Q: Acute knee injury. Which of the cruciate and collateral ligaments are torn?

History:

A 68 year old male with knee pain.

Images:

1a and 1b Sagittal PD SPAIR and PD images.

1a

1b

2a and 2b Coronal PD SPAIR and PD images.

2a

2b

3 Axial PD image

3

 Image Findings:

The anterior cruciate ligament is markedly expanded, with widening of the intercondylar notch appreciable on the coronal and axial images. There is ganglion formation within the adjacent bone. Although there is a mild diffuse hyperintensity, there is no evidence of fibre discontinuity to indicate a tear.

Answer:

Mucoid degeneration of the anterior cruciate ligament.

Discussion:

Mucoid degeneration of the ACL involves interstitial glycosaminoglycan deposition among collagen bundles resulting in hypertrophy with knee pain and a restricted range of motion. It is believed to arise from a primary synovial lesion and is associated with arthritis or the sequelae of trauma. While reportedly rare, it is probably underappreciated and present on up to 5% of knee MRIs in one study of 1215 patients with a mean age of 44 years.

Clinical findings are most typically posterior pain exacerbated by flexion or climbing stairs, and sometimes painful limitation of extension. There is no evidence of ACL laxity, although there may be limited flexion to around 100 degrees. Grinding or catching symptoms may be present.

Imaging findings include fusiform expansion of the ACL with diffuse hyperintensity on T2 weighted imaging, but no evidence of fibre discontinuity that would indicate a tear. Both bundles should intact fibres from origin to insertion. The fibres are relatively poorly visualised on T1 and PD weighted imaging, but better appreciated on T2 weighted imaging. The appearance has been likened to a “celery stalk”. While differential diagnoses include an ACL tear or malignancy, in the majority of circumstances MRI findings are sufficiently diagnostic.

Management is initially conservative, but surgical options include partial or complete ACL resection, and notchplasty to counteract the impingement, with the decision for surgery balanced against the potential risk of instability.

References:

1. Lintz F, Pujol N, Boisrenoult P, Bargoin K, Beaufils P, Dejour D. Anterior cruciate ligament mucoid degeneration: a review of the literature and management guidelines. Knee Surg Sports Traumatol Arthrosc 2011;19:1326-1333.
2. Salvati F, Rossi F, Limbucci N, Pistoia ML, Barile A, Masciocchi C. Mucoid metaplastic-degeneration of anterior cruciate ligament. J Sports Med Phys Fitness 2008;48(4):483-7.
3. Bergin D, Morrison WB, Carrino JA, Nallamshetty SN, Bartolozzi AR. Anterior cruciate ligament ganglia and mucoid degeneration: coexistence and clinical correlation. AJR 2004;182:1283-1287.
4. Papadopoulou P. The celery stalk sign. Radiology 2007;245:916-917.

We have the solution! IOPMobile allows you to view your patient’s visits on yourAndroid!

Simply download IOPMobile for free from the Google Play Store.

IOPMobile enables you to:

• Access results anywhere/anytime
• View Images and Reports from all visits
• Email key images and reports to colleagues
• Secure access

 For those already using IOP Online (InteleViewer) just use your existing login details.

Don’t have an InteleViewer account?

Full registration and authorisation is required to use this application and is available to all doctors holding a valid Australian provider number. Call Lauren Agati to set up an account on 0420 222 448 or email your name, clinic address, contact number and provider number to l.agati@iop.net.au.

IOPMobile is also available from iTunes for iPads and iPhones.

Many Australians are affected by Osteoarthritis; it is disease of the joint. The bones of a joint are normally protected by smooth, cushioning material called cartilage. In osteoarthritis, cartilage breaks down, causing pain and stiffness in the joint.

The most common symptoms of osteoarthritis include:

• painful joints, that usually worsen with exercise or repetitive use
• swelling of the affected joint
• creaking, and pain and stiffness that restrict movement
• weakened muscles surrounding the affected joint and
• joint deformity

 Hands, shoulders, spine, hips and knees are common joints where osteoarthritis develops.

What are the benefits of Orthokine injections?

Clinical trial results have shown that Orthokine injections relieve pain and may delay the need for surgery in some patients. As Orthokine is based on using only substances that originate from the body of the patient it is well tolerated.

 Patients often experience an improvement of their symptoms; this may include reduced pain, improved mobility.

Am I suitable of this therapy?

You will be required to arrange an appointment with our radiologists with a referral from your GP or sports medicine provider to assess your suitability to undertake this type of injection therapy and treatment. We’ve found that the candidate responds better and receives greater benefit if the osteoarthritis is mild to moderate. You could also be a candidate if you have a chronic tendon or ligament tear that has failed all other forms of therapy.

