Joanna Costello

The Influence of Meniscal and Anterolateral Capsular Injury on Knee Laxity in Patients with Anterior Cruciate Ligament Injuries

Background: The role of the anterolateral capsule (ALC) as a secondary restraint to quantitative rotatory laxity of patients with an anterior cruciate ligament (ACL) injury is currently debated. Purpose/Hypothesis: The purpose was to determine the influence of concomitant ALC injuries as well as injuries to other soft tissue structures on rotatory knee laxity in patients with an ACL injury. It was hypothesized that a concomitant ALC injury would be associated with increased rotatory knee laxity as measured during a quantitative pivot-shift test. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Forty-one patients with an ACL injury (average age, 23 ± 6.9 years) were enrolled. Two blinded musculoskeletal radiologists reviewed magnetic resonance imaging (MRI) scans for the presence of ACL injuries and concomitant soft tissue injuries including the ALC, medial collateral ligament, lateral collateral ligament, posterolateral corner, medial meniscus, and lateral meniscus. A standardized pivot-shift test was performed under anesthesia, and rotatory laxity was quantified according to anterior translation of the lateral tibial compartment during the pivot-shift maneuver. The Student t test was used to analyze the data. Statistical significance was set at P < .05. Results: A complete ACL rupture was confirmed in all of the patients. MRI evidence of an ALC injury was observed in 21 (51%) of the patients. Patients with MRI evidence of an ALC injury had significantly higher rotatory knee laxity (3.6 ± 1.5 mm) compared with those without an ALC injury (2.7 ± 1.5 mm; P = .04). Lateral and medial meniscus injuries were detected in 17 (41%) and 19 (46%) patients, respectively. Patients with MRI evidence of either a medial meniscus injury or lateral meniscus injury had significantly higher rotatory knee laxity compared with patients without these injuries (medial meniscus: 3.7 ± 1.4 mm vs 2.7 ± 1.6 mm, respectively; lateral meniscus: 3.7 ± 1.7 mm vs 2.7 ± 1.3 mm, respectively) (P = .03 for both). Conclusion: MRI evidence of a concomitant injury to the ALC, medial meniscus, or lateral meniscus is associated with increased knee rotatory laxity in patients with an ACL injury. These structures may function as important secondary stabilizers in an ACL-injured knee. Careful assessment and proper treatment of injuries to these secondary stabilizers should be considered, especially in knees with a high level of the pivot shift.

MRI evaluation and complications of medial patellofemoral ligament reconstruction

Medial patellofemoral ligament (MPFL) reconstruction is a relatively new surgical technique for the treatment of recurrent patellar instability and dislocation. Radiologic findings following MPFL reconstruction are not well described in the existing literature. Here, we review the anatomy and biomechanics of the MPFL, review imaging findings following double-bundle MPFL reconstruction, and show examples of complications arising from reconstruction.

Clinical relevance and imaging features of isolated single bundle anterior cruciate tear and single bundle augmentation

The anterior cruciate ligament (ACL) consists of two anatomic and functional bundles, the anteromedial and posterolateral bundle. Depending on the mechanism of injury, there are different injury patterns, demonstrating a wide spectrum of partial ACL tears. Single bundle partial ACL tears can be treated with augmentation. Theoretically, sparing the intact parts of the ACL may increase vascularization and proprioception and may result in better stability and improved clinical outcome for the patient. In this article, we review the anatomy and function of ACL bundles and demonstrate cases of single bundle ACL tear with subsequent augmentation.

Coronal oblique imaging of the knee: Can it increase radiologists' confidence in diagnosing posterior root meniscal tears?

