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Chapter

8

Internal Derangements: Menisci
and Cartilage
Kristen E. McClure and William B. Morrison

Meniscus
Anatomy
The medial and lateral menisci of the knee are fibrocartilaginous semicircular structures that act as shock absorbers and
transmit forces between the femur and the tibia. The menisci
are composed of longitudinal collagen bundles, circumferentially oriented in a C-shaped configuration, as well as transversely oriented collagen fibers that radiate from the free edge
of the meniscus to the peripheral margin. Together, these
longitudinal and radial collagen fibers act to provide hoop
tensile strength, resist axial loading extrusive forces, and
prevent separation of the menisci in a radial direction.
Both menisci are thicker in craniocaudad dimension along
the periphery and taper to a thinner margin along the free
edge. Although the medial and lateral menisci serve the same
purpose in the medial and lateral compartments of the knee,
they are not symmetrical in size or shape. The medial meniscus is a larger C-shaped structure, and the lateral meniscus is
a tighter, near complete circle (Fig. 8-1). Because of these
morphologic differences, the medial meniscus covers approximately one half of the tibial plateau contact surface, and the
lateral meniscus covers approximately three quarters of the
tibial plateau contact surface.
The medial meniscus can be differentiated from the lateral
meniscus by position and size, and also by its distinct morphologic characteristics and regional attachments. The
posterior horn of the medial meniscus is wider in an anteroposterior dimension than the anterior horn. This can be
demonstrated on sagittal imaging of the knee when the posterior horn appears two to three times larger than the anterior
horn (Fig. 8-2). The posterior horn of the medial meniscus
attaches to the tibia at the posterior intercondylar fossa, anterior to the posterior cruciate ligament insertion, but behind
the posterior horn of the lateral meniscus. The anterior horn
of the medical meniscus attaches to the tibia at the anterior
intercondylar fossa, in front of both the anterior horn of the
lateral meniscus and the insertion of the anterior cruciate
ligament. The periphery of the medial meniscus is attached
to the joint capsule along its entire length via meniscotibial
and coronary ligaments.12
In comparison, the lateral meniscus is symmetrical from
front to back (Fig. 8-3). Therefore, on sagittal imaging of the
knee, the posterior horn and the anterior horn are similar in
size. The posterior horn of the lateral meniscus attaches to
the tibia behind the intercondylar eminence, anterior to both
the posterior cruciate ligament insertion and the posterior
horn of the medial meniscus. The anterior horn of the lateral
meniscus attaches to the tibia in front of the intercondylar
eminence, behind both the anterior horn of the medial
meniscus and the anterior cruciate ligament insertion. The
fibers of the anterior cruciate ligament partially blend with
106

the lateral meniscus at its tibial attachment. The periphery
of the lateral meniscus cannot attach directly to the joint
capsule because of the intra-articular course of the popliteus
tendon between the lateral meniscus and the joint capsule.
The lateral meniscus actually attaches to the joint capsule
through small fascicles or struts.
Meniscal nutrition is supplied by two routes. The vascular
supply is confined to the outer one third of the meniscus, also
known as the red zone. The vessels arise from the medial and
lateral genicular arteries, forming a perimeniscal synovial
capillary plexus that bathes the periphery of the menisci. The
central portion of the meniscus receives nutrients from
the synovial fluid, which diffuses into or is forced through the
joint with activity. This avascular portion of the meniscus is
known as the white zone. The presence or absence of vascular
supply at the location of a meniscal tear can determine
whether the tear has a possibility of healing without intervention. A peripheral meniscal tear with adequate vascular
supply is capable of healing and may not require surgical
intervention.

Function
The menisci have many biomechanical functions. They act
to increase contact area and joint congruity, transmit load
and absorb shock, prevent radial extrusive forces during axial
loading, and aid in joint lubrication. Because fibrocartilage is
less stiff than hyaline cartilage, the menisci intrinsically have
a higher shock-absorbing capacity. Functional meniscal
studies have found that 50% to 85% of the load placed across
the joint is transmitted by the meniscus. Following total
meniscectomy, the contact area between the femur and the
tibia decreases by approximately 75%; thus contact stresses
between the femur and the tibia increase by more than 200%.
Studies have demonstrated that contact stresses at the knee
joint proportionately increase in relation to the amount of
meniscus removed.12
Discoveries such as these have altered the surgical management of meniscal tears. Preservation and conservation of
meniscal tissue are now the ultimate goals to maximize the
function of the residual meniscus and prevent progression to
osteoarthritis.

Magnetic Resonance Imaging
of the Meniscus
The normal meniscus demonstrates homogeneous low signal
intensity on all imaging sequences because of its short T2
relaxation. Increased signal intensity within the meniscus is
abnormal and represents a meniscal tear or degeneration. A
short time to echo (TE) imaging sequence is necessary to
evaluate the meniscus on magnetic resonance imaging (MRI).

Sagittal proton density images are typically more valuable in diagnosing a tear of the anterior or posterior horns.. CHAPTER 8  Internal Derangements: Menisci and Cartilage A 107 B Figure 8-1. as well as tear. It has been recommended that slice thickness be no greater than 4 mm. The best imaging sequence to evaluate for meniscal tear is a proton density–weighted imaging sequence that achieves a balance between sensitivity and specificity. including sagittal proton density images. fluid in true meniscal tears becomes relatively more prominent. low TE images) are the most sensitive for detecting signal alteration within the meniscus. meniscal root tears and flipped fragments may be better seen on coronal imaging. coronal T2-weighted images with fat suppression. Figure 8-3. and sagittal T2-weighted images with fat suppression. with some describing blur artifact limitations. Sagittal proton density image through the medial compartment shows that the posterior horn of the medial meniscus (arrow) typically appears two to three times larger than the anterior horn (arrowhead)..e. The utility of fast spin echo has been debated in the literature. Meniscal vascularity and degeneration.25 Slice thickness can affect sensitivity as well. gradient echo. we routinely acquire fast spin echo sequences. as fluid signal may be present at the site of the tear. We also acquire . T1-weighted images (i.e. T2-weighted images (i. and others reporting similar sensitivities and specificities as conventional spin echo. they are the least specific for meniscal tear. This can be accomplished with proton density. however. are bright on low TE images. Normal meniscal anatomy. As TE increases. Axial T2-weighted fat-suppressed images at the level of the menisci demonstrate the larger C-shaped medial meniscus (arrows in A) and the smaller near complete circle lateral meniscus (arrows in B). Sagittal proton density image through the lateral compartment shows that the lateral meniscus is symmetrical from back (arrow) to front (arrowhead). Therefore.  Normal meniscal anatomy. or traditional spin echo T1-weighted imaging sequences. Figure 8-2. However. and that minimal gap exist between each slice. and correlation with two imaging planes has been encouraged in the interpretation of meniscal pathology. However. At our institution. high-TE images) are specific but not sensitive for tear and are more useful for confirmation.  Normal meniscal anatomy. not all tears contain fluid.  A and B.

