Katherine Coyner

ISAKOS classification of meniscal tears—illustration on 2D and 3D isotropic spin echo MR imaging

Magnetic Resonance Imaging is modality of choice for the non-invasive evaluation of meniscal tears. Accurate and uniform documentation of meniscal pathology is necessary for optimal multi-disciplinary communication, to guide treatment options and for validation of patient outcomes studies. The increasingly used ISAKOS arthroscopic meniscus tear classification system has been shown to provide sufficient interobserver reliability among the surgeons. However, the terminology is not in common use in the radiology world. In this article, the authors discuss the MR imaging appearances of meniscal tears based on ISAKOS classification on 2D and multiplanar 3D isotropic spin echo imaging techniques and illustrate the correlations of various meniscal pathologies with relevant arthroscopic images.

T2 black lesions on routine knee MRI: differential considerations

AbstractThe majority of abnormal findings or lesions on T2-weighted fast spin-echo (FSE) magnetic resonance imaging (MRI) are hyperintense due to increased perfusion or fluid content, such as infections, tumours or synovitis. Hypointense lesions on T2-weighted images (both fat-suppressed and non-fat-suppressed) are less common and can sometimes be overlooked. Such lesions have limited differential diagnostic possibilities, and include vacuum phenomenon, loose body, tenosynovial giant cell tumour, rheumatoid arthritis, haemochromatosis, gout, amyloid, chondrocalcinosis, hydroxyapetite deposition disease, lipoma arborescens, arthrofibrosis and iatrogenic lesions. These lesions often show characteristic appearances and predilections in the knee. In this article, the authors describe the MRI features of hypointense T2 lesions on routine knee MRI and outline a systematic diagnostic approach towards their evaluation. Key Points• Hypointense lesions on T2 images (T2 Dark Lesions) encompass limited diagnostic possibilities.• T2 Dark lesions often show characteristic appearances and predilections in the knee.• A systematic diagnostic approach will help radiologists make the correct diagnosis.

Bone and joint modeling from 3D knee MRI: feasibility and comparison with radiographs and 2D MRI

PURPOSE The purpose was to evaluate feasibility of bone and joint segmentations from three-dimensional magnetic resonance imaging (3D MRI). METHODS Segmented joint models from 3D MRI data set were obtained for 42 patients. Blinded angular and joint space measurements were performed on 3D MRI model, two-dimensional (2D) MRI, and radiography (XR). RESULTS Medial joint space was similar on both XR and 3D MRI (P=.3). The XR measurements were statistically different but closer to 3D MRI for lateral patellar tilt angle, patellar tendon length, and lateral knee joint space, whereas 2D MRI measurements were closer to XR in terms of trochlear depth, sulcal angle, and patellar length. CONCLUSION 3D bone and joint segmentations are feasible from isotropic MRI data sets.

Anterior Cruciate Ligament Tears: Impact of Delayed Presentation on Intra-Articular Injuries

