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All right. Hello, everybody. Welcome to the third session of the B s s R grand rounds. Um, I have the pleasure of inviting our first speaker, Doctor, uh, the Yukon, who is the fellow at the Oxford University Hospital in, uh, Field. And, uh, he is actually starting his consultant job soon in Royal Liverpool University Hospital. So, uh, todays team is knee pain, and, uh, we will first start with doctor can, presenting some acute knee conditions to us, and, uh, we will then be joined by Doctor Charry, who is the consultant? Musculoskeletal radiologist from Oxford University Hospital. Uh, he's also part of the Sakuma board and the regional sports Oxford Oxford Medicine. So he will be joining us, Uh, soon. So, uh, you can take the flow. Thank you. So, first of all, thanks. Prayer for the very kind introduction and also for setting meeting up. And so thank you to everyone who's taking your time off your busy afternoons today to join us for our presentation. So in my presentation, I will be showing you a few cases of things that I've commonly encountered in my practice. Um, and due to time constraints, I'll be mainly share ing soft tissue injuries. Um, and there there, there will be no fractures. So in the first case And, um so there are 10 cases in total just so you know where we are at any time of the presentation. So in the first case, what we have is a abnormal looking p a c l. You can see that the ACL is thickened and it has a bit of an irregular contour with intrinsic high signal. And so the questions that we'll be on our mind is whether is there a tear? So what I tend to do then, is to look at the other, um, slices. So on the actual you can see that the ACL is intact and and present in the in the intercondylar notch and again, this is confirmed on the Corona view. So here I can confidently say that ACL is intact and I've got this a new card degeneration of the ACL, and I'm sharing this because I think you called degeneration is very important differentials and assessing for ACL tear. And in a different example of an abnormal looking ACL, we can see once again there is abnormal high signal within, um, expected region of the ACL. And you can see that the unlike the first case, the tendon fibers are less well defined. And this is also confirmed on the axial view where there's absence of a cl with bone, Adama just deep to the proximal attachment at the femur. And so I would call this either a high grade or a complete ACL tear. So in yet another example of an abnormal looking ACL can see once again, that's, uh, there is a flicker with your microphone. It comes, uh, thing, can you just adjust your microphone, please? Yeah, sure. It's actually in built into my laptop. Is it? Is it better now? Wow. Maybe if you just go, OK, let me try this. What? What about now? Uh, Okay, let's try that. Yeah. Okay. I think it may be because I've blocked in my power, So I've removed the charger, and also hopefully, it's better. Um, okay. No, I think I think it's still, you know, if you're getting, uh, kind of, uh uh, like a crackle. Oh, right. Okay. Uh, the only thing is, they said, uh oh, you can hear now. Is that better? So just continue speaking because I think if I speak, it's fine. But when you start, we can hear a cracker. Right? What about now? Is it any better? Uh, I think what we said was, if you have logged in the safari, it causes a crackle kind of a thing, like, you know, Yeah. I'm not really sure why. I can try changing, um, the the speaker just to see we had, uh um it helps. Just try. Okay, fine. So sorry. Sorry for the, uh, yeah. Then he just changing the source of the mike just to see whether that helps. Meanwhile, for the delegates and the audience who have joined us, uh, and, you know, taken time to attend the session. What did you think about the radiograph? When you login on the login pay, there's a question we asked about, You know, which syndrome do you think this is? I think the Southwest trainees and trainers may know the answer, so please do not answer for now. Uh, it's open people like, so sorry. Pre. I couldn't hear you earlier. Was it better with the second Mike? Yes. This is better Now it's better now. Is it? This is better now, Now it's okay. Yeah, it's okay. Sure. If it happens again, just let me know, and I will know. This is this is absolutely fine. So you can read. Uh, that's brilliant. Thank you. Sorry about that. Um, yeah. So it's I t issues. So yeah. So going back to the ACL. So this is another look at normal looking ACL. And here, once again, there is, uh, intrinsic like, abnormal signal change. But you can see that the proximal and distal attachments are still, um, intact. And so, in this case, I would call this a form of interest substance, ACL, tear, which is a form of partial tear of the ACL. So essentially, we can see complete or partial test of the ACL. And the time kind of partials that we can see is when there is attacking one of the two bundles or like example that showed you earlier when there's just a interstitial hiring and most commonly, uh, in the proximal mid portion of the ACL. And the findings that you would see is increased signal, although sometimes a bit of intermediate or high. You know, it can be not normal. It may just be separation of the antral media and posterolateral bundles and in chronic conditions, um, all you would see is a fat in the expected location of the ACL, also known as the empty notch sign. So, fortunately, sometimes a C R tests are more straightforward, such as in this case, you can see here in the proximal portion that the ACL is completely gone and notice the distal stump is more horizontal than expected, and this is confirmed on the X cereal. So this is a complete proximal ACL tear. So the ACL consists of two fibers, namely the antral media and the posterolateral bundles. And in extension, the antral media bundle is lax about the posterolateral bundle is taught. And what happens when the knee flexes is that the proximal part of the posterolateral bundle just wraps around the antral media bundle in an adequate pattern, and it becomes lax while the antral media bundle becomes taught. So the entity of partial thickness ACL tear is debatable. I've spoken to some people who do not actually believe they exist, although it is quite well documented in literature, and this is an example from step DX. I've taken which shows, um, complete tear of the antral media bundle as highlighted by the straight arrow. And you can see that the posterolateral bundle, as highlighted by the curved arrow, shows that the bundle is partly intact. So this is a partial ACL tear, and you can get ancillary signs in ACL tear, such as in this case where there is anterior tibial translation, since the ACL is actually the primary restraints of anterior translation of the knee. So if that is ruptured, then you get, um, anterior tibial translation. And there's also a condo defect there. And the other classic findings that you've seen ACL tear is the P word shift pattern of injury when you get married