1
|
Buturoiu MM, Ghiea S, Weber MA. Subchondral insufficiency fractures: overview of MRI findings from hip to ankle joint. ROFO-FORTSCHR RONTG 2024. [PMID: 39029510 DOI: 10.1055/a-2344-5337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2024]
Abstract
Subchondral insufficiency fracture (SIF) represents a potentially severe condition that can advance to osteoarthritis, with collapse of the articular surface. SIF manifests as a fracture in bone weakened by non-tumorous disease, precipitated by repetitive physiological stress, without a clear history of major trauma. It is observed along the central weight-bearing region of the femoral condyle, with a higher incidence in the medial femoral condyle, but also in other large weight-bearing synovial joints, such as the femoral head, tibial plateau, or talus.A review of the literature from the past six years was performed by searching PubMed and ScienceDirect databases, using the keywords "subchondral insufficiency fracture" and "spontaneous osteonecrosis of the knee". The inclusion criteria were scientific papers presented in the English language that reported on the magnetic resonance imaging (MRI) aspects of SIF of the lower limb.Detecting SIF at the level of the hip, knee, and ankle may present challenges both clinically and radiologically. The MRI appearance is dominated by a bone marrow edema-like signal and subchondral bone changes that can sometimes be subtle. Subchondral abnormalities are more specific than the pattern of bone marrow edema-like signal and are best shown on T2-weighted and proton-density-weighted MR images. MRI plays an important role in accurately depicting even subtle subchondral fractures at the onset of the disease and proves valuable in follow-up, prognosis, and the differentiation of SIF from other conditions. · Subchondral insufficiency fractures may affect the hip, knee, and ankle.. · Subchondral insufficiency fractures may heal spontaneously or progress to collapse.. · MRI is important for the detection, follow-up, and prognosis of subchondral insufficiency fractures.. · Differential diagnosis may include transient osteoporosis and osteonecrosis of systemic origin.. · Buturoiu MM, Ghiea S, Weber M. Subchondral insufficiency fractures: overview of MRI findings from hip to ankle joint. Fortschr Röntgenstr 2024; DOI 10.1055/a-2344-5337.
Collapse
Affiliation(s)
- Monica Maria Buturoiu
- Radiology, University of Medicine and Pharmacy Carol Davila Bucharest, Bucharest, Romania
| | - Sorin Ghiea
- Imaging Department, Monza Hospital, Bucharest, Romania
| | - Marc-André Weber
- Rostock University Medical Center, Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock, Germany
| |
Collapse
|
2
|
Clark SC, Pareek A, Hevesi M, Okoroha KR, Saris DBF, Camp CL, Krych AJ. High incidence of medial meniscus root/radial tears and extrusion in 253 patients with subchondral insufficiency fractures of the knee. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38769782 DOI: 10.1002/ksa.12271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 05/02/2024] [Accepted: 05/05/2024] [Indexed: 05/22/2024]
Abstract
PURPOSE The demographic and radiological risk factors of subchondral insufficiency fractures of the knee (SIFK) continue to be a subject of debate. The purpose of this study was to associate patient-specific factors with SIFK in a large cohort of patients. METHODS Inclusion criteria consisted of patients with SIFK as verified on magnetic resonance imaging (MRI). All radiographs and MRIs were reviewed to assess characteristics such as meniscus tear presence and type, subchondral oedema presence and location, location of SIFK, mechanical limb alignment, osteoarthritis as assessed by Kellgren-Lawrence grade and ligamentous injury. A total of 253 patients (253 knees) were included, with 171 being female. The average body mass index (BMI) was 32.1 ± 7.0 kg/m2. RESULTS SIFK was more common in patients with medial meniscus tears (77.1%, 195/253) rather than tears of the lateral meniscus (14.6%, 37/253) (p < 0.001). Medial meniscus root and radial tears of the posterior horn were present in 71.1% (180/253) of patients. Ninety-one percent (164/180) of medial meniscus posterior root and radial tears had an extrusion ≥3.0 mm. Eighty-one percent (119/147) of patients with SIFK on the medial femoral condyle and 86.8% (105/121) of patients with SIFK on the medial tibial plateau had a medial meniscus tear. Varus knees had a significantly increased rate of SIFK on the medial femoral condyle in comparison to valgus knees (p = 0.016). CONCLUSION In this large cohort of patients with SIFK, there was a high association with medial meniscus root and radial tears of the posterior horn, meniscus extrusion ≥3.0 mm as well as higher age, female gender and higher BMI. Additionally, there was a particularly strong association of medial compartment SIFK with medial meniscus tears. As SIFK is frequently undiagnosed, identifying patient-specific demographic and radiological risk factors will help achieve a prompt diagnosis. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- Sean C Clark
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ayoosh Pareek
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Mario Hevesi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kelechi R Okoroha
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel B F Saris
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Orthopedic Surgery, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Christopher L Camp
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
3
|
Yokota S, Ishizu H, Miyazaki T, Takahashi D, Iwasaki N, Shimizu T. Osteoporosis, Osteoarthritis, and Subchondral Insufficiency Fracture: Recent Insights. Biomedicines 2024; 12:843. [PMID: 38672197 PMCID: PMC11048726 DOI: 10.3390/biomedicines12040843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 03/31/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
The increased incidence of osteoarthritis (OA), particularly knee and hip OA, and osteoporosis (OP), owing to population aging, have escalated the medical expense burden. Osteoarthritis is more prevalent in older women, and the involvement of subchondral bone fragility spotlights its association with OP. Notably, subchondral insufficiency fracture (SIF) may represent a more pronounced condition of OA pathophysiology. This review summarizes the relationship between OA and OP, incorporating recent insights into SIF. Progressive SIF leads to joint collapse and secondary OA and is associated with OP. Furthermore, the thinning and fragility of subchondral bone in early-stage OA suggest that SIF may be a subtype of OA (osteoporosis-related OA, OPOA) characterized by significant subchondral bone damage. The high bone mineral density observed in OA may be overestimated due to osteophytes and sclerosis and can potentially contribute to OPOA. The incidence of OPOA is expected to increase along with population aging. Therefore, prioritizing OP screening, early interventions for patients with early-stage OA, and fracture prevention measures such as rehabilitation, fracture liaison services, nutritional management, and medication guidance are essential.
