RU2789428C1 - Knee joint pathology diagnosing method - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to traumatology and orthopaedics, and may be used for diagnosing knee joint pathology. Magnetic resonance imaging is used to simultaneously scan both joints. A patient is placed in a supine position. The lower limbs are positioned in parallel in a neutral position with respect to the internal and external rotation in the hip joints with bending in the knee joints by 20 degrees by placing a roller in the popliteal fossae, which allows forming a parallel horizontal position of the posterior contours of the femoral condyles with respect to the table plane.

EFFECT: method provides for accurate diagnosing the ligament and tendon tears extent, differentiating dysplastic bone changes from variant anatomy, detecting cartilage and meniscus damage in comparison with the opposite joint, and reducing scanning time by means of positioning the patient and simultaneously scanning both limbs.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, can be used to diagnose dysplastic, degenerative and traumatic pathology of bone and soft tissue structures of the knee joints in children and adults.

The relevance of the problem of identifying complete and partial ruptures of ligaments and tendons, differentiating dysplastic bone changes from variant anatomy, as well as identifying areas of cartilage and meniscus damage is due to their high frequency of occurrence and an ambiguous clinical picture.

The method of ultrasonography of the knee joint is known. When scanning the ligaments or meniscus with ultrasound, the doctor evaluates and compares the condition of both joints. The anterior, lateral and posterior surfaces of the joint are sequentially examined (Abdullaev R.Ya., Dzyak GV et al. Ultrasonography of the knee joint. Kharkiv: New Word, 2010. - P. 10-29). The disadvantages of the method can be considered high operator and instrument dependence, which affects the quality of interpretation of the data obtained.

The method of arthroscopy of the knee joint is known. Arthroscopy is performed under local anesthesia, epidural anesthesia or general anesthesia. An arthroscope is inserted into the cavity of the knee joint, with the help of a special optical device, intra-articular structures are examined (Levitsky A.F., Lomnitsky O.Ya., Kosyakov A.N., Bebeshko A.V., Krisyuk S.A. The use of arthroscopy for knee injuries joint in children and adolescents // Orthopedics, Traumatology and Prosthetics: Republican Interdepartmental Collection - 1989. - Issue 19. - P. 67-68). Arthroscopy is the "gold" standard in the detection of damage to the intra-articular structures of the knee joint, however, the disadvantages of the method can be considered, first of all, the high cost of equipment and immediate surgical intervention, and secondly, postoperative complications.

A known method of computed tomographic arthrography of the knee joint is known. The study is carried out with the patient lying on his back after preliminary preparation, which includes the intra-articular injection of 30-40 ml of a solution of a non-ionic iodine-containing contrast agent. For puncture, the upper lateral sections of the knee joint are most often used. Next, patients are asked to walk for 15 minutes or bend and unbend the leg at the knee joint. To reduce the volume of the bags of the knee joint and, accordingly, a more pronounced contrasting of its central part, the suprapatellar sections are bandaged with an elastic bandage. The study is carried out with the least collimation of the slice; it is recommended to scan with the knee joint bent to 15°. To assess the changes, the reconstruction algorithms of "high resolution" and "soft" mode are used (Filisteev P.A., Nasnikova I.Yu., Morozov S.P. Possibilities of CT arthrography in knee joint injury. Kremlin medicine. Clinical Bulletin No. 2. - 2010. - S. 71-76). The disadvantages of the method can be considered the lack of visualization of degenerative changes in structures, intraligamentous damage, the possibility of an allergic reaction to the introduction of an iodine-containing contrast agent, and exposure of the patient to ionizing X-rays.

