AJR 2004; 182:955-962
© American Roentgen Ray Society
Normal Anatomy and Pathology of the Posterior Capsular Area of the Knee: Findings in Cadaveric Specimens and in Patients
Michel De Maeseneer1,2,
Peter Van Roy1,
Maryam Shahabpour2,
Robert Gosselin2,
Filip De Ridder2 and
Michel Osteaux2
1 Department of Experimental Anatomy, Vrije Universiteit Brussel, Jette,
Belgium.
2 Department of Radiology, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090
Jette, Belgium.
Received April 7, 2003;
accepted after revision September 8, 2003.
Address correspondence to M. De Maeseneer
(midema{at}village.uunet.be).
Supported by the Katholieke Universiteit Leuven, Belgium, by means of the
Professor Doctor A. L. Baert Prize.
Introduction
The imaging anatomy of the medial and lateral supporting structures of the
knee has been previously described
[1–3].
Normal anatomy and pathology of structures making up the posteromedial and
posterolateral corners of the knee have also been discussed
[2]. However, to our knowledge
no articles have directly addressed the posterior capsular area of the knee at
the level of the popliteal fossa. This area is well depicted on sagittal MR
images. Fibers from the posteromedial and posterolateral knee do contribute to
the posterior capsule. From the medial side of the knee, a portion of the
distal semimembranosus tendon extends along the posterior aspect of the knee.
This portion is referred to as the oblique popliteal ligament
[1]. From the lateral side of
the knee, fibers from the arcuate ligament contribute to the posterior knee
capsule [3]. Pathologic
conditions commonly affect the posterior knee capsule or intercondylar area.
Hence, a correct understanding of the normal imaging anatomy of the posterior
capsular area is necessary for precise location of a lesion. Precise location
of a lesion is important for the surgical approach and for the differential
diagnosis.
We present the normal anatomy of the posterior capsular area based on an
MRI–anatomic correlation in three knee specimens, and we illustrate
anatomic findings with pathology cases that were retrospectively selected by
two authors from our osteoradiology teaching files. The three cadaveric knee
specimens were obtained from deceased elderly patients (65, 71, and 80 years
at the time of death) and were frozen. After the specimens were thawed, MRI
was performed in the coronal (n = 1), transverse (n = 1),
and sagittal (n = 1) planes. Anatomic slices corresponding to the MR
images were obtained with a band saw using a method described by Hodler et al.
[4]. MRI in specimens and
patients was performed on either a Gyroscan Intera clinical system (Philips)
or a Vision clinical system (Siemens) using routine MRI sequences.
Normal Anatomy of the Posterior Capsular Area
On sagittal anatomic slices, the structures making up the posterior knee
capsule were assessed and photographs were taken. On the most medial slices,
the capsule was well depicted as a thick bandlike structure adjacent to the
posterior horn of the medial meniscus (Fig.
1A,
1B). Superiorly, the capsule
attaches to the posterior femoral cortex a few centimeters above the level of
the most superior aspect of the joint cartilage. Inferiorly, the capsule
attaches to the posterior aspect of the tibia 1–2 cm below the level of
the joint line. A bursa is evident between the capsule and the semimembranosus
tendon. On more lateral slices, the semimembranosus tendon is replaced by the
medial gastrocnemius tendon, but similar relationships with the posterior knee
capsule are maintained. Superiorly, the knee capsule joins the medial
gastrocnemius tendon. A joint recess that is in continuity with the
intraarticular joint space is located posterior to the medial femoral condyle
and deep in relation to the capsule and medial gastrocnemius tendon.
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Fig. 1A. —Medial aspect of posterior knee in cadaver. Photograph of
sagittal anatomic slice of posterior knee capsule (medial side) shows capsule
is well delineated (1). Superiorly, capsule fuses (f) with more superficial
gastrocnemius tendon (arrows). Capsule attaches superiorly to cortex
of posterior femoral condyle, forming retrocondylar joint recess (r). Between
capsule and gastrocnemius tendon, portion of subgastrocnemius bursa
(asterisks) is seen.
