Knee MR-arthrography in assessment of meniscal and chondral lesions

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.

SSR white paper: guidelines for utilization and performance of direct MR arthrography

OBJECTIVE

Direct magnetic resonance arthrography (dMRA) is often considered the most accurate imaging modality for the evaluation of intra-articular structures, but utilization and performance vary widely without consensus. The purpose of this white paper is to develop consensus recommendations on behalf of the Society of Skeletal Radiology (SSR) based on published literature and expert opinion.

MATERIALS AND METHODS

The Standards and Guidelines Committee of the SSR identified guidelines for utilization and performance of dMRA as an important topic for study and invited all SSR members with expertise and interest to volunteer for the white paper panel. This panel was tasked with determining an outline, reviewing the relevant literature, preparing a written document summarizing the issues and controversies, and providing recommendations.

RESULTS

Twelve SSR members with expertise in dMRA formed the ad hoc white paper authorship committee. The published literature on dMRA was reviewed and summarized, focusing on clinical indications, technical considerations, safety, imaging protocols, complications, controversies, and gaps in knowledge. Recommendations for the utilization and performance of dMRA in the shoulder, elbow, wrist, hip, knee, and ankle/foot regions were developed in group consensus.

CONCLUSION

Although direct MR arthrography has been previously used for a wide variety of clinical indications, the authorship panel recommends more selective application of this minimally invasive procedure. At present, direct MR arthrography remains an important procedure in the armamentarium of the musculoskeletal radiologist and is especially valuable when conventional MRI is indeterminant or results are discrepant with clinical evaluation.

Improving visualization of the articular cartilage of the knee with magnetic resonance imaging under axial traction: a comparative study of different traction weights

OBJECTIVE

Lesions of the articular cartilage of the knee, especially early grades, are not always accurately detected by magnetic resonance imaging (MRI) because of contact between the articular cartilage surfaces of the femur and the tibia. This study aimed to assess the effects of axial leg traction during knee MRI examination on joint space widening and articular cartilage visualization and evaluate the ideal weight for traction.

METHODS

MRI was performed on ten healthy volunteers using a 3-T MRI unit with a 3D dual-echo steady-state gradient-recalled echo sequence. Conventional MRI was performed first, followed by traction MRI. The traction weight increased in the order of 5 kg, 10 kg, and 15 kg. Joint space widths were measured, and articular cartilage visualization was assessed at the medial and lateral tibiofemoral joints. Volunteers were asked to evaluate pain and discomfort using a visual analog scale during each procedure with axial traction to assess the safety of traction MRI.

RESULTS

The medial tibiofemoral joint space width significantly increased, and the visualization of the articular cartilage significantly improved by applying traction. The joint space width and the articular cartilage visualization showed no significant differences among traction weights of 5 kg, 10 kg, and 15 kg. Pain and discomfort during traction MRI examination were lowest with a traction weight of 5 kg.

CONCLUSION

Traction MRI examination may be useful in evaluating articular cartilage lesions at the medial tibiofemoral joint. A traction weight of 5 kg may be sufficient with minimum pain and discomfort.

Correlation between Magnetic Resonance Imaging and Arthroscopic Findings in Knee Lesions

Background: Magnetic resonance imaging (MRI) is a noninvasive diagnostic method with no known side effects and a high sensitivity for detecting meniscal lesions as well as lesions of the anterior and posterior cruciate ligaments. For a correct and complete diagnosis, MRI results must be interpreted in the context of clinical examination and anamnesis. MRI results can support the surgical indication for arthroscopy, which is a minimally invasive intervention that facilitates the visualization, investigation, diagnosis, and treatment of intra-articular lesions of the knee. The purpose of this study was to assess the correlation between MRI results and the intra-articular lesions detected arthroscopically.

Material and methods: This retrospective study evaluated a total of 60 patients admitted and treated between January 1, 2013 and January 1, 2014 in the Clinic of Orthopedics and Traumatology of Mureș County Hospital, Târgu Mureș, Romania.

