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ORIGINAL ARTICLE
Year : 2014  |  Volume : 14  |  Issue : 2  |  Page : 99-102

Ganglion cyst of knee associated with anterior cruciate ligament: A report of three cases


Department of Orthopaedics, Peoples Education Society Institute of Medical Sciences and Research (PESIMSR), Kuppam, Andhra Pradhesh, India

Date of Web Publication9-Oct-2014

Correspondence Address:
Ajith Krishnamurthy
Department of Orthopaedics, Peoples Education Society Institute of Medical Science and Research (PESIMSR), Kuppam - 517 425, Chittoor District, Andhra Pradesh
India
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DOI: 10.4103/1319-6308.142355

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  Abstract 

Purpose: Ganglion cysts of the knee associated with anterior cruciate ligament (ACL) are a very rare entity and commonly a missed clinical diagnosis. High clinical suspicion and magnetic resonance imaging (MRI) scan aids in the diagnosis. Materials and Methods: We present three cases (2 men and a woman) of ganglion cysts associated with ACL. All of them had knee pain for more than a year without any prior injury. Clinical examination revealed joint line tenderness and significant restriction in range of movements. MRI showed ganglion cyst closely associated with ACL. Arthroscopic examination and cyst excision was done. In one patient after the cyst was debrided, only a few fibers of ACL were attached to the femoral site. Intra-operatively, the Lachman's test was positive and an ACL reconstruction using hamstring tendon was performed. Results: Post operatively, all the patients were relieved of pain and regained full range of movements with a minimum follow up of one year. Conclusion: Although a rare condition, ganglion cyst has to be considered as a differential diagnosis in young patients without injury presenting with significant knee pain and restricted movements. Arthroscopy is an effective tool in the management of such condition.

  Abstract in Arabic 

كييسة الركبة المرتبطة بالرباط الصليبي الأمامي
كييسة الركبة المرتبطة بالرباط الصليبي الأمامي حالة نادرة عادة يصعب تشخيصها سريريا ، و يساعد التصوير بالرنين المغنطيسي في تشخيصها.
المواد ومنهج البحث: يصف هذا المقال ثلاث حالات لرجلين و امرأة ، كانوا يعانون ألماً في الركبة لأكثر من سنّة دون تعرضهم لأصابة سابقة.
وقد أظهر الفحص السريري ضعفا في المفصل و ضعفا في الحركة وأظهر التصوير بالرنين المغناطيسي كييسة في الركبة مرتبطة ارتباطا وثيقا بالرباط الصليبي الأمامي ، و بعد فحص الكييسة بالمنظار تم اسئصالها و تم تثبيت أنسجة الرباط الصليبي الأمامي على جانب الفخذ عن طريق التدخل الجراحيّ.
وقد كان استخدام اختبار Lachman مفيدا وقد أجريت عملية إعادة بناء الرباط الصليبي باستخدام وتر المأبض.
النتائج والخلاصة : بعد إجراء العملية تخلّص المرضى جميعهم من الألم و استعادوا حركتهم ، بقليل من المتابعة لمد ةعام.

Keywords: Anterior cruciate ligament, arthroscopy, ganglion cyst


How to cite this article:
Krishnamurthy A, Soraganvi P, Kumar J M, Naik PH. Ganglion cyst of knee associated with anterior cruciate ligament: A report of three cases . Saudi J Sports Med 2014;14:99-102

How to cite this URL:
Krishnamurthy A, Soraganvi P, Kumar J M, Naik PH. Ganglion cyst of knee associated with anterior cruciate ligament: A report of three cases . Saudi J Sports Med [serial online] 2014 [cited 2020 Sep 18];14:99-102. Available from: http://www.sjosm.org/text.asp?2014/14/2/99/142355


  Introduction Top


Ganglion cysts are common findings around the knee and other joints but association with either the anterior cruciate (ACL) or posterior cruciate ligament (PCL) is considered rare. These cysts are often symptomatic. A ganglion is a cystic lesion containing mucin-rich fluid associated with a joint or tendon sheath. [1] The prevalence of ganglia associated with the ACL is reported to be 0.12-0.44% on MRI. [2],[3] The prevalence of mucoid degeneration of the ACL has been reported to be 0.43%. [4] The etiology of both ganglion cysts and mucoid degeneration is unknown. [5],[6] Further relationships with intra-osseous bone formation are not explained in the literature. ACL ganglia and mucoid degeneration can cause pain and decreased range of movement in the knee. We report ACL ganglion cyst in 3 different patients, who presented to us with gradually increasing dysfunction of knee. The clinical findings, MRI, arthroscopic findings, and outcome are described.


