Knee Images Research Articles

Radiographic Reference Points Are Inaccurate With and Without a True Lateral Radiograph

Background: Studies have reported methods for radiographically delineating medial patellofemoral ligament (MPFL) femoral tunnel position on a true lateral knee radiograph. However, obtaining a true lateral fluoroscopic radiograph intraoperatively can be challenging, rendering radiographic methods for tunnel positioning potentially inaccurate. Purpose: To quantify the magnitude of MPFL femoral tunnel malposition that occurs on true lateral and aberrant lateral knee radiographs when using a previously reported radiographic technique for MPFL femoral tunnel localization. Study Design: Descriptive laboratory study. Methods: Ten fresh-frozen cadaveric knees were dissected to expose the MPFL femoral insertion and surrounding medial knee anatomy. True lateral and aberrant lateral knee radiographs at 2.5°, 5°, and 10° off-axis were obtained with a standard mini C-arm in 4 orientations: anterior to posterior, posterior to anterior, caudal, and cephalad. A previously reported radiographic method for MPFL femoral localization was performed on all radiographs and compared in reference to the anatomic MPFL attachment center. Results: The radiographic point, as previously described, was a mean distance of 4.1 mm from the anatomic MPFL attachment on a true lateral knee radiograph. The distance between the anatomic MPFL attachment center and the radiographic point significantly increased on aberrant lateral knee radiographs with as little as 5° of rotational error in 3 of 4 orientations of rotation when a standard mini C-arm was used. This corresponded to a malposition of 7.5, 9.2, and 8.1 mm on 5°-aberrant radiographs in the anterior-posterior, posterior-anterior, and cephalad orientations, respectively (P < .005). In the same 3 orientations of rotation, MPFL tunnel malposition on the femur exceeded 5 mm on 2.5° aberrant radiographs. Conclusion: The commonly utilized radiographic point, as previously described for MPFL femoral tunnel placement, results in inaccurate tunnel localization on a true lateral radiograph, and this inaccuracy is perpetuated with aberrant radiography. Aberrant lateral knee imaging of as little as 5° off-axis from true lateral has a significant effect on placement of a commonly used radiographic point relative to the anatomic MPFL femoral attachment center and results in nonanatomic MPFL tunnel placement. Clinical Relevance: This study demonstrates that radiographic localization of the MPFL femoral tunnel results in inaccurate tunnel placement on a true lateral radiograph, particularly when there is deviation from a true lateral fluoroscopic image, which can be difficult to obtain intraoperatively. Assessing anatomy directly intraoperatively, rather than relying solely on radiographs, may help avoid MPFL tunnel malposition.

Water Selective Imaging and bSSFP Banding Artifact Correction in Humans and Small Animals at 3T and 7T, Respectively.

IntroductionThe purpose of this paper is to develop an easy method to generate both fat signal and banding artifact free 3D balanced Steady State Free Precession (bSSFP) images at high magnetic field.MethodsIn order to suppress fat signal and bSSFP banding artifacts, two or four images were acquired with the excitation frequency of the water-selective binomial radiofrequency pulse set On Resonance or shifted by a maximum of 3/4TR. Mice and human volunteers were imaged at 7T and 3T, respectively to perform whole-body and musculoskeletal imaging. “Sum-Of-Square” reconstruction was performed and combined or not with parallel imaging.ResultsThe frequency selectivity of 1-2-3-2-1 or 1-3-3-1 binomial pulses was preserved after (3/4TR) frequency shifting. Consequently, whole body small animal 3D imaging was performed at 7T and enabled visualization of small structures within adipose tissue like lymph nodes. In parallel, this method allowed 3D musculoskeletal imaging in humans with high spatial resolution at 3T. The combination with parallel imaging allowed the acquisition of knee images with ~500μm resolution images in less than 2min. In addition, ankles, full head coverage and legs of volunteers were imaged, demonstrating the possible application of the method also for large FOV.ConclusionIn conclusion, this robust method can be applied in small animals and humans at high magnetic fields. The high SNR and tissue contrast obtained in short acquisition times allows to prescribe bSSFP sequence for several preclinical and clinical applications.

Position of anterior cruciate ligament after single-bundle arthroscopic reconstruction.

