Clinical Implications of Bone Bruise Patterns Accompanying Anterior Cruciate Ligament Tears

Automated quantitative assessment of bone contusions and overlying articular cartilage following anterior cruciate ligament injury

Quantitative methods to characterize bone contusions and associated cartilage injury remain limited. We combined standardized voxelwise normalization and 3D mapping to automate bone contusion segmentation post-anterior cruciate ligament (ACL) injury and evaluate anomalies in articular cartilage overlying bone contusions. Forty-five patients (54% female, 26.4 ± 11.8 days post-injury) with an ACL tear underwent 3T magnetic resonance imaging of their involved and uninvolved knees. A novel method for voxelwise normalization and 3D anatomical mapping was used to automate segmentation, labeling, and localization of bone contusions in the involved knee. The same mapping system was used to identify the associated articular cartilage overlying bone lesions. Mean regional T1ρ was extracted from articular cartilage regions in both the involved and uninvolved knees for quantitative paired analysis against ipsilateral cartilage within the same compartment outside of the localized bone contusion. At least one bone contusion lesion was detected in the involved knee within the femur and/or tibia following ACL injury in 42 participants. Elevated T1ρ (p = 0.033) signal were documented within the articular cartilage overlying the bone contusions resulting from ACL injury. In contrast, the same cartilaginous regions deprojected onto the uninvolved knees showed no ipsilateral differences (p = 0.795). Automated bone contusion segmentation using standardized voxelwise normalization and 3D mapping deprojection identified altered cartilage overlying bone contusions in the setting of knee ACL injury.

Bone Bruises and Concomitant Meniscus and Cartilage Damage in Anterior Cruciate Ligament Injuries: A Systematic Review and Meta-Analysis

(1) Background: Bone bruises in acute anterior cruciate ligament (ACL) injuries are closely linked to the occurrence of simultaneous meniscal and cartilage damage. Despite the frequent occurrence of associated injuries including bone bruises, meniscus, and cartilage damage in patients with ACL injuries, a systematic review of the relationships between the presence of bone bruises and the extent of meniscus and cartilage injuries has yet to be conducted. (2) Methods: Multiple comprehensive databases, including MEDLINE, EMBASE, and the Cochrane Library, were searched for studies that evaluated the relationship between bone bruises and meniscus or cartilage injuries following ACL injuries. Study selection, data extraction, and meta-analysis were performed. The Methodological Index for Non-Randomized Studies (MINORS) was used for quality assessments, and Review Manager 5.3 was used for data analysis. (3) Results: Data were extracted from 22 studies encompassing a total of 2891 patients with ACL injuries. Among the included studies, six studies investigated the relationships between bone bruises and medial meniscus (MM) or lateral meniscus (LM) injuries, while three studies investigated the relationships between bone bruises and cartilage injuries. There were no significant correlations between the presence of bone bruises and MM injuries (relative risk (RR) = 1.32; p = 0.61). A quantitative analysis indicated that individuals with bone bruises had a 2.71-fold higher likelihood of sustaining LM injuries than those without bone bruises (RR = 2.71; p = 0.0003). The analysis confirmed a significant relationship between bone bruises and cartilage injuries (RR = 6.18; p = 0.003). (4) Conclusions: Bone bruises occur most frequently in the lateral compartment. Bone bruises resulting from ACL injuries are related to accompanying LM injuries and cartilage injuries. Knowing these associations and the frequency of injuries may allow orthopedic surgeons to promptly address ACL-related meniscus and cartilage injuries on MRI results and in future clinical practice.

Bone marrow edema at ligament insertion is an accurate MRI sign of deltoid ligament injury

BACKGROUND

Magnetic resonance imaging (MRI) is effective in diagnosing deltoid ligament (DL) injury but its sensitivity in chronic cases is low. Additional diagnostic signs are required to reduce the risk of a false negative diagnosis.

PURPOSE

To evaluate the added diagnostic value of bone marrow edema at the ligament insertion (BMELI) of DL to the MRI assessment of chronic DL injury.

MATERIAL AND METHODS

One hundred patients who consecutively came to our institution between November 2018 and December 2021 and underwent arthroscopic surgery for chronic ankle instability (CAI) were enrolled in the present study. Preoperative MR images were retrospectively reviewed by two orthopedic surgeons to evaluate the sensitivity, specificity and interobserver reliability of three MRI signs in diagnosing chronic DL injury, namely, abnormal ligamentous morphological characteristics (ALMC), BMELI and medial clear space (MCS).

RESULTS

Taking arthroscopy as the reference standard, there were 34 patients with and 66 without DL injury. ALMC had 64.71% (22/34; 46.47-79.70) sensitivity and 83.33% (55/66; 71.71-91.00) specificity, BMELI had 70.59% (24/34; 52.33-84.29) sensitivity and 95.45% (63/66; 86.44-98.82) specificity and MCS had 26.47% (9/34; 13.51-44.65) sensitivity and 92.42% (61/66; 82.50-97.18) specificity. Compared with ALMC, BMELI had similar efficacy in superficial cases (P = 0.06) and greater efficacy in deep cases (P = 0.04). All three signs showed good interobserver agreement (kappa values all above 0.7).

