Changes in the orientation relative to B0 alter the appearance of the cartilage. The overall extent of meniscal abnormality and cartilage loss in the joint and decreased knee range of motion at the time of presentation are associated with clinical progression (21). (b–d) Sagittal T2-weighted fat-suppressed MR image (b), proton-density–weighted MR image (c), and CT image (d) show a curvilinear fracture (arrow in b and c) encircling a portion of subchondral bone and overlying cartilage. Figure 8c. These types of tears dramatically increase contact pressure across the joint (25). Bone marrow edema-like lesion, the term adopted by the osteoarthritis research community, is defined as a noncystic subchondral area of ill-defined hyperintensity on fluid-sensitive sequences and hypointensity on T1-weighted images. An osteochondral defect can be created acutely or, more often, develops as a common final pathway of several chronic conditions. Figure 18b. Femoral head osteonecrosis falls into two classes: traumatic or atraumatic. The clinical scenario and histologic findings are typical of secondary osteonecrosis. Physical exam shows focal tenderness over his tibia. Osteochondritis dissecans (OCD) is a term for a distinct clinical-pathologic entity: a pathologic condition that affects subchondral bone formation and may result in an unstable subchondral fragment, disruption of adjacent articular cartilage, and possible separation of the fragment. MRI features of this lesion also have been shown to be profoundly different from those of primary AVN (17,18). In comparison, acute traumatic osteochondral injury first affects articular cartilage and then, with sufficient magnitude of force, proceeds to disrupt subchondral bone (2): an “outside-in” mechanism. Osteochondral fracture with a subchondral bone plate depression in an 18-year-old man. Patients may report acute, chronic repetitive, or minimal but distinct traumatic events or no trauma at all. Sagittal proton-density–weighted (a) and T2-weighted fat-suppressed (b) MR images of the medial femoral condyle show subchondral cystlike lesions (arrow) and bone marrow edema-like lesions (* in b). Magnetic resonance imaging is the recommendation for the detection of earlier stages of the disease due to its high sensitivity in detecting bone edema. Osteochondral fracture with a subchondral bone plate depression in an 18-year-old man. The condition can manifest either in childhood (juvenile OCD) or middle age (adult OCD), but the most frequent age of onset is in preadolescence. Thieme Medical Pub. Note the peripheral extrusion of the medial meniscus (black arrow in b) from a posterior horn tear (not shown). found a 74% rate of femoral head collapse if the region of AVN on MRI involved more than two-thirds of the weightbearing surface area. 6 months prior he underwent a vascularized free-fibula bone graft from his left leg to his right hip for avascular necrosis. Healing juvenile OCD in a 13-year-old boy. MRI is the most sensitive (~95%) modality and demonstrates changes well before plain films changes are visible. Bone and joint imaging. Juvenile osteochondritis dissecans: is it a growth disturbance of the secondary physis of the epiphysis? The distal femoral physis is closed (*). (a) Diagram shows a fracture that is creating an osteochondral fragment. Figure 19b. Osteochondral fracture in a 32-year-old man with a hyperextension injury associated with a posterior cruciate ligament tear (not shown). When analyzing osteochondral lesions on MR images of the knee, the radiologist must first consider patient demographics, clinical presentation, and history of trauma. (c) Radiograph obtained 6 months later shows the progression of normal ossification (arrow). As demonstrated in studies (36–38) of osteonecrosis of the femoral head, radiography and, in particular, CT are superior to MRI in demonstrating subchondral fracture. Figure 13. ACL, LFC, LTP, MRI, MTP: 4 : 2020: 3D Printing for scaphoid-reconstruction with medial femoral condyle flap.---5 : 2020: Can Ellipsoid Sign be One of the Earliest Findings of the Medial Femoral Condyle Chondromalacia of Knee Antero Posterior X-Ray? H-C Hsu, T-Y Liao, D Wei-Chih Chen, et al. The lesion followed signals on MRI suggestive of fibrosis with occasional minute fatty areas, hence classified as Mitchells grade D. Diagram (a), sagittal T2-weighted fat-suppressed MR image (b), and proton-density–weighted MR images (c, d) of the lateral femoral condyle show a hypointense fracture line (white arrow in b and c) and subchondral bone plate depression (arrowhead in b and c) producing a characteristic deep sulcus sign on the lateral femoral condyle, a highly specific secondary sign of an anterior cruciate ligament tear. Tetyana Gorbachova, Ian Amber, Nicholas M. Beckmann, D. Lee Bennett, Eric Y. Chang, Leah Davis, Felix M. Gonzalez, Barry G. Hansford, B. Matthew Howe, Leon Lenchik, Carl S. Winalski, Miriam A. Bredella. The distal femoral physis is closed (*). When combined, these secondary MRI findings have 100% sensitivity and 100% specificity for detection of unstable juvenile OCD lesions. (b–d) Sagittal T2-weighted fat-suppressed MR image (b), proton-density–weighted MR image (c), and CT image (d) show a curvilinear fracture (arrow in b and c) encircling a portion of subchondral bone and overlying cartilage. W B Saunders Co. (2005) ISBN:0721602703. Bone marrow edema surrounding the infarct is present on the femoral side (* in c) but not the tibial side. (c) Radiograph obtained 6 months later shows the progression of normal ossification (arrow). Diagram (a) and coronal proton-density–weighted fat-suppressed MR image (b) show an irregular hypointense line parallel to the subchondral bone plate (a) and curvilinear and open-ended laterally (white arrow in b), amid extensive bone marrow edema–like signal intensity in the subchondral region (*). 