Osteoarthritis and Cartilage 22 (2014) 1429e1443

Review

Imaging following acute knee trauma

R. Kijowski y *, F. Roemer z x, M. Englund k ¶, C.J. Tiderius k, P. Swa
€rd k, R.B. Frobell k
y Department of Radiology, University of Wisconsin, Madison, WI, USA
z Department of Radiology, University of Erlangen-Nuremberg, Erlangen, Germany
x Department of Radiology, Boston University, Boston, MA, USA
k Department of Orthopedics, Clinical Sciences Lund, Lund, Sweden
¶ Clinical Epidemiology Research and Training Unit, Boston University, Boston, MA, USA

a r t i c l e i n f o s u m m a r y

Article history: Joint injury has been recognized as a potent risk factor for the onset of osteoarthritis. The vast majority of
Received 6 February 2014 studies using imaging technology for longitudinal assessment of patients following joint injury have
Received in revised form focused on the injured knee joint, specifically in patients with anterior cruciate ligament injury and
21 April 2014
meniscus tears where a high risk for rapid onset of post-traumatic osteoarthritis is well known. Although
Accepted 3 June 2014
there are many imaging modalities under constant development, magnetic resonance (MR) imaging is
the most important instrument for longitudinal monitoring after joint injury. MR imaging is sensitive for
Keywords:
detecting early cartilage degeneration and can evaluate other joint structures including the menisci, bone
Post-traumatic
Osteoarthritis
marrow, tendons, and ligaments which can be sources of pain following acute injury. In this review,
Imaging focusing on imaging following acute knee trauma, several studies were identified with promising short-
Knee term results of osseous and soft tissue changes after joint injury. However, studies connecting these
Ligament promising short-term results to the development of osteoarthritis were limited which is likely due to the
Meniscus long follow-up periods needed to document the radiographic and clinical onset of the disease. Thus, it is
recommended that additional high quality longitudinal studies with extended follow-up periods be
performed to further investigate the long-term consequences of the early osseous and soft tissue changes
identified on MR imaging after acute knee trauma.
© 2014 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.

Introduction Advanced imaging techniques including magnetic resonance

Joint injury is a well-known and potent risk factor for osteoar-
thritis1. The driving mechanisms of the increased risk remain un-
known, but various factors are thought to influence the likelihood
of developing post-traumatic osteoarthritis including the severity
of injury, the joint tissues involved, the age at the time of injury, and
the time from the onset of injury2. Investigating the pathogenesis of
post-traumatic osteoarthritis in human subjects is challenging and
requires non-invasive methods to monitor joint injury. Radiog-
raphy is the imaging modality primarily used to detect the onset
and progression of joint degeneration following trauma, but the
development of radiographic features of osteoarthritis may take
decades to occur3e7.
* Address correspondence and reprint requests to: R. Kijowski, Department of
Radiology, University of Wisconsin School of Medicine and Public Health, Clinical
Science Center-E3/311, 600 Highland Avenue, Madison, WI 53792-3252, USA. Tel: 1-
608-265-3247; Fax: 1-608-263-5112.
E-mail address: rkijowski@uwhealth.org (R. Kijowski).
(MR) imaging have recently been used for longitudinal assessment
of patients following acute trauma and show great promise for
detecting early manifestations of joint degeneration. The vast ma-
jority of longitudinal studies using imaging technology have
focused on the injured knee joint, specifically in patients with
anterior cruciate ligament (ACL) injury and meniscus tears where a
high risk for rapid onset of post-traumatic osteoarthritis is well
known8e10. Few longitudinal studies have used advanced imaging
technology to investigate the progression of joint degeneration
from its earliest stages after acute injury to the onset of radio-
graphic and clinical manifestations of osteoarthritis.
This article will review the imaging modalities currently avail-
able for longitudinal joint assessment in patients with acute knee
trauma and will discuss the current knowledge on imaging based
structural injury and longitudinal changes in joint structures after
knee trauma. The article will also review the current evidence on
the association between imaging based structural injury following
knee trauma and clinical outcome, molecular changes in joint tis-
sue, and the onset of osteoarthritis. The review is based on an
extensive PubMed literature search which included but was not

