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CT-guided aspiration of an anterior cruciate ligament ganglion cyst with mucoid degeneration
European Journal of Radiology Extra 69 (2009) e105–e107
Contents lists available at ScienceDirect
European Journal of Radiology Extra journal homepage: intl.elsevierhealth.com/journals/ejrex
CT-guided aspiration of an anterior cruciate ligament ganglion cyst with mucoid degeneration A case report A. Askri a,∗ , R. Hajri b , K. Benabdelghani b , S. Chekili b , M. Mestiri c , L. Zakraoui b , L. Hendaoui a a b c
Department of Radiology, Mongi Slim Hospital, Sidi Daoud, 2046 la Marsa, Tunisia Department of Rheumatology, Mongi Slim Hospital, Sidi Daoud, Tunisia Department of Orthopaedic Surgery, Institut M T Kassab d’orthopédie, 2010 Ksar Said, Tunisia
a r t i c l e
i n f o
Article history: Received 1 August 2008 Accepted 1 September 2008
a b s t r a c t We report a symptomatic case of mucoid degeneration of the anterior cruciate ligament with a ganglion cyst that was treated successfully with percutaneous CT-guided aspiration. © 2008 Elsevier Ireland Ltd. All rights reserved.
Keywords: Anterior cruciate ligament Knee Ganglion cyst Percutaneous treatment
1. Introduction Meniscal tears and cartilage lesions of the knee are common causes of knee pain without trauma. Mucoid degeneration and ganglion cysts of the anterior cruciate ligament (ACL) are rare. Traditional treatment is surgical and arthroscopic debridement effectively relieves symptoms. We report a case of a patient with intraligamentous mucoid degeneration associated with a ganglion cyst arising from the ACL. We describe imaging features and we also discuss the role of percutaneous treatment in the management of these rare entities.
2. Case presentation A 37-year-old woman who had no prior significant trauma presented with a 7 months history of pain of insidious onset in the back of the left knee and flexion difficulty. Physical examination revealed left-sided posterior knee pain exacerbated by end range flexion. The range of motion of the knee was limited from 0◦ to 90◦ with terminal flexion pain. There was no swelling and maneuvers for instability were all negative.
∗ Corresponding author. Tel.: +216 98631562; fax: +216 71764477. E-mail addresses: [email protected], [email protected] (A. Askri). 1571-4675/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2008.09.001
A plain X-ray of the knee showed no abnormality. Poplital soft-tissue ultrasonography of the left knee showed a well circumscribed ovoid hypoechoetic mass in the intercondylar fossa (Fig. 1). Magnetic resonance imaging (MRI) demonstrated an ACL that appeared bulky, occupying almost the entire intercondylar notch and its fibres were intact but displaced by material containing high signal on T2-weighted sequences. It revealed also a well demarcated and multiloculated cystic mass extensively occupying the intercondylar fossa, adjacent to the femoral attachment of the ACL. It measured 3 × 2 cm with intermediate intensity on T1-weighted sequences and high inhomogeneous intensity on T2-weighted and fat-suppressed sequences (Fig. 2). Enhanced T1weighted sequences showed enhancement of walls and septa of the cystic mass. There were also areas of focally high signal in relation to its femoral attachment. No meniscal pathology was identified. These findings were suggestive of mucoid degeneration of the ACL with a ganglion cyst in the intercondylar fossa. We performed CT-guided fine needle aspiration of the cyst. After sterile preparation, draping, and local anesthesia with 1% lidocaine, a 10 cm-long, 18 G needle was advanced using an angled approach with a medial to lateral axis, avoiding midline popliteal vessels. Cyst puncture induced excruciating pain that reproduced presenting symptomatology. It yielded 4 ml of jelly-like, yellow viscous fluid (Fig. 3). Next, intralesional corticosteroid was injected. Percutaneous treatment resulted in pain relief within a week and improved the range of motion without instability. Symptoms recurred at 3
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A. Askri et al. / European Journal of Radiology Extra 69 (2009) e105–e107
Fig. 1. Transverse sonogram of the intercondylar region of the posterior distal femur showing a well circumscribed ovoid hypoechoetic mass in the intercondylar fossa.
