mri assessment of osteonecrosis

Luis Corrales, HMS III

Gillian Lieberman, MD

MRI Assessment of MRI Assessment of

OsteonecrosisOsteonecrosis

Luis Corrales, Harvard Medical School Luis Corrales, Harvard Medical School

Year IIIYear III

Gillian Lieberman, MDGillian Lieberman, MD

March, 2005

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Luis Corrales, HMS IIIGillian Lieberman, MD IntroductionIntroduction

�� OsteonecrosisOsteonecrosis used to describe spectrum of pathological and radiological used to describe spectrum of pathological and radiological

changes within bone due to ischemia.changes within bone due to ischemia.

�� Can occur in Can occur in subarticularsubarticular bone or epiphysis (ischemic bone, AVN, aseptic bone or epiphysis (ischemic bone, AVN, aseptic

necrosis), necrosis), metaphysismetaphysis and and diaphysisdiaphysis (bone infarction).(bone infarction).

�� Common condition affecting a relatively young population.Common condition affecting a relatively young population.

�� 2020--50 yrs (average age at 50 yrs (average age at DxDx 40yrs)40yrs)

�� Corticosteroids and excessive alcohol use reported to account foCorticosteroids and excessive alcohol use reported to account for majority of r majority of

cases cases

�� If untreated eventually leads to If untreated eventually leads to articulararticular collapse and secondary osteoarthritis.collapse and secondary osteoarthritis.

�� In U.S. there are an estimated 10,000In U.S. there are an estimated 10,000--20,000 new patients diagnosed per year20,000 new patients diagnosed per year

�� Responsible for roughly 18% of all total hip Responsible for roughly 18% of all total hip arthroplastiesarthroplasties in U.S.in U.S.

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Luis Corrales, HMS IIIGillian Lieberman, MD

Conditions and Risk Factors Associated with Conditions and Risk Factors Associated with

OsteonecrosisOsteonecrosis

�� TraumaTrauma-- Fracture, dislocation, vascular trauma, fat embolism, thermal Fracture, dislocation, vascular trauma, fat embolism, thermal injuryinjury

�� HemoglobinopathiesHemoglobinopathies-- Sickle cell, Sickle cell, polycythemiapolycythemia

�� Metabolic/EndocrineMetabolic/Endocrine-- Diabetes, Diabetes, GaucherGaucher’’ss disease, Cushingdisease, Cushing’’s, s, pregnancy, chronic renal failurepregnancy, chronic renal failure

�� GastrointestinalGastrointestinal-- Pancreatitis, IBDPancreatitis, IBD

�� VasculitidesVasculitides-- SLE, RA, SLE, RA, ankylosingankylosing spondylitisspondylitis

�� EnvironmentalEnvironmental-- Alcoholism, smoking, decompression syndromeAlcoholism, smoking, decompression syndrome

�� IatrogenicIatrogenic-- Corticosteroids, radiotherapy, transplantation, Corticosteroids, radiotherapy, transplantation, hemodialysishemodialysis

�� Idiopathic Idiopathic

�� In ChildrenIn Children

�� LeggLegg--CalveCalve--PerthesPerthes

�� Slipped capital femoral epiphysisSlipped capital femoral epiphysis

�� Congenital hip dislocationCongenital hip dislocation

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PathophysiologyPathophysiology

�� Pathogenesis of Pathogenesis of atruamaticatruamatic osteonecrosisosteonecrosis is believed to is believed to

result from ischemic injury to bone and marrowresult from ischemic injury to bone and marrow

�� One or more of three mechanisms are believed to One or more of three mechanisms are believed to

occur:occur:

�� 1. Compromise of vessel wall integrity1. Compromise of vessel wall integrity

�� 2. 2. IntraosseousIntraosseous vascular compression (increased vascular compression (increased

marrow pressure)marrow pressure)

�� 3. Intravascular occlusion3. Intravascular occlusion

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Host response to bone ischemia and infarctionHost response to bone ischemia and infarction�� Body mounts an inflammatory and reparative response at margins oBody mounts an inflammatory and reparative response at margins of infarct which can be divided f infarct which can be divided

into various ZONESinto various ZONES

�� Acutely no radiographic abnormalities because initially only a mAcutely no radiographic abnormalities because initially only a marrow cellular phenomenon, and arrow cellular phenomenon, and

mineralized bone remains unaltered.mineralized bone remains unaltered.

�� Eventual mechanical instability causes Eventual mechanical instability causes microfracturemicrofracture of of subchondralsubchondral trabeculaetrabeculae ((““Crescent signCrescent sign””

on radiographs)on radiographs)

�� Subsequent Subsequent articulararticular collapse occurs and results in secondary osteoarthritis.collapse occurs and results in secondary osteoarthritis.

