Case report - calcification of the medial collateral ligament of the knee with simultaneous calcifying tendinitis of the rotator cuff

Ultrasound-guided treatment of medial collateral ligament calcification of the knee with TenJet™: a case report

Calcification of the medial collateral ligament is a rare cause of medial knee pain along with functional impairment. Most cases are asymptomatic but those that are symptomatic typically respond to conservative management. However, in those instances with persistent symptoms that desire further intervention but want to minimize the risks associated with surgery, we present a novel approach for calcium removal with an ultrasound-guided percutaneous needle tenotomy with TenJet™ as a reasonable treatment modality.

Atraumatic Calcific Tendinitis in Medial Collateral Ligament: A Case Report

Introduction

Calcific tendinitis is a commonly treated in the shoulder and wrist, but it is rarely seen in the medial collateral ligament (MCL). There is not satisfactory orthopedic literature for diagnosis and treatment of this condition.

Case Report

A healthy 50-year-old woman presented with medial sided right knee pain. She did not have any history of trauma to the knee nor instability. She was diagnosed with calcific tendinitis of her MCL and was treated with US-guided lavage. This was her 4th documented location of symptomatic calcific tendinitis including her right shoulder, left wrist, and contralateral knee MCL.

Conclusion

We present a case of a 50-year-old female with a history of multifocal, symptomatic calcific tendinitis, who had atraumatic mineral deposition in her MCL. Ultrasound-guided lavage is a successful minimally invasive treatment for calcific tendinitis.

Ultrasound-guided Percutaneous Lavage as Treatment for Pellegrini-Stieda Syndrome with Suspected Same Patho-mechanism as Rotator Cuff Syndrome: A Case Report

Introduction

Pellegrini-Stieda syndrome is described as pain and restriction at the range of motioncaused by calcification in the medial collateral ligament (MCL) around the knee with the recognized radiographic findings of the lesion in the affected site. The pathomechanism of Pellegrini-Stieda is suspected to be similar as calcification of the rotator cuff that is thought to be reactive calcification followed by resorption and tendon remodeling involving four phases (pre-calcific, formative, resorptive, and healing) without any trauma history. Since the calcium deposit in the rotator cuff has been well managed by percutaneous lavage, in this case report, we assumed that the pathomechanism of Pellegrini-Stieda Syndrome is similar to calcification of the rotator cuff, thus can be treated with the same principle using ultrasound-guided percutaneous lavage (UGPL).

Objective

The aim of the study was to discuss UGPL as management for Pellegrini-Stieda with suspected similar pathomechanism to rotator cuff calcification.

Case Report

A 52-year-old woman came to the outpatient clinic with a week of severe pain in her right knee. The patient had difficulty walking due to stiffness and pain that is aggravated by moving her knee. Radiographic examination confirmed calcified lesions located within the MCL on the right knee. In consideration of the acute pain, we opted to perform UGPL procedure. Follow-ups were done 1 week and 1 month after the procedure. The patient reported no pain when walking and bending her knee during the follow-up examination and there was no complication noted. Overall, she was very satisfied with the result. We also interviewed her for the lower extremity functional scale Score which the patient gave 64 points and 72 points out of 80 for week 1 and 1 month, respectively, indicating favorable results.

Conclusion

Based on our case, UGPL can be an option for treating Pellegrini-Stieda Syndrome because it produces the same result as UGPL on rotator cuff calcification. Surgery should be the last resort if this procedure fails. Future high-quality randomized controlled trials were required to determine the reliability of this method.

Heterotopic Mineralization of the Medial Collateral Ligament: Our Experience Treating Two Cases of Calcific Versus Ossific Lesions With Ultrasonic Vacuum Debridement

Chronic injury to the medial collateral ligament (MCL) is common following an acute knee injury. This case report presents two patients that failed to respond to conservative treatment with clinical evidence of an MCL injury and radiographic finding of a benign-appearing soft tissue lesion in the MCL. Calcified or ossified lesions have been described with chronic MCL injuries. Ossification and calcification of the MCL have been observed as potential causes of chronic MCL pain. Here, we detail the distinction between these two distinct intra-ligamentous heterotopic deposits and describe a novel treatment approach using ultrasonic percutaneous debridement, a technique that is typically reserved for tendinopathies. In both cases, pain improved, and they were able to return to their prior level of function.

