insufficiency fracture knee radiology

Standard weight-bearing anteroposterior (AP) radiographs at 0 and 30 of flexion, sunrise radiographs, and lateral radiographs of the knee should be ordered to evaluate the level of osteoarthritis or presence of osteochondritis dissecans lesions. All 10 complications occurred between 2 and 9 months after injection: six (60%) in the hip and four (40%) in the knee. about navigating our updated article layout. Post-arthroscopic osteonecrosis of the medial tibial plateau: a case series. The typical findings of subchondral insufficiency fracture of the knee on magnetic resonance imaging (MRI) include cortical thickening associated with high-intensity MRI scans and the identification of risk factors and associated lesions. We use cookies to help provide and enhance our service and tailor content. At 1 year postoperatively, the patient had complete resolution of knee pain and was able to resume working. Typical MRI findings in insufficiency fractures include a pattern of bone marrow edema with a low-signal-intensity line (resp. sharing sensitive information, make sure youre on a federal . Epub 2018 Aug 17. The histopathological findings suggest that the primary event leading to spontaneous osteonecrosis of the knee is a subchondral insufficiency fracture and that the localized osteoarthritic changes seen in association with this disease is the result of a fracture. " " - . Subchondral insufficiency fracture of the knee (SIFK) is a potentially devastating disorder that may progress rapidly to osteoarthritis with articular surface collapse. Unable to load your collection due to an error, Unable to load your delegates due to an error. Histopathologic findings of spontaneous osteonecrosis of the knee at an early stage: a case report. Yuna Inaba, Kosuke Makihara, and Masanori Hisaoka, who diagnosed the patient and obtained photographs of resected specimens and histological images. The authors declare that there are no conflicts of interest. Low-intensity pulsed ultrasound modulates RhoA/ROCK signaling of rat mandibular bone marrow mesenchymal stem cells to rescue their damaged cytoskeletal organization and cell biological function induced by radiation. Of the included 1000 patients, 545 (54%) were women, but they had nine of the 10 (90%) complications ( P = .02). If diagnosed early enough, conservative therapy may lead to healing without subsequent collapse and fragmentation of the subchondral bone. Spontaneous osteonecrosis of the knee: the result of subchondral insufficiency fracture. After perioperative ifosfamide and doxorubicin chemotherapy and surgical resection, adjuvant radiation therapy was administered, with a total of 60 Gy in 30 fractions. (1999) Seminars in arthritis and rheumatism. Marshall RA, Mandell JC, Weaver MJ, Ferrone M, Sodickson A, Khurana B. , , Two cases of subchondral insufficiency fractures of the femoral head are reported, and magnetic resonance imaging establishes the diagnosis and rules out other conditions. recruited the patient, performed the operation, and provided supervision in writing the manuscript. Characterization and pathological characteristics of spontaneous osteonecrosis of the knee. We appreciate the help of Dr. Sanshiro Inoue in the discussion section. We report a case of radiation-associated insufficiency fracture of the tibial plateau after surgery and RT for synovial sarcoma of the calf that was successfully treated with LIPUS. The typical findings of subchondral Mears SC, McCarthy EF, Jones LC, Hungerford DS, Mont MA. will also be available for a limited time. Federal government websites often end in .gov or .mil. Epub 2021 Nov 29. Radiographs are the initial imaging test in patients with pain localized to the skeleton. Corresponding Author: Tomoya Matsunobu, e-mail: Received 2021 Aug 11; Revised 2021 Nov 29; Accepted 2021 Oct 27. We adopted the spacer block technique and resected the tibia first. Subchondral insufficiency fracture of the knee: review of current concepts and radiological differential diagnoses. Depending on the tumor location, concomitant surgical resection of the periosteum might be required; periosteum stripping and RT reportedly increase the risk of the pathological fracture [4]. Looser zones are also a type of insufficiency fracture. It should also be noted that multiple pelvic insufficiency fractures are frequently found, particularly in the presence of pubic or acetabular fractures, and careful search for concomitant fractures is warranted. , , , , , , . sharing sensitive information, make sure youre on a federal AJR Am J Roentgenol. Outcome of SIFK depends on several factors, including the initial subchondral fracture size, patient BMI, degree of osteopenia. This site needs JavaScript to work properly. Subchondral insufficiency fractures of the knee (SIFK) are painful, nontraumatic fractures that occur predominantly in the medial femoral condyle of postmenopausal osteoporotic women in their fifth and sixth decades of life. Therefore, a simple and easy method to accelerate radiation-associated fracture healing must be developed. Preoperative CT. (a) Axial and (b) coronal plain CT images of left knee demonstrated flattening of the lateral femoral condyle and a subchondral lesion. For conventional tibial plateau fractures, internal fixation with locking plates using the minimally invasive percutaneous osteosynthesis technique could be an option. Accuracy for differentiating malignant fractures from stress fractures was reported to be highest with MRI (9398%) followed by CT (8288%) and radiographs (8894%) (Fayad et al. The patients pain was exacerbated with knee extension. Treatment of post-radiation fractures can be challenging. Regarding radiological investigations, the