Anterior cruciate ligament
injury: post-traumatic bone marrow oedema correlates with long-term prognosis.
injury: post-traumatic bone marrow oedema correlates with long-term prognosis.
Filardo G,
Kon E, Tentoni F, Andriolo L, Di Martino A, Busacca M, Di Matteo B, and
Marcacci M. Int Orthop. 2015. [Epub Ahead of Print]
Kon E, Tentoni F, Andriolo L, Di Martino A, Busacca M, Di Matteo B, and
Marcacci M. Int Orthop. 2015. [Epub Ahead of Print]
Take Home Message: Knees with bone marrow oedema 3 or more
months after an anterior cruciate ligament injury are less likely to return to
activity when compared with knees without oedema.
months after an anterior cruciate ligament injury are less likely to return to
activity when compared with knees without oedema.
Bone marrow oedema
(BME) is commonly seen on magnetic resonance (MR) images among knees with an anterior
cruciate ligament (ACL) rupture. In these cases, BME is often referred to as a bone
bruise or bone contusion. BME patterns may relate to the mechanism and severity
of injury. It remains unclear if BME may be predictive of patient outcomes
years after an injury. Understanding
this would help clinicians better communicate the long-term expectations to
their patients following an ACL injury. Therefore, Filardo and colleagues
completed a retrospective cohort study to assess the relationship between BME shortly
after an ACL injury and return to play as well as clinical outcomes at least 5
years after an injury. The authors selected 134 patients (98 men, ~32 years
old) who had an ACL tear, were between 16 and 50 years of age at the time of their
MR imaging, underwent an MR scan within 6 months of injury, and had a clinical
follow-up at least 5 years after the injury. Fifty percent of the patients
underwent an ACL reconstruction. Two independent and blinded reviewers
evaluated the MR images for BME presence and size. Patient outcomes were
assessed using the International Knee Documentation Committee Subjective Knee Form and
Tegner activity score. Overall, the readers
found that 65% of knees with an MR scan within 3 months of injury had a BME while
only 25% of knees had BME when scanned after 3 months post-injury. Among the
patients who had an MRI after 3 months post-injury, the authors found that
everyone with BME failed to achieve full return to pre-injury levels of sport.
In contrast, 54% of patients who had a later MR scan and had no BME were able
to achieve at least 90% of their pre-injury level of sport competition. A
similar pattern was also observed when the authors only evaluated patients who
underwent an ACL reconstruction, regardless of when the MR scan was acquired.
(BME) is commonly seen on magnetic resonance (MR) images among knees with an anterior
cruciate ligament (ACL) rupture. In these cases, BME is often referred to as a bone
bruise or bone contusion. BME patterns may relate to the mechanism and severity
of injury. It remains unclear if BME may be predictive of patient outcomes
years after an injury. Understanding
this would help clinicians better communicate the long-term expectations to
their patients following an ACL injury. Therefore, Filardo and colleagues
completed a retrospective cohort study to assess the relationship between BME shortly
after an ACL injury and return to play as well as clinical outcomes at least 5
years after an injury. The authors selected 134 patients (98 men, ~32 years
old) who had an ACL tear, were between 16 and 50 years of age at the time of their
MR imaging, underwent an MR scan within 6 months of injury, and had a clinical
follow-up at least 5 years after the injury. Fifty percent of the patients
underwent an ACL reconstruction. Two independent and blinded reviewers
evaluated the MR images for BME presence and size. Patient outcomes were
assessed using the International Knee Documentation Committee Subjective Knee Form and
Tegner activity score. Overall, the readers
found that 65% of knees with an MR scan within 3 months of injury had a BME while
only 25% of knees had BME when scanned after 3 months post-injury. Among the
patients who had an MRI after 3 months post-injury, the authors found that
everyone with BME failed to achieve full return to pre-injury levels of sport.
In contrast, 54% of patients who had a later MR scan and had no BME were able
to achieve at least 90% of their pre-injury level of sport competition. A
similar pattern was also observed when the authors only evaluated patients who
underwent an ACL reconstruction, regardless of when the MR scan was acquired.
