[Congenital absence of the anterior cruciate ligament: eight cases in the same family]

Bilateral congenital absence of the anterior cruciate ligament associated with bilateral knee and hip osteoarthritis: Case report

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Reports of the progression of congenital absence of cruciate ligament were very rare in old age.

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Authors reported a case of congenital absence of cruciate ligament with severe knee instability, knee and hip osteoarthritis.

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Congenital absence of cruciate ligament may progress to osteoarthritis, so early detection and proper management is needed.

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Total knee arthroplasty is useful for the treatment of arthritis and instability following congenital absence of cruciate ligament.

Introduction

Congenital absence of the cruciate ligaments is very rare condition. Its association with congenital abnormalities of the spine, knee and hip, has been rarely reported. Most of the case reports were mostly reported before adolescence, so reports of the progression of this congenital disease at old age were extremely rare.

Presentation of case

A 65-year-old woman had a 7-year history of both knee and hip pain. On physical examination, valgus and varus instability on both knees and painful limitation of motion in both hip joints were observed. Radiography and magnetic resonance imaging showed the absence of the anterior cruciate ligament with osteoarthritis on both knees and hip osteoarthritis. Total knee and hip arthroplasties were performed on both knee joints and total hip arthroplasty. The pain and instability of both knees and hips were lost for follow up of more than a year, and the patient is doing well in daily life.

Discussion

Congenital absence of cruciate ligament may progress to osteoarthritis, do early detection and proper management is needed. In the treatment of older aged patients. Reports of treatment for this disorder are also very rare in older age. In old age, arthroplasty can be a useful treatment when the severe osteoarthritis is accompanied by instability.

Conclusion

Since the congenital absence of the ACL in old age could lead to hip and knee osteoarthritis, periodic follow-up is necessary and arthroplasty can be a useful treatment when the severe osteoarthritis is accompanied by instability.

Reconstruction of Symptomatic Congenital Anterior Cruciate Ligament Insufficiency

BACKGROUND

Hypoplasia or congenital absence of the anterior cruciate ligament (ACL) is a rare disorder occurring in ∼1 in every 6000 births. Although some patients with hypoplasia or agenesis of the ACL may not complain of instability, others desire to participate in more demanding activities that require the stability of a competent ACL. There are limited reports of surgical treatment of this patient population. The purpose of this study was to report ACL reconstruction in a case series of patients with symptomatic congenital ACL deficiency.

METHODS

A retrospective medical record review of the surgical treatment of 14 knees (13 patients) with congenital absence of the ACL at a tertiary care institution from 1995 to 2012 was performed. Patients with a minimum of 1 year of clinical follow-up were eligible for inclusion.

RESULTS

The mean age at time of surgery was 12.6 (range, 3 to 22), including 6 patients <12 years of age. Mean follow-up was 2.9 years (range, 1 to 6.6). Nine of 13 patients (69%) had underlying congenital abnormalities/associated syndromes. Preoperative Lachman and pivot shift examination was International Knee Documentation Committee grade C or D in all but 1 knee. ACL reconstruction was performed with combined intra-articular/extra-articular physeal sparing reconstruction with iliotibial band (n=5), autograft hamstring (n=2) or bone-patellar tendon-bone (n=3), or allograft (n=4). Multiligament reconstruction of associated ligamentous deficiency was performed in 7 knees (50%). Postoperative Lachman and pivot shift testing was International Knee Documentation Committee (IKDC) grade A or B in all but 1 knee. One patient with congenital absence of multiple knee ligaments required revision ACL reconstruction surgery, with concurrent first-time posterior cruciate ligament reconstruction, due to persistent instability. None required revision surgery due to graft tear at a minimum of 1-year follow-up.

CONCLUSIONS

Surgical stabilization of symptomatic congenital ACL insufficiency, with associated ligamentous reconstruction as required on a case-by-case basis, results in improved stability at early clinical follow-up, with low complication rates.

LEVEL OF EVIDENCE

Level IV-retrospective case series.

Review and Long-Term Outcomes of Cruciate Ligament Reconstruction versus Conservative Treatment in Siblings with Congenital Anterior Cruciate Ligament Aplasia

There is no consensus on the best treatment for anterior cruciate ligament hypoplasia or aplasia. To our knowledge, no comparative study between operative and conservative treatment of this condition has ever been performed. Conservative treatment is a viable alternative to surgery for ACL aplasia. Two siblings were examined at our outpatient clinic. The male patient underwent bilateral ACL reconstruction, while his sister was treated conservatively. Our results show a worse long-term outcome for the operative patient. At her last follow-up, the female patient treated conservatively showed subjective improvement in stability and gait. A review of the literature shows inconsistent outcomes after reconstruction in contrast to reports with cruciate ligament agenesis that did not undergo reconstruction with acceptable to good outcomes. Cruciate reconstruction should be reserved for cases of impaired articular instability, objectively manifest in the frequency of giving-way episodes. Treatment depends on the patient's condition and expectations. Surgery should therefore only be suggested after proper patient counseling.