AVASCULARCELLS

Ischemic injury

Reactive hyperemia

Normal Bone

Hyperemic marrow appears on radiographs as area of osteoporosis

adjacent to viable bone

Progressive loss of mechanical support causes:

• osteoblasticc reinforcement of adjacent viable trabecular

bone

• peripheral rim of sclerosis referred to as CREEPING APPOSITION

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Imaging ModalitiesImaging Modalities�� ConvetionalConvetional radographsradographs

�� lack sensitivity in early diseaselack sensitivity in early disease

�� Only become diagnostic after Only become diagnostic after subchondralsubchondral fracture and fracture and

development of development of ““crescent sign.crescent sign.””

�� Computed tomography (CT)Computed tomography (CT)

�� Most sensitive for detecting Most sensitive for detecting subchondralsubchondral fracturesfractures

�� Bone ScanBone Scan

�� Has sensitivity to detect early changes of Has sensitivity to detect early changes of osteonecrosisosteonecrosis but but

lacks specificity.lacks specificity.

�� MRIMRI

�� Has emerged as most accurate technique for detecting initial Has emerged as most accurate technique for detecting initial

changes of changes of osteonecrosisosteonecrosis

�� Sensitivity and specificity approach 100%Sensitivity and specificity approach 100%

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Sites Sites OsteonecrosisOsteonecrosis Can AffectCan Affect

�� Femoral head most commonFemoral head most common

�� Humeral headHumeral head

�� Femoral Femoral condylescondyles

�� Carpal bones (especially Carpal bones (especially scaphoidscaphoid, and , and lunatelunate))

�� Proximal tibiaProximal tibia

�� PatellaPatella

�� TalusTalus

�� Tarsal Tarsal navicularnavicular

�� VertebraeVertebrae

�� Facial bonesFacial bones

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Staging Staging OsteonecrosisOsteonecrosis

�� StagingStaging —— The Association of Research Circulation Osseous (ARCO) The Association of Research Circulation Osseous (ARCO) has recently developed a staging system.has recently developed a staging system.

�� Stage 0 Stage 0 --Asymptomatic, normal radiographsAsymptomatic, normal radiographs

�� Stage 1 Stage 1 --Plain radiographs normal, MRI positive and biopsy Plain radiographs normal, MRI positive and biopsy positive.positive.

�� Stage 2 Stage 2 --Radiographs positive (Radiographs positive (radiolucencyradiolucency and sclerosis) but no and sclerosis) but no collapse.collapse.

�� Stage 3 Stage 3 --Crescent sign, normal contourCrescent sign, normal contour

�� Stage 4 Stage 4 --Flattening of femoral head, Flattening of femoral head, subchondralsubchondral collapsecollapse

�� Stage5 Stage5 ––Degenerate bone diseaseDegenerate bone disease

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Imaging Features of Imaging Features of OsteonecrosisOsteonecrosis on Plain Filmson Plain Films

Duke Medical. www.wheelessonline.com

•Subchondral lucent area

•Represents subchondral collapse

•Seen in advance stages of osteonecrosis

Crescent sign

Areas of central lucency with

sclerotic border due to medullary

infarct

Saini A, Saifuddin A. MRI of Osteonecrosis. Clin Radiology 2004; 59: 1079-1093

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MRI Appearance of MRI Appearance of OsteonecrosisOsteonecrosis

�� NECROTIC areas demonstrateNECROTIC areas demonstrate

�� HYPOINTENCE SI on both T1W and T2W sequencesHYPOINTENCE SI on both T1W and T2W sequences

�� Patterns of abnormalityPatterns of abnormality

�� Homogenous pattern: wellHomogenous pattern: well--defined area of defined area of HYPOintenceHYPOintence SI confined to SI confined to subarticularsubarticular regionregion

�� InhomogenousInhomogenous pattern: large irregular areas of decreased SIpattern: large irregular areas of decreased SI

�� Ring pattern: ring of decreased SI surrounding an area of relatiRing pattern: ring of decreased SI surrounding an area of relatively vely normal intensitynormal intensity

�� ““Double line signDouble line sign””

�� Virtually diagnostic change on T2W sequencesVirtually diagnostic change on T2W sequences

�� Occurs at interface of viable and nonOccurs at interface of viable and non--viable tissue.viable tissue.

