! The treatment of idiopathic osteonecrosis of the medial femoral condyle with arthroscopic debridement. The Journal of the American Academy of Orthopaedic Surgeons. 2. 2010;194 (4): 1061-4. Upon admission, the patient was found to have left knee tenderness, predominantly over the lateral joint line. Osteoporosis is the most common cause of insufficiency fractures, although there are many causes 7-9: ADVERTISEMENT: Supporters see fewer/no ads. Clinical management of radiation-associated pathological fractures is challenging because of the high nonunion rate and potential for morbidity. Typical MRI findings in insufficiency fractures include a pattern of bone marrow edema with a low-signal-intensity line (resp. HHS Vulnerability Disclosure, Help Preoperative MRI. MRI features of a malignant fracture are diffusely or focally abnormal bone marrow signal which may be either well-defined or ill-defined and does not follow fracture lines. Wide local resection is the mainstay of treatment for high-grade soft tissue sarcoma in the extremities [1]. Burgener FA, Kormano M, Pudas T. Bone and Joint Disorders. Learn more , , , , -SIT . 2022, Received in revised form: All authors read and approved the final manuscript. (d) Lateral UKA was performed. It should be suspected in It should also be noted that multiple pelvic insufficiency fractures are frequently found, particularly in the presence of pubic or acetabular fractures, and careful search for concomitant fractures is warranted. Histological examination of core needle biopsy specimens led to a pathological diagnosis of synovial sarcoma. For conventional tibial plateau fractures, internal fixation with locking plates using the minimally invasive percutaneous osteosynthesis technique could be an option. Kabra U, Subchondral insufficiency fracture of the knee. Early MRI diagnosis and non-surgical management of spontaneous osteonecrosis of the knee. 2022. The features seen on CT are bone marrow abnormality which may be well-defined, ill-defined, permeative or moth-eaten, endosteal scalloping, periosteal reaction, and a soft-tissue mass. Gortzak Y, Lockwood GA, Mahendra A, et al. The United States Food and Drug Administration approved LIPUS for fracture healing in 1994 [6]. Data Analysis It should be Alonso-Bartolom P, Martnez-Taboada VM, Blanco R, et al. 61-year-old female patient with a history of bronchial carcinoma, FDG-PET-CT showing only moderate metabolic activity in the thoracic spine with several compression fractures. Semantic Scholar is a free, AI-powered research tool for scientific literature, based at the Allen Institute for AI. Mild internal enhancement was observed on gadolinium-enhanced fat-suppressed T1-weighted images (Figure 2). Magnetic resonance imaging (MRI) showed a tumor with clear margins in the popliteus muscle. This article presents a 51-year-old postmenopausal woman, a physician, who had subchondral insufficiency fractures of the knee associated with prolonged standing during clinical work and was treated with partial weight bearing on crutches and viscosupplementation to improve bone healing. In experimental models, LIPUS played an important role in promoting fracture healing in pathological conditions. Dickie CI, Parent AL, Griffin AM, et al. buzzword, , . 2022 The Authors. (c) Sagittal images showed a displaced intra-articular radiopaque curvilinear fragment. Recent progress in RT has led to better outcomes and fewer adverse events. Therefore, LIPUS could be a safe and effective treatment option in the management of radiation-associated fractures. Recently, low-intensity pulsed ultrasound (LIPUS) has been widely used to treat fresh and nonunion fractures [6]. On bone scan, there is increased activity at the site of the fracture. Most cases involve the medial femoral condyle, and the lateral femoral condyle is rarely affected. Keywords sharing sensitive information, make sure youre on a federal Posterior spinal fusion Th12-S1 with loosening of T12 pedicle screws, AP radiograph of the sacrum after orthopaedic trans-sacroiliac screw fixation of bilateral sacral insufficiency fractures at the S1 level, Axial CT image at the level of the hip joints demonstrates insufficiency fracture of the left pubic bone (. (a) Coronal proton-density-weighted fat-suppressed and (b) T1-weighted MRI images of left knee demonstrated subchondral insufficiency fracture at the lateral femoral condyle with a curvilinear hypodensity parallel to the femoral condyle subchondral bone plate. Please enable it to take advantage of the complete set of features! Knee Surgery, Sports Traumatology, Arthroscopy. The lesion was resected during the distal femur cut (, Postoperative radiographs of the knee and lower limb scanogram showed