Evaluation of soft tissue release in mild-to-moderate medial knee osteoarthritis in the presence of medial synovial plica, using clinical and MRI parameters

doi:10.21203/rs.3.rs-2310358/v1

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Evaluation of soft tissue release in mild-to-moderate medial knee osteoarthritis in the presence of medial synovial plica, using clinical and MRI parameters

https://doi.org/10.21203/rs.3.rs-2310358/v1

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Objective.

To evaluate the clinical outcomes of an arthroscopic soft tissue release procedure for the treatment of mild to moderate knee osteoarthritis.

Materials and methods.

This study involved 40 subjects who underwent arthroscopic release in knee osteoarthritis including Kellgren–Lawrence grades 2 and 3 between January 2019 and January 2021. The Western Ontario and McMaster Universities (WOMAC) scores at baseline and at 6 months following surgery were recorded. Magnetic resonance imaging (MRI) was performed pre- and postoperatively (6 months). The parameters for patellar instability, including patellar tilt angle, bisect offset, tibial tuberosity–trochlear groove distance and the Insall–Salvati ratio, were measured preoperatively and postoperatively. Quantitative measurements of bone marrow lesions were also conducted.

Results.

The mean WOMAC score for pain and the total score improved statistically 6 months after surgery. The pain and overall scores improved significantly (reductions of 64.6% and 39.3%, respectively) at 6 months. Pain score improved from 7.0 ± 3.0 to 2.5 ± 2.8 (P < 0.05), with the total score improving from17.8 ± 10.3 to 10.8 ± 10.6 (P < 0.05). Bone marrow lessions decreased from 8503 mm³ to 2250 mm³ (P < 0.05). Patellar tilt decreased from 5.11 to 4.24 (P < 0.05). The Insall–Salvati ratio decreased significantly from 1.13 ± 0.13 to 1.08 ± 0.12 (P < 0.05).

Conclusion.

Overall, the results suggest that soft tissue release has clinical symptoms and structure-modifying effects in patients with knee osteoarthritis.

soft tissue release

medial plica

patellofemoral alignment

MRI

knee osteoarthritis

Osteoarthritis (OA) is the most common form of arthritis and one of the leading causes of disability. The major findings of osteoarthritis of knee are cartilage degeneration and osteophyte formation.

Previous arthroscopic treatments for knee OA, including lavage, debridement, abrasional chondroplasty and microfracture, have shown unpredictable outcomes [1–2]. Medial abrasion and lateral compression syndromes have been suggested to promote the pathogenesis of knee OA [3–5].

Medial plica could cause various degrees of abrasion on the medial femoral condyle, it would gradually degenerate to be fibrotic change. The scraped cartilaginous debris could directly deposit in the medial compartment to cause mechanical wear or / and trigger the infra-patellar fat pad inflammation change to give rise to clinical symptoms of anterior knee pain. Abrasion of medial femoral condyle could be aggravated by either less elastic joint capsule or/and concurrent patellar lateral tilt, in which the tight lateral retinaculum could pull the medial joint capsule[3–5]. Favero et al., found that more inflamed, vascularized and fibrous of infrapatellar fat pad in OA knee patients compared to non-OA controls [6]. OA knee and anterior knee pain were associated with infrapatellar fat pad signal intensity alternation and decrease volume on MRI examination [7–8].

Surgical approaches for soft tissue release include medial plicectomy, medial release for medial abrasion syndrome and lateral release and excision of the infrapatellar fat pad for maltracking patella. In 1960, Loeffler described a procedure which included the resection of the medial collateral ligament for medial compartment OA. Ara et al. reported a medial capsulotomy for OA and found the long-term results were maintained over a 20-year period [9]. Lyu and Lin modified the procedure and included infrapatellar fat pad resection and lateral release to treat knee OA [10–11].They found that the procedure can introduce favourable effects for OA and can lead to the improvement of the environment of the knee joint and relief of the symptoms.

