Osteonecrosis can develop when the lesion’s vascularity is disrupted. The etiology of subchondral cysts is unknown. If the cartilage is damaged, perform a subchondral cyst approach as I have detailed above. In particular cases also alternative diagnoses can be made on basis of CBCT (Figure 11). Skeletal Radiol. Arthroscopy. subchondral bone marrow edema on dual-energy CT; MRI. 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. The majority of those lesions occur in active patients and are related to trauma. 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. Journal of the Belgian Society of Radiology, vol. Usually, subchondral fractures present as linear or curvilinear structures often paralleling the subchondral bone plate, with or without areas of subchondral collapse 2. 101, no. Cartilage damage may have a variable imaging appearance ranging from a small fissure, a distinct defect, flap formation or delamination. 4 (3): 173-80. A subchondral fracture is a fracture of the trabecular cancellous bone just beneath the subchondral bone plate without disruption of the articular surface 1. comments powered by Useful MR scoring parameters include lesion location, lesion size in 3 planes, subchondral bone marrow edema, subchondral cyst formation and/or sclerosis, status of the overlying cartilage, contour depression of the articular bone plate. 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). Schematic drawings of OCL classification according to Anderson. Journal of the Belgian Society of Radiology 101 (S2): 1. Subchondral cysts are often a part of the joint degenerative process and occurs where there are breaks in the hip joint cartilage. Coronal fat suppressed T2-WI (intermediate weighting) showing BME (white asterisk) at the lateral corner of the talar dome (a). They can also occur in conjunction with twisting and ligamentous injuries. 44 (2): 102-5. S2 (2017): 1. Articular cartilage lining remains homogenous without any signal changes (Figure 7). Foot Ankle Surg. Foot Ankle Int. 2003; 19(4): 353–9. A suggested grading system based on MRI findings is 9: Low-grade subchondral fractures in particular, if there is no collapse of the subchondral bone plate, can be treated conservatively with restricted weight-bearing 2,3 and non-steroidal anti-inflammatory drugs. 2016; 2016: 3594253. Example of understaging of the cartilage defect of an OCL on MRI compared to CBCT arthrography. (2019) Skeletal radiology. Subchondral cysts are of variable size from a f… With widespread use of MR it is now not uncommon in clinical practice to observe this progression of findings. High-grade fluid-filled lesions with cortical collapse and severe osteoarthritis might require arthroplasty. Joint preserving surgical treatments of subchondral fractures include microfracture, drilling, subchondroplasty 10, or in the hip joint: transtochanteric osteotomy 11. DOI: http://doi.org/10.5334/jbr-btr.1377, Posadzy M, Desimpel J and Vanhoenacker FM, ‘Staging of Osteochondral Lesions of the Talus: MRI and Cone Beam CT’ (2017) 101 Journal of the Belgian Society of Radiology 1 DOI: http://doi.org/10.5334/jbr-btr.1377, Posadzy, Magdalena, Julie Desimpel, and Filip M. Vanhoenacker. 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). 1991; 7(1): 101–4. Subchondral fractures due to trauma can occur at any age. 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. 2014; 20(1): 57–60. T1 andT2-weighted axial, oblique coronal, and oblique sagittal images were analysed for the presence, location, number,shape, size, and connection to the joint cavity of subchondral cysts. in 2003. 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. 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 … The authors have no competing interests to declare. 9. MR imaging of the ankle at 3 Tesla and 1.5 Tesla: Protocol optimization and application to cartilage, ligament and tendon pathology in cadaver specimens. However, other arthritic conditions like rheumatoid arthritis also play a key role in an individual developing Subchondral Bone Cysts. Subchondral cysts are a common finding in osteoarthritic knees. DOI: https://doi.org/10.1016/j.fas.2013.10.005, Pritsch, M, Horoshovski, H and Farine, I. Arthroscopic treatment of osteochondral lesions of the talus. Subchondral lucency (SCL), also referred to as subchondral bone cysts, can cause clinical problems in horses and humans. 11. Compared to the articular cartilage of the knee, cartilage of the ankle joint is very thin and the spatial resolution of MRI may be insufficient for detection of small lesions. Journal of the Belgian Society of Radiology 101, no. 280 (1): 21-38. An alternative MRI staging system has been proposed by Mintz  et al. Anatomy of the talocrural joint. The cartilage at the talar dome is slightly irregularly delineated (white arrow). Subchondral cysts of the tibia secondary to osteoarthritis of the knee. Finally, when fluid flows underneath the defect, the OCD can become unstable and may result in a corpus liberum. This term covers a wide spectrum of pathologies including (sub)chondral contusion, osteochondritis dissecans, osteochondral fracture and osteoarthritis resulting from longstanding disease. Treatment depends on the location and size of the defect as well as the presence of secondary degenerative changes. 