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Aim and objectives: In forensic age estimation e.g. for judicial proceedings surpassed age thresholds can be legally relevant. To examine age related differences in skeletal development the recommendations by the Study Group on Forensic Age Diagnostics (AGFAD) are based on ionizing radiation (among others orthopantomograms, plain x-rays of the hand). Vieth et al. and Ottow et al. proposed MRI-classifications for the epiphyseal-diaphyseal fusion of the knee joint to define different age groups in healthy volunteers. The aim of the present study was to directly compare these two classifications in a large German patient population. Materials and methods: MRI of the knee joint of 900 patients (405 female, 495 male) from 10 to 28 years of age were retrospectively analyzed. Acquired T1-weighted turbo spin-echo sequence (TSE) and T2-weighted sequence with fat suppression by turbo inversion recovery magnitude (TIRM) were analyzed for the two classifications. The different bony fusion stages of the two classifications were determined and the corresponding chronological ages assigned. Differences between the sexes were analyzed. Intra- and inter-observer agreements were determined using Cohen's kappa. Results: With the classification of Ottow et al. it was possible to determine completion of the 18th and 21st year of life in both sexes. With the classification of Vieth et al. completion of the 18th year of life for female patients and the 14th and 21st year of life in both sexes could be determined. The intra- and inter-observer agreement levels were very good (κ > 0.82). Conclusion: In the large German patient cohort of this study it was possible to determine the 18th year of life with for both sexes with the classification of Ottow et al. and for female patients with the classification of Vieth et al. It was also possible to determine the 21st year of life for all bones with the classification of Ottow et al. and for the distal femur with the classification of Vieth et al. [ABSTRACT FROM AUTHOR]

Introduction: The Wrisberg variant of the discoid lateral meniscus is a very rare disorder and is characterized by the hypermobility and instability of the meniscus caused by the absence of its posterior tibial attachment, with only its meniscofemoral junction (Wrisberg's ligament) maintained, and inserted in the posterior horn of the meniscus. As a result, the posterior horn of the lateral meniscus is mobile; often subluxing into the joint. Materials and methods: A total of eight skeletally immature patients with symptomatic Wrisberg variant of the discoid lateral meniscus were included in this study. Each knee was evaluated with MRI and arthroscopy. We graded unstable discoid menisci according to their discoid morphology (complete vs. incomplete), meniscal intra-substance degeneration, and the presence or absence of meniscal tears. All eight menisci were evaluated as degenerated with no meniscal tears. Five of them were evaluated as complete. Due to the severely degenerated meniscus, we considered it unnecessary to repair the detached posterior tibial ligament, so we performed a reshaping of the discoid meniscus, restoring a C-shape, excising the hypertrophied central part of the meniscus, and creating a posterior horn with a remaining rim of 6–8 mm. For evaluation of the knee function preoperatively and postoperatively we used the online International Knee Documentation Committee (IKDC) system. The purpose of this study is to emphasize the importance of MRI in identifying and revealing the unstable (Wrisberg variant) type of discoid meniscus in children. Results: The mean patient age at the time of surgery was 8.25 ± 2.91 years (range 5–13 years). The average follow-up was 3.75 ± 0.46 years (range 3–4) years. The mean preoperative IKDC score was 22.37 ± 1.50 (range 21–25) points. The mean postoperative IKDC score was 80.50 ± 1.77 (range 79–84) points. Conclusions: MRI is a valuable tool in the evaluation of the shape, stability, and consistency of symptomatic discoid menisci. It is helpful for the detection of the unstable Wrisberg variant. [ABSTRACT FROM AUTHOR]