Collapse
Affiliation(s)
| | | | | | | | | | - Tomohiro Shimizu
- Department of Orthopedic Surgery, Faculty of Medicine, Graduate School of Medicine, Hokkaido University, Sapporo 060-8638, Japan; (S.Y.); (H.I.); (T.M.); (D.T.); (N.I.)
| |
Collapse
|
4
|
Guermazi A, Roemer FW, Jarraya M, Hayashi D. A call for screening MRI as a tool for osteoarthritis clinical trials. Skeletal Radiol 2023; 52:2011-2019. [PMID: 37126081 DOI: 10.1007/s00256-023-04354-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 04/21/2023] [Accepted: 04/23/2023] [Indexed: 05/02/2023]
Abstract
Conventional radiography is the most commonly used imaging modality for the evaluation of osteoarthritis (OA) in clinical trials of disease-modifying OA drugs (DMOADs). Unfortunately, radiography has many shortcomings as an imaging technique to meaningfully assess the pathological features of OA. In this perspective paper, we will describe the reasons why radiography is not an ideal tool for structural OA assessment and why magnetic resonance imaging (MRI) should be preferred for such purposes. These shortcomings include a lack of reproducibility of radiographic joint space measurements (if conducted without using a standardized positioning frame), a lack of sensitivity and specificity, an insufficient definition of disease severity, a weak association of radiographic structural damage and pain, a lack of ability to depict many faces of OA, and incapability to depict diagnoses of exclusion. MRI offers solutions to these limitations of radiography. Several different phenotypes of OA have been recognized and it is important to recruit appropriate patients for specific therapeutic approaches in DMOAD trials. Radiography does not allow such phenotypical stratification. We will explain known hurdles for widespread deployment of MRI at eligibility screening and how they can be overcome by technological advances and the use of simplified image assessment.
Collapse
Affiliation(s)
- Ali Guermazi
- Department of Radiology, Boston University School of Medicine, Boston, MA, USA
- VA Boston Healthcare System, West Roxbury, MA, USA
| | - Frank W Roemer
- Department of Radiology, Boston University School of Medicine, Boston, MA, USA
- Department of Radiology, Universitätsklinikum Erlangen & Friedrich-Alexander Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Mohamed Jarraya
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daichi Hayashi
- Department of Radiology, Boston University School of Medicine, Boston, MA, USA.
- Department of Radiology, Tufts Medical Center, Tufts Medicine, Floating 4, 800 Washington Street, Boston, MA, USA.
- Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| |
Collapse
|
5
|
Kraai T, Aldershof C, Olde Heuvel J, Hoogeslag R. Bilateral trochlear subchondral insufficieny fracture of the knee in a professional cyclist. BMJ Case Rep 2023; 16:e255577. [PMID: 37798037 PMCID: PMC10565160 DOI: 10.1136/bcr-2023-255577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
This case report presents a rare case of subsequent ipsilateral and contralateral subchondral insufficiency fracture of the knee (SIFK) in the trochlea of the femur within months, manifested in a professional cyclist. SIFKs in the trochlea have not yet been reported in the literature; however, their appearance in a professional cyclist might be explained by the amount of repetitive pressure on the patellofemoral joint when cycling. In both instances, atraumatic anterior knee pain occurred, resolving after conservative treatment for 6-9 weeks. The patient reached their previous activity level. The authors believe SIFK in the younger population may be more common than currently perceived due to its self-limiting behaviour and a lack of performing immediate MRIs in this younger group whenever an overload injury is suspected.
Collapse
Affiliation(s)
- Tijmen Kraai
- Department of Orthopedic Surgery and Sports Medicine, Orthopedisch Centrum Oost Nederland, Hengelo, The Netherlands
| | - Camiel Aldershof
- Department of Orthopedic Surgery and Sports Medicine, Orthopedisch Centrum Oost Nederland, Hengelo, The Netherlands
| | - Judith Olde Heuvel
- Department of Orthopedic Surgery and Sports Medicine, Orthopedisch Centrum Oost Nederland, Hengelo, The Netherlands
| | - Roy Hoogeslag
- Department of Orthopedic Surgery and Sports Medicine, Orthopedisch Centrum Oost Nederland, Hengelo, The Netherlands
| |
Collapse
|
6
|
Malghem J, Lecouvet F, Vande Berg B, Kirchgesner T, Omoumi P. Subchondral insufficiency fractures, subchondral insufficiency fractures with osteonecrosis, and other apparently spontaneous subchondral bone lesions of the knee-pathogenesis and diagnosis at imaging. Insights Imaging 2023; 14:164. [PMID: 37782395 PMCID: PMC10545656 DOI: 10.1186/s13244-023-01495-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 07/17/2023] [Indexed: 10/03/2023] Open
Abstract
Subchondral insufficiency fractures (SIFs) and SIFs with osteonecrosis (SIF-ONs) of the knee (previously misnamed spontaneous osteonecrosis of the knee (SONK)) are bone lesions that appear without prior traumatic, tumoral, or inflammatory event.Both conditions are characterized in the early stages by epiphyseal bone marrow edema (BME)-like signal at MRI. However, while SIFs usually heal spontaneously, they can also evolve to osteonecrosis (i.e., SIF-ON), which may progress to an irreversible collapse of the articular surface. Careful analysis of other MRI signs may help differentiate the two conditions in the early phase. In SIFs, the BME edema-like signal extends to the area immediately adjacent to the subchondral plate, while in SIF-ONs, this subchondral area shows low signal intensity on fluid-sensitive MR images due to altered bone marrow. The thickness and length of subchondral areas with low fluid-sensitive signal intensity are important factors that determine the prognosis of SIF-ONs. If they are thicker than 4 mm or longer than 14 mm, the prognosis is poor. The differential diagnosis of SIFs and SIF-ONs include bone lesions associated with the "complex regional pain syndrome" (CRPS), epiphyseal osteonecrosis of systemic origin, and those related to cartilage pathology.Clinical relevance statement Imaging plays an essential role in diagnosing subchondral insufficiency fractures (SIFs) from subchondral insufficiency fractures with osteonecrosis (SIF-ONs) and collapse, as well as in distinguishing them from other spontaneous knee subchondral bone lesions presenting with bone marrow edema-like signal.Key points• Subchondral insufficiency fractures may affect the knee, especially in older adults.• Subchondral insufficiency fractures usually heal spontaneously.• Sometimes, subchondral osteonecrosis and collapse may complicate subchondral insufficiency fractures.• Bone marrow-like edema is an aspecific sign seen in all these lesions.• Degraded marrow in osteonecrosis complicating fractures is hypointense on fluid-sensitive sequences.
Collapse
Affiliation(s)
- Jacques Malghem
- Department of Radiology, Cliniques Universitaires Saint-Luc, UCLouvain, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Frédéric Lecouvet
- Department of Radiology, Cliniques Universitaires Saint-Luc, UCLouvain, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Bruno Vande Berg
- Department of Medical Imaging, Clinique CHC Montlégia, Boulevard Patience Et Beaujonc 2, 4000, Liège, Belgium
| | - Thomas Kirchgesner
- Department of Radiology, Cliniques Universitaires Saint-Luc, UCLouvain, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Patrick Omoumi
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV) and University of Lausanne, Rue du Bugnon 46, 1010, Lausanne, Switzerland.
| |
Collapse
|
7
|
Musbahi O, Waddell L, Shah N, Smith SE, Chen AF, Bisson L, Katz JN. Subchondral Insufficiency Fractures of the Knee: A Clinical Narrative Review. JBJS Rev 2023; 11:01874474-202310000-00005. [PMID: 37812676 DOI: 10.2106/jbjs.rvw.23.00084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
» Subchondral insufficiency fractures of the knee (SIFKs) are subchondral plate fractures with a prevalence of 2% to 4% of all knee injuries.» Magnetic resonance imaging is the gold standard for evaluating SIFK, while plain radiographs have limited the use in the diagnosis of SIFK.» Among patients with SIFK, 50% to 100% have meniscal pathology.» Medical therapies and standard treatments traditionally used in the management of knee osteoarthritis differ from recommended management of SIFK patients.» Randomized controlled trials and cohort studies with long-term follow-up are needed to determine the optimal rehabilitation protocol, interventional therapy, and prognosis of SIFK patients.
