Mapping tibiofemoral gonarthrosis: an MRI analysis of non-traumatic knee cartilage defects

OBJECTIVE Arthroscopy is "the gold standard" for the diagnosis of knee cartilage lesions. However, it is invasive and expensive, and displays all the potential complications of an open surgical procedure. Ultra-high-field MRI now offers good opportunities for the indirect assessment of the integrity and structural changes of joint cartilage of the knee. The goal of the present study is to determine the site of early cartilaginous lesions in adults with non-traumatic knee pain. METHODS 3-T MRI examinations of 200 asymptomatic knees with standard and three-dimensional double-echo steady-state (3D-DESS) cartilage-specific sequences were prospectively studied for early degenerative lesions of the tibiofemoral joint. Lesions were classified and mapped using the modified Outerbridge and modified International Cartilage Repair Society classifications. RESULTS A total of 1437 lesions were detected: 56.1% grade I, 33.5% grade II, 7.2% grade III and 3.3% grade IV. Cartographically, grade I lesions were most common in the anteromedial tibial areas; grade II lesions in the anteromedial L5 femoral areas; and grade III in the centromedial M2 femoral areas. CONCLUSION 3-T MRI with standard and 3D-DESS cartilage-specific sequences demonstrated that areas predisposed to early osteoarthritis are the central, lateral and ventromedial tibial plateau, as well as the central and medial femoral condyle. ADVANCES IN KNOWLEDGE In contrast with previous studies reporting early cartilaginous lesions in the medial tibial compartment and/or in the medial femoral condyle, this study demonstrates that, regardless of grade, lesions preferentially occur at the L5 and M4 tibial and L5 and L2 femoral areas of the knee joint.

Lesion characteristics of patients with chronic critical limb ischemia that determine choice of treatment modality

This paper will review the literature in order to define lesion characteristics that determine decision for surgical or endovascular therapy in patients with chronic critical limb ischemia (CLI). The typical pattern of disease is multilevel, infrainguinal disease. The great majority of patients with CLI can be treated by endovascular means, and the pathoanatomical pattern of disease dictates the choice of treatment modality. Long iliac artery occlusions, in particular, if associated with common femoral artery pathology and long superficial femoral artery occlusions crossing the knee joint so far remain a domain of surgery. However, there is an ongoing shift from surgery to endovascular treatment.

Gadolinium diethylenetriaminepentaacetate enhancement kinetics in the menisci of asymptomatic subjects: a first step towards a dedicated dGEMRIC (delayed gadolinium-enhanced MRI of cartilage)-like protocol for biochemical imaging of the menisci

It was our aim to investigate the gadolinium diethylenetriaminepentaacetate (Gd-DTPA(2-) ) enhancement kinetics in the menisci of the knee joint over a prolonged period of time. Six asymptomatic volunteers (four men and two women; mean age, 25 ± 2.4 years) were enrolled. Sagittal, T(1) -weighted, spin-echo MR sequences of the right knee joint were obtained at 3 T. Imaging was performed before (baseline), 1 h after and in half-hour intervals up to 9 h after the intravenous administration of 0.2 mmol/kg of Gd-DTPA(2-) . To measure the rates of contrast enhancement relative to the baseline, regions of interest that covered the anterior and posterior horns of the medial and lateral meniscus were defined on each of two adjacent sections, and enhancement curves were constructed. An enhancement peak between 2.5 and 4.5 h after Gd-DTPA(2-) administration was observed, and analysis of variance also revealed no significant difference (p=0.94), in terms of enhancement, within this time interval. Pair-wise, post hoc testing also revealed no significant differences between 2.5 and 3, 3 and 3.5, 3.5 and 4, and 4 and 4.5 h post Gd-DTPA(2-) application. Our preliminary data therefore suggest that the time window suitable for a dGEMRIC (delayed gadolinium-enhanced MRI of cartilage)-like T(1) mapping of the menisci is relatively short, and lies between 2.5 and 4.5 h after Gd-DTPA(2-) injection.

