الفهرس 
Radiological AnatomyOnly 14 pages are availabe for public view
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Abstract
Significance of Ultrasound in Assessment of Painful Knee: A Comparative Study to Magnetic Resonance Imaging
Nadine Mohamed Sayed Ibrahim, Prof. Dr. Marwa Ibrahim Mohamed Fahmy, Dr. Shaimaa El-Metwaly EL-Diasty El-Metwaly
Department of Radiodiagnosis, Faculty of Medicine, Ain Shams University
Corresponding author: Nadine Mohamed Sayed Ibrahim
Phone: 01061819611
Email: nadine.mohamed@med.asu.edu.eg
Abstract
Background: Knee pain is one of the most frequent symptoms that bring patients to the hospital. It affects approximately 25% of adults, with an increasing incidence nowadays the pain may result from the muscles, ligaments, tendons, and menisci, from trauma due to non-traumatic injuries like infection, bursitis, osteoarthritis, and tendinitis.
Aim of the Work: Aim of study is to evaluate the role of US in assessment of painful knee compared to conventional MRI sequences as an alternative cost-effective screening modality for an accurate diagnosis.
Patients and methods: This study is a cross-sectional study was conducted at Ain Shams University Hospitals at Radiology department. Our study included forty patients complaining of acute knee pain from (1 day to 3 months’ duration). The main source of data for this study was the prospectively conducted scans and clinical history of the patients referred to the MRI section of the department of Radiology, Ain Shams University Hospitals at 6 months.
Results: Forty patients complaining of acute knee pain from. Every single one of them went through MRI and US assessments indiscriminately and independently, US succeeded in evaluating soft tissue structures pathologies including knee effusion, meniscal injury (degeneration, tear, and extrusion), MCL, LCL, bursitis. muscle, tendon injury and osteoarthritic changes. aside from the cruciate ligaments. US showed an overall sensitivity of 70.1% and specificity of 99.2% with accuracy of 95.2%. The overall PPV and NPV were 93.1% and 95.5% respectively.
Conclusion: US has proved that it can be used as an alternative cost effective screening modality for patients complaining of acute pain, US has reasonable sensitivity, specificity and accuracy in detecting knee effusion, meniscal injury including degeneration, tear, and extrusion, collateral ligaments, bursitis, baker cyst. Muscle, tendon injury and osteoarthritic changes, with no contraindications it can be used as the first choice in assessment of acute knee pain. MRI can be reserved for further workup if clinically warranted.
Keywords: Ultrasound, Painful Knee, Magnetic Resonance Imaging
Introduction
Knee pain is one of the most frequent symptoms that bring patients to the hospital. It affects approximately 25% of adults, with an increasing incidence of almost 65% over the past 20 years (Bunt et al., 2018).
Knee pain resulting from trauma led to impairment of the soft tissue structures that stabilize the knee joint, including the muscles, ligaments, tendons, and menisci, or due to non-traumatic injuries like infection, bursitis, Osteoarthritis, patellar tendinitis, and patellofemoral pain syndrome (Bhandari and Mangal, 2019).
The Magnetic Resonance Imaging (MRI) is the gold standard accurate non-invasive sensitive imaging tool used in diagnosis of early knee pathology, detecting any change, with the ability of this technology to investigate joint structural abnormalities beyond gross changes in bone and in the joint
space, This Technology have saved the patients from unnecessary arthroscopy (Ahmed et al., 2021 and Koch et al., 2021).
However, there are many limitations of MRI the most important of them which affects the result accuracy is knee Joint replacement or prosthesis High-quality images are assured only if patient is able to remain calm and still while the images are being captured. Anxious, irritable patients or presence of severe pain, may interfere with proper positioning of patient during imaging. A bent knee that cannot be extended is also difficult to image. Obese patient may not fit into the opening of a conventional MRI machine (Ghadimi and Sapra, 2021).
Nowadays Ultrasonography (US) is becoming more popular and alternative to MRI because it’s reliable, done safely with no side effects, quick with no waste of time, inexpensive with less cost. Moreover, sonography is capable to assess soft tissues in the anterior aspect of the knee, which could be the main source of pain (Rabay et al., 2020).
US was first used in the diagnosis of some musculoskeletal pathologies for the differentiation of Baker cyst and thrombophlebitis, then few years later, US was used to diagnose arthritis and to recognize treatment outcomes. Since then, the application of US has been in diagnosis of other musculoskeletal disorders. Recently, it tends to become one of the primary imaging methods for most musculoskeletal disorders (Brom et al., 2020).
It showed high diagnostic accuracy in detecting most causes of anterior knee pathology. The MRI may be warranted if a patellar cartilage defect is clinically suspected or the US yielded negative results (Brom et al., 2020).