edema in the antiviral plateau and also in the lateral femoral condyle, although it's not as clearly demonstrated here due to the slice that images taken. But what is on this slice is a subchondral defect in the terminal sulcus of the lateral femoral condom, also called the Deep sulcus sign, and you also see Siegen fractures, which are strongly associated with a C L tests. So in my second case, it's only right that I show you a case of a PCL tear as well, since I actually showed your ACL tear and this case just like the ACL. Um, there's complete tearing of the proximal part and you can see that the distal stump there is still intact and these are shown on the axial images at the respective levels. So this is an example of a complete approximal tear of the PCL. So PCL tear basically happens in any mechanism injury that causes the tibia two to be translated posteriorly in relation to the FEMA. And this is seen in dashboard injuries or falling on the flex knee, and the other mechanism is in hyper extension of the knee, just like the ACL it can be partial or complete usually involves the mid portion. About 40% of them are isolated, although more often than not, there are many accompanying injuries, such as injuries to the posterolateral corner. So this is another example of PCL 10, where you can see that the fiber is somewhat intact, but you can see some intrinsic high signal within it. And unlike the PCL, unlike the ACL sorry the ACL, it's okay for ACL to have a bit of intrinsic high signal or intermediate signal, but in PCL, it should be uniformly black, unlike in this case. So if you look into this a proximal portion, so there's a bit of high signal there compared to the relatively normal distal portion that is uniformly black. So this is an intra substance PCL tear. And just like a cl, there can be new, quite degeneration of PCR, as shown here, giving rise to the tram track appearance. So in the third case, um, the clue of the abnormality in this case is to look at the body of the medial meniscus, which is truncated here and on scrutinizing the images clearer. Further, you can see that there is an extra substance here in the in the candle, a notch, which shouldn't be there. They're really only should be the ACL and PCL in the notch. And when you see that, you should be thinking of on whether there is a flip fragment, as you can see here, which we all know, it's called the bucket handle tear and essentially what a bucket handle tear is. It's a form of longitudinal vertical tech along the circumference of the meniscus, and what happens is the inner portion flips towards and into the intercondylar notch, giving us the bucket handle appearance and on the sectional view, we sometimes see the classic Double PCL sign, although it's very important to note that a Double PCL sign. Although it's classical, it's not necessarily send um specific for a bucket handle tear, because you can see similar appearances in conditions in like Men ischiofemoral ligaments. And it's just important to be mindful of that. So this is just a slight summarizing everything I've talked about earlier and let's move on to the fourth case. So in the fourth case you can see here the abnormality is in the lateral meniscus. Here there's a nice and clear cleft at the junction of the anterior horn and body of the um, lateral meniscus. And whenever I assess radio test, I often like to look at the X ray images because I feel that it gives a much clearer picture of how the test looks like, as in this case, and this just also highlights the importance of actually I think the radiograph for know to actually get the right slice where the normality is, and also to use very thin slices to get the best image possible. So radio tests are most common at the junction of the anterior horn and body. But they can also happen at the posterior horn, and what you see is a vertical cleft, uh, vertical defect or collapse sign. So this is a different example of a much more smaller and subtle radio tear can see a small defect here on the sagittal view. And once again looking at the exit of you, you get a better career of how the tear actually looks like and yet another example of a radio tech in the posterior route. And you can see it quite clearly on the X ray of you as well. And the posterior route is actually one of my review areas because it's very easy to miss a small radio tear there, especially when it's small. And it has, um, potential significant repercussions. So the possible complications that can happen is that if this is not detected, it can be extrusion of the meniscus, um, and which changes the distribution of stress within the knee leading to premature osteoarthritis or subchondral insufficiency, fractures. And if you look at the surgical image at the level of the defect. You notice that they're the the positive meniscal absent. And this is called the ghost meniscus sign. And the other thing, I will say that if you see an absence of the meniscus, always look at, uh, cracking his back again. Is it back? Oh, gosh. I suspect it may be my internet connection. Um, but let me try changing the mic again and see whether that helps. Sorry, but I think I mean, the presentation is going well, but, you know, uh, there was a lot of spackling. So is it Gee, are you on safari rather than chrome? I am on safari. Gee, does that affect the quality? Sure. Safari will be correctly pre a nose. This OK? Should I Downward chrome now? Or would that be too? Gee, do you have for the sake of your delegates, do you have a second that you can literally close this and reopen and come back into the call? Just the sake of the delegates having a clear talk from you? We checked, tested on chrome's would be really good if we can get you back on chrome. Is that alright? Korea? Yeah, sure. Actually tested it on on the same browser the last time. Um, but I'll try downloading chrome and just give me one minute. All right? I will just log out now. Apologies for that. It's fine. It's fine. Don't worry. Sorry. Pria. Yeah, I finished. There's all my case as well. So, you know, uh, unless Roge has a case that he can, uh, through two delegates, uh, that they can think about while we wait for, uh, I do logging again. I'll have to through my presentation. Um, it, um if if that's what they want, I I could, um I could start presenting while, uh, I think let's do that, Judge. So welcome. Welcome to the, uh, platform and, uh, thank you for your time, uh, to present at the, uh, grand rounds and, uh, please take it away. Thank you very much. Prayer. And, uh, sorry to cheat that. I'm I'm I'm stealing. Um, this show, um, hope you can see my presentation, and you can hear me clearly. Okay. All right. So thank you very much for the opportunity. Um, and this great initiative of grand rounds and Bs are, um and, uh, and in the neck, uh, half an hour or so, I'll show you a few cases, Uh, and talk briefly about the theory behind these. Um, these are all commonly encountered. Uh, any problems? Um, I won't be able to cover everything, but I'll do my best to go through as many cases as