Skip to main content
SpringerLink
Log in

Inverted deltoid posterior cruciate ligament femoral insertion accompanied with medial synovial fold: a case of a complex posterior cruciate ligament anatomical variation recalcitrant to conservative treatment

  • Anatomic Variations
  • Published:
Surgical and Radiologic Anatomy Aims and scope Submit manuscript

Abstract

Purpose

The present study aims to report a symptomatic rare anatomical variation of the posterior cruciate ligament (PCL) that was encountered during arthroscopy.

Case presentation

A 34-year-old female suffered from dull anterior pain in the right knee, along with stiffness and the presence of an audible click and occasionally locking during deep knee flexion. Physical examination revealed only slight pain during single-leg squatting and mild knee effusion with painful limitation of the last degrees of flexion. Following unsuccessful conservative treatment, knee arthroscopy was performed in which the PCL was found to be hypertrophic, having a broad femoral insertion that almost completely occupied the intercondylar notch and impinged the anterior cruciate ligament. Moreover, the PCL presented a large medial synovial fold that formed a plica inserting to the medial meniscus's posterior horn. Ligamentoplasty was performed by excising one-third of the PCL lateral portion. The PCL medial synovial fold and the plica attaching to the medial meniscus were resected. The patient was allowed to return to full activity when her symptoms resolved, and the knee function was restored, at 5 weeks post-operatively.

Conclusion

The current study presented a rare and complex anatomical variation of the PCL that was symptomatic and recalcitrant to conservative treatment. Magnetic resonance imaging (MRI) can reveal the variant morphology of the PCL, and arthroscopy provides the definite treatment. This case report may be useful for orthopaedic surgeons and radiologists to consider anatomical PCL variations during differential diagnosis in patients with non-specific clinical presentation and findings.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

Data availability

Not applicable.

Code availability

Not applicable.

References

  1. Agel J, Arendt EA, Bershadsky B (2005) Anterior cruciate ligament injury in national collegiate athletic association basketball and soccer: a 13-year review. Am J Sports Med 33:524–530. https://doi.org/10.1177/0363546504269937

    Article  PubMed  Google Scholar 

  2. Ahmed F, Ibrahim SA, Soliman A, Khirat S (2010) Ganglion cyst of the posterior cruciate ligament. BMJ Case Rep 2010:bcr0920092263. https://doi.org/10.1136/bcr.09.2009.2263

    Article  PubMed  PubMed Central  Google Scholar 

  3. Apsingi S, Bull AM, Deehan DJ, Amis AA (2009) Review: femoral tunnel placement for PCL reconstruction in relation to the PCL fibre bundle attachments. Knee Surg Sports Traumatol Arthrosc 17:652–659. https://doi.org/10.1007/s00167-009-0747-7

    Article  PubMed  Google Scholar 

  4. Arendt E, Dick R (1995) Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. Am J Sports Med 23:694–701. https://doi.org/10.1177/036354659502300611

    Article  CAS  PubMed  Google Scholar 

  5. Arnoczky SP (1983) Anatomy of the anterior cruciate ligament. Clin Orthop Relat Res 172:19–25

    Google Scholar 

  6. Arnoczky SP, Dodds JA, Wickiericz TL (1996) Basic science of the knee. In: McGinty JB (ed) Operative arthroscopy. Lippincott-Raven, Philadelphia, pp 215–217

    Google Scholar 

  7. Bernard M, Hertel P, Hornung H, Cierpinski T (1997) Femoral insertion of the ACL: radiographic quadrant method. Am J Knee Surg 10:14–22

    CAS  PubMed  Google Scholar 

  8. Colombet P, Robinson J, Christel P et al (2006) Morphology of anterior cruciate ligament attachments for anatomic reconstruction: a cadaveric dissection and radiographic study. Arthroscopy 22:984–992. https://doi.org/10.1016/j.arthro.2006.04.102

