Magnetic resonance imaging of proximal tibial fractures in short-distance runners

Transcription

1 Magnetic resonance imaging of proximal tibial fractures in short-distance runners Poster No.: C-0781 Congress: ECR 2015 Type: Scientific Exhibit Authors: A. Tagliafico, B. Bignotti, S. Airaldi, F. Zaottini, G. Tagliafico, C. Martinoli; Genova/IT Keywords: DOI: Musculoskeletal bone, Musculoskeletal system, MR, Diagnostic procedure /ecr2015/C-0781 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 12

2 Aims and objectives To describe magnetic resonance (MR) imaging findings of the tibia in novice symptomatic short-distance runners. Methods and materials Patient selection The study was approved by the Local Ethics Committee and written informed consent was obtained. Between June 2012 and September 2014, we prospectively included novice runners with written request for MR imaging evaluation of the knee. We considered novice runners who began to run the previous two months and followed a short-distance program (below 4 miles per session and/or below 12 miles per week). All patients had previous negative standard radiographic examinations of the knee performed in the previous months from the MR imaging. Exclusion criteria were: age under 18 years; contraindications to MR imaging; injury of the lower extremity in the last 3 months before MR imaging; pregnancy; and history of a cardiovascular, pulmonary, endocrine, metabolic, neurological, neuromuscular, oncological or musculoskeletal disorder, previous head and spinal surgery. MR imaging was performed within two months the end of the short-distance program. Baseline characteristic, including age, body mass index, running experience, sport activities, previous injury at the lower extremities, were recorded. Running experience was considered a previous participation on running on a regular basis as described in literature [11]. Associated sport activities practiced beyond running were subdivided into axial loading (eg. tennis) and without axial loading (eg. swimming). MR imaging The MR imaging examination was performed using both a GE Signa HDxt 3.0 T scanner (General Electric Medical Systems, Milwaukee, WI, USA) with a 2-channels phasedarray extremity coil and with a 1.5 T Siemens with an 8 channels knee coils depending on scanner availability. The subject was positioned supine with the knee extended and Page 2 of 12

3 fixed with a fitting pad to avoid motion. Table 1 shows MR imaging protocol for knee examination. The MR imaging protocol included T1-turbo spin-echo (T1-TSE) sequence and an axial T2-turbo spin-echo (T2-TSE) sequence with fat saturation in all three planes. For the clinical suspect, we considered not necessary to perform diffusion-weighted sequences and contrast enhance weighted sequences. The total acquisition time of the entire MR imaging protocol was 30 min approximately. The MR images were fully anonimized and stored in a dedicated study hard disk different from that of the Hospital. A unique code was assigned to each image set. We added 40 data sets with negative MR imaging of the knee randomly selected from our radiological research database. The image sets were randomised in reading sequence for the purpose of interpretation using a randomisation table made in Excel (Microsoft, version for Mac), to keep authors blind to clinical data, as previously describe in literature [16]. Two authors (A.T. and B.B.), with 7 and 3 years of experience in musculoskeletal imaging and MR imaging research respectively, evaluated all MR images independently and in different sessions. The two authors were not involved in the previous sections of this study and were blinded to clinical symptoms. The same authors, blinded to the initial results, repeated the image analysis 4 weeks after the initial session, to assess intraobserver variability. The grading system of Fredericson [10] were used for MR images evaluation: - grade 0: normal MR imaging findings; - grade 1: periosteal edema or reaction; - grade 2: bone marrow edema on T2-weighted fat-suppressed images; - grade 3: high signal intensity in the marrow on T2-weighted fat-suppressed images and low signal intensity in the marrow on gradient-echo T1-weighted images; - grade 4: fracture line. Page 3 of 12

4 Bone marrow edema (BME) was classified as presence of cloud-like and amorphous with indistinct margins of increased T2-weighed images. This patchy pattern of BME was not measured due to their discontinued margins, as suggested by previous report [2]. Medial, central or lateral location of the findings within the tibia was given. In addition, presence and grade (mild, moderate, severe) of effusion and the presence of knee bursitis were recorded. Statistical Analysis Statistical analysis was performed by one author, with 8 years of experience in statistical analysis, using statistical software (SPSS, version , SPSS, Excel 2007, Microsoft and MedCalc, Version 11.4-MedCalc Software, Broekstraat 52, 9030 Mariakerke, Belgium). Descriptive statistics were used for MR imaging findings. Intra- and inter-reader agreement for tibial stress reaction was determined by using generalised weighted K statistics and was classified as excellent (k values > 0.80), good (k = ), moderate (k = ), fair (k = ), or poor (k #0.20) [17]. The Pearson test and linear regression analysis were used to correlate tibial stress reactions with patient's age, body mass index, previous injury at the lower extremities, previous running experience and previous sport activities. P<0.05 was considered statistically significant for all statistical testing. Results Forty knees MR imaging evaluations of thirty-eight adult patients were performed. The mean body mass index was calculated as weight in kilograms/height in meters: males 23 ± 3; females 22 ± 4; the patient age was: males: 42 ± 11; females 39± 10. Patients' characteristics are shown in Table 2. Page 4 of 12