satisfactory alignment (, In the initial description by Ahlbck etal., a cohort of patients with knee osteonecrosis in the absence of other known clinical entities were first labelled as having SONK [. . An official website of the United States government. Coronal T1-weighted images (AD), sagittal T1-weighted images (EH), and sagittal T2-weighted images with fat suppression of the right knee taken immediately after the onset of the knee pain, and 4 months, 10 months, and 16 months after initiation of LIPUS therapy. Typical MRI findings in insufficiency fractures include a pattern of bone marrow edema with a low-signal-intensity line (resp. MRI signals and time course of the resolution for the insufficiency fracture in the proximal medial tibia. official website and that any information you provide is encrypted . Three questions need to be answered. Outcome of SIFK depends on several factors, including the initial subchondral fracture size, patient BMI, degree of osteopenia, as well as early diagnosis and initial treatment. Heckman JD, Ryaby JP, McCabe J, et al. The histopathological findings suggest that the primary event leading to spontaneous osteonecrosis of the knee is a subchondral insufficiency fracture and that the localized osteoarthritic changes seen in association with this disease is the result of a fracture. On laboratory testing, serum calcium and phosphorus and renal and liver function were within normal limits. Jpn J Radiol. LIPUS could be a safe and effective treatment option in the management of radiation-associated pathological fractures. 11 (3): 191-194. After 3 courses of neoadjuvant chemotherapy with ifosfamide and doxorubicin hydrochloride, we performed surgery. The lesion had low and high signal intensity on T1- and T2-weighted images, respectively (Figure 2). Federal government websites often end in .gov or .mil. Soft-tissue dissection was limited to what was necessary for exposure only. In particular, initially she only performed partial weight bearing starting at 30% of her body weight for 3 months, and steadily built up to full weight bearing as tolerated for the next 4 months. Looser zones are also a type of insufficiency fracture. Careers. Her physical examination revealed a hard, tender, palpable 65 cm mass with moderate mobility under the right proximal calf without restriction of right knee range of motion. 2001;40 (9): 1065-6. Parasymphyseal and pubic ramus fractures often are misinterpreted as malignant lesions. In addition to LIPUS, she started non-weight-bearing walking for the first 3 weeks. There was Osteonecrosis of the knee: a review of three disorders. . (a) Radiograph of left knee taken upon presenting to the emergency department showed an area of osteonecrosis over the lateral femoral condyle on the anteroposterior view with an associated curvilinear bony lesion on the lateral view. Although skeletal complications are infrequent, radiation-associated bone fractures are still serious complications in 220% of patients treated with limb-sparing surgery and RT [7]. Plain radiographs showed no obvious abnormal findings (Figure 5A, 5B, 5G, 5H). buzzword, , . . Insufficiency fractures are a type of stress fracture, which are the result of normal stresses on abnormal bone. Conclusion government site. We appreciate the help of Drs. image, Download .pdf (.72 1Department of Orthopedic Surgery, Kyushu Rosai Hospital, Kitakyushu, Fukuoka, Japan, 2Department of Radiology, Kyushu Rosai Hospital, Kitakyushu, Fukuoka, Japan, Unusual or unexpected effect of treatment. To update your cookie settings, please visit the, Distal Femoral Replacement and Extensor Mechanism Repair Reinforced With Synthetic Mesh for Distal Femur Fracture With Patellar Ligament Avulsion. We report a case of radiation-associated insufficiency fracture of the tibial plateau after surgery and RT for synovial sarcoma of the calf that was successfully treated with LIPUS. , () (CRM), . The site is secure. Characterization and pathological characteristics of spontaneous osteonecrosis of the knee. 1. The Bethesda, MD 20894, Web Policies Bone scintigraphy is highly sensitive, but not specific. Bonewald LF, Dallas SL. 6. Two cases of subchondral insufficiency fractures of the femoral head are reported, and magnetic resonance imaging establishes the diagnosis and rules out other conditions. After perioperative ifosfamide and doxorubicin chemotherapy and surgical resection, adjuvant radiation therapy was administered, with a total of 60 Gy in 30 fractions. Radiographics. However, there have been no reports that such methods could prevent the collapse of the articular surface in the case of a radiation-associated fracture. Azuma Y, Ito M, Harada Y, et al. Her height and weight were 146.9 cm and 57.2 kg, respectively. Insufficiency fractures of the tibia and fibula. Histopathologic findings of spontaneous osteonecrosis of the knee at an early stage: a case report. MeSH Re-evaluation of low intensity pulsed ultrasound in treatment of tibial fractures (TRUST): Randomized clinical trial. Corresponding Author: Tomoya Matsunobu, e-mail: Received 2021 Aug 11; Revised 2021 Nov 29; Accepted 2021 Oct 27. fracture) on the T1-weighted images parallel to the subchondral bone. