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Zbýň Š, Kajabi AW, Nouraee CM, Ludwig KD, Johnson CP, Tompkins MA, Nelson BJ, Zhang L, Moeller S, Marette S, Metzger GJ, Carlson CS, Ellermann JM. Evaluation of lesion and overlying articular cartilage in patients with juvenile osteochondritis dissecans of the knee using quantitative diffusion MRI. J Orthop Res 2023; 41:1449-1463. [PMID: 36484124 DOI: 10.1002/jor.25505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/06/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022]
Abstract
Current clinical MRI of patients with juvenile osteochondritis dissecans (JOCD) is limited by the low reproducibility of lesion instability evaluation and inability to predict which lesions will heal after nonoperative treatment and which will later require surgery. The aim of this study is to verify the ability of apparent diffusion coefficient (ADC) to detect differences in lesion microstructure between different JOCD stages, treatment groups, and healthy, unaffected contralateral knees. Pediatric patients with JOCD received quantitative diffusion MRI between January 2016 and September 2020 in this prospective research study. A disease stage (I-IV) and stability of each JOCD lesion was evaluated. ADCs were calculated in progeny lesion, interface, parent bone, cartilage overlying lesion, control bone, and control cartilage regions. ADC differences were evaluated using linear mixed models with Bonferroni correction. Evaluated were 30 patients (mean age, 13 years; 21 males), with 40 JOCD-affected and 12 healthy knees. Nine patients received surgical treatment after MRI. Negative Spearman rank correlations were found between ADCs and JOCD stage in the progeny lesion (ρ = -0.572; p < 0.001), interface (ρ = -0.324; p = 0.041), and parent bone (ρ = -0.610; p < 0.001), demonstrating the sensitivity of ADC to microstructural differences in lesions at different JOCD stages. We observed a significant increase in the interface ADCs (p = 0.007) between operative (mean [95% CI] = 1.79 [1.56-2.01] × 10-3 mm2 /s) and nonoperative group (1.27 [0.98-1.57] × 10-3 mm2 /s). Quantitative diffusion MRI detects microstructural differences in lesions at different stages of JOCD progression towards healing and reveals differences between patients assigned for operative versus nonoperative treatment.
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Affiliation(s)
- Štefan Zbýň
- Department of Radiology, Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Abdul Wahed Kajabi
- Department of Radiology, Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Cyrus M Nouraee
- Department of Radiology, Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kai D Ludwig
- Department of Radiology, Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Casey P Johnson
- Department of Radiology, Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Veterinary Clinical Sciences, University of Minnesota, St. Paul, Minnesota, USA
| | - Marc A Tompkins
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
- TRIA Orthopedic Center, Minneapolis, Minnesota, USA
- Gillette Children's Specialty Healthcare, St. Paul, Minnesota, USA
| | - Bradley J Nelson
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
- TRIA Orthopedic Center, Minneapolis, Minnesota, USA
| | - Lin Zhang
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Steen Moeller
- Department of Radiology, Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shelly Marette
- Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Gregory J Metzger
- Department of Radiology, Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, Minnesota, USA
| | - Cathy S Carlson
- Department of Veterinary Clinical Sciences, University of Minnesota, St. Paul, Minnesota, USA
| | - Jutta M Ellermann
- Department of Radiology, Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA
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Kajabi AW, Zbýň Š, Johnson CP, Tompkins MA, Nelson BJ, Takahashi T, Shea KG, Marette S, Carlson CS, Ellermann JM. Longitudinal 3T MRI T 2 * mapping of Juvenile osteochondritis dissecans (JOCD) lesions differentiates operative from non-operative patients-Pilot study. J Orthop Res 2023; 41:150-160. [PMID: 35430743 PMCID: PMC9573934 DOI: 10.1002/jor.25343] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/21/2022] [Accepted: 04/13/2022] [Indexed: 02/04/2023]
Abstract
Juvenile osteochondritis dissecans (JOCD) is an orthopedic joint disorder of children and adolescents that can lead to premature osteoarthritis. Thirteen patients (mean age: 12.3 years, 4 females), 15 JOCD-affected and five contralateral healthy knees, that had a baseline and a follow-up magnetic resonance imaging (MRI) (mean interval of 8.9 months) and were treated nonoperatively during this interval were included. Retrospectively, patients were assigned to operative or nonoperative groups based on their electronic medical records. Volumetric mean T2 * values were calculated within regions of interest (progeny lesion, interface, parent bone) and region matched control bone in healthy contralateral knees and condyles. The normalized percentage difference of T2 * between baseline and follow up MRI in nonoperative patients significantly increased in progeny lesion (-47.8%, p < 0.001), parent bone (-13.9%, p < 0.001), and interface (-32.3%, p = 0.011), whereas the differences in operative patients were nonsignificant and below 11%. In nonoperative patients, the progeny lesion (p < 0.001) and interface T2 * values (p = 0.012) were significantly higher than control bone T2 * at baseline, but not at follow-up (p = 0.219, p = 1.000, respectively). In operative patients, the progeny lesion and interface T2 * values remained significantly elevated compared to the control bone both at baseline (p < 0.001, p < 0.001) and follow-up (p < 0.001, p < 0.001), respectively. Clinical Significance: Longitudinal T2 * mapping differentiated nonhealing from healing JOCD lesions following initial nonoperative treatment, which may assist in prognosis and improve the ability of surgeons to make recommendations regarding operative versus nonoperative treatment.
