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Evaluation of the knee joint with ultrasound and magnetic resonance imaging

Siddharth Pandya
Siddharth Pandya
 y 
David M. Melville
David M. Melville
   | 23 nov 2023
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Article Category: Review Paper
Publicado en línea: 23 nov 2023
Páginas: e239 - e250
Recibido: 04 jul 2023
Aceptado: 21 jul 2023
DOI: https://doi.org/10.15557/jou.2023.0032
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© 2023 Siddharth Pandya et al., published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Fig. 1.

62-year-old female with minimally displaced tibial plateau fracture and lipohemarthrosis. Longitudinal grayscale US image superior to the patella demonstrates non-dependent echogenic material (curved arrow) deep to patellar tendon (arrowheads) and subtle layering heterogeneous debris (arrow), representing fat and hemorrhage, respectively, with distinct fat-fluid level in a large joint effusion. P – patella, F – femur
62-year-old female with minimally displaced tibial plateau fracture and lipohemarthrosis. Longitudinal grayscale US image superior to the patella demonstrates non-dependent echogenic material (curved arrow) deep to patellar tendon (arrowheads) and subtle layering heterogeneous debris (arrow), representing fat and hemorrhage, respectively, with distinct fat-fluid level in a large joint effusion. P – patella, F – femur

Fig. 2.

57-year-old female with osteoarthritis and synovitis. A. Longitudinal color Doppler US image superior to the patella (P) demonstrates small suprapatellar joint effusion (arrow) with hyperemic, thickened peripheral synovium (arrowheads). B. Post-contrast axial spoiled gradient echo MR image of the knee shows thickened and enhancing synovium, most prominent in the lateral gutter (curved arrow), compared to normal synovial enhancement of a Baker’s cyst (arrow). P – patella
57-year-old female with osteoarthritis and synovitis. A. Longitudinal color Doppler US image superior to the patella (P) demonstrates small suprapatellar joint effusion (arrow) with hyperemic, thickened peripheral synovium (arrowheads). B. Post-contrast axial spoiled gradient echo MR image of the knee shows thickened and enhancing synovium, most prominent in the lateral gutter (curved arrow), compared to normal synovial enhancement of a Baker’s cyst (arrow). P – patella

Fig. 3.

76-year-old male with acute-onset left knee pain and history of gout. Transverse grayscale US image at the level of the femoral trochlea demonstrates smooth hyperechoic layer (black arrowheads) overlying the hypoechoic hyaline articular cartilage and paralleling the hyperechoic subchondral bone (white arrowheads), consistent with layering uric acid crystals
76-year-old male with acute-onset left knee pain and history of gout. Transverse grayscale US image at the level of the femoral trochlea demonstrates smooth hyperechoic layer (black arrowheads) overlying the hypoechoic hyaline articular cartilage and paralleling the hyperechoic subchondral bone (white arrowheads), consistent with layering uric acid crystals

Fig. 4.

39-year-old male with tophaceous gout presenting as a palpable peri-patellar mass. A. Sagittal proton-density-weighted fat-suppressed MR image shows expansile intermediate-signal soft tissue (arrowheads) within the patellar tendon, extending superficial to the anterior patella. B. Axial proton-density-weighted fat-suppressed image shows the mass in the patellar tendon (arrow), as well as additional heterogeneously intermediate-signal nodules within the popliteus tendon (curved arrow) and along the medial femoral condyle (arrowhead), in a distribution characteristic of tophaceous gout
39-year-old male with tophaceous gout presenting as a palpable peri-patellar mass. A. Sagittal proton-density-weighted fat-suppressed MR image shows expansile intermediate-signal soft tissue (arrowheads) within the patellar tendon, extending superficial to the anterior patella. B. Axial proton-density-weighted fat-suppressed image shows the mass in the patellar tendon (arrow), as well as additional heterogeneously intermediate-signal nodules within the popliteus tendon (curved arrow) and along the medial femoral condyle (arrowhead), in a distribution characteristic of tophaceous gout

Fig. 5.

