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Comparison of MRI & direct MR arthrography with arthroscopy in diagnosing ligament injuries of wrist
Journal of Orthopaedics 19 (2020) 203–207
Contents lists available at ScienceDirect
Journal of Orthopaedics journal homepage: www.elsevier.com/locate/jor
Original Article
Comparison of MRI & direct MR arthrography with arthroscopy in diagnosing ligament injuries of wrist
T
Blessin S. Cheriana,1, Anil K. Bhata, K.V. Rajagopalb, Satish B. Maddukurib,2, Don Paulb, Naveen Joseph Mathaia,3,∗ a b
Unit of Hand & Microsurgery, Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Karnataka, 576104, India Department of Radiodiagnosis, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Karnataka, 576104, India
A R T I C LE I N FO
A B S T R A C T
Keywords: TFCC Wrist arthroscopy MRI MRA Ligament injuries
Introduction: Ligament injuries around the wrist leading to chronic wrist pain are often a diagnostic dilemma.Various imaging modalities like wrist radiographs, CT and MRI have been used to improve the diagnostic accuracy. The objective of this study was to assess the value of MRI & direct magnetic resonance arthrography (MRA) of the wrist for detecting & evaluating tears of the triangular fibrocartilage complex (TFCC) & scapholunate & luno triquetral interosseous ligament (LTIL & SLIL) injuries in comparison with arthroscopy of the wrist. Materials & methods: All patients presenting with chronic wrist pain of more than 3 months duration with suspected ligament injuries were included. MRI was performed with 8 channel wrist coil on 1.5 T machine. (PHILIPS, Netherlands). MRA was performed after obtaining consent. Retrospective MR findings were then correlated with results in those patients who underwent arthroscopy. Arthroscopic correlation was obtained in 22 (46.8%) cases out of the 45 patients who underwent both MRI & MRA. Results: The gold standard arthroscopic procedure diagnosed 15 peripheral & 6 central TFCC tears in 22 patients. 4 scapholunate ligament tears were also identified. MRI diagnosed 16 peripheral & 5 central TFCC tears in these 22 patients. MRA identified 9 central tears and 14 peripheral tears. The sensitivity in diagnosing an overall TFCC tears with MRI as well as MRA was 94.4 & 100%. The specificity of the MRI and MRA in diagnosing an overall TFCC tear was 100% & 75% respectively. Discussion & conclusions: Direct MRA has better sensitivity in detecting TFCC central tears. In view of ‘substantial’ agreement between MRI & MRA with Kappa analysis, conventional MRI can be relied on, in diagnosing TFCC injury. With comparatively low specificity, caution and restraint is advised in interpreting MRA, which may influence decision on surgery.
1. Introduction Ligament injuries around the wrist leading to chronic wrist pain are often a diagnostic dilemma. These ‘back pain’ of the wrist are often overlooked due to its complexity and poor understanding of the wrist anatomy. The common ligament injuries of the wrist include Triangular fibrocartilage complex (TFCC), Scapholunate (SL) & Lunotriquetral (LT) tears.1,2 Various imaging modalities like wrist radiographs, computed tomography (CT) & Magnetic Resonance imaging (MRI) have been used to improve the diagnostic accuracy.2–4 MRI is the standard investigation
to define soft tissue lesions. Combining arthrography with CT & MRI has been utilized to diagnose these ligamentous injuries as it delineates them better.1–6 Arthrography with MRI (MRA) increases the accuracy and makes lesions more detectable.8–11 Even though, the gold standard investigation of choice is wrist arthroscopy to visualize these lesions.5,6 The steep learning curve, technical difficulty and unavailability associated with wrist arthroscopy makes it a less feasible option in many centres. The objective of this study was to assess the value of MRI & direct magnetic resonance arthrography (MRA) of the wrist for detecting &
∗
Corresponding author. E-mail address: [email protected] (N.J. Mathai). 1 Muthoot Hospitals, Kozhencherry, Kerala, India. 2 Manipal Hospital, Vijayawada, India. 3 University Hospital Of Wales, Cardiff, UK. https://doi.org/10.1016/j.jor.2019.11.014 Received 20 October 2019; Accepted 3 November 2019 Available online 12 November 2019 0972-978X/ Crown Copyright © 2019 Published by Elsevier B.V. on behalf of Professor P K Surendran Memorial Education Foundation. All rights reserved.
Journal of Orthopaedics 19 (2020) 203–207
B.S. Cherian, et al.
evaluating tears of the triangular fibrocartilage complex (TFCC) & scapholunate & luno triquetral interosseous ligament (LTIL & SLIL) injuries in comparison with arthroscopy of the wrist in our population. In view of MRI being an invasive investigation we wanted to know whether MRI would suffice for a decision making towards arthroscopy or conservative management. 2. Materials & Methods This was a prospective study conducted in Department of Orthopaedics & Radiodiagnosis at our hospital after obtaining ethical committee clearance. All patients presenting with chronic wrist pain of more than 3 months duration with suspected ligament injuries of the wrist were included in the study. All patients underwent detailed clinical examination including the provocative tests to document their suspected injuries. Patients with history of localized bone or skin infections, clinical features suggestive of inflammatory arthritis, and neuropathies were excluded from the study. All patients were evaluated using plain radiographs (anteroposterior view, lateral view, and clench fist views), conventional MRI, and MR arthrography. Patients with MRI findings suggestive of inflammatory arthritis, infection, neuropathy, were further excluded from the study. MRI was performed with 8 channel wrist coil on 1.5 T machine. (PHILIPS, Netherlands). PDFS images (proton density fat saturation sequences) in axial, coronal and sagittal plane, T1 coronal, T2 GRE coronal and cartilage sensitive sequence (WATS sequence) in coronal planes were taken. After obtaining patients’ consent we then proceeded to MRA. For MR arthrography, injection with a concoct of 0.1 ml gadolinium (Magnevist, Schering, Germany), 10 ml of normal saline, 5 ml of iodinated contrast medium and 5 ml of 2% lignocaine were injected into the radiocarpal joint. (Fig. 1).It was performed under ultrasound and fluoroscopic guidance using strict aseptic precautions using a 24G, 25 mm long needle. Post contrast T1 fat saturated images were taken in coronal, sagittal and axial planes. However these sequences were not cartilage sensitive. Both the MRI and MR arthrogram were read by two radiologists specialized in musculoskeletal surgery(Fig. 2). 45 patients who had undergone MRI & MRA as per our inclusion criteria were included in the study. Among these 45 patients, 22 underwent arthroscopic procedure as a therapeutic intervention. The rest sufficed conservative therapy which included analgesics & splint, above elbow cast in supination & local steroid injection at times as they had features of associated synovitis.
