LATERAL MENISCAL VARIANTS

MICHAEL R. JORDAN, MD

The term lateral meniscal variant encompasses several different entities, some of which are symptomatic. The most
common variant, the discoid lateral meniscus, is often encountered incidentally. When pathological, this and other
variants require careful preoperative planning and treatment consideration. The clinical presentation may be similar
to that of a routine torn lateral meniscus or may be the classic snapping-knee syndrome. Evaluation should include
magnetic resonance imaging (MRI) and arthroscopic examinations when symptoms warrant and treatment is
contemplated. Treatment options include observation; partial meniscectomy for stable types; stabilization (with or
without partial meniscectomy, depending on shape) for unstable types; and complete meniscectomy. An attempt
should be made to salvage the meniscus, if reasonable. If complete meniscectomy is necessary, however, a child may
respond better than with lateral meniscectomy in the normal knee.
KEY WORDS: discoid lateral meniscus

Occasionall); the orthopedic surgeon encounters an
aberrant lateral meniscus in his or her practice. This may
be an incidental finding during the treatment of another
lesion in the knee or may actually be the symptomatic
pathology sought during the joint inspection. If not sus-
pected preoperatively, however, it can often be a surprise.
The purpose of this article is to review the different lateral
meniscal variants and the treatments thereof to better
prepare the orthopedic surgeon for these encounters.
BACKGROUND
An experienced arthroscopist certainly recognizes the nor-
real variability of the size and mobility of the lateral
meniscus. ~ Also, subtle differences in the meniscal thick-
ness and a m o u n t of tibial plateau coverage during routine
arthroscopy are often noticed. This variability is also found
in the several types of lateral meniscal anomalies seen.
Although abnormal, these variants may be asymptomatic
and incidental or may be pathological and require creative
treatment.
The most well-recognized lateral meniscal variant (LMV)
is known as the discoid lateral meniscus (DLM) and was
popularized by Watanabe et al. 2 Discoid implies greater
coverage of the tibial plateau and usually increased thick-
ness. This may involve all or only part of the meniscus. It is
referred to as an anterior or posterior megahorn when it
only involves 1 horn. There has even been a circular
meniscus described 3 that has also been commonly found in
animals other than man. 4 Other meniscal variants may
have normal shape, but abnormal mobility. The true cause
of this hypermobility is unclear, but speculations have
included congenitally abnormal attachments posteriorly
From the Middle Tennessee Medical Center; and Murfreesboro Orthope-
dics and Sports Medicine, Murfreesboro, TN.
Address reprint requests to Michael R. Jordan, MD, 525 North Univer-
sity St, Murfreesboro, TN 37130.
Copyright ,~ 2000 by W.B. Saunders Company
1048-6666/00/1003-0009510.00/0
doi:10.1053/otor.2000.5339
and posterior capsular separation, either acutely or chroni-
cally.I,4-m
Watanabe et al published the most well-known classifica-
tion system, based on arthroscopic appearance (Fig 1). The
complete type has a discoid shape (usually increased
thickness) that covers the entire tibial plateau. It has firm
tibial attachments and may or may not have a meniscofemo-
ral (Wrisberg a n d / o r H u m p h r y ) ligament attachment. The
incomplete type is basically the same, but covers less tibial
plateau. The Wrisberg-ligament type is shown as a hyper-
mobile meniscus of nearly normal shape, but with abnor-
mal attachments. The posterior tibial attachment was
lacking, rather having an attachment to the meniscofemo-
ral ligament (Wrisberg). 2 Since his description, however,
many different sizes and shapes have been included as
Wrisberg-ligament types because of hypermobility. 1,4.~,7,1°
In fact, the size or shape has often not been discussed.
In 1993, Jordan et al u proposed a new classification
system based on arthroscopic findings, but incorporating
tears, symptoms, and treatment needs. They grouped
stable types together, regardless of anatomy, and then
subgrouped them based on s y m p t o m s and tears. The
unstable types were also grouped together and then
subgrouped based on shape, tears, and symptoms.
I consider all stable types similar because they have firm
anterior and posterior tibial attachments with or without a
meniscofemoral ligament attachment. S y m p t o m s in this
group are usually caused by tears or degeneration. I
consider all unstable types similar, despite their size,
shape, or reason for instability. Symptoms in this group
may be caused by tears a n d / o r instability. These are so
grouped because this influences treatment options that will
be discussed later. It is also important to understand that
stable types may become unstable over time either because
of capsular separation 7 or to a tear.
The chances of finding a LMV are likely. The actual
prevalence is probably 4% to 5% in the United States. The
reported prevalences range from 0.4% to 16.6% with a
higher percentage in Asian populations. 1,-~-7.1°,1-'-1~'One re-
cent study noted 22 patients (27 DLM), who were less than
18 years old, out of 275 MRI scans (259 patients) performed

