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15 October 2020: Clinical Research  

Morphological Analysis of Normal Meniscus on Magnetic Resonance Imaging (MRI)-Based Three-Dimensional Reconstruction Models in Healthy Chinese Adults

Xianyue Shen1CE, Jianlin Zuo1D, Zhao Li2B, Jianlin Xiao1F, Tong Liu1AG*

DOI: 10.12659/MSM.927101

Med Sci Monit 2020; 26:e927101

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Abstract

BACKGROUND: The purpose of this cross-sectional observational study was to determine the morphological meniscus characteristics in a normal Chinese population and assess possible relationships between demographic data and meniscal morphological parameters.

MATERIAL AND METHODS: We examined 116 menisci (58 lateral and 58 medial) from 29 healthy Chinese volunteers (10 men, 19 women, mean age 26 years [range, 20–33 years]) with MRI and three-dimensional reconstruction using Mimics software. The width, thickness, anteroposterior distance (APD), lateral-medial distance (LMD), and covering angle (CA) were measured on reconstructed models. Univariate analysis was used to evaluate the differences of morphological parameters between the medial and lateral menisci, between sides, and between males and females. Pearson correlation analysis was used to evaluate the correlation between meniscal morphological parameters and body height, weight, and body mass index (BMI).

RESULTS: Univariate analysis demonstrated that the width, thickness, APD, LMD, and CA were significantly different between lateral and medial menisci. The LMD and APD of menisci in men were significantly larger than in women. There was no significant difference in meniscal thickness and CA between males and females. The lateral meniscus dimensions were slightly larger in the right knee. According to Pearson correlation analysis, the APDs of both lateral and medial menisci were strongly correlated with height and weight (lateral: r=0.596, r=0.500; medial: r=0.684, r=0.680).

CONCLUSIONS: The morphologies of medial and lateral menisci were different and were not significantly correlation with each other. The meniscal width and diameter were correlated with demographic data, but the thickness and CA did not significantly differ by sex, height, or BMI.

Keywords: Imaging, Three-Dimensional, Magnetic Resonance Imaging, Menisci, Tibial, Asians, Cross-Sectional Studies

Background

The meniscus is an important protective structure of the human knee joint. Meniscal tear is one of the most common knee joint sports injuries and causes serious adverse consequences to the knees of athletes [1]. At present, the treatment of meniscus injury is mainly focused on surgical suture repair or meniscectomy [2]. Arthroscopic meniscus suture repair can usually be performed for injuries situated at the red-red zone, while white-white zone injuries and complex meniscal tears require meniscectomy, and large meniscal resection can cause quadriceps atrophy, osteoarthritis (OA), and even knee deformity. In cases of symptomatic segmental or total meniscectomy, meniscal allograft transplantation (MAT) becomes the last choice in an attempt to restore knee contact forces and reduce meniscal-related symptoms. However, the sources of MAT are relatively scarce and it is estimated that there are only 0.24 procedures performed per year per 100 000 patients. Successful meniscal transplantation is highly dependent on accurate size matching of the allograft to the native meniscus.

In recent decades, the construction of artificial menisci for MAT has been a research hotspot in sports medicine. Lee et al. [3] and Zhang et al. [4] reported that anatomic meniscal grafts in animals using three-dimensional (3D) printing technology achieve good structural matching, and the procedures can effectively prevent progressions of knee osteoarthritis.

Few studies have assessed the morphology of the human meniscus, and many anatomical dimensions of the normal meniscus are still unknown. The present study performed comprehensive morphological evaluations of the meniscus in normal Chinese adults by using 3D-reconstructed magnetic resonance image (MRI) meniscal models. It was hypothesized that meniscal anatomical parameters were significantly correlated with demographics in healthy Chinese adults. The goal of this study was to provide accurate morphological parameters for the design of an artificial meniscus and to provide anatomical principles to guide allograft selection in meniscal MAT.

