Bruno Giuffre

Weight loss in obese people has structure-modifying effects on medial but not on lateral knee articular cartilage

Background Obesity is an important risk factor for knee osteoarthritis (OA), Weight loss can reduce the symptoms of knee OA. No prospective studies assessing the impact of weight loss on knee cartilage structure and composition have been performed. Objectives To assess the impact of weight loss on knee cartilage thickness and composition. Methods 111 obese adults were recruited from either laparoscopic adjustable gastric banding or exercise and diet weight loss programmes from two tertiary centres. MRI was performed at baseline and 12-month follow-up to assess cartilage thickness. 78 eligible subjects also underwent delayed gadolinium-enhanced MRI of cartilage (dGEMRIC), an estimate of proteoglycan content. The associations between cartilage outcomes (cartilage thickness and dGEMRIC index) and weight loss were adjusted for age, gender, body mass index (BMI) and presence of clinical knee OA. Results Mean age was 51.7±11.8 years and mean BMI was 36.6±5.8 kg/m2; 32% had clinical knee OA. Mean weight loss was 9.3±11.9%. Percentage weight loss was negatively associated with cartilage thickness loss in the medial femoral compartment in multiple regression analysis (β=0.006, r2=0.19, p=0.029). This association was not detected in the lateral compartment (r2=0.12, p=0.745). Percentage weight loss was associated with an increase in medial dGEMRIC in multiple regression analysis (β=3.9, r2=0.26; p=0.008) but not the lateral compartment (r2=0.14, p=0.34). For every 10% weight loss there was a gain in the medial dGEMRIC index of 39 ms (r2=0.28; p=0.014). The lowest weight loss cut-off associated with reduced medial femoral cartilage thickness loss and improved medial dGEMRIC index was 7%. Conclusions Weight loss is associated with improvements in the quality (increased proteoglycan content) and quantity (reduced cartilage thickness losses) of medial articular cartilage. This was not observed in the lateral compartment. This could ultimately lead to a reduced need for total joint replacements and is thus a finding with important public health implications.

Bone Bruises Associated With ACL Rupture Correlation With Injury Mechanism

Background Different patterns of bone bruising are seen on magnetic resonance imaging in acute anterior cruciate ligament ruptures. These patterns may relate to the mechanism of injury. Hypothesis There is a correlation between the mechanism of anterior cruciate ligament injury and bone bruise patterns on magnetic resonance imaging. Study Design Cohort study; Level of evidence, 2. Methods Data regarding the mechanism of anterior cruciate ligament rupture were collected prospectively on patients who had anterior cruciate ligament reconstructions. Inclusion criteria included a clear history of mechanism, magnetic resonance imaging within 6 weeks of injury, and no previous knee injury. Patients were divided into noncontact and contact mechanism groups. Bone bruise frequency, location, depth, and intensity were analyzed using magnetic resonance imaging and correlated with the mechanism of injury. Results Two hundred fifty-six patients were identified; 100 met the inclusion criteria, 86 were in the noncontact mechanism group, and 14 were in the contact mechanism group. The proportion of bone bruises in the lateral compartment in both groups was higher (P < .001) than in the medial compartment. Bone bruising was more frequent, deeper, and more intense in the non-contact group, with frequency (P = .019) and intensity (P < .001) scores reaching significance at the lateral tibial plateau. Medial compartment bone bruising was seen more frequently than previously reported, particularly in the noncontact group. Conclusion The noncontact mechanism appears to cause more severe bone bruising in both the medial and lateral compartments.

Articular Cartilage Changes in Patients With Osteoarthritis After Osteotomy

Background: High tibial osteotomy (HTO) is a method used to treat medial compartmental osteoarthritis in the knee. The realignment of the knee changes the loading patterns within the joint and may allow for regeneration of articular cartilage. Magnetic resonance imaging methods can be used to assess the quality of the regenerated cartilage. Hypothesis: Altering mechanical alignment through HTO will have predictable effects on articular cartilage, allowing cartilage preservation and possible regeneration. Quality of regenerated cartilage will be inferior to normal articular cartilage. Study Design: Case series; Level of evidence, 4. Methods: Ten patients undergoing medial opening wedge HTO were evaluated using dGEMRIC methods (ie, delayed gadolinium-enhanced magnetic resonance imaging of cartilage) preoperatively and at 6 months, 1 year, and 2 years after HTO. Magnetic resonance images were evaluated by hand segmentation, and T1Gd relaxation times reflective of glycosaminoglycan content were determined for these regions of interest using magnetic resonance imaging analysis software. Results: The lateral compartment displayed higher T1Gd values than the medial compartment at baseline. Initially, a decrease in T1Gd values on the medial side were observed for all patients at 6 months and remained reduced for all but 2 participants at 1 year and 2 years after HTO. However, on the medial side after 6 months, the rate of change for T1Gd values shifted from being negative (−9.6 milliseconds per month) to being positive (1.7 milliseconds per month). A positive change in the T1Gd of the medial tibial plateau was responsible for the positive overall change in the medial compartment. There was no significant difference in the rate of change on the lateral side (P = .141), with the average over the 2-year period being a decrease of 2.28 milliseconds per month. Conclusion: Medial opening wedge HTO provides subjective improvements in pain and quality of life, but the potential benefit of allowing articular cartilage preservation and possible regeneration is not well established. Results showed that after a nonweightbearing period, the rate of change in the medial compartment changes from negative to positive, indicating the potential for articular cartilage recovery secondary to an improved mechanical environment.

