Wk 3, Case 4 - Review

Patient History
59-year-old man with severe pain, discoloration, swelling and weakness of the left knee after sustaining an injury at work.

Findings

Menisci:

Medial Meniscus: Chronic complex tear with radial and horizontal components, extending from the posterior root to the anterior body horn junction, measuring approximately 4 cm in length. Associated meniscal body failure with slight partial extrusion.

Lateral Meniscus: Chronic complex tear with radial and horizontal cleavage components involving the posterior horn and body, measuring approximately 3 cm in length. Chronic fraying of the inner edge of the meniscal body. Associated meniscal failure with slight partial extrusion of the body.

Ligaments:

Anterior Cruciate Ligament: Thickened ACL with chronic myxoid degeneration and florid notch synovitis.

Posterior Cruciate Ligament: Expanded mid to proximal PCL with intrasubstance hyperintensity, consistent with chronic tear and hypertrophic myxoid change. Posterior tibial translation, consistent with PCL deficiency.

Medial Collateral Ligament: Intact. Low-grade inflammation and periligamentous edema adjacent to the proximal portion of the tibial collateral ligament, consistent with a low-grade sprain and reactive TCL bursitis.

Lateral Collateral Ligament: Intact.

Posterolateral Corner Structures: Intact.

Posteromedial Corner Structures: Intact.

Extensor Mechanism:

Patellar Tendon: Acute complete full-thickness rupture of the mid patellar tendon, with a defect measuring 2.5-3.0 cm in length. Prolapse/retraction of the proximal and distal tendon fragments observed. Associated proximal retraction of the patella (acquired acute patella alta with an Insall-Salvati ratio of approximately 2.0). Extensive surrounding edema and marked prepatellar bursal thickening with a small effusion measuring 6.1 cm length x 0.5 cm depth.

Distal Quadriceps Tendon: Intact.

Medial Patellofemoral Ligament: Suspect high-grade injury.

Medial and Lateral Patellar Retinacula: Markedly thickened, lax and edematous bilaterally.

Hoffa’s Fat Pad: Edematous/contused.

Articulations:

Patellofemoral Compartment: Diffuse high-grade chronic patellofemoral chondromalacia, particularly involving the central femoral component. Prominent patellofemoral osteophytosis.

Medial Compartment: Diffuse high-grade medial tibiofemoral chondromalacia with moderate chronic subchondral stress reaction involving the medial aspect of the medial compartment. Prominent marginal osteophytosis.

Lateral Compartment: Diffuse intermediate to high-grade chondromalacia involving the posterior and central weight-bearing surfaces of the lateral femoral condyle. No penetrating osteochondral erosion. Mild patellofemoral osteophytosis.

General:

Bones: Subchondral insufficiency related osteoedema involving the medial aspect of the medial compartment as described above. No micro or macro trabecular fracture. No suspicious os

Effusion: Small knee joint effusion.

Baker’s Cyst: None.

Loose Bodies: None.

Soft tissue and neurovascular structures: Unremarkable.

Conclusion

1.Complete full-thickness mid patellar tendon rupture with retraction and prolapse of the proximal and distal tendon fragments. Acute acquired patella alta (Insall-Salvati ratio 2.0), due to proximal retraction of the patella. Marked adjacent soft tissue edema and reactive prepatellar bursitis/seroma.

2.Medial compartment failure with chronic complex medial meniscus tear involving the posterior horn to body, associated high-grade medial compartment chondromalacia and subchondral insufficiency related osteoedema. Kellgren-Lawrence 3 osteoarthropathy.

3.Early lateral compartment failure with chronic complex tear involving the posterior horn and body lateral meniscus with adjacent intermediate to high-grade chondromalacia involving the weight-bearing surface of the lateral femoral condyle. Kellgren-Lawrence 1-2 osteoarthropathy.

4.Low-grade injury or inflammation involving the proximal portion of the medial collateral ligament complex.

5.Incidental posterior cruciate ligament hypertrophic tear with florid notch synovitis and moderate patellofemoral osteoarthropathy. Resultant PCL deficient “tibial sag sign.”