Magnetic resonance imaging of cartilage and cartilage repair

Imaging of Cartilage and Chondral Defects: An Overview

A healthy articular cartilage is paramount to joint function. Cartilage defects, whether acute or chronic, are a significant source of morbidity. This review summarizes various imaging modalities used for cartilage assessment. While radiographs are insensitive, they are still widely used to indirectly assess cartilage. Ultrasound has shown promise in the detection of cartilage defects, but its efficacy is limited in many joints due to inadequate visualization. CT arthrography has the potential to assess internal derangements of joints along with cartilage, especially in patients with contraindications to MRI. MRI remains the favored imaging modality to assess cartilage. The conventional imaging techniques are able to assess cartilage abnormalities when cartilage is already damaged. The newer imaging techniques are thus targeted at detecting biochemical and structural changes in cartilage before an actual visible irreversible loss. These include, but are not limited to, T2 and T2* mapping, dGEMRI, T1ρ imaging, gagCEST imaging, sodium MRI and integrated PET with MRI. A brief discussion of the advances in the surgical management of cartilage defects and post-operative imaging assessment is also included.

Quantitative MRI for Evaluation of Musculoskeletal Disease: Cartilage and Muscle Composition, Joint Inflammation, and Biomechanics in Osteoarthritis

ABSTRACT

Magnetic resonance imaging (MRI) is a valuable tool for evaluating musculoskeletal disease as it offers a range of image contrasts that are sensitive to underlying tissue biochemical composition and microstructure. Although MRI has the ability to provide high-resolution, information-rich images suitable for musculoskeletal applications, most MRI utilization remains in qualitative evaluation. Quantitative MRI (qMRI) provides additional value beyond qualitative assessment via objective metrics that can support disease characterization, disease progression monitoring, or therapy response. In this review, musculoskeletal qMRI techniques are summarized with a focus on techniques developed for osteoarthritis evaluation. Cartilage compositional MRI methods are described with a detailed discussion on relaxometric mapping (T 2 , T 2 *, T 1ρ ) without contrast agents. Methods to assess inflammation are described, including perfusion imaging, volume and signal changes, contrast-enhanced T 1 mapping, and semiquantitative scoring systems. Quantitative characterization of structure and function by bone shape modeling and joint kinematics are described. Muscle evaluation by qMRI is discussed, including size (area, volume), relaxometric mapping (T 1 , T 2 , T 1ρ ), fat fraction quantification, diffusion imaging, and metabolic assessment by 31 P-MR and creatine chemical exchange saturation transfer. Other notable technologies to support qMRI in musculoskeletal evaluation are described, including magnetic resonance fingerprinting, ultrashort echo time imaging, ultrahigh-field MRI, and hybrid MRI-positron emission tomography. Challenges for adopting and using qMRI in musculoskeletal evaluation are discussed, including the need for metal artifact suppression and qMRI standardization.

Efficacy of a Deep Thermal Therapy System for Osteoarthritis of the Knee

BACKGROUND

This study sought to assess the efficacy of a deep-tissue thermal therapy system with a resonant cavity applicator (DTT-RCA), which safely heats deep joint tissue for treating osteoarthritis (OA) of the knee.

METHODS

Two groups of participants were recruited. The DTT-RCA group comprised 20 knees. Kellgren-Lawrence (K-L) grade was I and II in 8 knees (DTT-RCA I/II group) [mean age 73.3 years (standard deviation 11.4) ], III and VI in 12 knees (DTT-RCA III/IV group) [75.4 (8.6) years]. The control group comprised 13 knees [68.2 (10.8) years]. K-L grade was I in 7 knees and II in 6 knees. This group received exercise therapy. The DTT-RCA I/II group and the control group were imaged by MRI T2 mapping at baseline and 6 months to determine the area of cartilage degeneration.

RESULTS

Visual Analogue Scale improved only in the DTT-RCA I/II post-intervention (p < 0.01). Japanese Orthopedic Association knee rating scores (DTT-RCA I/II: p < 0.01, control group: p < 0.01), the Japanese Knee Osteoarthritis Measure (DTT-RCA I/II: p < 0.05, control: p < 0.01), and the Knee injury and Osteoarthritis Outcome Score (DTT-RCA I/II: p < 0.01, DTT-RCA III/IV: p < 0.05, control: p < 0.01) post-intervention. The magnitude of change did not differ significantly between the three groups. The area of cartilage degeneration did not change significantly post-intervention in the DTT-RCA I/II group, not even relative to the control group.