Clinically, synovial plicae are normal anatomical structures of the knee comprising the medial, suprapatellar, infrapatellar and lateral plicae. They may become symptomatic when it becomes inflamed, thickened and/or less elastic. Published studies found that the medial plica was more commonly found in patients with OA knees and that the severity of the degeneration was positively correlated with the severity of the state of the medial plica and patient age [4]. The medial plica is involved in the inflammatory process of knee OA. During arthroscopic examinations, foci of cartilaginous lesions on the medial femoral condyle, and the corresponding medial plica were noted [11]. Lyu et al. (2012) reported 505 knees in 326 patients treated with medial and lateral release. The subjective satisfactory rate for the whole series was 85.5% [10]. Yilmaz et al. reported that plicectomy and retinacular band excision improved outcomes in 24 knees with plica syndrome [12]. Patellofemoral osteoarthritis might be caused by malalignment due to overload on the lateral side of the knee, including the patellar abnormal Q-angle, patellar tilt or torsion of the distal femur [13]. Patellar maltracking would increase patellar lateral pressure and tighten lateral retinacular restraints [5]. Lateral release has been performed to reduce the pain of symptomatic patellofemoral osteoarthritis and lateral patellar compression syndrome[14, 15].

MRI permits the visualization of all components of the joint, including soft tissue and bone. This study uses MR images to assess multiple features of the osteoarthritic knee. Namely, the presence of bone marrow lesions (BMLs), patellar tilt (PT) angle, bisect offset (BO), tibial-tuberosity-trochlear groove (TT-TG) distance and Insall-Salvati (IS) ratio. BMLs have been shown to be positively associated with degenerative knee and cartilage defect and change in volume at 3 months to one year following surgery [16].There is strong evidence that knee OA is associated with both trochlear morphology and frontal plane knee alignment in a consistent manner in the sagittal and axial planes. Macri et al. suggested that alignment should be evaluated clinically in individuals with knee OA[17]. Greater lateral patellar malalignment and tilt were associated with joint space narrowing and osteophytes. PT angle, BO, TT–TG distance were axial markers for knee OA and the IS ratio was a sagittal marker for knee OA. A larger PT angle was associated with patellofemoral osteoarthritis [17]. A larger BO was associated with minor cartilage defects and patellar osteophytes [18]. Jibri et al. (2012) reported a control case study and identified the association of infrapatellar fat pad oedema with patellar alta, lateral patellar displacement and lateral patellar tilt [19]. An IS index value > 1.3 was defined as patella alta [20]. Patellofemoral maltracking is one of the most common causes of infrapatellar fat pad impingement. The most important variations causing patellofemoral maltracking are trochlear dysplasia, patella alta and lateralisation of the tibial tuberosity. The IS index and trochlear sulcus angle values were significantly higher in the chondromalasia group [20]. Campagna et al. (2012) reported that a high-riding patella and an increased TT–TG distance were associated with infrapatellar fat pad impingement [21].

The purpose of this study was to examine the association of soft tissue release in knee OA according to the presence and severity of symptoms of knee pain, knee radiographic changes and knee OA-related MRI changes in elderly patients.

2.1. Study design

This retrospective study evaluated patients who underwent the soft tissue release procedure throughout the indicated time period and were willing to undergo MRI examination before and after surgery. The preoperative MRI examinations were performed within 30 days before surgery date. The study involved 40 subjects who underwent capsule release for mild to moderate stages of knee OA including Kellgren–Lawrence (K/L) grades 2 and 3, between January 2019 and January 2021. MRI was performed pre- and postoperatively (6 months).

2.2. Study population and selection criteria

All aspects of the study and the consent form were approved by the institutional review board prior to implementation. All participants were required to provide full informed consent, and were willing and able to comply with all study requirements according to the following criteria. The operation included medial release, plicectomy, lateral release and excision of impingement of infrapatellar fat pad.