Collapse
Affiliation(s)
- Omar Musbahi
- Orthopedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Imperial College London, London, United Kingdom
| | - Lily Waddell
- Orthopedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nehal Shah
- Harvard Medical School, Boston, Massachusetts
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stacy E Smith
- Harvard Medical School, Boston, Massachusetts
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Antonia F Chen
- Orthopedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Leslie Bisson
- Department of Orthopedic Surgery, University of Buffalo, Buffalo, New York
| | - Jeffrey N Katz
- Orthopedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Epidemiology, Harvard Chan School of Public Health, Boston, Massachusetts
| |
Collapse
|
8
|
Mukai S, Nakagawa Y, Nishitani K, Sakai S, Nakamura R, Takahashi M. Mosaicplasty With High Tibial Osteotomy for Knee Subchondral Insufficiency Fracture Had Better Magnetic Resonance Observation of Cartilage Repair Tissue Scores With Less Bone Marrow Edema and Better Plug Union and Less Plug Necrosis Compared With Mosaicplasty Alone. Arthroscopy 2023; 39:337-346. [PMID: 36064155 DOI: 10.1016/j.arthro.2022.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 07/20/2022] [Accepted: 07/28/2022] [Indexed: 02/09/2023]
Abstract
PURPOSE To determine the magnetic resonance imaging (MRI) findings after mosaicplasty (MOS) for knee subchondral insufficiency fracture (SIFK), and to analyze the relationship between MRI findings and clinical outcomes. METHODS We retrospectively reviewed the cases of consecutive patients who underwent MOS for SIFK with/without high tibial osteotomy (HTO) between January 1998 and December 2015. The MRI findings at 12 months after the surgery were assessed by the modified magnetic resonance observation of cartilage repair tissue (MOCART) score to determine the degree of bone marrow edema (BME), plug union, and plug necrosis. The clinical outcomes were assessed by Lysholm score to clarify the minimal clinically important difference (MCID) and patient acceptable symptom state analysis. RESULTS In total, 58 patients (17 men and 41 women) were enrolled in this study. Among them, 30 knees were treated by MOS alone and 28 knees were treated by MOS with HTO. The MOCART scores of patients who received MOS alone were significantly lower in BME score (P = .0060), plug union score (P = .0216), and in plug necrosis score (P = .0326) than patients who received MOS with HTO. BME lesion was less likely to persist among elderly (odds ratio 1.20, P = .0248) and female (OR 41.8, P = .0118) patients. The MCID of Lysholm score was 6.6 in MOS alone and 8.4 in MOS with HTO cases, but there were no significant association between MRI findings and the postoperative Lysholm score. CONCLUSIONS The MOS with HTO cases had better MOCART scores with less BME, better plug union, and less plug necrosis compared with MOS alone cases. Female and older patients had better resolution of BME, but there was no significant correlation between MRI findings and the postoperative Lysholm score. All cases in both groups showed improvement of Lysholm score exceeding MCID; thus, MOS may be effective as a joint preserving surgery for SIFK. LEVEL OF EVIDENCE Level IV, clinical case series.
Collapse
Affiliation(s)
- Shogo Mukai
- Department of Orthopedic Surgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan.
| | - Yasuaki Nakagawa
- Department of Orthopedic Surgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Kohei Nishitani
- Department of Orthopedic Surgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan; Department of Orthopedic Surgery, Kyoto University, Kyoto, Japan
| | - Sayako Sakai
- Department of Orthopedic Surgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Ryouta Nakamura
- Department of Orthopedic Surgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Motoi Takahashi
- Department of Orthopedic Surgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| |
Collapse
|
9
|
Martins M, Araújo R, Pinheiro R, Costa A, Carvalho JL. Beyond Gonarthrosis in the Elderly: A Case Report of Subchondral Insufficiency Fracture of the Knee. Cureus 2023; 15:e34366. [PMID: 36874692 PMCID: PMC9975902 DOI: 10.7759/cureus.34366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2023] [Indexed: 01/31/2023] Open
Abstract
Subchondral insufficiency fracture of the knee (SIFK) is a non-traumatic condition that has been, historically, associated with the elderly. Early diagnosis and management are essential to prevent evolution to subchondral collapse and secondary osteonecrosis, developing prolonged pain and functional losses. This article presents the case of an 83-year-old patient with severe right knee pain with 15 months of evolution, with sudden onset, and no history of trauma or sprain. Upon observation, the patient presented with a limping gait, antalgic posture with the knee in semi-flexion, pain on palpation of the joint medial line, severe pain on passive mobilization, limited joint range of motion, and a positive McMurray test. The X-ray only demonstrated a gonarthrosis grade 1 in the Kellgren and Lawrence classification with medial compartment affection. Due to the exuberant clinical picture with marked functional compromise, as well as clinical radiological dissociation, MRI was requested to rule out SIFK, which was later confirmed. The therapeutic orientation was then adjusted with an indication for non-weight bearing and analgesia, as well as orientation to an orthopedics consultation to request a surgical evaluation. SIFK is difficult to diagnose and may have an unpredictable outcome due to delayed treatment approaches. This clinical case encourages clinicians to consider subchondral fracture in the differential diagnosis of knee pain when an older patient, with subnormal radiographic findings, reports severe knee pain in the absence of overt traumatic injury.
Collapse
Affiliation(s)
- Mariana Martins
- Physical Medicine and Rehabilitation, Centro Hospitalar Universitário de Lisboa Central, Lisboa, PRT
| | - Raquel Araújo
- Physical Medicine and Rehabilitation, Centro Hospitalar Universitário do Porto, Porto, PRT
| | - Rosana Pinheiro
- Orthopaedic Surgery, Unidade Local de Saúde do Nordeste, Bragança, PRT
| | - Ana Costa
- Centro de Reabilitação do Norte, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
| | - José Luís Carvalho
- Intervention and Musculoskeletal Rehabilitation Unit, Centro de Reabilitação do Norte, Vila Nova de Gaia, PRT
| |
Collapse
|
10
|
Catapano M, Ahmed M, Breslow RG, Borg-Stein J. The aging athlete. PM R 2022; 14:643-651. [PMID: 35441493 DOI: 10.1002/pmrj.12814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 03/28/2022] [Accepted: 04/04/2022] [Indexed: 11/09/2022]
Abstract
Aging athletes, those 60 years and older, are a growing population of mature, active individuals who value sports and exercise participation throughout their lifespan. Although recommendations for younger and masters athletes have been extrapolated to this population, there remains a paucity of specific guidelines, treatment algorithms, and considerations for aging athletes. The benefits of living an active lifestyle must be weighed against the risks for unique cardiovascular, metabolic, and musculoskeletal injuries requiring diagnostic and therapeutic interventions. In this article, we review the unique cardiovascular and muscular physiology of aging athletes and how it influences the risk of specific medical conditions. We also discuss general prevention and treatment strategies. Finally, we identify areas of future research priorities and emerging treatments.