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Fig. 1B. —Medial aspect of posterior knee in cadaver. Corresponding
sagittal proton density–weighted image (TR/TE, 2,400/18) shows capsule
has intermediate to low signal intensity (1). Tendon of medial gastrocnemius
muscle is also seen (arrows).
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Along the middle aspect of the knee, the anterior and posterior cruciate
ligaments can be seen (Fig. 2A,
2B). The cruciate ligaments are
in an extrasynovial but intraarticular location
[5]. Between the cruciate
ligaments is an area of fatty tissue that has previously been designated as
the "triangular space of the cruciate ligaments"
[5]. Small joint recesses are
located in front of the anterior cruciate ligament, and both in front of and
behind the posterior cruciate ligament. The posterior capsule in this area is
made up of thin fiber-like structures that incompletely separate
intraarticular from extraarticular fat. The popliteal artery and vein are
located behind the capsule, and openings in the capsule allow vascular
structures and nerves to penetrate the knee joint.
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Fig. 2A. —Intercondylar area of knee in cadaver. Photograph of sagittal
anatomic slice at intercondylar area shows posterior cruciate ligament (p).
Capsule is thin and incomplete (arrowheads) and contains perforations
that vascular and neural structures may penetrate (arrow). Popliteal
vessels (v) are seen superficially to capsule.
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Fig. 2B. —Intercondylar area of knee in cadaver. Corresponding proton
density–weighted image (TR/TE, 2,400/18) shows incomplete capsule as
hypointense bandlike structure (arrowheads). Perforations for
vascular and neural structures are seen (arrow). Cruciate ligaments
(C) are also shown.
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On sagittal slices obtained at the lateral side of the knee, the popliteal
hiatus is evident (Fig. 3A,
3B). The popliteal tendon has
an intraarticular but extrasynovial location and is firmly attached to the
posterior capsule. A popliteal recess may extend deep in relation to the
capsule and behind the posterior aspect of the tibia. The knee joint may show
continuity in this area with the proximal tibiofibular joint. More medially,
the posterior capsule receives contributions from the tendon of the lateral
gastrocnemius muscle and from the arcuate ligament.
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Fig. 3A. —Lateral aspect of posterior knee in cadaver. Photograph of
sagittal anatomic slice of posterior knee (lateral side) shows popliteal
hiatus adjacent to lateral meniscus (M). Note popliteal tendon
(asterisk) covered by synovium (arrow) and extrasynovial
location. Posterior capsule is reinforced by fibers originating from fibular
head (1). More superficially, part of lateral gastrocnemius tendon (g) is
seen.
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Fig. 3B. —Lateral aspect of posterior knee in cadaver. Corresponding MR
image (TR/TE, 2,400/18) shows meniscus (m) and popliteal tendon
(star). Capsular layer (c) and gastrocnemius tendon with intermediate
signal intensity are also seen.
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On T1- and proton density–weighted spin-echo MR images, the posterior
capsule can be seen as a bandlike area of intermediate signal intensity (Figs.
1A,
1B,
2A,
2B,
3A,
3B,
4A,
4B,
4C,
4D,
5,
6,
7,
8A,
8B). On T2-weighted spin-echo
MR images, the capsule can be well depicted as a band of low signal intensity
embedded in hyperintense fatty tissue. At the lateral side of the knee, a
small amount of fat is interposed between the meniscus and the capsule,
whereas medially the meniscus is more intimately attached to the capsule.
However, a small amount of fat may be evident behind the medial meniscus in
some patients. Superficially to the capsule, the tendons of the
semimembranosus, popliteus, and gastrocnemius muscles are evident. The
subgastrocnemius bursa did not contain any fluid in the examined cadaveric
specimens and hence is not depicted on MR images of these specimens. Also, the
internal synovial layer is too thin to be identified separately from the
capsule on MR images. The capsule is incomplete in the intercondylar area of
the knee.
