Direct magnetic resonance arthrography of the knee: utility of axial traction

SSR white paper: guidelines for utilization and performance of direct MR arthrography

OBJECTIVE

Direct magnetic resonance arthrography (dMRA) is often considered the most accurate imaging modality for the evaluation of intra-articular structures, but utilization and performance vary widely without consensus. The purpose of this white paper is to develop consensus recommendations on behalf of the Society of Skeletal Radiology (SSR) based on published literature and expert opinion.

MATERIALS AND METHODS

The Standards and Guidelines Committee of the SSR identified guidelines for utilization and performance of dMRA as an important topic for study and invited all SSR members with expertise and interest to volunteer for the white paper panel. This panel was tasked with determining an outline, reviewing the relevant literature, preparing a written document summarizing the issues and controversies, and providing recommendations.

RESULTS

Twelve SSR members with expertise in dMRA formed the ad hoc white paper authorship committee. The published literature on dMRA was reviewed and summarized, focusing on clinical indications, technical considerations, safety, imaging protocols, complications, controversies, and gaps in knowledge. Recommendations for the utilization and performance of dMRA in the shoulder, elbow, wrist, hip, knee, and ankle/foot regions were developed in group consensus.

CONCLUSION

Although direct MR arthrography has been previously used for a wide variety of clinical indications, the authorship panel recommends more selective application of this minimally invasive procedure. At present, direct MR arthrography remains an important procedure in the armamentarium of the musculoskeletal radiologist and is especially valuable when conventional MRI is indeterminant or results are discrepant with clinical evaluation.

Improving visualization of the articular cartilage of the knee with magnetic resonance imaging under axial traction: a comparative study of different traction weights

OBJECTIVE

Lesions of the articular cartilage of the knee, especially early grades, are not always accurately detected by magnetic resonance imaging (MRI) because of contact between the articular cartilage surfaces of the femur and the tibia. This study aimed to assess the effects of axial leg traction during knee MRI examination on joint space widening and articular cartilage visualization and evaluate the ideal weight for traction.

METHODS

MRI was performed on ten healthy volunteers using a 3-T MRI unit with a 3D dual-echo steady-state gradient-recalled echo sequence. Conventional MRI was performed first, followed by traction MRI. The traction weight increased in the order of 5 kg, 10 kg, and 15 kg. Joint space widths were measured, and articular cartilage visualization was assessed at the medial and lateral tibiofemoral joints. Volunteers were asked to evaluate pain and discomfort using a visual analog scale during each procedure with axial traction to assess the safety of traction MRI.

RESULTS

The medial tibiofemoral joint space width significantly increased, and the visualization of the articular cartilage significantly improved by applying traction. The joint space width and the articular cartilage visualization showed no significant differences among traction weights of 5 kg, 10 kg, and 15 kg. Pain and discomfort during traction MRI examination were lowest with a traction weight of 5 kg.

CONCLUSION

Traction MRI examination may be useful in evaluating articular cartilage lesions at the medial tibiofemoral joint. A traction weight of 5 kg may be sufficient with minimum pain and discomfort.

Mechanical traction from different knee joint angles in patients with knee osteoarthritis: A randomized controlled trial

OBJECTIVE

To compare the effect of mechanical traction from different knee angles on pain, physical function, and range of motion in patients with knee osteoarthritis.

DESIGN

A single-blinded, randomized controlled trial.

SETTING

Outpatient public and governmental Hospital clinics.

PARTICIPANTS

One hundred and twenty patients with knee osteoarthritis were randomly assigned into 4 equal groups with 30 patients in each group.

INTERVENTIONS

Group (A) received conventional physiotherapy(CPT) treatment; group (B) received CPT with knee traction from full extension, group (C) received CPT with knee traction from 90° flexion, while group (D) received CPT with knee traction from 20° flexion. Interventions were applied 3 sessions a week for 4 weeks.

OUTCOME MEASUREMENTS

Visual analog scale (VAS), knee passive range of motion and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were measured at baseline, immediately after 4 weeks of intervention, and after 4 weeks of no intervention as a follow-up.

