Association Between Patellar Tendon Abnormality and Land-Jump Biomechanics in Male Collegiate Basketball Players During the Preseason.

Background: Patellar tendinopathy is a degenerative condition that predominantly affects jumping athletes. Symptoms may be subtle or nonexistent at preseason, but structural abnormalities may be present. Assessing patellar tendon abnormality (PTA) through magnetic resonance imaging (MRI) and ultrasound (US) and classifying symptoms using the Victorian Institute for Sport Assessment-Patellar tendon (VISA-P) may provide useful insights if combined with biomechanics measurements. Purpose: To (1) assess whether land-jump biomechanical patterns are associated with clinically pertinent PTA as seen on imaging and through VISA-P scores and (2) model the contributing risk and accuracy of biomechanics to classify PTA and symptomatic observations. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 26 National Collegiate Athletic Association Division I and II male basketball players (n = 52 limbs) were recruited during the preseason. We collected VISA-P scores, bilateral PTA through US and MRI morphology measurements, and bilateral 3-dimensional lower extremity kinematics and kinetics measurements from a land-jump test from an 18-inch-high (45.7-cm-high) box. Statistically, each limb was treated independently. The association of biomechanics with PTA and symptoms (VISA-P score <80) was tested with multivariate models and post hoc tests. Logistic regression modeled relative risk and accuracy of biomechanical variables to classify PTA and symptomatic limbs. Results: There were 19 to 24 limbs with PTA depending on US and MRI measurements. Differences in hip and knee kinematic strategies and ground-reaction loads were associated with PTA and symptomatic limbs. Peak landing vertical ground-reaction force was significantly decreased (169 ± 26 vs 195 ± 29 %body weight; P = .001), and maximum hip flexion velocity was significantly increased (416 ± 74 vs 343 ± 94 deg/s; P = .005) in limbs with versus without PTA on imaging. Knee flexion at the initial contact was decreased in symptomatic versus healthy limbs (17°± 5° vs 21°± 5°, respectively; P = .045). Regression models classified PTA limbs and symptomatic limbs with 71.2% to 86.5% accuracy. Hip and knee maximum flexion velocity and vertical ground-reaction force variables were most common across models observing clinically pertinent PTA. Conclusion: Our findings suggested that functional kinematic and kinetic biomechanical strategies at the hip and knee were associated with PTA, identified on imaging, and symptomatic limbs.

MAVRIC based T2 mapping assessment of infrapatellar fat pad scarring in patients with total knee arthroplasty.

The infrapatellar fat pad (IPFP) has been implicated as a source of postoperative knee pain. Imaging the IPFP is challenging in patients with total knee arthroplasty (TKA) due to metallic susceptibility artifact. Multi-Acquisition Variable-Resonance Image Combination (MAVRIC)-based T2 Mapping has been developed to mitigate this artifact and can generate quantitative T2 data. Objectives of this study were to (1) measure T2 values of the IPFP in patients with TKAs using a MAVRIC based T2 mapping technique and (2) determine if IPFP T2 values are related to the degree of fat pad scarring or clinical magnetic resonance imaging (MRI) findings. Twenty-eight subjects (10 males, 18 females, Age: 66 + 7.2 years [Mean ± standard deviations]) undergoing clinical MRIs were sequentially recruited. Morphological imaging and quantitative T2 mapping sequences were performed on a clinical 1.5 T scanner. The morphologic images were graded for the presence and severity of fat pad scarring and clinical outcomes. T2 values were calculated in the total fat pad volume, a normal regions of interest (ROI), and an abnormal ROI. T2 values were shortened in the total IPFP volume (p = 0.001) and within abnormal regions (p = 0.003) in subjects with more severe IPFP scarring. The difference between T2 values in normal-abnormal regions was greater in subjects with severe versus no scarring (+1426.1%, p = 0.008). T2 values were elevated in patients with MRI findings of osteolysis (+32.3%, p = 0.02). These findings indicate that MAVRIC-based T2 Mapping may be used as a quantitative biomarker of postoperative IPFP scarring in individuals following TKA.

Articular cartilage thickness changes differ between males and females 4 years following anterior cruciate ligament reconstruction.

