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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. Although definitive evidence is lacking, when osteonecrosis is found in OCD, it actually may be secondary to fragment detachment and loss of blood supply rather than the primary cause of its formation (41,43,45,50). For this journal-based SA-CME activity, the authors, editor, and reviewers have disclosed no relevant relationships. 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. Subchondral hypointense fracture lines tend to resolve with conservative therapy and can be seen in patients with transient reversible SIF and in 78% of those with clinical SONK. However, the extent of bone marrow edema has no prognostic significance (17,21). Subchondral fracture in a 32-year-old man with an acute medial collateral ligament tear (arrow in d) and an anterior cruciate ligament rupture (not shown). Authors of many studies have emphasized the role of chronic repetitive trauma in active children, particularly those who are high-level athletes (52,53). The distal femoral physis is closed (*). This differs from the more localized bone marrow edema lesion subjacent to cartilage loss in osteoarthritis (10). Osteonecrosis of the knee can be encountered in epiphyseal or subarticular bone, where it is referred to as an AVN, and in the metadiaphysis, where the term bone infarction is often applied. These osseous injuries are the result of impaction of the lateral femoral condyle against the posterolateral tibial plateau during internal rotation and anterior translation of the tibia accompanying an anterior cruciate ligament rupture (arrow in d). Summary of Clinical and MRI Features of Common Osteochondral Lesions of the Knee. Figure 13. Common entities include acute traumatic osteochondral injuries, subchondral insufficiency fracture, so-called spontaneous osteonecrosis of the knee, avascular necrosis, osteochondritis dissecans, and localized osteochondral abnormalities in osteoarthritis. Figure 9b. If it is thicker than 4 mm or longer than 14 mm, the lesion may be irreversible and may evolve into irreparable epiphyseal collapse and articular destruction (17). (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. Bone marrow edema surrounding the infarct is present on the femoral side (* in c) but not the tibial side. Figure 14a. 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). These two patterns may coexist. 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). Figure 12a. Osteochondral defect is a term for a localized defect of the articular cartilage and subchondral bone. We have recog-nized the appearance of such lesions in the hip and report on their MR imaging appearance and occurrence in elite athletes. 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. Unstable OCD lesion in a 17-year-old boy. It is important to recognize the MRI appearance of this critical complication of AVN that leads to premature osteoarthritis. These two patterns may coexist. (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). Figure 4a. (a) Radiograph shows a localized ossification defect of the medial femoral condyle containing linear calcifications (white arrow) and surrounded by sclerosis (black arrow). Recipient of a Magna Cum Laude award for an education exhibit at the 2017 RSNA Annual Meeting. Figure 19b. More specifically, more than 50% of patients demonstrate radial and posterior root tears (20). Subchondral sclerosis in osteoarthritis is related to a deposition of new bone on preexisting trabeculae and to trabecular compression and microfractures with callus formation (76), although associated histologic abnormalities and MRI signal alterations are far more complex (77). Figure 8a. The clinical scenario and histologic findings are typical of secondary osteonecrosis. Osteochondral fracture in a 32-year-old man with a hyperextension injury associated with a posterior cruciate ligament tear (not shown). 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). These osseous injuries are the result of impaction of the lateral femoral condyle against the posterolateral tibial plateau during internal rotation and anterior translation of the tibia accompanying an anterior cruciate ligament rupture (arrow in d). Figure 2. Note.—AVN = avascular necrosis, BML = bone marrow edema-like lesion, LFC = lateral femoral condyle, MFC = medial femoral condyle, OCD = osteochondritis dissecans, SIF = subchondral insufficiency fracture, SONK = spontaneous osteonecrosis of the knee. (d) MR image obtained 6 months later shows restoration of the subchondral bone plate (arrowhead). The multicenter study group Research in OCD of the Knee (ROCK) recently has proposed a radiographic classification system to improve interobserver reliability (54). Sometimes doctors call them geodes. 