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Intraoperative arthroscopic view showing ganglion cyst within the substance of ACL ACL: anterior cruciate ligament
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Ganglion cyst and mucoid degeneration of the anterior cruciate ligament are the non-traumatic lesions that present with chronic knee pain and severe limitation in terminal range of motion of the knee. These are often of insidious onset, without any history of significant trauma, and they do not respond to conventional NSAIDs and physiotherapy. Thes...
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Citations
... Ganglion cysts (GC) are synovial cysts filled with gelatinous mucinoid material believed to arise from repetitive microtrauma resulting in mucinous degeneration of connective tissue. 1 GC are commonly encountered in orthopedic practice and well known to occur in the dorsal wrist, palm, and shoulder, with up to 60% of GC occurring on the dorsal wrist. 2 Furthermore, GC may arise from intra or extra-articular, soft tissue, intraosseous, or periosteal locations with symptoms varying according to size and origin. 2 Intra-articular GC of the knee are rare and have been reported to arise from the cruciate ligaments, menisci, popliteal tendons, alar folds, and subchondral bone. [3][4][5] Additionally, GC arising from the lateral portion of the knee have been described in recent literature following arthroscopic medial meniscus repair that were both subsequently excised surgically. 6 This case report presents a case of an atraumatic intraarticular, extrasynovial ganglion cyst of the lateral knee located deep to the iliotibial (IT) band and superficial to both the fibular collateral ligament and lateral femoral condyle that was successfully treated nonoperatively through repeat joint aspirations. ...
... Intra-articular GC of the knee are clinically rare in orthopedic practice but have been reported to occur in the cruciate ligaments, menisci, subchondral bone, alar folds, patellar tendon, and fat pad. [3][4][5][6][7] Commonly detected as incidental findings on MRI, intra-articular GC are reported to have a prevalence between 0.9% and 1.3%. 8,9 GC of the lateral knee has been described in the available literature, with two cases occurring following arthroscopic meniscectomy and an atraumatic case arising from Hoffa's fat pad, all of which were subsequently treated with surgical excision of the cyst with variable postoperative outcomes and no recurrence. ...
Key Clinical Message
We highlight the rare case of an atraumatic, intra‐articular ganglion cyst of the lateral knee deep to the iliotibial band that was successfully treated nonoperatively, a pathology yet to be reported in orthopedic literature.
Abstract
Ganglion cysts are mucin‐filled synovial cysts commonly found on the dorsal surface of the hands and feet. Intra‐articular ganglion cysts of the knee are rare, and when they present clinically, are typically treated operatively through arthroscopic surgery. We present the first reported case of an atraumatic intraarticular, extra‐synovial ganglion cyst of the lateral knee located deep to the iliotibial band that was successfully treated without operative intervention through repeated intra‐articular aspirations of the knee.
... An MRI of the knee is diagnostic in cases where a mucoid ACL is suspected. The classic findings of mucoid ACL include bulky and ill-defined ACL and increased intra-ligamentous signals (intermediate signal intensity on T1-weighted images, high signal intensity on T2-weighted images) with the celery stalk appearance [23]. However, overall, ACL fibers remain intact [8]. ...
... However, overall, ACL fibers remain intact [8]. It is crucial to highlight that MD of ACL is frequently misidentified on MRI scans as a partial ACL rupture [8,23]. Further, using Bergin's criteria, one must differentiate a mucoid ACL from a mucoid cyst [16,23]. ...
... It is crucial to highlight that MD of ACL is frequently misidentified on MRI scans as a partial ACL rupture [8,23]. Further, using Bergin's criteria, one must differentiate a mucoid ACL from a mucoid cyst [16,23]. Mucoid cysts have a mass effect on ACL fibers, lobulated margins, fluid signals within the substance of the ACL, and intact ACL fibers. ...
Introduction: Mucoid degeneration (MD) of the anterior cruciate ligament (ACL) is an unusual cause of knee pain and restricted movement, predominantly affecting the middle-aged population. Arthroscopic partial or total debridement of the mucoid ACL is the surgical treatment of choice. However, little is discussed in the literature regarding subsequent knee instability and functional outcomes following complete ACL excision.