Aim of the Work
Our aim is to evaluate the role of US in assessment of painful knee compared to conventional MRI sequences as an alternative cost effective modality for an accurate diagnosis.
Patients and Methods
This study is a cross-sectional study was conducted at Ain Shams University Hospitals at Radiology department. The main source of data for this study was the prospectively conducted scans and clinical history of the patients referred to the MRI section of the department of Radiology, Ain Shams University Hospitals at 6 months. Patients with acute knee pain (less than three months duration) or chronic pain with acute exacerbation.
• Inclusion Criteria:
- Any patient with acute pain (Pain for less than three months duration) or chronic Pain (acute exacerbation) will be included, either following traumatic insult, or associated with Swelling, deformity &/or Limitation of movement.
• Exclusion criteria:
1. Patient with operative history in knee joint.
2. Patients aged less than 18 years.
3. Presence of one or more of the contraindications to MRI
Clinical history and imaging findings of the included patients were prospectively obtained from the picture archiving and communications system (PACS) of the Radiology Department, Ain Shams University Hospitals. This study included forty patients and was conducted in the period from April 2022, following approval by our institutional review board. Patients were informed consent prior to the US and MRI, The Patients were referred to the MRI department performed US first after the consent followed by MRI. Each patient who was included in the study was subjected to full clinical history taking.
Technique
US technique was performed using a high-frequency linear transducer (7.5–12 MHz) by musculoskeletal radiology experts in our department. The patient lied supine on the examining table with both knees exposed. All patients had standardized US of the knee joint with gel and the findings were correlated with the point of maximal tenderness and readily compared with those obtained in the contralateral joint routine US examination of the knee starts with its anterior aspect, followed by the medial, lateral and posterior aspects in both longitudinal and transverse planes.
MRI Technique is performed using a standard high field MR unit closed type machine (Achieva Philips Healthcare). The MRI study included the following pulse sequences and MRI Reports are written by two different expert radiologists using the following sequences Axial T2 Wis, Axial PD fat sat WIs., Sagittal PD Wis, Sagittal T2 WIs, Sagittal PD fat sat Wis, Coronal PD fat sat and Coronal T1 WIs.
Statistical analysis
The present study included 40 patients coming to the MRI unit of Ain Shams University Hospitals with acute onset of knee pain. The study was conducted over a period of 6 months from April 2022 to October 2022. The p-value was considered significant as the following: P-value > 0.05: Non significant (NS), P-value < 0.05: Significant (S), P-value < 0.01: Highly significant (HS).
Cases CASE (1)
63 Years old female presented with anterior knee pain movement, clicking and painful flexion of the right knee for 6 weeks, both MRI and US showed Meniscus Extrusion.
Fig. 1: MRI PD Fat Supressed (a) Coronal and (b) Sagittal show AHMM shows abnormal increased signal with extrusion, in (b) it shows also a well-defined cystic lesion detected at the postro-medial aspect representing baker cyst.
Fig. 2: US longitudinal image showing medial side of left knee shows medial meniscus extrusion.
CASE (2):
42 Years old female presented with right anterior knee pain and crepitation’s for 10 days duration, both MRI and US Showed Osteoarthritis Changes.
Fig. 3: Coronal PD fat supressed images diffuse cartilage substance loss is seen in femoral and tibial weight-bearing regions of medial compartment and marginal osteophytes.
Fig. 4: Sagittal PD fat supressed images show diffuse cartilage substance loss associated with horizontal meniscal tear at PHMM.
Fig. 5: US image showing loss of sharpness the femoral condylar hyaline cartilage and irregularities of the cartilage and changes in the anechoic echotexture.
Results
The age of the study group ranged from 18 to 65 years with Median (IQR) 35 (21.5 − 47.5). The male patients represented the majority of our cases presenting and were 28 out of 40 (70%). The female patients were 12 (30.0%) as demonstrated in Fig 6.
Fig. 6: chart demonstrating gender distribution among the cases.
Table 1: Comparison between US and MRI results.