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Affiliation(s)
- Abdul Wahed Kajabi
- Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, MN, USA
- Department of Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Štefan Zbýň
- Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, MN, USA
- Department of Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Casey P. Johnson
- Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, MN, USA
- Department of Veterinary Clinical Sciences, University of Minnesota, St. Paul, MN, USA
| | - Marc A. Tompkins
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Bradley J. Nelson
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Takashi Takahashi
- Department of Radiology, University of Minnesota, Minneapolis, MN, USA
| | | | - Shelly Marette
- Department of Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Cathy S. Carlson
- Department of Veterinary Clinical Sciences, University of Minnesota, St. Paul, MN, USA
| | - Jutta M. Ellermann
- Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, MN, USA
- Department of Radiology, University of Minnesota, Minneapolis, MN, USA
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Armstrong AR, Bhave S, Buko EO, Chase KL, Tóth F, Carlson CS, Ellermann JM, Kim HKW, Johnson CP. Quantitative T2 and T1ρ mapping are sensitive to ischemic injury to the epiphyseal cartilage in an in vivo piglet model of Legg-Calvé-Perthes disease. Osteoarthritis Cartilage 2022; 30:1244-1253. [PMID: 35644462 PMCID: PMC9378508 DOI: 10.1016/j.joca.2022.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 04/27/2022] [Accepted: 05/17/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine if the quantitative MRI techniques T2 and T1ρ mapping are sensitive to ischemic injury to epiphyseal cartilage in vivo in a piglet model of Legg-Calvé-Perthes disease using a clinical 3T MRI scanner. We hypothesized that T2 and T1ρ relaxation times would be increased in the epiphyseal cartilage of operated vs contralateral-control femoral heads 1 week following onset of ischemia. DESIGN Unilateral femoral head ischemia was surgically induced in eight piglets. Piglets were imaged 1 week post-operatively in vivo at 3T MRI using a magnetization-prepared 3D fast spin echo sequence for T2 and T1ρ mapping and a 3D gradient echo sequence for cartilage segmentation. Ischemia was confirmed in all piglets using gadolinium contrast-enhanced MRI. Median T2 and T1ρ relaxation times were measured in the epiphyseal cartilage of the ischemic and control femoral heads and compared using paired t-tests. Histological assessment was performed on a subset of five piglets. RESULTS T2 and T1ρ relaxation times were significantly increased in the epiphyseal cartilage of the operated vs control femoral heads (ΔT2 = 11.9 ± 3.7 ms, 95% CI = [8.8, 15.0] ms, P < 0.0001; ΔT1ρ = 12.8 ± 4.1 ms, 95% CI = [9.4, 16.2] ms, P < 0.0001). Histological assessment identified chondronecrosis in the hypertrophic and deep proliferative zones within ischemic epiphyseal cartilage. CONCLUSIONS T2 and T1ρ mapping are sensitive to ischemic injury to the epiphyseal cartilage in vivo at clinical 3T MRI. These techniques may be clinically useful to assess injury and repair to the epiphyseal cartilage to better stage the extent of ischemic damage in Legg-Calvé-Perthes disease.
