mri for the initial evaluation of acute wrist, knee, and ankle trauma

184 Pages·2012·31.72 MB·English

MRI FOR THE INITIAL EVALUATION OF
ACUTE WRIST, KNEE, AND ANKLE TRAUMA
Jeroen J. Nikken
The work of this thesis was conducted at the department of Radiology and the
department of Epidemiolof,'Y & Biostatistics of the Erasrnus MC Rotterdam, the
Netherlands.
The study was supported by the department of Radiology, the Revolving Fund from
the Erasmus University Medical Center Rotterdam and by an unrestricted grant
from Esaote S.p.A., Genoa, Italy.
Financial support by the department of Radiology of the Erasmus MC and by
Schering Nederland BV for the printing of this thesis is gratefully acknowledged.
ISBN 90-9017191-6
Lay-out : Andries W. Zwamborn
Cover
photography : Jeroen Stout
design : Andries. W. Zwamborn
after an idea of Hugh Turvey
Printed by Ridderprint B. V. Ridderkerk
© 2003, J.J. Nikken
No part of this book may be reproduced, distributed, stored in a retrieval system or
transmitted in any form or by any means, without permission of the author, or,
when appropriate, of the publishers of the publications.
MRI FOR THE INITIAL EVALUATION OF
ACUTE WRIST, KNEE, AND ANKLE TRAUMA
MRl voor de initiele evalllatie van aClIlIt pols, knie en enkelletsel
I'ROEFSCI-IRIFT
ter verkrijging van de graad v<ln doctor aan de
EraS111l1S Universiteit Rotterdam
op gezag van de
Rector Magn ificllS
Pror.clr.ir. J.I-I. van Bemmel
en volgens besluit van het College voor Promories.
De openbare verdecliging zal pbatsvinden op
woensclag I oktober 2003 om 9.45 lIl1r
c100r
Jeroen JooP Nikken
geboren re Den J-1aag.
PROMOTIECOMMISSIE
Promotoren: Prof.dr. M.G.M. Hllnink
Prof.clr. G.P. Krestin
Overige leden: Prof.dr. B.W. Koes
Prof.dr. lA.N. Verham'
Prof.clr. A.B. van Vllgt
Copromotor: Dr. A.Z. Ginai
Contents
Chapter 1 Introduction 7
Chapter 2 MR illlaging of the menisci and cruciate ligaments: 13
Cl systematic review
Chapter 3 Comparison of short and standard protocols in dedicated 41
extremity MR I of wrist, knee, ~l1lcl ankle injury
Chapter 4 AClIte wrist traUIllJ -the value of a short dedicated 51
extremity MR! examination in predicting subsequent
treatment.
Chapter 5 Traumatic knee injury: the value of a short dedicated 69
extremity MR I examination in the early stage in predicting
subsequent treatment.
Chapter 6 Acute ankle [rilum8. -the value of Cl short dedicated 89
extremity MRI examination in predicting subsequent
treatment.
Chapter 7 A short low-field M RI examination in all patients with 107
acute peripheral joint injury -results of a ranclomized
controlled trial.
Chapter 8 Costs and effects of a short low-field MRI examination in 129
acute knee injury.
Chapter 9 Value of information analysis directing further research: 147
assessing the use of M RI for acute knee traun)a.
Chapter 10 Summary and discussion. 163
Chapter 11 Samenvatting en discussie 171
Donkwoord 181
About the author 185
Introduction
7
Introduction
Magnetic resonance imaging has obtained a firm position in the diagnostic
evaluation of Il1l1sculoskelcra\ abnormalities. It is, however, not widdy lIsed as a
routine examination rool in rhe initial examination of aClIte trauma of wrist, knee
and ankle. The high costs ilnd the long duration of the examination are nlrljor
hindrances for the use of MR.I in this respect. Moreover, whether MRI in acute
joint (rClUIll(l is lIseful is Cl matter of debate. The issue about the yet largely unknown
potential of M RI in aClIte skeleral trauma has recenrly been brought lip by Rogers,
the ediror in chief of the Americ;111 Journal of Radiology, stating that there is still a
lot to know and mllch to be learned abollt the potential role of MR imaging in
acute skeletal trauma (1,2). Reports about the effect of MRI in acllte knee injury on
treatment decisions arc conflicting; whereas M:lurer founel [hilt MRI reduced the
nurnber of arthroscopic procedures, improved clinician diagnostic cerrainty, and
assisted management decisions (3), Oclgaarcl found in 90 consecutive patients that
the MRI result changed treatment in only 6 cases and did not prevent any planned
arthroscopy (4). For the wrist the effect of early MRI after trauma has only been
studied in relation to scaphoid fractures. These studies show that M RI is very
sensitive in the detection of fractures of the scaphoid bone that arc not evident on
plain radiographs (5·7), but no fonnal cos[-effecri\"cness studies on this subject from
the socieral perspecri\'c have been published. The effect of MRI on rhe management
of acute ankle injury has only been studied in children with suspected physeal ankle
fractures. Carey found that MRI changed management in 5 of 14 children with
suspected or known growrhplate injury (8), however, Lohman fOLlnd no change in
management after MR.I examination in 60 consecutive children with suspected
ankle fracture or ankle ligament tear (9).
