Musculoskeletal Imaging • Original Research

Roemer et al.
MRI of Patellofemoral Synovitis

Musculoskeletal Imaging
Original Research

Hoffa’s Fat Pad: Evaluation

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on Unenhanced MR Images as
a Measure of Patellofemoral
Synovitis in Osteoarthritis
Frank W. Roemer 1,2 OBJECTIVE. The purpose of this study was to compare synovitis-like signal changes in
Ali Guermazi1 Hoffa’s fat pad on unenhanced proton density–weighted fat-suppressed sequences with sig-
Yuqing Zhang 3 nal alterations in Hoffa’s fat pad and peripatellar synovial thickening on T1-weighted fat-sup-
Mei Yang 3 pressed contrast-enhanced sequences in patients with osteoarthritis.
David J. Hunter4 SUBJECTS AND METHODS. Fifty patients with osteoarthritis of the knee partici-
pated in the study. MRI was performed with triplanar proton density–weighted fat-suppressed
Michel D. Crema1
sequences and a sagittal T1-weighted fat-suppressed contrast-enhanced sequence. Signal in-
Klaus Bohndorf 2 tensity alterations in Hoffa’s fat pad were scored semiquantitatively on unenhanced and con-
trast-enhanced images by two radiologists in consensus. Peripatellar synovial thickness was
Roemer FW, Guermazi A, Zhang Y, et al. measured on the T1-weighted fat-suppressed contrast-enhanced images in six locations. Agree-
ment between scoring of signal changes on unenhanced and contrast-enhanced sequences
was assessed with kappa statistics. The sensitivity, specificity, and accuracy of scoring of sig-
nal-intensity changes on unenhanced images were calculated with T1-weighted contrast-en-
hanced MRI as the reference standard. In addition, we also examined the relation between sig-
Keywords: gadolinium, knee, MRI, osteoarthritis,
nal changes and summed synovial thickness using Spearman’s rank correlation coefficient.
scoring, synovitis RESULTS. Agreement between unenhanced and contrast-enhanced MRI was fair to
moderate (weighted κ = 0.35 and 0.45). The sensitivity of signal intensity changes in Hoffa’s
DOI:10.2214/AJR.08.2038 fat pad on proton density–weighted fat-suppressed images was high, but specificity was low.
Correlations of signal intensity changes in Hoffa’s fat pad with synovial thickness were lower
Received November 2, 2008; accepted after revision
December 1, 2008. for unenhanced scans but all were statistically significant.
CONCLUSION. Signal intensity alterations in Hoffa’s fat pad on unenhanced images
Supported by a grant from the Private Practice for do not always represent synovitis but are a nonspecific albeit sensitive finding. Semiquan-
Musculoskeletal MRI, Stadtbergen, Germany. titative scoring of synovitis of the patellofemoral region in osteoarthritis ideally should be
A. Guermazi is president of Boston Imaging Core Lab,
performed with T1-weighted contrast-enhanced sequences and should include scoring of sy­
LLC, a company providing radiologic image assessment novial thickness.
services. He is a shareholder of Synarc, Inc.
F. W. Roemer, M. D. Crema, and K. Bohndorf are