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Affiliation(s)
- A R Armstrong
- Department of Veterinary Clinical Sciences, University of Minnesota, St. Paul, MN, USA.
| | - S Bhave
- Department of Veterinary Clinical Sciences, University of Minnesota, St. Paul, MN, USA.
| | - E O Buko
- Department of Veterinary Clinical Sciences, University of Minnesota, St. Paul, MN, USA; Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, MN, USA.
| | - K L Chase
- Department of Veterinary Clinical Sciences, University of Minnesota, St. Paul, MN, USA.
| | - F Tóth
- Department of Veterinary Clinical Sciences, University of Minnesota, St. Paul, MN, USA.
| | - C S Carlson
- Department of Veterinary Clinical Sciences, University of Minnesota, St. Paul, MN, USA.
| | - J M Ellermann
- Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, MN, USA; Department of Radiology, University of Minnesota, Minneapolis, MN, USA.
| | - H K W Kim
- Center for Excellence in Hip, Scottish Rite for Children, Dallas, TX, USA; Department of Orthopedic Surgery, UT Southwestern Medical Center, Dallas, TX, USA.
| | - C P Johnson
- Department of Veterinary Clinical Sciences, University of Minnesota, St. Paul, MN, USA; Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, MN, USA.
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Zbýň Š, Santiago C, Johnson CP, Ludwig KD, Zhang L, Marette S, Tompkins MA, Nelson BJ, Takahashi T, Metzger GJ, Carlson CS, Ellermann JM. Compositional evaluation of lesion and parent bone in patients with juvenile osteochondritis dissecans of the knee using T 2 * mapping. J Orthop Res 2022; 40:1632-1644. [PMID: 34637164 PMCID: PMC9001743 DOI: 10.1002/jor.25187] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 09/13/2021] [Accepted: 09/30/2021] [Indexed: 02/04/2023]
Abstract
Juvenile osteochondritis dissecans (JOCD) lesions contain cartilaginous, fibrous and osseous tissues which are difficult to distinguish with clinical, morphological magnetic resonance imaging (MRI). Quantitative T2 * mapping has earlier been used to evaluate microstructure and composition of all aforementioned tissues as well as bone mineral density. However, the ability of T2 * mapping to detect changes in tissue composition between different JOCD lesion regions, different disease stages, and between stable and unstable lesions has not been demonstrated. This study analyzed morphological and T2 * MRI data from 25 patients (median age, 12.1 years) with 34 JOCD-affected and 13 healthy knees. Each lesion was assigned a stage reflecting the natural history of JOCD, with stages I and IV representing early and healed lesion, respectively. T2 * values were evaluated within the progeny lesion, interface and parent bone of each lesion and in the control bone region. T2 * was negatively correlated with JOCD stage in progeny lesion (ρ = -0.871; p < 0.001) and interface regions (ρ = -0.649; p < 0.001). Stage IV progeny showed significantly lower T2 * than control bone (p = 0.028). T2 * was significantly lower in parent bone than in control bone of patients with stable lesions (p = 0.009), but not in patients with unstable lesions (p = 0.14). Clinical significance: T2 * mapping enables differentiation between different stages of JOCD and quantitative measurement of the ossification degree in progeny lesion and interface. The observed T2 * decrease in healed and stable lesions may indicate increased bone density as a result of the active repair process. T2 * mapping provides quantitative information about JOCD lesion composition.
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Affiliation(s)
- Štefan Zbýň
- Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, Minnesota, USA,Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Cassiano Santiago
- Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, Minnesota, USA
| | - Casey P. Johnson
- Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, Minnesota, USA,Department of Veterinary Clinical Sciences, University of Minnesota, St. Paul, Minnesota, USA
| | - Kai D. Ludwig
- Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, Minnesota, USA,Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lin Zhang
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shelly Marette
- Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Marc A. Tompkins
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA,TRIA Orthopedic Center, Minneapolis, Minnesota, USA,Gillette Children’s Specialty Healthcare, St. Paul, Minnesota, USA
| | - Bradley J. Nelson
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA,TRIA Orthopedic Center, Minneapolis, Minnesota, USA
| | - Takashi Takahashi
- Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Gregory J. Metzger
- Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, Minnesota, USA
| | - Cathy S. Carlson
- Department of Veterinary Clinical Sciences, University of Minnesota, St. Paul, Minnesota, USA
| | - Jutta M. Ellermann
- Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, Minnesota, USA,Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA
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Osteochondritis Dissecans Lesion of the Trochlear Groove: A Case of Nonsurgical Management for a Rare Lesion. Case Rep Orthop 2021; 2021:9776362. [PMID: 34938584 PMCID: PMC8687841 DOI: 10.1155/2021/9776362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 11/30/2021] [Indexed: 11/18/2022] Open
Abstract
Osteochondritis dissecans (OCD) lesions are potential causes of knee pain in pediatric patients, with lesions most frequently found on the lateral and medial femoral condyles. This case discusses an OCD lesion of the trochlear groove, a rare location for OCD lesions, in an 11-year-old female athlete. The patient presents after several years of knee pain that had acutely worsened, and both X-ray and MRI demonstrated the lesion, with MRI confirming a stable lesion. While previous literature has leaned towards surgical management, this patient was successfully managed nonoperatively in a locked knee brace for 12 weeks. She then went through 4 weeks of physical therapy and a 4 week progression back into soccer activity with return to full activity in 5 months.
