 Greetings from Trichy Esaram Medical College. Good day everyone. Today we are going to see about Sainovel Nei Pleike, a bouquet of case series. Introduction. Sainovel Pleike of the Nei are folds in the lining of the joint, thought to represent as remnants from embryologic development. They are common incidental findings on cadaveric pathroscopic and MRA examinations. The infrapatular Pleike was first reported by the Salias in the 16th century. Median lateral and suprapatular Pleike were described by the early 20th century. A possible association of Pleike with Nei derangement was first suggested in 1918. 15 was the first investigated to focus on Pleike as an etiology for Nei symptoms in 1980. Embryology of the Nei Sainovel Pleike. The Nei develops from mesodermal elements and is initially separated into three compartments. Median lateral and suprapatular. The membrane separating the compartments is resolved between the 19th to 12th week of gestation forming a single joint compartment by the 16th week. One theory of Pleike formation hypothesize that the Pleike are remnants of this embryologic membrane which are not properly resolved. Another theory of Pleike formation is based on the observation that the Nei is initially filled with mesotermal tissue at 7 weeks of gestation. Cavitations within the mesoterm pile us to form the joint cavity by 10 weeks. In this theory, Pleike are thought to represent areas of incomplete cavitation with differentiation of residual mesotermal tissue into Sainovel folds. Anatomy of Nei Sainovel Pleike. On gross examination, normal Pleike are thin, flexible folds with a Sainovel lining around fibroelastic connective tissue protruding into the joint. The corresponding MRI appearance is a thin, linear, high-pointed object in the joint which is connected to the Sainovel lining outlined by joint fluid. Medial Patellar Pleike classification. Medial Patellar Pleike may become inflamed and symptomatic by many different mechanisms. Direct trauma, pristine injury, repetitive motion, increased activity, surgery and various causes of intraarticular Sainovelitis have all been reported as etiologies. Inflamed Pleike become thickened and fibroetic often with irreblem margins. Such Pleike are less flexible and more likely to cause mechanical symptoms during normal joint movement such as snapping as it moves over the medial femoral droplet and patella. Inflammation of the Pleike may be painful as the disease progresses. Associated articular cartilage loss and traction on adjacent Sainovel contribute to patient symptoms. The left side image shows the Sakakibara classification of medial Patellar Pleike. This is the type A, this is the type B and this is the type C and this one is the type D of Sakakibara classification of medial Patellar case illustration 1. Normal Sakakibara type A medial Patellar Pleike. Axial and sedative fat suppressed FSC proton density weighted images in a 41 year old male demonstrate a thin uniform hypo intense band in medial joint outlined by a joint effusion. Case illustration 2. Progressive thickening of a type B medial Patellar Pleike over Sainovelis. Axial fat suppressed FSC proton density weighted images of a 45 year old male initially demonstrate a normal thin medial Patellar Pleike shown by the arrow. Follow-up MRI 7 months later reveals a prominent thickening of the medial Pleike shown by this arrow with intramedial intrasubstance heterogeneous signal a loose body is also visible in the lateral gutter. Case illustration 3. Normal type C medial Patellar Pleike. Axial FSC proton density weighted images in a 57 year old male with anterior knee pain reveals a prominent irregular medial Patellar Pleike in the medial Patellar Pneumomeral joint shown by this arrow. Articular partilage, thinning and surface fragmentation are present along the lower medial Patellar shown by this arrow heads. Case illustration 4. Normal type D medial Patellar Pleike a 56 year old female presented with anterior knee pain. Axial and sagittal fat suppressed FSC proton density weighted images reveal a thickened medial Patellar Pleike with the essential perforation protruding into the Patellar Fumeral joint. Associated Articular Partilage population with subconvial marrow edema shown by this arrow heads in the medial Patellar. Infra-Patellar Pleike. A wheat classified by Kim et al. into four types based on morphology including the separate type completely separated from the ACL which accounts for 60.5%. The split type separate from the ACL and loyally divided which accounts for 13.5%. A vertical septum type attached to the ACL which accounts 10.5% and the fenestrat type similar to the vertical septum type with the fenestration. The Infra-Patellar