Anterior cruciate ligament injury and reconstruction (ACLR) affects articular cartilage thickness profiles about the tibial, femoral, and patellar surfaces; however, it's unclear whether the magnitudes of change in cartilage thickness, as well as the locations and areas over which these changes occur, differ between males and females. This is important to consider as differences exist between the sexes with regard to knee biomechanics, patellofemoral pain, and anatomic alignment, which influence risk of an index and repeated injury. Subjects underwent ACLR with a bone-patella tendon-bone autograft. At 4-year follow-up, they had asymptomatic knees; however, significant ACL injured-to-contralateral normal knee differences in articular cartilage thickness values were observed. Both thickening and thinning of cartilage occurred about the tibiofemoral and patellofemoral joints, relative to matched control subjects with normal knees. Further, the location of the areas and magnitudes of thickening and thinning were different between females and males. Thickening (swelling) of articular cartilage is an early finding associated with the onset of posttraumatic osteoarthritis (PTOA). Therefore, the increases in cartilage thickness that were observed in this cohort may represent early signs of the onset of PTOA that occur prior to the patient developing symptoms and radiographic evidence of this disease. The different locations of areas that underwent a change in cartilage thicknesses between males and females suggest that each sex responds differently to knee ligament trauma, reconstruction, rehabilitation, and return to activity, and indicates that sex-specific analysis should be utilized in studies of PTOA.

Improvement of peripheral nerve visualization using a deep learning-based MR reconstruction algorithm.

OBJECTIVE: To assess a new deep learning-based MR reconstruction method, "DLRecon," for clinical evaluation of peripheral nerves. METHODS: Sixty peripheral nerves were prospectively evaluated in 29 patients (mean age: 49 ± 16 years, 17 female) undergoing standard-of-care (SOC) MR neurography for clinically suspected neuropathy. SOC-MRIs and DLRecon-MRIs were obtained through conventional and DLRecon reconstruction methods, respectively. Two radiologists randomly evaluated blinded images for outer epineurium conspicuity, fascicular architecture visualization, pulsation artifact, ghosting artifact, and bulk motion. RESULTS: DLRecon-MRIs were likely to score better than SOC-MRIs for outer epineurium conspicuity (OR = 1.9, p = 0.007) and visualization of fascicular architecture (OR = 1.8, p < 0.001) and were likely to score worse for ghosting (OR = 2.8, p = 0.004) and pulsation artifacts (OR = 1.6, p = 0.004). There was substantial to almost-perfect inter-reconstruction method agreement (AC = 0.73-1.00) and fair to almost-perfect interrater agreement (AC = 0.34-0.86) for all features evaluated. DLRecon-MRI had improved interrater agreement for outer epineurium conspicuity (AC = 0.71, substantial agreement) compared to SOC-MRIs (AC = 0.34, fair agreement). In >80% of images, the radiologist correctly identified an image as SOC- or DLRecon-MRI. DISCUSSION: Outer epineurium and fascicular architecture conspicuity, two key morphological features critical to evaluating a nerve injury, were improved in DLRecon-MRIs compared to SOC-MRIs. Although pulsation and ghosting artifacts increased in DLRecon images, image interpretation was unaffected.

Quantitative T2 -mapping magnetic resonance imaging for assessment of muscle motor unit recruitment patterns.

INTRODUCTION: In this study, we aimed to determine whether muscle transverse relaxation time (T2 ) magnetic resonance (MR) mapping results correlate with motor unit loss, as defined by motor unit recruitment patterns on electromyography (EMG). METHODS: EMG and 3-Tesla MRI exams were acquired no more than 31 days apart in subjects referred for peripheral nerve MRI. Two musculoskeletal radiologists qualitatively graded T2 -weighted, fat-suppressed sequences for severity of muscle edema-like patterns and manually placed regions of interest within muscles to obtain T2 values from T2 -mapping sequences. Concordance was calculated between qualitative and quantitative MR grades and EMG recruitment categories (none, discrete, decreased) as well as interobserver agreement for both MR grades. RESULTS: Thirty-four muscles (21 abnormal, 13 control) were assessed in 13 subjects (5 females and 8 males; mean age, 46 years) with 14 EMG-MRI pairs. T2 -relaxation times were significantly (P < .001) increased in all EMG recruitment categories compared with control muscles. T2 differences were not significant between EMG grades of motor unit recruitment (P = .151-.702). T2 and EMG score concordance was acceptable (Harrell's concordance index [c index]: rater A, 0.71; 95% confidence interval [CI], 0.51-0.87; rater B, 0.77; 95% CI, 0.57-0.91). Qualitative MRI and EMG score concordance was poor to acceptable (c index: rater A, 0.60; 95% CI, 0.50-0.79; rater B, 0.72; 95% CI, 0.55-0.89). T2 values had moderate-to-substantial ability to distinguish between absent vs incomplete (ie, decreased or discrete) motor unit recruitment (c index: rater A, 0.78; 95% CI, 0.50-1.00; rater B, 0.86; 95% CI, 0.57-1.00). DISCUSSION: Quantitative T2 MR muscle mapping is a promising tool for noninvasive evaluation of the degree of motor unit recruitment loss.