Collapse
Affiliation(s)
- Michael Catapano
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Charlestown, Massachusetts, USA.,Division of Sports Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marwa Ahmed
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Charlestown, Massachusetts, USA.,Division of Sports Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Joanne Borg-Stein
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Charlestown, Massachusetts, USA.,Division of Sports Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
11
|
BALTA O, ŞAHİN K, ZENGİN Ç, EREN MB, ALTINAYAK H, DEMİR O. Severity of subchondral insufficiency knee fracture: is it associated with increasing age, femorotibial angle, and severity of meniscus extrusion? JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1065127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
|
12
|
Ochi J, Nozaki T, Nimura A, Yamaguchi T, Kitamura N. Subchondral insufficiency fracture of the knee: review of current concepts and radiological differential diagnoses. Jpn J Radiol 2021; 40:443-457. [PMID: 34843043 PMCID: PMC9068663 DOI: 10.1007/s11604-021-01224-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/19/2021] [Indexed: 12/27/2022]
Abstract
Subchondral insufficiency fracture of the knee (SIFK) is a common cause of knee joint pain in older adults. SIFK is a type of stress fracture that occurs when repetitive and excessive stress is applied to the subchondral bone. If the fracture does not heal, the lesion develops into osteonecrosis and results in osteochondral collapse, requiring surgical management. Because of these clinical features, SIFK was initially termed "spontaneous osteonecrosis of the knee (SONK)" in the pre-MRI era. SONK is now categorized as an advanced SIFK lesion in the spectrum of this disease, and some authors believe the term "SONK" is a misnomer. MRI plays a significant role in the early diagnosis of SIFK. A subchondral T2 hypointense line of the affected condyle with extended bone marrow edema-like signal intensity are characteristic findings on MRI. The large lesion size and the presence of osteochondral collapse on imaging are associated with an increased risk of osteoarthritis. However, bone marrow edema-like signal intensity and osteochondral collapse alone are not specific to SIFK, and other osteochondral lesions, including avascular necrosis, osteochondral dissecans, and osteoarthritis should be considered. Chondral lesions and meniscal abnormalities, including posterior root tears, are also found in many patients with SIFK, and they are considered to be related to the development of SIFK. We review the clinical and imaging findings, including the anatomy and terminology history of SIFK, as well as its differential diagnoses. Radiologists should be familiar with these imaging features and clinical presentations for appropriate management.
Collapse
Affiliation(s)
- Junko Ochi
- Department of Diagnostic Radiology, Suita Tokushukai Hospital, 21-1, Senriokanishi, Suita-shi, Osaka, 565-0814, Japan.
| | - Taiki Nozaki
- Department of Radiology, St. Luke's International Hospital, 9-1, Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Akimoto Nimura
- Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Takehiko Yamaguchi
- Department of Pathology, Dokkyo Medical University Nikko Medical Center, 632 Takatoku, Nikko, Tochigi, 321-2593, Japan
| | - Nobuto Kitamura
- Department of Orthopaedic Surgery, St Luke's International Hospital, 9-1, Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan
| |
Collapse
|
13
|
Subchondral insufficiency fracture of the knee: unicompartmental correlation to meniscal pathology and degree of chondrosis by MRI. Skeletal Radiol 2021; 50:2185-2194. [PMID: 33866392 DOI: 10.1007/s00256-021-03777-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/28/2021] [Accepted: 03/29/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the relationship between low- and high-grade subchondral insufficiency fracture of the knee (SIFK) and meniscal tear/type/location, severity of meniscal extrusion, grade of chondrosis, and extent of surrounding edema-like marrow signal intensity. MATERIALS AND METHODS Our retrospective study included 219 patients with knee pain and SIFK seen on MRI. SIFK lesions were categorized from grade 1 to 4 with a low grade (1 and 2) vs high grade (3 and 4) distinction. Associations between SIFK grade, location, lesion dimensions, edema-like marrow signal intensity, incidence of meniscal tears/type/location, and chondrosis (grade 0 to grade 4), as well as patients' age and weight, were assessed. RESULTS Our analysis consisted of 115 males and 104 females with 17% of the patients showing grade 1 SIFK, 59% grade 2, 16% grade 3, and 8% grade 4. No chondrosis or low-grade chondrosis was mostly present in patients with low-grade SIFK (68.9%), whereas high-grade chondrosis was mostly present in patients with high-grade SIFK lesions (65.4%) (p < 0.01). Further sub-analysis demonstrated that high-grade SIFK was associated with high-grade chondrosis in the same compartment (p < 0.01) but not in the adjacent compartment. There was a significant difference in the extent of edema-like marrow signal intensity between the two groups, with high-grade SIFK more frequently demonstrating severe edema-like marrow signal intensity compared to low-grade SIFK (p < 0.01). CONCLUSION High-grade SIFK lesions are associated with unicompartmental high-grade chondrosis.
Collapse
|
14
|
Zimmerman ZE, Bisson LJ, Katz JN. Perspective on subchondral insufficiency fracture of the knee. OSTEOARTHRITIS AND CARTILAGE OPEN 2021; 3:100183. [DOI: 10.1016/j.ocarto.2021.100183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/14/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022] Open
|
15
|
Lateral femoral condyle insufficiency fractures: imaging findings, demographics, and analysis of outcomes. Skeletal Radiol 2021; 50:189-199. [PMID: 32699952 DOI: 10.1007/s00256-020-03548-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 07/12/2020] [Accepted: 07/13/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe imaging characteristics and demographics of lateral femoral condyle insufficiency fractures (LFCIFs) and identify characteristics associated with progression to epiphyseal collapse. MATERIALS AND METHODS A retrospective review of 105 consecutive patients with LFCIF was performed (mean age 58.1 years) after excluding post-traumatic and pathological fractures. Lesion size and location, presence of bone marrow edema-like signal, soft tissue edema, chondrosis grade, and meniscus pathology were documented. Demographics were recorded from the electronic patient record. Follow-up MRI and/or radiographs were evaluated for healing/stability or progression to epiphyseal collapse. Bone mineral density was assessed from dual-energy x-ray absorptiometry (DEXA) scans and/or radiographs. RESULTS Fifty-six female and 49 male subjects were included. Female subjects were older at presentation (60.5 versus 56.3 years, p = .02). A total of 61.7% of the subjects with available DEXA and/or radiographs had osteopenia/osteoporosis. The central weight-bearing (61%) and outer condyle (54.3%) were most involved. High-grade chondrosis was present in ≥ 1 compartment in 70.5% including 42% in the lateral compartment. A total of 67.6% had ≥ 1 meniscus tear with similar frequency of medial and lateral tears (47.6% versus 41%). Bone marrow edema-like signal was present in all cases; soft tissue edema was present in 83.8%. Fifty-three subjects had available follow-up MRI (n = 24) and/or radiographs (n = 29). Increased age, fracture dimensions, presence of medial meniscus tears, and high-grade patellofemoral chondrosis were associated with progression (p ≤ .05). CONCLUSION LFCIFs are associated with meniscus tears, high-grade chondrosis, and osteopenia/osteoporosis with more global knee pathology present when compared with medial femoral condyle insufficiency fracture. Increased age, medial meniscus tears, fracture dimensions, and high-grade patellofemoral chondrosis were associated with progression.