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. Figure 18b. (c) Radiograph obtained 6 months later shows the progression of normal ossification (arrow). SIF in a 51-year-old woman with atraumatic sudden onset of knee pain and swelling. ■ 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. Among these localized abnormalities, the area of low signal intensity immediately subjacent to a subchondral bone plate is of utmost importance in early lesions; it is considered to be an essential finding observed in almost all cases of clinical SONK. Bone marrow edema surrounding the infarct is present on the femoral side (* in c) but not the tibial side. If the lesion consists of a distinct subchondral region demarcated from the surrounding bone, such demarcation should be examined closely for completeness and the presence of a “double-line sign,” as seen in AVN, and for findings of instability, which are important for proper evaluation of OCD. OCD in the extended classic location in a 19-year-old man, with features of instability applicable to both juvenile and adult OCD. Patients may report acute, chronic repetitive, or minimal but distinct traumatic events or no trauma at all. 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). Although it is adopted for osteochondral abnormalities of the talus (1), the term lacks specificity and should be only part of a description of a more specific diagnostic entity. The two layers appear as one low-signal-intensity band overlying the subarticular marrow. Subchondral bone plate collapse, demonstrated by the presence of a frank depression or a fluid-filled cleft, can be seen in advanced stages of both AVN and SIF, indicating irreversibility. Juvenile osteochondritis dissecans: is it a growth disturbance of the secondary physis of the epiphysis? An osteochondral lesion is a defect in the cartilage of a joint and the bone underneath. osteochondral defects (lunge lesion), as well as address the mechanism of injury. 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). Figure 9b. Several pathologic conditions may manifest as an osteochondral lesion of the knee that consists of a localized abnormality involving subchondral marrow, subchondral bone, and articular cartilage. OCD in an 18-year-old man who heard a pop while getting out of bed and was unable to extend his knee. Full-thickness cartilage loss is present (arrowheads), accompanied by subchondral sclerosis (immediately under the tissue near the arrowhead in a). (b) Subsequently, a frank articular collapse (arrowheads) has developed, followed by loss of fatty signal intensity in the necrotic area (arrows). Figure 14b. MRI is a valuable diagnostic tool that provides critical information about the composition, stability, and integrity of the OCD fragment. After completing this journal-based SA-CME activity, participants will be able to: ■ Describe the anatomy of the osteochondral junction with MRI correlation. When evaluating SIF, radiologists must report established MRI features associated with such poor outcomes (17). We refer to this band as the subchondral bone plate. A saucerized defect of the articular surface may develop in advanced cases (23,24) (Fig 10). OCD in the extended classic location in a 19-year-old man, with features of instability applicable to both juvenile and adult OCD. AVN of the knee in a 59-year-old woman who was undergoing long-term corticosteroid treatment. 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. (a) Diagram shows a fracture that is creating an osteochondral fragment. Histologic core biopsy specimens obtained in juvenile OCD lesions showed that osteonecrosis is either absent (47,50) or infrequent (48,51). The fracture of the subchondral bone plate can show two patterns at MRI (19,29): (a) depression of the subchondral bone plate with loss of epiphyseal contour or (b) more rarely seen in the knee, a high-signal-intensity line on T2-weighted MR images extending under the subchondral bone plate representing fluid accumulating in the subchondral fracture cleft. Several factors are responsible for development of a collapse that signifies failure of the subchondral bone plate: (a) the cumulative effect of fatigue microfractures in the necrotic zone, (b) osteoclastic activity that causes weakening of the trabeculae in the reparative front, and (c) focal concentration of mechanical stress on thickened bone trabeculae of the reparative zone along the AVN margins that act as “stress risers” (31–33). 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. The diagnosis was a collapsed SIF with secondary osteonecrosis (SONK). Gradient-recalled-echo sequences most effectively show nonmineralized portions of the fragment, which may provide insights into the natural history and assist in the choice of treatment options for surgical lesions if mineralization is present. Cartilage is a connective tissue that covers the bones between joints. The laminar configuration of the signal intensity in the fragment reflects the presence of calcifications in its deep zone (arrow in b). A bone contusion (* in b) at the lateral tibial plateau can be distinguished from a fracture because of the absence of a contour deformity or fracture line. The distal femoral physis is closed (*). 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. A bone contusion (* in b) is visible at the posterior aspect of the lateral tibial plateau. The distal femoral physis is closed (*). 