http://dx.doi.org/10.1016/j.joca.2014.06.024
1063-4584/© 2014 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.
1430 R. Kijowski et al. / Osteoarthritis and Cartilage 22 (2014) 1429e1443
limited to the following search terms: ACL, trauma, sports injury,
knee, imaging, radiography, computed tomography (CT), MR im-
aging, osteoarthritis, treatment, and outcome. While every attempt
has been made to incorporate all relevant literature into the review,
it must be acknowledged that this manuscript is a narrative review
and not a systematic review according to PRISMA guidelines.
Panorama of structural injury following acute knee trauma
Acute rotational trauma combined with a rapid effusion of the
knee joint is highly suggestive of a significant intra-articular
injury11,12. Clinical examination of the injured knee is often diffi-
cult in the acute setting, and a lack of accuracy for detecting intra-
articular pathology has been well documented13,14. A study from
2007 highlights the benefit of using MR imaging to determine the
extent of structural damage following knee trauma by showing that
only 12% of transient patellar dislocations and 50% of ACL tears
identified on MR imaging were clinically suspected in the ortho-
pedic emergency room14. The overall panorama of structural injury
after acute knee trauma is not well known. A recent abstract from a
large study on 1145 patients with acute knee trauma, who were
evaluated with MR imaging within a median of 8 days after injury,
showed an ACL tear, transient patellar dislocation, and medial
collateral ligament tear in 52%, 17%, and 28% of individuals
respectively15. The majority of patients, except those with transient
patellar dislocations, suffered from a combination of structural in-
juries. A concomitant meniscus tear was identified in 55% of pa-
tients with ACL injury, while an isolated ACL tear was found in only
17% of individuals15. Osseous injuries including traumatic bone
marrow lesions16e22 and cortical fractures23,24 were also identified
in a large proportion of patients with ACL tear. The combination of
structural injuries sustained during acute knee trauma may
potentially influence long-term clinical outcome and the develop-
ment of osteoarthritis.
Imaging methods for longitudinal assessment of patients
following acute knee trauma
Radiography
Radiography is commonly used to evaluate patients following
acute knee trauma. Various radiographic grading scales including
the Osteoarthritis Research Society International (OARSI) atlas25,
KellgreneLawrence26, Ahlback27, and Brandt28 systems are
currently available to assess the degree of joint degeneration based
upon the presence of osteophytes, subchondral cysts and sclerosis,
and joint space narrowing. As the OARSI atlas grading scheme in-
corporates a compartmental assessment of osteoarthritis features
and scores joint space narrowing and osteophyte presence as
separate items, it seems best suited for the assessment of post-
traumatic osteoarthritis when compared to composite scales like
the KellgreneLawrence system. However, for knee phenotypic
characterization and patient inclusion in longitudinal studies, the
KellgreneLawrence scale is still commonly applied and has been
found to be a helpful instrument.
Quantitative measurement of joint space width on standing
flexion anterioreposterior knee radiographs, acquired using stan-
dardized positioning and imaging protocols, has also been shown
to have high precision and is thus well suited as a longitudinal
assessment measure of cartilage degeneration29e32. Quantitative
assessment of knee radiographs has been found to be comparable
to MR imaging for detecting osteoarthritis progression and is
possibly superior when considering cost-effectiveness33. However,
fixed-location radiographic measures are incapable of determining
the spatial distribution of tibiofemoral cartilage loss34.
Furthermore, it should be noted that joint space narrowing on knee
radiographs can be due to factors other than cartilage loss35,36 and
that radiographs have poor sensitivity for detecting early cartilage
degeneration37 and progressive cartilage loss over time38. There-
fore, long follow-up periods are needed to document the onset and
progression of joint degeneration in patients with knee injury using
radiography. Despite its limitations, radiography was the first im-
aging method to document the high incidence of osteoarthritis in
patients with ACL injury and meniscus tears (Fig. 1)3e7.
CT arthrography
CT arthrography with intra-articular contrast has been used to
evaluate patients following acute knee trauma and has been shown
to have high sensitivity for detecting various features of joint
degeneration including meniscus and ligament tears, cartilage loss,
subchondral cysts and sclerosis, and osteophytes39e42. The tech-
nique can also be used to assess the thickness43,44 and proteoglycan
concentration45,46 of articular cartilage which may provide quan-
titative measures for longitudinal joint assessment. However, CT
arthrography is an invasive procedure and involves radiation
expose which limits its use in longitudinal studies. CT arthrography
can be useful for detecting fractures following acute knee trauma
and as an alternative imaging modality for longitudinal joint
assessment in patients with contraindications to MR imaging.
Morphological MR imaging
Due to its ability to detect early morphologic degeneration in
joint structures, MR imaging is a powerful tool for longitudinal
assessment of patients following acute knee trauma47,48. MR imaging
is sensitive for detecting early cartilage degeneration when using
high field strength scanners and advanced imaging protocols49 and
can evaluate other joint structures including the menisci, bone
marrow, tendons, and ligaments which can be sources of pain
following acute injury50. Several semi-quantitative MR-based
scoring systems are currently available for longitudinal evaluation of
knee osteoarthritis in research studies51e53. However, these in-
struments are only partially applicable in patients with ACL injury as
they do not include a detailed description of the baseline injury
patterns which may influence clinical outcome. Furthermore, sub-
chondral bone marrow changes due to trauma need to be differen-
tiated from degenerative bone marrow lesions, which are not
covered by commonly used osteoarthritis scoring tools, and ligament
graft signs of inflammation and laxity need to be considered54e56.
An MR-based instrument incorporating acute traumatic and
subsequent degenerative alterations was recently introduced, the
Anterior Cruciate Ligament OsteoArthritis Score (ACLOAS)57.
ACLOAS evaluates baseline structural joint damage such as osseous
injuries and meniscus tears and also assesses features of osteoar-
thritis including degenerative bone marrow lesions, osteophytes,
and cartilage loss (Fig. 2). In addition, signs of inflammation and
laxity of the ligament graft are evaluated. ACLOAS was developed
and tested using data from the Knee Anterior cruciate ligament
NON-operative versus operative treatment (KANON) trial KANON
trial58,59, and its applicability was shown for cross-sectional and
longitudinal scoring with good to excellent reliability for most
features57. However, its validity in regard to clinical outcomes
needs to be further investigated in longitudinal follow-up studies.
MR imaging morphometry
Morphometry is a quantitative MR analysis method used to
derive three-dimensional measures of tissues and can be applied to
cartilage, meniscus, bone, or muscle. Typically, measures of
 R. Kijowski et al. / Osteoarthritis and Cartilage 22 (2014) 1429e1443 1431

