Real-time three-dimensional MRI for the assessment of dynamic carpal instability

Measurement of Scapholunate Joint Space Width on Real-Time MRI-A Feasibility Study

INTRODUCTION

The scapholunate interosseous ligament is pivotal for wrist stability, and its impairment can result in instability and joint degeneration. This study explores the application of real-time MRI for dynamic assessment of the scapholunate joint during wrist motion with the objective of determining its diagnostic value in efficacy in contrast to static imaging modalities.

MATERIALS AND METHODS

Ten healthy participants underwent real-time MRI scans during wrist ab/adduction and fist-clenching maneuvers. Measurements were obtained at proximal, medial, and distal landmarks on both dynamic and static images with statistical analyses conducted to evaluate the reliability of measurements at each landmark and the concordance between dynamic measurements and established static images. Additionally, inter- and intraobserver variabilities were evaluated.

RESULTS

Measurements of the medial landmarks demonstrated the closest agreement with static images and exhibited the least scatter. Distal landmark measurements showed a similar level of agreement but with increased scatter. Proximal landmark measurements displayed substantial deviation, which was accompanied by an even greater degree of scatter. Although no significant differences were observed between the ab/adduction and fist-clenching maneuvers, both inter- and intraobserver variabilities were significant across all measurements.

CONCLUSIONS

This study highlights the potential of real-time MRI in the dynamic assessment of the scapholunate joint particularly at the medial landmark. Despite promising results, challenges such as measurement variability need to be addressed. Standardization and integration with advanced image processing methods could significantly enhance the accuracy and reliability of real-time MRI, paving the way for its clinical implementation in dynamic wrist imaging studies.

Development and stability analysis of carpal kinematic metrics from 4D magnetic resonance imaging

OBJECTIVE

To develop MRI-derived carpal kinematic metrics and investigating their stability.

METHODS

The study used a 4D MRI method to track scaphoid, lunate, and capitate movements in the wrist. A panel of 120 metrics for radial-ulnar deviation and flexion-extension was created using polynomial models of scaphoid and lunate movements relative to the capitate. Intraclass correlation coefficients (ICCs) analyzed intra- and inter-subject stability in 49 subjects, 20 with and 29 without wrist injury history.

RESULTS

Comparable degrees of stability were observed across the two different wrist movements. Among the total 120 derived metrics, distinct subsets demonstrated high stability within each type of movement. For asymptomatic subjects, 16 out of 17 metrics with high intra-subject stability also showed high inter-subject stability. The differential analysis of ICC values for each metric between asymptomatic and symptomatic cohorts revealed specific metrics (although relatively unstable) exhibiting greater variability in the symptomatic cohort, thereby highlighting the impact of wrist conditions on the variability of kinematic metrics.

CONCLUSION

The findings demonstrate the developing potential of dynamic MRI for assessing and characterizing complex carpal bone dynamics. Stability analyses of the derived kinematic metrics revealed encouraging differences between cohorts with and without wrist injury histories. Although these broad metric stability variations highlight the potential utility of this approach for analyzing carpal instability, further studies are necessary to better characterize these observations.

Dynamic assessment of scapholunate ligament status by real-time magnetic resonance imaging: an exploratory clinical study

OBJECTIVE

Clinical-standard MRI is the imaging modality of choice for the wrist, yet limited to static evaluation, thereby potentially missing dynamic instability patterns. We aimed to investigate the clinical benefit of (dynamic) real-time MRI, complemented by automatic analysis, in patients with complete or partial scapholunate ligament (SLL) tears.

MATERIAL AND METHODS

Both wrists of ten patients with unilateral SLL tears (six partial, four complete tears) as diagnosed by clinical-standard MRI were imaged during continuous active radioulnar motion using a 1.5-T MRI scanner in combination with a custom-made motion device. Following automatic segmentation of the wrist, the scapholunate and lunotriquetral joint widths were analyzed across the entire range of motion (ROM). Mixed-effects model analysis of variance (ANOVA) followed by Tukey's posthoc test and two-way ANOVA were used for statistical analysis.

RESULTS

With the increasing extent of SLL tear, the scapholunate joint widths in injured wrists were significantly larger over the entire ROM compared to those of the contralateral healthy wrists (p<0.001). Differences between partial and complete tears were most pronounced at 5°-15° ulnar abduction (p<0.001). Motion patterns and trajectories were altered. Complete SLL deficiency resulted in complex alterations of the lunotriquetral joint widths.