Glycosaminoglycan content of knee cartilage following posterior cruciate ligament rupture demonstrated by delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC). A case report.

Following joint trauma and during the early stages of cartilage degeneration, typical changes become apparent in tissue structure and composition, including the loss of glycosaminoglycan1,2. These changes often are not apparent on conventional magnetic resonance imaging or visible at arthroscopy, thereby precluding diagnosis. Delayed gadolinium-enhanced magnetic resonance imaging of cartilage, or dGEMRIC, is an emerging in vivo method for the assessment of the biochemical composition of articular cartilage and provides a surrogate measure of glycosaminoglycan content3,4. When injected intravenously, the anionic contrast agent gadolinium diethylene triamine penta-acetic acid (Gd-DTPA2–) penetrates cartilage both from the synovial surface and from the subchondral bone3,5. Given sufficient time, the anionic contrast agent distributes inversely to the fixed negative charge associated with the cartilage glycosaminoglycan content in accordance with the Donnan principle of equilibrium. Gd-DTPA2-therefore distributes in relatively higher concentrations in regions of low glycosaminoglycan, and vice versa. Gd-DTPA2-has a concentration-dependent effect on the magnetic resonance imaging parameter T1; therefore, T1 imaging in the presence of Gd-DTPA2– (T1Gd) reflects the cartilage Gd-DTPA2–concentration and, hence, glycosaminoglycan concentration. We present the case of a patient (one of the authors [A.A.Y.]) who sustained an injury to the posterior cruciate ligament of the knee while enrolled as a “normal” control subject in a dGEMRIC study of the knee. This incidental occurrence provided us with a unique opportunity to visualize the temporal and spatial changes that occur in cartilage biochemistry following an acute posterior cruciate ligament rupture. Athirty-year-old man (one of the authors [A.A.Y.]) was involved in a motor-vehicle accident in which he sustained a direct blow to the anterior aspect of the proximal portion of the right tibia at 90° of knee flexion (a typical “dashboard” type of …

Cartilage defects are associated with physical disability in obese adults

OBJECTIVE To describe the associations between physical disability measures and knee cartilage defects in obese adults. METHODS One hundred and eleven obese subjects were recruited from laparoscopic adjustable gastric banding or exercise/diet weight loss programmes. All subjects completed disease-specific (WOMAC) and general health status (SF-36) questionnaires, and were assessed for range of knee motion, tibiofemoral alignment and quadriceps strength. Knee cartilage defects were graded on MRI according to established protocol. Regression analysis was adjusted for age, gender, BMI and presence of clinical knee OA. RESULTS The association between higher whole compartment cartilage defect scores and increasing BMI, age and clinical knee OA was confirmed in this obese cohort (r = 0.27, P = 0.01; r = 0.26, P = 0.007; P < 0.0001, respectively), whereas new associations were found with reduced knee range of motion (r = 0.5, P < 0.0001). No associations were found between defect scores and quadriceps strength. Varus malalignment was associated with higher medial cartilage defect scores (r = 0.33, P = 0.013). Higher levels of pain, stiffness and physical disability (WOMAC, SF-36) were associated with higher medial compartment and patella cartilage defect scores. CONCLUSIONS Knee cartilage defects increase with increasing obesity and are associated with both objective and self-reported measures of physical disability. Longitudinal studies are required to assess the potential for change or improvement in cartilage defects with weight loss.

Delayed gadolinium-enhanced magnetic resonance imaging of cartilage: clinical associations in obese adults.

Objective. Delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC) is used to assess cartilage glycosaminoglycan distribution. Our aim was to determine the relationships between self-reported pain and disability, clinical variables, and serum leptin, and dGEMRIC indices in obese subjects with and without clinical knee osteoarthritis (OA). Methods. Seventy-seven subjects were recruited from laparoscopic adjustable gastric banding or exercise and diet-weight loss programs. The dGEMRIC index was assessed on MRI according to established protocol. Regression analysis adjusted for age, sex, body mass index (BMI), and presence of clinical knee OA. Results. Mean age and BMI were 51 ± 12.7 years and 39.6 ± 6.2 kg/m2. Twenty-three subjects (30%) had clinical knee OA (American College of Rheumatology criteria). The medial and lateral dGEMRIC indices were 538 ± 80 ms and 539 ± 86 ms. Age correlated negatively with medial (r = −0.40, p < 0.001) and lateral (r = −0.29, p = 0.012) dGEMRIC index. Subjects with clinical knee OA had significantly lower medial dGEMRIC index; however, no association was found for BMI. Varus alignment correlated with lower medial dGEMRIC index (r = −0.43, p < 0.006), while quadriceps strength correlated positively with lateral dGEMRIC index (r = 0.32, p = 0.008). There was also a negative correlation between serum leptin and lateral dGEMRIC index in women (r = −0.39, p = 0.035), with a trend in men (r = −0.52, p = 0.08). There were weak associations with physical disability, as self-reported on the WOMAC questionnaire. Conclusion. In obese subjects, knee dGEMRIC index was associated with age, clinical knee OA, abnormal tibiofemoral alignment, and quadriceps strength. Longitudinal studies are required to assess the potential for improvement in dGEMRIC index with interventions such as strength training.