2.3. Inclusion criteria

The inclusion criteria included the presence of OA of the medial compartment of the knee with a tibiofemoral angle of varus < 10°, intact knee ligaments, normal range of motion (minimum of 120° of flexion) and a body mass index (BMI) < 35, grade 2 and grade 3 K/L OA and the presence of medial plica on arthroscopic examination.

2.4. Exclusion criteria

The exclusion criteria included a history of inflammatory or septic arthritis, inability to undergo MRI examination, the presence of osteoarthritis of the lateral tibiofemoral compartments, unstable meniscal fragments, instability owing to previous ligament injury or post-traumatic OA.

2.4. Medial release and plicaectomy

With the arthroscope inserted through the inferolateral portal, an electronic shaver was inserted through the superolateral and inferomedial portals to remove fibrotic medial plica (Fig. 1a). A No.11 scalpel was inserted through the inferomedial portal with the blade facing medially to cut through medial joint capsule at locations which were approximately 1 cm superior to the knee joint line, and extended far beyond the medial margin of femoral medical condyle (Fig. 1b). A straight longitudinal medial capsular release was achieved with the use of straight basket forceps (Fig. 1c); this began with the previously cut end, and extended proximally until the instant at which the muscle fibres of the vastus medialis were exposed; these completed the entire medial release. The tight and obliterated medial facet of the patellofemoral joint was then widely open. This was verified by easily passing the arthroscope beneath the patella with the knee in the full extension position (Fig. 1).

2.5. Lateral release and excision of impingement of infrapatellar fat pad

With the arthroscope inserted through the inferolateral portal, an electronic shaver was inserted through the inferomedial portal to remove inflammatory and fibrotic portion of the infrapatellar fat pad. For the knees with lateral compression syndrome, lateral release was performed by inserting the No.11 scalpel into the inferolateral portal and by cutting the lateral retinaculum percutaneously. The extent and adequacy of the release could be evaluated directly by visual inspection through the arthroscope.

The whole procedure included eradicating the inflammatory synovium and medial plica occupying the space over the inferomedial region of the patella and medial gutter, the tight and obliterated medial facet of the patellofemoral joint was released. After medial release, the patella was always deviated laterally, tightened lateral retinaculum could be felt by moving the patella medially, then lateral release was performed. The extent and adequacy of the release was evaluated by direct vision through arthroscope.

2.6. Clinical outcome measurements

The Western Ontario and McMaster Universities (WOMAC) score was initially developed in 1982, and has undergone multiple revisions. The WOMAC is a psychometrically valid and responsive 24-item, disease-specific, outcome measure for knee OA that assesses pain, stiffness and physical function using visual analogue or five-point Likert scales. Likert scale scores for each domain of the Likert scale WOMAC were calculated by summing item scores and by dividing by the number of items in each domain to obtain scores in the range of 0 to 4, with higher scores reflecting more pain, stiffness and poorer physical function. At each dimension, there were question designs which were used to assess the clinical severity of the disease (5 questions for pain, 2 questions for stiffness and 17 questions for physical function). It is available in 5-point Likert. In the Likert version, each item offers five responses: ‘none’ equivalent to a score of 0, ‘mild’ with a score of 1, ‘moderate’ with a score of 2, ‘severe’ with a score of 3 and ‘extreme’ with a score of 4 [22]. In 1994, a consensus meeting recommended the use of WOMAC as a primary measure of efficacy in OA [23]. The WOMAC score was measured by the patient with assistance from M-J Chen on admission for surgery and 6 months after operation.

2.7. Knee MRI acquisitions

MRI scans were performed at baseline and 6 months after surgery using 1.5 Tesla Magnetom Avanto scanners (Siemens Healthineers, Erlangen, Germany) with a dedicated eight-channel knee coil.

