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Bioscience Research
Print ISSN: 1811-9506 Online ISSN: 2218-3973
Journal by Innovative Scientific Information & Services Network
RESEARCH ARTICLE BIOSCIENCE RESEARCH, 2021 18(1): 374-379. OPEN ACCESS
Performance and utility of ultrasound in evaluating
knee joint diseases
Elgeili Yousif1*, Qurain Turki Alshammari1, Bushra Abdelmalik1, Elfadil Elnour1,
Moawia Gameraddin2, Omer Loaz3 and Mohamed Salih1
1College of Medical Applied Sciences, Department of Diagnostic Radiology Sciences, Hail University, Hail, Kingdom
of Saudi Arabia
2Faculty of applied medical sciences, Department of diagnostic Radiologic technology, Taibah, Al-Madinah University,
Kingdom of Saudi Arabia
3 Faculty of applied medical sciences, Department of Radiological sciences, King Khalid University, Kingdom of Saudi
Arabia
*Correspondence: jrama6@hotmail.com Received 16-10-2020, Revised: 20-01-2021, Accepted: 07-03-2021 e-Published: 08-
03-2021
Several people all over the world recently suffer from knee joint diseases. The ultrasound plays an
effective role in characterizing knee joint disease since it is safe, rapid, cheap, and has dynamic
evaluation and real-time imaging. Aim of the study; to evaluate the performance of ultrasound (US)
examination in assessing various types of knee joint pathologies in Saudi Arabian. This is a descriptive
cross-sectional study including 224 patients with knee joint pain, attended to the Radiological Center,
College of Applied Medical Sciences, King Khalid University, Saudi Arabia, from October 2014 to June
2018 G, with knee joint symptoms. They were referred from different orthopedic clinics to do the US. One
hundred ninety-two were males (85.7%), and 32 were females (14.3%). The age range was 12 – 80
years. The knee joint ultrasound examination was performed with GE-USA Medical System Logic 3
Expert 2007, using linear probes with a high frequency of 7.5 to 12 MHz. The technique protocol meets
the standard by the American Institute of Ultrasound in Medicine (AIUM). Results: The most prevalent
sonographic findings of knee pathologies were joint effusion 139 (62), bursitis 18 (8%), meniscus tear 10
(4.5%), Baker’s cyst 8 (3.6%), synovial cyst 8 (3.6%), deep vein thrombosis (DVT) 6 (2.7%), loose bodies
4(1.8%), anterior cruciate ligament tear (ACL) 9 (4%), and arthritis 8 (3.6%). US proves the better
sensitivity (91.7%), specificity (60%), and accuracy (91.1%), PPV (99%), and NPV (14.13%) for the
diagnosis of knee joint pathologies. Ultrasound is effective to evaluate the knee joint diseases with
excellent sensitivity and adequate accuracy. It should have considered as a primary imaging modality for
Knee joint pathologies.
Keywords: Ultrasound, sensitivity, Knee joint disease, osteoarthritis.
INTRODUCTION contribute significantly to the burden of health.
Many people worldwide suffer from knee joint Pathologies of knee soft tissue represent one
diseases such as osteoarthritis (OA), which is of the more common musculoskeletal disorders
considered the most prevalent form worldwide. that cause knee pain and related symptoms. The
(Murphy, 2012; Helmick, 2012) The incidence of pain is related to damage to one or more of the
Knee joint disease (OA) among Saudi people was knee joint's soft tissue structures such as muscles,
13%, but this may reach 30-60 % in some regions. ligaments, tendons, and menisci (Crossley,2016;
Al-Arfaj, et al (2003) Therefore, Knee disorders Callaghan, 2016; Linschoten, 2016;
Yousif et al. Performance of ultrasound for evaluating knee joint pathologies
Patellofemora,2016; Sports2016 and Llopis,2007; and females was demonstrated in table 2 and
Padrón,2007; Radiol.2007) The US can provide figure 2. The joint effusion was the most frequent
accurate, useful information on a wide range of one; it counted 139 cases (62.1%), loose bodies 4
pathologies affecting the knee joint structures, (1.8%), synovial cyst 8 (3.6%), as anechoic lesion,
including the tendons, ligaments, synovial space, quadriceps tendon rupture 3 cases (1.3%). The
articular cartilage, muscles, and surrounding soft meniscus tear was found in 10 cases (4.5%),
tissues. Color and power Doppler methods can be tumors 2 (.09%), bursitis 18 (8%). The incidence of
applied to assess neovascularization within the knee arthritis was 8 cases (3.6%), Baker cyst 8
synovial lining of the joints, tendons, and ligaments (3.6%), and deep vein thrombosis (DVT) was 6
soft-tissue masses.( Razek,2009; Fouda,2009; cases (2.7%). The incidence of medial collateral
Elmetwaley,2009; Elbogdady,2009) ligament tears was 3 (1.3%), and lateral collateral
The US of the knee joint has the advantage ligament 2 (0.9%). The incidence of anterior
over magnetic resonance imaging (MRI) since it is cruciate ligament tear (ACL) was 4% (9 cases). We
cheaper, convenient, safe, fair spatial resolution, did not wholly visualize the posterior cruciate
and dynamic assessment. (Iagnocco, 2010; ligament tear (PCL); however, Doppler US showed
Rheumatol,2010) The study aims to assess the increased vascular flow. It was found in 4 cases
US's performance for evaluating knee (1.8%). It was observed that Baker cyst, arthritis,
abnormalities in patients who complained of pain at and DVT were more prevalent in females than
the region of the knee joints. males (6 vs. 2. 6 vs. 2, and 4 vs. 2), respectively.