O
steoarthritic joints regularly ex-
shareholders of Boston Imaging Core Lab.
hibit signs of synovitis, even in
1
Department of Radiology, Boston University Medical the early phase of the disease [1–
Center, Boston, MA. 5]. The amount of synovitis ap-
pears to correlate with pain and may be a
2
Present address: Department of Radiology, Klinikum marker of structural change and clinical out-
Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany.
Address correspondence to F. W. Roemer
come [6–8]. Whether synovitis is a primary
(froemer@bu.edu). or secondary phenomenon in the course of
the disease remains to be determined [1, 9].
3 
Clinical Epidemiology Research and Training Unit, MRI studies of synovitis in rheumatoid ar-
Boston University School of Medicine, Boston, MA.
thritis and osteoarthritis have shown that the
4
Division of Research, New England Baptist Hospital, alterations of synovitis are ideally quantified
Boston, MA. with contrast-enhanced T1-weighted MRI
[5, 10–13]. Quantitative markers of synovial
AJR 2009; 192:1696–1700
activation on MR images include volume of
0361–803X/09/1926–1696 effusion and synovial enhancement and
thickening [4, 14–16]. Therefore, contrast
© American Roentgen Ray Society material sometimes is administered for as-
sessment of the synovitis of osteoarthritis in
the clinical setting. However, because con-
trast injection is costly and can have side ef-
fects [17–19], contrast-enhanced MRI has
not been routinely used in large epidemio-
logic studies or clinical trials of therapies
for osteoarthritis.
To date, semiquantitative assessment of
synovitis in large studies of osteoarthritis is
usually performed on unenhanced T2-weight-
ed or proton density–weighted fat-suppressed
images [14, 20, 21]. Commonly, signal altera-
tions (areas of high intensity) in Hoffa’s fat
pad are scored as surrogates for synovitis [20,
22]. One study showed that areas of signal
change in the fat pad on T1-weighted spin-
echo or T2-weighted gradient-echo unen-
hanced images correlate histologically with