To assess axial, coronal and sagittal alignments and morphology, the following sequences were obtained:

axial: two-dimensional (2D) gradient multiecho, slice thickness: 4 mm, gap: 0 mm, matrix 256 × 256; repetition rate (TR): 564 mm; echo time (TE): 8 ms; flip angle: 30°, number of excitations (NEX): 1;

coronal: longitudinal-relaxation-weighted (T1W) turbo spin-echo (TSE), slice thickness: 3 mm, gap: 0.6 mm, matrix: 256 ×256, TR: 550 mm, TE: 8 ms, flip angle: 30°, NEX: 1; coronal: proton density fat saturation (PD-FS) TSE, slice thickness: 3 mm, gap: 0.6 mm, matrix: 256 × 256, TR: 2000 mm; TE: 19 mm, flip angle: 90°. NEX: 1,

sagittal: T1W TSE, slice thickness: 3 mm, gap: 0.6 mm, matrix: 256 × 256, TR: 510 mm, TE: 810 ms, flip angle: 150°, NEX: 1; sagittal: PD-FS TSE, slice thickness: 3 mm, gap: 0.6 mm, matrix: 256 × 256, TR: 2190 mm, TE: 21 ms, flip angle: 150°, NEX: 1; sagittal PDW_TSE, slice thickness: 3 mm, gap: 0.6 mm, matrix: 256 × 256, TR: 2190 mm, TE: 21 ms, flip angle: 150, NEX: 1; sagittal: transverse relaxation (T2) fast field echo, slice thickness: 1.5 mm, gap: 0 mm, matrix: 256 × 256, TR: 510 mm, TE: 10 ms, flip angle: 150° and NEX: 1.

The examination name and parameters are described in Table 1.

Table 1

MRI acquisition parameters in sequence and views
	sequence	view
BML (Fig. 3)	PD-FS	Coronal and sagittal
PT (Fig. 4)	Gradient mutliecho	Axial
BO (Fig. 5)	Gradient mutliecho	Axial
TT–TG distance (Fig. 6)	Gradient mutliecho	Axial
IS ratio (Fig. 7)	T1W	Sagittal

2.8. Definition of bone marrow lessions(BMLs) on MRI

BMLs were defined as ill-defined areas with high-signal intensities in PD-FS MR images located within 1.0 cm of the articular cartilage, which were present on either ≧ 2 sagittal and/or ≧ 2 coronal images. These were classified in four regions.

2.9. Measurement volume of BMLs on MRI

Cross-sectional areas were determined on coronal images. For each lesion, the linear measurement tool was used to mark the BML edges that defined the largest BML cross-section areas. In the sagittal image, the anterior-posterior (AP) dimension was measured. We defined multiple cross-sectional areas in the AP dimension to represent the approximate volume of each BML (Fig. 2 and Fig. 3).

2.10. Evaluation of patellar instability

There are parameters for patellar instability that include the PT angle, BO, TT–TG distance and IS ratio.

2.11. Patellar tilt (PT) angle

A method was used to assess the patellar tilt which was based on the definition of the angle formed by lines joining the maximum width of the patella (PW) and the posterior femoral condyles (PCL). All tilt measurements will be reported in degrees (°). Normal tilt ranges from 0°–5°, and tilt angles > 10° are abnormal (Fig. 4).[39]

2.12. Bisect offset (BO)

BO measures the patellar width medially and laterally to the deepest part of the trochlear groove [24]. The BO is the % of the patella lateral to midline of the trochlea (the midline is transposed from the slice with the largest posterior condylar line to the slice with the widest patella). A larger valve implies an increased lateral displacement [17]. For BO measurements, we described in caption of (Fig. 5).

2.13. Tibial-tuberosity-trochlear groove (TT–TG) distance

The TT–TG distance was assessed by measuring the distance between the trochlear groove and the tibial tuberosity. We measured it as described in the caption of Fig. 6. The TT–TG distance measured the increase in the lateral position of the tibial tubercle relative to the trochlear groove. We had previously assessed this as the ‘Q’ angle. Lateralization of the tibial tubercle might weaken the vastus medialis muscle and cause lateral retinaculum contraction [25].