Fig. 2. MRI and MRA suggestive of TFCC injury respectively.
Fig. 3. Position of patient during arthroscopy.
treatment & presence of ligament tears on imaging which correlated with clinical signs. For those patients consenting for arthroscopy, the procedure was performed under general anaesthesia or brachial block with the patient in supine position and the shoulder abducted to 90° and elbow flexed to 90°. Fingers were suspended with 5–10 lbs weight (Fig. 3) with the help of chinese finger traps attached to a traction tower. We used a pneumatic tourniquet for all our surgeries. Arthroscopic surgery was performed in twenty two patients by a single upper limb fellowship-trained orthopedic surgeon. The findings recorded in arthroscopy were presence of full/partial thickness ligament tears (Fig. 4), exact location of these tears, synovitis, and degenerative changes in the joint. Patients who required treatment in terms of debridement of tears, repairs & synovectomy underwent the same. Retrospective MR findings were then correlated with results in those patients who underwent arthroscopy. Arthroscopic correlation was obtained in 22 (46.8%) cases out of the 45 patients who underwent both MRI & MRA.
2.1. Arthroscopy The indication for arthroscopy in our study was patients with persistent and debilitating symptoms despite a trial of conservative
Fig. 1. Radiocarpel injection of gadolinium under ultrasound and fluoroscopic guidance.
Fig. 4. Image on the left suggestive of centraltear; on the right picture suggestive of a peripheral tear. 204
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3. Statistical analysis
Table 2 Distribution of SLIL & LTIL tears.
MRI and MRA interpretations were compared using arthroscopic findings as standards of reference. We assessed sensitivity, specificity, accuracy, positive predictive value and negative predictive value of MRI and MRA for diagnosis of tears of SLIL/LTIL and TFCC. All percentages were calculated with 95% confidence interval. Agreement between MRI & MRA with arthroscopy in TFCC ligament tears was computed using Cohen's Kappa coefficient. Statistical analysis was undertaken by a reviewer who was neither involved in the diagnosis nor the surgery.
INVESTIGATION
MRI MRA ARTHROSCOPY
There were 38 males and 7 females in the study. The age group of patients varied from 18 to 59 years with a mean of 23.9 years. Out of 45 patients, 35 patients (74.4%) reported trauma as mechanism of injury and were of age group 15–25 years (n = 35). All our patients were right hand dominant. Out of 45 subjects, 23 subjects having varied diagnosis like Scapholunate ligament sprain (4), acute type 1 (palmer classification) TFCC injuries (16) & ECU tendinitis (3) were managed with NSAIDS and immobilisation in splints/casts. These subjects reported relief of symptoms and hence managed conservatively. Rest of the 22 patients who had persistent symptoms were arthroscopically evaluated. The gold standard arthroscopic procedure diagnosed 15 peripheral & 6 central TFCC tears in 22 patients. 4 scapholunate ligament tears were also identified. MRI diagnosed 16 peripheral & 5 central TFCC tears in these 22 patients respectively (Table 1). MRA identified 9 central tears and 14 peripheral tears. There were three subjects who had both central & peripheral tears. The number of intact and torn ligaments diagnosed in MRI and MRA are depicted in Table 1. It can be inferred that MRA has identified more central tears compared to MRI which were factually three false positive results. The identification rate of peripheral TFCC tears of MRI & MRA are comparable (Table 1). Four SLIL and one LTIL injuries were diagnosed by MRA. Only three SLIL injuries were detected by MRI. However, arthroscopy showed four SLIL tears but no LTIL tears (Table 2). The sensitivity in diagnosing an overall TFCC tears with MRI as well as MRA was 94.4 & 100%. However, MRI was more accurate. For detecting central tears, MRA was more sensitive but less accurate than MRI (Table 3). To detect a peripheral tear MRI was more sensitive than MRA. However both were equally accurate. The specificity of the MRI and MRA in diagnosing an overall TFCC tear was 100% & 75% respectively (Table 3). The specificity of MRA in detecting a central tear was low in comparison to MRI but for a peripheral tear, it was high. The Cohen's Kappa value showed substantial agreement for detecting an overall TFCC tear between MRI & arthroscopy (0.63) and between MRA & arthroscopy (0.77). For detecting a central TFCC tear the cohen's kappa between MRA & Arthoscopy is 0.8 suggesting ‘almost perfect agreement’. 5. Discussion In literature the reported sensitivity and specificity of MRI for Table 1 Distribution of TFCC tears.