234 Operative Techniquesin Orthopaedics, Vol 10, No 3 (July), 2000: pp 234-244

 ' . . . -

Posterior cruciateligament ~ i e riorcru~iateJigament . .

L i g a m e n t of Wrisberg . L a t e r a l meniscus . ,

B t, .[,, E

Karapeku

Fig 1. Posterior views of menisci. (A) Normal meniscus. Note the normal shape and posterior tibial attachment. The presence
or absence of a meniscofemoral ligament is variable. (B) Complete discoid meniscus. (C) Incomplete discoid meniscus. Note
the intact posterior tibial attachments in both discoid types. (D) Wrisberg-type meniscal variant with nearly normal shape. (E)
Wrisberg variant with discoid shape. In Wrisberg variants, the posterior tibial attachment is lacking, leaving the Wrisberg
ligament as the posterior attachment.

on children between March 1989 and February 1994.17
Washington et al reported on 34 discoid lateral meniscecto-
mies in children out of a total of 4,092 meniscectomies
performed at the Hospital for Special Surgery between
January 1955 and December 1983 (0.8%).18
The majority of these variants are of the stable (complete
and incomplete) type, whereas the unstable Wrisberg-
ligament type comprises anywhere from 0% to 33%.4,6,9,14,18"24
Previously, bilateral occurrence has been reported as high
as 20%.~ Recently, bilateral occurrence was found in 9 of 10
children who underwent bilateral MRI, regardless of bilat-
eral symptoms. The entire study included 10 other children
who underwent unilateral MRI earlier in the study. 24
Washington et al noted that 5 of 34 patients had bilateral
findings) s Thus, the likelihood of bilateral occurrence may
be higher than previously thought, especially in children.
The etiology of the LMV is not completely understood at
this time. Smillie6 hypothesized that the discoid meniscus
was a congenital aberration that resulted from arrested
normal meniscal maturation. This has been supported by
Soren, 26 but disputed by others. 2,4 Kaplan 4 suggested that
the discoid shape results from trauma to a previously
normally shaped meniscus. This trauma is the repetitive
medial to lateral motion seen when the attachments are
abnormal, creating excessive mobility: Although this mech-
anism may be plausible, Woods and Whelan 7 pointed out
that Kaplan's hypothesis could not account for the stable
atraumatic discoid meniscus, the most commonly encoun-
tered type. It must also be pointed out that Kaplan's
hypothesis was based on observation at open surgery.
Woods and Whelan 7 further suggested that the unstable,
discoid-shaped, lateral meniscus was the result of poste-
rior capsular separation of a previously stable congenital
discoid meniscus (ie, complete or incomplete type). This
separation was caused by chronically increased shear
forces posteriorly, a result of increased thickness and
increased normal mobility laterally.
Originally, Watanabe et al 2 pictured the Wrisberg-
ligament type as normal in shape, but having abnormal
attachments. Since then, other unstable variants have been
included in this category, although the exact anatomic
descriptions are often either lacking or unclear. 1A,5,1°A4,19.21
In fact, many investigators state the number of Wrisberg-
ligament types found, but do not describe the size, shape,
or attachments. These unstable types are more likely
responsible for the snapping-knee syndrome.
There are probably several different types of unstable
LMVs, possibly with different origins. Watanabe et al's 2
original description of a nearly normal shape with abnor-
mal attachments is supported by Neuschwander et al's 5
description of a "lateral meniscal variant with absence of
the posterior coronary ligament." However, the presence
or absence of a meniscofemoral ligament attachment is not
documented. It would also be conceivable that a normal
lateral meniscus could detach from the tibia posteriorly
(propagation of the popliteal hiatus) because of injury or