Fig. 1. 26-year-old male who sustained an acute rotational knee injury. (A) Sagittal fat-suppressed T2-weighted fast spin-echo image showing a complete ACL tear (small solid white
arrow), a large knee joint effusion (large solid white arrow), and a displaced meniscus fragment within the intercondylar notch (black outlined arrow). (B) Corresponding coronal
fat-suppressed T2-weighted fast spin-echo image showing extensive traumatic bone marrow lesions on the posterior medial and lateral tibial plateau (small solid white arrows) and
a posterior horn lateral meniscus tear (large solid white arrow) with a displaced meniscus fragment within the intercondylar notch (black outlined arrow). (C) Baseline flexion
anterioreposterior radiograph performed following ACL reconstruction and partial lateral meniscectomy showing normal lateral joint space width (small arrow). Note the sub-
optimal almost vertical orientation of the femoral tunnel (large arrow). (D) Follow-up flexion anterioreposterior radiograph performed 5 years after surgery shows narrowing of the
lateral joint space (arrow) indicating the onset of osteoarthritis.

thickness, volume, and surface area are derived by segmentation of methods since they are not observer dependent, and very small
serial MR images, either manually or automatically, to identify changes in metric variations can be detected. The major limitations
changes that are not visually apparent. Consequently, morphom- of the method is that it is time consuming, requires specialized
etry measures are more objective than semi-quantitative scoring software, and has low sensitivity for detecting focal changes in