RESULTS

After eight weeks, the mean (SD) for VAS scores were 30.97 ± 8.68, 24.0 ± 8.8, 15.43 ± 6.31, and 16.17 ± 6.11 mm; for total WOMAC scores were 26.77 ± 9.19, 20.3 ± 8.52, 13.27 ± 6.25, and 13.43 ± 7.14 for groups A, B, C and D, respectively. The three traction groups showed statistically significant changes in pain scores, physical function, and total WOMAC, but not for knee passive range of motion, in favor of traction groups C and D than the conventional group (P < 0.05).

CONCLUSIONS

Traction from 90°and 20° of knee flexion was found superior to full extension knee in improving pain and physical function, but not for knee passive range of motion, in patients with knee osteoarthritis.

Effects of Magnetic Resonance Imaging With Axial Traction of the Thumb Carpometacarpal Joint on Articular Cartilage Visibility: A Feasibility Study

Objectives

The objective of this study was to verify the usefulness of magnetic resonance imaging (MRI) with axial traction of the thumb for observing articular cartilage.

Materials and methods

Eleven healthy adult volunteers (39.7 ± 7.4 years) without thumb carpometacarpal joint arthritis or trauma were included in this study. A 3-tesla (3T) MRI (Magnetom Skyra, Siemens Healthineers AG, Munich, Germany) of the right thumb with axial traction applied by a finger trap with three traction weights (0, 2, and 5 kg) was performed. A 3D T2* multiecho data imaging combination (MEDIC) was selected to visualize the articular cartilage. After multiplanar reconstruction, sagittal and coronal images of the thumb carpometacarpal joint were used to evaluate the articular cartilage visibility and joint space widths at five locations. Articular cartilage visibility was evaluated using our original classification method that used the percentage of the cartilage detectable area. The Friedman test was used to compare the differences between each traction weight and location.

Results

Articular cartilage visibility significantly improved with axial traction. The average joint space widths with the 5-kg application were 1.9 ± 0.8, 3.9 ± 0.6, 2.0 ± 0.9, 3.9 ± 1.1, and 2.5 ± 1.4 mm at the center, volar edge, dorsal edge, radial edge, and ulnar edge, respectively. The joint space widths significantly increased proportionally with the traction weight at all locations. The joint space widths at the volar and radial edges were significantly greater than those at other locations.

Conclusion

Applying axial traction to the thumb increased the joint space widths and improved the visibility of the articular cartilage in the carpometacarpal joint on MRI.

Effect of elbow MRI with axial traction on articular cartilage visibility-a feasibility study

OBJECTIVE

Accurate evaluation of the articular cartilage of the elbow using MRI is sometimes challenging because of its anatomical complexity and relatively small size. Moreover, the articular cartilage of the humerus is in close contact with the opposing cartilage surfaces. Magnetic resonance arthrography with traction was reported to resolve this issue; however, less invasive methods are desirable. This study aimed to assess the effect of MRI with axial traction (without arthrography) on joint space widening and cartilage outline visibility of the elbow.

MATERIALS AND METHODS

We enrolled 10 volunteers (female = 1; mean age, 36.7 ± 8.6; range 28-56) and performed MRI with and without axial traction on the elbow. Joint space widths were measured, and the humeral articular cartilage outline visibility was evaluated at the radiocapitellar joint and lateral one-third and medial one-third of the ulnohumeral joints. Measurements were compared using the Wilcoxon signed-rank test. Significance was set at p < 0.05. Volunteers scored pain and discomfort during MRI with traction using the visual analog scale in a questionnaire format.

RESULTS

Traction significantly increased joint space width at the radiocapitellar joint. Humeral articular cartilage outline visibility also significantly improved at the radiocapitellar joint. Pain and discomfort scores during traction MRI were low.

CONCLUSION

MRI of the elbow with traction widens joint space and enables better articular cartilage visibility at the radiocapitellar joint. Anatomical features of the elbow might have affected these results. Therefore, it would be safe and useful for evaluating elbow injuries involving articular cartilage lesions.