CONCLUSION

BMELI can reliably indicate concomitant injury to the DL in CAI patients. Using BMELI as a sign of chronic DL injury when ALMC is unclear may reduce the risk of a false negative diagnosis.

Social media may cause emergent SARMs abuse by athletes: a content quality analysis of the most popular YouTube videos

OBJECTIVES

Selective Androgen Receptor Modulators (SARMs) social media interest is at an all-time high. The aim of this study is to analyze the: (1) quality; (2) educational content; and (3) reliability of the most relevant YouTube videos on SARMs to explain growing SARMs abuse by recreational and professional athletes.

METHODS

'SARMs' was queried (28 November 2021) through the YouTube video library. The top 100 videos filtered by relevance were categorized by source, type of content, educational quality by Global Quality Score (GQS), reliability by Journal of American Medicine Association (JAMA) criteria, YouTube tags, attitude toward SARMs use, and whether the video provided specific support on how to use SARMs. For all outcome variables, descriptive statistics and comparison among source types and category types were performed.

RESULTS

Mean JAMA score was 1.6 ± 0.7 out of 4. Mean GQS score was 2.5 ± 1.1 out of 5. Patient videos were of lower educational quality than athletic trainer videos (GQS: 2.11 ± 0.95 vs. 2.95 ± 1.00, p < 0.01), and videos categorized as user experience were of lower educational quality than videos categorized as general SARMs information (GQS: 1.92 ± 0.90 vs. 2.72 ± 1.07, p < 0.05). User experience and dosing recommendation videos were statistically significantly more positive in attitude than both general SARMs information and SARMS vs. other PEDs.

CONCLUSION

Quality, content, and reliability of SARMs YouTube videos was low. Social media likely causes SARMs abuse through disseminating biased SARMs misinformation. These results serve to educate public health oversight bodies, healthcare providers, and sports team members to better identify signs of SARMs abuse, and promote discussion to discourage SARMs abuse.

Examining the Distribution of Bone Bruise Patterns in Contact and Noncontact Acute Anterior Cruciate Ligament Injuries

BACKGROUND

Bone bruises are commonly seen on magnetic resonance imaging (MRI) in acute anterior cruciate ligament (ACL) injuries and can provide insight into the underlying mechanism of injury. There are limited reports that have compared the bone bruise patterns between contact and noncontact mechanisms of ACL injury.

PURPOSE

To examine and compare the number and location of bone bruises in contact and noncontact ACL injuries.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Three hundred twenty patients who underwent ACL reconstruction surgery between 2015 and 2021 were identified. Inclusion criteria were clear documentation of the mechanism of injury and MRI within 30 days of the injury on a 3-T scanner. Patients with concomitant fractures, injuries to the posterolateral corner or posterior cruciate ligament, and/or previous ipsilateral knee injury were excluded. Patients were stratified into 2 cohorts based on a contact or noncontact mechanism. Preoperative MRI scans were retrospectively reviewed by 2 musculoskeletal radiologists for bone bruises. The number and location of the bone bruises were recorded in the coronal and sagittal planes using fat-suppressed T2-weighted images and a standardized mapping technique. Lateral and medial meniscal tears were recorded from the operative notes, while medial collateral ligament (MCL) injuries were graded on MRI.

RESULTS

A total of 220 patients were included, with 142 (64.5%) noncontact injuries and 78 (35.5%) contact injuries. There was a significantly higher frequency of men in the contact cohort compared with the noncontact cohort (69.2% vs 54.2%, P = .030), while age and body mass index were comparable between the 2 cohorts. The bivariate analysis demonstrated a significantly higher rate of combined lateral tibiofemoral (lateral femoral condyle [LFC] + lateral tibial plateau [LTP]) bone bruises (82.1% vs 48.6%, P < .001) and a lower rate of combined medial tibiofemoral (medial femoral condyle [MFC] + medial tibial plateau [MTP]) bone bruises (39.7% vs 66.2%, P < .001) in knees with contact injuries. Similarly, noncontact injuries had a significantly higher rate of centrally located MFC bone bruises (80.3% vs 61.5%, P = .003) and posteriorly located MTP bruises (66.2% vs 52.6%, P = .047). When controlling for age and sex, the multivariate logistical regression model demonstrated that knees with contact injuries were more likely to have LTP bone bruises (OR, 4.721 [95% CI, 1.147-19.433], P = .032) and less likely to have combined medial tibiofemoral (MFC + MTP) bone bruises (OR, 0.331 [95% CI, 0.144-0.762], P = .009) compared with those with noncontact injuries.