Material and Methods

STUDY SUBJECTS:

This cross-sectional observational study was approved by the Institutional Review Board Ethics Committee of China-Japan Union Hospital (IRB No. 2016-nsfc028). All subjects provided signed informed consent prior to undergoing the MRI examination. All eligible volunteers were required to undergo MRI of the selected knee for review in the clinical imaging system using a Phillips 3.0-T MRI scanner. Volunteers were placed in the supine position with the knee fully extended. MRI scans were performed in coronal, sagittal, and horizontal position of the knee joint by 3-D dual-echo steady-state (3D-DESS), with a layer thickness of 0.5 mm. From January 2018 to January 2019, 40 (out of 98) volunteers were recruited from the community through use of research flyers. Eleven participants were later found to meet the exclusion criteria after taking MRI scans, and were therefore excluded from the present study. The inclusion criteria were: no knee joint pain or instability, skeletally mature, and healthy. The exclusion criteria were: congenital meniscus dysplasia, meniscus-related lesions, and preexisting cruciate ligament injuries. Finally, 29 subjects (10 men, 19 women, mean age 26 years [range, 20–33 years]) with 116 menisci (58 lateral and 58 medial) were included in the study (Figure 1).

3D RECONSTRUCTION:

The scan data from included subjects were extracted, deposited to a personal computer in Digital Imaging and Communications in Medicine (DICOM) format, and imported to Mimics 17.0 software (Materialise, Belgium) for 3D reconstruction. The luminance was set as 50~200, and the meniscus images of each section were inspected by the researchers layer by layer through the steps of threshold analysis, region growth, and mask editing. After 3D calculation, the 3D meniscus models were further trimmed by limited smoothing, and then were ready for subsequent measurements. We selected 3 discrete points of the tibial plateau to best fit the tibial plateau plane (Figure 2).

DATA ACQUISITION AND MEASUREMENTS:

The 3D models of the meniscus and tibial plateau plane were imported into 3-matic software, and the meniscal models were 2D-projected onto the tibial plateau planes. Then, best-fit circles were used to outline the projected images to depict the sector covering the area of the medial and lateral meniscus (Figure 3). The covering angle (CA) of a meniscus was defined as the angle enclosed with lines connecting the center of the best-fit circle and the 2 most medial points of the anterior horn (AH) and posterior horn (PH) in a lateral meniscus (the 2 most lateral points in a medial meniscus). The lateral-medial distance (LMD) and anteroposterior distance (APD) of each meniscus was obtained on the same projection. For measuring the LMD, the line defined with the 2 most medial points in a lateral meniscus was set as the a line; another line parallel to the a line was drawn through the most lateral point of the meniscal body (BD) was defined as the b line; the distance between lines a and b is LMD. For measuring the APD, 2 lines were drawn perpendicular to line a through the most anterior point and the most posterior point of the meniscus, respectively, named the c line and d line. APD was defined as the distance between lines c and d. For obtaining the widths of each meniscus, 3 sections were equally defined as meniscal anterior horn (AH), body (BD), and posterior horn (PH). The widths were measured at the middle of each section (Figure 4).

The meniscal thicknesses were acquired under Geomagic Control environment (Geomagic, USA), and the 3D models of the menisci and tibial plateau planes were imported into the software. The XY plane of the global 3D coordinate system was aligned with each of the tibial plateau planes, and the value of the Z axis in each selected top edge point of the models equals the thickness of the meniscus (Figure 5).

STATISTICAL ANALYSIS:

All statistical analyses were performed using SPSS version 17.0 (SPSS, Inc., Chicago, IL), and P<0.05 was considered to be statistically significant. The mean and standard deviations were calculated for continuous data. To assess the statistical significance of differences among anatomical parameters, independent and paired t tests were used for univariate analyses. Pearson’s correlation analysis was used to assess the potential association between demographic data and anatomical parameters.

