(2009) Osteoarthritis and cartilage. Coronal (c) and sagittal (d) reformatted CBCT-A show a focal bony lesion with peripheral sclerosis in the distal tibia and talus. The fracture can be seen as irregular linear or curvilinear subchondral low signal intensity structure near the subchondral bone plate of low signal intensity in T1-weighted images and also sometimes, but not always in T2-weighted images 1,2,4-8. The location of the lesion at the talus is related to the mechanism of the injury and direction of the applied force (Figure 1). MRI-detected subchondral bone marrow signal alterations of the knee joint: terminology, imaging appearance, relevance and radiological differential diagnosis. Conventional radiography, Mortise View (b). Physical examination should include evaluation of local tenderness and swelling. The majority of those lesions occur in active patients and are related to trauma. Unstable lesions – if left untreated – predispose for early osteoarthritis. (2010) Clinical orthopaedics and related research. Subchondral bone involvement can be manifested by bone marrow edema (BME), fracture, sclerosis and/or cyst formation. Subchondral means under the cartilage and refers to fluid filled cavities within the bone that is under the cartilage. Therefore, for more accurate evaluation of cartilage covering of articular surfaces of the talar dome and distal tibia and fibula, direct arthrographic techniques combined with CT and MRI may be useful (Figure 2d). Note also partial filling of the subchondral cyst (black arrowhead) with contrast as an indirect sign of joint communication through a cartilage lesion. In particular cases also alternative diagnoses can be made on basis of CBCT (Figure 11). As MRI is inaccurate for the evaluation of the articular cartilage compartment, further staging with direct arthrographic techniques are often mandatory if an OCL is detected on MRI and in those scenarios in which arthrosopic treatment is considered. Similar to the Outerbridge classification widely used in staging of cartilage lesions of the knee, a modified staging system for evaluation of the depth of cartilage defects with correlation to arthroscopy may be used in the ankle (Figure 10). DOI: https://doi.org/10.1177/0363546508316773, Dipaola, JD, Nelson, DW and Colville, MR. Characterizing osteochondral lesions by magnetic resonance imaging. 2004; 233(3): 768–73. These cysts are produced in areas of damaged articular cartilage, subjacent to the underlying subarticular cortical plate. S2, 2017, p. 1. Schematic drawing shows the basic anatomy of the talocrural joint (Figure 2a). 4. There is slight irregular delineation of the cartilage (white arrow). Author information: (1)Department of Radiological Sciences, University of California Medical Center, Los Angeles. The overlying cartilage is difficult to assess on MRI but seems to be slightly inhomogeneous (white arrow). The accuracy also depends of the strength of the field and is lower on 1.5 Tesla magnets in comparison to 3T [11]. Subchondral cysts of the tibia secondary to osteoarthritis of … Although Conventional Radiography (CR) is still the initial diagnostic modality used for evaluation of ankle pain, later studies showed that 30–43% of talar OCL diagnosed on MRI were invisible on CR [5]. The articular cartilage layer of the talocrural joint is indicated in blue. In this regard, CBCT-Arthrography (CBCT-A) may be very promising technique for precise staging of cartilage lesions of the ankle as an alternative for Multi Detector Computed Tomography (MDCT). Although Magnetic Resonance Imaging (MRI) at 1.5 Tesla is the leading cross-sectional modality for detection and staging of OCL, lack of spatial resolution hampers accurate assessment of thin articular cartilage. DOI: http://doi.org/10.5334/jbr-btr.1377, Posadzy M, Desimpel J, Vanhoenacker FM. Stage 1 lesion according to Anderson classification. MRI is an excellent imaging tool, able to detect osteoarthritis indicators such as chondromalacia (with a magnet strength of 1.5 T, it has a sensitivity of 100% for grade III and IV lesions) 20, 21, subchondral edema, and subchondral cysts … Nowadays MR staging of OCL on MRI is usually done by the Anderson classification [9], which is another modification of the initial staging system based on plain film evaluation by Berndt and Harty (Figure 6). J Bone Joint Surg Br 1955;37:663. Subchondral insufficiency fractures are more common in elderly women 1,4,6. Example of improved visualization of communication of subchondral cysts with the joint through deep articular cartilage lesions on CBCT arthrography. This is not Kienbock's disease, where cystic changes develop more diffusely. Symptoms of subchondral cystic lesions can be mild to severe and can be of an acute onset. Coronal (b) and sagittal (c) reformatted CBCT-A show subtle subchondral sclerosis (black arrow) at the superolateral aspect of the talar dome, but the overlying cartilage is intact. DOI: https://doi.org/10.1155/2016/3594253, Posadzy, M., Desimpel, J. and Vanhoenacker, F.M., 2017. 