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Partially Ruptured Posterior Cruciate Ligament Causing Medial Tibiofemoral Joint Impingement
Case Report
Partially Ruptured Posterior Cruciate Ligament Causing Medial Tibiofemoral Joint Impingement Young-Mo Kim, M.D., Sung-Jae Kim, M.D., Kwang-Jin Rhee, M.D., June-Kyu Lee, M.D., Soon-Tae Kwon, M.D., and Jin-Man Kim, M.D.
Abstract: Impingement syndrome resulting from a partially torn posterior cruciate ligament (PCL) stump has not been reported in the English-language literature. We present 2 cases of impingement caused by the torn stump of a partially ruptured PCL. Both patients suffered from severe knee joint pain during knee flexion over 70° to 90° and medial joint-line tenderness after the injury. Magnetic resonance imaging (MRI) showed the partial rupture of the PCL, mainly in the posteromedial (PM) bundle. In both cases, arthroscopic examination revealed that the rupture of the PCL involved the femoral side of the PM bundle, and the torn stump of the PCL was entrapped in the medial tibiofemoral joint (TFJ). The torn stump was removed completely, and the symptoms improved significantly. Partial ruptures of the PCL occur frequently, and it is anticipated that many patients may suffer from pain arising from impingement of a partially torn PCL entrapped in the medial TFJ. Therefore, studies on this subject should continue. Key Words: Knee—Posterior cruciate ligament—Partially ruptured PCL—Impingement syndrome.
T
Case 1
From the Department of Orthopaedic Surgery (Y-M.K., K-J.R., J-K.L.), Diagnostic Radiology (S.T.K.), and Pathology (J-M.K.), Chungnam National University College of Medicine, Daejeon; and the Department of Orthopaedic Surgery, Yonsei University College of Medicine (S-J.K.), Seoul, Korea. Address correspondence and reprint requests to Young-Mo Kim, M.D., Department of Orthopaedic Surgery, Chungnam National University College of Medicine, 640 Daesa-dong, Jung-gu, Daejeon 301-721, Korea. E-mail: [email protected] © 2007 by the Arthroscopy Association of North America Cite this article as: Kim Y-M, Kim S-J, Rhee K-J, Lee J-K, Kwon S-T, Kim J-M. Partially ruptured posterior cruciate ligament causing medial tibiofemoral joint impingement. Arthroscopy 2007;23: 565.e1-565.e4 [doi:10.1016/j.arthro.2005.12.042]. 0749-8063/07/2305-5228$32.00/0 doi:10.1016/j.arthro.2005.12.042
A 52-year-old male patient was hospitalized for right knee joint pain after he slipped 3 months earlier. In the standing position, he had no pain. However, he was afraid of performing knee joint flexion over 90° because of pain while squatting. His history was nonspecific. On physical examination, the medial joint line was tender, particularly in the mid-medial area. The McMurray test was positive with pain and crepitus. Instability was absent. On simple radiographs, no specific findings were detected. On magnetic resonance imaging (MRI), a partially ruptured PCL was identified (Fig 1A, B). We performed arthroscopy and found that the torn stump of the partially ruptured PCL, which was attached to the tibia and part of the PM bundle, was located in the intercondylar notch and impinged into the medial TFJ (Fig 1C). Fraying of the adjacent tibial articular cartilage was identified. Specimens were obtained for biopsy, and the remnant of the torn stump of the PCL was removed completely (Fig 1D). The biopsy result showed dense connective tissue and synovial hypertrophy with diffuse fibrosis
he posterior cruciate ligament (PCL) is composed of the anterolateral (AL) and posteromedial (PM) bundles.1 Conservatively treated isolated PCL injury has a good functional outcome, with half the patients returning to the same sport at the same level, without increasing laxity over time.2 Therefore, it is recommended to treat a partially ruptured PCL nonoperatively. We experienced 2 cases of partially ruptured PCL that caused impingement in the medial tibiofemoral joint (TFJ), which required excision.
CASE REPORTS
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 5 (May), 2007: pp 565.e1-565.e4
565.e1
FIGURE 1. MRIs of a partially ruptured PCL in the right knee of a 52-year-old man. (A) Sagittal T2-weighted image and (B) coronal fat-suppressed T2-weighted image show partial rupture of the PCL with swelling and increased signal intensity, mainly in the PM bundle (arrow). Note the intervening low-signal-intensity granulation tissue (arrows) between the medial tibial condyle and posterolateral aspect of the medial femoral condyle. (C) Arthroscopic image showing the partially torn PCL entrapped in the medial TFJ. (D) The partially torn PCL stump, which was part of the PM bundle, was removed completely. (E) A tissue section shows synovial hypertrophy with diffuse fibrosis (H&E, original magnification ⫻100).
