10 14 15 MRI Arthroscopy Knee Syllabus
2015-10-14
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10/13/2015 Disclosures Cree Gaskin: • Thieme Med Pub – Book Royalties • Oxford Univ Press – Book Royalties Mark Miller: • Elsevier/LWW – Book Royalties • MRC – Founder/Director Acknowledgments Cree Gaskin: • Some images courtesy of: Mark W. Anderson, M.D. Mark Miller: • Some images from: • Miller et al. Sports Medicine Conditions – Return to Play. Wolters Kluwer 1 10/13/2015 Overview • Introduction – Anatomy of the ACL – MRI of the ACL • • • • • Case 1: ACL & “Bone Bruise” Case 2: Pedi ACL Case 3: Revision ACL Case 4: ALL Augmentation Conclusion Knee—ACL Anatomy and Biomechanics Tibia => LFC • 33 mm x 11 mm • 2 Bundles: – AM (tight in flexion) – PL (tight in extension) • Middle Geniculate A. Femoral Insertion Alignment Changes With Knee Flexion AM bundle Extension PL bundle Flexion PL AM PL AM AM PL 2 10/13/2015 ACL Arthroscopy ACL ACL ACL Arthroscopy View from Anterolateral Portal View from Anteromedial Portal Normal ACL • Sagittal – Taut – Parallel • intercondylar roof (aka - Blumenstaat’s line) • Signal intensity – Low / intermediate – Striated Evaluate in all planes 3 10/13/2015 Coronal 4 10/13/2015 AM PL AM PL AM PL 5 10/13/2015 AM Different patient: ACL may blend with anterior horn lateral meniscus 6 10/13/2015 Axial: Best for proximal to mid-portion of ligament PL AM 7 10/13/2015 PL AM PL AM PL AM 8 10/13/2015 Case 1 HPI • 17 yo M soccer player s/p non-contact pivoting injury to L knee during game 8 weeks prior • Attempted to continue playing but had 2 recurrent pivoting episodes, most recently 5 days prior to presentation • L knee swelling, pain, and locking with incomplete extension on most recent episode Case 1 PE • (+) effusion • ROM 15-90 • (+) Lachman • (+) lateral joint line tenderness No XRs provided, brought in MRI from OSH performed after last instability episode 9 10/13/2015 MRI – ACL Tear MRI – Lateral Meniscus Tear MRI – Chondral Defect/Loose Body 10 10/13/2015 ACL: Complete Tear Primary signs • • • • edematous mass “empty notch” irregular, horiz contour focal disruption Case 1 Diagnosis • Left knee ACL tear • Left knee complex bucket-handle lateral meniscus tear • Left knee lateral femoral condyle chondral fracture with loose body Procedure • Left knee ACL reconstruction with B-PT-B autograft • Left knee PLM • Left knee removal of loose body • Left knee OATS to LFC ACL Tear 11 10/13/2015 Removal of Loose Body Lateral Meniscus Tear Chondral Defect 12 10/13/2015 ACL Graft OATS Plugs Case 2 HPI • 14 yo boy S/P attempted ACL eminence repair one year prior @ Outside Hospital. CT • Recurrent instability 1 yr • 2+ Lachman earlier • + Pivot Shift 13 10/13/2015 New MRI: failed repair MRI Findings ACL Reconstruction ACL Laxity Lateral Bifurcate Ridge ACL Guide Pin Placement Femoral: Below Physis (All-Epiphyseal) Tibial: Trans Physeal--Verticla 14 10/13/2015 Tibial Physis Case 2: Pediatric ACL Over-the-Top Case Example • 11 year old boy with pivoting injury (football) • Up to 12” growth remaining • Failed non-operative management (recurrent instability) Pedi ACL Case • 7-mm Central Vertical Tibial Tunnel • 18-gauge looped wire passed from “over the top” and out the Tibial Tunnel 15 10/13/2015 Pedi ACL Case • ACL Hamstring Graft Placed “Over the Top” Pedi ACL Case • Post-Operative Films 4 Year Follow-up 16 10/13/2015 Adult Reconstruction • Trans-Tibial – Less disruption of femoral physis – Non-anatomic • Independent Drilling – Substantial risk to the physis* *Nelson J, Miller MD; JBJS-A 2011; 18:93 e53: 1-4 ACL Avulsion Repair EMcD 2481546 HPI: 19M with left knee pain, had a noncontact injury playing flag football and planted his foot on 9/12/14. He heard a pop and had immediate pain and swelling. Evaluated at ED, pain with WBAT, using crutches Exam: 10° Loss of Extension; 2+ Lachman, + Pivot XR: tibial spine avulsion 17 10/13/2015 MRI: tibial spine avulsion MRI: avulsion/AHLM root tear 18 10/13/2015 19 10/13/2015 Case 3 Revision ACL Case • 19yo Female S/P L ACL Revision x2 – First ACL at age 15 BPTB T-T Allograft • Failed at 10 months—Soccer “injury” – Second ACL at