Efficacy of the Rotational Traction Method in the Assessment of Glenohumeral Cartilage Surface Area in Computed Tomography Arthrography

OBJECTIVE

We aimed to investigate the efficacy of the rotational traction method in expanding the joint space and enabling the assessment of an extended surface area.

METHODS

Sixty patients who underwent computed tomography arthrography were evaluated in the study: 30 with and 30 without the help of rotational traction. The subgroups consisted of patients with adhesive capsulitis, habitual luxation, or labral tears. Areas of obscured joint surface by coalescent cartilages were calculated using computer software, and those belonging to the traction and nontraction groups along with subgroups were compared statistically.

RESULTS

There was a significant difference between the traction and nontraction group regarding the contact surface area (P < 0.001 for both observers). In patients with adhesive capsulitis, the contact surface area was larger compared with the other subgroups (P = 0.002 for observer 1 and P = 0.002 for observer 2). In patients with habitual luxation, the contact surface area was smaller compared with the other subgroups (P = 0.002 for observer 1 and P = 0.001 for observer 2).

CONCLUSIONS

Expansion of joint distance is important for assessing the joint cartilage. The rotational traction method provides effective separation of the joint space. For this reason, rotational traction can be used effectively in patients in whom the joint cartilage is to be evaluated.

Ankle Traction During MRI of Talar Dome Osteochondral Lesions

OBJECTIVE

The objective of our study was to assess the impact of axial traction during MRI of talar dome osteochondral lesions using a small-FOV coil.

SUBJECTS AND METHODS

A prospective study of 33 patients undergoing high-resolution MRI of the ankle using a microscopy coil with and without axial traction was performed. Two radiologists independently measured the tibiotalar joint space width and semiquantitatively graded intraarticular joint fluid dispersion, cartilage surface visibility of the osteochondral lesion, and cartilage surface visibility elsewhere in the tibiotalar joint before and after traction. Patients were instructed to report any discomfort during ankle traction.

RESULTS

None of the patients reported discomfort or other symptoms during ankle traction. The tibiotalar joint space significantly increased (increase in cartilage-cartilage distance, 0.5-0.7 mm; all, p < 0.05) after traction compared with before traction. The degree of intraarticular joint fluid dispersion and the cartilage surface visibility at the osteochondral lesion and elsewhere in the tibiotalar joint improved after traction (all, p < 0.05).

CONCLUSION

Traction MRI of the ankle is safe and technically feasible. This study is the first to date to investigate the effect of ankle traction on the MRI assessment of talar dome osteochondral lesions. Traction improves cartilage surface visibility of talar dome osteochondral lesions.

Axial traction magnetic resonance imaging (MRI) of the glenohumeral joint in healthy volunteers: initial experience

OBJECTIVE

Evaluate technical feasibility and potential applications of glenohumeral (GH) joint axial traction magnetic resonance imaging (MRI) in healthy volunteers.

MATERIALS AND METHODS

Eleven shoulders were imaged in neutral and with 4kg axial traction at 3T. Quantitative measurements were assessed.

RESULTS

Axial traction was well tolerated. There was statistically significant widening of the superior GH joint space (p=0.002) and acromial angle (p=0.017) with traction. Inter-rater agreement was high.

CONCLUSION

GH joint axial traction MRI is technically feasible and well tolerated in volunteers. Traction of the capsule, widening of the superior GH joint space and acromial angle were observed.

Effects of Axial Traction during Direct MR-Arthrography of the Wrist in Sports Injuries

Purpose:

To evaluate the degree of joint distraction during direct MR arthrography with axial traction in sports injuries. To confirm the effect of axial traction on the quality of wrist opacification.