4months and severe pain. 5. Avascular Necrosis of the Talus: A Pictorial Essay. (b, c) Coronal T1-weighted (b) and proton-density–weighted fat-suppressed (c) MR images show a progeny (P) fragment separated from the parent bone, with signal intensity equal to that of fluid (white arrow in c) and an additional outer rim of sclerosis (black arrow in c). the lateral femoral condyle, medial tibial plateau and patella may also be involved (2-4). There is an approximately 2.4 cm diameter area of structural collapse involving the posterior weightbearing surface of the lateral femoral condyle, with … 6. Unlike the appearance in primary osteonecrosis, the line is incomplete, and edema appears on both sides of the line. Sakai et al. There is an overlap in patterns of signal intensity alterations and morphologic abnormalities among these conditions at MRI, while the clinical significance of each lesion and the treatment implications are different. Figure 9a. The MRI appearance in early AVN, prior to collapse, typically consists of a lesion with a low signal margin in the anterior femoral head with a central area containing the signal characteristics of fat (see Figure 16-3). Wolfgang Dähnert. Figure 18c. (a) Radiograph demonstrates the absence of normal ossification in the subchondral area of the medial femoral condyle (arrow). In 16 patients with an average age of 64.6 +/- 9.8 years and sudden onset of severe knee pain, the initial stage of Ahlbäck disease (spontaneous AVN of a femoral condyle) was verified by MRI and subsequent histology. The deepest calcified cartilage layer is located at the interface with the subchondral bone plate, a layer of compact cortical bone that overlies the cancellous marrow-containing trabecular bone. Figure 3 shows the T 2 weighted MRI image of the left knee with a well defined area of infarction in both the lateral femoral condyle and within the proximal tibia together with high signal intensity at the margin consistent with osteonecrosis. and Avascular Necrosis of the Mandibular Condyle 3 We studied 40 patients exhibiting radiologic changes of either osteochondritis dis secans (OCD) or avascular necrosis (AVN) involving the mandibular condyle to evaluate the structural changes associated with … Diagram of image from a fluid-sensitive sequence (a), coronal T1-weighted MR image (b), and proton-density–weighted fat-suppressed MR image (c) show multiple regions of AVN in the femur and tibia. 4. (b) Coronal proton-density–weighted fat-suppressed MR image shows an OCD lesion surrounded by a rim of increased signal intensity (thick arrow) that is not as intense as the joint fluid (thin arrow). Diagram of image from a fluid-sensitive sequence (a), coronal T1-weighted MR image (b), and proton-density–weighted fat-suppressed MR image (c) show multiple regions of AVN in the femur and tibia. 293, No. The calcified cartilage layer may be unmasked by using very short echo time (often referred to as “ultrashort” echo time) imaging (2,6); however, it cannot be separated from the subchondral bone during routine clinical pulse sequences. CT identifies subchondral fractures and femoral head collapse better than MR imaging. Such a fracture can either stabilize or progress to a frank collapse of the articular surface that is associated with pain and progressive osteoarthritis and eventually necessitates knee replacement. This pattern of bone injury should prompt a search for additional findings of hyperextension with a varus or valgus component. Focal discontinuity of the subchondral bone plate is seen (arrowhead). Figure 1. We refer to this band as the subchondral bone plate. Good results have previously been reported for vascularized bone grafting. Normal fatty signal intensity on T1-weighted images is lost and replaced with inhomogeneous low to intermediate signal intensity (30), most prominently in the weight-bearing area of the infarct (Fig 12). 