MRI of Arthritis Ashley G. Grindol1, Edward Derrick, Kurt F. Scherer, Christopher Wasyliw, Laura W. Bancroft

The shoulders, hips, spine, and sacroiliac joints are often in- can occur subjacent to areas of articular cartilage loss and is hypoin- cluded in the imaging fields of chest, abdominal, and pelvic MRI tense on T1-weighted images and hyperintense on T2-weighted se- examinations interpreted by body imagers. Therefore, body im- quences because of the increased water content of marrow. In- agers should be familiar with the MRI features of the common traarticular osteochondral bodies may also occur with more advanced arthritides and be comfortable proposing a limited differential di- OA, sometimes because of fractured osteophytes. Intraarticular bod- agnosis when encountered in the axial joints and spine. Although ies, subchondral BME, and cysts in conjunction with osteophytes several arthritides have relatively specific characteristics, others and cartilage destruction are nearly pathognomonic for OA and are have nonspecific, overlapping imaging features. In this chapter, frequently encountered in the elderly population. the imaging findings of osteoarthritis (OA), inflammatory arthri- The spine is another common location for degenerative change, tis (rheumatoid arthritis [RA] and juvenile idiopathic arthritis and Modic and colleagues [3] described a spectrum of degenerative [JIA]), seronegative (axial spondyloar- disk disease (DDD) characterized by bandlike signal-intensity abnor- thritis [AS], enteropathic , and ), malities in the vertebral body endplates and associated changes in septic arthritis, crystal-deposition and other deposition-induced the adjacent intervertebral disks. Type 1 Modic changes reflect acute arthropathies, and synovium-based processes will be discussed. reaction of the vertebral endplates to disk degeneration, with T1-hy- pointense and T2-hyperintense endplate signal changes [3, 4] (Fig. 1). Osteoarthritis Occasionally, type 1 Modic changes can be potentially confused with OA, or osteoarthrosis, is the most prevalent arthritis and is the osteomyelitis; however, there are important imaging features that can most common chronic musculoskeletal cause of morbidity and be used to differentiate between the two causes. The intervertebral disability in the elderly population [1]. It is characterized by ar- disk is usually T2-hypointense due to disk desiccation in DDD unlike ticular cartilage wear and joint failure secondary to dysfunctional the T2-hyperintense disk signal seen in infectious discitis [4]. Erosive compensatory changes. Although conventional radiography is endplate changes develop with osteomyelitis, whereas no endplate commonly used as the initial assessment for OA to assess for joint destruction is seen in Modic changes [4]. Type 2 Modic changes oc- space narrowing and osteophytes, MRI is better able to depict the cur with progression of DDD, which is characterized by fatty marrow osseous and soft-tissue structures of the joint, including the articu- at the endplates causing hyperintense signal on T1- and T2-weighted lar cartilage and . Common findings of OA on MRI images [3]. In type 3 Modic change, there is hypointense signal on all include articular cartilage loss, osteophyte formation, bone mar- sequences secondary to endplate sclerosis [3]. Vacuum phenomenon row edema (BME), , joint effusions, and meniscal or ac- of the intervertebral disks is another common finding associated with etabular labral and glenoid labral abnormalities [1] (Fig. 1). MRI degenerative change and occurs when nitrogen gas enters the disks also allows evaluation of surrounding soft-tissue components such because of negative pressure generated by loss of disk fluid [4]. The as the joint capsule, extraarticular ligaments, tendons, and muscle. vacuum phenomenon is characterized by hypointense signal on all Several grading systems have been developed to assess the sever- MRI sequences. Unlike gas in other soft tissues, gas is rare in infec- ity of OA using arthroscopic or imaging criteria. One of the more tious discitis and its presence is almost always seen in DDD and ef- commonly used classification systems for the assessment of articular fectively excludes infection [4]. cartilage damage is the system proposed by the International Carti- lage Repair Society [2]. This grading system can be applied when Inflammatory Arthritides interpreting MRI: Grade 0 is assigned for normal, grade 1 for super- RA is a chronic autoimmune disorder that most commonly af- ficial cartilage cracks and fissures, grade 2 for lesions involving less fects women older than 65 years old [5, 6]. It is characterized than 50% of the cartilage depth, grade 3 for lesions involving greater mainly by systemic inflammation, autoantibodies, and persistent than 50% of the cartilage depth but not extending to bone, and grade polyarticular synovitis [5]. Early diagnosis and treatment of RA are 4 for cartilage lesions extending to the subchondral bone [2]. BME paramount to the prevention of disease progression, and early treat-

1All authors: Department of Radiology, Florida Hospital, 601 E Rollins St, Orlando, FL 32803. Address correspondence to L. W. Bancroft ([email protected]).

