Subchondral Insufficiency Fracture in the Lateral Compartment of the Knee in a 64-Year-Old Marathon Runner

Treatment and Rehabilitation Approaches for Stress Fractures in Long-Distance Runners: A Literature Review

Stress fractures (SFs) result from repetitive mechanical stress on bones, leading to an imbalance in osseous tissue adaptation and resulting in cortical fractures. The majority of SFs occur in the lower limb due to excessive mechanical loads. Long-distance runners are highly susceptible to SFs, especially when there is a significant increase in the load or intensity of their activity. Various intrinsic and extrinsic factors contribute to the development of SFs. Common SF locations in long-distance runners include the tibial shaft, femur, metatarsal, and pelvic region. Diagnosis may be delayed due to mild symptoms and unremarkable imaging tests. However, the chronicity and recurrence of misdiagnosed SFs may lead to debilitating complete fractures that are even more challenging to treat. In this review, we present data revealed from published case reports and case series studies obtained through PubMed and Embase databases focusing on the management of SFs in long-distance runners and correlate treatment outcomes with rehabilitation and return to high-level athletic performance.

Subchondral Insufficiency Fractures of the Knee: A Clinical Narrative Review

» 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.

Beyond Gonarthrosis in the Elderly: A Case Report of Subchondral Insufficiency Fracture of the Knee

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.

Magnetic resonance imaging of subchondral insufficiency fractures in the knee (literature review)

Stress fractures are an actual problem of modern medicine. A fracture associated with insufficiency of the bone tissue of the knee condyles is a new type of stress fracture that occurs in people aged 50–55 years in response to a normal daily activity, but with damage to the weakened subchondral bone tissue of the joint caused by various reasons. This literature review is mainly based on data from foreign medical sources, since there is very little information on this type of fracture in Russian sources. This is primarily due to the fact that initially the world and Russian medical communities designated this type of fracture as a spontaneous osteonecrosis of the knee (SONK). In recent years, this term has been revised abroad and replaced by a more suitable one – subchondral insufficiency fracture of the knee (SIF/SIFK). According to modern concepts, it is necessary to clearly distinguish among the concepts of osteonecrosis and subchondral insufficiency fracture of the knee. The reason for this is not only differences in the pathogenesis of these pathologies, but also fundamentally different approaches to managing these patients. Thus, taking into account the fundamental differences in the treatment of patients with stress fracture associated with bone insufficiency and patients with osteonecrosis, and also the relevance of stress fracture of the knee condyles, we state the following aim – to study the available literature on this problem.

Technique for Treatment of Subchondral Compression Fracture of the Lateral Femoral Condyle Associated With ACL Tear

Excessive knee pivoting that causes a complete anterior cruciate ligament (ACL) tear may result in a subchondral compression fracture on the lateral femoral condyle after impacting the lateral tibial condyle. Because this mechanism is similar to the humeral head that has an impact on the glenoid during an anterior shoulder dislocation, such an osteochondral fracture can be considered equivalent to a "Hill-Sachs lesion of the knee." Restoring the native anatomy of the lateral femoral condyle articular surface is crucial, because its depression alters knee biomechanics, leading to bony knee instability, potentially greatly elevating the risk of ACL reconstruction failure and meniscal tears. In addition, bony knee instability increases the forces acting on the cartilage, which may impair one's quality of life and lead to the development of osteoarthritis. The fact that many patients with complete ACL tears are relatively young emphasizes the key role of osteoarthritis prevention. The aim of this report is to present a minimally invasive procedure to treat the "Hill-Sachs-like" knee lesion, a tricky enemy of knee stability.

Alternate treatment approach to subchondral insufficiency fracture of the knee utilizing genicular nerve cooled radiofrequency ablation and adjunctive bisphosphonate supplementation: A case report

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.

Subchondral insufficiency fracture of the knee: grading, risk factors, and outcome

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.

Intra-articular Corticosteroid Injections in the Hip and Knee: Perhaps Not as Safe as We Thought?

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.

Nomenclature of Subchondral Nonneoplastic Bone Lesions

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.

Idiopathic Charcot Arthropathy of the Knee Presenting as a Bicondylar Tibial Plateau Fracture

Charcot arthropathy is an infrequent condition that primarily involves the foot and ankle; rarely, it has been reported to affect the knee. Risk factors for Charcot arthropathy are well described with diabetes being the most common cause. Idiopathic Charcot arthropathy without a secondary etiology is extremely rare, with only a few cases described involving the foot and shoulder. Clinically, idiopathic Charcot arthropathy presents a notable challenge because delayed diagnosis can lead to surgical complications and advancement of joint destruction. We report idiopathic Charcot arthropathy of the knee presenting as a bicondylar tibial plateau fracture successfully managed with total knee arthroplasty after failed open reduction internal fixation. We diagnosed the patient when the clinical/surgical presentation was indicative of Charcot arthropathy and after excluding all other diagnoses. This previously unreported case describes the complexity of idiopathic Charcot arthropathy with subsequent fractures and highlights the importance of patient history, presentation, and surgical intervention.