radiographs usually show no characteristic findings at early stages of the disease. Dickie CI, Parent AL, Griffin AM, et al. The treatment regime based on high-dose vitamin D administered orally and intravenous application of 3mg ibandronate two times within 8weeks decreased the pain level and functional limitations within a short-time period and eliminated the pathological findings in the MRI of all cases studied. . Pathology They tend to occur when normal physiological forces are repeatedly applied to an area of bone. Osteoporosis is the most common cause of insufficiency fractures, although there are many causes 7-9: ADVERTISEMENT: Supporters see fewer/no ads. 2022 The Authors. National Library of Medicine This is the first case report to describe the multiple occurrence of collapsed subchondral insufficiency fracture both in the femoral head and medial femoral condyle in a 69-year-old obese man. (c) Sagittal proton-density-weighted fat-suppressed sequence showed a displaced osteochondral lesion. By clicking accept or continuing to use the site, you agree to the terms outlined in our. There was no collapse or deformity of the knee joint. We appreciate the help of Drs. Radiation-associated pathologic fractures tend to have a high nonunion rate and could be a major cause of morbidity. Spontaneous osteonecrosis of the lateral femoral condyle of the knee: a report of 11 cases. The site is secure. The https:// ensures that you are connecting to the https://radsource.us/subchondral-insufficiency-fracture-of-the-knee , SIT. . Polymerase chain reaction showed SS18-SSX1 gene rearrangement (data not shown). This work is licensed under Creative Common Attribution-NonCommercial-NoDerivatives 4.0 International (, Fractures, Bone; Radiotherapy; Sarcoma; Ultrasonic Waves. Magnetic resonance imaging (MRI) showed a tumor with clear margins in the popliteus muscle. Subchondral insufficiency fractures are non-traumatic fractures that occur immediately below the cartilage of a joint. (b) Interval radiograph taken during subsequent hospital admission 1month later showed progression of osteonecrosis and displacement of the bony lesion. Whether new arthroscopic techniques can provide the necessary intervention to halt osteoarthritic sequelae remains unanswered. J Med Case Rep. 2016 Oct 19;10(1):291. doi: 10.1186/s13256-016-1063-8. , . In addition, fractures involving the wrist are known to be strongly associated with osteoporosis. The answer appears to be "maybe" as non-weight-bearing conservative therapy has not consistently prevented progression of the disease. Patients with subchondral insufficiency fracture characteristically have unremarkable plain radiographs, while MRI examination may reveal extensive bone marrow edema and subchondral bone collapse. Subchondral insufficiency fractures of the knee is also known as spontaneous osteonecrosis of the knee (SONK). 1 article features images from this case Low bone mineral density is associated with the onset of spontaneous osteonecrosis of the knee. Re-evaluation of low intensity pulsed ultrasound in treatment of tibial fractures (TRUST): Randomized clinical trial. Effect of ibandronate on spontaneous osteonecrosis of the knee: a randomized, double-blind, placebo-controlled trial. To update your cookie settings, please visit the, Distal Femoral Replacement and Extensor Mechanism Repair Reinforced With Synthetic Mesh for Distal Femur Fracture With Patellar Ligament Avulsion. Case study, Radiopaedia.org (Accessed on 05 Dec 2022) https://doi.org/10.53347/rID-88093 PMC legacy view Careers. We assumed that this insufficiency fracture resulted from the stripping of the periosteum from the proximal tibia and adjuvant RT. (D) T2-weighted coronal image. An important differential diagnosis of a stress/insufficiency fracture is a fracture due to malignant disease. Insufficiency fracture. Insufficiency fractures are a type of stress fracture, which are the result of normal stresses on abnormal bone. They should not be confused with fatigue fractures which are due to abnormal stresses on normal bone, or with pathological fractures, the result of diseased, weakened bone due to focal pathology such as tumours Subchondral insufficiency fracture of the knee is Low-intensity pulsed ultrasound accelerates rat femoral fracture healing by acting on the various cellular reactions in the fracture callus. The patient was treated with LIPUS for 1 year. This article presents a 51-year-old postmenopausal woman, a physician, who had subchondral insufficiency fractures of the knee associated with prolonged standing during clinical work and was treated with partial weight bearing on crutches and viscosupplementation to improve bone healing. Imaging Features and Management of Stress, Atypical, and Pathologic Fractures. For the patients with advanced disease who failed conservative management, TKA has been the last-resort treatment. Department of Orthopaedics and Traumatology, Tuen Mun Hospital, Tuen Mun, New Territories, Hong Kong. The timeline of the clinical course is summarized in Figure 7. More cases are needed to gather more therapeutic experience. Distinct radiolucent areas at the lateral femoral condyle may be observed in advanced cases with subchondral collapse. The new PMC design is here! Subchondral insufficiency fracture of the knee (SIFK) is a potentially devastating disorder that may progress rapidly to osteoarthritis with articular surface collapse. mri features that aid in diagnosis of acute traumatic injuries, subchondral insufficiency fracture, and its potentially irreversible form, spontaneous osteonecrosis of the knee include the location and extent of bone marrow edema, the presence of a fracture line, a hypointense area immediately subjacent to the sub