months necessitating a repeat CT-guided procedure. At a 14-month follow-up after the second percutaneous treatment the patients was symptom free. 3. Discussion Mucoid degeneration and ganglion cyst of the ACL are rare causes of knee pain. The etiology of both of them is unknown. They affect active middle-aged people without a single significant traumatic episode [1,2]. Patients may be asymptomatic or can cause pain and decreased range of movement in the knee. Ganglion cysts have been described close to joints or tendinous sheaths, frequently found in the wrist. Intra-articular ganglia of the knee are rare, and most of them are located in the anterior cruciate ligament [3,4]. They are filled with a clear mucinous fluid. Most reported cases are asymptomatic and are found incidentally. The incidence rate of intra-articular ganglion cysts have reported prevalence in the range from 0.29% to 0.44% on knee MRI [5,6] and 0.43% to 1.1% on knee arthroscopy [2,7]. Unlike ganglion cysts of the ACL, mucoid degeneration is not a well-known entity. A limited number of cases of mucoid degeneration have been described in the literature [8–12]. It has been recently suggested that mucoid degeneration incidence is in fact very much higher than previously thought, and that it is probably underdiagnosed or misdiagnosed as partial ruptures of the ACL or as cystic ganglia [13]. Anterior cruciate ligament ganglia and mucoid degeneration are theorized to be related and their coexistence has been reported [1]. Bergin et al. gave some evidence to suggest that these two entities may share a similar pathogenesis and may represent different manifestations of a degenerative process [1]. With joint and tissue motion, the mucin substance dissects the ligament fibers and may be found at the ligament attachments or in the intercondylar notch of the knee [14].
Fig. 2. MRI of the knee (A) sagittal T2-weighted image showing increased intraligamentous signal with several linear low-signal-intensity fibers and multiloculated cyst adjacent to the femoral attachment of the ACL. (B) Sagittal contrast enhanced T1-weighted image shows a bulky ACL with enhancement of walls and septa of the cystic mass.
MRI is the most useful examination for differentiating between mucoid degeneration of the ACL and intraligamentous ganglion as well as other lesions in the knee joint [1]. The characteristic features of intraligamentous ganglion of the ACL on MRI include sharply demarcated, homogeneous, hyperintense signal intensity on T2weighted and proton-weighted images [1]. Imaging criteria for mucoid degeneration include thickened and ill-defined ACL fibers of increased intraligamentous signal intensity on T2-weighted and proton-weighted images. In contrast to intraligamentous ganglion of the ACL, there are linear, low-signal-intensity fibers in the substance of the ACL and the demarcation of the ligament is not clear [1,11]. Mucoid degeneration of the ACL might be confused with ganglia or with ligamentous tear [1]. Erosion of cortical bone and intraosseous cyst formation are commonly associated with mucoid degeneration of the ACL and intraligamentous ganglia suggesting that these two entities may share a similar pathogenesis which may be a degenerative process [1]. Therapeutic management of these lesions seems to be different. Arthroscopic debridement is the treatment of choice for mucoid
A. Askri et al. / European Journal of Radiology Extra 69 (2009) e105–e107
e107
Conflict on interest statement I certify that there is no actual or potential conflict of interest in relation to this article. References
Fig. 3. Axial computed tomography shows needle placement from medial to lateral oblique approach, avoiding midline popliteal vessels. Note erosion in the inner aspect of the lateral femoral condyle.
degeneration [8–12]. When ganglion cysts of the ACL become symptomatic, they can be treated successfully with percutaneous aspiration and infiltration [15–19]. Arthroscopic resection should be reserved for failed percutaneous approach because it can results in a thinned ACL, which could compromise joint stability [4,20]. Most previously reported cases of minimally invasive percutaneous needle aspiration of intraligamentous ganglion cysts were under CT guiadnce [15–17]. The use of ultrasound guidance has been also previously described in the treatment of cruciate ligament ganglion cysts [18,19]. The significant pain relief and improve of the range of movement after percutaneous aspiration could attributed to the decreased volume and tension within the ligament. The risk of failure after percutaneous approach is even higher when the cyst is partitioned [19]. 4. Conclusion Mucoid degeneration and ganglion cyst of the ACL are rare causes of knee pain. Percutaneous aspiration of cruciate ligament ganglion cysts has both diagnostic and therapeutic value. It is a reasonable therapeutic option which is technically successful, associated with low complication rates and short hospitalization period allowing an immediate return to activities. Although sample numbers are limited, percutaneous treatment of ganglion cysts could possibly be considered as an alternative to arthroscopic decompression which should be reserved for failed cases.