Ring-shaped lateral meniscus with hypoplasic anterior cruciate ligament

Knee joint lesions can be solitary or occur concomitantly with other lower limb abnormalities. Ring-shaped lateral meniscus (RSM) and hypoplasic anterior cruciate ligament (ACL) are two rare malformations. The therapeutic management of such abnormalities is not consensual, and highly depends on clinical symptomatology. We report a case of a 25-year-old girl with progressive knee pain whose MRI demonstrated a continuous segment of lateral meniscus situated along the medial aspect of the lateral compartment, continuous with the otherwise normal-appearing lateral meniscus, compatible with an RSM. This anatomic variant can be mistaken by a displaced meniscal fragment, like a bucket-handle tear, a central tear of a discoid meniscus, or incomplete discoid meniscus, as previously reported. Her MRI examination also showed a thinned ACL with anomalous lateral course. This abnormality may be mistaken for an ACL rupture and/or a meniscofemoral ligament with agenesis of ACL. Multiple images in different planes as well as following the course of meniscal and ligaments are critical clues to avoid misdiagnosis. As a result, the diagnosis of an RSM along with hypoplasic ACL with abnormal attachment was assumed based on MRI and confirmed during arthroscopy. The patient was treated conservatively with clinical outcome improvement.

Copy number variation in CEP57L1 predisposes to congenital absence of bilateral ACL and PCL ligaments

Background

Absence of the anterior (ACL) or posterior cruciate ligament (PCL) are rare congenital malformations that result in knee joint instability, with a prevalence of 1.7 per 100,000 live births and can be associated with other lower-limb abnormalities such as ACL agnesia and absence of the menisci of the knee. While a few cases of absence of ACL/PCL are reported in the literature, a number of large familial case series of related conditions such as ACL agnesia suggest a potential underlying monogenic etiology. We performed whole exome sequencing of a family with two individuals affected by ACL/PCL.

Results

We identified copy number variation (CNV) deletion impacting the exon sequences of CEP57L1, present in the affected mother and her affected daughter based on the exome sequencing data. The deletion was validated using quantitative PCR (qPCR), and the gene was confirmed to be expressed in ACL ligament tissue. Interestingly, we detected reduced expression of CEP57L1 in Epstein–Barr virus (EBV) cells from the two patients in comparison with healthy controls. Evaluation of 3D protein structure showed that the helix-binding sites of the protein remain intact with the deletion, but other functional binding sites related to microtubule attachment are missing. The specificity of the CNV deletion was confirmed by showing that it was absent in ~700 exome sequencing samples as well as in the database of genomic variations (DGV), a database containing large numbers of annotated CNVs from previous scientific reports.

Conclusions

We identified a novel CNV deletion that was inherited through an autosomal dominant transmission from an affected mother to her affected daughter, both of whom suffered from the absence of the anterior and posterior cruciate ligaments of the knees.

Electronic supplementary material

The online version of this article (doi:10.1186/s40246-015-0053-z) contains supplementary material, which is available to authorized users.

Bilateral agenesis of the anterior cruciate ligament: MRI evaluation

Bilateral agenesis of the anterior cruciate ligament (ACL) is extremely rare. We describe a 13-year-old girl who presented with bilateral knee pain without history of trauma; she has two family members with knee instability. Magnetic resonance imaging showed bilateral absence of the ACL, and medial posterior horn meniscal tears. Bilateral arthroscopic partial meniscectomy and anterior cruciate ligament reconstruction was performed.

Surgical treatment of a rare isolated bilateral agenesis of anterior and posterior cruciate ligaments

The isolated bilateral agenesis of both cruciate ligaments is a rare congenital disorder. A 17-year-old male came to our attention due to an alteration in gait pattern, pain, and tendency to walk on the forefoot with his knee flexed. The patient did not recall previous injuries. Upon physical examination anterior and posterior chronic instability were observed. Radiographic examination of both knees showed hypoplasia of the tibial eminence, a hypoplastic lateral femoral condyle, and a narrow intercondylar notch. MRI brought to light a bilateral agenesis of both posterior cruciate ligaments. Arthroscopic evaluation confirmed bilateral isolated agenesis of both cruciate ligaments. We recommended a rehabilitation program to prepare the patient for the arthroscopic construction of both cruciate ligaments.

