Книги по МРТ КТ на английском языке / MRI for Orthopaedic Surgeons Khanna ed 2010

Fig. 14.8 Axial (A) and sagittal (B) FSE images after a left patellar dislocation in a 15-year-old boy show an osteochondral fracture of the medial facet (arrow). This injury can be distinguished from an isolated chondral shear injury because there is a displaced osteochondral fragment (arrowhead) with the presence of high signal intensity bone

MRI to an invasive procedure.32–34 Mintz et al.35 evaluated 92 patients with noncontrast imaging before hip arthroscopy and concluded that an optimized protocol can identify labral and chondral abnormalities. The authors’ protocol includes a screening examination of the whole pelvis, acquired with the use of coronal inversion recovery and axial proton-density sequences. This procedure is followed by the use of a surface coil over the hip joint, with high-resolution, cartilage-sensitive images acquired in three planes (sagittal, coronal, and oblique axial) with the use of an FSE pulse sequence and intermediate TE.

Acute isolated traumatic articular surface injuries most commonly occur from impact loading across the hip joint. The type and degree of injury vary depending on the amount and direction of the impact load. A posteriorly directed force can lead to hip subluxation, in which the femoral head is forced against the labrum and rim of the posterior wall. This subluxation can lead to shear injuries at the level of the articular cartilage and associated fractures of the subchondral bone (Fig. 14.10). Moorman et al.36 described the pathognomonic MRI triad of posterior acetabular lip fracture, hemarthrosis, and iliofemoral ligament disruption. In addition, MRI is useful for monitoring for the detection of subsequent osteonecrosis that can help determine whether an athlete may return to play.

The concept of femoroacetabular impingement as a source of anterosuperior chondral and labral damage was introduced by Ganz et al.37 Abnormal contact between the

marrow, a low signal intensity subchondral plate, and intermediate signal intensity cartilage in the displaced fragment. (From Potter HG, Foo LF. Articular cartilage. In: Stoller D, ed. Magnetic Resonance Imaging in Orthopaedics and Sports Medicine. Baltimore: Lippincott Williams & Wilkins; 2007:1099–1130. Reprinted by permission.)

femoral head–neck junction and the anterior acetabulum during terminal hip flexion leads to a reproducible pattern of anterosuperior labral and chondral injury. Based on anatomic features, they classified femoroacetabular impingement into two distinct entities: cam and pincer. Cam impingement results from pathologic contact between an abnormally shaped femoral head and neck with a morphologically normal acetabulum. During hip flexion, this abnormal region engages the anterior acetabulum and results in the characteristic anterosuperior chondral injury with a relatively untouched labrum.38 Pincer impingement is the result of contact between a typically normal femoral head–neck junction and an abnormal acetabular rim. This abnormal anterior acetabular “over-coverage” can be the consequence of di erent anatomic variants, including the following:

•Acetabular retroversion

•Coxa profunda (protrusio)

•Deformity after trauma or periacetabular osteotomies

This type of impingement can lead to degeneration, ossification, and tears of the anterosuperior labrum as well as a characteristic posteroinferior contre-coup pattern of cartilage loss over the femoral head and corresponding acetabulum. Despite the two types of distinct anatomic variants of femoroacetabular impingement, most cases involve a combination of femoral-side and acetabular-side lesions38–40 (Fig. 14.11) (see Chapter 7 for additional details).

C

Fig. 14.9 Sagittal fat-suppressed (A) and coronal non–fat-suppressed

(B) FSE images of the knee showing a small, stable OCD lesion (arrowhead on each). In comparison, sagittal fat-suppressed (C) and coronal non–fat-suppressed(D)FSEimagesshowalarge,unstablelesion(arrow on each), with low signal intensity sclerosis at the margins of the

D

underlying bone, indicating the presence of a “mature” bed. (From Shindle MK, Foo LF, Kelly BT, et al. Magnetic resonance imaging of cartilage in the athlete: current techniques and spectrum of disease. J Bone Joint Surg Am 2006;88:27–46. Reprinted by permission.)

