INTERVENTIONAL PROCEDURES IN

MUSCULOSKELETAL RADIOLOGY I1 0033-8389/98 $8.00 + .OO

KNEE ARTHROGRAPHY
Evolution and Current Status

James M. Coumas, MD, and William E. Palmer, MD

The knee is one of the most functionally
complex and commonly injured joints. In ad-
dition to traumatic injuries, the knee is fre-
quently affected by inflammatory processes,
systemic disorders, and neoplasm. Develop-
mental and congenital abnormalities may also
afflict the knee. Long before the availability
of CT and MR imaging, conventional arthrog-
raphy was performed to evaluate the joint
capsule and other intra-articular structures.
Today, the most powerful diagnostic tech-
niques combine CT and MR imaging with
arthrography.
Arthrography is derived from the Greek
words artkros (joint) and gvapkie (to write or
record), which taken together imply the
drawing or delineation of the joint. A multi-
tude of contrast media have been utilized to
image the knee joint with reports dating back
to 1905.95Early iodinated contrast media
proved too toxic and water-soluble contrast
media was subsequently introduced in the
1940s. Single-contrast examinations were ini-
tially utilized in which the entire joint recess
was filled providing a positive relief to the
joint cavity. Once intra-articular structures
were outlined by contrast material, diagnostic
emphasis was centered on the evaluation of
menisci, articular cartilage, loose bodies, and
synovial capsule. Double-contrast arthrogra-
phy was soon to follow, providing a thin ra-
diopaque coating contrasted by air- or gas-
distended joint cavities. Double-contrast knee
arthrography proved to be the radiologic pro-
cedure of choice for evaluation of menisci
over the subsequent two decades. Progressive
improvements in contrast media, fluoroscopic
equipment, and diagnostic techniques led to
reported accuracies of 90% or better for the
evaluation of meniscal tears.33Although ex-
aminer-dependent, the fine art of knee
arthrography was optimized so as to evaluate
extrameniscal abnormalities, such as articular
cartilage defects, loose bodies, anterior cruci-
ate tears, synovitis, and joint degeneration. Its
greatest limitation was its inability to evaluate
extrasynovial structures about the knee. For a
complete understanding and review of single-
and double-contrast knee arthrography, excel-
lent texts authored by Freiberger and Faye37
and Goldman4*are recommended.
Tomographic imaging techniques were fre-
quently combined with arthrography. Plain
tomography performed after knee arthrogra-
phy was first used in the evaluation of articu-
lar cartilage defects but was soon replaced by

~ ~ ~

From Charlotte Radiology, Charlotte; and the Department of Radiology, Carolinas Medical Center (JMC), Charlotte,
North Carolina; and Bone and Joint Radiology, Massachusetts General Hospital (WEP), Boston, Massachusetts

RADIOLOGIC CLINICS OF NORTH AMERICA

VOLUME 36 * NUMBER 4 JULY 1998 703

704 COUMAS & PALMER
CT due to a marked improvement in ana-
tomic delineation, contrast resolution, and vi-
sualization of extrasynovial soft tissues. CT
(unenhanced) and CT arthrography of the
knee were evaluated intermittently between
1978 and 1987.3,21, 63, M, 76 Promising early re-
sults by Passariello et aln suggested conven-
tional unenhanced CT of the knee may be
competitive with arthrography for the diag-
nosis of meniscal tears. Blinded studies by
Steinbach et alB8were less optimistic and
showed variable sensitivities and accuracies
dependent Dn instrumentation utilized.
Manco et aP4 corroborated accuracy rates of
91.5% for meniscal tears utilizing unenhanced
CT of the knee.
The rapid evolution and acceptance of knee
MR imaging limited the development of CT
as an important tool for assessing intra-articu-
lar abnormalities of the knee. At present, MR
imaging is the dominant noninvasive imaging
technique currently available for evaluation
of the knee. Superior soft tissue discrimina-
tion, superb spatial resolution, multiplanar
capabilities, noninvasive nature, and lack of
ionizing radiation have combined to limit sin-
gle-contrast arthrography to the evaluation
of joints with metal prostheses for loosening,
wear, or infection, or patients in whom MR
imaging is contraindicated. Prior to the ad-
vent of open-bore magnets, patients too large
to be evaluated by standard 60-cm bores were
also forced to undergo single- or double-con-
trast arthrographic examinations. In the rural
or community hospital setting, arthrography
of the knee may be rarely performed to docu-
ment preoperative meniscal abnormalities
principally due to unavailability of MR im-
aging equipment or cost containment.
Currently, MR imaging is the most com-
monly performed radiologic test in the assess-
ment of intra-articular knee abnormalities.
Posttraumatic prearthroscopic MR imaging
evaluation, although initially controversial,
has proved to be cost-effe~tive.'~Although
arthroscopy has revolutionized the diagnosis
and treatment of knee disorders, most ortho-
pedists acknowledge the invasiveness of the
procedure; limitations in evaluation of extra-
articular pathology; cost, and, albeit uncom-
mon, potential complications associated with
the procedure. They are receptive to accurate
diagnostic imaging complementing their clin-
ical evaluation and providing a global intra-
articular and extra-articular assessment of the
knee. Clinicians utilize MR imaging to sup-
port nonsurgical management or to confirm
injuries that benefit from arthroscopic or open
surgical treatment. Technical improvements
in arthroscopic instrumentation have paral-
leled the technical advances in MR imaging
and have expanded the surgical procedures
now performed by arthroscopy. Although it
is the clinical assessment that determines
therapy, the MR imaging examination com-
plements arthroscopy by providing a nonin-
vasive, painless, and morbidity-free modality
for accurate preoperative anatomic assess-
ment that is well accepted by patients.
MENISCI
Conventional Arthrography
In experienced hands, the technique of
double-contrast arthrography has shown ac-
curacy that approaches 99% for medial menis-
cal tears and 93% for lateral meniscal tears?,
32* ss, 90 Unfortunately, these results have not
been universal because the technique is sig-
nificantly operator-dependent. False-positive
rates of 7% have been Double-con-
trast arthrographic evaluation of anterior cru-
ciate ligament tears has shown accuracies as
low as 50Y0.~~ Multiple studies comparing the
diagnostic accuracy of arthrography to
arthroscopy for the evaluation of menisci
have been perf~rmed.~, 32, 5s, The accuracy
rate for arthrography was equal or superior
to that of arthroscopy in several large studies.
ThijngOreported accuracy rates of 93% and
86%, respectively, for arthrography and
arthroscopy in a series of 367 patients. Similar
results were published by Dumas and Edde.32
Some of these studies noted that arthroscopy
was limited in the evaluation of posterior and
peripheral tears involving the medial joint
compartment and arthrography showed a
high false-negative result in the evaluation
of edge (meniscal apex) tears. Together, each
technique was complementary with overall
accuracy rates of 97%.