Purpose: The outcome of a tibial plateau fracture (TPF) depends on the fracture reduction achieved and the extent of soft-tissue lesions, including lesions in the ligaments, cartilage, and menisci. Sub-optimal treatment can result in poor knee function and osteoarthritis. Preoperative planning is primarily based on conventional X-ray and computed tomography (CT), which are unsuitable for diagnosing soft-tissue lesions. Magnetic resonance imaging (MRI) is not routinely performed. To date, no literature exists that clearly states the indications for preoperative MRI. This systematic review aimed to determine the frequency of soft-tissue lesions in TPFs, the association between fracture type and soft-tissue lesions, and the types of cases for which MRI is indicated. Methods: A systematic review of the literature was based on articles located in PubMed/MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL), supplemented by searching the included articles' reference lists and the ePublication lists of leading orthopedic and trauma journals. Results: A total of 1138 studies were retrieved. Of these, 18 met the eligibility criteria and included a total of 877 patients. The proportion of total soft-tissue lesions was 93.0%. The proportions of soft-tissue lesions were as follows: medial collateral ligament 20.7%, lateral collateral ligament 22.9%, anterior cruciate ligament 36.8%, posterior cruciate ligament 14.8%, lateral meniscus 48.9%, and medial meniscus 24.5%. A weak association was found between increasing frequency of LCL and ACL lesions and an increase in fracture type according to Schatzker's classification. No standard algorithm for MRI scans of TPFs was found. Conclusion: At least one ligament or meniscal lesion is present in 93.0% of TPF cases. More studies with higher levels of evidence are needed to find out in which particular cases MRI adds value. However, MRI is recommended, at least in young patients and cases of high-energy trauma. [ABSTRACT FROM AUTHOR]

Purpose: Many children who undergo MR of the knee to evaluate traumatic injury may not undergo a separate dedicated evaluation of their skeletal maturity, and we wished to investigate how accurately skeletal maturity could be automatically inferred from knee MRI using deep learning to offer this additional information to clinicians.Materials and Methods: Retrospective data from 894 studies from 783 patients were obtained (mean age 13.1 years, 47% female). Coronal and sagittal sequences that were T1/PD-weighted were included and resized to 224 × 224 pixels. Data were divided into train (n = 673), tune (n = 48), and test (n = 173) sets, and children were separated across sets. The chronologic age was predicted using deep learning approaches based on a long short-term memory (LSTM) model, which took as input DenseNet-121-extracted features from all T1/PD coronal and sagittal slices. Each test case was manually assigned a bone age by two radiology residents using a reference atlas provided by Pennock and Bomar. The patient's age served as ground truth.Results: The error of the model's predictions for chronological age was not significantly different from that of radiology residents (model M.S.E. 1.30 vs. resident 0.99, paired t-test = 1.47, p = 0.14). Pearson correlation between model and resident prediction of chronologic age was 0.96 (p < 0.001).Conclusion: A deep learning-based approach demonstrated ability to infer skeletal maturity from knee MR sequences that was not significantly different from resident performance and did so in less than 2% of the time required by a human expert. This may offer a method for automatically evaluating lower extremity skeletal maturity automatically as part of every MR examination. [ABSTRACT FROM AUTHOR]

Objective: To assess the accuracy of routine knee MRI in detecting acute popliteal artery and/or common peroneal nerve (CPN) dysfunction following multiligamentous knee injury (MLKI), with correlation of MRI findings to clinical outcome. Materials and methods: Routine MRI knee examinations in 115 MLKI patients (54/115 with acute neurovascular injury, 61/115 without neurovascular injury) were retrospectively reviewed. Cases were classified by injury mechanism and ligamentous injuries sustained. MRI examinations were reviewed by two readers for vascular (arterial flow void, arterial calibre, intimal flap, perivascular hematoma) and CPN (intraneural T2-hyperintensity, calibre, discontinuity, perineural hematoma) injuries. Accuracy of routine knee MRI in the diagnosis of acute neurovascular injury and correlation of MRI findings to clinical outcome were evaluated. Results: Patients included 86/115 males, mean age 33 years. The accuracy of MRI in diagnosis of acute CPN injury was 80.6%, 83.6% (readers 1 and 2): sensitivity (78%, 79.7%), specificity (80%, 86.7%), PPV (78%, 82.5%), and NPV (82.7%, 84.4%). Increased intraneural T2 signal showed a significant correlation to acute CPN dysfunction (p < 0.05). MRI was 75%, 69.8% (readers 1 and 2) accurate in detecting acute vascular injury: sensitivity (73.3%, 86.7%), specificity (75.2%, 67.3%), PPV (30.5%, 36.1%), and NPV (95%, 97.1%). No MRI features of vascular injury showed a statistical correlation with clinical outcome. Neurovascular complications were more common in ultra-low-energy injuries and KD-V3L pattern of ligament disruption. Conclusion: Routine MRI is of limited accuracy in assessing vascular complication, but higher accuracy in assessing CPN injury following MLKI. Increased intraneural T2 signal on conventional knee MR imaging shows statistically significant association with clinically documented acute CPN dysfunction following MLKI. [ABSTRACT FROM AUTHOR]

