A chain is only as strong as its weakest link

Abstract

The paper by Amadi et al. ‘‘A biomechanical study of the meniscofemoral ligaments and their contribution to contact pressure reduction in the knee’’ again stresses ‘‘chain-like’’ related points in the knee joint. Knee osteoarthrosis can be regarded as an organ failure. Like other organ failures, e.g. of the kidney or liver, osteoarthrosis is a final common pathway induced by several factors. Biomechanical and biological causes can be distinguished. Here a ‘‘minor’’ anatomical element appears to help realize appropriate stress distribution in the knee. The very presence of Humphrey’s and Wrisberg’s ligaments through the lateral meniscus seems to contribute to stabilization of the knee joint as well as having a load-sharing function. It may also suggest the paramount importance of the ‘‘meniscal wall presence’’—or absence!—in the homeostasis of the individual knee joint, since both ligaments have their insertion on the meniscal outer wall. However, the fact that they both have a posterior attachment in only 50% of knee joints may help explain differences in the ‘‘final common pathway’’ among individual knee joints. It may also be reflected in the variability of results when orthopaedic surgeons try to repair posterolateral injuries to the lateral meniscus and its ligamentous components. Also, in meniscal transplantation, discussion continues whether meniscal allografts really need bone block fixation for optimal function or whether good clinical results can be expected with stable fixation on the remnant meniscal wall (and its ligamentous elements posteriorly in the lateral compartment of the knee...). Amadi et al. [1] come to the conclusion that no major difference is seen when good peripheral fixation is obtained. The presence of Humphrey’s and Wrisberg’s ligaments plays an important role in this respect. The more deleterious an injury, therefore, the more impact a good and complete repair may have on restoration of the original anatomy and homeostasis, taking into account individual patient demands. Thus, neglect of any small link in the ‘‘chain’’ may become disastrous if overlooked and not properly attended to during surgery.