1696 AJR:192, June 2009


mild chronic synovitis in the same location
[2]. It is not known whether these signal al-
terations correlate well with the expressions
of synovitis seen on T1-weighted images after
contrast administration. To our knowledge, in
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only one study [22] has scoring of changes
in signal intensity in Hoffa’s fat pad on un-
enhanced images been compared with scor-
ing on contrast-enhanced images in a sample
of patients with radiographic osteoarthritis.
Those authors found agreement in 65% of
the analyzed knees, most of the disparity be-
ing due to underestimation of the amount of
synovitis on unenhanced images with con-
trast-enhanced images as the reference stan-
dard. However, some radiologic differen-
tial diagnoses of signal alterations in Hoffa’s
fat pad, such as nonspecific edema, overuse,
Hoffa’s impingement, and nonpathologic ve-
nous structures, can lead to overestimation
of synovitis on unenhanced T2-weighted and
proton density–weighted images [23].
The first aim of our study was to evalu-
ate agreement between signal alterations in
Hoffa’s fat pad scored on unenhanced and
contrast-enhanced images and to assess the
accuracy of changes in the fat pad on unen-
hanced images using enhanced images as
the reference standard. Second, using assess-
ment of peripatellar synovial thickness on
contrast-enhanced images as the reference
standard, we analyzed the diagnostic perfor-
mance of assessment of signal alterations on
contrast-enhanced and unenhanced images
in Hoffa’s fat pad in the detection of synovi-
tis [4, 16]. We addressed these research ques-
tions with patients who had clinically con-
firmed osteoarthritis of the knee and were
referred for routine MRI of the knee because
of chronic nontraumatic knee pain.
Subjects and Methods
Patients
The study included all patients older than 55
years who has been consecutively referred to our
institution for assessment of chronic knee pain
between August 2006 and June 2007 and who
fulfilled the American College of Rheumatology
clinical criteria for having osteoarthritis [24]. To
define whether they had clinical osteoarthritis,
patients were asked to fill out a standard
questionnaire concerning pain, morning stiff­ness,
and crepitation on active motion. The pa­tients
underwent clinical examinations for bony
tenderness, crepitation, enlargement, and palpable
warmth of the joint. All patients were ambulatory
at the time of imaging. Patients were excluded if
they had had a history of rheumatoid arthritis,
AJR:192, June 2009 1697
MRI of Patellofemoral Synovitis
other inflammatory rheumatic condition, or knee
trauma within the last 6 months. The local
institutional review board approved the study
design. The details of the examination, including
possible side effects of the contrast agent, were
explained to the patients. Written informed consent,
including a statement that the investigators were
blinded to patient name, birth date, and institution
on the imaging reports and questionnaire and that
the data would be used for research, was obtained
from all patients before the examination.
MRI
All imaging was performed with a 1.5-T MRI
system (Symphony, Siemens Healthcare) and a
phased-array knee coil. A positioning device was
used to ensure uniform placement of the knee at
10° flexion. An unenhanced non-fat-suppressed
T1-weighted spin-echo sequence was performed
with the following parameters: TR/TE, 720/15;
slice thickness, 3.0 mm; slice gap, 0.3 mm;
field of view, 18 × 16.3 cm; matrix size, 384 ×
282; number of signals averaged, 2. For proton
density–weighted fat-suppressed fast spin-echo
images in the sagittal, coronal, and axial planes,
the pulse sequence parameters were as follows:
5,080/32; slice thickness, 3.0 mm; slice gap, 0.3
mm; echo-train length, 7; field of view, 18 × 16.3
cm; matrix size, 384 × 282; number of signals