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Fig. 4A. —Line drawings of posterior capsular area of knee. As seen on
most medial aspect, capsule is made up of capsule proper (c,
arrowhead), receiving fibers from semimembranosus (ME) tendon and
tendon sheath (thin arrow). Possible fluid collections in this area
extend from subgastrocnemius bursa (thick arrow) and deep (d) and
superficial (s) pockets of semimembranosus bursa. Also note meniscus (M).
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Fig. 4B. —Line drawings of posterior capsular area of knee. Drawing
shows insertion of medial gastrocnemius tendon (g) on femur. Capsule
(small arrowheads) is separated from medial gastrocnemius tendon by
subgastrocnemius bursa (s, arrowhead). Superiorly, capsule and
gastrocnemius tendon become inseparable. Superficially to gastrocnemius
tendon, Baker's cyst (B, arrowhead) is shown. Note extension of
intraarticular joint fluid (j, black area) along posterior aspect of
medial femoral condyle, deep in relation to capsule. Small bursa (b) is seen
at insertion site of gastrocnemius tendon on posterior femur. M =
meniscus.
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Fig. 4C. —Line drawings of posterior capsular area of knee. At
intercondylar area, capsule (arrowheads) is outlined by intra- and
extraarticular fatty tissue. Joint recess (a, curved arrow) can be
seen in front of anterior cruciate ligament (A). Posterior joint recess is
seen (p, curved arrow) behind posterior cruciate ligament (P).
Capsule is incomplete at intercondylar area and contains openings for vascular
structures and nerves to enter knee.
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Fig. 4D. —Line drawings of posterior capsular area of knee. Lateral
aspect of knee capsule (arrowheads) is intimately attached to lateral
gastrocnemius muscle and tendon (arrow). Popliteal tendon (p) is
intraarticular but extrasynovial and is attached to capsule. Fibers from
posterolateral corner (PL) and arcuate ligament originating from fibular head
contribute to capsule. M = meniscus.
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Fig. 5. —Line drawing in transverse plane illustrates relationships of
posterior capsule. Superficially (1, arrowheads), structures of
popliteal fossa are covered by superficial fascia. Deep in relation to fascia,
medial (mg) and lateral (lg) gastrocnemius muscles can be seen, as well as
biceps muscle (b) and semimembranosus (Sm) and semitendinosus (St) tendons.
Second layer (2, arrow) can be seen posteromedially and
posterolaterally. At level of posteromedial and posterolateral corners, this
layer is intimately fused with synovial layer (3, arrows). At
intercondylar area, synovium separates from capsule and covers cruciate
ligaments (AC, PC, arrowheads). Lateral collateral ligament (LCL) can
be seen in close proximity to posterolateral capsule.
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Fig. 6. —Transverse MR image (TR/TE, 2,400/18) shows posterolateral
and posteromedial capsule (white arrows). At intercondylar area,
capsule is poorly delineated (black arrows). Note fabella (f) in
origin of lateral gastrocnemius tendon. On medial side, note gastrocnemius
tendon (g) and more superficial semimembranosus tendon (m).
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Fig. 7. —Photograph of transverse anatomic section from cadaver shows
posterior capsular relationships. Capsule (c) is seen along posteromedial and
posterolateral sides and is inseparable from synovial layer. At intercondylar
area, synovium covers cruciate ligaments and adjacent fat (stars).
Capsule is discontinuous at intercondylar area (arrow). Note
subgastrocnemius bursa (b) and Baker's cyst (B) on posteromedial aspect of
knee.
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Fig. 8A. —Sagittal MR images (TR/TE, 3,000/22) in 32-year-old male
volunteer. Image of knee in extended position shows vascular structures (v) of
popliteal fossa. Capsule (arrows) is straightened but
discontinuous.
