With the advent of new treatments for articular cartilage disorders, accurate noninvasive assessment of articular cartilage, particularly with MR imaging, has become important. Understanding the MR imaging features of articular cartilage has led to the development of two types of routinely available MR imaging techniques which have demonstrated clinical accuracy and interobserver reliability.

The purpose of this review article is to present the advantages and limitations of magnetic resonance imaging (MRI), computed tomography (CT) and arthrography for evaluating articular pathology. Techniques, patient selection, indications and contraindications for each modality are reviewed.

Summary T0 assess the accuracy of cartilage thickness measurements in magnetic resonance imaging (MRI), we compared data ::o]~tained by cartilage thickness measurements in MRI with corresponding histological sections of 14 human proximal tibial articular surfaces. Each proximal tibial articular surface was cut into five medial and lateral slices and each of these slices was divided into three sectors providing 420 sectors, 406 of which were evaluated in our study. The overall correlation coefficient (r) was 0.96. Topographical differences were found. The lowest correlation coefficient in our series was observed in the anterior part of the medial tibial plateau (r = 0.88). Cartilage thickness measurements in MRI were more accurate in cartilage thicker than 2 mm (r = 0.94) than in thinner cartilage layers (r = 0.73). There were no significant differences in cartilage thickness measurements in different grades of osteoarthritis. However, the mean percentage difference between cartilage thickness in MRI and histology was about 10% in our series.

Recently developed magnetic resonance (MR) imaging techniques allow accurate detection of moderate- and high-grade articular cartilage defects. There has been increased interest in MR imaging of articular cartilage in part because it is useful in identifying patients who may benefit from new articular cartilage replacement therapies, including chondrocyte transplantation, improved techniques for osteochondral transplantation, chondroprotective agents, and cartilage growth stimulation factors. The modality also has the potential to play an important role in the follow-up of patients during and after treatment. Detection of articular cartilage defects is beneficial for patients undergoing arthroscopy for other injuries, such as meniscal tears, because the presence of articular cartilage injury worsens prognosis and may modify therapy options.

RATIONALE AND OBJECTIVES The authors assess the accuracy of three-dimensional (3D) computer representations based on magnetic resonance images of articular cartilage lesions, using actual cartilage lesions as reference standards. METHODS Grade 2 and grade 3 articular lesions were created on articular surfaces of five porcine knee joints. The knees were then imaged using 3D fat-suppressed SPGR acquisition at four different slice thicknesses. Magnetic resonance imaging data sets were transferred to a computer workstation for image processing and 3D reconstruction. Lesion dimensions (length, width, and depth) based on the 3D reconstructed image were compared with the dimensions measured using actual lesions. RESULTS The average percent error of lesion length, width, and depth based on the 3D images ranged from approximately 8% to 12% when using the thinnest magnetic resonance slice thickness (0.7 mm). CONCLUSIONS Three-dimensional reconstructed images derived from thin-slice magnetic resonance imaging can provide reasonable representations of true articular cartilage lesion dimensions.

Preliminary results from in vivo sodium MRI of human patellar articular cartilage are presented. Sodium images generated of an in vitro bovine patella clearly distinguish the region of proteoglycan depletion from the region of healthy cartilage. This provides the first evidence that sodium imaging may be used to detect changes due to osteoarthritis in vivo. The process of optimizing imaging time and signal‐to‐noise ratio, as well as potential implications in the detection of osteoar‐thritic change, are discussed.

Powerful techniques with MR imaging are being developed for evaluating articular cartilage. Pharmaceutical and biotechnology development is driven largely by the search for novel therapeutic solutions to the growing problem of arthritis in our aging society. Accordingly, imaging tools that will be used to direct patients to specific therapies and then to monitor treatment effectiveness and safety presently are being refined and validated in rigorous multicenter and multinational clinical trials aimed at gaining regulatory approval. As trials approach completion, radiologists can anticipate an increased demand for expertise and experience in evaluating articular cartilage disorders. This article reviews this novel mechanism for evolving imaging techniques for clinical use through clinical drug trials, lists the most promising MR imaging markers available for evaluating cartilage integrity, and speculates on how these techniques will find their way into clinical practice.

