Anterior Cruciate Ligament (ACL) Mucoid Degeneration: Difference between revisions
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== Introduction == | == Introduction == | ||
Anterior Cruciate Ligament is an important structure of the knee joint. Anatomically, it is arranged in a crossed pattern | Anterior Cruciate Ligament, is an important structure of the knee joint. Anatomically, it is arranged in a crossed pattern with the Posterior Cruciate Ligament,forming an 'X', therefore, it is also known as cruciform ligament. This ligament conists of two fibers, mainly, the anterio-medial and postero-lateral fibers, respectively. The ligament is mainly responsible for restraning anterior translation of knee. Along with that, it also controls the internal rotation. Therefore, Anterior Cruciate Ligament tear is more susceptible during any injury to the knee.The cruciate ligament have mechanoreceptors, which are responsible to detect any change in position of the knee, direction, speed and tension.It is lined by the synovial fluid, which provides the nutrition and plays an integral part in healing. | ||
== What is Anterior Cruciate Ligament Mucoid Degeneration? == | == What is Anterior Cruciate Ligament Mucoid Degeneration? == | ||
This is a rare pathological condition, in which there is increased signal from within the ligament. Mucoid degeneration, is irreversible degeneration of the tissue with the infiltration of mucin within the fibers<ref>Palmer, W., Bancroft, L., Bonar, F. ''et al.'' Glossary of terms for musculoskeletal radiology. ''Skeletal Radiol'' 49, 1–33 (2020). <nowiki>https://doi.org/10.1007/s00256-020-03465-1</nowiki></ref><ref name=":1" />. Multiple theories have been put forth that explains the pathological disorganisation in the collagen fibers of the Anterior Cruciate Ligament, such as synovial, traumatic, and degenerative, | This is a rare pathological condition, in which, there is increased signal from within the ligament. Mucoid degeneration, is the irreversible degeneration of the tissue with the infiltration of mucin(glycosaminoglycans) within the fibers<ref>Palmer, W., Bancroft, L., Bonar, F. ''et al.'' Glossary of terms for musculoskeletal radiology. ''Skeletal Radiol'' 49, 1–33 (2020). <nowiki>https://doi.org/10.1007/s00256-020-03465-1</nowiki></ref><ref name=":1" />. Multiple theories have been put forth that explains the pathological disorganisation in the collagen fibers of the Anterior Cruciate Ligament, such as synovial, traumatic, and degenerative,"<u>Synovial” theory</u>- states that there is accumulation of synovial fluid inside the substance of ACL in a herniated pouch of synovium."<u>Traumatic” theory</u> - post injury, ACL fibroblasts secrete glycosaminoglycans, the mucin substance within the ACL. Other theories include “<u>Degenerative” theory</u>- MD could occur due to ageing.<ref name=":0">Pandey, Vivek et al. “Mucoid degeneration of the anterior cruciate ligament: Management and outcome.” ''Indian journal of orthopaedics'' vol. 48,2 (2014): 197-202. doi:10.4103/0019-5413.128765</ref> | ||
== Clinical Findings == | == Clinical Findings == | ||
Painful terminal knee flexion<ref name=":1">''Khalid Ibn el Kadi et al. Mucoid degeneration of the anterior cruciate ligament: a case report. Pan African Medical Journal. 2013;15:59. [doi: 10.11604/pamj.2013.15.59.2534]''</ref><ref name=":0" /> | * Painful terminal knee flexion<ref name=":1">''Khalid Ibn el Kadi et al. Mucoid degeneration of the anterior cruciate ligament: a case report. Pan African Medical Journal. 2013;15:59. [doi: 10.11604/pamj.2013.15.59.2534]''</ref><ref name=":0" /> | ||
* Stiffness<ref name=":1" /> | |||
Stiffness<ref name=":1" /> | * No instability<ref name=":1" /><ref name=":0" /> | ||
* No extension block<ref name=":0" /> | |||
No instability<ref name=":1" /><ref name=":0" /> | * Joint line tenderness<ref name=":0" /> | ||
* Swelling<ref name=":0" /> | |||
No extension block<ref name=":0" /> | * Crepitation<ref name=":0" /> | ||
* Posterior knee pain<ref name=":0" /><ref name=":2">Lintz F, Pujol N, Dejour D, Boisrenoult P, Beaufils P. Anterior cruciate ligament mucoid degeneration: selecting the best treatment option. Orthopaedics & Traumatology: Surgery & Research. 2010 Jun 1;96(4):400-6.</ref> | |||
Joint line tenderness<ref name=":0" /> | * Difficulty in climbing stairs, cross-leg sitting, squatting<ref name=":4">Loganathan D, Soma Sundar S, Sundar S, Sahanand S, Rajan DV. Mucoid degenerated anterior cruciate ligament (ACL) managed by arthroscopic ACL reconstruction: A case series. International Journal of Orthopaedics. 2018;4(4):875-80.</ref> | ||
Swelling<ref name=":0" /> | |||
Crepitation<ref name=":0" /> | |||
Posterior knee pain<ref name=":0" /><ref name=":2">Lintz F, Pujol N, Dejour D, Boisrenoult P, Beaufils P. Anterior cruciate ligament mucoid degeneration: selecting the best treatment option. Orthopaedics & Traumatology: Surgery & Research. 2010 Jun 1;96(4):400-6.</ref> | |||
== Causes == | == Causes == | ||