  Materials and methods Top


Three patients, 2 men aged 20 years (case 1) and 31 years (case 2) and a woman aged 37 years (case 3) presented with more than 12-month history of knee pain of insidious onset. No episodes of trauma and no previous knee problems were reported. The problem began as stiffness and pain had worsened in the last 3 to 4 months to the extent that they had difficulty in performing daily activities. The pain was more in terminal flexion and extension movements. Physical examination revealed mild effusion, joint line tenderness, pain exacerbated by end range flexion and extension. Atrophy of the quadriceps was present in the first 2 cases. Tests to assess ligament stability such as anterior drawer, posterior drawer, and Lachman's tests were negative.

Physiotherapy was initially undertaken in order to improve range of movement. At follow up, no improvement was seen. X-ray was unremarkable. MRI scans showed an abnormal anterior cruciate ligament (ACL). Its fibers were intact but displaced by a ganglion at the femoral attachment in first case [Figure 1]. Cyst within the substance of ACL at its tibial attachment was seen in the other two cases.
Figure 1: MRI (sagittal section) showing abnormal anterior cruciate ligament with cyst at femoral attachment

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Based on these findings, an arthroscopy was undertaken. Arthroscopy revealed a ganglion in the ACL around the tibial insertion in case 2 [Figure 2] and case 3. Both menisci were intact and cartilage was normal. The posterior cruciate ligament (PCL) was normal. Cyst was debrided and excised using shaver. There was a large ganglion in the substance of ACL near its femoral attachment in case 1 [Figure 3]. The ganglion was debrided, the femoral attachment of the ACL was very flimsy, and the ACL was lax. Intraoperatively, Lachman's test was positive, since the patient was a young adult and a recreational sportsman, it was decided for ACL reconstruction. ACL reconstruction with quadrupled hamstring tendon was performed [Figure 4]. Postoperatively, patient was put on with the ACL rehabilitation protocol of our institute.
Figure 2: Ganglion cyst within the substance of ACL at femoral insertion site (left knee)

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Figure 3: Arthroscopic picture of cyst arising from tibial insertion of ACL

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Figure 4: Final picture after cyst excision, debridement, and reconstruction using quadrupled semitendinosus (left knee)

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  Results Top


At 12 weeks follow up, all the patients had complete relief of pain and regained full range of movements. The patients were followed up for a minimum of one year, with no evidence of recurrence. None of the patients were willing for MRI during the follow up, as they were symptom free.


  Discussion Top


Ganglion cysts are cystic structures, which contain a yellow viscous fluid surrounded by a thin capsule. They are commonly found around the joints with a particular affinity for the wrist. [3],[7],[8] While it is unclear how or why ganglion cysts originate, theories include Displacement of synovium into the surrounding tissue, which may occur during development, herniation of synovium into the surrounding tissues, or degenerative and proliferative changes of pluripotent mesenchymal cells following trauma. [7] One theory involves the cellular response to trauma that liberates a mucin substance, hyaluronic acid. This is interspersed with the fibers of the ligament, causing its fusiform dilatation. With joint and tissue motion, the mucin substance dissects the ligament fibers and may be found at the ligament attachments or in the intercondylar notch of the knee. [4]

Ganglion cysts within the knee are mostly found around ACL, but they are also seen in different locations like around posterior cruciate ligament (PCL), within the substance of ACL, infrapatellar fat pad, beneath medial meniscus, and over the lateral meniscus. [4],[7],[9],[10] Ganglion cysts of knee associated with ACL has to be strongly considered as a differential diagnosis in any young patient presenting with chronic knee pain and restricted range of motion. Other conditions, which mimic similar clinical presentation, are meniscus tear, loose body, chondral lesions, and meniscus cyst. [2],[4] MRI is the specific, sensitive, and non-invasive test for diagnosis of these lesions. [2],[7],[11],[12] It also gives information on the extent of cyst and associated lesions within the joint thus helping in the treatment plan.

Excision of the cyst was initially done by open arthrotomy with satisfactory results in the past. [13],[14] CT-guided aspiration has also been tried by few authors. [15],[16] Many surgeons with favorable results have successfully carried out arthroscopic cyst excision. [17],[18],[19] After excision of the cyst sometimes, the remaining ACL fibers may not be sufficient enough to provide the stability in high demand patients. Reporting on five cases, Narvekar et al. concluded that because none of the patients participated in any type of sporting activity, the thinned ACL mass probably sufficed to provide the requisite stability for day-to-day activities. [20] Nishimori et al. concluded that if their patients had participated in any type of sport, they might have had to consider augmentation or reconstruction of the ACL after resection of the lesion. [21]

Unlike ganglion cysts in other sites like wrist and ankle joint, recurrence of the cyst is very rare after excision. None of our patients who were followed for minimum one year had symptoms of recurrence. As the patients were asymptomatic, none of them were willing to get a repeat MRI done during their follow up.


  Conclusion Top


This rare diagnosis and treatment option should be considered when a young patient presents with significant knee pain and reduced range of motion without preceding trauma. Arthroscopy plays a very important role in the management of such lesions.