CONCLUSIONS

This was the first study to test a DTT-RCA system in patients with knee OA. The system reduced the clinical symptoms of knee OA and could potentially be effective for conservative therapy.

A partial hemi-resurfacing preliminary study of a novel magnetic resonance imaging compatible polyetheretherketone mini-prosthesis for focal osteochondral defects

BACKGROUND

The use of partial articular resurfacing surgery with a mini-implant has been gradually increasing; the implant is mainly made of cobalt-chromium metal material, and cartilage changes cannot be monitored after implantation. Thus, we aimed to develop a novel local articular resurfacing polyetheretherketone (PEEK) mini-implant and investigate its feasibility for postoperative magnetic resonance imaging (MRI) monitoring of implant location, bone changes, and cartilage degeneration without artefacts.

METHODS

Nine skeletally mature female standardised goats were used and divided into the sham, PEEK, and cobalt-chromium-molybdenum alloy (Co-Cr-Mo) groups. The animals underwent local articular resurfacing operation with Co-Cr-Mo alloy (Co-Cr-Mo group) and PEEK (PEEK group) mini-implants. X-ray, computed tomography, and MRI examinations were performed at 12 weeks postoperatively. The sham group underwent a similar surgical procedure to expose the femoral head but without implantation. Gross necropsy and surface topography measurement of the articular cartilage of the acetabulum were performed after sacrificing the animals. Imaging artefacts and opposing cartilage degeneration in the acetabulum were also examined.

RESULTS

Cartilage damage occurred in both the Co-Cr-Mo and PEEK groups, and the damaged cartilage area was markedly larger in the Co-Cr-Mo group than in the PEEK group, as assessed by gross necropsy and histological staining. The mean surface roughness of the opposing cartilage was approximately 65.3, 117.4, and 188.4 ​μm ​at 12 weeks in the sham, PEEK, and Co-Cr-Mo groups, respectively. The Co-Cr-Mo mini-implant was visualised on radiographs, but computed tomography and MR images were markedly affected by artefacts, whereas the opposing cartilage and surrounding tissue were clear on MR images in the PEEK group. Opposing cartilage damage and subchondral bone marrow oedema could be detected by MRI in the PEEK group.

CONCLUSIONS

The PEEK mini-implant can be a novel alternative to the Co-Cr-Mo mini-implant in articular resurfacing to treat focal osteochondral defects with less cartilage damage. It is feasible to postoperatively monitor the PEEK implant location, surrounding bone changes, and opposing cartilage degeneration by MRI without artefacts.

THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE

The use of MRI to monitor changes in the opposing cartilage after prosthesis implantation has not been widely applied because MR images are generally affected by artefacts generated by the metal prosthesis. This study revealed that the PEEK mini-implant can be a novel alternative to the Co-Cr-Mo mini-implant in articular resurfacing to treat focal osteochondral defects, and it is feasible to monitor the PEEK implant location, surrounding bone changes, and opposing cartilage damage/degeneration by MRI without artefacts postoperatively.

Effect of physical therapy on early knee osteoarthritis with medial meniscal posterior tear assessed by MRI T2 mapping and 3D-to-2D registration technique: A prospective intervention study

Objectives: The purpose of this study was to verify that exercise aimed at improving knee kinematics in early-stage knee osteoarthritis (OA) patients with medial meniscus posterior root tears (MMPRTs) reduces knee adduction angle during gait and prevents rapid cartilage degeneration in the medial compartment of the knee.Methods: Subjects were randomly assigned to an adapting alignment exercise (AAE) group, with the goal of improving knee kinematics, and a muscle training and exercise (MTE) group. Before the start of the six-month intervention and following its completion, we performed an analysis of knee kinematics during gait using a 3D-to-2D registration technique and identified the area of cartilage degeneration using MRI T2 mapping.Results: The amount of change between pre- and post-intervention measurements of the maximum angle of adduction was 0.48° (95% CI: -0.14, 1.09) in the MTE group and -0.40° (-0.84, 0.04) in the AAE group (p = .039). The amount of change in the area of cartilage degeneration according to MRI T2 mapping expressed as MTE/AAE group was 7.7 mm² (-0.4, 15.8)/-2.7 mm² (-10.8, 5.3) at the posterior knee (p = .043).Conclusion: AAE could be a potential treatment method that improves the natural course of knee OA with MMRPTs.