    Article  PubMed  Google Scholar 

  9. Dargel J, Pohl P, Tzikaras P, Koebke J (2006) Morphometric side-to-side differences in human cruciate ligament insertions. Surg Radiol Anat 28:398–402. https://doi.org/10.1007/s00276-006-0107-y

    Article  PubMed  Google Scholar 

  10. Dargel J, Schmidt-Wiethoff R, Feiser J et al (2011) Relationship between human femorotibial joint configuration and the morphometry of the anterior cruciate ligament. Arch Orthop Trauma Surg 131:1095–1105. https://doi.org/10.1007/s00402-011-1345-y

    Article  PubMed  Google Scholar 

  11. Deutsch A, Veltri DM, Altchek DW, Potter HG, Warren RF, Wickiewicz TL (1994) Symptomatic intraarticular ganglia of the cruciate ligaments of the knee. Arthroscopy 10:219–223. https://doi.org/10.1016/s0749-8063(05)80098-2

    Article  CAS  PubMed  Google Scholar 

  12. Ellison AE, Berg EE (1985) Embryology, anatomy, and function of the anterior cruciate ligament. Orthop Clin North Am 16:3–14

    Article  CAS  Google Scholar 

  13. Estes K, Cheruvu B, Lawless M, Laughlin R, Goswami T (2015) Risk assessment for anterior cruciate ligament injury. Arch Orthop Trauma Surg 135:1437–1443. https://doi.org/10.1007/s00402-015-2292-9

    Article  CAS  PubMed  Google Scholar 

  14. Fuss FK (1989) Anatomy of the cruciate ligaments and their function in extension and flexion of the human knee joint. Am J Anat 184:165–176. https://doi.org/10.1002/aja.1001840208

    Article  CAS  PubMed  Google Scholar 

  15. Gardner E, O’Rahilly R (1968) The early development of the knee joint in staged human embryos. J Anat 102(Pt 2):289–299

    CAS  PubMed  PubMed Central  Google Scholar 

  16. Gupte CM, Bull AM, Thomas RD, Amis AA (2003) A review of the function and biomechanics of the meniscofemoral ligaments. Arthroscopy 19:161–171. https://doi.org/10.1053/jars.2003.50011

    Article  PubMed  Google Scholar 

  17. Harner CD, Baek GH, Vogrin TM, Carlin GJ, Kashiwaguchi S, Woo SL (1999) Quantitative analysis of human cruciate ligament insertions. Arthroscopy 15:741–749. https://doi.org/10.1016/s0749-8063(99)70006-x

    Article  CAS  PubMed  Google Scholar 

  18. Harner CD, Livesay GA, Kashiwaguchi S, Fujie H, Choi NY, Woo SL (1995) Comparative study of the size and shape of human anterior and posterior cruciate ligaments. J Orthop Res 13:429–434. https://doi.org/10.1002/jor.1100130317

    Article  CAS  PubMed  Google Scholar 

  19. Harner CD, Xerogeanes JW, Livesay GA et al (1995) The human posterior cruciate ligament complex: an interdisciplinary study. Ligament morphology and biomechanical evaluation. Am J Sports Med 23:736–745. https://doi.org/10.1177/036354659502300617

    Article  CAS  PubMed  Google Scholar 

  20. Hoher J, Scheffler S, Weiler A (2003) Graft choice and graft fixation in PCL reconstruction. Knee Surg Sports Traumatol Arthrosc 11:297–306. https://doi.org/10.1007/s00167-003-0408-1

    Article  PubMed  Google Scholar 

  21. Hoteya K, Kato Y, Motojima S et al (2011) Association between intercondylar notch narrowing and bilateral anterior cruciate ligament injuries in athletes. Arch Orthop Trauma Surg 131:371–376. https://doi.org/10.1007/s00402-010-1254-5

    Article  PubMed  Google Scholar 

  22. Kim M, Lee S, Lee BG, Paik DJ, Bae J (2014) The medial synovial fold of the posterior cruciate ligament: cadaveric investigation together with magnetic resonance imaging and histology. J Comput Assist Tomogr 38:503–506. https://doi.org/10.1097/rct.0000000000000089