Overuse and Traumatic Injuries of the Elbow

MR imaging is a useful modality for evaluating athletes presenting with elbow pain. Osteochondral injuries and ligamentous injuries are well seen on MR imaging. Ligamentous injuries may be associated with clinical instability syndromes, the secondary signs of which may be evident on MR images. Enthesopathies and distal biceps tendon injuries are common clinical problems that may be seen in both professional and recreational athletes. Nerve compression syndromes may be investigated using MR imaging; however, the usual aim of imaging is to exclude an underlying space-occupying lesion. This article reviews the basic anatomy of the elbow joint and discusses the common osteochondral injuries, ligamentous injuries, instability syndromes, and tendinous pathologies at the elbow joint. The role of imaging in compressive neuropathies is briefly discussed.

The Accuracy of Magnetic Resonance Imaging Scanning and Its Influence on Management Decisions in Knee Surgery

PURPOSE The purpose of our study was to evaluate the impact of preoperative magnetic resonance imaging (MRI) assessment of articular knee pathology on the clinical management of patients presenting with joint line pain. METHODS A preliminary study on 100 patients was performed to assess the accuracy of specific MRI sequences, using arthroscopy as a gold standard. Six hundred and eighteen consecutive patients with knee symptoms presenting to 2 specialist knee surgeons were then recruited. A clinical diagnosis of an arthroscopically treatable lesion was made in all cases. Clinical assessment data were correlated to subsequent MRI findings, recording any discrepancy and in particular whether or not MRI findings influenced management decisions. RESULTS In the preliminary study, MRI sequences had an overall sensitivity of 83.2% and a specificity of 94.3% for the detection of chondral lesions. However, when considering arthroscopic grade III and IV lesions, MRI sensitivity and specificity were improved to 84.5% and 97.1%. In the second phase of the study, 141 (22.8%) of the 618 patients presenting with knee symptoms had an altered clinical management subsequent to MRI. The presence of unexpected chondral lesions was found in 77 of these patients. Conversely, 22 patients with clinical symptoms suspicious for simple chondral degeneration had unstable meniscal tears. CONCLUSIONS We suggest that preoperative MRI scanning identifies a group of patients who have more advanced degenerative joint disease than the clinical assessment and the plain radiographs suggest. This would expedite definitive surgery in patients with advanced osteoarthritis on MRI scans. LEVEL OF EVIDENCE Level II, development of diagnostic criteria on basis of consecutive patients with universally applied gold standard.

Osteoarthritis: What does imaging tell us about its etiology.

Osteoarthritis (OA) is the most common joint disorder and a leading cause of disability. Due to an aging population and increasing obesity, the incidence of OA is rising. The etiology of OA is multifactorial and complex; thus prevention of OA remains challenging. Risk factors can be divided into person-level factors such as age, sex, obesity, genetics, race/ethnicity, and diet, and joint-level factors including injury, malalignment, and abnormal loading of the joints. This review provides a brief overview of the person-level risk factors and a more in-depth analysis of those at the joint level. It is only through an improved understanding of risk factors for the disease that we may be able to intervene meaningfully and prevent its occurrence.

Pubic apophysitis: a previously undescribed clinical entity of groin pain in athletes

Background Sport-related pubalgia is often a diagnostic challenge in elite athletes. While scientific attention has focused on adults, there is little data on adolescents. Cadaveric and imaging studies identify a secondary ossification centre located along the anteromedial corner of pubis beneath the insertions of symphysial joint capsule and adductor longus tendon. Little is known about this apophysis and its response to chronic stress. Aim We report pubic apophysitis as a clinically relevant entity in adolescent athletes. Methods The clinical and imaging findings in 26 highly trained adolescent football players (15.6 years±1.3) who complained of adductor-related groin pain were reviewed. The imaging features (X-ray 26/26, US 9/26, MRI 11/26, CT 7/26) of the pubic apophyses in this symptomatic group were compared against those of a comparison group of 31 male patients (age range 9–30 years) with no known history of groin pain or pelvic trauma, who underwent pelvic CT scans for unrelated medical reasons. Results All symptomatic subjects presented with similar history and physical findings. The CT scans of these patients demonstrated open pubic apophyses with stress-related physeal changes (widening, asymmetry and small rounded cyst-like expansions) that were not observed in the comparison group. No comparison subject demonstrated apophyseal maturity before 21 years of age, and immaturity was seen up to the age of 26 years. Conclusions This retrospective case series identifies pubic apophyseal stress (or ‘apophysitis’) as an important differential consideration in the adolescent athlete who presents with groin pain.