5 Concerning previous running experience, it was the first running experience in 21 patients. Associated sport activities practiced beyond running were determined in 16 novice runners. N=11 novice runners declared to had had a previous injury at the lower extremities, but in all the cases injuries occurred at least twelve months before begin to run. In all cases previous injuries were at the level of the tibia. N=26 MR imaging exams were done using the 1.5-T equipment and total of 14 exams using the 3.0-T equipment. MR imaging revealed tibial stress reactions in four knee MR examinations. Among stress reactions, two patients presented a grade 4 tibial stress reaction, one patient presented MR imaging findings classified as grade 3 tibial stress reaction bilaterally. No tibial stress reactions were found in the others 36 knees. MR imaging showed bursitis (one prepatellar, five semimetendinosus and gastrocnemius bursitis) and effusion in six knees, including three patients with tibial stress reactions and two patients with no tibial stress reaction. Table 3 shows MR imaging findings and the corresponding grade. All of the tibial stress reactions were observed at the level of the medial tibial plate. Figures 1 to 3 show tibial stress reactions found in three novice runners. Overall intra- and inter-observer agreement with 95% confidence intervals (95%CI) among the two readers were 0.73% (95%CI: 0.68%-0.88%) and 0.71% (95%CI: 0.66%-0.85%). K values are reported as weighted with linear weights and are considered good. No significant correlation of patient's age and body mass index and previous injury at the lower extremities and stress reaction was observed (p values not significant). A negative correlation between previous running experience and additional sport activities and tibial stress reaction (r2=0,15; 95% confidence interval for r2: 0.08 to 0.20; P=0.05; and r2=0,13; 95% confidence interval for r2: 0.07 to 0.18; P=0.05, respectively) was found. Table 1: MR imaging protocol Page 5 of 12

6 Repetition time (ms) T1-w TSE sequences T2-w TSE fat-suppresed sequence 3-T MR imaging 1,5-T MR imaging 3-T MR imaging 1,5-T MR imaging Echo time (ms) Flip angle FOV Voxel size (mm) 0.2x0.2x2 0.2x0.2x2 0.2x0.2x2 0.2x0.2x2 Matrix 320x x x x320 Slice thickness (mm) Phase resolution Echo train length per slide Bandwidth Hz/ px SAR (W/kg body weight) Acquisition time 5 min. 14 s 5 min. 45 s 5 min. 10 s 6 min. 36 s Table 2: Patients' characteristics. Novice runner (=38) Age, mean ± SD years 40 ± 12 Female (%) 15 (39,4%) Male (%) 23(60,6%) Body mass index, 23 ± 5 Page 6 of 12

7 mean ± SD years Running experience (%) Yes 17 (44,7%) No 21 (55,3%) Sport activities No 22 (57,9%) With axial load 10 (26,3%) Without axial load 6 (15,8%) Previous injury at the lower extremities No 27 (71%) >12 months 11(29%) Table 3: MR imaging findings Total knee evaluated (=40) Tibial stress reaction Grade 0 36 Grade 1 0 Grade 2 0 Grade 3 2 Grade 4 2 Location of tibial stress reaction Medial 4 Lateral 0 Bursitis or effusion 6 mild 3 moderate 2 severe 1 Page 7 of 12

8 Images for this section: Fig. 1: Figure 1: A 41 years old woman with bilateral knee pain. MR imaging coronal T1- weighted (a,c) and T2-weighted fat-suppressed images show a tibial stress reaction of grade 3, according to Fredericson's grade, at the level of medial tibial plate, bilaterally. (a,b) Right knee; (c,d) Left knee. Page 8 of 12

9 Fig. 2: Figure 2: A 45 years old man with left knee pain. MR imaging sagittal T1-weighted (a) and T2-weighted fat-suppressed (b) and coronal T1-weighted images (c) show a distinct fracture line at the level of the medial tibial plate (grade 4 of tibial stress reaction). Fig. 3: Figure 3: A 40 years old man with left knee pain. MR imaging coronal T1-weighted (a) and T2-weighted fat-suppressed (b) images show a distinct fracture line at the level of the medial tibial plate (grade 4 of tibial stress reaction). Page 9 of 12

