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Normal MR Imaging Anatomy of the Knee

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Normal MR Imaging Anatomy of the Knee Normal MR Imaging Anatomy of the Knee Saifuddin Vohra, DO, George Arnold, MD, Shashin Doshi, MD, David Marcantonio, MD* KEYWORDS Anatomy Knee MR imaging Pitfalls There are several keys to successfully interpreting In general, optimal evaluation is achieved when MR imaging examinations. Initially, constructing the imaging planes are oriented perpendicular to a solid foundation consisting of a good under- and parallel to the long axis of the structure in standing of basic MR imaging principles and question. The multiplanar capability of MR imaging imaging protocols as well as the appearance of allows for oblique sagittal image acquisition normal imaging anatomy is crucial. This knowl- oriented parallel to the lateral femoral condyle, edge can be then applied to one’s understanding which optimizes evaluation of the anterior cruciate of pathology commonly encountered in the area ligament (ACL), horns of the menisci, femorotibial of interest. Careful attention should be focused joint and femoral trochlear articular cartilage, on awareness of commonly encountered normal cruciate ligaments, and extensor mechanism. variants and diagnostic pitfalls to improve accu- The coronal plane of imaging is preferred for eval- racy and avoid misinterpretation. In this article, uation of the body of the menisci, and medial and MR imaging of a healthy volunteer was performed lateral stabilizing structures. The axial plane is on a 3-T MR imaging unit (Siemens, Munich, used to evaluate the patellar articular cartilage, Germany). Normal anatomy is depicted at repre- quadriceps tendon, and medial and lateral stabi- sentative levels throughout the knee, and descrip- lizing structures. tions of frequently encountered anatomic variants The routine knee MR imaging protocol at the are provided. authors’ institution (Table 1) consists of axial intermediate PD with fat saturation, PD sagittal PROTOCOLS oblique without fat saturation, PD coronal without fat saturation, intermediate T2 coronal with fat At the authors’ institution, a combination of saturation, and intermediate T2 sagittal oblique intermediate-weighted proton density (PD) and with fat saturation sequences. When indicated, T2-weighted fast spin echo sequences with and intravenous gadolinium contrast may help to without fat suppression are used to provide excel- further characterize neoplastic, infectious, and lent anatomic detail and localize pathology. Fat inflammatory processes. Prior to gadolinium suppression accentuates bone marrow and soft contrast administration, an axial T1-weighted tissue edema on fluid-sensitive sequences, and sequence with fat suppression is obtained as non–fat-suppressed images increase conspicuity a control sequence. Following intravenous gado- of bone marrow abnormalities on short echo time linium contrast administration, T1-weighted fat- (TE) sequences. Furthermore, fast spin echo PD suppressed sequences are obtained in the axial sequences employing fat saturation are accurate plane, and at least one additional orthogonal and sensitive for evaluation of meniscal tears and plane. Indications for intra-articular dilute gadoli- articular cartilage disruption. nium contrast administration include suspected The authors having nothing to disclose. Division of Musculoskeletal Radiology, Department of Diagnostic Radiology-Imaging Center, William Beau- mont Hospital, 3601 West 13 Mile Road, Royal Oak, MI 48073, USA * Corresponding author. E-mail address: [email protected] Magn Reson Imaging Clin N Am 19 (2011) 637–653 doi:10.1016/j.mric.2011.05.012 1064-9689/11/$ – see front matter Ó 2011 Elsevier Inc. All rights reserved. mri.theclinics.com 638 Vohra et al Table 1 Routine MR imaging protocol: knee (volume surface phased array) coil Fat Slice Thickness/Gap Sequence Saturation FOV (cm) Matrix TR (ms) TE (ms) (mm) Intermediate PD axial Y 14 313 Â 384 4430 11 3/0.6 Intermediate T2 sagittal Y 14 200 Â 256 2920 56 3/0.6 oblique Intermediate T2 coronal Y 14 200 Â 256 4050 56 3/0.6 PD coronal N 14 314 Â 448 1200 15 3/0.6 PD sagittal oblique N 14 314 Â 448 1200 15 3/0.6 Setup: Feet first, supine, knee minimally flexed, neutral to slightly externally rotated; 3-T MR unit (Siemens, Germany). Post-gadolinium contrast T1-weighted sequences are obtained in at least 2 orthogonal planes with fat suppression. Abbreviations: FOV, field of view; PD, proton density; TE, echo time; TR, repetition time. meniscal retear after meniscectomy, and evalua- oblique ligament, a major stabilizer of the postero- tion for instability of an osteochondral lesion. medial knee. The MCL bursa is located along the The field strength, coil (volume surface phased middle third of the medial knee joint between the array), slice