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MRI of Cartilage in the Athlete Shindle.fm Page 27 Monday, October 30, 2006 1:38 PM 27 COPYRIGHT © 2006 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Magnetic Resonance Imaging of Cartilage in the Athlete: Current Techniques and Spectrum of Disease BY MICHAEL K. SHINDLE, MD, LI F. FOO, FRCR, BRYAN T. KELLY, MD, A. JAY KHANNA, MD, BENJAMIN G. DOMB, MD, ADAM FARBER, MD, TONY WANICH, MD, AND HOLLIS G. POTTER, MD Introduction other collagen types (types IV, VI, IX, X, and XI) have been n the athletic population, reproducible imaging of carti- identified1. Collagen provides the structural framework and lage damage is vital for treatment considerations. With tensile strength of articular cartilage. Chondroitin and keratin I appropriate pulse sequencing, magnetic resonance imag- sulfates are the predominant types of proteoglycan molecules ing has been shown to be an accurate noninvasive method for that are negatively charged and attract cations and water, the evaluation of articular cartilage injuries and for evaluating which provides compressive strength to the cartilage. postoperative changes following chondral repair. In addition, The normal thickness of articular cartilage ranges from magnetic resonance imaging does not utilize ionizing radia- 2 to 5 mm and is determined by the contact pressures that tion, has direct multiplanar capabilities, and allows high- occur across a joint. Higher peak pressures result in thicker resolution imaging of soft-tissue structures. The purposes of cartilage, and the patellofemoral joint has the thickest artic- the present review are to update orthopaedic surgeons on the ular cartilage in the body. Articular cartilage can be divided applications and techniques for magnetic resonance imaging into four distinct zones. The superficial zone accounts for of cartilage in the athletic population, to define the normal 10% to 20% of the thickness and has the highest collagen magnetic resonance imaging characteristics of articular carti- content. In this zone, the collagen fibers are highly organized lage, to illustrate the spectrum of articular cartilage lesions that are detectable with magnetic resonance imaging, and to review normal and abnormal magnetic resonance imaging findings following cartilage repair. Educational Objectives fter reviewing this article, the reader should (1) have a Abasic understanding of pulse sequences and terminology for cartilage-sensitive magnetic resonance imaging, includ- ing proton-density-weighted high-resolution fast-spin-echo sequences; (2) be able to identify normal and abnormal ar- ticular cartilage in the hip, knee, elbow, shoulder, and ankle; and (3) be able to identify normal and abnormal findings on postoperative magnetic resonance images after chondral re- pair techniques. Basic Science of Articular Cartilage n understanding of the structure of articular cartilage is Acrucial in order to understand the magnetic resonance imaging appearance of normal and abnormal cartilage mor- phology and is also the basis for the development of new im- aging techniques. Articular cartilage is a viscoelastic material Fig. 1 composed of chondrocytes (approximately 1%) embedded in Sagittal non-fat-suppressed T1-weighted spin-echo magnetic resonance an organized extracellular matrix composed primarily of wa- image of the knee, demonstrating poor differential contrast between ter (65% to 80%), collagen, and proteoglycan. The predomi- the intermediate signal intensity of cartilage and the low to intermedi- nant collagen is type II (95%), although smaller amounts of ate signal intensity of joint fluid. Shindle.fm Page 28 Monday, October 30, 2006 1:38 PM 28 THE JOURNAL OF BONE & JOINT SURGERY · JBJS.ORG MAGNETIC RESONANCE IMAGING OF CARTILAGE IN THE ATHLETE: VOLUME 88-A · SUPPLEMENT 4 · 2006 CURRENT TECHNIQUES AND SPECTRUM OF DISEASE Fig. 2 Sagittal non-fat-suppressed T2-weighted spin-echo magnetic resonance Fig. 3 image of the knee, demonstrating poor distinction between the deep Sagittal three-dimensional fat-suppressed T1-weighted gradient-echo components of cartilage and the adjacent subchondral plate. magnetic resonance image of the knee, demonstrating high contrast between hyperintense articular cartilage and hypointense bone. and oriented parallel to the cartilage surface, which ac- counts for the high tensile strength. The transitional or mid- dle zone accounts for 40% to 60% of the thickness and has a higher compressive modulus than the superficial zone. The collagen fibers are randomly oriented in this zone2. The ra- dial zone has highly organized collagen fibers that are ori- ented parallel to the cartilage surface. In addition, this zone has the highest proteoglycan content and the lowest water content. The final zone is the calcified cartilage layer. The tidemark is a