mri assessment of osteonecrosis
TRANSCRIPT
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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Luis Corrales, HMS IIIGillian Lieberman, MD
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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Luis Corrales, HMS IIIGillian Lieberman, MD
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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Luis Corrales, HMS IIIGillian Lieberman, MD
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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Luis Corrales, HMS IIIGillian Lieberman, MD
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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Luis Corrales, HMS IIIGillian Lieberman, MD
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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Luis Corrales, HMS IIIGillian Lieberman, MD
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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Luis Corrales, HMS IIIGillian Lieberman, MD
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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Luis Corrales, HMS IIIGillian Lieberman, MD
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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Luis Corrales, HMS IIIGillian Lieberman, MD
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
Saini A, Saifuddin A. MRI of Osteonecrosis. Clin Radiology 2004; 59: 1079-1093
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Luis Corrales, HMS IIIGillian Lieberman, MD
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
Saini A, Saifuddin A. MRI of Osteonecrosis. Clin Radiology 2004; 59: 1079-1093
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Luis Corrales, HMS IIIGillian Lieberman, MD
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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Luis Corrales, HMS IIIGillian Lieberman, MD
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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Luis Corrales, HMS IIIGillian Lieberman, MD
Patient 1 Frontal RadiographPatient 1 Frontal Radiograph
Courtesy of Dr. HallNo definite abnormality
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Luis Corrales, HMS IIIGillian Lieberman, MD
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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Luis Corrales, HMS IIIGillian Lieberman, MD
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.
Courtesy of Dr. Hall
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Luis Corrales, HMS IIIGillian Lieberman, MD
Patient 1 MRI T1W Coronal imagesPatient 1 MRI T1W Coronal images
Courtesy of Dr. Hall
Ring pattern
of
Hypointense
SI
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Luis Corrales, HMS IIIGillian Lieberman, MD
Patient 1 MRI T1W Coronal imagesPatient 1 MRI T1W Coronal images
Courtesy of Dr. Hall
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Luis Corrales, HMS IIIGillian Lieberman, MD
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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Luis Corrales, HMS IIIGillian Lieberman, MD
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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Luis Corrales, HMS IIIGillian Lieberman, MD
SagittalSagittal MRI T1W Images of KneeMRI T1W Images of Knee
Semimembranosus M.
Quadraceps M.
BIDMC
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Luis Corrales, HMS IIIGillian Lieberman, MD
SagittalSagittal MRI T1W Images of KneeMRI T1W Images of Knee
Med. Femoral condyle
Tibia
BIDMC
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Luis Corrales, HMS IIIGillian Lieberman, MD
SagittalSagittal MRI T1W Images of KneeMRI T1W Images of Knee
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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Luis Corrales, HMS IIIGillian Lieberman, MD
SagittalSagittal MRI T1W Images of KneeMRI T1W Images of Knee
Osteonecrosis extending to
articular surface
BIDMC
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Luis Corrales, HMS IIIGillian Lieberman, MD
SagittalSagittal MRI T1W Images of KneeMRI T1W Images of Knee
Area of Hypointense
SI within Tibial
PlateuBIDMC
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Luis Corrales, HMS IIIGillian Lieberman, MD
SagittalSagittal MRI T1W Images of KneeMRI T1W Images of Knee
Serpingenous pattern of
Hypointense SI
BIDMC
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Luis Corrales, HMS IIIGillian Lieberman, MD
SagittalSagittal MRI T1W Images of KneeMRI T1W Images of Knee
Patella
Quadriceps TendonCortical Bone
PCL
Intrapatellar fat pad
BIDMC
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Luis Corrales, HMS IIIGillian Lieberman, MD
SagittalSagittal MRI T1W Images of KneeMRI T1W Images of Knee
BIDMC
Lateral femoral condyle
Area of inhomogenous low SI
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Luis Corrales, HMS IIIGillian Lieberman, MD
SagittalSagittal MRI T1W Images of KneeMRI T1W Images of Knee
BIDMC
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Luis Corrales, HMS IIIGillian Lieberman, MD
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
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Luis Corrales, HMS IIIGillian Lieberman, MD
T2W Coronal Images of KneeT2W Coronal Images of Knee
BIDMC
Homogenous area of low
SI in Medial condyle
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Luis Corrales, HMS IIIGillian Lieberman, MD
T2W Coronal Images of KneeT2W Coronal Images of Knee
BIDMC
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Luis Corrales, HMS IIIGillian Lieberman, MD
T2W Coronal Images of KneeT2W Coronal Images of Knee
Double line sign
BIDMC
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Luis Corrales, HMS IIIGillian Lieberman, MD
T2W Coronal Images of KneeT2W Coronal Images of Knee
Double line sign
BIDMC
Osteonecrosis
extending into
posterior aspect of
femoral condyles
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Luis Corrales, HMS IIIGillian Lieberman, MD
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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Luis Corrales, HMS IIIGillian Lieberman, MD
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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Luis Corrales, HMS IIIGillian Lieberman, MD
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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Luis Corrales, HMS IIIGillian Lieberman, MD
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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Luis Corrales, HMS IIIGillian Lieberman, MD
AcknowledgementsAcknowledgements
�� Ferris Hall, MDFerris Hall, MD
�� Eric Eric NiendorfNiendorf, MD, MD
�� Gillian Lieberman, MDGillian Lieberman, MD
�� Pamela Pamela LepkowskiLepkowski
�� Larry Larry BarbarasBarbaras