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Abstract
Objective: A review of the anatomy of the synovial recesses of the knee is important to better understand the different effusion presentations, update the diagnosis criteria of knee effusion based on the measured synovial recesses and discuss the differentiation of some effused recesses from other lesions around the knee. Method: This review focuses on the anatomy of the synovial recesses of the knee and classifies them into three groups (anterior, parameniscal, and posterior recesses), as well as provides an overview on the etiology of knee effusion, its sonographic detection, and diagnosis criteria. Results: Knee effusion is a very common pathological finding in sonography of the knee. The unique joint structure of the knee provides the possibility to host complex synovial recesses. Fluid in some of the synovial recesses is valuable for the diagnosis of knee effusion, while in certain situations, some recesses may impose diagnostic uncertainty. Knowledge of these synovial recesses is essential to avoid diagnostic pitfalls. Conclusion: This review provides an important discussion of the differentiation of some recesses effusions from other lesions around the knee.
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Affiliation(s)
- Tony Y. Li
- Department of Diagnostic Imaging, Albany Medical Clinic, Toronto, ON, Canada
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Gursoy M, Mete BD, Dag F, Bulut T. The distribution of loose bodies determined on knee magnetic resonance imaging: joint compartments, recesses and bursae including arthroscopic blind spots. Acta Radiol 2019; 60:1286-1293. [PMID: 31216177 DOI: 10.1177/0284185119856262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Merve Gursoy
- Izmir Democracy University, Faculty of Medicine, Department of Radiology, Izmir, Turkey
| | - Berna Dirim Mete
- Izmir Democracy University, Faculty of Medicine, Department of Radiology, Izmir, Turkey
| | - Fatih Dag
- Manisa Turgutlu State Hospital, Department of Radiology, Manisa, Izmir, Turkey
| | - Tugrul Bulut
- Izmir Katip Celebi University, Ataturk Training and Research Hospital, Department of Orthopaedics and Traumatology, Izmir, Turkey
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Lapègue F, Sans N, Brun C, Bakouche S, Brucher N, Cambon Z, Chiavassa H, Larbi A, Faruch M. Imaging of traumatic injury and impingement of anterior knee fat. Diagn Interv Imaging 2016; 97:789-807. [PMID: 27118690 DOI: 10.1016/j.diii.2016.02.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 02/24/2016] [Indexed: 11/17/2022]
Abstract
Fat is not just used by the body as bulk tissue. In addition to its role in storing energy and regulating hormone action, fat is used in some parts of the body for its mechanical properties. The anatomy of anterior knee fat is more complex than it appears at first sight and is capable of withstanding considerable compressive and shear stress. Specific lesions occur when such mechanical stress exceeds the physiological limits and are yet little known. Superficial fat can be the site of either acute injury by closed degloving called the Morel-Lavallée lesion or chronic injury, when subject to repeat excessive shear forces, due to more complex and less well-defined disruptions that result in pseudo-bursitis. There are three main anterior, intracapsular and extrasynovial fat pads in the knee joint, which are the infrapatellar fat pad (IFP) or Hoffa's fat pad, the quadriceps fat pad and the prefemoral fat pad. The IFP plays an important role as a mechanical shock absorber and guides the patella tendon and even the patella itself during flexion-extension movements. In response to repeated excessive stress, an inflammatory reaction and swelling of the IFP is first observed, followed by a fibrotic reaction with metaplastic transformation into fibrous, cartilaginous or bone tissue. More rarely, the two other deep fat pads (quadriceps and prefemoral) can, if subject to repeated stress, undergo similar restructuring inflammatory reactions with metaplasia resulting in tissue hardening, anterior pain and partial loss of function.