possible. So knee pain is very, very common. Approximately 25% of orders are suffering with knee pain. The prevalence has increased by 65% in the last 20 years because of multiple reasons. Increasing sports activities, aging population are side is etcetera now, common things common. Uh, 80% of the, uh, the pain causes relate to many sky ACL PCL, collateral ligaments and cartilage. Uh, I will kindly cover most of this. I think we'll leave the arthritis alone because of time constraint from this session. So my first case, uh, is a 40 year old builder with anterior knee pain. So you have there the sagittal and actual pedia fact that images, uh, and you can clearly see um um uh, fluid, uh, density shadow in the intra patella region. Well defined. No edema. Um, there are other things, but that that's the most pertinent finding So that's a Preper. That's the interpreter lab Bursa, and we'll talk about prep. It'll add an interpreter. Adverse it briefly. So most of these birthday are mechanical there, either. Clergyman Knee, As you can see there whether the way the clergyman sits, there is a pressure on the tibial tuberosity and the interpreter lot. Bertha comes up or it's also called a house made. Even there is pre patellar. You can see how the house made kneels down the pressure. Mechanical stress is in the pre patellar region, and the pre patellar birthday come up A lot of contact sports like wrestling. Uh, football. Uh, athletes can get this, uh, problem as well, But tradesmen like plumbers and Tyler's who constantly kneel down, get this very, very commonly. You can see them wearing knee pads to our to avoid this. Um, less common causes are, um, that's that's a mechanical bursa there. And the second image you see there, uh, is a case of rheumatoid arthritis and and bursa inflamed with rice bodies. Within the other inflammatory conditions, such as gout or Sinovel osteochondroma Tosis can all affect the birthday. Uh, but it's it's less common. Uh, infection is far less common unless it is a direct, um, uh, inoculation injury or open injury. And you can get septic per sided. My second case is a 17 year old girl she's presented with your knee pain back in 2007. She had a dynamic knee MRI. You can see with, uh, extension. You can see how high the patella goes and on the axles, and you can see how lightly tilted, uh, and displace the patellas are. So there's something, uh, wrong with the patellofemoral articulation. Uh, 2008, she underwent, uh, the correct procedure, which is standard transfer. You can't see it on the X ray, but there's there's, uh that's a that's a post operate a graph with that brain Insitu. But she seemed to continue to have the same problem. 2016. She presented back with, uh, any problems you can see there on the sagittal PD fat cat image. Uh, there is a significant bone marrow edema of the patella. The half a fat pad, the there's persisting patella. All to these are the axial images of the same patient. You can see the the the this full thickness cartilage lost partial thickness, cartilage irregularity, large effusion, half a fat pad edema. And also this edema on the lateral femoral condyle as well as the medial aspect of the patella. So we know that she's dislocated her, uh, patella recently. So still, the articulation is unhappy and the under half of fat pad is being pinched. And you can see the the the the patient has had You can see two bundles of tendon, which is which is a result of tanden transfer. So they tried to manage conservatively with vastly media, where media is, uh, fastest medialis exercise and whatever they do the the therapy wise. But you continue to be unhappy, and you can now see cartilage diseases progress that there's increasing edema with the half a fat pad on the actual imaging, you can now see lateral femoral condyle is poaching against the patella tendon, so if they don't do anything, this will get this lonely get worse. So what they did, they took her to theatre, and this time they've done something slightly different they've done is they've done an osteotomy where they've pulled the tibial tuberosity down and immediately and put some screws and hope this gives uh, symptomatic relief. Now, this is patella femoral pain Soon room, or you want to call patellofemoral? Um, uh, malformation or mild tracking or altered patella tracking are few. Terminology is used for this condition. It's a very complex multifactorial problem. Uh, for a very simple articulation, it can be functional or structural null alignment functional because you can imagine patella is hanging like a yo yo in the extensive mechanism. If there is a big abductors at the hip level or the version at the ankle level with the increased Q angle within the knee, you can. You could have altered biomechanics in the in that leg, and the patellar articulation with the femur can be altered structurally at the knee level. If there is a try popular dysplasia or patella all to, um, that could be incongruent. See as well. So these people, uh, typically young women the present with anterior knee pain. We need too often look beyond the knee for the reasons I've already mentioned. An earlier orthopedic referral is important so that they celebrate their cartilage. There's several measurements. Uh, I won't go into details, none of different, unfortunately, but we are trying to to sort of quantify the problem. Um, uh, we all know we they do the insults salvatti ratio. It's not very accurate. Uh, the t t t g is not very accurate in, uh, sometimes in normal patient, that t t t g is increased some times in bond or cases. The T T T G is about five or six and normal, uh, slightly more. Um, accurate measurement is, uh, the the ratio between the overlapping of the cartilage of the, uh, trochlea and patella less than 60.2 or more than 0.8 of that ratio is considered abnormal. So move. We move on to, uh, next case, uh, a 26 year old patient with insidious onset anterior knee pain. You have a sagittal and actual PD fact that images. You can see that the quadriceps or super popular fat pad is, uh, edematous and and swollen, and you can see the same on the actual imaging. You may have guessed it. That's correct. It's a quarter steps. Fat pad. Impingement. Now, what is quarter says fat pad impingement. The quarter sips fat pad is a normal fat pad situated superior to the, uh, patella tucked away behind the quarter steps attendant. Uh, if it gets inflamed, it's called, uh, impingement. And it can cause anti any pain. We do not, uh, understand the etiology, but we think it is because the micro trauma and fibrosis and hemorrhage this condition, uh, comes about, um there is no significant correlation, uh, with patellofemoral mile cracking or other patellofemoral problems. If there is no knee pain and you see a bit of edema in the quarter quarter ships, what? Do not call it because there is no correlation you, they're symptomatic. They're symptomatic. And the fat part is thicken And Ed, um, it is only then call it. Uh, clinicians often treat this conservatively, uh, with radiotherapy, and often they may ask