averaged, 3. While the patient remained in the
same position in the MRI unit, 0.2 mL/kg body
weight (0.1 mmol/kg body weight) gadodiamide
(Omniscan, GE Healthcare) was injected manu­
ally into a cubital vein through a cannula inserted
before the examination and followed by a 20-mL
saline flush. Injection time was 10–15 seconds.
The T1-weighted sequence was repeated with
fat suppression 5 minutes after the injection. The
sequence parameters were identical to those for the
contrast-enhanced sequence.
MRI Assessment
The examiners were blinded to patient name,
date of birth, and study number. They were
not blinded to sequence because the imaging
characteristics were typical for the sequences.
Before the readings, each MRI examination
was split into two sequence sets, one presenting
only the T1-weighted contrast-enhanced sagittal
images and the other presenting the triplanar
proton density–weighted fat-suppressed images.
The image sets were randomly mixed, and new
study numbers were assigned to each image set.
Thus, readers were not aware which two image
sets belonged to the same patient, minimizing the
risk of reader bias. The unenhanced T1-weighted
images were not assessed. All MR images were
read by two musculoskeletal radiologists in con­
sensus. Both readers had extensive experience
in semiquantitative scoring of osteoarthritis.
Readings were performed with the cine loop
function on a standard clinical PACS (Centricity,
GE Healthcare). Scoring was performed electron­
ically with a desktop computer and a designated
custom spreadsheet developed with Access soft­
ware (Microsoft).
Signal alterations in Hoffa’s fat pad were scored
semiquantitatively from 0 to 3 on the sagittal
unenhanced proton density–weighted fat-sup­
pressed images at the superior edge of the fat pad
adjacent to the patella and the internal fat pad, as
described previously [6, 20, 22]. On the sagittal
fat-suppressed T1-weighted images, enhancement
after contrast administration in the superior and
internal regions was scored semiquantitatively
from 0 to 3 in the same manner as the signal
alterations on the unenhanced proton density–
weighted fat-suppressed images.
Synovial thickening was scored semiquanti­
tatively in three peripatellar locations in two slices
in the sagittal plane. The first scoring was
performed on the image slice with the anterior
cruciate ligament visualized in its maximum
length. The second scoring was performed in a
slightly medial position in the slice of the posterior
cruciate ligament seen at its maximum extent.
Synovial thickness was measured 0.5 cm cranial to
the superior patellar pole, 1 cm cranial to the
femoral osteochondral junction on the femoral
side, and 1 cm caudal to the inferior patellar pole at
the surface of Hoffa’s fat pad (Fig. 1). Thickness
was measured and graded on a scale adapted from
Ostergaard et al. [10] as follows: 0, normal
synovial enhancement without thickening and
very thin, barely distinguishable synovial lining;
1, synovial thickening of 2 mm or less; 2,
thickening greater than 2 mm and up to 4 mm; 3,
thickening greater than 4 mm. Thickness scores of
the six locations were summed and subdivided
into three grades of summed thickness, as follows:
grade 1, summed scores 0–6; grade 2, summed
scores of 7–12; grade 3, summed scores 13–18.
Statistical Analysis
We used kappa statistics to assess the agreement
of scoring of signal alterations in Hoffa’s fat pad
between unenhanced and contrast-enhanced im­
ages. We calculated sensitivity, specificity, and
accuracy of signal alterations to detect active
inflammation in the fat pad on unenhanced images
using the scores on the contrast-enhanced images
as the reference standard. We also assessed the
relation between signal alterations and summed
peripatellar synovial thickness using Spearman’s
rank correlation coefficient (ρ). Finally, we deter­
mined the sensitivity, specificity, and accuracy of
 Roemer et al.