PURPOSE To prospectively assess T2 mapping characteristics of normal articular cartilage and of cartilage at sites of arthroscopic repair, including comparison with histologic results and collagen organization assessed at polarized light microscopy (PLM). MATERIALS AND METHODS Study protocol was compliant with the Canadian Council on Animal Care Guidelines and approved by the institutional animal care committee. Arthroscopic osteochondral autograft transplantation (OAT) and microfracture arthroplasty (MFx) were performed in knees of 10 equine subjects (seven female, three male; age range, 3-5 years). A site of arthroscopically normal cartilage was documented in each joint as a control site. Joints were harvested at 12 (n = 5) and 24 (n = 5) weeks postoperatively and were imaged at 1.5-T magnetic resonance (MR) with a 10-echo sagittal fast spin-echo acquisition. T2 maps of each site (21 OAT harvest, 10 MFx, 12 OAT plug, and 10 control sites) were calculated with linear least-squares curve fitting. Cartilage T2 maps were qualitatively graded as "organized" (normal transition of low-to-high T2 signal from deep to superficial cartilage zones) or "disorganized." Quantitative mean T2 values were calculated for deep, middle, and superficial cartilage at each location. Results were compared with histologic and PLM assessments by using kappa analysis. RESULTS T2 maps were qualitatively graded as organized at 20 of 53 sites and as disorganized at 33 sites. Perfect agreement was seen between organized T2 and histologic findings of hyaline cartilage and between disorganized T2 and histologic findings of fibrous reparative tissue (kappa = 1.0). Strong agreement was seen between organized T2 and normal PLM findings and between disorganized T2 and abnormal PLM findings (kappa = .92). Quantitative assessment of the deep, middle, and superficial cartilage, respectively, showed mean T2 values of 53.3, 58.6, and 54.9 msec at reparative fibrous tissue sites and 40.7, 53.6, and 61.6 msec at hyaline cartilage sites. A significant trend of increasing T2 values (from deep to superficial) was found in hyaline cartilage (P < .01). Fibrous tissue sites had no significant change with depth (P > .59). CONCLUSION Qualitative and quantitative T2 mapping helped differentiate hyaline cartilage from reparative fibrocartilage after cartilage repair at 1.5-T MR imaging.

PURPOSE To assess dual-detector spiral CT arthrography in the evaluation of the entire knee cartilage obtained from cadavers. MATERIALS AND METHODS Two independent observers characterized articular cartilage in 12 cadaver knees in which MR imaging and dual-detector spiral CT arthrography were performed and compared their findings to those found during macroscopic assessment. The sensitivity and specificity of MR imaging and spiral CT arthrography for detecting grade 2A or higher and grade 2B or higher cartilage lesions, the Spearman correlation coefficient between arthrographic and macroscopic grading, and kappa statistics for assessing interobserver reproducibility were determined. RESULTS At spiral CT arthrography, sensitivities and specificities ranged between 80% and 88% for the detection of grade 2A or higher cartilage lesions and ranged between 85% and 94% for the detection of grade 2B or higher cartilage lesions. At MR imaging, sensitivities and specificities ranged between 78% and 86% and between 76% and 91% for the detection of grade 2A or higher and grade 2B or higher cartilage lesions, respectively. Spearman correlation coefficients between spiral CT arthrography or MR imaging and macroscopic grading of articular surfaces were 0.797 and 0.702, respectively. CONCLUSION Dual-detector spiral CT arthrography of the knee is a valuable method for the assessment of open cartilage lesions of the entire knee.

OBJECTIVE We studied healthy volunteers with fat-suppressed three-dimensional (3D) spoiled gradient-recalled acquisition in the steady state (SPGR) to determine parameters that maximize positive contrast between knee articular cartilage and fluid, marrow fat, and muscle; and we compared the technique with conventional MR imaging sequences. The purpose was to determine if fat-suppressed 3D SPGR imaging is useful for detecting abnormalities of the articular cartilages. SUBJECTS AND METHODS The knees of 10 healthy volunteers were imaged in the axial plane. Fat-suppressed 3D SPGR imaging was performed with a TR of 60 msec, a TE ranging from 5 to 15 msec, and a flip angle ranging from 20 degrees to 80 degrees. This was followed by a similar set of fat-suppressed two-dimensional (2D) SPGR images, and conventional T1- and T2-weighted spin-echo and multiplanar gradient studies. Contrast-to-noise (C/N) ratios were determined for cartilage versus a saline fluid phantom, marrow fat, and muscle. Optimal parameters were determined both quantitatively and by a blinded subjective analysis. RESULTS A TE of 5 msec and a flip angle of 40 degrees demonstrated the greatest C/N ratio between the signals for cartilage and for fluid, marrow, and muscle. C/N ratios in the 3D sequences were higher than in the 2D, spin-echo, and gradient series, although the absolute C/N ratio values for the T2-weighted spin-echo sequence were higher than those for the 3D fat-suppressed SPGR sequence. Subjective analysis showed articular cartilage to have a consistent trilaminar appearance, and independent interpreters favored a 3D fat-suppressed SPGR sequence with a TE of 5 msec and a flip angle of 40 degrees. Three subjects with incidental joint fluid had C/N ratios within a 95% confidence range for cartilage versus the fluid phantom. CONCLUSION When a fat-suppressed 3D SPGR sequence of 60/5/40 degrees (TR/TE/flip angle) is used, MR images can show high positive contrast between articular hyaline cartilage and adjacent structures. This convenient technique is different from standard MR imaging sequences because it demonstrates greater signal intensity in cartilage than in fluid, marrow fat, and muscle, and because it consistently shows an organized internal architecture of hyaline cartilage. Fat-suppressed 3D SPGR imaging therefore has promise for detecting abnormalities of the articular cartilage.