Pleike was completely absent in 14.5% of their orthoscopic series. Infra-Patellar Pleike. Acute injury causing sprain or tear of the Infra-Patellar Pleike can result in hematheosis pain and a locking sensation. Less commonly the Infra-Patellar Pleike may become inflamed and symptomatic without acute injury similar to immediate Patellar Pleike. Compartmentalization due to a complete septum separating the median and lateral compartments can occur but is rare. On MR imaging normal Infra-Patellar Pleike are thin and often difficult to distinguish from the adjacent ACLs. A normal cleft in the Infra-Patellar fat pad may occur in up to 90% of patients just below the Infra-Patellar Pleike known as the horizontal cleft of the Infra-Patellar fat pad or ligamentum mucosum crisis. This cleft may be distended by joint fluid containing interarticular bodies or other pathology. Case illustration 5. Normal Infra-Patellar Pleike. A sagittal FSC proton density weighted image in a 47-year-old female visualizes a normal Infra-Patellar Pleike shown by these arrows coursing anterior to the ACL into the Infra-Patellar fat pad curving upward to the lower pole of the Patellar. Case illustration 6. Antromedial meniscofumeral ligament. Sagittal GRE and coronal FSC still images in a 72-year-old female demonstrate a band-like structure anterior to the ACL attaching to the anterior horn of the median meniscofumeral ligament near the meniscofumeral ligament. This ligament is very similar in appearance to the Infra-Patellar Pleike on sagittal images but is more medial in location and does not extend into the Infra-Patellar fat pad. Case illustration 7. A 47-year-old male with anterior knee pain and swelling for two months. The ACL in sagittal images demonstrate a thick irregular medial synovial pleica protruding far into the medial Patellar FSC nearly contacting the median ridge of the Patellar which are shown by these arrows. Senior Articular Patellar Loss is present along the lower medial Patellar and these findings are consistent with the chronically inflamed medial pleica and erosion of adjacent Articular Patellar Loss. Incidentally noted is a normal lateral Patellar pleica shown by this short arrow. Case illustration 8. A 58-year-old female with increasing supra-patellar pain and focal swelling for one year. On sagittal images a loculated fluid correction shown by the asterisk is in the supra-patellar bursa is separated from the remainder of the knee joint by a well-defined thin hypo intense septation consistent with a supra-patellar pleica causing compartmentalization. Fluid trap above the pleica extends the bursa contributing to pain and causing applicable abnormality on physical examination. The coronal image reveals diffuse synovitis within the joint relatively sparing the supra-patellar loculation. Case illustration 9. 15-year-old male football player with certain onset of anterior knee pain during football practice Diffuse edema is visible on the sagittal and axial fat-suppressed FSC proton density weighted images within an irregular fat-patellar pleica legamentum mucosum just anterior to the intact ACL extending into the infra-patellar fat pad. Intermediate signal thickening is presented on the T1 weighted images corresponding to the legamentum mucosum. Edema in the fat pad is focal and curvilinear shown by his arrowheads located along the usual course of the infra-patellar pleica. These findings are consistent with an acute sprain of the infra-patellar pleica. Case illustration 10. A 55-year-old male with anterior lateral pain axial and coronal fat-suppressed FSC proton density weighted images demonstrate prominent irregular thickening of the lateral-patellar pleica with shaggy margins and intersubstance heterogeneous signal consistent with inflammation of the pleica. Case illustration 11. Two different patients with prominent horizontal clefs of the infra-patellar fat pad. A sagittal FSC T2 weighted image in a 44-year-old male with a joint effusion demonstrates the joint filling the horizontal cleft. Note that the infra-patellar pleica forms the roof of the cleft. Sagittal and coronal fat-suppressed FSC proton density weighted images in a 71-year-old male reveal a cluster of small cartilaginous loose bodies and debris large in the cleft. Case illustration 12. Edema in the infra-patellar fat pad extending along the infra-patellar pleica a 68-year-old female presents with persistent anterior pain after an injury. Sagittal T1 weighted and the fat suppressed FSC proton density weighted images reveal edema in the infra-patellar fat pad surrounding the infra-patellar pleica shown by these arrows. Edema is more extensive than in case shown earlier and probably indicates contusion