Knee Ligaments and MTU

Transcription

1 Knee Ligaments and MTU Clinical US JL Gielen P Van Dyck J Veryzer Department of Morphology Department of Radiology

2 2 Outline Anatomy Pathology Staging US accuracy - Primary tool - Diagnostic tool Clinical significance Key facts MCL LCL Iliotibial friction syndrome Ruptured bursa Muscle tear - Biceps - Gastrocnemius - Soleus - Plantaris

3 3 Lateral Knee Pathology Clinical challenge - soft-tissue and intra-articular disorders Acute traumatic lesions - Ligamentary complex: LCL, ligamentum arcuatum complex, popliteus tendon, intra-articular lesions - Muscle sprain: biceps femoris Non traumatic acute and chronic focal lesions - Tendinopathy, paratenonitis, ganglia

4 US 4 Lateral and Posterior-lateral Knee Lateral collateral ligament Popliteus tendon Biceps tendon and muscle Iliotibial band

5 US 5 Lateral and Posterior-lateral Knee Lateral collateral ligament Popliteus tendon Biceps tendon and muscle Iliotibial band

6 US 7 Popliteus and LCL Origin, mid-, insertion Popliteal groove 10 Angle

7 US 8 Biceps Insertion

8 14 LCL Injury LCL rarely injured Related to complex trauma - Varus stresses with hyperextension and rotation - Associated with intra-articular lesions >MRI - Accurate assessment of the intra-articular structures (> US) - Ruptured ligament appears as a thickened and slack structure

9 Injury LCL and posterolateral LCL and capsule injury 16 structures - leg in internal rotation position with applied varus force Posterolateral corner injury - direct or noncontact forces that cause knee hyperextension or hyperextension and external rotation These injuries may be seen in conjunction with either an ACL and/or PCL injury

10 LCL and Popliteus T Tear, ACL Sprain 18 KMS 15y ed

11 LCL, Popliteus, ACL and PCL Tear 19 DPK 36y ed

12 LCL, Popliteus, ACL and PCL Tear 20 DPK 36y ed

13 Acute Local Pain with Swelling DPA 67y ed Courtesy of Ph. Tallieu

14 US 22 Lateral and Posterior-lateral Knee Lateral collateral ligament Popliteus tendon Biceps tendon and muscle Iliotibial band

15 23 Biceps Femoris 85% of hamstring injuries involve the long head of the biceps. - 37% biceps femoris lesion in association with semitendinosus strain (Slavotineck et al. 2002) - proximally at the level of the cranial myotendinous junction of the long head - distally where the fibers of the long head join the short head Semitendinosus is often injured at its distal myotendinous junction

16 24 BB 31y ed Biceps CL Grade III Tear Distal MTJ Short Head Long Head Long Head MTJ Short Head Long Head Short Head

17 25 Grading Muscle Tears Grade 1 - No fibre disruption: elongation US normal!!!, MRI edema Also typical history of sudden snap during activity - Minor fibre disruption (< 5%) Grade 2 - Fibre disruption 5-95% Grade 3 Further grading needed - Complete tear

18 26 Hamstrings, Biceps Femoris Time lost from competition - is not influenced by the specific muscle injured or by the intramuscular location of the lesion (Slavotineck et al. 2002) - is predicted by the length or relative transverse surface of the strain area (Connell et al. 2004, Slavotineck et al. 2002)

19 27 Area Measurement Abnormal cross sectional area = 43%

20 28 Craniocaudal Length T1 FS T2

21 30 M. Adductor Longus Strain

22 31 4 Days Lesion Length: 11mm Surface: <5% M. Adductor Longus Strain Grade 1

23 32 Temporal Evolution Hamstring Tears Abnormality present Time Ultrasound MRI Day 3 45/60 (75%) 42/60 (70%) Week 2 25/49 (51%) 29/49 (59%) Week 6 10/45 (22%) 15/42 (36%) Connell et al AJR 2004

24 US 33 Lateral and Posterior-lateral Knee Lateral collateral ligament Popliteus tendon Biceps tendon and muscle Iliotibial band

