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30 (); 12-17
doi:
10.1016/j.jor.2022.02.001

Comparison of conventional MRI, MR arthrography, MR arthrography with traction, MR arthrography with pressure in the evaluation of articular distension

, , , ,
a Department of Radiology, Faculty of Medicine, Istanbul Medipol University, Istanbul, Turkey
b Department of Anatomy, School of Medicine, Institute of Health Sciences, Istanbul Medipol University, Istanbul, Turkey
c Department of Orthopaedics and Traumatology, Faculty of Medicine, Istanbul Medipol University, Istanbul, Turkey
d Department of Anatomy, School of Medicine, Ankara Medipol University, Ankara, Turkey

∗Corresponding author: T. Ormeci. ormecitugrul@gmail.com

Received: , Accepted: ,
Professor P K Surendran Memorial Education Foundation
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

To evaluate the performance of conventional MRI, standard MR arthrography, MR arthrography with traction and MR arthrography with pressure in articular distension in patients with ACL injury.

The consecutive patients (7 female, 21 male) with acute ACL injured conventional MRI, MR arthrography, MR arthrography with traction and MR arthrography with pressure were evaluated.

The amount of distension in the joint was evaluated in the posterior, femorotibial and anterior compartments. Medially, between the meniscus posterior horn and the tibial corner, MRA with pressure was found to be more effective in showing this distance than MRA with traction (p < 0,05). Laterally, in measurements made between the posterior horn of the meniscus and the capsule, MRA with traction and MRA with pressure are more effective showing this distance than conventional MRI and standard MRA (p < 0,05). In measurements made medially, between the posterior horn of the meniscus and the capsule, MRA with traction is more effective in showing this distance than standard MRA (p < 0,05). In all three different MRA modalities, the lateral femorotibial joint distance was found to be statistically higher than conventional MRI (p < 0,05). Medial femorotibial joint distance was found to be statistically higher in MRA with pressure than in conventional MRI and standard MRA (p < 0,05). The medial infrapatellar distance was found to be statistically higher in MRA with pressure than standard MRA and MRA with traction (p < 0,05). The lateral infrapatellar distance is higher in MRA with pressure than in MRA with traction, and this height is statistically significant (p < 0,05).

Traction and pressure applications added to MRA will increase the effectiveness of the method by increasing the distension in the knee joint. Although both seem to be effective in creating distension in posterior compartment and femorotibial joint distance, MRA with pressure is more effective especially in anterior compartment.

Keywords

MR arthrography
MR arthrography with traction
MR arthrography with pressure
Articular distension
1

1 Introduction

In daily practice, knee pathologies occupy a very large place in musculoskeletal imaging. Although the use of radiography and computed tomography (CT) are useful to evaluate cortical pathologies, the use of magnetic resonance imaging (MRI) is at the forefront in the evaluation of ligamentous and fibrocartilaginous pathologies due to its major advantages such as increased soft tissue resolution and no radiation. The knee joint can be evaluated conventionally non-injected with MRI or MR arthrographically. Intra-articular effusion, which often occurs due to acute pathology, helps to better visualize intra-articular pathologies, especially on T2-weighted sequences. However, when this evaluation is insufficient, the contrast material given during magnetic resonance arthrography (MRA) causes distension of the joint capsule and it helps to better evaluate the pathologies by surrounding the intraarticular structures, reaching into the tears and being absorbed in these areas.1

There are many publications in the literature that MRA is superior to conventional MRI in diagnosing meniscus, anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), tibio-femoral articular cartilage, and patella chondromalacia lesions.2–4 This superiority is achieved both by the visualization-enhancing effect of the contrast agent administered to the joint cavity, and by the distension-increasing effect of this fluid.2–6 Therefore, the distension effect that occurs thanks to the contrast agent given in MRA is used in the evaluation of the anatomy of the region.

However, studies have been carried out to increase the success of MRA in detecting intraarticular pathologies by increasing the distension effect. For this purpose, traction force was applied to the craniocaudal axis of the knee joint7–11 or pressure on the suprapatellar recess has been tried.6,12–14 We think that the compartments of the knee joint, which are more difficult to evaluate radiologically, can be evaluated more effectively by these methods. However, there is no detailed information about pressure application in the literature.