chondral bone plate, and The treatment of idiopathic osteonecrosis of the medial femoral condyle with arthroscopic debridement. The lesion had low and high signal intensity on T1- and T2-weighted images, respectively (Figure 2). After 2 courses of adjuvant chemotherapy with ifosfamide and doxorubicin hydrochloride, adjuvant RT was administered, with a total of 60 Gy in 30 fractions (Figure 4). February 9, (c) Sagittal images showed a displaced intra-articular radiopaque curvilinear fragment. Kaplan P. Musculoskeletal MRI. JJ Abstract Subchondral insufficiency fracture of the knee (SIFK) is a common cause of knee joint pain in older adults. The features seen on CT are bone marrow abnormality which may be well-defined, ill-defined, permeative or moth-eaten, endosteal scalloping, periosteal reaction, and a soft-tissue mass. 8600 Rockville Pike Since soft tissue sarcoma has moderate radiation sensitivity, the recommended postoperative radiation dose is 6066 Gy in 1.82 Gy fractions [3]. The surrounding bone edema often involving the entire femoral condyle is in contrast to the more localized edema adjacent to cartilage loss observed in cases of osteoarthritis [. Subchondral insufficiency fracture refers to a type of stress fracture that occurs below the chondral surface on a weight-bearing surface of a bone due to mechanic failure of March 28, One of the important differential diagnoses of subchondral insufficiency fractures of the femoral head may include osteonecrosis. Spontaneous insufficiency fracture of the knee is a potentially devastating yet poorly understood disease entity that can lead to secondary osteoarthritis. Department of Orthopaedics and Traumatology, Tuen Mun Hospital, Tuen Mun, New Territories, Hong Kong. 3. Osteochondral lesions of the knee: differentiating the most common entities at MRI. Insufficiency fracture. Initial management of spontaneous ON of the knee and postarthroscopic ON is typically nonsurgical, with observation for clinical or radiographic progression, and early surgical intervention is recommended. Knee pain had completely disappeared 1 year after initiation of LIPUS therapy. buzzword, , . The potential benefits include preservation of the native joint kinematics and proprioception, lower risk of deep vein thrombosis, and less total blood loss [. The answer appears to be "no" because early subchondral fractures and early spontaneous osteonecrosis of the knee are treated conservatively and only the later changes of subchondral surface collapse are treated more aggressively with joint replacement. Haas RL, Delaney TF, OSullivan B, et al. Her physical examination revealed a hard, tender, palpable 65 cm mass with moderate mobility under the right proximal calf without restriction of right knee range of motion. Histological examination of core needle biopsy specimens led to a pathological diagnosis of synovial sarcoma. While MRI is the most sensitive technique in the visualization of insufficiency fractures, CT sometimes tends to depict the extent and stability of these fractures better. Unicompartmental knee arthroplasty for spontaneous osteonecrosis of the knee: a meta-analysis. Patients with subchondral insufficiency fracture characteristically have Tel. There may be a fluid-filled cleft underlying the subchondral bone plate, indicating gross collapse and separation. (a) Anteroposterior and (b) lateral radiographs of left knee taken at 6 months postoperatively, and (c) scanogram of lower limbs taken on postoperative day 5, showing in situ UKA implants. Background. LIPUS accelerated the repair of fractures during various steps of the fracture repair process in an animal model [11]. Arthroscopic microfracture treatment for osteonecrosis of the knee. In five of the authors' most recent MRIs in patients It should be Subchondral insufficiency fracture of the knee (SIFK) is an important differential diagnosis for knee pain. The pain typically Recently, low-intensity pulsed ultrasound (LIPUS) has been widely used to treat fresh and nonunion fractures [6]. Radiographs taken 3 and 6 months after LIPUS demonstrated intramedullary callus around the transverse fracture line in the proximal medial tibia (Figure 5C, 5D, 5I, 5J). 2022. Helmstedter CS, Goebel M, Zlotecki R, Scarborough MT. Burgener FA, Kormano M, Pudas T. Bone and Joint Disorders. Dose distribution of the radiation therapy was shown. The distal femoral cut was guided by the spacer block in extension. We also assumed that this would be a refractory fracture. PET-CT excludes malignant fractures due to underlying disease, A common site of fragility fractures is the distal forearm. LIPUS is a clinically established treatment used to accelerate long bone fracture healing. SIFK is a type of stress fracture that occurs when repetitive and excessive stress , . Clinical management of radiation-associated pathological fracture is challenging because of a high nonunion rate and potential for morbidity. All authors read and approved the final manuscript. MB), Redistribute or republish the final article, Translate the article (private use only, not for distribution), Reuse portions or extracts from the article in other works, Distribute translations or adaptations of the article. 