53-year-old female with knee pain, unable to undergo MRI. A. Longitudinal grayscale US image slightly oblique to the patellar tendon with knee flexion demonstrates no tear at the tibial insertion of the anterior cruciate ligament (ACL) (arrowheads). T – tibia, F – femur. B. Longitudinal grayscale US image at the central posterior tibial plateau with knee flexion demonstrates no tear at the tibial insertion of the posterior cruciate ligament (PCL) (arrowheads). The femoral origin of either ligament is not visible
53-year-old female with knee pain, unable to undergo MRI. A. Longitudinal grayscale US image slightly oblique to the patellar tendon with knee flexion demonstrates no tear at the tibial insertion of the anterior cruciate ligament (ACL) (arrowheads). T – tibia, F – femur. B. Longitudinal grayscale US image at the central posterior tibial plateau with knee flexion demonstrates no tear at the tibial insertion of the posterior cruciate ligament (PCL) (arrowheads). The femoral origin of either ligament is not visible

Fig. 6.

33-year-old male with partial posterior cruciate ligament tear. A. Longitudinal grayscale US image of the PCL demonstrates normal tibial attachment but indistinct, hypoechoic proximal fibers (curved arrow) with surrounding hypoechoic material (arrow). B. Sagittal proton-density-weighted fat-suppressed MR image shows edema and thickening of the proximal PCL (curved arrow) with surrounding edema and fluid (arrow)
33-year-old male with partial posterior cruciate ligament tear. A. Longitudinal grayscale US image of the PCL demonstrates normal tibial attachment but indistinct, hypoechoic proximal fibers (curved arrow) with surrounding hypoechoic material (arrow). B. Sagittal proton-density-weighted fat-suppressed MR image shows edema and thickening of the proximal PCL (curved arrow) with surrounding edema and fluid (arrow)

Fig. 7.

25-year-old female with anterior tibial pain and palpable lump following ACL reconstruction. A. Longitudinal power Doppler US image of the anterior tibial cortex in the area of focal pain identifies a protruding interference screw (arrow) with adjacent hyperemia and reactive bone formation (arrowhead). B. Follow-up knee radiograph identifies proud interference screw (curved arrow) corresponding to US findings
25-year-old female with anterior tibial pain and palpable lump following ACL reconstruction. A. Longitudinal power Doppler US image of the anterior tibial cortex in the area of focal pain identifies a protruding interference screw (arrow) with adjacent hyperemia and reactive bone formation (arrowhead). B. Follow-up knee radiograph identifies proud interference screw (curved arrow) corresponding to US findings

Fig. 8.

20-year-old male with complete ACL graft rupture. Sagittal protondensity-weighted fat-suppressed MR image shows complete disruption of the ACL graft (arrow) with anteriorly displaced torn graft fibers (curved arrow)
20-year-old male with complete ACL graft rupture. Sagittal protondensity-weighted fat-suppressed MR image shows complete disruption of the ACL graft (arrow) with anteriorly displaced torn graft fibers (curved arrow)

Fig. 9.

Illustrations of medial and lateral supporting structures at the knee joint superimposed on radiographs. A. Illustration of medial collateral ligament (MCL) complex superimposed on PA view of the knee shows the medial meniscal body (1) with deep layer consisting of the attached meniscofemoral and meniscotibial ligaments, middle layer consisting of the tibial collateral ligament (or superficial MCL) (2), with superficial layer composed of crural fascia (3). Note the fibular collateral ligament (4) and popliteus tendon (5) at the lateral knee. B. Illustration of lateral supporting structures, including the iliotibial band (1), fibular collateral ligament (2) running from the femoral condyle to the fibular head and attaching near the biceps femoris (BF) tendon insertion, as well as the posterolateral corner structures consisting of the popliteofibular ligament (3) arising from the fibular styloid and attaching to the popliteus (P) myotendinous junction, the Y-shaped arcuate ligament (4), and the fabellofibular ligament (5)
Illustrations of medial and lateral supporting structures at the knee joint superimposed on radiographs. A. Illustration of medial collateral ligament (MCL) complex superimposed on PA view of the knee shows the medial meniscal body (1) with deep layer consisting of the attached meniscofemoral and meniscotibial ligaments, middle layer consisting of the tibial collateral ligament (or superficial MCL) (2), with superficial layer composed of crural fascia (3). Note the fibular collateral ligament (4) and popliteus tendon (5) at the lateral knee. B. Illustration of lateral supporting structures, including the iliotibial band (1), fibular collateral ligament (2) running from the femoral condyle to the fibular head and attaching near the biceps femoris (BF) tendon insertion, as well as the posterolateral corner structures consisting of the popliteofibular ligament (3) arising from the fibular styloid and attaching to the popliteus (P) myotendinous junction, the Y-shaped arcuate ligament (4), and the fabellofibular ligament (5)

Fig. 10.

