Synovial knee disease: MRI differential diagnosis

Poster No.: C-2443

Congress: ECR 2013
Type: Educational Exhibit
Authors: 1 2
M. Teixidor Viñas , D. Martinez de la Haza , I. Santos Gomez ,
3

3 3 4 1
N. Rojo Sanchis , P. Santo Panero , M. Simonet ; Girona/
2 3
ES, Hospitalet de Llobregat/ES, Sant Boi de Llobregat/ES,
4
Barcelona/ES
Keywords: Inflammation, MR, Musculoskeletal soft tissue
DOI: 10.1594/ecr2013/C-2443

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Page 1 of 18
Learning objectives

1. Define the synovial membrane.

2. Describe a proper MRI technical study protocol.

3. Illustrate synovial pathology of the knee withMRIstudies. Emphases in the differential

diagnosis for this disease.

Background

According to Medical Disability Guidelines, synovitis is described as irritation and

inflammation of the joint lining, anatomically called synovium.

After an injury, the synovial membrane responds by producing liquid. This fact sets up
the classic symptoms of synovitis, characterized by swelling, pain and redness in the
affected joint.

This condition can be caused by infection, , hemorrhage, inflammation (rheumatoid

arthritis, gout) or be related to characteristics entities as pigmented villonodular synovitis
(PVNS), synovial chondromatosis or lipoma arborescens.

On a MRI study, the knee's synovial pathology is frequently observed.

The most classical radiological signs are joint effusion and synovial thickening.

Page 2 of 18
Fig. 1: 5 years patient with suspicious of osteomylitis. T1 DP weitghed images and
T1 fat sat postcontrast media injection showed a massive joint effusion and synovial
enhancement, in relation with septic acute arthritis.
References: Hospital general Parc sanitari Sant Joan de Deu

However, in some patients is possible to observe other MRI findings. These other MRI
signs can suggest what might be the cause of the disease.

At the same time, the blood test results and the medical history can help us to distinguish
between different etiologies.

For example, if we realize a MRI knee study in a traumatic patient, we can consider than
the visualization of bone marrow edema can be explained for the traumatic injury. But,
if we observe an heterogenic fluid signal on the gradient-echo MR image, with different
low signal intensity areas inside the synovial space, we must think about an hemorrhagic
etiology.

Page 3 of 18
Fig. 2: Patient with joint knee effusion. The MRI scan showed non- homogeneous
joint effusion, with low intensity areas in the T2 FFE weighted images, in relation with
hemosiderin deposition. Patient was diagnosed of Haemorrhagic synovitis.
References: Hospital general Parc sanitari Sant Joan de Deu

MRI is a suitable technique to discern between the different etiologies able to damage the
synovial membrane. So, MRI can decrease the requirements of an invasive diagnostic
procedure.

In view of the location of the lesion inside the knee, its appearance in different MRI
sequences performed and any other associated findings, the radiologist should suggest
the most likely etiology for each synovial pathology.

Page 4 of 18
Fig. 3: Young patient with a right patella dislocation. T2 weighted images showed
a bone contusion pattern involving the inferomedial pole of the patella and the
anterolateral aspect of the nonarticular portion of the lateral femoral condyle. The
MPFL is ruptured.
References: Hospital general Parc sanitari Sant Joan de Deu

Images for this section:

Page 5 of 18
Fig. 1: 5 years patient with suspicious of osteomylitis. T1 DP weitghed images and
T1 fat sat postcontrast media injection showed a massive joint effusion and synovial
enhancement, in relation with septic acute arthritis.

Page 6 of 18
Fig. 2: Patient with joint knee effusion. The MRI scan showed non- homogeneous
joint effusion, with low intensity areas in the T2 FFE weighted images, in relation with
hemosiderin deposition. Patient was diagnosed of Haemorrhagic synovitis.

Page 7 of 18
Fig. 3: Young patient with a right patella dislocation. T2 weighted images showed a
bone contusion pattern involving the inferomedial pole of the patella and the anterolateral
aspect of the nonarticular portion of the lateral femoral condyle. The MPFL is ruptured.

Page 8 of 18
Imaging findings OR Procedure details

Protocol for a good knee MRI study:

• patient supine with the knee slightly flexed and in external rotation.