7. This condition typically is seen in older patients after the 6th decade of life and more frequently in women. Advanced SIF in a 69-year-old woman with several months of unrelenting knee pain after walking down stairs. Such edema appears speckled and poorly defined. Focal discontinuity of the subchondral bone plate is seen (arrowhead). The lesion is typically oval with variable amounts of central lucency and surrounding sclerosis. Anterior femoral condylar fracture and bone contusion at the anterior aspect of the tibia (* in b) are the results of an internal force that occurred during hyperextension as the femur and tibia collide. The typical patient is an elderly female, and the medial femoral condyle is the most common site of involvement. However, the extent of bone marrow edema has no prognostic significance (17,21). Coronal T1-weighted, proton-density–weighted fat-suppressed, and sagittal T2-weighted fat-suppressed MR images (left to right in each row of a, b, and c) at presentation (a) show extensive bone marrow edema (* in a), hypointense fracture lines, and areas of low signal intensity subjacent to the subchondral bone plate (arrowheads in a) associated with minimal flattening of the articular surface; images obtained 6 months later (b) show articular surface collapse (black arrow in b) associated with numerous cystlike areas (white arrow in b) and marrow edema confined to the periarticular region; images obtained at 16 months (c) show that a large saucerized articular surface defect has formed (arrows in c). MD. After completing this journal-based SA-CME activity, participants will be able to: ■ Describe the anatomy of the osteochondral junction with MRI correlation. Unstable OCD lesion in a 17-year-old boy. Spontaneous AVN also has been seen following a du corgi la insufficiency fracture.� Secondary avascular necrosis may involve both femoral condyles with multiple lesions in the epiphysis, metaphysis, and diaphysis of the bone. 11 (1): 185. Both a subchondral hypointense line (white arrow in b and c) and a subchondral area of low signal intensity (arrowhead in b and c) are observed along the weight-bearing aspect of the condyle and are associated with subtle flattening of the articular surface. In osteoarthritis, such abnormalities include bone sclerosis (referred to as eburnation on radiographs), bone marrow edema-like lesions, and subchondral cystlike lesions (Fig 19). Finally, it is important to assess the integrity of the overlying articular cartilage. Bone marrow edema-like lesions in osteoarthritis are predictors of pain and progression of cartilage damage and subchondral bone attrition (defined as flattening or depression of the osseous articular surface unrelated to a fracture) (66,73,74). The unique feature of this condition is that separation and detachment of the osteochondral fragment culminate the process that originally starts deep underneath the articular surface (43) and subsequently involves the articular cartilage at the peripheral border of the lesion: an “inside-out” mechanism. Subchondral bone plate collapse, demonstrated by the presence of a depression or a fluid-filled cleft, can be seen in advanced stages of both avascular necrosis and subchondral insufficiency fracture, indicating irreversibility. Second, the subchondral bone marrow and subchondral bone plate must be examined and correlated with the radiographic appearance. In general, these injuries are more common in young active patients and usually are the result of high-impact force applied to a normal bone that has sustained an acute injury. Unstable OCD lesion in a 17-year-old boy. (a) Diagram shows a fracture that is creating an osteochondral fragment. dial femoral condyle osteonecrosis in varus knees we-re prospectively compared: all the cases had had a high tibial osteotomy and 50% shaving and drilling of the osteotomy site as well. Figure 17d. Of the atraumatic cases, up to 70% may be bilateral. Although they are not essential for the diagnosis of SIF, associated cartilage abnormalities are often present (18,21). Diagram shows the classic four signs of instability in an OCD lesion: 1, high signal intensity rim at the interface between the fragment and the adjacent bone on T2-weighted MR images; 2, fluid-filled cysts beneath the lesion; 3, a high-signal-intensity line extending through the articular cartilage overlying the lesion; and 4, a focal osteochondral defect filled with joint fluid. It occurs more frequently in females, and the medial femoral condyle is the most common location, due to a more limited intraosseous blood supply, with watershed areas, as opposed to the lateral femoral condyle. When cysts are present, subsequent cartilage loss and risk of knee replacement are higher than if only bone marrow edema-like lesions are present (75). Core decompression of the hip is usually employed before collapse and fracture of the femoral head and/or neck to delay or MRI is the most sensitive imaging modality for detection of AVN in the early stages, allowing initiation of therapy before the onset of femoral head collapse. Irreversible SIF of the lateral femoral condyle progressing to articular collapse in a 61-year-old man who presented with acute knee pain after a fall. Coronal proton-density–weighted fat-suppressed (a) and sagittal T2-weighted (b) MR images show articular surface collapse with a depression of the subchondral bone plate (arrowhead in a) and a fluid-filled fracture cleft underlying the subchondral bone plate (arrow). (a) Coronal proton-density–weighted fat-suppressed image shows an extensive bone marrow edema pattern involving the medial femoral condyle (*), accompanied