Methods: A retrospective study was conducted on patients who underwent arthroscopic total ACL excision for mucoid ACL. Pre- and post-operatively, the Tegner-Lysholm score, the International Knee Documentation Committee (IKDC) Subjective Knee Form, and subjective functional instability were used to grade the clinical outcomes.
Results: Ten out of the 13 patients who underwent complete ACL excision were available for evaluation. All patients presented with knee pain on deep flexion or extension with a painfully limited range of motion. Post-operatively, all patients were relieved of their original pain and dysfunction. The mean post-operative IKDC and Tegner-Lysholm scores were 74.96 and 83.6, respectively. All patients had a Lachman test positive, while only two had a grade 1 pivot shift test positive. Two patients had occasional functional instability only after strenuous exercises. None of the patients underwent subsequent ACL reconstruction.
Conclusion: All patients reported improved functional outcomes. Only two out of 10 reported occasional instability during strenuous activity. Therefore, complete debridement of mucoid ACL in sedentary patients is safe and efficacious. However, active young patients may experience instability and require ACL reconstruction if it hinders their daily activities.
... It is possible that myxoid degeneration is related to aging or normal wear and tear of the joint, but its real cause is currently unknown. In order to preserve meniscal tissue as much as possible, partial meniscectomy has become the preferred surgical procedure for patients with meniscal damage, and the concept of meniscal repair has been taken up and refined, with the introduction of arthroscopic surgical techniques (61,62). ...
Knee osteoarthritis (KOA) is a common chronic condition among the elderly population that significantly affects the quality of life. Imaging is crucial in the diagnosis, evaluation, and management of KOA. This manuscript reviews the various imaging modalities available until now, with a little focus on the recent developments with Artificial Intelligence. Currently, radiography is the first-line imaging modality recommended for the diagnosis of KOA, owing to its wide availability, affordability, and ability to provide a clear view of bony components of the knee. Although radiography is useful in assessing joint space narrowing (JSN), osteophytes and subchondral sclerosis, it has limited effectiveness in detecting early cartilage damage, soft tissue abnormalities and synovial inflammation. Ultrasound is a safe and affordable imaging technique that can provide information on cartilage thickness, synovial fluid, JSN and osteophytes, though its ability to evaluate deep structures such as subchondral bone is limited. Magnetic resonance imaging (MRI) represents the optimal imaging modality to assess soft tissue structures. New MRI techniques are able to detect early cartilage damage measuring the T1ρ and T2 relaxation time of knee cartilage. Delayed gadolinium-enhanced MRI of cartilage, by injecting a contrast agent to enhance the visibility of the cartilage on MRI scans, can provide information about its integrity. Despite these techniques can provide valuable information about the biochemical composition of knee cartilage and can help detect early signs of osteoarthritis (OA), they may not be widely available. Computed tomography (CT) has restricted utility in evaluating OA; nonetheless, weight-bearing CT imaging, using the joint space mapping technique, exhibits potential in quantifying knee joint space width and detecting structural joint ailments. PET-MRI is a hybrid imaging technique able to combine morphological information on bone and soft tissue alterations with the biochemical changes, but more research is needed to justify its high cost and time involved. The new tools of artificial intelligence, including machine learning models, can assist in detecting patterns and correlations in KOA that may be useful in the diagnosis, grading, predicting the need for arthroplasty, and improving surgical accuracy.
... 2,3 The incidence of ACL ganglion cysts is between 0.6% and 2% in arthoscopic studies and between 1 and 1.3% on magnetic resonance imaging (MRI) studies. [4][5][6][7][8][9] One of the reasons for this low prevalence is assumed to be the asymptomatic nature of these cysts. Indeed, only 10% of cases are symptomatic, and these patients present with vague pain in the knee, unexplained knee effusions, or limitations to activity without any history of real trauma. ...
... 3,4,[6][7][8] Moreover, the large majority of these cysts remain asymptomatic, and only 10% of cases manifest symptoms, such as vague knee pain, limitation of range of motion or even recurrent effusions. 2,3,5,[8][9][10][11] The exact cause and pathogenesis of ACL ganglion cysts still remain unclear. It is hypothesized that displacement of the synovium into the surrounding tissue during development, herniation of synovium into the surrounding tissues, or degenerative and proliferative changes of pluripotent mesenchymal cells following trauma may be causative. ...
