at MR imaging as the oblique meniscomeniscal ligament.
Index terms: Knee, anatomy, 452.92 • Knee, injuries, 452.4852, 452.4857 • Knee, ligaments, menisci, and cartilage, 452.1495, 452.4852, 452.4857 • Knee, MR, 452.1214, 452.121415, 452.121416
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Introduction
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Several normal ligamentous structures of the knee have been described that may mimic a meniscal tear at magnetic resonance (MR) imaging. The oblique meniscomeniscal ligament is an intermeniscal ligament that runs obliquely from the anterior horn of one meniscus to the posterior horn of the opposite meniscus. It has been previously described in both anatomy and arthroscopy literature and has a reported prevalence ranging from 1% to 4% (1–3).
The ligament is named for its anterior meniscal origin. The medial oblique meniscomeniscal ligament originates from the anterior horn of the medial meniscus and extends through the intercondylar notch to insert into the posterior horn of the lateral meniscus. The lateral oblique meniscomeniscal ligament originates from the anterior horn of the lateral meniscus and inserts into the posterior horn of the medial meniscus. In both cases, the intermeniscal ligament passes between the anterior and posterior cruciate ligaments as it traverses the intercondylar notch (Fig 1). We report on three cases with the oblique meniscomeniscal ligament on MR images with arthroscopic correlation.
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Figure 1. Line drawing shows the normal anatomy of the medial oblique meniscomeniscal ligament (lig) as it courses from the anterior horn of the medial (Med) meniscus to the posterior horn of the lateral (Lat) meniscus. It extends obliquely through the intercondylar notch, passing between the tibial attachments of the anterior and posterior cruciate ligaments—ACL and PCL, respectively. ANT = anterior, LAT = lateral, MED = medial, POST = posterior.
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MR Imaging Technique
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All images were acquired with a Signa 1.5-T imager (GE Medical Systems, Milwaukee, Wis). By using a 6.5-inch extremity coil for the knee (Quadrature coil; GE Medical Systems), dual-echo T2-weighted sagittal images were obtained (2,200/30 and 90 [repetition time msec/echo time msec], 4-mm section thickness, 1-mm intersection gap, one signal acquired, 256 x 192 matrix, 16-cm field of view). T1-weighted images were obtained in the coronal plane (400/14, 4-mm section thickness, 1-mm intersection gap, three signals acquired, 256 x 256 matrix, 16-cm field of view). Fast spin-echo T2-weighted images with frequency-selective fat saturation were obtained in the coronal and axial planes (3,000/70, echo train length of 12, 4-mm section thickness, 1-mm intersection gap, four signals acquired, 256 x 192 matrix, 16-cm field of view).
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Case Reports
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Case 1
A 14-year-old male adolescent complained of a 2-year history of right knee pain following a soccer injury. Physical examination by an orthopedic surgeon demonstrated no signs of instability but revealed a slight decrease in the range of motion and mild tenderness along the medial aspect of the knee. MR images obtained in all three imaging planes demonstrated a linear structure of low signal intensity that arose from the posterior horn of the lateral meniscus and extended into the intercondylar notch. On sagittal images, it mimicked the appearance of the double posterior cruciate ligament sign, a finding associated with a bucket-handle tear of the meniscus, but the meniscal morphology was otherwise normal (Fig 2) (4–6). This was prospectively interpreted as a flap tear extending from the posterior horn of the lateral meniscus.
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Figure 2a. Case 1. (a) Sagittal MR image, dual-echo T2-weighted (2,200/30 and 90), of the knee through the intercondylar notch at the level of the posterior cruciate ligament (curved arrow) demonstrates, just inferior to the posterior cruciate ligament, a thin linear structure of low signal intensity (straight arrow) that represents the oblique meniscomeniscal ligament. This was interpreted prospectively as a displaced meniscal fragment. (b) Coronal T1-weighted MR image (400/14) of the knee demonstrates the oblique meniscomeniscal ligament (arrowheads) as it passes through the intercondylar notch from the anterior horn of the medial meniscus to the posterior horn of the lateral meniscus. The ligament could be followed in its entirety on sequential coronal images (not shown).