The goal of this study was to assess the position of the reconstructed anterior cruciate ligament (ACL) in arthroscopic single-bundle ligamentoplasties through an anteromedial portal technique based on a clinical case series of 74 patients followed prospectively. This cohort study involved 100 patients who underwent arthroscopic ACL reconstruction between January 2012 and January 2014. Patients who underwent isolated ACL reconstruction were selected from 194 cases with associated lesions. Graft placement at the femoral side was within the femoral footprint of ACL. All patients received computed tomography scans and magnetic resonance imaging of both knees to compare ACL graft position to tht of the native ACL in the unaffected knee and to show whether drilling the femoral tunnel through the anteromedial portal closely approximates the native ACL alignment. Seventy-four patients were available for follow-up. Mean value for the sagittal angle was 52.6° ± 2.9° for the graft-Blumensaat angle was 4.73° ± 0.75°., closely matching measurements in the contralateral normal knee. Using the anteromedial portal for single-bundle arthroscopic ACL reconstruction enables graft positioning within the normal footprint and as close as possible to anatomic ACL orientation.

Articular cartilage of the knee 3 years after ACL reconstruction

Background and purpose — T1ρ or T2 relaxation imaging has been increasingly used to evaluate the cartilage of the knee. We investigated the cartilage of ACL-reconstructed knees 3 years after surgery using T2 relaxation times.Patients and methods — 10 patients with a clinically successful unilateral ACL reconstruction were examined 3 years after surgery. Multiple-TE fast-spin echo sagittal images of both knees were acquired using a 3T MRI scanner for T2 mapping of the tibiofemoral cartilage. T2 values of the superficial and deep zones of the tibiofemoral cartilage were analyzed in sub-compartmental areas and compared between the ACL-reconstructed and uninjured contralateral knees.Results — Higher T2 values were observed in 1 or more sub-compartmental areas of each ACL-reconstructed knee compared to the uninjured contralateral side. Most of the T2 increases were observed at the superficial zones of the cartilage, especially at the medial compartment. At the medial compartment of the ACL-reconstructed knee, the T2 values of the femoral and tibial cartilage were increased by 3–81% compared to the uninjured contralateral side, at the superficial zones of the weight-bearing areas. T2 values in the superficial zone of the central medial femoral condyle differed between the 2 groups (p = 0.002).Interpretation — The articular cartilage of ACL-reconstructed knees, although clinically satisfactory, had higher T2 values in the superficial zone of the central medial femoral condyle than in the uninjured contralateral side 3 years after surgery. Further studies are warranted to determine whether these patients would undergo cartilage degeneration over time.

Cartilage imaging of a rabbit knee using dual-energy X-ray microscopy and 1.0 T and 9.4 T magnetic resonance imaging

SummaryBackground/ObjectiveOsteoarthritis is a common chronic disease of the joints characterised by the degeneration of articular cartilages and subchondral bone. The most common diagnostic imaging used clinically is X-ray; however, it cannot directly image cartilage. Magnetic resonance imaging (MRI) is well suited for cartilage imaging, but it requires costly and lengthy scans. For preclinical work, microcomputed tomography provides high spatial resolution and contrast for bone, however, its standard application is not well suited for cartilage imaging.MethodsWe performed a preliminary investigation into the use of dual-energy X-ray microscopy (XRM) for cartilage imaging and analysis of a rabbit knee, and compared it to the MRI results from 9.4 T and 1.0 T small-animal scanners.ResultsThe XRM images offer a higher image resolution (∼25 μm nominal isotropic resolution) compared with the MRI (50–86 μm in plane, and 250 μm slice thickness). The cartilage-thickness measurements using the dual-energy XRM are on average 3.8% (femur) and 5.1% (tibia) thicker estimates than the 9.4 T MRI results. The cartilage-thickness measurements using the 1.0 T MRI are on average 10.9% (femur) and 2.3% (tibia) thinner estimates than the 9.4 T MRI results.ConclusionOur results suggest that the dual-energy XRM for articular-cartilage analysis is feasible and comparable to the MRI. This technology will provide good support for high-resolution animal-osteoarthritis studies, and in the future, it may be possible to apply dual energy in a clinical setting.