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Fabricant PD, Milewski MD, Kostyun RO, Wall EJ, Zbojniewicz AM, Albright JC, Bauer KL, Carey JL, Chambers HG, Edmonds EW, Ellis HB, Ganley TJ, Green DW, Grimm NL, Heyworth BE, Kocher MS, Krych AJ, Lyon RM, Mayer SW, Nepple JJ, Nissen CW, Pennock AT, Polousky JD, Saluan P, Shea KG, Tompkins MA, Weiss J, Clifton Willimon S, Wilson PL, Wright RW, Myer GD. Osteochondritis Dissecans of the Knee: An Interrater Reliability Study of Magnetic Resonance Imaging Characteristics. Am J Sports Med 2020; 48:2221-2229. [PMID: 32584594 DOI: 10.1177/0363546520930427] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Imaging characteristics of osteochondritis dissecans (OCD) lesions quantified by magnetic resonance imaging (MRI) are often used to inform treatment and prognosis. However, the interrater reliability of clinician-driven MRI-based assessment of OCD lesions is not well documented. PURPOSE To determine the interrater reliability of several historical and novel MRI-derived characteristics of OCD of the knee in children. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 3. METHODS A total of 42 OCD lesions were evaluated by 10 fellowship-trained orthopaedic surgeons using 31 different MRI characteristics, characterizing lesion size and location, condylar size, cartilage status, the interface between parent and progeny bone, and features of both the parent and the progeny bone. Interrater reliability was determined via intraclass correlation coefficients (ICCs) with 2-way random modeling, Fleiss kappa, or Krippendorff alpha as appropriate for each variable. RESULTS Raters were reliable when the lesion was measured in the coronal plane (ICC, 0.77). Almost perfect agreement was achieved for condylar size (ICC, 0.93), substantial agreement for physeal patency (ICC, 0.79), and moderate agreement for joint effusion (ICC, 0.56) and cartilage status (ICC, 0.50). Overall, raters showed significant variability regarding interface characteristics (ICC, 0.25), progeny (ICC range, 0.03 to 0.62), and parent bone measurements and qualities (ICC range, -0.02 to 0.65), with reliability being moderate at best for these measurements. CONCLUSION This multicenter study determined the interrater reliability of MRI characteristics of OCD lesions in children. Although several measurements provided acceptable reliability, many MRI features of OCD that inform treatment decisions were unreliable. Further work will be needed to refine the unreliable characteristics and to assess the ability of those reliable characteristics to predict clinical lesion instability and prognosis.
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Affiliation(s)
- Peter D Fabricant
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Matthew D Milewski
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Regina O Kostyun
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Eric J Wall
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Andrew M Zbojniewicz
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jay C Albright
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kathryn L Bauer
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - James L Carey
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Henry G Chambers
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Eric W Edmonds
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Henry B Ellis
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Theodore J Ganley
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Daniel W Green
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Nathan L Grimm
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Benton E Heyworth
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Mininder S Kocher
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Aaron J Krych
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Roger M Lyon
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Stephanie W Mayer
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jeffrey J Nepple
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Carl W Nissen
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Andrew T Pennock
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - John D Polousky
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Paul Saluan
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kevin G Shea
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Marc A Tompkins
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jennifer Weiss
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - S Clifton Willimon
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Philip L Wilson
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rick W Wright
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Gregory D Myer
- Investigation performed at the Hospital for Special Surgery, New York, New York, USA, and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Glaser C, Heuck A, Horng A. Update: Klinische Knorpelbildgebung – Teil 2. Radiologe 2019; 59:700-709. [DOI: 10.1007/s00117-019-0554-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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8
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Clinical Value of MRI in Assessing the Stability of Osteochondritis Dissecans Lesions: A Systematic Review and Meta-Analysis. AJR Am J Roentgenol 2019; 213:147-154. [PMID: 30995094 DOI: 10.2214/ajr.18.20710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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9