you to put some steroid and local anesthetic into the fat. So we move on to case four. Uh, it's a 62 year old lady with a Southern onset of medial knee pain. Uh, we have sagittal PFS and t. One image is here. Uh, you can see significant bone marrow edema of the medial summer of conduct with a with a subtle subchondral, uh, line, uh, deep to the bone plate. And there is some, uh, soft tissue edema around the, uh, conduct. So there is the subchondral subtle subchondral line, and these are the corresponding corona images PDFs and T one again. You can clearly see the fracture line now. Um, sorry. You can, uh, clearly see the fracture line here with bone marrow edema. And it's a It is a fairly common condition. Previously, it used to be called a song or spontaneous, often across the of the knee. But the correct terminology should be subchondral insufficiency fracture of the knee. So, uh, this condition can have in serious onset without any identifiable cause, uh, significantly associated with subchondral insufficiency. Fracture. Now it's a subchondral insufficiency fracture because of altered calcium profile in the body That could the accumulation of fluid, uh, in the marrow in the affected area, which then may result in ischemia and subsequent necrosis and not the other way around. As song, uh, would infer there is strong association with medical tests, uh, and also osteoarthritis with this condition. Uh, that's because, uh, with medical exclusions from meniscal tear, that could be tibiofemoral. Um uh, increased contact pressure. Um, this is this commonly seen in 50 or 60 year old uh, patient's female, uh, more than a male. They treat this conservatively with rest and all this year and often discourse minutes depending upon their bone mineral density. Um, this is a similar condition. You see, subchondral changes, but this is secondary osteonecrosis of the knee or avascular necrosis of the knee and should not be confused with the insufficiency factor we just saw to move on to the fifth case. Um, uh, there's a 22 year old athlete with medial knee pain. Work on weight bearing. You have, uh, you have lateral x ray and the sagittal PDFs. There you can see subchondral lucency, um, and corresponding, um, abnormality at the weight bearing aspect of the, uh, from a condom and you can see disease and osteochondral defect with, um, a subtle A fluid density cleft deep to that defect. Now, the patient was taken to theater. Um, and you see, on your left, uh, they you can see, uh, an anchor suture. They pinned it down, and patient had another MRI after 14 months, and you can see how beautifully that's, uh, now, uh, incorporated into the bone. Of course, there is, uh, some, uh, overlying bone plate irregularity. But without this procedure, the results could have been completely different. So this is an osteochondral defects. So osteo chondral defect. The term is used when bone plate and the overlying cartilage is involved. Uh, if you see, uh, fluid, cleft. The fragment of the affected, uh, defect is considered unstable. If not, this can be managed conservatively. Now, there are there are different reasons it can just spontaneously happen or acutely happen. But it can also happen secondary to various different other factors. If there was a fragment separated from a trauma, uh, it can progress to an osteochondral defect osteochondritis desiccants, which is which is, uh, an abnormality of bone formation deep to the bone plate. And then because of which the cartilage crumbled or the collapse of the sub Quantrill insufficiency, fracture avascular necrosis or subchondral test. Usually it's managed conservatively surgical management only if, uh, the fragment is unstable to move on to the next case. A 32 year old lady with the recurrent knee injuries from skiing on your, uh, on your left, you have, um, a P radiographs. And on your right, you have Corona PDFs, and you can see some calcification at or ossification, um, medial to the media funeral conduct. And correspondingly, there is a thickening of the proximal medial collateral ligament with internal signal change. This is Pellegrini, Seattle. Asian usually, um, these are a symptomatic These, uh, post, uh, dramatically after trauma when there is MCL injury. Um, this abnormality happens. This is an avulsion fracture of the medial, uh, femoral condyle attachment of the collateral ligament. When the avulsion fracture happens, the fracture is called C R a fracture, and it heals very well as we know. So, um, but post, uh, fracture healing that can be ossification of calcium or calcification in this area. Giving rise to this lesion. Mostly a symptomatic. But when symptomatic, this is called pelligrini status syndrome. Um, usually managed conservatively again. But if it is refractory, they go in and exercise the calcium. And and Rabel, the collateral ligament move on to the next case. Um, it's a 27 year old man. He's a runner. He's presented with lateral knee pay. It's subtle, but you can see some change deep to the iliotibial band as it passes. Adjusting to the lateral femoral conduct. It is also seen on the outside and images here on your left, you can see the fluid cleft deep to the idea. Tbl band one, um, important thing. You should not mistake normal fluid within the joint gutter, which also runs parallel to this area. When you evaluate on MRI ordered some be very careful and make sure it is identical band syndrome and not, uh, just a fluid, uh, just fluid from from, uh, the joint research. Now, this patient was duly treated with steroid injection into the influant area. And this is a little band friction syndrome. What is I'll eat evil band Friction syndrome. It is. It is a condition of altered biomechanics of the leg. Uh, the IUD. Well, band passes from the, um uh from the level of the pelvis down to the tibia on the lateral aspect where it comes in contact with the lateral femoral condyle. When there is repetitive motion of the knee, uh, flexion and extension. Like it runners, the cyclist there can be friction syndrome, and inflammation can happen. There's correlation between this condition and altered biomechanics of the patella, and and and FEMA, as well as the greater trochanter pain syndrome usually managed conservatively with physiotherapy and strengthening exercise of the quarter steps and painkillers. But there is a theory that, uh, some people said it was a birther and and birth ectomy have been, um, described in the literature as well. Moving on to the next case is a 52 year old man with multiple previous arthroscopies. Um, and he's presented with lateral knee pain. So here we have Corona Surgical and the PDFs images of the knee. Um, on the coronal, uh, image, uh, on all the images you can see a second distal I'll a tibial band. Now, what's different to the previous case we saw the problem there was between the the the lateral femoral condyle and the eyelid double band in that region. But this is an insertional problem. It's thickened with internal signal change and surrounding soft tissue edema, as you can see in the actual image here. So