Imaging technologist training the osteoarthritic knee 2014

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Carolyn Bonaceto, BSRT(R)(MR) Sr. Manager, Imaging and CAD Manufacturing CONFORMIS, Inc. 28 Crosby Drive | Bedford, MA | 01730 Imaging Support - 781.345.9170 (O) 781.345.9111 | (F) 781.345.0147 Connect @: www.Conformis.com Twitter: @ConforMIS Facebook: ConforMIS Page YouTube: PatientSpecific channel THE OSTEOARTHRITIC KNEE COMPANY CONFIDENTIAL © COPYRIGHT 2014 ConforMIS, Inc. 1

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Imaging technologist training the osteoarthritic knee 2014

Transcript of Imaging technologist training the osteoarthritic knee 2014

Page 1: Imaging technologist training the osteoarthritic knee 2014

Carolyn Bonaceto, BSRT(R)(MR)Sr. Manager, Imaging and CAD ManufacturingCONFORMIS, Inc. 28 Crosby Drive  |  Bedford, MA  |  01730Imaging Support - 781.345.9170(O) 781.345.9111  |  (F) 781.345.0147 Connect @:www.Conformis.comTwitter:       @ConforMISFacebook:  ConforMIS PageYouTube:    PatientSpecific channel

THE OSTEOARTHRITIC KNEE

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• This self-learning activity was approved for .50 Category A ARRT CE credits by the SMRT

• Directed readings, home study courses, or internet activities reported in a biennium may not be repeated for credit in the same or any subsequent biennium

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KNEE ANATOMY Osseous Structures and Articulations Internal and External Joint Support

KNEE PATHOLOGY Osteoarthritis Cartilage Injuries

IMAGING CR CT CT Arthroscopy MRI

SURGICAL TREATMENTS Arthroscopy Hemi-Arthroplasty Total Knee Repair

POST SURGICAL FIT ASSESMENT

Outline

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Osseous StructuresFemur-

Longest, largest, strongest skeletal bone Cylindrical shaft made up of cortical

bone and fat filled medullary Condyles defined by trochlea anteriorly

and intercondylar notch posteriorly

• Image from:http://en.wikipedia.org/wiki/Femur

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Knee Anatomy

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Osseous StructuresPatella-

Flat triangular sesamoid bone marking the anterior most portion of the knee joint

Thick superior border (base) and pointed inferior border (apex)

Cancellous bone enveloped by the quadriceps tendon

Image from: http://www.fpnotebook.com/_media/orthoLegPatellaAntGrayBB255.gif

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Knee Anatomy

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Osseous Structures Tibia-

Large superior portion, head, divided into two distinct portions, the medial and lateral condyles, separated by the tibial spine

Flat superior surface is called the plateau Articulates with the femoral condyles Tibial tuberosity found on the anterior

portion serves as an articulation point for the patellar ligament

Fibula- Most slender of the long bones Articulates anteriorly and laterally with the

lateral tibial condyle

Images from:http://en.wikipedia.org/wiki/Tibiahttp://en.wikipedia.org/wiki/Knee

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Knee Anatomy

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Medial femoral condyle

Femoral shaft, distal end

Lateral femoral condyle

Patella

Medial tibial plateau

Head of fibula

Lateral tibial plateau

Knee Anatomy

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Femoral shaft, distal end

Patella

Tibial plateau

Head of fibulaTibial Tuberosity

Femoral condyles

Knee Anatomy

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Cartilage Dense connective tissue

Made up of chondrocytes which produce the extracellular matrix of water, collagen, and proteoglycan Collagen is mostly type II, provides strength and structure No blood supply, nourishment is supplied by synovial fluid

Thickness Normally between 2 and 5mm’s

Thickness can be correlated with highest peak pressure areas. The thickest cartilage in the body is found in the patellofemoral joint

Four distinct zones Superficial zone- highest collagen content which is aligned parallel to the articular

surface, lowest concentration of proteoglycan, 10% to 20% of the overall thickness

Transitional zone- 40% to 60% of the overall thickness, collagen organization is random, composed almost exclusively of proteoglycans

Radial zone- distributes load and resists compression with parallel oriented highly organized collagen fibers, and lowest water content

Calcified cartilage zone- contains the tidemark which signals the transition between calcified and uncalcified cartilage

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Knee Anatomy

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Articular Cartilage

Knee Anatomy

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Joint Support External Support

Fibrous Capsule Encloses the joint, consists of

synovial membrane, thin connective tissue which secretes synovial fluid. This thick, high viscosity fluid helps lubricate the knee and reduce friction.

