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Osteochondritis Dissecans of the Knee: Value of MR Imaging in Determining Lesion Stability and the Presence of Articular Cartilage Defects
Osteochondntis dissecans is a lesion of articular surfaces that is of uncertain These lesions are seen on radiographs as a bony defect or fragmentation
etiology. of the
subchondral
may be an actual
surface
may be
Richard
H. Lange2
or fibrocartilage. Similarly, the apparent bone fragments may so they are unstable and prone to displacement or they may be firmly attached with fibrous tissue. Knowledge of fragment stability and the presence of an articular cartilage defect is useful in deciding on treatment. This information cannot be determined on plain films or clinical examination. We correlated MR examinations with arthroscopic findings in 21 patients with osteochondntis dissecans of the knee to see if MR imaging could be used to predict lesion stability and articular cartilage defects. A high-signal interface between the lesion and the femur was used as evidence of lesion instability and was found in 15 lesions. One of these lesions was questionably stable at surgery; the remainder were unstable and partially attached. The other six
patients had displaced fragments with large articular defects that were clearly visualized
on the MR examinations. We conclude that MR imaging is useful in evaluating lesion stability in patients with osteochondntis dissecans.
articular
surface
defects
and
AJR
155:549-553,
September
1990
Osteochondritis dissecans (OCD) of a femoral condyle is a common articular lesion in adolescents and young adults. Although most lesions are thought to be traumatic in origin, other proposed causes include mechanical stress, familial dysplasia, peripheral avascular necrosis, and fat emboli [1 , 2]. In some patients with OCD, the decision of whether to operate immediately or manage conservatively can be difficult [3, 4]. The plain films may show either a subchondral bone defect or fragmentation of the subchondral bone. If there are partially attached cartilage or bone fragments, the fragments should be fixed or drilled to help healing, or they should be debnded [5-7]. Plain films and clinical examination cannot determine whether fragments are
attached firmly or only partially. Accordingly, a number of techniques including radionuclide bone scanning [4, 8-1 0], computed arthrotomography [1 1], and MR
imaging
Received April 2, 1990; accepted May 7, 1990.
I
the status
of OCD OCD
lesions.
after revision
in using MR imaging
in 21 patients
to evaluate
femoral
lesion stability
in whom
and
arthro-
sin Clinical Science Center, 600 Highland Ave., Madison, WI 53792. Address reprint requests to A. A. De Smet. 2 Division of Orthopedic Surgery, University of
scopic correlation
Materials and
of the findings
was available.
Methods
Wisconsin
53792.
Madison,
WI
MR scans of the knees were obtained in 47 patients with OCD of one of the femoral condyles. The 21 patients who also had arthroscopic evaluation and treatment of OCD form the basis of this report. There were 1 8 men and three women with an average age of 19 years (range, 1 2-35). The adjacent growth plate was closed in 1 7 of the 21 patients. All the
550
DE
SMET
ET AL.
AJR:155, September
1990
patients
5 and
had chronic
7 months,
patients
displaced
fragments
within
the
joint
(Fig.
4D),
and
(5) defects
respectively;
remainder
years. Three of the patients who had a history of mild knee pain were shown to have acutely displaced bone fragments on radiographs.
The classification of plain film findings devised by Hughston et al.
the lesions
1), three
(Fig.
On the anteroposterior films, one lesion was in the femoral notch; 1 5 involved the notch and a portion of the central surface of the condyle; and five were localized to the central, nonmeniscal portion of the condyle. On the lateral films, 1 9 lesions were directly distal to a line projected down the posterior cortex of the femur, that is, on the weight-bearing surface while the patient was standing. Two
lesions flexion, were such posterior as when to this climbing line in a position of loading with knee stairs.
partially
placed was
attached those
the
fractures with
at in
lage were
intact fractures,
that were
fractures was
ballotable
In partially seen found
at arthroscopy.
attached arthroscopy
were often
were
ballotable
tissue
or could
be elevated
by probing.
the bases
Loose
fibrous
partially
granulation
All examinations were performed on a 1 .5-T General Electric MR unit (Milwaukee, WI) with a dedicated transmit-and-receive
tremity mm. two coil. The excitations
that could be elevated. A stable lesion bony union on plain films but at surgery
no cartilage softening, and was not
Slice thickness
of view were was used.
gap of 1.5
used.
field
of 256
600/20 (TR/TE), were used, as were two-echo 90, which were proton-density-weighted and
had coronal and sagittal Ti-weighted images
Results
Intensity of signal within the lesions did not differ between the stable or two categories of partially attached lesions. On Ti -weighted images, the lesions had inhomogeneous signal ranging from grades 0 to -2 (Fig. 36). Fragment appearance for the stable or partially attached lesions on T2-weighted images was more variable. Four lesions were homogeneous with -2 absent signal. The remainder had an inhomogeneous pattern with focal areas ranging from +2 high signal to -2 absent signal with marked variation between the lesions (Figs. iB, 2C, and 3C). Lesions with displaced fragments had only bone defects, so no partially attached fragment could be assessed for central signal or high signal at the adjacent bone interface. All six patients with displaced fragments had bony defects filled with joint fluid that was of intermediate signal on Ti -weighted images and of high signal on T2-weighted images (Figs. 4B and 4C). All patients with partially attached fragments had a highsignal line at the interface between the lesion and the femur
followed by a T2-weighted sequence in the plane in which the lesion was best visualized. The last 16 patients had both coronal and sagittal
T2-weighted images and Ti-weighted images only in the plane in
which
visualization
This protocol
was used
because the T2-weighted images best defined the joint surface and the reactive interface between the fragment and the femur.
