0:00

<v ->Let's go and I'll show you only one case,

0:04

one interesting case,

0:05

with several consecutive exams

0:07

to reinforce the teams presented by Don Resnick.

0:12

You'll be able to observe in this exam

0:16

the evolution of the osteochondral lesions.

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We are taking a look in the medial compartment.

0:23

This is a patient, male, 64 years old.

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He's a very good friend of mine,

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he's an orthopedist, knee specialist,

0:32

who presented pain in the anterior aspect of the knee.

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Clinically, he has a knee varus,

0:39

as you can appreciate here,

0:42

which proposing for overload in the medial compartment,

0:48

but without sign.

0:49

He didn't have any symptoms or signs

0:54

of lesion or pain in the medial aspect of the knee.

0:59

The only x-ray I have is this one,

1:02

that he gave me this x-ray.

1:04

But he himself request MR,

1:10

to analyze the possible injury to the patella cartilage,

1:14

and I'll begin to show you these images.

1:16

I'll try to put the, let me see...

1:23

The initial images in the bottom.

1:27

This is the initial images.

1:30

The patient, you see,

1:31

I will need to have more time,

1:33

because this is a seven MRs.

1:35

In this case, it is interesting,

1:37

because you see very small details

1:40

that usually sometimes we don't make attention,

1:47

but this is a nice case.

1:48

I'll try to zoom all the images to the medial compartment,

1:54

only to show you using high resolution image.

1:58

He has some fissures of the cartilage,

2:02

some fraying, the medial aspect of the cartilage,

2:05

which was his problem in the beginning.

2:09

But when you see the other compartment,

2:14

there is no problem in the medial compartment,

2:17

as you can see in the coronal view and the sagittal view,

2:22

you see only degeneration in a small fissure

2:29

of the medial meniscus,

2:31

as you can see here in this digital print.

2:35

He started the treatment for physiotherapy

2:39

and rely on the extensor mechanism.

2:42

But three months after the first MR,

2:45

after a long walk he presented acute pain

2:48

on the medial aspect of the knee.

2:50

He then did a second MR to investigate

2:55

a possible rupture of this meniscus.

2:59

Now I put the old in the top,

3:03

and the current in the bottom,

3:06

only to begin to compare the images.

3:08

I enlarge all of this to show better for you, okay?

3:15

This is the current,

3:17

and now we can see the true rupture of the meniscus.

3:25

We can see here, the vertical and longitudinal rupture

3:31

of the free edge of the meniscus.

3:34

If you look, the cartilage is completely normal,

3:37

as you can see.

3:38

Here we can see the lesion of the meniscus.

3:43

And after this exam,

3:47

he continued performing physiotherapy.

3:51

As he could not operate on this meniscus

3:53

due to professional commitments,

3:57

he preferred to do some physiotherapy and rest,

4:02

and he stayed like this.

4:05

Let me now put the second MR here in the top.

4:11

But the pain in the medial compartment,

4:15

continued to get worse,

4:17

and one month later he decided to do the third MR.

4:22

Let me put the third MR here,

4:26

stretched out in the coronal t2 image.

4:33

On this image it's possible to take a look.

4:36

I put the similar images,

4:41

and let's go to take a look.

4:45

Now, it's possible to see the rupture,

4:51

with the fragment of the meniscus

4:53

displace it in internal intercondylar region.

4:58

And we begin to see a small amount of edema,

5:05

subchondral edema.

5:06

Comparing to the previous exam,

5:09

we didn't see this edema,

5:10

and now we can see this edema.

5:14

Coronal t1 images.

5:20

It's very similar.

5:21

It's easier to see this line.

5:23

It's like a semi-circle line here in this area.

5:29

Now, he has an evolution for unstable meniscus tear.

5:36

It's an unstable meniscus tear.

5:39

The patient underwent antroscopy for meniscectomy

5:43

one week after this MRI.

5:46

He remains 15 days without load in this knee,

5:54

under physiotherapy treatment.

5:56

But when he put the weight on this knee,

5:59

he felt a strong and acute pain on the medial side.

6:03

Let's take a look in the fourth MR.

6:06

The fourth. I put the third here in the bottom.

6:11

Let's go. Okay.

6:15

And the fourth here.

6:22

And you see the natural history of his problem.

6:29

Let's go to the medial compartment.

6:32

And now we can see in the same place,

6:37

there is a line of fracture,

6:41

in the sub coronal portion of the conidial .

6:44

We can see the reduction of the meniscus after meniscectomy,

6:47

but there still have one fragment displaced here.

6:53

I don't know who did the surgery,

6:55

but (chuckles) they forgot a small piece of meniscus here.

7:00

And now look at this.

7:03

what was one 20 days difference?

7:07

This is 20 day difference.

7:09

And you see this line of fracture.

7:12

Don, what you think about this fluid,

7:14

between the sub contrail bone and the...

7:20

<v ->I think there must be a pathologic space there,

7:24

and that I would imagine,

7:25

the fluid is derived from the joint,

7:28

and has gotten through cracks in the cartilage

7:31

and subchondral bone plate,

7:33

and collecting within a fracture in there.

7:38

You know, it's a question of whether

7:39

it's a crescent sign or a fracture.

7:42

And I think it would be a little bit difficult

7:44

to be certain.

7:45

But I think the fluid did come from the joint space.