2000 Jun;82(6):858-66. doi: 10.2106/00004623-200006000-00013. Cruess RL. The histologic findings of avascular areas in biopsy specimens appear to be a secondary phenomenon and not the primary cause. Pathologic fractures after surgery and radiation for soft tissue tumors. There is a potential limitation in this study. MeSH At 5 months after surgery and 2 months after the completion of radiation therapy, she developed an insufficiency pathological fracture of the proximal tibia without any apparent trauma. Note the dose of 59 Gy was delivered to the posterior segment of the tibia (red line). Outcome of SIFK depends on several factors, including the initial subchondral fracture size, patient BMI, degree of osteopenia, as well as early diagnosis and initial treatment. , . Treatment depends on the location and whether the fracture is complete or incomplete. To the best of our knowledge, this is the first case report describing LIPUS being used to treat a radiation-associated insufficiency fracture. American volume. Options, therefore, include: Treatment of the underlying cause of bone weakness is also essential. 2001;40 (9): 1065-6. It is well-known that patients with distal radius fracture who are otherwise healthy have a preferential bone loss at the distal forearm. Please enable it to take advantage of the complete set of features! SIFK typically presents with acute knee pain localized to the area of the subchondral fracture [ 1, 2 ]. Spontaneous osteonecrosis of the knee: the result of subchondral insufficiency fracture. - . They are most often seen in the setting of osteoporosis, although any process which weakens bone is a risk factor. Obvious callus formation around the fracture site was observed at 3 and 6 months after treatment (arrows). First described in 1968, spontaneous osteonecrosis of the knee (SONK) is a distinct clinical entity that is a common cause of acute, unilateral knee pain and swelling. Published by Elsevier Inc. on behalf of The American Association of Hip and Knee Surgeons. MRI showed that the low-intensity area on T1-weighted images (Figure 6A, 6E, arrows) and the high-intensity area on short TI inversion recovery (STIR) images (Figure 6I, arrowhead) both decreased in size over time. DOI: https://doi.org/10.1016/j.artd.2022.04.002. The author(s) confirm that informed consent has been obtained from the involved patient(s) or if appropriate from the parent, guardian, power of attorney of the involved patient(s); and, they have given approval for this information to be published in this case report (series). Anteroposterior (AF) and lateral (GL) radiographs of the right knee taken immediately after the onset of the knee pain, and 1 month, 3 months, 6 months, 8 months, and 1 year after initiation of LIPUS therapy. Subsequent imaging studies revealed a spontaneous insufficiency fracture of the lateral femoral condyle. Findings include sclerosis, lytic fracture line, bone expansion, exuberant callus, and osteolysis. The patient remained free of symptoms and had no recurrences for 2 years after surgery. Radiographs of the knee was performed, but the patient was only reported to have degenerative joint disease (. appears to represent a subchondral insufficiency fracture another hypothesis is an association with a meniscal root tear Physical Exam Symptoms pain with weightbearing, especially sitting to standing Imaging Radiographs first line imaging studies AP knee lateral knee merchant view knee findings wedge-shaped lesion on imaging MRI most useful study (2017) Journal of children's orthopaedics. Posterior spinal fusion Th12-S1 with loosening of T12 pedicle screws, AP radiograph of the sacrum after orthopaedic trans-sacroiliac screw fixation of bilateral sacral insufficiency fractures at the S1 level, Axial CT image at the level of the hip joints demonstrates insufficiency fracture of the left pubic bone (. Parasymphyseal and pubic ramus fractures often are misinterpreted as malignant lesions. Case study, Radiopaedia.org (Accessed on 05 Dec 2022) https://doi.org/10.53347/rID-88093 Careers. 1Department of Orthopedic Surgery, Kyushu Rosai Hospital, Kitakyushu, Fukuoka, Japan, 2Department of Radiology, Kyushu Rosai Hospital, Kitakyushu, Fukuoka, Japan, Unusual or unexpected effect of treatment. In terms of safety, Busse et al reported no adverse events associated with LIPUS treatment in a randomized clinical trial (Re-evaluation of low-intensity pulsed ultrasound in treatment of tibial fractures (TRUST)) [14]. Subchondral insufficiency fracture of the knee: grading, risk factors, and outcome A SIFK grading system for MRI is introduced. 2016 May;45(5):713-6. doi: 10.1007/s00256-016-2328-4. Management of radiation-associated fractures. In this case report, a middle-aged lady with SIFK of the lateral femoral condyle was successfully treated with UKA with satisfactory improvement in symptom and functional performance. You will then receive an email that contains a secure link for resetting your password, If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password. , , , , -SIT . FOIA Anteroposterior radiograph of the pelvis demonstrates areas of sclerosis in both sacral ala (, Axial MRI (STIR-sequence) of the pelvis demonstrating bone marrow edema pattern in bilateral sacrum compatible with bilateral insufficiency fractures, Axial MRI (T1-w-sequence) demonstrating signal loss in both sacral ala compatible with bilateral insufficiency fractures in a 55-year-old woman after radiotherapy of the pelvis for cervical carcinoma, AP radiograph of both hip joints shows insufficiency fractures (, Coronal CT-reformation of the sacrum demonstrates sacral insufficiency fractures at S1 with fracture lines and sclerosis. Therefore, the entire popliteus muscle and the adjacent tibial periosteum were resected. Although skeletal complications are infrequent, radiation-associated bone fractures are still serious complications in 220% of patients treated with limb-sparing surgery and RT [7]. (2011). By definition,secondary osteonecrosis of the knee occurs secondary to an insult. On laboratory testing, serum calcium and phosphorus and renal and liver function were within normal limits. While prophylactic intramedullary nailing is a common approach for preventing radiation-associated fractures, especially