were overestimated and 12 underestimated. 0.53) signal alterations on contrast-enhanced

In two cases, overscoring by two grades on
the proton density–weighted fat-suppressed
images was observed. Overall agreement
for the internal fat pad signal alterations was
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images. The correlation for the unenhanced
images and summed peripatellar synovial
thickness was lower, having coefficients of
0.34 (superior edge) and 0.29 (internal fat

Fig. 1—56-year-old woman with osteoarthritis
and acute nontraumatic knee pain. Example of
peripatellar synovial thickness measurements.
Sagittal T1-weighted contrast-enhanced MR image
with anterior cruciate ligament ideally depicted in its
full length. Measurement locations are 0.5 cm cranial
to superior patellar pole (black arrow), 1 cm cranial to
the femoral osteochondral junction (arrowhead), and
1 cm caudal to inferior patellar pole (white arrow).
62% (31 cases). The proton density–weight-
ed fat-suppressed images for internal fat pad
signal changes were overestimated by one
grade in 13 cases and underestimated by
one grade in one case. In five cases the pro-
ton density–weighted fat-suppressed images
were overscored by two grades (Fig. 2). Test-
ing the diagnostic performance of the signal
changes in Hoffa’s fat pad on unenhanced
images for the detection of active inflam-
mation within the fat pad using the contrast-
enhanced sequence as a reference standard,
high sensitivity was achieved, but specificity
was low (Table 1).
Signal Alterations in Hoffa’s Fat Pad and
Peripatellar Synovial Thickness
Moderate-to-good correlation was found
for the summed thickness scores and supe-
rior-edge (ρ = 0.60) and internal fat pad (ρ =
pad) (Table 2). Nevertheless, all correlation
coefficients were statistically significant.
The testing of the diagnostic performance
of signal changes in Hoffa’s fat pad on unen-
hanced images for the detection of synovitis
using the summed synovial thickness scores
on the contrast-enhanced sequence as a ref-
erence standard showed high sensitivity and
low specificity (Table 3).
Discussion
We compared semiquantitative scoring
of unenhanced and contrast-enhanced MR
images in the assessment of patellofemo-
ral joint synovitis in osteoarthritic knees
with contrast-enhanced MRI as the refer-
ence standard [4, 5, 10]. We also analyzed
possible correlations between signal alter-
ations in Hoffa’s fat pad and peripatellar
synovial thickening.

the signal alterations on unenhanced images in the

detection of synovitis using the summed scores of
peripatellar thickness as a reference. All statistical
analyses were performed with SAS software (version
9.1 for Microsoft Windows, SAS Institute).

Results
Of the 50 patients selected, 31 were women
and 19 were men. The mean age was 65.2 ±
9.37 (SD) years.

Signal Alterations in Hoffa’s Fat Pad:

Unenhanced Versus Contrast-Enhanced
Imaging
Low-to-moderate agreement of unenhanc­
ed and contrast-enhanced imaging was ob-
served with weighted kappa values of 0.35
for signal alterations in the superior edge of A B
Hoffa’s fat pad and 0.45 for internal signal Fig. 2—67-year-old man with osteoarthritis of the knee. Example of overestimation of possible synovitis with
alterations in the fat pad. Overall percentage proton density–weighted unenhanced fat-suppressed MRI.
agreement for superior-edge signal intensity A, Sagittal proton density–weighted unenhanced fat-suppressed MR image shows grade 2 superior-edge
signal alteration (arrows) and grade 2 internal fat pad signal alteration (arrowheads).
alterations was 44% (22 cases). Disagree- B, Sagittal T1-weighted fat-suppressed contrast-enhanced MR image shows discrete grade 1 superior-edge
ment of one grade was found in 26 cases: 14 signal alteration (mild enhancement) (arrow) and grade 0 internal fat pad signal alteration (no enhancement).

