骨坏死的MRI评估

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 2 Luis Corrales, HMS III Gillian 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. 3 Luis Corrales, HMS III Gillian 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 4 Luis Corrales, HMS III Gillian 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 5 Luis Corrales, HMS III Gillian 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. AVASCULAR CELLS 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 6 Luis Corrales, HMS III Gillian 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% 7 Luis Corrales, HMS III Gillian 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 8 Luis Corrales, HMS III Gillian 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 9 Luis Corrales, HMS III Gillian 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 10 Luis Corrales, HMS III Gillian 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 11 Luis Corrales, HMS III Gillian 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 12 Luis Corrales, HMS III Gillian 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 13 Luis Corrales, HMS III Gillian 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 14 Luis Corrales, HMS III Gillian 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 15 Luis Corrales, HMS III Gillian 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. 16 Luis Corrales, HMS III Gillian Lieberman, MD Patient 1 Frontal RadiographPatient 1 Frontal Radiograph Courtesy of Dr. HallNo definite abnormality 17 Luis Corrales, HMS III Gillian 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 18 Luis Corrales, HMS III Gillian 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. Obturator Externus M. Pectenius M. Courtesy of Dr. Hall 19 Luis Corrales, HMS III Gillian Lieberman, MD Patient 1 MRI T1W Coronal imagesPatient 1 MRI T1W Coronal images Courtesy of Dr. Hall Ring pattern of Hypointense SI 20 Luis Corrales, HMS III Gillian Lieberman, MD Patient 1 MRI T1W Coronal imagesPatient 1 MRI T1W Coronal images Courtesy of Dr. Hall 21 Luis Corrales, HMS III Gillian 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 22 Luis Corrales, HMS III Gillian 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 23 Luis Corrales, HMS III Gillian Lieberman, MD SagittalSagittal MRI T1W Images of KneeMRI T1W Images of Knee Semimembranosus M. Quadraceps M. BIDMC 24 Luis Corrales, HMS III Gillian Lieberman, MD SagittalSagittal MRI T1W Images of KneeMRI T1W Images of Knee Med. Femoral condyle Tibia BIDMC 25 Luis Corrales, HMS III Gillian Lieberman, MD SagittalSagittal MRI T1W Images of KneeMRI T1W Images of Knee Normal appearing Ant. Horn of Med. Meniscus Normal Articular cartilage Normal appearing Post. Horn of Med. Meniscus Inhomogenous subchondral hypointense SI pattern BIDMC 26 Luis Corrales, HMS III Gillian Lieberman, MD SagittalSagittal MRI T1W Images of KneeMRI T1W Images of Knee Osteonecrosis extending to articular surface BIDMC 27 Luis Corrales, HMS III Gillian Lieberman, MD SagittalSagittal MRI T1W Images of KneeMRI T1W Images of Knee Area of Hypointense SI within Tibial Plateu BIDMC 28 Luis Corrales, HMS III Gillian Lieberman, MD SagittalSagittal MRI T1W Images of KneeMRI T1W Images of Knee Serpingenous pattern of Hypointense SI BIDMC 29 Luis Corrales, HMS III Gillian Lieberman, MD SagittalSagittal MRI T1W Images of KneeMRI T1W Images of Knee Patella Quadriceps Tendon Cortical Bone PCL Intrapatellar fat pad BIDMC 30 Luis Corrales, HMS III Gillian Lieberman, MD SagittalSagittal MRI T1W Images of KneeMRI T1W Images of Knee BIDMC Lateral femoral condyle Area of inhomogenous low SI 31 Luis Corrales, HMS III Gillian Lieberman, MD SagittalSagittal MRI T1W Images of KneeMRI T1W Images of Knee BIDMC 32 Luis Corrales, HMS III Gillian 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 33 Luis Corrales, HMS III Gillian Lieberman, MD T2W Coronal Images of KneeT2W Coronal Images of Knee BIDMC Homogenous area of low SI in Medial condyle 34 Luis Corrales, HMS III Gillian Lieberman, MD T2W Coronal Images of KneeT2W Coronal Images of Knee BIDMC 35 Luis Corrales, HMS III Gillian Lieberman, MD T2W Coronal Images of KneeT2W Coronal Images of Knee Double line sign BIDMC 36 Luis Corrales, HMS III Gillian Lieberman, MD T2W Coronal Images of KneeT2W Coronal Images of Knee Double line sign BIDMC Osteonecrosis extending into posterior aspect of femoral condyles 37 Luis Corrales, HMS III Gillian 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 38 Luis Corrales, HMS III Gillian 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 39 Luis Corrales, HMS III Gillian 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.. 40 Luis Corrales, HMS III Gillian Lieberman, MD ReferencesReferences �� GillespyGillespy III T, III T, GenantGenant H, Helms CA. 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