Ligament balancing in TKA: Evaluation of a force-sensing device and the influence of patellar eversion and ligament release

Ligament balancing in total knee arthroplasty may have an important influence on joint stability and prosthesis lifetime. In order to provide quantitative information and assistance during ligament balancing, a device that intraoperatively measures knee joint forces and moments was developed. Its performance and surgical advantages were evaluated on six cadaver specimens mounted on a knee joint loading apparatus allowing unconstrained knee motion as well as compression and varus-valgus loading. Four different experiments were performed on each specimen. (1) Knee joints were axially loaded. Comparison between applied and measured compressive forces demonstrated the accuracy and reliability of in situ measurements (1.8N). (2) Assessment of knee stability based on condyle contact forces or varus-valgus moments were compared to the current surgical method (difference of varus-valgus loads causing condyle lift-off). The force-based approach was equivalent to the surgical method while the moment-based, which is considered optimal, showed a tendency of lateral imbalance. (3) To estimate the importance of keeping the patella in its anatomical position during imbalance assessment, the effect of patellar eversion on the mediolateral distribution of tibiofemoral contact forces was measured. One fourth of the contact force induced by the patellar load was shifted to the lateral compartment. (4) The effect of minor and major medial collateral ligament releases was biomechanically quantified. On average, the medial contact force was reduced by 20% and 46%, respectively. Large variation among specimens reflected the difficulty of ligament release and the need for intraoperative force monitoring. This series of experiments thus demonstrated the device's potential to improve ligament balancing and survivorship of total knee arthroplasty.

Magnetic resonance angiography in infrapopliteal arterial disease: prospective comparison of 1.5 and 3 Tesla magnetic resonance imaging

PURPOSE: To prospectively determine the accuracy of 1.5 Tesla (T) and 3 T magnetic resonance angiography (MRA) versus digital subtraction angiography (DSA) in the depiction of infrageniculate arteries in patients with symptomatic peripheral arterial disease. PATIENTS AND METHODS: A prospective 1.5 T, 3 T MRA, and DSA comparison was used to evaluate 360 vessel segments in 10 patients (15 limbs) with chronic symptomatic peripheral arterial disease. Selective DSA was performed within 30 days before both MRAs. The accuracy of 1.5 T and 3 T MRA was compared with DSA as the standard of reference by consensus agreement of 2 experienced readers. Signal-to-noise ratios (SNR) and signal-difference-to-noise ratios (SDNRs) were quantified. RESULTS: No significant difference in overall image quality, sufficiency for diagnosis, depiction of arterial anatomy, motion artifacts, and venous overlap was found comparing 1.5 T with 3 T MRA (P > 0.05 by Wilcoxon signed rank and as by Cohen k test). Overall sensitivity of 1.5 and 3 T MRA for detection of significant arterial stenosis was 79% and 82%, and specificity was 87% and 87% for both modalities, respectively. Interobserver agreement was excellent k > 0.8, P < 0.05) for 1.5 T as well as for 3 T MRA. SNR and SDNR were significantly increased using the 3 T system (average increase: 36.5%, P < 0.032 by t test, and 38.5%, P < 0.037 respectively). CONCLUSIONS: Despite marked improvement of SDNR, 3 T MRA does not yet provide a significantly higher accuracy in diagnostic imaging of atherosclerotic lesions below the knee joint as compared with 1.5 T MRA.

Cystic adventitial disease of the popliteal artery: an argument for the developmental theory

Cystic adventitial disease is a rare non-atheromatous cause of popliteal artery disease. We report a case of a 54-year-old patient with claudication of the right calf caused by cystic adventitial disease. Intra-operatively, a communication between the adventitia and the knee joint was identified. Connections between the adventitial cyst and the nearby joint have been reported in the literature that support the developmental theory. This theory suggests that cystic adventitial disease is a developmental manifestation of mucin-secreting cells derived from the mesenchyme of the adjacent joint. This case is the first, to our knowledge, in which a communication between joint and adventitia has been clearly documented by operative findings.