Fig. 2. 23-year-old male who sustained an acute rotational knee injury. (A) Coronal intermediate-weighted fast spin-echo image showing tear and extrusion of the body of the
lateral meniscus (arrow). (B) Follow-up coronal intermediate-weighted fast spin-echo image performed 5 years after injury showing incident osteophytes on the medial and lateral
femoral condyles (arrows) indicating the onset of early osteoarthritis.
1432 R. Kijowski et al. / Osteoarthritis and Cartilage 22 (2014) 1429e1443
larger joint structures60. Furthermore, the three-dimensional
gradient-echo sequences typically used for morphometry have
lower sensitivity for detecting superficial cartilage lesions when
compared to conventional fast spin-echo techniques49.
Morphometry has mainly been used in knees with established
osteoarthritis, and only a few studies are available on acutely
injured knees60,61. Nevertheless, with currently available high res-
olution MR techniques and sophisticated segmentation software,
morphometry measures of cartilage and bone can be acquired with
high repeatability and accuracy (Fig. 3)62e65.
Compositional MR imaging
Compositional MR techniques, including T2 mapping, T1-rho
mapping, and delayed gadolinium enhanced imaging (dGEMRIC),
are currently available for use in longitudinal studies and can
evaluate the articular cartilage of the knee joint with high repeat-
ability and in relatively short scan times66e68. These techniques can
detect changes in the composition and ultra-structure of cartilage
before cartilage loss occurs and can thereby document the onset of
joint degeneration in patients with acute knee trauma during the
earliest stages following injury.
T2 mapping measures the spinespin relaxation time of articular
cartilage which has been shown to have high sensitivity for
detecting early cartilage degeneration69e74. However, the T2
relaxation time of cartilage is a non-specific parameter which is
influenced by multiple factors including water and macromolecular
concentration75e78, organization of the collagen fiber network79e81,
cartilage loading82e84, and orientation of cartilage relative to the
main magnetic field85. Despite the large number of potentially
competing biological and mechanical factors that influence the
measurement, T2 relaxation time has been found to be useful for
detecting changes in cartilage composition and ultra-structure in
longitudinal studies involving patients with osteoarthritis69e73 and
acute cartilage injury86.
dGEMRIC measures the spin-lattice relaxation time of articular
cartilage in the presence of gadolinium contrast. The distribution of
Fig. 3. Bone surfaces generated by active appearance model search of images from a
single individual at six time points after acute ACL injury. Bone from later time points
(increasingly dark green color) lie outside the baseline image indicating where bone is
added over time. The area of added bone is primarily seen in the outer halves of the
articular surfaces. Note that this method cannot visualize where bone shrinks below
the baseline articular surface.
negatively charged gadolinium within cartilage is thought to be
indirectly proportional to the concentration of negatively charged
proteoglycan macromolecules. dGEMRIC measurements have been
shown to correlate strongly with the proteoglycan concen-
tration87e93 and compressive stiffness94e96 of cartilage. While
dGEMRIC may provide a sensitive and specific measure of the
proteoglycan content of cartilage, the technique requires a long
waiting period between contrast administration and MR imaging
which is inconvenient for patients and carries the risk of allergic
reactions and nephrogenic systemic sclerosis due to use of gado-
linium contrast97,98.
T1-rho mapping measures the spin-lattice in the rotating frame
relaxation time of articular cartilage which has been shown to have
high sensitivity for detecting early cartilage degeneration99e101. T1-
rho relaxation time is influenced by proton exchange between
water and proteoglycan macromolecules within cartilage102 and
has been shown to correlate strongly with the fixed charge den-
sity103 and proteoglycan concentration104e107 of cartilage. Howev-
er, T1-rho relaxation time is not a specific measure of the
proteoglycan content of cartilage and is also influenced by other
biological changes that occur with cartilage degeneration108,109,
cartilage loading110, and orientation of cartilage relative to the main
magnetic field74. Despite its lack of specificity for any one particular
component of articular cartilage, T1-rho relaxation time has been
found to be useful for detecting changes in cartilage composition
and ultra-structure in longitudinal studies involving patients with
osteoarthritis99,100 and acute cartilage injury86,111.
Longitudinal changes in joint structures following acute knee
trauma
Bone and bone marrow
Osseous injuries in patients with ACL tear are typically caused by
the pivot shift mechanism where a strong valgus load is applied to
the knee with the tibia in external rotation or the femur in internal
rotation. Disruption of the ACL leads to anterior translation of the
tibia with impaction of the anterior lateral femoral condyle against
the posterior lateral tibial plateau16,17,19e22. Osseous injuries to the
posterior medial tibial plateau may occur due to contre-coup forces
on the medial compartment during resolution of the valgus load112.
Traumatic bone marrow lesions, which represent trabecular micro-
fracture21 and correspond to areas of elevated water and unsatu-
rated lipid content and decreased saturated lipid content113, were
reported in 68e98% of patients with ACL injury16e19,23,24. Cortical
fractures were also reported in 60e72% of patients with ACL injury
and most frequently involved the articular cortex of the anterior
lateral femoral condyle and the non-articular cortex of the posterior
lateral tibial plateau (Fig. 4)23,24. Cortical fractures in patients with
ACL tear were associated with larger volumes of bone marrow
edema23,24 and higher likelihood of meniscus tears24 in the same
compartment indicating more severe compressive forces applied to
the articular surfaces. Traumatic bone marrow lesions were found
to resolve with a median time interval ranging between 4 months
and 8 months after acute knee trauma (Fig. 5)20,114e119. However,
cartilage loss adjacent to bone marrow lesions was reported several
years after knee injury (Fig. 6)120,121.
Bone morphometry
Bone is known to change in knees with osteoarthritis and is
integrated into the disease process122. Recently, new methods of
identifying bone shape changes were shown to discriminate be-
tween osteoarthritis knees and healthy control knees123 and more
importantly to predict the onset of osteoarthritis124. When such a
 R. Kijowski et al. / Osteoarthritis and Cartilage 22 (2014) 1429e1443 1433