• surface antenna, slice thickness 4mm.

• Sequences:

1. DP AXIAL fat / sat.

2. T1-weightedESFSAGITAL
3. GE T2-weighted SAGITAL
4. DP CORONAL fat / sat
5. CORONAL STIR-weighted
6. FSE T2-weighted SAGITAL ligament specific: To realize a good image of
the posterior cruciate ligament we need to oblique different planes in the
space. In the coronal view we need an obliquity from the inner end of the
lateral femoral condyle and to the midpoint of the tibial spines. In the axial
plane we need an obliquity from the inner margin of the lateral condyle to the
midpoint of the tibial spine.
7. If it is a TUMOR or an INFECTED PROCESS we should perform a T1-
weighted fat / sat before and after the contrast medium injection in the most
specific views per each case.

PIGMENTED VILLONODULAR SYNOVITIS (PVNS)

Rare disorder proliferation of the synovial membrane. It is a formation of villi and nodules
characterized by deposit of intracellular haemosiderin, that determines local or diffuse
thickening of the synovial membrane, exhibiting benign behaviour from a biological point
of view.

It may appear either in a diffuse or a localized (nodular) form.

The involvement of the knee is the most common location.

It affects men and women of the second to fourth decade.

The MRI study can suggest the diagnosis. However, such diagnosis can be confirmed
only on histology as the final diagnosis of PVNS.

Page 9 of 18
Differential diagnosis:

• other haemorrhagic synovites.

• chronic hyperplastic synovites.

The treatment of choice is surgical excision.

If the effect is local recurrence has a 10 to 20% and if it is widespread, 50%.

Fig. 4: Patient with pigmented villonodular synovitis. MRI study showed an intrarticular
mass located in the intercondilia space. It presence same intensity as the muscle in
T1WI and T2WI, but it has low intensity signal in T2 FFE. Joint effusion is noted too.
References: Hospital general Parc sanitari Sant Joan de Deu

The MRI findings are:

• Intraarticular low intensity or isointense mass on T1/T2 weighted images.

• Low intensity mass on T2-GE weighted.
• We can see haemosiderin deposits on T2-GE weighted.
• Spill

Page 10 of 18
 • Possible bone erosions associated with bone edema
• Possible soft tissue edema.

SYNOVIAL CHONDROMATOSIS

Benign tumor characterized by nodules of hyaline cartilage tissue located in subsynovial,

tendons or bursa. This process determines a distension of the synovial space.

It is observed in adult men.

The most common site is the knee, and the second one the shoulder.

There are two types of synovial chondromatosis:

1. Primary: multiple presence of foreign bodies inside the joint, with equal
shape and size, which frequently presents cartilages calcification in its
central and peripheral part.
2. Secondary: hyaline cartilage injury related with trauma, osteochondritis
dissecans, neuropathic osteoarthropathy, osteoarthritis or infectious
arthritis / unspecific inflammatory disease. It is characterized by the
presence of intraarticular foreign bodies that have different shapes and
sizes, with the presence of various ring calcifications.

MR findings associated with CT findings are pathognomonic.

At CT we expect:

• Synovial thickened, which present low dense density

• Presence of calcified nodules, which are the calcified chondral bodies.
These chondral bodies present a single ring or small specks. The large
calcified bodies often have radiolucent centers secondary to incomplete
calcification or ossification. Frequently, the plain film is not useful, and just in
5-30% of them we can notice calcifications.
• Late stages: Presence of chondral and soft fat tissue calcifications.
• Erosion of adjacent bones, on changes of secondary osteoarthritis may be
the only indicators of disease.
• Often: widening of the joint space.

Page 11 of 18
Fig. 6: Patient with synovial chondromatosis: Although the example is in a patient with
shoulder disease, the axial MRI and CT images showed multiple nodules inside the
joint space. The nodules presented peripheral high intensity sign in the postcontrast
medium study.
References: - Girona/ES
In the MRI study:

• # joint space: It is isointense to muscle on T1 weighted and high intensity on

T2 weighed images.
• First stage: notice of areas that have high intensity on T2 weighted images.
It is relative to the cartilage bodies.
• Late stages: focal areas of avoid signal on all the differentMRIsequences, in
relation with calcifications, that we can correlate on the CT study.
• Post- contrast media injection sequences: the nodules present high
peripheral intensity, in relation to the synovial membrane.