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Affiliation(s)
- F Lapègue
- Service d'imagerie, CHU de Toulouse-Purpan, bâtiment Pierre-Paul-Riquet, place du Dr-Baylac, TSA 40031, 31059 Toulouse cedex 9, France; Centres d'imagerie du Languedoc, 26, rue Ernest-Cognacq, ZAC Bonne source, 11100 Narbonne, France.
| | - N Sans
- Service d'imagerie, CHU de Toulouse-Purpan, bâtiment Pierre-Paul-Riquet, place du Dr-Baylac, TSA 40031, 31059 Toulouse cedex 9, France
| | - C Brun
- Service d'imagerie, CHU de Toulouse-Purpan, bâtiment Pierre-Paul-Riquet, place du Dr-Baylac, TSA 40031, 31059 Toulouse cedex 9, France
| | - S Bakouche
- Service d'imagerie, CHU de Toulouse-Purpan, bâtiment Pierre-Paul-Riquet, place du Dr-Baylac, TSA 40031, 31059 Toulouse cedex 9, France
| | - N Brucher
- Service d'imagerie, CHU de Toulouse-Purpan, bâtiment Pierre-Paul-Riquet, place du Dr-Baylac, TSA 40031, 31059 Toulouse cedex 9, France
| | - Z Cambon
- Service d'imagerie, CHU de Toulouse-Purpan, bâtiment Pierre-Paul-Riquet, place du Dr-Baylac, TSA 40031, 31059 Toulouse cedex 9, France
| | - H Chiavassa
- Service d'imagerie, CHU de Toulouse-Purpan, bâtiment Pierre-Paul-Riquet, place du Dr-Baylac, TSA 40031, 31059 Toulouse cedex 9, France
| | - A Larbi
- Service d'imagerie médicale, CHU de Nîmes, place du Pr-R.-Debré, 30029 Nîmes cedex 9, France
| | - M Faruch
- Service d'imagerie, CHU de Toulouse-Purpan, bâtiment Pierre-Paul-Riquet, place du Dr-Baylac, TSA 40031, 31059 Toulouse cedex 9, France
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Magnetic resonance imaging of Hoffa's fat pad and relevance for osteoarthritis research: a narrative review. Osteoarthritis Cartilage 2016; 24:383-97. [PMID: 26455999 DOI: 10.1016/j.joca.2015.09.018] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 09/08/2015] [Accepted: 09/22/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To give an illustrative overview of Hoffa's fat pad pathology with a radiologic emphasis on the anatomy, on technical considerations, and on imaging differential diagnoses in the context of osteoarthritis (OA) imaging research. DESIGN A PubMed database search including only English literature and covering a 20 year period was performed. The search was based on but no limited to the query terms "Hoffa", "Hoffa's fat pad" or "infrapatellar fat pad (IPFP)" in combination with "synovitis", "OA", and "magnetic resonance imaging (MRI)". The literature search yielded 289 publications that were screened for relevance; additional references were included when these were considered of importance. RESULTS Several anatomic variants and pathologic conditions may be encountered when assessing Hoffa's fat pad including tumors and tumor-like lesions such as osteochondroma, tenosynovial giant cell tumor (TGCT) (and pigmented nodular synovitis) and arthrofibrosis, traumatic changes including contusions and anatomic variants such as recesses. The latter may be accountable for differences in cross-sectional area or volume changes over time. Signal changes are commonly used in OA research as surrogate markers for synovitis but are non-specific findings. CONCLUSIONS Quantitative approaches to evaluate 3D parameters of Hoffa's fat pad are increasingly applied and their role in regard to structural progression and clinical manifestations of disease needs to be further elucidated. In applying such approaches, knowledge of the detailed anatomy and potential pitfalls that may be a result of anatomical variants, inflammatory disease manifestations and additional diverse pathologies encountered seems to be paramount.