Collapse
|
16
|
Husain R, Nesbitt J, Tank D, Verastegui MO, Gould ES, Huang M. Spontaneous osteonecrosis of the knee (SONK): The role of MR imaging in predicting clinical outcome. J Orthop 2020; 22:606-611. [PMID: 33311863 DOI: 10.1016/j.jor.2020.11.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/15/2020] [Indexed: 10/23/2022] Open
Abstract
Background/aim We try to investigate the association between patterns of imaging findings in patients who had a diagnosis of subchondral fracture around the knee, formerly known as SONK and their clinical outcome. Materials and methods We retrospectively identified 43 knees of 37 patients (28 males, 15 females) who had diagnosis of subchondral fractures around the knee. The mean age is 56-year-old (range 17-83). Musculoskeletal fellowship trained radiologist evaluated all 43 knee MRI in: 1)location of marrow edema 2)peri-osseous edema; 3) subchondral fracture line; 4) subchondral articular surface contour; 5)meniscal tear and extrusion; 6)adjacent soft tissue edema; 7) joint effusion. Independent clinical chart review was performed for clinical outcome with follow up time average of 13.3 months (range 0-88 months). Bad outcome was defined as worsening on imaging, continued complaint with surgical management and knee replacement or another episode of SONK. Chi-square analysis and Student's T tests were conducted to test the statistical significance of association between MR findings and outcomes. Statistical significance was set at p = 0.05 level. Results Of 43 knees, 6 patients had another episodes of SONK (14%), 11 patients were not improving or needed injection vs arthroscopy (26%), 4 patients required arthroplasty (9%), 22 patients had no negative outcome (51%). Gender, age, diabetic status, and location of the subchondral fracture show no influence on outcome. Worse outcome group had a significantly higher average BMI (31.7 vs. 28.0, P = 0.02). Positive change of subchondral articular surface contour is the only imaging finding with positive association with worse outcome (80% vs. 39.9%, P = 0.02). Presence of positive findings of above 3), 4), 5) and 6) had higher percentage of bad outcome (77.8%) compared to those with less positive findings (47.2%). Conclusion MR imaging findings may help at identifying SONK patient with potential risk of developing bad outcome.
Collapse
Affiliation(s)
- Rola Husain
- Diagnostic, Molecular and Interventional Radiology, Mount Sinai Health System, New York, NY, USA
| | - Jared Nesbitt
- Department of Radiology, Stony Brook Medicine, NY, USA
| | - Dharmesh Tank
- Department of Radiology, Stony Brook Medicine, NY, USA
| | | | | | - Mingqian Huang
- Diagnostic, Molecular and Interventional Radiology, Mount Sinai Health System, New York, NY, USA
| |
Collapse
|
17
|
Broida SE, Wong PKW, Umpierrez E, Kakarala A, Reimer NB, Gonzalez FM. Alternate treatment approach to subchondral insufficiency fracture of the knee utilizing genicular nerve cooled radiofrequency ablation and adjunctive bisphosphonate supplementation: A case report. Radiol Case Rep 2020; 15:691-696. [PMID: 32280400 PMCID: PMC7138926 DOI: 10.1016/j.radcr.2020.02.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 02/23/2020] [Accepted: 02/26/2020] [Indexed: 12/20/2022] Open
Abstract
Subchondral insufficiency fractures of the knee are commonly misdiagnosed fractures that are both very painful and difficult to treat. A conservative treatment modality to control symptoms during rehabilitation has not previously been described. This case report presents the alternate use of cooled radiofrequency ablation technique of the genicular nerves for pain relief and bisphosphonate infusion to address the underlying poor bone mineralization/density with imaging follow-up before and after instituted treatments. A middle-aged female patient presenting with atraumatic pain in the medial aspect of the left knee diagnosed on an original magnetic resonance imaging as an insufficiency fracture and debilitating pain. Multiple-surgeon opinions of total knee arthroplasty were not a consideration the patient wanted or could consider given her lifestyle. Cooled radiofrequency ablation of the genicular nerve branches was performed with significant-complete pain relief achieved that lasted at least 6 months. Bisphosphonate infusions were instituted to address the underlying osteoporosis detected by a dual energy X-ray absorptiometry (DEXA) scan. Clinical performance after the radiofrequency ablations was followed with clinically validated surveys (The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)/Knee Injury and Osteoarthritis Outcome Score (KOOS)) at 2 weeks, 1, 3, and 6 months. Patient was also asked to follow a restricted-modified weight-bearing plan for 3 months followed by physical therapy. Eight weeks apart of bisphosphonate infusions were delivered after proper administration of vitamin D. There was resolution of the insufficiency fracture at the medial femoral condyle between the magnetic resonance imaging exams within 4.5 months apart treated with restricted weight-bearing regimen. Pain resolution, significant improved function, and range of motion were the end results of our instituted treatment plan. This case reports presents an alternate pathway for the treatment of this condition especially when there is lack of consensus among physicians in how to best address this condition.