To assess interobserver reliability, 2 experienced surgeons independently performed the 3D reconstructions and measurements. To assess intraobserver reliability, the 3D reconstructions and the measurements were performed twice by the same researcher 1 month apart. The intraclass correlation coefficient (ICC) was used to calculate interobserver and intraobserver effects.

Results

The mean CA, LMD, and APD were 320.16°, 34.57 mm, and 36.03 mm, respectively, for the lateral meniscus, compared with 265.55°, 33.18 mm, and 45.41 mm in the medial meniscus group. The paired t test revealed statistically significant differences in all anatomical parameters between the lateral meniscus and medial meniscus groups (Table 1). Statistically significant differences were found in the width at all 3 sections between the lateral and medial meniscus groups (P<0.001, Table 1). The meniscal widths of AH and BD sections in the lateral meniscus were significantly wider than those in the medial meniscus, but the width at PH section in the lateral meniscus was significantly narrower. For a medial and lateral meniscus, the widest locations were in PH and BD sections, and the narrowest location was AH in both sides. As depicted in Table 1, the thickness at AH and PH (6.85±1.10 mm and 7.20±1.09 mm) of the medial meniscus group were greater than in the lateral group (5.51±0.71 mm and 6.47±0.66 mm). Nevertheless, the thickness at BD section on the medial meniscus was significantly smaller (P=0.003, Table 1). The thickest locations were at PH and BD sections in the medial and lateral meniscus (Figure 6).

Between the left and right sides of the same subject, most of the morphological parameters of the medial meniscus were similar in both knees, but the APD in the right medial component was slightly smaller than the left (44.51±2.77 mm vs. 46.31±4.04 mm). In the lateral meniscus, the width and thickness at BD of the right knee were significantly greater than that of the left knee, but the difference was small (width: 10.68±1.97 mm vs. 10.10±1.81 mm; thickness: 7.49±0.88 mm vs. 6.93±0.74 mm); the APD and LMD measurements were also greater in the right (APD: 36.55±2.63 mm vs. 35.52±2.574mm; LMD: 35.25±2.63 mm vs. 33.88±2.62 mm) (Tables 2, 3).

When the measurements were stratified by sex, the CAs of bilateral menisci in women were close to those in men. For APD and LMD measurements, the results were significantly greater in men than in women. The meniscus was significantly wider in males than in females in all sections, but the widths of AH were similar. Finally, there was no difference in thickness between males and females (Tables 4, 5).

Between the meniscal anatomical parameters and body height and weight, as well as BMI, the APD of the lateral meniscus was positively correlated with height and weight (r=0.596, r=0.500), and this was also true for the medial meniscus group (r=0.684, r=0.680) (Tables 6, 7).

The reliabilities of measurements of meniscal anatomical parameters were assessed by ICC. The intraobserver ICCs (range, 0.92 to 0.98) and the interobserver ICCs (range, 0.84 to 0.91) both had excellent reliability.

Discussion

LIMITATIONS:

Some limitations should be considered when interpreting the results of this study. Firstly, differences in meniscus shape changes may be underestimated due to the non-weight-bearing condition during MRI acquisition [25]. Although it is sufficient to investigate the normal morphology of meniscus with the current methodology, mechanical loading treatments during MRI scanning are needed to mimic the working status of weight-bearing in the human meniscus. Secondly, the age range of the population recruited in this study was relatively narrow. However, the purpose of this study was to summarize the meniscal anatomy of healthy Chinese adults, and inclusion of more elderly people would have involved more degenerated knees. Finally, although the number of subjects included in this study was relatively small, we believe it was sufficient for studying the morphology of the meniscus in young healthy adults.

Conclusions

In conclusion, the present study described the meniscus morphology in vivo on MRI-based 3D reconstruction models. The meniscal width and diameter were correlated with the demographic data, but the thickness and covering angle were did not substantially differ by sex, height, or BMI. This information will be helpful for the evaluation and diagnosis of meniscal dysplasia or injuries, providing normal geometries for the construction of bionic menisci and increasing the reliability of meniscal sizing in MAT.

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