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Draghi F, Urciuoli L, Alessandrino F, Corti R, Scudeller L, Grassi R. Joint effusion of the knee: potentialities and limitations of ultrasonography. J Ultrasound 2015; 18:361-71. [PMID: 26550074 DOI: 10.1007/s40477-015-0180-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 08/26/2015] [Indexed: 11/29/2022] Open
Abstract
PURPOSE This study aimed at comparing the diagnostic accuracy of ultrasonography (US) and magnetic resonance imaging (MRI) for the detection of joint effusion of the knee. METHODS For this retrospective study, approbation by the institutional review board was not required, and written informed consent from the patients was waived. One hundred and fifty-eight patients (83 men and 75 women; median age 41.2 years; age range 13-81 years) who underwent US and MRI of the knee were included in the study. The sensitivity and specificity of US with respect to MRI in the evaluation of the effusion of the knee and in each recess were compared. RESULTS In evaluating joint effusion of the knee, compared with MRI, US correctly identified 78 of 96 patients with joint effusion, showing a sensitivity of 81.3 % and a specificity of 100 %, with a positive predictive value (PPV) of 100 % and a negative predictive value (NPV) of 77.5 % (p value = 0.001). Various results were obtained comparing ultrasound with MRI, regarding the various recesses. CONCLUSION US showed high specificity and sensitivity in diagnosing knee joint effusion and could be used in patients who cannot undergo MRI.
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Affiliation(s)
- Ferdinando Draghi
- Institute of Radiology, University of Pavia, Viale Golgi 5, 27100 Pavia, Italy
| | - Luigi Urciuoli
- Institute of Radiology, Second University of Naples, Naples, Italy
| | | | - Riccardo Corti
- Institute of Radiology, University of Pavia, Viale Golgi 5, 27100 Pavia, Italy
| | - Luigia Scudeller
- Biostatistics and Clinical Epidemiology Unit, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Roberto Grassi
- Institute of Radiology, Second University of Naples, Naples, Italy
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Kinsella SD, Sennett BJ, Carey JL. Extra-Articular Pigmented Villonodular Synovitis of the Deep Infrapatellar Bursa: A Case Report. JBJS Case Connect 2013; 3:e133. [PMID: 29252289 DOI: 10.2106/jbjs.cc.m.00165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Stuart D Kinsella
- Perelman School of Medicine at the University of Pennsylvania, 295 John Morgan Building, 3620 Hamilton Walk, Philadelphia, PA 19104.
| | - Brian J Sennett
- Penn Sports Medicine Center, Weightman Hall, 1st floor, 235 South 33rd Street, Philadelphia, PA 19104
| | - James L Carey
- Penn Sports Medicine Center, Weightman Hall, 1st floor, 235 South 33rd Street, Philadelphia, PA 19104
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MRI characteristics of cysts and "cyst-like" lesions in and around the knee: what the radiologist needs to know. Insights Imaging 2013; 4:257-72. [PMID: 23479129 PMCID: PMC3675245 DOI: 10.1007/s13244-013-0240-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 02/14/2013] [Accepted: 02/19/2013] [Indexed: 11/30/2022] Open
Abstract
Objectives and Methods A variety of benign cystic or “cyst-like” lesions may be encountered during a routine magnetic resonance imaging (MRI) of the knee. These lesions comprise a diverse group of entities from benign cysts to complications of underlying diseases. In addition, normal anatomic bursae and recesses may be misdiagnosed as an intra-articular cystic lesion when they are distended. However, the majority of the aforementioned lesions have characteristic MR appearances that allow a confident diagnosis, thus obviating the need for additional imaging or interventional procedures. Results This article includes a comprehensive pictorial essay of the characteristic MRI features of common and uncommon benign cysts and “cyst-like” lesions in and around the knee joint. Discussion For accurate assessment of the “cystic structure”, a radiologist should be able to identify typical MRI patterns that contribute in establishing the correct diagnosis and thus guiding specific therapy and avoiding unwarranted interventional procedures such as biopsy or arthroscopy. Teaching points • Cystic lesions are common in knee MRI and the commonest, the Baker’s cyst, has an incidence of 38 %. • Synovial cysts, meniscal cysts, normal knee bursae and recesses have characteristic MR appearances. • Miscellaneous “cyst-like” lesions may require a more dedicated MR protocol for a correct diagnosis.