The other lesions were more common in males
MATERIALS AND METHODS than females, as shown in table 2.
This study is a descriptive cross-sectional one Table 3 summarizes the performance of the
conducted at the Radiological Center, College of US for assessing knee joint pathologies. It has high
Applied Medical Sciences, King Khalid University, sensitivity (91.7%), specificity (60%), accuracy
Saudi Arabia, from October 2014 to June 2018G. (91.1%), PPV (99%), and NPV (14.3 %) for
A total of 224 patients with knee joint pathology characterizing the knee joint pathologies.
referred from different clinics to do the US. The 250
knee joint ultrasound examination was performed
with GE-USA Medical System Logic 3 Expert 2007, 200
using linear probes with a high frequency of 7.5 to 150
12MHz. The technique protocol meets the standard
by the American Institute of Ultrasound in Medicine 100
(AIUM). (Ian B et al (2012) 50
Statistical analysis 0
Data were collected in the tabulated database male female Total
sheet and analyzed using SPSS version 23 (IBM Frequency Percent
corporation, Armonk, SY, USA). Descriptive
statistics describe the qualitative data as frequency Figure 1: Gender frequency of the study
and mean with standard deviation (SD). The sample
statistical diagnostic test was applied to find the Table1: distribution of age groups of the
US's sensitivity, specificity, and accuracy in participants with the mean BMI.
diagnosing various knee joint lesions. Age groups Frequency Percent
12-20 9 4.0
RESULTS 21-29 58 25.9
A total of 224 patients with knee joint 30-38 37 16.5
pathologies referred from different clinics to do the 39-47 42 18.8
US. They were 192 males (85.7%), and 32 were 48-56 43 19.2
females (14.3%) (Figure 1); the age range was 12 57-65 21 9.4
to 80 years. The mean age was 40.52± 14.8 years, 66-74 14 6.3
and the mean body mass index (BMI) was Mean age =
27.42±3.42 (table 1). Most of the patients were 40.52± 14.8 years
frequent in 21-29 years, then 48-56 years and 39- Mean BMI =
46 years (table 1). The distribution of sonographic 27.42±3.42
Total 224 100.0
findings of the knee joint pathologies among males
Bioscience Research, 2020 volume 18(1): 374-379 375Yousif et al. Performance of ultrasound for evaluating knee joint pathologies
Table 2: Distribution of ultrasound findings of knee joint pathologies according to gender
Pathology finding frequency percent Males females
Effusion 139 62.1 128 11
Bursitis 18 8.0 12 6
Meniscus tear 10 4.5 10 0
Loose body 4 1.8 3 1
Baker cyst 8 3.6 2 6
Synovial cyst 8 3.6 6 2
Quadriceps Tendon
3 1.3 3 0
Rupture
Arthritis 8 3.6 2 6
DVT 6 2.7 2 4
Tumor 2 0.9 2 0
ACL tear 9 4.0 9 0
PCL tear 4 1.8 4 0
Medial Collateral
3 1.3 3 0
Ligament Tear
Lateral Collateral
2 0.9 2 0
Ligament Tear
Total 224 100.0 192 32
frequency
160
140
120
100
80
60
40
20 frequency
0
Medial…
Quadriceps…
Lateral…
Bursitis
Tumor
Baker cyst
Arthritis
ACL tear*
Effusion
DVT***
Synovial cyst
PCL tear**
Meniscus tear
Loose body
Figure 2: Distribution of sonographic findings of knee joint diseases
Table 3: performance of US in the diagnosis of knee joint pathologies
Absence or presence of Knee Values
pathologies
True positive (TP) 201
True negative (TN) 3
False-positive (FP) 2
False-negative (FN) 18
Performance of US in the diagnosis of knee joint pathologies
Sensitivity 91.7%
Specificity 60%
Accuracy 91.1%
Positive predictive value (PPV) 99 %
Negative predictive value (NPV) 14.3%
Bioscience Research, 2020 volume 18(1): 374-379 376Yousif et al. Performance of ultrasound for evaluating knee joint pathologies
Image 1: a sonogram shows a transverse section of a knee joint that shows Baker's cyst in a 35-
year old male.