Fig. 4. 19-year-old female who sustained an acute rotational knee injury. (A) Lateral radiograph showing depression of the anterior weight-bearing surface of the lateral femoral
condyle (small arrow) with an associated knee joint effusion (large arrow). (B) Corresponding sagittal fat-suppressed T2-weighted fast spin-echo image showing a cortical
depression fracture involving the anterior weight-bearing surface of the lateral femoral condyle (small arrow) with an adjacent traumatic bone marrow lesion (large arrow).

method was applied to evaluate patients following ACL injury, rapid
changes in the shape of all the bones of the injured knee were re-
ported over the first 2 years125. The largest change was observed in
the medial femur with an almost 3% increase in bone area over the
first 2 years with the shape changes continuing over the subse-
quent 3 years although at a slower rate. The observed changes in
bone shape possibly represent early measures of osteophyte for-
mation125. Similar changes in bone shape were reported using
another method in the same cohort of patients with ACL injury
where increased body mass index, meniscal injury, and surgical
reconstruction of the ACL were associated with increased flattening
(i.e., less convexity) of the femur and increased depression (i.e.,
greater concavity) of the tibia126. Although these findings are
interesting, the clinical relevance of bone shape changes as well as
their relationship to treatment of the ACL injury needs to be further
explored.
Cartilage morphometry
Only a few reports exist on longitudinal changes in cartilage
thickness and volume after acute knee trauma. In a sub-sample of
the patient cohort from the KANON trial, a randomized controlled
study on surgical vs non-surgical treatment strategy after acute ACL
injury58,59, a reduction in volume, thickness, and surface area was
reported over the first year after injury for most cartilage sub-
regions except for the central medial femur where an increase
was found117. The increased cartilage thickness in the central
medial femur remained constant the second year after injury, and
the 4.3% decrease in cartilage thickness noted in the femoral
trochlea 2 years after injury was twice as high as the rate of carti-
lage loss in established osteoarthritis. An ACL reconstruction was a
direct and significant risk factor for greater changes in cartilage
morphometry variables within the femoral trochlea and central
medial femur over a 1-year, but not 2-year, follow-up period117,118.
A slightly different methodology was applied to the entire patient
cohort of the KANON trial over a 5-year period after injury where
similar cartilage thickness increases were reported within the
medial compartment. No significant differences were found be-
tween knees treated with early or delayed ACL reconstruction or
with rehabilitation alone127. In another cohort of patients with ACL
injury, a significant increase in cartilage thickness was noted in all
cartilage sub-regions over a 2-year follow-up period111. However, a
cross-sectional study from a different patient cohort using the
healthy contralateral knee as a reference to the ACL injured knee

Fig. 5. 23-year-old male who sustained an acute rotational knee injury. (A) Coronal fat-suppressed intermediate-weighted fast spin-echo image showing large traumatic bone
marrow lesions on the posterior medial and lateral tibial plateau (arrows). (B) Follow-up coronal fat-suppressed intermediate-weighted fast spin-echo image performed 1 year after
injury showing complete resolution of the bone marrow lesions (arrows).
1434 R. Kijowski et al. / Osteoarthritis and Cartilage 22 (2014) 1429e1443

Fig. 6. 23-year-old male who sustained an acute rotational knee injury. (A) Coronal fat-suppressed T2-weighted fast spin-echo image showing large traumatic bone marrow lesions
on the lateral femoral condyle and lateral tibial plateau (arrows). (B) Follow-up coronal fat-suppressed T2-weighted fast spin-echo image performed 5 years after injury showing
complete resolution of the post-traumatic bone marrow lesions (small solid white arrows). However, there is now a focal full-thickness cartilage defect on the central medial
femoral condyle (black outlined arrow) with an adjacent degenerative bone marrow lesion (large solid white arrow).