Patients and methods:

Seventeen patients (11 male, 6 female) underwent wrist MR arthrography without (mean: 39 years (SD 11.6))., and 20 patients (16 male, 4 female) with axial traction (mean: 28 years (SD 7.1)). Subgroups were defined according to pathology: degenerative, ligamentous, traumatic, normal (ie patients without MR-arthrography lesions). Radioscaphoid, radiolunate, lunocapitate, ulna Triangular Fibrocartilage (TFC), scapho-lunate, luno-triquetral, ulnocarpal, Carpo-Metacarpal (CMC) I and III and distal radio-ulnar spaces were measured for all patients. Differences in joint space width were compared between subgroups. Joint space opacification was subjectively scored from 0 (no opacification) to 3 (fully opacified), and compared between the groups with and without traction.

Results:

The difference in joint space was statistically significant (p<0.05) for radioscaphoid, radiolunate, lunocapitate and ulnocarpal spaces, but only in patients with ligamentous tears. Opacification score was significantly higher for ulnocarpal (p=0.0275) and CMC III joint spaces (p=0.0272) with axial traction.

Conclusion:

Axial traction resulted in a significantly higher radioscaphoid, radio-lunate, lunocapitate and ulnocarpal joint spaces width. This positive effect of axial traction raises the suspicion of sports ligamentous lesions.

Elbow MR arthrography with traction

OBJECTIVE

To assess the effect of axial traction during MR arthrography (MRA) of the elbow joint on joint space widening, contrast dispersion between opposing cartilage surfaces and cartilage surface visibility.

METHODS

11 patients with elbow MRA with and without axial traction were prospectively studied. Two radiologists independently measured the elbow joint space width and semi-quantitatively graded contrast material dispersion between the opposing cartilage surfaces as well as the articular cartilage surface visibility before and after traction. The detection and visibility of articular cartilage defects were also compared before and after traction. Patients were instructed to report on pain or any other symptoms during elbow traction.

RESULTS

No patient reported discomfort, pain or any other symptoms related to traction on immediate and intermediate-term follow-up. Joint space width increased, more at the radiocapitellar joint space (Δ = 0.63 mm, p = 0.005) than at the ulnotrochlear joint space (Δ = 0.17 mm, p = 0.012), with contrast dispersion into the radiocapitellar joint and cartilage visibility of the radiocapitellar joint space significantly improving after traction (all p < 0.05). All of these parameters also improved at the ulnotrochlear joint, although this did not reach statistical significance. Traction improved the visibility of cartilage defects.

CONCLUSION

This is the first study to evaluate the effect of traction on MRA of the elbow joint. This technique is safe and technically feasible. Traction MRA improves the cartilage surface visibility and cartilage defect visibility.

ADVANCES IN KNOWLEDGE

This technique is safe and technically feasible. Traction MRA improves cartilage surface visibility and cartilage defect visibility.

Magnetic resonance arthrography of the wrist with axial traction: An iconographic review

Stress maneuvers inspired by arthroscopic techniques have been previously studied for MRA of shoulder, hip, knee and wrist. Axial traction in MRA of the wrist is advantageous to study intrinsic ligaments and cartilage, but seems useless to assess tendons or nerves disorders. Based on our experience and a well-chosen iconography, we would like to emphasize the contribution of axial traction in MRA of wrist disorders.

3-T direct MR arthrography of the wrist: value of finger trap distraction to assess intrinsic ligament and triangular fibrocartilage complex tears

PURPOSE

To determine the value of applying finger trap distraction during direct MR arthrography of the wrist to assess intrinsic ligament and triangular fibrocartilage complex (TFCC) tears.

MATERIALS AND METHODS

Twenty consecutive patients were prospectively investigated by three-compartment wrist MR arthrography. Imaging was performed with 3-T scanners using a three-dimensional isotropic (0.4 mm) T1-weighted gradient-recalled echo sequence, with and without finger trap distraction (4 kg). In a blind and independent fashion, two musculoskeletal radiologists measured the width of the scapholunate (SL), lunotriquetral (LT) and ulna-TFC (UTFC) joint spaces. They evaluated the amount of contrast medium within these spaces using a four-point scale, and assessed SL, LT and TFCC tears, as well as the disruption of Gilula's carpal arcs.