Results: In the 43 patients with lesion of the anterior cruciate ligament, the lesions were seen on MRI in 40 patients (93%) and confirmed arthroscopically in 37 patients (86%). In 34 cases (79.1% of the total of 43), the MRI and arthroscopic results were similar, the Kappa coefficient showing a high degree of correlation (0.90).

Conclusion: By assessing the Kappa coefficient to highlight the correlation between MRI results and arthroscopic diagnosis for knee injuries, a statistically relevant correlation between the two methods was found. This suggests that a correct diagnosis can be achieved by both methods.

The relationship between early-onset chondromalacia and the position of the patella

Background

There are many underlying accelerator factors for chondromalacia and one of the well-known factors is patellar malalignment.

Purpose

To evaluate the relationship between early-onset chondromalacia and patellar position; and, second, to evaluate the value of patellar malalignment criteria.

Material and Methods

Patients aged 18–40 years with advanced chondromalacia were included. For comparison, a control group was defined with the same number of individuals of the same mean age. The magnetic resonance imaging (MRI) sagittal view with the greatest patellar length was used to obtain the patellar height measurement with the Insall-Salvati index. For the remaining three indices—modified Insall-Salvati, Caton-Deschamps, and Blackburne-Pell—a sagittal view with the greatest patellar articular surface was used. Discordance was defined as contradiction with the measured index and the other three indices.

Results

Both patella alta and baja were found to be predisposing factors for chondromalacia. Modified Insall-Salvati index was the most concordant measurement to define patella alta.

Conclusion

Both patella alta and patella baja were found to predispose to chondromalacia. Patella baja is rare, which may explain why it is not often mentioned as a predisposing factor. The modified Insall-Salvati index ratio was the best patella alta indicator that showed chondral status, more than patellar placement, and was more concordant with the other indices. Blackburne-Pell had the second highest number and ratio of discordance. BP cannot be optimally calculated because deciding the location of the tibial plateau seems to be problematic since it is a three-dimensional and complicated structure.

Comparison of Indirect MR Arthrography With Conventional MRI in the Diagnosis of Knee Pathologies in Patients With Knee Pain

Background

Knee pain is a common problem in the general population. In order to determine the extent of the injury and the appropriate treatment, MRI provides the most accurate imaging method. This may be done through conventional MRI techniques or by injecting a contrast material (MR arthrography).

Objectives

The purpose of this study was to compare the diagnostic value of these two methods.

Patients and Methods

The study involved the diagnostic evaluation on 60 patients with knee pain who received treatment over the course of a one-year period. Referred patients were randomly divided into two groups: indirect MR arthrography was performed on one group, and conventional MRI was performed on the other group. Both groups then underwent arthroscopy. The results from both groups were compared with the arthroscopic findings.

Results

In all of the pathologies studied, the sensitivity, specificity, and the positive and negative predictive values were evaluated. A high rate of accuracy was found between MR arthrography and arthroscopy (P < 0.05) for all knee injuries, however a similar rate of accuracy between conventional MRI and arthroscopy was only seen in patients with damage to the posterior cruciate ligament (PCL), the tibio-femoral articular cartilage, and patella chondromalacia (P < 0.05). The highest rate of accuracy was seen in cases where indirect MR arthrography was used for the diagnosis of anterior cruciate ligament (ACL) damage (K = 1).

Conclusions

Our results have shown that indirect MR arthrography had greater diagnostic accuracy in regards to the sensitivity, specificity, and positive and negative predictive values than conventional MRI in knee pathologies.

MR-arthrography assessment after repair of chronic meniscal tears

PURPOSE

The aims of this study were to assess the healing rate of repair of chronically torn meniscal tear with MR-arthrography and to evaluate the relationship between the clinical and the radiographic outcomes and the impact of the meniscal section on healing.

METHODS

MR-arthrography was performed at a median of 10.5 months (range 6-55) after surgery in 28 patients and healing assessed using Henning's criteria. All lesions were chronic (>3 months). Repairs were carried out at a median 14 months (range 6-80) from initial diagnosis. Eleven patients (39%) had ACL ligament reconstruction as well. All lesions were located in the red or red-white zone. Patients were followed for a median of 18.5 months (range 8-68). Functional outcomes were evaluated using Barrett's healing criteria, Lysholm and Tegner score pre- and postoperatively.