Purpose: The medical examination ("medical") is an important procedure in professional soccer since it has high economic relevance. In addition to clinical tests, magnetic resonance imaging (MRI) is used to assess joint health. In the present study, the reliability of semiquantitative knee MRI during the "medical" in professional soccer was tested, and its relationship with clinical data and days missed due to knee injury was observed. Methods: In this cross-sectional study, between 2012 and 2019, 69 newly assigned players (age 18–35 years) from a professional soccer club underwent MRI (3.0 T) of both knee joints during their "medical". Reported knee injuries and previously missed days due to injury were obtained from player anamnesis and the "transfermarkt.com" database. Based on the established "Whole-Organ Magnetic Resonance Imaging Score" (WORMS), two independent radiologists graded the MRI results. Further evaluation was based on the mean score of both knees. Results: The mean WORMS for all subjects was 13.9 (median 10.5, range 0–61). Players with previous injuries had significantly higher scores than players without reported injuries (22.1 ± 17.7 vs. 8.9 ± 4.4, p < 0.002). Three outliers (previously undetected injuries) in the group of players without reported injuries were observed (6.7%). The WORMS was significantly correlated with a prior knee injury (r: 0.424, p < 0.0001) and days missed due to injury (r: 0.489, p < 0.001). Age was correlated with the WORMS (r: 0.386, p < 0.001). In a linear regression model, prior injury was the only significant predictor of a high WORMS (p = 0.001). The WORMS was a significant predictor of days missed due to injury (p < 0.0002) and prior injury (sensitivity: 78%, specificity: 91%, p = 0.006). The intraclass correlation coefficient was excellent (0.89). Conclusion: Semiquantitative knee MRI for WORMS determination during the soccer "medical" is a robust and reliable method. Prior injury, even in players without documented trauma, was detected by the WORMS, and previously missed days due to injury were correlated with the semiquantitative MR knee score. Level of evidence: Level III. [ABSTRACT FROM AUTHOR]

Background: This work was conducted to assess the diagnostic efficiency of isotropic three-dimensional VISTA-fast spin echo versus standard two-dimensional fast spin echo at 1.5 T MRI, in the assessment of internal knee derangement in symptomatic patients, aiming to obtain similar diagnostic accuracy in a shorter time span, with reduction of partial volume artifacts by thin continuous sections. Results: This was a non-randomized control study including 39 patients (32 male and 7 females, mean age 37 years old). A correlative study was done utilizing MRI standard 2D FSE (protocol A) versus 3D-VISTA-FSE (protocol B) for medial meniscus (MM) and lateral meniscus (LM), as well as anterior cruciate ligament ACL lesions, comparing the MRI results with the findings of arthroscopy as the gold standard. Both protocols depicted medial meniscus lesions with accuracy, specificity, and sensitivity (97.44%, 96.30%, and 100% respectively), lateral meniscus lesions with accuracy, specificity, and sensitivity (97.44%, 100%, and 50% respectively), and ACL lesions with accuracy, specificity, and sensitivity (100%, 100%, and 100% respectively), while there were no PCL lesions depicted through the study population. Comparing the time factor between both protocols revealed protocol A to consume 13.7 min, while protocol B consumed 6.6 min. Conclusion: Three-dimensional isotropic VISTA-FSE sequence, although having similar accuracy in diagnosing cruciate and meniscal lesions as the standard sequences, facilitates thin-section data acquisition and multi-planar image reformation in standard and non-standard planes, without intersection gaps that are crucial for the detection and dissection of compound structures; also, it allows a shorter time span, which is more advantageous for patients, particularly the traumatized and emergency patients. [ABSTRACT FROM AUTHOR]

