Severity of subchondral insufficiency knee fracture: is it associated with increasing age, femorotibial angle, and severity of meniscus extrusion?

Abstract

Aim: To evaluate the relationship between severity of subchondral insufficiency fracture of the knee (SIFK) and age, gender, knee alingment, meniscus tear, type and location, severity of meniscus extrusion, and degree of knee osteoarthritis. Material and Method: This retrospective study included 308 patients with SIFK seen on MRI. SIFK lesions were categorized as grade 1 to 4, with distinction between low grade (1 and 2) and high grade (3 and 4). The relationships between SIFK grade and patients' age, body mass index (BMI), femorotibial angle (FTA), meniscus tear,type and location meniscusextrusiongrade and osteoarthritis (grade 0 to grade 4) evaluated. Results: According to the gender, 39.3% were men and 60.7% were women. The distrubutin of the SIFK grades were respectively 42.2% grade 1, 30.8% grade 2, 22.7% grade 3 and 4.2% grade 4. FTAwas positively correlated with SIFK grade (from grade 1 to grade 4, respectively; 4.42±2.57, 5.09±2.26, 5.74±2.78 and 5.95±2.54) (p=0.002). No statistically significant difference was observed between height, weight and BMI and the degree of SIFK.The mean FTA was 4.99±2.57° in SIFK. The FTA angles showed a stastistically significance between low (4.73±2.48°) and high (5.71±2.69°)grade SIFK (p:0.003). Roc analysis showed that the FTA above 3.1° and the age above 52 year old were at risk. The mean extent of meniscal extrusion was larger in high grade SIFK (p=0.001). Multivariable logistic regression analysis showed that compared with low grade SIFK, high grade SIFK was more closely associated with age, FTA, lateral meniscus extrusion and medial meniscus tear type. Conclusion: High-grade SIFK lesions are associated with higher FTA and older age. In particular, patients with acute knee pain, older than 52 years of ageanda higher FTA than 3.1°, we recommend to perform knee MRI if possible.

Keywords

• subchondral insufficiency fracture
• SIFK
• knee alingment
• meniscus tear
• severity of meniscus extrusion
• degree of knee osteoarthritis

References

1. Hussain ZB, Chahla J, Mandelbaum BR, Gomoll AH, LaPrade RF. The role of meniscal tears in spontaneous osteonecrosis of the knee: a systematic review of suspected etiology and a call to revisit nomenclature. Am J Sports Med 2019; 47: 501-7.
2. Pathria MN, Chung CB, Resnick DL. Acute and stress-related injuries of bone and cartilage: pertinent anatomy, basic biomechanics, and imaging perspective. Radiology 2016; 280: 21-38.
3. Ahlbäck S, Bauer GC, Bohne WH. Spontaneous osteonecrosis of the knee. Arthritis Rheumatism 1968; 11: 705-33.
4. Yamamoto T, Bullough PG. Spontaneous osteonecrosis of the knee: the result of subchondral insufficiency fracture. JBJS 2000; 82: 858.
5. Tanaka Y, Mima H, Yonetani Y, Shiozaki Y, Nakamura N, Horibe S. Histological evaluation of spontaneous osteonecrosis of the medial femoral condyle and short-term clinical results of osteochondral autografting: a case series. The Knee 2009; 16: 130-5.
6. Mears SC, McCarthy EF, Jones LC, Hungerford DS, Mont MA. Characterization and pathological characteristics of spontaneous osteonecrosis of the knee. The Iowa Orthopaedic J 2009; 29: 38.
7. Higuchi H, Kobayashi Y, Kobayashi A, Hatayama K, Kimura M. Histologic analysis of postmeniscectomy osteonecrosis. Am J Orthop 2013; 42: e2.
8. Madry H, van Dijk CN, Mueller-Gerbl M. The basic science of the subchondral bone. Knee Surgery Sports Traumatology Arthroscopy 2010; 18: 419-33.

