0:01

<v ->Yes for the last,

0:02

so, we are in the last part,

0:05

the last block of case presentation,

0:08

and let's finish up in great style

0:11

showing three nice cases here, okay?

0:17

For this first case,

0:19

let me put the case here, is this one.

0:22

For this first case I'd like to thank Dr. (indistinct)

0:28

from Portugal.

0:29

He sent me this case that I will present you right now.

0:35

So thank you Dr. (indistinct) about this case.

0:39

And this is a case of a female patient,

0:43

14 years old volleyball player with anterior knee pain

0:48

and swelling above the patella for five weeks.

0:53

So we can see here,

0:59

there is suprapatellar plica here.

1:02

It's a complete suprapatellar plica here,

1:05

and it is compartmentalizing the knee joint

1:09

in two separate regions.

1:11

And we can see this heterogeneous lesion

1:15

on the suprapatellar pouch,

1:17

or the suprapatellar bursa in this area.

1:23

In her case, look, the post Gatalino image,

1:28

we can see some synovitis here, but inside the lesion

1:32

we don't see too much enhancement.

1:35

So in this case, we were in doubt about our question.

1:40

It could be a hematoma like,

1:46

or hemarthrosis,

1:47

or it could be a synovial inflammatory synovial lesion,

1:53

but we are more forward.

1:58

We are going more forward to the diagnosis

2:01

of a chronic hematoma, a chronic,

2:06

some previous trauma here, acute or chronic trauma.

2:13

And the patient ends up with this lesion.

2:18

compartmentalized lesion

2:20

in this region because of the suprapatellar pouch.

2:29

And in cases like this, it's hard to decipher the mechanism

2:33

of lesion, and it can be a chronic or acute traumatic lesion

2:39

as well, inflammatory lesion.

2:42

And sometimes the patient, the synovial plica,

2:49

the suprapatellar plica,

2:51

it can be stressed when the knee's flexed

2:54

for more than 70 degrees.

2:57

And this mechanism of knee flexion can,

3:01

when the knee flex more than 70 degrees,

3:04

the plica can be compressed against the extensor mechanism

3:09

and against the femoral condyles,

3:12

and it can irritate the plica, and because of that

3:18

the patient can have problems in,

3:22

patients with complete plica,

3:24

and patients also with incomplete plicas.

3:28

And for example, I wanna show here a companion case.

3:32

This is a case of

3:34

another female patient

3:37

18 years old with the thickened fibrotic,

3:40

and inflammant partial suprapatellar plica,

3:44

with localized synovitis below the plica.

3:50

Here, when I also have an x-ray of this case,

3:54

we can also see a calcification in this area.

3:59

It seems that that is the area of the insertion

4:05

of the plica near to the capsule right here.

4:10

We can see this.

4:12

And the treatment here, the orthopedic surgeons,

4:15

they generally, they enter and they resect the plica,

4:20

especially when they see

4:21

there are synovitis around the plica.

4:25

And one thing that I keep thinking about

4:28

is what came first here?

4:31

Like, the egg or the chicken?

4:35

Like, what happened first, the synovitis,

4:37

or what happened first was the mechanical stress,

4:41

and that was the thing that thickened the plica,

4:45

and after that the disease started?

4:49

So, what came first, a plica that was prone to lesion

4:55

like, the plica started everything,

4:57

or was the mechanical chronic trauma

5:01

that thickened the plica,

5:03

and after that, the patient had a lesion in this region?

5:09

What do you think, Don?

5:11

<v ->Well, I don't know in this case, but I can tell you

5:14

I have some cases where we had followed patients

5:18

who had a thin plica,

5:20

and over time that plica thickened.

5:23

And then after that they developed synovitis.

5:26

So in some cases, the plica came first,

5:29

but I don't know in a case like this,

5:31

which came first,

5:32

but I think, it's interesting to me

5:35

and pointed out by your case,

5:37

and by some I showed, how often the pathology

5:40

is either right above or right below the area of this plica.

5:45

<v ->Yeah. I've read in the orthopedic literature

5:48

that sometimes just during their antroscopy,

5:50

that they can find a little bit of synovial inflammation

5:54

around the plica,

5:55

and they assume that the lesion is related to the plica,

6:00

and they take out the plica.

6:02

And another thing about orthopedic literature

6:05

that I found interesting

6:07

is the patients with incomplete plica,

6:10

they can, complete plica too,

6:11

they can have a snapping sensation

6:14

during knee flexion, and important knee locking

6:18

after prolonged knee flexion in a sitting position,

6:23

that some researchers they call that the sinema sign.

6:27

<v ->Oh, okay.

6:28

<v ->Yeah. So yeah.

6:29

It's a catchy name.

6:30

It's yeah, it's a good one.

6:34

Okay, so let's go to the second case.