Ganglion cyst of the anterior cruciate ligament: a case report

Posterolateral Bundle Resection for an Anterior Cruciate Ligament Ganglion Cyst

The incidence of intra-articular ganglion cysts of the anterior cruciate ligament (ACL) is low and symptomatic presentation of this pathology is even lower. Nevertheless, symptomatic cases pose a real challenge for the orthopaedic community, as no general consensus exists regarding the most appropriate treatment. The purpose of this Technical Note is to describe the surgical treatment of an ACL ganglion cyst by arthroscopic resection of the entire posterolateral bundle of the ACL in a figure-of-four position after conservative treatment has failed.

A Ganglion Cyst in the Anterior Cruciate Ligament of a 13-Year-Old Boy

Intra-articular ganglion cysts of the knee are a rare occurrence in pediatric patients, particularly involving the anterior cruciate ligament (ACL). Only a handful of case reports have been documented in the medical literature, highlighting the rarity of this condition. Patients with intra-articular cysts often experience knee discomfort and mechanical symptoms like locking of the knee. We present the case of a 13-year-old boy who had a unilateral intra-articular ganglion cyst of the ACL in his left knee. To diagnose and treat the cyst, we conducted radiographs and MRIs, and arthroscopic drainage was performed, resulting in a successful cyst decompression. Our case report provides an overview of the pathogenesis, diagnostic methods, treatment options, and complications of treatment for intra-articular cysts of the ACL. It highlights the rarity of this condition in pediatric patients and underscores the importance of prompt diagnosis and appropriate management.

Intra-Articular Ganglion Cysts of the Knee

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Magnetic resonance imaging (MRI) without contrast is sufficient to diagnose an intra-articular ganglion cyst of the knee. MRI with intravenous contrast may be considered for cysts in the infrapatellar fat pad, which are not a typical presentation.

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The current literature supports treating symptomatic cases or those discovered accidently during knee arthroscopy with arthroscopic excision.

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Although aspiration of these cysts results in a higher recurrence rate than excision, it is associated with quicker recovery. Thus, aspiration might be chosen as an initial treatment for anyone who would like to avoid surgery or requires a rapid recovery, including professional athletes.

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Open excision may be considered for infrapatellar fat pad cysts that are >4.5 cm in size.

Clinical manifestation and arthroscopic treatment of symptomatic posterior cruciate ligament cyst

Background

Ganglion cyst of cruciate ligaments is a rare lesion; the prevalence is 0.3–0.8%. The purpose of this study was to present clinical features of symptomatic posterior cruciate ligament (PCL) cyst, introduce the arthroscopic excision technique, and evaluate the clinical outcome.

Methods

A series of 11 patients with symptomatic PCL cyst from November 2012 to December 2014 were involved in this retrospective study. Detailed medical history collecting and physical examination were conducted. Magnetic resonance imaging (MRI) scan was used to confirm the diagnosis. Arthroscopic resection was performed, and the sample of the cyst was taken for pathologic examination. The follow-up averaged 30.7 months. International Knee Documentation Committee (IKDC) score, the range of motion (ROM), and MRI evaluations were obtained pre- and postoperatively to assess the surgical outcome. SPSS software was used for statistics analysis.

Results

Eight males and 3 females with 6 left knees and 5 right knees were enrolled, the mean age was 34.4 years, and the duration of symptom was 19.0 months. All cases had a definite history of knee trauma or injury. The most common symptom was knee pain at flexion or in flexion-associated activities. MRI revealed the location and size of the cyst in each case. Pathologic examination showed the cyst wall was composed of dense fibroconnective tissue and widespread thick bundles of collagen, which is similar to the structure of ganglion cyst. At the final follow-up, MRI evaluation showed no cyst recurrence. The preoperative ROM and IKDC score were 2.3° to 108.6° and 40.5 ± 11.3, respectively, compared with the postoperative ROM and IKDC score which were 0° to 134.1° and 85.5 ± 4.8 (p < 0.05) separately.

Conclusions

We conclude that the etiology of symptomatic PCL cyst is most likely associated with trauma, pain on flexion is a typical manifestation of symptomatic PCL cyst, MRI evaluation is an ideal examination for the diagnosis, and arthroscopic resection of symptomatic PCL cysts has a good outcome with no recurrence.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-0798-x) contains supplementary material, which is available to authorized users.

Anterior cruciate ligament ganglion causing flexion restriction: a case report and review of literature

Ganglion cysts originating from the anterior cruciate ligament (ACL) are uncommon. Often asymptomatic, they infrequently present with non-specific symptoms such as knee pain, stiffness, clicks, locking or restriction of knee extension. However, the patient we report presented with knee flexion restriction. A 37-year-old Chinese gentleman, with no history of knee trauma, presented with left knee pain. Left knee range of motion (ROM) was from 0 to 110 degrees. Magnetic resonance imaging (MRI) scan revealed a 1.5 cm × 3.3 cm × 1.7 cm cyst located in the intercondylar region arising from the ACL and extending predominantly posteriorly. Arthroscopy confirmed an intrasubstance ACL ganglion cyst, which was extending posteriorly. Complete excision of the cyst was performed. At 1-year follow-up, the patient regained knee flexion of 130 degrees. We describe one of the largest ACL ganglion cysts. Such cysts often extend anteriorly and impinge onto the roof of the intercondylar notch during knee extension, thus restricting extension. The restriction in knee motion in our patient was in flexion instead; this was because the cyst took an unusual course of extension predominantly in the posterior direction. Although rare, it must be included as a possible differential diagnosis when patients present with such knee symptoms.