Body MRI 187 Grindol et al.

Fig. 1—Degenerative change on MRI. A, Axial T2-weighted fat-suppressed image of left shoulder in 46-year-old man with osteoarthritis (OA) shows full-thickness glenohumeral articular cartilage loss (arrowheads) with joint space narrowing, osteophyte formation (arrows), and joint effusion with debris. B, Sagittal T2-weighted image of 55-year-old man shows diffuse degenerative disk disease with multifocal disk desiccation, disk bulges and protrusions, hypointense vacuum disk phenomenon (arrowhead), and Modic type 1 changes in L4–L5 (arrow).

A B ment has been associated with improved patients with RA. Rice bodies are thought progresses, periarticular bone demineraliza- clinical outcomes. MRI is not only benefi- to be dissociated, infarcted synovium and tion, cartilage destruction, and eventually cial in aiding in the diagnosis of early RA will be low signal intensity on T1-weighted, subchondral bone erosions will follow [5]. inflammation, but also helpful in tracking T2-weighted, and intermediate-weighted Erosions appear as sharply demarcated jux- treatment response and verifying disease re- sequences (Fig. 2). BME is another com- taarticular bone lesions and will be visible mission [7]. Similar to other inflammatory mon finding in RA that occurs in response in at least two planes [11] (Fig. 2). arthritides, the earliest imaging finding in to synovitis. BME is seen on fluid-sensitive JIA shares many imaging findings with RA is often synovitis. Synovitis manifests sequences as ill-defined areas of hyperin- RA and is the leading cause of childhood as increased synovial thickness, synovial tense signal and will have corresponding ill- rheumatic disease [13]. JIA occurs in chil- volume, and synovial enhancement on con- defined hypointense signal on T1-weighted dren younger than 16 years old and persists trast-enhanced sequences [8]. Synovial vol- images [11, 12]. for more than 6 weeks without an underly- ume correlates with joint swelling and ten- The natural progression of RA after ing identifiable cause [14]. JIA is character- derness and is predictive of clinical disease early synovitis and simple synovial prolif- ized by chronic inflammation and synovitis, activity [9]. The rate and magnitude of sy- eration is pannus formation [5]. A pannus which can lead to devastating structural dam- novial enhancement have been shown to be is essentially hypervascular, hypertrophied age and growth abnormalities. In 55–75% of related to the severity of inflammation [10]. synovium and displays intermediate to hy- patients, JIA presents as monoarticular or Rice bodies are small intraarticular loose pointense signal on T1-weighted and T2- oligoarticular arthritis [15]. The most com- bodies the size of rice that may develop in weighted sequences (Fig. 2). As the disease monly involved joint at onset is the knee

Fig. 2—Rheumatoid arthritis (RA) of shoulder. A, Sagittal intermediate-weighted MR image of 48-year-old woman with RA shows large glenohumeral joint effusion with synovial proliferation with rice bodies (asterisks) and humeral head erosions (arrows). B, Axial T1-weighted image of left shoulder in 57-year-old woman with long-standing inactive RA shows large erosions of anteromedial and posterolateral humeral head (asterisks). A B

188 Body MRI MRI of Arthritis

Fig. 3—Sequela of juvenile idiopathic arthritis in 33-year-old woman. A and B, Sagittal T1-weighted images through cervical spine show diminutive cervical vertebrae (arrow, A) relative to normal-sized thoracic vertebrae (arrowhead, A), ankylosed cervicothoracic junction (white asterisks), and facet joints (black asterisks, B).

A B

Fig. 4—Active versus inactive sacroiliitis. A and B, Coronal oblique T1-weighted (A) and axial T2-weighted fat-suppressed (B) images of sacroiliac joints in 56-year-old man with active sacroiliitis show bilateral, asymmetric T1-hypointense and T2-hyperintense signal (arrows) paralleling indistinct sacroiliac joints. C and D, Coronal oblique T1-weighted (C) and T2-weighted fat-suppressed (D) images through sacroiliac joints in 17-year-old man with AS show bandlike iliac (arrows) and patchy sacral T1-hyperintense signal (asterisks, C) and A B T2-hypointense signal (asterisks, D) from fatty marrow replacement surrounding irregular sacroiliac joints.