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Fig. 8B. —Sagittal MR images (TR/TE, 3,000/22) in 32-year-old male
volunteer. Image of knee in semiflexed position shows shortening and bowing of
capsule (straight arrow). Penetrating vascular structure (curved
arrow) can be seen entering knee joint through opening
(arrowheads) in capsule.
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Traumatic Injuries of the Posterior Capsule
The posterior capsule may be injured in hyperextension trauma. However,
injuries of the posterior capsule are often associated with lesions of the
menisci and the cruciate ligaments. MRI allows an accurate assessment of the
posterior knee capsule. In contradistinction, this knee region represents a
blind area for the arthroscopist. MRI signs of a tear of the posterior capsule
include frank disruption and high signal intensity in or adjacent to the
capsule on T2-weighted MR images. In the intercondylar area, however, normal
openings for the vascular structures and nerves may be present, and these
should not be confused with tears. In a chronic stage of injury after trauma,
the capsule may appear hypointense and thickened on T2-weighted MR images
(Fig. 9). Lesions may also
extend to the posteromedial and posterolateral corners of the knee.
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Fig. 9. —Sagittal T2-weighted MR image (TR/TE, 2,300/90) in
36-year-old man with medial meniscal tear at arthroscopy. Posterior capsule is
thickened and its outline is irregular (asterisks). Note fluid
reaction (f) superficially to capsule.
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Tears of the anterior cruciate ligament may be located at the ligament's
proximal insertion onto the lateral femoral condyle. Fluid collections
associated with anterior cruciate ligament rupture are not expected to extend
outside the posterior capsule. However, the capsule may be displaced by edema
and hematoma. Fluid may also be located in the triangular space between the
cruciate ligaments. Normally, no fluid can be seen in this region. However, at
the medial aspect of the knee, a small synovial recess may insert itself
between the anterior and posterior cruciate ligaments, and in some patients
joint fluid may normally collect in this area
(Fig. 10).
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Fig. 10. —Sagittal proton density–weighted spin-echo MR image
(TR/TE, 2,800/20) in 43-year-old man shows hematoma (h) related to rupture of
proximal portion of anterior cruciate ligament. Hematoma abuts capsule
(arrowheads) but does not extend through it.
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Intraarticular Effusion
Intraarticular fluid collections may extend around the cruciate ligaments.
Differentiating effusions from other cystic lesions located in the
intercondylar and posterior capsular areas of the knee may be difficult (Figs.
11,12,13).
Joint fluid is typically located in front of the anterior cruciate ligament.
Occasionally, this effusion extends into the Hoffa fat pad, forming a cleft
[6]. Joint fluid may also
collect behind the posterior cruciate ligament. In this instance, the fluid
must be differentiated from ganglionic cysts or meniscal cysts extending into
this locationic [7]. If
sagittal images remain inconclusive, axial images may show a direct
communication between the intercondylar fluid collection and the
intraarticular joint fluid adjacent to the posterior femoral condyles. The
triangular space between both cruciate ligaments normally does not contain
joint fluid [5]. However, on
the medial aspect a small invagination of joint fluid may be present.
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Fig. 11. —Sagittal T2-weighted MR image (TR/TE, 2,400/80) in
30-year-old man with meniscal tear shows fluid collection (fa, arrow)
with intraarticular location in front of anterior cruciate ligament. Fluid
collection results in slight cleavage (c) of Hoffa fat pad.
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Fig. 12. —Sagittal STIR image (TR/TE, 2,000/180; inversion time, 120
msec) in 30-year-old man with meniscal tear at arthroscopy shows
intraarticular fluid collections in recesses behind (fp) and in front of (fi)
posterior cruciate ligament.