FIGURE 2. MRIs of a partially ruptured PCL in the left knee of a 62-year-old man. (A) Sagittal proton-density and (B) coronal fat-suppressed T2-weighted image show partial rupture of the PCL with swelling and increased signal intensity, mainly in the PM bundle (arrow). Note the intervening low-signal-intensity granulation tissue with heterogeneous signal intensity (arrows) between the medial tibial condyle and posterolateral aspect of the medial femoral condyle. (C) Arthroscopic image showing the partially torn PCL entrapped in the medial TFJ. (D) This was associated with chondral injury of the posterior portion of the medial femoral condyle. (E) A tissue section shows dense connective tissue with myxoid degeneration and disorganized fibrous tissue (H&E, magnification ⫻200).
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(Fig 1E). After surgery, passive range of motion exercise was performed immediately. The pain during knee joint motion gradually improved. One year after surgery, a normal range of motion can be performed by the patient, and his visual analog scale pain score has decreased from 90 to 10. Case 2 A 62-year-old man was hospitalized because of severe left knee pain on motion. He was diagnosed with a partial rupture of the PCL caused in a traffic accident while he was driving. He was treated conservatively for 9 months, but the symptoms did not improve. The pain was absent in extension. However, pain occurred during flexion and extension with weight bearing. In particular, the pain was severe during flexion over 70°, although the pain disappeared slowly while squatting. On physical examination, there was tenderness on the anteromedial joint line. No instability was detected. On simple radiography, mild degenerative change was observed. On MRI, a grade II-III rupture of the PCL and impingement into the tibiofemoral joint were observed (Fig 2A, B). During arthroscopy, we found that the torn stump of a partially ruptured PCL fiber, which was part of the PM bundle attached to the tibia, impinged into the medial TFJ (Fig 2C, D). Outerbridge grade II chondral injury on the posterior portion of the medial femoral condyle was identified (Fig 2D). The entrapped torn PCL stump was removed completely. Beginning the day after surgery, continuous passive motion exercise was initiated. The biopsy examination results showed dense connective tissue with myxoid degeneration and disorganized fibrous tissue (Fig 2E), and synovial hyperplasia. Four weeks after surgery, the pain had improved significantly during knee motion, particularly during flexion. Eight weeks after surgery, the patient was able to perform a normal range of knee motion. Ten months after surgery, his visual analog scale pain score had decreased from 80 to 20. DISCUSSION Cyclops syndrome, a kind of anterior cruciate ligament impingement syndrome, is well known,3 and notch impingement resulting from a deltoid-shaped
anterior cruciate ligament has been reported.4 However, a partially ruptured PCL entrapped in the medial TFJ causing severe pain during movement of the knee joint has not been reported. In our cases, the symptoms improved significantly after removing the torn stump of the partially ruptured PCL, which was attached to the tibia and entrapped in the medial TFJ. Both of our cases had similar features. First, the patients felt severe pain while flexing the knee over 70° to 90°, which increases posterior translation of the tibia greatly.5 Second, the partially torn PCL stump from the intercondylar notch was entrapped in the medial TFJ, resulting in severe pain. Both biopsy results showed the presence of dense connective tissue, reflecting a ligament structure with myxoid degeneration and disorganized fibrous tissue (Fig 2E). Moreover, in 1 of our patients, an Outerbridge grade II chondral injury was present on the posterior portion of the medial femoral condyle, which was in contact with the partially torn PCL stump (Fig 2D); in the other case, there was chondral fraying on the tibial plateau contacting the partially torn PCL stump. Third, the synovium surrounding the PCL became fibrotic. The biopsy results showed synovial hypertrophy with diffuse fibrosis (Fig 1E), reflecting chronic irritation. Partial ruptures of the PCL occur frequently, and it is anticipated that many patients may suffer from pain arising from impingement of a partially torn PCL entrapped in the medial TFJ. Therefore, study on this subject should continue. REFERENCES 1. Johnson DH, Fanelli GC, Miller MD. PCL 2002: Indications, double-bundle versus inlay technique and revision surgery. Arthroscopy 2002;18:40-52. 2. Shelbourne KD, Davis TJ, Patel DV. The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries. A prospective study. Am J Sports Med 1999;27: 276-283. 3. Veselko M, Rotter A, Tonin M. Cyclops syndrome occurring after partial rupture of the anterior cruciate ligament not treated by surgical reconstruction. Arthroscopy 2000;16:328-331. 4. Çalpur OU, Özcan M, Gürbüz H. Deltoid (triangular)-shaped anterior cruciate ligament that caused notch impingement. A report of two cases. Arthroscopy 2004;20:637-640. 5. Gollehon DL, Torzilli PA, Warren RF. The role of the posterolateral and cruciate ligaments in the stability of the human knee. A biomechanical study. J Bone Joint Surg Am 1987;69:233242.