AIM To investigate the utility of the coronal oblique sequence in the interrogation of posterior root meniscal lesions. MATERIALS AND METHODS Following international review board approval, 62 consecutive knee arthroscopy cases were referred to the musculoskeletal (MSK) radiologists from the same orthopaedic surgeon for imaging/surgical correlation of the posterior meniscal roots. Of 62 cases, 45 lateral and 46 medial menisci met the inclusion criteria. Imaging evaluation was performed with standard magnetic resonance imaging (MRI) sequences, including a coronal oblique proton density sequence. Two blinded fellowship-trained MSK radiologists independently evaluated the menisci on standard sequences indicating whether a tear was identified and then specifying a confidence score using a scale of 1-3 on each study interpreted. Immediately thereafter, the coronal oblique sequence was evaluated using the same method. Statistics were performed on meniscal lesions involving the posterior horn/root junction or isolated root tears comparing confidence scores. RESULTS Reader A identified nine posterior horn/root junction tears and 14 isolated root tears. Following the addition of the coronal oblique sequence, confidence scores increased in three of 14 (21.4%) isolated root tears. All three final reads were concordant with arthroscopy. Reader B identified 10 posterior horn/root junction tears and 19 isolated root tears. The confidence score increased in six cases: five of 19 (26.3%) isolated root tears and one of 10 (10%) posterior horn/root junction tears. All six final reads were concordant with arthroscopy. Kappa coefficients indicated near perfect agreement. CONCLUSION The coronal oblique sequence increased reader confidence in nearly 24% of the posterior root cases identified in this series.

Effect of patient age on accuracy of primary MRI signs of long head of biceps tearing and instability in the shoulder: an MRI-arthroscopy correlation study

ObjectiveTo determine the effect of patient age on the accuracy of primary MRI signs of long head of biceps (LHB) tendon tearing and instability in the shoulder using arthroscopy as a reference standard.Materials and methodsSubjects with MRI studies and subsequent arthroscopy documenting LHB tendon pathology were identified and organized into three age groups (18–40, 41–60, 61–87). Normal and tendinopathic tendons were labeled grade 0, partial tears grade 1 and full tears grade 2. Two radiologists blinded to arthroscopic data graded MRI studies independently. Prevalence of disease, MRI accuracy for outcomes of interest, and inter-reader agreement were calculated.ResultsEighty-nine subjects fulfilled inclusion criteria with 36 grade 0, 36 grade 1 and 17 grade 2 tendons found at arthroscopy. MRI sensitivity, regardless of age, ranged between 67–86% for grade 0, 72–94% for grade 1 and 82–94% for grade 2 tendons. Specificity ranged between 83–96% for grade 0, 75–85% for grade 1 and 99–100% for grade 2 tendons. MRI accuracy for detection of each LHB category was calculated for each age group. MRI was found to be least sensitive for grade 0 and 1 LHB tendons in the middle-aged group with sensitivity between 55–85% for grade 0 and 53–88% for grade 1 tendons. Agreement between MRI readers was moderate with an unweighted kappa statistic of 62%.ConclusionMRI accuracy was moderate to excellent and agreement between MRI readers was moderate. MRI appears to be less accurate in characterizing lower grades of LHB tendon disease in middle-aged subjects.

Accuracy of magnetic resonance imaging in predicting the intraoperative tear characteristics of pectoralis major ruptures.

BACKGROUND Magnetic resonance imaging (MRI) is the preferred study of choice for pectoralis major ruptures. Because this is a rare injury, no large case series have evaluated the efficacy of MRI for diagnosing and characterizing pectoralis major ruptures. We hypothesized that MRI would be accurate for diagnosis of the location and grade of pectoralis major tears. METHODS The study included 36 operative cases of pectoralis major ruptures with detailed descriptions of tear location and grade and satisfactory preoperative MRIs. Two musculoskeletal fellowship-trained radiologists interpreted the MRIs, which were then compared with the operative findings for location: tendon-bone junction or myotendinous junction, and tear grade (G): G2 (incomplete high grade partial tear) or G3 (complete tear). The sensitivity, specificity, positive predictive value, and negative predictive value were calculated. RESULTS The MRI sensitivity was 1.00 for diagnosing complete G3 tears at the sternal head and clavicular head in acute ruptures. The sensitivity of MRI for diagnosing tendon-bone tears at the sternal and clavicular heads was 0.93 and 0.90, respectively. The sensitivity of MRI in diagnosing myotendinous and G2 tears diminishes, but specificity and negative predictive value remain high for sternal and clavicular head ruptures. CONCLUSIONS Our data support the use of MRI in diagnosing the tear grade and location of pectoralis major tendon ruptures, particularly for acute, tendon-bone, and G3 tears. The diagnostic accuracy of MRI decreases when chronic tears are evaluated. MRI remains a useful adjunct in diagnosing and guiding treatment of pectoralis major ruptures.

