The visibility of the lesion depends on its location and on the amount of knee flexion used. (b) Subsequently, a frank articular collapse (arrowheads) has developed, followed by loss of fatty signal intensity in the necrotic area (arrows). Note articular surface collapse of the medial femoral condyle (arrowhead in b and c), with depression of the subchondral bone plate (c) and loss of subchondral fatty signal intensity (b). Patient demographics, the clinical presentation, and the role of trauma are critical for differential diagnosis. 3, © 2020 Radiological Society of North America, Evaluation and management of osteochondral lesions of the talus, Acute and stress-related injuries of bone and cartilage: pertinent anatomy, basic biomechanics, and imaging perspective, In vitro MR imaging of hyaline cartilage: correlation with scanning electron microscopy, The tibial subchondral plate. (b, c) Coronal T1-weighted (b) and proton-density–weighted fat-suppressed (c) MR images show a progeny (P) fragment separated from the parent bone, with signal intensity equal to that of fluid (white arrow in c) and an additional outer rim of sclerosis (black arrow in c). Additional secondary criteria are employed for a juvenile OCD lesion to increase specificity. Healing juvenile OCD in a 13-year-old boy. Figure 2. AVN of the medial femoral condyle in a 29-year-old woman with lupus. Advanced SIF in a 69-year-old woman with several months of unrelenting knee pain after walking down stairs. Contrast and compare common entities that manifest as osteochondral lesions of the knee: acute traumatic osteochondral injuries, AVN, SIF of the knee, OCD, bone marrow edema-like lesions, and subchondral cystlike lesions in … Figure 8b. 2 of 7 Posadzy et al: Staging of Osteochondral Lesions of the Talus Figure 1: Location of the OCL according to the mechanism of trauma. In addition to osteoarthritis, subchondral cystlike lesions may be prominent in rheumatoid arthritis and calcium pyrophosphate deposition disease (67). Anterior femoral condylar fracture and bone contusion at the anterior aspect of the tibia (* in b) are the results of an internal force that occurred during hyperextension as the femur and tibia collide. The deepest calcified cartilage layer is located at the interface with the subchondral bone plate, a layer of compact cortical bone that overlies the cancellous marrow-containing trabecular bone. Figure 16a. Figure 6b. (a) Radiograph shows a localized ossification defect of the medial femoral condyle containing linear calcifications (white arrow) and surrounded by sclerosis (black arrow). Two misconceptions contributed to a long evolution of the understanding of this disorder: (a) a pre–MRI-era hypothesis that attributed it to a primary AVN, resulting in the misnomer, and (b) an effort to distinguish it fundamentally from SIF, largely impelled by differences in prognosis. The laminar configuration of the signal intensity in the fragment reflects the presence of calcifications in its deep zone (arrow in b). In osteoarthritis, such abnormalities include bone sclerosis (referred to as eburnation on radiographs), bone marrow edema-like lesions, and subchondral cystlike lesions (Fig 19). Healing juvenile OCD in a 13-year-old boy. Illustration shows the hypothesized pathogenesis of juvenile OCD as a growth disturbance of the secondary physis that causes a localized delay of ossification and subchondral bone formation, followed by either healing or failure of the overlying cartilage and localized articular surface fragmentation and separation. (a) Diagram shows a fracture that is creating an osteochondral fragment. The distal femoral physis is closed (*). As demonstrated in studies of osteonecrosis of the femoral head (35), bone marrow edema distal to the infarct constitutes an indirect sign of articular collapse. Subchondral fracture in a 32-year-old man with an acute medial collateral ligament tear (arrow in d) and an anterior cruciate ligament rupture (not shown). Patient demographics, the clinical presentation, and the role of trauma are critical for differential diagnosis. Osteochondral fracture in a 32-year-old man with a hyperextension injury associated with a posterior cruciate ligament tear (not shown). In early uncomplicated AVN, the marrow signal in the infarct is preserved, representing mummified fat, and there is no surrounding bone marrow edema. Focal discontinuity of the subchondral bone plate is seen (arrowhead). A