An Unusual Case of Lateral Knee Calcific Tendonitis within the Popliteofibular Ligament-Arcuate Complex: A Novel Minimally Invasive Treatment Option

Acute calcinosis of the ligaments and soft tissues surrounding the knee joint is a rare pathology typically presenting with acute pain. Here we describe a 40 year old lady who presented with acute lateral knee pain which was subsequently confirmed on MRI scan to be caused by calcification within the popliteofibular ligament-arcuate complex. After failure of simple analgesia, full resolution of symptoms was achieved using ultrasound guided therapeutic needle aspiration (barbotage) and steroid injection. Reviewing the literature there is a small series of cases of calcific tendonitis in the knee. However to our knowledge this is the first documented case specifically involving the popliteofibular ligament-arcuate complex and the successful management with ultrasound-guided barbotage and steroid injection. Davis J*, Smith G and Leigh W Department of Orthosports, Millennium Institute of Sport and Health, New Zealand Davis J, et al., Annals of Clinical Case Reports Orthopedics Remedy Publications LLC., | http://anncaserep.com/ 2016 | Volume 1 | Article 1129 2 Discussion Throughout the literature acute calcinosis of the soft tissues surrounding the joint is described using a variety of names, perhaps most appropriately referred to as “calcific periarthritis” [20]. It results from the deposition of hydroxyapatite crystals in periarticular soft tissues [20]. Such calcifications may remain asymptomatic in up to 65% of people and blood tests are of limited utility in the absence of overt inflammation [20]. Initially thought to be a form of dystrophic calcification resulting from repeated trauma, the exact pathophysiology remains unclear [21]. Surprisingly, metabolic disturbances involving calcium and phosphate rarely contribute [21]. Although most commonly described when involving the shoulder joint, classically the supraspinatus tendon, the literature is rich with descriptions of calcific periarthritis affecting other sites including the hip, wrist, elbow, hand, neck and the knee [20-21]. Clinically, it presents with acute pain, however, depending on the location of the tissues involved it can present with other clinical signs often mimicking other common pathologies [20]. For example, when involving the knee joint it may cause fixed-flexion deformities, “locked-knee” or even sciatic nerve irritation [20-21]. Therapeutic needle aspiration (barbotage) of the calcium deposits is a well described and recognised management option in the treatment of refractory supraspinatus tendinitis [20]. Although the efficacy of barbotage is yet to be tested by means of a rigorous randomised control trial, a 2014 systematic review which included over 900 patients concluded that ultrasound-guided barbotage is a safe procedure with a high success rate and a low complication rate [22]. To put this case in context our research team conducted acomprehensive literature review. Using the keywords “calcinosis+ and + knee” across Medline (both EBSCO and Ovid), CINAHL,Cochrane and Up-to-date databases. This resulted in a total of 19case reports involving calcinosis around the knee (7 MCL, 6 LCL, 4popliteal, 1 ACL, 1 PCL) [1-19]. Specifically, no cases were identifiedthat made specific mention to the popliteofibular ligament-arcuatecomplex. The management strategies employed in these casesranged from conservative (simple analgesia and steroid injection)to operative (surgical excision of the calcification). Nowhere to ourknowledge was there a case which described the usage of ultrasoundguided barbotage together with steroid injection in the managementof calcific periarthritis of the knee joint.Unfortunately, the low prevalence of this pathology precludesthe possibility of a rigorous randomized comparison of operative andnon-operative interventions. However, based on our experience withthis case we suggest the consideration of ultrasound-guided barbotageand steroid injection as a possible early therapeutic option in themanagement of these patients, potentially allowing the avoidance ofunnecessary surgical and anaesthetic risk.AcknowledgementsWe would like to thank our patient for allowing us to presenttheir case. Dr Anthony Lawson (Radiologist).References 1. Tibrewal SB. Acute calcific tendinitis of the popliteus tendonan unusualsite and clinical syndrome. Ann R Coll Surg Engl. 2002; 84: 338-341. 2. White WJ, Sarraf KM, Schranz P. 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