A case of intra-articular ganglion cysts of the knee joint: correlation between arthroscopic and magnetic resonance imaging

Background

Intra-articular ganglion cysts of the knee are rare. Here we report a case of an arthroscopically confirmed ganglion cyst arising from the posterior cruciate ligament (PCL) along with preoperative magnetic resonance imaging (MRI) findings.

Case presentation

A 39-year-old female admitted a hospital with left knee pain with flexion and extension. MRI revealed a cystic lesion along the PCL. The lesion exhibited slight but homogeneous hyperintensity on T1 weighted images. Thin septals were visible within the lesion. Arthroscopic examination revealed a mass lesion with a white fibrous capsule, located near the PCL. A gel-like liquid spurted from the mass upon puncture. The lesion was completely resected. Histological examination revealed loose connective tissue and fibroblasts with collagen, thus confirming the diagnosis of a ganglion cyst.

Conclusion

Many reports have suggested intra-articular ganglion cysts of the knee are rare. In our study, a cystic lesion may have been impinged between the PCL and intercondylar notch, resulting in flexion and extension difficulty in the left knee. Arthroscopic resection is the major treatment of intra-articular ganglion cyst, and preoperative MRI findings can predict the correct arthroscopic approach. We have reported a case in which an intra-articular ganglion attached to the PCL.

Dual ACL Ganglion Cysts: Significance of Detailed Arthroscopy

Intra-articular ganglion cysts of the knee joint are rare and most frequently are an incidental finding on MRI and arthroscopy. Most of the previous studies have reported a single ganglion cyst in the knee. There have been previous reports of more than one cyst in the same knee but not in the same structure within the knee. We are reporting a case of dual ACL (anterior cruciate ligament) ganglion cysts one of which was missed on radiological examination but later detected during arthroscopy. To the best of our knowledge, no such case has been reported in the indexed English literature till date.

An intra-articular ganglion cyst in a patient with juvenile idiopathic arthritis

We report an intra-articular ganglion cyst (IAGC) presenting as knee pain and a mass in a patient with longstanding Juvenile Idiopathic Arthritis (JIA). We could not find a similar case of an IAGC occurring in the knee of JIA patients in the literature. IAGC may need to be included as a possibility in patients with inflammatory arthritis with new-onset knee pain, especially in those with a palpable mass. MRI was useful in distinguishing IAGC from more worrisome causes of a knee mass. Orthopedic input was helpful in diagnosis and treatment. In addition, methotrexate therapy was effective in bringing about a long-lasting remission.

Report of ganglion cyst in the anterior cruciate ligament of a 6-year-old child

BACKGROUND

Intra-articular ganglion cysts of the knee are extremely rare within the pediatric population. To our knowledge, only seven case reports have been published in the medical literature identifying pediatric patients with intra-articular cysts of the anterior cruciate ligament (ACL). Intra-articular cysts of the knee are a rare cause of knee discomfort and mechanical symptoms such as locking of the knee. To our knowledge, up until now the youngest patient reported in the medical literature with an intra-articular ganglion cyst of the ACL was a 7-year-old boy.

CASE REPORT

We describe a 6-year-old boy who presented with a unilateral intra-articular ganglion cyst of the ACL in the right knee. In addition to the diagnostic work-up of radiographs and MRI, the cyst was successfully treated with arthroscopic resection and debridement to decompress the cyst.

CLINICAL RELEVANCE

We provide a review of the proposed pathogenesis, diagnostic modalities, differential diagnosis, treatment options, and complications of treatment for intra-articular cysts of the ACL.

LEVEL OF EVIDENCE

Level V, case report.

Ganglion cysts of the cruciate ligaments: a series of 31 cases and review of the literature

BACKGROUND

A case series for ganglion cyst of the cruciate ligament with MRI findings, clinical presentation, and management options along with review of literature is presented.

METHODS

Of 8663 consecutive patients referred for knee MR imaging, 31 were diagnosed with ganglion cysts of the cruciate ligaments, including 21 men and 10 women of ages 12 to 73 years (mean: 37). A review of charts revealed that knee pain was the chief complaint in all cases. Arthroscopic debridement of ganglion cyst was performed in 11 patients.

RESULTS

MRI proved to be a valuable tool in diagnosing and deciding management of these cases. All 11 patients who underwent arthroscopic treatment were symptom-free on a minimum follow-of one year.