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. The presence of intraarticular contrast and high spatial resolution improves visualization of the cartilage surfaces compared to routine MRI on 1.5 Tesla. 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. All were located in the … (2016) AJR. Assess range of motion to evaluate for pain and limitation as well as clicking or catching of the joint. 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). The majority of those lesions occur in active patients and are related to trauma. 56 (6): 714-9. Coronal (a) fat suppressed T2-WI show adjacent BME (white asterisk) at the superolateral aspect of the talar dome. Schematic drawing shows the basic anatomy of the talocrural joint (Figure 2a). MRI sensitivity in detection of OCL of the talus, correlated with arthroscopic correlation, varies according to different studies and has been reported as high as 81% . 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. 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. 7. Subchondral cystic lesions are common features that are associated with many arthropathies and synovial-based processes. Thus, “cyst” is not an accurate term for the lesions encountered at imaging of subchondral bone. Fluid-fluid levels, consistent with secondary formation of aneurysmal bone cysts, are seen in 14% of cases. This is not Kienbock's disease, where cystic changes develop more diffusely. Posadzy M, Desimpel J, Vanhoenacker FM. DOI: https://doi.org/10.1177/107110079902001206, Ferkel, RD, Zanotti, RM, Komenda, GA, Sgaglione, NA, Cheng, MS, Applegate, GR, et al. 3. DOI: https://doi.org/10.1007/s00330-006-0446-4, El-Khoury, GY, Alliman, KJ, Lundberg, HJ, Rudert, MJ, Brown, TD and Saltzman, CL. AJR Am J Roentgenol 1977;128:799–806. It uses a conical X-ray beam and flat-panel detector collecting all volumetric data in one rotation of the gantry. Schematic drawing of the normal talocrural joint (a). The overlying cartilage is difficult to assess on MRI but seems to be slightly inhomogeneous (white arrow). Alternative diagnosis on CBCT compared to MRI. (2012) Clinics in orthopedic surgery. DOI: http://doi.org/10.5334/jbr-btr.1377, Posadzy, M., Desimpel, J., & Vanhoenacker, F. M. (2017). Polesello G, Sakai DS, Ono NK, et al. Unstable lesions – if left untreated – predispose for early osteoarthritis. [6, 20]. Sagittal (a) and coronal (b) fat suppressed T2-WI showing multilocular subchondral cysts (black arrowheads) at the medial aspect of the talar dome. 1986; 68(6): 862–5. All MR images wereobtained using a 1.5 Tesla unit after intraarticular injection of 20ml of diluted contrast material. Smooth articular surfaces (arrows) of the talocrural joint with normal trabecular bone appearance (stars). 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. Subchondral bone cysts (SBCs) are sacs filled with fluid that form inside of joints such as knees, hips, and shoulders. This process can evolve into cyst formation. Symptoms of subchondral cystic lesions can be mild to severe and can be of an acute onset. 207 (6): 1257-1262. 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. When the latter is present, then joint replacement is often the only feasible treatment. Recently, Cone Beam Computed Tomography (CBCT) of small joints has been introduced as an alternative technique for Multi Detector CT, combining a very high spatial resolution, low radiation dose and low cost . 2017;101(S2):1. In humans, SCLs occur in youths and adolescents  due to … J Bone Joint Surg Am. The symptoms you will likely notice are: Lameness may be acute or hardly noticed unless the horse is working at specific increased speeds or when involved in specific activities - intermittent, especially in older horses but can be noted in horses of any age 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). Coronal reformatted CBCT-A (c) barely shows subtle subchondral sclerosis at the superolateral aspect of the talar dome and intact overlying cartilage. Because the plasticity of the cartilage in children and adolescents is higher than in adults, OCL lesions in young patients are often characterized by isolated subchondral bony changes without overlying cartilage disruption (Figure 5). 1959; 41–A: 988–1020. The sac is usually primarily filled with hyaluronic acid. Additional CBCT-Arthrography is, however, very useful for more accurate cartilage staging and should be considered in those clinical scenarios where arthroscopic treatment of the lesion is considered. 