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MRI-detected subchondral bone marrow signal alterations of the knee joint: terminology, imaging appearance, relevance and radiological differential diagnosis 

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Presentation on theme: "MRI-detected subchondral bone marrow signal alterations of the knee joint: terminology, imaging appearance, relevance and radiological differential diagnosis "— Presentation transcript:

1 MRI-detected subchondral bone marrow signal alterations of the knee joint: terminology, imaging appearance, relevance and radiological differential diagnosis  F.W. Roemer, R. Frobell, D.J. Hunter, M.D. Crema, W. Fischer, K. Bohndorf, A. Guermazi  Osteoarthritis and Cartilage  Volume 17, Issue 9, Pages (September 2009) DOI: /j.joca Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

2 Fig. 1 Subchondral BML in OA. (A) Sagittal PD FS image. Tibial BML is depicted as diffuse hyperintensity (arrows). (B) T1w FS image after intravenous (i.v.) gadolinium DTPA administration shows BML with similar extent (arrowheads). Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

3 Fig. 2 Comparison of FSE and GRE-type sequences for visualization of BMLs and diffuse marrow changes at 3T MRI. (A) Sagittal IW image shows large BML in the lateral trochlea (arrows). Note small cyst directly subchondrally within large BML. (B) DESS sequence does not depict BML at all but visualizes the cyst clearly (arrow). (C) Sagittal IW sequence shows subchondral BML in the central lateral tibia (arrow). Note also metaphyseal marrow reconversion in the distal femur (arrowheads). (D) DESS sequence does not show non-cystic BML but depicts only the small cyst within the BML (arrow). Marrow reconversion is not visualized. Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

4 Fig. 3 Sclerotic lesion. (A) Sagittal T1w SE sequence shows small hypointense lesion subchondrally. Sclerotic changes commonly show marked hypointensity on T1w images. (B) On the sagittal PD FS sequence lesion is barely visualized as both lesions and marrow are hypointense. T1w FS sequence without fat suppression is mandatory for characterizing sclerotic lesions. Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

5 Fig. 4 Susceptibility artifacts due to metallic implant after ACL reconstruction surgery. Coronal PD FS image. Insufficient fat suppression in the medial subchondral tibia makes differentiation of pathologic subchondral BML and artifact impossible. Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

6 Fig. 5 Segmentation of BMLs for quantitative analysis. (A) Sagittal PD FS image. A large traumatic subchondral BML is depicted in the lateral tibia (white arrows). (B) Color-coded segmentation of cartilage (purple, orange) and BML (black arrows). Image courtesy of VirtualScopics Inc., Rochester, NY, USA. Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

7 Fig. 6 Examples of traumatic bone contusions illustrating the injury mechanism. (A) Sagittal PD FS image shows bone contusions in the lateral femur and anterior lateral tibia after a hyperextension injury and associated PCL disruption. (B) Sagittal STIR image. Characteristic bone contusions in the postero-lateral tibia (arrowheads) and central lateral femur (arrows) in association with an ACL tear (arrows). Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

8 Fig. 7 Osteochondral fractures. (A) Osteochondral fracture associated with an ACL disruption. Coronal PD FS image shows depression of the chondral articular surface (white arrow) and fracture line extending subchondrally (arrowhead). (B) T1w image depicts osteochondral fracture in the lateral femur. Chondral disruption is shown (arrowhead) as well as subchondral fracture line (arrow). (C) Sagittal PD FS image. Small osteochondral depression fracture in the lateral femur is depicted (arrow). Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

9 Fig. 8 Insufficiency fracture in a 65-year-old woman with generalized osteoporosis. Subchondral fracture line in the postero-lateral femur is shown (arrows). Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

10 Fig. 9 Diffuse tibial BML due to repetitive microtrauma in a 40-year-old patient woman practicing for a first-time marathon (arrows). Note missing signs of cartilage defects or OA. Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

11 Fig. 10 Traction edema at the tibial insertion of the PCL. Diffuse BML is shown in the subspinous region of the tibia adjacent to the insertion of the PCL (arrows). Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

12 Fig. 11 Epiphyseal bone infarct and secondary collapse of the articular surface. (A) Sagittal PD FS image. The infarct displays hypointense central fatty marrow characteristics and is associated with a peripheral rim of reactive tissue in process of gradual restitution (arrows). (B) T1w SE image shows that the subchondral extension of the medial femoral condylar infarct is associated with the complication of an osteochondral fracture (arrows). Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