US MRI Sensitivity Specificity PPV NPV Accuracy
Effusion No 4 (10.0%) 4(10.0%) 100.0% 100.0% 100.0% 1.000 1.000
Yes 36 (90.0%) 36(90.0%)
Meniscus Degeneration
AHMM No 39 (97.5%) 39 (97.5%) 100.0% 100.0% 100.0% 100.0% 1.000
Yes 1 (2.5%) 1 (2.5%)
PHMM No 31 (77.5%) 26 (65.0%) 57.19% 96.2% 88.9% 80.65% 0.825
Yes 9 (22.5%) 14 (35.0%)
AHLM No 40 (100.0%) 40 (100.0%) 0.0% 100.0% 0.0% 100.0% 1.000
Yes 0 (0.0%) 0 (0.0%)
PHLM No 40 (100.0%) 40 (100.0%) 0.0% 100.0% 0.0% 100.0% 1.000
Yes 0 (0.0%) 0 (0.0%)
Meniscus Tear
AHMM No 40 (100.0%) 40 (100.0%) 100.0% 100.0% 97.37% 0.975 1.000
Yes 0 (0.0%) 0 (0.0%)
PHMM No 31 (77.5%) 31 (77.5%) 66.7% 90.3% 66.7% 90.3% 0.850
Yes 9 (22.5%) 9 (22.5%)
AHLM No 38 (95.0%) 38 (95.0%) 100.0% 100.0% 100.0% 100.0% 1.000
Yes 2 (5.0%) 2 (5.0%)
PHLM No 40 (100.0%) 40 (100.0%) 0.0% 100.0% 0.0% 100.0% 1.000
Yes 0 (0.0%) 0 (0.0%)
Meniscus Extrusion No 38 (95.0%) 37 (92.5%) 66.7% 100.0% 100.0% 97.37% 0.975
Yes 2 (5.0%) 3 (7.5%)
MCL Injury No 38 (95.0%) 36 (90.0%) 66.7% 100.0% 100.0% 97.37% 0.975
Yes 2 (5.0%) 4 (10.0%)
LCL Injury No 39 (97.5%) 38 (95.0%) 50.0% 100.0% 100.0% 97.44% 0.975
Yes 1 (2.5%) 2 (5.0%)
Bursitis No 38 (95%) 37 (92.5%) 66.7% 100.0% 100.0% 97.37% 0.975
Yes 2 (5%) 3 (7.5%)
ACL Injury No 40 (100.0%) 32 (80.0%) 0.0% 100.0% 0.0% 80.0% 0.800
Yes 0 (0.0%) 8 (20.0%)
Muscle/Tendon Injury No 38 (95.0%) 38 (95.0%) 100.0% 100.0% 100.0% 100.0% 1.000
Yes 2 (5.0%) 2 (5.0%)
Bone Contusion No 40 (100.0%) 35 (87.5%) 0.0% 100.0% 0.0% 87.5% 0.875
Yes 0 (0.0%) 5 (12.5%)
Osteroarthric Changes No 35 (87.5%) 31 (77.5%) 55.60% 100.0% 100.0% 88.57% 0.900
Yes 5 (12.5%) 9 (22.5%)
Discussion
My Study included 40 patients with acute onset of knee pain (1 day – 3 months) or chronic pain with acute exacerbation unlike Sadeghian et al. (2018) which included patients with chronic onset of knee pain, My Study included 28 males representing (70%) of the study and 12 females representing (30%) of the study, while Basha et al. (2020) included (55%) male patients and (45%) female patients and Mostafa et al. (2019) included (62%) male patients and (38%) female patient.
Regarding Joint Effusion Both US and MRI detected joint effusion in 36 cases, and joint effusion in 4 cases. Our study revealed sensitivity and specificity of US in detecting joint effusion of 100% and 100% respectively with 100 PPV and 100% NPV and insignificant p-value (1.000) which shows close results to Basha et al., 2020 which showed a sensitivity of 91.5% and specificity of 95.8% in detecting knee effusion. but in disagreement with Draghi et al., 2015 that showed sensitivity and specificity of 81.3% and 100%. This may be due to that the US examination in our study performed after the MRI examination by a few hours to days in average due to the patient’s inconvenience in the study which may lead to progression of the minimal and mild degree of effusion in this gap between the two examinations (Basha et al., 2020; Draghi et al., 2015).
Regarding Meniscus degeneration, the menisci are important components of knee joint function. injury of menisci can be assessed on US and appears in the form of hypoechoic area within the meniscus substance, US detected degeneration in 10 meniscal horns, while MRI detected degeneration in 15 meniscal horns, my study showed that US has 57.1% sensitivity, 96.2% specificity, 88.9% PPV, 80.6% NPV and insignificant p-value (1.000) which agrees with Mostafa et al., 2019 that showed similar US sensitivity and specificity of 63.6% and 88.9% respectively (Mostafa et al., 2019).
Regarding Meniscal horn tear, US detected tear in 8 horns, while MRI detected tear in 11 horns. Our study showed that US has 72.7% sensitivity, 89.7% specificity, 72.7% PPV, 89.7% NPV and insignificant p-value (1.000), which is slightly different than Mostafa et al., 2019 that showed slightly higher US sensitivity and slightly lower specificity of 88.9% and 77.3% respectively (Mostafa et al., 2019).