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Unable to load your collection due to an error, Unable to load your delegates due to an error. All 10 complications occurred between 2 and 9 months after injection: six (60%) in the hip and four (40%) in the knee. There was a 1.5 5-cm subchondral defect at the weight-bearing surface of the lateral femoral condyle. in 1968, where a group of patients with atraumatic severe knee pain were found to have primary osteonecrosis [. LIPUS is a clinically established treatment used to accelerate long bone fracture healing. Bookshelf (D) T2-weighted coronal image. - . 2022 May; 40 (5):443-457. Unicompartmental knee arthroplasty for spontaneous osteonecrosis of the knee: a meta-analysis. (2005) ISBN:1588904458. It is well-known that patients with distal radius fracture who are otherwise healthy have a preferential bone loss at the distal forearm. While prophylactic intramedullary nailing is a common approach for preventing radiation-associated fractures, especially in the diaphysis of long bones [4], it has been suggested that prophylactic nailing should not be routinely performed because the risk of fracture is low. Findings include sclerosis, lytic fracture line, bone expansion, exuberant callus, and osteolysis. Funding: This study did not receive any funding. Bone fractures following external beam radiotherapy and limb-preservation surgery for lower extremity soft tissue sarcoma: Relationship to irradiated bone length, volume, tumor location and dose. LIPUS, low-intensity pulsed ultrasound; M, months. Radiographs are the initial imaging test in patients with pain localized to the skeleton. Insufficiency fractures at the spine are a leading cause for acute low back pain without an acute traumatic event. Spontaneous insufficiency fracture of the knee is a potentially devastating yet poorly understood disease entity that can lead to secondary osteoarthritis. ? Subchondral insufficiency fracture of the knee (SIFK) is a potentially devastating disorder that may progress rapidly to osteoarthritis with articular surface collapse. All figures submitted have been created by the authors who confirm that the images are original with no duplication and have not been previously published in whole or in part. and transmitted securely. 8600 Rockville Pike Dose distribution of the radiation therapy was shown. {"url":"/signup-modal-props.json?lang=gb\u0026email="}, Gaillard F, Yap J, Baba Y, et al. Local tenderness resolved within 6 months. The Koshino classification was first described in 1979, where small radiolucent lesions measuring <3.5 cm, The options of nonoperative treatment for early-stage SIFK include physiotherapy, analgesics, nonsteroidal anti-inflammatory drugs, and bisphosphonates [. Cruess RL. The pain typically This is the first report of radiation-associated pathological fracture that was successfully treated with LIPUS. Subchondral insufficiency fracture of the knee (SIFK) is a common cause of knee joint pain in older adults. 2000 Jun;82(6):858-66. doi: 10.2106/00004623-200006000-00013. Although we assumed that a negative-margin R0 resection was achieved, the lesion was in close proximity to the tibial artery and nerve. The treatment of SIFK can be nonoperative or operative depending on the size and radiological staging of the lesion. Depending on the tumor location, concomitant surgical resection of the periosteum might be required; periosteum stripping and RT reportedly increase the risk of the pathological fracture [4]. We adopted the spacer block technique and resected the tibia first. : +852 2468 5111. If diagnosed early enough, conservative therapy may lead to healing without subsequent collapse and fragmentation of the subchondral bone. Thus, it appears most patients with what has been called spontaneous osteonecrosis of the knee actually have subchondral insufficiency fractures. , , . Arthroscopic microfracture treatment for osteonecrosis of the knee. Regarding radiological investigations, the radiographs usually show no characteristic findings at early stages of the disease. CT-guided core needle biopsy was performed. FOIA Regarding the effect of radiation on osteogenesis, an in vitro experiment showed that LIPUS restored the viability of suppressed cells and osteogenic differentiation of radiation-damaged rat mandible-derived bone marrow mesenchymal stem cells [13]. Fresh osteochondral allograft transplantation for spontaneous osteonecrosis of the knee: a case series. 