Return to Play After PRP and Rehabilitation of 3 Elite Ice Hockey Players With Ulnar Collateral Ligament Injuries of the Elbow

Background: Ulnar collateral ligament (UCL) injury is a well-described etiology of pain and decreased performance for the overhead athlete. Despite a growing volume of literature regarding the treatment of these injuries for overhead athletes, there is a paucity of such data regarding stickhandling collision sport athletes, such as ice hockey players. Purpose/Hypothesis: The purpose of this study was to characterize this injury among 3 elite ice hockey players and to describe the ability of these athletes to return to play, as well as to review the unique sport-specific implications of this injury, evaluation, nonsurgical management, and considerations for return to play. The authors hypothesized that elite ice hockey players will be able to return to play at the same level following nonoperative treatment of UCL injury. Study Design: Case series; Level of evidence, 4. Methods: Data from 3 elite professional ice hockey players who sustained a high-grade injury to the UCL were retrospectively reviewed. All athletes underwent 2 autologous conditioned plasma injections as part of their treatment and were evaluated with ultrasonography and magnetic resonance imaging. Results: Three consecutive elite ice hockey players were included in this study, and no patients were excluded. Players were cleared to full return to play at a mean 36 days postinjury. Follow-up examination at this time point demonstrated full range of motion of the elbow for all athletes, without tenderness to palpation over the UCL, including no tenderness over the humeral insertion site. Stability examination improved as well, demonstrating a soft to moderate endpoint with valgus stress, although this was not symmetric to the contralateral side. All athletes were able to continue to play at the same level of competition as before the injury occurred, without any complaints. No players had repeat injury during the same or following seasons. Conclusion: The authors present 3 elite-level ice hockey players who sustained a high-grade injury to the UCL. Successful return to play was possible after nonoperative treatment with injection of autologous conditioned plasma at a mean 36 days following injury. Athletes who injure either the top or bottom hand can return to play at the same elite level following this injury.

Value of anterosuperior rotator cuff and labral tears at MRI for predicting long head of biceps tearing at arthroscopy

AIM To determine whether magnetic resonance imaging (MRI) signs of subscapularis (SBT), supraspinatus (SST), or superior labral tearing predict long head of biceps (LHB) tendon tearing at arthroscopy. MATERIALS AND METHODS Subjects with MRI studies followed by arthroscopy were collected. Radiologists graded rotator cuff (RC) tendons and the superior labrum using three grade classifications and blinded to arthroscopy. Correlation between imaging variables and surgical outcome was expressed in terms of odds ratios and determined using a stepwise logistic regression model. RESULTS Selection criteria identified 89 participants. Statistically significant increase in odds of finding a partial LHB tendon tear at arthroscopy were noted for both MRI readers with any SBT tear (OR=4.1-5.6, p<0.0001 to 0.002), full-thickness SST (OR=8-20.4, p=0.002 to 0.006), and combined SST-SBT tears (OR=5.1-7.6, p<0.0001 to 0.002) and relative to grade 0 MRI scores for those categories. Statistically significant increase in the odds of finding any LHB tendon tear at arthroscopy were noted for both MRI readers with any SBT tear (OR=9.6 to 14.6, p<0.0001), full-thickness SST (OR=9.0 to 52.0, p<0.0001 to 0.0004) and combined SST-SBT tears (OR=8.2 to 15.1, p<0.0001) at MRI and relative to grade 0 MRI scores for these categories. No significant predictive effect was found for the labral categories. CONCLUSION LHB tendons should be closely scrutinised if anterosuperior rotator cuff tears, and SBT tears in particular, are found on MRI.