C D followed by the hands and wrist joints, hips, mation with enhancement. Chronic fibrotic adult RA and can cause loss of motion and ankles, and tarsal joints [15]. Hip involve- disease is characterized by a lack of pannus significant growth disturbances [16] (Fig. 3). ment is a major source of morbidity, with enhancement, subchondral bone changes, total hip replacement needed in 26–44% of erosions, and eventual deformations of joint Spondyloarthropathies children within the first 10 years from onset surfaces [16, 17]. In the spine, these areas of The seronegative spondyloarthropathies [16]. MRI assessment of a patient with ac- inflammation can lead to spondylodiscitis are a group of disorders with common tive JIA will yield findings similar to those and other complications such as spinal ste- clinical, laboratory, and genetic features, seen in a patient with RA, such as synovitis, nosis and subluxations. Ankylosis resulting with the most important being human leu- increased synovial volume, and pannus for- from chronic JIA is more common than in kocyte antigen (HLA)-B27 positivity [18].

Body MRI 189 Grindol et al.

A B C

Fig. 5—Classic imaging features of axial spondylitis (AS). A, Sagittal T2-weighted image of 42-year-old man with AS shows multiple edematous foci of endplate corner enthesis (arrowheads) and anterior Romanus lesions. B, Sagittal T1-weighted image of thoracic spine in 62-year-old man with advanced AS shows bamboo spine with thick ossification of anterior longitudinal ligament (arrowheads), partial ankylosis across posterior disk space (arrow), and heterogeneously high signal intensity in remaining disks. C, Sagittal T2-weighted image of 35-year- old man with AS shows extensive reactive edema (asterisks) and early Andersson lesion (arrowheads) caused by noninfectious spondylodiscitis. D and E, Sagittal T1-weighted image (D) and 2D reconstruction from CT (E) of paraplegic 62-year-old man with advanced AS shows pathologic fracture (arrows) through mid thoracic spine.

D E The most common spondyloarthropathies sessment of Spondyloarthritis International ical features (including, but not limited to, include AS (previously known as ankylos- Society characterizes disease on the basis of inflammatory back pain, arthritis, enthesitis, ing spondylitis), psoriatic arthritis, reactive sacroiliitis detected on imaging, HLA-B27 psoriasis, Crohn disease, and a positive fam- arthritis, and enteropathic arthritis. The As- positivity, and the presence of defining clin- ily history of ) [18].

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A B Fig. 6—Septic arthritis. A, Coronal T2-weighted image of right hip in 45-year-old man with late-stage septic arthritis shows femoral and acetabular erosions (asterisks), synovitis, and extensive periarticular inflammatory change (arrows). B and C, Axial T1-weighted (B) and T2-weighted fat-suppressed (C) images of 44-year-old man with right sacroiliac joint septic arthritis shows periarticular T1-hypointense marrow signal (asterisks, B); mildly distended sacroiliac joint (arrow, C); and inflammatory changes involving iliopsoas asterisk( , C) and gluteal (arrowheads, C) muscles.

C

AS is the prototypical spondyloarthropa- be responsible for clinical symptoms such as T2-weighted fat-suppressed sequences and thy, is more common in men than women, inflammatory back pain and morning stiff- STIR sequences. Findings suggestive of ac- and usually affects the axial skeleton [18]. ness [18]. The earliest presenting symptoms tive sacroiliitis include loss of the normal AS is characterized by inflammatory lesions of patients with AS are inflammatory back thin band of cartilage on T1-weighted im- of the entheses or the junctional areas be- pain with alternating gluteal pain secondary ages, T2-hyperintense synovial signal, sub- tween the and the tendons, ligaments, to sacroiliitis [19]. Sacroiliitis is well evalu- chondral BME, erosions, and synovial and fascia, or capsules. Enthesitis is thought to ated on fluid-sensitive sequences, such as subchondral bone marrow enhancement [19]

Fig. 7—24-year-old woman with pigmented of left hip. A and B, Coronal intermediate-weighted fat- suppressed (A) and sagittal T2-weighted (B) images of left hip show extensive low-signal- intensity synovial proliferation (asterisks), joint effusion, and acetabular erosions arrowheads( ). In B, A = anterior, P = posterior. A B

Body MRI 191 Grindol et al.