Extracapsular Ligaments Anterior - Patella ligament Lateral – Lateral collateral

ligament Medial – Medial collateral

ligament Posterior- Oblique popliteal

ligament and arcuate ligament

Image from:http://papruddenmor.blogspot.com/2011_05_01_archive.html

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Knee Anatomy

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Joint Support Internal Support

Anterior cruciate ligament (ACL) – provides rotation for the joint and prevents displacement anteriorly

Posterior cruciate ligament (PCL)- prevents posterior draw

Image from:http://www.ehealthmd.com/yms_images/anterior_cruciate_375.jpg

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Knee Anatomy

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Menisci (from Greek meniskos, “crescent”) Medial and Lateral Fibrocartilaginous concave semicircles Articulates with the tibial plateaus Provides gliding surface for knee movement and absorbs tension

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Knee Anatomy

Image from:http://morphopedics.wikidot.com/meniscal-tear

© COPYRIGHT 2014 ConforMIS, Inc.

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Muscular SupportExtensors

Quadriceps femoris muscle group Rectus femorisVastus lateralis,Vastus medialusVastus intermedius

FlexorsHamstring muscle group

SemitendinosusSemimembranosusBiceps femoris

Assisting musclesGracilisSartoriusPopliteus COMPANY CONFIDENTIAL © COPYRIGHT 2014 ConforMIS, Inc. 14

Quadriceps tendon

Cortical bone

Cancellous bone

Vastus medialus

Semimembranosus Biceps femoris

Sartorius

Vastus lateralis

Knee Anatomy

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Anterior cruciate ligament

Medial femoral condyle

Anterior cruciate ligament

Lateral femoral condyle

Tibial plateau

Head of the fibula

Medial compartment

Lateral collateral ligament

Lateral compartment

Knee Anatomy

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Knee Anatomy

Posterior cruciate ligament

Patellofemoral compartment

Articular cartilage

Tibial spine

Patellar tendon

Quadriceps tendon

Lateral meniscus

Cartilage bone interface

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Knee anatomy and pathology is generally demonstrated using

Routine radiographs, CR/DRCT with or without arthrogram contrastMR with or without arthrogram contrast

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Diagnostic Imaging

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CR AP Lateral Tangential (sunrise) Full Leg – used for alignment

measurement

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Demonstrates Cartilage loss/Joint space

narrowing Osteophytes/bone spurs Subchondral cysts Sclerosis Bone marrow edema Traumatic injuries

Diagnostic Imaging

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AP - Position central ray at right angles to the joint space with no rotation. The resulting image should demonstrate the epicondyles in profile and the intercondylar eminence of the tibia centered within the intercondylar fossa of the femur

UnacceptableAcceptable

Diagnostic Imaging

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Lateral -Position central ray at right angles to the joint space with no rotation of the knee. The resulting image should demonstrate the posterior aspects of the femoral condyles superimposed.

Acceptable Unacceptable

Diagnostic Imaging

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CT Demonstrates

Joint space narrowing Subchondral cysts Sclerosis Osteophyte formations

Reconstructions Axial Sagittal Coronal images

CT Arthrogram The use of diluted contrast in joint

delineates articular cartilage and ligaments

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MRI Used to evaluate soft tissue

structures Grade articular cartilage

damage Evaluate ligaments integrity Evaluate meniscal tears

*Knee MR protocols vary from site to site and can be dependent on the system

used to acquire the images*

Diagnostic Imaging

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Pathology commonly associated with patients considering a knee implant Osteoarthritis (OA) – defined as chronic inflammation characterized by

degeneration of the joints causing pain, stiffness, and swelling. OA is sometimes referred to as degenerative joint disease (DJD). Radiographically OA can be identified by the presence of osteophytes, bone edema, sclerosis, joint space narrowing and cyst formations.