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A study of the anatomy and injection techniques of the ovine stifle by positive contrast arthrography, computed tomography arthrography and gross anatomical dissection. Vet J 2012; 193:426-32. [PMID: 22264645 DOI: 10.1016/j.tvjl.2011.12.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2011] [Revised: 12/09/2011] [Accepted: 12/15/2011] [Indexed: 11/22/2022]
Abstract
Although ovine stifle models are commonly used to study osteoarthritis, meniscal pathology and cruciate ligament injuries and repair, there is little information about the anatomy of the joint or techniques for synovial injections. The objectives of this study were to improve anatomical knowledge of the synovial cavities of the ovine knee and to compare intra-articular injection techniques. Synovial cavities of 24 cadaver hind limbs from 12 adult sheep were investigated by intra-articular resin, positive-contrast arthrography, computed tomography (CT) arthrography and gross anatomical dissection. Communication between femoro-patellar, medial femoro-tibial and lateral femoro-tibial compartments occurred in all cases. The knee joint should be considered as one synovial structure with three communicating compartments. Several unreported features were observed, including a communication between the medial femoro-tibial and lateral femoro-tibial compartments and a latero-caudal recess of the lateral femoro-tibial compartment. No intermeniscal ligament was identified. CT was able to define many anatomical features of the stifle, including the anatomy of the tendinous synovial recess on the lateral aspect of the proximal tibia under the combined tendon of the peroneus tertius, extensor longus digitorum and extensor digiti III proprius. An approach for intra-articular injection into this recess (the subtendinous technique) was assessed and compared with the retropatellar and paraligamentous techniques. All three injection procedures were equally successful, but the subtendinous technique appeared to be most appropriate for synoviocentesis and for injections in therapeutic research protocols with less risk of damaging the articular cartilage.
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Zwolak P, Kühnel SP, Fuchs B. Extraarticular knee resection for sarcomas with preservation of the extensor mechanism: surgical technique and review of cases. Clin Orthop Relat Res 2011; 469:251-6. [PMID: 20419485 PMCID: PMC3008904 DOI: 10.1007/s11999-010-1359-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2009] [Accepted: 04/07/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Sarcomas in or contaminating the knee are rare but extremely challenging to treat. Complete resection of the joint is necessary, and often the entire extensor mechanism is removed as well. Reconstruction of the knee is challenging, and the resulting function may be compromised. DESCRIPTION OF TECHNIQUE We describe a surgical technique of extraarticular resection of the knee while preserving the extensor mechanism combined with prosthetic reconstruction. The medial and lateral retinaculum is prepared such that it allows extraarticular placement of K-wires that are driven through the patella and the proximal tibia, serving as in situ guides for the osteotomies. PATIENTS AND METHODS We retrospectively reviewed 11 patients with sarcomas contaminating the knee. The minimum followup was 14 months (mean, 38 months; range, 14-80 months). RESULTS At last followup patients had a mean flexion of 88° (range, 65°-120°). We observed no complications related to the extensor mechanism, and there was one local recurrence. CONCLUSIONS We believe extraarticular resection of the knee with preservation of the extensor mechanism is a reasonable treatment option for intraarticular sarcomas with functional scores comparable to those for patients having intraarticular resections. LEVEL OF EVIDENCE Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Pawel Zwolak
- Department of Orthopaedics, Division of Orthopaedic Oncology, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008 Zurich, Switzerland
| | - Stefanie P. Kühnel
- Department of Orthopaedics, Division of Orthopaedic Oncology, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008 Zurich, Switzerland
| | - Bruno Fuchs
- Department of Orthopaedics, Division of Orthopaedic Oncology, Balgrist University Hospital, University of Zurich, Forchstrasse 340, CH-8008 Zurich, Switzerland