failed to identify differences in cartilage thickness within any
cartilage sub-region 7 years following ACL reconstruction128. The
pathogenesis and long-term significance of the increase in cartilage
thickness noted within certain sub-regions of the knee joint
following ACL injury in multiple studies remain unknown. How-
ever, animal models of osteoarthritis have suggested that cartilage
hypertrophy precedes cartilage breakdown, and thus the increase
in cartilage thickness may represent the earliest stages of cartilage
degeneration129,130.
Meniscus
When compressive forces are applied to the knee during acute
trauma, the healthy meniscus is prone to split in the vertical and
longitudinal direction as there are much fewer radially oriented
than circumferentially oriented collagen fibers maintaining the
strength of the meniscus131. MR imaging of the acutely injured knee
is a useful method for detecting meniscus tears as it has high
sensitivity and specificity132 and an accurate clinical diagnosis is
often challenging133,134. However, caution is warranted as inci-
dental meniscus pathology is highly prevalent in the normal pop-
ulation, especially in middle aged and elderly individuals135. Hence,
meniscal tears identified on MR imaging may be clinically irrele-
vant and not necessarily related to the acute knee trauma nor
indicative of treatment.
The primary function of the meniscus is to distribute load which
reduces stress on the articular surface during joint movement136.
Loss of the normal meniscal architecture due to injury or partial
resection was shown to significantly increase the force transmitted
across the knee joint which may potentially lead to chronic over-
load of articular cartilage and other joint structures136e138. This
hypothesis is supported by studies using quantitative MR imaging
which found early changes in cartilage composition and ultra-
structure in patients with untreated meniscus tears139 and partial
menisectomy140. In addition, studies using radiography reported a
high incidence of osteoarthritis in patients with meniscus tears
treated with both conservative therapy6,141 and partial surgical
resection7,142e149. Meniscus tears were also found to be an inde-
pendent risk factor for the presence and enlargement of bone
marrow lesions150. These results suggest that disruption of the
normal meniscal architecture places increased stress on sub-
chondral bone as well as articular cartilage which may further
accelerate the onset of joint degeneration.
Cartilage compositional MR imaging
Compositional MR imaging has been used for longitudinal
assessment of cartilage composition and ultra-structure in two
cohorts of patients with ACL injury. In one patient cohort, elevated
T2 and T1-rho relaxation time was found within the posterior
lateral tibial plateau in areas of acute cartilage injury during the
early phase after trauma151,152, which persisted at both 1-year86,152
and 2-year111 follow-up despite resolution of adjacent bone
marrow lesions. Increased T2 and T1-rho relaxation time within the
central medial femoral condyle and increased T1-rho relaxation
time within the central medial tibial plateau were also noted 2
years after ACL injury (Fig. 7)111. In the other patient cohort with
ACL injury, decreased dGEMRIC index indicating lower proteogly-
can concentration was present within the medial and lateral
femoral condyle in the early phase after trauma153. At 2-year
follow-up, the dGEMRIC index normalized within the lateral
compartment but remained low in the medial compartment indi-
cating persistent decreased proteoglycan concentration within
cartilage154. Meniscus tears in patients with ACL injury were
associated with increased T2 and T1-rho relaxation time within the
medial compartment86 and decreased dGEMRIC index within the
medial and lateral compartments154. Cross-sectional studies also
found increased T2 relaxation time within the tibial plateau in
patients with isolated meniscus tears139 and decreased dGEMRIC
index within the medial compartment following partial menis-
cectomy in patients without ACL injury140. These studies further
emphasize the strong relationship between meniscal injuries and
the onset of early cartilage degeneration within the knee joint.
Association between imaging findings and clinical outcome
following acute knee trauma
There is high agreement between studies that traumatic bone
marrow lesions resolve over time and have little influence on
clinical outcome after ACL injury18,24,155,156. However, one study in
patients with ACL injury reported an association between cortical
fractures and lower clinical outcome scores at 1-year follow-up
(Fig. 8)24. There is less agreement in the literature regarding the
influence of meniscus tears and cartilage lesions on clinical
outcome after ACL injury. Some retrospective studies reported
lower clinical outcome scores in patients with ACL injury and
concomitant meniscus tears and cartilage lesions157e159. A multi-
 R. Kijowski et al. / Osteoarthritis and Cartilage 22 (2014) 1429e1443 1435

Fig. 7. 23-year-old male who was evaluated 3 years after ACL reconstruction. (A) Sagittal fat-suppressed spoiled gradient-echo image showing normal cartilage morphology on the
medial tibial plateau (arrow). (B) Corresponding T2 map showing increased T2 relaxation time on the posterior medal tibial plateau (arrow illustrating loss of normal low T2
relaxation time, scaled in red, in the deep cartilage layer) indicating early cartilage degeneration. (C) Corresponding T1-rho map showing increased T1-rho relaxation time on the
posterior medal tibial plateau (arrow illustrating loss of normal low T1-rho relaxation time, scaled in red, in the deep cartilage layer) indicating early cartilage degeneration.