this is a distal iliotibial band syndrome different to the friction syndrome. This is an insertional, uh, anticipate the, uh, the I iliotibial band very similar to its proximal counterpart at the level of the, um uh, the A crest. You can have similar problem, and it is called proximal iliotibial band syndrome. Um, patient's can present with localized pain. Um, and and often this is seen in patients who have had multiple surgeries and and reason for repetitive strain. So moving on to the case. Nine. It's a 33 year old man with recurrent knee swelling and diffused knee pain. These are surgical peaches. Um, uh, we have actual t two images and postcontrast t one image. You'll see. You can see nodular thickening of the joint capsule Nadella's synovitis, in other words, but what's different on t to these are quite dark. This large effusion with contrast this part enhancement and and the the darkness a nodularity person You guess it right? This is P V E N s um P V N s is a neoplastic condition of the sign of the, um where not a large synovitis progressive with a fusion and erosion. Um, it's considered a subtype of, uh, Tino Sinovel giant cell tumor that we see elsewhere. Um, it can be locally aggressive, and recurrence rate is very, very high. We pick these up very easily on, uh, gradient echo sequence because of the chemistry route deposition that happens from recurrent him a trusts of the Nautilus. Invited, uh, surgeon's going and do the Kennebec to be There are trials of radiotherapy and drug therapy with monoclonal antibodies and stuff, but, uh, there's no clear evidence it keeps coming back. Uh, in our experience, the next case is a 42 year old lady with nice swelling and ache. So on the on on the left, you have a magical t one and in the middle image security one taken 18 months later and the corresponding actual you can see um, uh, significant proliferation of the fat along the line of the, um um the like finger like fatty projections with effusion. Uh, and this is like coma are VeriSign's. Now what is like Omar VeriSign's are VeriSign's means free like appearance. The sub synovial fat gets proliferated, uh, from the mature fat cells or metaplasia of the fat cells. Uh, and it is associated with other conditions such as effusion, osteoarthritis and sinusitis. Uh, it is a non neoplastic condition. It slows. Uh, it's slowly growth. And there's no, uh, there's no signs of local aggression. Often, symptoms are from its main cause, such as synovitis of various different causes. the osteoarthritis. This this treated with synovectomy and treated, uh, and treating the primary cause of the problem. Um, we see quite a lot of this in subtle rheumatology cases with chronic sinusitis. Um, those ones, I tend to call it fatty metaplasia. And wouldn't I? Don't mention the world like Omar. Worse, just because it unnecessarily causes, um, uh, panic amongst rheumatologist that they send the patient to sarcoma, uh, for nothing. So next case is a 43 year old man with medial knee pain and swelling and catching sensation. So on the, uh, lateral and AP radiographs, I don't know whether it's projects very well. You can see subtle, uh, speckled calcium deposition and the the corresponding MRI shows quite significant. Fine. Calcium shadow. Uh, within the half a sod. Bad posterior joint races as well as extending into the popliteal cyst. This is primary Sinovel osteochondroma Tosis. The primary Sinovel osteochondroma Tosis is the meta plastic condition. Um, the Sinovel, uh, nodules get thick and thick and they get meta plus sized, uh, and form Aasif it bodies and they're detached and get accumulated. Uh, in the joint, Uh, they are typically monoarticular, and they are completely different from the secondary. Sinovel osteochondroma Tosis Uh, which is not a meta plastic, uh, condition. What happened there is, uh if the cartilage fragment has detached and it's lodged in the capsule elsewhere, it gets new, uh, new blood supply and becomes big. So it is completely different from the primary from primary sign. I will osteochondroma, Tosis. And, uh, surgeons love to go in and take this out. Typically, 12 case is a 38 year old lady with knee pain and intermittent swelling here on the, uh, a P and sagittal radiographs. You can see there is significant loss of joint space in the medial and lateral compartments with sabbatical sclerosis. What's, um, striking is with that degree of joint space loss and subchondral bone chain. There is no marginal electorate formation and bones generally look osteopenic with its inflammatory ultra pretty. That's probably correct. And what do we do next? Look at everything else the patient may have had, um, in this hand X ray, you can see subtle a radial deviation of, uh, the the fingers on the right hand side at the level of metacarpophalangeal joints. Also, loss of joint space of multiple metacarpal phalangeal joints. Now the diseases along the metacarpal phalangeal joint level, the the interphalangeal joints are spared. And now we come to a conclusion that this is rheumatoid arthritis. Rheumatoid arthritis is a very common condition. Usually polio arthritic, Um uh, which involves the highland cartilage thinning it as the disease progresses. Um, very minimal margin lodge for information, as I said, predominantly presents with synovitis of various, uh, joints and in the body with effusion. Um, as the disease progresses, peripheral effusions, um, happen in typically nonweightbearing aspect. Um, an MRI and X rays are helpful to pick up typical findings of Lemtrada arthritis periodical Osteopenia is a classical finding, uh, due to, um, uh, loss of, um, um nutrition supply to the subarticular bone, which usually happens through the through the joint moving on to the next case. It's a 52 year old man with the previous medial unit compartment and knee replacement. They're presented with lateral knee pain, and the clinicians think now he may have developed lateral compartment of er private. So X ray shows a lucency in the lateral, uh, formal condyle. As soon as you see that, we're not worried that it could be, uh, something more sinister. On the CT, you can see a lesion, which is very well, uh, contrived with sclerotic margin. But there is cortical breach. Um, you could be benign, but cortical breaches worrisome. So we think What's going on? Um, in further, uh, images, you see more lucency suggest into the the tibial, uh, prosthesis and the patient duly had a biopsy turned out to be a particle disease. So what is particle disease? Particle disease is also called us aggressive granulomatosis. Sometimes it's used as a post operative osteolysis or cement disease. Um, the shredded components of, uh, polyethylene, where or cement can cause histiocyte ick response and macrophage reaction and cause this kind of bone license. And they present typically as radiolucent areas. Um, compared to other conditions such as infection, there is no secondary bone response such as, uh, periodical reaction of bones, sclerosis, etcetera. But often the scan, uh, progress with loosening of the prosthesis and