line that represents the boundary between un- calcified and calcified cartilage. Cartilage-Insensitive Pulse Sequences any different pulse sequences have been described for Mthe evaluation of articular cartilage. Traditional T1- weighted imaging provides poor differential contrast between the intermediate signal intensity of cartilage and the low to in- termediate signal intensity of joint fluid (Fig. 1). In addition, this pulse sequence requires relatively long scan times. In con- ventional spin-echo T2 weighting, the long echo time results in poor delineation between the subchondral bone and the deep component of cartilage. This results in factitious thick- ening of the subchondral bone and thinning of the articular Fig. 4 cartilage (Fig. 2). Sagittal non-fat-suppressed intermediate echo-time fast-spin-echo mag- netic resonance image of the knee, demonstrating the intermediate Cartilage-Sensitive Pulse Sequences signal intensity of articular cartilage and gray-scale stratification, which 1-weighted three-dimensional fat-suppressed gradient- corresponds to cartilage zonal anatomy. T echo imaging demonstrates high contrast between the low signal intensity of bone and the high signal intensity of thickness measurements. However, this sequence is less sensi- articular cartilage (Fig. 3). This makes it amenable to semi- tive to partial-thickness cartilage defects, is not suitable for automated cartilage segmentation algorithms for volume and meniscal or ligamentous evaluation, undergoes degradation of Shindle.fm Page 29 Monday, October 30, 2006 1:38 PM 29 THE JOURNAL OF BONE & JOINT SURGERY · JBJS.ORG MAGNETIC RESONANCE IMAGING OF CARTILAGE IN THE ATHLETE: VOLUME 88-A · SUPPLEMENT 4 · 2006 CURRENT TECHNIQUES AND SPECTRUM OF DISEASE Fig. 5-A Fig. 5-B Figs. 5-A and 5-B Coronal fast-spin-echo magnetic resonance image (Fig. 5-A) and corresponding gradient-echo magnetic resonance image (Fig. 5-B) of the elbow in a patient with medial collateral ligament reconstruction, demonstrating susceptibility artifact in the presence of metallic suture anchor fixation (arrowheads). the signal in the presence of metal, and requires a relatively can occur at the subchondral bone-cartilage interfaces. This long scan time3. can be minimized by the use of a wider received bandwidth3. Intermediate echo-time two-dimensional non-fat-sup- When fat suppression is applied to intermediate echo- pressed fast/turbo spin-echo imaging provides good differen- time fast/turbo spin-echo imaging, the previously subtle dif- tial contrast between the intermediate signal intensity of ferences between cartilage, fluid, and synovium become more articular cartilage, the low signal intensity of fibrocartilage, readily discernable. In addition, as the contrast range is “re- and the high signal intensity of synovial fluid (Fig. 4). This scaled,” the detection of bone marrow and soft-tissue edema sequence also demonstrates gray-scale stratification, which becomes possible (Fig. 6). This technique may provide an in- corresponds to cartilage zonal anatomy. Thus, the signal cor- creased level of detail, but objective differences in accuracy responding to the deep zone of normal articular cartilage is have not been demonstrated5. In addition, the use of fat sup- hypointense because of the highly ordered collagen orienta- pression typically requires lower in-plane resolution in order tion and restriction of water mobility. Water is less restricted to maintain an adequate signal-to-noise ratio. in the middle and superficial zones and thus has a relatively Many authors have advocated the use of magnetic reso- higher signal compared with the deep zone and subchondral nance arthrography for the evaluation of articular cartilage bone. This subtly increasing signal is referred to as gray-scale because of its ability to accurately delineate intra-articular stratification. With proper technique, this sequence has the structures6-8. However, this converts magnetic resonance imag- ability to detect partial-thickness chondral lesions4. The other ing into an invasive procedure and is associated with increased advantages of this sequence are that it is sensitive even in the cost and imaging time. presence of metal (Figs. 5-A and 5-B) and has very good dif- Although the optimal pulse sequence is controversial, ferential contrast between the underlying bone, cartilage, liga- the Articular Cartilage Imaging committee, a subcommittee of ments, menisci, and joint fluid. A potential disadvantage is the International Cartilage Repair Society (ICRS), recom- that a factitious loss of the subchondral plate and abnormal mends using fast-spin-echo imaging with proton density- high signal in cartilage due to chemical shift misregistration weighted imaging with or without fat saturation, T2-weighted Shindle.fm
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