Trends in morphological changes of knee joints revealed by ultrasound imaging

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Abstract

Aim: to evaluate the nature of ultrasound changes in some structures of the knee joints among patients seeking outpatient medical care. Using the example of a clinical case to demonstrate the importance of differential diagnosis of diseases of the knee joints with vascular pathology of the lower extremities.

Material and methods. 380 volunteers aged 18 to 86 years were examined. SonoAce R7 diagnostic equipment was used. The results were entered into spreadsheets, followed by grouping and statistical analysis using MS Excel, IBM SPSS Statistics 20, and plotting distribution using StatSoft Statistica 10.

Results. The average age of the participants diagnosed with Baker’s cysts was 57.9±9.1 years: 56.5±8.5 years for men and 58.3±9.2 years for women. The signs of osteoarthritis, including sharpened articular surface edges and prominent osteophytes, were detected in 67.3% (256) of cases. These manifestations were detected in 56.1% of men and 75.9% of women. Synovitis was observed in 22.1% (84) cases, 24.4% for men and 20.4% for women. Baker’s cysts were diagnosed in 23.7% (90) cases, 12.2% for men and 32.4% for women. Similar dynamics in the development of structural changes in the knee joints were noted, regardless of the patient’s gender.

Conclusion. Determining the etiology of pathological changes and assessing their role in the development of associated symptoms and potential complications allows for more effective diagnosis and treatment, as well as the selection of optimal patient management strategies.

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INTRODUCTION

Among the diseases of the locomotor system, the degenerative and dystrophic changes remain the leading reason why patients seek medical assistance [1]. Numerous published works demonstrate the importance of improvement of early diagnostics of such diseases as osteoarthritis in order to enhance efficacy of treatment and improve quality of life of patients [2]. Difficulties in the staging and early diagnosis of this group of diseases are due to their polyetiological nature, variability of the clinical presentation and late presentation of patients for medical care [3, 4].

The reasons for seeking medical assistance often comprise the following symptoms: constrained movements in the morning, pain under physical exercise, feeling of fullness and swelling in the joint area, increased manifestations of the disease after a period of intense movement activity [5]. Excess weight and obesity aggravate the progression of the disease. Pharmacological and non-pharmacological treatment methods are instrumental in relieving the pain and improving physical activity, but they can not remove the pathological and X-ray changes characteristic of osteoarthritis of the knee joint [6-8]. As a result, the pathological changes progress, and functional disorders aggravate [10].

Modern methods of instrumental diagnostics of diseases of the locomotor system, among them the knee joint, include X-ray and ultrasound imaging and arthroscopic examination [10-12]. The X-ray method is the simplest and leads in the determination of the stage of the disease, but it has limitations in the possibilities of assessment of changes of the surrounding soft tissue [13].

Computed tomography and magnetic resonance imaging provide possibilities to get more information about the extent of changes and to assess the condition of neighboring structures; they are more used in the preoperative stages in complex clinical cases. Unlike other methods, ultrasound imaging allows for assessment of the external perimeter of the osseous structures, changes in the surrounding tissue, and for a detailed condition of the cartilage elements of the locomotor system [14]. Wide availability and relative ease of performance make methods of ultrasound imaging highly successful in the assessment of periarticular tissues and assessment of condition of the hyaline cartilage [10]. An important advantage was the identification of such concomitant conditions as Baker’s cysts, varicose veins, etc. [10, 11].

Depending on the combination of factors manifested in patients with diseases of the locomotor system caused by the extent of pathologic changes and concomitant diseases, various approaches to treatment organization are used including pharmacological [15] and traditional methods [16], physiotherapy [17], use of braces and physical exercise [3, 6, 9]. Surgical methods may include prosthetics and treatment of concomitant changes.

One of important problems is the synovial cysts of the popliteal cysts and varicose dilatation of veins of the lower limbs [15, 12, 18]. In clinical practice, differential diagnosis of pathological changes of the knee joint with hemodynamic disorders of the lower leg is often needed [10, 19].