10 Conclusion Tibial stress injuries may occur in novice short-distance runners. MRI can efficiently demonstrate tibial stress reactions in novice symptomatic short-distancerunners. Tibial fracture in novice short-distance runners occurred in the medial tibial plate. Personal information References 1. Jones BH, Thacker SB, Gilchrist J, Kimsey CD Jr, Sosin DM. (2002) Prevention of lower extremity stress fractures in athletes and soldiers: a systematic review. Epidemiol Rev 24: Hadid A, Moran DS, Evans RK, Fuks Y, Schweitzer ME, Shabshin N. (2014) Tibial Stress Changes in New Combat Recruits for Special Forces: Patterns and Timing at MR Imaging. Radiology 273: Yagi S, Muneta T, Sekiya I. (2013) Incidence and risk factors for medial tibial stress syndrome and tibial stress fracture in high school runners. Knee Surg Sports Traumatol Arthrosc 21: Bennell K, Matheson G, Meeuwisse W, Brukner P. (1999) Risk factors for stress fractures. Sports Med 28: Shipway R, Holloway I. (2010) Running free: embracing a healthy lifestyle through distance running. Perspect Public Health130: Ooms L, Veenhof C, de Bakker DH. (2013) Effectiveness of Start to Run, a 6-week training program for novice runners, on increasing health-enhancing physical activity: a controlled study. BMC Public Health13:697 Page 10 of 12

11 7. Buist I, Bredeweg SW, van Mechelen W, Lemmink KA, Pepping GJ, Diercks RL. (2008) No effect of a graded training program on the number of running-related injuries in novice runners: a randomized controlled trial. Am J Sports Med 36: Gaeta M, Minutoli F, Scribano E, Ascenti G, Vinci S, Bruschetta D, et al. (2005) CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology 235: Kiuru MJ, Pihlajamaki HK, Hietanen HJ, Ahovuo JA. (2002) MR imaging, bone scintigraphy, and radiography in bone stress injuries of the pelvis and the lower extremity. Acta Radiol 43: Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. (1995) Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med 23: Bergman AG, Fredericson M, Ho C, Matheson GO. (2004) Asymptomatic tibial stress reactions: MRI detection and clinical follow-up in distance runners. AJR Am J Roentgenol 183: Gaeta M, Minutoli F, Vinci S, Salamone I, D'Andrea L, Bitto L, et al. (2006) Highresolution CT grading of tibial stress reactions in distance runners. AJR Am J Roentgenol 187: Vossinakis IC, Tasker TP. (2000) Stress fracture of the medial tibial condyle. Knee 7: Wall J, Feller JF. (2006) Imaging of stress fractures in runners. Clin Sports Med 25: Buist I, Bredeweg SW, Lemmink KA, van Mechelen W, Diercks RL. (2010) Predictors of running-related injuries in novice runners enrolled in a systematic training program: a prospective cohort study. Am J Sports Med 38: Tagliafico A, Mariscotti G, Durando M, Stevanin C, Tagliafico G, Martino L. (2015) Characterisation of microcalcification clusters on 2D digital mammography (FFDM) and digital breast tomosynthesis (DBT): does DBT underestimate microcalcification clusters? Results of a multicentre study. Eur Radiol 25:9-14 Page 11 of 12

12 17. Altman DG, Gardner MJ. (1989) Statistics with Confidence - Confidence Intervals and Statistical Guidelines, BMJ, London, Gallo RA, Plakke M, Silvis ML. (2012) Common leg injuries of long-distance runners: anatomical and biomechanical approach. Sports Health 4: Subburaj K, Kumar D, Souza RB, Alizai H, Li X, Link TM, et al. (2012) The acute effect of running on knee articular cartilage and meniscus magnetic resonance relaxation times in young healthy adults. Am J Sports Med 40: Froeling M, Oudeman J, Strijkers GJ, Maas M, Drost MR, Nicolay K, et al. (2014) Muscle Changes Detected by Diffusion-Tensor Imaging after Long-Distance Running. Radiology 3: [Epub ahead of print] 21. Kornaat PR, Van de Velde SK. (2014) Bone marrow edema lesions in the professional runner. Am J Sports Med 42: Dao D, Sodhi S, Tabasinejad R, Peterson D, Ayeni OR, Bhandari M, et al. (2014) Serum 25-Hydroxyvitamin D Levels and Stress Fractures in Military Personnel: A Systematic Review and Meta-analysis. Am J Sports Med pii: [Epub ahead of print] 23. Tagliafico AS, Ameri P, Bovio M, Puntoni M, Capaccio E, Murialdo G, et al. (2010) Relationship between fatty degeneration of thigh muscles and vitamin D status in the elderly: a preliminary MRI study. AJR Am J Roentgenol 194: Bignotti B, Cadoni A, Martinoli C, Tagliafico A. (2014) Imaging of skeletal muscle in vitamin D deficiency World J Radiol 6: Page 12 of 12