Collapse
Affiliation(s)
| | - Philip Kin-Wai Wong
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Erica Umpierrez
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Aparna Kakarala
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Felix M Gonzalez
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
18
|
Roemer FW, Collins J, Kwoh CK, Hannon MJ, Neogi T, Felson DT, Hunter DJ, Lynch JA, Guermazi A. MRI-based screening for structural definition of eligibility in clinical DMOAD trials: Rapid OsteoArthritis MRI Eligibility Score (ROAMES). Osteoarthritis Cartilage 2020; 28:71-81. [PMID: 31513920 PMCID: PMC7235947 DOI: 10.1016/j.joca.2019.08.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 08/06/2019] [Accepted: 08/28/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE Our aim was to introduce a simplified MRI instrument, Rapid OsteoArthritis MRI Eligibility Score (ROAMES), for defining structural eligibility of patients for inclusion in disease-modifying osteoarthritis drug trials using a tri-compartmental anatomic approach that enables stratification of knees into different structural phenotypes and includes diagnoses of exclusion. We also aimed to define overlap between phenotypes and determine reliability. METHODS 50 knees from the Foundation for National Institutes of Health Osteoarthritis Biomarkers study, a nested case-control study within the Osteoarthritis Initiative, were selected within pre-defined definitions of phenotypes as either inflammatory, subchondral bone, meniscus/cartilage, atrophic or hypertrophic. A focused scoring instrument was developed covering cartilage, meniscal damage, inflammation and osteophytes. Diagnoses of exclusion were meniscal root tears, osteonecrosis, subchondral insufficiency fracture, tumors, malignant marrow infiltration and acute traumatic changes. Reliability was determined using weighted kappa statistics. Descriptive statistics were used for determining concordance between the a priori phenotypic definition and ROAMES and overlap between phenotypes. RESULTS ROAMES identified 43 of 50 (86%) pre-defined phenotypes correctly. Of the 50 participants, 27 (54%) had no additional phenotypes other than the pre-defined phenotype. 18 (36%) had one and 5 (10%) had two additional phenotypes. None had three or four additional phenotypes. All features of ROAMES showed almost perfect agreement. One case with osteonecrosis and one with a tumor were detected. CONCLUSIONS ROAMES is able to screen and stratify potentially eligible knees into different structural phenotypes and record relevant diagnoses of exclusion. Reliability of the instrument showed almost perfect agreement.
Collapse
Affiliation(s)
- Frank W. Roemer
- Quantitative Imaging Center, Department of Radiology, Boston University School of Medicine, FGH Building, 4th floor, 820 Harrison Avenue, Boston, MA 02118, USA,Department of Radiology, Friedrich-Alexander University Erlangen-Nürnberg (FAU) and Universitätsklinikum Erlangen, Erlangen, Germany, Maximiliansplatz 3, 91054 Erlangen, Germany
| | - Jamie Collins
- Orthopaedics and Arthritis Center of Outcomes Research, Brigham and Women’s Hospital, Harvard Medical, School, 75 Francis Street, BTM Suite 5016 Boston, MA 02115 Boston, Massachusetts
| | - C. Kent Kwoh
- University of Arizona Arthritis Center & University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724, USA
| | - Michael J. Hannon
- Pinney Associates, 201 N Craig St # 320, Pittsburgh, PA 15213, USA & Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, S700 Biomedical Science Tower, 3500 Terrace Street, Pittsburgh, PA 15261, USA (former affiliation at time of study)
| | - Tuhina Neogi
- Boston University School of Medicine, Section of Rheumatology, 650 Albany Street, Suite X-20, Boston, MA, 02118, USA
| | - David T. Felson
- Boston University School of Medicine, Section of Rheumatology, 650 Albany Street, Suite X-20, Boston, MA, 02118, USA
| | - David J. Hunter
- Department of Rheumatology, Royal North Shore Hospital and Institute of Bone and Joint Research, Kolling Institute, University of Sydney, Pacific Hwy, St Leonards, NSW 2065, Australia
| | - John A. Lynch
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th St, San Francisco, CA 94158, USA
| | - Ali Guermazi
- Quantitative Imaging Center, Department of Radiology, Boston University School of Medicine, FGH Building, 4th floor, 820 Harrison Avenue, Boston, MA 02118, USA
| |
Collapse
|
19
|
Subchondral insufficiency fracture of the knee: grading, risk factors, and outcome. Skeletal Radiol 2019; 48:1961-1974. [PMID: 31250037 DOI: 10.1007/s00256-019-03245-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 05/03/2019] [Accepted: 05/14/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To propose an magnetic resonance imaging (MRI) grading system for subchondral insufficiency fracture of the knee (SIFK) to predict outcome and assess risk factors. MATERIALS AND METHODS A total of 50 SIFK patients were retrospectively reviewed utilizing two MRI examinations approximately a year apart and compared them with 51 control subjects. A grading system was introduced that classifies lesions as low- vs high-grade. Lesion location 3D dimensions, extent of bone marrow edema (BME), location of meniscal tears and associated extrusion, degree of chondrosis and among other parameters were stratified according to lesion grade and compared with follow-up examinations. Statistical analyses were performed (Pearson's correlation, binary logistic regression, and Chi-squared analysis). RESULTS The majority of SIFK lesions were low-grade (LG; 78%) and most of them (70%) were observed in the medial femoral condyle. Predictor variables comparing low-grade and high-grade SIFK lesions included meniscal tear (p = 0.01), degree of extrusion (p < 0.003), chondrosis (p = 0.01), medial chondrosis grade (p = 0.001), medial femoral condyle (p = 0.01), surface collapse (p < 0.0001), marrow edema improvement (p < 0.0001), first MRI anteroposterior dimension (p = 0.001), transverse dimension (p < 0.001), and ellipsoid volume (p = 0.02). Predictor variables found to be significantly different between controls and patients were meniscal tear (p = 0.024), location of the medial meniscal tear (p < 0.0001), degree of extrusion (p < 0.0001), chondrosis (p < 0.0001), joint effusion (p < 0.0001), Baker's cyst (p < 0.0001), knee lock (p = 0.03) and buckle (p = 0.01), and history of trauma (p = 0.01). CONCLUSION A SIFK grading system for MRI is introduced. Surrogate markers of high-grade lesions include medial meniscus posterior root tears with associated moderate to severe extrusion, high-grade chondrosis, larger lesion sizes (anteroposterior/transverse), and articular surface collapse. Improvement of BME on follow-up was highly predictive of low-grade disease.
Collapse
|
20
|
Kompel AJ, Roemer FW, Murakami AM, Diaz LE, Crema MD, Guermazi A. Intra-articular Corticosteroid Injections in the Hip and Knee: Perhaps Not as Safe as We Thought? Radiology 2019; 293:656-663. [PMID: 31617798 DOI: 10.1148/radiol.2019190341] [Citation(s) in RCA: 160] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Osteoarthritis (OA) of the hip and knee is among the most common joint disorders. Intra-articular corticosteroid (IACS) injections are frequently performed to treat OA and other joint-related pain syndromes; however, there is conflicting evidence on their potential benefit. There is a lack of prospective and large retrospective studies evaluating potential joint findings, including increased risk for accelerated OA progression or adverse joint events, after treatment with IACS injection. Four main adverse joint findings have been structurally observed in patients after IACS injections: accelerated OA progression, subchondral insufficiency fracture, complications of osteonecrosis, and rapid joint destruction, including bone loss. Physicians, including radiologists, should be familiar with imaging findings and patient characteristics that may help them identify potential joints at risk for such events. The purpose of this report is to review the existing literature, describe observed adverse joint events after IACS injections, and provide an outlook on how this may affect clinical practice. Additional research endeavors are urgently needed to better understand and identify risk factors prior to intervention and to detect adverse joint events after injection as early as possible to prevent or minimize complications.