Figure 1. Unenhanced CT of meniscus. Axial 1.5-mrn-
thick CT section through normal lateral meniscus
(arrows). No discontinuity or change in attenuation was
noted.
CT
Conventional CT without enhancement has
been utilized for the evaluation of menisci,
osteochondritis, cruciate, and collateral liga-
ment injury, as well as capsular ligamentous
lesions of the knee joint.76Osteochondral
loose bodies and osteochondral fractures
about the knee can also be evaluated by this
technique. Accuracy rates in the evaluation of
meniscal injury by conventional CT have
been reported at 89% for the medial meniscus
and 96% for the lateral meniscus (Fig. 1).T7
Higher accuracy rates have been reported in
patients with associated ligamentous or cap-
sular injury. This finding may suggest a
higher incidence of significant morphologic
change in the configuration of the meniscus
with concomitant ligamentous or capsular in-
jury. The experience is, however, very limited
and operator-dependent.
Limitations of conventional CT in screening
for meniscal injury include motion artifact,
suboptimal examination due to hemarthrosis
or thrombus, poor evaluation of horizontal
cleavage tears of the meniscus, as well as
poor evaluation of the meniscocapsular junc-
tion and nondispl-aced peripheral tears. Ab-
normal intrameniscal attenuation or meniscal
degeneration can be misinterpreted as a
meniscal tear. Finally, the cost of conventional
CT at most institutions exceeds that of
arthrography.
CT arthrography of the knee for the evalua-
KNEE ARTHROGRAPHY 705
tion of meniscal injury was compared with
double-contrast arthrography by Ghelman.4I
Due to the high sensitivity of double-contrast
arthrography in the evaluation of meniscal
tears, high-resolution CT arthrography of the
knee did not improve sensitivity or accuracy
in this limited study. The resolution of the
meniscal tear, the degree of meniscal fraying,
irregularity, and evaluation of the meniscal
apex was improved by the elimination of
overlying superimposed structures. CT
arthrography for meniscal assessment today
is reserved for patients with contraindications
to MR imaging evaluation or those patients
who may be severely claustrophobic or too
large to be accommodated by conventional
MR imaging bore size (Fig. 2). The progres-
sive deployment of open-bore MR imaging
magnets will eventually accommodate these
individuals.
MR Imaging
MR imaging of menisci has been shown to
be more sensitive, specific, and accurate in the
evaluation of meniscal tears when compared
with conventional single- or double-contrast
arthrography. It is the negative predictive
value of MR imaging that has taken on a
greater significance in clinical medicine. Pre-
viously, when single- or double-contrast con-
ventional arthrography did not correlate with
the clinical examination, the orthopedic sur-
geon was very likely to perform arthroscopy.
The very high negative predictive value of
MR imaging, however, makes the likelihood
of missing a clinically significant meniscal
tear unlikely and may redirect the clinical
examination and foster conservative manage-
ment. False-positive MR imaging findings
may be attributable to errors in radiologic
interpretation or suboptimal arthroscopy but
more typically are due to significant intrasub-
stance tears that do not extend to the menis-
cal surface. This difference can be partially
overcome by maintaining good lines of com-
munication between the radiologist and the
orthopedic surgeon who can then pursue ag-
gressive probing of localized areas at the time
of arthroscopy. Nevertheless, in those cases
where no irregularity of the rneniscal surface
706 COUMAS & PALMER

Figure 2. CT arthrography of knee meniscus. A, Anteroposterior (AP) scout radiograph shows

extensive internal fixation of the femur which obscured images of menisci when MR imaging was
attempted. B, CT arthrogram shows a tear at the apex of the anterior horn lateral meniscus (arrow).
Despite thin axial sections (1.5 mm), it is difficult to encompass entire meniscus on a single image.

is perceived, or no evidence of scar or granu- comes more important in the presence of a

lation tissue is noted at the time of arthros-
copy, the determination of a clinically signifi-
cant intrasubstance tear (also referred to as a
delaminating injuvy) can be difficult.
False-positive findings in the past have
been attributable to normal variants that, with
experience and improved resolution, have be-
come less problematic. A recent study has
shown little difference in the accuracy of
meniscal tear evaluation when comparing
mid field strength (0.5 T) and high field
strength (1.5 T) MR imaging units.4 Mid field
strength MR imaging units compensate for
the lower signal-to-noise ratio by increasing
the number of acquired signals or data.82This
increase in scan time has to some degree been
compensated for by new fast scan techniques.
Meniscal tears are defined as abnormal in-
trameniscal signal that extends to the articu-
lating surface of the meniscus or abnormal
meniscal morphology. Controversies in inter-
pretation may arise as to whether intramenis-
cal pathology extends to the surface or is
complicated by an overlying layer of granula-
tion tissue. Our own experience parallels that
of most studies in which the proton spin im-
joint effusion, which is referred to as creating
an arthrographic e f l e ~ t DeSmet
.~~ et alZ have
shown that the accuracy in detection of
meniscal tears is improved when abnormal
signal is seen to extend to the articulating
surface of the meniscus on multiple contigu-
ous sections or in multiple imaging planes.
Possible tears or questionable extension of
abnormal signal to the articulating meniscal
surface when only viewed in a single image
in only one plane is not reported as a tear in
our practice.
Accuracy rates for multiple studies have
been well summarized by Bonamo and Sap-
erstein: with mean accuracy rates of 92% for
both medial and lateral menisci. Missed
meniscal tears (false-negative readings) more
frequently involve the posterior horn of the
lateral meniscus.23 False-negative and false-
positive readings are of equal frequency in
the medial meniscus. Multiple large studies
have confirmed the reliability of abnormal
meniscal detection by MR imaging with sen-
sitivities of 92% to 97% for the medial menis-
cus and 92% to 94% for the lateral meniscus.'s,
53, 70 Despite these excellent results, 10% to

ages are found best for meniscal evaluation 12% of cases with abnormal signal extending
and TZweighed or T2*-weighted imaging be- to the meniscal articular surface are not con-
 KNEE ARTHROGRAPHY 707

firmed at arthros~opy.~~ This discrepancy may

represent old injury and subsequent healed
scar or a true meniscal tear not visualized at
arthroscopy. Utilizing second-look arthros-
copy in a retrospective review of 32 patients
treated nonsurgically for meniscal tears
showed 65% of longitudinal meniscal tears
and 17% of radial meniscal tears healed spon-
tane0usly.9~A native joint effusion or saline
or gadolinium arthrogram may prove helpful
in distinguishing spontaneously healed tears
from persistent or recurrent tears. Despite
limitations in clinical assessment of the trau-
matized patient, orthopedists have reported
overall accuracy rate of their clinical examina-
tion alone at between 70% and 75?'0.~ MR
imaging remains more accurate than the clini-
cal examination in the diagnosis of meniscal
tears, regardless of whether an isolated
meniscal injury or associated anterior cruciate
ligament injury exists.36

Postoperative Menisci Figure 3. Postoperative meniscus with conventional MR

As the number of arthroscopic meniscal re-
sections and repairs increase, the percentage
of postoperative knee evaluations increases.
The postoperative knee is clinically more dif-
ficult to evaluate and the young population
more prone to reinjury. This is the very popu-
lation for which the clinicians rely on an accu-
rate MR imaging evaluation to correlate with
the clinical examination. Postoperative partial
meniscectomy or meniscal repair display con-
ventional MR imaging criteria for a meniscal
tear. Abnormal signal extending to the menis-
cal articulating surface and abnormal mor-
phology are usually both present (Fig. 3). No
imaging criteria have helped in the differenti-
ation of postoperative meniscal change from
a persistent retained or a recurrent meniscal
tear.
The evaluation of postoperative meniscal
resection utilizing conventional MR imaging
sequences and estdblished criteria for menis-
cal tear by Deutsch et alZ7showed good corre-
lation with arthroscopy when less than 25%
of the meniscus had been resected. If trunca-
tion of the meniscal apex was excluded, accu-
racy of retear was reported at When
25% to 75% of the meniscus had been resected
imaging. Sequential sagittal proton density-weighted im-
ages (TFVTE of 2000/20).A, Abnormal morphology to the
superior articulating surface of the posterior horn medial
meniscus in a patient with prior partial meniscectomy
(arrow). 6,Abnormal intrameniscal signal that does ex-
tend to the superior and inferior articulating meniscal sur-
faces seen on multiple adjacent images (curved arrow).
At arthroscopy, no tear was noted; this was felt to repre-
sent postoperative meniscal conversion and scar.
utilizing conventional criteria, the accuracy
fell to 64%. This group represents the largest
subset of patients having undergone partial
meniscectomy. An increase in the T2-
weighted signal intensity within the meniscus
was noted to be an indicator of retear within
this population. Utilizing this criteria, an ac-
curacy of approximately 85% was reported in
menisci that had undergone more than 75%
resection. Similar results were noted in a
study by Smith and Totty.86When more
than 75% of the meniscus has been resected,
it is unlikely that a small, oblique tear or
recurrent tear at the surgical resection site
produces mechanical instability and a clini-
cally significant lesion. In these cases, the
presence of an unstable meniscal fragment of
the remnant meniscus can be excluded and
secondary posttraumatic degenerative
708 COUMAS & PALMER

