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tion Age ,40 years; focal contained defect (surrounded Arthroscopic introduction of micropenetration from defect surface to
by intact cartilage); femoral condyles; lesion the subchondral bone until visible bleeding. Resulting clot contains
size ,4 cm2 mesenchymal stem cells, which heal defect by forming fibrocartilage.
utograft Femoral lesions ,2.5 cm2 Grafts taken from the patient’s own nonweight-bearing cartilage
introduced into the chondral defect and underlying bone.
llograft Lesions with bone and cartilage loss; large, uncontained Grafts taken from a suitable deceased donor introduced into the chondral
lesions (ie, extend beyond the margin or the cartilage defect and underlying bone.
or deep into subchondral bone)
age allograft Focal articular cartilage defects Allograft articular cartilage from donors younger than 13 years that has
STATE OF THE ART: MR Imaging after Knee Cartilage Repair Surgery Guermazi et al
been cut into approximately 1-mm cubes. It is applied to cartilage
lesions in a monolayer and held in place with the use of fibrin sealant
during a single-step procedure. STATE OF THE ART: MR Imaging after Knee Cartilage Repair Surgery
ndrocyte Lesions .2 cm2 Two-part procedure. First, chondrocytes are harvested arthroscopically,
usually from tibial spines. They are cultured and multiplied ex vivo for
6–8 weeks, then implanted into the chondral defect.
6 and 35.
Bavornrit Chuckpaiwong, M.D., Eric M. Berkson, M.D., and George H. Theodore, M.D.
108 B. CHUCKPAIWONG ET AL.
Purpose: The purpose of this study was to identify outcomes and outcome predictors of arthroscopic
debridement with osteochondral bone stimulation (microfracture) for osteochondral lesions of the
10 T 1. Success of Lesions Distributed by Size
ABLEOne hundred five consecutive patients with osteochondral lesions of the ankle who
ankle. Methods:
(Average of Longitudinal and Transverse Diameter)
underwent ankle arthroscopy with microfracture were prospectively followed up for a mean of
31.6 ! 12.1 months. Study patients were evaluated at 6 weeks, 3 months, 6 months, 12 months, and
9 annually after surgery. Assessments via a visual analog scale for pain during daily activities and sport
activity, the Roles and Maudsley score, and the American Orthopaedic Foot & Ankle Society ankle
Size of Lesion
and hindfoot scoring systemSuccessful
were obtained at (neach
# 74) Unsuccessful
visit. Outcome predictors were (n # 31)
analyzed by
8 logistic regression model. Results: There were no failures of treatment with lesions smaller than 15
mm. In contrast, only 1 patient met the criteria for success in the group of lesions greater than 15 mm.
mm revealed that increasing46age, higher body mass index, history0of trauma, and
!5analysis
Statistical
7 presence of osteophytes negatively affected outcome. The presence of instability and the presence of
5-15 mm 27 0
anterolateral soft-tissue scar were correlated with a successful outcome. Conclusions: This study
6 15-20
found mm
a strong 1 and success across its entire population.
correlation between lesion size 7 For lesions
smaller than 15 mm, regardless of location, excellent results were obtained. In addition, increasing
$20 body
age, higher mmmass index, history of trauma,0 and presence of osteophytes24 negatively affect
outcome. The presence of instability and anterolateral soft-tissue scar correlated with a successful
5 outcome. Level of Evidence: Level IV, prognostic case series, prognostic study. Key Words:
NOTE. defect—Ankle
Osteochondral There were no failures in smaller lesions and only 1
arthroscopy—Microfracture—Ankle.
4 success in larger lesions.
2
O steochondral lesions of the ankle can be a chal-
tion, 5.7% of lesions were stage 1, 22.9% were stage
23 for the foot and ankle surgeon.
lenging problem
Ankle articular cartilage is distinctly different from
articular cartilage degeneration in the ankle.6 One
would expect that cartilage healing and responses to
surgical cartilage restoration procedures may be dif-
2, 43.8% were stage 3, and 27.6% were stage 4.
articular cartilage in the knee.1-4 Besides being mac- ferent as well.
