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ACL recon image ap and lat

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Monica Khanna

on 25 August 2017

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Transcript of ACL recon image ap and lat


The Perioperative Knee
Image guided intervention of the Post operative knee
Monica Khanna
Imperial College Healthcare NHS Trust
London, UK

Knee Operations
Meniscal repair
OCD debridement
ACL reconstruction
PCL reconstruction
MCL repair
Posterolateral corner repair
Fracture fixation

Semi constrained

Knee Arthropalsty
44% of patients undergoing TKA suffer from persistent post surgical pain of any severity, severe (15%), extremely severe (6%)
Patients at higher risk of developing infection
Obese patients
Rheumatoid arthritis
Haemophilic arthropathy
Role of imaging
US/MR confirmation of an effusion/synovitis
1-3% risk of developing TKA infection
Septic loosening
Most frequent organisms involved
Staphylococcus aureus
Coagulase-negative staphylococcus
Refers to inflammation of the bursa and usually presents clinically with localized pain and occasionally a palpable mass resulting from a fluid-filled bursa.
Next Step
Imaging +/- image guided intervention
Essential to:
Understand the operation that has been performed
Discussion with orthopaedic surgeon paramount
Which form of imaging to use ?
Accessible (to GPs)
Add interventional procedure at time of examination.
Superior spatial resolution c.f. MRI and CT
Change in obliquity of tendons or ligaments can result in difficulty identifying or evaluating them on MRI
MARS (Metallic Artefact Reduction Sequence)
Any metal work within the knee
Intended to reduce the size and intensity of susceptibility artifacts resulting from magnetic field distortion.

Simple changes can greatly reduce artifacts.

STIR for fat suppression
Spin echo instead of gradient echo where possible
Shorter echo spacing
Increase bandwidth
Thinner slices
Maintain good SNR
Metal reduction protocols
Excellent for osseous evlauation
Periprosthetic fractures
Periprosthetic lucency - loosening
Intraosseous collection
Imaging plays a vital role in the diagnosis and management of complications of TKA
Complications of TKA
Polethylene wear
Particle disease/osteolysis
Periprosthetic fractures
Tendon Pathology
US guided Joint aspiration is a quick and recommended test
Important to maintain an antibiotic-free window period of approximately 15 days prior to the test.
(AAOS Clinical Practice Guideline Summary. Diagnosis of Periprosthetic Joint Infections of the Hip and Knee. 2011)
US Guided knee aspiration
Periprosthetic lucency
Cement mantle fracture
Periprosthetic lucency
Periosteal reaction
Proposed algorithm summarising diagnostic and therapeutic approach to the patient with persistent hip or knee pain
Panoramic view
Suprapatellar pouch effusion
If an acute infection of the knee is suspected
Aspirated fluid should should be sent for biochemical and microbiological analysis.
For microbiology it has been recommended that the aspirate be injected into into blood culture bottles, since some authors have found this medium yields better microorganism identification
Lateral approach
Medial Collateral ligament impingement
Prior partial menisectomy
Prior multiligamentous injury, persistent deep MCL synovitis
Pes anserinus Bursitis
Superolateral Hoffas fat pad impingement
Parameniscal cyst aspiration and injection
Fluoroscopic guided injection
Infected TKA
Contrast introduced into medial patellofemoral articulation
lateral sinus tract extending from the joint to the skin
Dense joint effusion
SP Pouch
Unicompartmental knee replacement
Complete loss of joint space
Marked polethylene wear
CT Arthrogram
Recurrent meniscal tears
Chondral defects
Unstable OCD
US/Fluoroscopic guided injection of contrast
Contrast entering a meniscal tear
Contrast tracking along periprosthetic luceny to confirm loosening
No contrast extending around components
Intact polyethylene
Osteolysis medial femoral condyle
CT Arthrogram
Medial Unicompartmental prosthesis
Minimal metallic artefact because of metallic artefact reduction techniques
Excellent visualisation of bone beneath metallic hardware
Can asses lateral compartment cartilage
Heart Sink topic
We hope that symptoms would be cured by surgery
Recurrent or persistent pain is a disappointment
Orthopaedic Surgeon
Prolonged post procedure rehabilitation
Preoperative incorrect diagnosis
Imaging with metal hardware
Distorted anatomy
We will discuss an approach and the role of intervention in diagnostic and therapeutic procedures
Excellent for soft tissue evaluation
Recurrent meniscal tears
Recurrent ACL/PCL tears post reconstruction
Cartilage evaluation
Osseous bone marrow oedema
Joint aspiration
Cellular counts

A threshold leukocytic count of 1100 WBC/ml, have yielded 91% sensitivity and 88% specificity for infection.
Parvizi et al. considered the value of C-reactive protein in synovial fluid as a prosthetic knee infection predictor with good results.
Study 63 patients were divided into two groups:
septic group (20)
aseptic group (40).
Significant differences were found between the two.