Objective: To assess the accuracy of routine knee MRI in detecting acute popliteal artery and/or common peroneal nerve (CPN) dysfunction following multiligamentous knee injury (MLKI), with correlation of MRI findings to clinical outcome. Materials and methods: Routine MRI knee examinations in 115 MLKI patients (54/115 with acute neurovascular injury, 61/115 without neurovascular injury) were retrospectively reviewed. Cases were classified by injury mechanism and ligamentous injuries sustained. MRI examinations were reviewed by two readers for vascular (arterial flow void, arterial calibre, intimal flap, perivascular hematoma) and CPN (intraneural T2-hyperintensity, calibre, discontinuity, perineural hematoma) injuries. Accuracy of routine knee MRI in the diagnosis of acute neurovascular injury and correlation of MRI findings to clinical outcome were evaluated. Results: Patients included 86/115 males, mean age 33 years. The accuracy of MRI in diagnosis of acute CPN injury was 80.6%, 83.6% (readers 1 and 2): sensitivity (78%, 79.7%), specificity (80%, 86.7%), PPV (78%, 82.5%), and NPV (82.7%, 84.4%). Increased intraneural T2 signal showed a significant correlation to acute CPN dysfunction (p < 0.05). MRI was 75%, 69.8% (readers 1 and 2) accurate in detecting acute vascular injury: sensitivity (73.3%, 86.7%), specificity (75.2%, 67.3%), PPV (30.5%, 36.1%), and NPV (95%, 97.1%). No MRI features of vascular injury showed a statistical correlation with clinical outcome. Neurovascular complications were more common in ultra-low-energy injuries and KD-V3L pattern of ligament disruption. Conclusion: Routine MRI is of limited accuracy in assessing vascular complication, but higher accuracy in assessing CPN injury following MLKI. Increased intraneural T2 signal on conventional knee MR imaging shows statistically significant association with clinically documented acute CPN dysfunction following MLKI. [ABSTRACT FROM AUTHOR]

Purpose: To compare a faster, new, high-resolution accelerated 3D-fast-spin-echo (3D-FSE) acquisition sequence (CS-SPACE) to traditional 2D and high-resolution 3D sequences for knee 3-T magnetic resonance imaging (MRI).Materials and Methods: Twenty patients received knee MRIs that included routine 2D (T1, PD ± FS, T2-FS; 0.5 × 0.5 × 3 mm3; ∼10 min), traditional 3D FSE (SPACE-PD-FS; 0.5 × 0.5 × 0.5 mm3; ∼7.5 min), and accelerated 3D-FSE prototype (CS-SPACE-PD-FS; 0.5 × 0.5 × 0.5 mm3; ∼5 min) acquisitions on a 3-T MRI system (Siemens MAGNETOM Skyra). Three musculoskeletal radiologists (MSKRs) prospectively and independently reviewed the studies with graded surveys comparing image and diagnostic quality. Tissue-specific signal-to-noise ratios (SNR) and contrast-to-noise ratios (CNR) were also compared.Results: MSKR-perceived diagnostic quality of cartilage was significantly higher for CS-SPACE than for SPACE and 2D sequences (p < 0.001). Assessment of diagnostic quality of menisci and synovial fluid was higher for CS-SPACE than for SPACE (p < 0.001). CS-SPACE was not significantly different from SPACE but had lower assessments than 2D sequences for evaluation of bones, ligaments, muscles, and fat (p ≤ 0.004). 3D sequences had higher spatial resolution, but lower overall assessed contrast (p < 0.001). Overall image quality from CS-SPACE was assessed as higher than SPACE (p = 0.007), but lower than 2D sequences (p < 0.001). Compared to SPACE, CS-SPACE had higher fluid SNR and CNR against all other tissues (all p < 0.001).Conclusions: The CS-SPACE prototype allows for faster isotropic acquisitions of knee MRIs over currently used protocols. High fluid-to-cartilage CNR and higher spatial resolution over routine 2D sequences may present a valuable role for CS-SPACE in the evaluation of cartilage and menisci. [ABSTRACT FROM AUTHOR]