Treatment of osteochondral lesions of the talus with autologous collagen-induced chondrogenesis: clinical and magnetic resonance evaluation at one-year follow-up

PURPOSE

the aim of this study is to report the clinical and imaging results recorded by a series of patients in whom osteochondral lesions of the talus (OLTs) were repaired using the autologous collagen-induced chondrogenesis (ACIC) technique with a completely arthroscopic approach.

METHODS

nine patients (mean age 37.4±10 years) affected by OLTs (lesion size 2.1±0.9 cm(2)) were treated with the ACIC technique. The patients were evaluated clinically both preoperatively and at 12 months after surgery using the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) and a visual analog scale (VAS). For morphological evaluation, the magnetic resonance observation of cartilage repair tissue (MOCART) score was used.

RESULTS

the AOFAS score improved from 51.4±11.6 preoperatively to 71.8±20.6 postoperatively, while the VAS value decreased from 6.9±1.8 to 3.2±1.9. The mean MOCART score was 51.7±16.6 at 12 months of follow-up; these scores did not directly correlate with the clinical results.

CONCLUSION

use of the ACIC technique for arthroscopic repair of OLTs allowed satisfactory clinical results to be obtained in most of the patients as soon as one year after surgery, with no major complications or delayed revision surgery. ACIC is a valid and low-invasive surgical technique for the treatment of chondral and osteochondral defects of the talus.

LEVEL OF EVIDENCE

therapeutic case series, level IV.

Cartilage repair surgery: outcome evaluation by using noninvasive cartilage biomarkers based on quantitative MRI techniques?

BACKGROUND

New quantitative magnetic resonance imaging (MRI) techniques are increasingly applied as outcome measures after cartilage repair.

OBJECTIVE

To review the current literature on the use of quantitative MRI biomarkers for evaluation of cartilage repair at the knee and ankle.

METHODS

Using PubMed literature research, studies on biochemical, quantitative MR imaging of cartilage repair were identified and reviewed.

RESULTS

Quantitative MR biomarkers detect early degeneration of articular cartilage, mainly represented by an increasing water content, collagen disruption, and proteoglycan loss. Recently, feasibility of biochemical MR imaging of cartilage repair tissue and surrounding cartilage was demonstrated. Ultrastructural properties of the tissue after different repair procedures resulted in differences in imaging characteristics. T2 mapping, T1rho mapping, delayed gadolinium-enhanced MRI of cartilage (dGEMRIC), and diffusion weighted imaging (DWI) are applicable on most clinical 1.5 T and 3 T MR scanners. Currently, a standard of reference is difficult to define and knowledge is limited concerning correlation of clinical and MR findings. The lack of histological correlations complicates the identification of the exact tissue composition.

CONCLUSIONS

A multimodal approach combining several quantitative MRI techniques in addition to morphological and clinical evaluation might be promising. Further investigations are required to demonstrate the potential for outcome evaluation after cartilage repair.

MR imaging assessment of articular cartilage repair procedures

Because articular cartilage is avascular and has no intrinsic capacity to heal itself, physical damage to cartilage poses a serious clinical problem for orthopedic surgeons and rheumatologists. No medication exists to treat or reconstitute physical defects in articular cartilage, and pharmacotherapy is limited to pain control. Developments in the field of articular cartilage repair include microfracture, osteochondral autografting, osteochondral allografting, repair with synthetic resorbable plugs, and autologous chondrocyte implantation. MR imaging techniques have the potential to allow in vivo monitoring of the collagen and proteoglycan content of cartilage repair tissue and may provide useful additional metrics of cartilage repair tissue quality.

Quantitative MRI using T1ρ and T2 in human osteoarthritic cartilage specimens: correlation with biochemical measurements and histology

PURPOSE

A direct correlation between T(1ρ), T(2) and quantified proteoglycan and collagen contents in human osteoarthritic cartilage has yet to be documented. We aimed to investigate the orientation effect on T(1ρ) and T(2) values in human osteoarthritic cartilage and to quantify the correlation between T(1ρ), T(2) vs. biochemical composition and histology in human osteoarthritic cartilage.

MATERIALS AND METHODS

Thirty-three cartilage specimens were collected from patients who underwent total knee arthroplasty due to severe osteoarthritis and scanned with a 3T MR scanner for T(1ρ) and T(2) quantification. Nine specimens were scanned at three different orientations with respect to the B(0): 0°, 90° and 54.7°. Core punches were taken after MRI. Collagen and proteoglycan contents were quantified using biochemical assays. Histology sections were graded using Mankin scores. The correlation between imaging parameters, biochemical contents and histological scores were studied.