In the septic group, the average level was 40 mg/L as opposed to 2 mg/L in the aseptic group (P<0.001)
this indicator is especially useful for chronic prosthetic infections.

Right suprapatellar effusion and synovitis
The Unusual
Sagittal T1 W MR
Hypointense mass lesion at the anterior tibial tuberosity

70-year-old female patient with total knee replacement.
Ax T1 W FS post Gadolinium
MR image demonstrates mass with contrast
Semiconstrained total knee arthroplasty
Lobulated expansile lucency adjacent to femoral component

Sagittal T1
T1 post Gad
Rim enhancing posterior mass with synovitis and debris
Implant Impingement post total arthroplasty
Medial or lateral gutter synovitis
Impingment of prosthesis
Coexistent synovitis
Superficial MCL
Meniscofemoral component of the deep MCL
Meniscotibial component of the deep MCL
Post mulitligament reconstrucion
Persistent medial pain
Deep MCL synovitis
US Guided injection
Deep MCL Synovitis
US guided injection
Deep MCL synovitis
Local anaesthetic bupivicaine, 2 ml of 0.5%
Steroid (Triamcinolone acetonide, 40 mg in 1 ml) superficial and deep to the deep MCL.
US allows for accurate injection of hypertrophic scar tissue
Neovascularisation on colour doppler
34 patients persistent medial joint pain following grade I/II MCL sprain
MRI confirmed pathology at the deep MCL.
A single corticosteroid injection provided an excellent clinical outcome 20 months post injection.

Jones et al The Knee 16 (2009) 64–68

chemical mediators
joint instability following injury
Causes for ongoing pain from the deep MCL remains unclear.
Bone patellar tendon bone ACL Reconstruction
ACL Reconstructions
Compications of ACL reconstruction
Graft rupture
Graft impingement ~ tunnel position
Tunnel lysis
Intra articular bodies
Fixation hardware failure
Ganglion formation
Complications of the graft harvest site of the BPTB graft
Patellar tendinosis
Rupture of the patellar tendon - most common immediate post op period
Patellar fracture
Patellofemoral arthrosis
Partial patellar tendon tear
Thickening and abnormal signal within the tendon
Difficult to diagnose solely on MR imaging <1 year post surgery
Interference screw fixation
Patellar tendinosis/partial tear
Most commonly during the first year of harvest
MR in the first year at harvest site
Abnormal MR signal
Thickening and defect within central third
Gradually tendon fibrosis and filling in over time
Patellar tendinopathy/partial tear
US evaluation
Fusiform thickening
Increased neovascularity on Doppler imaging
Irregularity inferior pole of the patella with focal intrasubstance partial tearing
Medial unicompartmental replacement
SPECT-CT demonstres marked bony uptake at the site of the periprosthetic luceny
Increased in blood pool phase in keeping with infection
US guided intervention
Dry Needling +/- steroid injection
Autologous blood/PRP treatment
US guided injection of local anaesthetic into Hoffas fat pad
Axial PD FS image
increased signal within fat interposed between the lateral aspect of the patellar tendon and the lateral trochlear ridge.
Mild lateral patellar subluxation
Sagittal PD FS image
increased signal (arrow) within the fat below the caudal margin of the patella
patella alta (arrowhead).

Dry Needling
Dry Needling
Patellar maltracking
Post BPTB graft harvest
Us guided injection of superolateral Hoffas fat pad
US guided pes anserinus bursal injection
needle position
Bursitis is usually aseptic and related to repetitive trauma or friction of the adjacent soft tissue structures in post operative cases
Post operative cases
Post arthroscopic procedures
main function of a bursa is to reduce friction between adjacent moving structures
Pes anserine bursa separates the pes anserine tendons from the subjacent distal portion of the tibial collateral ligament and the bony surface of the medial tibial condyle.