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Figure 2b. Case 1. (a) Sagittal MR image, dual-echo T2-weighted (2,200/30 and 90), of the knee through the intercondylar notch at the level of the posterior cruciate ligament (curved arrow) demonstrates, just inferior to the posterior cruciate ligament, a thin linear structure of low signal intensity (straight arrow) that represents the oblique meniscomeniscal ligament. This was interpreted prospectively as a displaced meniscal fragment. (b) Coronal T1-weighted MR image (400/14) of the knee demonstrates the oblique meniscomeniscal ligament (arrowheads) as it passes through the intercondylar notch from the anterior horn of the medial meniscus to the posterior horn of the lateral meniscus. The ligament could be followed in its entirety on sequential coronal images (not shown).
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Follow-up arthroscopy revealed no meniscal tear; however, a cordlike structure with a synovial lining was identified that originated from the anterior horn of the medial meniscus and extended through the intercondylar notch, passed between the cruciate ligaments, and inserted into the posterior horn of the lateral meniscus. The posterior portion of the ligament was easily visualized; however, the anterior portion was enveloped by intraarticular synovium and fat, which required débridement to allow full visualization. Retrospective review of the MR images revealed a cordlike structure that originated from the anterior horn of the medial meniscus and inserted into the lateral meniscus (Fig 2).
Case 2
A 27-year-old man complained of a 2-month history of right knee pain and swelling following an injury incurred while playing soccer. Examination by an orthopedic surgeon revealed knee effusion and an incompetent anterior cruciate ligament. MR imaging demonstrated a complete tear of the anterior cruciate ligament. In addition, a thin cordlike structure that originated from the anterior horn of the medial meniscus and inserted into the posterior horn of the lateral meniscus (Fig 3) was seen extending through the intercondylar notch. This was prospectively interpreted as the medial oblique meniscomeniscal ligament.
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Figure 3a. Case 2. (a) Sagittal dual-echo, T2-weighted MR image (2,200/30 and 90) of the knee demonstrates complete disruption of the anterior cruciate ligament (curved arrow). The oblique meniscomeniscal ligament (straight arrow) is a thin structure that demonstrates low signal intensity and courses inferior to the anterior cruciate ligament. (b) Coronal T1-weighted image (400/14) of the knee demonstrates the low-signal-intensity oblique meniscomeniscal ligament (arrowheads) extending through the intercondylar notch. On multiple contiguous coronal images (not shown), this structure could be traced from the anterior horn of the medial meniscus to the posterior horn of the lateral meniscus.
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Figure 3b. Case 2. (a) Sagittal dual-echo, T2-weighted MR image (2,200/30 and 90) of the knee demonstrates complete disruption of the anterior cruciate ligament (curved arrow). The oblique meniscomeniscal ligament (straight arrow) is a thin structure that demonstrates low signal intensity and courses inferior to the anterior cruciate ligament. (b) Coronal T1-weighted image (400/14) of the knee demonstrates the low-signal-intensity oblique meniscomeniscal ligament (arrowheads) extending through the intercondylar notch. On multiple contiguous coronal images (not shown), this structure could be traced from the anterior horn of the medial meniscus to the posterior horn of the lateral meniscus.
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Follow-up arthroscopy revealed complete disruption of the anterior cruciate ligament. A taut, cordlike structure with a synovial lining was identified that extended through the intercondylar notch and inserted into the posterior horn of the lateral meniscus. Arthroscopic visualization of the most anterior portion of the ligament could not be accomplished because the structure was completely invested in the intraarticular fat, and meticulous dissection would have been required to demonstrate its origin.
Postsurgical review of the MR images confirmed the presence of a cordlike structure that could be traced from the anterior horn of the medial meniscus to the posterior horn of the lateral meniscus. It was thought that the arthroscopic findings confirmed the presence of a medial oblique meniscomeniscal ligament, even though the most anterior segment of the ligament was not fully visualized secondary to the surrounding intraarticular synovium.