Partially Ruptured Posterior Cruciate Ligament Causing Medial Tibiofemoral Joint Impingement Young-Mo Kim, M.D., Sung-Jae Kim, M.D., Kwang-Jin Rhee, M.D., June-Kyu Lee, M.D., Soon-Tae Kwon, M.D., and Jin-Man Kim, M.D.
Abstract: Impingement syndrome resulting from a partially torn posterior cruciate ligament (PCL) stump has not been reported in the English-language literature. We present 2 cases of impingement caused by the torn stump of a partially ruptured PCL. Both patients suffered from severe knee joint pain during knee flexion over 70° to 90° and medial joint-line tenderness after the injury. Magnetic resonance imaging (MRI) showed the partial rupture of the PCL, mainly in the posteromedial (PM) bundle. In both cases, arthroscopic examination revealed that the rupture of the PCL involved the femoral side of the PM bundle, and the torn stump of the PCL was entrapped in the medial tibiofemoral joint (TFJ). The torn stump was removed completely, and the symptoms improved significantly. Partial ruptures of the PCL occur frequently, and it is anticipated that many patients may suffer from pain arising from impingement of a partially torn PCL entrapped in the medial TFJ. Therefore, studies on this subject should continue. Key Words: Knee—Posterior cruciate ligament—Partially ruptured PCL—Impingement syndrome.
T
Case 1
From the Department of Orthopaedic Surgery (Y-M.K., K-J.R., J-K.L.), Diagnostic Radiology (S.T.K.), and Pathology (J-M.K.), Chungnam National University College of Medicine, Daejeon; and the Department of Orthopaedic Surgery, Yonsei University College of Medicine (S-J.K.), Seoul, Korea. Address correspondence and reprint requests to Young-Mo Kim, M.D., Department of Orthopaedic Surgery, Chungnam National University College of Medicine, 640 Daesa-dong, Jung-gu, Daejeon 301-721, Korea. E-mail: [email protected] © 2007 by the Arthroscopy Association of North America Cite this article as: Kim Y-M, Kim S-J, Rhee K-J, Lee J-K, Kwon S-T, Kim J-M. Partially ruptured posterior cruciate ligament causing medial tibiofemoral joint impingement. Arthroscopy 2007;23: 565.e1-565.e4 [doi:10.1016/j.arthro.2005.12.042]. 0749-8063/07/2305-5228$32.00/0 doi:10.1016/j.arthro.2005.12.042
A 52-year-old male patient was hospitalized for right knee joint pain after he slipped 3 months earlier. In the standing position, he had no pain. However, he was afraid of performing knee joint flexion over 90° because of pain while squatting. His history was nonspecific. On physical examination, the medial joint line was tender, particularly in the mid-medial area. The McMurray test was positive with pain and crepitus. Instability was absent. On simple radiographs, no specific findings were detected. On magnetic resonance imaging (MRI), a partially ruptured PCL was identified (Fig 1A, B). We performed arthroscopy and found that the torn stump of the partially ruptured PCL, which was attached to the tibia and part of the PM bundle, was located in the intercondylar notch and impinged into the medial TFJ (Fig 1C). Fraying of the adjacent tibial articular cartilage was identified. Specimens were obtained for biopsy, and the remnant of the torn stump of the PCL was removed completely (Fig 1D). The biopsy result showed dense connective tissue and synovial hypertrophy with diffuse fibrosis
he posterior cruciate ligament (PCL) is composed of the anterolateral (AL) and posteromedial (PM) bundles.1 Conservatively treated isolated PCL injury has a good functional outcome, with half the patients returning to the same sport at the same level, without increasing laxity over time.2 Therefore, it is recommended to treat a partially ruptured PCL nonoperatively. We experienced 2 cases of partially ruptured PCL that caused impingement in the medial tibiofemoral joint (TFJ), which required excision.
CASE REPORTS
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 5 (May), 2007: pp 565.e1-565.e4
565.e1
FIGURE 1. MRIs of a partially ruptured PCL in the right knee of a 52-year-old man. (A) Sagittal T2-weighted image and (B) coronal fat-suppressed T2-weighted image show partial rupture of the PCL with swelling and increased signal intensity, mainly in the PM bundle (arrow). Note the intervening low-signal-intensity granulation tissue (arrows) between the medial tibial condyle and posterolateral aspect of the medial femoral condyle. (C) Arthroscopic image showing the partially torn PCL entrapped in the medial TFJ. (D) The partially torn PCL stump, which was part of the PM bundle, was removed completely. (E) A tissue section shows synovial hypertrophy with diffuse fibrosis (H&E, original magnification ⫻100).