[1] Bergin D, Morrison WB, Carrino JA, Nallamshetty SN, Bartolozzi AR. Anterior cruciate ligament ganglia and mucoid degeneration: coexistence and clinical correlation. AJR Am J Roentgenol 2004;182(5):1283–7. [2] Parish EN, Dixon P, Cross MJ. Ganglion cysts of the anterior cruciate ligament: a series of 15 cases. Arthroscopy 2005;21(4):445–7. [3] Andrikoula SI, Vasiliadis HS, Tokis AV, Kosta P, Batistatou A, Georgoulis AD. Intra-articular ganglia of the knee joint associated with the anterior cruciate ligament: a report of 4 cases in 3 patients. Arthroscopy 2007;23(July (7)):1–6, 800. Epub 2006 November 27. [4] Rolf C, Watson TP. Case report: intra-tendinous ganglion of the anterior cruciate ligament in a young footballer. J Orthop Surg 2006;2(November (1)): 11. [5] Huang GS, Lee CH, Chan WP, et al. Ganglion cysts of the cruciate ligaments: MR findings with clinical correlation. Acta Radiologica 2002;43:419–24. [6] Do-Dai DD, Youngberg RA, Lanchbury FD, Pitcher JD, Garver TH. Intraligamentous ganglion cysts of the anterior cruciate ligament: MR findings with clinical and arthroscopic correlations. J Comput Assist Tomogr 1996;20: 80–4. [7] Brown MF, Dandy DJ. Intra-articular ganglia in the knee. Arthroscopy 1990;6:322–3. [8] Kumar A, Bickerstaff DR, Grimwood JS, Suvarna SK. Mucoid cystic degeneration of the cruciate ligament. J Bone Joint Surg 1998;81-B:304–5. [9] Fealy S, Kenter K, Dines JS, Warren RF. Case report. Mucoid degeneration of the anterior cruciate ligament. Arthroscopy 2001;17:E37. [10] Narvekar A, Gajjar S. Mucoid degeneration of the anterior cruciate ligament. Arthroscopy 2004;20:141–6. [11] Nishimori M, Sumen Y, Sakaridani K. Mucoid degeneration of the anterior cruciate ligament—a report of two cases. Magn Reson Imaging 2004;22: 1325–8. [12] McIntyre J, Moelleken S, Tirman P. Mucoid degeneration of the anterior cruciate ligament mistaken for ligamentous tears. Skeletal Radiol 2001;30:312–5. [13] Fernandes JL, Viana SL, Mendonc¸a JL, et al. Mucoid degeneration of the anterior cruciate ligament: magnetic resonance imaging findings of an underdiagnosed entity. Acta Radiol 2008;49(Feb (1)):75–9. [14] Bui-Mansfield LT, Youngberg RA. Intra-articular ganglia of the knee: prevalence, presentation, etiology, and management. AJR Am J Roentgenol 1997;168: 123–7. [15] Antonacci VP, Foster T, Fenlon H, Harper K, Eustace S. Technical report: CTguided aspiration of anterior cruciate ligament ganglion cysts. Clin Radiol 1998;53(10):771–3. [16] Nokes SR, Koonce TW, Montanez J. Ganglion cysts of the cruciate ligaments of the knee: recognition on MR images and CT-guided aspiration. AJR Am J Roentgenol 1994;162(6):1503. [17] Campagnolo DI, Davis BA, Blacksin MF. Computed tomography–guided aspiration of a ganglion cyst of the anterior cruciate ligament: a case report. Arch Phys Med Rehabil 1996;77(7):732–3. [18] DeFriend DE, Schranz PJ, Silver DA. Ultrasound-guided aspiration of posterior cruciate ligament ganglion cysts. Skeletal Radiol 2001;30(7):411–4. [19] Drain O, Vialle R, Coudert X. Synovial cyst of the intercondylar fossa of the knee: three symptomatic cases and a review of the literature. Rev Chir Orthop Reparatrice Appar Mot 2002;88(Apr (2)):182–7. [20] Kakutani K, Yoshiya S, Matsui N, Yamamoto T, Kurosaka M. An intraligamentous ganglion cyst of the anterior cruciate ligament after a traumatic event. Arthroscopy 2003;19(November (9)):1019–22.