OBJECTIVE This study assessed the three-dimensional accuracy of magnetic resonance imaging (MRI) for measuring articular surface topographies and cartilage thicknesses of human cadaveric knee joints, by comparison with the calibrated stereophotogrammetric (SPG) method. METHODS Six fresh frozen cadaveric knees and the knees of four volunteers were imaged with a three-dimensional spoiled gradient-recalled acquisition with fat suppression using a linear extremity coil in a 1.5 T superconducting magnet. The imaging voxel size was 0.47 x 0.47 x 1.0 mm. Both a manual and a semi-automated segmentation method were employed to extract topographic measurements from MRI. Following MRI, each of the six cadaveric knees was dissected and its articular surfaces quantified using stereophotogrammetry. The MRI surface measurements were compared numerically with the SPG measurements. RESULTS For six cadaveric knees, the average accuracies of cartilage and subchondral bone surface measurements were found to be 0.22 mm and 0.14 mm respectively and the thickness measurements demonstrated an average accuracy of 0.31 mm. It was found that while most of the error may be attributed to random measurement error, the accuracy was somewhat affected by systematic errors. For each bone of the knee, accuracies were most favorable in the patella, followed by the femur and then the tibia. The more efficient semi-automated method provided equally good and sometimes better accuracies than manual segmentation. CONCLUSIONS This study demonstrates that clinical MRI can provide accurate measurements of cartilage topography, thickness, contact areas and surface curvatures of the knee.

OBJECTIVE The purpose of this work was to evaluate the results from sodium and proton magnetic resonance imaging (MRI) in detecting small changes in proteoglycan (PG) content in bovine articular cartilage specimens. DESIGN Articular cartilage from 15 specimens of bovine patellae were subjected to partial PG depletion with different concentrations of trypsin for 30 min. Sodium and proton MR images of the intact specimen were obtained on a 4T GE clinical MRI system. Two custom-built 7 cm-diameter solenoid coils tuned to proton and sodium frequencies were employed. Fast gradient echo and spin echo imaging sequences were used to determine sodium density, proton density and proton relaxation times (T(1)and T(2)) of the specimens. Spectrophotometric assay was performed after MRI to determine PG concentrations of the cartilage specimens. RESULTS The sodium signal change correlated well with the observed PG loss (R(2)=0.85, P< 0.01) whereas the proton signal change was inconsistent (R(2)=0.10, P< 0.8). The change in proton T(1)and T(2)between the two regions did not correlate with PG loss (R(2)=0. 07 and R(2)=0.06, respectively). CONCLUSIONS Results from these studies demonstrate that sodium MRI is both sensitive and specific in detecting small changes in PG concentration, whereas proton density and relaxation properties are not sensitive to small changes in PG content.

OBJECTIVE The purpose of this article is to review the current understanding of the MRI appearance of articular cartilage and its relationship to the microscopic and macroscopic structure of articular cartilage, the optimal pulse sequences to be used in imaging, the appearance of both degenerative and traumatic chondral lesions, the appearance of the most common cartilage repair procedures, and future directions and developments in cartilage imaging. CONCLUSION Articular cartilage plays an essential role in the function of the diarthrodial joints of the body but is frequently the target of degeneration or traumatic injury. The recent development of several surgical procedures that hold the promise of forming repair tissue that is hyaline or hyalinelike cartilage has increased the need for accurate, noninvasive assessment of both native articular cartilage and postoperative repair tissue. MRI is the optimal noninvasive method for assessment of articular cartilage.