1991; 7(1): 101–4. Ostlere SJ(1), Seeger LL, Eckardt JJ. 7. Posadzy M, Desimpel J, Vanhoenacker FM. The main reason for that is the fact that we need images with high spatial resolution to detect early changes of articular cartilage of the ankle joint. 2015; 44(8): 1111–7. A subchondral cyst without superficial cartilage damage is rare and requires a different approach. Case 2: subchondral insufficiency fracture, subchondral insufficiency fracture of the knee, directly visible subchondral trabecular discontinuity on high resolution, signs of subcortical impaction visible as subchondral hyperdensity, grade 2: bone marrow edema with low signal intensity fracture line, grade 3: fluid-filled fracture line and cysts, grade 4: cortical collapse with a step off, concave, smooth half-moon/crescentic appearing necrotic segment, usually in conjunction with chondral damage. Usually, subchondral fractures present as linear or curvilinear structures often paralleling the subchondral bone plate, with or without areas of subchondral collapse 2. Image Findings: Spondylosis deformans (Osteophytes and osseoous ridging), Intervetebral osteochondrosis (disc spcae narrowing, Intradiscal vaccum phenomenom, disc calcification, subchondral bone sclerosis, Schmorl nodes), Uncovertebral joint osteoarthritis (Sclerosis, hypertrophy, joint spce narrowing, subluxation, capsular laxity, synovial cyst) There are two theories of pathogenesis of subchondral cyst formation: the synovial fluid intrusion theory, which proposes that articular surface defects and increased intra-articular pressure allow intrusion of synovial fluid into the bone, leading to formation of cavities; and the bone contusion theory, according to which non-communicating cysts arise from subchondral foci of bone necrosis that are the … Despite the combination of these MR parameters, accurate cartilage evaluation remains often illusive. Due to its noninvasiveness, absence of radiation exposure and its ability to visualize associated concomitant soft tissue abnormalities, MRI is the initial technique for exclusion/confirmation of an osteochondral lesion of the ankle. Disqus. The purpose of this pictorial review is to illustrate the strength of each imaging method. In osteoarthritis, the overloading and the vascular obstruction within the subchondral bone leads to subchondral sclerosis, bone marrow edema and bleeding, and subchondral cysts. A subchondral fracture is a fracture of the trabecular cancellous bone just beneath the subchondral bone plate without disruption of the articular surface 1. These patients have inferior outcomes for arthroscopic treatment of FAI compared with patients with similar age and activity level without MRI subchondral … Moreover, despite several modifications of the staging systems on MRI, not all combination of the degree of involvement of the cartilage and subchondral bone are included and therefore these classification systems remain uncomprehensive, complicated and less valuable for use in daily routine. An alternative MRI staging system has been proposed by Mintz [8] et al. The area between the fracture line and the articular surface should be of high signal in T2 weighted images 2,4. The articular surface of the talus is large and its blood supply is critical in the watershed areas [1] explaining an impaired healing process and predisposition to posttraumatic necrosis in those vulnerable areas. On CBCT arthrographic images, the contrast separating the OCL fragment from the talar dome can be evaluated with more confidence (Figure 8). in 2003. This article highlights some of the causes and treatment options for Subchondral Bone Cysts. They can also occur in conjunction with twisting and ligamentous injuries. The exact pathogenesis of these degenerative cysts is not certain.26,27 Subchondral cysts are most often seen in association with osteoarthritis, but may occur as the result of degeneration or injury of the overlying articular cartilage by other causes. MRI is the most sensitive method to depict this stage without any correlating signs on CR or CBCT with injection of intraarticular contrast. More severe symptoms tend to occur in the radiographically more advan… DOI: http://doi.org/10.5334/jbr-btr.1377. Fluid-fluid levels, consistent with secondary formation of aneurysmal bone cysts, are seen in 14% of cases. (2012) Clinics in orthopedic surgery. Their walls consist of a cell layer resembling synovium, and the surrounding wall is osteosclerotic. The overlying cartilage is difficult to assess on MRI. Schematic drawing of the normal talocrural joint (a). 