Osteochondritis Defects (or Dissecans) (OCD) is characterized by cracks that occur in the articular cartilage and the underlying subchondral bone as a result of decreased blood flow. Avascular necrosis (AVN) or bone death as a result of the loss of blood flow leaves the articular cartilage vulnerable. Fragmentation of cartilage and bone, and subsequently loose bodies occur within the joint space, causing pain and additional damage. Radiographically loose bodies (bone fragments) can be seen. MR images demonstrate and stage OCD lesions in the cartilage.

Knee Pathology

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Osteoarthritis (OA)Morbidity

Affects as many as 26.9 million AmericansOne of the most common causes of disability due to limitations in joint movement. By age 40 almost 90% of the American population will have some form of OA in their weight-bearing joints OA results in 632,000 joint replacements each year300,000 TKR surgeries annually in the US for end-stage arthritis of the knee joint.

Causes ObesityGeneticsTraumaMetabolic disorders

SymptomsPain SwellingLoss of mobility

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OsteoarthritisJoint space narrowing

AP Lateral

Osteophyte formation

Tangential View (aka sunrise or merchant view)

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Osteophyte

Weight bearing AP knees

Note- Because the image was acquired bilaterally neither knee is demonstrated in a true AP position since the central beam was focused between the knees.

OsteoarthritisJoint space narrowing

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Osteoarthritis

Image from:http://www.washingtonknee.com/knee-treatments/knee-osteoarthritis/

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Osteophyte

Grade 1- Superficial lesions, cracks, and indentations

Grade 2 - Fraying, lesions extending down to <50% of cartilage depth

Grade 3 - Partial loss of cartilage thickness, cartilage defects extending down to >50% of cartilage depth as well as down to calcified layer

Grade 4 - Complete loss of cartilage thickness, bone only

ICRS Hyaline Cartilage Lesion Classification System

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Grade 4 articular cartilage loss- exposed subchondral bone, complete loss of cartilage

Grade 3 articular cartilage loss - >50%

Grade 3 articular cartilage loss - > 50%

Grade 4 articular cartilage loss- exposed subchondral bone, complete loss of cartilage

Cartilage LossMR images

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Grade 3 articular cartilage loss - >50%

Grade 3 articular cartilage loss - > 50%

Grade 4 articular cartilage loss- exposed subchondral bone, complete loss of cartilage

Grade 4 articular cartilage loss- exposed subchondral bone, complete loss of cartilage

Cartilage LossCT Arthrogram images

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Grade 3 articular cartilage loss - > 50%

Subchondral CystMR images

Osteophyte formation

Osteophyte formation

Subchondral cyst

Subchondral cyst

Subchondral cyst

Subchondral cyst

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Grade 3 articular cartilage loss - > 50%

Subchondral CystCT Arthrogram images

Osteophyte formation

Osteophyte formation

Subchondral cystSubchondral cyst

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SclerosisCR Images

Sclerotic changes – increased bone density

Sclerotic changes – increased bone density

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Bone Marrow EdemaMRI Image

Bone marrow edema

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Osteochondritis Defect (OCD)

Injury to the cartilage and underlying bone

Results from interrupted blood flow to the area

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Osteochondritis Defect (OCD)

Stage Appearance on MRI & Stability of lesion Stage 1- Articular Cartilage Damage only Stage 2 - Cartilage injury with underlying fracture

a. Surrounding bony edema b. Without edema

Stage 3 - Detached but non-displaced fragment Stage 4 - Detached and displaced fragment

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OCD-MRI Image

Stage II OCDStage II OCD

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OCD-MRI Image

Stage II OCD

Stage II OCD

Stage III OCDStage IV OCD

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Surgical Treatments

Surgeons- Seek the least invasive method Encourage bone preservation

Less bleeding and post surgical pain Shorter recovery times Still have bone to work with for potential revisions; Prosthesis failure

rate requiring revision is ~1 percent per year

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Surgical Treatments

Arthroscopy – via a scope inserted through a small incision the surgeon views the joint capsule and can perform small repairs including removal of damaged cartilage and any loose bodies.