Correlation between μCT imaging, histology and functional capacity of the osteoarthritic knee in the rat model of osteoarthritis

BackgroundTo acquire the most meaningful understanding of human arthritis, it is essential to select the disease model and methodology translatable to human conditions. The primary objective of this study was to evaluate a number of analytic techniques and biomarkers for their ability to accurately gauge bone and cartilage morphology and metabolism in the medial meniscal tear (MMT) model of osteoarthritis (OA).MethodsMMT surgery was performed in rats to induce OA. A dynamic weight bearing system (DWB) system was deployed to evaluate the weight-bearing capacity of the front and hind legs in rats. At the end of a 10-week study cartilage pathology was evaluated by micro computed tomography (μCT), contrast enhanced μCT (EPIC μCT) imaging and traditional histology. Bone tissue was evaluated at the tibial metaphysis and epiphysis, including the subchondral bone. Histological techniques and dynamic histomorphometry were used to evaluate cartilage morphology and bone mineralization.ResultsThe study results showed a negative impact of MMT surgery on the weight-bearing capacity of the operated limb. Surgery caused severe and extensive deterioration of the articular cartilage at the medial tibial plateau, as evidenced by elevated CTX-II in serum, EPIC μCT and histology. Bone analysis by μCT showed thickening of the subchondral bone beneath the damaged cartilage, loss of cancellous bone at the metaphysis and active osteophyte formation.ConclusionsThe study emphasizes the need for using various methodologies that complement each other to provide a comprehensive understanding of the pathophysiology of OA at the organ, tissue and cellular levels. Results from this study suggest that use of histology, μCT and EPIC μCT, and functional DWB tests provide powerful combination to fully assess the key aspects of OA and enhance data interpretation.

Streptococcal septic oligoarthritis after tonsillitis

A 15-year-old boy had tonsillitis with sore throat and acute high fever up to 39.5° for two days. Initially he recovered without presenting to his doctor and without receiving antibiotics.  Eight days later the fever recurred without tonsillitis, but with oligoarthritis. After two days of oral antibiotics (amoxicillin with clavulanic acid) he was admitted to hospital since his symptoms progressed. On admission the patient was febrile (38.5°C), but otherwise his general condition was good. In the painless right hip the internal-external rotation was slightly reduced. The right knee showed hyperthermia, swelling, reduced flexion of 90° (150° in the asymptomatic left knee), and pain around the patella and in the popliteal space. Blood samples indicated inflammation (C-reactive protein 87 mg/L, erythrocyte sedimentation rate 30 mm/hour (normal: < 10 mm/hour), and 16,000 leucocytes/mL with 85% granulocytes, 11% lymphocytes, and 4% monocytes). Sonography identified joint effusion of the right hip and of the swollen, painful right knee. Arthrocentesis of the hip revealed empyema (Fig. 1) with 39,900 leucocytes/mL, 93% granulocytes and Gram-positive cocci at microscopy. Contrast-enhanced magnetic resonance imaging (MRI) of the right knee showed a popliteal abscess (Fig. 2, arrows) ___________________________________________

Fast isotropic banding-free bSSFP imaging using 3D dynamically phase-cycled radial bSSFP (3D DYPR-SSFP)

AimsDynamically phase-cycled radial balanced steady-state free precession (DYPR-SSFP) is a method for efficient banding artifact removal in bSSFP imaging. Based on a varying radiofrequency (RF) phase-increment in combination with a radial trajectory, DYPR-SSFP allows obtaining a banding-free image out of a single acquired k-space. The purpose of this work is to present an extension of this technique, enabling fast three-dimensional isotropic banding-free bSSFP imaging. MethodsWhile banding artifact removal with DYPR-SSFP relies on the applied dynamic phase-cycle, this aspect can lead to artifacts, at least when the number of acquired projections lies below a certain limit. However, by using a 3D radial trajectory with quasi-random view ordering for image acquisition, this problem is intrinsically solved, enabling 3D DYPR-SSFP imaging at or even below the Nyquist criterion. The approach is validated for brain and knee imaging at 3 Tesla. ResultsVolumetric, banding-free images were obtained in clinically acceptable scan times with an isotropic resolution up to 0.56mm. ConclusionThe combination of DYPR-SSFP with a 3D radial trajectory allows banding-free isotropic volumetric bSSFP imaging with no expense of scan time. Therefore, this is a promising candidate for clinical applications such as imaging of cranial nerves or articular cartilage.