Contents lists available at ScienceDirect
European Journal of Radiology Extra journal homepage: intl.elsevierhealth.com/journals/ejrex
CT-guided aspiration of an anterior cruciate ligament ganglion cyst with mucoid degeneration A case report A. Askri a,∗ , R. Hajri b , K. Benabdelghani b , S. Chekili b , M. Mestiri c , L. Zakraoui b , L. Hendaoui a a b c
Department of Radiology, Mongi Slim Hospital, Sidi Daoud, 2046 la Marsa, Tunisia Department of Rheumatology, Mongi Slim Hospital, Sidi Daoud, Tunisia Department of Orthopaedic Surgery, Institut M T Kassab d’orthopédie, 2010 Ksar Said, Tunisia
a r t i c l e
i n f o
Article history: Received 1 August 2008 Accepted 1 September 2008
a b s t r a c t We report a symptomatic case of mucoid degeneration of the anterior cruciate ligament with a ganglion cyst that was treated successfully with percutaneous CT-guided aspiration. © 2008 Elsevier Ireland Ltd. All rights reserved.
Keywords: Anterior cruciate ligament Knee Ganglion cyst Percutaneous treatment
1. Introduction Meniscal tears and cartilage lesions of the knee are common causes of knee pain without trauma. Mucoid degeneration and ganglion cysts of the anterior cruciate ligament (ACL) are rare. Traditional treatment is surgical and arthroscopic debridement effectively relieves symptoms. We report a case of a patient with intraligamentous mucoid degeneration associated with a ganglion cyst arising from the ACL. We describe imaging features and we also discuss the role of percutaneous treatment in the management of these rare entities.
2. Case presentation A 37-year-old woman who had no prior significant trauma presented with a 7 months history of pain of insidious onset in the back of the left knee and flexion difficulty. Physical examination revealed left-sided posterior knee pain exacerbated by end range flexion. The range of motion of the knee was limited from 0◦ to 90◦ with terminal flexion pain. There was no swelling and maneuvers for instability were all negative.
∗ Corresponding author. Tel.: +216 98631562; fax: +216 71764477. E-mail addresses: [email protected], [email protected] (A. Askri). 1571-4675/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2008.09.001
A plain X-ray of the knee showed no abnormality. Poplital soft-tissue ultrasonography of the left knee showed a well circumscribed ovoid hypoechoetic mass in the intercondylar fossa (Fig. 1). Magnetic resonance imaging (MRI) demonstrated an ACL that appeared bulky, occupying almost the entire intercondylar notch and its fibres were intact but displaced by material containing high signal on T2-weighted sequences. It revealed also a well demarcated and multiloculated cystic mass extensively occupying the intercondylar fossa, adjacent to the femoral attachment of the ACL. It measured 3 × 2 cm with intermediate intensity on T1-weighted sequences and high inhomogeneous intensity on T2-weighted and fat-suppressed sequences (Fig. 2). Enhanced T1weighted sequences showed enhancement of walls and septa of the cystic mass. There were also areas of focally high signal in relation to its femoral attachment. No meniscal pathology was identified. These findings were suggestive of mucoid degeneration of the ACL with a ganglion cyst in the intercondylar fossa. We performed CT-guided fine needle aspiration of the cyst. After sterile preparation, draping, and local anesthesia with 1% lidocaine, a 10 cm-long, 18 G needle was advanced using an angled approach with a medial to lateral axis, avoiding midline popliteal vessels. Cyst puncture induced excruciating pain that reproduced presenting symptomatology. It yielded 4 ml of jelly-like, yellow viscous fluid (Fig. 3). Next, intralesional corticosteroid was injected. Percutaneous treatment resulted in pain relief within a week and improved the range of motion without instability. Symptoms recurred at 3
e106
A. Askri et al. / European Journal of Radiology Extra 69 (2009) e105–e107
Fig. 1. Transverse sonogram of the intercondylar region of the posterior distal femur showing a well circumscribed ovoid hypoechoetic mass in the intercondylar fossa.