Calcific Enthesopathy of the Superior Extensor Retinaculum - An Unusual Cause of Medial Ankle Pain

AIM OF THE STUDY

Ankle pain can present a clinical dilemma to the foot and ankle surgeons, with a multitude of entities to which the symptoms could potentially be attributed. Enthesopathy around the ankle joint could be due to overuse, injury, inflammation or infection. Calcific ligamentous enthesopathy around the ankle is a well-recognised condition with a spectrum of causes.

CASE DESCRIPTION

To our knowledge, a clinically symptomatic presentation of calcific enthesopathy specifically affecting the entheses of the superior extensor retinaculum has not been described in the literature. We report the first case of symptomatic calcific enthesopathy of the superior extensor retinaculum in a healthy young female, and highlight the role of radiological interventions in its diagnosis. The condition was managed successfully by ultrasound-guided barbotage.

CONCLUSIONS

Calcific enthesopathy of the attachment of the superior extensor retinaculum is a rare condition that should be considered in the differential diagnosis of patients with medial ankle pain.

Calcific Enthesopathy of the Superior Extensor Retinaculum - An Unusual Cause of Medial Ankle Pain

AIM OF THE STUDY

Ankle pain can present a clinical dilemma to the foot and ankle surgeons, with a multitude of entities to which the symptoms could potentially be attributed. Enthesopathy around the ankle joint could be due to overuse, injury, inflammation or infection. Calcific ligamentous enthesopathy around the ankle is a well-recognised condition with a spectrum of causes.

CASE DESCRIPTION

To our knowledge, a clinically symptomatic presentation of calcific enthesopathy specifically affecting the entheses of the superior extensor retinaculum has not been described in the literature. We report the first case of symptomatic calcific enthesopathy of the superior extensor retinaculum in a healthy young female, and highlight the role of radiological interventions in its diagnosis. The condition was managed successfully by ultrasound-guided barbotage.

CONCLUSIONS

Calcific enthesopathy of the attachment of the superior extensor retinaculum is a rare condition that should be considered in the differential diagnosis of patients with medial ankle pain.

A Novel Treatment of Painful Medial Collateral Ligament Calcification (Pellegrini-Stieda Syndrome): A Case Report

A 63-year-old healthy woman was diagnosed clinically and radiographically with Pellegrini-Stieda syndrome. She had failed to improve with 6 months of conservative management using oral anti-inflammatories and physiotherapy. Local corticosteroid injections were offered on 2 occasions, 4 months apart, and provided excellent but only temporary relief of symptoms. The patient agreed to undergo ultrasound-guided percutaneous lavage, followed by platelet-rich plasma infiltration of the Pellegrini-Stieda lesion instead of being referred for surgery. The patient was assessed clinically and radiographically at 12 weeks and 18 months postprocedure. At both appointments, the patient reported a significant reduction in pain and improvement in function as rated by the Lower Extremity Function Scale (improvement of 20 points at 12 weeks and an improvement of 16 points at 18 months postprocedure). Radiographically, the Pellegrini-Stieda lesion was no longer visible at either follow-up interval. In conclusion, ultrasound-guided percutaneous calcific lavage followed by autologous platelet-rich plasma infiltration may be an effective way to treat refractory cases of Pellegrini-Stieda syndrome.

The novel epiligament theory: differences in healing failure between the medial collateral and anterior cruciate ligaments

According to current literature, 90% of knee ligament injuries involve the medial collateral ligament or the anterior cruciate ligament. In contrast to the medial collateral ligament, which regenerates relatively well, the anterior cruciate ligament demonstrates compromised healing. In the past, there were numerous studies in animal models that examined the healing process of these ligaments, and different explanations were established. Although the healing of these ligaments has been largely investigated and different theories exist, unanswered questions persist.

Therefore, the aim of this article is 1) to review the different historical aspects of healing of the medial collateral ligament and present the theories for healing failure of the anterior cruciate ligament; 2) to examine the novel epiligament theory explaining the medial collateral ligament healing process and failure of anterior cruciate ligament healing; and 3) to discuss why the enveloping tissue microstructure of the aforementioned ligaments needs to be examined in future studies.

We believe that knowledge of the novel epiligament theory will lead to a better understanding of the normal healing process for implementing optimal treatments, as well as a more holistic explanation for anterior cruciate ligament healing failure.