Hemi-Arthroplasty –

Uni-compartmental Arthroplasty – this procedure replaces only the damaged area of a single joint compartment with a prosthetic device.

Duo-compartmental Arthroplasty – this procedure replaces only the damaged area of the patella femoral joint and either the medial or the lateral compartment with a prosthetic device.

Osteotomy – a high tibial osteotomy involves removal of a wedge shaped piece of bone that results in realignment allowing the patients weight to be distributed away from the damage compartment.

Total Knee Arthroplasty – involves replacing all joint surfaces

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“The success of primary TKR in most patients is stronglysupported by more than 20 years of followup data. Thereappears to be rapid and substantial improvement in thepatient's pain, functional status, and overall health-relatedquality of life in about 90 percent of patients; about 85 percentof patients are satisfied with the results of surgery.”

-NIH Consensus Statement on Total Knee Replacement

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Surgical Treatments

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Surgical Treatments

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ConforMIS iUni® is a Uni-Compartmental Device

ConforMIS iTotal® is a Total Knee Device

ConforMIS iDuo® is a Bi-Compartmental Device

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ConforMIS CT Order Form

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ConforMIS CT Protocol Immobilize the patient and remind them of the importance of holding still for the exam.

The patients toes should be straight up.

Do not place a pillow or bolster under the affected knee so that alignment between the hip, knee and ankle is maintained.

If the patient has an implant in the opposite knee please bend that knee out of the way so that the artifact does not run through the joint space of the knee of interest.

Slice positioning is critical. Please review the guides for examples of proper positioning.

Always check all series to verify that your scan meets coverage requirements and that there are no motion artifacts.

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ConforMIS CT Protocol

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Series

1 Scout FULL LEG, Hip through Ankle

Kernel /Algorithm

AxialReconstruction

Thickness X Increment

Projection

2Hip – Femoral head

only(acetabulum only)

Bone2mm X 2mm

or2.5mm X 2.5mm

Axial

3

Knee – distal 1/3 of the femur through

proximal 1/3 of tibia (should include the

entire patella through the fibula

head)

Bone1mm X .5mm

or1.25mm

X .625mm Axial

4

Ankle – center at tibiotalar joint space scan 2cm above the joint to 2cm below

Bone2mm X 2mm

or2.5mm X 2.5mm

Axial

5Multi Planar

Reformat– knee only

Bone 1mm X 1mm Coronal

6Multi Planar

Reformat– knee only

Bone 1mm X 1mm Sagittal

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Post Surgical Radiographic Assessment

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Routine CR images are acquired as part of a clinical assessment of patients post knee arthroplasty to evaluate for common post operative complications that can cause pain and the need for revision surgeries.

Assess for fit – overhang or underhang of either component can lead to post–op pain

Alignment – one of the goals of PKR or TKR is to restore mechanical alignment

Loosening – Failure of PKR and TKR can be associated with component loosening

Osteolysis – bone reabsorption can occur in the area of the prosthetic

Wear – can occur in some of the components of the prosthetic

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Post Surgical Radiographic Assessment

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Proper positioning is critical- unless directed to do so by your radiologists or the orthopedic surgeon avoid bilateral images. The central beam should be directed at the knee joint

Weight bearing full leg –assess for alignment and leg length

AP and Lateral – assess for component position and fit

Tangential (aka sunrise or merchant view) – demonstrates the PF joint

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Post Surgical Radiographic Assessment

AP

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Acceptable positioning Poor positioning

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Post Surgical Radiographic Assessment

Lateral

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Acceptable positioning Poor positioning

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Post Surgical Radiographic Assessment

Tangential

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Acceptable positioning Poor positioning

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Post Test1. The Patella is cancellous bone surrounded by the _____________

a. Lateral collateral ligamentb. Medial collateral ligamentc. Patella tendond. Quadriceps tendon