Image 2: A sonogram of a 33-year old male presents with severe knee joint pain shows meniscus
tears
Image 3: A sonogram of the knee joint shows a soft tissue mass continuing with the suprapatellar
recess in a 40-years old male.
that affect the knee joint. The study has reviewed
DISCUSSION the sonographic findings and appearances of the
Ultrasound is a safe imaging modality for knee joints.
assessing the knee joint abnormalities, and it In this study, as a total of 224 patients with
provides useful information for several pathologies knee joint complaints who had been examined with
Bioscience Research, 2020 volume 18(1): 374-379 377Yousif et al. Performance of ultrasound for evaluating knee joint pathologies
the US. The prevalence of knee joint pathologies pathologies. Similar to our findings, (Catay E et al
was more frequent in males than females; 192 (2012) reported high sensitivity of the US for knee
males (85.7%) vs. 32 females (14.3%). In general, effusion (89.8) and osteophytes (85.8 %). Another
the incidence is different among males and study reported that the US has a sensitivity of 86.67
females. In previous studies, arthritis is more % and 100% specificity for detecting bursitis (18).
frequent in females than females, while DVD was Furthermore, Brom et al.(2020) reported a 95%
most common in males. (Hunter, 2019; Bierma, sensitivity for assessing OA by the US.
2019 and Bauersachs et al (2010)). On the other
hand, the study found that PCL and ACL tears were Limitations
more prevalent in males than females. This finding The study had faced some problems as the US
is consistent with previous studies that reported a offers little information for demonstrating internal
significant difference between females and males. structures such as the cruciate ligaments.
(Owesen et al (2017) and Silvers, 2007; Secondly, the sample size is not large enough to
Mandelbaum, 2007)In contrast, some studies accurately estimate the prevalence of knee joint
reported that the ACL was more common in pathologies' sonographic findings.
females than males.( Huston,2000;
Greenfield,2000 and Kirkendall,2000 Garrett, 2000 CONCLUSION
and lee et al (1999) and Arendt, 1995; Dick1995 Effusion, bursitis, meniscus tears are the most
and Gwinn,2000; Wilckens,2000; McDevitt,2000; common sonographic findings of knee pathologies.
Ross, 2000; Kao, 2000) The etiology of this Baker cyst, arthritis, and DVT were more prevalent
discrepancy was not thoroughly explained in the in females than males. The US has high sensitivity,
literature. The increased incidence of ACL and PCL specificity, and accuracy for evaluating the knee
tear in males is attributed to males' participation in joint diseases. It should have been considered a
sport more than females. primary imaging modality, and we recommend
The present study found that knee effusion being used as complementary to MRI for Knee joint
was the most common finding (64.5%). This result pathologies.
was similar to Eid et al (2012) who reported that
the effusion existed in most of the patients CONFLICT OF INTEREST
complaining of knee joint pain. It was observed that The authors declared that present study was
bursitis was the second finding in patients performed in absence of any conflict of interest.
complains of knee pain. In agreement with this
result,(Draghi,2015; Corti,2015; Urciuoli,2015; ACKNOWLEGEMENT
Alessandrino,20015; Rotondo,2015) reported that We would like to thank the clinical staff and
bursitis was found in 15 out of 143 patients. They Radiologists at the radiology department of King
reported that the US has high sensitivity to evaluate Khalid University, College of Applied Medical
bursitis. On the other hand, the incidence of Sciences, Department of Radiological Sciences,
meniscus tear, arthritis, and baker cyst comes after Abha Kingdom of Saudi Arabia for their generous
knee effusion and bursitis. Regarding these help.
lesions, Bevers et al. reported that the US was
useful imaging for protrusion of the medial AUTHOR CONTRIBUTIONS
meniscus and excellent for Bakers' cyst.( Bevers K Qurain Turki Alshammari contributed to the
et al (2012) They concluded that the US has good study design and literature search. Mohammed
reproducibility in assessing various mechanical, Salih: definition of intellectual content, Bushra
inflammatory, and degenerative features of knee Abdel Malik: edited and reviewed the manuscript.
osteoarthritis (OA), and they advised the use of US Moawia Gameraddin: performed the statistical
in knee OA as a useful modality in research and analysis. Omer Loaz prepared the manuscript,
clinical practice. Elfadil Elnour: manuscript preparation and data
The present study showed that the US has acquisition. Elgeili Yousif: data acquisition.
high sensitivity (91.7%), specificity (60%), and
overall accuracy of 91.2% for evaluating various Copyrights: © 2021@ author (s).
knee pathologies. The study evaluated the US's This is an open access article distributed under the
overall performance, whereas other studies terms of the Creative Commons Attribution License
assessed the sensitivity for each finding of the knee (CC BY 4.0), which permits unrestricted use,
joint. The reported high sensitivity in result reflected distribution, and reproduction in any medium,
good reproducibility of the US in detecting knee
Bioscience Research, 2020 volume 18(1): 374-379 378Yousif et al. Performance of ultrasound for evaluating knee joint pathologies
provided the original author(s) and source are credited Eid AS, Burrows V, Murray JRM, Smitham P,
and that the original publication in this journal is cited, Ahmad R, Miller R, Butt U. Are we managing
in accordance with accepted academic practice. No acute knee effusion well? BJMP 2012;5(1):
use, distribution or reproduction is permitted which a504
does not comply with these terms. Gwinn DE, Wilckens JH, McDevitt ER, Ross G,
Kao TC. The relative incidence of anterior
cruciate ligament injury in men and women at
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