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Tóth F, Tompkins MA, Shea KG, Ellermann JM, Carlson CS. Identification of Areas of Epiphyseal Cartilage Necrosis at Predilection Sites of Juvenile Osteochondritis Dissecans in Pediatric Cadavers. J Bone Joint Surg Am 2018; 100:2132-2139. [PMID: 30562294 PMCID: PMC6738538 DOI: 10.2106/jbjs.18.00464] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The pathogenesis of human juvenile osteochondritis dissecans (JOCD) remains poorly understood, with multiple factors implicated, including ischemia, repetitive trauma, and genetic predisposition. Similarities in the predilection site and the diagnostic and clinical features of JOCD to the well-characterized veterinary counterpart, osteochondrosis dissecans, suggest that, similar to the animal disease, the pathogenesis JOCD may also be initiated in the first few years of life, when disruption of blood supply to the epiphyseal growth cartilage leads to failure of endochondral ossification. To gather data in support of the hypothesis that JOCD and osteochondrosis dissecans have a shared pathogenesis, biopsy specimens obtained from predilection sites of JOCD in juvenile human cadavers were histologically examined to determine whether they contained lesions similar to those found in animals diagnosed with subclinical osteochondrosis dissecans. METHODS In this descriptive laboratory study, 59 biopsy specimens (6 mm in diameter) were harvested from the central aspect (i.e., the notch side) of the femoral condyles of 26 human cadavers (1 month to 11 years old). Specimens were histologically evaluated for the presence of areas of cartilage necrosis and the morphology of cartilage canal blood vessels. RESULTS Locally extensive areas of necrotic epiphyseal cartilage were identified in 4 specimens obtained from 3 donors (ages 2 to 4 years). Areas of cartilage necrosis accompanied by focal failure of endochondral ossification or surrounded by subchondral bone were identified in biopsy specimens from 4 donors (ages 4 to 9 years). CONCLUSIONS The identification of epiphyseal cartilage necrosis identical to that described in animals with subclinical osteochondrosis, found in biopsy specimens obtained from femoral predilection sites of JOCD in pediatric cadavers, suggests a shared pathogenesis of JOCD in humans and osteochondrosis dissecans in animals. CLINICAL RELEVANCE These findings imply that the pathogenesis of human JOCD likely starts 5 to 10 years prior to the development of clinical symptoms. Enhanced understanding of the temporal features of JOCD pathogenesis provides an opportunity for earlier diagnosis and treatment, likely resulting in improved outcomes for this condition in the future.
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Affiliation(s)
- Ferenc Tóth
- Department of Veterinary Population Medicine, University of Minnesota, St. Paul, Minnesota
| | - Marc A Tompkins
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota
- TRIA Orthopedic Center, Minneapolis, Minnesota
| | - Kevin G Shea
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, California
| | - Jutta M Ellermann
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, Minnesota
| | - Cathy S Carlson
- Department of Veterinary Clinical Sciences, University of Minnesota, St. Paul, Minnesota
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10
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Olstad K, Shea KG, Cannamela PC, Polousky JD, Ekman S, Ytrehus B, Carlson CS. Juvenile osteochondritis dissecans of the knee is a result of failure of the blood supply to growth cartilage and osteochondrosis. Osteoarthritis Cartilage 2018; 26:1691-1698. [PMID: 30248503 DOI: 10.1016/j.joca.2018.06.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 05/25/2018] [Accepted: 06/09/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Juvenile osteochondritis dissecans (JOCD) is similar to osteochondrosis dissecans (OCD) in animals, which is the result of failure of the cartilage canal blood supply, ischemic chondronecrosis and delayed ossification, or osteochondrosis. The aim of the current study was to determine if osteochondrosis lesions occur at predilection sites for JOCD in children. METHOD Computed tomographic (CT) scans of 23 knees (13 right, 10 left) from 13 children (9 male, 4 female; 1 month to 11 years old) were evaluated for lesions consisting of focal, sharply demarcated, uniformly hypodense defects in the ossification front. Histological validation was performed in 11 lesions from eight femurs. RESULTS Thirty-two lesions consisting of focal, uniformly hypodense defects in the ossification front were identified in the CT scans of 14 human femurs (7 left, 7 right; male, 7-11 years old). Defects corresponded to areas of ischemic chondronecrosis in sections from all 11 histologically validated lesions. Intra-cartilaginous secondary responses comprising proliferation of adjacent chondrocytes and vessels were detected in six and two lesions, whereas intra-osseous responses including accumulation of chondroclasts and formation of granulation tissue occurred in 10 and six lesions, respectively. One CT cyst-like lesion contained both a pseudocyst and a true cyst in histological sections. CONCLUSION Changes identical to osteochondrosis in animals were detected at predilection sites for JOCD in children, and confirmed to represent failure of the cartilage canal blood supply and ischemic chondronecrosis in histological sections.