RESULTS

Both mean T(1ρ) and T(2) at 54.7° were significantly higher than those measured at 90° and 0°, with T(1ρ) showing less increase compared to T(2). R(1ρ) (1/T(1ρ)) values had a significant but moderate correlation with proteoglycan contents (R=.45, P=.002), while R(2) (1/T(2)) was not correlated with proteoglycan. No significant correlation was found between relaxation times (T(1ρ) or T(2)) and collagen contents. The T(1ρ) values of specimen sections with high Mankin scores were significantly higher than those with low Mankin scores (P<.05).

CONCLUSIONS

Quantitative MRI has a great potential to provide noninvasive imaging biomarkers for cartilage degeneration in osteoarthritis.

Evaluation of bone cortex and cartilage of spondyloarthropathic sacroiliac joint: efficiency of different fat-saturated MRI sequences (T1-weighted, 3D-FLASH, and 3D-DESS)

RATIONALE AND OBJECTIVES

Accurate assessment of the morphology of sacroiliac joint (SIJ) bone cortex and cartilage bears importance in terms of detecting sacroiliitis in its earliest period. The aim of this study was to evaluate the efficacies of fat-saturated T1-weighted (T1WFS) spin-echo, three-dimensional (3D)-fast low angle shot (3D-FLASH), and 3D-double excitation in the steady-state (3D-DESS) sequences for the detection of SIJ cartilage and bone cortex abnormalities in patients with clinically suspected active sacroiliitis.

MATERIALS AND METHODS

Magnetic resonance imaging (MRI) was performed in 9 controls and 30 patients with suspected active sacroiliitis. T1WFS, short tau inversion recovery, 3D-DESS with FS, 3D-FLASH with FS, postcontrast (the same precontrast T1WFS sequence) T1WFS, and subtracted images were obtained in all the cases. The bone cortex and cartilaginous morphology were visually scored on the T1WFS, 3D-DESS, and 3D-FLASH images. MRI findings were statistically evaluated.

RESULTS

Active sacroiliitis was observed in 28 patients (49 SIJs) that were examined by postcontrast and subtracted images. T1WFS, 3D-DESS, and 3D-FLASH images revealed cartilage erosions in 26 (47 SIJs), 28 (55 SIJs), and 28 (55 SIJs) patients, respectively. Cartilage and bone cortex erosion scores in SIJs were significantly higher in 3D-DESS and 3D-FLASH images than in T1WFS images (P < .05). Bone erosion scores assessed on T1WFS and 3D-FLASH images of active sacroiliitis patients, were found to be significantly different (P < .05). A similar relationship was not determined between 3D-DESS and T1WFS sequences (P > .05).

CONCLUSION

3D-FLASH sequence with FS is recognized as the most useful sequence for the detection of cartilaginous and cortical bone abnormalities.

[Application of magnetic resonance imaging in evaluating the effects of manipulation on knee osteoarthritis]

OBJECTIVE

To observe and evaluate the effects of manipulation on knee osteoarthritis (KOA) using T2-mapping and magnetic resonance imaging (MRI)-based volume measurements.

METHODS

Forty-five cases of KOA were involved retrospectively in the study, and the patients were composed of 9 males and 36 females with the mean age of (57.4+/-6.1) years. The cases were treated with manipulative therapy once or twice per week for 12 months. MRI of each knee was performed separately by using 1.5-T MRI equipment before and during the treatment. Average cartilage depth, MRI grading of cartilage defects, cartilage volume, average T2 values in patella cartilage and femoral condyle, and bone marrow edema area were detected respectively.

RESULTS

The knee joint cartilage thickness from MRI began to increase after 6-month treatment (P<0.05). The cartilage volume increase was obviously observed after 12-month treatment, and there was a significant difference (F=14.64, P<0.01). MRI grading of cartilage defects decreased from IIIA to IIB after 3-month treatment (Z=17.96, P<0.05). The average T2 value in patella cartilage decreased after 9-month treatment (F=3.11, P<0.05), but there were no differences in cartilage from tibial plateau and femoral condyle compartments after the treatment. The bone marrow edema area in femoral condyle began to diminish at 3-month treatment (t=-4.53, P<0.01), and the bone marrow edema area in cartilage patella was diminished after 6-month treatment (t=-5.53, P<0.01).