8600 Rockville Pike 2016 May;45(5):713-6. doi: 10.1007/s00256-016-2328-4. Distinct radiolucent areas at the lateral femoral condyle may be observed in advanced cases with subchondral collapse. Thrombophilia-Associated Factors in Patients with Spontaneous Osteonecrosis of the Knee. Federal government websites often end in .gov or .mil. Helmstedter CS, Goebel M, Zlotecki R, Scarborough MT. (b) A 1.5 5-cm intra-articular dislodged cartilage fragment was retrieved. After 2 courses of adjuvant chemotherapy with ifosfamide and doxorubicin hydrochloride, adjuvant RT was administered, with a total of 60 Gy in 30 fractions (Figure 4). We assumed that this insufficiency fracture resulted from the stripping of the periosteum from the proximal tibia and adjuvant RT. [1] Unlike secondary osteonecrosis or post-arthroscopic osteonecrosis, there is no consensus with regards to the etiology of the condition. HHS Vulnerability Disclosure, Help Preoperative imaging showed no apparent bone invasion. Zhang R, Wang Z, Zhu G, et al. , . Chemo chemotherapy; LIPUS low-intensity pulsed ultrasound. Radiographics : a review publication of the Radiological Society of North America, Inc. MRI features that aid in diagnosis of acute traumatic injuries, subchondral insufficiency fracture, and its potentially irreversible form, spontaneous osteonecrosis of the knee include the location and extent of bone marrow edema, the presence of a fracture line, a hypointense area immediately subjacent to the sub chondral bone plate, and deformity of the subChondralBone plate. The most common finding is a sclerotic band or line. Subchondral insufficiency fracture of the knee (SIFK) is a potentially devastating disorder that may progress rapidly to osteoarthritis with articular surface collapse. The clinical data used during the current study are available from the corresponding author on reasonable request. Sacral insufficiency fracture--a case of post-coital back pain. Case study, Radiopaedia.org (Accessed on 05 Dec 2022) https://doi.org/10.53347/rID-88093 Marx A, Beier A, Taheri P, Rpke M, Kalinski T, Halder AM. In terms of safety, Busse et al reported no adverse events associated with LIPUS treatment in a randomized clinical trial (Re-evaluation of low-intensity pulsed ultrasound in treatment of tibial fractures (TRUST)) [14]. We also assumed that this would be a refractory fracture. J Bone Joint Surg Am. It should be suspected in the appropriate clinical setting, as in early stages it is usually indistinct on initial plain radiographs and magnetic resonance imaging is required for a definitive diagnosis. Zagars GK, Ballo MT. Total and unicondylar knee arthroplasty are equivalent treatment options in end-stage spontaneous osteonecrosis of the knee, and the size of the lesion has no influence on the results. Intraoperative photos. Accessibility Clinical management of radiation-associated pathological fracture is challenging because of a high nonunion rate and potential for morbidity. Subchondral insufficiency fracture of the knee (SIFK) is a potentially devastating disorder that may progress rapidly to osteoarthritis with articular surface collapse. SIFK typically presents with acute knee pain localized to the area of the subchondral fracture [ 1, 2 ]. (2011). Subchondral insufficiency fracture of the knee is The answer is "probably," but much more rarely than initially believed. The patient was treated with LIPUS for 1 year. collected clinical data and prepared the manuscript. Gorbachova T, Melenevsky Y, Cohen M, Cerniglia BW. Epub 2016 Jan 14. Standard weight-bearing anteroposterior (AP) radiographs at 0 and 30 of flexion, sunrise radiographs, and lateral radiographs of the knee should be ordered to evaluate the level of osteoarthritis or presence of osteochondritis dissecans lesions. The patient remained free of symptoms and had no recurrences for 2 years after surgery. Y.H.B.T. - , , ? Subchondral insufficiency fracture refers to a type of stress fracture that occurs below the chondral surface on a weight-bearing surface of a bone due to mechanic failure of , . Therefore, the entire popliteus muscle and the adjacent tibial periosteum were resected. Subchondral insufficiency fracture refers to a type of stress fracture that occurs below the chondral surface on a weight-bearing surface of a bone due to mechanic failure of subchondral cancellous bone. Insufficiency fracture. Insufficiency fractures are a type of stress fracture, which are the result of normal stresses on abnormal bone. They should not be confused with fatigue fractures which are due to abnormal stresses on normal bone, or with pathological fractures, the result of diseased, weakened bone due to focal pathology such as tumours An official website of the United States government. (c) From left to right: the resected SIFK lesion during distal femur cut, the dislodged cartilage fragment, and the tibia cut. 28 (6): 413-20. T1WI, T1-weighted images; STIR, short TI inversion recovery; LIPUS, low-intensity pulsed ultrasound; M, months. 