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Affiliation(s)
- K Olstad
- Department of Companion Animal Clinical Sciences, Equine Section, Norwegian University of Life Sciences, Oslo, Norway.
| | - K G Shea
- Department of Orthopedics, St. Luke's Sports Medicine, Boise, ID, USA.
| | - P C Cannamela
- Department of Orthopedics, St. Luke's Sports Medicine, Boise, ID, USA.
| | - J D Polousky
- Children's Health Specialty Center Plano Campus, Andrews Institute/Children's Health, Plano, TX, USA.
| | - S Ekman
- Department of Biomedicine and Veterinary Public Health, Division of Pathology, Swedish University of Life Sciences, Uppsala, Sweden.
| | - B Ytrehus
- Terrestrial Department, Norwegian Institute for Nature Research, Trondheim, Norway.
| | - C S Carlson
- Department of Veterinary Population Medicine, College of Veterinary Medicine, University of Minnesota, St. Paul, Minnesota, USA.
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11
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Gorbachova T, Melenevsky Y, Cohen M, Cerniglia BW. Osteochondral Lesions of the Knee: Differentiating the Most Common Entities at MRI. Radiographics 2018; 38:1478-1495. [PMID: 30118392 DOI: 10.1148/rg.2018180044] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Several pathologic conditions may manifest as an osteochondral lesion of the knee that consists of a localized abnormality involving subchondral marrow, subchondral bone, and articular cartilage. Although understanding of these conditions has evolved substantially with the use of high-spatial-resolution MRI and histologic correlation, it is impeded by inconsistent terminology and ambiguous abbreviations. Common entities include acute traumatic osteochondral injuries, subchondral insufficiency fracture, so-called spontaneous osteonecrosis of the knee, avascular necrosis, osteochondritis dissecans, and localized osteochondral abnormalities in osteoarthritis. Patient demographics, the clinical presentation, and the role of trauma are critical for differential diagnosis. A localized osteochondral defect can be created acutely or can develop as an end result of several chronic conditions. MRI features that aid in diagnosis include the location and extent of bone marrow edema, the presence of a fracture line, a hypointense area immediately subjacent to the subchondral bone plate, and deformity of the subchondral bone plate. These findings are essential in diagnosis of acute traumatic injuries, subchondral insufficiency fracture, and its potentially irreversible form, spontaneous osteonecrosis of the knee. If the lesion consists of a subchondral region demarcated from the surrounding bone, the demarcation should be examined for completeness and the presence of a "double-line sign" that is seen in avascular necrosis or findings of instability, which are important for proper evaluation of osteochondritis dissecans. Subchondral bone plate collapse, demonstrated by the presence of a depression or a fluid-filled cleft, can be seen in advanced stages of both avascular necrosis and subchondral insufficiency fracture, indicating irreversibility. Once the diagnosis is established, it is important to report pertinent MRI findings that may guide treatment of each condition. ©RSNA, 2018 An earlier incorrect version of this article appeared online. This article was corrected on August 23, 2018.
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Affiliation(s)
- Tetyana Gorbachova
- From the Department of Radiology, Einstein Healthcare Network, 5501 Old York Rd, Philadelphia, PA 19141 (T.G, M.C., B.W.C.) and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (Y.M.)
| | - Yulia Melenevsky
- From the Department of Radiology, Einstein Healthcare Network, 5501 Old York Rd, Philadelphia, PA 19141 (T.G, M.C., B.W.C.) and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (Y.M.)
| | - Micah Cohen
- From the Department of Radiology, Einstein Healthcare Network, 5501 Old York Rd, Philadelphia, PA 19141 (T.G, M.C., B.W.C.) and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (Y.M.)
| | - Brett W Cerniglia
- From the Department of Radiology, Einstein Healthcare Network, 5501 Old York Rd, Philadelphia, PA 19141 (T.G, M.C., B.W.C.) and Department of Radiology, University of Alabama at Birmingham, Birmingham, Ala (Y.M.)