MRI MRA ARTHROSCOPY
TFCC CENTRAL (N = 22)
TFCC PERIPHERAL (N = 22)
TFCC (COMBINED)
INTACT
TORN
INTACT
TORN
INTACT
TORN
17 13 16
5 9 6
6 8 7
16 14 15
3 3 4
17 19 18
LTIL (N = 22)
INTACT
TORN
INTACT
TORN
19 18 18
3 4 4
21 21 22
1 1 0
diagnosing TFCC tear & other ligament injuries vary widely, between 44% and 100%.1–3,5 Wide variations in practice, such as the resolution of the scanner used, the thickness of the sections, the use of dedicated surface coil, and the inter-rater variability among radiologists may be the reason for the variation.7 In our study we noted no superiority of MRA over MRI in detecting the overall TFCC tear. However, MRA had high sensitivity in detecting central TFCC tear compared to MRI. Similar extensive studies comparing MRA over MRI in detection of wrist ligament injuries are there in literature (Tables 4 and 5).7,14,15 Few have highlighted superior advantage of MRA over the MRI.13–15,19 Meier et al. reported a sensitivity of 94%, specificity of 89%, and accuracy of 94% in their large series of 125 patients who underwent direct MR arthrography.14 The positive and negative predictive value in their series was 91% and 93%, respectively.14 MRA was done at 1.5 T and the results were compared with arthroscopy. Our study showed MRI to be equal or more accurate in detecting all types of TFCC tears compared to MRA, as MRA was highly sensitive leading to false positive. Further to this, in our study, the specificity of MRA in detecting an overall TFCC tear was 75%. The low specificity recorded may be attributed to the low proportion of intact ligaments in comparison to the torn ligaments. The probability of diagnosing an intact TFCC central ligament as a tear is high with MRA due to false positives as is evident from the results of this study. Understandably, from the surgeon's perspective, conversion to an arthroscopic procedure is high if a TFCC injury is diagnosed with MRA. On analyzing the literature in Tables 4 and 5, we observe that MRA has high sensitivity and relative low specificity compared to MRI in detecting a TFCC tear.16 Similar conclusions were drawn by Magee et al.15 In their study which involved arthroscopy in 49 patients, they found 86% sensitivity & 100% specificity in conventional MR imaging and 100% sensitivity in MR arthrography. Micro perforations in the extrinsic ligaments cause the dye to extravasate between the radiocarpal space to the midcarpal space. This may be interpreted as a tear which leads to false positive results in MR arthrography. They concluded that MRI at 3 T is highly sensitive for detection of TFCC tears & intrinsic ligaments. Lee et al. in their study reported a high sensitivity of three dimensional T1 highresolution isovolumetric examination (3D-THRIVE) MRA in detecting TFCC central tears.20 However, they concluded that MRI at 3 T provided equal results for the depiction and localization of intrinsic ligaments & TFCC tears in comparison to conventional MRA.20 MR arthrography is often essential in delineating ligament injuries in the small joints. It has higher sensitivity in detecting Scapholunate interosseous & lunotriquetral interosseous ligament injuries as well. This is again explained by the fact that the midportion of the scapho lunate ligament may not have a watertight seal, which may also account for the false-positive findings on conventional MR arthrography.14 In view of rarity of the injuty & small sample size we could not compare results of SLIL & LTIL tear to the existing data in literature and it is to be noted that in our small sample size MRI missed one SLIL injury. The American College of Radiology (ACR Appropriateness Criteria) has reported that direct MR arthrography is an appropriate imaging modality if wrist ligament tears are suspected and radiographs are normal or non-specific, especially in patients with ulnar-sided wrist
4. Results
INVESTIGATION
SLIL (N = 22)
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B.S. Cherian, et al.
Table 3 Diagnostic accuracy of MRI and MRA in the diagnosis of tears of the SLIL, LTIL and TFCC. MRI
MRA
Tear
Sen (%)
Spe (%)
PPV
NPV
Acc
Sen (%)
Spe (%)
PPV
NPV
Acc
Arthroscopy (tear)
TFCC central TFCC peripheral TFCC(overall) SLIL LTIL
83 100 94.4 75
93.8 85.7 100 100 95.4
83.3 93.7 100 100
93.7 100 80 94.7 100
90.9 95.45 95.4 95.4 95.4
100 93.3 100 100
81.2 100 75 100 95.4
66.6 100 94.7 100
100 87.5 100 100 100
86.4 95.5 95.4 100 95.4
6 15 18 4 0
Table 4 Accuracy Of MRA in TFCC tears in reviewed studies. TFCC tear [ number of subject]
Sensitivity
Specificity
Positive predictive value
Negative predictive value
Accuracy
Magee et al. (2009)15[35] Pahwa et al. (2014)17[16] Abdelsattar (2012)18[51] Al Hiari et al. (2013)19[42] Mahmood et al. (2012)[30] Joshy et al. (2008)7[24] Lee et al. (2013)20[48] Our study
100 100 94.2% 93.3% 90.0% 74% 100% 100%
100 100 100 80.0% 75% 80.0% 100% 75%
100 NA NA 85.0% 95.0% NA 90%
100 NA NA 80.0% 50.0% NA 100
100 95.45 85.0%
Sensitivity
Specificity
Positive predictive value
Negative predictive value
Accuracy
86.0% 75.0% 88.57% 94.6 94.4%
100% 100% 100% 100 100%
90.0%
50.0%
75.0% 90.9%
94.7
100
95.4%
79% 90.9%
Table 5 Accuracy of MRI in TFCC tears in reviewed studies. TFCC tear MRI 15
Magee et al. (2009) [49] Pahwa et al. (2014)17[16] Abdelsattar et al. (2012)18[51] Lee et al. (2013)20[48] Our study
TFCC injury. Even though the superiority of MRA over MRI is debatable as per literature, we feel, from an orthopaedicist's perspective that MRI should be adequate in majority of the cases and an invasive investigation can thus be avoided. With comparatively low specificity, caution and restraint should be advised while interpreting MRA, which may influence the decision on surgery.
