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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;
Bioscience Research - Innovative Scientific Information & Services ...
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                                         375
Yousif 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                                376
Yousif 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                                377
Yousif 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                                  378
Yousif 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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                             Bioscience Research, 2020 volume 18(1): 374-379                                   379
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