The incidence of intra-articular ganglion cysts of the anterior cruciate ligament (ACL) is low and symptomatic presentation of this pathology is even lower. Nevertheless, symptomatic cases pose a real challenge for the orthopaedic community, as no general consensus exists regarding the most appropriate treatment. The purpose of this Technical Note is to describe the surgical treatment of an ACL ganglion cyst by arthroscopic resection of the entire posterolateral bundle of the ACL in a figure-of-four position after conservative treatment has failed.
... A discontinuity in the ligament and an abnormal contour of the ACL, along with an empty notch sign, are characteristics of an ACL tear (Fig. 17.5). Mucoid degeneration and the ACL sometimes resemble an ACL tear on the MRI and hence must carefully be evaluated [7] . ...
... MDACL was subject of many clinical cases and short heterogeneous series [1][2][3][7][8][9][10][11][12][13][14][15][16][17][18]. All previous studies confirmed that clinical symptoms of MDACL include mostly posterior knee pain with limitation of the range movement and sometimes deteriorated ligament stability [10,11,[17][18][19]. Moreover, most patients did not have a trauma prior to the onset of knee pain and their symptoms did not respond to nonsteroidal anti-inflammatory drugs and physiotherapy. ...
Introduction
The pathology of a mucoid degeneration of the anterior cruciate ligament (MDACL) has been mentioned in several publications but due to its rare incidence it is not a well-known pathology. Partial or complete resection of the ACL is the option of choice after failed non-surgical treatment. However, the success rate of both surgical techniques and the subsequent risk of an ACL instability is not known. The purpose of this study was to compare the clinical and radiological outcome between partial resection and complete resection of the ACL in patients with MDACL.
Materials and methods
Patients with MDACL verified by MRI and persistent knee pain were treated by partial (Group I) or complete resection (Group II) of the ACL and were included in a controlled clinical trial after unsuccessful conservative treatment for at least 6 months. Demographic, clinical and radiological data including the thickness of ACL, ACL/intercondylar ratio, patient’s age at the time of surgery, the presenting symptoms, range of motion and ligament stability assessed by the ACL ligament score (Lachman test) were collected. In addition, Tegner activity score and Lysholm score were evaluated preoperatively and at final follow-up after a minimum of 12 months.
Results
At final follow-up with a mean of 16.8 ± 8.8 months (range 12–41; Group I: 18.3 ± 9.7 vs. Group II: 15.3 ± 8.0; ns), all patients were pain free. Postoperatively, positive Lachman tests were noted in all patients (100%) in Group II ( n = 5 patients with grade II and n = 5 patients with grade III). In Group I, 8 patients (80%) showed a negative Lachman test (grade I) and 2 patients (20%) a slightly elongated Lachman test with a firm stop (grade II). The mean knee flexion at follow-up examination was 132° ± 7° (range 120°–140°; Group I: 129° ± 9° vs. Group II: 135° ± 4°; ns). In pairwise comparison, flexion angle increased significantly in both groups (Group I: p = 0.0124 and Group II: p < 0.001). Pairwise comparison of thickness of the ACL and ACL/intercondylar ratio prior to and post-surgery in Group I showed non-significant differences.
Conclusion
Both arthroscopic debridement and complete resection of the ACL lead to improvement of clinical and radiological findings in isolated MDACL. However, complete resection of the ACL will result in higher instability. Therefore, partial resection might be the better treatment option, especially in young patients with MDACL.
... Mucoid degeneration (MD) of the anterior cruciate ligament (ACL) is a well-recognized pathology characterized by the degradation of collagen fibers and infiltration of a mucoidlike substance, [1,2] resulting in notch impingement, limited range of motion, and posterior knee pain associated with a bulky ACL [3][4][5]. The findings of MD-ACL on magnetic resonance imaging (MRI) include thickened, ill-defined ACL fibers showing a celery stalk sign with high signal intensity on all sequences, [6,7] often coexisting with a ganglion cysts [8]. ...