2.14. IS (Insall-Salvati) ratio

The IS ratio was measured as described in the caption of Fig. 7. Values of the tendon length/patellar length (LT/LP) < 1.1 were accepted as patella baja, and values > 1.3 were accepted as patella alta (Fig. 7).

2.15 X-ray assessement and KL classification

Bilateral views of the tibiofemoral compartment of the knee joint were obtained using the fixed-flexion technique, and skyline views were obtained of the patellofemoral joint. For the skyline view, each knee was imaged with the participant in a standing position and the limb flexed at 30 degrees during weight bearing.

The radiographic severity of OA was graded according to the K/L criteria, where grade 0 = normal; grade 1 = doubtful narrowing of joint space and possible osteophytic lipping; grade 2 = definite osteophytes and possible narrowing of the joint space; grade 3 = moderate multiple osteophytes, definite narrowing of joint space and grade 4 = severe joint space narrowing with at least small definite osteophytes and deformity, cysts or sclerosis.

All X-ray parameters, including BMLs and intrarater intraclass correlation coefficients, were measured by a senior doctor (C-H C). Interrater intraclass correlation coefficients were assessed by C-H Chou and H-P Lee.

2.16. Statistical analysis

Descriptive statistics were performed for all variables in the study. Measures of central tendency (mean) and standard deviation were performed for all continuous variables, and a proportion was calculated for categorical variables. The intraobserver and interobserver variability were assessed using interclass and intraclass correlation coefficients (ICCs). The paired Student’s t-test and two-sided Wilcoxon test were used to compare the preoperative and postoperative WOMAC scores, BO, TT–TG distance and IS ratio. The volume of the BMLs and PT angles were assessed by the nonparametric two-sided Wilcoxon test.

Forty patients (29 female and 11 male) with knee OA were treated with arthroscopic soft tissue release. The mean age of the patients at the time of surgery was 64.9 years (range, 55–81). Twenty six knees were classified as K/L grade 2, and 14 knees were classified as K/L grade 3. Interrater and intrarater ICCs were good to excellent for BML, PT, BO, TT–TG distance and IS ratio (Table 2).

Table 2

Reliability assessment for BML, PT, BO, TT–TG distance and IS ratio measurements.
Variable	Interrater	Intrarater
BML	0.94	0.98
PT	0.79	0.86
BO	0.80	0.87
TT–TG distance	0.82	0.80
IS ratio	0.80	0.85

There was an improvement at 6 months following surgery in the primary symptom outcomes represented by the WOMAC pain, stiffness, function and total scores. Statistically significant reductions of pain and total WOMAC scores were identified. The pain and total WOMAC scores led to significant pain score reductions from 7.0 ± 3.0 before surgery to 2.5 ± 2.8 at 6 months following surgery, and a total score from 17.8 ± 10.3 to 10.8 ± 10.5. The pain scores improved significantly, with a reduction of 64.6% at 6 months. The overall scores also improved significantly at 6 months by 39.3% (Table 3).

Table 3

Preoperative and postoperative WOMAC scores.
	Preop n = 40	Postop n = 40	P value
Pain	7.0 ± 3.0	2.5 ± 2.8	0.000
Stiffness	1.8 ± 1.6	1.7 ± 1.7	0.587
Physical function	8.9 ± 7.3	6.5 ± 7.1	0.061
Total	17.8 ± 10.3	10.8 ± 10.5	0.000

All differences in treatments after 6 months relative to baseline were assessed using paired, Student’s t-test comparisons.

The volume of BML and PT angle were determined by the two-sided Wilcoxon test. We found that BML decreased from 8503 mm³ to 2250 mm³ (P < 0.05). PT angle significantly decreased from 5.11 to 4.24 (P < 0.05). A normal tilt ranges from 0°–5°, with tilt angles greater than 10° being considered abnormal (Table 4).