Figure 4. Postoperative partial meniscectomy of the lateral meniscus in a professional female

basketball player. A, Coronal proton density-weighted image ( T W E of 3983/40)shows
arthrographic effect of a joint effusion (arrowhead) with small remnant of posterior horn lateral
meniscus (brig straight arrow), full thickness articular cartilage defect (smaW arrows) and
abnormal intrasubstance change to articular cartilage (white arrow). Note absent marrow
edema. 6, Coned-down view shows overhanging margin of articular cartilage (arrow), large
articular defect (small arrows), and dense subchondral reactive sclerosis and condensation
of trabeculae caused by secondary degenerative arthritis.

change, loose body, or progressive articular
cartilage damage is frequently documented
(Fig. 4).
Meniscal Repair
Evaluation of postoperative meniscal repair
parallels the findings in partial meniscal re-
section with abnormal MR imaging signal ex-
tending to the articular surface of the repair
in asymptomatic individuals who, at arthrog-
raphy or arthroscopy, show no evidence of
retear.12,14, 34, 78 Surgical failure rates as high as
35% have been reported for meniscal repair
in the unstable knee.2oConventional MR im-
aging criteria for retear are not reliable. Per-
sistent abnormal meniscal signal extending to
the meniscal articular surface (grade 3 signal)
has been documented 27 months after sur-
gery in healed menisci and is referred to as
meniscal conversion.28,35 Detection of a dis-
placed or free meniscal fragment with intra-
vasation of fluid on T2-weighted sequences
into the defect is more reliable and specific for
retear in the postoperative meniscus. Farley et
a134concluded that conventional arthrography
is more accurate than conventional MR im-
aging in the postoperative knee for evaluation
of meniscal retear. The intravasation of con-
trast material into the repaired meniscal tear
was specific for incomplete healing or retear
at arthrography.
The arthrographic effect of a native joint
effusion on conventional T2-weighted MR
imaging studies improved detection of recur-
rent tear in only 56Y0.~ The positive predictive
value was, however, 90% for the evaluation
of recurrent tears when joint fluid was seen
tracking into the tear? The accuracy of the
arthrographic effect can be improved with
saline instillation and T2 weighting. The in-
creased volume load, distention of the joint
recess and capsular margins, increased hydro-
static pressure, as well as a diminished viscos-
ity of the effusion, when present, all foster
intravasation of fluid into the tear.
The introduction of gadolinium arthrogra-
phy provides, in addition to the aforemen-
tioned benefits of saline arthrography, an
improvement in resolution associated with
T1-weighted sequences as well as the ability
to differentiate between intrameniscal con-
trast (gadolinium) and fibrovascular change
 KNEE ARTHROGRAPHY 709

or granulation tissue within the meniscus. In

a comparison of conventional MR imaging
and gadolinium MR arthrography for the
evaluation of recurrent meniscal tears,
Applegate et a12 found no significant im-
provement in accuracy for the detection of
tears when a meniscal repair or partial resec-
tion involved less than 25% of the meniscus.
In the more typical scenario of 25% to 75%
involvement of meniscal resection or repair, a
significant improvement in overall accuracy
from 66% (conventional MR imaging) to 88%
(intra-articular gadolinium arthrogram) was
noted. The improvement in accuracy with
gadolinium arthrography was of greatest sig-
nificance when more than 75% of meniscal
resection or repair had occurred (Fig. 5).*
The intravenous administration of gadolin-
ium gadopentetate dimeglumine (Gd-DTPA)
or gadolinium tetra-azacyclododecanetetra-
acetic acid (Gd-DOTA) produces enhance-
ment of synovial fluid and demonstrates an
arthrographic effect on T1-weighted se-
q u e n c e ~ .96~Delayed
~, imaging is required be-
cause synovial fluid enhancement is time de-
pendent with peak enhancement obtained at Figure 5. Normal postmeniscectomychange in a 38-year-
30 minutes in the nonmobilized knee.31Knee old patient. A, After direct intra-articular administration of
mobilization hastens gadolinium concentra- gadopentetate dimeglumine, fat-suppressed T1-weighted
( T W E of 500/16) sagittal MR arthrogram through the
tion in the synovial fluid with a twofold in- medial compartment of the knee shows contrast solution
crease in effusion enhancement at 10 mi- outlining the posterior horn of the medial meniscus
n u t e ~Knee
. ~ ~ mobilization plays an important (straight arrow). The meniscus has mildly irregular con-
tour and increased signal intensity, but gadolinium does
role in producing a uniform enhancement of not leak into a focal defect. Healing tear and stable menis-
the joint effusion, an increase in the contrast cal remnant were verified at repeat arthroscopy. The ante-
concentration, and a diagnostic arthrographic rior horn is normal (curved arrow). Recurrent or residual
medial meniscal tear after partial arthroscopic resection
effect.96Mobilization may be most important in a 42-year-old patient. B, After direct intra-articular ad-
in patients with large pre-existing joint effu- ministration of gadopentetate dimeglumine, fat-sup-
sions. In the evaluation of meniscal tears by pressed T1-weighted (TRITE of 350115 ) sagittal M R
arthrogram through the medial compartment of the knee
conventional MR imaging, Drape et al3I shows contrast solution filling a vertical tear (black arrow)
showed that intravenous gadolinium allowed of the posterior horn of the residual medial meniscus.
for accurate interpretation in seven of eight The central meniscal fragment is diminished in height
following partial meniscectomy. At repeat arthroscopy, ex-
meniscal tears judged equivocal by conven- tensive meniscal resection was necessaty. Irregular carti-
tional MR imaging. To date, no large prospec- lage loss over the femoral condyle (white arrows) indi-
tive study has compared intra-articular MR cates degenerative change.
gadolinium arthrography with intravenous
gadolinium MR arthrography for the evalua-
tion of meniscal tears. meniscal injury are widely utilized and estab-
In the evaluation of meniscal tears, it must lished. Meniscal allograft transplantation is
also be noted that meniscal abnormalities and currently underway with fixation and posi-
tears do exist in the asymptomatic individual tioning of cadaveric meniscal allograft as-
with an increasing prevalence with increasing sessed by fast spin echo MR imaging tech-
age as documented by Kornick et al.56 At niques with good correlation at second-look
present, orthopedic resection and repair of arthros~opy.~~
710 COUMAS & PALMER
MR Arthrographic Technique
The MR arthrographic solution utilized for
injection into the knee is also suitable for
evaluation of the shoulder or any other joint.
The T1 relaxation time of this solution is de-
pendent on the concentration of gadolinium.
To optimize the paramagnetic effect on T1-
weighted images and, therefore, to maximize
its signal intensity, gadolinium formulations
currently marketed by pharmaceutical com-
panies must be diluted to a concentration of
2 mM.48
To obtain this concentration, 0.6 mL of Gd-
DTPA (Magnevist, Berlex Laboratories,
Wayne, NJ) or other gadolinium formulations
can be added to 100 mL of normal saline. In
a 35-mL syringe, 24 mL of this solution can
be mixed with 8 mL of lidocaine 1% (final
dilution ratio equals 1:250). After intra-articu-
lar position of the needle is documented with
a test injection of nonionic contrast material,
the gadolinium solution is administered until
the joint capsule becomes distended (approxi-
mately 20 to 30 mL in the knee). Single-con-
trast technique, in which fluid is injected
without gas, is necessary to avoid magnetic
susceptibility artifact on the MR images. Any
pre-existing joint effusion should be aspirated
to avoid excessive dilution of gadolinium.
MR imaging is initiated within 30 minutes
following arthrography to minimize the ab-
sorption of contrast solution and the loss of
capsular distention. The same dedicated coils
and imaging planes are used in both arthro-
graphic and conventional MR imaging. In MR
arthrography, the field of view may often be
decreased because the examination is directed
at the visualization of intra-articular struc-
tures, not extra-articular structures.
Following gadolinium injection, T1-weighted
spin echo pulse sequences take advantage of
the paramagnetic effect of gadolinium on T1-
relaxation time. They generate high signal-to-
noise ratio, excellent spatial resolution, and
contiguous images (interleaved acquisition)
within relatively short examination times. A
T2-weighted sequence is helpful in the identi-
fication of extra-articular fluid collections and
the characterization of incidental marrow le-
sions or periarticular masses.
Fat suppression is critical in MR arthrogra-
phy. Diagnostic difficulty may arise because
fat and gadolinium may have identical signal
intensities on T1-weighted images. Fre-
quency-selective fat suppression utilizes the
difference (chemical shift) in the precessional
frequencies of fat and water by applying a
presaturation pulse that is identical to the
precessional frequency of fat. Thus, fat sup-
pression decreases the signal from fat, pre-
serves the signal from the contrast solution,
and delineates the boundary between con-
trast solution and fat. Fat suppression also
minimizes chemical shift and truncation arti-
facts, which occur at the interface between
water and fat and can interfere with the eval-
uation of hyaline cartilage. Fat-suppressed
images, however, cannot completely replace
standard T1-weighted images because they
obscure juxta-articular fascia1planes and mar-
row abnormalities.
ARTICULAR CARTILAGE
Despite over a decade of experience in MR
imaging of the knee, there is considerable
controversy with regard to the radiologic as-
sessment of hyaline cartilage. Widespread
variation in sensitivities (30% to 100%) and
specificities (50% to 100%) are reported.49,50, 87
This variability has thus far been tolerated
to some degree by the orthopedic surgeons
because no clear consensus of orthopedic
treatment for chondral and osteochondral de-
fects exists. A plethora of MR imaging pulse
sequences including fat-saturated (intermedi-
ate) proton spin-weighted, two-dimensional
and three-dimensional spoiled gradient re-
called echo (SPGR), pulsed saturation trans-
fer, and magnetization transfer contrast se-
quences have all been reported as cartilage
sensitive or specific in the radiology litera-
ture. The orthopedic corollary includes mi-
crofracture technique, abrasion arthroplasty,
laser abrasion, osteochondral grafting, autolo-
gous chondrocyte implantation, and chondro-
protective drugs.’l These techniques have all
been reported treatment for chondral and 0s-
teochondral defects in the orthopedic litera-
ture. Praemer et alsonotes that approximately
95,000 total knee replacements in addition to
41,000 orthopedic procedures are performed