Pes anserinus bursitis
Longitudinal image
Axial image
Deep MCL Bursitis
Medial collateral ligament bursa
Located between the superficial and deep layers of the medial collateral ligament
MCL bursa
Prior partial medial menisectomy
Medial meniscal extrusion
Severe chondrosis medial tibiofemoral compartment
Iliotibial Band Friction syndrome
High-signal intensity of ITB
Fluid collection deep to the ITB
Focal thickening of ITB
Edema lateral epicondyle
US guided injection for ITBFS
Panoramic view
Lateral femoral conyle
Gerdy's tubercle
US guided injection for ITBFS
Local anaesthetic and steroid
Bakers cyst
Gelatinous fluid
Parameniscal cyst arising from the body of the lateral meniscus with soft tissue extension
Occur in 1% of meniscal tears
Most common laterally 75-90%
weaker lateral meniscocapsular attachments compared to tightly adherent meniscocapsular junction
symptomatic parameniscal cysts can be accurately diagnosed and safely treated with US guided percutaneous aspiration and injection.
Temporising measure ?
18 patients
10 complete resolution
2 occasional pain
6 delayed return of pain
Iliotibial band friction syndrome
Dislodged cross pin
Rare complication after ACL reconstruction
1-5 years post-operatively
occasionally symptomatic.
Proposed theories of etiology
Foreign-body reaction ~ PLLA bioabsorable interfernce screw
lack of complete graft osteo-integration, and intravasation of articular fluid.
MR Imaging
tibial tunnel widening
multilocular or unilocular cyst formation in the graft tibial tunnel, pretibial space, intercondylar notch,
ACL ganglion cyst post ACL reconstruction
45yr old gentleman
ACL ganglion cyst within the tibial tunnel extending to the pretibial entry point
Tunnel widening
US Guided musculoskeletal intervention
Provides the ability to document exact needle placement in real time confirming accurate placement of therapeutic injections, fluid aspiration, and soft tissue biopsies
Basic sterile tray
Local anesthetic
Intrarticular and bursal injections
Periarticular/tendon sheath injections
Intra articular injections
Persistent synovitis/aseptic effusion
Kenalog intra articular injection
Intra articular Durolane injection
Single injection
Transparent gel which contains high levels of HA (Hyaluronic Acid)
relieve pain
restore lubrication and cushioning which improves joint function
Helps maintain fluid balance within the joint
442 participants
single-injection NASHA was well tolerated and non-inferior to MPA at 12 weeks
Benefit of NASHA was maintained to 26 weeks while that of MPA declined.
Patients with well-defined tendinosis of the patella tendon on sonography showed significant clinical improvement 4 weeks after sonographically guided tendon fenestration.
45 patella tendons
76% (34 of 45) of patella tendons showed clinical improvement
24% (11 of 45) showed no change;
Kannan et al J Ultrasound Med 2013; 32:771–777
Injection of an irritant: hyperosmolar dextrose, into the area of tendinosis - 50% glucose
Irritant improves symptoms by either
causing inflammation, which introduces growth factors that promote healing
acting as a vascular sclerosing agent.
disparities over its optimal indications, protocols and injection preparations
Autologous whole-blood injection/Platelet rich plasma (PRP)
peripheral blood is drawn from the patient’s arm and reinjected into the pathologic tendon using ultrasound guidance.

no metal susceptibility artefact
Can aid in the diagnosis of septic or aseptic loosening
Axial PD FS sequence
1ml of 50% glucose diluted with 1ml of 1% lignocaine injected into neovessels 2 weekly intervals
Use of a centrifuge
PRP has more concentrated platelets, therefore better the clinical response.
Autologous whole-blood tendon injection,
Autologous platelets within the whole blood will increase the concentration of growth factors to the region and promote healing
Benefits are currently being debated.
Both are often combined with dry needling
Presence of an underlying tendon tear deserves discussion : risk of tendon rupture
Dry needling with tendinosis, interstitial tearing, or partial- thickness tearing up to 50% of the tendon thickness
Avoid dry needling if a tear is >50% of the tendon thickness.
Imaging +/-Image guided intervention in the post operative knee can be very useful
Understanding the orthopaedic procedure and discussion with the orthopaedic surgeon is paramount
TKA and knee surgery is increasing .........image guided post operative intervention also likely to increase
Treatment consideration
US guided injection of steroid or local anesthetic
82 year old with lateral gutter synovitis
Diagnostic and therapeutic procedure
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