TABLE 1: Agreement and Diagnostic Performance of Signal Alterations in Hoffa’s Fat Pad on Unenhanced Images
With Signal Alterations on T1-Weighted Contrast-Enhanced Images, the Reference Standard
Feature on Proton Density– No. of Findings
Weighted Fat-Suppressed Fast Sensitivity Specificity Accuracy Agreement
Spin-Echo Images True-Positive True-Negative False-Positive False-Negative (%) (%) (%) (Weighted κ)
Superior-edge signal alterations 29 5 9 7 80 36 68 0.35 (0.17–0.53)
Internal fat pad signal alterations 38 3 9 0 100 25 82 0.45 (0.26–0.65)
Note—Values in parentheses are 95% CIs.

1698 AJR:192, June 2009

 MRI of Patellofemoral Synovitis
TABLE 2: Peripatellar Summed Synovial Thickness and Its Association With
Signal Alterations in Hoffa’s Fat Pad
Comparison of Features ρ p
Proton density–weighted fat-suppressed fast spin-echo sequence
  Synovial thickness and superior-edge signal alterations 0.34 0.02
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  Synovial thickness and internal fat pad signal alterations 0.29 0.04
T1-weighted fat-suppressed contrast-enhanced sequence
  Synovial thickness and superior-edge signal alterations 0.60 < 0.001
  Synovial thickness and internal fat pad signal alterations 0.53 < 0.001
Note—Statistical significance was defined as p < 0.05.
TABLE 3: Diagnostic Performance of Signal Alterations in Hoffa’s Fat
Pad on Unenhanced Images With the Reference Standard of
Summed Peripatellar Synovial Thickness Measured on
T1-Weighted Fat-Saturated Contrast-Enhanced Images
Feature on Proton No. of Findings
Density–Weighted
Fat-Suppressed Fast True- True- False- False- Sensitivity Specificity Accuracy
Spin-Echo Images Positive Negative Positive Negative (%) (%) (%)
Superior-edge 25 8 13 4 86 38 66
signal alterations
Internal fat pad 28 2 19 1 97 10 60
signal alterations
In several studies [6, 20, 22, 25] investi- visualization of high signal intensity within
gators have used semiquantitative scoring of the fat pad despite the presence of synovitis
signal alterations in Hoffa’s fat pad on unen- [23]. The most important is nonspecific ede-
hanced sagittal fat-suppressed images as a ma, which can be attributed to minor trau-
surrogate for regional or global synovitis in ma and even daily activities such as kneeling
osteoarthritis. Most of these investigators re- or be a manifestation of generalized edema.
fer to work by Fernandez-Madrid et al. [2], Another reason may be previous synovitis
who reported that signal alterations in the fat or Hoffa’s disease, which may not cause en-
pad correspond histologically to mild chron- hancement if no active inflammation is pres-
ic inflammation. In that study, unenhanced ent at the time of imaging. However, high
T1-weighted sequences and 3D T2-weight- signal intensity on proton density–weighted
ed gradient-echo imaging were used. To our fat-suppressed images, representing fibro-
knowledge, no other data correlate signal al- sis or scarring, may be persistently visual-
terations in Hoffa’s fat pad on unenhanced ized. Underestimation of signal alterations in
MR images with histologic findings. Hoffa’s fat pad on proton density–weighted
When comparing signal alterations ob- fat-suppressed images compared with con-
served at the superior edge of the fat pad and trast-enhanced images can be explained by
in the internal region of Hoffa’s fat pad, we better visualization of signs of synovitis on
found fair to moderate agreement between contrast-enhanced images.
enhanced and unenhanced images. With the We further assessed the correlation be-
contrast-enhanced sequence as the reference tween signal alterations in Hoffa’s fat pad
standard for active inflammation within the (superior edge and interior) and peripatellar
fat pad, signal alterations were often over- synovitis reflected in the summed synovial
estimated on the unenhanced images, espe- thickness scores. The correlations were mod-
cially in scoring of the intercondylar region. erate but statistically significant for all asso-
These results suggest that high signal inten- ciations of thickness and signal alterations.
sity in Hoffa’s fat pad, especially when it is Consistently higher correlations were found
only low grade, is a nonspecific finding. for contrast-enhanced assessments compared
The posterior and superior surfaces and with unenhanced proton density–weighted
the clefts of Hoffa’s fat pad are lined with fat-suppressed sequence assessments. Con-
synovium, but there are several reasons for trast enhancement within the fat pad may
AJR:192, June 2009 1699
represent an inflammatory reaction concom-
itant with peripatellar synovial thickening.
Assessment of the diagnostic performance
of signal alterations in Hoffa’s fat pad in the
detection of true patellofemoral joint synovi-
tis with peripatellar synovial thickness mea-
surements as the reference standard shows
high sensitivity but low specificity.
Several limitations of our study are worth
noting. First, semiquantitative scoring of pa-
tellofemoral knee synovitis on contrast-en-
hanced images should probably be performed
not only on sagittal but also on axial imag-
es [11, 26]. We did not acquire axial images
because we wanted to compare signal altera-
tions scored in the sagittal plane. Restraints of
time and cost allowed only one sequence after
contrast administration. Although histologic
findings were not available for comparison of
our findings, the findings in the literature on
synovitis in rheumatoid arthritis and osteo-
arthritis support contrast-enhanced MRI as a
reliable and well-accepted tool for assessment
of syno­vitis [1, 4, 10]. Treatment might have
influenced the degree of synovitis observed,
but information on treatments was not avail-
able to us. However, this factor should not
have affected the associations we analyzed.
With the contrast-enhanced sequence as the
reference standard for signal alterations in the
fat pad, the results with unenhanced sequenc-
es yielded high sensitivity but low specificity
in the detection of active inflammation within
the fat pad. A similar result was observed for
the diagnostic performance of signal altera-
tions in the detection of patellofemoral joint
synovitis with peripatellar synovial thickness
as the reference standard. In interpretation of
these findings, the difficulty of semiquantita-
tive differentiation from low-grade synovial
thickening on contrast-enhanced images has
to be considered in all cases. Nonpatholog-
ic synovial tissue may also become discrete-
ly enhanced after contrast administration [27,
28]. Pathologic correlation studies are need-
ed to better establish a cutoff between normal
and pathologic enhancement.
We found that agreement between scoring
of signal alterations in Hoffa’s fat pad on un-
enhanced and contrast-enhanced images was
fair to moderate. We also found that signal
alterations in Hoffa’s fat pad at proton densi-
ty–weighted unenhanced fat-suppressed
MRI are a nonspecific finding because active
inflammation in the fat pad is likely to be
overestimated on unenhanced images. We
found only moderate but significant correla-
tions of signal alterations in Hoffa’s fat pad