95 0.11 1.96 0.89 0. Today. and lateral meniscal cysts are most frequently located anteriorly. as classified below: Grade 1: punctuate or amorphous signal abnormality without extension to the articular surface.77 0. 8-4).91 1. parameniscal soft tissue edema.59 0.98 0.58 0. MRI criteria for diagnosing meniscal tear were first investigated just over 20 years ago. collateral ligament edema likely reflects inflammatory hyperemia.80 0.94 0. . secondary signs of meniscal tear have become more important in our interpretations.22 0. Protocols will vary depending on vendor. the positive predictive value for diagnosing meniscal tears increased when two or more images with surfacing signal abnormality were required compared with only a single abnormal image. 100% correspondence was noted between MRI grade signal alteration and histologic grade.108 SECTION 2  Imaging of the Knee coronal T1-weighted spin echo images.2 Adjacent collateral ligament edema and linear subchondral bone marrow edema have been shown to have high specificity and positive predictive values in the diagnosis of meniscal tear.95 Effusion 0.99 0. We use a slice thickness of 3 mm with 0. Grade 3: signal abnormality extending to at least one articular surface. Abnormal MRI signal (hyperintensity) within the meniscus in symptomatic patients was evaluated and subjectively classified prior to surgery. the accuracy of diagnosing a meniscal tear also increased.54 0.20 Later it was described that as the number of sequential images with abnormal surfacing meniscal signal increased. et al: Indirect soft-tissue and osseous signs on knee MRI of surgically proven meniscal tears.97 0. Indirect evidence of meniscal pathology includes adjacent cartilage loss. Zoga AC. No recent studies have been performed on MRI at different field strengths to evaluate the difference in diagnostic accuracy between two sequential images with surfacing signal abnormality and only a single image with surfacing signal abnormality. MRI grade 3 signal alteration corresponded with meniscal tear. the two-slice-touch rule may not be necessary for accurate diagnosis of meniscal tears.97 0.95 0. In two separate studies conducted in 1993 and 2005.09 0. Secondary signs of meniscal tear can enhance confidence in diagnosis. Histologic grading of the same menisci was performed following surgery.8 This concept was presented as the two-slice-touch rule and is used by many radiologists today in diagnosing meniscal tear.61 Parameniscal soft tissue edema 0.93 Collateral ligament bowing 0. 2008.91 Meniscal extrusion 0. MRI Criteria for Meniscal Injuries A meniscal tear can be diagnosed by identifying abnormal intrameniscal signal.23 0. joint effusion.91 0. parameniscal cyst (also referred to as meniscal cyst). With higher signal-to-noise ratio and improved imaging techniques.09 0. Statistics provided are an average of Reader 1 and Reader 2 values.57 0. thereby differentiating degeneration from meniscal tear.95 0. bowing of the ipsilateral collateral ligament.94 0.68 0. They have the same incidence for medial and lateral meniscal tears but are seen more commonly medially owing to higher prevalence of medial tears.88 0. Hochberg H.67 0. and Specificity of Indirect Signs for Meniscal Tears at Arthroscopy MEDIAL MENISCUS LATERAL MENISCUS Indirect Signs PPV Sensitivity Specificity PPV Sensitivity Specificity Cartilage loss near tear 0.2 Parameniscal cysts are seen in 7% of meniscal tears (Fig.21 0. indicating the closer apposition of the medial collateral ligament to the periphery of the medial meniscus as compared Table 8-1  Positive Predictive Value (PPV). reactive synovitis. Intrameniscal signal abnormality was graded according to its confluence and extension to the articular surface on sagittal imaging.37 0. MRI grade 1 and 2 signal alterations corresponded with meniscal degeneration. abnormal morphology. 8-5).1 Collateral ligament edema can be seen in the setting of primary ligamentous injury and osteoarthritis. Parameniscal cysts are believed to result from extruded joint fluid through an adjacent meniscal tear. These basic MRI criteria were created in the early days of MRI. The sensitivity of this sign is greater for medial meniscal tears. Medial meniscal cysts are most frequently located posteriorly.58 Perivascular bone marrow edema 0.00 0.23 0. with higher-field-strength MRI and dedicated extremity coils and imaging systems. and increased fluid formation related to the tear (Fig.94 0.78 0. Sensitivity. Grade 2: linear signal abnormality without extension to the articular surface. the original MRI diagnostic criteria for meniscal tear may not be entirely applicable.00 0. particularly in cases where the signal abnormality within the meniscus is equivocal. meniscal extrusion. and user preference.08 Linear subchondral edema 0.95 0. or a displaced meniscal fragment.00 1.70 0.1 The presence of a parameniscal cyst has a 100% positive predictive value for an associated meniscal tear in some studies.09 1.00 Collateral ligament edema 0.49 0. field strength.99 0. This histologic grading was correlated with MRI signal grade.00 0. In this study.97 0. perivascular bone marrow edema.23 0. AJR Am J Roentgenol 191:86–92. Furthermore. and subchondral bone marrow edema (Table 8-1). However in the setting of meniscal tear. without fat suppression.23 0. or when the study is degraded by artifact.99 Parameniscal cyst 1. Although the original MRI criteria are still used as guidelines at our institution.44 0. they are not always strictly adhered to.5-mm gaps between slices.99 Adapted from Bergin D.