CONCLUSION

T2-mapping and cartilage volume measurement are suitable for evaluating the manipulative therapy on KOA. Traditional Chinese manipulation therapy is an effective method for KOA in the cartilage recovery.

In situ crosslinking elastin-like polypeptide gels for application to articular cartilage repair in a goat osteochondral defect model

The objective of this study was to evaluate an injectable, in situ crosslinkable elastin-like polypeptide (ELP) gel for application to cartilage matrix repair in critically sized defects in goat knees. One cylindrical, osteochondral defect in each of seven animals was filled with an aqueous solution of ELP and a biocompatible, chemical crosslinker, while the contralateral defect remained unfilled and served as an internal control. Joints were sacrificed at 3 (n = 3) or 6 (n = 4) months for MRI, histological, and gross evaluation of features of biomaterial performance, including integration, cellular infiltration, surrounding matrix quality, and new matrix in the defect. At 3 months, ELP-filled defects scored significantly higher for integration by histological and gross grading compared to unfilled defects. ELP did not impede cell infiltration but appeared to be partly degraded. At 6 months, new matrix in unfilled defects outpaced that in ELP-filled defects and scored significantly better for MRI evidence of adverse changes, as well as integration and proteoglycan-containing matrix via gross and histological grading. The ELP-crosslinker solution was easily delivered and formed stable, well-integrated gels that supported cell infiltration and matrix synthesis; however, rapid degradation suggests that ELP formulation modifications should be optimized for longer-term benefits in cartilage repair applications.

Combined autologous chondrocyte implantation and allogenic meniscus transplantation: a biological knee replacement

Meniscus deficient knees develop early osteoarthritis in the knee. Autologous Chondrocyte Implantation has provided a new dimension to the treatment of chondral defects in the knee, with 85% good to excellent results and a long-term durable outcome of up-to 11 years. However, it is contraindicated in meniscus deficient knees. Allogenic Meniscus Transplantation gives good symptomatic relief in meniscus deficient knees, with a success rate of 89%. However, it is contraindicated in advanced cartilage degeneration. We hypothesized that combination of these two might be a solution for bone-on-bone arthritis in young individuals. We studied a consecutive series of eight patients, with mean age of 43 years, presenting with large kissing chondral defects, secondary to the previous meniscectomy. All the patients were treated with a combination of Autologous Chondrocyte Implantation and Allogenic Meniscus Transplantation. Mean pre-operative Lysholm score was 49, which rose to mean of 66 at 1 year, an average increase by 16.4 points. Six patients showed significant improvement at one year. MRI scans showed good integration of the menisci with the capsule, without any rejection. Histology confirmed the integration. All the patients could lead an active life-style. Five patients maintained the improvement at a mean follow-up of 3.2 years. We could not find any deleterious effects of the combination of these two techniques. So we conclude that the combination of these two techniques together may act a one step towards a true biological knee replacement.

Accuracy of MRI diagnosis of internal derangement of the knee in a non-specialized tertiary level referral teaching hospital

This study was designed to assess the accuracy of knee MRI examinations carried out in a general tertiary referral hospital without a musculoskeletal fellowship trained radiologist. The study included all patients who had undergone a knee arthroscopy carried out within a 2-year period and who had had a prior MRI knee examination, where both were carried out at this institution. The accuracy of the MRI knee examination was determined by correlation to the arthroscopy report. The accuracy for diagnosis of meniscal and cartilage injuries, in this setting, was found to be similar to a published meta-analysis of previous studies correlating knee MRI and arthroscopy. The overall accuracy of this study was better than the previous similar study. However, the accuracy for diagnosing ACL injuries was lower than in the meta-analysis. The potential reasons for this and other sources of error are discussed.

Meniscal allografts: indications and outcomes

Meniscal allograft transplantation was introduced into clinical practice now over 20 years ago for the treatment of the symptomatic postmeniscectomy patient who has not yet developed osteoarthritis. Over the years, the indications have been fine-tuned and certain risk factors for failure have been identified. As the number of publications increases steadily, we now know that meniscal allografting significantly reduces pain and improves function. Recent data also suggest a potential chondroprotective effect in a subpopulation of patients. However, the major drawback in all meniscus allograft studies is the general lack of a control population. To improve our knowledge, future prospective studies should include objective outcome tools to evaluate the status of the allograft in addition to the clinical scoring systems. Future research should focus to elucidate the biologic and cellular processes involved in graft repopulation and remodelation.