1999; 20(12): 789–93. A subchondral cyst (Fig. The first system of classification has been reported by Berndt and Harty in 1959 [4], including four stages based on their radiological appearance. CBCT-Arthrography (CBCT-A) of the talocrural joint, coronal reformatted image (d) showing smooth cartilage lining covering the normal subchondral bone of the talus (arrow) and tibia (arrowhead). The pathologic definition of a cyst is a cavitary, fluid-filled lesion with an epitheli-al lining [21]. There are two generally accepted theories on the etiology of subchondral cysts. CBCT following intra-articular injection of Iodine contrast (CBCT-Arthrography) may render exquisite detail of the articular cartilage using very thin slices and multiplanar reformation. Diagnostic value of CT arthrography for evaluation of osteochondral lesions at the ankle. Foot Ankle Int. DOI: https://doi.org/10.1053/jars.2003.50041, Anderson, IF, Crichton, KJ, Grattan-Smith, T, Cooper, RA and Brazier, D. Osteochondral fractures of the dome of the talus. Yamamoto T, Iwasaki K, Iwamoto Y. Transtrochanteric rotational osteotomy for a subchondral insufficiency fracture of the femoral head in young adults. Coronal reformatted CBCT-A (b) demonstrates more clearly the OCL fragment (arrow) separated from the adjacent talus by thin rim of surrounding contrast (arrowheads). Frequently, these lesions occur with ligamentous injury and one should thoroughly examine for instability.One may obtain radiographic imaging to evaluate for cystic or chondral changes, but bear in mind that these studies are insufficient for complete diag… 1959; 41–A: 988–1020. Coronal fat suppressed T2-WI (intermediate weighting) showing BME (white asterisk) at the lateral corner of the talar dome (a). Osteoarthritis is one of the most prevalent and disabling chronic conditions affecting older adults and a significant public health problem among adults of working age. Articular cartilage lining remains homogenous without any signal changes (Figure 7). RESULTS: We identified 58 subchondral cystsin 43(71.7%) of 63 cases. 9. Some authors suggest that … MRI coronal PD fat suppressed image (1.5 Tesla equipment) of the talocrural joint (c) with normal appearance of the thin cartilage layer (arrows) of intermediate signal, low signal of subchondral bone and homogenous bone marrow signal (stars). DOI: https://doi.org/10.1007/s00256-015-2127-3, Berndt, AL and Harty, M. Transchondral fractures (osteochondritis dissecans) of the talus. In fact, Subchondral Bone Cyst is one of the parameters that physicians look at when diagnosing osteoarthritis. A comparison of arthroscopic and MRI findings in staging of osteochondral lesions of the talus. Subchondral fractures are usually a consequence of compressive forces, transmitted from the cartilage to the subchondral bone plate and from there to the trabeculae, which fail to resist that force and break or fracture 3. 2016; 2016: 3594253. Based on the combination of MRI and CBCT findings the diagnosis of a subchondral insufficiency fracture (SIF) was made. Furthermore, cartilage lesions may be isolated (one defect), complex (one lesion with variable depth of the lesion) or multifocal (involving multiple areas of the talus or tibia). 2017;101(S2):1. Studies on cadavers performed on CT arthrography [12] showed more accurate cartilage thickness measurements in comparison to standard MRI, which is in line with a superior evaluation of OCL with CT arthrographic techniques [13] (Figure 9). This term covers a wide spectrum of pathologies including (sub)chondral contusion, osteochondritis dissecans, osteochondral fracture and osteoarthritis resulting from longstanding disease. Accurate staging of cartilage lesions is of utmost importance, as this will have a major impact on the treatment strategy and ultimate prognosis. This process can evolve into cyst formation. All were located in the … 2003; 19(4): 353–9. Eur Radiol. Articular cartilage covering the articular surfaces (blue), cortical bone (black), normal bone marrow (yellow) and ligaments (brown). MRI allows for distinguishing normal cartilage from subchondral bone as well as evaluating the adjacent bone marrow, ligaments and other surrounding soft tissues (Figure 2c). Radiology. Due to the widespread use of fluid-sensitive sequences on MRI, even subtle foci of BME may be seen adjacent to a cartilage defect, particularly in acute or subacute OCL lesions. 56 (6): 714-9. In our patients, from the follow-up X-ray and MRI we observed a satisfied regeneration of the subchondral bone without bone resorption or recurrence of the cyst, indicating that cancellous bone autograft is an effective method for treating subchondral cysts.Furthermore, the successful reconstruction of the subchondral bone significantly relieved the patients' symptoms, as the … Check for errors and try again. They can progress to subchondral collapse, osteochondral injury, and osteochondral defects 1. Ikemura S, Yamamoto T, Motomura G, et al. Cone Beam Computed Tomography (CBCT) arthrography is better suited for precise staging of cartilage lesions. Later on, this grading system has been modified to computed tomographic evaluation and correlated with arthroscopy, distinguishing cystic lesion of talar dome seen in primary stages with or without communication to the articular surface and detached fragment in more advanced lesions [6]. The fracture can be seen as irregular linear or curvilinear subchondral low signal intensity structure near the subchondral bone