0:01

This was a 72 year old male with knee pain, no injury.

0:07

Starting from the medial side. We have soft tissue inflammation.

0:11

The medial meniscus is looking okay. I didn't see a definite tear. 72 year old.

0:16

Uh, the articular cartilage, um, doesn't look healthy. If you see there, there,

0:21

there is some abnormal signal in the cartilage. So this,

0:24

this will be areas of gait. Grade two to three cartilage loss over here.

0:27

Looks like it's almost full thickness cartilage loss. Over here,

0:31

there is superficial cartilage freeing over here. Also,

0:33

there is superficial cartilage freeing and some loss.

0:36

So it is of grade two to three cartilage loss in the medial compartment.

0:44

Your cruciate are normal,

0:46

but you can see that gray signal in the interoral notch.

0:49

So there is some synovitis in the joint

0:54

coming onto the lateral side against lateral meniscus,

1:00

no big tear. The, there is like free edge, uh, frank, uh,

1:05

and then abnormal signal in the anterior hand of the lateral meniscus.

1:09

So abnormal signal in the anterior horn of the lateral meniscus can often, uh,

1:13

be result of, um,

1:15

degenerative changes in the ACL because both the tibial insertion of ACL and the

1:19

anterior hand of, um, lateral meniscus, like those fibers intermingle.

1:23

So there's ACL degeneration that signal, um,

1:28

or the degenerative changes involve the anterior one of lateral meniscus as

1:32

well. So here I don't see a lot of, um, um, changes in the ACL.

1:36

So this might be like a small degenerative tear of the anterior,

1:39

one of the lateral meniscus. Um, then we have joint effusion,

1:43

and what we see is a lot of abnormality in the extensor, uh,

1:49

component of the knee joint. So the quadriceps tendon is thickened,

1:52

and if you see there's abnormal soft tissue that's, uh,

1:55

interspersed in between the fibers. We have, um,

1:59

pre particular soft tissue single abnormality as if there's like intermediate

2:02

signal soft tissue deposit here. And similarly, even the particular tendon,

2:07

uh, is thickened shows abnormal intermediate signal as if, um,

2:11

there's some infiltration of the particular tendon.

2:18

And we have this, uh, can make out what is it on sattal images. So we can, uh,

2:23

look at the axial images. And as I was saying about that,

2:26

v this is your nice fibular collateral ligament seen on the sagittal images.

2:30

And this is the biceps tendon.

2:33

So that's your posterolateral complex structure.

2:35

Both insert on the tip of the fibula,

2:40

starting strong pen. Again, we see that quadricep tendon abnormalities.

2:45

If you see there's something external, uh,

2:47

on the surface of the quadricep tendon that's infiltrating the fibers,

2:51

anteriorly joint effusion,

2:57

soft tissue edema,

3:02

then you have signal abnormality in the ular tendon. And, uh,

3:07

remember we saw something on the lateral side. So that's the abnormality along.

3:12

Um, this is where the, the, the popliteus notches.

3:16

And if you see this is the fibular, uh,

3:19

fibular collateral ligament attachment on the lateral femoral condyle. So again,

3:23

there is like an erosion, um, along the lateral femoral condyle with, again,

3:27

that soft tissue, which is intermediate signal. So, um,

3:32

this, uh, is actually a classic. It's a really nice case, a classic imaging, uh,

3:36

appearance of gout in knee. Um,

3:40

the demographics are perfect and early males have very high chances of, uh,

3:44

especially if they're, um, um,

3:47

if high protein and take their hyperuricemia from uh, uh, whatever reason. Uh,

3:52

if they have, um,

3:54

like elderly males are more predisposed to have gout, uh,

3:58

specifically if they have, uh, hyperuricemia things like leukemia, um,

4:04

renal disease, uh, where, um, or inborn errors of metabolism where the,

4:08

the urate levels are high. And you, um, uh,

4:11

what is gout is deposition of monos sodium urate crystals. Um,

4:16

and a gout classically gives rise to, um,

4:22

juxta articular marginal erosions. And, uh,

4:25

another classic manifestation of gout is deposition of tophus. So this,

4:30

um, deposition of crystals, um, is usually the per articular location.

4:36

Um, and they give rise to these intermediate signal intensity masses around the

4:40

joint that can eventually cause, uh, bone erosion.

4:42

So that's your example of a tophus deposition.

4:45

You have this intermediate signal,

4:46

intensity soft tissue resulting in bone erosion. And then sometimes these, um,

4:51

so your classic location is the first MTP joint of the, the foot. Again,

4:55

you'll have nice, um, um,

4:57

just strat erosions with overhanging margins because the articular surfaces, uh,

5:02

um, get affected late in the, uh, disease process. The articular cut, uh,

5:07

uh, cortex remains intact for a long time.

5:10

So the joint space narrowing sets in really late.

5:12

But what you get is a ni nice punch out erosion in the, uh,

5:17

juxta articular, um, cortex with, uh,

5:21

an MR is excellent in demonstrating these tophi. So on on, so, uh,

5:25

radiographs you see dense soft tissue overlying these erosions and an mri.