Molecular Imaging: Integration of Molecular Imaging into the Musculoskeletal Imaging Practice

Chronic musculoskeletal diseases such as arthritis, malignancy, and chronic injury and/or inflammation, all of which may produce chronic musculoskeletal pain, often pose challenges for current clinical imaging methods. The ability to distinguish an acute flare from chronic changes in rheumatoid arthritis, to survey early articular cartilage breakdown, to distinguish sarcomatous recurrence from posttherapeutic inflammation, and to directly identify generators of chronic pain are a few examples of current diagnostic limitations. There is hope that a growing field known as molecular imaging will provide solutions to these diagnostic puzzles. These techniques aim to depict, noninvasively, specific abnormal cellular, molecular, and physiologic events associated with these and other diseases. For example, the presence and mobilization of specific cell populations can be monitored with molecular imaging. Cellular metabolism, stress, and apoptosis can also be followed. Furthermore, disease-specific molecules can be targeted, and particular gene-related events can be assayed in living subjects. Relatively recent molecular and cellular imaging protocols confirm important advances in imaging technology, engineering, chemistry, molecular biology, and genetics that have coalesced into a multidisciplinary and multimodality effort. Molecular probes are currently being developed not only for radionuclide-based techniques but also for magnetic resonance (MR) imaging, MR spectroscopy, ultrasonography, and the emerging field of optical imaging. Furthermore, molecular imaging is facilitating the development of molecular therapies and gene therapy, because molecular imaging makes it possible to noninvasively track and monitor targeted molecular therapies. Implementation of molecular imaging procedures will be essential to a clinical imaging practice. With this in mind, the goal of the following discussion is to promote a better understanding of how such procedures may help address specific musculoskeletal issues, both now and in the years ahead.

Meniscal allograft transplantation: long-term clinical results with radiological and magnetic resonance imaging correlations

Long-term data on the clinical outcome and the fate of the meniscus allograft after transplantation are scarce. In this study we present the clinical, radiological and MRI outcome of the meniscus graft and the articular cartilage after 42 meniscus allograft transplantations in 41 patients with a minimum follow-up of 10 years. A total of 27 medial and 15 lateral meniscal allografts were transplanted. Eleven of the medial allograft procedures were associated with a high tibial osteotomy. The patients were evaluated clinically at the time of transplantation and at the final follow-up using the modified HSS scoring system. The knee injury and osteoarthritis outcome score (KOOS) was used as an evaluation tool for patient-related outcome at the final follow-up. Joint space width narrowing and Fairbank changes were radiological outcome parameters, which were available for 32 patients. Femoral and tibial cartilage degeneration, graft extrusion and signal intensity were scored on MRI scans obtained in 17 patients approximately 1 year after transplantation and at the final follow-up (>10 years). For statistical analysis the patients were divided into three groups: lateral meniscal allograft (LMT), medial meniscal allograft transplantation with a high tibial osteotomy (MMT+HTO) and without (MMT). The modified HSS score revealed a significant improvement in pain and function at the final follow-up for all groups. Further analysis also revealed that an MMT+HTO procedure resulted in a greater improvement at the final follow-up when compared to MMT. Nonetheless, the KOOS scores obtained at the final follow-up revealed the presence of substantial disability and symptoms, in addition to a reduced quality of life. Radiographical analysis revealed no further joint space narrowing in 13/32 knees (41%). Fairbank changes remained stable in 9/32 knees (28%). MRI analysis showed no progression of cartilage degeneration in 6/17 knees (35%). An increased signal intensity of the allograft was present, as was partial graft extrusion in the majority of patients at the final follow-up. Seven cases had to be converted to a total knee arthroplasty during the follow-up; the overall failure rate was 18%. Long-term results after viable meniscus allograft transplantation are encouraging in terms of pain relief and improvement of function. Despite this significant improvement, substantial disability and symptoms were present in all investigated subgroups. Progression of further cartilage degeneration or joint space narrowing was absent in a considerable number of cases, indicating a potential chondroprotective effect. Level of evidence is therapeutic study, Level IV and retrospective analysis of prospectively collected data.