2022 May;40(5):443-457. doi: 10.1007/s11604-021-01224-3. However, MRI revealed transverse bone marrow edema with low signal intensity on T1-weighted images and high signal intensity on T2-weighted images in the proximal medial tibia, indicating an insufficiency pathological fracture caused by RT (Figure 6). Haas RL, Delaney TF, OSullivan B, et al. Treatment of post-radiation fractures can be challenging. Subchondral insufficiency fracture of the knee | Radiology Reference Article | Radiopaedia.org. Subchondral insufficiency fracture of the knee: review of current concepts and radiological differential diagnoses. The histologic findings of avascular areas in biopsy specimens appear to be a secondary phenomenon and not the primary cause. 9. Usually a concave or wedge-shaped deformity of the affected vertebra is found and a wide range of the vertebral height ratios and fracture distribution were reported (Kawaguchi et al. One of the important differential diagnoses of subchondral insufficiency fractures of the femoral head may include osteonecrosis. LIPUS could be a safe and effective treatment option for the management of radiation-associated pathological fractures. Osteochondral Lesions of the Knee: Differentiating the Most Common Entities at MRI. Preoperative CT. (a) Axial and (b) coronal plain CT images of left knee demonstrated flattening of the lateral femoral condyle and a subchondral lesion. Therefore, we decided to use a conservative non-surgical treatment. Radiology Review Manual. 2018 Sep-Oct;38(5):1478-1495. doi: 10.1148/rg.2018180044. The typical findings of subchondral Patients with subchondral insufficiency fracture characteristically have unremarkable plain radiographs, while MRI examination may reveal extensive bone marrow edema and subchondral bone collapse. Subchondral insufficiency fractures of the knee is also known as spontaneous osteonecrosis of the knee (SONK). 1 article features images from this case The treatment regime based on high-dose vitamin D administered orally and intravenous application of 3mg ibandronate two times within 8weeks decreased the pain level and functional limitations within a short-time period and eliminated the pathological findings in the MRI of all cases studied. Outcome of SIFK depends on several factors, including the initial subchondral fracture size, patient BMI, degree of osteopenia. Department of Orthopaedics and Traumatology, Tuen Mun Hospital, Tuen Mun, New Territories, Hong Kong. In a review by Sibilska etal., the prevalence of SIFK is reported at 3.4% in elderly patients [. The patient was treated with LIPUS generated by a sonic accelerated fracture healing system (SAFHS Exogen, Teijin, Tokyo, Japan) 20 minutes daily for 1 year. FOIA MRI showed that the low-intensity area on T1-weighted images (Figure 6A, 6E, arrows) and the high-intensity area on short TI inversion recovery (STIR) images (Figure 6I, arrowhead) both decreased in size over time. American volume. The new PMC design is here! Post-arthroscopic osteonecrosis of the medial tibial plateau: a case series. In these subjects pharmacotherapy for osteoporosis is warranted (Mallmin and Ljunghall. Distal radius fractures are also associated with generally low bone mass and elevated fracture risk at other skeletal sites. SIFK is a type of stress fracture that occurs when repetitive and excessive stress official website and that any information you provide is encrypted Her body mass index was 27.67 kg/m2. UKA appears to be a favorable surgical option, while the optimal treatment modality of SIFK of lateral femoral condyle is still uncertain due to rarity of the disease entity and paucity of high-quality evidence. Also, 76% of acetabular fractures had concomitant fractures present (Cabarrus et al. We only described 1 case and summarized our experience with therapeutic evaluation of LIPUS for insufficiency radiation-associated fracture of the tibial plateau. 