AIM

To evaluate the nature of ultrasound changes in some structures of the knee joints among patients seeking outpatient medical care.

MATERIAL AND METHODS

In outpatient care conditions, 380 volunteers were examined. They presented various complaints related to the knee joint. Their age was 18 to 86 years (median age: 52.3±11.9 years). The study did not involve patients after surgical interventions, including total knee replacement. The diagnostic equipment was the Samsung Medison SonoAce R7 (Republic of South Korea) with a high-frequency linear sensor. The study protocol was approved by the local ethics committee; all participants signed a voluntary informed consent to participate in the study. The anonymized results were placed in electronic spreadsheets with subsequent grouping and statistical analysis.

Statistical processing of data was performed in Microsoft Excel 2007 and IBM SPSS Statistics v. 20.0. Extreme values (Min–Max), means and standard deviations (M±SD), medians (Me), first and third quartiles of the distribution [Q1–Q3], and the coefficient of variation (CV, %) were analyzed. The reliability of the study data was assessed using Student’s t-test for independent and paired samples, as well as by constructing graphs to confirm the normality of the evaluated parameters using StatSoft Statistica 10.

RESULTS

There were 164 men and 216 women among the participants of the study. The average age of men was 48.0±13.6 years; the average age of women was 55.5±13.6 years. The distribution of values for all participants of the observation is presented on the distribution normality chart (Fig. 1).

 

Figure 1. Diagram of the normality of the probable age distribution (years) among men and women in the study.

Рисунок 1. Диаграмма нормальности вероятного распределения возраста (лет) среди мужчин и женщин в наблюдении.

 

One of the most important metrics in the diagnostics of knee joint diseases is the assessment of thickness of the hyaline cartilage. In our study, the value was measured in the area of the weight-bearing surface of the medial femoral condyle, and the general data on the distribution of measurement results are presented as a chart of normality of value distribution (Fig. 2).

 

Figure 2. Diagram of the normality of the probable distribution of hyaline cartilage thickness (mm) among men and women in the study.

Рисунок 2. Диаграмма нормальности вероятного распределения толщины гиалинового хряща (мм) среди мужчин и женщин в наблюдении.

 

The thickness of the hyaline cartilage within our study was in the range (Min-Max) of 1.0-3.3 mm, and the average for all participants was 1.9±0.4 mm, Me: 1.9 mm, Q1-Q3: 1.6-2.1 mm. Among the men, the values were (Min-Max): 1.3-3.3 mm, the average thickness of the hyaline cartilage was 2.0±0.4 mm. The median (Me) was 2.0 mm, first and third quartiles [Q1-Q3] among men were 1.7-2.2 mm, CV: 21.9%.

Among the women in the study, the thickness of the hyaline cartilage in the area of the weight-bearing surface of the medial femoral condyle was (Min-Max) as follows: 1.0-3.0 mm, mean value (M±SD): 1.9±0.4 mm, Ме: 1.8 mm, Q1-Q3: 1.6-2.1 mm, CV: 20.1%.

Signs of osteoarthritis, viz. sharpening of edges of articular surfaces and manifested osteophytes, were identified in 67.3% of examinations (256 cases). Among men, such manifestations were seed in 56.1%, and among women, in 75.9%. Signs of synovitis were seed in 22.1% (84 cases): among men, in 24.4%, among women, in 20.4%. Baker’s cysts were diagnosed in 23.7% of examinations (90 cases): among men, in 12.2%, among women, in 32.4%.

The median age of participants of the study, in whom Baker’s cysts were diagnosed, was (M±SD) 57.9±11.3 years, (Min-Max) 23-86 years, (Me) 59.0 years, interquartile interval among all participants [Q1-Q3] was 50.0-67.0 years, CV-19.6%. Male group: (Min-Max) 44-73 years, (M±SD) 56.5±9.8 years, (Me) 50.0-66.0 years, CV-17.3%. In the female group, cysts were identified at the age of (Min-Max) 23-86 years, (M±SD) 58.3±11.8 years, (Me) 52.0-67.0 years, CV – 20.2%. The obtained data is shown in the box plot (Fig. 3).