    Article  PubMed  Google Scholar 

  23. Krudwig WK, Schulte KK, Heinemann C (2004) Intra-articular ganglion cysts of the knee joint: a report of 85 cases and review of the literature. Knee Surg Sports Traumatol Arthrosc 12:123–129. https://doi.org/10.1007/s00167-003-0372-9

    Article  CAS  PubMed  Google Scholar 

  24. Lee DY, Kim DH, Park JS et al (2014) Systematic review of cadaveric studies on anatomic posterior cruciate ligament reconstruction: the landmarks in anatomic posterior cruciate ligament reconstruction. Knee Surg Relat Res 26:191–198. https://doi.org/10.5792/ksrr.2014.26.4.191

    Article  PubMed  PubMed Central  Google Scholar 

  25. Mao Y, Dong Q, Wang Y (2012) Ganglion cysts of the cruciate ligaments: a series of 31 cases and review of the literature. BMC Musculoskelet Disord 13:137. https://doi.org/10.1186/1471-2474-13-137

    Article  PubMed  PubMed Central  Google Scholar 

  26. Mérida-Velasco JA, Sánchez-Montesinos I, Espín-Ferra J, Mérida-Velasco JR, Rodríguez-Vázquez JF, Jiménez-Collado J (1997) Development of the human knee joint ligaments. Anat Rec 248:259–268. https://doi.org/10.1002/(SICI)1097-0185(199706)248:2%3c259::AID-AR13%3e3.0.CO;2-O

    Article  PubMed  Google Scholar 

  27. Mihata LC, Beutler AI, Boden BP (2006) Comparing the incidence of anterior cruciate ligament injury in collegiate lacrosse, soccer, and basketball players: implications for anterior cruciate ligament mechanism and prevention. Am J Sports Med 34:899–904. https://doi.org/10.1177/0363546505285582

    Article  PubMed  Google Scholar 

  28. Moorman CT 3rd, Murphy Zane MS, Bansai S et al (2008) Tibial insertion of the posterior cruciate ligament: a sagittal plane analysis using gross, histologic, and radiographic methods. Arthroscopy 24:269–275. https://doi.org/10.1016/j.arthro.2007.08.032

    Article  PubMed  Google Scholar 

  29. Odensten M, Gillquist J (1985) Functional anatomy of the anterior cruciate ligament and a rationale for reconstruction. J Bone Joint Surg Am 67:257–262

    Article  CAS  Google Scholar 

  30. Parish EN, Dixon P, Cross MJ (2005) Ganglion cysts of the anterior cruciate ligament: a series of 15 cases. Arthroscopy 21:445–447. https://doi.org/10.1016/j.arthro.2004.12.008

    Article  PubMed  Google Scholar 

  31. Reiman PR, Jackson DW (1987) Anatomy of the anterior cruciate ligament. In: Jackson DW, Drez D (eds) The anterior cruciate deficient knee: new concepts in ligament repair. CV Mosby & Co, St. Louis, pp 17–26

    Google Scholar 

  32. Sayampanathan AA, Koh TH, Lee KT (2016) Anterior cruciate ligament ganglion causing flexion restriction: a case report and review of literature. Ann Transl Med 4:219

    Article  Google Scholar 

  33. Schindler OS (2014) “The Sneaky Plica” revisited: morphology, pathophysiology and treatment of synovial plicae of the knee. Knee Surg Sports Traumatol Arthrosc 22:247–262. https://doi.org/10.1007/s00167-013-2368-4

    Article  PubMed  Google Scholar 

  34. Schmeiser G, Hempfling H, Bühren V et al (2001) The popliteal region an anatomical study and a new approach to the tibial attachment of the posterior cruciate ligament. Surg Radiol Anat 23:9–14. https://doi.org/10.1007/s00276-001-0009-y

