Assessment and Correlation of Knee Ligament Injuries on MRI with Outerbridge Classification System
DOI:
https://doi.org/10.70749/ijbr.v3i4.1088Keywords:
Anterior Cruciate Ligament (ACL), Posterior Cruciate Ligament (PCL), Medial Cruciate Ligament (MCL), Lateral Cruciate Ligament (LCL), Outerbridge Classification System (OCS)Abstract
Background: Knee ligament injuries, particularly to the ACL, PCL, MCL, and LCL, are common causes of joint instability and long-term functional impairment. MRI serves as the preferred imaging modality for accurately evaluating both ligamentous damage and associated cartilage degeneration. The Outerbridge Classification System provides a standardized method for grading cartilage lesions, originally via arthroscopy and now increasingly applied through MRI. Understanding the correlation between ligament injuries and cartilage damage is essential for early diagnosis, effective treatment, and prevention of osteoarthritis. Objective: This study aims to assess ligament injuries on MRI and correlate them with Outerbridge grades to improve diagnostic accuracy and guide clinical management. Methodology: This descriptive cross-sectional study is conducted over four months from December, 2024 to March, 2025 with a sample size of 64 participants, selected through convenience sampling. It includes sports-injured patients and patients with confirmed ligament injury. Patients with previous knee surgery, concurrent lower limb injuries, and chronic knee conditions are excluded to avoid confounding imaging findings. Results: Out of 64 patients, the majority present with ligament injuries involving the MCL (98.4%) and LCL (96.9%), followed by the PCL (67.2%) and ACL (28.1%). A significant association is observed between ligament injuries and higher Outerbridge cartilage grades, particularly Grades 3 and 4. Synovitis and joint effusion are also frequently identified. Cartilage degeneration is more prevalent in older age groups, and MRI effectively demonstrates both ligament and cartilage pathology. These findings support a strong correlation between ligamentous injury and progressive chondral damage. Conclusions: Ligament injuries, particularly involving the ACL, PCL, MCL, and LCL, are frequently associated with advanced cartilage damage. MRI proves to be a valuable tool for comprehensive knee evaluation, enabling early detection of both soft tissue injuries and degenerative changes.
Downloads
References
Braaten, J. A., Schreier, F. J., Rodriguez, A. N., Monson, J., & LaPrade, R. F. (2022). Modern treatment principles for multiligament knee injuries. Archives of Bone and Joint Surgery, 10(11), 937. https://doi.org/10.22038/ABJS.2021.60188.2971
Schenck, R. C. (2004). Classification of knee dislocations. The Multiple Ligament Injured Knee, 37-49. https://doi.org/10.1007/978-0-387-22522-7_3
Steineman, B. D., Moulton, S. G., Haut Donahue, T. L., Fontboté, C. A., LaPrade, C. M., Cram, T. R., Dean, C. S., & LaPrade, R. F. (2016). Overlap between anterior cruciate ligament and Anterolateral Meniscal root insertions: A scanning electron microscopy study. The American Journal of Sports Medicine, 45(2), 362-368. https://doi.org/10.1177/0363546516666817
Ziegler, C. G., Pietrini, S. D., Westerhaus, B. D., Anderson, C. J., Wijdicks, C. A., Johansen, S., Engebretsen, L., & LaPrade, R. F. (2010). Arthroscopically pertinent landmarks for tunnel positioning in single-bundle and double-bundle anterior cruciate ligament reconstructions. The American Journal of Sports Medicine, 39(4), 743-752. https://doi.org/10.1177/0363546510387511
Siegel, L., Vandenakker-Albanese, C., & Siegel, D. (2012). Anterior cruciate ligament injuries. Clinical Journal of Sport Medicine, 22(4), 349-355. https://doi.org/10.1097/jsm.0b013e3182580cd0
Pache, S., Aman, Z. S., Kennedy, M., Nakama, G. Y., Moatshe, G., Ziegler, C., & LaPrade, R. F. (2018). Posterior cruciate ligament: current concepts review. Archives of Bone and Joint Surgery, 6(1), 8. https://pmc.ncbi.nlm.nih.gov/articles/PMC5799606/
Anderson, C. J., Ziegler, C. G., Wijdicks, C. A., Engebretsen, L., & LaPrade, R. F. (2012). Arthroscopically pertinent anatomy of the Anterolateral and Posteromedial bundles of the posterior cruciate ligament. Journal of Bone and Joint Surgery, 94(21), 1936-1945. https://doi.org/10.2106/jbjs.k.01710