 

Figure 3. Age range diagram for men and women in cases of Baker’s cysts diagnosis.

Рисунок 3. Диаграмма размаха для возраста среди мужчин и женщин в случаях диагностики кист Бейкера.

 

The values of the thickness of the hyaline cartilage in the area of the weight-bearing surface of the medial femoral condyle in the diagnostics of Baker’s cysts were as follows: (Min-Max) 1.0-3.0 mm, the median value for all observations (M±SD) was 2.0±0.4 mm, (Me): 1.9 mm, Q1-Q3: 1.7-2.2 mm, CV: 20.4%.

In the male group, at the diagnosis of the Baker’s cysts the cartilage thickness was in the range (Min-Max) of 1.4-3.0 mm, (M±SD): 2.1±0.5 mm, (Me): 2.0 mm, Q1-Q3: 1.7-2.4 mm, CV: 26.0%. In the female group, the minimum and maximum values of hyaline cartilage thickness art the diagnosis of the Baker’s cysts were as follows: (Min-Max), 1.0-2.7 mm, (M±SD): 1.9±0.3 mm, (Me): 1.9 mm, Q1-Q3: 1.7-2.1 mm, CV: 17.8%. The generalized data on the distribution of values are shows in the box diagram (Fig. 4).

 

Figure 4. Span diagram for the thickness of hyaline cartilage in the area of the supporting surface of the medial condyle of the femur, depending on the detection of Baker’s cysts.

Рисунок 4. Диаграмма размаха для толщины гиалинового хряща в области опорной поверхности медиального мыщелка бедра в зависимости от выявления кист Бейкера.

 

The analysis of the contents of the cysts showed the following. In 32.6% of the cases, signs of presence of inclusions and bridges were identified, and in 27% signs of a finely dispersed suspension were seen. Special attention was paid to measuring the thickness of walls of Baker’s cysts. For all observations, the cyst wall thickness (Min-Max) was 0.7-3.8 mm, (M±SD): 1.8±0.6 mm, (Me): 1.7 mm, Q1-Q3: 1.4-2.2 mm, CV: 33.5%. In the male group, the cyst wall thickness (Min-Max) was 1.2-1.6 mm, (M±SD): 1.8±0.4 mm, (Me): 1.8 mm, Q1-Q3: 1.7-2.0 mm, CV: 23.8%. In the female group, the cyst wall thickness (Min-Max) was 0.7-3.8 mm, (M±SD): 1.8±0.7 mm, (Me): 1.6 mm, Q1-Q3: 1.4-2.3 mm, CV: 35.9%.

The presented data demonstrate a similar pattern of echographic changes in the knee joints between men and women. Differences in changes among men and women show a small variance, while the reliability of the analyzed parameters, as calculated using Student’s t-test, corresponds to P< 0.001 when comparing data between participant groups.

DISCUSSION

Current clinical practices have a wide range of instrumental diagnostic tools to determine the extent of changes of the joints and the periarticular structures [20]. The X-ray method is fast and efficient for the assessment of osseous structures [13]. Magnetic resonance imaging allows studying the problems by using the advantages offered by multiparametric visualization, but the procedure is rather lengthy and expensive [20]. Computed tomography provides sufficient diagnostic information and is rather fast. At the same time, it provides higher radiation exposure than the standard X-ray of the joints.

Ultrasound imaging allows addressing a wide range of practical tasks without using costly expert-level machines. A significant advantage is the possibility of multiparametric scanning (using various working frequencies and sensor configurations) in solving specific practical tasks [10]. The possibility of direct communication with the patient during the examination allows for a more detailed inspection of areas with the most pronounced pain and manifested external changes. Another great advantage of ultrasound imaging is the possibility of functional evaluation of joints. It is possible to enhance the diagnostic procedure considering the patterns reflecting the character of changes in the periarticular tissue in cases of a manifested edema or suspected development of phlebothrombosis.