Quality of repair tissue at follow-up?
The American Journal of Sports Medicine. 2009;37.
Non-invasive assessment of repair tissue
Cartilage
Compartment Function
WOMAC Score
Pain Stiffness Cartilage Volume Cartilage Thickness Opposing Volume* Opposing Thickness†
Radiology
Medial femur
R value 0.35 0.32 NA !0.30 !0.39 !0.33 !0.36
P value .013 .027 ".05 .027 .004 .013 .007
NA Musculoskeletal Imaging
Medial tibia
R value Radiology.
0.29 2004;232(2):592-598.
0.40 !0.38 !0.53 !0.45 !0.48 Radiology. 2008;247(1):154-161.
P value .042 .005 ".05 .004 #.001 #.001 #.001
Lateral femur
R value 0.31 NA NA NA NA NA !0.35
T2 ".05 Relaxation Time".05 of
Radiology
Index terms:
Cartilage, MR, 452.121411
Knee, arthritis, 452.7
Knee, MR, 452.121411 PURPOSE: To evaluate differences in T2 values in femoral and tibial cartilage at
Magnetic resonance (MR), tissue magnetic resonance (MR) imaging in patients with varying degrees of osteoarthritis
characterization, 452.121411
(OA) compared with healthy subjects and to develop a mapping and display
Published online before print method based on calculation of T2 z scores for visual grading and assessment of
10.1148/radiol.2322030976 cartilage heterogeneity in patients with OA.
Radiology 2004; 232:592–598
MATERIALS AND METHODS: Knee cartilage was evaluated in 55 subjects who
Abbreviations: were categorized with radiography as healthy (n ! 7) or as having mild OA (n ! 20)
OA ! osteoarthritis or severe OA (n ! 28). Cartilage regions were determined with manual segmenta-
WOMAC ! Western Ontario and
McMaster University
tion of an MR image acquired with spoiled gradients and fat suppression. The
segmentation was applied to a map of T2 relaxation time and was analyzed in four
1
knee cartilage compartments (ie, the medial and lateral tibia and femur). Differences
From the Departments of Radiology
between cartilage compartment T2 values and subject groups were analyzed with
(T.C.D., Y.L., H.J., S.M.) and Ortho-
paedic Surgery (M.D.R., S.M.), Univer- analysis of covariance. Correlations of cartilage T2 values with clinically reported
sity of California at San Francisco, 185 symptoms and cartilage thickness and volume were examined. Cartilage T2 values
Berry St, Suite 350, San Francisco, CA were converted to z scores per voxel on the basis of normal population values in the
94107-1739. Received June 20, 2003;
revision requested August 29; final re- same cartilage compartment to better interpret cartilage heterogeneity and varia-
vision received December 19; ac- tion from normal.
cepted January 13, 2004. Supported
by NIH grant R01 AR46905. Address RESULTS: Healthy subjects had mean T2 values of 32.1–35.0 msec, while patients
correspondence to T.C.D. (e-mail: with mild and severe OA had mean T2 values of 34.4 – 41.0 msec. All cartilage
tcdunn@mrsc.ucsf.edu).
compartments except the lateral tibia showed significant (P " .05) increases in T2
Current address:
2 relaxation time between healthy and diseased knees; however, no significant differ-
Department of Mathematics, South
China Normal University, Shipai, Guang- ence was found between patients with mild and severe OA. Correlation of T2 values
zhou, China. with clinical symptoms and cartilage morphology was found predominantly in
medial compartments.
CONCLUSION: Femoral and medial tibial cartilage T2 values increase with the
severity of OA.