pain. They state that it has the highest accuracy for diagnosing abnormalities of the TFCC and intrinsic ligaments. However an MRI at 3 T may have equivalent results in detecting TFCC tears when direct MR arthrography is not available14–16 Treiser et al. in a metaanalysis comparing MRA and MRI for diagnosing TFCC injuries suggested a superior diagnostic accuracy over MRI. However, the study was cautious in concluding the same as the published evidence contained a number of methodological limitations.21 A recent meta-analysis by Wang et al. on the performance of MRI in TFCC injury concluded that the accuracy of MRI for diagnosing TFCC injuries are good. It is less time consuming, cost-effective and non invasive in comparison to MR arthrography and hence preferred by most surgeons.22 Direct MR arthrography is not without disadvantages. It is invasive and costly. There are reports of infection following arthrography. Complications including chemical synovitis, exacerbation of pain, vasovagal attack have been reported. In our setup where the cost of investigation is borne by the patient, comparison of the sensitivity and specificity of MRA over MRI is desirable, thus determining the ideal investigation of choice. With high sensitivity and false positive results, as evident from our study & debatable literature, we feel that, MRA as an OPD diagnostic procedure is impractical, for patients with chronic and vague ulnar sided wrist pain. MRI would be able to guide the surgeon in planning the management of a patient for proceeding to arthroscopy.
6.1. Limitations Our study were not without limitations. Only 22 cases out of our group of 45 cases underwent arthroscopy. The relatively small sample size limits us to draw significant statistical conclusions. Tears of ventral, dorsal or central segments of a ligament were not considered separately. Financial support & sponsorship Nil. Declaration of competing interest There are no conflicts of interest. References 1. Cerofolini E, Luchetti R, Pederzenni L, et al. MR evaluation of triangular fibrocartilage complex tears in the wrist: comparison with arthrography and arthroscopy. J Comput Assist Tomogr. 1990;14:963–967. 2. Golimbu CN, Firooznia H, Melone Jr CP, et al. Tears of the triangular fibro cartilage of the wrist: MR imaging. Radiology. 1989;173:731–733. 3. Haims AH, Schweitzer ME, Morrison WB, et al. Internal derangement of the wrist: indirect MR arthrography versus unenhanced imaging. Radiology. 2003;227:701–707.
6. Conclusions Direct MRA has better sensitivity in detecting TFCC central tears. In view of ‘substantial’ agreement between MRI & MRA with Cohen Kappa analysis, we feel that conventional MRI can be relied on, in diagnosing 206
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wrist arthroscopy. Handchir Mikrochir Plast Chir. 2005;37(2):85–89. 15. Magee T. Comparison of 3T MRI and arthroscopy of intrinsic wrist ligament and TFCC tears. AJR Am J Roentgenol. 2009;192:80–85. 16. ACR Appropriateness Criteria®. Overview. Rubin: American College of Radiology. 2012; 2012 Electronic Copies: Available in Portable Document Format (PDF) from the American College of Radiology (ACR) Web Site. 17. Pahwa S, Srivastava DN, Sharma R, Gamanagatti S, Kotwal PP, Sharma V. Comparison of conventional MRI and MR arthrography in the evaluation of wrist ligament tears: a preliminary experience. Indian J Nucl Med. 2014;24(3):259. 18. Abdelsattar MH, Hassaan MA, Kamal HA. Conventional magnetic resonance imaging versus MR arthrography (MRA) of the wrist in the evaluation of triangular fibrocartilage lesions. Egypt J Radiol Nucl Med. 2012;43(2):235–244. 19. Al-Hiari AA. The role of wrist magnetic resonance arthrography in diagnosing triangular fibrocartilage complex tears: experience at king Hussein medical center, Jordan. Sultan Qaboos Univ Med J. 2013 May;13(2):280. 20. Lee YH, Choi YR, Kim S, Song HT, Suh JS. Intrinsic ligament and triangular fibrocartilage complex (TFCC) tears of the wrist: comparison of isovolumetric 3DTHRIVE sequence MR arthrography and conventional MR image at 3 T. Magn Reson Imaging. 2013;31(2):221–226. 21. Treiser MD, Crawford K, Iorio ML. TFCC Injuries: Meta-analysis and comparison of diagnostic imaging modalities. J Wrist Surg. 2018 Jul;7(3):267–272. 22. Wang ZX, Chen SL, Wang QQ, Liu B, Zhu J, Shen J. The performance of magnetic resonance imaging in the detection of triangular fibrocartilage complex injury: a meta-analysis. J Hand Surg. 2015 Jun;40(5):477–484.