Synovial tissue volume: a treatment target in knee osteoarthritis (OA)

BackgroundSynovitis occurring frequently in osteoarthritis (OA) may be a targeted outcome. There are no data examining whether synovitis changes following intra-articular intervention.MethodsPersons aged 40 years and older with painful knee...

Utilization of a balanced steady state free precession signal model for improved fat/water decomposition.

Chemical shift based fat/water decomposition methods such as IDEAL are frequently used in challenging imaging environments with large B0 inhomogeneity. However, they do not account for the signal modulations introduced by a balanced steady state free precession (bSSFP) acquisition. Here we demonstrate improved performance when the bSSFP frequency response is properly incorporated into the multipeak spectral fat model used in the decomposition process. Balanced SSFP allows for rapid imaging but also introduces a characteristic frequency response featuring periodic nulls and pass bands. Fat spectral components in adjacent pass bands will experience bulk phase offsets and magnitude modulations that change the expected constructive and destructive interference between the fat spectral components. A bSSFP signal model was incorporated into the fat/water decomposition process and used to generate images of a fat phantom, and bilateral breast and knee images in four normal volunteers at 1.5 Tesla. Incorporation of the bSSFP signal model into the decomposition process improved the performance of the fat/water decomposition. Incorporation of this model allows rapid bSSFP imaging sequences to use robust fat/water decomposition methods such as IDEAL. While only one set of imaging parameters were presented, the method is compatible with any field strength or repetition time.

Automatic segmentation of high- and low-field knee MRIs using knee image quantification with data from the osteoarthritis initiative.

Clinical studies including thousands of magnetic resonance imaging (MRI) scans offer potential for pathogenesis research in osteoarthritis. However, comprehensive quantification of all bone, cartilage, and meniscus compartments is challenging. We propose a segmentation framework for fully automatic segmentation of knee MRI. The framework combines multiatlas rigid registration with voxel classification and was trained on manual segmentations with varying configurations of bones, cartilages, and menisci. The validation included high- and low-field knee MRI cohorts from the Center for Clinical and Basic Research, the osteoarthritis initiative (QAI), and the segmentation of knee images10 (SKI10) challenge. In total, 1907 knee MRIs were segmented during the evaluation. No segmentations were excluded. Our resulting OAI cartilage volume scores are available upon request. The precision and accuracy performances matched manual reader re-segmentation well. The cartilage volume scan-rescan precision was 4.9% (RMS CV). The Dice volume overlaps in the medial/lateral tibial/femoral cartilage compartments were 0.80 to 0.87. The correlations with volumes from independent methods were between 0.90 and 0.96 on the OAI scans. Thus, the framework demonstrated precision and accuracy comparable to manual segmentations. Finally, our method placed second for cartilage segmentation in the SKI10 challenge. The comprehensive validation suggested that automatic segmentation is appropriate for cohorts with thousands of scans.

Knee bursitis: a sonographic evaluation.

To evaluate the use of ultrasound for the diagnosis of knee bursitis. One-hundred and fifty-eight patients who, from May 2013 to May 2014, had an ultrasound examination of the knee and magnetic resonance imaging (MRI) of the knee during the following month were eligible for the study. The exams were reviewed by two musculoskeletal radiologists with 20years of experience. Of these patients, 15 (7 men, 8 women) had bursitis, while 143 (76 men, 67 women) had no bursitis. In evaluating knee bursitis, US, when compared to MRI, correctly identified 13 out of 15 cases of bursitis, showing a sensitivity of 86.67%, specificity 100%, and K index of 0.92. Particularly in the suprapatellar bursa, ultrasound showed bursitis in 5 cases versus 7 by MRI (sensitivity of 71.4%, specificity of 100%, and K index of 0.82). Ultrasound can be used as a valuable tool for the evaluation of bursitis of the superficial bursae in patients who cannot undergo MRI.

Accelerated T1ρ acquisition for knee cartilage quantification using compressed sensing and data-driven parallel imaging: A feasibility study.