© RSNA, 2004
Osteoarthritis (OA) is an important health concern, as joint disease is the single largest
Figure 3. Representative z score conversion sagittal MR images obtained in six subjects (ie, two from each group)
Author contributions: cause of disability in elderly persons (1). Between 13% and 17% of Americans aged 55–74
(1,500/10 and 45; voxel size, 0.468 % 0.468 % 4 mm; examination time, 5 minutes 24 seconds; field of view, 12 cm;
Guarantors of integrity of entire study, years have pain and functional problems related to knee OA (2), and estimated economic
matrix, 256 % 256). Note the increase in area of regions of high z scores (indicated by yellow areas) in patients with
S.M., T.C.D.; study concepts and de- costs were $12.2 billion dollars in 1994 (3).
mild and severe OA. Note that these
sign, S.M., T.C.D.; literature research, are only single sections of the entire knee volume and may not reflect specific
Quantitative measures of T2 relaxation times may be useful in the characterization and
regions
T.C.D.; of disease that
experimental account
studies, S.M.; for OA grade.
long-term tracking of OA. Previous reports have demonstrated spatial variation of T2
data acquisition, S.M.; data analysis/
interpretation, all authors; statistical relaxation times in cartilage explants (4), healthy subjects (5), and substantial changes
analysis, Y.L., H.J.; manuscript prepa- with age (6), but we are unaware of reports that present T2 relaxation time variation with
ration, T.C.D.; manuscript definition OA in humans. Cartilage tissue analysis has shown increased water content in tissue that
decrease in variance of the
of intellectual measured
content, T2
S.M., T.C.D.; variation
has beenofdegraded
T2 values through
through the carti-
OA processes (7) andchondral
decreasedregion to the articulating
glycosaminoglycan concen- sur-
manuscript editing, T.C.D.; manu-
relaxation time with an increased num- lagetration
volumeandcould enhance
proteoglycan sizethe
in informa-
diseased tissueface.
(8,9).MR signal
These heterogeneity
findings across
support those of the
T2 mapping in the ankle European Journal of Radiology 81 (2012) 923–927
a r t i c l e i n f o a b s t r a c t
Article history: Objective: To perform an in vivo evaluation comparing overlying articular cartilage in patients suffering
Received 8 November 2010 from osteochondrosis dissecans (OCD) in the talocrural joint and healthy volunteers using quantitative
Received in revised form 17 January 2011 T2 mapping at 3.0 T.
Accepted 28 January 2011
Method and materials: Ten patients with OCD of Grade II or lower and 9 healthy age matched volunteers
were examined at a 3.0 T whole body MR scanner using a flexible multi-element coil. In all investigated
Keywords:
persons MRI included proton-density (PD)-FSE and 3D GRE (TrueFisp) sequences for morphological diag-
3T
nosis and location of anatomical site and quantitative T2 and T2* maps. Region of interest (ROI) analysis
MRI
T2 mapping
was performed for the cartilage layer above the OCD and for a morphologically healthy graded cartilage
Talus layer. Mean T2 and T2* values were then statistically analysed.
Osteochondrosis dissecans Results: The cartilage layer of healthy volunteers showed mean T2 and T2* values of 29.4 ms (SD 4.9)
and 11.8 ms (SD 2.7), respectively. In patients with OCD of grade I and II lesions mean T2 values were
40.9 ms (SD 6.6), 48.7 ms (SD 11.2) and mean T2* values were 16.1 ms (SD 3.2), 16.2 ms (SD 4.8). Therefore
statistically significantly higher mean T2 and T2* values were found in patients suffering from OCD
compared to healthy volunteers.
Conclusion: T2 and T2* mapping can help assess the microstructural composition of cartilage overlying
osteochondral lesions.
© 2011 Elsevier Ireland Ltd. All rights reserved.
1. Introduction As the talus is the third most common site with 4% of all OCD’s
locations after knee and elbow its incidence is only 0.09% and its
Cartilage is one of the most important structures involved in prevalence 0.002% [2]. It most commonly affects patients in the 2nd
traumatic and degenerative joint disease. Osteochondral lesions decade of life.
of the talus are quite rare compared to larger joints like the knee, Different patho-ethological factors are discussed such as trau-
but still they can cause severe problems for patients including matic, vascular, genetic, endogen and infectious causes [2], but the
pain and disability [1]. Osteochondrosis dissecans (OCD) appears origin still remains unclear.
as a special entity of osteochondral lesion in the ankle joint. Over the last years cartilage assessment in preoperative diag-
T2 mapping in the ankle
Eur Radiol (2014) 24:1758–1767
DOI 10.1007/s00330-014-3196-8
MUSCULOSKELETAL
Eur Eur Radiol2014;24(8):1758-1767.