4. Kato H, Nakumara R, Shinoya K, et al. Does high resolution MR imaging have better accuracy than standard MR imaging for evaluation of the triangular fibro cartilage complex. J Hand Surg [Br]. 2001;26(5):502–503. 5. Levisohn EM, Rosen ID, Palmer AK. Wrist arthrography: value of the three compartment injection method. Radiology. 1991;179:231–239. 6. Metz VM, Mann FA, Gilula LA. Three compartment wrist arthrography: correlation of the pain site with location of uni- and bidirectional communications. Am J Roentgenol. 1993;160:819–822. 7. Joshy S, Lee K, Deshmukh SC. Accuracy of direct magnetic resonance arthrography in the diagnosis of triangular fibrocartilage complex tears of the wrist. Int Orthop. 2008;32(2):251–253. 8. Manaster BJ. The clinical efficacy of triple-injection wrist arthrography. Radiology. 1991;178:267–272. 9. Wilson AJ, Gilula LA, Mann FD. Unidirectional joint communication in wrist arthrography: an evaluation of 250 cases. AJR. 1991;157:105–112. 10. Herbert TJ, Faithfull RG, McCann DJ, et al. Bilateral arthrography of the wrist. J Hand Surg Br. 1990;15:233–239. 11. Cantor RM, Stern PJ, Wyrick JD, et al. The relevance of ligament tears or perforations in the diagnosis of wrist pain: an arthrographic study. J Hand Surg Am. 1994;19:945–949. 13. Potter HG, Asnis-Ernberg L, Weiland AJ, et al. The utility of high-resolution magnetic resonance imaging in the evaluation of the triangular fibrocartilage complex of the wrist. J Bone Joint Surg Am. 1997;79:1675–1684. 14. Meier R, Schmitt R, Krimmer H. Wrist lesions in MRI arthrography compared with
207
Contents lists available at ScienceDirect
Journal of Orthopaedics journal homepage: www.elsevier.com/locate/jor
Original Article
Comparison of MRI & direct MR arthrography with arthroscopy in diagnosing ligament injuries of wrist
T
Blessin S. Cheriana,1, Anil K. Bhata, K.V. Rajagopalb, Satish B. Maddukurib,2, Don Paulb, Naveen Joseph Mathaia,3,∗ a b
Unit of Hand & Microsurgery, Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Karnataka, 576104, India Department of Radiodiagnosis, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Karnataka, 576104, India
A R T I C LE I N FO
A B S T R A C T
Keywords: TFCC Wrist arthroscopy MRI MRA Ligament injuries
Introduction: Ligament injuries around the wrist leading to chronic wrist pain are often a diagnostic dilemma.Various imaging modalities like wrist radiographs, CT and MRI have been used to improve the diagnostic accuracy. The objective of this study was to assess the value of MRI & direct magnetic resonance arthrography (MRA) of the wrist for detecting & evaluating tears of the triangular fibrocartilage complex (TFCC) & scapholunate & luno triquetral interosseous ligament (LTIL & SLIL) injuries in comparison with arthroscopy of the wrist. Materials & methods: All patients presenting with chronic wrist pain of more than 3 months duration with suspected ligament injuries were included. MRI was performed with 8 channel wrist coil on 1.5 T machine. (PHILIPS, Netherlands). MRA was performed after obtaining consent. Retrospective MR findings were then correlated with results in those patients who underwent arthroscopy. Arthroscopic correlation was obtained in 22 (46.8%) cases out of the 45 patients who underwent both MRI & MRA. Results: The gold standard arthroscopic procedure diagnosed 15 peripheral & 6 central TFCC tears in 22 patients. 4 scapholunate ligament tears were also identified. MRI diagnosed 16 peripheral & 5 central TFCC tears in these 22 patients. MRA identified 9 central tears and 14 peripheral tears. The sensitivity in diagnosing an overall TFCC tears with MRI as well as MRA was 94.4 & 100%. The specificity of the MRI and MRA in diagnosing an overall TFCC tear was 100% & 75% respectively. Discussion & conclusions: Direct MRA has better sensitivity in detecting TFCC central tears. In view of ‘substantial’ agreement between MRI & MRA with Kappa analysis, conventional MRI can be relied on, in diagnosing TFCC injury. With comparatively low specificity, caution and restraint is advised in interpreting MRA, which may influence decision on surgery.
1. Introduction Ligament injuries around the wrist leading to chronic wrist pain are often a diagnostic dilemma. These ‘back pain’ of the wrist are often overlooked due to its complexity and poor understanding of the wrist anatomy. The common ligament injuries of the wrist include Triangular fibrocartilage complex (TFCC), Scapholunate (SL) & Lunotriquetral (LT) tears.1,2 Various imaging modalities like wrist radiographs, computed tomography (CT) & Magnetic Resonance imaging (MRI) have been used to improve the diagnostic accuracy.2–4 MRI is the standard investigation
to define soft tissue lesions. Combining arthrography with CT & MRI has been utilized to diagnose these ligamentous injuries as it delineates them better.1–6 Arthrography with MRI (MRA) increases the accuracy and makes lesions more detectable.8–11 Even though, the gold standard investigation of choice is wrist arthroscopy to visualize these lesions.5,6 The steep learning curve, technical difficulty and unavailability associated with wrist arthroscopy makes it a less feasible option in many centres. The objective of this study was to assess the value of MRI & direct magnetic resonance arthrography (MRA) of the wrist for detecting &
∗
Corresponding author. E-mail address: [email protected] (N.J. Mathai). 1 Muthoot Hospitals, Kozhencherry, Kerala, India. 2 Manipal Hospital, Vijayawada, India. 3 University Hospital Of Wales, Cardiff, UK. https://doi.org/10.1016/j.jor.2019.11.014 Received 20 October 2019; Accepted 3 November 2019 Available online 12 November 2019 0972-978X/ Crown Copyright © 2019 Published by Elsevier B.V. on behalf of Professor P K Surendran Memorial Education Foundation. All rights reserved.