OBJECTIVE The purpose of our study was to evaluate several commonly used MR sequences to determine how accurately each demonstrates the thickness of the articular cartilage of the humeral head. MATERIALS AND METHODS Ten cadaveric shoulders (age at death, 58-92 years; mean, 79 years) were imaged with fat-suppressed transaxial T1-weighted spin-echo three-dimensional gradient-recalled sequences, both before and after injection of 12 ml of diluted gadopentetate dimeglumine. Articular cartilage was measured to the nearest 10th of a millimeter on the MR images and corresponding anatomic sections. RESULTS Cartilage could not be differentiated from surrounding structures in 14 of 112 locations (13%) on the spin-echo images obtained without contrast material, in 4 of 112 locations (4%) on the spin-echo images obtained with contrast material, in 4 of 112 locations (4%) on the gradient-echo images obtained without contrast material, and in 6 of 112 locations (5%) on the gradient-echo images obtained with contrast material. Mean true cartilage thickness was 1.23 mm (SD, 0.52 mm). The mean MR-anatomic differences (absolute values) were 0.38 mm for the spin-echo images obtained without contrast material, 0.42 mm for the spin-echo images obtained with contrast material, 0.49 mm for the gradient-echo images obtained without contrast material, and 0.37 mm for the gradient-echo images obtained with contrast material. There was a tendency to overestimate thin cartilage and to underestimate thick cartilage. CONCLUSION Several of the routinely used MR sequences, with and without intraarticular contrast medium, may cause errors in the assessment of the articular cartilage of the humeral head. Some of these errors result from either insufficient contrast between cartilage and surrounding structures or inadequately concentrated contrast medium.

OBJECTIVE Previous studies suggest that MR imaging is capable of providing accurate data on knee joint cartilage volume and thickness in vitro, but the reproducibility of these data in living subjects has not been analyzed rigorously. Our aim was therefore to determine the in vivo reproducibility of volume and thickness measurements from replicated data sets, applying three-dimensional (3D) postprocessing methods. SUBJECTS AND METHODS Eight healthy volunteers were imaged six times at a resolution of 2 x 0.31 x 0.31 mm with a fat-suppressed fast low-angle shot 3D sequence, the knee being repositioned in between replicated examinations. Three-dimensional reconstructions of the articular cartilage surfaces were obtained from sagittal data sets, and the cartilage volumes were calculated. The thickness distribution was analyzed throughout the joint surfaces independent of the section orientation, using a previously validated 3D minimal-distance algorithm. RESULTS In the volunteers, the coefficient of variation for replicated volume measurements ranged from 1.3% (patella) to 3.4% (lateral tibia), and the standard deviation of the individual cartilage volumes ranged from +/- 16% (lateral tibia) to +/- 22% (femur). The intraclass correlation coefficient ranged from .959 (lateral tibia) to .995 (patella). The interobserver evaluation was similar to the interscan reproducibility. The mean interscan deviation of the maximal cartilage thickness interval ranged from 0.1 to 0.3 cartilage thickness intervals (of 0.5 mm); only in rare cases did we record deviations greater than one thickness interval. CONCLUSION MR imaging can be used to determine cartilage volume and thickness in the knee joints of living subjects with high precision, provided that a fat-suppressed gradient-echo sequence with adequate resolution and 3D digital image processing are used.

OBJECTIVE Our objective was to assess the diagnostic ability of MDCT arthrography for acetabular and femoral cartilage lesions in patients with hip dysplasia. MATERIALS AND METHODS A disorder of the articular cartilage was evaluated in 20 hips of 18 patients with acetabular dysplasia who did not have osteoarthritis or who had early stage osteoarthritis before undergoing pelvic osteotomy surgery. The findings on fat-suppressed 3D fast spoiled gradient-echo MRI and MDCT arthrography of the hip were evaluated by two independent observers, and sensitivity, specificity, and accuracy were determined using arthroscopic findings as the standard of reference. Kappa values were calculated to quantify the level of interobserver agreement. RESULTS The sensitivity and specificity for the detection of any cartilage disorder (grade 1 or higher) were (observer 1/observer 2) 49%/67% and 89%/76%, respectively, on MRI, and 67%/67% and 89%/82%, respectively, on CT arthrography. The sensitivity and specificity for the detection of cartilage lesions with substance loss (grade 2 or higher) were (observer 1/observer 2) 47%/53% and 92%/87%, respectively, on MRI, and 70%/79% and 93%/94%, respectively, on CT arthrography. CT arthrography provided significantly higher sensitivity in the detection of grade 2 or higher lesions than MRI for both observers. Interobserver agreement in the detection of grade 2 or higher cartilage lesions was moderate (kappa = 0.53) on MRI and substantial (kappa = 0.78) on CT. CONCLUSION MDCT arthrography is a sensitive and reproducible method for assessing articular cartilage lesions with substance loss in patients with hip dysplasia.