months necessitating a repeat CT-guided procedure. At a 14-month follow-up after the second percutaneous treatment the patients was symptom free. 3. Discussion Mucoid degeneration and ganglion cyst of the ACL are rare causes of knee pain. The etiology of both of them is unknown. They affect active middle-aged people without a single significant traumatic episode [1,2]. Patients may be asymptomatic or can cause pain and decreased range of movement in the knee. Ganglion cysts have been described close to joints or tendinous sheaths, frequently found in the wrist. Intra-articular ganglia of the knee are rare, and most of them are located in the anterior cruciate ligament [3,4]. They are filled with a clear mucinous fluid. Most reported cases are asymptomatic and are found incidentally. The incidence rate of intra-articular ganglion cysts have reported prevalence in the range from 0.29% to 0.44% on knee MRI [5,6] and 0.43% to 1.1% on knee arthroscopy [2,7]. Unlike ganglion cysts of the ACL, mucoid degeneration is not a well-known entity. A limited number of cases of mucoid degeneration have been described in the literature [8–12]. It has been recently suggested that mucoid degeneration incidence is in fact very much higher than previously thought, and that it is probably underdiagnosed or misdiagnosed as partial ruptures of the ACL or as cystic ganglia [13]. Anterior cruciate ligament ganglia and mucoid degeneration are theorized to be related and their coexistence has been reported [1]. Bergin et al. gave some evidence to suggest that these two entities may share a similar pathogenesis and may represent different manifestations of a degenerative process [1]. With joint and tissue motion, the mucin substance dissects the ligament fibers and may be found at the ligament attachments or in the intercondylar notch of the knee [14].
Fig. 2. MRI of the knee (A) sagittal T2-weighted image showing increased intraligamentous signal with several linear low-signal-intensity fibers and multiloculated cyst adjacent to the femoral attachment of the ACL. (B) Sagittal contrast enhanced T1-weighted image shows a bulky ACL with enhancement of walls and septa of the cystic mass.
MRI is the most useful examination for differentiating between mucoid degeneration of the ACL and intraligamentous ganglion as well as other lesions in the knee joint [1]. The characteristic features of intraligamentous ganglion of the ACL on MRI include sharply demarcated, homogeneous, hyperintense signal intensity on T2weighted and proton-weighted images [1]. Imaging criteria for mucoid degeneration include thickened and ill-defined ACL fibers of increased intraligamentous signal intensity on T2-weighted and proton-weighted images. In contrast to intraligamentous ganglion of the ACL, there are linear, low-signal-intensity fibers in the substance of the ACL and the demarcation of the ligament is not clear [1,11]. Mucoid degeneration of the ACL might be confused with ganglia or with ligamentous tear [1]. Erosion of cortical bone and intraosseous cyst formation are commonly associated with mucoid degeneration of the ACL and intraligamentous ganglia suggesting that these two entities may share a similar pathogenesis which may be a degenerative process [1]. Therapeutic management of these lesions seems to be different. Arthroscopic debridement is the treatment of choice for mucoid
A. Askri et al. / European Journal of Radiology Extra 69 (2009) e105–e107
e107
Conflict on interest statement I certify that there is no actual or potential conflict of interest in relation to this article. References
Fig. 3. Axial computed tomography shows needle placement from medial to lateral oblique approach, avoiding midline popliteal vessels. Note erosion in the inner aspect of the lateral femoral condyle.
degeneration [8–12]. When ganglion cysts of the ACL become symptomatic, they can be treated successfully with percutaneous aspiration and infiltration [15–19]. Arthroscopic resection should be reserved for failed percutaneous approach because it can results in a thinned ACL, which could compromise joint stability [4,20]. Most previously reported cases of minimally invasive percutaneous needle aspiration of intraligamentous ganglion cysts were under CT guiadnce [15–17]. The use of ultrasound guidance has been also previously described in the treatment of cruciate ligament ganglion cysts [18,19]. The significant pain relief and improve of the range of movement after percutaneous aspiration could attributed to the decreased volume and tension within the ligament. The risk of failure after percutaneous approach is even higher when the cyst is partitioned [19]. 4. Conclusion Mucoid degeneration and ganglion cyst of the ACL are rare causes of knee pain. Percutaneous aspiration of cruciate ligament ganglion cysts has both diagnostic and therapeutic value. It is a reasonable therapeutic option which is technically successful, associated with low complication rates and short hospitalization period allowing an immediate return to activities. Although sample numbers are limited, percutaneous treatment of ganglion cysts could possibly be considered as an alternative to arthroscopic decompression which should be reserved for failed cases.