RESULTS

Clinical healing of the lesion according to Barrett's criteria was achieved in 24 patients (85.7%). Both Lysholm and Tegner scores improved significantly after the surgery (p < 0.05). According to Henning's criteria, 15 of the menisci healed completely (53.5%), 10 partially (35.7%) and 3 failed (10.8%). There was no significant difference between the healing process in the posterior horn and the body of the meniscus (n.s.). No correlation was found between the healing results and the clinical scores. ACL reconstruction did not influence the healing process (n.s.). Patients waiting more than 1 year from lesion to surgery seem to have a higher rate of failure (p = 0.02).

CONCLUSIONS

The results found suggest good short-term clinical and anatomic outcomes post-repair of meniscal lesions, despite their chronic nature. Longer waiting times may have negative effects on the healing process. Partial healing occurred often, but the meniscus was painless and stable.

LEVEL OF EVIDENCE

Retrospective case series, Level IV.

The acutely injured knee

Acute knee pain is a common complaint among patients presenting to outpatient clinics. Although most injuries are minor and resolve without surgical intervention, some injuries, such as extensor mechanism injuries, tibial plateau fractures, and multi-ligament knee injuries, require prompt evaluation by an orthopedic surgeon. A thorough history and physical examination combined with radiographs are usually sufficient to diagnose these more urgent injuries. If the diagnosis remains uncertain, magnetic resonance imaging is the imaging modality of choice in diagnosing ligamentous, tendinous, meniscal, and chondral injuries.

Accuracy of magnetic resonance imaging in grading knee chondral defects

PURPOSE

To determine the accuracy of routine magnetic resonance imaging (MRI) in the grading of knee cartilage lesions through a meta-analysis.

METHODS

A search of English-language literature published before February 2012 was carried out in PubMed. Articles using arthroscopy as a gold standard, a 6-knee region dividing method, and a 5-level grading system were included in our meta-analysis. After data extraction, a bivariate mixed-effects model and hierarchical weighted symmetric summary receiver operating curve were used to pool the results of diagnostic tests. A sensitivity analysis was conducted to explore the potential sources of heterogeneity.

RESULTS

Overall, 8 studies were included in the meta-analysis. The overall sensitivity, specificity, diagnostic odds ratio, positive likelihood ratio, and negative likelihood ratio were 75% (95% confidence interval [CI], 62% to 84%), 94% (95% CI, 89% to 97%), 47 (95% CI, 18 to 122), 12.5 (95% CI, 6.5 to 24.2), and 0.27 (95% CI, 0.17 to 0.42), respectively. There was substantial heterogeneity among the results. Sensitivity analysis showed the inconsistency of 2 studies. However, eliminating the 2 studies had no significant impact on the overall results.

CONCLUSIONS

Our results showed that MRI was effective in discriminating normal morphologic cartilage from disease but was less sensitive in detecting knee chondral lesions (higher than grade 1). The negative results of MRI should not prevent a diagnostic arthroscopy.

LEVEL OF EVIDENCE

Level II, meta-analysis of Level I and II studies.

The current state of imaging the articular cartilage of the upper extremity

MR imaging has increasingly been used to image joints since its inception. Historically, there has been more emphasis on the evaluation of internal derangement rather than cartilaginous disease. This article reviews cartilaginous diseases of the upper extremity emphasizing those that can be assessed using current clinical MR imaging protocols and addresses the limitations of current imaging techniques in evaluating the articular cartilage of smaller joints. It also provides a brief overview of novel techniques that may be instituted in the future to improve the diagnostic performance of MR imaging in the evaluation of the articular cartilage of the upper extremity.

Arthroscopic all-inside meniscal repair--Does the meniscus heal? A clinical and radiological follow-up examination to verify meniscal healing using a 3-T MRI

OBJECTIVE

The purpose of this study was to correlate clinical and radiological results using a 3-T MRI to verify meniscal healing after arthroscopic all-inside meniscus repair.