One of the aims of this study is to evaluate the performance of conventional MRI, standard MRA, MRA with traction and MRA with pressure in articular distension in patients with ACL injury. The other is to create a standardization in the pressure application, which is one of these applications.

2

2 Material and methods

2.1

2.1 Study population

Between february 2020 and october 2021, 28 consecutive patients (7 female, 21 male; mean age 33.4 years) with ACL injured referred for MRA of the knee were included in this prospective study. The institutional review board of University approved this study. All patients gave informed consent. Inclusion criteria were the cases with no previous history of operation and suspected ACL tear on physical examination due to trauma in the last month. Exclusion criteria were previous surgery, severe osteoarthritis, inflammatory and autoimmune arthritis, more than 1 month between imaging and trauma. A multiligamentous injury that could affect interpretation of MRI scans, and MR imaging with an inadequate sequence or poor MR image quality were other exclusion criteria.

2.2

2.2 Conventional knee MRI protocol

In our center, we obtain PD SPAIR TSE axial, T1 TSE sagittal, PD SPAIR TSE coronal, T1 TSE coronal sequences in knee MRI. Finally, we take the PD SPAIR TSE sagittal sequence that we used for comparison in this research. The parameters of this sequence are: repetition time (TR)/echo time (TE) 3500 ms/30 ms, 3.5-mm section thickness, 160-mm field of view (FOV), 228x210 matrix, NEX 1.

2.3

2.3 MR arthrography

2.3.1

2.3.1 Standard MRA

Following informed consent, the patient lying in the supine position, after the skin was cleaned under appropriate conditions, intra-articular injection was performed with medial patellofemoral approach using a 22-gauge needle under fluoroscopic control. Although it varies according to the tolerability of the patient, approximately 30–35 ml of contrast material was administered in accordance with the literature.15 The used intraarticular gadolinium (gadoteric acid, Dotarem; Guerbet, France) concentration was applied as 2 mmol/L in accordance with the literature.16,17 MRI was performed within 30–45 min following the administration of the contrast agent. In the meantime, the patient was allowed to walk for 5–10 min before the MRI in order to ensure a better distribution of the contrast agent in the joint. Before the coil was placed, the traction device was placed, but no weight was applied. Again, the apparatus was placed on the knee for pressure examination, but no pressure was applied. Thanks to these preparations in advance, it was ensured that all sections pass almost in the same plane. The MR examination was performed on a 3-T MR imaging unit (MRI Systems Achieva Release 3.2.3.1, Philips Medical Systems, Holland) with a dedicated knee coil (8-channel SENSE; Philips Medical Systems). First, standard MRA examination was performed: Axial fat-suppressed T1-weighted sequence (repetition time (TR)/echo time (TE) 663 ms/11 ms, 3.5-mm section thickness, 160-mm field of view (FOV), 244x215 matrix, NEX 1), coronal fat-suppressed T1-weighted sequence (repetition time (TR)/echo time (TE) 609 ms/10 ms, 3.5-mm section thickness, 160-mm field of view (FOV), 356x312 matrix, NEX 1), sagittal fat-suppressed T1-weighted sequence (repetition time (TR)/echo time (TE) 646 ms/11 ms, 3.5-mm section thickness, 160-mm field of view (FOV), 248x214 matrix, NEX 1), sagittal proton density SPAIR (SPectral Attenuated Inversion Recovery) sequence (repetition time (TR)/echo time (TE) 3744 ms/30 ms, 3.5-mm section thickness, 160-mm field of view (FOV), 228x196 matrix, NEX 1).

2.3.2

2.3.2 MRA with traction

Then, the sagittal fat-suppressed T1-weighted sequence was repeated with the same parameters by applying weight and traction. An MRI-compatible orthopedic skin traction device (Fig. 1 A) was used. The traction device consists of an adhesive cover that surrounds the crural region of the patient and two straps on each side. These bands are connected to the weight by a pulley system at the foot side of the table. There are different publications in the literature on the weight used to provide adequate traction.10,12,18,19 In our study, we applied 12-15-kg traction weight consisting of a standard sand bag according to the tolerability of the cases.