(Fig. 4). Imaging of inactive sacroiliitis will rior elements, posterior aspects of the verte- matogenous spread, direct inoculation, or transition to more distinct (yet irregular) joint bral bodies and adjacent ribs, enthesitis of contiguous spread of infection [26]. Early margins and fatty metaplasia of the adjacent the spinal ligaments, and syndesmophytes diagnosis of septic arthritis is paramount marrow, showing signal intensity equal to [18, 21]. Enthesitis of the spinal ligaments for optimal outcome because delayed di- that of fat on all MRI sequences (Fig. 4). will present with hyperintense signal at the agnosis can lead to cartilage and joint de- Sacroiliitis is commonly bilateral and osseous insertions on fluid-sensitive and struction. The most sensitive findings for symmetric in later stages of AS but can be enhanced sequences and has a specificity of acute septic arthritis in a study conducted unilateral in the early stages of disease and 87% for spondyloarthropathy [18, 21]. by Karchevsky and colleagues [27] was in psoriatic arthritis, other spondyloarthropa- Chronic inflammatory lesions of the spine synovial enhancement (98% sensitive), thies, and infectious sacroiliitis [20]. Kang in AS include syndesmophytes, ankylosis, which likely indicates increasing vascu- and colleagues [20] reported that findings and fat metaplasia. Syndesmophytes are ver- larity. Joint effusions were also common such as large bone erosions, thick capsu- tically oriented new bone that forms along (especially in large axial joints), and peri- litis, extracapsular fluid collections, and the periphery of the disks, resulting in a bam- articular edema (likely due to increased periarticular muscle edema favor infectious boo spine appearance [18] (Fig. 5). Disks capillary permeability) was 84% specific sacroiliitis, whereas iliac-dominant BME can become heterogeneous and hyperintense for septic arthritis [27]. Kang and col- and joint space enhancement are suggestive in signal, and ankylosis can develop partially leagues [20] determined that periarticular of sacroiliitis associated with spondyloar- or completely across the intervertebral disks muscle edema was the strongest predictor thropathy. In fact, they found that periar- [18] (Fig. 5). Chronic postinflammatory fatty of infectious sacroiliitis when differentiat- ticular muscle edema was the most pertinent bone marrow metaplasia is common in the ing septic arthritis and spondyloarthropa- predictor for infectious sacroiliitis [20]. Ero- corners of the vertebral bodies, evidenced by thies. Late inflammatory changes include sions will be hypointense on unenhanced hyperintense signal on T1-weighted imaging inflammatory pannus formation, destruc- sequences and, if confluent or large enough, and hypointense signal on T2-weighted im- tion of articular cartilage with joint space can mimic joint space widening [18]. Sub- aging. Finally, long-standing AS can result narrowing, marginal and central erosions chondral sclerosis can develop on both sides in erosions of the posterior spinal elements that can cause apparent joint space widen- of the sacroiliac joint and is characterized by and arachnoid diverticula [22]. This process ing (Fig. 6), fibrosis, and bony ankylosis. T2-hypointense nonenhancing foci. begins with atrophy of the peridural tissues Pyogenic spondylitis is most often Spinal involvement is also common in and adherence of the dura to adjacent struc- caused by Staphylococcus aureus and has a AS with