Sensitivity of routine 1.0-Tesla magnetic resonance imaging versus arthroscopy as gold standard in fresh traumatic chondral lesions of the knee in young adults

Editorial Commentary: Evaluation for Cartilage Lesions on Magnetic Resonance Imaging Continues to Improve: Artificial Intelligence Applications May Result in Higher Sensitivity and Specificity

Accurate detection of cartilage lesions of the knee is required to offer patient-specific care and can alter surgical intervention options. To date, diagnostic arthroscopy remains the gold standard yet often requires the need for staged operative procedure for treatment. Magnetic resonance imaging (MRI) is the most accurate imaging modality with high specificity, yet even with recent advances, MRI has limited specificity. Newer scanners (3 T) and updated scanning sequences (3-dimensional MRI and quantitative MRI) are most sensitive in characterizing cartilage lesions of the knee, but these resources are not available to all users. Promising new avenues for patient-specific MRI scans along with the utilization of artificial intelligence will more accurately identify and quantify lesion size, location, and depth.

Quantitative Magnetic Resonance Imaging Had Greater Sensitivity in Diagnosing Chondral Lesions of the Knee: A Systematic Review and Meta-Analysis

PURPOSE

To investigate the accuracy and reliability of magnetic resonance imaging (MRI) in identifying and grading chondral lesions and explore the optimal imaging technique to image cartilage.

METHOD

A comprehensive search was conducted on Medline, Embase, and Cochrane Library. Eligible cohort studies published before August 2022 were included. The study reports used MRI to diagnose and grade cartilage lesions, with intraoperative findings as the reference standard. Summary estimates of diagnostic performance were obtained. The reliability of MRI interpretation was summarized. Subgroup analyses were performed based on assessed imaging techniques, field strength, and joint surface.

RESULTS

Forty-three trials and 3,706 patients were included in the systematic review. The overall area under curve for hierarchical summarized receiver operating characteristics was 0.91 (95% confidence interval [CI] 0.88-0.93). The pooled sensitivity for quantitative MRI, 3-dimensional MRI, and 2-dimensional MRI was 0.82 (95% CI 0.64-0.92), 0.79 (95% CI 0.74-0.83), and 0.63 (95% CI 0.51-0.73), respectively. The pooled sensitivity of 3 Tesla (3T), 1.5 Tesla (1.5T), and <1.5 Tesla MRI was 0.79 (95% CI 0.72-0.85), 0.67 (95% CI 0.60-0.74), and 0.55 (95% CI 0.39-0.71), respectively. There were differences in interobserver consistency across different studies.

CONCLUSIONS

In general, MRI had high specificity in discriminating normal cartilage, but its sensitivity for identifying chondral lesions is less optimal. Further analysis showed that quantitative MRI, 3D MRI, and 3T MRI demonstrate greater sensitivity compared with 2D MRI, 1.5T MRI, and <1.5 Tesla MRI.

LEVEL OF EVIDENCE

Level III, systematic review of Level II-III studies.

The anterolateral ligament of the knee is not a solid structure in human fetuses

PURPOSE

The purpose of this study was to investigate if the anterolateral ligament of the knee (ALL) is present in the human fetus and describe its topography along with other structures of the region.

METHODS

Forty human fetuses knee joints, at mean age 34 weeks (± 2.57 weeks), fixed in 10% formalin, were submitted to cross-sectional dissection and mesoscopic analysis.

RESULTS

The ALL was not identified, although the usual topography of the region was identified in all specimens: skin, subcutaneous tissue, iliotibial tract (ITT), fibular collateral ligament, popliteal muscle tendon, lateral meniscus, patellar ligament, infrapatellar fat pad, lateral patellar retinaculum, knee joint capsule, lateral inferior genicular vessels, and the biceps femoris tendon. The ITT reveals anterior (n = 12) and lateral thickening (n = 17) in some specimens. This thickening was found in both knees of the same subject in 6/20 specimens.

CONCLUSION

The anterolateral ligament of the knee is not a congenital or solid structure. Our results suggest that the ALL may be a deep layer of the ITT or part of the knee joint capsule, or its identification is evaluator dependent.

Risks and Complications Associated With Intra-articular Arthroscopy of the Knee and Shoulder in an Office Setting

BACKGROUND

Classically, arthroscopy has been considered one of the diagnostic gold standards for assessing intra-articular knee and shoulder abnormality.