thickness, field of view, matrix size, superficial and deep components of the MCL.2 and other select imaging parameters are opti- The lateral femorotibial compartment is formed mized with the goal of increasing the signal to by the lateral femoral condyle and lateral noise ratio and decreasing scan time, thereby tibial plateau articulation, and houses the lateral decreasing motion artifact. Metal artifact reduction meniscus and articular cartilage. It can communi- can be achieved by orienting the long axis of cate with the proximal tibiofibular joint in a minority metallic prosthesis parallel to both magnetic field of individuals. Lateral joint stabilizers are com- and frequency encoding axis, employing fast posed of muscles, tendons, and ligaments. The spin echo techniques with increased echo train anterolateral joint is stabilized by the joint capsule length, increasing receiver band width, decreasing and the iliotibial tract, which inserts on Gerdy’s field of view, and increasing the matrix size in the tubercle along the anterolateral tibia, and is a fascial direction of the frequency encoding gradient.1 extension of the tensor fascia lata. The posterolat- eral corner is a complex anatomic area providing IMAGING ANATOMY stabilization, achieved by several structures in- cluding the fibular (lateral) collateral ligament The knee, a hinge-type joint, is primarily composed (FCL), biceps femoris tendon, popliteus muscle of 3 articulating compartments: patellofemoral, and tendon, popliteal fibular and popliteal meniscal medial femorotibial, and lateral femorotibial. A ligaments, oblique popliteal, arcuate, and fabello- combination of muscles, tendons, ligaments, and fibular ligaments, and lateral gastrocnemius extensions of the joint capsule collectively help to muscle. These structures are collectively referred offer multidirectional stability to the knee, while al- to as the arcuate ligament complex. The major lowing for necessary mobility. Numerous bursae stabilizers of the posterolateral corner are ade- about the knee allow for ease of motion of the stabi- quately visualized on routine knee MR imaging lizing structures in relation to one another. examinations. The FCL has an oblique course The medial femorotibial compartment is formed from the lateral femoral condyle, immediately ante- by the medial femoral condyle and medial tibial rior to the origin of the lateral head of the gastrocne- plateau articulation, and houses the medial mius muscle, to the fibular head. The biceps meniscus and articular cartilage. Major medial femoris common tendon, directly posterior to the stabilizers include the deep (coronary ligaments) iliotibial tract at the level of the femoral condyles, and superficial portions of the medial collateral liga- joins the FCL to form the conjoint tendon before in- ment (MCL), medial tendons (sartorius, gracilis, serting upon the fibular head. The intra-articular semitendinosus, and semimembranosus), and segment of the popliteus tendon originates just deep crural fascia of vastus medialis, which helps below and passes beneath the FCL (through the to form the medial patellar retinaculum anteriorly. popliteus hiatus), and then the arcuate ligament. Posteriorly, the deep portion of the MCL, with The extra-articular segment of the tendon quickly contributing fibers from the semimembranosus joins its muscle belly, which in turn attaches to the tendon and synovial sheath, form the posterior posteromedial proximal tibial surface. Normal MRI Anatomy of the Knee 639 The menisci are C-shaped structures composed of the medial femoral condyle and tapers as it of relatively small anterior and larger posterior inserts along the posterior mid tibia approximately horns and a central body. The menisci are divided 1 cm below the joint line.7 Both cruciate ligaments into an inner avascular or white-white zone (>5 mm have two distinct components, an anterolateral from the capsule), middle hypovascular or red- and posteromedial bundle. A normal recess, which white zone (3–5 mm from the capsule), and outer can accumulate fluid, is located posterior to the vascular or red-red zone (<3 mm from the PCL.8 capsule).3,4 The extensor mechanism of the knee is Several potential diagnostic pitfalls exist in- composed of the quadriceps tendon, prepatellar volving the menisci, and awareness of anatomic quadriceps continuation, and patellar tendon.9 variants related to these structures is essential to The quadriceps tendon is striated in appearance, avoid misinterpretation. The most common menis- due to interspersed fat between 4 contributing comeniscal ligament is the anterior transverse muscles: vastus lateralis, vastus intermedius meniscal ligament, which can be a potential diag- (deep), rectus femoris (superficial), and vastus me- nostic pitfall because the junction of the ligament
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