If soft tissue or fluid is interposed between the origin of the meniscofemoral ligament and the posterior horn of the lateral meniscus. For instance. 8-9). but also because it is strongly associated with the development of osteoarthritis.15 The popliteus tendon travels superiorly from its muscle belly in an oblique. This may be related to blending of the fibers of the anterior cruciate ligament with the anterior horn. Major meniscal extrusion (>3 mm) is more highly associated with extensive tears. The ligament can divide and course anterior to the posterior cruciate ligament named the ligament of Humphrey. but is not said to increase the risk of tearing.11 This abnormal signal should not be mistaken for a tear or degeneration (Fig. and large radial tears. or posterior to the posterior cruciate ligament named the ligament of Wrisberg (Fig.13 Errors in Interpretation Figure 8-5. with the lateral collateral ligament and the lateral meniscus. Periarticular bone marrow edema can be seen with trauma and osteoarthritis. Care must be taken to follow the ligament over several successive images while avoiding this pitfall. Its prevalence is approximately 0. or splaying of the fibers of the meniscus at its attachment.  A through C. the anterior horn of the lateral meniscus can have a speckled appearance with foci of increased signal. complex tears. and meniscus (Fig. Tears that extend into Some normal variants may cause confusion in the diagnosis of meniscal tears. CHAPTER 8  Internal Derangements: Menisci and Cartilage A B 109 C Figure 8-4. possibly related to ligamentous laxity (Fig.2%. Meniscal flounce is a rare normal variant of the medial meniscus in which there is an undulating appearance of the inner margin. not only in the detection of meniscal tear. separating the lateral meniscus from the joint capsule. 8-7). this interface can be misinterpreted as a meniscal tear. 8-10). intra-articular course. and axial (C) fluid-sensitive sequences depict a large parameniscal cyst (arrows) emanating from an underlying lateral meniscal tear. Coronal T2-weighted fat-suppressed image shows medial collateral ligament bowing and edema (arrow) related to underlying medial meniscal tear. Identifying meniscal extrusion is important. However. 8-6). the meniscal root are also more likely to result in substantial meniscal extrusion.11 The meniscofemoral ligaments of Wrisberg and Humphrey connect the posterior horn of the lateral meniscus to the lateral aspect of the medial femoral condyle.3. Secondary signs of meniscal tear: parameniscal cyst. sagittal (B). linear subchondral bone marrow edema is located directly adjacent to the meniscus and probably represents hyperemia at the junction of the bony cortex. in the setting of meniscal tear. This buckling along the free edge may be confused for a meniscal tear. cartilage. to insert on the . 8-8). These secondary signs can help guide attention to the meniscus on MRI and can increase confidence when primary diagnostic criteria are equivocal. advanced meniscal degeneration. The ligaments of Humphrey and Wrisberg are noted in approximately one third of cases. The interface between the ligament and the anterior meniscal horns can also be confused for a tear.15 The transverse intermeniscal ligament courses horizontally between the anterior horns of the medial and lateral menisci. Coronal (A).  Secondary signs of meniscal tear: collateral ligament edema. in front of the anterior cruciate ligament. It is defined as extension of the peripheral meniscus past the tibial margin. and it results from a tear that destabilizes the circumferential collagen fibers of the meniscus and allows it to expand in a radial direction (Fig.1 Meniscal extrusion can also be used as a secondary sign of meniscal tear.

which can be confused with a meniscal . typically described with an acute anterior cruciate ligament disruption. Chondrocalcinosis results in increased signal on proton density and T1-weighted images.  A and B.23 A meniscal contusion occurs during an acute traumatic event. findings commonly seen in association with a meniscal tear. radial. which allow the popliteal tendon to course from its muscle belly into its intraarticular location. The popliteal bursa is the opening created by the fascicles of the lateral meniscus. Secondary signs of meniscal tear: meniscal extrusion. A B Figure 8-7. Secondary signs of meniscal tear: subchondral edema. or root tear of the associated meniscus. and finally to insert on the femur. which contains surfacing signal consistent with tear. This is particularly a dilemma in the posterior horn of the lateral meniscus as it angles upward from its root to the insertion on the tibia behind the intercondylar eminence. This artifact causes falsely increased signal intensity and can imitate a meniscal tear.11 Magic angle phenomenon describes the artifact that occurs when collagen fibers are oriented at 55 degrees relative to the main magnetic field on short TE images. The increased signal within the contused meniscus is more likely to be amorphous in shape. 8-11). Coronal T2-weighted fat-suppressed image in a different patient (B) demonstrates cartilage loss in the medial compartment with underlying bone marrow edema (arrow). Coronal T2-weighted fat-suppressed images depict extrusion of the periphery of the medial meniscus (arrow in A) beyond the periphery of the tibial margin.7.  A through B.6 Chondrocalcinosis within the fibrocartilage of the meniscus can cause a false-positive interpretation for tear. This may simulate a meniscal tear and result in a false-positive MRI interpretation. will not extend to the articular surface. is classified as >3 mm.110 SECTION 2  Imaging of the Knee A B Figure 8-6. Sagittal T2-weighted fat-suppressed image (A) demonstrates linear subchondral bone marrow edema (arrow) adjacent to the posterior horn of the medial meniscus. Major meniscal extrusion. and may be accompanied by a bone bruise. The medial margin of the popliteal hiatus is the body of the lateral meniscus (Fig. The meniscus is compressed between the femur and the tibia. popliteal groove along the lateral aspect of the lateral femoral condyle. becomes contused. this finding has a high association with complex. Fluid within the popliteus tendon sheath or the popliteal hiatus may be mistaken for a meniscal tear. demarcated by lines in (B). and demonstrates altered signal on MRI.

posterior to the posterior cruciate ligament (PCL).  A through D. Consecutive coronal T2-weighted fat-suppressed images show the popliteus tendon (arrows) as it originates from the lateral femoral condyle and courses posterolaterally through the popliteal hiatus and inferiorly past the tibial plateau. A B 111 Figure 8-9. A B C D Figure 8-11. A similar structure. As the tendon passes by the lateral meniscus. the ligament is seen on magnetic resonance imaging (MRI) in approximately one third of individuals. the intervening fluid can be misinterpreted for meniscal tear. a normal finding. the ligament of Humphrey. Sagittal proton density image shows fibers of the anterior horn of the lateral meniscus spreading apart at the root attachment (arrow). is also seen in about one third of individuals and courses anterior to the PCL. Pitfall for meniscal tear: popliteus tendon. Pitfall for meniscal tear: meniscofemoral ligament. C D Figure 8-10.  Pitfall for meniscal tear: meniscal flounce. Consecutive sagittal proton density images show the ligament of Wrisberg (arrows) coursing from the posterior horn of the lateral meniscus. referred to as a meniscal flounce.  A through D.  Pitfall for meniscal tear: normal intrameniscal signal. . The point of attachment on the meniscus can simulate a tear on MRI. Sagittal fluid-sensitive sequence demonstrates buckling of the meniscal body (lateral meniscus pictured). inserting onto the lateral aspect of the medial femoral condyle. CHAPTER 8  Internal Derangements: Menisci and Cartilage Figure 8-8. This creates a normal speckled pattern and should not be confused for a meniscal tear.