PURPOSE

To assess the risks associated with in-office needle arthroscopy.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective case series analysis was performed by evaluating consecutive diagnostic needle arthroscopies performed by 13 physicians at 13 independent institutions. The findings of both major and minor complications were reported by each of the 13 surgeons based on office documentation. The data were analyzed as a lump sum of both knee and shoulder cases and then subdivided and examined separately. The patients' ages ranged from 14 to 78 years, and no statistical difference was noted between the numbers of men and women. A major complication was defined as infection, chondral toxicity, or the need for alternative treatment at an urgent care or emergency room secondary to the procedure. Minor complications were defined as a vasovagal event, pain that persisted after 24 hours, or the need for crutches or sling postprocedure.

RESULTS

Of the 1419 cases, no major complications were reported. The overall rate of vasovagal events was 1.9% for all procedures (1.6% in knees, 3% in shoulders). Persistent pain longer than 24 hours postprocedure was reported in 0.3% of cases. No patient required crutches or a sling. Postarthroscopy magnetic resonance imaging was needed in 1.4% of cases. No device failures were reported.

CONCLUSION

Previous literature has evaluated the efficacy, sensitivity, and specificity of in-office diagnostic arthroscopy, and this study validates needle arthroscopy as safe in the office setting, with minimal risk of major or minor complications.

A Prospective, Blinded, Multicenter Clinical Trial to Compare the Efficacy, Accuracy, and Safety of In-Office Diagnostic Arthroscopy With Magnetic Resonance Imaging and Surgical Diagnostic Arthroscopy

PURPOSE

The purpose of this study was to compare the efficacy, accuracy, and safety of in-office diagnostic arthroscopy with magnetic resonance imaging (MRI) and surgical diagnostic arthroscopy.

METHODS

A prospective, blinded, multicenter, clinical trial was performed on 110 patients, ages 18 to 75 years, who presented with knee pain. The study period was April 2012 to April 2013. Each patient underwent a physical examination, an MRI, in-office diagnostic imaging, and a diagnostic arthroscopic examination in the operating room. The attending physician completed clinical report forms comparing the in-office arthroscopic examination and surgical diagnostic arthroscopy findings on each patient. Two blinded experts, unaffiliated with the clinical care of the study's subjects, reviewed the in-office arthroscopic images and MRI images using the surgical diagnostic arthroscopy images as the "control" group comparison. Patients were consecutive, and no patients were excluded from the study.

RESULTS

In this study, the accuracy, sensitivity, and specificity of in-office arthroscopy was equivalent to surgical diagnostic arthroscopy and more accurate than MRI. When comparing in-office arthroscopy with surgical diagnostic arthroscopy, all kappa statistics were between 0.766 and 0.902. For MRI compared with surgical diagnostic arthroscopy, kappa values ranged from a low of 0.130 (considered "slight" agreement) to a high of 0.535 (considered "moderate" agreement). The comparison of MRI to in-office arthroscopy showed very similar results as the comparison of MRI with surgical diagnostic arthroscopy, ranging from a low kappa of 0.112 (slight agreement) to a high of 0.546 (moderate agreement). There were no patient-related or device-related complications related to the use of in-office arthroscopy.

CONCLUSIONS

Needle-based diagnostic imaging that can be used in the office setting is statistically equivalent to surgical diagnostic arthroscopy with regard to the diagnosis of intra-articular, nonligamentous knee joint pathology. In-office diagnostic imaging can provide a more detailed and accurate diagnostic assessment of intra-articular knee pathology than MRI. Based on the study results, in-office diagnostic imaging provides a safe, accurate, real-time, minimally invasive diagnostic modality to evaluate intra-articular pathology without the need for surgical diagnostic arthroscopy or high-cost imaging.

LEVEL OF EVIDENCE

Level II, comparative prospective trial.

Subchondral bone scan uptake correlates with articular cartilage degeneration in osteoarthritic knees

AIM

The aim of this study was to analyze subchondral bone scan uptake in osteoarthritic knees with reference to subchondral bone microstructure and articular cartilage histology.

METHODS

This cross-sectional, laboratory study evaluated 123 human distal femoral condyle specimens of 67 patients after joint replacement surgery. All patients were preoperatively examined with bone scan of the knee joint. Specimens were evaluated for cartilage histology and micro-computed tomography analysis of subchondral bone. Data between bone scan, histology and micro-computed tomography were statistically analyzed using either coefficient of correlation, Student's t-test or one-way analysis of variance with Tukey post hoc test.

RESULTS

Bone scan grading and histological articular cartilage degeneration scores showed significant correlation (r = 0.812, P < 0.001). Both bone scan positive and histologically confirmed osteoarthritis samples showed increase in subchondral trabecular bone volume and thickness, reflected in micro-computed tomography. Overall, positive predictive value (%) of bone scan for osteoarthritic cartilage lesions was 91.9%, and the sensitivity and specificity were 88.3% and 60%, respectively. Histology showed that bone scan has both a high positive predictive and a low negative predictive value for detection of osteoarthritic cartilage lesions.