RESULTS

With finger trap distraction, both readers found a significant increase in width of the SL space (mean Δ = +0.1mm, p ≤ 0.040), and noticed more contrast medium therein (p ≤ 0.035). In contrast, the differences in width of the LT (mean Δ = +0.1 mm, p ≥ 0.057) and UTFC (mean Δ = 0mm, p ≥ 0.728) spaces, as well as the amount of contrast material within these spaces were not statistically significant (p = 0.607 and ≥ 0.157, respectively). Both readers detected more SL (Δ = +1, p = 0.157) and LT (Δ = +2, p = 0.223) tears, although statistical significance was not reached, and Gilula's carpal arcs were more frequently disrupted during finger trap distraction (Δ = +5, p = 0.025).

CONCLUSION

The application of finger trap distraction during direct wrist MR arthrography may enhance both detection and characterisation of SL and LT ligament tears by widening the SL space and increasing the amount of contrast within the SL and LT joint spaces.

Cartilage assessment of the metacarpophalangeal joints: cadaveric study with magnetic resonance arthrography and finger traction

We investigated the efficacy of axial traction of the fingers combined with magnetic resonance (MR) arthrography in assessing the metacarpophalangeal (MCP) joint cartilage in cadavers. Cartilage was imaged and graded before/after MR arthrography, with/without traction, then correlated with cadaveric sectioning. The application of traction with MR arthrography is a promising technique for improved visualization of the articular cartilage of the MCP joints compared with similar imaging without traction and/or without arthrography, but its true benefit requires further study.

Direct MR arthrography of the shoulder under axial traction: feasibility study to evaluate the superior labrum-biceps tendon complex and articular cartilage

PURPOSE

To assess the value of adding axial traction to direct MR arthrography of the shoulder, in terms of subacromial and glenohumeral joint space widths, and coverage of the superior labrum-biceps tendon complex and articular cartilage by contrast material.

MATERIALS AND METHODS

Twenty-one patients investigated by direct MR arthrography of the shoulder were prospectively included. Studies were performed with a 3 Tesla (T) unit and included a three-dimensional isotropic fat-suppressed T1-weighted gradient-recalled echo sequence, without and with axial traction (4 kg). Two radiologists independently measured the width of the subacromial, superior, and inferior glenohumeral joint spaces. They subsequently rated the amount of contrast material around the superior labrum-biceps tendon complex and between glenohumeral cartilage surfaces, using a three-point scale: 0 = no, 1 = partial, 2 = full.

RESULTS

Under traction, the subacromial (Δ = 2.0 mm, P = 0.0003), superior (Δ = 0.7 mm, P = 0.0001) and inferior (Δ = 1.4 mm, P = 0.0006) glenohumeral joint space widths were all significantly increased, and both readers noted significantly more contrast material around the superior labrum-biceps tendon complex (P = 0.014), and between the superior (P = 0.001) and inferior (P = 0.025) glenohumeral cartilage surfaces.

CONCLUSION

Direct MR arthrography of the shoulder under axial traction increases subacromial and glenohumeral joint space widths, and prompts better coverage of the superior labrum-biceps tendon complex and articular cartilage by contrast material.

A randomized controlled trial on the efficacy of intermittent and continuous traction for patients with knee osteoarthritis

Objective:

To investigate the efficacy of intermittent and continuous traction in the treatment of knee osteoarthritis.

Design:

A randomized, controlled, observer-blind seven-week trial.

Setting:

Hospital-based outpatient practice.

Subjects:

Ninety-eight patients with stage 3 knee osteoarthritis according to Kellgren–Lawrence radiological rating scale.

Interventions:

All 98 patients were randomly assigned to three treatment groups, for three weeks (weekends excluded). The control group ( n=30, mean age: 59.30±8.16) received hot pack and short wave diathermy; the intermittent group ( n=30, mean age: 58.20±7.78) received hot pack, short wave diathermy and intermittent traction; and the continuous group ( n=30, mean age: 57.97±9.53) received hot pack, short wave diathermy and continuous traction.

Outcome measurements:

The values of the Turkish version of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale, and knee passive range of motion were measured at baseline, three-week and seven-week follow-up.

