Wk 4, Case 1 - Review

Patient History
48-year-old male complaining of anterior knee pain, weakness and swelling for 3 weeks. Evaluate for meniscus tear or loose body.

Findings
Menisci:

Medial Meniscus: Intact.

Lateral Meniscus: Intact.

Ligaments:

Anterior Cruciate Ligament: ACL intact. Prominent notch synovitis noted.

Posterior Cruciate Ligament: Intact.

Medial Collateral Ligament: Intact.

Lateral Collateral Ligament: Intact.

Posterolateral Corner Structures:Mild capsulitis throughout the popliteus hiatus. Otherwise unremarkable.

Posteromedial Corner Structures: Intact.

Extensor Mechanism:

Patellar Tendon: Complex multiloculated cystic lesion insinuating throughout the the majority of the medial aspect of the patellar tendon, measuring approximately 4.0 cm craniocaudal, 2.0 cm AP and 2.3 cm transversely. Lesion expands the patellar tendon and extends superiorly along the prepatellar plate into the distal quadriceps tendon. The lesion has areas of intermediate and high signal on T2-weighted imaging and contains areas that are cystic, nodular or papillary in appearance, suggesting extensive synovitis. Deep infrapatellar bursal thickening with a small effusion, consistent with bursitis.

Distal Quadriceps Tendon: Synovitic complex multiloculated process described above extends into the superficial distal insertional quadriceps tendon. Remainder of the quadriceps tendon is intact and unremarkable in appearance. Mild enthesophyte formation at the upper pole of the patella.

Medial Patellofemoral Ligament: Intact.

Medial and Lateral Patellar Retinacula: Intact.

Hoffa’s Fat Pad: Multiloculated synovitis process described above protrudes into the superficial aspect of Hoffa’s fat pad superiorly.

Articulations:

Patellofemoral Compartment: No patellofemoral dysplasia. Grade 2-3 chondromalacia involving the patellar ridge and medial facet as evidenced by chondral fissuring. Grade 2-3 chondromalacia involving the trochlear sulcus. No penetrating high-grade chondromalacia.

Medial Compartment: Grade 2-3 chondromalacia involving the lateral aspect of the medial femoral condyle. Smooth intermediate to high-grade chondromalacia involving the medial tibial plateau. No penetrating high-grade osteochondral erosion.

Lateral Compartment: Grade 2-3 chondromalacia involving the mid weight-bearing surface of the lateral femoral condyle and lateral tibial plateau. No penetrating high-grade osteochondral erosion.

General:

Bones: Normal.

Effusion: Moderate to large sized suprapatellar effusion with florid diffuse reactive synovitis.

Baker’s Cyst: Moderate-sized Baker cyst without evidence for dehiscence or rupture. Baker cyst extends medially. No extension into the popliteal fossa or involvement of the popliteal neurovascular bundle.

Loose Bodies: None.

Soft tissue and Neurovascular: Diffuse prepatellar and superficial infrapatellar bursal edema and thickening, consistent with bursitis. No bursal collection.

Conclusion
1.Multiloculated complex cystic lesion insinuating into and expanding the patellar tendon, extending along the prepatellar plate and into the distal superficial insertional quadriceps tendon. Components of florid multifocal synovitis are noted within the lesion. The constellation of findings favor gout. Other less likely differential diagnoses include CPPD, amyloid or focal nodular synovitis.

2.Grade 2-3 patellofemoral, lateral compartment and medial compartment chondromalacia as described above.

3.No meniscus tear.