Quantitative T1ρ imaging is beneficial for early detection for osteoarthritis but has seen limited clinical use due to long scan times. In this study, we evaluated the feasibility of accelerated T1ρ mapping for knee cartilage quantification using a combination of compressed sensing (CS) and data-driven parallel imaging (ARC-Autocalibrating Reconstruction for Cartesian sampling). A sequential combination of ARC and CS, both during data acquisition and reconstruction, was used to accelerate the acquisition of T1ρ maps. Phantom, ex vivo (porcine knee), and in vivo (human knee) imaging was performed on a GE 3T MR750 scanner. T1ρ quantification after CS-accelerated acquisition was compared with non CS-accelerated acquisition for various cartilage compartments. Accelerating image acquisition using CS did not introduce major deviations in quantification. The coefficient of variation for the root mean squared error increased with increasing acceleration, but for in vivo measurements, it stayed under 5% for a net acceleration factor up to 2, where the acquisition was 25% faster than the reference (only ARC). To the best of our knowledge, this is the first implementation of CS for in vivo T1ρ quantification. These early results show that this technique holds great promise in making quantitative imaging techniques more accessible for clinical applications.

The associations between disc degeneration and co-existent structural abnormalities in the lumbosacral spine – A 3.0T MRI study of community-based adults

The associations between disc degeneration and co-existent structural abnormalities in the lumbosacral spine – A 3.0T MRI study of community-based adults

Diseased Region Detection of Longitudinal Knee Magnetic Resonance Imaging Data.

Magnetic resonance imaging (MRI) has become an important imaging technique for quantifying the spatial location and magnitude/direction of longitudinal cartilage morphology changes in patients with osteoarthritis (OA). Although several analytical methods, such as subregion-based analysis, have been developed to refine and improve quantitative cartilage analyses, they can be suboptimal due to two major issues: the lack of spatial correspondence across subjects and time and the spatial heterogeneity of cartilage progression across subjects. The aim of this paper is to present a statistical method for longitudinal cartilage quantification in OA patients, while addressing these two issues. The 3D knee image data is preprocessed to establish spatial correspondence across subjects and/or time. Then, a Gaussian hidden Markov model (GHMM) is proposed to deal with the spatial heterogeneity of cartilage progression across both time and OA subjects. To estimate unknown parameters in GHMM, we employ a pseudo-likelihood function and optimize it by using an expectation-maximization (EM) algorithm. The proposed model can effectively detect diseased regions in each OA subject and present a localized analysis of longitudinal cartilage thickness within each latent subpopulation. Our GHMM integrates the strengths of two standard statistical methods including the local subregion-based analysis and the ordered value approach. We use simulation studies and the Pfizer longitudinal knee MRI dataset to evaluate the finite sample performance of GHMM in the quantification of longitudinal cartilage morphology changes. Our results indicate that GHMM significantly outperforms several standard analytical methods.

Knee MRI under varying flexion angles utilizing a flexible flat cable antenna.

The aim of this study is to fabricate and test a novel flexible flat cable antenna (FFCA) for MRI of the knee at different flexion angles. The FFCA was made of a flat cable, a tuning/matching circuit and a signal transmission line. To test its feasibility and validity, in vitro and in vivo experiments were carried out on a 3.0 T MR scanner. The in vitro experiment suggested that the proposed FFCA could achieve a high signal-to-noise ratio (SNR) of 336, while the SNR of an eight-channel knee coil was 291, and phantom images from the FFCA are homogeneously distributed. In the in vivo experiment, the FFCA had a higher SNR of 169 in the region of interest and more than 48.5 cm of longitudinal coverage, while the corresponding values for the commercial coil were 153 and 22.5 cm. Finally, five sagittal knee images at different flexion angles were acquired. The FFCA could acquire satisfactory knee images at different flexion angles, with the advantages of simplicity, low cost, large field of view and high SNR. It may therefore be further used to improve MR image quality of the knee joint.

Acute Anterior Cruciate Ligament Injury with Medial and Lateral Bucket-Handle Meniscus Tears

We report the case of a healthy 31-year-old female professional billiard player presented with a 5-day history of severe left knee pain after a fall. A magnetic resonance imaging of the left knee showed that she had suffered an anterior cruciate ligament (ACL) rupture along with buckle-handle tears of both the medial and lateral meniscus. Both of these menisci had flipped anterior and centrally to the femoral condyles and were lodged in the notch. The patient had also suffered a mild injury to the medial collateral ligament. Repair of both menisci was performed using an inside-out technique. Following this, an ACL reconstruction was done using a quadrupled hamstring autograft. Endobutton fixation (Smith & Nephew, Andover, MA) was used on the femur with a screw and sheath used for tibial fixation. The patient tolerated the procedure well and was sent home the same day. This case demonstrates the typical signs and symptoms of a displaced bucket-handle meniscus tear as well as imaging and arthroscopic pictures.