... The prevalence of trochlear dysplasia and pathological patella alta (> 1.2 of Insall-Salvati ratio) in this study might not have been sufficient to reach statistical significance. Overall, smaller and narrower intercondylar notch geometry can be associated with an increased risk of MD-ACL, through a possible mechanism of increased strain and microtrauma on the ACL along with the presence of a steeper tibial slope and patellofemoral anatomy, possibly associated with the intercondylar notch geometry, and with the presence of MD-ACL [8,12,15,19,40,43]. Furthermore, the amount of ATT in patients with MD-ACL was increased and the ACL slope was decreased when compared with those in the normal controls, which might be associated with ACL dysfunction and degenerative arthritis of the knee. ...
... Furthermore, the amount of ATT in patients with MD-ACL was increased and the ACL slope was decreased when compared with those in the normal controls, which might be associated with ACL dysfunction and degenerative arthritis of the knee. The degenerative change of the knee, which was reported to be associated with the MD-ACL in previous studies, [4,5,8,9] might be a result of dysfunction of MD-ACL, not the reason for MD-ACL. However, the amount of ATT in this study was found to have a sub-clinical relevance (approximately 1.5 mm), although a previous study reported significant ACL dysfunction [17], and hence further research is needed. ...
Introduction
Mucoid degeneration (MD) of the anterior cruciate ligament (ACL) is a well-recognized pathology characterized by the degradation of collagen fibers and infiltration of a mucoid-like substance. This study is to determine the anatomical associated factors for MD-ACL using radiographic and magnetic resonance imaging (MRI).
Materials and methods
This was a retrospective study on patients who had undergone knee arthroscopy between 2011 and 2020. The patients with MD-ACL were defined and enrolled by the MRI and arthroscopy. Eventually, 52 patients in the MD-ACL group (group 1) and 52 patients in the control group (group 2) were enrolled, following sex and age matching. Radiologic evaluation included the assessment of Kellgren–Lawrence (K–L) grade, mechanical hip–knee–ankle (HKA) angle, posterior tibial slope (PTS) angle, and Insall-Salvati ratio. The notch width index and transverse notch angle were measured on MRI, and the grade of trochlear dysplasia was defined. Logistic regression analysis, receiver operating characteristic (ROC) curves, and area under curve (AUC) were performed.
Results
The ROM was significantly decreased in group 1, whereas the PTS angle was significantly larger in group 1. Combined ganglion cysts of ACL were found in 42/52 patients (80.7%) in group 1. The risk of MD-ACL was associated with a steeper PTS angle, increased Insall-Salvati ratio, male sex, higher K–L grade, and decreased transverse notch angle and notch width index. The cutoff values in ROC analysis were found to be ≤ 28.27% for the notch width index (AUC, 0.849; p < 0.001), > 12.2° for the PTS angle (AUC, 0.765; p < 0.001), and ≤ 47.4° for the transverse notch angle (AUC, 0.711; p < 0.001), but not significant for Insall-salvati ratio.
Conclusion
A steeper PTS angle, decreased notch width index, and transverse notch angle are significantly associated with the presence of MD-ACL. These factors should be considered during diagnosis or when determining the treatment strategy for symptomatic MD-ACL patients.
Level of evidence
Level IIIb.
... 5,19,25,41 However, if meticulous partial resection of hypertrophied ACL is performed, notchplasty is seldom required. 7,24,40,42,43 Conversely, Lee et al. 20 suggested starting with lateral wall notchplasty, which can reduce the need for excessive partial resection of the ACL, thus preventing symptomatic instability. During surgery, passive extension is frequently needed to check for adequate resection and impingement-free motion between the ACL and the notch. ...
Background: Mucoid degeneration of the anterior cruciate ligament (ACL) is an uncommon non-traumatic cause of knee pain and motion restriction, typically seen in a middle-aged population. Primarily, the management consists of partial arthroscopic debridement and notchplasty, which has proven satisfactory clinical and functional outcomes.
Study objectives: This review aims to highlight key clinical, radiological and arthroscopic findings of mucoid ACL degeneration, and also to provide an approach to manage a symptomatic middle-aged athlete.