Table 4

Preoperative and postoperative bone marrow lesion and patellar tilt.
Label	Preoperative n = 40	Postoperative n = 40	P value^a
BML^b	8503	2250	0.000
Patellar tilt^c	5.11	4.24	0.024
^aP values were accessed by two-sided Wilcoxon test.
^bBML decreased from 8503 mm³ to 2250 mm³ (P < 0.05).
^cPatellar tilt significantly decreased from 5.11 to 4.24 (P < 0.05). Normal tilt ranges from 0°–5°, and tilt angles greater than 10° are abnormal.

The IS ratio significantly decreased from 1.13 ± 0.13 to 1.08 ± 0.12 (P < 0.05), despite all such values being within the normal ranges of patellar alignment (Table 5).

Table 5

Preoperative and postoperative biomarkers of patellar instability.
Label	Preoperative n = 40	Postoperative n = 40	P value^a
Bisect offset (BO)	60.55 ± 8.34	59.25 ± 7.16	0.21
tibial-tuberosity–trochlear-groove distance (TT–TG)	9.67 ± 3.10	9.44 ± 2.66	0.539
Insall–Salvati (IS) ratio (IS ratio)	1.13 ± 0.13	1.08 ± 0.12	0.002
^aP values were assessed with paired Student’s t-test comparisons.

Soft tissue release, including medial plicectomy, and medial and lateral releases had been used for the treatment of knee OA, and it appeared be an effective treatment modality for mild to moderate knee OA. Previous reports evaluated the clinical symptoms and X-ray findings following operations [9–12, 26, 27]. This study is the first to use quantitative MRI to assess the arthroscopic treatment of knee OA.

4.1. BMLs and parameters for knee OA

BMLs regression may represent changes that lead to decreased knee pain sensations [28]. Volume assessments of BMLs are variable given the difficulty of defining the borders and three dimensions of the lesions. BMLs are strongly related to focal overloading in the joint that is usually attributed to malalignment [29]. BML were noted to be common in knee OA, and have been associated with knee pain. These lesions have been linked to subsequent cartilage loss which is usually superficial to the lesion. The histopathological findings of these lesions suggest that they are caused by traumatic focal stress to the bone, and that reduction of focal stress across the joint should cause them to shrink. Kijowski et al. reported findings from 132 patients and found that articular cartilage defects are associated with subchondral bone marrow oedema [29]. Targeting BMLs may offer an achievable alternative that may expedite and facilitate the testing of new treatments [16]. Previous studies had found brace and strontium ranelate in the treatment of knee OA may reduce BMLs progression [30–31].This is the first study to evaluate the BMLs on arthroscopic treatments for moderate knee OA.

The IS ratio was measured with the use of the sagittal section where the maximum length of the patella was visualised (typically the section in which the anterior cruciate ligament can be visualised). A tendon LT/LP value > 1.3 is accepted as the patella alta [32]. The patellar alta is associated with several clinical conditions. Significant causes of recurrent patellar dislocation can be associated with the patellar alta. This dislocation due to the patellar alta had been explained in light of delays in the tendo-femoral contact and concomitant increase in the magnitude of patellofemoral contact with increased flexion of the knee. Kannus et al. (1992) found that idiopathic retropatellar pain is closely associated with the patellar alta [33]. Lu et al. (2016) compared 1703 MRI findings on patients who underwent knee examinations. The IS ratio was correlated with patellar cartilage defects [34]. Stefanik et al. reported 907 cases and noted that high IS ratio values were associated with structural features of OA in the patellofemoral joint. Furthermore, it was also associated with an increased risk of worsening OA as a function of time [35]. Despite the fact that in this study, IS ratios are within normal ranges, the IS ratio changed from 1.13 to 1.08 (P < 0.05). Patellar tendon length is about the distance between patellar tip to tibial tuberosity. Release of fibrotic and inflammatory synovium and capsule in joint cavity include suprapatellar pouch might release the tension of patellar tendon and decreased the distance from patellar tip to tibial tuberosity.