25 US 34 Iliotibial Tract Insertion and Distal Third Landmark: Gerdy s Tubercle

26 Iliotibial Band Friction Syndrome Distal Iliotibial Band Tendinopathy 37 Friction syndrome - Clinical diagnosis Edema - Bursitis (de novo) - Tendinopathy rare but clinical relevant: failure of conservative therapy - US staging Distal tendinopathy - Total knee prosthesis - Osteoarthritis

27 Iliotibial Band Friction Syndrome 38 Runners Knee Contacts lateral femoral condyle, moving forward in extension and backward in flexion Clinical diagnosis - Long-distance runners, cyclists, soccer players and weightlifters - Chronic friction of iliotibial band against lateral condyle may lead to local inflammation and pain US: - Early: fluid distension of the bursa - Late: thickening of the band

28 MRI Iliotibial Band Friction Syndrome - Changes in bursal shape - Marrow edema on lateral condyle - Focal band thickening 41 VHK

29 Iliotibial Band Friction Syndrome 42 VRJ 68y ed

30 Iliotibial Band Friction Syndrome 43 VRJ 68y ed

31 44 Distal Iliotibial Band Tendinopathy Local pain and tenderness over the preinsertional portion of the band Middle-aged with total knee prosthesis or OA - Deep boundary iliotibial band may impinge over the sharp metallic edge of the tibial prosthetic component - OA: probably secondary to increased stress forces on the band during walking as a result of an altered weight related to varus-valgus deformity

32 45 Distal Iliotibial Band Tendinopathy Straight appearance and superficial location - Coronal US: middle and distal portions of the band in the same image for comparison - Transverse US: increase in the cross-sectional area US signs - Swollen with echotextural abnormalities: hypoechoic with loss of the fibrillar pattern - Comparison with contralateral and US-palpation

33 From: Ultrasound of the Musculoskeletal System, Bianchi and Martinolli Springer 2007 US Medial collateral ligament - Superficial layer - Deep layer Meniscofemoral ligaments Meniscotibial ligaments Pes anserinus Inferior medial geniculate artery 48 Medial Knee MGL

34 50 MCL US Coronal plane - Elongated band 1 3 mm thickness Two hypo-echoic layers reflecting the superficial part and the deep meniscofemoral and meniscotibial components separated by a slight hyper-echoic line related to fatty tissue US Transverse plane - Crescentic-shaped hyperechoic structure located just over the femoral and tibial cortex Examine the entire length of the ligament!

35 51 MCL Between the two components of the medial collateral ligament, a synovial bursa (medial collateral ligament bursa) creates a gliding plane with knee flexion Described in more than 90% of knees on cadaveric studies, it cannot be demonstrated at US because of its thin walls and absence of sufficient internal fluid

36 52 Dynamic US images obtained during valgus stress during slight flexion (10-20 ) can improve the assessment of integrity of this ligament MCL

37 53 Pes Anserinus Tendons of sartorius, gracilis, semitendinosus Insertion - anteromedial aspect of the tibial metaphysis, 5 6 cm below the joint line - more proximal: individual tendons of the pes anserinus can be distinguished - distal insertion: blend together and cannot be differentiated from one another

38 54 Synovial Bursae Located among these tendons and between them and the tibial cortex: attenuate local frictional stresses. In normal states not visible with US. US Landmark: inferior medial genicular artery. Between the straight pes anserinus tendons and the concave medial cortex of the tibial metaphysis.

39 US 55 MCL, Origin, Insertion Meniscotibial Ligament

40 US 56 Pes Anserinus

41 US 57 Pes Anserinus Medial Geniculate Artery

42 US 58 Pes Anserinus Pes Anserinus Posterior

43 US 60 Pes Anserinus Transverse Tendons blend together and cannot be differentiated from one another

44 Normal Proximal and Distal MCL 61 CR 44y ed

45 62 Medial Knee Pathology Traumatic injuries of the medial collateral ligament Pes anserinus tendinopathy and bursitis

46 63 Medial Collateral Ligament Injury Sport trauma: - soccer, ski - excessive force on flexed, valgus and exorotated knee Majority: tears of proximal part of - superficial layer of MCL - deep: meniscofemoral ligament Minority: - cortical avulsion at the cranial part of the meniscofemoral ligament

47 64 Medial Collateral Ligament Injury Acute phase - Pain - Local soft-tissue swelling - Coexistence of an intra-articular effusion Associated intra-articular lesions: meniscal, ACL > MRI - Frequently no associated articular effusion > US 3-grade scale based on the severity