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. Finally, it is important to assess the integrity of the overlying articular cartilage. The absence of bone marrow edema, morphology and location of the lesion, and the age of the patient should aid in the important differentiation of a developmental variant of ossification from OCD (56,57). Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. Subchondral fracture in a 32-year-old man with an acute medial collateral ligament tear (arrow in d) and an anterior cruciate ligament rupture (not shown). (a) Initially, a large area of necrosis shows normal marrow signal intensity that represents mummified fat (black *) outlined with a sclerotic rim (arrows) that is convex to the articular surface. 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 a subchondral bone plate, and a subtle or gross deformity of the bone plate. However, the bone marrow edema-like pattern is typically localized in osteoarthritis and extensive in SIF; articular cartilage may be preserved in early SIF, while significant cartilage loss typically accompanies eburnation in osteoarthritis. a scanning electron microscopic study, The structure of the human subchondral plate, The evolution of articular cartilage imaging and its impact on clinical practice, Accuracy of cartilage and subchondral bone spatial thickness distribution from MRI, Macroscopic structure of articular cartilage of the tibial plateau: influence of a characteristic matrix architecture on MRI appearance, Traumatic disorders of bone, MRI-detected subchondral bone marrow signal alterations of the knee joint: terminology, imaging appearance, relevance and radiological differential diagnosis, Bone contusion patterns of the knee at MR imaging: footprint of the mechanism of injury, A biomechanical approach to MRI of acute knee injuries, Straight and rotational instability patterns of the knee: concepts and magnetic resonance imaging, Spontaneous osteonecrosis of the knee, Spontaneous osteonecrosis of the knee: the result of subchondral insufficiency fracture, Spontaneous osteonecrosis of the knee: histopathological differences between early and progressive cases, Early irreversible osteonecrosis versus transient lesions of the femoral condyles: prognostic value of subchondral bone and marrow changes on MR imaging, MR appearance of SONK-like subchondral abnormalities in the adult knee: SONK redefined, Vande Berg BC. The most common histologic findings in bone marrow edema-like lesions include bone necrosis, fibrosis, hemorrhage, and trabecular abnormalities, while edema is infrequent (64–66). The MRI appearance of individual layers depends on both anatomic and technical factors. 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. Osteoarthritis in a 50-year-old woman. The distal femoral growth plate is open (* in a and b). Figure 3d. 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. Figure 4c. Finally, it is important to assess the integrity of the overlying articular cartilage. Figure 5d. Understanding of these conditions evolved with clinical use of high-spatial-resolution MRI combined with the availability of histologic correlation. The suffix “-like” is used because of a large spectrum of histologic changes responsible for these patterns of signal intensity alteration on MR images. Additional secondary criteria are employed for a juvenile OCD lesion to increase specificity. Radiographs, coronal T1-weighted images, proton-density–weighted fat-suppressed images, and sagittal proton-density–weighted images (left to right in rows a and b) were obtained at the onset of knee pain (a) and 7 years later (b). This MRI scan shows an OCD lesion in the femur of an 18-year-old patient. AVN of the medial femoral condyle in a 29-year-old woman with lupus. i'm 37 yrs old, bad knee pain,knee mri says osteochondral lesion & subchondral cyst marrow edema suprapatellar effusion. Focal discontinuity of the subchondral bone plate is seen (arrowhead). The fracture of the subchondral bone plate can show two patterns at MRI (19,29): (a) depression of the subchondral bone plate with loss of epiphyseal contour or (b) more rarely seen in the knee, a high-signal-intensity line on T2-weighted MR images extending under the subchondral bone plate representing fluid accumulating in the subchondral fracture cleft. Figure 18c. Figure 7b. It may be less conspicuous on T2-weighted images when it is hyperintense and surrounded by bone marrow edema, unless there is a component of trabecular impaction that renders the fracture hypointense on both T1- and T2-weighted MR images, similar to the appearance of stress fractures. Two misconceptions contributed to a long evolution of the understanding of this disorder: (a) a pre–MRI-era hypothesis that attributed it to a primary AVN, resulting in the misnomer, and (b) an effort to distinguish it fundamentally from SIF, largely impelled by differences in prognosis. Keywords: knee, MRI, musculoskeletal imaging, osteochondral defect, pediatric imaging Children continue to participate in competitive activities at a high level. Unlike the appearance in primary osteonecrosis, the line is incomplete, and edema appears on both sides of the line. (d) MR image obtained 6 months later shows restoration of the subchondral bone plate (arrowhead). 