plate of low signal intensity in T1-weighted  images and also sometimes, but not always in T2-weighted images 1,2,4-8. Journal of the Belgian Society of Radiology 101 (S2): 1. The IW fs sequence depicted subchondral bone marrow edema-like lesions to a larger extent than DESS (p < 0.0001), and the opposite was true for subchondral cysts. Osteochondral Lesions of the Knee: Differentiating the Most Common Entities at MRI. “Staging of Osteochondral Lesions of the Talus: MRI and Cone Beam CT”. (2018) Radiographics : a review publication of the Radiological Society of North America, Inc. 38 (5): 1478-1495. In humans, SCLs occur in youths and adolescents [1] due to … The synovial fluid intrusion theory suggests that elevated intra-articular pressure forces joint fluid into the subchondral bone via fissured or ulcerated cartilage,, creating a cyst. (2019) Skeletal radiology. Roemer FW, Frobell R, Hunter DJ, et al. DOI: https://doi.org/10.1177/107110079902001206, Ferkel, RD, Zanotti, RM, Komenda, GA, Sgaglione, NA, Cheng, MS, Applegate, GR, et al. Subchondral bone cysts commonly occur adjacent to a treated focal cartilage defect and are possibly connected to the joint cavity. 195 (1): W63-8. 2. Agten CA, Kaplan DJ, Jazrawi LM, et al. Pathria MN, Chung CB, Resnick DL. A mnemonic for the causes of subchondral cysts is: COORS Mnemonic C: CPPD O: osteoarthritis O: osteonecrosis R: rheumatoid arthritis S: synovial-based tumors See also Geode DOI: https://doi.org/10.1016/j.fas.2013.10.005, https://doi.org/10.2106/00004623-198668060-00007, https://doi.org/10.1007/s00256-015-2127-3, https://doi.org/10.2106/00004623-195941060-00002, https://doi.org/10.1177/107110079902001206, https://doi.org/10.1016/0749-8063(91)90087-E, https://doi.org/10.2106/00004623-198971080-00004, https://doi.org/10.1007/s00167-008-0607-x, https://doi.org/10.1007/s00330-006-0446-4, https://doi.org/10.1148/radiol.2333031921. Sagittal fat suppressed T2-WI (intermediate weighting) showing BME (white asterisk) at the lateral corner of the talar dome (b). ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. DOI: http://doi.org/10.5334/jbr-btr.1377, Posadzy, M., et al.. “Staging of Osteochondral Lesions of the Talus: MRI and Cone Beam CT”. DOI: http://doi.org/10.5334/jbr-btr.1377, Posadzy, Magdalena, Julie Desimpel, and Filip M. Vanhoenacker. American journal of roentgenology. On a corresponding sagittal reformatted CBCT-A (c), there is almost complete detachment of the cartilage at the superolateral aspect of the talar dome (black arrow). DOI: http://doi.org/10.5334/jbr-btr.1377, Posadzy, M., Desimpel, J., & Vanhoenacker, F. M. (2017). Patients will usually present with pain on weight-bearing in the affected joint, improving with rest 2. AJR Am J Roentgenol 1977;128:799–806. Down staging of an OCL on CBCT compared to MRI. Osteochondral lesions of the talus: A new magnetic resonance grading system with arthroscopic correlation. The red arrow indicates the direction of the applied force. 24) is an intraosseous cyst which occurs beneath an articular surface of a bone. Foot Ankle Surg. Prostaglandin I-1 and/or bisphosphonates might be considered 5. Osteonecrosis can develop when the lesion’s vascularity is disrupted. 45, No. With the advent of MRI, this grading system was further revised including evaluation of structures invisible on conventional radiology, such as the integrity of the cartilage and presence of BME. Schematic drawing of talocrural joint injury in pronation (a) results in sprain of the medial collateral ligaments (brown) and lateral-sided OCL of the talar dome and/or kissing tibial lesion (orange zones), whereas injury in supination (b) causes sprain of the lateral ligaments and medial-sided OCL of the talar dome and/or kissing lesions at the tibia (orange zones). Although the incidence of osteoarthritis increases with age, the condition is not a normal part of the aging process. Although not comprehensive in scope, this article correlated the pathophysiology and imaging features of several of these disorders to better understand the associated subchondral lucencies. Sclerotic lines as a result of impaction or as slight deformities of the joint line in case of subchondral collapse can sometimes be seen particularly at a later stage 4. What Is a Subchondral Bone Cyst? Subchondral cysts and intraosseous ganglion cysts cannot be differentiated histologically. Subchondral cysts are typically found within the hip joint. (2010) AJR. Anatomy of the talocrural joint. Jose J, Pasquotti G, Smith MK, et al. Coronal PD fat suppressed coronal image (a) showing an OCL fragment completely detached from talar dome without displacement (arrow), bone marrow oedema (star) of adjacent part of the talus. 17 (9): 1115-31. MRI evaluation of collapsed femoral heads in patients 60 years old or older: Differentiation of subchondral insufficiency fracture from osteonecrosis of the femoral head. The weight-bearing joints such as the knee, hip, and ankle joints are more commonly affected ref. 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