bone contusion (* in b) is visible at the posterior aspect of the lateral tibial plateau. MRI features that aid in diagnosis include the location and extent of bone marrow edema, the presence of a fracture line, a hypointense area immediately subjacent to the subchondral bone plate, and deformity of the subchondral bone plate. Figure 7b. A study by Yamamoto and Bullough (15), which was supported by results of a later study (16), showed that the primary event is a SIF, followed by secondary necrosis limited to the area between the fracture line and the subchondral bone plate. Conditions that affect articular cartilage are frequently accompanied by abnormalities in the subchondral marrow. Note the peripheral extrusion of the medial meniscus (black arrow in b) from a posterior horn tear (not shown). A bone contusion (* in b) at the lateral tibial plateau can be distinguished from a fracture because of the absence of a contour deformity or fracture line. (d) MR image obtained 6 months later shows restoration of the subchondral bone plate (arrowhead). For this journal-based SA-CME activity, the authors, editor, and reviewers have disclosed no relevant relationships. Figure 10b. The terms bone bruise or bone contusion refer to trabecular microfractures that manifest as a pattern of bone marrow edema on MR images, without contour abnormalities or a discrete fracture line (2,9,10). MRI features of this lesion also have been shown to be profoundly different from those of primary AVN (17,18). OCD in an 18-year-old man who heard a pop while getting out of bed and was unable to extend his knee. Once a characteristic pattern of osseous injury is recognized on MR images, the radiologist must seek specific additional soft-tissue and osseous injuries. Once SIF progresses to collapse and articular surface destruction, distinguishing it from primary osteoarthritis at imaging may be impossible, and it is likely to be clinically irrelevant. Diagram of image from a fluid-sensitive sequence (a), coronal T1-weighted MR image (b), and proton-density–weighted fat-suppressed MR image (c) show multiple regions of AVN in the femur and tibia. Figure 11b. More important are the localized abnormalities in the subchondral region, best shown on T2-weighted and proton-density–weighted MR images. Juvenile osteochondritis dissecans: is it a growth disturbance of the secondary physis of the epiphysis? SIF in a 64-year-old woman with a complex tear in the medial meniscus with peripheral extrusion (arrow in a). ■ Evaluate MRI findings of each condition and how they pertain to treatment. Figure 18a. The distal femoral growth plate is open (* in a and b). From the Department of Radiology, Einstein Healthcare Network, 5501 Old York Rd, Philadelphia, PA 19141 (T.G, M.C., B.W.C.) (b–d) Sagittal T2-weighted fat-suppressed MR image (b), proton-density–weighted MR image (c), and CT image (d) show a curvilinear fracture (arrow in b and c) encircling a portion of subchondral bone and overlying cartilage. (d) Sagittal T2-weighted fat-saturated MR image shows disruption of the subchondral bone plate (arrowhead). Diagram of the fluid-sensitive MR image (a) and sagittal T2-weighted fat-suppressed (b), coronal T1-weighted (c), and proton-density–weighted fat-suppressed (d) MR images show a subchondral fracture (arrow in b and c) as a curvilinear hypointensity surrounded by bone marrow edema, without associated contour deformity. Note the peripheral extrusion of the medial meniscus (black arrow in b) from a posterior horn tear (not shown). Note the lack of edema in the necrotic segment. We offer a summary of current concepts for each condition to aid in their differentiation at MRI. Once the diagnosis is established, it is important to report pertinent MRI findings that may guide appropriate treatment of each condition. Osteochondral fracture with a subchondral bone plate depression in an 18-year-old man. Collapse begins at the lateral boundary of the necrotic lesion and, depending on the size of the lesion, propagates either along the subchondral region or in the deep necrotic region (33). Patients present with acute onset of pain and have a clear history of preceding trauma. The purpose of this study was to directly compare the MRI … Several factors are responsible for development of a collapse that signifies failure of the subchondral bone plate: (a) the cumulative effect of fatigue microfractures in the necrotic zone, (b) osteoclastic activity