center prospective study using the Swedish National ACL Register
with almost 18,000 patients also found that individuals with ACL
injury and concomitant meniscus tears and cartilage lesions had
lower clinical outcome scores at 1-year follow-up. However, only
the sports and recreation portion of the clinical outcome score in
these patients was lower at 5-year follow-up indicating no long-
term effects of meniscus tears and cartilage lesions on clinical
symptoms160.
However, the majority of publications to date had low retention
rates and were confounded by indication bias in which the choice of
treatment of patients with ACL injury was potentially influenced by
patient prognosis. A recent 12-year follow-up study in patients
with ACL injury with 82% retention rate showed no differences in
clinical outcome scores in individuals with and without cartilage
lesions identified on both baseline and follow-up MR imaging18.
However, the MR examinations in this study were performed on a

Fig. 8. 22-year-old male who sustained an acute rotational knee injury. (A) Sagittal fat-suppressed T2-weighted fast spin-echo image showing a cortical depression fracture
involving the articular surface of the lateral tibial plateau (small arrow) with an adjacent large traumatic bone marrow lesion (large arrow). (B) Follow-up sagittal fat-suppressed T2-
weighted fast spin-echo image performed 5 years after injury showing healing of the fracture (small solid white arrow) with complete resolution of the bone marrow lesion (large
solid white arrows). However, there is now a focal partial-thickness cartilage defect on the posterior lateral tibial plateau (black outlined arrow) in the area of acute cartilage injury.
1436 R. Kijowski et al. / Osteoarthritis and Cartilage 22 (2014) 1429e1443
low field strength scanner without the use of state-of-the-art pulse
sequences which may have limited the identification of early
cartilage degeneration. In a recently published prospective study
involving 1512 patients with ACL injury and 88% retention rate, the
presence of cartilage lesions and meniscus tears identified at the
time of ACL reconstruction were significant predictors of decreased
clinical outcome scores at 6-year follow-up161. Additional well
designed longitudinal studies are needed to determine whether a
combination of structural injuries sustained during acute knee
trauma has an adverse effect on clinical outcome.
Association between imaging findings and wet biomarkers
following acute knee trauma
The local inflammatory response to acute knee trauma is
influenced by multiple factors including the extent of tissue dam-
age, the amount of bleeding, and the age of the patient162e165.
While the inflammatory response could persist over time and be
involved in the development of post-traumatic osteo-
arthritis162e165, the relationship between pro-inflammatory and
pro-catabolic biomarkers and imaging findings in patients with
acute knee injury is not well understood. The severity of surgically
detected post-traumatic cartilage damage was found to positively
correlate with synovial fluid concentrations of InterLeukin 1 Beta
(IL1-b), Tumor Necrosis Factor Alpha (TNF-a), C2C, and osteopontin
and negatively correlate with concentrations of InterLeukin 1 Re-
ceptor Agonist (IL-1ra) and keratan sulfate166e168. However, similar
studies using imaging methods to assess for acute cartilage injury
have not been performed. In the acute phase after knee injury, a
strong correlation was found between synovial fluid glycosami-
noglycan concentration and the dGEMRIC index of cartilage153.
Higher concentrations of pro-inflammatory biomarkers within sy-
novial fluid were also found in patients with acute ACL injury who
had associated cortical fractures identified on MR imaging169. At
longer follow-up periods in patients with ACL tear, more severe
cartilage damage on MR imaging was associated with increased
serum biomarkers of bone and cartilage turnover 20 years after
injury170 and with increased serum concentrations of the small
nucleolar RNA U38 1 year after injury171. Higher collagen cleavage-
to-synthesis ratio was also noted in patients with abnormal joint
space width on knee radiographs 4 years after ACL injury172.
Additional longitudinal studies in patients with acute knee trauma
investigating both imaging findings and pro-inflammatory and pro-
catabolic biomarkers are needed to better understand the patho-
genesis of post-traumatic osteoarthritis.
Fig. 9. 29-year-old male who was evaluated 2 years after ACL reconstruction and partial medial meniscectomy. (A) Sagittal fat-suppressed T2-weighted fast spin-echo image
showing normal cartilage morphology on the posterior medial femoral condyle (small arrow). Also note the deformed posterior horn of the medial meniscus (large arrow) from
prior partial resection. (B) Corresponding T1-rho map showing increased T1-rho relaxation time on the posterior lateral femoral condyle (arrow illustrating loss of normal low T1-
rho relaxation time, scaled in red and yellow, in the deep cartilage layer) indicating early cartilage degeneration.
Association between imaging findings and osteoarthritis
following acute knee trauma
ACL injury is a well-known risk factor for the onset of early
osteoarthritis of the knee joint173. Multiple studies have inves-
tigated the association between concomitant joint injuries
identified at surgery and the development of radiographic oste-
oarthritis in patients with ACL injury with almost all studies