annually in the treatment or repair of osteo-
chondral abnormalities of the knee. This is
a vexing problem for both orthopedists and
rheumatologists because the articular carti-
lage is avascular with limited propensity for
healing or repair with conservative manage-
ment. A comprehensive review of each im-
aging pulse sequence or new and evolving
surgical and pharmacologic advancement is
beyond the scope of this article. At the knee,
osteochondral injuries most commonly in-
volve three specific sites, which are covered
in greater depth. Osteochondritis dissecans
(OCD) involving the femoral condyle, chon-
dromalacia patella, and focal condylar carti-
lage defects on a posttraumatic or degenera-
tive basis are reviewed.
OCD
OCD is a focal injury of the articular sur-
face characterized by separation of a segment
of the cartilage and the subchondral bone.
Although the etiology is unknown, trauma,
ischemia, abnormality of ossification, and ge-
netic predisposition have all been advanced
as possible etiologies. OCD is usually classi-
fied as either a juvenile form seen in children
between 5 and 15 years of age or the adult
form applied to occurrences after physeal fu-
sion.=
Plain film radiographs frequently show the
lesion, often requiring a tunnel or notch pos-
teroanterior radiograph when involving the
most common location at the junction of the
femoral notch and the weight-bearing medial
femoral condyle. In the past, conventional
arthrography was performed to evaluate the
integrity of the overlying articular cartilage.
Utilizing a modified Clanton and DeLee stag-
ing criteria, all grades 1 and 2 lesions were
missed and no comment on stability of the
underlying lesion was possible.16 CT alone
was of little utility in evaluating the articular
cartilage; however, CT arthrography is ex-
pected to evaluate the articular surface as
well as the subarticular lesion. The most com-
mon location of OCD in the knee, however,
does not lend itself to imaging in a plane
perpendicular to the lesion but rather tangen-
tially. This makes CT arthrography of limited
KNEE ARTHROGRAPHY 711
utility for OCD of the knee at its most com-
mon location.
Studies have documented high sensitivity
(92%) and specificity (goo/,) in establishing the
stability of the underlying cartilaginous bony
interface by MR imaging (Fig. 6)?*, Contro-
versy in accurately delineating the integrity
of the overlying articular cartilage was noted
with conventional MR imaging.68 Improve-
ment in accurately predicting the articular
cartilage involvement and appropriate stag-
ing of OCD lesions was shown by MR gado-
linium arthrography when compared with
conventional MR imaging with arthroscopy
as the gold standard.59* 89 OCD evaluation by
gadolinium arthrography with arthroscopic
documentation was found to be correct in
92.9% of patients with conventional spin echo
sequences and 100% of patients utilizing gra-
dient echo sequences.59
More recently, Loew et aP2 reported on in-
direct MR arthrography of the knee in pa-
tients with OCD. Patients were initially evalu-
ated utilizing conventional MR imaging spin
echo sequences with and without fat satura-
tion followed by intravenous Gd-DTPA (0.1
mmol/kg) and active mobilization (walking)
over a 30-minute period and reimaged. Im-
proved assessment in the vitality of the OCD
fragment, vascular enhancement versus no
vascular enhancement, as well as determina-
tion of fragment stability postintravenous
gadolinium arthrogram was reported (Fig. 7).
Although still early and additional trials are
required, this technique may eliminate the
necessity of the more invasive arthrographic
component of MR arthrography as well as
provide a solution to stand-alone MR imaging
centers without fluoroscopic capability for the
performance of MR arthrography.
Diagnostic arthroscopy has been usurped
by MR imaging for the staging of OCD in
skeletally immature patients who are symp-
tomatic. Treatment remains varied and con-
troversial. General consensus is conservative,
nonoperative management in the asymptom-
atic and skeletally immature patient. In gen-
eral, operative therapy is directed toward pa-
tients who are skeletally mature and
symptomatic at presentation, those who pre-
sent with intra-articular loose bodies, or pa-
tients who have failed a conservative trial of
712 COUMAS & PALMER

Figure 6. Osteochondritisdissecans with discontinuityof overlying articular cartilage and subchondral

cortex. A, Sagittal proton density-weighted ( T W Eof 2500114) image shows osteochondral abnormal-
ity with discontinuity of articular cartilage and subchondral cortex (arrow). B, Sagittal T2-weighted
image ( T W E of 2500/70) shows fluid from the effusion tracking freely into osteochondral defect
(arrow). C, Coronal inversion recovery image (TR/TI/TE of 5000/140/45) shows the arthrographic
effect of fluid (arrow) and lack of associated marrow edema.

therapy.45Operative techniques include pin
(Kirschner wire) fixation; screw (Herbert)
fixation; drilling (Kirschner wire or biode-
gradable pin); bone grafting; bone peg fixa-
tion; and osteochondral autografts and allo-
graft~.~~
Focal Articular Cartilage Defects
Hyaline cartilage is a well-organized, mul-
tilayered tissue structure with limited capac-
ity for repair or regeneration. The composi-
tion of hyaline cartilage by weight is
principally water (65% to 80%); proteoglycan
(10% to 30%); and collagen (5% to 65
Hyaline cartilage is typically divided into
three superficial noncalcified histologic zones
and a single deep calcified or mineralized
zone (Fig. Q8’ The superficial layer (tangen-
tial zone) maintains a high collagen and low
proteoglycan content with dense tangentially
oriented collagen fibrils at the articular sur-
face. A transitional zone is next seen with
a higher proteoglycan content and oblique
orientation to collagen fibrils. The radial zone
is composed of an upper and a deep compo-
nent. The deep radial zone maintains the
highest proteoglycan content and lowest wa-
ter concentration. The deepest histologic zone
(deep zone) separates articular cartilage from
subchondral bone and anchors the vertically
oriented collagen fibrils traversing the radial
zone. Calcified cartilage is noted adjacent to
subchondral bone and referred to as the tide
murk. The orientation and organization of col-
lagen fibrils throughout these histologic zones
is felt to reflect the ability of the hyaline carti-
lage scaffolding to accommodate various vec-
tors of mechanical force. Charged hydrophilic
 KNEE ARTHROGRAPHY 713