48 65 Medial Collateral Ligament Injury Grade 1 - ligament stretching with no associated laxity Grade 2 - partial ligament discontinuity and moderate instability Grade 3 - complete ligament tear associated with instability

49 66 Medial Collateral Ligament Injury Treatment - Depends on the presence of associated intraarticular lesions - Isolated MCL tears: conservatively - Combined lesions involving meniscus and ACL arthroscopic surgery

50 67 Medial Collateral Ligament Injury US - Thickened and heterogeneous ligament - Partial-thickness tears most commonly: affect meniscofemoral ligament can be difficult to differentiate from complete ruptures

51 68 Soccertrauma 3 d old MCL Gr II Tear FV 16y ed

52 71 Valgus Torsion Trauma 1 week Old Sprain Grade II MCL VJ 34y ed Coronal Transverse

53 US 74 Meniscofemoral tear with Meniscocapsular Separation with Bursa 53y ed110412

54 US 75 MP Hemophylia, Traumatic rupture and hematoma at meniscofemoral ligament

55 US 76 MP Hemophylia, Traumatic rupture and hematoma at meniscofemoral ligament

56 77 Medial Collateral Ligament Injury Rare - Avulsed bony fragment at the femoral insertion of meniscofemoral ligament - Injuries of the meniscotibial component are difficult to assess with US

57 78

58 79 Medial Collateral Ligament Injury Pellegrini-Stieda lesion - Healing of the femoral insertion of the superficial ligament with formation of a calcification - Painful and may limit sport activity - US: calcification located at the proximal insertion of the ligament

59 US 80 MCL Tear, Chronic Angiogenesis

60 82 Pes Anserinus Bursitis Bursitis and ganglion cysts can develop at the level of the pes anserinus complex Present clinically as local soft-tissue masses - Ganglia: painless and firm (mucoid viscid content) - Bursitis: can be painful and softer observed in patients affected by rheumatoid arthritis and type II diabetes mellitus (Unlu et al. 2003)

61 83 Pes Anserinus Bursitis US: anechoic mass located in close proximity to the synovial bursae interspersed among the pes anserinus tendons (Voorneveld et al. 1989) Pressure with the probe can reveal shape changes of the bursa secondary to fluid displacement. Intramural flow signals are detected in acute inflammation

62 US 85 Pes Anserinus Bursitis VS 29y ed

63 86 Pes Anserinus Bursa

64 US 88 Rubor, Calor, Dolor and Swelling VSC 56y ed Cloaca, Sinus Tract, Abcess, Sequestrum: osteomyelitis

65 US 89 Pes Anserinus Tenderness at insertion of pes anserinus - Lesions in a small percentage of patients on US with this clinical presentation J. Usón, P. Aguado, M. Bernad, L. Mayordomo, E. Naredo and A. Balsa et al., Pes anserinus tendino-bursitis: what are we talking about?, Scand J Rheumatol 29 (2000), pp

66 US 91 OA and Knee Pain

67 94 Rauber Console CR ed y

68 95 Medial Patellofemoral Ligament DD 31y ed Contusion, sprain grade II left

69 96 Medial Patellofemoral Ligament DD 31y ed Contusion, sprain grade II left

70 97 Medial Leg Gastrocnemius - Medial head Soleus Plantaris From: Ultrasound of the Musculoskeletal System, Bianchi and Martinolli Springer 2007

71 98 Soleus, Medial Gastrocnemius

72 99 Plantaris Tendon

73 100 Plantaris Tendon Plantaris Musculotendinous Junction

74 101 Medial Gastrocnemius Strain Tear at the distal MTU of the medial gastrocnemius is frequent Tennis Leg Hemorrhage is usually seen, and has been severe enough to result in development of compartment syndrome The clinical diagnosis of the specific injury is inexact Sudden snap on the back of the leg during activity

75 102 Medial Gastrocnemius Strain Tennis Leg Grade 1 tears: longitudinal US images demonstrate a heterogeneous irregular area interposed between the distal aponeurosis and the distal belly of the medial head related to hemorrhagic infiltration Careful analysis of the pattern of fibroadipose septa can help the diagnosis by showing them retracted at a variable distance from the aponeurosis. In larger ruptures,

76 103 Fluid, haematoma Fiber interruption gap

77 Grade 2 tears 104 Medial Gastrocnemius Strain Tennis Leg - fluid collection distal to the medial head and posterior to a normal aponeurosis. The effusion is anechoic and reflects the local serosanguinous collection. Major grade 2 or grade 3 - more than half the width of the muscle, and in complete tears, the aponeurosis of the medial head is torn - fluid collection dissects the medial head and the soleus.

