Learning from Cases
This case was judged to be triggered by knee pain.
It's important to know about these cases because knee pain is one of the most common symptoms.
What is the case?
A 61-year-old woman was referred to a knee surgeon with a 6-month history of pain in the distal left anterior thigh with ipsilateral knee instability and stiffness.
The pain was aggravated by walking up and down stairs, squatting, and kneeling, and was worse at night, but was relieved by resting with the knee extended.
Otherwise, the patient was doing well with no history of previous knee injuries.
She had the strength to walk six miles daily for many years. Her significant medical history included shock wave treatment for left rotator cuff calcification many years ago. On examination, the patient had 3-4 cm of tenderness proximal to the left patella associated with effusion and quadriceps muscle wasting.
Simple radiographs and an MRI scan of the left knee were then performed.
Now, let's anticipate the diagnosis.
Diagnosis.
The radiographic appearance and MRI signal changes confirmed calcification rather than ossification or intussusception. Electrolytes and renal function, bone profile, parathyroid hormone, ESR and CRP were unremarkable.
Despite conservative management, her symptoms persisted and she underwent surgery. The surgical procedure began with arthroscopy.
Synovitis was identified in the suprapatellar bursa where a focal area of calcified material protruded from the quadriceps tendon.
An arthroscopic shaver was used to resect the calcified deposits prior to open surgery. A 12-cm longitudinal incision in the distal anterior thigh was used to expose the quadriceps tendon, and approximately 10% of the tendon was resected to remove as much visible calcification and surrounding paste-like material as possible.
Calcified foci in deeper portions of the tendon, including the vastus lateralis, were preferentially removed. After the synovial layer was closed, the remaining tendon was tubularized and the wound was closed.
On the third day after surgery, the knee was extended and the patient was discharged from the hospital, fully weight bearing on the left leg.
Her striae gradually decreased, allowing progressive flexion for four weeks.
Two weeks after the surgery, the patient was more comfortable than before the surgery. Histology of the resected material revealed chronic inflammatory synovium as well as fibrous tissue with aggregates of calcified material, without evidence of dysplasia or malignancy.
Ten months after surgery, the patient was pain free and able to flex the left knee to 120°. The Fulkerson modification of the Lysholm score was 99/100.
Conclusion
This was a case of calcific tendonitis.
This kind of calcification itself is not very uncommon.
As a matter of fact, I often meet people who have a history of calcification.
Physiologically, I have never heard of a way to completely prevent calcification.
What I have been told is that if you want to prevent it, you need to avoid chronic inflammation. Exercise is a great thing, and it is important, but it is important to control the frequency and load.