Devices used in MRA with traction examination (A) and MRA with pressure examination (B).
Fig. 1 Devices used in MRA with traction examination (A) and MRA with pressure examination (B).
2.3.3

2.3.3 MRA with pressure

Finally, traction was terminated and pressure was applied to the suprapatellar recess. A special device was wrapped in the distal thigh to apply pressure to above knee level before the examination. For this purpose, disposable medical tpu pressure infusion cuff with piston gauge and adhesive cuff were combined (Fig. 1 B). Standard pressure was applied depending on the thigh thickness of the patients and to the extent allowed by the coil width. Pressure was applied on the apparatus at least up to the first line (150 mmHg and above). However, the applied pressure was terminated at the point where the patients complained of pain. The sagittal fat-suppressed T1-weighted sequence was repeated with the same parameters.

2.3.4

2.3.4 Image analysis

One of the radiologists prepared the cases for measurement by removing the patient names on the PACS before the measurements so that the evaluation would be blind. For a quantitative analysis the parameters below were measured by other radiologist and orthopedist blinded to which type of MRI. In case of disagreement, a consensus was reached. All measurements were taken using a picture archiving and communication system (PACS) workstation (Centricity Universal Viewer 7.0 SPO 0.4.4, GE Healthcare, Chicago, USA).

2.3.5

2.3.5 The following criteria were assessed

Quantitative measurements were made in the sagittal plane. Posterior compartment measurements were measured in the sagittal plane by calculating the midpoint of the tibial plateau in the axial and coronal planes. A line parallel to the tibial plateau was drawn in the sagittal plane and a perpendicular line was drawn to this line passing through the posterior tibial cortex. The distance between this line and the posterior horn of the meniscus was measured (measurements 1 and 5) (Fig. 2). In addition, the distance between the posterior horn of the meniscus and the joint capsule was measured (measurements 2 and 6) (Fig. 2). The middle of the posterior contours of the posterior horns of the meniscus was taken as the measurement level. Measurement was made at the narrowest part of the femorotibial joint space (measurements 3 and 7) (Fig. 2). At the anterior infrapatellar level, the largest distance between the inner border of the hoffa fat pad and the femoral cartilage was measured (measurements 4 and 8) (Fig. 2). All of these measurements were repeated at the same level for all three MRA forms, both laterally and medially. For conventional MRI, measurements 1–3 and 5–7 were repeated, while measurements 4 and 8 were not evaluated in this modality.

Measurements used in the evaluation of distension in MRA in the knee joint. For the posterior compartment on the lateral side of the knee joint, the distance between the posterior of the meniscus and the tibial corner (1), the distance between the posterior of the meniscus and the capsule (2), the femoro-tibial distance (3), the anterior compartment (infrapatellar) distance (4) in (A). For the posterior compartment on the medial side of the knee joint, the distance between the posterior of the meniscus and the tibial corner (5), the distance between the posterior of the meniscus and the capsule (6), the femoro-tibial distance (7), the anterior compartment (infrapatellar) distance (8) in (B).
Fig. 2 Measurements used in the evaluation of distension in MRA in the knee joint. For the posterior compartment on the lateral side of the knee joint, the distance between the posterior of the meniscus and the tibial corner (1), the distance between the posterior of the meniscus and the capsule (2), the femoro-tibial distance (3), the anterior compartment (infrapatellar) distance (4) in (A). For the posterior compartment on the medial side of the knee joint, the distance between the posterior of the meniscus and the tibial corner (5), the distance between the posterior of the meniscus and the capsule (6), the femoro-tibial distance (7), the anterior compartment (infrapatellar) distance (8) in (B).
2.3.6

2.3.6 Statistical analysis

The data were analyzed using SPSS software, version 16. Statistical analysis the difference in the amount of distension in the joint was evaluated in the posterior, femorotibial and anterior (infrapatellar) compartments width conventional MRI, MRI arthrography, MR arthrography with traction, MR arthrography with pressure the parameters were analyzed using the t-test for continuous variables. A p-value less than 0,05 was considered statistically significant. Interobserver agreements were calculated with regression analysis.