A skyline-view imaging technique for axial projection of the patella: a clinical study.

Our purpose in this study was to evaluate the clinical usefulness of a new skyline-view imaging technique for axial projection of the patella with use of the anterior border of the patella and tibial tuberosity as position indicators. Our database consisted of pairs of axial images of the patella of the same patients, obtained with use of conventional and new techniques for the radiographic diagnosis of knee-joint diseases. A total of 118 pairs of knee images were obtained from 103 patients ranging in age from 16 to 86years (mean age 49.7years). The patellar axial positioning errors were determined in each of the images obtained with the two techniques. The relative error according to the patellar tilt was determined from each of the axial images of the patellas of the same patients obtained with the conventional and new techniques for the radiographic diagnosis of knee-joint diseases. The patellar axial positioning error was 0.40 with the conventional technique, whereas that with the new technique was significantly different at 0.30. This clinical study confirmed that the new skyline-view imaging technique, which uses the anterior border of the patella and the tibial tuberosity as position markers that can be confirmed by palpation, provides more accurate axial images than the conventional imaging technique.

Definitions for the sonographic features of joints in healthy children.

Musculoskeletal ultrasonography (US) has potential in the assessment of disease activity and structural damage in childhood arthritides. In order to assess pathology, the US characteristics of joints in healthy children need to be defined first. The aim of this study was to develop definitions for the various components of the normal pediatric joint. The definitions were developed by an expert group and applicability was assessed on a collection of standardized scans of the knee and ankle joints by scoring the scans on a Likert scale. The definitions were then modified and applicability was reassessed before sending the definitions for approval to a larger panel of experts. A final scoring on stored images of all relevant joints at different ages followed. Five definitions were developed addressing the articular bone, cartilage, joint capsule, epiphyseal ossification center, and synovial membrane. In total, 224 US images of knees and ankles were acquired, of which 172 were selected for scoring. An agreement of ≥80% was not met for any of the definitions, but after modifications, 81-97% agreement was reached. This version of the definitions was approved by 15 US experts. In the final validation exercise, all definitions reached an agreement of ≥80% for the shoulder, elbow, wrist, metacarpophalangeal hip, knee, ankle and metatarsophalangeal joint. US definitions for the normal pediatric joint were successfully developed through a Delphi process and validated in a practical exercise. These results provide the basis to develop definitions for pathology and to support the standardized use of US in pediatric rheumatology.

Development and optimization of a high-throughput micro-computed tomography imaging method incorporating a novel analysis technique to evaluate bone mineral density of arthritic joints in a rodent model of collagen induced arthritis

Rheumatoid arthritis (RA) is a chronic autoimmune disease resulting in joint inflammation, pain, and eventual bone loss. Bone loss and remodeling caused by symmetric polyarthritis, the hallmark of RA, is readily detectable by bone mineral density (BMD) measurement using micro-CT. Abnormalities in these measurements over time reflect the underlying pathophysiology of the bone. To evaluate the efficacy of anti-rheumatic agents in animal models of arthritis, we developed a high throughput knee and ankle joint imaging assay to measure BMD as a translational biomarker. A bone sample holder was custom designed for micro-CT scanning, which significantly increased assay throughput. Batch processing 3-dimensional image reconstruction, followed by automated image cropping, significantly reduced image processing time. In addition, we developed a novel, automated image analysis method to measure BMD and bone volume of knee and ankle joints. These improvements significantly increased the throughput of ex vivo bone sample analysis, reducing data turnaround from 5days to 24hours for a study with 200 rat hind limbs. Taken together, our data demonstrate that BMD, as quantified by micro-CT, is a robust efficacy biomarker with a high degree of sensitivity. Our innovative approach toward evaluation of BMD using optimized image acquisition and novel image processing techniques in preclinical models of RA enables high throughput assessment of anti-rheumatic agents offering a powerful tool for drug discovery.