Objectives: Chronic anterior cruciate ligament (ACL) injury is associated with increased risk for meniscal and chondral injuries. The purpose of this study was to examine what intra-articular injuries occur related to the cartilage and meniscus in the setting of chronic ACL deficiency. Methods: A cross-sectional cohort study was conducted using a retrospective chart review for all patients who sustained an ACL injury and underwent reconstruction from January 1, 2009 to May 14, 2015. Demographic variables were age, gender, and BMI (Body Mass Index). Additionally, days from injury to surgery, presence of meniscus tears and presence of articular cartilage injury were recorded. Data was analyzed to determine the association between delay of surgery and cartilage or meniscus injury as well as gender, BMI and age at the time of surgery. Results: 410 patients were included in this study. The average age was 27 ± 8.8 years (range of 14-59 years). 58.5% of patients had a BMI >25. 70.5% of the patients were male. 27.3% of patients were treated within 3 months of injury, 23.6% between 3-6 months, 18% between 6-12 months, 24.1% between 12-60 months, and 6.9% >60 months (Table 1). Male gender and older age were significant predictive factors for delaying ACL surgery (P < .01). Male gender was significantly associated with presence of lateral meniscus tear (LMT) (P < .001) and lateral femoral condyle (LFC) injury (P< .01). The 40+ age group was significantly more likely to have an medial femoral condyle (MFC) injury (P < .01), medial tibial plateau (MTP) injury (P < .001), lateral tibial plateau (LTP) injury (P < .01), and patellofemoral (PF) injury (P < .001) as compared to those <20 years old. Patients with BMI >25 were significantly more likely to have an MFC injury (P< .05). There was a significant correlation of medial meniscus tear (MMT) with MFC and MTP injury (P < .001, OR 4.8; P < .05, OR 2.6). There was also a significant correlation of LMT and LTP injury (P < .05, OR 2.0). An increase in the presence of MMT was seen in longer delay to time of surgery (P < .001). When compared to the < 3 months group, the 6 to < 12 months group (OR 2.1), the 12 to < 60 months group (OR 4.2) and the 60 months or greater group (OR 6.2) were more likely to have a MMT. A similar trend was seen with MFC injury (P < .001) in the 6 to < 12 months group (OR 2.7), the 12 to < 60 months group (OR 3.1), and the 60 months or greater group (OR 8.3). Presence of LTP injury and LFC injury was also significantly increased with surgical delay, but this association did not occur until 12 to < 60 months (P < .05; OR 5.6) and 60 months or greater (P < .001; OR 21.5) (Figure 1). Conclusion: Delaying ACL surgery for 6 months or longer is associated with an increased presence of medial meniscus tears and chondral injury (MFC, LFC, and LTP), with increased incidence in longer delays. This data supports not delaying surgery more than 6 months following an ACL tear to prevent the incidence of secondary meniscus tears and articular cartilage injury. In addition, particular attention should be paid to those who are older age and male gender as they are at increased risk for more severe cartilage and meniscal injuries. Table 1. Demographic Factors and Associated Meniscal and Chondral Injuries Identified in Surgerya BMI Age (years) Gender <25 25 to <30 30+ <20 20 to <30 30 to <40 40+ Male Female MMT 69/138 (50.0) 98/167 (58.7) 46/73 (63.0) 39/77 (50.6) 101/187 (54.0) 64/104 (61.5) 27/40 (67.5) P=NS 166/288 (57.6) 66/121 (54.5) P=NS LMT 75/138 (54.3) 98/167 (58.7) 49/73 (67.1) P=NS 49/77 (63.6) 119/188 (63.3) 58/104 (55.8) 15/40 (37.5) OR, 0.3 P < 0.5 187/289 (64.7) OR, 2.3 54/121 (44.6) P < .001 MFC Injury 25/138 (18.1) 53/167 (31.7) OR, 2.1 22/73 (30.1) OR, 1.9 P < .05 12/77 (15.6) 47/188 (25.0) 33/104 (31.7) OR, 2.5 19/40 (47.5) OR, 4.9 P < .01 72/289 (24.9) 40/121 (33) P=NS LFC Injury 8/138 (5.8) 22/167 (13.2) 9/73 (12.3) P=NS 1/76 (1.3) 26/188 (13.8) 11/104 (10.6) 2/40 (5.0) P=NS 35/288 (12.1) OR, 3.2 5/121 (4.1) P < .05 MTP Injury 2/137 (1.5) 12/167 (7.2) 5/72 (6.9) P=NS 1/76 (1.3) 4/187 (2.1) 6/104 (5.8) 10/40 (25.0) OR, 25.0 P < .001 19/288 (6.6) 2/118 (1.7) P=NS LTP Injury 13/138 (9.4) 20/167 (12.0) 11/73 (15.1) P=NS 2/76 (2.6) 18/188 (9.6) 19/104 (18.3) OR, 8.3 8/40 (20.0) OR, 9.2 P < .01 31/288 (10.8) 16/121 (13.2) P = NS PF Injury 22/138 (15.9) 35/167 (21.0) 21/73 (28.8) P=NS 5/77 (6.5) 17/188 (9.0) 35/104 (33.7) OR, 7.3 25/40 (62.5) OR, 24.0 P < .001 55/289 (19) 27/121 (22.3) P=NS aValues are expressed as n (%). P < .05 considered statistically significant, OR, odds ratio; NS, not significant, OR listed for groups significantly different from comparison group. Female gender was used as the comparison group for gender.

Treatment options other than total knee arthroplasty in young patients with knee osteoarthritis: Part I

Nonarthroplasty management of symptomatic knee arthritis in young patients is now and will continue to be a significant challenge for orthopaedic surgeons. Efforts to forestall knee arthroplasty should be made whenever feasible, however. This review focuses on nonarthroplasty options in the treatment of symptomatic knee osteoarthritis.

The Role of Osteotomy

Reconstruction of the multiple ligament-injured knee can be challenging due to the many factors necessary to achieve a stable, functional joint. Historically the treatment of multiple ligament-injured knees has been based solely on soft tissue constraints and has lead to some disappointing results. Recent evidence suggests that joint alignment may be just as important in maintaining joint stability, particularly in cases of chronic ligamentous laxity.