3

3 Results

Cases with a history of trauma and suspected ACL injury in the clinical examination were evaluated with four different MRI techniques. These cases, which were also examined arthroscopically, were included in our study. Conventional MRI and MRA with pressure images of some patients could not be obtained. 16 conventional MRI, 28 standard MRA, 28 MRA with traction and 21 MRA with pressure images were included in the study.

In our study, it was found that there was agreement between the two observers for all parameters (p < 0.05). Laterally, there was no significant difference between the measurements made between the posterior horn of the meniscus and the tibial corner (measurement 1) (Fig. 2 A). In the measurements made medially, between the meniscus posterior horn and the tibial corner, comparison of standard MRA and MRA with traction and comparison of MRA with traction and MRA with pressure were found significant. MRA with traction was more effective in showing distance than standard MRA, and this distance was found to be statistically higher in MRA with traction. MRA with pressure was more effective in showing distance than MRA with traction, and this distance was found to be statistically higher in MRA with pressure (measurement 5) (Fig. 2 B) (Table 1).

Table 1 The distance between the posterior horn of the meniscus and tibial corner at medially.
Mean ± SD p
MR Arthrography - MR Arthrography with Traction -,870 ± 1,583 <0,05
MR Arthrography with Traction - MR Arthrography with Pressure ,917 ± 1,499 <0,05

Laterally, the comparisons of conventional MRI and MRA with traction, conventional MRI and MRA with pressure, standard MRA and MRA with traction, and standard MRA and MRA with pressure were found to be statistically significant in the measurements made between the meniscus posterior horn and the capsule. MRA with traction and MRA with pressure are more effective in showing this distance than conventional MRI and standard MRA (measurement 2) (Fig. 2 A) (Table 2).

Table 2 The distance between the posterior horn of the meniscus and the capsule laterally.
Mean ± SD p
Conventional MRI - MR Arthrography with Traction −1,397 ± 2,291 <0,05
Conventional MRI - MR Arthrography with Pressure −1,873 ± 2,610 <0,05
MR Arthrography - MR Arthrography with Traction -,570 ± 1,294 <0,05
MR Arthrography - MR Arthrography with Pressure −1,045 ± 1,409 <0,05

The comparisons between conventional MRI and MRA with pressure and standard MRA with MRA with traction were significant in the measurements made medially between the meniscus posterior horn and the capsule. MRA with pressure is more effective in showing this distance than conventional MRI. MRA with traction is more effective in showing this distance than standard MRA (measurement 6) (Fig. 2 B) (Table 3).

Table 3 The distance between the posterior horn of the meniscus and the capsule medially.
Mean ± SD p
Conventional MRI - MR Arthrography with Pressure −1,755 ± 2,394 <0,05
MR Arthrography - MR Arthrography with Traction -,443±,941 <0,05

In all three different MRA modalities, the lateral femorotibial joint distance was found to be statistically higher than with conventional MRI (measurement 3) (Fig. 2 A) (Table 4).

Table 4 Lateral femorotibial joint distance.
Mean ± SD p
Conventional MRI - MR Arthrography −1,334 ± 1,357 <0,05
Conventional MRI - MR Arthrography with Traction −1,509 ± 1,310 <0,05
Conventional MRI – MR Arthrography with Pressure −1,805 ± ,1579 <0,05

Medial femorotibial joint distance was found to be statistically significant in comparison of conventional MRI with MRA with pressure and standard MRA with MRA with pressure. In MRA with pressure, this distance was found to be statistically higher than conventional MRI and standard MRA (measurement 7) (Fig. 2 B) (Table 5).

Table 5 Medial femorotibial joint distance.
Mean ± SD p
Conventional MRI - MR Arthrography with Pressure -,927 ± 1,247 <0,05
MR Arthrography - MR Arthrography with Pressure -,731±,914 <0,05

Medial infrapatellar distance was statistically significant in comparison of standard MRA with MRA with pressure and MRA with traction with MRA with pressure. This parameter was found to be statistically higher in MRA with pressure than standard MRA and MRA with traction (measurement 8) (Fig. 2 B). The lateral infrapatellar distance was found to be statistically significant when comparing MRA with traction and MRA with pressure. This parameter is higher in MRA with pressure than in MRA with traction, and this height is statistically significant (measurement 4) (Fig. 2 A) (Table 6). In addition, although it was found that MRA with pressure caused more distension in the lateral than standard MRA, this difference was not statistically significant.