CONCLUSION

Real-time MRI may improve the functional diagnosis of SLL insufficiency and aid therapeutic decision-making by revealing dynamic forms of dissociative instability within the proximal carpus. Static MRI best differentiates SLL-injured wrists at 5°-15° of ulnar abduction.

Real-time MRI of the moving wrist at 0.55 tesla

OBJECTIVES

Magnetic resonance imaging (MRI) using 1.5T or 3.0T systems is routinely employed for assessing wrist pathology; however, due to off-resonance artifacts and high power deposition, these high-field systems have drawbacks for real-time (RT) imaging of the moving wrist. Recently, high-performance 0.55T MRI systems have become available. In this proof-of-concept study, we tested the hypothesis that RT-MRI during continuous, active, and uninterrupted wrist motion is feasible with a high-performance 0.55T system at temporal resolutions below 100 ms and that the resulting images provide visualization of tissues commonly interrogated for assessing dynamic wrist instability.

METHODS

Participants were scanned during uninterrupted wrist radial-ulnar deviation and clenched fist maneuvers. Resulting images (nominal temporal resolution of 12.7-164.6 ms per image) were assessed for image quality. Feasibility of static MRI to supplement RT-MRI acquisition was also tested.

RESULTS

The RT images with temporal resolutions < 100 ms demonstrated low distortion and image artifacts, and higher reader assessment scores. Static MRI scans showed the ability to assess anatomical structures of interest in the wrist.

CONCLUSION

RT-MRI of the wrist at a high temporal resolution, coupled with static MRI, is feasible with a high-performance 0.55T system, and may enable improved assessment of wrist dynamic dysfunction and instability.

ADVANCES IN KNOWLEDGE

Real-time MRI of the moving wrist is feasible with high-performance 0.55T and may improve the evaluation of dynamic dysfunction of the wrist.

Stability of the distal radioulnar joint with and without activation of forearm muscles

The purpose of this study was to quantify the effect of the flexor carpi ulnaris and the extensor carpi ulnaris muscles on distal radioulnar joint stability. The anteroposterior ulnar head translation in relation to the radius was measured sonographically when the forearm was in a neutral resting position and when the hand was actively pressed on to a surface, with and without intentional flexor carpi ulnaris and extensor carpi ulnaris activation, while also being monitored by an electromyogram. Data on 40 healthy participants indicated a mean anteroposterior translation in the distal radioulnar joint of 4.1 mm (SD 1.08) without and 1.2 mm (SD 0.54) with muscle activation. Our results indicate that intentional ulnar forearm muscle activation results in 70% less anteroposterior ulnar head translation and greater distal radioulnar joint stability. Therefore, the flexor carpi ulnaris and extensor carpi ulnaris muscles serve as dynamic stabilizers of the distal radioulnar joint. This finding may be clinically significant since ulnar forearm muscles strengthening may increase distal radioulnar joint stability.

Extended and weightbearing wrist 3-T MRI using a novel harness and flexible 24-channel glove coil to evaluate carpal kinematics: a pilot study in 10 volunteers

BACKGROUND

Wrist pain in the extended or extended weightbearing positions may be incompletely evaluated using standard magnetic resonance imaging (MRI) with standard rigid clamshell coils in the neutral position.

PURPOSE

To evaluate a flexible 24-channel glove coil and harness when imaging the wrist in neutral, dorsally extended, and weightbearing positions.

MATERIAL AND METHODS

Ten wrists in 10 asymptomatic volunteers (mean age = 29 years) were scanned. Participants underwent 3-T MRI using the harness and flexible glove coil, acquiring sagittal turbo spin echo (TSE) and half-Fourier acquisition single-shot turbo spin echo (HASTE) pulse sequences. Static TSE images were obtained in neutral, extended, and weightbearing positions using proton density parameters and independently evaluated by two radiologists for: dorsal radiocarpal ligament thickness; radiocapitate, radiolunate, and capitatolunate angles; palmar translation of the lunate on the radius; angulation of the extensor tendons; and distance from the distal extensor retinaculum to Lister's tubercle. Cine HASTE images were dynamically acquired between neutral-maximum extension to measure the radiocapitate angle.

RESULTS

Good reader agreement was observed (r > 0.73) for all measurements except palmar translation in the neutral position (r = 0.27). Significant increases in dorsal radiocarpal ligament thickness; radiocapitate, radiolunate and capitolunate angulation; and extensor tendon angulation were observed between the neutral and extended positions (P < 0.001). A further significant increase in these metrics between extended and weightbearing positions was also seen (P < 0.01).