age 16 BPTB T-T Allograft (again) • Failed again at 10 months—Soccer “injury” – Hardware removal and allograft bone grafting Revision ACL Case (Continued) • On Presentation (4 months S/P bone grafting), patient (and parents) complained of recurrent instability and requested a second opinion • Radiographs suggested tunnel osteolysis and vertical femoral tunnel placement 20 10/13/2015 CT Femoral Tunnel 18mm Tibial Tunnel ACL Case 1 (Continued) • Labs: – Knee Aspirate: 600 WBC, Gram Stain -, No Growth – Systemic Labs: WBC, ESR, CRP all Normal ACL Case 1 ARS Question 1 • What would you do next? – A. – B. – C. – D. One Stage Revision ACL with Allograft One Stage Revision ACL with Autograft Two Stage Revision ACL—Allograft Bone Graft Two Stage Revision ACL—Autograft Bone Graft 21 10/13/2015 ACL Case 1 Management • Planned 2 stage Revision • Tibia – Overdrilling (up to 18mm) – ICBG (“Sandwich” Technique) ACL Case 1 Management • Planned 2 stage Revision • Femur – Overdrilling (10 mm) – Allograft Cloward Dowel • Transtibial placement after tibial overdrilling Revision ACL—Stage 1 22 10/13/2015 CT—3 ½ months S/P Bone Grafting ACL Case 1 ARS Question 2 • What would you do next? – A. – B. – C. – D. Wait for Bone Graft to further incorporate Repeat Bone Grafting of Tibial Tunnel Proceed with Revision ACL with Allograft Proceed with Revision ACL with Autograft 2nd Stage: ACL reconstruction 23 10/13/2015 2nd Stage: ACL reconstruction 2nd Stage: ACL reconstruction 2nd Stage: ACL reconstruction BPTB Autograft 24 10/13/2015 2nd Stage: ACL reconstruction Revision ACL Plug Technique Guide wire placed In old tibial tunnel. Drilled to 10 mm, 10 mm Dowel Placed, New Tunnel Placed Behind Old Tunnel Cloward Plugs— Allograft Dowels used to fill in defects from hardware removal or tunnel osteolysis Battaglia T, Miller MD; Arthroscopy 2005; 21:767 CT: 5mos post ACL single stage revision with bone dowel Bone dowel filling tunnel from first ACL reconstruction Patellar bone graft 25 10/13/2015 Anterolateral Ligament (ALL) • • • • Controversial Not really “New” What is it’s role? Europeans (Claes and others) recommend Repair/Reconstruction in Patients with: 1. Segond Fx’s 2. Huge Pivots 3. Revisions ACL: Complete Tear Secondary signs • • • bone contusions “deep notch” Segond fracture 26 10/13/2015 ALL reconstruction ALL Reconstruction 27 10/13/2015 Conclusion • Introduction – Anatomy of the ACL – MRI of the ACL • • • • • Case 1: ACL & “Bone Bruise” Case 2: Pedi ACL Case 3: Revision ACL Case 4: ALL Augmentation Conclusion Thank You 28 10/13/2015 MRI – Arthroscopy Correlations of the Knee: Menisci Gabrielle P. Konin, MD Robert G. Marx, MD, MSC, FRCSC Assistant Professor of Radiology Hospital for Special Surgery Weill Cornell Medical College New York, NY Professor of Orthopedic Surgery Hospital for Special Surgery Weill Cornell Medical College New York, NY Disclosures Robert G Marx: Books and copyrights: – Marx, RG (Editor). Revision ACL Reconstruction: Indications and Technique. Springer. 273 pages. New York, 2013. – Marx RG, Myklebust G, Boyle B. The ACL Solution: Prevention and Recovery from Sports’ Most Devastating Knee Injury. Demos Health. 174 pages. New York, 2012. Journal Editorship: – Deputy Editor for Sports Medicine, The Journal of Bone & Joint Surgery – Associate Editor for Evidence Based Orthopedics, The Journal of Bone & Joint Surgery – Senior Associate Editor, The HSS Journal Gabrielle Konin: No relevant financial disclosures. • Semilunar (C–shaped) – Medial is more C-shaped and larger and lateral more rounded and smaller • Divided into anterior and posterior horns and body • Wedge shaped with biconcavity 1 10/13/2015 Medial Meniscus • Posterior horn is larger than anterior horn • Non-mobile – more firmly attached to the joint capsule • Meniscofemoral and meniscotibial (coronary) ligaments Lateral Meniscus • Anterior = Posterior Horn • Fibers of ACL extend into anterior horn • Posterior root attaches anterior to PCL • Meniscofemoral ligaments – Humphrey & Wrisberg • Popliteomeniscal fascicles Lateral Meniscus • Fascicles (2-3) – Meniscocapsular extension around popliteal hiatus – Anteroinferior: body