CONCLUSION

Bone scan uptake correlated with articular cartilage degeneration in osteoarthritic knees. Bone scan may be a useful diagnostic tool that reflects pathologic changes of cartilage in osteoarthritis.

Diagnosis and classification of chondral knee injuries: comparison between magnetic resonance imaging and arthroscopy

PURPOSE

To compare the magnetic resonance imaging (MRI) findings of patients undergoing knee arthroscopy for chondral lesions. The hypothesis was that MRI displays low sensitivity in the diagnosis and classification of chondral injuries.

METHODS

A total of 83 knees were evaluated. The MRIs were performed using the same machine (GE SIGNA HDX 1.45 T). The MRI results were compared with the arthroscopy findings, and an agreement analysis was performed. Thirty-eight of the 83 MRI exams were evaluated by another radiologist for inter-observer agreement analysis. These analyses were performed using the kappa (κ) coefficient.

RESULTS

The highest incidence of chondral injury was in the patella (14.4 %). The κ coefficient was 0.31 for the patellar surface; 0.38 for the trochlea; 0.46 for the medial femoral condyle; 0.51 for the lateral femoral condyle; and 0.19 for the lateral plateau. After dividing the injuries into two groups (ICRS Grades 0-II and Grades III and IV), the following κ coefficients were obtained as follows: 0.49 (patella); 0.53 (trochlea); 0.46 (medial femoral condyle); 0.43 (medial plateau); 0.67 (lateral femoral condyle); and 0.51 (lateral plateau). The MRI sensitivity was 76.4 % (patella), 88.2 % (trochlea), 69.7 % (medial femoral condyle), 85.7 % (medial plateau), 81.8 % (lateral femoral condyle) and 75 % (lateral plateau). Comparing the radiologists' evaluations, the following κ coefficients were obtained as follows: 0.73 (patella); 0.63 (trochlea); 0.84 (medial femoral condyle); 0.72 (medial plateau); 0.77 (lateral femoral condyle); and 0.91 (lateral plateau).

CONCLUSION

Compared with arthroscopy, MRI displays moderate sensitivity for detecting and classifying chondral knee injuries. It is an important image method, but we must be careful in the assessment of patients with suspected chondral lesions.

LEVEL OF EVIDENCE

III.

Is MRI adequate to detect lesions in patients with ankle instability?

BACKGROUND

Chondral lesions, peroneal tendon tears, and other disorders in patients with chronic ankle instability may not be detected by preoperative MRI. Also, MRI often is obtained and interpreted at the referring institution, leading to variability in reading.

QUESTIONS/PURPOSES

We assessed the accuracy of the radiologists' and orthopaedic surgeon's reading of preoperative MRI for diagnosing ankle lesions in patients with ankle instability warranting surgery.

PATIENTS AND METHODS

We retrospectively reviewed 133 patients who underwent 135 surgeries for lateral ankle ligament reconstruction with concomitant ankle arthroscopy and who had preoperative MRI.

RESULTS

We found 72 associated lesions in 66 of the 135 surgeries, including 38 chondral injuries, 18 peroneus brevis tears, seven loose bodies, and nine other miscellaneous abnormalities. Eliminating eight lesions for which the decision to operate was not based on operative findings, there were 127 surgeries with 64 associated lesions that required intraoperative confirmation or were detected intraoperatively. In the original reports, the radiologists identified 39% (15) of the chondral injuries, 56% (10) of the peroneal tears, and 57% (four) of the loose bodies. Radiologists' MRI sensitivity for detecting lesions was 45%. The attending surgeon identified 47% (18) of the chondral injuries, 89% (16) of the loose bodies, 71% (five) of the peroneus brevis tears, and the posterior talus process lesion, with a sensitivity of 63%.

CONCLUSIONS

Our data suggest orthopaedic surgeons should review preoperative MRIs and also suggest the sensitivity of MRI may not be adequate to detect lesions in these patients before surgery.

LEVEL OF EVIDENCE

Level IV, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

The role of preoperative MRI in knee arthroscopy: a retrospective analysis of 2,000 patients

The aim of this study was to investigate, to what extent routine preoperative MRI scans could set the indications for knee arthroscopies and reduce the number of diagnostic arthroscopies. For this retrospective cohort study, 1,000 patients who had knee arthroscopies documented in 1994/1995 were compared with 1,000 patients that were treated in 2004/2005. The preoperative diagnoses that gave indications for knee arthroscopy were compared with the intraoperative findings. The congruence of preoperative diagnosis with the intraoperative findings was evaluated comparing both study populations. The number of patients who were referred to orthopaedic trauma surgeons with MRI increased from 24% to 56%. A high congruence of preoperative diagnosis and intraoperative findings was found in 49% in 1994/1995 and 55% in 2004/2005. However, regarding the most important outcome parameter, the number of diagnostic arthroscopies, no improvement was found (3% in both periods). The presented data suggests that MRI scans are not routinely necessary as an indication for knee arthroscopy, as clinical examination and plain radiograph are sufficient. However, MRI scans do allow a more detailed characterization of the expected findings and can therefore be helpful in therapy planning.