[1] Bergin D, Morrison WB, Carrino JA, Nallamshetty SN, Bartolozzi AR. Anterior cruciate ligament ganglia and mucoid degeneration: coexistence and clinical correlation. AJR Am J Roentgenol 2004;182(5):1283–7. [2] Parish EN, Dixon P, Cross MJ. Ganglion cysts of the anterior cruciate ligament: a series of 15 cases. Arthroscopy 2005;21(4):445–7. [3] Andrikoula SI, Vasiliadis HS, Tokis AV, Kosta P, Batistatou A, Georgoulis AD. Intra-articular ganglia of the knee joint associated with the anterior cruciate ligament: a report of 4 cases in 3 patients. Arthroscopy 2007;23(July (7)):1–6, 800. Epub 2006 November 27. [4] Rolf C, Watson TP. Case report: intra-tendinous ganglion of the anterior cruciate ligament in a young footballer. J Orthop Surg 2006;2(November (1)): 11. [5] Huang GS, Lee CH, Chan WP, et al. Ganglion cysts of the cruciate ligaments: MR findings with clinical correlation. Acta Radiologica 2002;43:419–24. [6] Do-Dai DD, Youngberg RA, Lanchbury FD, Pitcher JD, Garver TH. Intraligamentous ganglion cysts of the anterior cruciate ligament: MR findings with clinical and arthroscopic correlations. J Comput Assist Tomogr 1996;20: 80–4. [7] Brown MF, Dandy DJ. Intra-articular ganglia in the knee. Arthroscopy 1990;6:322–3. [8] Kumar A, Bickerstaff DR, Grimwood JS, Suvarna SK. Mucoid cystic degeneration of the cruciate ligament. J Bone Joint Surg 1998;81-B:304–5. [9] Fealy S, Kenter K, Dines JS, Warren RF. Case report. Mucoid degeneration of the anterior cruciate ligament. Arthroscopy 2001;17:E37. [10] Narvekar A, Gajjar S. Mucoid degeneration of the anterior cruciate ligament. Arthroscopy 2004;20:141–6. [11] Nishimori M, Sumen Y, Sakaridani K. Mucoid degeneration of the anterior cruciate ligament—a report of two cases. Magn Reson Imaging 2004;22: 1325–8. [12] McIntyre J, Moelleken S, Tirman P. Mucoid degeneration of the anterior cruciate ligament mistaken for ligamentous tears. Skeletal Radiol 2001;30:312–5. [13] Fernandes JL, Viana SL, Mendonc¸a JL, et al. Mucoid degeneration of the anterior cruciate ligament: magnetic resonance imaging findings of an underdiagnosed entity. Acta Radiol 2008;49(Feb (1)):75–9. [14] Bui-Mansfield LT, Youngberg RA. Intra-articular ganglia of the knee: prevalence, presentation, etiology, and management. AJR Am J Roentgenol 1997;168: 123–7. [15] Antonacci VP, Foster T, Fenlon H, Harper K, Eustace S. Technical report: CTguided aspiration of anterior cruciate ligament ganglion cysts. Clin Radiol 1998;53(10):771–3. [16] Nokes SR, Koonce TW, Montanez J. Ganglion cysts of the cruciate ligaments of the knee: recognition on MR images and CT-guided aspiration. AJR Am J Roentgenol 1994;162(6):1503. [17] Campagnolo DI, Davis BA, Blacksin MF. Computed tomography–guided aspiration of a ganglion cyst of the anterior cruciate ligament: a case report. Arch Phys Med Rehabil 1996;77(7):732–3. [18] DeFriend DE, Schranz PJ, Silver DA. Ultrasound-guided aspiration of posterior cruciate ligament ganglion cysts. Skeletal Radiol 2001;30(7):411–4. [19] Drain O, Vialle R, Coudert X. Synovial cyst of the intercondylar fossa of the knee: three symptomatic cases and a review of the literature. Rev Chir Orthop Reparatrice Appar Mot 2002;88(Apr (2)):182–7. [20] Kakutani K, Yoshiya S, Matsui N, Yamamoto T, Kurosaka M. An intraligamentous ganglion cyst of the anterior cruciate ligament after a traumatic event. Arthroscopy 2003;19(November (9)):1019–22.