Memarzadeh, A., & Melton, J. T. (2019). Medial collateral ligament of the knee: Anatomy, management and surgical techniques for reconstruction. Orthopaedics and Trauma, 33(2), 91-99. https://doi.org/10.1016/j.mporth.2019.01.004
DeLong, J. M., & Waterman, B. R. (2015). Surgical techniques for the reconstruction of medial collateral ligament and Posteromedial corner injuries of the knee: A systematic review. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 31(11), 2258-2272.e1. https://doi.org/10.1016/j.arthro.2015.05.011
Phisitkul, P., James, S. L., Wolf, B. R., & Amendola, A. (2006). MCL injuries of the knee: current concepts review. The Iowa orthopaedic journal, 26, 77. https://pmc.ncbi.nlm.nih.gov/articles/PMC1888587/
LaPrade, R. F., Ly, T. V., Wentorf, F. A., & Engebretsen, L. (2003). The posterolateral attachments of the knee. The American journal of sports medicine, 31(6), 854-860. https://doi.org/10.1177/03635465030310062101
Yan, J., Sasaki, W., & Hitomi, J. (2009). Anatomical study of the lateral collateral ligament and its circumference structures in the human knee joint. Surgical and Radiologic Anatomy, 32(2), 99-106. https://doi.org/10.1007/s00276-009-0547-2
Wilson, W. T., Deakin, A. H., Payne, A. P., Picard, F., & Wearing, S. C. (2012). Comparative analysis of the structural properties of the collateral ligaments of the human knee. Journal of Orthopaedic & Sports Physical Therapy, 42(4), 345-351. https://doi.org/10.2519/jospt.2012.3919
Cruells Vieira, E. L., Vieira, E. Á., Teixeira da Silva, R., Dos Santos Berlfein, P. A., Abdalla, R. J., & Cohen, M. (2007). An anatomic study of the Iliotibial tract. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 23(3), 269-274. https://doi.org/10.1016/j.arthro.2006.11.019
Moatshe, G., Chahla, J., LaPrade, R. F., & Engebretsen, L. (2017). Diagnosis and treatment of multiligament knee injury: State of the art. Journal of ISAKOS, 2(3), 152-161. https://doi.org/10.1136/jisakos-2016-000072
Engebretsen, L., Risberg, M. A., Robertson, B., Ludvigsen, T. C., & Johansen, S. (2009). Outcome after knee dislocations: A 2–9 years follow-up of 85 consecutive patients. Knee Surgery, Sports Traumatology, Arthroscopy, 17(9), 1013-1026. https://doi.org/10.1007/s00167-009-0869-y
Moatshe, G., Dornan, G. J., Løken, S., Ludvigsen, T. C., LaPrade, R. F., & Engebretsen, L. (2017). Demographics and injuries associated with knee dislocation: A prospective review of 303 patients. Orthopaedic Journal of Sports Medicine, 5(5). https://doi.org/10.1177/2325967117706521
Werner, B. C., Gwathmey, F. W., Higgins, S. T., Hart, J. M., & Miller, M. D. (2013). Ultra-low velocity knee dislocations. The American Journal of Sports Medicine, 42(2), 358-363. https://doi.org/10.1177/0363546513508375
Arendt, E. A., Agel, J., & Dick, R. (1999). Anterior cruciate ligament injury patterns among collegiate men and women. Journal of athletic training, 34(2), 86. https://pmc.ncbi.nlm.nih.gov/articles/PMC1322895/
Myklebust, G., & Bahr, R. (2005). Return to play guidelines after anterior cruciate ligament surgery. British Journal of Sports Medicine, 39(3), 127-131. https://doi.org/10.1136/bjsm.2004.010900
Peskun, C. J., & Whelan, D. B. (2011). Outcomes of operative and nonoperative treatment of Multiligament knee injuries. Sports Medicine and Arthroscopy Review, 19(2), 167-173. https://doi.org/10.1097/jsa.0b013e3182107d5f
Dedmond, B. T., & Almekinders, L. C. (2001). Operative versus nonoperative treatment of knee dislocations: a meta-analysis. The American journal of knee surgery, 14(1), 33-38. https://europepmc.org/article/med/11216717
Levy, B. A., Dajani, K. A., Whelan, D. B., Stannard, J. P., Fanelli, G. C., Stuart, M. J., Boyd, J. L., MacDonald, P. A., & Marx, R. G. (2009). Decision making in the multiligament-injured knee: An evidence-based systematic review. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 25(4), 430-438. https://doi.org/10.1016/j.arthro.2009.01.008
Nozaki, T., Rafijah, G., Hitt, D., & Yoshioka, H. (2016). Osteoarthritis grading of the ulnar sided wrist using outerbridge classification at 3 Tesla high-resolution MRI. Osteoarthritis and Cartilage, 24, S252. https://doi.org/10.1016/j.joca.2016.01.482
Zhang, C., Wei, X., Chen, C., Cao, K., Li, Y., Jiao, Q., Ding, J., Zhou, J., Fleming, B., Chen, Q., Shang, X., & Wei, L. (2014). Indian hedgehog in synovial fluid is a novel marker for early cartilage lesions in human knee joint. International Journal of Molecular Sciences, 15(5), 7250-7265. https://doi.org/10.3390/ijms15057250