Correlation between arthroscopic and histopathological grading systems of articular cartilage lesions in knee osteoarthritis

PURPOSE

Arthroscopic and particularly histopathological assessments have been used to evaluate alterations of knee cartilage in osteoarthritis (OA). The aim of this study was to examine the correlation between an arthroscopic method to grade the severity of chondropathies and the histological/histochemical grading system (HHGS) applied to the corresponding articular cartilage areas in knee OA.

METHODS

The articular cartilage surface was examined by chondroscopy using the Beguin and Locker severity criteria, analysing the lesions in 72 chondroscopic areas. Afterwards, samples were obtained by dividing the cartilage surface of the medial tibiofemoral compartment of three OA knee joints into equal squares and they were evaluated histologically using the HHGS. The correlation between both grading methods was assessed using the weighted Kappa coefficient (K(w)).

RESULTS

The results obtained with both scores showed good agreement (K(w): mean+/-standard deviation, 0.619+/-0.071). While the average HHGS scores of the chondral samples showed a better agreement with arthroscopic grades 0, I and II, the arthroscopic evaluation has a tendency to overestimate chondral lesions for histological grades III and IV. The intra- and inter-observer reliability of the HHGS evaluation of chondral lesions was excellent (Intraclass Correlation Coefficient: 0.909 and 0.941, respectively).

CONCLUSION

In this study, we found a good quantitative correlation between established arthroscopic severity and histopathological scoring systems, particularly in less advanced lesions. Our results suggest that the arthroscopic method is a valuable tool in clinical research to score chondropathies in the medial femorotibial compartment of the OA knee, although some limitations should not be overlooked.

Assessment and management of posttraumatic haemarthrosis of the knee

Traumatic haemarthrosis of the knee poses significant diagnostic difficulty in the acute phase. Orthopaedic follow up is essential. An update of current recommended practice is provided, and the pros and cons of arthroscopy and magnetic resonance imaging are discussed.

Patellofemoral arthroplasty in the treatment of patellofemoral arthritis: rationale and outcomes in younger patients

Patellofemoral degenerative disease encompasses a spectrum of articular wear from severe chondrosis to advanced arthrosis. The rationale and timing for many operative approaches currently advocated for the relief of symptomatic patellofemoral degeneration can be the subject of intense surgical debate in any one patient. Unfortunately, the limited efficacy of many commonly advocated operative procedures has left a legacy of patellofemoral disability in many younger individuals. While total knee arthroplasty has an established role in the treatment of advanced patellofemoral arthritis in the older patient (age >60 years), the performance of what some have called "a knee joint amputation" in younger patients (age <45 years) remains controversial and less acceptable to patients. The Avon patellofemoral prosthesis is a second-generation knee joint-conserving device that has consistently achieved good to excellent results in both the primary treatment and salvage of patellofemoral degenerative disease in younger patients. In addition, patellofemoral arthroplasty has demonstrated success as a unique functional, tibial-femoral joint-conserving solution in a variety of other patellofemoral extensor mechanism problems.

Comparison of image quality in magnetic resonance imaging of the knee at 1.5 and 3.0 Tesla using 32-channel receiver coils

We examined to what degree the visualization of anatomic structures in the human knee is improved using 3.0-T magnetic resonance imaging (MRI) and many element RF receive coils as compared to 1.5 T. We imaged 20 knees at 1.5 and 3.0 T using T2-weighted STIR, T2-weighted gradient echo, T1-weighted spin-echo, true-FISP and T2-weighted fast spin echo techniques in conjunction with 32-element RF coil arrays. The 3.0-T examination was considerably faster than its 1.5-T counterpart. A superior subjective visibility at 3.0 T vs 1.5 T was found in 27 of 50 evaluated structures (meniscus, ligaments) with the exception of true-FISP techniques. The 3.0-T examination provided a better visibility (evaluated by blinded consensus-reading by two radiologists) of small structures such as the ligamentum transversum genu. Also, cartilage was better delineated at 3.0 T. A 23% increased average signal-to-noise ratio as assessed using a temporal filter was observed at 3.0 T as compared to 1.5 T. At 3.0 T, imaging of the human knee is faster and results in a subjective visibility of anatomic structures that is superior to and competitive with 1.5 T.