FIGURE 2. MRIs of a partially ruptured PCL in the left knee of a 62-year-old man. (A) Sagittal proton-density and (B) coronal fat-suppressed T2-weighted image show partial rupture of the PCL with swelling and increased signal intensity, mainly in the PM bundle (arrow). Note the intervening low-signal-intensity granulation tissue with heterogeneous signal intensity (arrows) between the medial tibial condyle and posterolateral aspect of the medial femoral condyle. (C) Arthroscopic image showing the partially torn PCL entrapped in the medial TFJ. (D) This was associated with chondral injury of the posterior portion of the medial femoral condyle. (E) A tissue section shows dense connective tissue with myxoid degeneration and disorganized fibrous tissue (H&E, magnification ⫻200).
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(Fig 1E). After surgery, passive range of motion exercise was performed immediately. The pain during knee joint motion gradually improved. One year after surgery, a normal range of motion can be performed by the patient, and his visual analog scale pain score has decreased from 90 to 10. Case 2 A 62-year-old man was hospitalized because of severe left knee pain on motion. He was diagnosed with a partial rupture of the PCL caused in a traffic accident while he was driving. He was treated conservatively for 9 months, but the symptoms did not improve. The pain was absent in extension. However, pain occurred during flexion and extension with weight bearing. In particular, the pain was severe during flexion over 70°, although the pain disappeared slowly while squatting. On physical examination, there was tenderness on the anteromedial joint line. No instability was detected. On simple radiography, mild degenerative change was observed. On MRI, a grade II-III rupture of the PCL and impingement into the tibiofemoral joint were observed (Fig 2A, B). During arthroscopy, we found that the torn stump of a partially ruptured PCL fiber, which was part of the PM bundle attached to the tibia, impinged into the medial TFJ (Fig 2C, D). Outerbridge grade II chondral injury on the posterior portion of the medial femoral condyle was identified (Fig 2D). The entrapped torn PCL stump was removed completely. Beginning the day after surgery, continuous passive motion exercise was initiated. The biopsy examination results showed dense connective tissue with myxoid degeneration and disorganized fibrous tissue (Fig 2E), and synovial hyperplasia. Four weeks after surgery, the pain had improved significantly during knee motion, particularly during flexion. Eight weeks after surgery, the patient was able to perform a normal range of knee motion. Ten months after surgery, his visual analog scale pain score had decreased from 80 to 20. DISCUSSION Cyclops syndrome, a kind of anterior cruciate ligament impingement syndrome, is well known,3 and notch impingement resulting from a deltoid-shaped
anterior cruciate ligament has been reported.4 However, a partially ruptured PCL entrapped in the medial TFJ causing severe pain during movement of the knee joint has not been reported. In our cases, the symptoms improved significantly after removing the torn stump of the partially ruptured PCL, which was attached to the tibia and entrapped in the medial TFJ. Both of our cases had similar features. First, the patients felt severe pain while flexing the knee over 70° to 90°, which increases posterior translation of the tibia greatly.5 Second, the partially torn PCL stump from the intercondylar notch was entrapped in the medial TFJ, resulting in severe pain. Both biopsy results showed the presence of dense connective tissue, reflecting a ligament structure with myxoid degeneration and disorganized fibrous tissue (Fig 2E). Moreover, in 1 of our patients, an Outerbridge grade II chondral injury was present on the posterior portion of the medial femoral condyle, which was in contact with the partially torn PCL stump (Fig 2D); in the other case, there was chondral fraying on the tibial plateau contacting the partially torn PCL stump. Third, the synovium surrounding the PCL became fibrotic. The biopsy results showed synovial hypertrophy with diffuse fibrosis (Fig 1E), reflecting chronic irritation. Partial ruptures of the PCL occur frequently, and it is anticipated that many patients may suffer from pain arising from impingement of a partially torn PCL entrapped in the medial TFJ. Therefore, study on this subject should continue. REFERENCES 1. Johnson DH, Fanelli GC, Miller MD. PCL 2002: Indications, double-bundle versus inlay technique and revision surgery. Arthroscopy 2002;18:40-52. 2. Shelbourne KD, Davis TJ, Patel DV. The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries. A prospective study. Am J Sports Med 1999;27: 276-283. 3. Veselko M, Rotter A, Tonin M. Cyclops syndrome occurring after partial rupture of the anterior cruciate ligament not treated by surgical reconstruction. Arthroscopy 2000;16:328-331. 4. Çalpur OU, Özcan M, Gürbüz H. Deltoid (triangular)-shaped anterior cruciate ligament that caused notch impingement. A report of two cases. Arthroscopy 2004;20:637-640. 5. Gollehon DL, Torzilli PA, Warren RF. The role of the posterolateral and cruciate ligaments in the stability of the human knee. A biomechanical study. J Bone Joint Surg Am 1987;69:233242.