When is the therapy not recommended?

This treatment should not be started if you are

• suffering from acute infection or fever
• have had diarrhea in the last three days
• have taken antibiotics at any time in the previous week
• if you have received a vaccination in the last four weeks
• if your religious beliefs prohibit  blood transfusions

Process

As your own (autologous) blood is used, it is first collected by venesection using the Orthokine Syringe; the same procedure used in blood tests or blood donations.

The site of the venesection is usually a large vein in your arm. Typically 50 – 60ml of blood is collected.

This blood is then processed. Firstly, it is labeled and incubated at 37°C for 24 hours; at this stage the proteins are being synthesized. The blood will then be spun down in a centrifuge for 10 minutes. Following this the concentrated IL-1Ra cells are drawn up from the Orthokine Syringe using a 20-ml syringe and a drawing up needle, normally between 10 – 15 mls. The cells are further filtered to remove any unwanted blood components and bacteria leaving pure concentrate IL-1Ra cells. These smaller syringes are labeled and stored ready to be re-injected. 

You receive an injection into the affected joint 1-2 times per week or as the radiologist recommends. Your blood can be stored up to 7 months.

Are there any risks or side effects?

There are risks or side effects associated with any form of treatment, but significant complications with Orthokine therapy injections are rare.

• Mild to moderate pain or joint stiffness
• Minimal or no benefit from the treatment
• Swelling and/or bruising
• Redness, warmth or bleeding at the injection site
• Numbness for up to 2 hours at the injection site (depending on the area).

Post Procedure

When the anesthetic wears off you may ache at the injection site.

• You may experience pain for 48 hours.
• You should not participate in strenuous activity/ exercise for 48 hours.  
• If you are concerned that you are having untoward after effects from your injection, please ring Imaging @ Olympic Park or your Referring Doctor.

Concerns

It is important you understand why and how we will be assisting you. Please feel free to contact our friendly staff at any time if you have any questions or concerns on 03 9420 1700.

From Tuesday 16th April, Imaging @ Olympic Park will be trialling the new Planmed Verity Extremity CT Scanner for a number of weeks.  The Planmed Verity utilises CBCT (Cone Beam Computed Tomography) technology to provide high resolution volumetric (3D) images of the extremities at a particularly low dose. One of the most intriguing new applications of the extremity CT scanner is its weight- bearing option.

• The Planmed scanner has a weight-bearing option in which the patient stands inside the gantry during imaging acquisition. Weight-bearing imaging of the foot/ankle or knee shows the anatomy under natural load.

• Adaptable gantry with soft surface. Very often patients have limited mobility and cannot easily be positioned on the examination table, this is not a problem with the Planmed Verity as it has an adjustable height and tilt gantry.

• The Tear Drop shaped bore offers excellent targeting visibility and access, and less anxiety and claustrophobia for the patient

• The bone healing process can be visualised in a novel way without removing the cast.

Saturdays will now be open from 8.00am – 4.00pm for MRI, CT scans and X-rays. From 9.00am – 1.00pm a radiologist will be onsite to perform ultrasounds and interventional procedures.

In addition to these longer hours, IOP will be open on Sundays for MRI scanning between 10.00am and 1.00pm.

Andrew graduated from Monash University in 2005 and completed his radiology training at the Alfred Hospital. He underwent subspecialty fellowship training in magnetic resonance imaging, gaining advanced skills in musculoskeletal and neuroradiology. He is a strong advocate for science-based medicine and has published several research articles and presented at international meetings. He is a managing editor for Radiopaedia.org, one of the world’s leading radiology websites and in 2012 he founded the RadiologyChannel, a popular educational channel on YouTube.

Dr Peter Counsel completed radiology training in Perth, Western Australia. He underwent adult Musculoskeletal Radiology subspecialty training there at Fremantle Hospital and then further subspecialty training in Paediatric Radiology in Dublin, Ireland. In addition to adult sports radiology and musculoskeletal intervention, he continues to have a keen interest in the musculoskeletal conditions of children and adolescents.

We provide imaging services to many elite athletes, especially from Melbourne based sporting clubs.

To see what’s involved with an MRI knee please link on the below link (we’re featured 14:00 minutes in).

http://www.essendonfc.com.au/video/2013-04-10/btv-the-hangar-episode-3-2013

MRI factsheets are available in the patient section.

Please click on the below link:

http://www.hss.edu/newsroom_prp-treatment-potential-for-knee-osteoarthritis.asp