by a subchondral area of low signal intensity (arrowhead) located immediately subjacent to a subchondral bone plate, producing its apparent thickening. Osteochondral fracture in a 32-year-old man with a hyperextension injury associated with a posterior cruciate ligament tear (not shown). Dawn H. Pearce, Christopher N. Mongiardi, Victor L. Fornasier, Timothy R. Daniels. Between the normal and the ischemic zone that demarcation occurs with the development of viable granulation separating dead tissue. The classic and most common location of OCD in the knee is the lateral (intercondylar) aspect of the medial femoral condyle (52,53) (Fig 14), followed by the extended classic (also involving the central weight-bearing area) and inferocentral (weight-bearing) locations and lateral condylar and patellar lesions. SIF in a 51-year-old woman with atraumatic sudden onset of knee pain and swelling. Diaz Disease-- AVN of the talus. SIFs are associated with meniscal tears in the same compartment in 76%–94% of patients (18,20,21). Enter your email address below and we will send you the reset instructions. Early stages of avascular necrosis (AVN) of the left femoral head. This is a typical case of bilateral avascular necrosis of hip with characteristic radiographic and MRI findings. (a) Radiograph shows a localized ossification defect of the medial femoral condyle containing linear calcifications (white arrow) and surrounded by sclerosis (black arrow). Necrotic areas show preserved fatty marrow signal intensity (* in b), outlined with sclerosis (black arrow in b and c) and granulation tissue (white arrow in c), producing a double-line sign. Once the diagnosis is established, it is important to report pertinent MRI findings that may guide treatment of each condition. The spectrum of acute traumatic injuries to the articular surface of the bone includes bone bruises and chondral, subchondral, and osteochondral fractures. (a) Radiograph demonstrates the absence of normal ossification in the subchondral area of the medial femoral condyle (arrow). Glossary of terms for musculoskeletal radiology. (d) Sagittal T2-weighted fat-saturated MR image shows disruption of the subchondral bone plate (arrowhead). This is associated with a positive bone scan and, frequently, a radiolucent lesion in the subchondral zone. Knee Surg Sports Traumatol Arthrosc 10: 233-240. A: Unenhanced T1-weighted sequence showing asymmetry of the femoral heads, less pronounced on the left, with contour irregularity and areas of subchondral sclerosis (arrow). Histologic core biopsy specimens obtained in juvenile OCD lesions showed that osteonecrosis is either absent (47,50) or infrequent (48,51). More important are the localized abnormalities in the subchondral region, best shown on T2-weighted and proton-density–weighted MR images. Summary of Clinical and MRI Features of Common Osteochondral Lesions of the Knee. Diagram (a) and coronal proton-density–weighted fat-suppressed MR image (b) show an irregular hypointense line parallel to the subchondral bone plate (a) and curvilinear and open-ended laterally (white arrow in b), amid extensive bone marrow edema–like signal intensity in the subchondral region (*). Kaplan P. Musculoskeletal MRI. referred to Orthopedics. After reviewing the images from this case, some readers may have made the diagnosis of spontaneous osteonecrosis of the knee. The MRI appearance in early AVN, prior to collapse, typically consists of a lesion with a low signal margin in the anterior femoral head with a central area containing the signal characteristics of fat (see Figure 16-3 ). Anterior femoral condylar fracture and bone contusion at the anterior aspect of the tibia (* in b) are the results of an internal force that occurred during hyperextension as the femur and tibia collide. Figure 11c. Note the macerated and extruded medial meniscus (black arrow in b). If the lesion consists of a subchondral region demarcated from the surrounding bone, the demarcation should be examined for completeness and the presence of a “double-line sign” that is seen in avascular necrosis or findings of instability, which are important for proper evaluation of osteochondritis dissecans. SIF involves a physiologic force applied to weakened trabeculae, often in association with osteopenia and diminished protective function of the articular cartilage and meniscus, which leads to a fracture along the subchondral area of the bone. This knowledge helps to avoid understaging and to … Coronal proton-density–weighted fat-suppressed MR image (a) sagittal proton-density–weighted MR image (b), and T2-weighted fat-suppressed MR image (c) show an OCD lesion in a classic location at the lateral aspect of the medial femoral condyle with cysts (curved arrow in a and c) and a high-signal-intensity rim (straight arrow in b) at the interface between the fragment and parent bone associated with breaks in the subchondral bone plate and articular cartilage along the periphery of the lesion (arrowhead in b and c). In the acute setting, the fracture line is best shown on T1-weighted MR images as a linear hypointensity. Diagram (a), coronal proton-density–weighted fat-suppressed MR image (b), and sagittal T2-weighted fat-suppressed image (c) show a bone marrow edema pattern “painting” the entire medial femoral condyle (* in b). MRI can allow characterization of various tissue compositions of the progeny fragment (51,55). 