Even though manifestations of osteoarthritis are well known and described, development and availability of diagnostic opportunities of equipment regularly necessitates updates of the known information [21]. On the other hand, the progress of osteoarthritis is associated with numerous factors, including lifestyle and physical activity; therefore, the prevalence of identified changes with respect to the patients’ age and concomitant processes requires regular follow-ups from the scientific community [22]. Our study demonstrates a similar trend in the progression of osteoarthritis described in the work of A.S. Povzun et al., with a greater number of women in the total sample. Thanks to the opportunities provided by the method of ultrasound imaging, correlations were shown in the dynamics of development of structural changes. Due to a considerable number of participants, the obtained results allow for a more detailed assessment of the character of changes among patients who sought medical assistance in the outpatient care stage. The obtained data can be used with a high degree of confidence for applied purposes, including the development of specialized software and the refinement of age- and sex-specific morphometric parameters.

Domestic and international publications highlight the importance of a comprehensive patient analysis in the diagnosis of joint diseases, as well as the need to supplement clinical examination findings with data from radiography and ultrasound imaging [2, 4, 23]. The results obtained within our study enable a demonstration of prevalence of some echographic signs in the process of development of knee joint diseases. Some of the most visual manifestations concomitant with the complex of pathological changes, are the signs of synovitis and identification of Baker’s cysts, which, in some cases, require differential diagnostics.

Ultrasound imaging enables rapid, effective, and informative resolution of complex clinical issues while simultaneously ruling out both rarer complications, such as cyst rupture or hematoma, and concomitant thrombophlebitis of the deep veins of the lower leg. Such clinical cases have been described in studies demonstrating the importance of echographic verification and the clinical significance of periarticular structures [23]. E.A. Skripchenko et al. describe the importance of possibilities offered by ultrasound imaging to assess condition of periarticular structures in osteoarthritis and to correlate the results with X-ray imaging data in the assessment of severity of pathological processes. Another important aspect is the determination of compression of elements of the neurovascular bundle in the popliteal area and exclusion of pathological processes of a different etiology. A clinical case of compression of the popliteal artery by a Baker’s cyst was described in the paper of D.I. Markevich et al. [19]. The authors describes a pattern of hemodynamic disorder which resulted from a combination of such factors as atherosclerotic alterations along the way of arteries of lower limbs and processes associated with a synovial cyst in the popliteal area. In its turn, the prevalence of diseases of veins of lower limbs and Baker's cysts was the reason for the development of methods of simultaneous surgical treatment of such patients by combined phlebectomy and removal of the synovial cyst of the popliteal region [24]. Implementation of advantages of laser and minimally invasive technologies allowed for the use of the method of simultaneous laser thermal obliteration of recurrent lower extremity veins and Baker’s cysts [18].

CONCLUSIONS

The data obtained by us demonstrates a complex of correlated changes in osteoarthritis diagnosed by ultrasound imaging of structures of the knee joint. Signs of osteoarthritis are identified in 67.3% cases, and synovitis, in 22.1%. Baker’s cysts are diagnosed in 23.7% of examinations. Baker’s cysts were diagnosed in the age of 57.9±9.1 years. In general, there was found a similar dynamic of development of structural changes of the knee joints independent of the patients’ sex.

Determination of etiology of pathological changes, assessment of their role in the development of concomitant symptoms and possible complications allows for improvement of efficacy of diagnostics and treatment, and for the selection of optimal tactics of patient management.

 

ADDITIONAL INFORMATION

ДОПОЛНИТЕЛЬНАЯ ИНФОРМАЦИЯ

Ethical approval. The study was approved by the Ethics Committee of Orel State University named after I.S. Turgenev (Protocol № 25, November 16, 2022).

Этическая экспертиза. Исследование было одобрено ЛЭК Орловского государственного университета имени И.С. Тургенева (протокол №25, 16 ноября 2022 г.).