Combined Injury to the ACL and Lateral Meniscus Alters the Geometry of Articular Cartilage and Meniscus Soon After Initial Trauma.

Combined injury to the anterior cruciate ligament (ACL) and meniscus is associated with earlier onset and increased rates of post-traumatic osteoarthritis compared with isolated ACL injury. However, little is known about the initial changes in joint structure associated with these different types of trauma. We hypothesized that trauma to the ACL and lateral meniscus has an immediate effect on morphometry of the articular cartilage and meniscus about the entire tibial plateau that is more pronounced than an ACL tear without meniscus injury. Subjects underwent magnetic resonance imaging scanning soon after injury and prior to surgery. Those that suffered injury to the ACL and lateral meniscus underwent changes in the lateral compartment (increases in the posterior-inferior directed slopes of the articular cartilage surface, and the wedge angle of the posterior horn of the meniscus) and medial compartment (the cartilage-to-bone height decreased in the region located under the posterior horn of the meniscus, and the thickness of cartilage increased and decreased in the mid and posterior regions of the plateau, respectively). Subjects that suffered an isolated ACL tear did not undergo the same magnitude of change to these articular structures. A majority of the changes in morphometry occurred in the lateral compartment of the knee; however, change in the medial compartment of the knee with a normal appearing meniscus also occurred. Statement of clinical significance: Knee injuries that involve combined trauma to the ACL and meniscus directly affect both compartments of the knee, even if the meniscus and articular cartilage appears normal upon arthroscopic examination. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:759-767, 2020.

MRI of Hip Arthroplasties: Comparison of Isotropic Multiacquisition Variable-Resonance Image Combination Selective (MAVRIC SL) Acquisitions With a Conventional MAVRIC SL Acquisition.

OBJECTIVE. The objective of our study was to compare the quality and diagnostic utility of the following three metal artifact reduction sequences in evaluating hip arthroplasties: conventional multiacquisition variable-resonance image combination selective (MAVRIC SL), isotropic MAVRIC SL, and reduced-TR isotropic MAVRIC SL. SUBJECTS AND METHODS. Ninety-three hip arthroplasties (85 total hip replacements and eight hip resurfacings [nine bilateral hips]) in 84 patients (38 men and 46 women; mean age ± SD, 69.1 ± 9.7 years old) were imaged and evaluated. A calibration scan determined the number of spectral bins needed for each implant, and isotropic and conventional MAVRIC SL images were acquired. Reduced-TR isotropic MAVRIC SL scans were acquired for 40 arthroplasties. Two board-certified radiologists blinded to MRI acquisition evaluated images for clinical and image quality features and compared images using a mixed-effects ordinal logistic regression model and odds ratios. Rater agreement was assessed with Gwet agreement coefficients. Scanning times were compared using mixed-effects linear regression. Significance was set at p < 0.05. RESULTS. Calibration scans decreased the number of bins needed (median, 12 bins; interquartile range, 10-16 bins). Isotropic MAVRIC SL (mean scanning time, 7 minutes 16 seconds; 95% CI, 7 minutes 7 seconds-7 minutes 25 seconds) acquisitions had the longest scanning time, and conventional (mean, 5 minutes 46 seconds; 95% CI, 5 minutes 37 seconds-5 minutes 55 seconds) and reduced-TR isotropic (5 minutes 28 seconds; 95% CI, 5 minutes 15 seconds-5 minutes 41 seconds) MAVRIC SL acquisitions had scanning times that were similar. Both isotropic and reduced-TR isotropic MAVRIC SL images showed decreased blurring and improved visualization of the synovium and periprosthetic bone compared with conventional MAVRIC SL images (p < 0.001). Isotropic MAVRIC SL acquisitions more effectively improved signal-to-noise ratio (SNR), visualization of the synovium and periprosthetic bone, and lesion conspicuity and decreased blurring compared with reduced-TR isotropic MAVRIC SL acquisitions (p < 0.032). CONCLUSION. Isotropic MAVRIC SL acquisitions improve SNR, conspicuity of lesions, and visualization of synovium and periprosthetic bone and decrease blurring compared with conventional MAVRIC SL acquisitions.

Magnetic Resonance Imaging of Articular Cartilage within the Knee.