�� Consists of a LOW SI outer rim (sclerotic bone) with an adjacentConsists of a LOW SI outer rim (sclerotic bone) with an adjacent inner inner rim of HIGH SI (corresponding to rim of HIGH SI (corresponding to vascularizedvascularized granulation tissue)granulation tissue)

�� On T1W images double line appears as a single LOW SI bandOn T1W images double line appears as a single LOW SI band

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DiffentialDiffential Diagnosis Diagnosis

�� IllIll--defined marrow area of Low SI on T1W and defined marrow area of Low SI on T1W and

intermediate of high SI intensity on T2W (intermediate of high SI intensity on T2W (““Bone Bone

marrow edemamarrow edema”” pattern) at epiphysis pattern) at epiphysis

�� OsteonecrosisOsteonecrosis

�� Posttraumatic or stress fracturesPosttraumatic or stress fractures

�� Transient osteoporosis Transient osteoporosis

�� Reactive changes of degenerative Reactive changes of degenerative articulararticular diseasedisease

�� Transient bone marrow edema syndromeTransient bone marrow edema syndrome

�� InfectionInfection

�� Infiltrative neoplasmInfiltrative neoplasm

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Variable appearance of Variable appearance of OsteonecrosisOsteonecrosis on on SagittalSagittal

TIW image of Distal Femoral TIW image of Distal Femoral CondyleCondyle

Med Femoral Condyle

Tibia

Ant. Horn of Med. Meniscus

Post. Horn of Med. Meniscus

Articular Cartilage

•Inhomogeneous area of

Hypointense SI

•Serpiginous subchondral

pattern

Homogeneous band of

Hypointense SI subchondral

pattern


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Double Line Sign on MRIDouble Line Sign on MRI

•Sagittal T2W image

•Distal femoral and proximal

tibial metaphysial bone infarcts

Outer rim of LOW SI- Sclerotic bone

Inner rim of HIGH SI-

edema/hypervascular granulation tissue


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OsteonecrosisOsteonecrosis of Femoral Headof Femoral Head

�� Most common site affected by Most common site affected by osteonecrosisosteonecrosis

�� SusceptabilitySusceptability

�� Large area covered by Large area covered by articulararticular cartilage which limits cartilage which limits

arterial inflow and venous outflowarterial inflow and venous outflow

�� Venous outflow from femoral head is restricted at Venous outflow from femoral head is restricted at

the much narrower the much narrower metaphysealmetaphyseal neck and neck and

predisposes to increased predisposes to increased intramedullaryintramedullary pressure.pressure.

�� Has large weight bearing stresses which lead to local Has large weight bearing stresses which lead to local

high marrow pressurehigh marrow pressure

�� Vascular supply susceptible to traumatic interruptionVascular supply susceptible to traumatic interruption

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Patient 1Patient 1

�� HxHx::

�� 30 year old female with history of 30 year old female with history of sarcoidsarcoid and and

corticosteroid treatment.corticosteroid treatment.

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Patient 1 Frontal RadiographPatient 1 Frontal Radiograph

Courtesy of Dr. HallNo definite abnormality

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Patient 1Patient 1-- Frog Leg View Left HipFrog Leg View Left Hip

•Flattening of Femoral head•Secondary to subchondral fracture and collapse

Courtesy of Dr. Hall

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Patient 1 MRI T1W Coronal imagesPatient 1 MRI T1W Coronal images

Subchondral

band of

Hypointense SI

Psoas M.

Iliacus M.

Gluteus Minimus M.

Acetabulum M.

ObturatorExternus M.

Pectenius M.


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Ring pattern

of

Hypointense

SI

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OsteonecrosisOsteonecrosis of Femoral of Femoral condylescondyles�� SpontaneusSpontaneus (Idiopathic) (Idiopathic) osteonecrosisosteonecrosis of kneeof knee

�� Occurs in elderlyOccurs in elderly-- typically women > 60yrstypically women > 60yrs

�� Presents with spontaneous onset of severe painPresents with spontaneous onset of severe pain

�� Typically affects only the medial femoral Typically affects only the medial femoral condylecondyle

�� Secondary Secondary osteonecrosisosteonecrosis of knee of knee

�� Younger populationYounger population

�� Presents with vague onset of knee painPresents with vague onset of knee pain

�� More commonly bilateral and multifocalMore commonly bilateral and multifocal

�� Equal involvement of medial and lateral Equal involvement of medial and lateral condylescondyles

�� OsteonecrosisOsteonecrosis in in hemopoietichemopoietic cell transplantationcell transplantation

�� Presence of graft versus host disease and duration of Presence of graft versus host disease and duration of

corticosteroid use are risk factorscorticosteroid use are risk factors

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Index PatientIndex Patient

�� HxHx::

�� 45 year old female with history of AML 45 year old female with history of AML s/ps/p bone bone

marrow transplant, chemotherapy, corticosteroid marrow transplant, chemotherapy, corticosteroid

treatment, and graft versus host disease.treatment, and graft versus host disease.

�� Presents with left knee painPresents with left knee pain

�� Outside plain films show sclerosis of femoral Outside plain films show sclerosis of femoral

condylescondyles

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SagittalSagittal MRI T1W Images of KneeMRI T1W Images of Knee

Semimembranosus M.