13 Fig. 12 SONK following partial meniscectomy. (A) Medial meniscal extrusion and a horizontal tear of the body are depicted (black arrow). Diffuse reactive BME is shown in the medial femur and tibia (white arrows). (B) Six months post-partial meniscectomy (arrow) diagnosis of SONK with dislocation of osteochondral fragment commencing (arrowhead). Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

14 Fig. 13 SONK. Sudden onset of medial knee pain in a 52-year-old man. Diffuse BML is shown in the medial femoral condyle (white arrows). Note subchondral area of necrosis (black arrow). Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

15 Fig. 14 Classic BML in conjunction with cartilage damage. (A) Sagittal PD FS image shows ill-defined hyperintensity adjacent to the subchondral plate (white arrows). Note superficial cartilage defect adjacent to BML. (B) T1w SE image depicts BML as diffuse hypointensity (black arrows). Note that full size of lesion can only be appreciated on the PD FS image. Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

16 Fig. 15 BMLs in conjunction with OA at 3T MRI. (A) Sagittal IW image shows large subchondral BML in the femoral condyle (arrowheads) and smaller BMLs in the central medial tibia (arrows). (B) Marked regression of BMLs is seen in the tibia and femur 12 months later. Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

17 Fig. 16 Transient migratory bone marrow edema syndrome over a course of 4 years. Sudden onset of left medial knee pain without trauma in a 56-year-old man. (A) Coronal PD FS image shows diffuse BML in the medial femoral condyle also extending laterally (arrows). After 12 weeks of non-weight bearing the BML vanished and pain resolved completely. (B) New pain 13 months later in the same knee. Diffuse BML is shown in the lateral femoral condyle (arrows). Regression of BML and pain after non-weight bearing for 23 months. (C) New hindfoot pain in the right foot 16 months later. Diffuse BML is shown in the subtalar calcaneus (arrows). (D) Sudden onset of left-sided ankle pain 1 ½ years later. This time a diffuse BML pattern is shown in the talar corpus, neck and head (arrows). Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

18 Fig. 17 Osteochondritis dissecans in a 12-year-old boy. In situ osteochondral fragment (large arrow) with intact overlying chondral surface. Note also accompanying BML surrounding the lesion (small arrows). Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

19 Fig. 18 Inflammatory edema in rheumatoid arthritis. Sagittal PD FS image shows reactive BME in the epiphyseal femur, tibia and patella (arrows). Note concomitant aseptic effusion in the joint cavity. Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

20 Fig. 19 Enchondroma. Classic appearance and location. Coronal PD FS image shows a very hyperintense multi-lobulated lesion in the metaphyseal femur (arrow). Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

21 Fig. 20 Thalassemia. Sagittal IW image at 3T MRI. Diffuse hyperintense marrow changes are shown in the meta- and epiphyseal femur and tibia. Thalassemia is caused by an inherited abnormality in globin production and is characterized by ineffective erythropoiesis, hemolysis and anemia. Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

22 Fig. 21 Post-surgical BMLs after cartilage repair. (A) Microfracturing. Sagittal PD FS image shows fibro-cartilaginous reparation tissue at the site of the former full-thickness trochlear defect (arrowheads). (B) Osteochondral autologous transplantation. Sagittal FS spoiled GRE-type T1w image. Osteochondral plug is depicted in central part of lateral femur (arrowheads). Note smooth articular surface and BML surrounding the osteochondral plug (arrows). Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

23 Fig. 22 Subchondral cyst. (A) Chronic lateral knee pain in 23-year-old man. Radiograph shows well-defined radiolucency in the lateral tibia representing a cystic lesion (arrow). (B) Sagittal PD FS image shows well-defined subchondral cyst (arrow) with surrounding BML (arrowheads). Cyst not associated with OA. Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

24 Fig. 23 Red bone marrow. Coronal PD FS image. Non-pathologic remnant of metaphyseal red marrow in a 20-year-old woman (arrow). Osteoarthritis and Cartilage  , DOI: ( /j.joca ) Copyright © 2009 Osteoarthritis Research Society International Terms and Conditions

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