CONCLUSION

Significantly different bone bruise patterns were observed on MRI based on ACL injury mechanism, with contact and noncontact injuries demonstrating characteristic findings in the lateral tibiofemoral and medial tibiofemoral compartments, respectively.

The anterior cruciate ligament injury severity scale (ACLISS) is an effective tool to document and categorize the magnitude of associated tissue damage in knees after primary ACL injury and reconstruction

PURPOSE

To develop a tool allowing to classify the magnitude of structural tissue damage occurring in ACL injured knees. The proposed ACL Injury Severity Scale (ACLISS) would provide an easy description and categorization of the wide spectrum of injuries in patients undergoing primary ACL reconstruction, reaching from isolated ACL tears to ACL injuries with a complex association of combined structural damage.

METHODS

A stepwise approach was used to develop the ACLISS. The eligibility of each item was based on a literature search and a consensus between the authors after considering the diagnostic modalities and clinical importance of associated injuries to the menisci, subchondral bone, articular cartilage or collateral ligaments. Then, a retrospective analysis of associated injuries was performed in 100 patients who underwent a primary ACL reconstruction (ACLR) by a single surgeon. This was based on acute preoperative MRI (within 8 weeks after injury) as well as intraoperative arthroscopic findings. Depending on their prevalence, the number of selected items was reduced. Finally, an analysis of the overall scale distribution was performed to classify the patients according to different injury profiles.

RESULTS

A final scoring system of 12 points was developed (12 = highest severity). Six points were attributed to the medial and lateral tibiofemoral compartment respectively. The amount of associated injuries increased with ACLISS grading. The median scale value was 4.5 (lower quartile 3.0; higher quartile 7.0). Based on these quartiles, a score < 4 was considered to be an injury of mild severity (grade I), a score between ≥ 4 and ≤ 7 was defined as moderately severe (grade II) and a score > 7 displayed the most severe cases of ACL injuries (grade III). The knees were graded ACLISS I in 35%, ACLISS II in 49% and ACLISS III in 16% of patients. Overall, damage to the lateral tibiofemoral compartment was predominant (p < 0.01), but a proportional increase of tissue damage could be observed in the medial tibiofemoral compartment with the severity of ACLISS grading (p < 0.01).

CONCLUSIONS

The ACLISS allowed to easily and rapidly identify different injury severity profiles in patients who underwent primary ACLR. Injury severity was associated with an increased involvement of the medial tibiofemoral compartment. The ACLISS is convenient to use in daily clinical practice and represents a feasible grading and documentation tool for a reproducible comparison of clinical data in ACL injured patients.

LEVEL OF EVIDENCE

Level III.

Proteomic Profile Analysis of Synovial Fluid in Patients With Anterior Cruciate Ligament Tears

BACKGROUND

Anterior cruciate ligament (ACL) tears are associated with posttraumatic osteoarthritis, but the early biological changes that initiate joint degeneration after this injury are not well characterized. ACL tears typically result in effusion in the knee, which may provide insight into the initial response of the joint to injuries.

HYPOTHESIS

Patient- and injury-specific factors are associated with the proteomics of synovial fluid in knees with ACL tears.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Synovial fluid was collected from 105 patients (38 male, 67 female) with an acute traumatic ACL tear. Patient- and injury-specific factors such as age, sex, body mass index, time from injury, presence/absence of concomitant meniscal tears, and location of concomitant bone bruises (if present) were recorded. The protein concentration of synovial fluid was measured, followed by benchmarking of samples for multi-affinity high-abundance protein depletion. An isotropically labeled high-resolution nano-liquid chromatography with tandem mass spectrometry-based proteomic approach was used to determine the synovial fluid protein profile. Data were processed, quality controlled, and analyzed computationally for each patient and injury factor.

RESULTS

The proteomics of synovial fluid from ACL tears was associated with patient sex, injury pattern, and location of bone bruises but not with patient age, body mass index, or time from injury. Knees with an isolated ACL tear had higher glutathione peroxidase 1 (GPX1) and plastin 3 levels than knees with an ACL tear and meniscal tear. A bone bruise on the lateral femoral condyle was associated with elevated leptin and glucose-6-phosphate dehydrogenase (G6PD) levels. A bone bruise on the lateral tibial plateau was associated with decreased GPX1 levels. Male patients had higher matrix metalloproteinase 9 and lower G6PD levels than female patients.

CONCLUSION

Patient sex, injury pattern, and bone bruise location were important determinants of the proteomic profile of effusion resulting from ACL tears.

CLINICAL RELEVANCE

Longitudinal follow-ups to see if and how proteomic differences relate to clinical outcomes and mechanistic studies to assess the role that specific proteins play in the joint are warranted. Ultimately, these investigations could lead to better approaches to predict clinical outcomes and identify possible interventions to optimize outcomes in these patients.