5:29

You can see this intermediate signal, intensity soft tissue, and,

5:34

um, uh, deposits in, in soft tissues as well. And your pre particular,

5:39

um,

5:40

areas is a classic location for gout tophus deposition.

5:45

So if you see an intermediate signal soft tissue along the superior pole

5:50

anterior aspect of the particular in an elderly male, uh, that's, that's a,

5:54

um, a very classic presentation of gout. Another, uh,

5:58

great location for gout is, uh,

6:01

the reon bursa of the elbow. So if you have, uh,

6:06

reon a person who presents with reon bursitis, but that bursa has dense, uh,

6:11

appearance on, on radio grabs.

6:13

And if you do Mr and if you see similar looking intermediate signal,

6:16

intensity soft tissue in the lone bursa, um,

6:19

that's another classic manifestation of gout. Uh,

6:22

and then it can eventually cause erosions here. So again,

6:25

erosion along the anterior superior patella is, uh,

6:28

if they short on radiographs,

6:29

it's some soft tissue intensity overlaying it that suggests gout. Um,

6:33

even an elbow, uh, it can result in erosions, um, shoulder.

6:37

You get that hatchet deformity, uh, when you have AS lateral erosion in the,

6:41

in the shoulder. So, yeah, uh,

6:46

so this, this will be gout where we have the tophus deposition, uh, um,

6:52

in the distal, uh,

6:53

soft tissue infiltrating the distal quadriceps tendon tous overlying the

6:57

anterior superior pole of the patella, um, thickening of the patula tendon,

7:01

and you have a nice erosion along the lateral femoral condyle close to theus

7:05

tendon insertion with small tous deposition.

7:10

I, I found this case very challenging. I I missed the diagnosis. Mm-Hmm mm-Hmm.

7:15

So, mm-hmm. With all the changes within the soft tissue structures,

7:18

I was confused whether this is actually chronic trauma and, uh,

7:22

tendinosis rather than, um, a crystal deposition disease. So,

7:27

um, what's the actual, uh,

7:30

important point to pick up when you see these cases as, uh,

7:33

as the most major finding?

7:37

Um, uh, I mean it's the, yeah. I mean,

7:41

the thing with gout is, uh, we always, uh, read about the,

7:45

the classic like involvement of the first meta of fedal joint, but we, we don't,

7:50

uh, get to see, uh, more often in teaching, um,

7:55

is these kind of, uh, manifestations of gout. Um, and this is a, when you, um,

8:00

read, uh, a book on, um, arthritis or, um, um,

8:05

a fellow level, uh, reading and, and then MSK imaging,

8:08

you'll realize that this is a, it's, it's,

8:10

it's a classic presentation of gout where we have this tofus deposition. So, uh,

8:15

trauma should not, like, can result in tendon changes,

8:18

but should not give rise to this, uh, soft tissue, right? If there's, there's a,

8:22

there's a nice soft tissue, intermediate signal,

8:25

or almost likely to dark signal, uh, soft tissue, um, tissue that is getting,

8:31

uh, deposited along the anterior aspect of the patula.

8:35

So, um, that, and knowing, uh, that, I mean, this is a,

8:40

a known, uh, presentation of gout and just knowing the, the other locations,

8:45

uh, classic locations for gout, I think that, that, that will help in, uh,

8:49

making the diagnosis is

8:52

That involvement in this case also,

8:54

it looks a very ground glass and thickened is, is that another thing that could

8:59

Possibly, sorry, what appearance of what?

9:01

The cartilage.

9:03

Cartilage, okay. Let's see. So cartilage and, uh, this patient is,

9:07

I think he's 72. It's, it's not a very healthy looking cartilage. There are, uh,

9:11

areas of grade two to three cartilage loss. Um,

9:15

and then if you see there are these other dark fo so this is, uh,

9:19

I sometimes when there is old cartilage injury, um, uh,

9:23

that gray appearance is for normal highline cartilage.

9:26

And when there's cartilage injury, sometimes that can heal on itself, but, um,

9:30

it'll never give you back your highline cartilage. Uh,

9:33

the highline cartilage gets replaced with fibrocartilage.

9:36

So those T two duct areas are either fibrocartilage, um, and, and sometimes, um,

9:40

there's crystal deposition on the articular cartilage surface itself.

9:45

So all these things are making the cartilage look, yeah, definitely abnormal.

9:49

This is not healthy cartilage that you've seen in younger individuals with no

9:53

cartilage injury.

9:54

Uh, on sagittal proton density, uh, sequences.

9:57

The cartilage looks a bit thickened on the sal proton density

10:02

pd, uh, non non-fat, just the pd,

10:06

No. Here,

10:07

I think you are losing the contrast resolution between the articular cartilage

10:11

and the cartilage itself. So the articular cortex and the cartilage.

10:15

So you're seeing both combined as this high point and signal.

10:20

I think it's just to do with the, I don't, uh,

10:22

I'm not seeing the TETR time on this. It has to do with the, the settings,

10:26

like the parameters of the sequence. Uh, but this, this is a good sequence, uh,

10:31

at, at least in this, uh, study, uh,

10:33

that tells you the articular cart and it doesn't look thickened.