destruction of the bone purely for mechanical reasons. Um uh, as you saw in this case, the the shredded, worn out particles can get transported in the joint food and get embedded elsewhere and cause ostracized in that region. Uh, 14th case is a 47 year old lady with lower leg pain on exertion. You see, these are actual PD fact that images as you go down keep an eye on the posterior aspect of the joint. I go back the media head that the GASTROCNEMIUS has a rather anomalous origin. And what that's doing to the to the political artery is, uh is making a political artery take a different course. And probably there's more to it on the Corona. Uh, corresponding images. You can see the anomalous, um uh, medial gastronomy his head and you can see the probability is curving around and there is something going on here. What's happened here is political arteries being pinched and there is secondary dissection. So this is a property artery Intropin syndrome. Um, there are different kinds of entrepreneurs syndrome. Uh, it is mainly because of extensive compression on the populace artery. It can be because the artery itself is aberrant or anomalous. Course of media, that of gas anemia's as you've just seen. Or sometimes there could be fibrous bands or accessory muscles, causing a pinching effect on the population artery or a combination of any of these. There's a huge classification if you want to read about it often, it's a very challenging condition to diagnose, because the the, um, the symptoms are elsewhere. Usually it's exertion pain of the lower leg. So they exhaust all other investigations of of of calf and, uh, and activists and and D d t and stuff. And then, um, finally, we may end up, uh, looking at the at the popliteal first, um, when we do do a thorough job and often dynamic duplex ultrasound help. Um, so finally, it is supposed to be case 15, isn't it? My, uh, wrong number. So finally, it's a long case, and I'll let you go after this, so I won't give you any history. So we have sagittal axial and coronal PD Fact that images of the knee, um, the the only pertinent finding is large effusion. Now, I can tell you the meniscus You were normal. ACL PCL. Collateral ligaments were all normal cartilage of all the three compartments of normal. As you can. As you can see from here, there's no obvious uh, synovitis. So you're not getting anywhere with that. Everything is normal. Why is the knee blowing up now the history was recurrent knee swelling. Effusions have been aspirated four times. No crystals, no bugs. But the pain is still ongoing. That made me think, and I looked at it slightly more carefully. I windowed it down and I see a band. I see a band in the medial aspect of the patella which is thickened and subtle. Sign the whitest. As you can see here, this is a medial like a syndrome. The plica are multiple Sinovel folds that we come across in the in the knee. Uh, the most symptomatic one is a medial plica which can get thickened. And usually there's this fold of, uh, sign of a, um uh, A thick ban slides freely on the media from our condo because there is some amount of joint fluid and this could viscosity. But when there is a fusion that this viscosity is lost, then they can have attaching sensation this take a chicken and egg situation. We you have a chicken plica, which is not a tracking very well on the media from our condyle and, um, causes effusion. Effusion causes more, um, catching of this. This sign a bill fold against the medial from your condyle. The although it sounds very surgical that they may go in and snap it. Um, uh, the preferred treatment is quarters of strengthening and inter article or injections. Very rarely. They go in and do anything about this, like so with that, I come to a conclusion. Um, as you saw in the last case, clinical history and physical examination is very, very important. Um, have a systemic approach When you when you look at the knee, uh, I have my own layout of how I keep my images, and I go from one side to the other without being, um uh, disturbed by other of other findings. I look at what? I have to look carefully and then come and look at everything else in a systematic manner, Have an eye for detail. Do not dissect every grayscale and call anything and everything. Um, uh, I think as a clinician, uh, and and clinical relevance of other findings that you're gonna call common things are common. Uh, you should definitely get them uncommon things. You should definitely pick them, uh, where possible. And think beyond the box. Uh, and think of other rarer conditions. Uh, if if the if the situation is tricky. Thank you. Thank you very much. And, uh, sorry. Uh, I will let you continue, and we will take the questions in the end. Thank you. Bria. Yes. Thank you, Raj. Um, that was a very good, uh, comprehensive review of all the non traumatic causes for knee pain. Um, including, you know, included processes as well. And, uh, the conundrum for the vascular team with the property lottery syndrome. So you have covered everything there. So, chi, are we ready to go back to your cases now? Yes, I am. Please. Uh, you know, type in your questions. Keep them ready. We will go through the questions. I have one on dynamic need scan. So we'll come to that just after she finishes. Brilliant. Thank very much Raj and Preah. And once again, apologies for the I T issues. Now that I've changed my browser, I hope that things are better now. But if you if you hear the same crackles let me know I have a headset here by my side as backup. It's fine. It's fine. I think I think we have the test run where you know, it was crackling with safari, so I will show your chrome, but now you're you're sounding fine, so you can take brilliant. That's excellent. So I'm just going to share my screen now and go back to where I was. It's good to hear that there's no more killing. Amazing. Um, okay, so just to just to come back to where we were. So in summary I've talked about I've talked about three main cases so far. So first of all, we have seen a different presentation of ACL tear. In the second case, we've seen different types of PCR tear as well. We've seen a classic bucket handle, sign, bucket, handle, tear. And now we're just towards the end of the the radio tear. So I think this is where I left off. Essentially, this, like, just shows a more subtle posterior route tear here, which is only appreciable on the Corona view and the central will. All you see is a bit of truncation of the posterior horn. So essentially, posture route is a very important review area because test that can be missed easily missed and it can have significant repercussions for the patient and The fifth case is a very unique kind of radio tear. So if you look at the Corona view, you can see radio tear there and you look at the search the view. You see a another radio tear. So the question is whether it's that to test or is it part of the same condition? So, just as I always do, I then look at the axial view, and on this image you can see a very beautiful picture of a type of radio tear called the Parrot Big