Table 6 Medial and lateral infrapatellar distance (anterior compartment).
Mean±SD p
Med. infrapatellar MR Arthrography - MR Arthrography with Pressure -,940 ± 1,915 <0,05
Med. infrapatellar MR Arthrography with Traction - MR Arthrography with Pressure −1,105 ± 1,300 <0,05
Lat. infrapatellar MR Arthrography with Traction - MR Arthrography with Pressure −1,526 ± 2,199 <0,05
4

4 Discussion

MRA can be done directly or indirectly. Contrast material is given intra-articularly in direct MRA and this study is related to this MRA. Direct MRA distends the joint and creates signal intensity differences between intra-articular structures. This facilitates the evaluation of hidden or suspicious intra-articular abnormalities.

Palhais et al. say that if adequate joint distension cannot be achieved with direct MRA, contrast agent may not enter enough between cartilage and meniscus.4 For this reason, various ways have been sought to both increase distension and increase visibility. Gentle exercise in MRA can increase the penetration of contrast material into meniscal lesions.15 In the evaluation of subtle pathologies, MRA with traction and MRA with pressure may be useful to increase the visibility by increasing the distension.

We can see the first applications of traction in the study of Vegter and Broek with direct radiography on the hip joint in order to better evaluate the articular surfaces. This work by the authors using the vacuum phenomenon is important in showing the effect of traction on the joint.11 This (traction) method used to increase intra-articular visibility is combined with MRI. There are publications in the literature that MRA with traction gives better results in this sense.7,9,10 With traction, the visibility of the joint cartilages increases. However, this increase is even greater when traction is combined with MRA. Because the increased contrast resolution effect caused by dispersing the contrast material to the joint spaces between the opposing joint surfaces contributes to the traction effect. In addition to this contribution of the contrast material, the expansion of the joint spaces as a result of traction is higher in MRA than in evaluations without arthrography.8 One of the advantages of MRA is the distention effect it creates on the joint. In order to increase this effect, wrap or tourniquet was applied around the leg above the patella to prevent the fluid from filling the suprapatellar recess and to create more distension in the joint.6 This practice is also mentioned in some other publications.13,14,20 However, the effect of this practice has not been evaluated in detail. The main purpose of this study was to compare the degrees of joint distension created by conventional MRI, standard MRA, MRA with traction and MRA with pressure. The amount of distension in the joint was evaluated in the posterior, femorotibial and anterior (infrapatellar) compartments.

One of the measurements we used to evaluate the posterior compartment of joint was the measurement between the line passing through the posterior of meniscus and the corner of the tibia, and no difference was detected in the lateral (measurement 1, Fig. 2 A). For the same measurement in the posteromedial, MRA with traction and especially MRA with pressure had a greater distension effect (measurement 5, Fig. 2 B).

Acute ACL tears are accompanied by meniscal tears at rates ranging from 41% to 82%.21 In the study of Ordu et al., ACL lesion was detected in 25.1% of patients with meniscal tear, and 53.4% of these lesions were in the form of total rupture.22 Of the patients with total ACL rupture, 66% had medial, 19.1% had lateral, 14.9% had both medial and lateral meniscus tears. Medial meniscal tear was more common in patients with ACL tear (p < 0.001).22 In another study, it was found that the tear accompanied partial ACL rupture in 12 cases in the medial meniscus and in only 3 cases in the lateral meniscus in arthroscopy.23

In our study, the accompanying meniscal tear was more common in the medial and this was consistent with the literature (57.1% in the medial and 32.1% in the lateral). It was thought that the medial meniscus could move more anteriorly because the tears observed in the posterior horn of the medial meniscus and root attachment were more than the lateral ones. While there was no difference between the measurements in the lateral, the difference between the measurements in the medial was attributed to this. Due to the tears, pressure and traction MRA caused an increase in this distance.