The Effect of Injury to Anterolateral Capsular Structures on Outcomes of ACL Injured Patients 24 Months after Anatomic ACL Reconstruction

Objectives: The purpose of this study was to determine the effect of injury of anterolateral capsular structures (ALC) on outcomes of ACL injured patients 24 months after anatomic ACL reconstruction (ACLR). It was hypothesized that injury to ALC determined on Magnetic Resonance Imaging (MRI) scans would significantly affect patient reported outcomes (PROs) as well as in vivo joint kinematics during downhill running 24 months after ACLR. Methods: Subjects included a subset of ACL injured patients participating in a randomized clinical trial to compare single- and double bundle ACLR using quadriceps autograft. Subjects were divided into two groups based on the presence or absence of injury to ALC, as determined by a fellowship trained radiologist on Magnetic Resonance Imaging (MRI) scans performed within 6 weeks of injury (Kendall’s tau-b for Inter-observer reliability = 0.75). ACLR outcomes were measured 24 months after surgery and included PROs (International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) and Knee injury and Osteoarthritis Outcome Score (KOOS)) as well as in vivo joint kinematics during downhill running. In vivo joint kinematics were assessed while subjects performed downhill treadmill running (3.0 meters/second, 10° slope) within a Dynamic Stereo X-ray system (DSX). Knee kinematics were determined using a validated method for matching DSX images to tibiofemoral bone models obtained from subject specific computed tomography scans. A subset of joint kinematic variables (side-to-side differences for peak internal rotation, range of internal/external rotation, peak adduction and range of abduction/adduction) were evaluated in this study. These variables were selected based on the proposed function of the ALC for restraining internal knee rotation. The PROs and knee kinematics were compared between groups with and without ALC injury using independent t-tests. Statistical significance was set at p<0.05. Results: Thirty-five subjects (mean age: 22.8 ± 8.5 years) were enrolled in this study. The average interval between injury and performing the MRI scans was 9.5 ± 10 days. ALC injury was observed in 17 (48%) patients (grade 1: 6, grade 2: 10 and grade 3: 1). No differences were detected in PROs between groups with and without ALC injury (Figure 1 and Table 1). Likewise, no significant kinematic differences were found between groups. There was a slight trend towards greater external rotation in ACLR knees with ALC injury. Figure 1: Examples of (A) kinematics during downhill running (range of internal and external rotation) and (B) patient reported outcome (Internation Knee Documentation Committee Subjective Knee Form (IKDC-SKF)). No significant difference was observed between groups. Table 1: In vivo joint kinematics and patient reported outcome in patients with and without Anterolateral capsular structures (ALC) injury. No significant difference was observed. Variable No ALC injury mean (SD) ALC injury mean (SD) p -value In Vivo JointKinematics Peak Internal rotation (degrees) -0.29* (3.34) -1.94* (3.20) 0.18 Range of internal/external rotation (degrees) 3.03 (1.55) 2.73 (1.55) 0.6 Peak adduction (degrees) -0.56** (1.04) -0.79** (1.32) 0.61 Range of abduction/adduction (degrees) 0.96 (0.65) 0.94 (0.77) 0.95 PatientReportedOutcomes IKDC- SKF 91.59(10.74) 87.97 (11.18) 0.37 KOOS Symptoms 89.96 (7.52) 84.52 (11.10) 0.12 KOOS Pain 96.01 (6.49) 93.15 (13.56) 0.46 KOOS Function in Daily Living 99.17(2.08) 96.86 (11.35) 0.43 KOOS Function in Sports and Recreation 91.56(13.00) 90.33 (11.72) 0.79 KOOS Knee Related Quality of Life 88.67(17.26) 77.50 (24.75) 0.15 *Negative value denotes external rotation** Negative value denotes abduction Conclusion: The most significant finding of this study was that combined injury to ALC did not significantly affect PROs or knee kinematics 24 months post ACLR. Based on these findings, performing additional reconstruction/repair surgery to reduce excess rotational laxity due to presence of ALC injury is not supported. Accordingly, it is recommended to observe MRI detectable injuries to the ALC.

Intramedullary Osteosclerosis: an incidental sclerotic lesion in a trauma patient

Intramedullary osteosclerosis, a rare entity, is usually diagnosed after the exclusion of more sinister etiologies. It typically affects the lower extremity and is more common in females. While the lesion may be discovered incidentally during imaging, presenting symptoms may include pain in the affected bone that is exacerbated with physical activity. Laboratory values are normal, and the lesion is not associated with familial skeletal dysplasias. Common imaging findings include a mono-ostotic or polyostotic sclerotic lesion that lacks a periosteal reaction, soft-tissue component, and nidus. We present a case of intramedullary osteosclerosis that was incidentally discovered in a trauma patient.