Journal of Orthopaedics 19 (2020) 203–207
B.S. Cherian, et al.
evaluating tears of the triangular fibrocartilage complex (TFCC) & scapholunate & luno triquetral interosseous ligament (LTIL & SLIL) injuries in comparison with arthroscopy of the wrist in our population. In view of MRI being an invasive investigation we wanted to know whether MRI would suffice for a decision making towards arthroscopy or conservative management. 2. Materials & Methods This was a prospective study conducted in Department of Orthopaedics & Radiodiagnosis at our hospital after obtaining ethical committee clearance. All patients presenting with chronic wrist pain of more than 3 months duration with suspected ligament injuries of the wrist were included in the study. All patients underwent detailed clinical examination including the provocative tests to document their suspected injuries. Patients with history of localized bone or skin infections, clinical features suggestive of inflammatory arthritis, and neuropathies were excluded from the study. All patients were evaluated using plain radiographs (anteroposterior view, lateral view, and clench fist views), conventional MRI, and MR arthrography. Patients with MRI findings suggestive of inflammatory arthritis, infection, neuropathy, were further excluded from the study. MRI was performed with 8 channel wrist coil on 1.5 T machine. (PHILIPS, Netherlands). PDFS images (proton density fat saturation sequences) in axial, coronal and sagittal plane, T1 coronal, T2 GRE coronal and cartilage sensitive sequence (WATS sequence) in coronal planes were taken. After obtaining patients’ consent we then proceeded to MRA. For MR arthrography, injection with a concoct of 0.1 ml gadolinium (Magnevist, Schering, Germany), 10 ml of normal saline, 5 ml of iodinated contrast medium and 5 ml of 2% lignocaine were injected into the radiocarpal joint. (Fig. 1).It was performed under ultrasound and fluoroscopic guidance using strict aseptic precautions using a 24G, 25 mm long needle. Post contrast T1 fat saturated images were taken in coronal, sagittal and axial planes. However these sequences were not cartilage sensitive. Both the MRI and MR arthrogram were read by two radiologists specialized in musculoskeletal surgery(Fig. 2). 45 patients who had undergone MRI & MRA as per our inclusion criteria were included in the study. Among these 45 patients, 22 underwent arthroscopic procedure as a therapeutic intervention. The rest sufficed conservative therapy which included analgesics & splint, above elbow cast in supination & local steroid injection at times as they had features of associated synovitis.
Fig. 2. MRI and MRA suggestive of TFCC injury respectively.
Fig. 3. Position of patient during arthroscopy.
treatment & presence of ligament tears on imaging which correlated with clinical signs. For those patients consenting for arthroscopy, the procedure was performed under general anaesthesia or brachial block with the patient in supine position and the shoulder abducted to 90° and elbow flexed to 90°. Fingers were suspended with 5–10 lbs weight (Fig. 3) with the help of chinese finger traps attached to a traction tower. We used a pneumatic tourniquet for all our surgeries. Arthroscopic surgery was performed in twenty two patients by a single upper limb fellowship-trained orthopedic surgeon. The findings recorded in arthroscopy were presence of full/partial thickness ligament tears (Fig. 4), exact location of these tears, synovitis, and degenerative changes in the joint. Patients who required treatment in terms of debridement of tears, repairs & synovectomy underwent the same. Retrospective MR findings were then correlated with results in those patients who underwent arthroscopy. Arthroscopic correlation was obtained in 22 (46.8%) cases out of the 45 patients who underwent both MRI & MRA.
2.1. Arthroscopy The indication for arthroscopy in our study was patients with persistent and debilitating symptoms despite a trial of conservative
Fig. 1. Radiocarpel injection of gadolinium under ultrasound and fluoroscopic guidance.
Fig. 4. Image on the left suggestive of centraltear; on the right picture suggestive of a peripheral tear. 204
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3. Statistical analysis
Table 2 Distribution of SLIL & LTIL tears.
MRI and MRA interpretations were compared using arthroscopic findings as standards of reference. We assessed sensitivity, specificity, accuracy, positive predictive value and negative predictive value of MRI and MRA for diagnosis of tears of SLIL/LTIL and TFCC. All percentages were calculated with 95% confidence interval. Agreement between MRI & MRA with arthroscopy in TFCC ligament tears was computed using Cohen's Kappa coefficient. Statistical analysis was undertaken by a reviewer who was neither involved in the diagnosis nor the surgery.
INVESTIGATION
MRI MRA ARTHROSCOPY
There were 38 males and 7 females in the study. The age group of patients varied from 18 to 59 years with a mean of 23.9 years. Out of 45 patients, 35 patients (74.4%) reported trauma as mechanism of injury and were of age group 15–25 years (n = 35). All our patients were right hand dominant. Out of 45 subjects, 23 subjects having varied diagnosis like Scapholunate ligament sprain (4), acute type 1 (palmer classification) TFCC injuries (16) & ECU tendinitis (3) were managed with NSAIDS and immobilisation in splints/casts. These subjects reported relief of symptoms and hence managed conservatively. Rest of the 22 patients who had persistent symptoms were arthroscopically evaluated. The gold standard arthroscopic procedure diagnosed 15 peripheral & 6 central TFCC tears in 22 patients. 4 scapholunate ligament tears were also identified. MRI diagnosed 16 peripheral & 5 central TFCC tears in these 22 patients respectively (Table 1). MRA identified 9 central tears and 14 peripheral tears. There were three subjects who had both central & peripheral tears. The number of intact and torn ligaments diagnosed in MRI and MRA are depicted in Table 1. It can be inferred that MRA has identified more central tears compared to MRI which were factually three false positive results. The identification rate of peripheral TFCC tears of MRI & MRA are comparable (Table 1). Four SLIL and one LTIL injuries were diagnosed by MRA. Only three SLIL injuries were detected by MRI. However, arthroscopy showed four SLIL tears but no LTIL tears (Table 2). The sensitivity in diagnosing an overall TFCC tears with MRI as well as MRA was 94.4 & 100%. However, MRI was more accurate. For detecting central tears, MRA was more sensitive but less accurate than MRI (Table 3). To detect a peripheral tear MRI was more sensitive than MRA. However both were equally accurate. The specificity of the MRI and MRA in diagnosing an overall TFCC tear was 100% & 75% respectively (Table 3). The specificity of MRA in detecting a central tear was low in comparison to MRI but for a peripheral tear, it was high. The Cohen's Kappa value showed substantial agreement for detecting an overall TFCC tear between MRI & arthroscopy (0.63) and between MRA & arthroscopy (0.77). For detecting a central TFCC tear the cohen's kappa between MRA & Arthoscopy is 0.8 suggesting ‘almost perfect agreement’. 5. Discussion In literature the reported sensitivity and specificity of MRI for Table 1 Distribution of TFCC tears.