Collapse
Affiliation(s)
- Andrew J Kompel
- From the Department of Radiology, Boston University School of Medicine, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118 (A.J.K., F.W.R., A.M.M., L.E.D., M.D.C., A.G.); Department of Radiology, Friedrich-Alexander University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany (F.W.R.); Department of Radiology, Veterans Affairs Hospital, Boston, Mass (L.E.D., A.G.); and Institute of Sports Imaging, French National Institute of Sports (INSEP), Paris, France (M.D.C.)
| | - Frank W Roemer
- From the Department of Radiology, Boston University School of Medicine, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118 (A.J.K., F.W.R., A.M.M., L.E.D., M.D.C., A.G.); Department of Radiology, Friedrich-Alexander University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany (F.W.R.); Department of Radiology, Veterans Affairs Hospital, Boston, Mass (L.E.D., A.G.); and Institute of Sports Imaging, French National Institute of Sports (INSEP), Paris, France (M.D.C.)
| | - Akira M Murakami
- From the Department of Radiology, Boston University School of Medicine, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118 (A.J.K., F.W.R., A.M.M., L.E.D., M.D.C., A.G.); Department of Radiology, Friedrich-Alexander University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany (F.W.R.); Department of Radiology, Veterans Affairs Hospital, Boston, Mass (L.E.D., A.G.); and Institute of Sports Imaging, French National Institute of Sports (INSEP), Paris, France (M.D.C.)
| | - Luis E Diaz
- From the Department of Radiology, Boston University School of Medicine, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118 (A.J.K., F.W.R., A.M.M., L.E.D., M.D.C., A.G.); Department of Radiology, Friedrich-Alexander University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany (F.W.R.); Department of Radiology, Veterans Affairs Hospital, Boston, Mass (L.E.D., A.G.); and Institute of Sports Imaging, French National Institute of Sports (INSEP), Paris, France (M.D.C.)
| | - Michel D Crema
- From the Department of Radiology, Boston University School of Medicine, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118 (A.J.K., F.W.R., A.M.M., L.E.D., M.D.C., A.G.); Department of Radiology, Friedrich-Alexander University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany (F.W.R.); Department of Radiology, Veterans Affairs Hospital, Boston, Mass (L.E.D., A.G.); and Institute of Sports Imaging, French National Institute of Sports (INSEP), Paris, France (M.D.C.)
| | - Ali Guermazi
- From the Department of Radiology, Boston University School of Medicine, 820 Harrison Ave, FGH Building, 3rd Floor, Boston, MA 02118 (A.J.K., F.W.R., A.M.M., L.E.D., M.D.C., A.G.); Department of Radiology, Friedrich-Alexander University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany (F.W.R.); Department of Radiology, Veterans Affairs Hospital, Boston, Mass (L.E.D., A.G.); and Institute of Sports Imaging, French National Institute of Sports (INSEP), Paris, France (M.D.C.)
| |
Collapse
|
21
|
The role of radiography and MRI for eligibility assessment in DMOAD trials of knee OA. Nat Rev Rheumatol 2019; 14:372-380. [PMID: 29752462 DOI: 10.1038/s41584-018-0010-z] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Currently, no disease-modifying osteoarthritis drugs (DMOADs) have been approved. Past clinical trials have failed for several reasons, including the commonly applied definition of eligibility based on radiographic assessment of joint structure. In the context of precision medicine, finding the appropriate patient for a specific treatment approach will be of increasing relevance. Phenotypic stratification by use of imaging at the time of determining eligibility for clinical trials will be paramount and cannot be achieved using radiography alone. Furthermore, identification of joints at high risk of rapid progression of osteoarthritis is needed in order to enable a more efficient DMOAD trial design. In addition, joints at high risk of collapse need to be excluded at screening. The use of MRI might offer advantages over radiography in this context. Technological advances and simplified image assessment address many of the commonly perceived barriers to the application of MRI to assessment of eligibility for DMOAD clinical trials.
Collapse
|
22
|
Abstract
OBJECTIVE. The purpose of this article is to summarize the nomenclature of nonneoplastic conditions affecting subchondral bone through a review of the medical literature and expert opinion of the Society of Skeletal Radiology Subchondral Bone Nomenclature Committee. CONCLUSION. This consensus statement summarizes current understanding of the pathophysiologic characteristics and imaging findings of subchondral nonneoplastic bone lesions and proposes nomenclature to improve effective communication across clinical specialties and help avoid diagnostic errors that could affect patient care.
Collapse
|
23
|
Salehi S, Abedi A, Gross JS, Gholamrezanezhad A. Prayer's fracture: rare cases of knee insufficiency fracture in non-weight-bearing femoral condyle. Clin Imaging 2019; 58:80-83. [PMID: 31279988 DOI: 10.1016/j.clinimag.2019.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/30/2019] [Accepted: 06/21/2019] [Indexed: 11/18/2022]
Abstract
Insufficiency fractures are a relatively common sub-type of stress fractures and occur as a result of decreased bone resistance due to underlying conditions such as osteoporosis. Insufficiency fractures of the knee most commonly occur at the central weight-bearing zone of the medial femoral condyle. We present five unusual cases of insufficiency fractures occurring at the posterior non-weight-bearing zone of condyles. After investigating commonalities between these patients, we discovered that all of these patients performed the daily practice of prayer rituals that include high knee flexion. We have chosen to coin this type of fracture a "Prayer's fracture". Considering the mechanics of high knee flexion, transient changes in the weight-bearing zone of knee explain the unusual location of this fracture. We describe these cases, the characteristic imaging appearance, and the probable biomechanics that we believe predispose patients to this type of injury.
Collapse
Affiliation(s)
- Sana Salehi
- Department of Radiology, Keck School of Medicine, University of Southern California, 1500 San Pablo Street, Los Angeles, CA 90033, USA
| | - Aidin Abedi
- Department of Radiology, Keck School of Medicine, University of Southern California, 1500 San Pablo Street, Los Angeles, CA 90033, USA; Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1520 San Pablo St #2000, Los Angeles, CA 90033, USA.
| | - Jordan S Gross
- Department of Radiology, Keck School of Medicine, University of Southern California, 1500 San Pablo Street, Los Angeles, CA 90033, USA
| | - Ali Gholamrezanezhad
- Department of Radiology, Keck School of Medicine, University of Southern California, 1500 San Pablo Street, Los Angeles, CA 90033, USA
| |
Collapse
|
24
|
Magnetic resonance imaging of subchondral insufficiency fractures of the lower limb. Skeletal Radiol 2019; 48:1011-1021. [PMID: 30706108 DOI: 10.1007/s00256-019-3160-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/04/2018] [Accepted: 01/10/2019] [Indexed: 02/02/2023]
Abstract
Subchondral insufficiency fracture (SIF) is a non-traumatic condition that has historically been associated with elderly, osteoporotic women and patients with systemic conditions. There has been much work done to determine the pathogenesis of SIF, which has previously been regarded as idiopathic, rapid-progressive osteoarthritis or osteonecrosis of the hip, spontaneous osteonecrosis of the knee (SONK), osteochondral defect (OCD) of the talus and adult-onset Freiberg infraction of the metatarsal head. Early diagnosis and management are crucial to prevent subchondral collapse, secondary osteonecrosis and early-onset osteoarthritis. Magnetic resonance imaging (MRI) plays an important role in the diagnosis of SIF, which is often inconspicuous on initial radiographs. In this article, the authors provide an update on the role of MRI in identifying key imaging features of SIF in various joints of the lower limb to aid in its correct diagnosis.