2020 May 6;102(9):821-829. doi: 10.2106/JBJS.19.00381. First, does spontaneous osteonecrosis of the knee in fact exist? National Library of Medicine Many guidelines recommend adjuvant RT if margin-positive resection is anticipated [1]. Spontaneous insufficiency fracture of the knee is a potentially devastating yet poorly understood disease entity that can lead to secondary osteoarthritis. LIPUS accelerated the repair of fractures during various steps of the fracture repair process in an animal model [11]. Unable to process the form. Management of radiation-associated fractures. Osteonecrosis of bone. Several studies have reported a nonunion rate as high as 45% in patients with sarcoma who have post-radiation fractures [5]. In addition, we must be careful because deep infection rates up to 20% after surgery have been reported for radiation-associated fractures in some series [5,8]. Four patients developed osteonecrosis; three, insufficiency fractures; and three, rapid progressive OA. In general, the circumscribed lesions on MRI, which are commonly observed in osteonecrosis, are not found (Yamamoto et al. Subchondral insufficiency fracture of the knee typically affects individuals that are 55 or older and presents with sudden non traumatic unilateral knee pain. Imaging Features and Management of Stress, Atypical, and Pathologic Fractures. The timeline of the clinical course is summarized in Figure 7. Subchondral insufficiency fracture of the knee: review of current concepts and radiological differential diagnoses. (B) Immunohistochemical staining with an anti-SS18-SSX fusion-specific antibody revealed strong diffuse nuclear positivity. Twelve cases are described in which the clinical entity of oste onecrosis of the femoral condyle was diagnosed because the patients had a clinical picture identical to that of osteonecrosis and also had positive bone scans, however, roentgenographic changes supposedly diagnostic of the condition were not seen. W B Saunders Co. (2001) ISBN:0721690270. If the radiographs are inconclusive and pain persists, either MRI or CT will be performed. Long-term bisphosphonate use has also been associated with insufficiency fractures 5. Pathophysiology may represent a subchondral insufficiency fracture also believed to be caused by a meniscal root tear Presentation Symptoms sudden onset of severe knee pain effusion limited range of motion secondary to pain tenderness over medial femoral condyle Imaging Radiographs recommended views standing AP and lateral of hip, knee and ankle UK guidelines for the management of soft tissue sarcomas. The https:// ensures that you are connecting to the February 9, Radiographs of the knee was performed, but the patient was only reported to have degenerative joint disease (. (a) A 1.5 5-cm subchondral defect was found at the weight-bearing surface of the lateral femoral condyle. If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. Multidetector computed tomography (MDCT) is currently standard and allows multiplanar reconstruction, near isotropic 3D reconstructions of anatomical structures, reduction of artefacts as well as thin-section high-resolution imaging which is beneficial to visualizing also subtle fracture lines. Chen C, Chandnani V, Kang HS et-al. (A) Axial view, (B) sagittal view, and (C) coronal view. Anteroposterior radiograph of the pelvis demonstrates areas of sclerosis in both sacral ala (, Axial MRI (STIR-sequence) of the pelvis demonstrating bone marrow edema pattern in bilateral sacrum compatible with bilateral insufficiency fractures, Axial MRI (T1-w-sequence) demonstrating signal loss in both sacral ala compatible with bilateral insufficiency fractures in a 55-year-old woman after radiotherapy of the pelvis for cervical carcinoma, AP radiograph of both hip joints shows insufficiency fractures (, Coronal CT-reformation of the sacrum demonstrates sacral insufficiency fractures at S1 with fracture lines and sclerosis. Case study, Radiopaedia.org (Accessed on 05 Dec 2022) https://doi.org/10.53347/rID-88093 There may be a fluid-filled cleft underlying the subchondral bone plate, indicating gross collapse and separation. Ethics approval was obtained from the New Territories West Cluster Research Ethics Committee of Hospital Authority, Hong Kong. At 5 months after surgery and 2 months after the completion of radiation therapy, she developed an insufficiency pathological fracture of the proximal tibia without any apparent trauma. " " - . The typical findings of subchondral insufficiency fracture of the knee on magnetic resonance imaging (MRI) include cortical thickening associated with high-intensity MRI scans and the identification of risk factors and associated lesions. Disclaimer, National Library of Medicine There is a potential limitation in this study. Before We appreciate the help of Dr. Sanshiro Inoue in the discussion section. JJ Abstract Subchondral insufficiency fracture of the knee (SIFK) is a common cause of knee joint pain in older adults. 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