Acute/Repeated Trauma<ref name=":2" /><ref name=":3">Lintz, Francois, et al. "Anterior Cruciate Ligament Mucoid Degeneration: a Review of the Literature and Management Guidelines." ''Knee Surgery, Sports Traumatology, Arthroscopy : Official Journal of the ESSKA,'' vol. 19, no. 8, 2011, pp. 1326-33.</ref> | * Acute/Repeated Trauma<ref name=":2" /><ref name=":3">Lintz, Francois, et al. "Anterior Cruciate Ligament Mucoid Degeneration: a Review of the Literature and Management Guidelines." ''Knee Surgery, Sports Traumatology, Arthroscopy : Official Journal of the ESSKA,'' vol. 19, no. 8, 2011, pp. 1326-33.</ref> | ||
* Ageing | |||
Ageing | * Primary condition- Osteoarthritis, degenerative menisci, meniscal tear<ref name=":0" />, Menisectomy<ref name=":2" /> | ||
Primary condition- Osteoarthritis, degenerative menisci, meniscal tear<ref name=":0" />, Menisectomy<ref name=":2" /> | |||
== Complications == | == Complications == | ||
Impingement of the soft tissue in the vicinity<ref name=":0" /> | * Impingement of the soft tissue in the vicinity<ref name=":0" /> | ||
* Ganglionic cyst | |||
Ganglionic cyst | * Tendon tear/ Tendon rupture | ||
Tendon tear/ Tendon rupture | |||
== Radiological Findings == | == Radiological Findings == | ||
=== MRI: === | === MRI: === | ||
Characteristic:"celery stalk" appearance,<ref name=":2" /> reflects ACL degeneration. | * Characteristic:"celery stalk" appearance,<ref name=":2" /> reflects ACL degeneration. | ||
* Ligaments and tendons are accumulated by mucoid change might display a thickened and/or hypertrophied appearance, with an increase in signal intensity.<ref name=":0" /><ref name=":2" /> | |||
Ligaments and tendons are accumulated by mucoid change might display a thickened and/or hypertrophied appearance, with an increase in signal intensity.<ref name=":0" /><ref name=":2" /> | * Narrowing of the intercondylar notch<ref name=":4" /> | ||
* Sometimes, it is mislead as ACL tear on MRI findings, hence requires probing and histopathology for definitive diagnosis.<ref name=":0" /><ref name=":2" /> | |||
Sometimes, it is mislead as ACL tear on MRI findings, hence requires probing and histopathology for definitive diagnosis.<ref name=":0" /><ref name=":2" /> | |||
=== ARTHROSCOPY: === | === ARTHROSCOPY: === | ||
Arthroscopically ACL is intact but fibrillated, yellowish and hypertrophied, with interspersed yellowish mucinous material along the fibers, lack of synovial linning of the ACL<ref name=":2" /> | * Arthroscopically ACL is intact but fibrillated, yellowish and hypertrophied, with interspersed yellowish mucinous material along the fibers, lack of synovial linning of the ACL<ref name=":2" /> | ||
== Differential Diagnosis == | == Differential Diagnosis == | ||
| Line 62: | Line 51: | ||
== Treatment == | == Treatment == | ||
=== <u>Conservative</u>- === | |||
NSAIDS and Physiotherapy | |||
=== <u>Surgical</u>- === | |||
# Partial/Total ACL resection arthroscopically- There is marked improvement in the range and reduced posterior pain, but at the cost of increased post-operative knee laxity.<ref name=":0" /><ref name=":2" /><ref name=":3" />in some cases,and may lead to instability. The prognosis depends upon the age of the patient, and the associated injuries<ref name=":1" /> | # Partial/Total ACL resection arthroscopically- There is marked improvement in the range and reduced posterior pain, but at the cost of increased post-operative knee laxity.<ref name=":0" /><ref name=":2" /><ref name=":3" />in some cases,and may lead to instability. The prognosis depends upon the age of the patient, and the associated injuries<ref name=":1" /> | ||
# Arthroscopic debridement<ref name=":2" /> | # Arthroscopic debridement<ref name=":2" /> | ||
# Notchplasty<ref name=":0" /><ref name=":3" /> | # Notchplasty<ref name=":0" /><ref name=":3" /> | ||
=== <u>Postoperative Rehabilitation-</u> === | |||
# Wear knee brace | |||
# Intially partial weightbearing is allowed | |||
# ACL reconstruction protocol is followed | |||
== References == | == References == | ||
Revision as of 13:18, 20 September 2020
Original Editor - User Name
Top Contributors - Keta Parikh, Kim Jackson and Leana Louw
Introduction[edit | edit source]
Anterior Cruciate Ligament, is an important structure of the knee joint. Anatomically, it is arranged in a crossed pattern with the Posterior Cruciate Ligament,forming an 'X', therefore, it is also known as cruciform ligament. This ligament conists of two fibers, mainly, the anterio-medial and postero-lateral fibers, respectively. The ligament is mainly responsible for restraning anterior translation of knee. Along with that, it also controls the internal rotation. Therefore, Anterior Cruciate Ligament tear is more susceptible during any injury to the knee.The cruciate ligament have mechanoreceptors, which are responsible to detect any change in position of the knee, direction, speed and tension.It is lined by the synovial fluid, which provides the nutrition and plays an integral part in healing.