    Article  CAS  PubMed  Google Scholar 

  35. Schulz MS, Russe K, Weiler A, Eichhorn HJ, Strobel MJ (2003) Epidemiology of posterior cruciate ligament injuries. Arch Orthop Trauma Surg 123:186–191. https://doi.org/10.1007/s00402-002-0471-y

    Article  CAS  PubMed  Google Scholar 

  36. Tena-Arregui J, Barrio-Asensio C, Viejo-Tirado F, Puerta-Fonollá J, Murillo-González J (2003) Arthroscopic study of the knee joint in fetuses. Arthroscopy 19:862–868. https://doi.org/10.1016/s0749-8063(03)00739-4

    Article  PubMed  Google Scholar 

  37. Tilmann B (1974) Zur funktionellen Morphologie der Gelenkentwicklung. Orthop Prax 12:328–342

    Google Scholar 

  38. Vaishya R, Esin Issa A, Agarwal AK, Vijay V (2017) Anterior cruciate ligament ganglion cyst and mucoid degeneration: a review. Cureus 9:e1682. https://doi.org/10.7759/cureus.1682

    Article  PubMed  PubMed Central  Google Scholar 

  39. Vielgut I, Weiglein A, Biber SM et al (2020) Successful reconstruction of the posterior cruciate ligament: assessment of posterior cruciate ligament footprints using an objective coordinate system. Surg Radiol Anat 42:1219–1223. https://doi.org/10.1007/s00276-020-02520-9

    Article  PubMed  PubMed Central  Google Scholar 

  40. Wang CJ, Chen C, Chen LM, Yeh WL (2000) Posterior cruciate ligament and coupled posterolateral instability of the knee. Arch Orth Traum Surg 120:525–528. https://doi.org/10.1007/s004020000141

    Article  CAS  Google Scholar 

  41. Yoon KH, Tak DH, Park JS, Joo YB, Lee S (2016) Medial Synovial fold of the posterior cruciate ligament on knee magnetic resonance imaging and arthroscopy: retrospective investigation of impingement. J Comput Assist Tomogr 40:799–802. https://doi.org/10.1097/rct.0000000000000429

    Article  PubMed  Google Scholar 

Download references

Funding

No funds, grants, or other support was received.

Author information

Authors and Affiliations

  1. Thessaloniki Minimally Invasive Surgery (The-MIS) Orthopaedic Center, St. Luke’s Hospital, 55236, Thessaloniki, Greece

    Ioannis Terzidis, Efthymios Papasoulis, Theodorakys Marin Fermin & Trifon Totlis

  2. Department of Traumatology, Hospital Universitario Periferico de Coche, Caracas, Venezuela

    Theodorakys Marin Fermin

  3. Department of Anatomy and Surgical Anatomy, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece

    Trifon Totlis

Authors
  1. Ioannis Terzidis
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Efthymios Papasoulis
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Theodorakys Marin Fermin
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Trifon Totlis
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the study conception and design. Patient management and surgical treatment were performed by IT. EP and TT prepared the MRI and arthroscopic figures. The first draft of the manuscript was written by TMF and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Trifon Totlis.

Ethics declarations

Conflict of interest

The authors have no relevant financial or non-financial interests to disclose.

Ethical approval

All procedures performed were in accordance with the ethical standards of the institutional Scientific Committee (IRB) and with the 1964 Helsinki Declaration and its later amendments. The Scientific Committee (IRB) of St. Luke’s Hospital approved this study.

Consent to participate

Written informed consent was obtained from the patient.

Consent for publication

The participant has consented to the submission of the case report to the journal.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Terzidis, I., Papasoulis, E., Marin Fermin, T. et al. Inverted deltoid posterior cruciate ligament femoral insertion accompanied with medial synovial fold: a case of a complex posterior cruciate ligament anatomical variation recalcitrant to conservative treatment . Surg Radiol Anat 43, 1667–1672 (2021). https://doi.org/10.1007/s00276-021-02801-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00276-021-02801-x

Keywords

Search

Navigation