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. Subchondral cysts in the superior outer and middle third of the femoral head (pressure zone) may arise from bone contusion and synovial intrusion or osteoclastic resorption of necrotic trabeculae following avascular necrosis 1. Staging of Osteochondral Lesions of the Talus: MRI and Cone Beam CT. Journal of the Belgian Society of Radiology, 101(S2), 1. Subchondral means under the cartilage and refers to fluid filled cavities within the bone that is under the cartilage. 3. Accurate staging of cartilage lesions is of utmost importance, as this will have a major impact on the treatment strategy and ultimate prognosis. 2. Lomax, A, Miller, RJ, Fogg, QA, Jane Madeley, N and Senthil Kumar, C. Quantitative assessment of the subchondral vascularity of the talar dome: A cadaveric study. Patients will usually present with pain on weight-bearing in the affected joint, improving with rest 2. 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. 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. Sayyid S, Younan Y, Sharma G, et al. They can progress to subchondral collapse, osteochondral injury, and osteochondral defects 1. On the other hand, although MRI a very useful and sensitive technique for evaluation of the subchondral compartment (showing either BME or cyst formation), the precise depth and extent of the overlying cartilage lesion is often not accurately staged. Stage 2 refers to partial detachment of OCL with subchondral cyst formation or fissure incompletely separating the lesion from the talar dome. Prostaglandin I-1 and/or bisphosphonates might be considered 5. high signal subchondral cysts; Treatment and prognosis. (2018) Radiographics : a review publication of the Radiological Society of North America, Inc. 38 (5): 1478-1495. The presence of a subchondral edema with an acetabular cyst on MRI is indicative of a full-thickness cartilage lesion at the time of arthroscopy. Direct comparison of conventional radiography and cone-beam CT in small bone and joint trauma. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. 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 . They're especially common at the knee or hip. Check for errors and try again. Hallmarks of osteoarthritis include the presence of marginal osteophytes and subchondral cysts in the tibiofemoral joint. J Bone Joint Surg Am. Ikemura S, Yamamoto T, Motomura G, et al. Diagnostic value of CT arthrography for evaluation of osteochondral lesions at the ankle. Subchondral bone cysts commonly occur adjacent to a treated focal cartilage defect and are possibly connected to the joint cavity. The location of the lesion at the talus is related to the mechanism of the injury and direction of the applied force (Figure 1). Background: Cystic lesions of the carpal bones are rare entities that are infrequently reported in the literature. DOI: https://doi.org/10.2106/00004623-195941060-00002, Hepple, S, Winson, IG and Glew, D. Osteochondral lesions of the talus: A revised classification. Gorbachova T, Melenevsky Y, Cohen M, et al. Studies on cadavers performed on CT arthrography  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  (Figure 9). Down staging of an OCL on CBCT compared to MRI. Coronal reformatted CBCT-A (b) demonstrates more clearly the OCL fragment (arrow) separated from the adjacent talus by thin rim of surrounding contrast (arrowheads). In addition, the trabecular architecture of subchondral bone is far better visualized on CBCT than on CR. The overlying cartilage is intact at the talus, whereas there is subtle cartilage lesion at the distal tibia (arrow). 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. American journal of roentgenology. Stage 1 lesions are due to bone marrow contusion. 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. Coronal (a) and sagittal (b) fat suppressed T2-WI show adjacent kissing areas of bone marrow edema (white arrowheads) at the distal tibia and talar dome. 48 (12): 1961-1974. In stage 3 an undisplaced completely separated fragment can be seen on MRI with adjacent BME. 4. The articular surface of the talus is large and its blood supply is critical in the watershed areas  explaining an impaired healing process and predisposition to posttraumatic necrosis in those vulnerable areas. Biomed Res Int. The red arrow indicates the direction of the applied force. The pathologic definition of a cyst is a cavitary, fluid-filled lesion with an epitheli-al lining . MRI evaluation of collapsed femoral heads in patients 60 years old or older: Differentiation of subchondral insufficiency fracture from osteonecrosis of the femoral head. (2009) Osteoarthritis and cartilage. 1999; 20(12): 789–93. Subchondroplasty: What the Radiologist Needs to Know. More severe symptoms tend to occur in the radiographically more advan… Coronal (c) and sagittal (d) reformatted CBCT-A show a focal bony lesion with peripheral sclerosis in the distal tibia and talus. DOI: https://doi.org/10.2106/00004623-198971080-00004, Lee, KB, Bai, LB, Park, JG and Yoon, TR. Conventional radiography, Mortise View (b). 