reporting concomitant meniscus tears10,173e184 and two study
reporting concomitant cartilage lesions174,185 as risk factors for
the onset of joint degeneration. However, it remains unclear
whether the meniscus tears and cartilage lesions themselves,
their treatment, or a combination thereof were responsible for
the increased risk of osteoarthritis. In a systematic review of the
influence of meniscus status at the time of ACL reconstruction on
the development of radiographic osteoarthritis at a minimum of
5-year follow-up, the presence of a meniscus tear requiring
partial meniscectomy was found to significantly increase the risk
of osteoarthritis186. Multiple studies have also documented the
high incidence of radiographic osteoarthritis in patients with
meniscus tears and no associated ACL injury who were treated
with partial meniscectomy7,142e149 and conservative therapy6,141.
Only one previous study was identified which investigated the
association between imaging findings and the development of
radiographic osteoarthritis in patients following acute knee
trauma. In this study, 12 of 14 patients with radiographic joint
space narrowing 12 years after ACL injury had meniscus tears on
either baseline or follow-up MR imaging18.
Various studies using quantitative MR techniques have investi-
gated the association between imaging findings in patients with
ACL injury and the onset of early cartilage degeneration. Elevated
T2 and T1-rho relaxation time in cartilage overlying traumatic bone
marrow lesions was noted in patients with ACL injury and persisted
at 1-year follow-up152,187. The volume of bone marrow lesion was
found to be a strong predictor of the degree of cartilage T1-rho
relaxation time elevation152 and the progression of cartilage loss
over time120. Concomitant meniscus tears in patients with ACL
injury were associated with increased T2 and T1-rho relaxation
time86,152 and decreased dGEMRIC index154 within the same
compartment at 2-year follow-up (Fig. 9). Patients with ACL injury
and concomitant cartilage lesions were also found to have elevated
cartilage T1-rho relaxation time 1 year after ACL reconstruction188.
However, none of these studies followed patients with ACL injury
until the onset of radiographic osteoarthritis. Thus, the relationship
between early imaging findings and the onset of joint degeneration
 R. Kijowski et al. / Osteoarthritis and Cartilage 22 (2014) 1429e1443
must be further investigated by following patient cohorts over
longer time periods needed to document the presence of radio-
graphic osteoarthritis.
Conclusion
Studies using imaging technology have shown that joint trauma
results in structural injury to several tissues of the injured joint.
Although there are many imaging modalities under constant
development, MR imaging is the most important instrument for
longitudinal monitoring after joint injury. In this review, focusing
on imaging following acute knee trauma, several studies were
identified with promising short-term results of osseous and soft
tissue changes following joint injury. However, studies connecting
these promising short-term results to the development of osteo-
arthritis were limited which is likely due to the long follow-up
periods needed to document the radiographic and clinical onset
of the disease. Although a continuous development of new and
improved imaging methods is of great importance, the conclusion
of this review is that focus may need to shift towards establishing
firm relationships between early imaging based structural changes
after injury and the risks of developing radiographic and clinical
manifestations of osteoarthritis. Thus, it is recommended that
additional high quality longitudinal studies with extended follow-
up periods be performed to further investigate the long-term
consequences of the early osseous and soft tissue changes identi-
fied on MR imaging after acute knee trauma.
Contributions
A declaration of contributions for each of the authors is provided
below:
Richard Kijowski, M.D.
 Conception and design
 Analysis and interpretation of the data
 Drafting of the article
 Critical revision of the article for important intellectual content
 Final approval of the article
Frank Roemer, M.D., Ph.D.
 Analysis and interpretation of the data
 Drafting of the article
 Critical revision of the article for important intellectual content
 Final approval of the article
Martin Englund, M.D., Ph.D.
 Analysis and interpretation of the data
 Drafting of the article
 Critical revision of the article for important intellectual content
 Final approval of the article
Carl J. Tiderius, M.D., Ph.D.
 Analysis and interpretation of the data
 Drafting of the article
 Critical revision of the article for important intellectual content
 Final approval of the article
€rd, M.D.
Per Swa
 Analysis and interpretation of the data
 Drafting of the article
1437
 Critical revision of the article for important intellectual content
 Final approval of the article
Richard B. Frobell, P.T., Ph.D.
 Conception and design
 Analysis and interpretation of the data
 Drafting of the article
 Critical revision of the article for important intellectual content
 Final approval of the article
All authors take responsibility for the integrity of the work from
inception to finished article.
Role of funding source
There was no source of funding for this work.
Competing interests
None of the authors have any conflicts of interests to declare.
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