In this thesis we study the application of MRI in acute trauma of wrist, knee, and
ankle, evaluilring its porenriaIs, its effects, ilnd its costs. Our nim \V~lS to lIse MRI in
all parients with acute trauma of wrist, knee, and ankle, without increasing rhe
overall costs to society, potentially even reducing these costs.
We lIsed a relatively inexpensiyc low field dedicated extremity MRI system
(Anoscan M, Esaore, Genoa, Italy) for our srudy. There has been debate regarding
the diagnostic performance of low field MRI versus high field MRI (10-25).
However, most studies conclude that the diagnostic quality of low field MRI
approaches the high field systems. We feel that skepticism toward low field MRI is
often based on first impressions of [he low field MRI images and not on dam of
comparative clinical [rials.
8
Chapter 1
In chnprer 2 wc present a mcra-Jnaiysis of earlier published studies on the
diagnostic performance of MRI of the menisci and crllci:1tc ligaments combined
with an (lsseSSl11cl1t of the effect of magnetic field strength on diagnostic
perforrnance.
We developed a shortened scanning protocol on the low field MRI system,
reducing both time <1I1e! costs of the examination to be lIsed for iniri •. i evaluation of
wrist, knee, and ankle injury (ChapTer 3). A reduction in examination time was
necessary since a st:1ndard MRI examinal"ion takes about 30 to 45 minutes, which
would be too long and probably too expensive for rOlltine examination of all
patients with acute joint rr<luma.
In Chapter 4, 5, ,lIld 6 wc describe <l ll1ultivariable logistic regression analysis for
acute wrist, knee, and ankle trauma to assess if the addition of a short MRI
examination contributes in discriminating between pMients that will need
additional thempy ,Ifter their initizd visit to the hospital and patients that can be
sent home without need for follow~llp. Furthermore we study if the short MR!
examinMion can replace radiography for this purpose.
The strategy of perforrning a short MR! examination in addition the current
[Q
diagnostic \vork~lIp is only feasible if it is cost·effective. However, it is not very likely
th(lt an initial short M RI examin(ltion would lead to an overall increase in quality
of life in rhe long term if all patients with acute traum:1 of wrist, knee, or ankle were
to undergo a short M RI exan1ination. It may be true for the radiographically occult
scaphoid fracture, since a delay in rre:1tment could lead to pseudo~arthrosis,
osteonecrosis and arthrosis in the end. However, for the majority of possible lesions
a delay in diagnosis and treatment is not necessarily detrimental and therefore we
did not anticipate a general increase in long term quality of life as a result of the
M RI examination. We rather expectecl the advantage to be a shorter convalescence
in a subgroup of patients in whom the earlier final diagnosis would lead to earlier
treatment and an earli~r recovery. An earlicr recovery is favorable for the pati~nt
and may also reduce the time off work and thus save costs. For the radiology
department an extra MR! examination would always be more expensive. For the
health care payer (e.g. insurance comp;lny) there may be some fin:-1I1ci;l1 ;ldvantages:
potentially less follow-up visits, less tempornry treatment me;lsures if the diagnosis is
not yet clear at initial l:valuation, and possibly less diagnostic procedures during
follow~up, including (diagnostic) arthroscopies. There is ,dso the possibility of a
false positive MRI result, which could lcad to unwarranted treatment, which would
incre;lse the costs and decrease patient utility. On the other hand, cost-savings can
be expectcd from the socictal perspective by a reduction in lost productivity.
9
Introduction
The associated COSt reduction may have a major impact on the overall costs (26) and
may well be the decisive factor in the cost-effectiveness analysis. I n Chapter 7 both
the costs and the effects of performing a short MRI examination in addition to
history raking, physical examination and radiogr:lphy are assessed from the sociewi
perspective for acute trauma of the wrist, knee, and ankle.
Chapter 8 focuses on improving the cos[~cffcC[iveness of MRI in patients with aClIte
knee injury by identifying a subgroup of patients that would profit Illost frol11 the
eady MRI examination.