Figure 7. Osteochondritis dissecans and a clinical concern of fragment stability and viability. A,
Coronal T l -weighted image ( T W E of 400/16) shows abnormal signal in the medial femoral condyle
consistent with OCD (arrow). 13,Coronal inversion recovery image ( T W I n E of 5866/140/51) shows
intact cortex (/ongarrow) but increased signal deep to the OCD fragment (short arrows). No definite
extension to subchondral cortex is noted. Note subtle marrow edema. C, Coronal fat-suppressedT1-
weighted image ( T W E of 500/14) after intravenous gadolinium contrast shows enhancement of
signal intensity deep to OCD fragment (arrows) consistent with granulation tissue and extension of
abnormal signal to the femoral cortex (brig arrow). lnhomogeneous enhancement of OCD fragment
is noted (curved arrow).

ansitional Zone

Upper Radial Zone

Figure 8. Hyaline cartilage organization. Note the varying orientation

and concentration of long collagen fibrils as they traverse multiple
zones within hyaline cartilage to ultimately become anchored in
calcified cartilage at the tide mark. The orientation of collagen fibers
throughout these histologic zones of nonmineralized and mineralized
cartilage is an important component in the ability of hyaline cartilage to
accommodate varying vectors of mechanical force.
714 COUMAS & PALMER
proteoglycans also stratify throughout the
collagen latticework maintaining a balanced
level of hydration of cartilage. It is this very
complex stratification of water, proteoglycans,
and collagen fibrils that limits conventional
MR imaging sequences in the evaluation of
hyaline cartilage. Sensitivities for MR im-
aging of hyaline cartilage lesions have been
reported at between 30% and ~OOYO.~~
The clinical diagnosis of a focal chondral
injury is difficult. The symptoms may mimic
a meniscal tear with catching or locking. h i -
tial symptoms may be minimal or masked by
associated injury with only limited disability.
Chondral injuries are frequently overlooked
during the clinical examination. Characteris-
tic injury patterns are noted that correlate
with skeletal maturity. Osteochondral frac-
tures are more common in children and ado-
lescents. In the third decade of life, progres-
sive skeletal maturity leads to mineralization
at the tidemark and full-thickness chondral
87 Partial-thickness chondral lesions
lesions.51*
are more common thereafter.
Speer et aP7 showed that prearthroscopic
and postarthroscopic sensitivities of MR im-
aging for articular cartilage abnormalities in
the knee were 41% and 839'0, respectively, uti-
lizing conventional spin echo imaging se-
quences and thin section three-dimensional
pulse sequences. The significant postarthros-
copy improvement in detection suggests a
significant radiologic learning curve in the
MR imaging evaluation of hyaline cartilage.
Magnetization transfer contrast, SPGR, and
three-dimensional fat-suppressed SPGR have
all been shown to improve spatial resolution
and image contrast in the evaluation of hya-
line cartilage when compared with conven-
tional MR imaging sequences.29* 30 Disler et
a P showed a sensitivity of 93% when com-
paring fat-suppressed three-dimensional
SPGR imaging with arthroscopy prospec-
tively detecting 14 of 15 cartilage defects doc-
umented at arthroscopy. The fat-suppressed
three-dimensional SPGR image sequence
shows a symmetric trilaminar appearance of
hyaline cartilage with suppression of marrow,
fat, subarticular cortex, and joint effusion.
Multiple cadaveric studies have shown in-
tra-articular Gd-DTPA arthrography can de-
tect chondral defects as small as 2 mm/6,47
Kramer et a158have shown an improvement
in detection and staging of articular cartilage
abnormalities when comparing three-dimen-
sional SPGR imaging sequences without
Gd-DTPA with intra-articular Gd-DTPA with
T1-weighted and three-dimensional SPGR se-
quences. A sensitivity of only 62% was ob-
tained when three-dimensional SPGR im-
aging without intra-articular Gd-DTPA was
evaluated. Sensitivities of 85% (TI-weighted
Gd-DTPA) and 87% (three-dimensional SPGR
plus Gd-DTPA) showed no statistical differ-
ence. The previous findings were also sup-
ported by Speer et al,87 who infers that the
presence of a joint effusion may have a bene-
ficial effect in the detection of chondral le-
sions.
From an orthopedic perspective, current
trends in the treatment of focal articular carti-
lage abnormalities require an accurate assess-
ment of lesion size; location; and depth (par-
tial or full thickness). To date, conventional
MR imaging has not shown the sensitivity
in evaluating articular cartilage abnormalities
nor the accuracy in classifying chondral ver-
sus osteochondral injury to compete with
arthroscopy. In a recent review by Minas and
Nehrer,'j9 the author clearly states that
arthroscopy is the gold standard for diagnosis
and yields more valuable information than
MR imaging.97This philosophy may be attrib-
utable in part to the classification systems in
use. Arthroscopists prefer either the Outer-
bridge classification or the Bauer and Jackson
classification because of their descriptive na-
tures and potential for dating an injury and its
possible etiology." 72 Most radiologists utilize a
modified Shahriaree classification developed
for chondromalacia without incorporating le-
sion ~ i z e . 8MR
~ Gd-DTPA arthrography with
three-dimensional thin section volume-ac-
quired SPGR cartilage-specific sequence in
addition to T1-weighted images may provide
the critical data necessary to supplant diag-
nostic arthroscopy prerepair. The documenta-
tion of unipolar involvement, exclusion of
significant secondary degenerative change, as
well as accurate assessment of lesion size and
depth is possible and an essential component
to the orthopedic treatment approach.
Lesion size and location are crucial because
large chondral lesions in weight-bearing re-
 KNEE ARTHROGRAI'HY 715

Figure 9. Progressive marrow congestion in a 28-year-old professional basketball player over a 4-

month period. A, Coronal inversion recovely image (TRTTITTE of 4700/140/45) performed prearthros-
copy shows early subchondral cyst (arrow) with associated marrow edema in the lateral femoral
condyle. At arthroscopy, large full-thickness hyaline cartilage defect noted, as well as degenerative
narrowing of the joint space. B, Coronal inversion recovery image (TWITTE of 5000/140/51) 4
months later shows progressive subchondral cyst formation in the lateral femoral condyle (arrow) as
well as residual marrow edema. New foci of marrow edema and congestion now noted at the tibial
eminence and lateral tibial plateau (arrows). No interval trauma reported.

gions are poorly tolerated and more suscepti-
ble to secondary degenerative osteoarthritis.
Full-thickness lesions are felt to be more
symptomatic and subject to subchondral reac-
tive vascular congestion (Fig. 9). MR imaging
should also provide insight into the subchon-
dral and adjacent marrow changes associated
with chondral injuries, which may alter or
help direct treatment options (Fig. 10).
In the past, treatment options that involved
marrow stimulation techniques, such as sub-
chondral drilling, abrasion arthroplasty, or
microfracture technique, have produced fi-
brocartilaginous repair tissue rather than true
hyaline cartilage with variable long-term re-
sults. The recent success of autologous trans-
plant implantation in young, active patients
with large lesions (often greater than 2 to 3
cm2)has shown hyaline cartilage at the defect
site with long-term follow-up to 9 years with-
out associated symptomatic o ~ t e o a r t h r i t i s . ~ ~ The term chondromalacia patella is frequently
Mosaicplasty (arthroscopic osteochondral
plug transplantation) from ipsilateral non-
weight-bearing articulating cartilage has
shown success rates of greater than 80% (Fig.
ll).40 Clearly, follow-up MR Gd-DTPA
arthrography in contrast to second-look
arthroscopy is less invasive and more cost-
effective, with minimal morbidity.
A recent report by Boutin et allo suggests
that early degeneration of hyaline cartilage
with morphologically intact articular cartilage
can be shown by MR imaging in vitro. A
decrease in glycosaminoglycan concentration
within hyaline cartilage is associated with
early degenerative change and preferentially
replaced by charged Gd-DTPA2- into the de-
generative cartilage, which can be imaged by
MR imaging within human cartilage samples.
To date, arthroscopy remains the gold stan-
dard in the evaluation, classification, and
treatment of chondral and osteochondral ab-
normalities. Current trends, however, support
the future role of gadolinium arthrography in
this arena.
Chondromalacia Patella
confused with, and incorrectly attributed to,
all anterior knee pain. Chondromalacia was
first coined by Aleman' in 1917 and today is
felt to represent a softening, fibrillation, or
degeneration of articular cartilage. Changes
in articular cartilage of the patella are age-
dependent and may be seen by the second to
third decade of life. O ~ t e r b r i d g e73~ ~noted
.
716 COUMAS & PALMER