LM to musculotendinous portion of popliteus – forms floor of hiatus – Posterosuperior: post horn LM to popliteus tendon – forms roof of popliteal hiatus – If ruptured, can render the LM hypermobile; pain and locking 2 10/13/2015 Discoid meniscus • Watanabe classification: Complete, Incomplete* and Wrisberg variants • Non-tapering of apex of meniscus • Radial diameter > 13 mm • Increased height >2mm than opp meniscus • Predisposes to degeneration and tear • Pain, clicking, mechanical locking Discoid meniscus Discoid meniscus 3 10/13/2015 8 year-old girl with posterior knee pain & clicking for a few years Radial tear 23 year old man s/p snowboarding injury • Slight compression of the bone plate and overlying cartilage with subchondral edema and chondral shear anteriorly 16 year-old girl with medial knee pain following soccer injury 4 10/13/2015 5 10/13/2015 Radial Tear at Tibial Root Radial Tear at Tibial Root 6 10/13/2015 Radial Tear at Tibial Root Radial Tear at Tibial Root Radial Tear at Tibial Root 7 10/13/2015 Radial Tear at Tibial Root Radial Tear at Tibial Root 8 10/13/2015 9 10/13/2015 10 10/13/2015 11 10/13/2015 12 10/13/2015 47 year-old female with medial knee pain. Prior history of meniscal root re-attachment. Radial tear One year later • Radial split at the post horn root junction MM. “Ghost sign” • Subacute subchondral medial plateau fracture with mild bone plate depression and focal area of devitalized bone 13 10/13/2015 Meniscal extrusion • Measured from outer meniscal edge to proximal tibial margin • Medial > 3 mm. Lateral > 1mm • Meniscal extrusion is 4 times more common medially Bucket handle • Circumferential longitudinal vertical tear w/ displacement of free internal fragment into intercondylar notch • MM > LM • MRI Signs – Double PCL – Double delta (lateral) – Large AH – Fragment in notch – Absent bow tie – Disproportionate horns Double PCL Large AH Double delta 48 year-old man with medial knee pain. Twisting injury a few months ago, heard a “crack”. 14 10/13/2015 Bucket handle 15 10/13/2015 Flap tear with displacement 16 10/13/2015 Flap tear with displacement • Important to recognize because gutters can be difficult to visualize at arthroscopy 35 year-old woman with history of subtotal lateral meniscectomy and subsequent meniscal allograft. Meniscal Allograft Transplantation • • • • The allograft bone slot is incorporated Mild extrusion of the body segment Satisfactory position of the horns No meniscal split 17 10/13/2015 Meniscal Allograft Transplantation Why implant an allograft? • “Arthroprotection” – Decrease contact stress on articular cartilage • Pain relief • Restore normal / near normal kinematics Thank you 18 10/12/2015 MRI -Arthroscopy Correlations: Cartilage Benjamin Levine, MD Assistant Professor UCLA Department of Radiology Frank Petrigliano, MD Assistant Professor UCLA Department of Orthopaedic Surgery Disclosures • Frank A. Petrigliano, MD: • Speaker - Biomet • Research Support – Musculoskeletal Transplant Foundation • Honoraria – Musculoskeletal Transplant Foundation • Committee Member – AOSSM Research Committee • Benjamin D. Levine, MD: • None 1 10/12/2015 Imaging Hyaline Cartilage Quantitative MRI Techniques Hyaline Cartilage Physiology Water (65-85%) Chondrocytes Type Proteoglycans • (4%) II Collagen (15-20%) (PGs) (3-10%) Protein core glycosaminoglycans (GAGs) Biophysical structure Matzat SJ et al. Quant Imaging Med Surg 2013;3(3): 162-174 Quantitative MRI of Cartilage • dGEMRIC • T1rho Mapping • T2 Mapping • Sodium MRI • Ultrashort TE • gagCEST • DWI 2 10/12/2015 dGEMRIC • Utilizes the fixed charge density (FCD) in cartilage to indirectly measure GAG content • Requires intravenous contrast, exercise, and delay between injection and image acquisition • Long scan times and contrast risk Bittersohl B, et al. Invest Radiol 2010;45:538-42. T1rho Mapping • Non invasive measure of GAG content • Inverse relation between T1rho relaxation time and PG/GAG content • T1rho increases with age • Potential tissue heating risk from the high RF power required Matzat SJ et al. Quant Imaging Med Surg 2013;3(3):162-174 T2 Mapping • Measures water content in cartilage • Indirect assessment of collagen content and orientation • May also be sensitive to PG content • Susceptible to magic angle, rendering inaccuracies • PG depletion occurs prior to collagen matrix degradation Mosher TJ, et al. Semin Musculoskelet Radiol 2004;8:355-68. 