The other measure we used to evaluate the posterior compartment of the joint was the distance between the posterior contour of the meniscus and the joint capsule (measurement 2 and 6, Fig. 2A and B). Both MRA with traction and MRA with pressure produced more joint distension laterally than both conventional MRI and standard MRA (Fig. 3). This positive effect of traction MRA was consistent with the literature.7–10 However, no significant difference was found between conventional MRI and standard MRA in the evaluation of this distance. It was thought that the lack of difference between the two may be due to the increased distension effect of the intra-articular effusion observed in cases with acute trauma on conventional MRI. This result showed that the distension effect of standard MRA alone in the evaluation of the posterolateral compartment may not be more than conventional MRI, especially in cases with acute trauma. It was thought that it would be beneficial to combine MRA with the effect of traction and pressure if an effective distension was desired. In the posterior contour of the meniscus and joint capsule measurements in the posteromedial (measurement 6, Fig. 2 B), no significant difference was found between conventional MRI and standard MRA in terms of the effects of distension. However, MRA with pressure was able to distend more than conventional MRI here as well as laterally. MRA with traction also caused more joint distension than standard MRA (Fig. 4).

Sagittal proton density SPAIR (SPectral Attenuated Inversion Recovery) sequence in conventional MRI (A), sagittal fat-suppressed T1-weighted sequence in standard MRA (B), sagittal fat-suppressed T1-weighted sequence in MRA with traction (C), sagittal fat-suppressed T1-weighted sequence in MRA with pressure (D). The most prominent distension at the infrapatellar level was achieved with MRA with traction and especially with MRA with pressure (open arrows in C and D). The best distension in the posterior compartment was achieved with MRA with pressure (circle in D). Meniscocapsular relationship was also best evaluated with MRA with traction and especially with MRA with pressure (circle in C and D).
Fig. 3 Sagittal proton density SPAIR (SPectral Attenuated Inversion Recovery) sequence in conventional MRI (A), sagittal fat-suppressed T1-weighted sequence in standard MRA (B), sagittal fat-suppressed T1-weighted sequence in MRA with traction (C), sagittal fat-suppressed T1-weighted sequence in MRA with pressure (D). The most prominent distension at the infrapatellar level was achieved with MRA with traction and especially with MRA with pressure (open arrows in C and D). The best distension in the posterior compartment was achieved with MRA with pressure (circle in D). Meniscocapsular relationship was also best evaluated with MRA with traction and especially with MRA with pressure (circle in C and D).
Sagittal proton density SPAIR (SPectral Attenuated Inversion Recovery) sequence in conventional MRI (A), sagittal fat-suppressed T1-weighted sequence in standard MRA (B), sagittal fat-suppressed T1-weighted sequence in MRA with traction (C), sagittal fat-suppressed T1-weighted sequence in MRA with pressure (D). The most prominent distension at the infrapatellar level was achieved with MRA with traction and especially with MRA with pressure (solid arrows in C and D). The meniscocapsular relationship was best evaluated with MRA with traction and especially with MRA with pressure (circle in C and D). Femorotibial distance was best achieved with MRA with traction and MRA with pressure (open arrows in C and D). In the case, a superior medial plica was detected incidentally and it is clearly observed in all MRA forms (asterisk in B, C, D).
Fig. 4 Sagittal proton density SPAIR (SPectral Attenuated Inversion Recovery) sequence in conventional MRI (A), sagittal fat-suppressed T1-weighted sequence in standard MRA (B), sagittal fat-suppressed T1-weighted sequence in MRA with traction (C), sagittal fat-suppressed T1-weighted sequence in MRA with pressure (D). The most prominent distension at the infrapatellar level was achieved with MRA with traction and especially with MRA with pressure (solid arrows in C and D). The meniscocapsular relationship was best evaluated with MRA with traction and especially with MRA with pressure (circle in C and D). Femorotibial distance was best achieved with MRA with traction and MRA with pressure (open arrows in C and D). In the case, a superior medial plica was detected incidentally and it is clearly observed in all MRA forms (asterisk in B, C, D).