acute inflammation presenting as tures, which causes reduced compliance and predilection for the lumbar spine [4]. Most spondylitis, spondylodiscitis, facet joint ar- elasticity of the caudal thecal sac. In turn, de- cases of pyogenic spondylitis involve two thritis, costovertebral arthritis, and enthesi- creased compliance leads to reduced ability adjacent vertebral bodies and the interven- tis of the spinal ligaments [18]. Spondylitis to diminish fluctuations in CSF pressure and ing disk and have the following MRI char- will result in hyperintense bone marrow eventually causes enlarging diverticula and acteristics: T1-hypointense and T2-hyper- signal involving the anterior or posterior scalloped erosions of the laminae, pedicles, intense vertebral body marrow, erosion of vertebral corners on fluid-sensitive and en- and posterior vertebral body [22]. vertebral endplates, disk T2 hyperintensity hanced sequences [18] (Fig. 5). Up to 67% The enteropathic arthropathies are in- and enhancement, paraspinous inflammato- of patients with spondyloarthropathy will cluded in the seronegative spondyloar- ry tissue, and a soft-tissue mass or fluid col- have anterior spondylitis, also known as a thropathies and often have manifestations lection [4]. When a Mycobacterium species Romanus lesion, and when three or more indistinguishable from AS [23]. Entero- is the responsible organism, the infection corners are involved without the presence of pathic arthropathies are associated with the may be more indolent and will differ in its osteophytes or Schmorl nodes, this finding inflammatory bowel diseases (IBDs) such progression as it spreads beneath the spinal is 81% specific or 97% specific in patients as Crohn disease and ulcerative colitis and longitudinal ligaments [4]. This mechanism younger than 40 years old [6, 21]. Spondy- with enteropathic infections such as Sal- of dissemination allows the involvement of lodiscitis or Andersson lesions are seen in monella, Shigella, and Yersinia infections adjacent vertebral bodies and sparing of the 33% of spondyloarthropathy patients, and and can occur after gastric bypass surgery. intervertebral disks, often resulting in ante- Andersson lesions have a specificity of Between 10% and 30% of patients with rior gouge defects. Mycobacterium infec- 59% for spondyloarthropathy [21]. Anders- IBD have symptomatic sacroiliitis [24]. tious spondylitis can also present with skip son lesions present as hyperintense signal at Enteropathic-associated arthritis of the ax- lesions and may involve only a portion of the cortical endplates adjacent to the inter- ial joints resembles AS with inflammatory the vertebral body, potentially mimicking vertebral disks with variable hyperintense lesions such as bilateral sacroiliitis, anky- lymphoma or metastatic disease [4]. signal in the center or throughout the inter- losis or vertebral fusion, syndesmophytes, Pyogenic sacroiliitis is most often unilat- vertebral space on STIR and fat-suppressed and bony sclerosis [25]. eral, and S. aureus is the most common in- contrast-enhanced T1-weighted sequences oculated pathogen [4]. MRI characteristics [18] (Fig. 5). Additional spinal findings in- Septic Arthritis include sacroiliac joint effusion, synovial clude facet joint and costovertebral arthritis Septic arthritis is most commonly outpouching, surrounding reactive BME characterized by BME involving the poste- monoarticular and can be caused by he- with enhancement of the sacrum and ilium,