Osteochondritis dissecans of the lateral tibial condyle associated with agenesis of both cruciate ligaments

Osteochondritis dissecans is a rare cause of painful knees in children. Only 10 cases of lateral tibial condyle involvement have been reported in the literature. Congenital agenesis of both cruciate ligaments has been described even less, and its prevalence is unknown. The authors report an atypical association of osteochondritis dissecans of the tibia with congenital absence of both cruciate ligaments. A 12-year-old male soccer player presented with a painful right knee. Magnetic resonance imaging revealed the diagnosis. The child was treated conservatively. At 18-month follow-up, radiographs showed osseointegration of the osteochondritis dissecans, and the patient had resumed normal athletic activity without pain. To the authors' knowledge, this is the only report describing such an association. The authors discuss the possible etiology of osteochondritis dissecans associated with agenesis of the cruciate ligaments and highlight the possibility of this association when osteochondritis dissecans of the tibia is diagnosed in a child with a painful knee. In this patient, the strain due to anteroposterior instability may have been the cause of osteochondritis. Conservative treatment should be considered in this setting.

Congenital absence of the cruciate ligaments

Congenital absence of the cruciate ligaments is a rare condition with a prevalence of 0.017 per 1,000 live births. The most important finding of this study was the presence of a posterior menisco-femoral ligament of Wrisberg with cruciate ligaments agenesia and the hypothesis advanced about the development of the ligamentous structures of the knee. Reviewing the literature, we assume that the congenital anomaly that causes the anatomical defect expresses itself around the 7th to 8th post-ovulatory week. Literature teaches us that the need for a knee replacement seems to be inevitable before or after and during the life of a patient without cruciate ligaments.

Ligament reconstruction in congenital absence of the anterior cruciate ligament: a case report

Congenital absence of the cruciate ligament is an extremely rare condition that was first reported in Giorgi's radiographic study in 1956. The authors report on a case of anterior cruciate ligament reconstruction performed on a 21-year-old female patient with congenital anterior cruciate ligament absence. We also discuss radiographic evidence that could provide clues to the congenital absence and possible difficulties that may be encountered during surgery with a review of the relevant literature.

Unilateral aplasia of both cruciate ligaments

Aplasia of both cruciate ligaments is a rare congenital disorder. A 28-year-old male presented with pain and the feeling of instability of his right knee after trauma. The provided MRI and previous arthroscopy reports did not indicate any abnormalities except cruciate ligament tears. He was referred to us for reconstruction of both cruciate ligaments. The patient again underwent arthroscopy which revealed a hypoplasia of the medial trochlea and an extremely narrow intercondylar notch. The tibia revealed a missing anterior cruciate ligament (ACL) footprint and a single bump with a complete coverage with articular cartilage. There was no room for an ACL graft. A posterior cruciate ligament could not be identified. The procedure was ended since a ligament reconstruction did not appear reasonable. A significant notch plasty if not a partial resection of the condyles would have been necessary to implant a ligament graft. It is most likely that this would not lead to good knee stability. If the surgeon would have retrieved the contralateral hamstrings at the beginning of the planned ligament reconstruction a significant damage would have occurred to the patient. Even in seemingly clear diagnostic findings the arthroscopic surgeon should take this rare abdnormality into consideration and be familiar with the respective radiological findings. We refer the abnormal finding of only one tibial spine to as the "dromedar-sign" as opposed to the two (medial and a lateral) tibial spines in a normal knee. This may be used as a hint for aplasia of the cruciate ligaments.

Advanced MR imaging of the cruciate ligaments

The anterior and posterior cruciate ligaments are crucial stabilizers of the knee. These ligaments are named by the location of their tibial attachments. Each ligament is composed of separate functional bundles that differ in size but are equally important in function. MR imaging is accurate and sensitive, making it the imaging technique of choice for evaluating these ligaments. Acute and chronic injuries involving the cruciate ligaments have typical appearances and associated findings. MR imaging interpretation must take into account atypical injuries and imaging pitfalls. Knowledge of normal ligament reconstruction techniques allows differentiation of the normal postoperative appearance from reconstruction failure and complications. Ligament reconstruction techniques, complications, and appearances are reviewed in this article.

Advanced MR Imaging of the Cruciate Ligaments

The anterior and posterior cruciate ligaments are crucial stabilizers of the knee. These ligaments are named by the location of their tibial attachments. Each ligament is composed of separate functional bundles that differ in size but are equally important in function. MR imaging is accurate and sensitive, making it the imaging technique of choice for evaluating these ligaments. Acute and chronic injuries involving the cruciate ligaments have typical appearances and associated findings. MR imaging interpretation must take into account atypical injuries and imaging pitfalls. Knowledge of normal ligament reconstruction techniques allows differentiation of the normal postoperative appearance from reconstruction failure and complications. Ligament reconstruction techniques, complications, and appearances are reviewed in this article.