Magnetic resonance imaging of amputated human knees was performed to determine optimal sequences for depicting articular cartilage. 24 knees were examined with eight different sequences in a 1.0 T imager. Each cartilage lesion was graded from 1 to 4 (Outerbridge staging system). The results of each sequence were compared with the macroscopic findings and statistically tested against each other. The FLASH sequence (TR = 50 ms) with combination of flip angle of 40 degrees and echo time of 10 ms and the FISP sequence (TR = 40 ms) with combination of flip angle of 40 degrees and echo time of 11 ms were best for depicting cartilage structure and internal detail. There was no significant difference between fat-saturated three-dimensional FLASH (FS-3D-FLASH) and FS-3D-FISP (p = 0.05). These FS-3D sequences were significantly better than sequences without fat saturation (p = 0.05). There was no significant difference between magnetization transfer (MT) 3D-FLASH, MT-3D-FISP and 3D-FISP. All 3D sequences showed significantly (p = 0.05) better results than spin echo or fast spin echo sequences. The T1 weighted SE pulse sequence was significantly (p = 0.005) better than the T2 weighted TSE sequence. Fast T2 weighted spin echo was not suitable for early and accurate detection of cartilage lesions.

Magnetic resonance (MR) imaging has been widely used to evaluate the thickness and volume of articular cartilage both in vivo and in vitro. While morphological information on the cartilage can be obtained using MR images, image processing for extracting geometric boundaries of the cartilage may introduce variations in the thickness of the cartilage. To evaluate the variability of using MR images to construct finite element (FE) knee cartilage models, five investigators independently digitized the same set of MR images of a human knee. The topology of cartilage thickness was determined using a minimal distance algorithm. Less than 8 percent variation in cartilage thickness was observed from the digitized data. The effect of changes in cartilage thickness on contact stress analysis was then investigated using five FE models of the knee. One FE model (average FE model) was constructed using the mean values of the digitized contours of the cartilage, and the other four were constructed by varying the thickness of the average FE model by +/- 5 percent and +/- 10 percent, respectively. The results demonstrated that under axial tibial compressive loading (up to 1,400 N), variations of cartilage thickness caused by digitization of MR images may result in a difference of approximately 10 percent in peak contact stresses (surface pressure, von Mises stress, and hydrostatic pressure) in the cartilage. A reduction of cartilage thickness caused increases of contact stresses, while an increase of cartilage thickness reduced contact stresses. Furthermore, the effect of variation of material properties of the cartilage on contact stress analysis was investigated. The peak contact stress increased almost linearly with the Young's modulus of the cartilage. The peak von Mises stress was dramatically reduced when the Poisson,s ratio was increased from 0.05 to 0.49 under an axial compressive load of 1,400 N, while peak hydrostatic pressure was dramatically increased. Peak surface pressure was also increased with the Poisson's ratio, but with a lower magnitude compared to von Mises stress and hydrostatic pressure. In conclusion, the imaging process may cause 10 percent variations in peak contact stress, and the predicted stress distribution is sensitive to the accuracy of the material properties of the cartilage model, especially to the variation of Poisson's ratio.

Knee cartilage topography, thickness, and contact areas from MRI: in-vitro calibration and in-vivo measurements B Z A. C, D M. MC*, S. D K, P L, F F, E J. C  G A. A Departments of Mechanical Engineering and Orthopaedic Surgery, Columbia University, New York, NY and *Department of Radiology, Columbia University, New York, NY

Excised patellar cartilage phantoms with artificial surface lesions were imaged in a 2 g/dl albumin solution to determine the effect of cartilage/fluid contrast on detection of early degenerative change. Surface lesions consisted of full‐thickness holes, superficial grooves, and coarse abrasion. Phantoms were imaged with a T1‐weighted fast low‐angle shot (FLASH) and T2*‐weighted dual‐echo in the steady state (DESS) sequence. Although both sequences were able to identify full‐thickness holes, they underestimated the presence of superficial grooves and extent of fibrillation. Despite greater bulk tissue contrast between cartilage and fluid for the FLASH sequence, detection of fibrillation was poorer compared with the DESS images. The results of this study suggest that surface properties of fibrillated cartilage contribute significantly to the insensitivity of magnetic resonance imaging in detecting superficial lesions. In contrast to previous papers suggesting that T1‐weighted spoiled gradient‐echo imaging provides the greatest accuracy for lesion detection, our results indicate that, in the presence of joint fluid, T2*‐weighted imaging increases detection of superficial lesions. J. Magn. Reson. Imaging 1999;10:178–182. © 1999 Wiley‐Liss, Inc.