0:01

<v ->This is our lab first case of the second block.

0:06

And we have a 43-year-old female patient with knee pain.

0:14

The medical suspicion was medial meniscal tear.

0:18

And here you can see clearly that the medial meniscus

0:22

and the lateral meniscus, they are normal in this case.

0:27

And the problem is related to the ACL.

0:30

We can see here that the ACL is not torn,

0:33

but we can see that the ligament is thickened.

0:36

And we can see high signal intensity, some fluids,

0:41

some high signal intensity between the fibers

0:44

of the ACL and around this, this ACL that's thickened.

0:50

And there is fluid between the fibers.

0:53

We can also see some cystic lesions

0:57

on the pericruciate fat

0:59

and in the infrapatellar fat near

1:03

to the ACL insertion at the tibial footprint.

1:09

So here we have the classic celery stalk morphology.

1:17

That is a hallmark of the ACL mucoid degeneration.

1:23

So that it's a case of mucoid degeneration of the ACL.

1:26

And another thing that we can see here

1:28

that Dr. Res, he talked in his lecture,

1:34

was that sometimes some of this mucoid fluid,

1:38

it can migrate to the bone,

1:40

and we can have some fibrocystic change near to the,

1:45

in the femoral footprint and in the tibial footprint.

1:49

And sometimes just,

1:50

it can help us to identify degenerative,

1:56

mucoid degeneration of the ACL.

1:58

And this case, it's not a tear.

2:02

It's a mucoid degeneration.

2:04

But sometimes the findings of the mucoid degeneration,

2:10

they look like in intra-substantial tear,

2:14

a deliminated tear, and sometimes it's difficult

2:16

to make a difference.

2:18

The difference between these two pathologies, especially

2:21

in middle aged in, in elderly patients

2:26

with history of trauma.

2:28

Okay, in this case, we don't have any problems.

2:30

There is no history of trauma,

2:31

and we can see beautiful here.

2:34

But sometimes we cannot see the fibers of the ACL very well.

2:40

And we can be, we can have this doubt

2:44

if it is mucoid degeneration or if it is a partial tear.

2:51

And that's something

2:52

that sometimes is easier said than done,

2:54

than differentiate between these two conditions.

2:58

And so the ACL mucoid degeneration is a disease

3:05

of middle-aged and elderly people,

3:08

but similar findings can be seen

3:11

in adolescents and young adults,

3:14

and suggesting maybe that the term degeneration

3:17

may be inappropriate.

3:19

Actually, I went to your book. (laughs)

3:25

And I wrote here, Dr. Res suggests in his book

3:29

that the term mutinous change

3:33

or cyst mutinous disease could be better,

3:35

especially in young patients.

3:38

So that's something that sometimes we face,

3:42

a knee of a young patient, and it's hard

3:47

to call that a degenerative change.

3:53

And I think that's a good observation.

3:58

And we don't know exactly what's the cause

4:04

of the mucoid degeneration of the ACL.

4:08

There are a lot of theories.

4:11

It's moot, factorial disease, could be a previous trauma,

4:15

a degenerative change.

4:16

But one thing that I found, I found very interesting.

4:19

It's the part, it's the participation

4:24

of the synovial membrane in this process.

4:27

There is a,

4:30

in the literature, there is some papers dealing with that.

4:36

They say that the damage

4:38

of the synovial membrane that covers the ligament

4:41

can play a role in the degenerative process of the ACL.

4:44

The membrane protects the ligament against lesions,

4:48

and it helps the healing process,

4:51

keeping the ligament out of contact with the synovial fluid.

4:55

When the lesions of the synovial membrane occur,

4:58

it lets the ACL more vulnerable

5:01

to chronic degenerative changes.

5:04

And in fact, I went to the orthopedic literature,

5:07

and I found that one of the criteria

5:10

to diagnose mucoid degeneration

5:15

of the ACL is the loss of the synovial membrane.

5:20

So that was something that I found very interesting

5:25

to comment here in this case.

5:30

And that's it.

5:31

The treatment generally, it's not surgical at the beginning,

5:34

but maybe the patient has a lot of pain

5:37

or impediment of the knee motion.

5:43

It can be treated surgically, debulking the ligament

5:45

and even maybe taking a piece of the ligament

5:48

and reconstructing, doing a reconstruction of the ACL.

5:53

So that's it for this first day.

5:55

Don, what?

5:56

<v ->This is an interesting case for me.

5:59

And some of the things you said are very interesting,

6:01

because I have observed in active adolescents,

6:06

particularly in soccer players, we don't have as many,

6:10

but in soccer players that they develop these linear areas

6:14

of high signal delamination between the collagen fibers,

6:18

particularly of the ACL.

6:20

And if you use the term cystic degeneration to describe that

6:24

in a 14 year old, the parents are not very happy.

6:28

And so I think activity can lead

6:30

to changes of delamination between the collagen fibers,

6:36

not a single episode of trauma, but more often stress.

6:40

And that the ligament is stable

6:42

and the prognosis is, you know, is fine.

6:45

And the other point I would make is something

6:48

that I remember from my days of standard orthography,

6:52

that when we did standard orthography of the knee,

6:55

there were occasional cases where contrast got

6:58

in between the fibers of the cruciate ligaments.

7:02

So although there's a synovial membrane over them,

7:06

as you've indicated,

7:07

there may be developmental changes that allow fluid

7:11

to get into that area.

7:13

And maybe that is why we end up with cystic change.

7:17

I don't know, but it's an interesting finding.

7:20

And that's a beautiful case showing it.

7:22

<v ->Okay, thank you.

7:24

So let's go to the second one.