The injury can condition Chondrosarcoma in 5% of cases.

LIPOMA ARBORESCENS

Page 12 of 18
Idiopathic and rare joint disease characterized by the deposition of fat in the synovial
membrane in the 100% of patients, with distension of the synovium space associated.

The deposit of fat is a diffusely villous proliferation secondary to chronic irritation.

Patients with lipoma arborescens can develope inflammatory arthritis.

Most frequent presentation disease: Unilateral involvement of the knee.

In 87% of cases is also observed meniscus cartilage degenerative changes. It can

involutes completely in 72% of the patients.

There are two known categories of lipoma arborescens:

1. Primary or idiopathic: common in young patients.

2. Secondary

Curative treatment is synovectomy.

Page 13 of 18
Fig. 5: Patient with lipoma arborescens. In the knee MRI study we can observe a
nodular mass around the synovial membrane. It has equal signal intensity than the soft
fat tissues, but has an extremely contrast captation in the fat sat T1WI postcontrast
media injection.
References: Hospital general Parc sanitari Sant Joan de Deu

The signs observed on MRI are:

• Homogenously synovial fat mass: It is high intense on T1 and T2 wegthed

images, and it is low intense on fat saturation sequences.
• Synovial effusion
• Bone and cartilage degenerative changes in 87% of cases.

Images for this section:

Page 14 of 18
Fig. 4: Patient with pigmented villonodular synovitis. MRI study showed an intrarticular
mass located in the intercondilia space. It presence same intensity as the muscle in T1WI
and T2WI, but it has low intensity signal in T2 FFE. Joint effusion is noted too.

Page 15 of 18
Fig. 6: Patient with synovial chondromatosis: Although the example is in a patient with
shoulder disease, the axial MRI and CT images showed multiple nodules inside the joint
space. The nodules presented peripheral high intensity sign in the postcontrast medium
study.

Page 16 of 18
Fig. 5: Patient with lipoma arborescens. In the knee MRI study we can observe a nodular
mass around the synovial membrane. It has equal signal intensity than the soft fat tissues,
but has an extremely contrast captation in the fat sat T1WI postcontrast media injection.

Page 17 of 18
Conclusion

The knee synovial pathology is a relatively common entity. It is becoming imperative

for the radiologist know its possible causes and guide to a correct diagnosis based on
characteristic MRI findings.

References

1. MRI features of pigmented villonodular synovitis (PVNS). Xiao G. Cheng, Yu

H. You, Wei Liu Tao Zhao, Hui Qu. Clin Rheumatol (2004) 23: 31-34
2. MRI Findings of Septic Arthritis and Associated Osteomyelitis in Adults.
Karchevsky M, Schweitzer M, Morrison W, Parellada A. AJR
2004;182:119-122.
3. MR Imaging of Patellar Instability: Injury Patterns and Assessment of
Risk Factors. Diederichs G, Issever A, Scheffler S. RadioGraphics 2010;
30:961-981.
4. From the Archives of the AFIP. Pigmented Villonodular Synovitis: Radiologic-
Pathologic Correlation. Murphey, M, Rhee J, Lewis R, Fanburg-Smith J,
Flemming D, Walker E. RadioGraphics 2008; 28:1493-1518
5. Nonseptic Monoarthritis: Imaging Features with Clinical and Histopathologic
Correlation. Llauger J, Palmer J, Rosón N, Bagué S, Camins A, Cremades R.
RadioGraphics 2000; 20:S263-S278
6. MR Imaging of Patellar Instability: Injury Patterns and Assessment of
Risk Factors. Diederichs G, Issever A, Scheffler S. RadioGraphics 2010;
30:961-981
7. Imaging of Intraartricular Masses. Sheldon P, Forrester D, Learch T.
RadioGraphics 2005; 25: 105- 119.
8. Imaging of Intraarticular Masses. Sheldon P, Forrester D, Learch
T.RadioGraphics 2005;25:105-119

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