Regarding Meniscal horn extrusion, appears as displacement of the meniscus beyond tibia end by 2 mm, US detected extrusion in 2 horns, and MRI detected extrusion in 3 horns. Our study showed US Showed 66.7 % sensitivity, 100 % specificity, 100 % PPV, 97.37 % NPV and insignificant p-value (0.644) which agrees Golshani et al., 2018 that showed US sensitivity 61% and specificity of 85%, while disagrees with Nogueira-Barbosa et al., 2015 that showed US sensitivity and specificity of 95.5% and 76% respectively (Golshani et al., 2018; Nogueira-Barbosa et al., 2015).
Regarding MCL injury, US detected MCL injury in 2 cases, while MRI detected MCL injury in 3 cases. Our study revealed US Showed 66.7 % sensitivity, 100 % specificity, 100 % PPV, 97.37 % NPV and insignificant P value (0.644) which agrees with Ghosh et al., 2017 that showed similar sensitivity but lower specificity of 67% and 83% respectively (Ghosh et al., 2017).
Regarding LCL injury, US detected LCL injury in 1 case, while MRI detected LCL injury in 2 cases, Our study revealed US Showed 50 % sensitivity, 100 % specificity, 100 % PPV, 97.44 % NPV and insignificant P value (0.556), which disagrees with Singh et al., 2018 that showed more higher sensitivity of 84.6% and specificity of 97.8% (Singh et al., 2018).
Regarding Bursitis, US Showed 66.7 % sensitivity, 100 % specificity, 100 % PPV, 97.37 % NPV,
97.5 % accuracy and P value was non-significant (0.644) which agrees with Draghi et al., 2015 who showed similar sensitivity and specificity, sensitivity of 71.4 %, specificity of 100 % for bursitis (Draghi et al., 2015).
Regarding Muscle and Tendon Injury, US showed US Showed 100 % sensitivity, 100 % specificity, 100 % PPV, 100 % NPV, 100 % accuracy and P value was (1.000) insignificant which is convenient with Basha et al., 2020 that showed lower sensitivity 87.5 and similar specificity 100% (Basha et al., 2020).
Regarding the diagnostic performance ACL injury of US, there was no statistically significant association found between results of MR and US with p value >0.05. The 32 patients who found negative by MR was found negative by US, which agrees with Mir et al., 2021 which showed sensitivity of 14.3%, specificity of 100% with p value >0.05, this is due to ACL oblique trajectory and deeper location. The Results indicated that US is not accurate to be used in detecting ACL injuries (Mir et al., 2021).
Regarding Bone Contusion US Showed no statistically significant association found between results of MR and US with 0 % sensitivity, 100 % specificity, 0 % PPV, 87.5 % NPV, 87.5 % accuracy and P value was significant, which agrees with Schmid et al., 2017 yet it shows good sensitivity and specificity for bone fracture sensitivity 74%, specificity 81%. Results indicated that US is not accurate to be used in detecting bone contusions injuries (Schmid et al., 2017).
Regarding osteoarthritic changes, it is characterized by focal degeneration and progressive loss of the articular cartilage. by US, cartilage pathology is characterized by loss of sharpness of the surface facing the joint cavity, focal or diffuse reduction of cartilage thickness and loss of homogeneity as a result of the water content loss US Showed 55.6 % sensitivity, 100 % specificity, 100 % PPV, 88.5 % NPV, 80
% accuracy and P value was significant (0.239) which disagrees with Brom et al., 2020 which showed sensitivity 95%, specificity 94%, may be because our study was done for patients with acute complain and osteoarthritis is a chronic degenerative disease changes detected by US slowly develop over years unlike Brom et al study which involved chronic cases (Brom et al., 2020).
Conclusion
US has proved that it can be used as an alternative cost effective screening modality for patients complaining of acute pain, US has reasonable sensitivity, specificity and accuracy in detecting knee effusion, meniscal injury including degeneration, tear, and extrusion, collateral ligaments, bursitis, baker cyst. muscle, tendon injury and osteoarthritic changes, with no contraindications it can be used as the first choice in assessment of acute knee pain. MRI can be reserved for further workup if clinically warranted.
Recommendations
In this study, MRI was considered the gold standard and patients did not undergo arthroscopy.
The accuracy of MRI in the diagnosis of knee pathologies were dependent on the experience of the interpreter. Arthroscopy was not performed routinely at our institution and not all patients needed arthroscopy. Of course, the accuracy of MRI, compared with arthroscopy, is 97%, so thus recommended comparison of US and arthroscopy to give more accurate results.
The main limitation of the present study was the small number of subjects that were enrolled. The sample size was calculated based on the results of the previous studies and due to the influence of sample size on diagnostic accuracy, it is thus recommended that the study be performed with larger sample size and multicenter.
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