A known method of obtaining a targeted image of the anterior cruciate ligament according to magnetic resonance imaging. On the sagittal tomogram depicting a fragment of the anterior cruciate ligament, three REF lines 4 mm thick are built through a gap of 1 mm, three oblique coronal tomograms are obtained, one of them is selected with an image of the central part of the joint, on which three REF lines 4 mm thick are built through an interval of 1 mm, corresponding to the anatomical attachment of the anterior cruciate ligament to obtain three oblique-sagittal tomograms of the knee joint, one of which shows a complete undistorted image of the anterior cruciate ligament (RF Patent No. "Kuzina I.R., Tolkaeva Zh.A., Aleinikov R.V., 2001). Also known is a method for obtaining a targeted image of the posterior cruciate ligament according to magnetic resonance imaging. On a sagittal tomogram with a partial image of the posterior cruciate ligament, 5 REF lines with a slice thickness of 4 mm are built, and 5 tomograms are obtained in the oblique coronal projection through a gap of 0 mm. From the obtained 5 oblique coronal tomograms, one is selected, which shows the central section of the joint, the anterointernal section of the medial condyle of the femur and the posterior intercondylar fossa of the tibia. On this tomogram, according to the anatomical attachment of the posterior cruciate ligament, 5 REF lines are built with a slice thickness of 4 mm through a gap of 0 mm. On one of these tomograms, a complete undistorted image of the posterior cruciate ligament is obtained (RF Patent No. 2173952 "Method for obtaining an image of the posterior cruciate ligament of the knee joint with magnetic resonance imaging" Kuzina I.R., Tolkaeva Zh.A., Aleinikov R.V., 2001). The disadvantages of these methods include a narrowly specialized spectrum of the considered pathology, limited within the framework of one ligamentous structure, an increase in the study time due to the addition of appropriate protocols.

A known method for diagnosing the internal structures of the knee joint by magnetic resonance imaging of the knee joint, in which, additionally, a block of 21 slices 4 mm thick with an interslice interval of 0.4 mm, weighted by proton density with a fat suppression algorithm, the direction of the slices is oblique-sagittal along the outer contour of the lateral condyle of the femur, parallel to the plane of the cruciate ligaments, with a turn of the meniscus plane at an angle, obtaining complete images of the cruciate ligaments and menisci in all anatomical regions (RF Patent No. 2656562 "Method diagnostics of internal structures of the knee joint” Stulov A.S., Tarasov A.N., 2018). The disadvantages of this method include the narrowly specialized spectrum of the pathology under consideration, which is limited only to the internal structures of the joint.

The closest to the proposed method is the standard MRI diagnostics in 3 mutually perpendicular planes, which allows you to see all the bones and ligaments of the joint, to suggest the extent of the lesion (Meller T.B. Styling and modes for magnetic resonance imaging / T.B. Meller, E Raif, translated from German, under the general editorship of Sh.Sh Shotemor, 2nd ed., Moscow: MEDpress-inform, 2014, pp. 142-145). However, the study is performed only in one joint, which excludes the possibility of a one-time synchronous comparative analysis with the opposite limb, with a sequential study of two joints, the scanning time is doubled.

The present invention is aimed at improving the accuracy of diagnosing all bone and soft tissue structures of two joints at the same time, including taking into account the synchronous comparative analysis in MRI without increasing the scanning time.

The specified technical result is achieved by the fact that the scanning of both joints is carried out at the same time, laying the patient in the supine position, while the lower limbs are parallel in a neutral position relative to internal and external rotation in the hip joints with flexion in the knee joints by 20 degrees by placing in the popliteal pits of the roller, reaching the formation of a parallel horizontal arrangement of the posterior contours of the condyles of the femur relative to the plane of the table.

The proposed method is explained by drawings where:

Fig. 1 is a general view of the laying and positioning of the radiofrequency coil for a one-stage MRI examination of 2 knee joints.

Fig. 2 - sighting view of the stacking for a one-time MRI study of 2 knee joints.

Fig. 3 - a viewing MP tomogram in a transval plane; a line of parallel horizontal arrangement of the posterior contours of the condyles of the femur relative to the plane of the table.

Fig. 4 - a viewing MP tomogram in the coronal plane; the lines indicate guided orthogonal planes corresponding to the standard direction of the slices, symmetrically for both joints.

The proposed invention is explained by the following details:

- scanning - the process of reading information (in the present study, an MP tomograph by means of complex physical and mathematical hardware calculations);

- laying the patient - a certain specially achieved static position of the body relative to the examining apparatus (in this study - MRI), which allows obtaining more information after scanning;

- neutral position - for the hip joints, the extension of the hips is considered to be located in the axis of the body with the patellas facing anteriorly (Marx V.O. Orthopedic diagnostics: a guide / V.O. Marx. Minsk: Science and technology, 1978. - 511 s .);

- terminology: "internal rotation", "external rotation", "flexion" - types of limb movements in orthopedics;

- terminology: "hip joints", "knee joints", "popliteal fossae", "posterior contours of the condyles of the femur" - human anatomical regions.