Case 3
A 37-year-old man complained of a 1-month history of persistent right knee pain and swelling after sustaining a twisting injury while playing basketball. Examination by an orthopedic surgeon revealed tenderness along the lateral aspect of the knee but no evidence of instability.
MR images revealed a discoid lateral meniscus with a radial tear of the midbody and a flap component that extended into the anterior horn (not shown). A thick cordlike structure originating from the anterior horn of the medial meniscus and passing through the intercondylar notch to insert into the posterior horn of the lateral meniscus was clearly seen in all imaging planes (Fig 4). This structure was prospectively interpreted as a medial oblique meniscomeniscal ligament.
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Figure 4a. Case 3. (a) Coronal fat-saturated T2-weighted fast spin-echo MR image (3,000/70) of the knee demonstrates a cordlike structure (arrow) that represents the oblique meniscomeniscal ligament coursing through the intercondylar notch. On multiple contiguous coronal images, it could be traced from its origin on the anterior horn of the medial meniscus to its insertion into the posterior horn of the lateral meniscus. (b) Axial fat-saturated T2-weighted fast spin-echo MR image (3,000/70) of the knee clearly demonstrates a thick, cordlike, oblique meniscal ligament (arrow) as it courses from the anterior horn of the medial meniscus to the posterior horn of the lateral meniscus.
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Figure 4b. Case 3. (a) Coronal fat-saturated T2-weighted fast spin-echo MR image (3,000/70) of the knee demonstrates a cordlike structure (arrow) that represents the oblique meniscomeniscal ligament coursing through the intercondylar notch. On multiple contiguous coronal images, it could be traced from its origin on the anterior horn of the medial meniscus to its insertion into the posterior horn of the lateral meniscus. (b) Axial fat-saturated T2-weighted fast spin-echo MR image (3,000/70) of the knee clearly demonstrates a thick, cordlike, oblique meniscal ligament (arrow) as it courses from the anterior horn of the medial meniscus to the posterior horn of the lateral meniscus.
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Follow-up arthroscopy confirmed the presence of a lateral discoid meniscus, lateral meniscal tear, and a medial oblique meniscomeniscal ligament (Fig 5).
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Figure 5a. Case 3. (a,c,e) Arthroscopic images and (b,d,f) line drawings of the medial oblique meniscomeniscal ligament. (a, b) The medial oblique meniscomeniscal ligament (arrow in a) is shown originating from the anterior horn of the medial meniscus. The ligament is thick and cordlike throughout its entire course, but débridement of the adjacent intraarticular fat had to be performed prior to visualization of its most anterior aspect. (c, d) Note that the location of the ligament is slightly posterior to that in a and b. The ligament (arrow in c) is seen in the anterior compartment of the knee joint and passes posteriorly to the anterior cruciate ligament (ACL). (e, f) Note that the location of the oblique meniscomeniscal ligament is posterior to that in c and d. The ligament (arrow in e) is seen in the posterior aspect of the knee as it passes behind the anterior cruciate ligament (ACL) and inserts into the posterior horn of the lateral meniscus.
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Figure 5b. Case 3. (a,c,e) Arthroscopic images and (b,d,f) line drawings of the medial oblique meniscomeniscal ligament. (a, b) The medial oblique meniscomeniscal ligament (arrow in a) is shown originating from the anterior horn of the medial meniscus. The ligament is thick and cordlike throughout its entire course, but débridement of the adjacent intraarticular fat had to be performed prior to visualization of its most anterior aspect. (c, d) Note that the location of the ligament is slightly posterior to that in a and b. The ligament (arrow in c) is seen in the anterior compartment of the knee joint and passes posteriorly to the anterior cruciate ligament (ACL). (e, f) Note that the location of the oblique meniscomeniscal ligament is posterior to that in c and d. The ligament (arrow in e) is seen in the posterior aspect of the knee as it passes behind the anterior cruciate ligament (ACL) and inserts into the posterior horn of the lateral meniscus.