Magnetic resonance imaging of articular cartilage: trauma, degeneration, and repair

The assessment of articular cartilage using magnetic resonance imaging has seen considerable advances in recent years. Cartilage morphologic characteristics can now be evaluated with a high degree of accuracy and reproducibility using dedicated pulse sequences, which are becoming standard at many institutions. These techniques detect clinically unsuspected traumatic cartilage lesions, allowing the physician to study their natural history with longitudinal evaluation and also to assess disease status in degenerative osteoarthritis. Magnetic resonance imaging also provides a more objective assessment of cartilage repair to augment the information obtained from more subjective clinical outcome instruments. Newly developed methods that provide detail at an ultrastructural level offer an important addition to cartilage evaluation, particularly in the detection of early alterations in the extracellular matrix. These methods have created an undeniably important role for magnetic resonance imaging in the reproducible, noninvasive, and objective evaluation and monitoring of cartilage. An overview of the advances, current techniques, and impact of magnetic resonance imaging in the setting of trauma, degenerative arthritides, and surgical treatment for cartilage injury is presented.

Magnetic resonance imaging characterization of osteochondral defect repair in a goat model at 8 T

OBJECTIVE

This study was performed to non-invasively visualize and characterize osteochondral (OC) repair in ex vivo goat stifles using an 8 T magnetic resonance imaging (MRI) scanner and to compare the MR morphology with images obtained from 1.5 T, gross morphology and histology.

METHODS

Mature, neutered male goats were assigned to an 8-week (n = 4) or 16-week (n = 4) study period. Two cylindrical OC defects (7 mm diameter, full cartilage thickness and 1mm into subchondral bone) were surgically created in the right stifle: one in the medial femoral condyle (MFC) and the other in the trochlear groove (TG). The implant matrices (non-woven or foam) were secured in the defect using a bottom anchored fixation device (FD). The contralateral left stifles served as time zero controls. At the day of necropsy, implants were placed at both defect sites (MFC and TG) on the normal left stifles. Following necropsy, the ex vivo goat stifles (intact and encapsulated) were disarticulated. Within 24 h postnecropsy, MR scans of the stifles along the mid-sagittal plane of the OC defect were acquired at 8 T and 1.5 T. MR relaxation times, T1 and T2, were measured at the region of repair tissue (RT) and adjacent native cartilage. Immediately after MR imaging, the stifles were dissected, grossly examined, and a sagittal OC block corresponding to the MR region of interest was prepared for formalin fixation.

RESULTS

The high-resolution MR images enabled visualization of cartilage and bone integrity surrounding the implant as well as delineating the margins of RT/implant matrix and the FD. On spin echo sequence, the RT variably appeared as high, intermediate or low MR signal intensity; whereas, the FD always appeared as low signal intensity. In general, the MR signal intensity of 8-week RT was slightly higher compared to 16-week RT; however, there was no difference in RT morphology of stifles implanted with the non-woven matrix or foam matrix. Subchondral sclerosis appeared as low signal intensity. The 8 T MR images showed better delineation of the stifle tissues compared to the images acquired at 1.5 T. The T2 relaxation time of the RT appears to indicate (inconclusive due to small number of samples) a slight variation in the RT type between 8 weeks and 16 weeks. At both study times, the defects grossly appeared whitish to reddish but did not have the characteristic hyaline appearance typical of articular cartilage (AC). The gross appearance of the MFC and TG RT differed, which was predominantly mottled and recessed with fissuring of adjacent native AC in the MFC. Histologically, the RT of both 8-week and 16-week postsurgical defects predominantly comprised fibrovascular connective tissue with only few samples showing the presence of fibrocartilaginous and/or hypertrophic chondrocytes within the defect RT at 8 weeks. Also, compared to 8-week, the 16-week RT appeared to be more fibrotic.

CONCLUSION

Using 8 T scanner, high-resolution MR images of ex vivo encapsulated goat stifles confirmed the capability of high-field MR imaging to distinguish the defect RT from the FD and adjacent joint tissues. The extent of OC repair and adjacent bone lesions (at 8 weeks and 16 weeks) observed in the MR images compared well with those observed on the corresponding histological sections.

3.0 vs 1.5 T MRI in the detection of focal cartilage pathology--ROC analysis in an experimental model

OBJECTIVE

To use receiver operator characteristics (ROC) analysis for assessing the diagnostic performance of three cartilage-specific MR sequences at 1.5 and 3 T in detecting cartilage lesions created in porcine knees.