Socio-economic background
The underlying question in this study frolll a sacio-economic point of \'icw is how
we should {re)allocate our financial and medical resources. The theoretical basis for
slIch an analysis is founded in the welfare theory, based on the utilitarian principle
of maximum social benefit (27). In the welfare theory several criteria are used: the
!'areto criterion for efficiency {introduced in 1890 by Vilfredo Pareto, an Italian
sociologist and economist} implies that certain allocation of means is efficient if
nobody in that situation can gain anyn'lOre without a reduced gain for sOInebody
else. A state is Pareto Efficient if no one's utility can be increased without
decreasing someone else's utility. Since this criterion almost ccrminly prevents any
improvement for society as a whole, the Kalclor Hicks criterion was introduced: a
certain allocation of means should be in1plen1entecl if those who experience a
reduced gain by this allocation could be compensated. A morc lenient point of view
is the Social Utility Maximization: under this criterion a certain allocation of means
is efficient if it maximizes the total utility of society, even if some people are made
worse off by the allocation (28). In the medical setting these principles form the
basis of modern cost-effectiveness analysis. For the current scudy the question
would be. considering all costs, benefits, and drawbacks, would society be willing to
pay for an additional MRI examination in all patients with acute wrist, knee, and
ankle trauma?
The relevance of this study is proportional to the number of wrist, knee, and ankle
injuries that occur annually and the resulting time·froIlHvork, time·from·
lIsual·activities, and the costs of medical management. To give an idea of the order
of magnitude of sports injuries: over 500 million Euro were spent on the
management of accidental falls (excluding motor vehicle accidents) in the
Netherlands in the year 1994 (Polder ea. Kosten van ziekten in Nederland in 1994).
Ankle, knee, and wrist trauma represent a substantial proportion of slIch accidents.
10
Chapter 1
References
1. Rogers LF. To sce or not to sce, thar is !"he question: MR i11laging of acute skeletal
rrauma.AJRArnJ RocntgcnoI2001;176(l):1.
2. Rogers LF. What is the role of MR! in acute skeletal traLlma~ AJR 2001; 177: 1245.
3. Maurer Ej, Kaplan PA, Duss:l.ult RC, Diduch OR, Schuett A, McCuc Fe, et al. Acutely
injured knee: effect of MR imaging on diagnosric and rher(lpeuric dl!cisions. Radialo!:,,)1
1997;204(3),799·805.
4. Oclgnarcl F, Tuxoe J, Joergenscn U, Lange 13, Lallsrcn G, Brettlau T, et al. Clinical
decision making in the acutely injured knee based on repeat dinicn\ examination and
MRI. Scand J Med Sci Sports 2002; l2(3), l54·62.
5. Gacbler C, Kukla C, Breitenseher M, Trattnig S, Mitrlboeck M, Vecsei V. Magnetic
resonance imaging of occult scaphoid fractures. J Trauma [996;410):73-6.
6. Dorsay TA, Major NM, Helms CA. Cost-effectiveness of immediate MR ilTlaging versus
traditional follow-up for revealing radiographically occult scaphoid fractures. AJR Am J
Roentgenol 200 I; 177(6), 1257·63.
7. Breitenseher MJ, Metz VM, Gilula LA, Gaebler C, Kukla C, Fleischmann 0, et al.
Radiographically occult scaphoid fractures: value of MR imaging in deteC[ion \see
comments!. Radiology 1997;203(1),245·50.
8. Carey J, Spence L, Blickman H, Eustace S. MRl of pediatric growth plate injury:
correlation with plain film radiographs ;md clinical outcOlTle. Skeletal Radiol
1998;27(5),250·5.
9. Lohman M, Kivisfl<lri A, Kallio P, Puntila 1. Vehm<ls T, Kivisaari L. Acute paediatric
<lnkle trauma: MRI versus plnin radiography. Skeletal Radiol 2001;30(9):504-11.
10. Run BK, Lee OH. The impact of fjeld streng!'ll on image quality in MR!. J Magn Reson
Imaging 1996;6( I )57·62.
11. Masciocchi C, Barile A, Sarragno L. Musculoskeletal MRL dedicated systems. Eur
Radiol 2000; 10 (2),250·5.
12. Arbogasr-Ravier S, Xu F, Choquet P, Brunnr 13, Consrantinesco A. Dedicated low-field
MRI: a promising low cost-technique. Med Bioi Eng CompLlt 1995;33(5):735-9.
13. Barnett MJ. MR diagnosis of internal derangements of the knee: effect of field strength
on efficacy. AJ R Am J Roentgel1ol 1993; 161 ( 1) , I l5·8.
14. Br;ldley WG. Future cost-effective MKI will be at high field. J Magn Reson Imflging
1996;6( I ),63·6.
15. Chevrot A, Drnpc J, Godefroy 0, Dupont A. Dedicated MRI, emergency,
cost-effectiveness. Abstrflct Industrial symposium 1997.
16. Davies A. Artoscan versus superconductive: (he bonomline. Abstract Industrial
symposium 1997.
17. Hayes E. Luw·field and dedicated MR1 gain credibility. Diagn Im Em
19 97(may)36-49.
18. Kasting-Sommerhoff 13, Gerhardt P, Golder \Y./, Hof N, Rid KA, Helmbetger H, et al.
IMRI of the knee joint: first results of a comparison of 0,2-T specialized system flnd
1,5-T high field strength mngnctl. Rofo Fortschr Geb Rontgenstr Nellcn Bildgeb
Verfahr 1995; 162(5)390·5.
11