MATERIALS AND METHODS

We selected 27 patients (14 men and 13 women) with an average age of 31 ± 9 years and retrospective clinical examinations and radiological assessments using a 3-T MRI after all-inside arthroscopic meniscal repair were conducted. Repair of the medial meniscus was performed in 19 patients and of the lateral meniscus in eight. In 17 patients (63%), we performed concomitant anterior cruciate ligament reconstruction. The mean follow-up period was 4.5 ± 1.7 years. The Lysholm score and Tegner activity index were used for clinical evaluation. Four grades were used to classify the radiological signal alterations within the meniscus: central globular (grade 1); linear horizontal or band-like (grade 2); intrameniscal alterations and linear signal alterations communicating with the articular surface (grade 3); and complex tears (grade 4).

RESULTS

At follow-up, the average Lysholm score was 76 ± 15 points, with ten of the patients placed in group 6 based on the Tegner activity index. MRI examinations revealed no signal alteration in three patients, grade 1 in 0, grade 2 in five, grade 3 in 13, and grade 4 in six. The MRI findings correlated positively with the clinical scores in 21 patients (78%).

CONCLUSIONS

Correlation of clinical and radiological examination was performed using 3-T MRI. In spite of satisfactory clinical outcomes at follow-up, a radiological signal alteration may still be visible on MRI, which was believed to be scar tissue, but could not be proven definitively. Imaging with a 3-Tesla MRI after meniscal suture surgery provides good but no definitive reliability on meniscus healing and therefore gives no advantage compared to 1.5-T MRI, with good clinical outcome using an all-inside arthroscopic meniscal repair.

CLINICAL RELEVANCE

3T-MRI can not substitute diagnostic arthroscopy in patients with persistent complaints after arthroscopic all-inside meniscal repair.

Clinical cartilage imaging of the knee and hip joints

OBJECTIVE

MRI is commonly used to evaluate the articular cartilage of the knee and hip joints in clinical practice. This article will discuss the advantages and limitations of currently available MRI techniques for evaluating articular cartilage.

CONCLUSION

Because of its high spatial resolution, multiplanar capability, and excellent tissue contrast, MRI is the imaging technique of choice for evaluating the articular cartilage of the knee and hip joints.

Arthroscopy vs. MRI for a detailed assessment of cartilage disease in osteoarthritis: diagnostic value of MRI in clinical practice

BACKGROUND

In patients with osteoarthritis, a detailed assessment of degenerative cartilage disease is important to recommend adequate treatment. Using a representative sample of patients, this study investigated whether MRI is reliable for a detailed cartilage assessment in patients with osteoarthritis of the knee.

METHODS

In a cross sectional-study as a part of a retrospective case-control study, 36 patients (mean age 53.1 years) with clinically relevant osteoarthritis received standardized MRI (sag. T1-TSE, cor. STIR-TSE, trans. fat-suppressed PD-TSE, sag. fat-suppressed PD-TSE, Siemens Magnetom Avanto syngo MR B 15) on a 1.5 Tesla unit. Within a maximum of three months later, arthroscopic grading of the articular surfaces was performed. MRI grading by two blinded observers was compared to arthroscopic findings. Diagnostic values as well as intra- and inter-observer values were assessed.

RESULTS

Inter-observer agreement between readers 1 and 2 was good (kappa = 0.65) within all compartments. Intra-observer agreement comparing MRI grading to arthroscopic grading showed moderate to good values for readers 1 and 2 (kappa = 0.50 and 0.62, respectively), the poorest being within the patellofemoral joint (kappa = 0.32 and 0.52). Sensitivities were relatively low at all grades, particularly for grade 3 cartilage lesions. A tendency to underestimate cartilage disorders on MR images was not noticed.

CONCLUSIONS

According to our results, the use of MRI for precise grading of the cartilage in osteoarthritis is limited. Even if the practical benefit of MRI in pretreatment diagnostics is unequivocal, a diagnostic arthroscopy is of outstanding value when a grading of the cartilage is crucial for a definitive decision regarding therapeutic options in patients with osteoarthritis.