CONCLUSION

Significant increases in dorsal radiocarpal ligament thickness, articular and tendon angulations occur during wrist extension, that further increase with dorsal weightbearing.

Assessment and comparison of image quality between two real-time sequences for dynamic MRI of distal joints at 3.0 Tesla

BACKGROUND

Real-time sequences allow functional evaluation of various joint structures during a continuous motion and help understand the pathomechanics of underlying musculoskeletal diseases.

PURPOSE

To assess and compare the image quality of the two most frequently used real-time sequences for joint dynamic magnetic resonance imaging (MRI), acquired during finger and ankle joint motion.

MATERIAL AND METHODS

A real-time dynamic acquisition protocol, including radiofrequency (RF)-spoiled and balanced steady-state free precession (bSSFP) sequences, optimized for temporal resolution with similar spatial resolution, was performed using a 3.0-T MRI scanner on 10 fingers and 12 ankles from healthy individuals during active motion. Image quality criteria were evaluated on each time frame and compared between these two sequences. Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were determined and compared from regions of interest placed on cortical bone, tendon, fat, and muscle. Visualization of anatomical structures and overall image quality appreciation were rated by two radiologists using a 0-10 grading scale.

RESULTS

Mean CNR was significantly higher with bSSFP sequence compared to RF-spoiled sequence. The grading score was in the range of 5-9.3 and was significantly higher with RF-spoiled sequence for bone and joint evaluation and overall image appreciation on the two joints. The standard deviation for SNR, CNR, and grading score during motion was smaller with RF-spoiled sequence for both the joints. The inter-reader reliability was excellent (>0.75) for evaluating anatomical structures in both sequences.

CONCLUSION

A RF-spoiled real-time sequence is recommended for the in vivo clinical evaluation of distal joints on a 3.0-T MRI scanner.

Twenty-four-channel high-impedance glove array for hand and wrist MRI at 3T

PURPOSE

To present a novel 3T 24-channel glove array that enables hand and wrist imaging in varying postures.

METHODS

The glove array consists of an inner glove holding the electronics and an outer glove protecting the components. The inner glove consists of four main structures: palm, fingers, wrist, and a flap that rolls over on top. Each structure was constructed out of three layers: a layer of electrostatic discharge flame-resistant fabric, a layer of scuba neoprene, and a layer of mesh fabric. Lightweight and flexible high impedance coil (HIC) elements were inserted into dedicated tubes sewn into the fabric. Coil elements were deliberately shortened to minimize the matching interface. Siemens Tim 4G technology was used to connect all 24 HIC elements to the scanner with only one plug.

RESULTS

The 24-channel glove array allows large motion of both wrist and hand while maintaining the SNR needed for high-resolution imaging.

CONCLUSION

In this work, a purpose-built 3T glove array that embeds 24 HIC elements is demonstrated for both hand and wrist imaging. The 24-channel glove array allows a great range of motion of both the wrist and hand while maintaining a high SNR and providing good theoretical acceleration performance, thus enabling hand and wrist imaging at different postures to extract kinematic information.

Real-Time Magnetic Resonance Imaging

Real-time magnetic resonance imaging (RT-MRI) allows for imaging dynamic processes as they occur, without relying on any repetition or synchronization. This is made possible by modern MRI technology such as fast-switching gradients and parallel imaging. It is compatible with many (but not all) MRI sequences, including spoiled gradient echo, balanced steady-state free precession, and single-shot rapid acquisition with relaxation enhancement. RT-MRI has earned an important role in both diagnostic imaging and image guidance of invasive procedures. Its unique diagnostic value is prominent in areas of the body that undergo substantial and often irregular motion, such as the heart, gastrointestinal system, upper airway vocal tract, and joints. Its value in interventional procedure guidance is prominent for procedures that require multiple forms of soft-tissue contrast, as well as flow information. In this review, we discuss the history of RT-MRI, fundamental tradeoffs, enabling technology, established applications, and current trends. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY STAGE: 1.