Each MR scan was evaluated by one observer without knowledge of the arthroscopic findings for fragment signal intensity, articular
cartilage defects, and was evidence of instability as listed in the following
sections.
weighted
Signal
images
the fragment
on both
the fragment
Ti-
and T2with
graded
by comparing
signal
decreased
signal equal
signal, 0
to that
moderately images
signal
increased
of joint
signal,
and
+2
markedly
The T2-weighted
of high
2B, 2C, and 3C), (2) disruption of the subchondral bone plate (Figs. 2B, 2C, 3C, 4B, and 4C), (3) adjacent focal cystic areas (Fig. 3D), (4)
Fig. 1.-Stable osteochondritis dissecans diagnosed at surgery. A, Preoperative plain film shows large medial condyle lesion. B, Sagittal MR image, 2000/90, shows highsignal line (arrowheads) above fragment; this resulted in false-positive MR diagnosis of unstable fragment. Two years after drilling, lesion appeared healed on plain film and MR (not shown).
AJR:155, September
1990
MR OF OSTEOCHONDRITIS
DISSECANS
OF THE
KNEE
551
Fig. 2.-Partially attached osteochondritis dissecans with intact cartilage. A, Plain film shows medial condyle defect with central fragment. B and C, Sagittal (B) and coronal (C) MR images, 2000/90. Bone-fragment Signal within fragment is nonspecific, being mostly -2 absent signal but with (arrows), although cartilage was intact at arthroscopy.
interface shows high signal (arrowheads), linear -1 and +2 signal within it. Subchondral
3.-Partially attached osteochondritis with cartilage fracture. A, Plain film shows lateral condyle defect. B-D, High signal on MR Images at fragmentbone Interface and cyst indicate fragment is unstable. MR reveals that large plain film defect is filled with fibrous tissue or fibrocartilage. On coronal MR image, 600/20 (B), fragment has central homogeneous -1 signaL On coronal MR image, 2000/90 (C), fragment has nonspecific mixed -Ilow (arrows) and -2 absent signal. On sagittal MR image, 2000/90 (0), subchondral plate is disrupted (arrow) with adjacent cyst (arrowhead).
Fig.
dissecans
552
DE SMET
ET AL.
AJR:155,
September
1990
Fig. 4.-Osteochondritis dissecans with displaced fragment. A, Plain film shows bony defect in medial femoral condyle (arrow). B-D, MR reveals that small plain film defect is actually a large surface cavity. On coronal MR image, 600/20 (B), defect is filled with intermediate-signal fluid. On sagittal MR image, 2000/ 90 (C), defect is filled with high-signal fluid. On sagittal MR image, 2000/90 (D), displaced fragment (arrow) is embedded in fat pad with overlying fluid.
:k
. . . ., :- . .
-.
:..4.
..
P,
mine lesion stability has been reported only for radionuclide imaging [4, 9, 1 0] and MR imaging [1 0]. With radionuclide scanning, findings between stable and unstable fragments overlap. Radionuclide scanning also provides no anatomic information on articular surface deformity. We expected that MR imaging would be ideal for evaluation of OCD because of its noninvasive nature, absence of ionizing radiation, excellent anatomic detail, and soft-tissue contrast allowing cartilage visualization. We had hoped that, in addition to detecting surface defects, MR could accurately distinguish between stable and unstable fragments. Our observation that one patient with a stable lesion had MR findings similar to the unstable lesions was disappointing but consistent with the literature. Mesgarzadeh et al. [1 0] found that MR imaging
(Figs. 2B, 2C, and 3C). Even the stable lesion had a definite high-signal line at the fragment-femur interface (Fig. 1 B). Nine of the 20 patients with partially attached or displaced fragments had round, cystlike areas in the femur adjacent to the OCD (Fig. 3D). These cystic areas were of intermediate signal intensity on Ti -weighted images and of very high signal intensity on T2-weighted images. The stable lesion did not have an adjacent cyst. The subchondral bone plate was disrupted on both Ti and
-
T2-weighted
images
in all 2i patients
4C). Loose bodies were found on MR imaging in all six patients with displaced fragments. These loose bodies were visualized as low-signal filling defects completely or partially surrounded by high-signal joint fluid on T2-weighted images (Fig. 4D). If there were multiple loose bodies, it was difficult to find all of the loose bodies on the MR scan. Correlation with the plain films was needed to confidently identify several fragments embedded in the synovium. Two loose bodies were cartilaginous and were seen on MR images but not seen on the plain films.