LATERAL MENISCAL VARIANTS 235


Fig 2. An asymptomatic stable LMV found incidentally dur-
ing the treatment of a medial meniscus tear in a 14-year-old
girl. Note the thickness of the meniscus and the posterior
knee attachment. The meniscus was left intact.
stress, but remain attached by a meniscofemoral ligament,
resulting in hypermobility with subluxation and reduction
of the meniscus, rather than dislocation.
The unstable types with a discoid shape may result from
1 of 3 possible situations. The first is a congenital discoid-
shaped meniscus with abnormal attachments. 1° The sec-
ond is a hypermobile normally shaped meniscus that is
transformed to a discoid shape by repetitive trauma. 4 The
third is a stable discoid-shaped meniscus that becomes
unstable by posterior capsular separation. 7,2° Overall, the
etiology is not as important as thoroughly evaluating the
pathology and identifying the type of LMV.
CLINICAL HISTORY
Although we most often hear about the snapping-knee
syndrome, it is much more common to encounter the usual
symptoms of a lateral meniscus tear (eg, pain, swelling,
mechanical s y m p t o m s ) . 1"4'5'7'8'10'12"17"25'27"28-30One should look
for a history of chronic joint symptoms; there may or may
not be a history of trauma. This presentation will depend
on the particular variant, as well as the presence or absence
of a tear. In children, there is not usually a history of
trauma, and the snapping-knee symptoms or mechanical
joint symptoms are usually insidious. The patient or
physician may notice an audible, visible, or palpable snap
or clunk at the terminal limits of flexion and/or extension.
Mechanical symptoms such as pain, clicking, swelling,
locking, and popping may also be reported. Clinical
findings may include an effusion, motion blocks, adjust-
ment of the knee at the limits of flexion and extension, and
noticeable bulge at the lateral joint line with full flexion,
quadriceps atrophy, a locked knee, and ambulation with a
flexion contracture. Woods and Whelan 7 noted that the
adjustment of the knee during extension opens the lateral
joint, allowing reduction of the displaced meniscus.
In my experience, many adults with LMV are asymptom-
atic, or if symptomatic, have joint-like routine lateral
meniscus tears. If the stable LMV becomes unstable, then it
may present in a snapping-knee fashion. There may or may
236
not be a long duration of symptoms with or without a
history of trauma.
Although most radiographs are normal, reported find-
ings include lateral joint lipping, a widened lateral joint
space, cupping of the lateral tibial plateau, flattening of the
lateral femoral condyle, calcification of the meniscus,
obliquity of the joint space, degenerative changes, and
abnormalities of the lateral meniscus. ?
Although, arthrography3° has been used in the past,
M R I 9'17'23'24'31-33 a n d / o r a r t h r o s c o p y 1,6,9,10,20,25,30 a r e the diag-
nostic tools of choice. Several MRI diagnostic criteria have
been established and include 1) 3 or more contiguous
5-mm sagittal sections that show the black bow-tie appear-
ance; 2) increased width of the meniscus in the coronal
view taken at the middle anteroposterior (AP) diameter; 3)
increased thickness of one or both horns or the entire
meniscus; 4) increased transverse diameter to greater than
15 mm; 5) a difference in height of greater than 2 mm
compared with the medial meniscus. Keep in mind that
these criteria are used to document an enlarged discoid
meniscus, but would not include a normally shaped
unstable type. Meniscotibial attachments and meniscofemo-
ral ligament attachments can be difficult to see on MRI
scan.
Other MRI findings may include an increase in inter-
meniscal signal that may or may not extend to the sur-
face. 17"23'24"33 Hamada et a133 showed that intrasubstance
high signal intensity (or flattening) correlated with intra-
substance degeneration in 18 symptomatic patients, but
only 3 had arthroscopic evidence of a tear. It was suggested
that this degeneration could lead to motion between the