Rationale: Due to the paucity of literature on ACL mucoid degeneration, symptomatic presentation in a middle-aged athlete can be challenging to manage. Diffuse central pain, motion restriction in extension or flexion, absence of trauma, and an intact enlarged ACL on Magnetic resonance imaging (MRI) should raise suspicion for mucoid degeneration in middle-aged athletes. Specific radiological and arthroscopic findings can help to confirm the diagnosis. In this review article, we have also described a new clinical test to mimic the pain due to anterior impingement in the presence of an enlarged ACL.
Conclusion: In symptomatic middle-aged athletes, knowledge of characteristic findings can help in the timely diagnosis of mucoid degeneration of ACL. Treatment options include arthroscopic debridement, notchplasty, ACL augmentation, and ACL reconstruction. The presence of associated injuries can influence return-to-sports prognosis.
... The cruciate ligaments are usually torn in knee injuries [1,4,13,21,27,35]. Ganglion cysts arising from them are another, not so common, clinical condition in which these ligaments may be associated with symptoms [11,38]. The ganglion cysts may occupy the intercondylar notch and protrude into either the anterior and/or the knee's posterior compartment [32]. ...
... The anatomical variation of the PCL that was found in the present study was mimicking a pseudo-mass within the intercondylar notch, such as cruciate ligaments ganglion cysts. Symptoms arising from ACL ganglion cysts may include pain, stiffness, clicking sensation, mechanical locking and limited range of motion [11,32,38]. The clinical presentation of the current patient was quite similar. ...
Purpose
The present study aims to report a symptomatic rare anatomical variation of the posterior cruciate ligament (PCL) that was encountered during arthroscopy.
Case presentation
A 34-year-old female suffered from dull anterior pain in the right knee, along with stiffness and the presence of an audible click and occasionally locking during deep knee flexion. Physical examination revealed only slight pain during single-leg squatting and mild knee effusion with painful limitation of the last degrees of flexion. Following unsuccessful conservative treatment, knee arthroscopy was performed in which the PCL was found to be hypertrophic, having a broad femoral insertion that almost completely occupied the intercondylar notch and impinged the anterior cruciate ligament. Moreover, the PCL presented a large medial synovial fold that formed a plica inserting to the medial meniscus's posterior horn. Ligamentoplasty was performed by excising one-third of the PCL lateral portion. The PCL medial synovial fold and the plica attaching to the medial meniscus were resected. The patient was allowed to return to full activity when her symptoms resolved, and the knee function was restored, at 5 weeks post-operatively.
Conclusion
The current study presented a rare and complex anatomical variation of the PCL that was symptomatic and recalcitrant to conservative treatment. Magnetic resonance imaging (MRI) can reveal the variant morphology of the PCL, and arthroscopy provides the definite treatment. This case report may be useful for orthopaedic surgeons and radiologists to consider anatomical PCL variations during differential diagnosis in patients with non-specific clinical presentation and findings.
... Many of these ganglion cysts were found incidentally without symptoms and often coexisted with MD-ACL. Although the pathogenesis of ACL ganglion cysts remains controversial [23,25,26], in our opinion, there are similarities to those of MD-ACL, including trauma theories. Krudwig et al. [9] reported that symptoms, such as pain and limited ROM, were found in only 11% of their cases, and that these symptoms were related to the size and location of the ganglion cysts [25]. ...
Background: Mucoid degeneration of the anterior cruciate ligament (MD-ACL) is a chronic degenerative process involving a hypertrophied ACL, which may lead to notch impingement syndrome. As a treatment method, there is consensus regarding arthroscopic resection for MD-ACL resulting in good clinical outcomes; however, additional notchplasty remains controversial. The purpose of this study was to investigate clinical outcomes after arthroscopic partial resection of the ACL and additional notchplasty performed to minimize volume reduction of the ACL. Study Design: Level IIIb retrospective cohort study. Methods: Of 1810 individuals who underwent knee arthroscopic surgery performed by the same surgeon between July 2011 and October 2020, 52 were included, while 10 were excluded due to a follow-up period of