9. Houpt JB, Pritzker KP, Alpert B, Greyson N, Gross AE, editors. Natural history of spontaneous osteonecrosis of the knee (SONK): a review. Seminars in Arthritis and Rheumatism; 1983: Elsevier.
10. Pape D, Seil R, Fritsch E, Rupp S, Kohn D. Prevalence of spontaneous osteonecrosis of the medial femoral condyle in elderly patients. Knee Surgery Sports Traumatology Arthroscopy 2002; 10: 233-40.
11. Koshino T, Okamoto R, Takamura K, Tsuchiya K. Arthroscopy in spontaneous osteonecrosis of the knee. The Orthopedic Clin North Am 1979; 10: 609-18.
12. Sayyid S, Younan Y, Sharma G, et al. Subchondral insufficiency fracture of the knee: grading, risk factors, and outcome. Skeletal Radiology 2019; 48: 1961-74.
13. Yasuda T, Ota S, Fujita S, Onishi E, Iwaki K, Yamamoto H. Association between medial meniscus extrusion and spontaneous osteonecrosis of the knee. Int J Rheumatic Dis 2018; 21: 2104-11.
14. Sung JH, Ha JK, Lee DW, Seo WY, Kim JG. Meniscal extrusion and spontaneous osteonecrosis with root tear of medial meniscus: comparison with horizontal tear. Arthroscopy J Arthroscopic Related Surg 2013; 29: 726-32.
15. Hunter DJ, Guermazi A, Lo GH, et al. Evolution of semi-quantitative whole joint assessment of knee OA: MOAKS (MRI Osteoarthritis Knee Score). Osteoarthritis and Cartilage 2011; 19: 990-1002.
16. Swamy N, Wadhwa V, Bajaj G, Chhabra A, Pandey T. Medial meniscal extrusion: detection, evaluation and clinical implications. Eur J Radiol 2018; 102: 115-24.
17. Bruns K, Svensson F, Turkiewicz A, et al. Meniscus body position and its change over four years in asymptomatic adults: a cohort study using data from the Osteoarthritis Initiative (OAI). BMC Musculoskeletal Disorders 2014; 15: 1-11.
18. Kohyama S, Ogawa T, Mamizuka N, Hara Y, Yamazaki M. A magnetic resonance imaging–based staging system for osteochondritis dissecans of the elbow: a validation study against the International Cartilage Repair Society classification. Orthopaedic J Sports Med 2018; 6: 2325967118794620.
19. Iranpour-Boroujeni T, Li J, Lynch J, Nevitt M, Duryea J, Investigators O. A new method to measure anatomic knee alignment for large studies of OA: data from the Osteoarthritis Initiative. Osteoarthritis and Cartilage 2014; 22: 1668-74.
20. Yamagami R, Taketomi S, Inui H, Tahara K, Tanaka S. The role of medial meniscus posterior root tear and proximal tibial morphology in the development of spontaneous osteonecrosis and osteoarthritis of the knee. The Knee 2017; 24: 390-5.
21. Nakayama H, Iseki T, Kanto R, Daimon T, Kashiwa K, Yoshiya S. Analysis of risk factors for poor prognosis in conservatively managed early-stage spontaneous osteonecrosis of the knee. The Knee 2016; 23: 25-8.
22. Cooke T, Sheehy L, Scudamore RA. What information must measures provide to demonstrate the problems in knee alignment and osteoarthritis? Osteoarthritis and Cartilage 2010; 18: 1544.
23. Tsukamoto H, Saito H, Saito K, et al. Radiographic deformities of the lower extremity in patients with spontaneous osteonecrosis of the knee. The Knee 2020; 27: 838-45.
24. Robertson D, Armfield D, Towers J, Irrgang J, Maloney W, Harner C. Meniscal root injury and spontaneous osteonecrosis of the knee: an observation. J Bone Joint Surg British 2009; 91: 190-5.
25. Plett SK, Hackney LA, Heilmeier U, et al. Femoral condyle insufficiency fractures: associated clinical and morphological findings and impact on outcome. Skeletal Radiology 2015; 44: 1785-94.
26. Hunter D, Zhang Y, Niu J, et al. The association of meniscal pathologic changes with cartilage loss in symptomatic knee osteoarthritis. Arthritis Rheumatism 2006; 54: 795-801.
27. Yao L, Stanczak J, Boutin RD. Presumptive subarticular stress reactions of the knee: MRI detection and association with meniscal tear patterns. Skeletal Radiology 2004; 33: 260-4.
28. Bessette GC. The meniscus. Orthopedics 1992; 15: 35-42.
29. Gale D, Chaisson C, Totterman S, Schwartz R, Gale M, Felson D. Meniscal subluxation: association with osteoarthritis and joint space narrowing. Osteoarthritis and Cartilage 1999; 7: 526-32.
30. Brahme SK, Fox J, Ferkel R, Friedman M, Flannigan B, Resnick D. Osteonecrosis of the knee after arthroscopic surgery: diagnosis with MR imaging. Radiology 1991; 178: 851-3.
31. Aglietti P, Insall J, Buzzi R, Deschamps G. Idiopathic osteonecrosis of the knee. Aetiology, prognosis and treatment. J Bone Joint sSurg British 1983; 65: 588-97.
32. Wilmot AS, Ruutiainen AT, Bakhru PT, Schweitzer ME, Shabshin N. Subchondral insufficiency fracture of the knee: a recognizable associated soft tissue edema pattern and a similar distribution among men and women. Eur J Radiol 2016; 85: 2096-103.
33. al-Rowaih A, Björkengren A, Egund N, Lindstrand A, Wingstrand H, Thorngren K-G. Size of osteonecrosis of the knee. Clin Orthopaedics Related Research 1993: 68-75.
34. Zanetti M, Romero J, Dambacher M, Hodler J. Osteonecrosis diagnosed on MR images of the knee: relationship to reduced bone mineral density determined by high resolution peripheral quantitative CT. Acta Radiologica 2003; 44: 525-31.