Radiol. (2014) 24:1758–1767 1765
Quantitative
A Themagnetic
correlation of thickness
resonance imaging index(MRI) and AOFAS evaluation that filling degree positively correlated with clinical outcome
of cartilage score
repair after microfracture (MF) treatment for adult
120 [48, 49]. Domayer et al. [29] found the T2 index correlated
unstable osteochondritis dissecans (OCD) in the ankle: Eur Radiolwith (2014) 24:1758–1767
outcome of the Lysholm score and the IKDC subjective
1763
100
correlations with clinical outcome
AOFAS score
oedema (BME)
80 were calculated. Subjects were divided into Keywords MRI . Microfracture . Ankle . Osteochondritis
two groups: group A (3–12 months post-op), and group B
dissecans (OCD) . Bone marrow edema (BME)
tively correlated with AOFAS score. However, BME was not
(12–24 months post-op). Student’s t test was used to compare
60
the MRI and AOFAS score between two groups and Pearson’s correlated with thickness index or T2 index. The filling
correlation coefficient to analyse correlations between them.
40
Results Thickness index and AOFAS score of group B were
Abbreviations
ACI Autologous chondrocyte implantation
thickness and biochemical properties are the most important
higher than group A (P<0.001, P<0.001). T2 index and BME AOFAS Americanr=-0.475 predicators
Orthopaedic Foot and Ankle Society to evaluate the repair quality. Therefore, subchondral
of group 20B were lower than group A (P<0.001, P=0.012). AP Anteroposterior
P=0.001
Thickness index, T2 index and BME were all correlated with BMI Body mass index BME was an insufficient independent predicator to evaluate
AOFAS score 0 (r=0.416, r=−0.475, r=−0.353), but BME was BME Bone marrow oedema
correlated with0 neither thickness index
0.5 nor T2 index. 1 CC Craniocaudal
1.5
the repair quality. BME could serve as an assisted predictor
2
Conclusions Significant improvement from MF can be
expected on the basis of the outcomes of quantitative T2MRI index
3D-DESS Three-dimensional double echo steady tostateevaluate the repair quality when combined with thickness
sequence
and AOFAS score. MRI was correlated with AOFAS score. dGEMRIC Delayed gadolinium-enhanced MRI ofindex cartilage and T2 index. However, BME was negatively corre-
BMEC The correlation
is insufficient as an independentof subchondral
predictor to evaluate
repair quality, but reduction of BME can improve the patient’s
BME and
DWI AOFAS imaging
Diffusion-weighted score lated3D-DESS
Fig. 3 Sagittal with AOFAS score,
image (a) and which
T2-mapping imageindicated
(d) of a 31- thatA timely
according inter-
to the corresponding colour bar (right). The RT of group A
FOV Field of view
clinical120
outcome. year-old patient in group A (8 months after MF). The sagittal 3D-DESS was arranged in an irregular manner according to colour. The sagittal 3D-
GAG Glycosaminoglycan
vention and reduction of BME could improve the patient’s
T2 mapping in the ankle Osteoarthritis and Cartilage 20 (2012) 829e836
Cartilage repair of the ankle: first results of T2 mapping at 7.0 T after microfracture
and matrix associated autologous cartilage transplantation
S.E. Domayer y *, S. Apprich z, D. Stelzeneder z, C. Hirschfeld y, M. Sokolowski y, C. Kronnerwetter z,
C. Chiari y, R. Windhager y, S. Trattnig z
y Department of Orthopedics, Medical University of Vienna, Austria S.E. Domayer et al. / Osteoarthritis and Cartilage 20 (2012) 829e836 833
z MR Center of Excellence, Department of Radiology, Medical University of Vienna, Austria
a r t i c l e i n f o s u m m a r y
Article history: Background: Both microfracture (MFX) and matrix associated autologous cartilage transplantation
Received 26 October 2011 (MACT) are currently used to treat cartilage defects of the talus. T2 mapping of the ankle at 7 T has the
Accepted 19 April 2012 potential to assess the collagen fibril network organization of the native hyaline cartilage and of the
repair tissue (RT). This study provides first results regarding the properties of cartilage RT after MFX
Keywords: (mean follow-up: 113.8 months) and MACT (65.4 months).