Overall, the current
study is interesting because the findings suggest that BME that lingers beyond 3
months after an injury may be a bad sign for an individual’s ability to return
to his/her pre-injury levels of activity. In a previous Sports Med Res post we described a
study that showed that BME usually diminishes within 12 months of injury. Knees
with BME that persist for 3 months or longer may have experienced a greater
injury, which could explain the poorer outcomes. Interestingly, the study in
the previous Sports Med Res post
found that about a third of knees redeveloped bone marrow lesions. This was
concerning since these lesions are often associated with osteoarthritis
progression. The prior study as well as the study reported here raises
questions about whether we should be getting follow-up MR imaging on our
patients 3-24 months after an injury. Future analysis may help clinicians
better understand how changes in BME after an injury could inform long-term
outcomes. It is important to appreciate that in this retrospective study the individuals
getting MR images 3 months after an injury may be experiencing joint problems
that prompted a physician to order the images. Improving our understanding of
the relationship between BME changes and long-term outcomes could lead to the
development of guidelines to treat patients based on the severity of the BME to
better preserve the long-term health of the joint. Until this time, BME can be
used to help advise patients with regards to their long-term prognosis regarding
their return to their desired or previous level of physical activity.
study is interesting because the findings suggest that BME that lingers beyond 3
months after an injury may be a bad sign for an individual’s ability to return
to his/her pre-injury levels of activity. In a previous Sports Med Res post we described a
study that showed that BME usually diminishes within 12 months of injury. Knees
with BME that persist for 3 months or longer may have experienced a greater
injury, which could explain the poorer outcomes. Interestingly, the study in
the previous Sports Med Res post
found that about a third of knees redeveloped bone marrow lesions. This was
concerning since these lesions are often associated with osteoarthritis
progression. The prior study as well as the study reported here raises
questions about whether we should be getting follow-up MR imaging on our
patients 3-24 months after an injury. Future analysis may help clinicians
better understand how changes in BME after an injury could inform long-term
outcomes. It is important to appreciate that in this retrospective study the individuals
getting MR images 3 months after an injury may be experiencing joint problems
that prompted a physician to order the images. Improving our understanding of
the relationship between BME changes and long-term outcomes could lead to the
development of guidelines to treat patients based on the severity of the BME to
better preserve the long-term health of the joint. Until this time, BME can be
used to help advise patients with regards to their long-term prognosis regarding
their return to their desired or previous level of physical activity.
Questions
for Discussion: Do you ever get MR images on your athletes
3-24 months after an ACL injury? Do you think bone bruises in knees with ACL
injuries can help us determine a patient’s prognosis?
for Discussion: Do you ever get MR images on your athletes
3-24 months after an ACL injury? Do you think bone bruises in knees with ACL
injuries can help us determine a patient’s prognosis?
Written by: Kyle Harris
Reviewed by: Jeffrey Driban
Related Posts:
Filardo, G., Kon, E., Tentoni, F., Andriolo, L., Di Martino, A., Busacca, M., Di Matteo, B., & Marcacci, M. (2015). Anterior cruciate ligament injury: post-traumatic bone marrow oedema correlates with long-term prognosis International Orthopaedics DOI: 10.1007/s00264-015-2672-3
I think that BME, while something that we recognize upon imaging, is often something that gets pushed to the back burner when found along with and ACL tear. As a clinician (Athletic Trainer), when seeing BME with an ACL tear on MRI, I have always leaned toward focusing on the torn ACL itself because there are options available for correcting that pathology. To my knowledge, rest is the only treatment for a bone bruise which makes it much easier to focus on the main issue at hand.
I have also suffered from a torn ACL myself (6 months post-op) and presented with Moderate BME myself. Although I had some other complications with my rehabilitation, I have not progressed as fast as I hoped. I would have been interested to see how much of the BME was still present following my surgery.
After reading this article, I have seen that requesting MRIs 3 months after a surgery would be useful in updating a prognosis, but as clinicans we also need to think about practicality. If you are working at a setting where MRI is readily available I can see the usefulness but at other settings, like a HS, this may be less feasible due to cost, availability, and time constrictions. I think that this study has opened up potential future research on how effective MRI can be when it comes to estimating total recovery of BME with ACL tears and various outcome measures and activity levels post injury.
Hi Kyle:
Great point about the feasibility of getting an MRI at 3 months. I think this would not get done based on whether the athlete was in a high school setting or a professional setting but something that may get ordered by the treating physician (e.g., the surgeon who did the ACL reconstruction). Hopefully, over time the cost of the MRIs will also come down. The scans needed to look for BMEs can be done pretty quick so it would be nice if we could do them for less money. I agree with you that this study is a nice eye opener and it will probably lead to more research into how we can use BMEs to inform clinical decision making. You may be interested in Richard Frobell's paper where they found that even after a BME resolves some knees develop a new bone marrow lesion at that location: https://www.ncbi.nlm.nih.gov/pubmed/21776546 Hopefully more research will look into the clinical implications of this finding.