75-year-old female with high-grade partial fibular collateral ligament (FCL) injury. A. Longitudinal grayscale US image along the course of the FCL (arrowheads) next to the femoral popliteal groove (F) and tibial plateau (T) demonstrates attenuated remnant fibers with surrounding fluid (arrow). Compare to the normal appearance of the FCL on longitudinal grayscale US image B. with anisotropy (curved arrow) at the proximal portion
75-year-old female with high-grade partial fibular collateral ligament (FCL) injury. A. Longitudinal grayscale US image along the course of the FCL (arrowheads) next to the femoral popliteal groove (F) and tibial plateau (T) demonstrates attenuated remnant fibers with surrounding fluid (arrow). Compare to the normal appearance of the FCL on longitudinal grayscale US image B. with anisotropy (curved arrow) at the proximal portion

Fig. 11.

A. 19-year-old male with displaced MCL tear. Coronal proton-density-weighted fat-suppressed MR image shows completely torn and proximally displaced MCL stump (curved arrow) superficial to the pes anserinus, consistent with a Stener-like lesion. B. 16-year-old male with flipped and entrapped MCL tear. Coronal proton-density-weighted fat-suppressed MR image shows completely torn and proximally displaced MCL stump entrapped at the medial joint line inferior to the meniscus (arrow), which also requires surgical repair despite lying deep to the pes anserinus.
A. 19-year-old male with displaced MCL tear. Coronal proton-density-weighted fat-suppressed MR image shows completely torn and proximally displaced MCL stump (curved arrow) superficial to the pes anserinus, consistent with a Stener-like lesion. B. 16-year-old male with flipped and entrapped MCL tear. Coronal proton-density-weighted fat-suppressed MR image shows completely torn and proximally displaced MCL stump entrapped at the medial joint line inferior to the meniscus (arrow), which also requires surgical repair despite lying deep to the pes anserinus.

Fig. 12.

37-year-old male with horizontal meniscal tear and smallparameniscal cyst. A. Sagittal proton-density-weighted fat-suppressed MR image demonstrates horizontal tear extendingfrom the free edge of the medial meniscus to the periphery, with associated parameniscal cyst (arrowhead). B. Longitudinal grayscale US image of the posterior knee shows a horizontally oriented, hypoechoic cleft, consistent with a tear (curved arrow), in the echogenic, triangular posterior meniscus with a small, contiguous parameniscal cyst (arrowhead). T – tibia, F – femur
37-year-old male with horizontal meniscal tear and smallparameniscal cyst. A. Sagittal proton-density-weighted fat-suppressed MR image demonstrates horizontal tear extendingfrom the free edge of the medial meniscus to the periphery, with associated parameniscal cyst (arrowhead). B. Longitudinal grayscale US image of the posterior knee shows a horizontally oriented, hypoechoic cleft, consistent with a tear (curved arrow), in the echogenic, triangular posterior meniscus with a small, contiguous parameniscal cyst (arrowhead). T – tibia, F – femur

Fig. 13.

33-year-old female with snapping sensation at the lateral knee. Dynamic US imaging (see Video 1) shows snapping of the tibial arm of the biceps femoris tendon. Note initial orientation of the probe in the longitudinal plane before turning to short axis before imaging about the fibular head. Sagittal PD SPACE MR image shows thickened tibial arm (arrowheads) bifurcating from the biceps femoris tendon (arrow) and coursing anterior to the fibular arm (curved arrow)
33-year-old female with snapping sensation at the lateral knee. Dynamic US imaging (see Video 1) shows snapping of the tibial arm of the biceps femoris tendon. Note initial orientation of the probe in the longitudinal plane before turning to short axis before imaging about the fibular head. Sagittal PD SPACE MR image shows thickened tibial arm (arrowheads) bifurcating from the biceps femoris tendon (arrow) and coursing anterior to the fibular arm (curved arrow)

Fig. 14.