Tear and essentially what the parrot Victor is. It's a type of radio tear with a small flap. And so there are many different kinds of descriptions of meniscal tests in literature. But essentially, I think there are three main tests, which are the horizontal tear, the vertical tear and the radio tear. And horizontal basically just means test that's orientated along the fiber, the collision fibers of the meniscus, whereas the radio tear is perpendicular to the fibers. And if when there is accommodation of more than one of these tests, we call it a complex tear, and this image is, uh, images I've taken from an article and Radiographics, which I think illustrates the three basic meniscal tear nicely. So the first on the left is it's a picture of horizontal tear, which is best seen on the sagittal and Corona views and submit, like taking a fog and prying the meniscus open into upper and lower halves. And the middle part is an example of a vertical care best seen on the Corona and axial view. And it's just like using a can opener and just cutting and splitting the meniscus into inner and outer haves. And the last one is a radio tear. And essentially, it's a bit like using a pizza cutter just to slice the meniscus perpendicular to the direction of it's normal fibers. And from those three basics tests, you can get more complex displays tests, including a flat tire, bucket handle, tear and big tear. So we have seen examples of bucket handle, tear and pretty big tear, so you can only guess that I'm probably going to show you a flat technics. So which leads us to case six. So this is a picture of the medial meniscus. The patient has had previous ACL reconstruction. Usually the meniscus is larger. Posteriorly But in this case you can notice that the anterior horn looks larger than posterior horn, which just give us a clue that that is abnormal. And what actually happened in this case is basically the posterior part of meniscus has actually torn and flip forward and lies adjacent to the anterior horn. It's a bit like a bucket handle tear, but the posterior part has detached completely from the native meniscus. So this is an example of a flip meniscus and the next case and yet another example of an abnormal meniscus. We can see that there is a complex multidirectional chair of the lateral meniscus with quite a prominent horizontal tear component, and you notice the inferior and outer part of the meniscus. It has extruded and flipped into the meniscal tbl recess, and it's quite nicely seen on the sagittal view here and also on the X ray view, which just demonstrates the importance of looking at the abnormality in all three sequences rebel possible. And the other thing I would say about medical exclusion is that when you see an exclusion, always think, whether could it be a tear, or is it a result of degeneration And if you see a medical extrusion in the younger patient, more often than not, it is secondary to 8 10. So this is an example of a complex flat tire. So, um, we're reaching towards, and now So this is case eight. So in this case, we can see that there is significant edema in the posterolateral corner. And this is the region where the soul proximal soldiers muscle lies deep through the immediate to the lateral head of the gastrocnemius. And so there's tearing off the soldiers. And here you can also see that there's disruption of the public tail tendon as well as the public tail fibula ligament. And there's lots of edema in that area. And that's probably also capsular disruption of the tibiofibular joint, which you can also see here on Corona view. So this is an example of posterolateral corner injury, so the posterolateral corner is a complex structure, and I can understand why some people are find this area challenging. There is there are variable arrangement of ligaments and tendons here, but what's important is to identify the main structures. So in a paper by radiographics, it lists the LCL Popliteus tendon and the detail fibula ligament or the PFL has the three major structures, Um, the three major stabilizers. But I would add 1/4 which is the biceps femoris tendon, because that is a large structure that is easily identifiable. So this just a recap of what the posterolateral corner is like so most most superficially, you have the biceps memories tendon here, and if you remove that, you get the LCL deep to it. You get the y shaped acquit, um, ligament with the medial and lateral limb. And if the patient has a farm, Bella, you get a far Bella fibula ligaments. And the deepest structure is the Popliteal tendon here, which just causes deep to the fibula fibula ligament, Arquit ligament and the LCL to attach to the lateral portion of the femur and just from the Myotendinous junction of the possibilities to to the fibula. You have this structure, which is called the Popliteal fibula ligament, and most of the posterolateral corner injuries. They do not occur in isolation, but they are part of a more complex injury pattern, and the importance of recognizing injury here is because when they coexist with other forms of injuries such as cruciate ligament. And if it's not recognized and repair, that can lead to failure of the cruciate ligament reconstruction. And although, although we know that there are lots of structures in the posterolateral corner in actual practice and in an acute situation, that usually is lots of edema in that region, which precludes the accurate assessment of the individual structures. And it is those cases actually more important to actually look for the main and large stabilizing structures that I've mentioned before. So this is an example of a partial injury partial tear to the LCL. You can see there's intrinsic signal change, and there's also, um, tearing off the properties tendon there. And what you also see here is that there's complete tear of the MCL and complete tearing of the PCL, and you can see the similar findings on the Paxil, you this injury. This picture is quite a nice picture, because on this single image alone, there are multiple co existing findings, and so I'll start with here this area where the pop detail tendency It's as you can see that there is edema and a partial tear at the Myotendinous junction there, and you can also see that there is has been attacked with the possibility of fibula ligament which extends from the Myotendinous junction. You can see that in the normal expected location of the liquid. Um, ligament, all you see is a Dema and so you can assume that the liquid tendon here is completely ruptured. And notice how the patient also has an ACL reconstruction. So what you see in this image is the anterior translation of the tibia. But what is not shown is that the patient actually also has a ACL graph rupture and you can see that there's a displaced posterior horn here which lies now lies anteriorly just adjacent to the anterior horn. And we can also see a subchondral fracture secondary to impaction injury. And here, once again, you can see that the pot liquor stand in my attending disjunction is torn. You can see the accurate ligament is torn and this is actually an whilst fragment from the lateral portion of the tibia. So this just this picture just shows you the different grade of LCL injury. Um, the way I assess SCL injuries by looking just to see whether it's great. 