MRI MRA ARTHROSCOPY
TFCC CENTRAL (N = 22)
TFCC PERIPHERAL (N = 22)
TFCC (COMBINED)
INTACT
TORN
INTACT
TORN
INTACT
TORN
17 13 16
5 9 6
6 8 7
16 14 15
3 3 4
17 19 18
LTIL (N = 22)
INTACT
TORN
INTACT
TORN
19 18 18
3 4 4
21 21 22
1 1 0
diagnosing TFCC tear & other ligament injuries vary widely, between 44% and 100%.1–3,5 Wide variations in practice, such as the resolution of the scanner used, the thickness of the sections, the use of dedicated surface coil, and the inter-rater variability among radiologists may be the reason for the variation.7 In our study we noted no superiority of MRA over MRI in detecting the overall TFCC tear. However, MRA had high sensitivity in detecting central TFCC tear compared to MRI. Similar extensive studies comparing MRA over MRI in detection of wrist ligament injuries are there in literature (Tables 4 and 5).7,14,15 Few have highlighted superior advantage of MRA over the MRI.13–15,19 Meier et al. reported a sensitivity of 94%, specificity of 89%, and accuracy of 94% in their large series of 125 patients who underwent direct MR arthrography.14 The positive and negative predictive value in their series was 91% and 93%, respectively.14 MRA was done at 1.5 T and the results were compared with arthroscopy. Our study showed MRI to be equal or more accurate in detecting all types of TFCC tears compared to MRA, as MRA was highly sensitive leading to false positive. Further to this, in our study, the specificity of MRA in detecting an overall TFCC tear was 75%. The low specificity recorded may be attributed to the low proportion of intact ligaments in comparison to the torn ligaments. The probability of diagnosing an intact TFCC central ligament as a tear is high with MRA due to false positives as is evident from the results of this study. Understandably, from the surgeon's perspective, conversion to an arthroscopic procedure is high if a TFCC injury is diagnosed with MRA. On analyzing the literature in Tables 4 and 5, we observe that MRA has high sensitivity and relative low specificity compared to MRI in detecting a TFCC tear.16 Similar conclusions were drawn by Magee et al.15 In their study which involved arthroscopy in 49 patients, they found 86% sensitivity & 100% specificity in conventional MR imaging and 100% sensitivity in MR arthrography. Micro perforations in the extrinsic ligaments cause the dye to extravasate between the radiocarpal space to the midcarpal space. This may be interpreted as a tear which leads to false positive results in MR arthrography. They concluded that MRI at 3 T is highly sensitive for detection of TFCC tears & intrinsic ligaments. Lee et al. in their study reported a high sensitivity of three dimensional T1 highresolution isovolumetric examination (3D-THRIVE) MRA in detecting TFCC central tears.20 However, they concluded that MRI at 3 T provided equal results for the depiction and localization of intrinsic ligaments & TFCC tears in comparison to conventional MRA.20 MR arthrography is often essential in delineating ligament injuries in the small joints. It has higher sensitivity in detecting Scapholunate interosseous & lunotriquetral interosseous ligament injuries as well. This is again explained by the fact that the midportion of the scapho lunate ligament may not have a watertight seal, which may also account for the false-positive findings on conventional MR arthrography.14 In view of rarity of the injuty & small sample size we could not compare results of SLIL & LTIL tear to the existing data in literature and it is to be noted that in our small sample size MRI missed one SLIL injury. The American College of Radiology (ACR Appropriateness Criteria) has reported that direct MR arthrography is an appropriate imaging modality if wrist ligament tears are suspected and radiographs are normal or non-specific, especially in patients with ulnar-sided wrist
4. Results
INVESTIGATION
SLIL (N = 22)
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Table 3 Diagnostic accuracy of MRI and MRA in the diagnosis of tears of the SLIL, LTIL and TFCC. MRI
MRA
Tear
Sen (%)
Spe (%)
PPV
NPV
Acc
Sen (%)
Spe (%)
PPV
NPV
Acc
Arthroscopy (tear)
TFCC central TFCC peripheral TFCC(overall) SLIL LTIL
83 100 94.4 75
93.8 85.7 100 100 95.4
83.3 93.7 100 100
93.7 100 80 94.7 100
90.9 95.45 95.4 95.4 95.4
100 93.3 100 100
81.2 100 75 100 95.4
66.6 100 94.7 100
100 87.5 100 100 100
86.4 95.5 95.4 100 95.4
6 15 18 4 0
Table 4 Accuracy Of MRA in TFCC tears in reviewed studies. TFCC tear [ number of subject]
Sensitivity
Specificity
Positive predictive value
Negative predictive value
Accuracy
Magee et al. (2009)15[35] Pahwa et al. (2014)17[16] Abdelsattar (2012)18[51] Al Hiari et al. (2013)19[42] Mahmood et al. (2012)[30] Joshy et al. (2008)7[24] Lee et al. (2013)20[48] Our study
100 100 94.2% 93.3% 90.0% 74% 100% 100%
100 100 100 80.0% 75% 80.0% 100% 75%
100 NA NA 85.0% 95.0% NA 90%
100 NA NA 80.0% 50.0% NA 100
100 95.45 85.0%
Sensitivity
Specificity
Positive predictive value
Negative predictive value
Accuracy
86.0% 75.0% 88.57% 94.6 94.4%
100% 100% 100% 100 100%
90.0%
50.0%
75.0% 90.9%
94.7
100
95.4%
79% 90.9%
Table 5 Accuracy of MRI in TFCC tears in reviewed studies. TFCC tear MRI 15
Magee et al. (2009) [49] Pahwa et al. (2014)17[16] Abdelsattar et al. (2012)18[51] Lee et al. (2013)20[48] Our study
TFCC injury. Even though the superiority of MRA over MRI is debatable as per literature, we feel, from an orthopaedicist's perspective that MRI should be adequate in majority of the cases and an invasive investigation can thus be avoided. With comparatively low specificity, caution and restraint should be advised while interpreting MRA, which may influence the decision on surgery.
