mri evaluation of cartilage - east melbourne | mri · • dwi • dti ... 2009 jan 20. ajr am j...
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MRI EVALUATION OF CARTILAGE
George Koulouris
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INTRODUCTION
• Anatomicimagingnotsufficient• Currenttechniquesdetectestablishedcar=lagedefectsandsubchondralchange(BME&cyst)
• Earlyinterven=onofcar=lageimaging&noveltreatments– demandforfunc=onal/biochemicalimaging– needtoimageearlycar=lagebreakdown
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RECENTINNOVATIONS
• T2Mapping • T1rhoimaging
• DWI
• DTI
• dGEMRIC(delayedgadoliniumMRIofcar=lage)currentlyonlytechniqueproventobepredic=veforfuturejointdegenera=on
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CARTILAGE
• CHONDROCYTES:(1‐2%)
• EXTRACELLULARMATRIX:
• Solid Proteoglycans(5‐10%) Collagens‐TypeII(15‐20%)
• FluidWater(70‐80%)
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COLLAGENNETWORK
• Proteoglycan: • draws water &
maintains osmotic pressure
• counteracts swelling pressures
• provides force in tension & shear
• resists compression
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• Extensivepolysaccharidechains• Formlargecomplexesofnega=velychargedproteoglycans
• maintain:– osmo=cpressure– fluidwithinthecar=lagematrix
– compressives=ffness
GLYCOSAMINOGLYCANS(GAG)
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GLYCOSAMINOGLYCANS(GAG)
• Car=lagebehavesasas=ffelas=cpolymertosuddenimpact
• Slowviscoelas=cdeforma=ontosustainedloading
• GAGlossisaknownearlyeventintheprogressionofOA
• ?earlybreakdownreversible
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dGEMRIC
• assessesearlycar=lagedamageasGAGlosspriortodevelopmentofmacroscopiccar=lagedefects
• nega=velychargedMRIcontrast(Gadolinium;Gd),(IVorintra‐ar=cular)isrepelledbynega=velychargedGAG
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―=Gadolinium
=GAG
dGEMRIC
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• lessGAGincar=lagelessnega=vechargerela,vetonormalcar=lagethemorethenega=velychargedcontrastwillpenetrateGAGdepletecar=lage(1)
• Gdpenetratesnormalcar=lage,high[GAG],inareciprocalmanner
dGEMRIC
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• ↑Gd↓T1value(MRIpropertyofGd)• Doublenega=ve:
↓[GAG]=↑Gd=↓T1↑[GAG]=↓Gd=↑T1
• [GAG]isdirectlypropor=onaltoT1value• T1value=T1relaxa=on=me=dGEMRICindex
dGEMRIC
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[GAG] = dGEMRIC index
TECHNIQUE
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TECHNIQUE
• IVGd–doubledose
• Exercise
• Wait30‐90minforpenetra=on(2)
• IAbeoerthanIV(3,4)
• T1mapsofcar=lagegenerated/manuallyplooed
• Nodifferencebetween1.5T&3T(5)
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VALIDATION
• Reproducible(6)
• Excellentinvitrocorrela=on(7)
• HigherdGEMRICindex(lessGd,higher[GAG])=higherresistancetomechanicalcompression(8,9)
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INTERPRETATION
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MARATHON
BEFORE 1DAY 1WEEK
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SHOULDERARTHROGRAM
HUMERALHEADdGEMRICINDEX GLENOIDdGEMRICINDEX
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• 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
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DYSPLASIA
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DYSPLASIA
• N=96dysplas=chipsOAdefinedas2SD<average,i.e.dGEMRIC<390msec
• MeandGEMRIC473cfnormalhipsof570[11]
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SUCFE
• 16pa=entsSUCFEfollowedupfor14.5years– T1valueslowerlaterallythancentrally– Goodcorrela=onbetweendGEMRICindex,painandalphaangles(degreeofoffset)[12]
• Perthe’sdisease:– lossofGAGmedially[13]
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SUCFE
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FAI
• Significantcorrela=onbetween:– dGEMRICindex– pain– alphaangle
• correla=onofdGEMRICwithalphaanglesuggeststhathipswithmorefemoraldeformityshowfeaturesofearlyOA[14]
• CamFAIlowerdGEMRICvaluesanterosuperiorly• PincerFAIgeneralizedcircumferen=alloss[15]
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ACLINJUREDKNEE
• dGEMRICevalua=onoftheACLinjuredkneeshows13%lowerdGEMRICindexinthemedialcompartmentwhencomparedwiththenormalcontralateralside[16]
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PCLINJURY
[17]
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KNEEDISLOCATION
[18]
MedialFacet LateralFacet
BilateralPatellarDisloca=on
411 426
UnilatDisloca=on–nondislocatedside
465 466
Normal 490 510
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• HigherGAGinfollowingMACIthanMFX[19]
CARTILAGERx
[19,20,21,22]
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• AlllowdGEMRICindexareasshowabnormalityonkneearthroscopy(N=16)[23]
• Kneepaininpa=entswithoutOAbutlowdGEMRICindexaremorelikelytodevelopradiographicallyevidentOAin6yrs[24]
• ValgusmalalignedknesslowerdGEMRICindexlaterallyandvarusknessmedially[25]
KNEEOA
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KNEEOA
• dGEMRICindexcorrelatesstronglywithkneeflexorandextensorstrength,sugges=ngthatstrongcoordinatedmusclesmayplayaroleinpreven=ngOA
• overweight&meniscetcomyareRFforOA–dGEMRICindex14%lower374vs437[26]
• ModerateincreaseindGEMRICindexofcar=lageinpa=entswithmoderateOA&whoexercise[27]
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OTHERJOINTS
• MatrixAssociatedAutologousChondrocyteImplanta=on(MACI)oftheankle[28]
• 1stCMCofthethumb[29]
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AFLAPPLICATIONS
• Knowninjury/congenital/developmentalissueinpoten=aldraycandidatewillFAIstanduptotherigorsofAFL?
• Assistsindiagnosisnocar=lagedefect,butisthatcamlesionsignificant?DoesthelowdGEMRICindexaccountforpain?Pubicsymphysis?
• ExplainsprolongedpaindespitenoapparentcausePostPCLinjury
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• Timingofreturntocompe==onPostbonebruising.Iswai=ngforBMEtoresolveinsufficient?
• Informedconsentregardingrisksofplayingvsre=rementArethereearlybutpermanentchangesindGEMRICindexpostmeniscectomy?
• Morerealis=cexpecta=onsfromplayer,club&medicalstafffollowinginjury?Decreasesfutureriskofli=ga=on
• Re=redAFLplayers&incidenceofOA
AFLAPPLICATIONS
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CONCLUSION
• dGMERICimagingvalidatedtechniqueinearlyGAGloss
• GAGloss:– precedesOA,?reversible– detectedbyGdpenetra=on&T1WI
• BestimagingpredictorofOA
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