 
  References Top

1.
Underwood JC, Hunter J. Underwood JCE General and Systemic Pathology. Edinburgh: Churchill Livingstone; 2004.  Back to cited text no. 1
    
2.
Do-Dai DD, Youngberg RA, Lanchbury FD, Pitcher JD Jr, Garver TH. Intraligamentous ganglion cysts of the anterior cruciate ligament: MR findings with clinical and arthroscopic correlations. J Comput Assist Tomogr 1996;20:80-4.  Back to cited text no. 2
    
3.
Huang GS, Lee CH, Chan WP, Taylor JA, Hsueh CJ, Juan CJ, et al. Ganglion cysts of the cruciate ligaments. Acta Radiol 2002;43:419-24.  Back to cited text no. 3
    
4.
Bui-Mansfield LT, Youngberg RA. Intra-articular ganglia of the knee: Prevalence, presentation, etiology, and management. AJR Am J Roentgenol 1997;168:123-7.  Back to cited text no. 4
    
5.
Tyrrell PN, Cassar-Pullicino VN, McCall IW. Intra-articular ganglion cysts of the cruciate ligaments. Eur Radiol 2000;10:1233-8.  Back to cited text no. 5
    
6.
Zantop T, Rusch A, Hassenpflug J, Petersen W. Intra-articular ganglion cysts of the cruciate ligaments: Case report and review of the literature. Arch Orthop Trauma Surg 2003;123:195-8.  Back to cited text no. 6
    
7.
Recht MP, Applegate G, Kaplan P, Dussault R, Schweitzer M, Dalinka MK, et al. The MR appearance of cruciate ganglion cysts: A report of 16 cases. Skeletal Radiol 1994;23:597-600.  Back to cited text no. 7
    
8.
Andrikoula SI, Vasiliadis HS, Tokis AV, Kosta P, Batistatou A, Georgoulis AD. Intra-articular ganglia of the knee joint associated with the anterior cruciate ligament: A report of 4 cases in 3 patients. Arthroscopy 2007;23:800.e1-6.  Back to cited text no. 8
    
9.
McLaren DB, Buckwalter KA, Vahey TN. The prevalence and significance of cyst-like changes at the cruciate ligament attachments in the knee. Skeletal Radiol 1992;21:365-9.  Back to cited text no. 9
    
10.
Kim MG, Kim BH, Choi JA, Lee NJ, Chung KB, Choi YS, et al. Intra-articular ganglion cysts of the knee: Clinical and MRI imaging features. Eur Radiol 2001;11:834-40.  Back to cited text no. 10
    
11.
Muddu BN, Morris MA, Fahmy NR. The treatment of ganglia. J Bone Joint Surg Br 1990;72:147.  Back to cited text no. 11
    
12.
Burk DL Jr, Dalinka MK, Kanal E, Schiebler ML, Cohen EK, Prorok RJ, et al. Meniscal and ganglion cysts of the knee: MR evaluation. AJR Am J Roentgenol 1988;150:331-6.  Back to cited text no. 12
    
13.
Levine J. A ganglion of the anterior cruciate ligament. Surgery 1948;24:836-40.  Back to cited text no. 13
    
14.
Muckle DS, Monahan P. Intra-articular ganglion of the knee: Report of two cases. J Bone Joint Surg Br 1972;54:520-1.  Back to cited text no. 14
    
15.
Antonacci VP, Foster T, Fenlon H, Harper K, Eustace S. Technical report: CT-guided aspiration of anterior cruciate ligament ganglion cysts. Clin Radiol 1998;53:771-3.  Back to cited text no. 15
    
16.
Nokes SR, Koonce TW, Montanez J. Ganglion cysts of the cruciate ligaments of the knee: Recognition on MRI images and CT-guided aspiration. AJR Am J Roentgenol 1994;162:1503.  Back to cited text no. 16
    
17.
Brown MF, Dandy DJ. Intra-articular ganglia in the knee. Arthroscopy 1990;6:322-3.  Back to cited text no. 17
    
18.
Mine T, Ihara K, Tanaka H, Taguchi T, Azuma E, Tanigawa Y, et al. A giant ganglion cyst that developed in the infrapatellar fat and partly extended into the knee joint. Arthroscopy 2003;19:E40.  Back to cited text no. 18
    
19.
Franceschi F, Rizzello G, Maffei MV, Papalia R, Denaro V. Arthroscopic ganglion cyst excision in the anterolateral aspect of the knee. Arthroscopy 2003;19:E32.  Back to cited text no. 19
    
20.
Narvekar A, Gajjar S. Mucoid degeneration of the anterior cruciate ligament. Arthroscopy 2004;20:141-6.  Back to cited text no. 20
    
21.
Nishimori M, Sumen Y, Sakaridani K. Mucoid degeneration of the anterior cruciate ligament-a report of two cases. Magn Reson Imaging 2004;22:1325-8.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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