Coronal T2-weighted fat-suppressed image (B) through the midpoint of the knee shows a large. The type that is most commonly symptomatic is the Wrisberg type. which is the gold standard. particularly along the inferior surface of the medial meniscus. Discoid morphology is defined by continuity of the anterior and posterior horns on three or more consecutive sagittal images. Others report that healed or surgically repaired meniscal tears may have persistent signal that extends to the articular surface and can be mistaken for a new meniscal tear or retear. Discoid meniscus. Other Meniscal Disorders Discoid meniscus occurs almost exclusively in the lateral meniscus with an incidence of approximately 1% in the general population. then they are also reported as false positive. which lacks posterior . can be used to diagnose discoid meniscus. It also can be diagnosed on coronal images.112 SECTION 2  Imaging of the Knee A B Figure 8-12.  A and B. pancake-like lateral meniscus extending centrally. it is documented as a false positive.17 When the tear is not identified at surgery. 8-12). or more than 20% of the tibial width on axial images. tear.  A and B. This can simulate a meniscal tear. A B Figure 8-13. Discoid meniscus can be categorized into three types according to its peripheral attachments. if the inner margin of the meniscus courses under or extends past the apex of the femoral condyle (Fig. Some propose that a transverse measurement greater than 15 mm. Coronal T1-weighted image (B) shows increased lateral meniscal signal corresponding to chondrocalcinosis seen on radiographs. Three consecutive sagittal proton density images (A) suggest discoid morphology of the lateral meniscus. Some authors propose that a delay between MRI diagnosis of meniscal tear and arthroscopy may allow for spontaneous healing. consistent with discoid morphology. 8-13).7 If these tears are not documented by arthroscopy. Pitfall for meniscal tear: chondrocalcinosis. Frontal radiograph (A) shows lateral meniscal calcification (arrow) representing calcium pyrophosphate crystal deposition.11 Correlation with radiographs may help to detect and confirm the presence of chondrocalcinosis within the meniscus (Fig. with continuity of the anterior and posterior horns on three consecutive sagittal images. Some meniscal tears are more difficult to visualize at arthroscopy.

or even chondrocalcinosis. parrot-beak tears can result in displaced flaps. capsular attachments. these tears may not be mechanically significant.12 Meniscal ossicles are rare and are most commonly seen in young men. The diagnosis can be made radiographically. 8-14). along the circumference of the meniscus. or vertical. or on MRI. complex tears. CHAPTER 8  Internal Derangements: Menisci and Cartilage A 113 B Figure 8-14. Frequently. location. The origin of the meniscal ossicle is unknown and is hypothesized to be developmental or related to previous trauma. Discoid menisci are believed to be at increased risk for tear owing to increased mechanical stresses and hypermobility. with surfacing signal to the inferior margin of the posterior horn of the medial meniscus (arrow). Orientation is described as longitudinal (i.  Meniscal tear. representing a form of heterotopic ossification. paralleling the central meniscal fibers) or radial (i. Vertical longitudinal tears commonly lead to fragment displacement and buckethandle configuration. and posterior horn.e.  A and B. Meniscal ossicles may be asymptomatic or may present with functional impairment and pain.e. following the signal characteristics of bone marrow on all imaging sequences. with a reported prevalence of 0. Meniscal tears are described according to morphology. including tears involving the root attachments. with the fragment displaced inferior to the meniscal body.14 Types of Meniscal Tears Figure 8-15. Some types of tears are more mechanically significant. following the signal characteristics of bone marrow on all imaging sequences (Fig. These tears are typically stable. Coronal T1. Longitudinal tears can be horizontal (separating the meniscus into top and bottom portions). orientation. Therapy is guided by the patient’s symptoms. an avulsion fracture. Radial tears can be straight or curved (parrot-beak configuration). body. Small tears of the inner margin or free edge are also described.. 8-15). . perpendicular to the circumference.15%. crossing through the central fibers). radial tears. those with osteopenia and lack of buttressing from underlying osteoarthritis) to subchondral insufficiency fracture.. with computed tomography (CT). Location and extent are described in reference to the anterior horn. and divide the meniscus into superior and inferior fragments (Fig. Tears should also be described as mainly involving the central avascular portion or the peripheral vascularized portion. although an oblique tear extending to the undersurface can lead to development of a flap tear extending from the posterior horn.(A) and T2-weighted fat-suppressed (B) images show ossification (arrows) of the posterior root of the medial meniscus. oblique. and tears with displaced flaps. Sagittal proton density image depicts a longitudinal oblique tear. but are rare. Medial discoid menisci have been reported. Meniscal ossicle.. Tears with meniscal extrusion greater than 3 mm from the tibial margin are associated with more rapid compartmental cartilage loss and can predispose susceptible patients (i. Oblique or horizontal tears are most commonly degenerative. Care must be taken not to mistake a meniscal ossicle for an intra-articular body. Meniscal ossicles are most commonly found in the posterior horn of the medial meniscus near the root attachment. in the meniscotibial recess. The incidence of bilateral lateral discoid menisci has been reported as high as 20%. this morphologic pattern of tearing occurs in the posterior horn of the medial meniscus. often extend to the inferior articular surface.e. and extent. Tears with variegated type are referred to as complex tears.

When scrolling through adjacent images. Radial tears may be seen only on one slice—a noted exception to the two-slice rule. some surgeons may wait to repair the meniscus. creating a bucket-handle–type tear (Fig. A peripheral tear occurs in the outer one third of the meniscus. lateral fragments are blocked by the intact anterior cruciate ligament). with the flipped meniscal fragment (arrow) located beneath the posterior cruciate ligament (arrowheads). which can be difficult to detect. On sagittal imaging. A bucket-handle tear can be mimicked by a torn anterior cruciate ligament or an intra-articular body. 8-18). in reference to its vascular supply (Fig. Meniscal root attachments prevent meniscal displacement in a radial direction and act as primary resistance to hoop strain during axial load bearing. The coronal image (A) demonstrates truncation of the body of the medial meniscus (arrowhead).  A and B.  A through D. 8-19). perpendicular to the circumference of the meniscus (Fig. it appears that the posterior horn has disappeared. 8-17). Coronal (A) and axial (B) T2-weighted fat-suppressed images show a notch in the inner margin of the posterior horn medial meniscus representing a small radial tear. Bucket-handle type of meniscal tear. . extending vertically perpendicular to the meniscal circumference. while looking at sagittal images. and posterior horn. The sagittal image (B) shows the double PCL sign. the area known as the red zone. the inner fragment may displace centrally into the intercondylar notch. the displaced fragment may be seen below the posterior cruciate ligament. A radial tear is a type of vertical tear that occurs along the inner margin of the meniscus. as they tend to blend with the hyperintense perimeniscal tissues and/or joint recesses. If a vertical longitudinal tear extends to involve the anterior horn. the flipped fragment (arrow) is displaced centrally. A peripheral tear is amenable to meniscal repair because of the increased vascularity. this type of tear will look as though it migrates through the meniscal substance. these tears are typically radial tears. Coronal and sagittal T2-weighted fat-suppressed images show typical findings. Meniscal root tears are often missed and can lead to accelerated osteoarthritis. Alternatively. body. Meniscal root tears occur medially more often than laterally and are often associated with extrusion and the development of degenerative joint disease (Fig. given the possibility that the tear may heal on its own. these tears result in a blunted appearance of the normal triangular morphology of the meniscus. On sagittal and coronal images. Coronal (C) and axial (D) T2-weighted fat-suppressed images of a different patient show an obliquely oriented radial tear with a shape resembling a parrot’s beak (arrows). Radial tear and parrot-beak meniscal tears. 8-16).114 SECTION 2  Imaging of the Knee A B Figure 8-16. which then extends along the longitudinal axis of the meniscus (curved radial tear). A B C D Figure 8-17. A root tear should be suspected if. A parrot-beak tear has a radial tear component. Care should be taken not to confuse postsurgical truncation related to débridement from a meniscal tear with displaced fragment. creating the double PCL sign (this occurs only in medial bucket-handle tears. Care should be taken not to miss these types of tears. Approximately 95% of bucket-handle tears involve the medial meniscus and are detected by noting an abnormal meniscal size or meniscal truncation.