DESIGN

Eighty-four cartilage lesions were created in 27 porcine knee specimens at the patella, the medial and lateral femoral and the medial and lateral tibial cartilage. MR imaging was performed using a fat saturated spoiled gradient echo (SPGR) sequence (in plane spatial resolution/slice thickness: 0.20 x 0.39 mm2/1.5 mm) and two fat saturated proton density weighted (PDw) sequences (low spatial resolution: 0.31 x 0.47 mm2/3 mm and high spatial resolution: 0.20 x 0.26 mm2/2 mm). The images were independently analyzed by three radiologists concerning the absence or presence of lesions using a five-level confidence scale. Significances of the differences for the individual sequences were calculated based on comparisons of areas under ROC curves (A(Z)).

RESULTS

The highest A(Z)-values for all three radiologists were consistently obtained for the SPGR (A(Z) = 0.84) and the high-resolution (hr) PDw (A(Z) = 0.79) sequences at 3T. The corresponding A(Z)-values at 1.5 T were 0.77 and 0.69; the differences between 1.5 and 3 T were statistically significant (P < 0.05). A(Z)-values for the low-resolution PDw sequence were lower: 0.59 at 3 T and 0.55 at 1.5 T and the differences between 1.5 and 3T were not significant.

CONCLUSION

With optimized hr MR sequences diagnostic performance in detecting cartilage lesions was improved at 3 T. For a standard, lower spatial resolution PDw sequence no significant differences, however, were found.

Nonarthroplasty treatment of glenohumeral cartilage lesions

Treatment of young, active persons with symptomatic cartilage lesions of the glenohumeral joint represents a significant challenge. Diagnosis of glenohumeral chondral defects is not always straightforward and effective treatment requires familiarity with a number of techniques. Low-demand individuals may accept palliative therapy in the form of arthroscopic debridement as a temporizing solution. However, younger, high-demand individuals require a careful, stepwise approach that includes reparative, restorative, and reconstructive strategies. Reparative strategies use marrow-stimulation techniques to induce formation of fibrocartilage. Restorative tactics attempt to replace damaged cartilage with hyaline or hyaline-like tissue using osteochondral or chondrocyte transplantation. Large lesions that are not candidates for reparative or restorative procedures can be approached using reconstruction methods such as biologic resurfacing. This review examines causes of chondral injury in the glenohumeral joint, discusses diagnostic strategies, and presents a practical framework including palliative, reparative, restorative, and reconstructive options with which one can formulate a treatment plan for these patients.

Evaluation of cartilage repair tissue after biomaterial implantation in rat patella by using T2 mapping

To evaluate the ability of MR T2 mapping (8.5 T) to characterize ex vivo longitudinally, morphologically and quantitatively, alginate-based tissue engineering in a rat model of patellar cartilage chondral focal defect. Calibrated rat patellar cartilage defects (1.3 mm) were created at day 0 (D0) and alginate sponge with (Sp/C+) or without (Sp/C-) autologous chondrocytes were implanted. Animals were sacrificed sequentially at D20, D40 and D60 after surgery and dissected patellae underwent MRI exploration (8.5 T). T2 values were calculated from eight SE images by using nonlinear least-squares curve fitting on a pixel-by-pixel basis (constant repetition time of 1.5 s, eight different echo times: 5.5, 7.5, 10.5, 12.5, 15.0, 20.0, 25.0 and 30.0 ms). On the T2 map, acquired in a transversal plane through the repair zone, global T2 values and zonal variation of T2 values of repair tissue were evaluated versus control group and compared with macroscopic score and histological studies (toluidine blue, sirius red and hematoxylin-eosin). "Partial", "total" and "hypertrophic" repair patterns were identified. At D40 and D60, Sp/C+ group was characterized by a higher proportion of "total" repair in comparison to Sp/C- group. At D60, the proportion of "hypertrophic" repair was two fold in Sp/C- group versus Sp/C+ group. As confirmed morphologically and histologically, the T2 map also permitted the distinction of three types of repair tissue: "total", "partial" and "hypertrophic". "Total" repair tissue was characterized by high T2 values versus normal cartilage (p<0.05). Zonal variation, reflecting the collagen network organization, appeared only at D60 for Sp/C+ group (p<0.05). "Hypertrophic" tissue, mainly observed at D60, presented high T2 global values without zonal variation with cartilage depth. These results confirm the potency of the MR T2 map (8.5 T) to characterize macroscopically and microscopically the patterns of the scaffold guided-tissue repair of a focal chondral lesion in the rat patella ("total", "partial" and "hypertrophic"). On T2 map, three parameters (i.e. MRI macroscopic pattern, T2 global values and zonal variation of T2 values) permit to characterize chondral repair tissue, as a virtual biopsy.