halves of the meniscus or swelling, causing symptoms, but
not necessarily giving a visual tear on the meniscal surface.
Araki et aF 3 recently reported on the accuracy of MRI in
determining the presence or absence of a tear in a DLM.
They found 3-dimensional MR superior to 2-dimensional
MR in elucidating small radial tears, intrasubstance tears,
and determining the presence of a DLM in severely
displaced tears. All specimens were confirmed at surgery.
They also concluded that clinically significant intrasub-
stance tears were represented by grade 2 linear meniscal
Fig 3. An asymptomatic stable LMV found incidentally in the
treatment of a 35-year-old man. The tibial plateau is almost
completely covered, but the meniscus is very thin.
MICHAEL R. JORDAN
signal. Interestingly, the investigators noted no evidence of
degeneration of the menisci.
Arthroscopy can be difficult, especially when dealing
with a thickened meniscus that is overstuffing the joint.
Just as a displaced bucket-handle tear of a normal menis-
cus can block access to a joint, so can a discoid meniscus. It
is important to try and evaluate the stability and morphol-
ogy of the LMV as well as the presence of tears. Recent MRI
studies have confirmed MRI as superior to arthroscopy in
detecting tears in symptomatic subjects. 17,~,24,33A posterior
portal may be needed to examine the posterior joint.
TREATMENT
The recommended treatment for LMVs is not clean The
options depend on the age of the patient, the duration and
magnitude of symptoms, the type of pathology, and the
presence or absence of tears. If surgery is considered, I
recommend an MRI scan to evaluate the necessary struc-
tures, as well as to determine the changes in the meniscus.
The treatment goals are to reduce symptoms and, at the
same time, to reduce the risk of future arthritis and the
need for further surgical procedures. The treatment ap-
proaches in children and adults are not necessarily the
same.
The most commonly encountered scenario is the unex-
pected finding of a stable, untorn, discoid-shaped menis-
Fig 4. (A-C). A stable LMV in a 47-year-old Hispanic woman
who became symptomatic secondary to a tear sustained
during a twisting injury. Note the chondral damage. She had
had minor problems intermittently before the injury. It was
treated by saucerization because of the stable rim. She
continues to have symptoms. Complete meniscectomy may
have been a better option.
LATERAL MENISCALVARIANTS
cus during the arthroscopic treatment of other pathology.
This should be left alone 7,1°,13,14,]7-19,~ (Figs 2 and 3). The
most common clinically significant scenario is the adult
patient with a history of lateral joint symptoms that may
have been present for years. There may or may not have
been a recent history of trauma, but the symptoms have
recently gotten worse. MRI scans may or may not reveal a
DLM with or without a tear. However, the surgeon must be
suspicious. This is most likely a torn stable LMV (other-
wise known as a DLM of the complete or incomplete type)
(Figs 4-6). Historically, open meniscectomy was the treat-
ment of choice. 6,24More recently, both partiaP °,13,18,29,26and
complete meniscectomy 14,27,26,3~have their proponents. Par-
tial excision resulted in good to excellent subjective results
in 55% of the patients of Vandermeer and Cunningham. 19
Factors associated with an unsatisfactory outcome in-
cluded persistent degenerative changes, increased age, and
female gender.
The proponents of complete meniscectomy recognize
that the treatment of a DLM is difficult and usually requires
a long recovery. 14,3s There were problems noted with
increased lateral instability and high rates of reoperation
for partial meniscectomy in these studies. The potential
reasons for failure with partial meniscectomy cited in-
cluded high stresses, concentrated at the thick meniscus
_J
237
 Fig 5. (A-C). A stable LMV with a small tear in the central
portion in a 25-year-old woman after a minimal twisting injury
at work. Note the thin nature of the meniscus, which was
treated with partial excision.