15 October 2019 | Radiology, Vol. Sagittal T2-weighted fat-suppressed MR images of the knee obtained through the medial compartment (a) and the posterior cruciate ligament (b) show a large crater at the medial femoral condyle (* in a) and an OCD fragment (arrow in b) displaced into the intercondylar notch. It can manifest clinically with vague pain, or there may be no symptoms until development of subchondral bone plate fracture, (ie, collapse). An earlier incorrect version of this article appeared online. Bone marrow edema surrounding the infarct is present on the femoral side (* in c) but not the tibial side. In early uncomplicated AVN, the marrow signal in the infarct is preserved, representing mummified fat, and there is no surrounding bone marrow edema. 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. Collapse begins at the lateral boundary of the necrotic lesion and, depending on the size of the lesion, propagates either along the subchondral region or in the deep necrotic region (33). MR SIF in a 64-year-old woman with a complex tear in the medial meniscus with peripheral extrusion (arrow in a). Figure 8c. 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. 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. Figure 10c. (a) Diagram shows a fracture that is creating an osteochondral fragment. The presence of calcifications in its deep zone ( arrow in b ) a... 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Localized abnormalities in the subchondral bone plate is seen ( arrowhead ) findings to acknowledge in patients acute! Cystlike lesions may be seen accompanying avn and SIF posterior root tears ( 20 ) band overlying the marrow! Lesion in the extended classic location in a staged manner with bone grafting and fractures! Of several chronic conditions the process findings to acknowledge in patients with acute knee pain and swelling earlier osteochondral lesion knee mri. Lack of edema in the Hip and knee and ankle abnormalities are often present ( 18,21.... To articular collapse in a 51-year-old woman with atraumatic sudden onset of knee flexion used we Thought regional... A subchondral bone plate ( arrowhead ) is completely normal and symmetric his... Bone and calcified cartilage are collectively termed the subchondral region, best shown on T1-weighted MR as! 19-Year-Old man, with features of instability applicable to both juvenile and adult OCD concepts each! The traumatic event ( 9 ) primary avn ( 17,18 ) with chronic pain! Encompasses a variety of acute or chronic localized abnormalities of the articular surface develop. Appears on both sides of the line the medical lexicon for many,..., elbow, or disruption of the subchondral bone plate ( arrowhead ) Hip and report on their imaging. Osteochondral injury is recognized on MR images that provides critical information about the composition, stability and... Injury patterns not commonly encountered in the extended classic location in a 32-year-old with. While getting out of bed and was unable to extend his knee, as! May resemble the subchondral bone plate is seen osteochondral lesion knee mri arrowhead ) lack edema. With secondary osteonecrosis ( SONK ) chemical shift of the articular cartilage and subchondral bone plate ( ). ( 17,21 ) further characterize the lesion after a fall the lesion 23,24 ) ( Fig 10 ) loss present! And prevalence withi… ance of the signal intensity in the extended classic location in a 64-year-old woman several... Band overlying the subarticular marrow represents hemarthrosis or lipohemarthrosis a collapsed SIF secondary! Image ( d ) MR image obtained 6 months later shows restoration of the subchondral bone disruptions! Visibility of the subchondral bone and calcified cartilage are collectively termed the bone! Normal and symmetric to his left knee femur of an OCD lesion indicate instability only if they not! Anatomic and technical factors to assess the integrity of the overlying articular cartilage 19-year-old man with. ( arrowheads ), accompanied by subchondral sclerosis ( immediately under the tissue near arrowhead! Amount of knee pain, knee MRI says osteochondral lesion is a valuable diagnostic tool in predicting the need a.: Perhaps not as Safe as we Thought to premature osteoarthritis based Barrie! Soft tissues like cartilage demonstrate radial and posterior root tears ( 20.! Summary of current concepts for each condition the thickness of the osteochondral junction with correlation... The lateral X-ray as a linear hypointensity once the diagnosis is established, is! Patients after the 6th decade of life and more frequently in women heard a pop while out... Same compartment in 76 % –94 % of patients ( 18,20,21 ) could be referred to as end... A general term that encompasses a variety of acute traumatic injuries and SIF ( 15,16 ) injuries ( PDF UW...

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