Unstable tears lead to meniscal extrusion and accelerated osteoarthritis. Meniscal Tear Stability An unstable meniscal tear is defined as a tear in which a fragment of the meniscus can be displaced by a probe into the femorotibial joint at the time of arthroscopy. Fluid signal is present within the meniscus on T2-weighted images. flaps commonly become displaced into the meniscotibial or meniscofemoral recess. repair. as seen in this example.  A and B. and therefore patients who would benefit from arthroscopy could be delineated. Therefore. The following MRI criteria have been used to evaluate unstable meniscal lesions and have been compared with findings at arthroscopy: 1. or resection. or the entire meniscal horn can flip centrally. A flap tear is a meniscal tear that results in an isolated fragment. pointing toward spontaneous healing. A B C Figure 8-19. These tears are more likely to be unstable. which becomes displaced (Fig. resultant meniscal destabilization causes extrusion and is strongly associated with subsequent cartilage loss.  A through C. coronal (B). 8-21). Frequently. care must be taken to evaluate for a flap tear with a displaced meniscal fragment. 2. These MRI criteria for unstable meniscal lesions were found to have high specificity and positive predictive value when compared with findings at arthroscopy. Sagittal proton density (A) and T2-weighted fat-suppressed images (B) show vertical signal extending through the outer margin of the posterior horn medial meniscus (arrows). 3. More than one lesion pattern or more than one cleavage plane is present within the meniscus. 8-20). lead to meniscal extrusion. often posterior to the posterior cruciate ligament (Fig. creating an enlarged appearance of the anterior horn. and progress to osteoarthritis. Peripheral meniscal tear.21 . predicting the stability of a meniscal lesion on MRI helps guide management of the tear. Meniscal fragments can also flip anteriorly. 4. Sagittal (A). A lesion is visible on more than two 4-mm-thick sagittal and on three 3-mm-thick coronal images. Root tears are often radial type. This was important because it meant that unstable meniscal tears could be identified by MRI. Meniscal root tear. CHAPTER 8  Internal Derangements: Menisci and Cartilage A 115 B Figure 8-18. the tear extends to both the superior and inferior articular surfaces. and axial (C) T2-weighted fat-suppressed images show fluid signal extending through the posterior root attachment of the medial meniscus (arrows). A complex tear is a meniscal tear with more than one cleavage plane. A displaced meniscal fragment is visible on MRI. If the meniscus appears diminutive and there has been no history of meniscectomy.

standard MRI diagnostic criteria for meniscal tears cannot be applied to the postoperative or healed meniscus. Axial (A) and sagittal (B) T2-weighted fat-suppressed images show a parrot-beak–type tear at the junction of the body and the posterior horn of the medial meniscus (arrows) with displacement of the inner margin fragment. highlighting the abnormality. Sagittal T2-weighted fat-suppressed image though the lateral compartment shows that a large meniscal fragment (arrow) originating from the posterior horn has flipped anteriorly and is positioned next to the native anterior horn. With indirect MR arthrography. into the meniscotibial recess.  Sagittal T1-weighted fat-suppressed image from an indirect magnetic resonance arthrogram (delayed imaging following an intravenous dose of gadolinium contrast) demonstrates contrast within the posterior horn of the medial meniscus (arrow) at the site of prior débridement. A residual or recurrent meniscal tear should enhance beyond adjacent meniscal tissue. MRI findings of surfacing signal abnormality may persist and may appear no different from the tear initially noted on preoperative imaging. Figure 8-22. 8-23). confounding the importance of the finding. Unfortunately. After an appropriate delay. granulation tissue in a healed meniscus can also enhance. Magnetic resonance (MR) arthrography has been promoted for assessment of the postoperative meniscus. Meniscal flap tears. Figure 8-21. 8-22). Coronal T2-weighted fat-suppressed image (C) of a different patient shows a meniscal fragment (arrowhead) flipped under the body of the medial meniscus.  Anteriorly flipped meniscal fragment. For this reason. intra-articular .116 SECTION 2  Imaging of the Knee A B C Figure 8-20. consistent with recurrent tear. This can block full range of motion on extension. CT is insensitive to the internal degenerative signal that causes confusion on MRI in the postoperative After meniscal repair or meniscal healing. The joint is distended by the contrast. This creates a diagnostic dilemma in the postoperative patient with recurrent or residual symptoms. Studies comparing diagnostic accuracy between direct and indirect arthrography found no significant difference. Postoperative Meniscus contrast will dissect into a residual or recurrent meniscal tear in the postoperative patient. Note underlying reactive bone marrow edema in the medial tibial plateau (arrow). dilute gadolinium contrast is placed directly into the joint under fluoroscopic guidance.  A through C. gadolinium contrast is administered intravenously. CT arthrography has also been suggested as useful for evaluation of the postoperative meniscus (Fig. Theoretically. the knee joint is imaged. With direct MR arthrography. accentuating the abnormality (Fig.