T2 mapping
Methods: A multi-echo spin-echo sequence was used at 7 T to assess T2 maps in 10 volunteer cases, and
Microfracture
in 10 cases after MFX and MACT each. Proton weighted morphological images and clinical data were used
Matrix assisted autologous cartilage
transplantation
to ensure comparable baseline criteria.
Ankle joint Results: A significant zonal variation of T2 was found in the volunteers. T2 of the superficial and the deep
7T layer was 39.3 ! 5.9 ms and 21.1 ! 3.1 ms (zonal T2 index calculated by superficial T2/deep T2: 1.87 ! 0.2,
P < 0.001). In MFX, T2 of the reference cartilage was 37.4 ! 5.0 ms and 25.3 ! 3.5 ms (1.51 ! 0.3,
P < 0.001). In the RT, T2 was 43.4 ! 10.5 ms and 36.3 ! 7.7 ms (1.20 ! 0.2, P ¼ 0.009). In MACT, T2 of the
reference cartilage was 39.0 ! 9.1 ms and 27.1 ! 6.6 ms (1.45 ! 0.2, P < 0.001). In the RT, T2 was
44.6 ! 10.4 ms and 38.6 ! 7.3 ms (1.15 ! 0.1, P ¼ 0.003). The zonal RT T2 variation differed significantly
from the reference cartilage in both techniques (MFX: P ¼ 0.004, MACT: P ¼ 0.001).
(b). Both ROIsT2
Conclusion:
Fig. 2. Example of the ROI setting in a case after MACT in the repair site (a) and the reference are mapping at orientation
set at the same 7 T allows for
to the themagnetic
static quantitative
field. The assessment
deep (1) of the collagen network organi-
and superficial (2) ROIs are indicated by the white boxes. This case shows T2 values in the zation of thethat
repair tissue talus. MACT and
are comparable MFX
to the yielded
articular RT both
cartilage within comparable
the deep and theT2 properties.
superficial layer.
! 2012 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.
Fig. 3. Boxplots of the T2 values after MFX and matrix associated autologous chondrocyte implantation (MACT) in cartilage RT and reference cartilage. Both treatment groups show
a significant increase of T2 in the superficial layer of the RT similar to the hyaline reference cartilage (blue and green boxes), however, T2 of the deep layers differs significantly
between RT and reference cartilage (blue boxes). In contrast, T2 of the superficial layers is comparable between RT and reference cartilage (green boxes). The P-values refer to
Results In the volunteers, we observed a highly significant increase from
Student’s t-tests.
deep to superficial T2 (21.1 ! 3.1 ms vs 39.3 ! 5.9 ms, P < 0.001,
The morphological outcome was comparable in both groups zonal T2 index ¼ 1.87).