3 10/12/2015 Sodium MRI • Sodium cations are attracted to negatively charged GAGs • Difficult to generate MR signal with Na ions • Need high magnetic field strength with special coils • Long scan times Matzat SJ et al. Quant Imaging Med Surg 2013;3(3):162-174 Case #1 • 30-year-old man with a acute on chronic left knee pain following an traumatic basketball injury • PE • Substantial effusion, TTP LJTL • ROM 20 – 90 degrees • Stable ligament exam • Neutral alignment MRI 4 10/12/2015 MRI Treatment? • Lesion Qualities • Etiology • Patient Qualities • Age • Trauma • Demand • AVN • BMI • OCD • Expectations • Location • Grade • Size (High v. Low) (>30) • Alignment • Meniscal • Knee Status Stability • Character • Chondral vs. Osteochondral 5 10/12/2015 Current Treatment Options in the USA Treatment Repair Tissue Fill Durability Marrow Stimulation Fibrocartilage Partial 2-3 Years Autologous OATS Hyaline Cartilage Near total 3-5 Years ACI Hyaline-like Fibrocartilage 2-5 Years Osteochondral Allograft Hyaline Cartilage Near total Particulated Hyaline-like Juvenile Allograft Fibrocartilage Partial to near total Partial to near total 5-10 Years UNKNOWN Brian J. Cole et al. J Bone Joint Surg Am 2009;91:17781790 Persistent lateral compartment pain despite adequate rehabilitation 6 10/12/2015 Post-op MRI A Companion Case B C Case #2 • 24-year-old male with a chief complaint of chronic knee pain. History of recurrent patellar dislocations. Pt complains of pain and intermittent buckling/catching of his right knee as well as clicking of his right knee. • PE • 0-130 • Stable •+ knee exam Patellar grind • Lateral patellar tilt • Positive • TT-TG J sign = 15 mm 7 10/12/2015 MRI MRI 8 10/12/2015 Case # 3 • 30-year-old male with ACL, PMM, MFC OCD treated initially with ACLR, partial meniscectomy, and microfracture and subsequent debridement one year later. • Pain with running and pivoting localized to medial compartment of knee • PE: • ROM • TTP 0-135 MFC • Stable Knee exam MRI 9 10/12/2015 MRI 2013 10 10/12/2015 Post-op Course • Did well for about a year • Moderate medial knee pain and catching/clicking sensation • PE: • Trace effusion • 0-130 • TTP over the MFC with click on flexion • Stable ligament exam • Repeat MRI MRI 2015 11 10/12/2015 Keys to successful cartilage surgery • Understand the basic physiology of cartilage repair & healing with each approach • Clarify relevant diagnoses stringent indications • Manage patient expectations • Attention to surgical detail and rehabilitation • Do the surgery with which you are most comfortable 12 10/14/2015 Patellofemoral Instability Jutta Ellerman, MD Associate Professor Department of Radiology University of Minnesota Marc Tompkins, MD Assistant Professor Department of Orthopaedic Surgery University of Minnesota/TRIA Orthopaedic Center We have no conflicts to declare. Patella Height • Caton Deschamps Index – C/D • Insall Salvati Ratio – A/B 1 10/14/2015 Patella Height : Patella Trochlear Index (PTI) • E/D Facet Asymmetry (Medial/Lateral) Sulcus Angle 2 10/14/2015 Tibial Tubercle Trochlear Groove Distance MEDIAL Patella MPFL Courtesy Liza Arendt, MD MPTL Case 1 • HX: • 18 y/o offensive lineman for high school football team • First injured 2 y/a – Valgus force & patellar dislocation • Reinjured playing football – Valgus force and re-dislocation 3 10/14/2015 Case 1 • Exam: • 2-3Q lateral patellar translation with soft endpoint • Patellar apprehension • Medial patellar TTP • Mild J sign • Tight lateral retinaculum • 4 10/14/2015 5 10/14/2015 6 10/14/2015 7 10/14/2015 8 10/14/2015 Case 2 • Hx/Exam: • 15 y/o M • Non contact injury following spin move playing football • First injury to the knee • + effusion, global patellar tenderness, & patellar apprehension 9 10/14/2015 10 10/14/2015 11 10/14/2015 12 10/14/2015 13 10/14/2015 Thank You 14
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