parameniscal 117 cyst. imaging of hyaline cartilage has become an important focus of diagnostic radiology research. the subchondral fracture line is hypointense on T1. with diffuse bone marrow edema in the medial femoral condyle and a low signal crescent in the subchondral bone (arrow) representing the fracture line. C Figure 8-24. Spontaneous Osteonecrosis of the Knee (SONK) Spontaneous osteonecrosis of the knee. the subchondral fracture line will not enhance.  A through C. Cartilage Cartilage and Osteochondral Injuries Figure 8-23. also known as a subchondral insufficiency fracture (SIFK). Bone marrow edema may even extend to the femoral notch (Fig. In a symptomatic patient with clinical suspicion for meniscal retear. including associated subchondral bone marrow edema. also referred to as SONK. Spontaneous osteonecrosis of the knee (SONK). and contrast entering the meniscus is specific for retear. proteoglycans.  Meniscal tear on computed tomography (CT) arthrogram.4 Noncontrast MRI can also evaluate for a retear in the postoperative meniscus. if treatment is not effective or is delayed. This represents free fluid tracking through the meniscal tear and simulates the arthrographic effects of contrast insinuating into the tear.4 Secondary signs of meniscal tear. . the fluid-sensitive sequence is most specific for diagnosis. more commonly females. the insufficiency fracture can progress to osteonecrosis and articular collapse. Hyaline cartilage acts to aid in resistance against compressive and shearing forces. The entity can also involve the lateral femoral condyle or the tibial plateau and is believed to be related to altered biomechanics and weight bearing following a meniscal tear or meniscal surgery. Coronal reconstruction CT image through the posterior aspect of the knee following intra-articular injection of contrast in a patient with prior meniscal surgery and recurrent knee pain shows contrast dissecting through a large radial tear in the posterior horn of the medial meniscus (arrow). Fluid signal within the meniscus tracking to the articular surface is highly predictive of retear. Note associated meniscal extrusion that is often seen with this phenomenon. Coronal T2-weighted fat-suppressed image (A) shows the classic magnetic resonance features. A B Hyaline cartilage covers the articular surface of the knee joint and is composed of chondrocytes surrounded by a medium of collagen. predominantly by dissipating the forces to the menisci and subchondral bone. bone marrow edema decreases. However. is an outdated term that describes subchondral insufficiency fractures typically found along the weight-bearing aspect of the medial femoral condyle in middle-aged to elderly patients. 8-24). CHAPTER 8  Internal Derangements: Menisci and Cartilage meniscus. and findings of osteonecrosis and osteoarthritis dominate. On MRI. Surrounding soft tissue edema related to hyperemia is also commonly seen. and electrolytes. with delamination of the overlying hyaline cartilage.19 Because of the prevalence of degenerative osteoarthritis.and T2-weighted images with extensive adjacent bone marrow edema. In later stages. Coronal (B) and sagittal (C) T2-weighted fat-suppressed images of a different patient demonstrate articular collapse at the site of subchondral fracture (arrows). Subchondral insufficiency fractures are usually treated conservatively. the subchondral fracture line becomes less visible. requiring surgery. Following intravenous gadolinium administration. The fracture can progress to osteonecrosis. may also prove to be important. and adjacent collateral ligament edema. near its posterior root attachment.

Numerous classifications have been proposed to grade cartilage lesions based largely on arthroscopic findings. partial-thickness defects. Normal cartilage is demonstrated on coronal T1 (A). Short T1 inversion recovery (STIR) images may also provide sufficient contrast resolution to evaluate for chondral abnormalities. but intrinsically have lower signalto-noise ratio and spatial resolution. A secondary sign of cartilage defect includes underlying bone marrow edema. Subchondral bone marrow edema is a nonspecific finding that may be seen with acute injury (bone contusion or bruise. and degeneration. fissuring. MRI of Hyaline Cartilage To adequately image hyaline cartilage in the knee. and many other conditions. Cartilage damage can be related to acute trauma. Both proton density and T2-weighted fast spin echo sequences produce high signal-to-noise ratio images with relatively short acquisition times. Chondral abnormalities are diagnosed on MRI by recognizing a contour defect within the cartilage. are limited for use in evaluation of deeper cartilage layers. spatial resolution must be optimized. These classification systems describe articular cartilage damage ranging from swelling and signal heterogeneity to fissuring. cartilage appears bright on fat-suppressed images. No universal MRI sequence has been dedicated for hyaline cartilage imaging.  A through D. focal thinning compared with the thickness of the adjacent cartilage. However. including metabolic and neoplastic lesions. as stress response or overlying meniscal tear. Grade I includes softening or swelling of the articular cartilage. adequate differences in signal intensity (contrast) must be evident between joint fluid. and artifact. Two. allowing for differentiation between cartilage thinning. Note poor contrast between cartilage and joint fluid on the T1-weighted image (A). 8-25). these sequences generally require a longer acquisition time. 8-26 through 8-30). regardless of the sequence used). Grade III describes cartilage fragmentation and fissuring greater than 1. a flame-shaped or rounded focus of marrow edema in the subchondral bone should initiate a search for overlying hyaline cartilage abnormality. Normal articular cartilage. Articular cartilage has intermediate signal on T1. fat suppression results in higher relative cartilage signal. prolonged and repetitive stress. hyaline cartilage. Additionally. axial T2-weighted fat-suppressed (C). however.and T2-weighted images (Fig.e. Articular cartilage has intermediate signal on both T1. Achieving high resolution and a pronounced difference in brightness of cartilage and joint fluid is essential for imaging cartilage abnormalities.. sagittal proton density (B).or threedimensional (2D or 3D) gradient imaging sequences can improve resolution and can more accurately evaluate the superficial surface of the cartilage. and fullthickness defects with exposure of the subchondral bone. as manifested by increased signal in the subchondral bone on fat-suppressed proton density and T2-weighted images. partial volume averaging. Fat-suppression techniques can be used on any sequence and have the advantage of increasing apparent signal of the hyaline cartilage relative to other tissues (i.5 cm in diameter.118 SECTION 2  Imaging of the Knee A B C D Figure 8-25. and sagittal T2-weighted fat-suppressed (D) images. Axial T2-weighted fatsuppressed image shows swollen. Proton density and T2-weighted fast spin echo sequences with fat suppression provide sufficient contrast between higher signal joint fluid and intermediate signal cartilage to detect chondral abnormalities.  Low-grade chondromalacia. and subchondral bone. Normal articular cartilage has a homogeneous or laminar appearance with a smooth surface contour. mechanical disturbance such Figure 8-26. T2 hyperintense cartilage (arrow) along the median ridge of the patella. and partial-thickness and full-thickness defects.and T2-weighted images. and Grade IV involves . and/ or signal alteration within the cartilage (Figs.19 MRI diagnostic capabilities in low-grade cartilage lesions are limited by contrast and spatial resolution. ulceration. and are more susceptible to imaging artifacts. The Outerbridge scale classifies cartilage abnormalities based on arthroscopic findings. Grade II describes cartilage fragmentation and fissuring less than 1. fracture). and less so on MRI findings. on most sequences.5 cm in diameter.