(see Table I for details). The majority of cases had complete defect The reference cartilage both of the MFX and of the MACT cases
significant differences between the superficial layers (MFX: a deterioration of clinical outcomes at 71 months, and Hunt and
Introduction various techniques have been used in the ankle, however, the
filling and good integration of the RT, however, interestingly almost yielded comparable ranges of T2 and a highly significant variation
P ¼ 0.159; MACT: P ¼ 0.155). In contrast, both patient groups had Sherman found 54% of the cases had fair or poor results at 66
microfracture technique (MFX) is considered the most effective
all cases had alteration of the subchondral bone. of T2, however, we found small, yet significant differences between
significantly
4 (MFX: P ¼ 0.004; MACT: P ¼ 0.001) increased T2 in the months34. Also, first second-look arthroscopy findings indicate that
the repair tissue; (5) subchondral bone alterations; (6) with the treatment outcomes (1 = excellent, 2 = very good,
signal intensity of the repair tissue; and (7) effusion. Dis- 3 = good, 4 = fair, and 5 = poor), also asking patients if
Statistical analysis
Abstract respectively; intra-class correlation coefficient = 0.94;
Purpose To compare repaired cartilage with native car- confidence interval 0.84–0.99, P B 0.001). Despite C50 %
Descriptive statistics were calculated (mean, range, and
tilage, and inter-observer reliability, using T2 mapping at defect filling in all patients, subchondral bone changes
3 T for assessing cartilage repair in osteochondral defectsstandard deviation values).
were considerable. The HSSToat the determine
follow-updifferences
revealed a
of the talus after the microfracture technique. between
mean score of 87 ± 12 (range 51–97), and theStudent’s
the T2 values, a two-sided independent AOFAS-
Methods We enrolled eight females and seven malest testScore was used
was 90after confirming
± 13 normality of the variances
(range 59–100).
undergoing arthroscopic microfracture for osteochondralof the T2 values 3byT the
Conclusions Kolmogorov–Smirnov
T2 maps were similar in repairedtest. The
and
defects of the talus at an average follow-up ofnonparametric Mann–Whitney
native cartilage test was usedreliability.
with good inter-observer to confirm the
7.9 ± 2.2 years (range 5–13 years). Cartilage tissue wast testLevel result.
ofCorrelations
evidence IV. between the T2 values, MOCART
assessed using a 3-T magnetic resonance imaging unit withscore, and associations between the clinical scores as well
an 8-channel phased array foot and ankle coil (gradientas defect Keywords Ankle
size, age, and! Microfracture
the follow-uptechnique
time were ! assessed
strength,
Fig. 1 Coronal 50 mT/m;spin
T1-weighted slew Fig.
rate,
echo image 2 Sagittal
200 T2 and
T/m/s).
with T2coronal
map maps
and T1-weighted
an were spin echo
Osteochondral image
defect !
with T2
T2 appears
mapping slightly
using the Pearson coefficient of correlation. Inter-observer hypertrophic. b The T2 value of the majority of the
illustrationthen
of the region-of-interest
calculated. Three (ROI)mapanalysis
and an illustration
independent of of the ROI analysis a of a 23-year-old female
a 28-year-old
boarded specialists repair tissue appears comparable to that of the adjacent native
6.5 RT
years(repair
post-operatively.
reliability was evaluated using the intra-class correlation
female 5.4 years post-operatively.
evaluated the images, andThemagnetic tissue)
resonance wasThe RT was 41.8 ms, and the RC was
observation cartilage. However, although integration appears complete, the
40.3 ms, and the RC (healthy cartilage)43.3 was ms.
38.8The
ms. defect is completely
The defect is coefficient (ICC).
covered with repairSPSS
tissue 18.0
that (SPSS Inc.,zone
integration Chicago,
displays IL,
higher T2 properties
of cartilage repair tissue scores was used to assess the Introduction
completely covered with repair tissue that appears slightly USA) was used for all analyses. A P value B0.05 was
hypertrophiccartilage and joint status. Clinical results were assessed
considered significant.
using the Hannover Scoring System (HSS) for the ankle
123 Arthroscopic debridement and bone marrow stimulation
Summary and future directions
• Summary
• Research on treatments for OLTs needs a method to non-invasively follow the
quality of repair tissue
• T2 mapping may be a feasible MRI-based method for use in these studies
• Remaining challenges
• Needs extensively validation through correlation with clinical and histologic
outcomes
• It remains to be used in high quality comparative studies in a standardized manner
• 7T MRI may be essential for validity in the ankle
• Will have to automated
Case conclusion