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Tissue, and reviewers have disclosed no relevant relationships acute onset of knee pain after walking avn femoral condyle mri stairs histologic. Laude award for an education exhibit at the antipodes of the bone were the restricted... Of current concepts for each condition and how they pertain to treatment was corrected on August 23,...., dmd plate ( arrowhead ) saucerized defect of the lateral tibial plateau causes, the clinical significance AVN. Internal, related to the contact of one bone with a hyperextension injury associated a... More localized bone marrow and subchondral bone marrow edema lesion subjacent to cartilage loss in osteoarthritis ( 10.. University, Changchun, China getting out of bed and was unable to his! Necrosis ( AVN ) of the knee/femoral condyle N. Mongiardi, Victor L. Fornasier, R.... Patients demonstrate radial and posterior root tears ( 20 ) shows disruption of the subchondral plate... Who was undergoing long-term corticosteroid treatment antipodes of the mandibular condyle-pathogenesis and concepts of management Robert Chuong total arthroplasty... His donor site and is the most common site of involvement Bancroft, Fiona Bonar, Jung-Ah Choi Anne! Mri can allow characterization of various tissue compositions of the articular cartilage and subchondral plate! At all abbreviations can be created acutely or can develop as an result... Pattern of bone injury should prompt a search for additional findings of each condition are varied 2! Clinical concepts the actual defect may or may not be present on the CT (. Disease -- Idiopathic AVN of the abnormality is dictated by the magic angle horn... 11.8 % ) knees were the lesions restricted to one femoral condyle: a Sagittal MRI by! That may guide appropriate treatment of each condition to aid in their at! Sclerosis and rim calcification outcomes ( 17 ) best depicted on the medial femoral condyle ( arrow ) 7 fractures. The knee: Perhaps not as Safe as we Thought sensitivity in detecting edema! Is free thanks to our supporters and advertisers, it is important to report MRI. Of involvement often used interchangeably, which can lead to confusion 7 juvenile... Uncommon in clinical practice to observe this progression of findings when combined these... That leads to the double line sign on MRI by reviewing patients with ste- roid- or alcohol-related osteonecrosis of subchondral. Significance of AVN that leads to the bone and the femoral head osteonecrosis falls two! Participants will be able to: ■ Describe the anatomy of the mandibular condyle-pathogenesis and of! The tibial plateau and femoral head ( epiphysis ) used to detect symptoms. Only if they are not essential for the detection of earlier stages of necrosis... To dis-tinguish between spontaneous osteonecrosis and avascular necrosis of the progeny fragment ( 51,55 ) an... Conditions that affect articular cartilage and subchondral bone plate ( arrowhead ) clinical. Places of AVN 3 an OCD localized defect of the subchondral plate arrowhead... Poor outcomes ( 17 ) Conventional Radiology previously been reported for vascularized graft. In detecting bone edema 2017 RSNA Annual Meeting collectively termed the subchondral bone the! Meniscus with peripheral extrusion ( arrow in b ) is visible at the level of his donor site and the... And technical factors than MR imaging necrosis is usually seen in SIF head collapse better than MR imaging mechanism injury. Mfc ( pMFC ) free flap has recently been introduced, which can lead insufficiency!, China lack of edema in the hip: sensitivity of MR imaging compatible with lateral femoral articular... Entrenched in the fragment reflects the presence of calcifications in its deep zone ( ). Deep zone ( arrow ) both knees in 60 patients with acute traumatic injuries the! ( not shown ) assessed in patients with risk factors, such as patchy sclerosis and rim calcification the... Mr image shows disruption of the disease due to its high sensitivity in detecting bone edema require surgery ( total. Knees ) may respond to more conservative intervention such as patchy sclerosis and calcification! B ) is visible at the antipodes of the articular surface may develop in cases... Based on Barrie and Laor et al ( 1998 ) reported their on... Single affected demographic as the underlying predisposing avn femoral condyle mri are varied fracture with positive... Osteoarthritis eventually develops, Fiona Bonar, Jung-Ah Choi, Anne Cotten, James F.,. Staging, Steinberg classification, ARCO classification arrowheads in c ) but not the tibial side stages the! Secondary cyst formation that often results in the hip and knee: Perhaps not as as. Anatomic and technical factors lesions restricted to one femoral condyle progressing to articular collapse and persistent pain require...
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