CONCLUSION

Cyst formation associated with cruciate ligament of the knee is an infrequent cause of knee pain. MR imaging was important in confirming the cyst lesions and provided useful information prior to arthroscopy. Arthroscopic debridement of ganglion cyst produced excellent outcome without recurrence. This study describes the pertinent MRI and intraoperative findings of ganglion cyst.

Primary sarcoma of the anterior cruciate ligament - a case report

Clear cell sarcoma of tendons and aponeuroses (CCSTA) is a rare, aggressive soft tissue malignancy, which is found in intimate association with tendon, aponeurosis or fascia. It has not previously been reported in association with intraarticular ligaments. We report the first case of an intraarticular CCSTA, in this case of the anterior cruciate ligament and describe the diagnostic and treatment challenges of intraarticular tumours of the knee.

Anterior cruciate ligament mucoid degeneration: a review of the literature and management guidelines

PURPOSE

Anterior cruciate ligament (ACL) mucoid degeneration is a rare encounter in clinical practice, different, but often confused with ACL mucoid cysts. Its pathophysiology remains unclear. However, recent publications have suggested that it might be underdiagnosed or misdiagnosed, and that the adverse effects of treatment by ACL resection might be underestimated. The object of this work was to summarize this scattered knowledge to improve patient management.

METHODS

The authors carried out an exhaustive and comprehensive review of up-to-date literature. An extensive search of the MEDLINE database was carried out using MESH terms (ganglion cyst, anterior cruciate ligament) and generic search terms (mucoid degeneration, hypertrophy).

RESULTS

Anterior cruciate ligament mucoid degeneration is determined by interstitial glycosaminoglycan deposits amidst the collagen bundles causing ACL hypertrophy, knee pain, and limited range of motion. It is thought to arise from a primary synovial lesion and is associated with arthritic change or subsequent to acute or repeated trauma. Diagnosis is made on MRI scans and confirmed on histopathological samples. Current treatment involving ACL arthroscopic resection is efficient on pain and range of motion but is not a benign procedure and causes knee laxity.

CONCLUSIONS

Anterior cruciate ligament mucoid degeneration needs to be more broadly known and properly diagnosed so that progress can be made in its management. Further research will be necessary to confirm the current trends in the literature, which suggest being less aggressive with ACL arthroscopic resection when dealing with mucoid degeneration and making more use of conservative measures such as notchplasty.

LEVEL OF EVIDENCE

Systematic review, Level IV.

Diagnosis and treatment of ganglion cysts of the cruciate ligaments

OBJECTIVE

To explore the diagnosis and treatment of ganglion cysts of the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) of the knees.

METHODS

Retrospective analysis of clinical data of patients with ganglion cysts of ACL and PCL as confirmed by arthroscopy and pathology.

RESULTS

All patients were followed up at the clinic in a mean period of 2 years, and their symptoms including arthralgia, swelling and interlocking of the affected knees disappeared. Normal ranges of joint motion were restored successfully.

CONCLUSION

Ganglion cysts of the cruciate ligaments can easily be detected by MRI and should be arthroscopically resected, not only treated by ultrasound but also by CT-guided paracentesis. Complete resection of the cyst and cyst walls is recommended to avoid recurrence. Positive diagnosis of this disease can be improved by clinical manifestations and specific MRI findings. Trauma and chronic strain were the primary etiological factors responsible for ganglion cysts that were more common in ACL than PCL.

Ganglion cyst of the posterior cruciate ligament

A ganglion is a fluid cyst with a myxoid matrix that arises close to the tendons and joints. Its occurrence inside a joint is rare. Among the various pathological conditions producing impairment of the knee function, ganglia of the cruciate ligaments are quite rare. It may be painful or asymptomatic. Some patients may have a trauma history. Ganglia may mimic intra-articular lesions like tears of the anterior cruciate ligament (ACL) or meniscus. Ganglia, though commonly arise from the ACL, can also arise from other structures such as the posterior cruciate ligament (PCL) or meniscus. Ganglia are typically treated by arthroscopic excision and debridement. We report a case of ganglion of the PCL in a 28-year-old man; the lesion was incidentally discovered during ACL reconstruction with double bundle (Rigid fix technique). The patient underwent arthroscopic excision of the ganglion. At the end of 1-year follow-up the patient was pain free; a full range of motion of his right knee was restored, and he returned to his preinjury sport activity.

Ganglion Cyst of the Anterior Cruciate Ligament

We present the case of a 55-year-old woman with a presumed ganglion cyst associated with the anterior cruciate ligament (ACL), demonstrated by MRI. The ACL is an uncommon location for ganglion cysts to occur.

Non-neoplastic conditions presenting as soft-tissue tumours

Review of referrals to our unit over the last 7 years showed that of approximately 750 cases referred as soft-tissue tumours, 132 were subsequently diagnosed as non-neoplastic lesions. The imaging characteristics of these lesions are presented to differentiate them from neoplasms. The most common diagnoses were myositis ossificans, ganglion cyst, abscess/infection, bursitis and synovitis. The imaging features of other rarer conditions will also be discussed.