Deep Learning-Based Post-Processing of Real-Time MRI to Assess and Quantify Dynamic Wrist Movement in Health and Disease

While morphologic magnetic resonance imaging (MRI) is the imaging modality of choice for the evaluation of ligamentous wrist injuries, it is merely static and incapable of diagnosing dynamic wrist instability. Based on real-time MRI and algorithm-based image post-processing in terms of convolutional neural networks (CNNs), this study aims to develop and validate an automatic technique to quantify wrist movement. A total of 56 bilateral wrists (28 healthy volunteers) were imaged during continuous and alternating maximum ulnar and radial abduction. Following CNN-based automatic segmentations of carpal bone contours, scapholunate and lunotriquetral gap widths were quantified based on dedicated algorithms and as a function of wrist position. Automatic segmentations were in excellent agreement with manual reference segmentations performed by two radiologists as indicated by Dice similarity coefficients of 0.96 ± 0.02 and consistent and unskewed Bland–Altman plots. Clinical applicability of the framework was assessed in a patient with diagnosed scapholunate ligament injury. Considerable increases in scapholunate gap widths across the range-of-motion were found. In conclusion, the combination of real-time wrist MRI and the present framework provides a powerful diagnostic tool for dynamic assessment of wrist function and, if confirmed in clinical trials, dynamic carpal instability that may elude static assessment using clinical-standard imaging modalities.

Interdisciplinary consensus statements on imaging of scapholunate joint instability

Objectives

The purpose of this agreement was to establish evidence-based consensus statements on imaging of scapholunate joint (SLJ) instability by an expert group using the Delphi technique.

Methods

Nineteen hand surgeons developed a preliminary list of questions on SLJ instability. Radiologists created statements based on the literature and the authors’ clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panellists consisted of twenty-seven musculoskeletal radiologists. The panellists scored their degree of agreement to each statement on an eleven-item numeric scale. Scores of ‘0’, ‘5’ and ‘10’ reflected complete disagreement, indeterminate agreement and complete agreement, respectively. Group consensus was defined as a score of ‘8’ or higher for 80% or more of the panellists.

Results

Ten of fifteen statements achieved group consensus in the second Delphi round. The remaining five statements achieved group consensus in the third Delphi round. It was agreed that dorsopalmar and lateral radiographs should be acquired as routine imaging work-up in patients with suspected SLJ instability. Radiographic stress views and dynamic fluoroscopy allow accurate diagnosis of dynamic SLJ instability. MR arthrography and CT arthrography are accurate for detecting scapholunate interosseous ligament tears and articular cartilage defects. Ultrasonography and MRI can delineate most extrinsic carpal ligaments, although validated scientific evidence on accurate differentiation between partially or completely torn or incompetent ligaments is not available.

Conclusions

Delphi-based agreements suggest that standardized radiographs, radiographic stress views, dynamic fluoroscopy, MR arthrography and CT arthrography are the most useful and accurate imaging techniques for the work-up of SLJ instability.

Key Points

• Dorsopalmar and lateral wrist radiographs remain the basic imaging modality for routine imaging work-up in patients with suspected scapholunate joint instability.

• Radiographic stress views and dynamic fluoroscopy of the wrist allow accurate diagnosis of dynamic scapholunate joint instability.

• Wrist MR arthrography and CT arthrography are accurate for determination of scapholunate interosseous ligament tears and cartilage defects.

Improved diagnostic accuracy for ulnar-sided TFCC lesions with radial reformation of 3D sequences in wrist MR arthrography

Objectives

Triangular fibrocartilage complex (TFCC) injuries frequently cause ulnar-sided wrist pain and can induce distal radioulnar joint instability. With its complex three-dimensional structure, diagnosis of TFCC lesions remains a challenging task even in MR arthrograms. The aim of this study was to assess the added diagnostic value of radial reformatting of isotropic 3D MRI datasets compared to standard planes after direct arthrography of the wrist.

Methods

Ninety-three patients underwent wrist MRI after fluoroscopy-guided multi-compartment arthrography. Two radiologists collectively analyzed two datasets of each MR arthrogram for TFCC injuries, with one set containing standard reconstructions of a 3D thin-slice sequence in axial, coronal and sagittal orientation, while the other set comprised an additional radial plane view with the rotating center positioned at the ulnar styloid. Surgical reports (whenever available) or radiological reports combined with clinical follow-up served as a standard of reference. In addition, diagnostic confidence and assessability of the central disc and ulnar-sided insertions were subjectively evaluated.

Results

Injuries of the articular disc, styloid and foveal ulnar attachment were present in 20 (23.7%), 10 (10.8%) and 9 (9.7%) patients. Additional radial planes increased diagnostic accuracy for lesions of the styloid (0.83 vs. 0.90; p = 0.016) and foveal (0.86 vs. 0.94; p = 0.039) insertion, whereas no improvement was identified for alterations of the central cartilage disc. Readers’ confidence (p < 0.001) and assessability of the ulnar-sided insertions (p < 0.001) were superior with ancillary radial reformatting.