Fig 6. (A and B) A torn symptomatic stable LMV that was treated with saucerization to a stable rim in a 30-year-old woman. Note
how the central portion is thickened and rolled under the posterior rim. (ol 996 American Academy of Orthopaedic Surgeons.
Reprinted from the Journal of the American Academy of Orthopaedic Surgeons. Volume 4(4), pp 191-200 with permission, zg)

238 MICHAEL R. JORDAN

remnant rim, and unrecognized degeneration extending to
the meniscus periphery. Either of these cases could lead to
further tearing of the abnormal meniscal rim.
MRI may be more helpful than arthroscopy in helping to
decide on partial versus complete meniscectomy. The
usefulness of MRI in evaluating intrasubstance tear and
degeneration in symptomatic, stable DLM was recently
reported by Hamada et al. 33 The findings of this study
suggest that MRI was more accurate at predicting the
histopathologic findings than arthroscopy. The recommen-
dation was total meniscectomy for MR-documented degen-
eration, visible on MRI scans, extending to the peripheral
rim and partial meniscectomy for degeneration or flatten-
ing limited to the central avascular portion. 33
Smith et a136 concluded that surgery should be ap-
proached cautiously because of the unpredictable result
after complete meniscectomy. He recommended using
MRI and arthroscopy to help delineate which lesion should
be treated with partial versus complete meniscectomy. If a
partial meniscectomy is undertaken, a rim of only 6 to 8
mm should be left to reduce the risk of retear. They
recommend complete meniscectomy only for complex,
unsalvagable tears.
Posterior
A
Anterior
Fig 7. Surgical techniques for
partial meniscectomy and/or
repair of lateral meniscal vari-
ants. (A) Partial excision of a
stable torn discoid-shaped
meniscus. (B) Partial resec-
tion and stabilization of an
unstable torn discoid-shaped
meniscus. (C) Stabilization of
an unstable LMV, with reduc-
tion of the posterior mega- j,-
horn.
LATERAL MENISCALVARIANTS
As with routine lateral meniscectomy, complete discoid
lateral meniscectomy should inherently carry the same risk
of arthritis. However, a persistent meniscal rim of abnor-
mal tissue may lead to continued symptoms and further
surgery. I would agree with partial meniscectomy if the
meniscus is salvageable with a stable rim and there is no
evidence of rim degeneration or a tear on MRI scans or at
arthroscopy.
Technical considerations in the excision or partial exci-
sion of discoid-shaped meniscus depends on the pathology
encountered (Fig 7). When a torn meniscus has flattened, it
is easy to remove piecemeal by using hand and motorized
equipment. Adjunctive instruments such as the laser,
electrocautery, or bipolar technologies may also be used.
The real difficulty is trying to remove a thick discoid-
shaped meniscus that is stuffing the joint. Even introducing
the arthroscope can be troublesome. I have removed these,
both in one piece and also piecemeal, and I believe
piecemeal to be much less time-consuming. The key is to
avoid injury to the joint surface (especially the tibia), which
you cannot see. Kim et aP 7 have published a unique
excision technique for one-piece excision by using specific
accessory portals. If a rim (6 to 8 mm) is to be left,
\
Karapelou
239
piecemeal excision is probably more practical. Remember,
however, that the thickness may inhibit use of routine hand
cutting instruments. Sometimes I will use combinations of
retrograde and forward cutting hand instruments (ie,
meniscitomes).
There is considerably less information on the treatment
of unstable menisci, but most surgeons have favored total
e x c i s i o n . 1,4,1°,14,18,25,26,29 However, there have been successful
reports of saucerization and reattachment of unstable,
discoid-shaped lateral menisci. 14,28As well, Neuschwander
et al 5 reported on arthroscopic reattachment alone of a
nearly normally shaped lateral meniscus (LMV with ab-
sence of the posterior coronary ligament). Even though
these are limited numbers of patients, the results seem to
have held up well over the short time.
I would make attempts to save the unstable variant, if
possible, especially in children (Figs 8 and 9). As with the
stable types, lack of meniscal degeneration at the periphery
is imperative for a successful outcome. As with all menis-
cus repair decisions, the patient's age, activity level, expec-
tations, and willingness to undergo further surgical treat-
ment in the event of failure are all factors. I would not
hesitate to bolster the repair with fibrin clot, if necessary,
especially in the avascular popliteal area. Any of the
current meniscal repair techniques available may be used.
These techniques are covered elsewhere in this issue. I
would suggest that getting a meniscus of nearly normal
shape and thickness to heal would be much easier than to
heal a saucerized, discoid-shape meniscus. I would tend to
be much more aggressive towards repair in the setting of
youth a n d / o r nearly normal shape.
In children, the risk of arthritis after total lateral menis-
cectomy is high, probably a function of time and activity
level. However, the literature does not necessarily bear this
out in the case of DLM. The results are mixed, but so are
the types of variants in the total meniscectomy studies. For