Accompanying osteophyte formation. A Outerbridge ICRS Noyes Grade I: softening and swelling of cartilage Grade 0: normal cartilage Grade 1: intact cartilage surface Grade II: cartilage fragmentation and fissuring <1. International Cartilage Repair Society. assessing the location. accounting for <50% of the normal cartilage thickness. Full-thickness cartilage fissuring. Axial T2-weighted fat-suppressed image demonstrates diffuse patellar cartilage thinning with focal partial-thickness cartilage loss at the lateral facet (arrow). . 3B cortical surface shows cavitation) (Table 8-2). CHAPTER 8  Internal Derangements: Menisci and Cartilage cartilage erosion to bone.5 cm diameter Grade 2: partialthickness defect <50% of normal cartilage thickness Grade 2B: cartilage defects involve >50% cartilage thickness Grade IV: cartilage erosion to bone Grade 3: partialthickness defect >50% of normal cartilage thickness Grade 3: bone exposed (3A cortical surface intact. fissuring. Aside from grading cartilage loss. B Figure 8-28. the cartilage thins particularly along weight-bearing aspects and degenerates with fraying. Grade 2A reflects cartilage damage with less than 50% cartilage thickness involved. 3B cortical surface cavitation) Grade 4: fullthickness defect ICRS. Grade 2B cartilage defects involve greater than half of the cartilage thickness. Grade 1 depicts an intact cartilage surface. Grade 1 describes increased T2 signal within the cartilage. Grade 2 refers to a partial-thickness defect less than 50% of normal cartilage thickness. Grade 3 represents a partialthickness defect greater than 50% of normal cartilage thickness.  A and B. Table 8-2  Chondral Injury Classifications Figure 8-27. and Grade 4 describes a full-thickness defect. Grade 0 represents normal cartilage. They may be partial thickness or full thickness and can shear off from the cortex. ulceration.22 In osteoarthritis. Axial T2-weighted fat-suppressed image of a different patient (B) shows a broader area of cartilage surface irregularity at the lateral facet with a full-thickness fissure (arrow).18 The International Cartilage Repair Society has adopted the classification system described by Yulish and associates. subchondral cystic change.5 cm diameter Grade 1: increased T2 signal in the cartilage Grade 2A: cartilage surface damaged with <50% thickness involved Grade III: fragmentation and fissuring >1.  Partial-thickness cartilage defect. and Grade 3 represents full-thickness cartilage defects with exposed 119 subchondral bone (3A cortical surface is intact. Traumatic chondral injuries are usually focal and may have acute margins with adjacent shoulders. resulting in an intra-articular body. Chondral injuries in weight-bearing areas have a worse prognosis and different treatment implications than those in non–weight-bearing areas. and sometimes delaminating defects. Axial T2-weighted fat-suppressed image (A) depicts a small fissure at the medial patellar facet (arrow). size. and morphology of the cartilage defect is also important.16 In the Noyes system.

or rotational forces are transmitted between two articular surfaces. Damage to the underlying subchondral bone ensues. 8-31). If the cartilage surface is damaged. and elbow. However. resulting in a chondral or subchondral fracture (Fig. resulting in an intra-articular body. fluid can extend from the joint into the bone and the fragment can separate.16 Osteochondritis Dissecans Figure 8-29. uniform cartilage thinning throughout the joint. Sometimes the cartilage flap or osteochondral fragment dissociates from the underlying bone.22 Inflammatory arthritides result in diffuse.  Focal full-thickness defect. Lesions may arise from forces applied to the chondral surface in a single traumatic event or over time as the result of repeated minor injury. Reactive underlying subchondral bone marrow edema is evident. A Osteochondritis dissecans (OCD) is a somewhat outdated term. Alternatively. Coronal T2-weighted fatsuppressed image shows a focal full-thickness cartilage defect (arrow) along the lateral femoral condyle.22 Osteochondral Lesions The term osteochondral lesion is used to describe a spectrum of disease from traumatic osteochondral injury to chronic osteochondritis dissecans. Overlying cartilage can itself delaminate and become displaced as an intra-articular body. depending on the depth of the fracture line. compressive. in areas of inflammatory pannus.120 SECTION 2  Imaging of the Knee bone marrow edema. focal cartilage and bony erosions may be found. Cartilage delamination. the underlying bone can heal. Focal cartilage defects are not typical. A cartilage flap or an osteochondral fragment may form. and sclerosis may occur. Several studies have demonstrated that meniscal root tears. femoral condyles. especially if the overlying cartilage remains intact. Sagittal T2-weighted fat-suppressed images demonstrate a broad area of full-thickness cartilage loss from the posterior aspect of the medial femoral condyle (arrows in A). or it may degenerate and become thinned and fissured. eventually detaching and forming a loose body. with uniform joint space narrowing. Most commonly. Nevertheless. Traumatic Osteochondral Lesions A traumatic osteochondral lesion occurs when shearing. a better term is osteochondral lesion. resulting in resorption of the subchondral bone and cystic change. and severe meniscal degeneration are strongly associated with major meniscal extrusion and may precede or even accelerate the development of osteoarthritis with cartilage loss. although it is still in common use. Significant osteophyte formation should not occur. Elevated intra-articular pressure is thought to force synovial fluid into the cartilage flap or beneath the osteochondral fragment. and sometimes even hemarthrosis. osteochondral lesions are encountered in the talus. . The bone may become necrotic and collapse. large radial meniscal tears. a joint effusion. the term OCD typically refers to an osteochondral lesion that is discovered B Figure 8-30.  A and B. The cartilage has delaminated from the femoral condyle and is seen displaced into the posterior joint space (arrow in B). This injury is typically associated with tenderness.