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Fig. 13. —Transverse T2-weighted MR image (TR/TE, 2,000/80) in
58-year-old woman with medial and lateral degenerative meniscal tears at
arthroscopy shows fluid collection (black arrow) behind posterior
cruciate ligament. Collection extends posteriorly to medial femoral condyle
(white arrow), confirming its intraarticular nature. Superficially to
capsule, subgastrocnemius bursa (B) is seen deep in relation to gastrocnemius
tendon (gs). Extension of this bursa (arrowhead) is also seen deep in
relation to semimembranosus tendon (m). Subgastrocnemius bursa communicates
with superficial Baker's cyst (BC).
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Cystic Lesions
Cystic lesions located behind the posterior cruciate ligament may
correspond to ganglionic cysts or meniscal cysts. Ganglionic cysts may occur
in a variety of locations and usually are round or lobulated
[7]. When ganglionic cysts of
the posterior cruciate ligament become larger, they may displace the posterior
knee capsule (Fig. 14).
Ganglionic cysts of the anterior cruciate ligament tend to follow the course
of the ligament fibers, and differentiation from edema related to a recent
tear may occasionally be difficult
[7]. When they enlarge,
ganglionic cysts may penetrate the openings in the posterior knee capsule, and
portions of the cyst may show an extraarticular extension (Fig.
15A,
15B). A ganglionic cyst of the
anterior cruciate ligament also causes hyperintense signal intensity in the
triangular space of the cruciate ligaments on T2-weighted MR images.
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Fig. 14. —Sagittal T2-weighted spin-echo MR image (TR/TE, 2,400/80) in
43-year-old man shows ganglionic cyst (G) behind posterior cruciate ligament
(p). Note location of ganglionic cyst within joint, deep in relation to
capsule (arrowheads).
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Fig. 15A. —58-year-old man with ganglionic cyst of anterior cruciate
ligament. Sagittal T2-weighted spin-echo MR image (TR/TE, 2,000/80) shows
anterior cruciate ligament (G). Extension of portion of cyst (arrow)
through capsule (arrowheads) is also shown.
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Fig. 15B. —58-year-old man with ganglionic cyst of anterior cruciate
ligament. Sagittal T1-weighted spin-echo MR image (700/20) shows posterior
capsule (arrows). Note hypointense ganglionic cyst (g) of anterior
cruciate ligament and extension (e) of part of cyst through capsule.
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Lektrakul et al. [8]
reported that meniscal cysts of the posterior horn of the menisci can show an
extension in a median direction and thus become located adjacent to the
cruciate ligaments. A meniscal tear is usually evident, and the cyst is
located adjacent to the meniscal abnormality. No fluid is normally seen
between the capsule and the posterior aspect of the medial meniscus. When a
cystlike collection is seen posterior to the meniscus, it likely corresponds
to a meniscal cyst (Fig. 16).
However, some joint fluid may be located superiorly to the meniscus between
the femoral condyle and the capsule. Meniscal tears and meniscal cysts are not
common at the level of the posterior aspect of the lateral meniscus
(Fig. 17).
Bursae
Bursae may be present on the posteromedial aspect of the knee. At its
insertion site, the semimembranosus tendon is surrounded by a bursa. When an
effusion is present in this bursa, hyperintense signal intensity may also be
evident around the deep aspect of the tendon as superficial to the tendon
(Fig. 18).
The subgastrocnemius bursa also may extend between the capsule and the
semimembranosus tendon. This bursal component is located above the joint
space, whereas the semimembranosus bursa is located below the joint space
(Fig. 19A,
19B). The subgastrocnemius
bursa is mainly deep in relation to the subgastrocnemius tendon and
superficial in relation to the capsule of the knee joint. The bursa has a
slitlike communication with the more superficially located Baker's cyst.
Posterolaterally, fluid may surround the popliteal tendon and may extend
posteriorly to the tibia (Fig.
20).
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Fig. 19A. —Subgastrocnemius bursa and Baker's cyst in 58-year-old man
are seen on sagittal T2-weighted MR images (TR/TE, 4,500/99). Semimembranosus
tendon is seen proximal to its insertion on tibia (arrowheads). Note
fluid in extension of subgastrocnemius bursa (s) between capsule (c) and
tendon.