Figure 10. Focal osteochondral defect in a 30-year-old male. A, Sagittal proton density-weighted
image (TRITE of 2500/20)shows blunting of posterior horn medial meniscus apex, irregular thinning
of articular cartilage (arrow) and subchondral bony changes. B,T2-weighted image (TRITE of 2500/
80) shows thinning of articular cartilage with arthrographic effect (arrow) and early subchondral cyst
formation (curved arrow). C,3D fat-suppressed volume acquired SPGR image (TRITE/flip angle of
46/8/35") shows focal loss of the normal increase in signal intensity of the articular cartilage (arrow)
of the medial femoral condyle. D, 3D fat-suppressed volume acquired SPGR image after direct intra-
articular Gd-DTPA shows MR arthrogram of focal full-thickness articular cartilage defect easily
measurable in length and depth. Note the absence of marrow change or imbibition of contrast on the
SPGR sequence. f, T1-weighted (TRITE of 350/15), fat-suppressed, MR arthrogram after direct
intra-articular Gd-DTPA injection shows the early subchondral cystic changes (curved arrow) not seen
on SPGR fat-suppressed image as well as focal full-thickness articular cartilage defect.

changes, such as surface fissuring and frag-
mentation, in 11 of 17 patients 20 to 29 years
of age. Similar results were reported by
Vascular, biochemical, and mechani-
cal overload have all been postulated as etio-
logies of chondromalacia patella.
Malalignment, patellar subluxation, abnor-
mal patellofemoral tracking, synovial plicae,
trauma, and patellofemoral dislocation have
all been associated with abnormalities of the
patellar articular cartilage. In each of the
aforementioned abnormalities, chondroma-
lacia of cartilage represented a secondary
change. In each of these entities, pathologic
change occurred initially at the superficial
layer of hyaline cartilage. Goodfellow et aim,"
described a specific lesion of articular carti-
lage termed basal degeneration, which he be-
lieved caused symptomatic knee pain and
showed an abnormality of the deep layers
of hyaline cartilage early in the pathologic
process with smooth and intact articular sur-
face.
From a mechanical perspective, the femoral
articular cartilage is stiffer, displays a lower
permeability, and a lower water content when

compared with patellar hyaline cartilage.38,71
To further support Goodfellow et al, 43,44 nor-
mal-appearing patellofemoral articular carti-
lage has been reported with classic chondro-
malacia patella pain symptoms. Darracott
and Vernon-R~berts'~ have reported macro-
scopically normal patellar articular cartilage
in 11 patients with underlying bony change
and clinical pain. Arthroscopically, early
chondromalacia patella shows an intact artic-
ular surface and manifests as a focus of soft-
ening to probing. Later stages show a bubble
or blistering of the articular surface with
eventual breakdown.
Radiographic evaluation by arthrography
was helpful in late stages and at demonstra-
ting mechanical abnormalities, such as post-
traumatic change, prominent plica, and intra-
articular loose bodies. Unenhanced CT was
initially performed at 15, 30, and 45 degrees
of flexion in an effort to evaluate patellofem-
oral. tracking abnormalities, patellar subluxa-
tion and dislocation, as well as congenital
variations of the patella and corresponding
femoral groove. Unenhanced CT examination
is limited for evaluation of the articular carti-
lage. Double-contrast CT arthrography is ex-
cellent for evaluation of the superficial articu-
lating cartilage of the patella. Asymmetry of
articular cartilage thickness, superficial fis-
suring, contrast imbibition, as well as retinac-
ular attachments are all well-demonstrated.
The intra-articular capsular distention with
air or contrast may produce displacement of
the patella (usually laterally), invalidating the
assessment of patellar subluxation or patellar
tracking abnormalitiesMA large native joint
effusion produces this same limitation. The
earliest manifestations of chondromalacia, ar-
ticular softening, cannot be assessed by CT
arthrography. Superficial fibrillation and con-
tour changes or blistering can, however, be
diagnosed (Fig. 12). As noted by Insall et
a1,% CT arthrography most frequently shows
abnormalities adjacent to the patellar crest,
extending medially or laterally and sparing
the superior and inferior thirds of the patella.
As with hyaline cartilage elsewhere in the
knee, MR imaging played a pivotal role in
the evaluation of chondromalacia patella. Uti-
lizing conventional spin echo techniques, a
number of early studies concluded that grade
KNEE ARTHROGRAPHY 717
3 and 4 (Shahriareeclassification) patellar car-
tilage abnormalities could be shown.17,24, 67,
91,98 Sensitivities of 72% to 86% and accuracies
of 79% to 82% were reported. A high rate
of false-positive findings was noted with T2-
weighted sequences, which retrospectively
are likely attributable to chemical shift artifact
and magic angle phenomenon.
A combination of newer techniques, such
as fat-suppressed fast spin T2-weighting, fat-
suppressed three-dimensional SPGR, and fat-
suppressed T1 and SPGR sequences coupled
with intra-articular Gd-DTPA has allowed the
diagnosis of grade 2 and grade 1 cartilage
lesions (Fig. 13). Unlike arthroscopic evalua-
tion, which requires probing to detect soften-
ing of the underlying hyaline cartilage with
an intact articular surface, true deep intrasub-
stance hyaline cartilage abnormalities are dis-
cernible by MR imaging and support the
pathologic process described as basal degenera-
tion. The arthrographic effect of a joint effu-
sion or the administration of intra-articular
Gd-DTPA is helpful in establishing the integ-
rity of the articular surface (Fig. 14). This is
supported by Gagliardi et al,39 whose study
shows that MR arthrography and CT arthrog-
raphy are superior to conventional MR im-
aging sequences for the evaluation of all
grades of chondromalacia patella (Fig. 15).
Gagliardi et a139compared T1-weighted, pro-
ton density weighted, T2-weighted, SPGR
with fat suppression, and T1-weighted Gd-
DTPA sequences and CT arthrography
(double-contrast) in 27 patients utilizing
arthroscopy as the gold standard. Only CT
arthrography and MR arthrography tech-
niques detected grade 1 lesions with a detec-
tion rate of 29% when compared with arthros-
copy. Grade 2 and 3 lesions showed progressive
improvements in detection with various con-
ventional MR imaging sequences culminating
in a 73% detection rate with CT arthrography
and 80% detection rate with MR arthrogra-
phy. Conventional MR imaging sequences
were much more successful in the detection of
grade 4 lesions with a 75% detection rate as
compared with a 100% detection rate for CT
arthrography and MR arthrography.
At present, MR Gd-DTPA arthrography uti-
lizing fat-suppressed T1-weighted and three-
dimensional SPGR volume-acquired se-
718 COUMAS & PALMER

Figure 11. MR arthrography with arthroscopic correlation in arthroscopic osteochondral plug trans-
plantation in a 29-year-old male. Anterior cruciate ligament (ACL) reconstructiondone simultaneously.
A, Prominent 1.4 cm2 full-thickness flap (arrows) arthroscopically delineated by probe in medial
femoral condyle (arrowhead). 5, Excision of full-thickness flap prior to ACL reconstruction. C, 1 year
follow-up arthroscopy shows progressive circumferential cartilage deterioration at the excision site of
the weight-bearing medial femoral condyle (arrows). D, Arthroscopic osteochondral plug transplanta-
tion harvested from non-weight-bearing posterior medial femoral condyle at 1 year post-ACL recon-
struction. (Courtesy of Jerry L. Barron, MD, Charlotte, North Carolina.) f,Sagittal T1-weighted image
shows the osteochondral plug transplantation in place (arrow) with no offset of the subchondral
cortical line. F; Sagittal T2-weighted image shows a subtle small focus of increased signal deep to
osteochondral plug transplant without signs of loosening or failure 1 month after surgery (arrow). G,
Sagittal SPGR image (TRITWflip angle of 46/8/35") after direct intra-articular Gd-DTPA shows focal
marginal thinning of the articular cartilage (arrow) but no intravasation of intra-articular contrast
material. H, Sagittal T1-weighted fat-suppressed image after direct intra-articulargadolinium confirms
the thinned articular cartilage adjacent to the osteochondral transplant without imbibition of contrast
(arrow). I, Axial SPGR fat-suppressed image (TRITWflip angle of 45/8/35") shows transplant donor
site from medial femoral condyle (arrow), patella harvest site for ACL reconstruction (curved arrow),
and artifact from ACL reconstruction (arrowhead).