63-year-old female with patellar clunk syndrome. Longitudinal grayscale US image shows ovoid and nodular echogenic foci (arrowheads) closely associated with the patella and quadriceps fat pad, located between the superficial quadriceps tendon and echogenic distal femoral arthroplasty hardware (arrow). Technical limitations prevented visualization of nodule motion, but dynamic evaluation elicited discomfort and characteristic clunk
63-year-old female with patellar clunk syndrome. Longitudinal grayscale US image shows ovoid and nodular echogenic foci (arrowheads) closely associated with the patella and quadriceps fat pad, located between the superficial quadriceps tendon and echogenic distal femoral arthroplasty hardware (arrow). Technical limitations prevented visualization of nodule motion, but dynamic evaluation elicited discomfort and characteristic clunk

Fig. 15.

74-year-old male with total knee arthroplasty and quadriceps tendon rupture. Longitudinal grayscale US image shows a full-thickness distal quadriceps tendon tear with retraction (between calipers) from the patella insertion with surrounding hematoma. Note brightly echogenic arthroplasty component (arrow) at the distal femur. P – patella, F – femur
74-year-old male with total knee arthroplasty and quadriceps tendon rupture. Longitudinal grayscale US image shows a full-thickness distal quadriceps tendon tear with retraction (between calipers) from the patella insertion with surrounding hematoma. Note brightly echogenic arthroplasty component (arrow) at the distal femur. P – patella, F – femur

Fig. 16.

65-year-old female with anterior knee pain. Longitudinal grayscale and transient elastography US images of the distal patellar tendon show focal hypoechogenicity and thickening (arrow) with corresponding increased stiffness denoted by overlying color map (increasing stiffness from blue to red), consistent with focal patellar tendinosis
65-year-old female with anterior knee pain. Longitudinal grayscale and transient elastography US images of the distal patellar tendon show focal hypoechogenicity and thickening (arrow) with corresponding increased stiffness denoted by overlying color map (increasing stiffness from blue to red), consistent with focal patellar tendinosis

Fig. 17.

A. 19-year-old male with Baker’s cyst. Transverse grayscale US image of the posterior knee shows bilobed anechoic fluid collection located between the semimembranosus (SM) and medial gastrocnemius (MG) tendons, consistent with a Baker’s cyst. Note anisotropy of the SM relative to MG tendon, not to be confused with debris. B. 85-year-old female with complex Baker’s cyst. Transverse grayscale US image shows thick-walled collection with internal septations and debris with otherwise typical location and appearance
A. 19-year-old male with Baker’s cyst. Transverse grayscale US image of the posterior knee shows bilobed anechoic fluid collection located between the semimembranosus (SM) and medial gastrocnemius (MG) tendons, consistent with a Baker’s cyst. Note anisotropy of the SM relative to MG tendon, not to be confused with debris. B. 85-year-old female with complex Baker’s cyst. Transverse grayscale US image shows thick-walled collection with internal septations and debris with otherwise typical location and appearance

Fig. 18.

Illustration of common bursae located about the knee joint, superimposed on a lateral knee radiograph shows the prepatellar bursa (1), superficial infrapatellar bursa (2), deep infrapatellar bursa (3), pes anserinus bursa (4) deep to the sartorius (S), gracilis (G), and semi-tendinosus (ST) tendons, MCL bursa (5) deep to the MCL, semimembranosus-tibial collateral ligament bursa (6), Baker cyst (7), medial (8) and lateral (not shown) gastrocnemius bursae
Illustration of common bursae located about the knee joint, superimposed on a lateral knee radiograph shows the prepatellar bursa (1), superficial infrapatellar bursa (2), deep infrapatellar bursa (3), pes anserinus bursa (4) deep to the sartorius (S), gracilis (G), and semi-tendinosus (ST) tendons, MCL bursa (5) deep to the MCL, semimembranosus-tibial collateral ligament bursa (6), Baker cyst (7), medial (8) and lateral (not shown) gastrocnemius bursae

Fig. 19.

69-year-old male with popliteal artery aneurysm. Transverse grayscale and color Doppler US images show enlarged popliteal artery (A) adjacent to the normal vein (V) with internal turbulent flow
69-year-old male with popliteal artery aneurysm. Transverse grayscale and color Doppler US images show enlarged popliteal artery (A) adjacent to the normal vein (V) with internal turbulent flow
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