We found that MRA with pressure caused the greatest distention of the joint in the anterior compartment at the infrapatellar level, both lateral and medial (Figs. 3 and 4). In MRA with traction, the direction of the main force vector applied to the joint is in the cranio-caudal axis. In MRA with pressure, the pressure applied to the suprapatellar level is directly reflected to the infrapatellar level. For these reasons, we think that the most distension can be done with MRA with pressure. If we consider the knee joint as a balloon because it is a closed volume, the size increase in the balloon pulled from both ends is mainly in the cranio-caudal axis. This may be one of the possible reasons why MRA with traction is not as effective as MRA with pressure in demonstrating the anterior and posterior compartments.

When the femorotibial joint distance was evaluated, we found that standard MRA, MRA with traction and MRA with pressure caused more distension in the lateral compartment than conventional MRI. However, no significant difference was found for this joint distance between the three different MRA modalities (Fig. 3). In the medial compartment, we found that MRA with pressure caused more joint distension than both conventional MRI and standard MRA. We found that MRA with traction did not make a significant difference at this level (Fig. 4). Palhais et al. found a slight but significant increase in both the lateral and medial compartments in their MRA study performed by applying traction.4

In our study, we found that MRA with pressure could expand more both laterally and medially than MRA with traction, but the difference between them was not statistically significant. Medial retinaculum, the oblique part of the m. vastus medialis, the medial patello femoral ligament, and the pes anserinus support the patella medially. Lateral retinaculum, m. vastus lateralis and tiger fibers of the iliotibial tract are located laterally. All these structures anatomically ensure that the joint capsule is stronger in the medial than in the lateral.24 Compared to conventional MRI, all three MRA forms could widen the lateral femorotibial joint distance more, while only MRA with pressure could make this difference medially. The amount of weight we used for MRA with traction may have been insufficient to provide the expected opening in the medial femorotibial joint, compared to the lateral one. We think that adequate joint expansion may not have been achieved due to voluntary or involuntary muscle contractions due to weight as Palhais et al. thought.4

The advantage of direct MRA in diagnosis depends on the optimal pressure generation and adequate visibility of the contrast agent on the intra-articular surfaces, and its proper extension between structures. However, there are also publications that do not report the sensitivity of MR arthrography as high in the evaluation of retropatellar cartilage (range, 29%–53%).25,26 In our study, although it was evaluated only in the sagittal plane, we could not find a significant difference between the examinations in terms of patellofemoral joint expansion.

In this study, we found that the effects of both MRA with pressure and MRA with traction on joint distension were greater in the posterior compartment of the joint and the femorotibial space (Figs. 3–4). In the anterior compartment of the joint, although both were effective, especially MRA with pressure created more distension. In terms of creating distension in acute trauma, intra-articular effusion can act like the contrast agent administered into the joint in MRA. Therefore, there may be no difference between conventional MRI and standard MRA. However, the amount of distension can be increased by applying traction and pressure with MRA.

There are some limitations of this study. The number and distribution of patients could have been more optimal. We think that the effectiveness of these methods will be better demonstrated with more patients. The patient's feeling of discomfort and pain due to the pressure applied in MRA with pressure and the weight applied in MRA with traction may have caused the limitation of MRA activities. Inflating the apparatus placed proximal to the joint to create pressure may cause problems in fitting the knee to the coil, which limits the pressure delivered. In addition, the lack of detailed studies on this method made it difficult to decide how much pressure to apply.

5

5 Conclusion

In cases with acute trauma, there may not be a significant difference in the effect of creating joint distension between conventional MRI and standard MRA, depending on the effusion in the joint. However, traction and pressure applications added to MRA will increase the effectiveness of the method by increasing the distension in the knee joint. Although both seem to be effective in creating distension in posterior compartment and femorotibial joint distance, MRA with pressure is more effective especially in anterior compartment.

Author contribution

TO and MAC were involved in examination of radiological images, preparing the specimen for photo documentation. IDS prepared images for measurements. IDS, BT and HMA were involved in writing/editing the manuscript and processing the photographs for publication. MAC was involved in examination of the patients and diagnosis of the disease.

Funding

No funding was received for this research.

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