Abnormal collagen fibrils in cartilage of matrilin-1/matrilin-3-deficient mice

Matrilins are oligomeric extracellular matrix adaptor proteins mediating interactions between collagen fibrils and other matrix constituents. All four matrilins are expressed in cartilage and mutations in the human gene encoding matrilin-3 (MATN3) are associated with different forms of chondrodysplasia. Surprisingly, however, Matn3-null as well as Matn1- and Matn2-null mice do not show an overt skeletal phenotype, suggesting a dominant negative pathomechanism for the human disorders and redundancy/compensation among the family members in the knock-out situation. Here, we show that mice lacking both matrilin-1 and matrilin-3 develop an apparently normal skeleton, but exhibit biochemical and ultrastructural abnormalities of the knee joint cartilage. At the protein level, an altered SDS-PAGE band pattern and a clear up-regulation of the homotrimeric form of matrilin-4 were evident in newborn Matn1/Matn3 and Matn1 knock-out mice, but not in Matn3-null mice. The ultrastructure of the cartilage matrix after conventional chemical fixation was grossly normal; however, electron microscopy of high pressure frozen and freeze-substituted samples, revealed two consistent observations: 1) moderately increased collagen fibril diameters throughout the epiphysis and the growth plate in both single and double mutants; and 2) increased collagen volume density in Matn1(-/-)/Matn3(-/-) and Matn3(-/-) mice. Taken together, our results demonstrate that matrilin-1 and matrilin-3 modulate collagen fibrillogenesis in cartilage and provide evidence that biochemical compensation might exist between matrilins.

Chondrogenic potential of human synovial mesenchymal stem cells in alginate

OBJECTIVE: In a recent study, we demonstrated that mesenchymal stem cells (MSCs) derived from the synovial membranes of bovine shoulder joints could differentiate into chondrocytes when cultured in alginate. The purpose of the present study was to establish the conditions under which synovial MSCs derived from aging human donors can be induced to undergo chondrogenic differentiation using the same alginate system. METHODS: MSCs were obtained by digesting the knee-joint synovial membranes of osteoarthritic human donors (aged 59-76 years), and expanded in monolayer cultures. The cells were then seeded at a numerical density of 4x10(6)/ml within discs of 2% alginate, which were cultured in serum-containing or serum-free medium (the latter being supplemented with 1% insulin, transferrin, selenium (ITS). The chondrogenic differentiation capacity of the cells was tested by exposing them to the morphogens transforming growth factor-beta1 (TGF-beta1), TGF-beta2, TGF-beta3, insulin-like growth factor-1 (IGF-1), bone morphogenetic protein-2 (BMP-2) and BMP-7, as well as to the synthetic glucocorticoid dexamethasone. The relative mRNA levels of collagen types I and II, of aggrecan and of Sox9 were determined quantitatively by the real-time polymerase chain reaction (PCR). The extracellular deposition of proteoglycans was evaluated histologically after staining with Toluidine Blue, and that of type-II collagen by immunohistochemistry. RESULTS: BMP-2 induced the chondrogenic differentiation of human synovial MSCs in a dose-dependent manner. The response elicited by BMP-7 was comparable. Both of these agents were more potent than TGF-beta1. A higher level of BMP-2-induced chondrogenic differentiation was achieved in the absence than in the presence of serum. In the presence of dexamethasone, the BMP-2-induced expression of mRNAs for aggrecan and type-II collagen was suppressed; the weaker TGF-beta1-induced expression of these chondrogenic markers was not obviously affected. CONCLUSIONS: We have demonstrated that synovial MSCs derived from the knee joints of aging human donors possess chondrogenic potential. Under serum-free culturing conditions and in the absence of dexamethasone, BMP-2 and BMP-7 were the most potent inducers of this transformation process.

Longitudinal evaluation of cartilage composition of matrix-associated autologous chondrocyte transplants with 3-T delayed gadolinium-enhanced MRI of cartilage

OBJECTIVE: The purposes of this study were to use delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) to evaluate the zonal distribution of glycosaminoglycans (GAGs) in normal cartilage and repair tissue and to use 3-T MRI to monitor the GAG content in matrix-associated autologous chondrocyte transplants. SUBJECTS AND METHODS: Fifteen patients who underwent matrix-associated autologous chondrocyte transplantation in the knee joint underwent MRI at baseline and 3-T follow-up MRI 1 year later. Total and zonal changes in longitudinal relaxivity (deltaR1) and relative deltaR1 were calculated for repair tissue and normal hyaline cartilage and compared by use of analysis of variance. RESULTS: There was a significant difference between the mean deltaR1 of repair tissue and that of reference cartilage at baseline and follow-up (p < 0.001). There was a significant increase in deltaR1 value and a decrease in GAG content from the deep layer to the superficial layer in the reference cartilage and almost no variation and significantly higher values for the repair tissue at both examinations. At 1-year follow-up imaging, there was a 22.7% decrease in deltaR1 value in the deep zone of the transplant. CONCLUSION: T1 mapping with dGEMRIC at 3 T shows the zonal structure of normal hyaline cartilage, highly reduced zonal variations in repair tissue, and a tendency toward an increase in global and zonal GAG content 1 year after transplantation.