Magnetic resonance imaging (MRI) provides an effective and noninvasive means by which to evaluate articular cartilage within the knee. Existing techniques can be utilized to detect and monitor longitudinal changes in cartilage status due to injury or progression of degenerative disease. Quantitative MRI (qMRI) techniques can provide a metric by which to evaluate the efficacy of cartilage repair techniques and offer insight into the composition of cartilage and cartilage repair tissue. In this review, we provide background on MR signal generation and decay, the utility of morphologic MRI assessment, and qMRI techniques for the biochemical assessment of cartilage (dGEMRIC, T2, T2*, T1ρ, sodium, gagCEST). Finally, the description and utility of these qMRI techniques for the evaluation of cartilage repair are discussed.

Diagnostic Accuracy of Zero-Echo Time MRI for the Evaluation of Cervical Neural Foraminal Stenosis.

STUDY DESIGN: A cohort study. OBJECTIVE: The aim of this study was to evaluate the clinical utility of Zero-Echo-Time (ZTE) magnetic resonance imaging (MRI) for the assessment of cervical neural foraminal stenosis (CNFS) through the comparison of inter-modality [computed tomography (CT) and ZTE-MRI] CNFS grade severity agreements. SUMMARY OF BACKGROUND DATA: Conventional MRI limited in its ability to provide direct visualization of cortical bone. The highly organized tissue structure of cortical bone results in very short T2 values that preclude acquisition of sufficient signal intensity and positive image contrast. ZTE imaging permits visualization of tissues with very short transverse relaxation times, and is capable of displaying images with CT-like contrast. METHODS: Thirty-four subjects were recruited from a clinical cohort of patients undergoing standard of care MRI and CT imaging for evaluation of CNFS. Standard of care CT imaging studies were obtained on all subjects within 6 months of their ZTE-MRI acquisition (mean time interval: 25.3 ±â€Š54.1 days; median: 0 days). ZTE-MRI and CT imaging studies were evaluated and severity of CNFS was graded on a scale from 0 to 5 (0 = none; 5 = severe). Weighted-kappa statistics were used to assess agreement between ZTE and CT grades of CNFS on both sides (right and left) of each motion segment. Ordinal logistic mixed-effects regression analyses evaluated the effects of inter-modality position differences (flexion-extension curvature) on inter-modality differences in CNFS grade. RESULTS: Substantial agreement (κ = 0.72) was found between ZTE- and CT-based grades of CNFS. Significant inter-modality differences in cervical spine curvature were found for all motion segments, except C2-3 and C3-4 (P < 0.05). However, no significant relationship was found between inter-modality differences in curvature, and inter-modality differences in CNFS grade for any motion segment (P = 0.28). CONCLUSION: Results of the current study suggest that ZTE-MRI is well-suited for the evaluation of CNFS and may have the potential to obviate the need for concurrent CT scans in some cases. LEVEL OF EVIDENCE: 2.

Geometric Characteristics of the Knee Are Associated With a Noncontact ACL Injury to the Contralateral Knee After Unilateral ACL Injury in Young Female Athletes.

BACKGROUND: Contralateral anterior cruciate ligament (CACL) injury after recovery from a first-time ACL rupture occurs at a high rate in young females; however, little is known about the risk factors associated with bilateral ACL trauma. HYPOTHESIS: The geometric characteristics of the contralateral knee at the time of the initial ACL injury are associated with risk of suffering a CACL injury in these female athletes. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Sixty-two female athletes who suffered their first noncontact ACL injury while participating in sports at the high school or college level were identified, and geometry of the femoral notch, ACL, tibial spines, tibial subchondral bone, articular cartilage surfaces, and menisci of the contralateral, uninjured, knee was characterized in 3 dimensions. We were unable to contact 7 subjects and followed the remaining 55 until either a CACL injury or an ACL graft injury occurred or, if they were not injured, until the date of last contact (mean, 34 months after their first ACL injury). Cox regression was used to identify risk factors for CACL injury. RESULTS: Ten (18.2%) females suffered a CACL injury. Decreases of 1 SD in femoral intercondylar notch width (measured at its outlet and anterior attachment of the ACL) were associated with increases in the risk of suffering a CACL injury (hazard ratio = 1.88 and 2.05, respectively). Likewise, 1 SD decreases in medial-lateral width of the lateral tibial spine, height of the medial tibial spine, and thickness of the articular cartilage located at the posterior region of the medial tibial compartment were associated with 3.59-, 1.75-, and 2.15-fold increases in the risk of CACL injury, respectively. CONCLUSION: After ACL injury, subsequent injury to the CACL is influenced by geometry of the structures that surround the ACL (the femoral notch and tibial spines). This information can be used to identify individuals at increased risk for CACL trauma, who might benefit from targeted risk-reduction interventions.

Relationship between geometry of the extensor mechanism of the knee and risk of anterior cruciate ligament injury.