What is Anterior Cruciate Ligament Mucoid Degeneration?[edit | edit source]
This is a rare pathological condition, in which, there is increased signal from within the ligament. Mucoid degeneration, is the irreversible degeneration of the tissue with the infiltration of mucin(glycosaminoglycans) within the fibers[1][2]. Multiple theories have been put forth that explains the pathological disorganisation in the collagen fibers of the Anterior Cruciate Ligament, such as synovial, traumatic, and degenerative,"Synovial” theory- states that there is accumulation of synovial fluid inside the substance of ACL in a herniated pouch of synovium."Traumatic” theory - post injury, ACL fibroblasts secrete glycosaminoglycans, the mucin substance within the ACL. Other theories include “Degenerative” theory- MD could occur due to ageing.[3]
Clinical Findings[edit | edit source]
- Painful terminal knee flexion[2][3]
- Stiffness[2]
- No instability[2][3]
- No extension block[3]
- Joint line tenderness[3]
- Swelling[3]
- Crepitation[3]
- Posterior knee pain[3][4]
- Difficulty in climbing stairs, cross-leg sitting, squatting[5]
Causes[edit | edit source]
- Acute/Repeated Trauma[4][6]
- Ageing
- Primary condition- Osteoarthritis, degenerative menisci, meniscal tear[3], Menisectomy[4]
Complications[edit | edit source]
- Impingement of the soft tissue in the vicinity[3]
- Ganglionic cyst
- Tendon tear/ Tendon rupture
Radiological Findings[edit | edit source]
MRI:[edit | edit source]
- Characteristic:"celery stalk" appearance,[4] reflects ACL degeneration.
- Ligaments and tendons are accumulated by mucoid change might display a thickened and/or hypertrophied appearance, with an increase in signal intensity.[3][4]
- Narrowing of the intercondylar notch[5]
- Sometimes, it is mislead as ACL tear on MRI findings, hence requires probing and histopathology for definitive diagnosis.[3][4]
ARTHROSCOPY:[edit | edit source]
- Arthroscopically ACL is intact but fibrillated, yellowish and hypertrophied, with interspersed yellowish mucinous material along the fibers, lack of synovial linning of the ACL[4]
Differential Diagnosis[edit | edit source]
Conditions that resembles the clinical findings are:
- Ligament tear
- Ligament rupture
- Fatty infiltration
- Ligament sprain
- Ganglion cyst
Treatment[edit | edit source]
Conservative-[edit | edit source]
NSAIDS and Physiotherapy
Surgical-[edit | edit source]
- Partial/Total ACL resection arthroscopically- There is marked improvement in the range and reduced posterior pain, but at the cost of increased post-operative knee laxity.[3][4][6]in some cases,and may lead to instability. The prognosis depends upon the age of the patient, and the associated injuries[2]
- Arthroscopic debridement[4]
- Notchplasty[3][6]
Postoperative Rehabilitation-[edit | edit source]
- Wear knee brace
- Intially partial weightbearing is allowed
- ACL reconstruction protocol is followed
References[edit | edit source]
- ↑ Palmer, W., Bancroft, L., Bonar, F. et al. Glossary of terms for musculoskeletal radiology. Skeletal Radiol 49, 1–33 (2020). https://doi.org/10.1007/s00256-020-03465-1
- ↑ 2.0 2.1 2.2 2.3 2.4 Khalid Ibn el Kadi et al. Mucoid degeneration of the anterior cruciate ligament: a case report. Pan African Medical Journal. 2013;15:59. [doi: 10.11604/pamj.2013.15.59.2534]
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 Pandey, Vivek et al. “Mucoid degeneration of the anterior cruciate ligament: Management and outcome.” Indian journal of orthopaedics vol. 48,2 (2014): 197-202. doi:10.4103/0019-5413.128765
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Lintz F, Pujol N, Dejour D, Boisrenoult P, Beaufils P. Anterior cruciate ligament mucoid degeneration: selecting the best treatment option. Orthopaedics & Traumatology: Surgery & Research. 2010 Jun 1;96(4):400-6.
- ↑ 5.0 5.1 Loganathan D, Soma Sundar S, Sundar S, Sahanand S, Rajan DV. Mucoid degenerated anterior cruciate ligament (ACL) managed by arthroscopic ACL reconstruction: A case series. International Journal of Orthopaedics. 2018;4(4):875-80.
- ↑ 6.0 6.1 6.2 Lintz, Francois, et al. "Anterior Cruciate Ligament Mucoid Degeneration: a Review of the Literature and Management Guidelines." Knee Surgery, Sports Traumatology, Arthroscopy : Official Journal of the ESSKA, vol. 19, no. 8, 2011, pp. 1326-33.