[Calcification of the medial collateral ligament of the knee: Rehabilitative management with radial electro shock wave therapy plus iontophoresis of a rare entity. Clinical case and review]

The medial collateral ligament (MCL) of the knee is a commonly injured ligament structure. Calcification of the MCL is very infrequent, benign, related to metabolic disorders and is a consequence of the deposition of calcium hydroxyapatite in the periarticular region. The clinical, histological and radiological picture of calcific tendonitis is defined and the etiology is multifactorial. Treatment is initially conservative and if it fails, interventionist; surgery being the last therapeutic step. There are very few reports in the literature, with only 10 cases/case series published. It is important to differentiate it from the Pellegrini-Stieda sign and/or syndrome, where the traumatic history is essential to diagnose it. The clinical case is that of a 64-year-old woman in whom we present the treatment of calcification of the MCL using radial electro shock wave therapy plus iontophoresis, we report the effectiveness of the treatment in the management of pain and calcification, and we carry out a brief review on the subject.

Calcium hydroxyapatite deposition disease: Imaging features and presentations mimicking other pathologies

OBJECTIVE

Calcium hydroxyapatite depositional disease (HADD) is usually asymptomatic and self-limiting; however, when there is an associated inflammatory process or HADD occurs in an unusual location, it may mimic trauma, infection, or neoplasm. The purpose of this article is to review the imaging features of HADD and how to distinguish it from more worrisome entities that can have similar appearances.

CONCLUSION

An understanding of the presentations of HADD is important to allow early and confident diagnosis. In particular, familiarity with presentations that resemble more ominous pathologies is essential to avoid costly and time-consuming workup or intervention.

A comparative study of the epiligament of the medial collateral and the anterior cruciate ligament in the human knee. Immunohistochemical analysis of collagen type I and V and procollagen type III

BACKGROUND

Recent reports in rat models have shown that fibroblasts in the epiligament, an enveloping tissue of the ligament, are not static cells and play an important role during the early ligament healing of isolated grade III injury of the collateral ligaments of the knee. Fibroblasts produce collagen types I, III and V and infiltrate within the ligament body via the endoligament. In addition, similarities have been reported between the structure of the epiligament of the medial collateral ligament and anterior cruciate ligament of the knee in rat and in human. In line with the ascribed role of the epiligament tissue and the synthesis of these collagens and their role in ligament healing, the aim of this study was to determine their presence in the normal epiligament of the aforementioned ligaments in humans, to compare their differential expression and to present a novel hypothesis about the failure of healing of the anterior cruciate ligament in contrast to the medial collateral ligament.

MATERIALS AND METHODS

We used samples from the mid-substance of the medial collateral and the anterior cruciate ligament of the knee joint, acquired from 12 fresh knee joints. Routine histological analysis was performed through hematoxylin and eosin stain, Mallory's trichrome stain and Van Gieson's stain. The immunohistochemical analysis was conducted using monoclonal antibodies against collagen type I and V and procollagen type III. The number of cells in the epiligament, endoligament and the ligament tissue was assessed quantitatively through a computerized system for image analysis NIS-Elements Advanced Research and Statistica software.

RESULTS

Our observations revealed certain differences in the morphology of the epiligament, as well as variations in the expression of the investigated molecules. Expression of collagen type I was mostly low-positive (1+) in the epiligament and positive (2+) in the ligament tissue of both ligaments. Expression of procollagen type III was mostly positive (2+) in the epiligament and ligament tissue of the medial collateral ligament, low-positive (1+) in the epiligament and negative (0) in ligament tissue of the anterior cruciate ligament. Expression of collagen type V was predominantly low-positive (1+) in the epiligament and negative (0) in the ligament tissue of both ligaments. The immunoreactivity for all three molecules was always higher in the epiligament of the medial collateral ligament than that of the anterior cruciate ligament.

CONCLUSIONS

The results of our study illustrate for the first time that fibroblasts in the human epiligament are indeed responsible for the synthesis of the main types of collagen participating in the early ligament healing, thus corresponding to previous data of the medial collateral ligament healing in animal models. The differences between the epiligament of the investigated ligaments could add a novel explanation for the failed anterior cruciate ligament healing.

Medial collateral ligament calcification: a rare knee pain entity with literature review

Medial knee pain can originate from both osseous and non-osseous soft tissue structures including medial collateral ligament (MCL), creating a raft for patients' sufferings. Previously published works demonstrated MCL calcification as a rare medial knee pain entity. Alongside physical examination, radio-imaging techniques, namely conventional X-ray, CT/MRI scanning, etc. have been reported to be useful in recognizing MCL calcification. The present study demonstrates MCL calcification in a 60-year-old Asian-Bangladeshi woman, using high frequency diagnostic ultrasonogram and is the first reported study in the literature. To have available literature review, PubMed, Cochrane, Embase, and Scopus databases were used.