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Fig. 19B. —Subgastrocnemius bursa and Baker's cyst in 58-year-old man
are seen on sagittal T2-weighted MR images (TR/TE, 4,500/99). Image in more
lateral position than A shows fluid in Baker's cyst (BC), superficially
in relation to medial gastrocnemius tendon (g), and also between capsule
(arrowheads) and gastrocnemius tendon in subgastrocnemius bursa
(s).
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Fig. 20. —Popliteal bursa in 28-year-old man. Sagittal T2-weighted MR
image (TR/TE, 4,000/80) shows popliteal tendon (asterisk) attached to
posterior capsule (arrow). Capsule is intimately fused with lateral
gastrocnemius muscle (g) and tendon. Note extension of popliteal bursa behind
tibia (arrowhead).
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Tumors and Pseudotumors
Primary bone tumors or metastatic disease to the bone may penetrate the
posterior cortex at the level of the intercondylar area and then may invade
the triangular space of the cruciate ligaments as well as the ligaments
themselves. The posterior knee capsule may form only a weak barrier against
further posterior extension of the tumor; hence, tumors may penetrate the
capsule and extend into the popliteal fossa
(Fig. 21). The extension of
tumors into this area may be intraarticular, intracapsular, or extraarticular.
This extension may lead to a different surgical approach, so an accurate
description of the precise location as seen on MR images is mandatory.
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Fig. 21. —40-year-old man with bladder carcinoma. Sagittal T1-weighted
MR image (TR/TE, 760/15) shows bone metastasis (t) invading posterior cruciate
ligament (arrow), triangular space of cruciate ligaments
(asterisk), and posterior capsule (arrowheads).
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Typical synovial tumors that may be found in the knee include pigmented
villonodular synovitis. This tumor may show a diffuse or focal form. The focal
form may be found in different areas of the knee. Pigmented villonodular
synovitis may be located behind the posterior aspect of the intercondylar area
of the femur (Fig. 22). Tumors
in this location may be easily missed on routine MR images. The intercondylar
area should always be examined carefully in young patients who have
unexplained joint effusions or unexplained knee pain. In addition, in this
location tumors cannot be seen at arthroscopy because of their posterior
position. Surgery using an arthroscopic approach is impossible, and posterior
arthrotomy will often be necessary for treatment of these posterior
tumors.
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Fig. 22. —37-year-old man with focal pigmented villonodular synovitis.
Sagittal proton density–weighted MR image (TR/TE, 2,400/20) shows focal
pigmented villonodular synovitis (t) superior to posterior cruciate ligament
(asterisk) and behind posterior cortex of femur. Tumor has
intraarticular location that is deep in relation to capsule
(arrowheads).
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Pseudotumors of the posterior intercondylar area may correspond to
intraarticular loose bodies. These bodies may be located in the joint recesses
that insinuate between the cruciate ligaments and in more superficial bursae
such as Baker's cyst (Fig.
23).
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Fig. 23. —53-year-old man with degenerative joint disease. Sagittal
T2-weighted MR image (TR/TE, 2,400/70) shows intraarticular loose body
(white i) in normal joint recess behind posterior cruciate ligament
(arrow). Second loose body (black i) is seen in Baker's cyst
(b).
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Conclusion
We have described the imaging anatomy of the posterior capsule of the knee
using a systematic approach based on anatomic observations. We acknowledge
that the number of specimens was limited and may not take into account all
possible anatomic variations. A variety of traumatic conditions may be located
in or adjacent to the posterior knee capsule. We have presented a pictorial
overview of findings in patients with trauma, fluid collections, cystic
lesions, bursae, tumors, and pseudotumors. A good understanding of the normal
anatomy of the posterior knee capsule allows correct diagnosis of disorders
and is helpful in the differential diagnosis of the various conditions.
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Introduction
Normal Anatomy of the...