in the diaphysis of long bones [4], it has been suggested that prophylactic nailing should not be routinely performed because the risk of fracture is low. The clinical data used during the current study are available from the corresponding author on reasonable request. Thus, it appears most patients with what has been called spontaneous osteonecrosis of the knee actually have subchondral insufficiency fractures. official website and that any information you provide is encrypted At 5 months after surgery and 2 months after the completion of radiation therapy, she developed an insufficiency pathological fracture of the proximal tibia without any apparent trauma. A healthy 52-year-old Japanese woman presented with a slowly growing, painful soft tissue mass over her proximal calf. in 1968, where a group of patients with atraumatic severe knee pain were found to have primary osteonecrosis [. Usually a concave or wedge-shaped deformity of the affected vertebra is found and a wide range of the vertebral height ratios and fracture distribution were reported (Kawaguchi et al. Busse JW, Bhandari M, Einhorn TA, et al. Significance of dose in postoperative radiotherapy for soft tissue sarcoma. Marx A, Beier A, Taheri P, Rpke M, Kalinski T, Halder AM. Histopathology findings were consistent with synovial sarcoma, monophasic type (Figure 3). Upon admission, the patient was found to have left knee tenderness, predominantly over the lateral joint line. MRI is as sensitive as bone scanning, with the added benefit of higher specificity, both in isolating the exact anatomic location and in distinguishing fractures from tumors or J Bone Joint Surg Am. Several studies have reported a nonunion rate as high as 45% in patients with sarcoma who have post-radiation fractures [5]. All figures submitted have been created by the authors who confirm that the images are original with no duplication and have not been previously published in whole or in part. Alonso-Bartolom P, Martnez-Taboada VM, Blanco R, et al. Therefore, we decided to use a conservative non-surgical treatment. , () (CRM), . 2018 Sep-Oct;38(5):1478-1495. doi: 10.1148/rg.2018180044. Chemo chemotherapy; LIPUS low-intensity pulsed ultrasound. MRI is as sensitive as bone scanning, with the added benefit of higher specificity, both in isolating the exact anatomic location and in distinguishing fractures from tumours or 2022, Received: In total, she was able to walk without crutches at 8 months after initiation of LIPUS therapy. Multidetector computed tomography (MDCT) is currently standard and allows multiplanar reconstruction, near isotropic 3D reconstructions of anatomical structures, reduction of artefacts as well as thin-section high-resolution imaging which is beneficial to visualizing also subtle fracture lines. Thrombophilia-Associated Factors in Patients with Spontaneous Osteonecrosis of the Knee. Three questions need to be answered. Spontaneous Osteonecrosis/Subchondral Insufficiency Fractures of the Knee: High Rates of Conversion to Surgical Treatment and Arthroplasty. (2005) ISBN:1588904458. 2022 May; 40 (5):443-457. Cheung WH, Chin WC, Qin L, Leung KS. Acceleration of tibial fracture-healing by non-invasive, low-intensity pulsed ultrasound. Twelve cases are described in which the clinical entity of oste onecrosis of the femoral condyle was diagnosed because the patients had a clinical picture identical to that of osteonecrosis and also had positive bone scans, however, roentgenographic changes supposedly diagnostic of the condition were not seen. and transmitted securely. Zagars GK, Ballo MT. : +852 2468 5111. Spontaneous insufficiency fracture of the knee (SIFK) was initially termed spontaneous osteonecrosis of the knee (SONK) and was first described by Ahlbck etal. Subchondral insufficiency fracture of the knee | Radiology Reference Article | Radiopaedia.org. LIPUS could be a safe and effective treatment option for the management of radiation-associated pathological fractures. 28 (6): 413-20. (c) From left to right: the resected SIFK lesion during distal femur cut, the dislodged cartilage fragment, and the tibia cut. T1WI, T1-weighted images; STIR, short TI inversion recovery; LIPUS, low-intensity pulsed ultrasound; M, months. Timeline of our patients clinical course. The https:// ensures that you are connecting to the (d) Lateral UKA was performed. Further progression of osteonecrosis at the lateral femoral condyle with a displaced curvilinear bony lesion was noted (, At 2weeks after the hospital admission, a left UKA for the lateral compartment was performed. However, there have been no reports that such methods could prevent the collapse of the articular surface in the case of a radiation-associated fracture. Learn more Many guidelines recommend adjuvant RT if margin-positive resection is anticipated [1]. HHS Vulnerability Disclosure, Help A lytic fracture line or cortical break rarely is observed. (a) Radiograph of left knee taken upon presenting to the emergency department showed an area of osteonecrosis over the lateral femoral condyle on the anteroposterior view with an associated curvilinear bony lesion on the lateral view. 5. Chest computed tomography (CT) revealed no apparent lung metastasis (data not shown). Accessibility The diagnosis of an insufficiency fracture was supported by CT follow-up studies that showed fracture lines more clearly and areas of increased sclerosis or periosteal bone formation; and by MRI follow-up studies that showed persistent or decreasing areas of bone marrow edema or better visualization of fracture lines. Total and unicondylar knee arthroplasty are equivalent treatment options in end-stage spontaneous osteonecrosis of the knee, and the size of the lesion has no influence