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. What Is a Subchondral Bone Cyst? Eur Radiol. (2009) Revista brasileira de ortopedia. Ostlere SJ(1), Seeger LL, Eckardt JJ. 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. In such a case, leave the cartilage alone and only check it with ankle arthroscopy. 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… 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. Subchondral bone involvement can be manifested by bone marrow edema (BME), fracture, sclerosis and/or cyst formation. Physical examination should include evaluation of local tenderness and swelling. Almost always there will be associated bone marrow edema best appreciated in fat-saturated T2-weighted and intermediate or proton-density weighted images 4. Subchondral insufficiency fractures are more common in elderly women 1,4,6. At earlier stages (stage 1 to 4), a number of options exist including: 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 cyst without superficial cartilage damage is rare and requires a different approach. (2010) Clinical orthopaedics and related research. Cartilage damage may have a variable imaging appearance ranging from a small fissure, a distinct defect, flap formation or delamination. It's a fluid-filled sac that forms in one or both of the bones that make up a joint. In adult patients, the depth of the cartilage lesions is often understaged (Figures 3 and 4). Although the incidence of osteoarthritis increases with age, the condition is not a normal part of the aging process. Nowadays MR staging of OCL on MRI is usually done by the Anderson classification , which is another modification of the initial staging system based on plain film evaluation by Berndt and Harty (Figure 6). The weight-bearing joints such as the knee, hip, and ankle joints are more commonly affected ref. On CBCT arthrographic images, the contrast separating the OCL fragment from the talar dome can be evaluated with more confidence (Figure 8). DOI: https://doi.org/10.1007/s00167-008-0607-x, Barr, C, Bauer, JS, Malfair, D, Ma, B, Henning, TD, Steinbach, L, et al. Note that the cystic changes are subchondral at the proximal ulnar portion of the lunate (L). Unable to process the form. Their walls consist of a cell layer resembling synovium, and the surrounding wall is osteosclerotic. 2008; 16(11): 1047–51. 2017;101(S2):1. Stage 3 according to Anderson classification. Stage 4 consists of a displaced fragment, often accompanied with surrounding bone marrow edema. Based on the combination of MRI and CBCT findings the diagnosis of a subchondral insufficiency fracture (SIF) was made. There are two generally accepted theories on the etiology of subchondral cysts. DOI: https://doi.org/10.1016/0749-8063(91)90087-E, Mintz, DN, Tashjian, GS, Connell, DA, Deland, JT, O’Malley, M and Potter, HG. 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. Besides the limitations of MRI in this field, it is still considered the most comprehensive imaging modality of the ankle because of its capability to assess soft tissue and bone marrow abnormalities on a single examination. Arthroscopy. Pathria MN, Chung CB, Resnick DL. GCT can mimic or be mimicked by other benign or malignant lesions at both radiologic evaluation and histologic analysis. DOI: http://doi.org/10.5334/jbr-btr.1377, Posadzy, Magdalena, Julie Desimpel, and Filip M. Vanhoenacker. (2016) Radiology. 8. 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 . Sagittal (a) fat suppressed T2-WI show a subchondral band-like area of low signal at the subchondral cortex (white arrow) with surrounding BME (white asterisk). THE IMPORTANCE OF THE DIAGNOSIS OF SUBCHONDRAL FRACTURE OF THE FEMORAL HEAD, HOW TO DIFFERENTIATE IT FROM AVASCULAR NECROSIS AND HOW TO TREAT IT. It combines high spatial resolution, relatively low radiation dose and low equipment cost and is useful for evaluation of trauma of small bones and joints, particularly when there is clinical suspicion for a fracture despite negative plain radiographs . Osteochondral lesions (OCL) of the talus are defined as any damage involving both articular cartilage and subchondral bone of the talar dome. Society of Radiology 101, no defined as any damage involving both articular cartilage lesions is of utmost,... Will have a variable imaging appearance ranging from a small fissure, a distinct defect, the depth the! The aging process be manifested by bone marrow edema ankle joints are more common in women... //Doi.Org/10.1007/S00256-015-2127-3, Berndt, al and Harty, M., Desimpel J Vanhoenacker... 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Rare subset of carpal bone cysts, are seen in 14 % of cases ( BME ) fracture... The talus: MRI and Cone Beam CT ” consistent with secondary formation of aneurysmal cysts! ) fat suppressed T2-WI show adjacent BME ( star ) in the hip joint cartilage fractures!
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