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Maurel B, Le Corroller T, Cohen M, Acid S, Bierry G, Parratte S, Flecher X, Argenson J, Petit P, Champsaur P. Le corps adipeux infra-patellaire : carrefour antérieur du genou. ACTA ACUST UNITED AC 2010; 91:841-55. [DOI: 10.1016/s0221-0363(10)70127-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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von Engelhardt LV, Tokmakidis E, Lahner M, Dàvid A, Haage P, Bouillon B, Lichtinger TK. Hoffa's fat pad impingement treated arthroscopically: related findings on preoperative MRI in a case series of 62 patients. Arch Orthop Trauma Surg 2010; 130:1041-51. [PMID: 20556618 DOI: 10.1007/s00402-010-1133-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The morphology of painful impingement of the infrapatellar fat pad (Hoffa's disease), which is characterized by inflammation, swelling, hypertrophy, fibrosis, and/or calcifications, has been well described. The purpose of this study was to investigate whether corresponding characteristic MRI findings could be assessed in patients with infrapatellar fat pad impingement. MATERIALS AND METHODS This study includes 62 patients with secondary symptomatic Hoffa's fat pad impingement. In these patients, the fat pad was partially resected until no impingement could be determined at full knee movement. Within a maximum of 3 months before arthroscopic surgery, patients had standardized MR imaging using a 1.5 Tesla unit with the following sequences: sagittal T1-TSE, coronal STIR-TSE, transversal fat-suppressed PD-TSE, and sagittal fat-suppressed PD-TSE (Siemens Magnetom Avanto syngo MR B 15). In this case series, the preoperative MRI appearance of the fat pad was evaluated and compared with a cohort of 255 patients without fat pad impingement but with various knee disorders at arthroscopy as well as the same standardized MRI protocol. RESULTS In patients with Hoffa's fat pad impingement, morphologic changes such as localized edema of the superior and/or posterior part of the fat pad, a deep fluid-filled infrapatellar bursa, non-visualization of vertical and/or horizontal clefts, fibrosis, and calcifications were noted on MR imaging with remarkable frequency. Besides a significant enlargement of the fat pad, each of these MRI findings was significantly associated with impingement of Hoffa's fat pad (P < 0.05). Besides a moderate kappa score for the detection of intrahoffatic calcifications and vertical clefts, kappa values for each finding showed good inter-observer agreement. Results of logistic regression revealed that edema of Hoffa's fat pad was one of the most important diagnostic MRI criteria for the diagnosis of Hoffa's fat pad impingement. CONCLUSION MR imaging allows identification of several changes that may be related to a symptomatic impingement of Hoffa's fat pad. In patients who are suspected of having infrapatellar fat pad impingement, such MRI findings should be considered and distinguished from other causes of anterior knee pain.
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Affiliation(s)
- Lars Victor von Engelhardt
- Department of Trauma and Orthopedic Surgery, HELIOS-Klinikum Wuppertal, University of Witten/Herdecke, Germany.
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Fenn S, Datir A, Saifuddin A. Synovial recesses of the knee: MR imaging review of anatomical and pathological features. Skeletal Radiol 2009; 38:317-28. [PMID: 18777177 DOI: 10.1007/s00256-008-0570-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Revised: 07/15/2008] [Accepted: 07/23/2008] [Indexed: 02/02/2023]
Abstract
The knee joint is a complex anatomical structure playing host to a wide variety of pathological processes. Knowledge of the anatomy of the synovial recesses and plicae relating to the knee is important, as the appearance of pathology in these unusual locations may, even for commonly encountered conditions, lead to diagnostic uncertainty. This review article discusses the magnetic resonance imaging (MRI) anatomy of the knee joint with an emphasis on the synovial recesses and plicae. The MRI appearance of a variety of synovial and osteochondral diseases that may involve these sites is illustrated.
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Affiliation(s)
- S Fenn
- Department of Radiology, The Princess Alexandra Hospital NHS Trust, Harlow, Essex, UK
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