quences is performed in patients with a high SYNOVIAL DISORDERS

clinical index of suspicion for chondromalacia
patella. The low detection rate of grade 1
lesions is not a deterrent to MR imaging eval-
uations nor a proponent for arthroscopic eval-
uation, because grade 1 lesions are treated
conservatively.
Direct and indirect MR arthrographic tech-
niques have been used to characterize syno-
vial disorders and inflammatory arthropa-
thies. Following direct intra-articular
administration of Gd-DTPA, contrast solution
 KNEE ARTHROGRAPHY 719

Figure 11. See legend on opposite page

720 COUMAS & PALMER

pigmented villonodular synovitis (PVNS), sy-

novial osteochondromatosis (SOC), and syno-
vial plica.

Rheumatoid Arthritis

Inflammatory synovitis, as results from

Figure 12. CT arthrogram of patella articular cartilage.
Subtle imbibition of contrast material and focal fibrillation
adjacent apex of patella articular cartilage is shown
(arrow). Note the symmetrical thinning of the medial facet
cartilage and deep subcortical cystic changes within the
patella.
fills the joint space, distends the capsule, sep-
arates intra-articular structures, and outlines
the contours of abnormal synovium or loose
bodies. Intravenous administration of Gd-
DTPA leads to the enhancement of hypervas-
cular synovial tissue and also provides an
arthrographic effect if sufficient amounts of
contrast material diffuse into the joint fluid.
This section presents the arthrographic MR
imaging features of inflammatory arthritis,
rheumatoid or psoriatic arthritis, is character-
ized by thickening of the synovium due to
hyperplasia of the intima and the subsynovial
tissue. Inflammatory cells infiltrate this tissue
and release vasogenic and cytotoxic sub-
stances that lead to the progressive destruc-
tion of cartilage and bone. Although plain
radiography is successful in demonstrating
joint space narrowing and erosive disease,
MR imaging is capable of showing pannus
before secondary cartilaginous and osseous
changes become evident.
Unenhanced MR imaging has been used to
assess both the inflammatory process (pannus
and effusion) as well as its structural sequelae
(bone erosion, cartilage destruction, and ten-
don disruption). Without intravenous con-
trast administration, heavily T2-weighted MR
images are most valuable in the detection of
synovitis and in the differentiation of hyper-
plastic synovial tissue from joint effusion. Un-
enhanced T1-weighted spin echo images or
fat-suppressed Tl-weighted gradient echo im-

Figure 13. Newer sequences used in evaluation of chondromalacia patella. (A, B, and C are the
same patient.) A, Sagittal, fat-suppressedSPGR (TWTWflip angle of 60/10/45") without intra-articular
Gd-DTPA, normal articular cartilage of patella and trochlear groove (open arrows). B, Sagittal, fat-
suppressed SPGR (TWTWflip angle of 32/8/20") image after direct intra-articular Gd-DTPA. C,
Sagittal, fat-suppressed T1-weighted (TWTE of 600/11) image after direct intra-articular Gd-DTPA.
 KNEE ARTHROGRAPHY 721

Figure 14. Arthrographic effect in chondromalacia patella. A, Sagittal TBweighted image (TRITE of
2500/90) shows a focal increase in signal intensity within the cartilage of the lateral trochlear notch
of the femur (arrow). B, Axial T2*-weighted gradient-echo image (TWWflip angle of 400/20/35")
shows the correspondingfocal articular defect (arrow) noted in Figure A as well as the thinned lateral
patella facet articular cartilage (curved arrow).

ages are excellent for the identification of
small marginal erosions that may not be visi-
ble on plain radiographs.
Contrast-enhanced MR imaging enables the
earliest diagnosis of synovitis (Fig. 16). Ac-
tive, proliferative pannus is hypervascular
and exhibits rapid enhancement after the in-
travenous administration of Gd-DTPA (see
Fig. 14). Contrast material accumulates rap-
idly in the extracellular space and flows freely
across the joint lining into the synovial fluid
(Fig. 17).31Because the enhancement of joint
fluid occurs within minutes and persists for
an hour or longer, MR images must be ob-
tained immediately following contrast injec-
tion to identify the interface between pannus
and In clinical -practice, confusion
between pannus and effusion has little sig-
nificance, but it may cause substantial prob-
lems in clinical trials designed to measure
treatment-related changes in the volume of
pannus. Volumetric quantification of enhanc-

Figure 15. MR gadolinium arthrography compared with conventional gradient-echo sequence for
evaluation of cartilage. A, Gradient-echo, T2'-weighted (TWWflip angle of 400/20/20") axial image
shows no focal defect of articular patella cartilage. A very subtle contour change of medial facet
cartilage is noted to suggest blistering (arrow). B, T1-weighted, fat-suppressed axial image (TW
TE of 466/16) after direct intra-articular Gd-DTPA shows focal imbibition of gadolinium contrast
agent (arrow).
722 COUMAS & PALMER

Figure 16. Synovial inflammation in 42-year-old man with rheumatoid arthritis. A, T2-weighted
( T W E of 2500180) sagittal M R image shows a large joint effusion (e). The presence of synovitis and
the degree of inflammation are difficult to diagnose, partly because pannus has signal intensities
similar to adjacent joint fluid and periarticularfat. 13,Immediately following intravenous administration
of gadopentetate dimeglumine, fat-suppressed, T1-weighted ( T W E of 450/15) sagittal image shows
circumferential linear and nodular enhancement of the joint lining (straight arrows). Although low-
signal effusion (e) remains visible, the apparent thickness of pannus is falsely increased because of
capillary leak and diffusion of contrast material from hypervascular synovium into adjacent fluid.
Enhancing pannus (curved arrow) invading infrapatellar fat was not visible on T2-weighted images.

Figure 17. Synovial inflammation in a 70-year-old

man. T1-weighted fat-suppressed image ( T W E of
650/12) after an 8 to 10 minute delay postintrave-
nous gadolinium enhancement shows contrast in the
extravascular space obscuring the interface between
inflamed synovium and joint effusion (arrows).
 KNEE ARTHROGRAPHY 723

ing pannus is only useful for monitoring and
comparing the efficacy of anti-inflammatory
drugs if the synovial tissue can be accurately
and reproducibly differentiated from enhanc-
ing joint fluid.”
PVNS
PVNS is a benign proliferative disorder of
the synovium that exhibits both diffuse and
localized forms. The cause of PVNS is un-
known. The diffuse form of PVNS involves
the entire synovial lining and consists of mat-
ted masses of villi, synovial folds, and sessile
or pedunculated nodules. This tissue may in-
vade the joint capsule and periarticular soft
tissues, including neurovascular structures, or
may invade bone in areas that are not pro-
tected by overlying articular cartilage. The
localized form of PVNS has the appearance
of a mass that may be lobulated or peduncu-
lated. Localized and diffuse PVNS both share
identical histologic features, including syno-
vial cell hyperplasia and the aggregation of
histiocytes. Important MR imaging features
of PVNS result from the presence of hemosid-
erin, which accumulates in the synovial lining
(extracellular) as well as macrophages (intra-
cellular).
The diffuse and localized forms of PVNS
are both monarticular disorders that affect the
knee far more commonly than other joints.
Diffuse PVNS extends into synovial recesses,
including extra-articular bursae and cysts
(e.g., Baker’s cyst). Localized nodular synovi-
tis usually presents as an anterior mass in the
infrapatellar fat pad. PVNS can also arise in
a tendon sheath separate from the joint (local-
ized nodular tenosynovitis, giant cell tumor
of tendon sheath), but this lesion occurs more
frequently in the hand and wrist or foot and
ankle than in the knee.
In conventional arthrography, diffuse
PVNS shows numerous irregular filling de-
fects that are fixed to the capsule and project
into the joint space.94Unfortunately, this ap-
pearance is nonspecific and similar to the ap-
pearance of early inflammatory arthritis.
Characteristic MR imaging findings reflect
the high concentration of hemosiderin in
PVNS.% The ferromagnetic properties of he-
mosiderin cause shortening of both the T1
and T2 relaxation times, resulting in de-
creased signal intensities from the synovium
on both T1- and T2-weighted images. Mag-
netic susceptibility effects from the hemosid-
erin cause a remarkable blooming phenome-
non, in which the low-signal regions appear
larger in size on gradient echo images and,
sometimes, T2-weighted images compared
with T1-weighted images (Fig. 18). This MR