In osteoarthritis, articular cartilage becomes thinner and degenerates, with fissuring, ulceration, and eventually full-

However, the bone marrow edema pattern is a nonspecific MRI finding; it does not necessarily indicate a traumatic

Fig. 14.11 (Continued) The oblique axial view (©2009 Hospital for Special Surgery, New York, NY) (D) and associated artist’s sketch (E) (arrow on each) accentuate the osseous defect (cam lesion). The sagittal image (©2009 Hospital for Special Surgery, New York, NY) (F) and associated artist’s sketch (G) show full-thickness cartilage loss

over the anterior acetabular dome (arrow on each) and an ossified labral tear (arrowhead on each). (Adapted from Shindle MK, Foo LF, Kelly BT, et al. Magnetic resonance imaging of cartilage in the athlete: current techniques and spectrum of disease. J Bone Joint Surg Am 2006;88:27–46. Adapted by permission.)

Fig. 14.12 Sagittal FSE image of the elbow in a professional baseball player, showing a partial-thickness cartilage injury overlying the capitellum (arrow). (From Shindle MK, Foo LF, Kelly BT, et al. Magnetic resonance imaging of cartilage in the athlete: current techniques and spectrum of disease. J Bone Joint Surg Am 2006;88:27–46. Reprinted by permission.)

repair secondary to the avascular nature of hyaline cartilage. Several techniques have been described for the repair of articular injuries, but the clinical outcomes and results have varied widely. To evaluate these techniques, most studies have relied on second-look surgery combined with biopsies.45 However, with advances in imaging techniques, MRI has become a noninvasive alternative for the evaluation of the results of articular cartilage repair procedures.7

After a cartilage repair procedure, several variables should be assessed on MRI46:

•Degree of defect filling

•Relative signal intensity of the regenerated cartilage as compared with the surrounding native tissue

•Absence or presence of displacement

•Degree of peripheral integration to adjacent cartilage or underlying bone

•Surface geometry and morphology of the repaired tissue

•Presence of proud subchondral bone formation

•Presence of any reactive synovitis

One of the most popular articular cartilage repair techniques is microfracture, which entails creating perforations in the underlying subchondral bone using a drill or pick.47,48 This procedure relies on the release of multipotential stem cells from the bone marrow that create a covering of largely

Fig. 14.13 Sagittal FSE images of the knee in a 32–year-old patient after microfracture. (A) At 5 months after surgery, there is irregularity of the subchondral plate (black arrow) adjacent to the repair cartilage that is hyperintense. (B) At 13 months after surgery, the mature reparative cartilage is now partially hypointense (white arrow)

compared with the adjacent hyaline cartilage. Note the presence of subtle osseous overgrowth of the subchondral bone. (From Shindle MK, Foo LF, Kelly BT, et al. Magnetic resonance imaging of cartilage in the athlete: current techniques and spectrum of disease. J Bone Joint Surg Am 2006;88:27–46. Reprinted by permission.)

Fig. 14.14 Images of the knee in a 52–year-old patient after the transfer of two autologous osteochondral plugs. Sagittal fatsuppressed (A) and non–fat-suppressed (B) FSE images show osseous incorporation of the plugs. Although the cartilage surface remains flush over the anterior plug, there is slight depression of the subchondral bone (black arrow in B). (C) There is slight sclerosis in the side walls of the plugs in the axial plane (white arrowheads), reflecting the

reparative fibrocartilage (type I collagen). At short-term follow-up, this reparative tissue created from the microfracture technique appears hyperintense compared with native hyaline cartilage (type II collagen) because it is less organized and has a higher water content.7,49 Over time, the signal intensity of reparative cartilage decreases as it matures (Fig. 14.13). Osseous overgrowth of the underlying subchondral bone has been reported after microfracture50; it may result in a thinner layer of reparative tissue, but it has not been shown to be a negative clinical prognostic factor.50

“press-fit” technique. (D) A fissure at the lateral interface with the native cartilage (white arrow) is shown on the coronal image. The medial tibial plateau has a degenerative pattern of partial-thickness cartilage loss. (From Shindle MK, Foo LF, Kelly BT, et al. Magnetic resonance imaging of cartilage in the athlete: current techniques and spectrum of disease. J Bone Joint Surg Am 2006;88:27–46. Reprinted by permission.)

Another cartilage repair technique is the use of autologous or allograft osteochondral plugs.51 The advantages of these plugs are that they can be used for a large defect and that they contain hyaline cartilage rather than a reparative fibrocartilage. Autologous osteochondral plugs are harvested from a non–weight-bearing portion of the knee, usually the side of the intercondylar notch or anterior margin of the femoral condyle. Allograft plugs are harvested from a cadaver and usually are inserted with use of a press-fit technique in which the plug and the recipient site are prepared to match-

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