The method is as follows.

The study is carried out on a Siemens Magnetom Avanto magnetic resonance tomograph with a magnetic field induction of 1.5 T using a Siemens multi-channel abdominal coil in three orthogonal planes.

The patient is placed in the supine position on the table deck, while the lower limbs are parallel in a neutral position with respect to internal and external rotation in the hip joints with flexion in the knee joints by 20 degrees by placing a roller in the popliteal fossae, thereby achieving the formation of a parallel horizontal arrangement of the posterior limbs. The contours of the femoral condyles relative to the plane of the table (Fig. 1-4). The time spent on simultaneous scanning of both knee joints, according to the proposed method, is 30 minutes. The time required to scan one joint according to the standard technique (prototype) is also 30 minutes, that is, the proposed scanning method is 2 times faster than sequentially scanning each of the joints using the standard technique.

An original Siemens abdominal coil is installed on the table deck of a magnetic resonance tomograph, which is placed on top of the joints under study (Fig. 1-2), fixed with tourniquets, the empty space is filled with soft elements, thereby fixing the static position of the joints. Then the table with the patient is started in the magnet tunnel. The research protocol is launched on the working console.

The anatomical structure, direction, structure, MP signal from the bone and soft tissue structures of both knee joints are studied. The planes of all structures in both joints coincide identically (Fig. 3-4), which allows them to be critically evaluated and more likely to make the right conclusion.

Slicing according to the standard technique using a quadrature knee coil does not require such critical stacking, but the study of 2 joints using the standard technique takes double the time and excludes the possibility of synchronous simultaneous comparative evaluation. The construction of sections using the abdominal coil, but without the proposed stacking method, violates the concept of orthogonal planes for both joints, which leads to a sharp decrease in the information content of the study.

This method allows accurately diagnosing the degree of ruptures of ligaments and tendons, differentiating dysplastic bone changes from variant anatomy, as well as identifying cartilage and meniscus damage in comparison with the opposite joint. Scan time does not increase.

The proposed method was successfully tested on 64 patients during 2018-2020. The studies were carried out on the basis of the diagnostic center LLC "LDC MIBS - Astrakhan".

Below are the test results.

Example 1. Patient S., born in 1995 was sent for examination to the MRI diagnostic center of MIBS in Astrakhan from a trauma center by a traumatologist with a diagnosis of a fracture of the patella of the right knee joint. From the anamnesis: he has been professionally engaged in handball for 8 years, he was injured 3 days ago, when he collided with an opponent during training and received a direct blow to the anterior joint. After the impact, he felt a sharp pain, about which, after the appearance and increase in edema, he went to the emergency room, where they performed a clinical examination and X-ray examination, according to the results of the latter, no bone-traumatic changes were found. A diagnosis of internal damage to the right knee was made. At the time of the study, during examination, the right knee joint was enlarged in volume, movements in it were limited, the patient protected his leg when walking. To begin with, a standard MP-tomographic study of the joint was carried out in order to determine the extent of damage for preoperative planning; it was found: the phenomenon of trabecular edema of the patella, damage to the cartilage of the patella by the type of crack, the phenomenon of post-traumatic synovitis. A zone of separation of the bone contour along the lateral surface was also identified, suspicious for a fracture, as well as for a developmental variant of the type of doubling of the patella. To compare and identify the nature of the formation of this zone, scanning of both joints was performed simultaneously, for this the patient was laid in the supine position, while the lower limbs were parallel in a neutral position relative to internal and external rotation in the hip joints with flexion in the knee joints by 20 degrees by placement in the popliteal fossa of the roller, thereby achieving the formation of a parallel horizontal arrangement of the posterior contours of the condyles of the femur relative to the plane of the table. According to the results of the study in the opposite joint, an identical intraosseous zone was noted along the lateral surface in shape and localization, which to a greater extent indicated the presence of an anatomical variant of the type of doubling of the patella. According to the results of MRI of two joints at the same time, a decision was made in favor of conservative treatment - physiotherapy for 10 days. The patient then returned to full-fledged sports without any complaints.