Differentiating normal hyaline cartilage from post-surgical repair tissue using fast gradient echo imaging in delayed gadolinium-enhanced MRI (dGEMRIC) at 3 Tesla

The purpose was to evaluate the relative glycosaminoglycan (GAG) content of repair tissue in patients after microfracturing (MFX) and matrix-associated autologous chondrocyte transplantation (MACT) of the knee joint with a dGEMRIC technique based on a newly developed short 3D-GRE sequence with two flip angle excitation pulses. Twenty patients treated with MFX or MACT (ten in each group) were enrolled. For comparability, patients from each group were matched by age (MFX: 37.1 +/- 16.3 years; MACT: 37.4 +/- 8.2 years) and postoperative interval (MFX: 33.0 +/- 17.3 months; MACT: 32.0 +/- 17.2 months). The Delta relaxation rate (DeltaR1) for repair tissue and normal hyaline cartilage and the relative DeltaR1 were calculated, and mean values were compared between both groups using an analysis of variance. The mean DeltaR1 for MFX was 1.07 +/- 0.34 versus 0.32 +/- 0.20 at the intact control site, and for MACT, 1.90 +/- 0.49 compared to 0.87 +/- 0.44, which resulted in a relative DeltaR1 of 3.39 for MFX and 2.18 for MACT. The difference between the cartilage repair groups was statistically significant. The new dGEMRIC technique based on dual flip angle excitation pulses showed higher GAG content in patients after MACT compared to MFX at the same postoperative interval and allowed reducing the data acquisition time to 4 min.

Three-dimensional magnetic resonance observation of cartilage repair tissue (MOCART) score assessed with an isotropic three-dimensional true fast imaging with steady-state precession sequence at 3.0 Tesla

INTRODUCTION: Cartilage defects are common pathologies and surgical cartilage repair shows promising results. In its postoperative evaluation, the magnetic resonance observation of cartilage repair tissue (MOCART) score, using different variables to describe the constitution of the cartilage repair tissue and the surrounding structures, is widely used. High-field magnetic resonance imaging (MRI) and 3-dimensional (3D) isotropic sequences may combine ideal preconditions to enhance the diagnostic performance of cartilage imaging.Aim of this study was to introduce an improved 3D MOCART score using the possibilities of an isotropic 3D true fast imaging with steady-state precession (True-FISP) sequence in the postoperative evaluation of patients after matrix-associated autologous chondrocyte transplantation (MACT) as well as to compare the results to the conventional 2D MOCART score using standard MR sequences. MATERIAL AND METHODS: The study had approval by the local ethics commission. One hundred consecutive MR scans in 60 patients at standard follow-up intervals of 1, 3, 6, 12, 24, and 60 months after MACT of the knee joint were prospectively included. The mean follow-up interval of this cross-sectional evaluation was 21.4 +/- 20.6 months; the mean age of the patients was 35.8 +/- 9.4 years. MRI was performed at a 3.0 Tesla unit. All variables of the standard 2D MOCART score where part of the new 3D MOCART score. Furthermore, additional variables and options were included with the aims to use the capabilities of isotropic MRI, to include the results of recent studies, and to adapt to the needs of patients and physician in a clinical routine examination. A proton-density turbo spin-echo sequence, a T2-weighted dual fast spin-echo (dual-FSE) sequence, and a T1-weighted turbo inversion recovery magnitude (TIRM) sequence were used to assess the standard 2D MOCART score; an isotropic 3D-TrueFISP sequence was prepared to evaluate the new 3D MOCART score. All 9 variables of the 2D MOCART score were compared with the corresponding variables obtained by the 3D MOCART score using the Pearson correlation coefficient; additionally the subjective quality and possible artifacts of the MR sequences were analyzed. RESULTS: The correlation between the standard 2D MOCART score and the new 3D MOCART showed for the 8 variables "defect fill," "cartilage interface," "surface," "adhesions," "structure," "signal intensity," "subchondral lamina," and "effusion"-a highly significant (P < 0.001) correlation with a Pearson coefficient between 0.566 and 0.932. The variable "bone marrow edema" correlated significantly (P < 0.05; Pearson coefficient: 0.257). The subjective quality of the 3 standard MR sequences was comparable to the isotropic 3D-TrueFISP sequence. Artifacts were more frequently visible within the 3D-TrueFISP sequence. CONCLUSION: In the clinical routine follow-up after cartilage repair, the 3D MOCART score, assessed by only 1 high-resolution isotropic MR sequence, provides comparable information than the standard 2D MOCART score. Hence, the new 3D MOCART score has the potential to combine the information of the standard 2D MOCART score with the possible advantages of isotropic 3D MRI at high-field. A clear limitation of the 3D-TrueFISP sequence was the high number of artifacts. Future studies have to prove the clinical benefits of a 3D MOCART score.