Quadraceps M.

BIDMC

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Med. Femoral condyle

Tibia

BIDMC

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Normal

appearing

Ant. Horn

of Med.

MeniscusNormal Articular cartilage

Normal appearing

Post. Horn of Med. Meniscus

Inhomogenous

subchondral

hypointense SI pattern

BIDMC

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Osteonecrosis extending to

articular surface

BIDMC

27



Area of Hypointense

SI within Tibial

PlateuBIDMC

28



Serpingenous pattern of

Hypointense SI

BIDMC

29



Patella

Quadriceps TendonCortical Bone

PCL

Intrapatellar fat pad

BIDMC

30



BIDMC

Lateral femoral condyle

Area of inhomogenous low SI

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BIDMC

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T2W Coronal Images of KneeT2W Coronal Images of Knee

Anterior ViewAnterior View

Med. Femoral Condyle

Band of Hypointense SI

adjacent to band of High SI

BIDMC

33



BIDMC

Homogenous area of low

SI in Medial condyle

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BIDMC

35



Double line sign

BIDMC

36



Double line sign

BIDMC

Osteonecrosis

extending into

posterior aspect of

femoral condyles

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STIR ImageSTIR Image

�� STIR(ShortSTIR(Short T1 inversion recovery) T1 inversion recovery) imagesimages

�� Detects bone edemaDetects bone edema

�� Suppresses marrow fat signalSuppresses marrow fat signal

�� Strong signal for granulation tissue Strong signal for granulation tissue and joint fluidand joint fluid

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Index Patient STIR imageIndex Patient STIR image

Serpiginous High SI margin with central Fat SI

BIDMC

Typical appearance of

Osteonecrosis on STIR images

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SummarySummary

�� Corticosteroid use is a common cause of Corticosteroid use is a common cause of osteonecrosisosteonecrosis

�� MRI is the most sensitive and specific imaging MRI is the most sensitive and specific imaging

technique for detecting technique for detecting osteonecrosisosteonecrosis

�� Necrotic tissue has Necrotic tissue has hypointensehypointense SI on T1W and T2W SI on T1W and T2W

imagesimages

�� Double line sign on T2W MR images is diagnosticDouble line sign on T2W MR images is diagnostic

�� STIR images show bone edema, and STIR images show bone edema, and hypervascularizedhypervascularized

granulation tissue has High SI, while fat has low SIgranulation tissue has High SI, while fat has low SI..

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ReferencesReferences

�� GillespyGillespy III T, III T, GenantGenant H, Helms CA. H, Helms CA. Radiologic Clinics of North AmericaRadiologic Clinics of North America 1986; Vol. 24, 1986; Vol. 24,

No.2: 193No.2: 193--208.208.

�� LecouverLecouver FE, FE, VandeVande Berg BC, Berg BC, MaldagueMaldague BE, et al. Early Irreversible BE, et al. Early Irreversible OsteonecrosisOsteonecrosis

VerususVerusus Transient Lesions of the Femoral Transient Lesions of the Femoral CondylesCondyles: Prognostic Value of : Prognostic Value of SubchondralSubchondral

Bone and Marrow Changes on MR Imaging. Bone and Marrow Changes on MR Imaging. American Journal of American Journal of RoentgenologyRoentgenology 1998; 1998; VolVol

170, No 1: 71170, No 1: 71--77.77.

�� Lufkin RB. Magnetic Resonance Imaging of Joints and Extremities.Lufkin RB. Magnetic Resonance Imaging of Joints and Extremities. Hurley, editor. Hurley, editor. The The

MRI Manual Second Edition. MRI Manual Second Edition. USA: Mosby; 1998. 407USA: Mosby; 1998. 407--423.423.

�� SainiSaini A, A, SaifuddinSaifuddin A. MRI of A. MRI of OsteonecrosisOsteonecrosis. . ClinClin RadiologyRadiology 20004; 59: 107920004; 59: 1079--10931093

�� Stevens K, Tao C, Lee S, et al. Stevens K, Tao C, Lee S, et al. SubchondralSubchondral Fractures in Fractures in OsteonecrosisOsteonecrosis of the Femoral of the Femoral

Head: Comparison of Radiography, CT, and MRI Imaging. Head: Comparison of Radiography, CT, and MRI Imaging. American Journal of American Journal of

RoentgenologyRoentgenology 2003; 180: 3632003; 180: 363--368368

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AcknowledgementsAcknowledgements

�� Ferris Hall, MDFerris Hall, MD

�� Eric Eric NiendorfNiendorf, MD, MD

�� Gillian Lieberman, MDGillian Lieberman, MD

�� Pamela Pamela LepkowskiLepkowski

�� Larry Larry BarbarasBarbaras

mri assessment of osteonecrosis

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