2. Normal knee cartilage is between ________ thicka. 2 and 5mm’s b. 1 and 3mm’sc. 6 and 7mm’sd. None of the above

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Post Test3. Cartilage is dense connective tissue that is ___________

a. Made up of chondrocytes which produce the extracellular matrix of water, collagen, and proteoglycan

b. Collagen which is mostly type II, providing strength and structurec. Has no blood supply, nourishment is supplied by synovial fluidd. All of the above

4. The following statement is true regarding diagnostic imaging of the knee.a. Joint space narrowing can only be identified on CT imagesb. CT arthrography will not help in the evaluation of articular cartilage lossc. CR images can demonstrate osteophyte formations d. MR images will not demonstrate soft tissue structures

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Post Test5. A true AP CR image of the knee is acquired with

a. Bilaterally with the central beam between the kneesb. Uni laterally with the central beam focused at the joint spacec. Bilaterally with the central beam focused on one knee or the otherd. The knee bent 30 degrees

6. Osteoarthritis can be identified radiographically by the presence ofa. Osteophytes and bone edemab. Sclerosis and cyst formationsc. Joint space narrowingd. All of the above

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Post Test7. By age 40 almost______of the American population will have some form of OA in their weight-

bearing joints a. 100%b. 50%c. 90% d. 20%

8. Osteoarthritis is caused by __________________e. Genetics and metabolic disordersf. Traumag. Obesityh. All of the above

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Post Test9. The Hyaline Cartilage Lesion Classification System (2000) describes Grade 4 lesions as

a. Superficial lesions, cracks, and indentationsb. Fraying, lesions extending down to <50% of cartilage depth 0 and 2mm’sc. Partial loss of cartilage thickness, cartilage defects extending down to >50% of cartilage

depth as well as down to calcified layerd. Complete loss of cartilage thickness, bone only

10. The Hyaline Cartilage Lesion Classification System (2000) describes Grade 2 lesions asa. Superficial lesions, cracks, and indentationsb. Fraying, lesions extending down to <50% of cartilage depth 0 and 2mm’s c. Partial loss of cartilage thickness, cartilage defects extending down to >50% of cartilage

depth as well as down to calcified layerd. Complete loss of cartilage thickness, bone only

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Post Test11. Sclerotic changes are identified as

a. Decreased bone densityb. Increased bone density c. Bone edemad. Bone cysts

12. Osteochondritis defects result from ___________a. injury to the cartilage and underlying boneb. Interrupted blood flow to the areac. (a) and (b) d. None of the above

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13. Osteochondritis Defects Stage III is identified on MRI by _____________a. Articular Cartilage Damage onlyb. Cartilage injury with underlying fracture c. Detached but non-displaced fragment d. Detached and displaced fragment

14. Osteochondritis Defects Stage IV is identified on MRI by _____________a. Articular Cartilage Damage onlyb. Cartilage injury with underlying fracture c. Detached but non-displaced fragment d. Detached and displaced fragment

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Post Test

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15. Bone preservation is desirable because ______. a. Surgeons prefer to seek the least invasive methodb. Surgical procedures that involve fewer bone cuts result in less bleeding and post surgical

pain, and shorter recovery time.c. Less drastic approaches to surgical repair early on means that later there is still bone to

work with when total knee arthroplasty is the only solutiond. All of the above

16. Prosthesis failure rate requiring revision is approximately _____ percent per yeare. 1 f. 5g. 15h. 25

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Post Test

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17. ________ hemi arthroplasty replaces only the damaged area of a single joint compartment with a prosthetic device

a. Duo compartmentalb. Uni compartmental c. (a) and (b) d. None of the above

18. High tibial osteotomy is a procedure that ___________a. involves removal of a wedge shaped piece of bone b. results in realignment c. allows the patient’s weight to be distributed away from the damage compartment d. All of the above

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Post Test

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19. Post surgical CR images are acquired to ___________a. Evaluate implant fitb. Assess for osteolysisc. Evaluate leg alignment d. All of the above

20. The Tangential view (aka sunrise or merchant view) is acquired to demonstrate the ___________

a. Lateral compartment of the knee jointb. Medial compartment of the knee jointc. Patellafemoral jointd. Tibiotalar joint

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Post Test