MRI EVALUATION OF CARTILAGE

George Koulouris

INTRODUCTION

•  Anatomicimagingnotsufficient•  Currenttechniquesdetectestablishedcar=lagedefectsandsubchondralchange(BME&cyst)

•  Earlyinterven=onofcar=lageimaging&noveltreatments– demandforfunc=onal/biochemicalimaging– needtoimageearlycar=lagebreakdown

RECENTINNOVATIONS

•  T2Mapping •  T1rhoimaging

•  DWI

•  DTI

•  dGEMRIC(delayedgadoliniumMRIofcar=lage)currentlyonlytechniqueproventobepredic=veforfuturejointdegenera=on

CARTILAGE

•  CHONDROCYTES:(1‐2%)

•  EXTRACELLULARMATRIX:

•  Solid Proteoglycans(5‐10%) Collagens‐TypeII(15‐20%)

•  FluidWater(70‐80%)

COLLAGENNETWORK

•  Proteoglycan: •  draws water &

maintains osmotic pressure

•  counteracts swelling pressures

•  provides force in tension & shear

•  resists compression

•  Extensivepolysaccharidechains•  Formlargecomplexesofnega=velychargedproteoglycans

•  maintain:– osmo=cpressure– fluidwithinthecar=lagematrix

– compressives=ffness

GLYCOSAMINOGLYCANS(GAG)

GLYCOSAMINOGLYCANS(GAG)

•  Car=lagebehavesasas=ffelas=cpolymertosuddenimpact

•  Slowviscoelas=cdeforma=ontosustainedloading

•  GAGlossisaknownearlyeventintheprogressionofOA

•  ?earlybreakdownreversible

dGEMRIC

•  assessesearlycar=lagedamageasGAGlosspriortodevelopmentofmacroscopiccar=lagedefects

•  nega=velychargedMRIcontrast(Gadolinium;Gd),(IVorintra‐ar=cular)isrepelledbynega=velychargedGAG

―=Gadolinium

=GAG

dGEMRIC

•  lessGAGincar=lagelessnega=vechargerela,vetonormalcar=lagethemorethenega=velychargedcontrastwillpenetrateGAGdepletecar=lage(1)

•  Gdpenetratesnormalcar=lage,high[GAG],inareciprocalmanner

dGEMRIC

•  ↑Gd↓T1value(MRIpropertyofGd)•  Doublenega=ve:

↓[GAG]=↑Gd=↓T1↑[GAG]=↓Gd=↑T1

•  [GAG]isdirectlypropor=onaltoT1value•  T1value=T1relaxa=on=me=dGEMRICindex

dGEMRIC

[GAG] = dGEMRIC index

TECHNIQUE

TECHNIQUE

•  IVGd–doubledose

•  Exercise

•  Wait30‐90minforpenetra=on(2)

•  IAbeoerthanIV(3,4)

•  T1mapsofcar=lagegenerated/manuallyplooed

•  Nodifferencebetween1.5T&3T(5)

VALIDATION

•  Reproducible(6)

•  Excellentinvitrocorrela=on(7)

•  HigherdGEMRICindex(lessGd,higher[GAG])=higherresistancetomechanicalcompression(8,9)

INTERPRETATION

MARATHON

BEFORE 1DAY 1WEEK

SHOULDERARTHROGRAM

HUMERALHEADdGEMRICINDEX GLENOIDdGEMRICINDEX

•  9/52PeriacetabularOsteotomy(PAO)failed

•  dGEMRICindex:–  usefulmeasureofearlyOA–  bestpredictoroffailure(P<0.02)–  iden=fiedpoorcandidatesforPAO

•  PoordGEMRICindex(<400msec)forconserva=vemanagement(injec=on,physio,debridement)

•  GooddGEMRICindex(>400msec)PAO•  Eliminatedtheneedtorelysolelyonradiographs(changes

occurtoolate)[10]

DYSPLASIA

DYSPLASIA

DYSPLASIA

•  N=96dysplas=chipsOAdefinedas2SD<average,i.e.dGEMRIC<390msec

•  MeandGEMRIC473cfnormalhipsof570[11]

SUCFE

•  16pa=entsSUCFEfollowedupfor14.5years– T1valueslowerlaterallythancentrally– Goodcorrela=onbetweendGEMRICindex,painandalphaangles(degreeofoffset)[12]

•  Perthe’sdisease:–  lossofGAGmedially[13]

SUCFE

FAI

•  Significantcorrela=onbetween:–  dGEMRICindex–  pain–  alphaangle

•  correla=onofdGEMRICwithalphaanglesuggeststhathipswithmorefemoraldeformityshowfeaturesofearlyOA[14]

•  CamFAIlowerdGEMRICvaluesanterosuperiorly•  PincerFAIgeneralizedcircumferen=alloss[15]

ACLINJUREDKNEE

•  dGEMRICevalua=onoftheACLinjuredkneeshows13%lowerdGEMRICindexinthemedialcompartmentwhencomparedwiththenormalcontralateralside[16]

PCLINJURY

[17]

KNEEDISLOCATION

[18]

MedialFacet LateralFacet

BilateralPatellarDisloca=on

411 426

UnilatDisloca=on–nondislocatedside

465 466

Normal 490 510

•  HigherGAGinfollowingMACIthanMFX[19]

CARTILAGERx

[19,20,21,22]

•  AlllowdGEMRICindexareasshowabnormalityonkneearthroscopy(N=16)[23]

•  Kneepaininpa=entswithoutOAbutlowdGEMRICindexaremorelikelytodevelopradiographicallyevidentOAin6yrs[24]

•  ValgusmalalignedknesslowerdGEMRICindexlaterallyandvarusknessmedially[25]

KNEEOA

KNEEOA

•  dGEMRICindexcorrelatesstronglywithkneeflexorandextensorstrength,sugges=ngthatstrongcoordinatedmusclesmayplayaroleinpreven=ngOA

•  overweight&meniscetcomyareRFforOA–dGEMRICindex14%lower374vs437[26]

•  ModerateincreaseindGEMRICindexofcar=lageinpa=entswithmoderateOA&whoexercise[27]

OTHERJOINTS

•  MatrixAssociatedAutologousChondrocyteImplanta=on(MACI)oftheankle[28]

•  1stCMCofthethumb[29]

AFLAPPLICATIONS

•  Knowninjury/congenital/developmentalissueinpoten=aldraycandidatewillFAIstanduptotherigorsofAFL?

•  Assistsindiagnosisnocar=lagedefect,butisthatcamlesionsignificant?DoesthelowdGEMRICindexaccountforpain?Pubicsymphysis?

•  ExplainsprolongedpaindespitenoapparentcausePostPCLinjury

•  Timingofreturntocompe==onPostbonebruising.Iswai=ngforBMEtoresolveinsufficient?

•  Informedconsentregardingrisksofplayingvsre=rementArethereearlybutpermanentchangesindGEMRICindexpostmeniscectomy?

•  Morerealis=cexpecta=onsfromplayer,club&medicalstafffollowinginjury?Decreasesfutureriskofli=ga=on

•  Re=redAFLplayers&incidenceofOA

AFLAPPLICATIONS

CONCLUSION

•  dGMERICimagingvalidatedtechniqueinearlyGAGloss

•  GAGloss:–  precedesOA,?reversible– detectedbyGdpenetra=on&T1WI

•  BestimagingpredictorofOA

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