on the results. The .gov means its official. If the radiographs are inconclusive and pain persists, either MRI or CT will be performed. Intraoperative photos. The Journal of the American Academy of Orthopaedic Surgeons. In addition, we must be careful because deep infection rates up to 20% after surgery have been reported for radiation-associated fractures in some series [5,8]. After 3 courses of neoadjuvant chemotherapy with ifosfamide and doxorubicin hydrochloride, we performed surgery. Findings suggested that SPONK was the result of a subchondral fracture rather than primary osteonecrosis, rather than antecedent bone infarction such as creeping substitution and bone marrow necrosis. The treatment of SIFK can be nonoperative or operative depending on the size and radiological staging of the lesion. Wide local resection is the mainstay of treatment for high-grade soft tissue sarcoma in the extremities [1]. April 3, (E) T2-weighted sagittal image with fat suppression. Mild internal enhancement was observed on gadolinium-enhanced fat-suppressed T1-weighted images (Figure 2). In view of the isolated compartment involvement, unicompartmental knee arthroplasty was performed with satisfactory outcome. Bonewald LF, Dallas SL. Before Disclaimer, National Library of Medicine The site is secure. Gorbachova T, Melenevsky Y, Cohen M, Cerniglia BW. 1 The prognosis may range from full recovery to rapidly escalating joint destruction. Porrino JA, Kohl CA, Taljanovic M et-al. In a review by Sibilska etal., the prevalence of SIFK is reported at 3.4% in elderly patients [. In addition abnormal intracortical, periosteal, or muscle signal intensity are found as well as endosteal scalloping and soft-tissue masses. Restoration of the trabecular structure was eventually observed without obvious collapse of the articular surface (Figure 5E, 5F, 5K, 5L). Subchondral insufficiency fractures are non-traumatic fractures that occur immediately below the cartilage of a joint. (a) A 1.5 5-cm subchondral defect was found at the weight-bearing surface of the lateral femoral condyle. 9. Plain radiographs of the knee joint at the first visit showed no abnormalities caused by the soft tissue tumor or osteoarthritis. Papanna MC, Tafazal S, Bell MJ, et al. However, as SIFK is predominantly localized to a single compartment, and in view of the favorable outcome of treating unicompartmental osteoarthritis with UKA, there has been growing interest in treating SIFK with UKA as an alternative to TKA. Osteonecrosis of bone. They should not be confused with fatigue fractures which are due to abnormal stresses on normal bone, or with pathological fractures, the result of diseased, weakened bone due to focal pathology such as tumours (both malignant and benign). Most patients with what has been called spontaneous osteonecrosis of the knee actually have subchondral insufficiency fractures, and the histologic findings of avascular areas in biopsy specimens appear to be a secondary phenomenon and not the primary cause. The Koshino classification was first described in 1979, where small radiolucent lesions measuring <3.5 cm, The options of nonoperative treatment for early-stage SIFK include physiotherapy, analgesics, nonsteroidal anti-inflammatory drugs, and bisphosphonates [. Data Analysis 2022 May;40(5):443-457. doi: 10.1007/s11604-021-01224-3. Coronal STIR MR sequence of both lower extremities demonstrating marrow edema and subtle fracture line due to insufficiency fracture at the right fibula, AP radiograph of the left knee demonstrating an old insufficiency fracture of the right fibula with callus formation after total knee replacement, Dorso-plantar radiograph of the right foot demonstrates insufficiency fracture of the second and third with massive callus formation in this 85-year-old female patient, AP radiograph of the right proximal femur with sclerosis and subtle fracture line at the medial aspect of the femur shaft below the lesser trochanter (, Patient with history of tumor endoprosthesis at the proximal femur and insufficiency fracture at the proximal tibia. Despite the large central defect at the lateral femoral condyle, we could still identify the correct extension gap with the remaining bone. After 1 year, remodeling of the fracture callus was complete. Insufficiency fractures of the fibula are typically found in patients with underlying rheumatic diseases, mainly rheumatoid arthritis (Alonso-Bartolome et al. In general, they are seen in the elderly, more frequently in women 2. The patient was treated with LIPUS generated by a sonic accelerated fracture healing system (SAFHS Exogen, Teijin, Tokyo, Japan) 20 minutes daily for 1 year. Parasymphyseal and pubic ramus fractures may have an aggressive appearance that depends on the stage of fracture maturity. The degree of confidence is low in sacral fractures because of osteoporosis, overlying bowel gas, and calcified vessels and is better at peripheral sites like in long bones and the metatarsal bones. Subchondral insufficiency fracture of the knee (SIFK) is a potentially devastating disorder that may progress rapidly to osteoarthritis with articular surface collapse. Keywords A lateral parapatellar approach was used. 6. MRI is used to confirm the presence of and evaluate subchondral signal ( Fig 1 ). Subchondral insufficiency fracture refers to a type of stress fracture that occurs below the chondral surface on a weight-bearing surface of a bone due to mechanic failure of subchondral cancellous bone. Second, will the actual diagnosis influence the treatment? There was surrounding bone marrow edema-like signals at the lateral femoral condyle. Thieme Medical Pub. On bone scan, there is increased activity at the site of the fracture. - , , ? (2018) Radiographics : a review publication of the Radiological Society of North America, Inc. 38 (7): 2173-2192. fractures involving a single facial buttress, Meyers and McKeevers classification (anterior cruciate ligament avulsion fracture), Watson-Jones classification (tibial tuberosity avulsion fracture), Nunley-Vertullo classification (Lisfranc injury), pelvis and lower limb fractures by region. We only described 1 case and summarized our experience with therapeutic evaluation of LIPUS for insufficiency radiation-associated fracture of the tibial plateau. 