pain. They state that it has the highest accuracy for diagnosing abnormalities of the TFCC and intrinsic ligaments. However an MRI at 3 T may have equivalent results in detecting TFCC tears when direct MR arthrography is not available14–16 Treiser et al. in a metaanalysis comparing MRA and MRI for diagnosing TFCC injuries suggested a superior diagnostic accuracy over MRI. However, the study was cautious in concluding the same as the published evidence contained a number of methodological limitations.21 A recent meta-analysis by Wang et al. on the performance of MRI in TFCC injury concluded that the accuracy of MRI for diagnosing TFCC injuries are good. It is less time consuming, cost-effective and non invasive in comparison to MR arthrography and hence preferred by most surgeons.22 Direct MR arthrography is not without disadvantages. It is invasive and costly. There are reports of infection following arthrography. Complications including chemical synovitis, exacerbation of pain, vasovagal attack have been reported. In our setup where the cost of investigation is borne by the patient, comparison of the sensitivity and specificity of MRA over MRI is desirable, thus determining the ideal investigation of choice. With high sensitivity and false positive results, as evident from our study & debatable literature, we feel that, MRA as an OPD diagnostic procedure is impractical, for patients with chronic and vague ulnar sided wrist pain. MRI would be able to guide the surgeon in planning the management of a patient for proceeding to arthroscopy.
6.1. Limitations Our study were not without limitations. Only 22 cases out of our group of 45 cases underwent arthroscopy. The relatively small sample size limits us to draw significant statistical conclusions. Tears of ventral, dorsal or central segments of a ligament were not considered separately. Financial support & sponsorship Nil. Declaration of competing interest There are no conflicts of interest. References 1. Cerofolini E, Luchetti R, Pederzenni L, et al. MR evaluation of triangular fibrocartilage complex tears in the wrist: comparison with arthrography and arthroscopy. J Comput Assist Tomogr. 1990;14:963–967. 2. Golimbu CN, Firooznia H, Melone Jr CP, et al. Tears of the triangular fibro cartilage of the wrist: MR imaging. Radiology. 1989;173:731–733. 3. Haims AH, Schweitzer ME, Morrison WB, et al. Internal derangement of the wrist: indirect MR arthrography versus unenhanced imaging. Radiology. 2003;227:701–707.
6. Conclusions Direct MRA has better sensitivity in detecting TFCC central tears. In view of ‘substantial’ agreement between MRI & MRA with Cohen Kappa analysis, we feel that conventional MRI can be relied on, in diagnosing 206
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wrist arthroscopy. Handchir Mikrochir Plast Chir. 2005;37(2):85–89. 15. Magee T. Comparison of 3T MRI and arthroscopy of intrinsic wrist ligament and TFCC tears. AJR Am J Roentgenol. 2009;192:80–85. 16. ACR Appropriateness Criteria®. Overview. Rubin: American College of Radiology. 2012; 2012 Electronic Copies: Available in Portable Document Format (PDF) from the American College of Radiology (ACR) Web Site. 17. Pahwa S, Srivastava DN, Sharma R, Gamanagatti S, Kotwal PP, Sharma V. Comparison of conventional MRI and MR arthrography in the evaluation of wrist ligament tears: a preliminary experience. Indian J Nucl Med. 2014;24(3):259. 18. Abdelsattar MH, Hassaan MA, Kamal HA. Conventional magnetic resonance imaging versus MR arthrography (MRA) of the wrist in the evaluation of triangular fibrocartilage lesions. Egypt J Radiol Nucl Med. 2012;43(2):235–244. 19. Al-Hiari AA. The role of wrist magnetic resonance arthrography in diagnosing triangular fibrocartilage complex tears: experience at king Hussein medical center, Jordan. Sultan Qaboos Univ Med J. 2013 May;13(2):280. 20. Lee YH, Choi YR, Kim S, Song HT, Suh JS. Intrinsic ligament and triangular fibrocartilage complex (TFCC) tears of the wrist: comparison of isovolumetric 3DTHRIVE sequence MR arthrography and conventional MR image at 3 T. Magn Reson Imaging. 2013;31(2):221–226. 21. Treiser MD, Crawford K, Iorio ML. TFCC Injuries: Meta-analysis and comparison of diagnostic imaging modalities. J Wrist Surg. 2018 Jul;7(3):267–272. 22. Wang ZX, Chen SL, Wang QQ, Liu B, Zhu J, Shen J. The performance of magnetic resonance imaging in the detection of triangular fibrocartilage complex injury: a meta-analysis. J Hand Surg. 2015 Jun;40(5):477–484.
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