The patellar tilt angle is the angle formed by lines joining the posterior femoral condyles and the maximum width of the patella [36]. Greater lateral patellar malalignment and tilt were associated with joint space narrowing and osteophytes. Macri et al. analysed MRI images from 985 participants and found that the patellar tilt and BOs were most strongly associated with damages throughout the entire thickness of the cartilage [17]. In this study, the procedure includes medial and lateral releases that correct the balance of the soft tissue in the medial and lateral sides. The patellar tilt angle was also improved.

The TT–TG distance is an objective marker of the lateral pull of the patellar tendon. Carlson et al. found that the TT–TG distance was greater in patients with patellofemoral pain (PFP) [37]. The MR-based measurement of the TT–TG distance for individuals with PFP was 12.6 mm, whereas that for the control group was 9.4 mm. In this study, we found no change in the TT–TG distance after surgery.

BO was used to quantify the patella with respect to the femur and lateral displacement of patella. A larger BO was associated with minor cartilage defects and patellar osteophytes. Hunter et al. found that increased BO was associated with a decreased progression of patellofemoral joint space narrowing [17]. There are still no definite findings regarding the relationship between BO and patellofemoral joint osteoarthritis. The postoperative changes in BO observed herein were also not significant.

4.2. Limitations of this study

There were some limitations associated with this study. The main limitation was its small sample size. Accordingly, some outcome measurements of biomarkers were not normally distributed. The BML volumes overestimated the true BML volumes despite the strong correlation of the estimates with the true BML volumes. By measuring the greatest area multiple anteroposterior dimensions, the current technique attempts to account for the potential limitations that a single image may not adequately describe the three-dimensional size of an irregularly shaped BML [38]. However, the measurements detected longitudinal changes during 6-month clinical trials and at the same levels of lesions. Furthermore, we did not have a formal control group with which outcomes could be compared.

Arthroscopic soft tissue release of mild to moderate knee OA minimised significantly pain sensations. MRI findings of BMLs demonstrated size decreases. Soft tissue release could also change patellar malalignment by improving the patellar tilt angle and IS ratio. Overall, the results suggest that soft tissue release induces clinical symptoms and structure-modifying effects in knee OA patients.

Funding

This study was supported in part by a grant from Ping-Tung Christian Hospital (PS109005).

Competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Contributors

Hsin-Pai Lee oversaw the study, evaluated the subjects and wrote the paper. Wen-Sheng Tzeng and Chun-Hsiung Chou oversaw the image acquisition and analysis and revised drafts of the paper. All authors have read and approved the final manuscript.

Ethics approval

All procedures were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was approved by the research Ethics Committee of Ping-Tung Christian Hospital (IRB Approval number:650A). In addition, the written informed consent was obtained from study participants.

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Evaluation of soft tissue release in mild-to-moderate medial knee osteoarthritis in the presence of medial synovial plica, using clinical and MRI parameters

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Abstract

Objective.

Materials and methods.

Results.

Conclusion.

Figures

1. Introduction

2. Materials And Methods

2.1. Study design

2.2. Study population and selection criteria

2.3. Inclusion criteria

2.4. Exclusion criteria

2.4. Medial release and plicaectomy

2.5. Lateral release and excision of impingement of infrapatellar fat pad

2.6. Clinical outcome measurements

2.7. Knee MRI acquisitions

2.8. Definition of bone marrow lessions(BMLs) on MRI

2.9. Measurement volume of BMLs on MRI

2.10. Evaluation of patellar instability

3. Results

4. Discussion

4.1. BMLs and parameters for knee OA

4.2. Limitations of this study

Declarations

References

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