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Figure 5c. Case 3. (a,c,e) Arthroscopic images and (b,d,f) line drawings of the medial oblique meniscomeniscal ligament. (a, b) The medial oblique meniscomeniscal ligament (arrow in a) is shown originating from the anterior horn of the medial meniscus. The ligament is thick and cordlike throughout its entire course, but débridement of the adjacent intraarticular fat had to be performed prior to visualization of its most anterior aspect. (c, d) Note that the location of the ligament is slightly posterior to that in a and b. The ligament (arrow in c) is seen in the anterior compartment of the knee joint and passes posteriorly to the anterior cruciate ligament (ACL). (e, f) Note that the location of the oblique meniscomeniscal ligament is posterior to that in c and d. The ligament (arrow in e) is seen in the posterior aspect of the knee as it passes behind the anterior cruciate ligament (ACL) and inserts into the posterior horn of the lateral meniscus.
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Figure 5d. Case 3. (a,c,e) Arthroscopic images and (b,d,f) line drawings of the medial oblique meniscomeniscal ligament. (a, b) The medial oblique meniscomeniscal ligament (arrow in a) is shown originating from the anterior horn of the medial meniscus. The ligament is thick and cordlike throughout its entire course, but débridement of the adjacent intraarticular fat had to be performed prior to visualization of its most anterior aspect. (c, d) Note that the location of the ligament is slightly posterior to that in a and b. The ligament (arrow in c) is seen in the anterior compartment of the knee joint and passes posteriorly to the anterior cruciate ligament (ACL). (e, f) Note that the location of the oblique meniscomeniscal ligament is posterior to that in c and d. The ligament (arrow in e) is seen in the posterior aspect of the knee as it passes behind the anterior cruciate ligament (ACL) and inserts into the posterior horn of the lateral meniscus.
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Figure 5e. Case 3. (a,c,e) Arthroscopic images and (b,d,f) line drawings of the medial oblique meniscomeniscal ligament. (a, b) The medial oblique meniscomeniscal ligament (arrow in a) is shown originating from the anterior horn of the medial meniscus. The ligament is thick and cordlike throughout its entire course, but débridement of the adjacent intraarticular fat had to be performed prior to visualization of its most anterior aspect. (c, d) Note that the location of the ligament is slightly posterior to that in a and b. The ligament (arrow in c) is seen in the anterior compartment of the knee joint and passes posteriorly to the anterior cruciate ligament (ACL). (e, f) Note that the location of the oblique meniscomeniscal ligament is posterior to that in c and d. The ligament (arrow in e) is seen in the posterior aspect of the knee as it passes behind the anterior cruciate ligament (ACL) and inserts into the posterior horn of the lateral meniscus.
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Figure 5f. Case 3. (a,c,e) Arthroscopic images and (b,d,f) line drawings of the medial oblique meniscomeniscal ligament. (a, b) The medial oblique meniscomeniscal ligament (arrow in a) is shown originating from the anterior horn of the medial meniscus. The ligament is thick and cordlike throughout its entire course, but débridement of the adjacent intraarticular fat had to be performed prior to visualization of its most anterior aspect. (c, d) Note that the location of the ligament is slightly posterior to that in a and b. The ligament (arrow in c) is seen in the anterior compartment of the knee joint and passes posteriorly to the anterior cruciate ligament (ACL). (e, f) Note that the location of the oblique meniscomeniscal ligament is posterior to that in c and d. The ligament (arrow in e) is seen in the posterior aspect of the knee as it passes behind the anterior cruciate ligament (ACL) and inserts into the posterior horn of the lateral meniscus.
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Discussion
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The oblique meniscomeniscal ligament is a relatively uncommon meniscomeniscal ligament and is rarely mentioned in the anatomy or arthroscopy literature. To our knowledge, this normal variant has not been previously described in the radiology literature.