12 or three in great one. All you see is a bit of periligamentous edema, but the there is no evidence of architectural distortion. In Grade two, you can see that it's intrinsic signal change and also a bit of thickening. But the tendon is still intact, and in great three you see that there's complete detachment, um, of the ligament from its attachment, and you will see laxity of the residual attendance giving it a linguini appearance. So MCL injury is basically the same. Um, so you can see there's a bit of periligamentous edema there with thickening and interstitial signal change. And here you can see that's complete tearing of the tendon with laxity of the attendant and the laxity of the tenants. Actually, a very good indicator that the attendant that the ligament is completely torn. So Case nine is quite a simple one. Essentially, I've included this case here of a quadriceps tendon rupture because this is one of the few conditions where ultrasound can actually be very helpful. Um, diagnostically and apart from just looking for the usual joint infusion and sinusitis, so in this case can see that there is a an echoic defect here between the torn portions of the tendon. And it's also very helpful to get the measurement of the widest gap between the torn tendons. And the only other thing I would say that is the quadricep expansion is actually quite a large structure, because if you think about it, there are four different kinds of muscles that attaches to a single point. So it's very important that when you assess for these injuries on ultrasound to make sure that you sweep all the way through the attendant, just to make sure that just to differentiate a partial from a complete tear and so ultrasound is actually very sensitive as picking up quadriceps injury, although it's less specific than MRI. And if you do have any suspicion on how the tear actually is like, you can always go on to do an MRI and finally the last case. So this case is actually in a 10 year old boy who's sustained an injury while playing football. He said that he felt a click, Um, and then sudden pain, and he was unable to weightbearing after. So on the plain Radiograph, all you see is a bit of a fusion, um, nothing, really too exciting. And even on the CT that was subsequently done. Nothing very exciting. But if you actually look at the knee in a different window, notice this like, more dense structure here. So So it makes you think that there is probably a loose body there, and the next thing to step to do is to unify. Where is it from? So patient subsequently had an MRI, which again shows the loose body. And it turns out that the patient actually has a condo defect from the lateral trochlea surface. So So this is just a summary of all applications that I've shown you so far, and I hope that it would have been helpful, and I think right. And I will be happy to take any questions now. So thank you for listening and apologies for the technical errors initially. Well, where is she? Your there. You've done it. So thank you. Thanks a lot. Uh, that was again, you know, especially the last case showing the limitation of plain film and also looking at, uh, soft tissue windows for the CT, you know, to identify something else. So, uh, that's really good. So I I have, um, just looking great cases. There have been comments about, you know, very good cases, but I don't have any questions. So I have one question for Raj. Like, uh, the first case you should you shared with us about patella mile tracking was, uh it showed dynamic scanning. Uh, what are the indications that you do it for or, um, we don't do a dynamic scanning anymore? As you can see, that case was in 2007. Um, so I used to see a few of the dynamics scans around 2015 2017 times, But we don't do them anymore. Um, they they're not very helpful. Of course. They show, uh, that the patella is high riding or patella tracks laterally that we know already. It's not adding anything new. Um, so we still stick to good m r. Scanning and measuring the patella alter T T T g. And looking at the half of bad, bad and and, uh, in for now, clinical information is very, very important. I say all these things in capital letter if it is 16 year old girl. Whereas I see the same thing in a 45 or 50 year old man, I I concentrate more on carbon. They say there are all these cartilage changes with a background of possible altered patellar tracking. So clinical information is paramount. Um uh, there's there's a lot of things that we could really don't understand about patella femoral articulation. Um, but but what's the space? They are thinking of, uh, coming up with, uh, tailored imaging for patella femoral articulation. But at the moment, we're back to the routine and the MRI. Thank you. And, um I mean, it's it's very helpful. Especially because, uh, but the change in the RCR curriculum now, you know, imaging and reporting of knee, um, ours is a general skill that, you know, many of the trainees are expected to have. So I think it is a good session for, you know, trainees, uh, also, uh, those who have practiced me, um, S K because, uh, you know, it's, uh, many of the other unusual cases that Rogen's also shared is very helpful. Uh, I have one question from same any Catholic sequence you do routine. Need any advantage in adding one routinely for younger patient's? Yeah, uh, I mean, we don't do any cartilage. Uh, imaging uh, I know some centers do. Um, but we we've not adopted any of that, and, uh, and we don't do any, So my experience of, uh, cartilage imaging is almost mail. I've only seen presentations when I go to the conferences of what other people are doing. Mm. Thank you. So I would like to first thank both our speaker's key and Raj for taking time, you know, to present at the grand rounds. And I would like to, uh, thank all of delegates for taking their time to attend. I think, uh, live attendance went over 110 or something like that. So, you know, thanks a lot for, you know, attending the, uh, session line. You will have access to the, uh, recording because you are registered for the event. And, uh, I I think, you know, there was a little bit traveling, but we could see the cases through, so don't worry about that. Go back and look at your cases. So it's there. And for the bs are members. It will be there on the website as well. And, uh, don't forget that we have the, uh, b s s are meeting in Leeds, so hoping to see many of you there. And it is open to, you know, non members as well. So, uh, we hope, you know, face to face meeting will be good. And the next week our grand rounds will most probably be on back pain. So we will get back to you with the details for that. So thank you. Thank you. Both Raj and Key and all that. Thank you very much. Thank you. Thank you, everyone. Thank you, madam. And thank you, Sue as well. Thank you.