T1(Gd) gives comparable information as Delta T1 relaxation rate in dGEMRIC evaluation of cartilage repair tissue

OBJECTIVES: To evaluate the relationship between T1 after intravenous contrast administration (T1Gd) and Delta relaxation rate (DeltaR1) = (1/T1(Gd) - 1/T1o) in the delayed Gadolinium-Enhanced MRI of cartilage (dGEMRIC) evaluation of cartilage repair tissue. MATERIALS AND METHODS: Thirty single MR examinations from 30 patients after matrix-associated autologous chondrocyte transplantations of the knee joint with different postoperative intervals were examined using an 8-channel knee-coil at 3T. T1 mapping using a 3D GRE sequence with a 35/10 degrees flip angle excitation pulse combination was performed before and after contrast administration (dGEMRIC technique). T1 postcontrast (T1(Gd)) and the DeltaR1 (relative index of pre- and postcontrast R1 value) were calculated for repair tissue and the weight-bearing normal appearing control cartilage. For evaluation of the different postoperative intervals, MR exams were subdivided into 3 groups (up to 12 months, 12-24 months, more than 24 months). For statistical analysis Spearman correlation coefficients were calculated. RESULTS: The mean value for T1 postcontrast was 427 +/- 159 ms, for DeltaR1 1.85 +/- 1.0; in reference cartilage 636 +/- 181 ms for T1 postcontrast and 0.83 +/- 0.5 for DeltaR1.The correlation coefficients were highly significant between T1 (Gd) and DeltaR1 for repair tissue (0.969) as well as normal reference cartilage (0.928) in total, and for the reparative cartilage in the early, middle postoperative, and late postoperative interval after surgery (R values: -0.986, -0.970, and -0.978, respectively). Using either T1(Gd) or DeltaR1, the 2 metrics resulted in similar conclusions regarding the time course of change of repair tissue and control tissue, namely that highly significant (P > 0.01) differences between cartilage repair tissue and reference cartilage were found for all follow-up groups. Additionally, for both metrics highly significant differences (P < 0.01) between early follow up and the 2 later postoperative groups for cartilage repair tissue were found. No statistical differences were found between the 2 later follow-up groups of reparative cartilage either for T1 (Gd) or DeltaR1. CONCLUSION: The high correlation between T1 (Gd) and DeltaR1 and the comparable conclusions reached utilizing metric implies that T1 mapping before intravenous administration of MR contrast agent is not necessary for the evaluation of repair tissue. This will help to reduce costs, inconvenience for the patients, simplifies the examination procedure, and makes dGEMRIC more attractive for follow-up of patients after cartilage repair surgeries.