Study funding. The study was the authors’ initiative without external funding.

Источник финансирования. Работа выполнена по инициативе авторов без привлечения финансирования.

Conflict of interest. The authors declare that there are no obvious or potential conflicts of interest associated with the content of this article.

Конфликт интересов. Авторы декларируют отсутствие явных и потенциальных конфликтов интересов, связанных с содержанием настоящей статьи.

Consent to publication. The authors obtained from the patients who took part in the study a voluntary informing consent.

Согласие на публикацию. Авторы получили от пациентов, принимавших участие в исследовании, добровольное информирование согласие.

Contribution of individual authors. Moshkin A.S.: study idea and design, article editing. Moshkina L.V.: data collection and processing. Kholikova K.D., Kryuchkov P.A.: data collection, writing of the text.

All authors gave their final approval of the manuscript for submission, and agreed to be accountable for all aspects of the work, implying proper study and resolution of issues related to the accuracy or integrity of any part of the work.

Участие авторов. Мошкин А.С.: идея и дизайн исследования, редактирование статьи. Мошкина Л.В.: сбор и обработка материала. Холикова К.Д., Крючков П.А.: сбор материала, написание текста.

Все авторы одобрили финальную версию статьи перед публикацией, выразили согласие нести ответственность за все аспекты работы, подразумевающую надлежащее изучение и решение вопросов, связанных с точностью или добросовестностью любой части работы.

Statement of originality. No previously published material (text, images, or data) was used in this work.

Оригинальность. При создании настоящей работы авторы не использовали ранее опубликованные сведения (текст, иллюстрации, данные).

Data availability statement. The editorial policy regarding data sharing does not apply to this work.

Доступ к данным. Редакционная политика в отношении совместного использования данных к настоящей работе не применима.

Generative AI. No generative artificial intelligence technologies were used to prepare this article.

Генеративный искусственный интеллект. При создании настоящей статьи технологии генеративного искусственного интеллекта не использовали.

Provenance and peer review. This paper was submitted unsolicited and reviewed following the standard procedure. The peer review process involved 2 external reviewers.

Рассмотрение и рецензирование. Настоящая работа подана в журнал в инициативном порядке и рассмотрена по обычной процедуре. В рецензировании участвовали 2 внешних рецензента.

 

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About the authors

Andrei S. Moshkin

Orel State University named after I.S. Turgenev

Author for correspondence.
Email: as.moshkin@internet.ru
ORCID iD: 0000-0003-2085-0718

MD, Cand. Sci. (Medicine), Associate professor of the Department of Anatomy, Operative Surgery and Disaster Medicine.

Russian Federation, Orel

Lyubov V. Moshkina

Orel State University named after I.S. Turgenev

Email: moshkina.l@internet.ru
ORCID iD: 0009-0008-1328-1880

MD, assistant at the Department of Anatomy, Operative Surgery and Disaster Medicine.

Russian Federation, Orel

Kseniya D. Holikova

Orel State University named after I.S. Turgenev

Email: holikovaxenia@yandex.ru
ORCID iD: 0009-0008-0588-0146

student of the Faculty of Medicine.

Russian Federation, Orel

Petr A. Kryuchkov

Orel State University named after I.S. Turgenev

Email: 995511122@mail.ru
ORCID iD: 0009-0000-4420-0424

student of the Faculty of Medicine.

Russian Federation, Orel

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Supplementary files

Supplementary Files
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2. Figure 1. Diagram of the normality of the probable age distribution (years) among men and women in the study.

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3. Figure 2. Diagram of the normality of the probable distribution of hyaline cartilage thickness (mm) among men and women in the study.

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4. Figure 3. Age range diagram for men and women in cases of Baker’s cysts diagnosis.

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5. Figure 4. Span diagram for the thickness of hyaline cartilage in the area of the supporting surface of the medial condyle of the femur, depending on the detection of Baker’s cysts.

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