78 Fiber interruption High SI Fuid, haematoma 105

79 106 Tennis Leg SB ed y

80 107 Tennis Leg SB ed y

81 108 Tennis Leg SB ed y

82 111 Medial Gastrocnemius Strain VDSH

83 112 Medial Gastrocnemius Strain VDSH From: Ultrasound of the Musculoskeletal System, Bianchi and Martinolli Springer 2007

84 113 Medial Gastrocnemius Strain VDSH

85 Hyperechoic strands within the fluid collection reflect loose connective tissue dissected by fluid Unaffected aponeurosis of the soleus retains a normal appearance Size of the serosanguinous collection does not correspond to the actual size of the tear. The muscle injury is usually confined to the distal part of the medial head. 116 Medial Gastrocnemius Strain Tennis Leg

86 Chronic longstanding lesions appear as a straight thickened hypoechoic fibrous band intervening between the medial head and the soleus on longitudinal images. The fibrous band assumes a typical oval appearance on transverse planes. 117 Medial Gastrocnemius Strain Tennis Leg

87 118 Complications Strain grade II -III - Fibrosis scar formation - US Recent (weeks): hyperreflective, similar to muscle regeneration Old (months): hyporeflective

88 119 Tennis Leg: Reflective Scar Tissue

89 120 Granulation Tissue >< Scar Tissue Muscle strain grade II 6 wks ago

90 123 Tennis Leg: Chronic 30 y Aponeurotic hyporeflective scar

91 Recurrent Tennisleg W Old Scar, Strain Muscle Regeneration 38y ed Longitudinal View Longitudinal View with power Doppler Axial View with power Doppler Old Scar at Aponeurosis Recent Muscle Regeneration

92 125 Medial Gastrocnemius Strain Differential diagnosis - Leg thrombophlebitis - Recent rupture of a Baker cyst - Achilles tendon tear

93 126 Gastrocnemius-Semimembranosus Recess Bakers Cyst

94 128 Soleus Strain Distal soleus MTU tear is typically located at the more proximal region of the distal MTU at the level of the medial gastrocnemius Relatively rare Probably related to aponeurotic scar after tennis leg with firm fusion of soleus and medial gastrocnemius

95 129 Plantaris Muscle Accessory plantar-flexion muscle of the calf Variable presence and anatomy - Absent in about 7% of individuals - Long and thin tendon - Distal part is typically part of the Achilles tendon - Formerly, this tendon was suspected to frequently rupture and result in the clinical syndrome of "tennis leg, currently it is proven that this clinical syndrome is caused by rupture of the medial head of the gastrocnemius muscle

96 130 Plantaris Muscle Plantaris tendon rupture is considered to be less severe than a rupture of triceps surae MTU components As the muscle is an accessory plantar foot flexor and has no essential function, the tendon is often used for grafts

97 133 The tendon is detected as a small oval structure deep to the medial gastrocnemiussoleus aponeurosis. In case of individual tendon insertion the plantaris tendon is the cause of retained ability to plantar flex the foot in case of total thickness tear of the Achilles tendon.

98 135 Plantaris MTJ Strain Grade III gastrocnemius soleus Musculotendinous junction Courtesy: Dr. Lien De Clercq

99 136 Acute Plantaris Tendon Tear VP 18y ed Proximal Mid portion Distal

100 137 Acute Plantaris Tendon Tear VP 18y ed Proximal Mid portion Distal

101 139 JC ed Snap 3 w ago M. Soleus Distal MTJ Tear 20% M. Plantaris tendon tear

102 168 Iliotibial tract: tendinopathy LCL: rarely isolated lesion Discussion MCL: frequently isolated, Pelegrini Stieda Pes Anserinus lesions: rare, referred pain Medial gastrocnemius strain: - frequent and complicated with scarring and recurrency - DD: Plantaris tear: not complicated Thromboflebitis Ruptured Baker s cyst