with peripatellar synovial thickness mea-
sured on sagittal T1-weighted fat-suppressed
images. The correlations were higher for the
enhanced images. With peripatellar synovial
thickness measurements as the reference
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standard for synovitis, high sensitivity and
low specificity were found for signal altera-
tions on unenhanced images.
On the basis of the data in this study, we
believe that reliable semiquantitative scoring
of patellofemoral synovitis in osteoarthritis
should ideally be performed with contrast-
enhanced T1-weighted images, including
peripatellar synovial thickness measure-
ments, because signal alterations in Hoffa’s
fat pad detected on unenhanced images are
not ideal surrogates.
Acknowledgments
We thank Ulf Wolkenstein, Klinikum
Augsburg, for technical support and for pre-
paring the image data for analysis.
We thank Holger Toepfer and Martin
Strauswald, both of Klinikum Augsburg, for
help in validating the scoring system.
We thank John Lynch, University of Cali-
fornia San Francisco, for development of the
electronic score sheet.
References
1. Loeuille D, Chary-Valckenaere I, Champigneulle
J, et al. Macroscopic and microscopic features of
synovial membrane inflammation in the osteoar-
thritic knee: correlating magnetic resonance im-
aging findings with disease severity. Arthritis
Rheum 2005; 52:3492–3501
2. Fernandez-Madrid F, Karvonen RL, Teitge RA,
Miller PR, An T, Negendank WG. Synovial thick-
ening detected by MR imaging in osteoarthritis of
the knee confirmed by biopsy as synovitis. Magn
Reson Imaging 1995; 13:177–183
3. Lindblad S, Hedfors E. Arthroscopic and immu-
nohistologic characterization of knee joint syno-
vitis in osteoarthritis. Arthritis Rheum 1987; 30:
1081–1088
4. Ostergaard M, Stoltenberg M, Lovgreen-Nielsen
P, Volck B, Jensen CH, Lorenzen I. Magnetic res-
onance imaging-determined synovial membrane
and joint effusion volumes in rheumatoid arthritis
and osteoarthritis: comparison with the macro-
scopic and microscopic appearance of the syno­
vium. Arthritis Rheum 1997; 40:1856–1867
5. Grainger AJ, Rhodes LA, Keenan AM, Emery P,
Conaghan PG. Quantifying peri-meniscal syno­
vitis and its relationship to meniscal pathology in
osteoarthritis of the knee. Eur Radiol 2007; 17:
119–124
1700 AJR:192, June 2009
Roemer et al.
6. Hill CL, Gale DG, Chaisson CE, et al. Knee effu-
sions, popliteal cysts, and synovial thickening:
association with knee pain in osteoarthritis. J
Rheumatol 2001; 28:1330–1337
7. Baker KR, Grainger A, Niu J, et al. Synovitis is
associated with knee pain in those without x-ray
OA. (abstract) Arthritis Rheum 2007; 56[suppl]:
S123
8. Ayral X, Pickering EH, Woodworth TG, Mackil-
lop N, Dougados M. Synovitis: a potential predic-
tive factor of structural progression of medial
tibiofemoral knee osteoarthritis—results of a 1
year longitudinal arthroscopic study in 422 pa-
tients. Osteoarthritis Cartilage 2005; 13:361–367
9. Pelletier JP, Martel-Pelletier J, Abramson SB. Os-
teoarthritis, an inflammatory disease: potential
implication for the selection of new therapeutic
targets. Arthritis Rheum 2001; 44:1237–1247
10. Ostergaard M, Hansen M, Stoltenberg M, et al.
Magnetic resonance imaging-determined syno­
vial membrane volume as a marker of disease ac-
tivity and a predictor of progressive joint destruc-
tion in the wrists of patients with rheumatoid
arthritis. Arthritis Rheum 1999; 42:918–929
11. Rhodes LA, Grainger AJ, Keenan AM, Thomas
C, Emery P, Conaghan PG. The validation of
simple scoring methods for evaluating compart-
ment-specific synovitis detected by MRI in knee
osteoarthritis. Rheumatology (Oxford) 2005; 44:
1569–1573
12. Clunie G, Hall-Craggs MA, Paley MN, et al.