that causes weakening of the trabeculae in the reparative front, and (c) focal concentration of mechanical stress on thickened bone trabeculae of the reparative zone along the AVN margins that act as “stress risers” (31–33). Both a subchondral hypointense line (white arrow in b and c) and a subchondral area of low signal intensity (arrowhead in b and c) are observed along the weight-bearing aspect of the condyle and are associated with subtle flattening of the articular surface. The unique feature of this condition is that separation and detachment of the osteochondral fragment culminate the process that originally starts deep underneath the articular surface (43) and subsequently involves the articular cartilage at the peripheral border of the lesion: an “inside-out” mechanism. Classic SIF in a 64-year-old man. (b) Subsequently, a frank articular collapse (arrowheads) has developed, followed by loss of fatty signal intensity in the necrotic area (arrows). The lack of skeletal maturity in this patient population can lead to injuries and injury patterns not commonly encountered in the adult population. Bone marrow edema-like lesion, the term adopted by the osteoarthritis research community, is defined as a noncystic subchondral area of ill-defined hyperintensity on fluid-sensitive sequences and hypointensity on T1-weighted images. These two patterns may coexist. (b) Subsequently, a frank articular collapse (arrowheads) has developed, followed by loss of fatty signal intensity in the necrotic area (arrows). Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. These osseous injuries are the result of impaction of the lateral femoral condyle against the posterolateral tibial plateau during internal rotation and anterior translation of the tibia accompanying an anterior cruciate ligament rupture (arrow in d). At MRI, SIF is associated with marked bone marrow edema emanating from the subchondral region and extending over large areas (10,17,18), often involving the entire femoral condyle. However, the extent of bone marrow edema has no prognostic significance (17,21). A bone contusion (* in b) at the lateral tibial plateau can be distinguished from a fracture because of the absence of a contour deformity or fracture line. Healing juvenile OCD in a 13-year-old boy. Figure 16a. Histologically, articular cartilage is organized into four layers, each characterized by a different cellular composition and orientation of collagen fibers that produce gradual variations in signal intensity: superficial, transitional, deep (radial), and calcified layers (2). MRI is shown in Image A. Authors of many studies have emphasized the role of chronic repetitive trauma in active children, particularly those who are high-level athletes (52,53). Coronal T1-weighted, proton-density–weighted fat-suppressed, and sagittal T2-weighted fat-suppressed MR images (left to right in each row of a, b, and c) at presentation (a) show extensive bone marrow edema (* in a), hypointense fracture lines, and areas of low signal intensity subjacent to the subchondral bone plate (arrowheads in a) associated with minimal flattening of the articular surface; images obtained 6 months later (b) show articular surface collapse (black arrow in b) associated with numerous cystlike areas (white arrow in b) and marrow edema confined to the periarticular region; images obtained at 16 months (c) show that a large saucerized articular surface defect has formed (arrows in c). Figure 18d. 26 years experience Physical Medicine and Rehabilitation. Figure 8b. Osteochondral injury is commonly associated with immediate effusion that represents hemarthrosis or lipohemarthrosis. Initial treatment of SIF is conservative, consisting of protected weight bearing and administration of analgesic medications to prevent development or worsening of subchondral bone collapse (27). Radiographs, coronal T1-weighted images, proton-density–weighted fat-suppressed images, and sagittal proton-density–weighted images (left to right in rows a and b) were obtained at the onset of knee pain (a) and 7 years later (b). An osteochondral lesion is a defect in the cartilage of a joint and the bone underneath. Figure 9a. (b–d) Sagittal T2-weighted fat-suppressed MR image (b), proton-density–weighted MR image (c), and CT image (d) show a curvilinear fracture (arrow in b and c) encircling a portion of subchondral bone and overlying cartilage. 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