Purpose: The medial patellofemoral ligament (MPFLL)/lateral patellar retinaculum (LPR) ratio were assessed in knees as a means to detect patellar malalignment. We also aimed to evaluate the prevalence of the various types of trochlear dysplasia in patients with patellar malalignment. Materials and methods: After approval of our institutional ethics committee, we conducted a retrospective study that included 450 consecutive patients to evaluate them for the presence of patellar malalignment. Parameters investigated were the trochlear type, sulcus angle, presence of a supratrochlear spur, MPFLL, LPR, patella alta, and patella baja by means of 1.5T magnetic resonance imaging (MRI). Overall, 133 patients were excluded because of the presence of major trauma, multiple ligament injuries, bipartite patella, and/or previous knee surgery. The Dejour classification was used to assess trochlear dysplasia. Two experienced radiologists (HKY, EEE) evaluated the images. Their concordance was assessed using the kappa (κ) test. Results: The frequencies of patellar malalignment and trochlear dysplasia were 34.7 and 63.7 %, respectively. The frequency of trochlear dysplasia associated with patellar malalignment was 97.2 %. An MPFLL/LPR ratio of 1.033-1.041 had high sensitivity and specificity for malalignment. The researchers' concordance was good (κ = 0.89, SE = 0.034, P < 0.001). Conclusion: Trochlear dysplasia is frequently associated with patellar malalignment. An increased MPFLL/LPR ratio is useful for detecting patellar malalignment on knee MRI, which is a novel quantitative method based on ligament length. [ABSTRACT FROM AUTHOR]

Objectives: Many studies show that a large portion of medical prescriptions for diagnostic examinations may be not useful for patient's management or unnecessary. Rapid technological advancement has made it possible for magnetic resonance imaging (MRI) to be increasingly used all over the world, particularly for musculoskeletal disorders. The aim of this study was to assess the appropriateness of the knee MRI prescriptions. Materials and methods: A panel of experts found standard clinical practice guidelines in the management of knee disorders. Secondly, the finalized set of guidelines chosen was compared with the data of 400 patients who underwent previous knee MRIs, which were then reported in a specific questionnaire prepared by the authors. The rate of appropriateness of knee MRI prescriptions was then calculated. Results: Almost 21 % of prescriptions were totally inappropriate, 18.8 % were uncertain, and 60.2 % could be considered totally appropriate. The most frequent prescription indication was for meniscal disorders that account for 26.8 % of the total indications. Conclusions: Our results demonstrate that approximately 40 % of the total prescriptions were totally inappropriate or uncertain and that most of these were made by general practitioners. In light of these results, the economic impact of inappropriate prescriptions on the Italian healthcare system has to be seriously considered. [ABSTRACT FROM AUTHOR]

Purpose To investigate the accuracy of MRI in assessment of sports related knee injuries. Materials and methods From August 2012 to March 2013 thirty patients referred for sports related knee pain have been included in this study. Patients were subjected to a dedicated MR knee study and correlated knee arthroscopy and surgery. Results The study included thirty patients complaining of sports related knee pain, only 5 patients (16.6%) were with normal MRI findings and 25 patients (83.4%) were with abnormal MRI findings. Among the 25 patients who had injuries of their knees, 15 patients (60%) had ACL injuries, 2 patients (8%) had PCL injuries, 10 patients (40%) had meniscal injuries, 8 patients (32%) had collateral ligament injuries, 5 patients (20%) had bone injuries and 2 patients (8%) had muscular injuries. Only 7 patients (28%) were represented with isolated injury and 18 patients (72%) were represented with combined injuries. In correlation with arthroscopies and surgeries, morphological analysis was true-positive in 23 (92%) patients of the 25 injured patients, and true-negative in 3 (60%) patients of the 5 normal patients. Morphological analysis revealed overall 92% sensitivity and 60% specificity. Regarding the 15 patients who had ACL injuries, 13 patients (86.6%) were true-positive and 8 patients (80%) of the 10 patients who had meniscal injuries were true-positive. Conclusion MRI represents the optimal imaging tool in the evaluation of the sports related knee injuries, which has been shown to be an accurate and non invasive method of diagnosing ligament, meniscal, cartilage and muscular knee injuries. [ABSTRACT FROM AUTHOR]