7:48

<v ->But if you look,

7:50

the cartilage is still intact.

7:54

We don't see fissures.

7:56

We don't see any lesion.

7:58

And there was a little bit of sinking

7:59

of the subchondral bone,

8:01

but the cartilage...

8:04

Maybe on the very far medial aspect.

8:08

But I'll bet that if you look histologically,

8:12

that there's probably cracks that is allowing fluid in.

8:15

Otherwise, why do you think it's...

8:17

What was your theory?

8:19

<v ->I really don't know why.

8:21

I really don't know,

8:22

but what I told you,

8:24

when I see this semicircular sign,

8:28

usually the prognosis of this fracture is not good.

8:31

Usually-

8:34

<v ->they have...

8:35

It's very difficult to heal in this fracture.

8:35

I don't know.

8:36

It's my impression.

8:39

Probably we need to take a look in more cases.

8:41

But every time when I see this semicircular sign,

8:46

the prognosis is not so good.

8:49

At the time, the patient still doing rehabilitation,

8:57

for three months, improvement the pain.

9:02

He as well has underwent a bariatric surgery,

9:07

with reduction of 25 kilograms,

9:08

it's about 55 pounds.

9:11

Nevertheless, he never stop having pain on,

9:15

or having difficult to walk.

9:18

And a few months later,

9:20

he did another MR and CT.

9:22

And they did the CT cause he's still having pain.

9:27

Let me show you the new MR.

9:30

And I put the images of CT together.

9:32

This is the new MR.

9:35

And you put the images of CT together.

9:39

Now we can take a look and see what has happened.

9:43

In this MR,

9:47

like to put the images of the coronal sagittal plane.

9:54

Oh, that's it.

10:00

Look at that.

10:02

Sometimes the CT is better

10:03

to see the sinking of the subchondral bone.

10:09

And now, there's less edema,

10:14

but we still looking for the line of fracture.

10:19

And now we can see,

10:21

we can appreciate a cyst,

10:25

in the interior portion of the fracture.

10:28

We didn't see the cyst before.

10:31

We can see the line of fraction in CT and the cyst.

10:37

We can see also the meniscus lesion still there,

10:42

the meniscus lesions a small rupture here.

10:45

The oblique rupture.

10:49

That's it.

10:51

Few months later in February, 2020,

10:55

all of this is came from three years difference,

11:00

between the first and the last examination.

11:04

After long walk at the airport,

11:06

he felt intense pain in the medial compartment.

11:10

And the sixth MR was performed.

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I will show you the sixth MRI.

11:18

Let me put in the bottom

11:20

this sagittal and this coronal images.

11:24

And let's take a look in the...

11:27

this is the last one.

11:32

This is the one. Sagittal t2 and coronal t2.

11:40

That's it.

11:41

Now we can take a look on the images.

11:46

Look at what it happens.

11:51

This is the same.

11:53

This is the last one that we just saw.

11:57

And we can see in this,

11:59

prominent sinking of the subchondral bone,

12:04

a lot of edema,

12:07

more fibrocystic changes in now the small extrusion,

12:14

or partial extrusion of the meniscus.

12:16

In only in this exam,

12:20

we can take a look.

12:23

We see the cartilage begin to be irregular,

12:27

and thickening of the cartilage.

12:30

He may need clinical treatment,

12:32

trying to avoid another procedure,

12:37

another surgery.

12:39

He's doing physiotherapy, avoid overloading.

12:44

He took analgesic and anti-flammatory drugs,

12:47

but in September,

12:49

means six months after this one,

12:52

he had the pain worse in this.

13:00

And he did the last MR.

13:01

And let's take a look at the last MR,

13:07

to show the evolution of the case.

13:17

That's it. Look at this.

13:20

We can see the before, after,

13:24

you can take a look,

13:26

see it's like an...

13:29

it's not an osteochondral dissecans,

13:32

but look like there is a two fragments

13:35

detached from the previous area of fracture.

13:40

We can see the observed appearance of an erosion

13:45

of the cartilage on the femur,

13:49

but in on the tibia,

13:51

all this cartilage is gone with one edema.

13:53

Means it's a necrosis,

13:58

and now he's waiting for prosthesis.

14:03

This is everything to show the history,

14:05

from the normal in three years,

14:08

to only compartment necrosis.

14:13

Still trying to do something here,

14:16

but he knows that is necessary to do prosthesis.

14:22

Let me put only the first MR to compare to the last one,

14:30

less than three years of evolution.

14:32

This is normal.

14:34

This is normal.

14:35

That's what he got. He gots.

14:38

This is a nice case to show the whole evolution

14:41

of everything that you told in your lecture.

14:45

<v ->Yeah. I wish I had a great explanation for it.

14:48

You know, it reminds me when you go back,

14:51

and look at the descriptions of sunk,

14:55

there were those who found

14:57

that there were insufficiency fractures,

15:01

and then areas of osteonecrosis

15:03

around the sites of insufficiency fracture.

15:08

So maybe there's a combination of events going by,

15:12

but I am sure if he weren't a friend

15:16

he wouldn't have had seven MR's,

15:19

so (chuckling), that must be close to a record.

15:23

<v ->Don, he didn't pay me.

15:25

(laughing)

15:26

<v ->No, I know.

15:28

<v ->I would try to do it one again.