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Review
. 2019 Dec;22(4):471-476.
doi: 10.1007/s40477-018-0353-y. Epub 2019 Feb 27.

Treatment of a calcific bursitis of the medial collateral ligament: a rare cause of painful knee

Lisa Galletti  1 , Vincenzo Ricci  2 , Ernesto Andreoli  3 , Stefano Galletti  4
Affiliations
Review

Treatment of a calcific bursitis of the medial collateral ligament: a rare cause of painful knee

Lisa Galletti et al. J Ultrasound. 2019 Dec.

Abstract
in English, Italian

Medial knee pain is common in clinical practice and can be caused by various conditions. In rare cases, it can even be by calcific bursitis of the medial collateral ligament (MCL). Treatment of calcific bursitis and/or calcification of the MCL classically includes observation, local injections, shockwave therapy and surgical resection. We report a case of nontraumatic medial knee pain poorly responsive to conservative treatments. Ultrasound (US) imaging revealed a massive lobed hyperechoic formation with partial acoustic shadow in the MCL context compatible with calcific bursitis, and magnetic resonance imaging (MRI) confirmed the presence of the bursa's calcific deposit surrounded by hyperintense signal compatible with pericalcific edema. We performed a double-needle ultrasound-guided percutaneous lavage (UGPL), which is today a fairly common treatment for many musculoskeletal disorders, such as rotator cuff calcific tendinopathy and elbow extensor tendons pathology, but regarding the knee, it is not part of ordinary care. This report shows the clinical and imaging presentation of calcific bursitis of the MCL and describes in detail the technique to perform the UGPL with a system of two needles, two syringes and a double connection to ensure a correct lavage of the calcium deposit without significant intrabursal pressure increase and consequently without pain during the procedure.

Il dolore localizzato alla regione mediale del ginocchio è di frequente riscontro nella pratica clinica e può essere causato da diverse condizioni patologiche, in rari casi anche da una borsite calcifica del legamento collaterale mediale (LCM). Il trattamento di una borsite calcifica e/o di una calcificazione del LCM prevede classicamente il monitoraggio clinico, le infiltrazioni locali, la terapia con onde d’urto ed infine la rimozione chirurgica. Riportiamo un caso di dolore localizzato alla regione mediale del ginocchio, non traumatico, scarsamente responsivo ai trattamenti conservativi. La valutazione ecografica ha rivelato la presenza di una voluminosa formazione iperecogena polilobata con parziale cono d’ombra posteriore nel contesto del LCM, compatibile con una borsite calcifica intra-ligamentosa; le scansioni di risonanza magnetica nucleare (RMN) hanno confermato la presenza del deposito endo-bursale circondato da segnale iperintenso compatibile con edema peri-calcifico. Abbiamo quindi eseguito una procedura di lavaggio percutaneo eco-guidato con due aghi, che ad oggi rappresenta un trattamento ampiamente utilizzato per diverse patologie del sistema muscolo scheletrico come la tendinopatia calcifica della cuffia dei rotatori della spalla e la patologia calcifica degli estensori di gomito, mentre per il ginocchio non rientra nei trattamenti eseguiti di routine. Questo articolo illustra le caratteristiche cliniche ed ecografiche della borsite calcifica del LCM ed ha l’obiettivo di descrivere in dettaglio la tecnica per eseguire un lavaggio percutaneo eco-guidato con un sistema di due aghi, due siringhe e un duplice tubo di raccordo per assicurare un completo lavaggio del deposito calcifico senza significativo aumento della pressione intra-bursale con l’obiettivo di minimizzare il dolore in corso di procedura.

Keywords: Calcific bursitis; Medial collateral ligament; Pain; Treatment; Ultrasound; Voshell’s bursa.

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Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
Schematic drawing shows a coronal section of the medial knee with a distended Voshell’s bursa (blue) between the superficial and the deep contingent of fibres of the MCL. MFC medial femoral condyle, T: tibia
Fig. 2
Fig. 2
Ultrasound imaging of the medial knee in coronal view shows the lobed calcific deposit (white arrows) in the MCL context (white arrowheads) with partial acoustic shadow (a). STIR coronal MRI of the left knee shows the calcification (white arrow) adjacent to the medial femoral condyle and the hyperintense pericalcific edema (asterisk) around it (b). T2-weighted axial MRI shows the extension of the calcific deposition in the posterior region of the knee (white arrow) (c). Ultrasound examination during the procedure of lavage shows the reduction of the calcification size and changes of the echostructure (white arrows) with disappearance of the partial acoustic shadow (d). MFC medial femoral condyle
Fig. 3
Fig. 3
In-plane visualization of the needle (white full arrow) during the procedure of lavage on the medial aspect of the knee (a). Real-time use of the two syringes, one to infuse under pressure the saline solution in the bursa and the other one to aspirate the washing liquid. This system allows controlling the intrabursal pressure and carrying out a minimally painful procedure for the patient (b). Clearance of the calcified fragments during the procedure of lavage (Cc)
Fig. 4
Fig. 4
Schematic drawing shows a closed circuit with two needles and connecting tubes. The technique involves the use of two syringes, one to infuse under pressure the saline solution in the bursa and the other one to aspirate the washing liquid. This system allows controlling the intrabursal pressure and carrying out a minimally painful procedure for the patient
See this image and copyright information in PMC

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