|Year : 2013 | Volume
| Issue : 1 | Page : 22-26
Clinico-radiological correlation in the diagnosis of ligament and meniscus injuries at knee joint: A prospective study
Kamini Gupta1, Munish Guleria2, Parambir Sandhu3, Ritu Galhotra3, Amit Goyal3
1 Department of Cardiac Radiology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
3 Department of Radiodiagnosis, Dayanand Medical College and Hospital, Ludhiana, India
|Date of Web Publication||28-May-2013|
Department of Radiodiagnosis, Dayanand Medical College and Hospital, Ludhiana - 141 001, Punjab
Source of Support: None, Conflict of Interest: None
Purpose: The purpose of this study was to determine the MRI appearances and various patterns of ligament and meniscus tears in knee joint injuries and to correlate the clinical findings with MRI findings. Materials and Methods: Our study included 50 patients, who were referred to radiology department for MRI of knee joint following injury. Prior to MRI, a detailed clinical and local examination was done in all the subjects. MRI was carried out on MAGNETOM Avanto 18 Channel 1.5 Tesla Machine by Siemens India Ltd and the standard protocol consisted of PD(TE 45 TR 2800), T2W(TE 73 TR 5090), fat suppressed T2W(TE 26 TR 5000) spin echo sequences in axial, sagittal and coronal planes. The MRI findings were compared with arthroscopic findings in 30 subjects and in rest of the subjects characteristic MRI features were considered diagnostic. Results: Diagnostic accuracy of clinical examination (83%) was relatively low as compared to MR examination (88%) in our study. The percentage correlation between clinical and MRI findings regarding presence or absence of ligament/meniscus tear was highest in case of PCL tears (94%). Amongst ligament injuries, complete tear of ACL alone was the most common injury (53%) and ACL injury was most commonly associated with MM injury (16%), intrasubstance tears were more common than attachment site tears. Conclusions: MR is unique in its ability to evaluate the architecture as well as the surface of ligaments and menisci. MRI is more sensitive than clinical examination in diagnosing ligament and meniscus injuries.
Keywords: Collateral ligament, cruciate ligament, magnetic resonance imaging, meniscus, tear
|How to cite this article:|
Gupta K, Guleria M, Sandhu P, Galhotra R, Goyal A. Clinico-radiological correlation in the diagnosis of ligament and meniscus injuries at knee joint: A prospective study. Saudi J Sports Med 2013;13:22-6
|How to cite this URL:|
Gupta K, Guleria M, Sandhu P, Galhotra R, Goyal A. Clinico-radiological correlation in the diagnosis of ligament and meniscus injuries at knee joint: A prospective study. Saudi J Sports Med [serial online] 2013 [cited 2023 May 31];13:22-6. Available from: https://www.sjosm.org/text.asp?2013/13/1/22/112217
| Introduction|| |
Knee injuries may be low velocity/sports related, or high velocity/in roadside accidents. Between 27 and 48% of knee injuries have been reported to be sports related. 
Patient's history regarding mechanism of injury and position of limb at the time of accident may provide clues to possible ligament involvement. 
Painful stress examinations are not always accurate in the acute injury. Hence MR is indicated for early diagnosis of acutely injured knee. 
Arthroscopy though gold standard, is invasive. The ability of MRI to reliably identify internal derangements, multiplanar imaging capabilities, outstanding resolution and non-invasiveness make it an important diagnostic modality. 
This prospective study aimed to study the MRI features and various patterns of ligament and meniscus tears in knee joint injuries and to correlate the clinical findings of knee joint injuries with MRI findings.
| Materials and Methods|| |
The ethics committee of our institute approved this prospective study. Informed consent was taken from all patients undergoing this study. We prospectively studied 50 patients in the age range of 11-60 years over a period of 18 months starting from January 2008. All patients of knee injury who underwent MR imaging were included in the study. Patients excluded from the study were those:
- With universal contraindications to MR.
- Prior arthroscopy or surgical intervention.
- Known joint disease like neoplasm, inflammatory or infectious disorder.
- History of old significant trauma to the currently injured knee.
Findings of specific local examination of injured knee were recorded in detail and a clinical diagnosis was established in all the cases. MR examination was done on all the patients and findings were documented as per proforma [Table 1].
MR scan in all the patients included in this study was carried out on MAGNETOM Avanto 18 Channel 1.5 Tesla MR Machine by Siemens India Ltd.
Preparation of the patient
Articles such as jewelery, keys, credit cards, watches, coins, and other metallic objects were placed in the locker provided. Before starting the MR study, the procedure was explained to the patient in his/her vernacular language to allay the fear and the anxiety. Length of the study in magnet was communicated to the patient who varied from 20 min to 35 min.
Patient was positioned supine and feet-first in the MR imager, with the knee to be imaged in approximately 100-150 degree external rotation to aid the imaging of the ACL in the sagittal plane. Studies were performed with a 5'/2-inch flat surface coil placed posterior to the knee of interest. The knee to be imaged was centered within the 16-cm field of view, including in the image both the suprapatellar bursa and the insertion of the patellar ligament on the tibial tubercle.