Conclusions

Access to the radial plane view of isotropic 3D sequences in MR arthrography improves diagnostic accuracy and confidence for ulnar-sided TFCC lesions.

Key Points

• In multi-compartment arthrography of the wrist, ancillary radial plane view aids assessability of the foveal and styloid ulnar-sided insertions of the triangular fibrocartilage complex.

• Assessment of peripheral TFCC injuries is more accurate with access to radial multiplanar reconstructions.

• Additional radial planes provide greater diagnostic confidence.

Improved 3D real-time MRI of speech production

PURPOSE

To provide 3D real-time MRI of speech production with improved spatio-temporal sharpness using randomized, variable-density, stack-of-spiral sampling combined with a 3D spatio-temporally constrained reconstruction.

METHODS

We evaluated five candidate (k, t) sampling strategies using a previously proposed gradient-echo stack-of-spiral sequence and a 3D constrained reconstruction with spatial and temporal penalties. Regularization parameters were chosen by expert readers based on qualitative assessment. We experimentally determined the effect of spiral angle increment and k_z temporal order. The strategy yielding highest image quality was chosen as the proposed method. We evaluated the proposed and original 3D real-time MRI methods in 2 healthy subjects performing speech production tasks that invoke rapid movements of articulators seen in multiple planes, using interleaved 2D real-time MRI as the reference. We quantitatively evaluated tongue boundary sharpness in three locations at two speech rates.

RESULTS

The proposed data-sampling scheme uses a golden-angle spiral increment in the k_x -k_y plane and variable-density, randomized encoding along k_z . It provided a statistically significant improvement in tongue boundary sharpness score (P < .001) in the blade, body, and root of the tongue during normal and 1.5-times speeded speech. Qualitative improvements were substantial during natural speech tasks of alternating high, low tongue postures during vowels. The proposed method was also able to capture complex tongue shapes during fast alveolar consonant segments. Furthermore, the proposed scheme allows flexible retrospective selection of temporal resolution.

CONCLUSION

We have demonstrated improved 3D real-time MRI of speech production using randomized, variable-density, stack-of-spiral sampling with a 3D spatio-temporally constrained reconstruction.

Imaging of Carpal Instabilities

Background The term “carpal instability” describes different debilitating wrist conditions, in which the carpus is unable to maintain its physiological range of motion and load transfer. Depending on the cause and location of the dysfunction, four groups can be defined: dissociative, non-dissociative, complex, and adaptive carpal instability. As the most common form by far, dissociative carpal instability can further be categorized as dorsal or palmar intercalated segment instability, contingent on the afflicted interosseous ligament.

Method This review article outlines the different entities of carpal instability, their pathophysiology, and their clinical presentation. It further discusses the diagnostic significance of different imaging methods as well as the established treatment options for each form of instability in context with the current literature.

Results and Conclusion Early detection and treatment of carpal instability are essential for preventing carpal osteoarthritis. Traumatic lesions of the scapholunate interosseous ligament are the most frequent cause of instability. They can occur in an isolated fashion or in context with other carpal injuries. While stress imaging and fluoroscopy facilitate the differentiation between dynamic and static forms of carpal instability, only MRI and CT/MR arthrography can directly reveal the extent of ligament discontinuity.

Key Points:

Citation Format

Dynamic MRI for articulating joint evaluation on 1.5 T and 3.0 T scanners: setup, protocols, and real-time sequences

Dynamic magnetic resonance imaging (MRI) is a non-invasive method that can be used to increase the understanding of the pathomechanics of joints. Various types of real-time gradient echo sequences used for dynamic MRI acquisition of joints include balanced steady-state free precession sequence, radiofrequency-spoiled sequence, and ultra-fast gradient echo sequence. Due to their short repetition time and echo time, these sequences provide high temporal resolution, a good signal-to-noise ratio and spatial resolution, and soft tissue contrast. The prerequisites of the evaluation of joints with dynamic MRI include suitable patient installation and optimal positioning of the joint in the coil to allow joint movement, sometimes with dedicated coil support. There are currently few recommendations in the literature regarding appropriate protocol, sequence standardizations, and diagnostic criteria for the use of real-time dynamic MRI to evaluate joints. This article summarizes the technical parameters of these sequences from various manufacturers on 1.5 T and 3.0 T MRI scanners. We have reviewed pertinent details of the patient and coil positioning for dynamic MRI of various joints. The indications and limitations of dynamic MRI of joints are discussed.