Collapse
|
25
|
Hussain ZB, Chahla J, Mandelbaum BR, Gomoll AH, LaPrade RF. The Role of Meniscal Tears in Spontaneous Osteonecrosis of the Knee: A Systematic Review of Suspected Etiology and a Call to Revisit Nomenclature. Am J Sports Med 2019; 47:501-507. [PMID: 29253348 DOI: 10.1177/0363546517743734] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The cause of spontaneous osteonecrosis of the knee (SONK) and postarthroscopic osteonecrosis of the knee is unknown, and the mechanisms involved have been poorly characterized. HYPOTHESIS/PURPOSE The purpose of this study was to perform a detailed systematic review of the literature to examine proposed etiological mechanisms for SONK in order to establish an improved understanding of the processes involved. We hypothesized that the etiology of SONK would be multifactorial. STUDY DESIGN Systematic review. METHODS A systematic review of the literature was performed by searching PubMed, Medline, Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials. Inclusion criteria were all original research articles presented in the English language that reported on the suspected etiology of SONK. Reviews, case reports with fewer than 3 patients, cost-effectiveness studies, technical reports, editorial articles, surveys, special topics, letters to the editor, personal correspondence, and studies that only proposed factors for the progression of SONK were excluded. RESULTS After a comprehensive review of 255 articles, 26 articles were included for final analysis. Twenty-one (80.7%) of 26 articles implicated the role of the meniscus in the development of SONK, in an association with either meniscal tears or its development after meniscectomy. The medial meniscus and posterior meniscal root tears were implicated more frequently. All 4 studies incorporating histological findings supported the insufficiency fracture hypothesis as a pathological basis of SONK. CONCLUSION Physicians should be cognizant of the high prevalence of medial meniscus root tears in patients with SONK. Meniscectomy and meniscal tears, particularly of the medial meniscus posterior root, increase contact pressures and create an environment from which insufficiency fractures can emanate. We believe the term SONK is a misrepresentation of the etiology and pathogenesis of the condition and should be replaced with subchondral insufficiency fractures of the knee. Further elucidation of the etiology is required.
Collapse
Affiliation(s)
| | - Jorge Chahla
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Andreas H Gomoll
- Cartilage Repair Center and Center for Regenerative Medicine, Brigham and Women's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Robert F LaPrade
- Steadman Philippon Research Institute, Vail, Colorado, USA.,The Steadman Clinic, Vail, Colorado, USA
| |
Collapse
|
26
|
Hu D, Huang Z, Zhang W, Lin J, Li W. [Analysis of medial unicompartmental knee arthroplasty for patients with spontaneous osteonecrosis of the knee]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:13-17. [PMID: 30644254 DOI: 10.7507/1002-1892.201805127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To analyse the effectiveness of unicompartmental knee arthroplasty (UKA) for the patients with spontaneous osteonecrosis of the knee (SONK). Methods Between January 2012 and December 2016, 31 patients with SONK was admitted and treated with medial UKA. All patients were examined by both plain radiography and magnetic resonance images. The patients were composed of 5 men and 26 women with an average age of 64.3 years (range, 48-79 years), and with 16 left joints and 15 right joints. The average disease duration was 14.7 months (range, 6-26 months). Preoperative visual analogue scale (VAS) was 6.00±1.15, Hospital for Special Surgery (HSS) score was 55.77±11.03, and knee range of motion (ROM) was (114.68±10.40)°. The imaging examinations showed that all the lesions were located in the medial compartment of the knee joint and there were 19 patients with Aglietti stage Ⅳ and 12 patients with Aglietti stage Ⅴ. Preoperative femorotibial angle (FTA) was (177.39±1.63)° and posterior tibial slope (PTS) was (84.05±1.39)°. Results All the incisions healed by first intention. All patients were followed up 14-46 months (mean, 25 months). At last follow-up, VAS score was 2.06±0.72 and HSS score was 86.45±3.67, which both improved significantly when compared with preoperative scores ( t=22.73, P=0.00; t=-14.72, P=0.00). ROM was (118.06±3.80)° with no significant difference when compared with preoperative ROM ( t=-1.78, P=0.08). The X-ray films showed there was no severe adverse events, such as periprosthetic infection, aseptic loosening, bearing dislocation, and so on. At last follow- up, PTS was (85.30±1.19)° with significant difference compared with preoperative one ( t=-4.07, P=0.00); while FTA was (177.51±1.98)° with no significant difference when compared with preoperative FTA ( t=-0.38, P=0.71). Conclusion UKA may be an optional management for SONK with minimally invasive, bone-preserving, and rapid recovery.
Collapse
Affiliation(s)
- Deqing Hu
- Department of Orthopaedics, the First Affiliated Hospital of Fujian Medical University, Fuzhou Fujian, 350005, P.R.China
| | - Zida Huang
- Department of Orthopaedics, the First Affiliated Hospital of Fujian Medical University, Fuzhou Fujian, 350005, P.R.China
| | - Wenming Zhang
- Department of Orthopaedics, the First Affiliated Hospital of Fujian Medical University, Fuzhou Fujian, 350005,
| | - Jianhua Lin
- Department of Orthopaedics, the First Affiliated Hospital of Fujian Medical University, Fuzhou Fujian, 350005, P.R.China
| | - Wenbo Li
- Department of Orthopaedics, the First Affiliated Hospital of Fujian Medical University, Fuzhou Fujian, 350005, P.R.China
| |
Collapse
|
27
|
An VV, Broek MVD, Oussedik S. Subchondral Insufficiency Fracture in the Lateral Compartment of the Knee in a 64-Year-Old Marathon Runner. Knee Surg Relat Res 2017; 29:325-328. [PMID: 29172394 PMCID: PMC5718795 DOI: 10.5792/ksrr.17.049] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/11/2017] [Accepted: 09/26/2017] [Indexed: 11/05/2022] Open
Abstract
A 64-year-old marathon runner presented to our clinic with a history of worsening pain in her left knee. Following magnetic resonance imaging, the diagnosis of subchondral insufficiency fracture of the knee (SIFK) was made. A course of conservative management via bisphosphonates was initiated. The patient successfully recovered and returned to full athletic function, having recently returned to competitive marathon running. This article aims to present this unusual case of lateral compartment SIFK and summarise the literature on this uncommon condition.
Collapse
Affiliation(s)
- Vincent Vg An
- Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Mathias van den Broek
- Department of Orthopaedics, University College London Hospitals NHS Trust, London, UK
| | - Sam Oussedik
- Department of Orthopaedics, University College London Hospitals NHS Trust, London, UK
| |
Collapse
|