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12
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Nguyen JC, Liu F, Blankenbaker DG, Woo KM, Kijowski R. Juvenile Osteochondritis Dissecans: Cartilage T2 Mapping of Stable Medial Femoral Condyle Lesions. Radiology 2018; 288:536-543. [PMID: 29762089 DOI: 10.1148/radiol.2018171995] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Purpose To determine whether a T2 mapping sequence could depict early changes in the composition and microstructure of cartilage overlying stable lesions of the medial femoral condyle in patients with juvenile osteochondritis dissecans (JOCD). Materials and Methods This retrospective study analyzed a sagittal T2 mapping sequence performed between September 1, 2015, and March 31, 2017, on 16 patients (10 boys and six girls; median age, 11.5 years) with 18 stable medial femoral condyle JOCD lesions and 18 age-, sex-, and skeletal maturation-matched control participants (11 boys and seven girls; median age, 11.5 years). Cartilage T2 values were quantitatively measured within regions of interest placed around the cartilage within and overlying the JOCD lesion in patients with JOCD and around the cartilage on the weight-bearing medial femoral condyle in patients with JOCD and controls. Wilcoxon signed rank and Wilcoxon rank sum tests were used to compare T2 values. Results T2 values were significantly higher (P < .001) for cartilage within the JOCD lesion than for cartilage overlying the JOCD lesion in patients with JOCD. However, there were no significant differences in T2 values between cartilage overlying the JOCD lesion and cartilage on the weight-bearing medial femoral condyle in patients with JOCD (P = .67) or in T2 values of the cartilage on the weight-bearing medial femoral condyle between patients with JOCD and controls (P = .30). Conclusion There were no significant quantifiable differences in T2 values of cartilage overlying stable JOCD lesions and normal cartilage on the medial femoral condyle, suggesting no substantial changes in cartilage composition and microstructure.
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Affiliation(s)
- Jie C Nguyen
- From the Department of Radiology (J.C.N., F.L., D.G.B., R.W.K.) and Department of Biostatistics and Medical Informatics (K.M.W.), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Fang Liu
- From the Department of Radiology (J.C.N., F.L., D.G.B., R.W.K.) and Department of Biostatistics and Medical Informatics (K.M.W.), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Donna G Blankenbaker
- From the Department of Radiology (J.C.N., F.L., D.G.B., R.W.K.) and Department of Biostatistics and Medical Informatics (K.M.W.), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Kaitlin M Woo
- From the Department of Radiology (J.C.N., F.L., D.G.B., R.W.K.) and Department of Biostatistics and Medical Informatics (K.M.W.), University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Richard Kijowski
- From the Department of Radiology (J.C.N., F.L., D.G.B., R.W.K.) and Department of Biostatistics and Medical Informatics (K.M.W.), University of Wisconsin School of Medicine and Public Health, Madison, Wis
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13
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Stone AV, Little KJ, Glos DL, Stringer KF, Wall EJ. Repetitive Stresses Generate Osteochondral Lesions in Skeletally Immature Rabbits. Am J Sports Med 2016; 44:2957-2966. [PMID: 27460999 DOI: 10.1177/0363546516654479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The origin of juvenile osteochondritis dissecans (OCD) is unknown. Existing experimental animal models of OCD most frequently involve surgically created lesions but do not examine repetitive stress as a possible cause of OCD. HYPOTHESIS Repetitive stresses can cause OCD-like lesions in immature animals. STUDY DESIGN Controlled laboratory study. METHODS Six juvenile rabbits were subjected to repetitive loading forces of approximately 160% body weight to the right hindlimb during five 45-minute sessions per week for 5 weeks. The contralateral limb was the unloaded control. After 5 weeks, rabbits were euthanized and examined with radiographs, micro-computed tomography, and gross and histopathologic analysis. RESULTS All 6 rabbits developed osteochondral lesions in loaded limbs on the medial and lateral femoral condyles, while contralateral unloaded limbs did not demonstrate lesions. Loaded limbs developed relative osteopenia in the femoral epiphysis and tibial metaphysis with associated decreased trabecular density. Loaded limbs also demonstrated increased femoral subchondral bone thickness near the lesions. Lesions did not have grossly apparent extensive articular cartilage damage; however, cartilage thickness increased on histology with reduced ossification. Loaded knees demonstrated abundant chondrocyte cloning, limited cartilage fissuring, and a focal loss of cellularity at the articular surface. CONCLUSION Low-grade lesions in human OCD have little gross articular cartilage involvement despite substantial changes to the subchondral bone as shown on magnetic resonance imaging and radiographs. Histopathology findings in this study included cartilage thickening and chondrocyte cloning resembling those of recently published human OCD biopsy studies. Our animal model supports the hypothesis that repetitive stress to immature knees may contribute to the development of human OCD. This model may be useful in understanding the pathophysiology and healing of human OCD. CLINICAL RELEVANCE Repetitive physiologic stress generated changes to the subchondral bone in immature animals without causing extensive articular damage. The similarities of these lesions in gross and histologic appearance with human OCD support repetitive stress as the likely the cause for human OCD.