Mederake, M., Scheibe, V., Dalheimer, P., Schüll, D., Marina, D., & Hofmann, U. K. (2024). Reliability and Accuracy of the Outerbridge Classification in Staging of Cartilage Defects. Orthopaedic Surgery, 16(5), 1187–1195. https://doi.org/10.1111/os.14016
Palanisamy, Y., Naidu, S. P., Prasad, A. R., Natarajan, S., & Rajan, D. V. (2023). When to Do Selective Patellar Resurfacing in Total Knee Arthroplasty: A Decision-Making Algorithm Based on Pre-operative and Intra-operative Findings. Indian Journal of Orthopaedics, 58(1), 30–39. https://doi.org/10.1007/s43465-023-01039-6
Hunter, D. J., & Bierma-Zeinstra, S. (2019). Osteoarthritis. The Lancet, 393(10182), 1745–1759. https://doi.org/10.1016/s0140-6736(19)30417-9
Lu, V., Andronic, O., Zhang, J. Z., & Khanduja, V. (2023). Outcomes of arthroscopy of the hip for femoroacetabular impingement based on intraoperative assessment using the Outerbridge classification. The Bone & Joint Journal, 105-B(7), 751-759. https://doi.org/10.1302/0301-620x.105b7.bjj-2022-0989.r1
Kosy, J. D., Matteliano, L., Rastogi, A., Pearce, D., & Whelan, D. B. (2018). Meniscal root tears occur frequently in multi-ligament knee injury and can be predicted by associated MRI injury patterns. Knee Surgery, Sports Traumatology, Arthroscopy, 26(12), 3731-3737. https://doi.org/10.1007/s00167-018-5009-0
Li, X., Hou, Q., Zhan, X., Chang, L., Ma, X., & Yuan, H. (2022). The accuracy of MRI in diagnosing and classifying acute traumatic multiple ligament knee injuries. BMC Musculoskeletal Disorders, 23(1). https://doi.org/10.1186/s12891-021-04976-1
Fortier, L. M., Stylli, J. A., Civilette, M., Duran, N. S., Hanukaai, S., Wilder, H., Sherman, W. F., & Kaye, A. D. (2022). An evidence-based approach to multi-ligamentous knee injuries. Orthopedic Reviews, 14(3). https://doi.org/10.52965/001c.35825
Potter, H. G., Jain, S. K., Ma, Y., Black, B. R., Fung, S., & Lyman, S. (2011). Cartilage injury after acute, isolated anterior cruciate ligament tear. The American Journal of Sports Medicine, 40(2), 276-285. https://doi.org/10.1177/0363546511423380
Khanda, G. E., Akhtar, W., Ahsan, H., & Ahmad, N. (2008). Assessment of menisci and ligamentous injuries of the knee on magnetic resonance imaging: correlation with arthroscopy. Journal of the Pakistan Medical Association, 58(10), 537. https://ecommons.aku.edu/pakistan_fhs_mc_radiol/45/
Sanchez-Munoz, E., Lozano Hernanz, B., Zijl, J. A., Passarelli Tirico, L. E., Angelini, F. J., Verdonk, P. C., Vuylsteke, K., Andrade, R., Espregueira-Mendes, J., Valente, C., Figueroa, F., Figueroa, D., & Maestro Fernández, A. (2023). Accuracy of magnetic resonance imaging in the diagnosis of multiple ligament knee injuries: A multicenter study of 178 patients. The American Journal of Sports Medicine, 51(2), 429-436. https://doi.org/10.1177/03635465221145697
Ravikanth, R., Abraham, M. J., Pilar, A., & Alapati, A. (2019). MRI diagnosis in multiligamentous injuries of knee with associated dislocations and neurovasacular sequelae: A retrospective analysis of injury patterns. Egyptian Rheumatology and Rehabilitation, 46(4), 278-284. https://doi.org/10.4103/err.err_22_19
Ali, A. A., & Abdelwahab, M. B. (2019). Short-term outcome of multi-ligament knee injury among sudanese patients. Open Access Macedonian Journal of Medical Sciences, 7(9), 1486-1493. https://doi.org/10.3889/oamjms.2019.282
BRITTBERG, M., & WINALSKI, C. S. (2003). Evaluation of cartilage injuries and repair. The Journal of Bone and Joint Surgery-American Volume, 85, 58-69. https://doi.org/10.2106/00004623-200300002-00008
Rosenberg, Z. S. et al. (1996). MRI of the knee: overview and protocol. Radiol Clin North Am, 34(2), 195–218.
Niethammer TR, et al. (2011). MRI assessment of cartilage degeneration in young adults with ACL injuries. Skeletal Radiol. 40(6), 651–658.
Frobell, R. B., Roos, E. M., Roos, H. P., Ranstam, J., & Lohmander, L. S. (2010). A randomized trial of treatment for acute anterior cruciate ligament tears. New England Journal of Medicine, 363(4), 331-342. https://doi.org/10.1056/NEJMoa0907797
Outerbridge, R. E. (1961). The etiology of chondromalacia patellae. The Journal of Bone and Joint Surgery. British volume, 43-B(4), 752-757. https://doi.org/10.1302/0301-620x.43b4.752
Downloads
Published
Issue
Section
License
Copyright (c) 2025 Indus Journal of Bioscience Research

This work is licensed under a Creative Commons Attribution 4.0 International License.