Localizer was taken in axial, sagittal and coronal planes after making proper positioning of the patient. The MRI protocol consisted of PD (TE 45 TR 2800), T2W (TE 73 TR 5090) And fat suppressed T2W (TE 26 TR 5000) spin echo sequences in axial, sagittal and coronal planes. A 170-mm field of view and a 256 × 192 matrix with one signal average was used. The slice thickness was 4 mm. Additional T1W (TE 11 TR 495) and T2*GRE(TE 20 TR 36) sequences in the sagittal and coronal plane were obtained wherever these sequences were required.
The images were interpreted by two qualified radiologists individually who had experience of about ten years in this field. All Clinical and MR Imaging findings were recorded as per proforma and subsequent analysis for comparison was undertaken.
| Results|| |
Specific history and relevant clinical examination of injured knee was done in all 50 patients and a clinical diagnosis was established. All of them underwent a dedicated MR knee examination as per the protocol. The final diagnosis was established when the findings were unequivocal on MRI or when MRI findings were confirmed on arthroscopy which 30 patients underwent.
The percentage correlation between clinical and MRI findings regarding presence or absence of ligament/meniscus tear was highest in case of PCL tears which came out to be 94% [Table 2]. Least correlation was found in Medial meniscus (MM) tears [Table 3]. Correlation was 76% for ACL injury [Table 4], 82 and 88% for Medial Collateral ligament (MCL) and Lateral Collateral ligament (LCL) injuries respectively and 81% for Lateral meniscus (LM) tears.
Single ligament injury (48%) was more common as compared to multiple ligament injury (30%). ACL injury resulted more often in complete tear than partial tear.
|Table 3: Correlation of clinical and MRI findings in medial meniscus (MM) injuries|
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In ligament injuries, intrasubstance tears were more common than attachment site tears.
Amongst ligament and meniscus injuries, ACL had the highest incidence of tears (72%) followed by MM tears (36%) [Table 5].
In meniscus injuries, most common site of meniscus tear was both posterior horn and body [Table 6].
Amongst ligament injuries, ACL tear alone was the most common injury (53%) and ACL injury was most commonly associated with MM injury (16%) [Table 7].
|Table 7: Breakdown of combination of ligament and meniscus tears in 22 patients identified on MR|
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The criterion to diagnose meniscus tear was hyperintense signal extending to the articular surface (Grade III signal) on PD and STIR seq [Figure 1].
|Figure 1: Linear intrasubstance high signal intensity is seen in the body of Medial Meniscus on STIR images (white arrow). The signal is extending till the inferior articular surface-Meniscus tear|
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Other findings in our study were a full-thickness longitudinal tear leading to the development of bucket handle tear, disruption of ACL and PCL [Figure 2]a and b, menisco-capsular separation of MCL [Figure 3] and tibial avulsion fracture [Figure 4], hyperinse signal in collateral ligaments.
|Figure 2: (a and b) There is disruption of ACL from its tibial attachment (black circle) with intermediate signal in the ligament (white arrow). The PCL is seen completely disrupted from its femoral attachment (black arrow) and is seen buckled towards the tibia|
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|Figure 3: High velocity trauma leading to Menisco-capsular separation of MCL, fracture of tibial plateau and marrow odema in tibial and femoral condyles|
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|Figure 4: PD FS Sagittal: There is tibial avulsion fracture (circle) at the site of insertion of ACL. Fractured fragment is displaced anteriorly and superiorly. Marrow edema in adjacent part of tibial plateau noted|
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| Discussion|| |
Of the musculoskeletal MRI, MRI of the knee is the quite often performed study and the single most common indication of performing a knee MRI is to diagnose the internal derangements in an injured knee.
Clinical examination may be difficult in acute injury and is inconclusive in cases with injuries of multiple ligaments/menisci.
MRI is vital in evaluation of ligament and meniscus injury and provides critical information in planning primary repair or reconstruction when needed. Being non invasive and a highly sensitive tool of investigation, early and subtle changes in the soft tissues often are picked up by MRI. Arthroscopy being highly sensitive and specific procedure is both diagnostic and therapeutic, but is invasive and has complications associated with it, thus limiting its use as a diagnostic modality alone.
In our prospective study of 50 patients the percentage correlation between clinical and MRI findings regarding presence or absence of ligament/meniscus tear was highest in case of PCL tears which came out to be 94%. Least correlation was found in MM lesions (68%), these findings are in almost complete agreement to the clinical examination findings in the study done by Odgaard et al. 
There is a paucity of published studies evaluating the incidence and breakdown of the major ligaments of the knee. Two of the studies by DeHaven  and Noyes et al,  evaluated the incidence of acute ligament injuries arthroscopically in patients with hemarthrosis, and both found the incidence of ACL tears (acute and partial) to be 72% which corresponds to incidence of ACL tears in our study.