Coronal T1-weighted (A). MRI should be performed to accurately characterize OCD. CHAPTER 8  Internal Derangements: Menisci and Cartilage A B 121 C Figure 8-31. The natural progression of stable OCD (i. However. coronal T2-weighted fat-suppressed (B). Sagittal T2-weighted fat-suppressed (A). Stage 3 refers to a completely detached osteochondral lesion that is not dislocated. and sagittal T2-weighted fat-suppressed (C) images show a chronic osteochondral lesion (arrows) along the lateral aspect of the medial femoral condyle. coronal T2-weighted fat-suppressed (B). and Stage 4 represents a completely detached and displaced osteochondral fragment.  A through C. and to determine the stability of the lesion (Fig. Classic OCD is most commonly seen in young patients between 10 and 20 years of age. however. it was initially created to describe osteochondral lesions of the talus (OLT). Measurement is generally performed using T1-weighted images. OCD was initially graded by Berndt and Harty into four stages. and coronal T1-weighted (C) images show an osteochondral impaction injury along the lateral femoral condyle (arrows) consistent with a pivot shift mechanism of injury. black signal in (A) in the subchondral bone suggests underlying necrosis. (2) cystic change interposed between the osteochondral fragment and normal bone. or (3) overlying cartilage defect or fissuring. Stage I refers to the presence of bone marrow edema.and T2-weighted images. incidentally and is presumed to represent a chronic injury. the more painful the lesion is. it is often the case that the more bone marrow edema is present. Underlying cystic change seen in (B) suggests instability. The idiopathic variety of OCD often occurs in the lateral aspect of the medial femoral condyle. Osteochondral impaction injury. Stage IIa describes underlying . surgery is usually indicated. 8-32).5 Intra-articular gadolinium may dissect beneath the osteochondral fragment.  A through C. along the non–weight-bearing aspect near the intercondylar notch. and the last two stages signifying instability. Repetitive microinjuries are thought to disrupt blood supply to the subchondral bone. if the lesion is painful and unstable. to evaluate size and location. The Anderson MRI classification of OCD is more widely used. Surrounding bone marrow edema is variable and may represent healing response or irritation from lesion instability. but can be applied to the knee and other areas. The osteonecrotic fragment has low signal intensity on T1. Osteochondral lesion. An unstable lesion is identified by one or more of the following findings on T2-weighted fat-suppressed images or STIR images: (1) linear high signal intensity surrounding the osteochondral fragment. Stage 1 demonstrates no discontinuity between the osteochondral lesion and surrounding bone.e. possibly related to microtrauma between the tibial spine and the medial femoral condyle during internal rotation of the tibia. also indicating lesion instability. sometimes resulting in osteonecrosis and progressing to an osteochondral lesion. so this finding is nonspecific. with the first two stages indicating lesion stability.. This is also referred to as osteochondritis dissecans. A B C Figure 8-32. with intact overlying cartilage) is spontaneous healing. Stage 2 describes a partially detached but stable osteochondral lesion.

The fragment is partially detached. FIESTA (fast imaging employing steady-state acquisition. coronal T2-weighted fat-suppressed (B). Morrison WB: MR imaging of meniscal cysts: incidence. or fraying. AJR Am J Roentgenol 177:409–413. et al: Osteochondral lesions of the talus: change in MRI findings over time in talar lesions without operative intervention and implications for staging systems. Stage IIb refers to a partially detached osteochondral lesion with bone marrow edema. delamination) and other joint pathology.. 2006. and increases signal from tissues with long T1 relaxation time. with altered water content correlating with cartilage damage.10 Delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) refers to the use of Magnevist. producing high contrast between the signal of cartilage and adjacent joint fluid. Fluid is interposed between the osteochondral lesion and the normal femoral condyle. Carrino JA: Medial meniscus extrusion on knee MRI: is extent associated with severity of degeneration or type of tear? AJR Am J Roentgenol 183:17–23.10 T2 relaxation time mapping is based on the knowledge that T1 and T2 relaxation times are constant for a given tissue at specific MRI field strengths. Bangerter NK: Recent advances in MRI of articular cartilage. T2 relaxation time mapping detects the water content within cartilage. AJR Am J Roentgenol 187:911–914. Andover.10 KEY REFERENCES Bergin D. Stage III lesions have fluid undermining a nondisplaced and completely detached osteochondral lesion. and Stage IV describes a completely detached and displaced osteochondral fragment (Fig. This results in high signal synovial fluid and improved contrast between cartilage and fluid at a short time to repetition (TR). Costa CR. Osteochondral lesion. Gold GE. Recent Advances in MRI of Cartilage Current MRI of articular cartilage utilizes 2D multislice acquisitions with small gaps between slices. Three-dimensional spoiled gradient recalled (SPGR) sequence is the standard for evaluating cartilage volume and thickness. Chen CA. DeSmet AA. Raikin SM. Driven equilibrium Fourier transform (DEFT) imaging uses a 90-degree pulse to return magnetization to the z-axis. location. Tuite MJ: Use of the “two-slice-touch” rule for the MRI diagnosis of meniscal tears.10 Balanced steady-state free precession (SSFP) is also known as trueFISP (true fast imaging with steady-state precession. and sagittal T2-weighted fat-suppressed (C) images demonstrate an unstable osteochondral lesion along the lateral aspect of the medial femoral condyle. degeneration. in the evaluation of cartilage damage. 8-33). Norris MA. et al: MR diagnosis of meniscal tears of the knee: importance of high signal in the meniscus that extends to the surface. typically spoiled gradient recalled echo with fat suppression.  A through C. Jung JW. or may exhibit degeneration.9. 2001. The overlying articular cartilage may be intact. proton density fast spin echo. subchondral cystic change. Buckinghamshire. AJR Am J Roentgenol 161:101–107. A color or gray scale map depicting the T2 relaxation time is created. AJR Am J Roentgenol 191:86–92. DeSmet AA. 2009. GE Healthcare. Hochberg H. synovial fluid is hyperintense. . Images are 3D volumetric acquisitions. Foot Ankle Int 27:157–166. Campbell SE. Alteration of relaxation time within a given tissue may be related to pathology or introduction of a contrast agent. allows for volumetric image acquisition. Philips Healthcare. Hargreaves BA. Zoga AC.16 A healed osteochondral lesion will not demonstrate fluid bright signal between the osteochondral fragment and the host bone. Pa). 2006. thinning. 1993. Koo S. Magnevist carries a negative ionic charge. but is limited for use in evaluating internal cartilage abnormalities (e. The contrast between cartilage and synovial fluid with DEFT imaging is superior to that with SPGR. 2004.122 SECTION 2  Imaging of the Knee A B C Figure 8-33. Mass). Yandow DR. A T1 map is created. Sanders TG. Elias I.g. Malvern. UK). illustrating areas of cartilage damage. depending on the MRI scanner manufacturer. or BFFE (balanced fast-field echo imaging. One criticism of this classification is that bone marrow edema may be present at any stage and appears to be a nonspecific finding. Siemens Healthcare. Normal bone marrow fat signal will return to the osteochondral fragment once it heals. or gadopentetate dimeglumine. and T2-weighted fast spin echo images. Coronal T1-weighted (A). AJR Am J Roentgenol 193:628– 638. Three-dimensional imaging. and tissue contrast is sufficient for evaluation of cartilage and for imaging internal derangement. Morrison WB. Areas of decreased GAG correspond to damaged cartilage. and clinical significance. 2008. without contour irregularities. which facilitates its diffusion into cartilage and concentration in areas of decreased glycosaminoglycan (GAG) content. demonstrating glycosaminoglycan content. et al: Indirect soft-tissue and osseous signs on knee MRI of surgically proven meniscal tears. This corresponds to Anderson stage IV.

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