Results:

Compared with baseline at weeks 3 and 7, all the outcome measures, except range of motion, were significantly reduced in all groups (all P≤0.001). In terms of the change data from baseline to week 3, both traction groups were significantly superior to the control in the WOMAC physical function scores. Considering the change data from baseline to week 7, both traction groups were significantly superior to the control in the pain scores, physical function and total scores, while only the continuous group was significantly better than the control in the stiffness scores (control: 1.17 ± 1.64; continuous: 2.38 ± 1.44) ( P=0.014). Compared with baseline at weeks 3 and 7, range of motion values significantly increased in both traction groups ( P<0.05) but not in the control ( P>0.05). However, there were no significant differences among the three groups considering the change data from baseline to week 7 in range of motion values ( P=0.300).

Conclusions:

Joint traction was found to be beneficial for the improvement of pain and physical function loss related to knee osteoarthritis.

Magnetic resonance-guided interventions of large and small joints

Magnetic resonance (MR)-guided interventions of large and small joints are feasible and safe procedures offering several advantages compared with standard guiding techniques. Nevertheless, MR-guided interventions are not routinely performed in daily practice apart from a few centers. Accurate injections are crucial for clinical outcome in diagnostic arthrography as well as therapeutic joint injections. In particular, palpatory joint puncture was shown to be inaccurate or uncertain in a substantial percentage of injections of the shoulder, the hip, and the knee. Magnetic resonance imaging offers respective merits of a cross-sectional technique with high soft-tissue contrast. Exact depiction of structures, which should be preserved, such as the labrum, should be aimed for. Areas with complex anatomy can be approached by adapting the right imaging plane(s) because of multiplanar capacity. Lack of ionizing radiation for patients is of growing interest particularly in young patients with repeated interventions. Magnetic resonance guidance alone allows an "all-in-one" MR arthrography combining precise targeting with high-field-strength imaging. Modern short-bore and open-bore high-field-strength systems offer a good comfort for patients as well as clinicians and enhance patient positioning options such as supine or prone position. Thus, a tailored approach such as a posterior technique for suspected anterior lesions in shoulder MR arthrography is possible.In this article, we describe the advantages and limitations of MR guidance in joint interventions with focus on shoulder and hip interventions. We review the requirements for needle material and MR sequences, discuss several different techniques developed to date, and present current results in clinical outcome.

Direct magnetic resonance arthrography of the wrist with axial traction: a feasibility study to assess joint cartilage

PURPOSE

To assess the impact of axial traction during acquisition of direct magnetic resonance (MR) arthrography of the wrist with regard to joint space width and amount of contrast material between the opposing cartilage surfaces.

MATERIALS AND METHODS

Fifteen consecutive patients (12 male, mean age 38.1 years) were included in this Institutional Review Board-approved prospective study. Three-compartment wrist MR arthrographies were performed between October and December 2009 on a 3 T unit using a fat-suppressed T1-weighted isotropic high-resolution volumetric interpolated breathhold examination (VIBE) sequence in the coronal plane, with and without axial traction (3 kg). Two radiologists measured radiocarpal (radioscaphoid, radiolunate) and midcarpal (lunocapitate, hamatolunate) joint space widths, with and without traction, and assessed the amount of contrast material between the opposing cartilage surfaces using a three-point scale: 0 = absence, 1 = partial, 2 = complete.

RESULTS

With traction, joint space width increased significantly at the radioscaphoid (Δ = 0.78 mm, P < 0.01), radiolunate (Δ = 0.18 mm, P < 0.01), and lunocapitate (Δ = 0.45 mm, P < 0.01) spaces, and both observers detected significantly more contrast material between the cartilage surfaces. At the hamatolunate space, the differences in joint space width (Δ = 0.14 mm, P = 0.54) and amount of contrast material were not significant.

CONCLUSION

Direct wrist MR arthrography with axial traction of 3 kg increases joint space width at the radiocarpal and lunocapitate spaces, and prompts better coverage of the articular cartilage by the contrast material.