61-year-old female patient with a history of bronchial carcinoma, FDG-PET-CT showing only moderate metabolic activity in the thoracic spine with several compression fractures. Spontaneous osteonecrosis of the knee (SONK/Morbus Ahlback) mainly affects the medial condyle of elderly women and the outcome is unpredictable in many cases. 11 (3): 191-194. Ethics approval was obtained from the New Territories West Cluster Research Ethics Committee of Hospital Authority, Hong Kong. The authors provide an update on the role of MRI in identifying key imaging features of SIF in various joints of the lower limb to aid in its correct diagnosis. Radiographics : a review publication of the Radiological Society of North America, Inc. MRI features that aid in diagnosis of acute traumatic injuries, subchondral insufficiency fracture, and its potentially irreversible form, spontaneous osteonecrosis of the knee include the location and extent of bone marrow edema, the presence of a fracture line, a hypointense area immediately subjacent to the sub chondral bone plate, and deformity of the subChondralBone plate. We report a case of radiation-associated insufficiency fracture of the tibial plateau after surgery, perioperative chemotherapy, and adjuvant radiation therapy for synovial sarcoma of the proximal calf that was successfully treated with low-intensity pulsed ultrasound (LIPUS). Abstract Objective: To assess the relationship between low- and high-grade subchondral insufficiency fracture of the knee (SIFK) and meniscal tear/type/location, severity of meniscal buzzword, , . 2019 Jan;10(1):53-60. doi: 10.1177/1947603517749920. FOIA Azuma Y, Ito M, Harada Y, et al. Radiographics. (A) Axial view, (B) sagittal view, and (C) coronal view. {"url":"/signup-modal-props.json?lang=gb\u0026email="}, Gaillard F, Yap J, Baba Y, et al. . However, we were concerned about postoperative complications such as deep infection because the surrounding soft tissue would be also compromised from RT. Check for errors and try again. , . The lesion, measuring 722217 mm on magnetic resonance imaging (MRI), appeared as a tumor with clear margins in the popliteus muscle. Most cases involve the medial femoral condyle, and the lateral femoral condyle is rarely affected. The United States Food and Drug Administration approved LIPUS for fracture healing in 1994 [6]. It is an intra-articular structure, but it is extra-synovial. The .gov means its official. Sacral, iliac, and supra-acetabular fractures often are difficult to detect. First, does spontaneous osteonecrosis of the knee in fact exist? Reference article, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-1505, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":1505,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/insufficiency-fracture/questions/1164?lang=gb"}. Plain radiographs of the right knee showed no abnormalities caused by the soft tissue tumor or osteoarthritis (Figure 1). Atypical uptake patterns may be difficult to interpret and abnormal uptake may persist for several months. However, MRI revealed transverse bone marrow edema with low signal intensity on T1-weighted images and high signal intensity on T2-weighted images in the proximal medial tibia, indicating an insufficiency pathological fracture caused by RT (Figure 6). Long-term bisphosphonate use has also been associated with insufficiency fractures 5. The lesion was resected during the distal femur cut (, Postoperative radiographs of the knee and lower limb scanogram showed satisfactory alignment (, In the initial description by Ahlbck etal., a cohort of patients with knee osteonecrosis in the absence of other known clinical entities were first labelled as having SONK [. Current concepts as to etiology and pathogenesis. fracture) on the T1-weighted images parallel to the subchondral bone. . Wolfgang Dhnert. this study, subchondral insufficiency fracture has been increasingly studied, including the identification of risk factors and associated lesions (3). Theoretically, minimally invasive techniques such as stabilization with locking plate augmentation could be applicable to any type of tibial plateau fracture. Conclusion Radiotherapy for management of extremity soft tissue sarcomas: Why, when, and where? ? Federal government websites often end in .gov or .mil. MB), Help with SIT, "-" , . Fresh osteochondral allograft transplantation for spontaneous osteonecrosis of the knee: a case series. [2] Marom N, Koch JE, Beer Y, Ellis M, Ganot G, Nyska M, Maoz G, Hetsroni I. Cartilage. Pathophysiology may represent a subchondral insufficiency fracture also believed to be caused by a meniscal root tear Presentation Symptoms sudden onset of severe knee pain effusion limited range of motion secondary to pain tenderness over medial femoral condyle Imaging Radiographs recommended views standing AP and lateral of hip, knee and ankle The imaging modality of choice is MRI with T2-weighted and proton-density-weighted sequences. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Protection and Quality Assurance in Bone Densitometry, Osteoporosis and Bone Densitometry Measurements. Femoral neck fractures in osteogenesis imperfecta treated with bisphosphonates. , , . In five of the authors' most recent MRIs in patients with clinically diagnosed or radiographically suggested spontaneous osteonecrosis of the knee, only one patient's images fulfilled the criteria for spontaneous osteonecrosis (Figure 3). Corresponding author. The synovium folds over the Therefore, LIPUS could be a safe and effective treatment option in the management of radiation-associated fractures. An official website of the United States government. Dangoor A, Seddon B, Gerrand C, et al. and transmitted securely. An official website of the United States government. Typical MRI findings in insufficiency fractures include a pattern of bone marrow edema with a low-signal-intensity line (resp. ! This is the first report of radiation-associated pathological fracture that was successfully treated with LIPUS. Abstract Objective: To propose an magnetic resonance imaging (MRI) grading system for subchondral insufficiency fracture of the knee (SIFK) to predict outcome and assess risk factors. Zhang R, Wang Z, Zhu G, et al. AJR Am J Roentgenol. government site. Bethesda, MD 20894, Web Policies Semantic Scholar is a free, AI-powered research tool for scientific literature, based at the Allen Institute for AI. government site. It is not clear whether LIPUS did decrease fracture healing time. Insufficiency fracture of the sternum caused by osteopenia: plain film findings in seven patients. A 1.5 5-cm intra-articular dislodged cartilage fragment was retrieved (, The lateral UKA was performed using the Zimmer Unicompartmental High Flex Knee system (ZUK; Zimmer, Warsaw, IN). Accepted: 2020 May 6;102(9):821-829. doi: 10.2106/JBJS.19.00381. Subchondral insufficiency fracture of the knee (SIFK) is a potentially devastating disorder that may progress rapidly to osteoarthritis with articular surface collapse. Third, is there any method of halting the progression of early subchondral changes before they progress into collapse, flattening, and loose-body formation? There was associated osteoarthritic changes at the lateral compartment of the femorotibial joint, while other compartments remained relatively unaffected. . Her body mass index was 27.67 kg/m2. Radiology Review Manual. A middle-aged lady presented with subacute left knee pain and a locked knee. Four patients developed osteonecrosis; three, insufficiency fractures; and three, rapid progressive OA. In general, the circumscribed lesions on MRI, which are commonly observed in osteonecrosis, are not found (Yamamoto et al. 8600 Rockville Pike Spontaneous insufficiency fracture of the knee is a potentially devastating yet poorly understood disease entity that can lead to secondary osteoarthritis. CT, computed tomography. 7. Radiographic findings depend on the site of the fracture. image, Download .pdf (.72 Bone scintigraphy is highly sensitive, but not specific. Funding: This study did not receive any funding. "-" , , . Kabra U, Subchondral insufficiency fracture of the knee. At 1month after the initial emergency department presentation, the patient returned to the hospital again and was admitted to the orthopaedics and traumatology unit. Subchondral insufficiency fracture of the knee (SIFK) is a common cause of knee joint pain in older adults. 2022, Received in revised form: Knee Surgery, Sports Traumatology, Arthroscopy. Epub 2018 Jan 7. Soft-tissue dissection was limited to what was necessary for exposure only. Spontaneous osteonecrosis/subchondral insufficiency fractures of the knee: high rates of conversion to surgical treatment and arthroplasty. The patient was treated with LIPUS for 1 year. Cannon CP, Lin PP, Lewis VO, Yasko AW. Osteochondral Lesions of the Knee: Differentiating the Most Common Entities at MRI. Approximately 5 months after surgery and 2 months after completion of RT, she revisited our outpatient clinic reporting moderate pain in the right knee without any apparent trauma. Bone fractures following external beam radiotherapy and limb-preservation surgery for lower extremity soft tissue sarcoma: Relationship to irradiated bone length, volume, tumor location and dose. HHS Vulnerability Disclosure, Help A subchondral insufficiency fracture (SIF) of the femoral head is a recently proposed concept, which needs to be differentiated from osteonecrosis. Low intensity pulsed ultrasound enhances fracture healing in both ovariectomy-induced osteoporotic and age-matched normal bones. Low signal intensity (A and E, arrows) on T1-weighted images and high signal intensity (I, arrowhead) on short TI inversion recovery (STIR) images in the proximal medial tibia disappeared over time. No tumor local recurrence or distant metastases were found during 24 months of follow-up. A 52-year-old Japanese woman with no significant medical history presented with a slowly growing and painful mass over her proximal calf. Rheumatology (Oxford). Kabra U, Subchondral insufficiency fracture of the knee. Insufficiency fracture Osteochondritis Dissecans Ligaments MR-signs of ligament tear Anterior Cruciate Ligament The ACL has interesting anatomy. Epub 2016 Jan 14. The most common finding is a sclerotic band or line. The characteristic findings of SIFK include a hypointense line in the subarticular bone marrow representing a subchondral fracture and focal depression of the subchondral bone plate. In addition to LIPUS, she started non-weight-bearing walking for the first 3 weeks. Radiograph of the left knee was repeated upon admission. Lateral radiograph of the distal femur and knee shows severe osteopenia but no fracture. MRI features of a malignant fracture are diffusely or focally abnormal bone marrow signal which may be either well-defined or ill-defined and does not follow fracture lines. 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