Measurement of synovial lining volume by mag-
netic resonance imaging of the knee in chronic
synovitis. Ann Rheum Dis 1997; 56:526–534
13. Ostergaard M, Ejbjerg B, Stoltenberg M, et al.
Quantitative magnetic resonance imaging as
marker of synovial membrane regeneration and
recurrence of synovitis after arthroscopic knee
joint synovectomy: a one year follow up study.
Ann Rheum Dis 2001; 60:233–236
14. Peterfy CG, Guermazi A, Zaim S, et al. Whole-
organ magnetic resonance imaging score
(WORMS) of the knee in osteoarthritis. Osteoar-
thritis Cartilage 2004; 12:177–190
15. Roemer FW, Guermazi A, Hunter DJ, et al. The
association of meniscal damage with joint effu-
sion in persons without radiographic osteoarthri-
tis: the Framingham and MOST osteoarthritis
studies. Osteoarthritis Cartilage 2008 Oct 17
[Epub ahead of print]
16. Ostergaard M, Stoltenberg M, Lovgreen-Nielsen
P, Volck B, Sonne-Holm S, Lorenzen I. Quantifi-
cation of synovitis by MRI: correlation between
dynamic and static gadolinium-enhanced mag-
netic resonance imaging and microscopic and
macroscopic signs of synovial inflammation.
Magn Reson Imaging 1998; 16:743–754
17. Collidge TA, Thomson PC, Mark PB, et al. Gado-
linium-enhanced MR imaging and nephrogenic
systemic fibrosis: retrospective study of a renal
replacement therapy cohort. Radiology 2007;
245:168–175
18. Sadowski EA, Bennett LK, Chan MR, et al. Neph-
rogenic systemic fibrosis: risk factors and inci-
dence estimation. Radiology 2007; 243:148–157
19. Murphy KP, Szopinski KT, Cohan RH, Mermil-
lod B, Ellis JH. Occurrence of adverse reactions
to gadolinium-based contrast material and man-
agement of patients at increased risk: a survey of
the American Society of Neuroradiology Fellow-
ship Directors. Acad Radiol 1999; 6:656–664
20. Hunter DJ, Lo GH, Gale D, Grainger AJ, Guer-
mazi A, Conaghan PG. The development and reli-
ability of a new scoring system for knee osteoar-
thritis MRI: BLOKS (Boston Leeds osteoarthritis
knee score). Ann Rheum Dis 2008; 67:206–211
21. Kornaat PR, Ceulemans RY, Kroon HM, et al.
MRI assessment of knee osteoarthritis: knee os-
teoarthritis scoring system (KOSS)—inter-ob-
server and intra-observer reproducibility of a
compartment-based scoring system. Skeletal Ra-
diol 2005; 34:95–102
22. Hill CL, Hunter DJ, Niu J, et al. Synovitis detect-
ed on magnetic resonance imaging and its relation
to pain and cartilage loss in knee osteoarthritis.
Ann Rheum Dis 2007; 66:1599–1603
23. Saddik D, McNally EG, Richardson M. MRI of
Hoffa’s fat pad. Skeletal Radiol 2004; 33:433–
444
24. Altman R, Asch E, Bloch D, et al. Development of
criteria for the classification and reporting of os-
teoarthritis: classification of osteoarthritis of the
knee. Diagnostic and Therapeutic Criteria Com-
mittee of the American Rheumatism Association.
Arthritis Rheum 1986; 29:1039–1049
25. Tarhan S, Unlu Z. Magnetic resonance imaging
and ultrasonographic evaluation of the patients
with knee osteoarthritis: a comparative study.
Clin Rheumatol 2003; 22:181–188
26. Pelletier JP, Abram F, Martel-Pelletier J. Magnetic
resonance imaging (MRI) allows for precise and
reliable assessment of synovial membrane thick-
ness in knee OA patients. (abstract) Osteoarthritis
Cartilage 2007; 15[suppl C]:C183–C184
27. Ejbjerg B, Narvestad E, Rostrup E, et al. Mag-
netic resonance imaging of wrist and finger joints
in healthy subjects occasionally shows changes
resembling erosions and synovitis as seen in rheu-
matoid arthritis. Arthritis Rheum 2004; 50:1097–
1106
28. Partik B, Rand T, Pretterklieber ML, Voracek M,
Hoermann M, Helbich TH. Patterns of gadopen-
tetate-enhanced MR imaging of radiocarpal joints
of healthy subjects. AJR 2002; 179:193–197