The complex inter-segmental forces that are developed across an extended knee by body weight and contraction of the quadriceps muscle group transmits an anteriorly directed force on the tibia that strain the anterior cruciate ligament (ACL). We hypothesized that a relationship exists between geometry of the knees extensor mechanism and the risk of sustaining a non-contact ACL injury. Geometry of the extensor mechanism was characterized using MRI scans of the knees of 88 subjects that suffered their first non-contact ACL injury and 88 matched control subjects with normal knees that were on the same team. The orientation of the patellar tendon axis was measured relative to the femoral flexion-extension axis to determine the extensor moment arm (EMA), and relative to tibial long axis to measure coronal patellar tendon angle (CPTA) and sagittal patellar tendon angle (SPTA). Associations between these parameters and ACL injury risk were tested with and without adjustment for flexion and internal rotation position of the tibia relative to the femur during MRI data acquisition. After adjustment for internal rotation position of the tibia relative to the femur there were no associations between EMA, CPTA, and SPTA and risk of suffering an ACL injury. However, increased internal rotation position of the tibia relative to the femur was significantly associated with increased risk of ACL injury in female athletes both in univariate analysis (Odds Ratio = 1.16 per degree of internal rotation of the tibia, p = 0.002), as well as after adjustment for EMA, CPTA, and SPTA.: © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:965-973, 2017.

Geometric Risk Factors Associated With Noncontact Anterior Cruciate Ligament Graft Rupture.

BACKGROUND: Anterior cruciate ligament (ACL) graft rupture occurs at a high rate, especially in young athletes. The geometries of the tibial plateau and femoral intercondylar notch are risk factors for first-time ACL injury; however, little is known about the relationship between these geometries and risk of ACL graft rupture. HYPOTHESIS: The geometric risk factors for noncontact graft rupture are similar to those previously identified for first-time noncontact ACL injury, and sex-specific differences exist. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Eleven subjects who suffered a noncontact ACL graft rupture and 44 subjects who underwent ACL reconstruction but did not experience graft rupture were included in the study. Using magnetic resonance imaging, the geometries of the tibial plateau subchondral bone, articular cartilage, meniscus, tibial spines, and femoral notch were measured. Risk factors associated with ACL graft rupture were identified using Cox regression. RESULTS: The following were associated with increased risk of ACL graft injury in males: increased posterior-inferior-directed slope of the articular cartilage in the lateral tibial plateau measured at 2 locations (hazard ratio [HR] = 1.50, P = .029; HR = 1.39, P = .006), increased volume (HR = 1.45, P = .01) and anteroposterior length (HR = 1.34, P = .0023) of the medial tibial spine, and increased length (HR = 1.18, P = .0005) and mediolateral width (HR = 2.19, P = .0004) of the lateral tibial spine. In females, the following were associated with increased risk of injury: decreased volume (HR = 0.45, P = .02) and height (HR = 0.46, P = .02) of the medial tibial spine, decreased slope of the lateral tibial subchondral bone (HR = 0.72, P = .01), decreased height of the posterior horn of the medial meniscus (HR = 0.09, P = .001), and decreased intercondylar notch width at the anterior attachment of the ACL (HR = 0.72, P = .02). CONCLUSION: The geometric risk factors for ACL graft rupture are different for males and females. For females, a decreased femoral intercondylar notch width and a decreased height of the posterior medial meniscus were risk factors for ACL graft rupture that have also been found to be risk factors for first-time injury. There were no risk factors in common between ACL graft injury and first-time ACL injury for males.

A decreased volume of the medial tibial spine is associated with an increased risk of suffering an anterior cruciate ligament injury for males but not females.

Measurements of tibial plateau subchondral bone and articular cartilage slope have been associated with the risk of suffering anterior cruciate ligament (ACL) injury. Such single-plane measures of the tibial plateau may not sufficiently characterize its complex, three-dimensional geometry and how it relates to knee injury. Further, the tibial spines have not been studied in association with the risk of suffering a non-contact ACL injury. We questioned whether the geometries of the tibial spines are associated with non-contact ACL injury risk, and if this relationship is different for males and females. Bilateral MRI scans were acquired on 88 ACL-injured subjects and 88 control subjects matched for sex, age and sports team. Medial and lateral tibial spine geometries were characterized with measurements of length, width, height, volume and anteroposterior location. Analyses of females revealed no associations between tibial spine geometry and risk of ACL injury. Analyses of males revealed that an increased medial tibial spine volume was associated with a decreased risk of ACL injury (OR = 0.667 per 100 mm(3) increase). Smaller medial spines could provide less resistance to internal rotation and medial translation of the tibia relative to the femur, subsequently increasing ACL strains and risk of ACL injury.