Overall, multiple ligament injuries accounted for 39% (15/39) of all patients with ligament injuries and occurred in 30% of the 50 patients with knee injuries. Two-ligament tears accounted for 23% (9 subjects) of the ligament-injured patients, three-ligament tears accounted for 8%, and 3 patients had tears of all four ligaments (ACL, PCL, MCL, and PLC). Majority of findings above match the findings of La Prade et al.  In their study out of 331 knee injuries, 265 ligament injuries occurred in 187 patients (56%). In their study, 67% had isolated ligament injuries and 33% had combined multiple ligament injuries. 44% had isolated ACL tears in their study while it was 53% in our study. ACL-MCL combination was seen in 16% patients with ligament injured knee in La Prade et al's study and ours.
In our study, site of ligament tear was most commonly encountered in the mid substance. Out of total 63 ligament tears, midsubstance tears occurred in 57% corresponding with Singh et al.  Injury at femoral attachment (27%) was commoner than at tibial/ibular attachment (17%) again corresponding with Singh et al. Grade III signal abnormality or meniscus tear was seen in 18 MM (36%) and in 8 LM (16%). These results are corresponding with the Singh et al study. Most common tear location was body and posterior horn in both the menisci which is in accordance with findings of Frobell et al.
In agreement with previous studies we opine that at least every second ACL tear is associated with meniscus injury. The unhappy triad involving ACL, MCL and MM was found in 3 out of 50 cases which is similar to the results of frobell et al.
Diagnostic accuracy of clinical examination (83%) was relatively low as compared to MR examination (88%) in our study. These results regarding diagnostic accuracy have also been shown in previous studies. The accuracy of the clinical diagnosis of meniscus tears is about 75 to 80%. (Rose et al,  Miller  ) compared with 88% to 90% for MRI. 
In conclusion, MRI is a useful non-invasive modality having high diagnostic accuracy. It saves many knees from unnecessary arthroscopies. MRI also provides surgeon with definitive details of the internal derangements and thus is instrumental in guiding and instituting a right treatment. 
| References|| |
|1.||Frobell RB, Lohmander LS, Roos HP. Acute rotational trauma to the knee: Poor agreement between clinical assessment and magnetic resonance imaging findings. Scand J Med Sci Sports 2007;17:109-14. |
|2.||Mendelsohn CL, Paiement GD. Physical examination of the knee. Prim Care 1996;23:321-8. |
|3.||Otani T, Matsumoto H, Suda Y, Niki Y, Jinnouchi M. Proper use of MR imaging in internal derangement of the knee (orthopedic surgeon's view). Semin Musculoskelet Radiol 2001;5:143-5. |
|4.||Winters K, Tregonning R. Reliability of magnetic resonance imaging of the traumatic knee as determined by arthroscopy. N Z Med J 2005;11:118(1209):U1301. |
|5.||Odgaard F, Tuxoe J, Joergensen U, Lange B, Lausten G, Brettlau T, et al. Clinical decision making in the acutely injured knee based on repeat clinical examination and MRI. Scand J Med Sci Sports 2002;12:154-62. |
|6.||DeHaven KE. Diagnosis of acute knee injuries with hemarthrosis. Am J Sports Med 1980;8:9-14. |
|7.||Noyes FR, Bassett RW, Grood ES, Butler DL. Arthroscopy in acute traumatic hemarthrosis of the knee. Incidence of anterior cruciate tears and other injuries. J Bone Joint Surg Am 1980;62:687-95. |
|8.||LaPrade RF, Wentorf FA, Fritts H, Gundry C, Hightower CD. A prospective magnetic resonance imaging study of the incidence of posterolateral and multiple ligament injuries in acute knee injuries presenting with a hemarthrosis. Arthroscopy 2007;23:1341-7. |
|9.||Singh JP, Garg L, Shrimali R, Setia V, Gupta V. MR Imaging of knee with arthroscopic correlation in twisting injuries. Indian J Radiol Imag 2004;14:33-40. |
|10.||Rose NE, Gold SM. A comparison of accuracy between clinical examination and magnetic resonance imaging in the diagnosis of meniscal and anterior cruciate ligament tears. Arthroscopy 1996;12:398- 405. |
|11.||Miller GK. A prospective study comparing the accuracy of the clinical diagnosis of meniscus tear with magnetic resonance imaging and its effect on clinical outcome. Arthroscopy 1996;12:406-13. |
|12.||MacKenzie R, Palmer CR, Lomas DJ, Dixon AK. Magnetic resonance imaging of the knee: Diagnostic performance studies. Clin Radiol 1996;51:251-7. |
|13.||Vincken PW, ter Braak BP, van Erkell AR, de Rooy TP, Mallens WM, Post W, et al. Effectiveness of MR imaging in selection of patients for arthroscopy of the knee. Radiol 2002;223:739-46. |
|14.||Fritz RC. MR imaging of meniscal and cruciate ligament injuries. Magn Reson Imag Clin N Am 2003;11:283-93. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]