Example 2. Patient 3., born in 1975. was sent from the district clinic by an orthopedic traumatologist for examination to the MRI diagnostic center for MIBS in Astrakhan with a diagnosis of arthrosis of the 1st degree of the right knee joint. There was no recent traumatic history; over the past two years, the patient gained weight by 25 kg, performed increased physical activity (running). Aching pain in the area of both knee joints began to be noted over the past 5 months, several times I noticed episodes of joint jamming. It was treated independently by taking analgesic drugs. On examination, the right knee joint was moderately swollen, movements in it were moderately limited, painful, accompanied by the sounds of "crunching", "rubbing", periodically - "clicking". On the presented survey radiographs of the right knee joint, there were no convincing data for the presence of bone-traumatic injuries, there was a thickening of the articular surfaces. A standard MRI scan of the right knee joint was performed, which revealed a widespread defect in the articular cartilage of both condyles of the medial joint, with the formation of a large zone of osteonecrosis of the medial femoral condyle, bone growths at the articular ends, degenerative rupture of the medial meniscus, and a moderate amount of fluid in the joint cavity. Taking into account the history of episodes of pain in the opposite joint, in order to exclude similar changes, it was decided to scan both joints at the same time, for this the patient was laid in the supine position, the lower limbs were placed parallel in a neutral position relative to internal and external rotation in the hip joints with flexion in the knee joints by 20 degrees by placing a roller in the popliteal fossae, thereby achieving the formation of a parallel horizontal arrangement of the posterior contours of the condyles of the femur relative to the plane of the table. According to the results of the study, a zone of osteonecrosis was also revealed in the left joint on the side of the medial femoral condyle and a degenerative rupture of the medial meniscus. Based on the results of MRI, a decision was made in favor of surgical treatment with meniscus resection, abrasive chondroplasty with further monitoring over time.

Example 3 Patient A., born in 1995 was sent from the city polyclinic by an orthopedic traumatologist for examination to the MRI diagnostic center for MIBS in Astrakhan with a preliminary diagnosis of chronic damage to the ligamentous apparatus of the right knee joint. There was no recent traumatic history, but noted an injury to this joint more than 4 years ago. During this time, complaints of severe instability and looseness in the joint, instability in gait, pain, limitation of movement. Have not received treatment before. On examination, the right joint is not edematous, the movements are in full, moderately painful, accompanied by a "click" sound. On the presented survey radiographs of the right ankle joint, there were no data for the presence of bone-traumatic injuries, manifestations of gonarthrosis of I-II degrees were noted. A standard MRI scan of the right knee joint was performed, which revealed thickening of the medial collateral ligament and anterior cruciate ligament, heterogeneity of their MP signal, which suggested the presence of chronic damage, however, it was not possible to assess the severity of the changes. For a comparative analysis and clarification of the degree of damage to the ligaments, it was decided to scan both joints at the same time, for this the patient was laid in the supine position, the lower limbs were parallel in a neutral position relative to internal and external rotation in the hip joints with flexion in the knee joints by 20 degrees by placing a roller in the popliteal fossae, thereby achieving the formation of a parallel horizontal arrangement of the posterior contours of the condyles of the femur relative to the plane of the table. According to the results of the study, a comparative analysis of the ligamentous complex of both joints revealed a complete rupture of the anterior cruciate ligament with the formation of scar tissue, a partial rupture of the medial collateral ligament, which was subsequently confirmed during surgery.

Thus, the method for diagnosing the pathology of the knee joints using magnetic resonance imaging increases the diagnostic accuracy and does not increase the scanning time, which allows the doctor to decide on the tactics of treating patients in a timely manner. Also, the method is non -invasive. The method is offered to wide implementation in practice.

Claims (1)

A method for diagnosing pathology of the knee joints using magnetic resonance imaging, characterized in that both joints are scanned at the same time, placing the patient in a supine position, while the lower limbs are parallel in a neutral position relative to internal and external rotation in the hip joints with flexion in knee joints by 20 degrees by placing a roller in the popliteal fossae, achieving the formation of a parallel horizontal arrangement of the posterior contours of the femoral condyles relative to the plane of the table.

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