stable variants, both Fujikawa et a112and Bellier et al 2s have
reported good short-term results with arthroscopic partial
lateral meniscectomy. Atay et al = have shown good
results and no degenerative changes at 2.7 years with the
same form of treatment, although obviously short-term
follow-up.
To the contrary, Hyashi et al 2° believed that complete
meniscectomy could result in a good outcome based on
their and other Japanese investigators' experience. Kuro-
saka et aP 8 reported 90% subjective good results 20 years
after complete meniscectomy, despite radiographic changes
in all knees. Moderate to severe arthritic changes noted in
75% of knees did not correlate with subjective findings.
Washington et aP 8 reported good to excellent results in 13
of 18 knees, 17 years after open complete lateral meniscec-
tomy for symptomatic DLM in children. There were mild
degenerative changes noted in 3 of the 9 knees evaluated
by radiography. In contrast, Raber et a127 noted poorer
results in a similar population and recommended avoiding
total meniscectomy whenever possible. Subjectively, 13 of
17 knees were normal or nearly normal, but 10 of 17 had
clinical symptoms of osteoarthrosis, 10 of 11 had radio-
graphic changes consistent with osteoarthrosis, and 2
developed osteochondritis dessicans. These results were
noted 19.8 years after open total meniscectomy.
240
Hayashi et al 2° explained better results after complete
meniscectomy based on the complete removal of abnormal
tissue and the ability for a child's abnormal knee to adapt.
Certainly, if an unstable traumatized meniscus is des-
troying the joint, complete excision seems reasonable.
Aichroth et a129 found a pseudomeniscus rim that cov-
ered the popliteus in 3 of 4 knees at 18 months after
arthroscopic complete lateral meniscectomy. This should
not occur because of the avascular popliteal hiatus, but less
is certainly known about the child's response to total
discoid lateral meniscectomy than that of a normal
meniscus.
In children, I would still recommend saving the menis-
cus when possible. The use of MRI should be helpful in
delineating the status of the peripheral rim, as well as the
extent of tears. If partial meniscectomy leads to evidence of
peripheral degeneration or tear, complete meniscectomy is
the only option. If the rim is unstable peripherally, but not
degenerated, I would perform an arthroscopic repair using
techniques described elsewhere in this volume.
The ultimate treatment option for an unsalvageable,
symptomatic DLM would be a meniscal transplant. Unfor-
tunately, its role is still being defined in the treatment of
routine arthritis in the young adult. The use of an allograft
of a normal meniscus in the discoid knee would certainly
be controversial. There is some degree of risk involved in
allografting, and there is no evidence in the literature that a
transplanted normal meniscus would function appropri-
ately in an abnormal knee. The amount of original menis-
cal thickness and changes to the joint surface would
certainly be important factors. If entertained, it would
probably work best when replacing a meniscus of nearly
normal thickness. It certainly should help decrease the
instance a n d / o r severity of lateral joint instability after
discoid meniscectomy. However, in the young patient with
continuing lateral joint symptoms after complete meniscec-
tomy for a torn DLM, meniscal transplant seems a viable, if
not the only, option.
CONCLUSION
The normal lateral meniscus is variable with respect to
shape, size, and mobility. So, too, is the abnormal lateral
meniscus. There may be several different entities described
in the past as DLM. I believe the most important aspects of
evaluation are to determine the size, shape, tear, and
stability, and formulate a treatment plan based on technical
skills and patient expectations. It seems inherently correct
to try and save meniscal tissue that is similar in size, shape,
and stability to the normal meniscus. However, saving
meniscal tissue that seems doomed to failure makes no
sense. The treatment decision process is very similar to that
in the normal meniscus: Can I technically save it? Will it
work? What is the chance of failure? Can the patient
handle failure and further surgery? A high index of
suspicion preoperatively leads to an adequate preopera-
tive counseling session that helps the surgeon make these
decisions intraoperatively.
MICHAEL R. JORDAN
Fig 8. (A-F). This 10-year-old boy has experienced pain, locking, and snapping for years. During the last year before treatment,
he was unable to continue daily activities. The unstable discoid-shaped variant was treated with partial excision and
stabilization with meniscal arrows. At 2 years, he is doing well and is asymptomatic.

LATERAL MENISCALVARIANTS 241

 ,

Fig 9. The MRI findings in the 10-year-old boy depicted in Fig

8. The patient presented with classic snapping-knee symp-
toms and had an unstable LMV. Note (A) the extension to the
notch on the mid-AP coronal views; (B) intermeniscal signal
in the central portion; (C) probable meniscofemoral ligament
attachment posteriorly.

242 MICHAEL R. JORDAN

Fig 9 (cont'd). (D and E) The anterior megahorn with intermeniscal signal and associated osteochondritis dessicans on the
sagittal view.
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MICHAEL R. JORDAN