nine stable
presence of a high-signal line as criteria for lesion instability. The most dramatic role for MR imaging is in visualizing the
presence cation of useful in about the Because bility, we and size of articular cartilage defects and identificartilaginous loose bodies. This information was preoperative planning and in advising the patient poorer prognosis with a large cartilage defect. of our one false-positive diagnosis of lesion instaare using the presence of a high-signal line beneath
Discussion
OCD
Although many imaging methods have been used to study fragments, imaging of large series of patients to deter-
AJR:155,
September
1990
MR OF OSTEOCHONDRITIS
DISSECANS
OF THE
KNEE
553
the lesion as a suggestive but not absolute indicator of an unstable lesion. Although our one false-positive case did not meet our arthroscopic criteria for an unstable lesion, we think but cannot prove that the lesion was still unstable. Although the lesion appeared stable at surgery, it had an overlying dimple and the arthroscopist drilled the lesion to induce healing. The lesion began healing immediately and was completely healed in 2 years. We think that although the lesion was stable to probing, microscopic fragment motion occurred under greater forces generated by weight bearing. This patients knee had been painful with activity for 2 years before we began caring for him. The patient was followed up for i
lesions
will be needed
to prove
that
cystic
areas
are never
surface defects. High signal at the fragment interlace was seen in all unstable lesions but also in one questionably stable lesion. Cystic lesions beneath the fragments were seen only
in unstable lesions. On the basis of these findings, we believe that MR imaging is useful in evaluating lesion stability and articular cartilage defects in patients with femoral OCD.
program
including
3 months
of knee
REFERENCES
1 . Cahill B. Treatment of juvenile osteochondritis dissecans and osteochondritis dissecans of the knee. Clin Sports Med 1985;4(2):367-384 2. Hughston JC, Hergenroeder PT, Courtenay BG. Osteochondritis dissecans of the femoral condyles. J Bone Joint Surg [Am] 1984;66-A(9): 1340-1348 3. Steiner ME, Grana WA. The young athletes knee: recent advances. Gun Sports Med 1988;7(3):527-546 4. Cahill BR, Phillips MA, Navarro A. The results of conservative management ofjuvenile osteochondritis dissecans using joint scintigraphy: a prospective study. Am J Sports Med 1989;17(5):601-606 5. Denoncourt PM, Patel D, Dimakopoulos P. Arthroscopy update #1 . Treatment of osteochondritis dissecans of the knee by arthroscoplc curettage. follow-up study. Orthop Rev 1986;15(10):652-657 6. Ewing JW, Voto SJ. Arthroscoplc surgical management of osteochondritis dissecans of the knee. Arthroscopy 1988;4(1):37-40 7. Thomson NL. Osteochondritis dissecans and osteochondral fragments managed by Herbert compression screw fixation. C!in Orthop 1987;
bracing and the use of crutches. The patient had knee pain with ambulation throughout the conservative management period but ran without knee pain within 7 months after surgery.
Mesgarzadeh
lesions had no high signal at the fragment interface. We also noted in a previous study [i 5] that the absence of a highsignal line in talar OCD was a reliable sign of a healed OCD. On the basis of these two studies, we have been assuming that patients with no high signal at the interface have healed lesions. Large series of patients with MR examinations and treating patients conservatively until bony union occurs will
be needed
reliable
to see if absence
lesion.
of a high-signal
interface
is a
sign of a stable
224:71-78
lesions
and intact cartilage had apparently disrupted cartilage on MR imaging in the presence of intact cartilage at arthroscopy is unknown. Mesgarzadeh et al. [1 0] also noted apparent carti-
lage discontinuity
on MR imaging
in i i of their unstable
lesions, but only five had disrupted cartilage at surgery. Presumably the cartilage suffers an initial injury with either reparative tissue or old hemorrhage persisting at that site. We cannot explain why this tissue in the articular cartilage and subchondral bone plate region would have persistent signal characteristics resembling fluid or granulation tissue. The high-signal interface at the junction between the fragment and the femur is not as puzzling. Histologic studies after MR imaging of avascular necrosis of the femoral head have found that granulation tissue at the margins of the necrotic
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14. Sims RE, Genant HK. Magnetic resonance imaging of joint disease. Radio! din North Am 1986;24(2): 179-188 15. De Smet AA, Fisher DR, Bumstein Ml, Graf BK, Lange RH. Value of MR imaging in staging osteochondral lesions of the talus (osteochondritis dissecans): results in 14 patients. AiR 1990;154:555-558 16. Bassett LW, Mirra JM, Cracchiolo A, Gold RH. lschemic necrosis of the femoral head. C!in Orthop 1987;223:181-187 17. Mitchell DG, Steinberg ME, Dalinka MK, Rao VM, Fallen M, Kressel HY. Magnetic resonance imaging of the hip: alterations within the osteonecrotic, viable, and reactive zones. C!in Orthop 1989;244:60-77
with these femoral head studies, we noted at surgery that partially attached fragments often had fibrous granulation tissue in the base of the defect. Focal cystic areas beneath the fragments were seen only
with unstable fragments. We previously showed that in talar OCD such cysts were seen only with unstable fragments
[i 5]. These
lation tissue
cysts were found to be cavities filled with granu[15]. Further study of patients with proven stable