Anatomy literature describes four different types of meniscomeniscal ligaments. The first and most prevalent is the anterior transverse meniscal ligament, with a reported frequency of 58% (1). The second meniscomeniscal ligament is the posterior transverse meniscal ligament, with a reported frequency of 1%–4% (1,3). It is described as a bundle of fibers that connect the posterior horns of the lateral and medial menisci. The last two meniscomeniscal ligaments described are the medial and lateral oblique meniscomeniscal ligaments, with a combined frequency of 1%–4% (1,3).
The oblique meniscomeniscal ligaments are named for their anterior attachment sites. The medial oblique meniscomeniscal ligament originates from the anterior horn of the medial meniscus and inserts into the posterior horn of the lateral meniscus. The lateral oblique meniscomeniscal ligament originates from the anterior horn of the lateral meniscus and inserts into the posterior horn of the medial meniscus. Both oblique meniscomeniscal ligaments pass between the anterior and posterior cruciate ligaments as they traverse the intercondylar notch. The oblique meniscomeniscal ligament has no known function (1).
The literature describes numerous potential pitfalls in evaluation of the meniscus for potential tears. Normal anatomic structures that are proximal to the meniscus and possess similar signal intensity characteristics can easily mimic a tear. These include the anterior transverse ligament, the meniscofemoral ligaments, the popliteal tendon, and the capsular attachments and collateral ligaments (7–13).
The oblique meniscomeniscal ligament also possesses signal intensity similar to that of meniscal tissue and attaches to the menisci. It may, therefore, closely resemble a displaced meniscal fragment at MR imaging and simulate a flap tear or bucket-handle tear. Displacement of a meniscal fragment is a well-described MR imaging finding that represents a tear of the meniscus (4–6,14).
In case 1, the ligament was prospectively interpreted at MR imaging as a flap tear of the lateral meniscus. Only after follow-up arthroscopy and retrospective review of the MR images did we appreciate that the structure extended all the way through the intercondylar notch from the anterior horn of the medial meniscus to the posterior horn of the lateral meniscus. In the following two cases, we were able to correctly identify the oblique intermeniscal ligament prospectively. In all three cases, the oblique intermeniscal ligament was easily traced along its entire course on the coronal images. In two cases, it was also clearly identified in the axial plane. In all three cases, the posterior portion of the ligament could easily be seen during arthroscopy, whereas the anterior portion of the ligament could be visualized only following meticulous dissection of the surrounding fat and synovium.
The oblique meniscomeniscal ligament may easily be mistaken at MR imaging for a displaced fragment of meniscal tissue such as a flap tear or bucket-handle tear. In this series, the ligament was prone to mimic a displaced meniscal fragment on the sagittal images. In all three cases, the ligament could be traced throughout its entire course on the coronal or axial images or both.
To correctly identify the oblique meniscomeniscal ligament, one needs to be familiar with the normal anatomy of this structure as it extends from the anterior horn of one meniscus to the posterior horn of the opposite meniscus. In addition, one needs to ensure that the adjacent meniscus demonstrates normal morphology at MR imaging, with no missing fragments. With these criteria met, the oblique meniscomeniscal ligament may be correctly identified at MR imaging as a normal anatomic variation rather than as a displaced meniscal fragment.
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Footnotes
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The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Air Force, Department of Defense, or the United States Government.
Author contributions: Guarantor of integrity of entire study, T.G.S.; study concepts and design, T.G.S., P.F.J.T., R.C.L.; definition of intellectual content, T.G.S.; literature research, T.G.S., C.H.; clinical studies, T.G.S., R.C.L., K.W.L.; data acquisition, T.G.S., R.C.L., K.W.L., C.H.; data analysis, T.G.S., R.C.L., K.W.L.; manuscript preparation, T.G.S.; manuscript editing, R.C.L., K.W.L., C.H.; manuscript review, P.F.J.T.
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TOP
Abstract
Introduction