and inflammation of the infra-patellar fat pad in addition to the frame of the supra-patellar pleica. The Zidane classification of supra-patellar pleica describes four types. Type 1 is a complete septum without communication between the knee joint and supra-patellar balsa. Type 2 is a perforated septum with one or multiple openings allowing passage of fluid. Type 3 demonstrates a small archivate pleica usually medial and type 4 representing complete absence of pleica. Case illustration 13 the thickened supra-patellar pleica with cartilaginous loose body in the supra-patellar pleica 39-year-old male with pain and swelling for 2 weeks Sagittal FSC T2 weighted images and the internal fat suppressed FSC proton density weighted images demonstrate a near complete Zidane 2 thickened and irregular supra-patellar pleica with a hypoendronous body large in the supra-patellar balsa Case illustration 14 compartmentalization of the supra-patellar balsa due to a complete supra-patellar pleica 15-year-old male patient presented after trauma with hematosis and palpable supra-patellar mass. Sagittal T1 weighted sagittal stiff and coronal sagittal T1 weighted images demonstrate a complex loculatel collection in the supra-patellar balsa separated from the remainder of the knee by a thick Zedane type 1 complete supra-patellar pleica. Hematosis in the knee is hyper intense on the T1 weighted images and does not involve the balsa. Case illustration 15 Lycoma Aghoracens is involving the supra-patellar pleica 40-year-old male with chronic sinusitis and swelling. Sagittal T1 weighted sagittal fat suppressed FSC proton density weighted coronal fat suppressed FSC proton density weighted images demonstrate Willers Lycoma Aghoracens synovial proliferation surrounding a thickened supra-patellar pleica. Case illustration 16 PVNS environmentally involving the supra-patellar balsa 30-year-old male with intermittent pain and swelling for one year. Sagittal FSC proton density weighted sagittal and coronal fat suppressed FSC proton density weighted images reveal multiple intermediate to low signal masses in the supra-patellar balsa shown by these asterisks. Zedane type 2 supra-patellar pleica shown by the arrow confines most of the synovial masses to the supra-patellar balsa but smaller lesions shown by the arrow heads can pass through the quota into the remainder of the joint. Lateral Patellar Pleica Most authors report a frequency of 1-3% who lose it all from an incidence of 20.7% on orthoscopy and 50% at gadauring dissection. The lateral Patellar Pleica can become inflamed and fibrotic like other pleica. Patients with lateral Patellar Pleica syndrome may report lateral pain and snapping on physical examination. A palpable lateral cut may be present with associated tenderness. The image on the left shows the lateral Patellar Pleica which is the least common of the four neat pleica. Case illustration 17 prominently thickened cut-like lateral Patellar Pleica 34-year-old male with anterolateral snapping, sensation and pain for three weeks. Coronel such as an axial fat suppress, FSC proton density weighted images reveal a prominent band-like ipoint and subject in the anterolateral knee joint shown by the arrows consistent with the thickened lateral pleica. A thin medial pleica shown by the arrowhead is also visible in the axial images. Treatment. Conservative treatment of symptomatic pleica includes arrest, NSAIDs to reduce inflammation and pain and physical therapy. Intraarticular or intrapleica injection of medication may be useful in some patients. If symptoms persist complete the section of the symptomatic pleica usually results in long-term relief. Division of incomplete section of a pleica may result in healing of the pleica with recurrence of symptoms. Surgery for a complete or near-complete suprapatellar pleica may require careful planning to avoid contamination with pathology confined to the suprapatellar compartment. Signable pleica of the knee are normal anatomic structures frequently encountered at MR imaging and orthroscopy. Most pleica occasionally pleica may become inflamed and thickened causing pain and cartilage damage with mechanical symptoms. Compartmentalization of the suprapatellar bursar due to a complete or near-complete suprapatellar pleica can produce a palpable abnormality along with pain. Diagnosis of symptomatic pleica is based on clinical findings. MRA can detect abnormal pleica as well as other intraarticular pathology which may happen for patient symptoms. The radiologist should document the presence and morphology of pleica associated with control abnormalities and other pathology which may cause patient symptoms. These are the references for my presentation.