Figure 18. Magnetic susceptibility in PVNS. A, Axial T1-weighted image ( T W E of 600/16)shows

abnormal posterior and medial soft-tissue mass, which is lower in signal intensity when compared
with adjacent muscle (arrows). Normal muscle (arrowhead). B,Axial T2-weighted image (TRTTE of
2900/90) shows a marked decrease in the signal intensity of the mass and the suggestion of an
increase in size consistent with magnetic susceptibility or blooming artifact. PVNS in a Baker’s cyst
was documented at surgery.
724 COUMAS & PALMER
imaging appearance is not pathognomonic
for PVNS, because similar low-signal regions
can be observed in hemophilic and amyloid
arthropathies, synovial hemangioma, and sy-
novial osteochondromatosis. Although direct
or indirect arthrographic MR images can
show abnormalities in both diffuse and local-
ized synovial proliferative disorders, there is
no definite advantage in diagnostic accuracy.
SOC
Primary SOC (synovial chondromatosis) is
an uncommon disorder characterized by the
metaplasia of synovium; the formation of nu-
merous cartilaginous nodules (which may or
may not become ossified); and the detach-
ment of these nodules resulting in intra-artic-
ular loose bodies. Similar to PVNS, synovial
involvement can be diffuse or localized, but
often is concentrated in capsular recesses at
the synovial-cartilaginous junctions. At mi-
croscopy, the nodules are composed of hya-
line cartilage that occasionally contains min-
eralized matrix, bony trabeculae, or mature
osteoid with bone marrow components. Sec-
ondary SOC may result from predisposing
disorders, such as osteoarthritis, avascular ne-
crosis, neuropathic osteoarthropathy, and
trauma.
Primary SOC is typically monarticular and
affects large joints. The knee is involved in
50% or more of cases, followed by the elbow,
hip, and shoulder.66In order to avoid second-
ary degenerative osteoarthritis, the most com-
mon complication of primary SOC, treatment
requires surgical removal of the loose bodies
and synovectomy. Unfortunately, the recur-
rence rate of this disorder remains relatively
high.
Primary SOC can be diagnosed from plain
radiographs when the loose bodies show
characteristic ossification. In the absence of
calcification or ossification, conventional
arthrography is an excellent technique for
confirming the presence of loose bodies and
also helps to differentiate primary SOC from
PVNS, which can closely simulate SOC on
plain radiographs. In PVNS, synovial fronds
project into the joint space but remain contig-
uous with the joint capsule because they are
attached at their bases. In SOC, the cartilagi-
nous nodules are completely surrounded by
contrast solution and separated from the cap-
sule. Arthrographic criteria may also be used
to distinguish primary SOC from secondary
SOC. Loose bodies in primary SOC are usu-
ally similar in size and distributed diffusely
throughout the joint, whereas loose bodies in
secondary SOC are more variable in size and
fewer in number.92
The MR imaging appearance of SOC de-
pends on the proportions of hyaline cartilage,
calcification, and ossification in the loose bod-
i e ~MR . ~ imaging
~ is valuable to confirm the
intra-articular location of ossified nodules
identified on plain radiographs. Ossified nod-
ules show the signal intensity of marrow fat,
whereas calcified nodules show foci of de-
creased signal intensity on all pulse se-
quences. In unsuspected SOC, noncalcified
cartilaginous nodules may not be visualized
prospectively on MR images. Diagnostic dif-
ficulty results from the isointensity in signal
(low signal intensity on T1-weighted images
and high signal intensity on T2-weighted im-
ages) from the closely packed cartilaginous
nodules and surrounding joint effusion. Ei-
ther intravenous or direct intra-articular ad-
ministration of gadolinium improves the de-
tection of cartilaginous nodules, because the
joint fluid becomes high in signal intensity on
T1-weighted images, whereas the loose bod-
ies remain low in signal intensity.
Synovial Plica
The three plicae of the knee ([l]suprapatel-
lar plica, [2] medial patellar plica, and [3]
infrapatellar plica) are remnants of the em-
bryologic synovium that separate the joint
into compartments during gestation. Partial
plical remnants are often identified at arthros-
copy, but they usually are considered inciden-
tal findings without clinical significance. The
medial patellar plica is most closely associ-
ated with symptoms. This plica is located me-
dial to the patella and courses vertically
through the joint from the suprapatellar
pouch to the infrapatellar fat pad. The pa-
thoetiology results from repeated knee flexion
and extension, during which the plica can

Figure 19. Symptomatic synovial plica. Axial T2*-
weighted gradient-echo image (TR/TE/flip angle of 400/
15/15") shows a focally thickened and irregular focus of
the medial patella plica (curved arrow) with early subtle
erosion of the adjacent medial femoral condyle (straight
arrow).
become irritated as it slides over the medial
femoral condyle. If the plica becomes in-
flamed or fibrotic, it may cause anterior knee
pain or mechanical symptoms, such as click-
ing or snapping.
Conventional MR imaging can show the
medial patellar plica in the patellofemoral
compartment between the medial patellar
facet and the medial femoral condyle. There
is no proof that MR imaging can reliably ex-
clude an abnormal medial patellar plica, how-
ever, or accurately differentiate between a
normal plica and an abnormally thickened
plica.6.13, As with other intra-articular struc-
tures, the medial patellar plica and its abnor-
malities may be better shown when outlined
by joint effusion or injected contrast solution.
Osseous changes resulting from chronic plical
inflammation also may be identified on MR
images (Fig. 19), but these changes are un-
usual and may not be clearly related to a
pathologic plica. Diagnostic difficulty using
MR imaging may not be surprising given the
controversy about diagnostic criteria, clinical
significance, and treatment options among or-
thopedists.
CONCLUSION
Arthrography of the knee has played a vital
role in the past and continues to maintain an
KNEE ARTHROGRAPHY 725
important role in the present and predictable
future in imaging of the knee. The utilization
of intravenous and intra-articular contrast
agents has become more commonplace as
musculoskeletal imaging has become more
subspecialized and clinically directed. Con-
ventional MR imaging has evolved as the
dominant, most commonly performed radio-
logic examination in the global assessment of
the knee. Although the high negative pre-
dictive value of conventional MR imaging has
taken on an important clinical significance,
we believe it is the positive predictive value
of contrast MR imaging when used judi-
ciously that will be heralded. MR gadolinium
arthrography of the knee has been shown to
be more accurate in the evaluation of the
postoperative meniscus and in the assessment
of articular cartilage abnormalities when com-
pared with conventional MR imaging. Intra-
venous gadolinium enhancement plays an
important role in the evaluation and assess-
ment of therapy for synovial-based processes.
MR imaging and arthroscopy should be used
as complementary modalities with the ortho-
pedic surgeon and radiologist cooperatively
directing the efficient diagnosis and therapy
of patients.
ACKNOWLEDGMENT
The authors thank Karen Costea for manuscript prepa-
ration and editorial support.
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James M. Coumas, MD
Department of Radiology
Carolinas Medical Center
1000 Blythe Boulevard
Charlotte, NC 28203