When it is accompanied by secondary osteoarthritis, it may be impossible to determine the original cause of epiphyseal deformity, and treatment options may be limited to joint replacement. 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. When analyzing osteochondral lesions on MR images of the knee, the radiologist must first consider patient demographics, clinical presentation, and history of trauma. In the talus, 96% of lateral lesions and 62% of m… Subchondroplasty, a procedure developed to treat bone marrow edema lesions by injecting a bone substitute, is one of the evolving treatment options for patients with SIF. Overview Osteochondral lesions or osteochondritis dessicans can occur in any joint, but are most common in the knee and ankle. 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 (*). SIFs typically are observed along the central weight-bearing aspect of the femoral condyle (60%–90%), but they also may involve the central tibial plateau, and less commonly, the periphery of the articular surface (18–21). ■ Contrast and compare common entities that manifest as osteochondral lesions of the knee: acute traumatic osteochondral injuries, AVN, SIF of the knee, OCD, bone marrow edema-like lesions, and subchondral cystlike lesions in osteoarthritis. Figure 7b. (d) Sagittal T2-weighted fat-saturated MR image shows disruption of the subchondral bone plate (arrowhead). (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. cartilage injury with associated subchondral fracture but without detachment 26 years experience Physical Medicine and Rehabilitation. More specifically, more than 50% of patients demonstrate radial and posterior root tears (20). This association and a link between SIF and meniscectomy (26) support the proposed role of mechanical stress in the development of SIF and emphasize the rationale for meniscal conservation. The distal femoral physis is closed (*). Diagram of the fluid-sensitive MR image (a) and sagittal T2-weighted fat-suppressed (b), coronal T1-weighted (c), and proton-density–weighted fat-suppressed (d) MR images show a subchondral fracture (arrow in b and c) as a curvilinear hypointensity surrounded by bone marrow edema, without associated contour deformity. 1). Figure 17b. Patients experience poorly localized knee pain for more than 1 year before diagnosis, often exacerbated by exercise (41), or with mechanical symptoms caused by dislodging of the fragment. Figure 7a. 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 (*). It is important to recognize the MRI appearance of this critical complication of AVN that leads to premature osteoarthritis. (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). This differs from the more localized bone marrow edema lesion subjacent to cartilage loss in osteoarthritis (10). 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) Radiograph demonstrates the absence of normal ossification in the subchondral area of the medial femoral condyle (arrow). 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. Figure 5b. Several pathologic conditions may manifest as an osteochondral lesion of the knee, which is a localized abnormality of the subchondral marrow, subchondral bone, and articular cartilage. Figure 11b. In osteoarthritis, such abnormalities include bone sclerosis (referred to as eburnation on radiographs), bone marrow edema-like lesions, and subchondral cystlike lesions (Fig 19). Second, the subchondral bone marrow and subchondral bone plate must be examined and correlated with the radiographic appearance. A contained grade IV lesion measuring approximately 8 mm involving the lateral femoral condyle. Figure 4b. Osteochondral fracture in a 32-year-old man with a hyperextension injury associated with a posterior cruciate ligament tear (not shown). The MRI appearance of individual layers depends on both anatomic and technical factors. 293, No. Figure 5a. 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. MRI features that aid in diagnosis include the location and extent of bone marrow edema, the presence of a fracture line, a hypointense area immediately subjacent to the subchondral bone plate, and deformity of the subchondral bone plate. Figure 5b. 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 18b. 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. Bone marrow edema surrounding the infarct is present on the femoral side (* in c) but not the tibial side. Figure 3a. Osteonecrosis tends to develop in adults, most commonly in the 4th and 5th decades of life (19). Osteochondral fracture in a 32-year-old man with a hyperextension injury associated with a posterior cruciate ligament tear (not shown). 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). AVN of the knee in a 59-year-old woman who was undergoing long-term corticosteroid treatment. Healing juvenile OCD in a 13-year-old boy. Enter your email address below and we will send you the reset instructions. and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (Y.M. Think Different: Sorting Out Osteochondral Lesions of the Knee, Subchondral Bone Marrow Edema in Patients with Degeneration of the Articular Cartilage of the Knee Joint, Search under the Cartilage: A Gamut of Subchondral Lesions, 3.0-T Evaluation of Knee Cartilage by Using Three-Dimensional IDEAL GRASS Imaging: Comparison with Fast Spin-Echo Imaging, Cartilage Disease of the Knee with Direct Arthroscopic Correlation. A study by Yamamoto and Bullough (15), which was supported by results of a later study (16), showed that the primary event is a SIF, followed by secondary necrosis limited to the area between the fracture line and the subchondral bone plate. It can manifest clinically with vague pain, or there may be no symptoms until development of subchondral bone plate fracture, (ie, collapse). Classic SIF in a 64-year-old man. 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. In early uncomplicated AVN, the marrow signal in the infarct is preserved, representing mummified fat, and there is no surrounding bone marrow edema. 15 October 2019 | Radiology, Vol. (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). These criteria were revised for juvenile OCD (62) with the addition of three secondary signs that all showed 100% specificity: (a) a T2-weighted high-signal-intensity rim surrounding a juvenile OCD lesion indicates instability only if it has the same signal intensity as that of joint fluid, (b) a second outer rim of T2-weighted low signal intensity, or (c) multiple breaks in the subchondral bone plate on T2-weighted MR images (Fig 18). Note the macerated and extruded medial meniscus (black arrow in b). Figure 14a. The two layers appear as one low-signal-intensity band overlying the subarticular marrow. Osteochondral fracture with a subchondral bone plate depression in an 18-year-old man. The literature on osteonecrosis of femoral condyles is often mixed with and sometimes dedicated entirely to spontaneous osteonecrosis of the knee. 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. Figure 18c. Plain radiographs are frequently diagnostic although magnetic resonance imaging (MRI) is typically necessary to further characterize the lesion. These two patterns may coexist. (a) Diagram shows a fracture that is creating an osteochondral fragment. If the address matches an existing account you will receive an email with instructions to reset your password. Note articular surface collapse of the medial femoral condyle (arrowhead in b and c), with depression of the subchondral bone plate (c) and loss of subchondral fatty signal intensity (b). This pattern of bone injury should prompt a search for additional findings of hyperextension with a varus or valgus component. Figure 14b. SIFs are associated with meniscal tears in the same compartment in 76%–94% of patients (18,20,21). More important are the localized abnormalities in the subchondral region, best shown on T2-weighted and proton-density–weighted MR images. Focal discontinuity of the subchondral bone plate is seen (arrowhead). In early uncomplicated AVN, the marrow signal in the infarct is preserved, representing mummified fat, and there is no surrounding bone marrow edema. 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). CLINICAL MRI OF OSTEOARTHRITIS AND OSTEOCHONDRAL INJURY As discussed in Chapter 2, the structural integrity and function of cartilage and underlying bone are intimately coupled. 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