Purpose: To compare magnetic resonance (MR) signal intensity in the medial meniscus at the time of displacement and after its reduction in patients with a displaced bucket-handle tear of the meniscus associated with anterior cruciate ligament (ACL) injury. Methods: Nine chronic ACL-deficient patients (3 male, 6 female, mean age 29 years) with locking due to a displaced fragment of the medial meniscus following a bucket-handle tear were involved in this study. In all patients, the following two-stage surgeries were planned as follows: first operation, arthroscopic reduction of the meniscus; second operation, meniscal repair and ACL reconstruction after immobilization for 1-2 weeks. Magnetic resonance imaging (MRI) evaluation using coronal T2*-weighted images was performed when the knee was locked and after the meniscus was reduced. Signal intensity before and after meniscal reduction was compared in the same patients. Results: In 8 of the 9 patients, the displaced fragment exhibited high signal intensity in 1 patient and mildly high in 7 patients. After its reduction, the signal intensity changed to low in all 8 patients. Conclusions: A high-intensity signal in the displaced fragment of the medial meniscus may change to low after its reduction to its original position. Therefore, at the time of decision-making regarding meniscus repair for a displaced meniscus in a locked knee, surgeons should give priority to arthroscopic findings rather than to signal intensity on MRI. Level of evidence: Diagnostic study, Level III. [ABSTRACT FROM AUTHOR]

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Objective: Although the popliteomeniscal fascicles are important stabilizers of the lateral meniscus, there have been few studies of their MR appearance. We wished to determine: (1) whether the fascicles are normally seen on MR imaging, and (2) whether certain imaging factors influenced their visualization.Design and Patients: We reviewed the sagittal MR images of 66 consecutive patients who had no evidence of injury to the lateral compartment. We determined the frequencies of MR visualization of the superior and inferior popliteomeniscal fascicles, and whether visualization was affected by the weighting of spin echo sequences, the presence of a joint effusion, slice placement relative to the fascicles, and windowing of the images.Results and Conclusions: Both popliteomeniscal fascicles were seen in 64 of the 66 patients. The fascicles were better seen on T2-weighted images than on proton-density weighted images (P<0.01). On the T2-weighted images, fascicle visualization was not significantly affected by the presence or absence of an effusion, slice placement or image windowing (P=0.2 to 1.0). On proton-density weighted images, fascicle visualization was significantly improved when high-contrast windowing was used (P=0.04). In conclusion, we found that the popliteomeniscal fascicles are normally seen on MR imaging of the knee when there are no lateral compartment injuries. The fascicles are significantly better visualized on T2-weighted than on proton-density weighted images. Visualization is not significantly affected by the presence of an effusion or slice placement. [ABSTRACT FROM AUTHOR]

In order to evaluate the normal amount of intra-articular fluid on knee MRI, we examined 36 knees of 18 normal volunteers on a 1.5-T MR system. Sagittal spin-echo T2-weighted images were obtained. We measured the maximum thickness and length of fluid seen in the suprapatellar pouch and in the posterior recesses of the joint. We also looked for fluid in other areas of the knee. The maximum thickness of fluid seen in the suprapatellar pouch was between 0 and 5 mm in all but three cases, where it reached 6, 8 and 9 mm. The maximal thickness of fluid seen in the posterior recesses of the joint was between 0 and 5 mm in all but two cases where it was 6 and 7 mm. The maximum lengths of fluid in the suprapatellar pouch and posterior recesses were much more variable than thickness and appear of less interest in establishing normal limits. We conclude that the best and easiest way to quantify fluid in the knee joint is to measure its maximum thickness in the suprapatellar pouch and in the posterior recesses. Normal values in these two areas is generally between 0 and 5 mm; in rare cases, it can be between 6 and 9 mm. When the maximum thickness in one of these two areas reach 10 mm or more, a pathological joint effusion should be suspected. [ABSTRACT FROM AUTHOR]