192 Body MRI MRI of Arthritis loss of normal cortical margins, and rim-en- such as the shoulder, elbow, wrist, patel- sions secondary to increased intraarticular hancing abscess formation in the iliopsoas lofemoral, and metacarpophalangeal joints pressure can also occur, especially in tight or paraspinal soft tissues (Fig. 6) [4]. [30]. It can also involve the pubic symphy- joints such as the hip. sis, acetabular labra, and annulus fibrosis. Pigmented villonodular synovitis Crystal and Deposition- Deposition will be evident on MRI as lin- (PVNS) is another synovial-based pro- Induced Arthritides ear or punctate areas of hypointense signal cess characterized by hyperplasia of the Gout is the most common crystalline within hyaline cartilage or intervertebral synovium with hypervascularity and ac- and the most common inflam- disks on all sequences, and the mineraliza- cumulation of histiocytes [33]. Masslike matory arthropathy in men. The hallmark tion may be more prominent on gradient- synovial and soft-tissue proliferation is of gout is hyperuricemia with deposition echo sequences or 3-T imaging. At the time usually monoarticular and most commonly of monosodium urate crystals in joints, of acute attacks, joint effusion and soft-tis- affects the knees, hips, ankles, and shoul- tendons, and soft tissues, which leads to sue edema will often be seen. Later stages ders [33]. Patients are typically young to inflammation and symptomatic disease. of disease can have an OA-like appearance middle-aged adults who present with joint There is a strong association of gout with or even neuropathic joint–like appearance pain, swelling, and limitation of motion. metabolic syndrome, myocardial infarc- with osseous fragmentation and collapse PVNS lesions have a propensity to bleed tion, diabetes mellitus, and premature and intraarticular bodies [30]. and cause accumulation of intra- and ex- death [28]. Gout is generally polyarticular Hydroxyapatite deposition tends to be tracellular hemosiderin [32]. The paramag- and asymmetric in distribution, with an asymptomatic but can be associated with netic effect from the hemosiderin deposits affinity for the lower extremities (particu- acute inflammation, soft-tissue deposition, causes the nodular intraarticular masses larly the first metatarsophalangeal joint); and chronic inflammation [31]. The hy- to be hypointense on all sequences (Fig. involvement of the spine is rare. Early droxyapatite deposits occur in fibrous con- 7), with blooming effect on gradient-echo gout has imaging features similar to other nective tissues and are usually amorphous, sequences. Joint space and bone mineral inflammatory arthropathies, such as syno- milky, or cheesy in quality. Deposition is density tend to be preserved until late in vitis and joint effusions. Marginal erosions most common in the shoulder—specifical- the disease process in PVNS. Erosions are with a so-called “overhanging edge” and ly, in the rotator cuff tendons [31]. The sur- less common compared with osteochon- BME can develop; gouty tophi (nodular rounding inflammatory changes induced dromatosis but can occur, especially in the masses of accumulated monosodium urate by the crystal disease in the shoulder can hip [32]. crystals) can form along tendons, liga- be detected as hyperintense signal changes ments, cartilage, and other soft tissues as and fluid in the subacromial or subdeltoid Conclusion well as within bones. Tophi typically have bursa and are best seen on fluid-sensitive Arthritic shoulders, hips, spine, and sac- intermediate to hypointense signal on T1- sequences. “Milwaukee shoulder” is an roiliac joints are often included in chest, weighted images, are heterogeneous sig- eponym for the extreme, destructive shoul- abdominal, and pelvic MRI examinations nal intensity on T2-weighted images, and der arthropathy caused by hydroxyapatite interpreted by body imagers. Common MRI may enhance homogeneously or heteroge- deposition, which was originally identified findings of OA include articular cartilage neously [28, 29]. in elderly women and is accompanied by loss, osteophyte formation, BME, synovi- Calcium pyrophosphate deposition dis- rotator cuff tears [31]. tis, joint effusions, meniscal abnormalities, ease (CPPD) is a metabolic disorder char- and acetabular and glenoid labral abnor- acterized by intraarticular and periarticular Synovial-Based Processes malities. RA is characterized by synovitis, accumulation of calcium pyrophosphate Synovial chondromatosis is a monoar- pannus formation, BME, and erosions. The dihydrate crystals. This disease often has ticular, benign neoplastic, synovial-based seronegative spondyloarthropathies have a alternating phases of modest chronic in- process that results in synovial generation strong association with HLA-B27 positiv- flammation with superimposed episodes of of multiple cartilaginous nodules. It is most ity, sacroiliitis, enthesitis, and inflammatory intense inflammation [30]. Pseudogout is prevalent in the third to fifth decades and af- back pain. Septic arthritis can be rapidly the most common manifestation of CPPD fects men 2–4 times more than women [32]. destructive and should be suspected in pa- and refers to the presence of goutlike ar- Patients typically present with joint pain, tients with bacteremia, leukocytosis, joint thritis and chondrocalcinosis or calcifica- swelling, and limitation of motion. The effusion, synovial enhancement, and peri- tion within fibrous or hyaline cartilage knee, hip, and elbow are the most common- articular edema. Gout rarely involves the structures [30]. CPPD is more common in ly involved joints. Cartilaginous nodules spine or axial joints but can show marginal women than men and is usually secondary can detach and become intraarticular bodies erosions with an overhanging edge, BME, to a familial cause or metabolic disorder and can also become ossified (osteochon- and tophi. Finally, PVNS has a characteris- such as hyperparathyroidism, hemochro- dromatosis). Unmineralized cartilaginous tic “blooming” synovial proliferation due to matosis, or hypothyroidism [30]. nodules are fairly isointense to hyaline car- hemosiderin deposition, and synovial chon- Pseudogout tends to be symmetric in dis- tilage on all sequences, and ossified bodies dromatosis should be considered in patients tribution and affects hyaline cartilage and will parallel medullary and cortical signal with joint pain, limited joint motion, and fibrocartilage of non–weight-bearing joints intensity on all sequences. Marginal ero- synovial-based or intraarticular bodies.

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