Quantification of Popliteal Artery Deformation During Leg Flexion in Subjects With Peripheral Artery Disease: A Pilot Study

Purpose: To quantify the in vivo deformations of the popliteal artery during leg flexion in subjects with clinically relevant peripheral artery disease (PAD). Methods: Five patients (4 men; mean age 69 years, range 56–79) with varying calcification levels of the popliteal artery undergoing endovascular revascularization underwent 3-dimensional (3D) rotational angiography. Image acquisition was performed with the leg straight and with a flexion of 70°/20° in the knee/hip joints. The arterial centerline and the corresponding branches in both positions were segmented to create 3D reconstructions of the arterial trees. Axial deformation, twisting, and curvatures were quantified. Furthermore, the relationships between the calcification levels and the deformations were investigated. Results: An average shortening of 5.9%±2.5% and twist rate of 3.8±2.2°/cm in the popliteal artery were observed. Maximal curvatures in the straight and flexed positions were 0.12±0.04 cm−1 and 0.24±0.09 cm−1, respectively. As the severity of calcification increased, the maximal curvature in the straight position increased from 0.08 to 0.17 cm−1, while an increase from 0.17 to 0.39 cm−1 was observed for the flexed position. Axial elongations and arterial twisting were not affected by the calcification levels. Conclusion: The popliteal artery of patients with symptomatic PAD is exposed to significant deformations during flexion of the knee joint. The severity of calcification directly affects curvature, but not arterial length or twisting angles. This pilot study also showed the ability of rotational angiography to quantify the 3D deformations of the popliteal artery in patients with various levels of calcification.

The influence of tibial morphology on the design of an anatomical tibial baseplate for TKA.

BACKGROUND Finding the right balance between tibial coverage and minimal implant overhang is an important factor in TKA. Another significant cause of failure is component malrotation. METHODS An average master shape of the proximal tibia at TKA resection level was calculated using fine slice computed tomographies of 117 cadaveric knees. To find out whether alternate implant contours would be necessary depending on the patient's body size, we established five subgroups to compare. CAD-Analysis was performed to simulate the overhang produced after ±4°/±7°/±10° rotation. RESULTS A master shape for the tibial resection cut (with a 5° posterior slope, 7 mm under lateral joint line) could be determined. Neither left vs. right knee joint, nor male vs. female nor the size subdivision appears to alter the calculated master shape significantly. The optimized shape allowing for ±4° of rotational freedom was found to be the best variant. CONCLUSIONS Valid methods have been obtained to design a two-dimensional average shape of the tibial plateau. The modifications described in this study might come in useful, when designing future implant designs. CLINICAL RELEVANCE An optimized fit at the tibial plateau and lower rates of component malrotation may result in better outcomes after TKA.

Effects of (un)predictable whole body vibrations on visual performance

Over recent years, it has repeatedly been shown that optimal gaze strategies enhance motor control (e.g., Foulsham, 2015). However, little is known, whether, vice versa, visual performance can be improved by optimized motor control. Consequently, in two studies, we investigated visual performance as a function of motor control strategies and task parameters, respectively. In Experiment 1, 72 participants were tested on visual acuity (Landolt) and contrast sensitivity (Grating), while standing in two different postures (upright vs. squat) on a ZEPTOR-platform that vibrated at four different frequencies (0, 4, 8, 12 Hz). After each test, perceived exertion (Borg) was assessed. Significant interactions were revealed for both tests, Landolt: F(3,213)=13.25, p<.01, ηp2=.16, Grating: F(3,213)=4.27, p<.01, ηp2=.06, elucidating a larger loss of acuity/contrast sensitivity with increasing frequencies for the upright compared with the squat posture. For perceived exertion, however, a diametrical interaction for frequency was found for acuity, F(3,213)=7.45, p<.01, ηp2=.09, and contrast sensitivity, F(3,213)=7.08, p < .01, ηp2=.09, substantiating that the impaired visual performance cannot be attributed to exertion. Consequently, the squat posture could permit better head and, hence, gaze stabilization. In Experiment 2, 64 participants performed the same tests while standing in a squat position on a ski-simulator, which vibrated with two different frequencies (2.4, 3.6 Hz) and amplitudes (50, 100 mm) in a predictable or unpredictable manner. Control strategies were identified by tracking segmental motion, which allows to derive damping characteristics. Considerable main effects were found for frequency, all F’s(1,52)>10.31, all p’s<.01, all ηp2’s>.16, as well as, in the acuity test, for predictability, F(1,52)=10.31, p<.01, ηp2=.17, and by tendency for amplitude, F(1,52)=3.53, p=.06, ηp2=.06. A significant correlation between the damping amplitude in the knee joint and the performance drop in visual acuity, r=-.97, p<.001, again points towards the importance of motor control strategies to maintain optimal visual performance.