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Affiliation(s)
- Austin V Stone
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Kevin J Little
- Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - David L Glos
- Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Keith F Stringer
- Department of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Eric J Wall
- Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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14
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Abstract
Osteochondritis dissecans (OCD) can cause knee pain and dysfunction in children. The etiology of OCD remains unclear; theories on causes include inflammation, ischemia, ossification abnormalities, genetic factors, and repetitive microtrauma. Most OCD lesions in skeletally immature patients will heal with nonoperative treatment. The success of nonoperative treatment decreases once patients reach skeletal maturity. The goals of surgical treatment include maintenance of articular cartilage congruity, rigid fixation of unstable fragments, and repair of osteochondral defects with cells or tissues that can adequately replace lost or deficient cartilage. Unsalvageable OCD lesions can be treated with various surgical techniques.
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Ellermann J, Johnson CP, Wang L, Macalena JA, Nelson BJ, LaPrade RF. Insights into the Epiphyseal Cartilage Origin and Subsequent Osseous Manifestation of Juvenile Osteochondritis Dissecans with a Modified Clinical MR Imaging Protocol: A Pilot Study. Radiology 2016; 282:798-806. [PMID: 27631413 DOI: 10.1148/radiol.2016160071] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To retrospectively determine if a modified clinical magnetic resonance (MR) imaging protocol provides information on the origin of juvenile osteochondritis dissecans (JOCD) lesions and allows for staging on the basis of the proposed natural history of JOCD to better guide clinical management of the disease. Materials and Methods This institutional review board-approved, HIPAA-compliant, retrospective study was performed in 13 consecutive patients (mean age, 14.9 years; age range, 10-22 years; nine male and four female patients) and one additional comparative patient (a 44-year-old man), in which 19 knees with 20 JOCD lesions were imaged. Seventeen lesions occurred in the medial femoral condyle, two occurred in the lateral femoral condyle, and one occurred in the medial trochlea. The clinical 3-T MR imaging protocol was supplemented with a routinely available multiecho gradient-recalled-echo sequence with the shortest attainable echo time of approximately 4 msec (T2* mapping). Results At the earliest manifestation, the lesion was entirely cartilaginous (n = 1). Subsequently, primary cartilaginous lesions within the epiphyseal cartilage developed a rim calcification that originated from normal subjacent bone, which defined a clear cleft between the lesion progeny and the parent bone (n = 9). Secondarily, progeny lesions became ossified (n = 7) while at the same time forming varying degrees of osseous bridging and/or clefting with the parent bone. Two healed lesions with a linear bony scar and one detached lesion were identified. Conclusion The modified MR imaging protocol allowed for identification of the epiphyseal cartilage origin and subsequent stages of ossification in JOCD. The approach allows further elucidation of the natural history of the disease and may better guide clinical management. © RSNA, 2016.
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Affiliation(s)
- Jutta Ellermann
- From the Department of Radiology and Center for Magnetic Resonance Research (J.E., C.P.J., L.W.) and Department of Orthopaedic Surgery (J.A.M., B.J.N.), University of Minnesota Medical Center, 2021 6th St SE, Minneapolis, MN 55455; and Complex Knee and Sports Medicine Surgery, The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colo (R.F.L.)
| | - Casey P Johnson
- From the Department of Radiology and Center for Magnetic Resonance Research (J.E., C.P.J., L.W.) and Department of Orthopaedic Surgery (J.A.M., B.J.N.), University of Minnesota Medical Center, 2021 6th St SE, Minneapolis, MN 55455; and Complex Knee and Sports Medicine Surgery, The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colo (R.F.L.)
| | - Luning Wang
- From the Department of Radiology and Center for Magnetic Resonance Research (J.E., C.P.J., L.W.) and Department of Orthopaedic Surgery (J.A.M., B.J.N.), University of Minnesota Medical Center, 2021 6th St SE, Minneapolis, MN 55455; and Complex Knee and Sports Medicine Surgery, The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colo (R.F.L.)
| | - Jeffrey A Macalena
- From the Department of Radiology and Center for Magnetic Resonance Research (J.E., C.P.J., L.W.) and Department of Orthopaedic Surgery (J.A.M., B.J.N.), University of Minnesota Medical Center, 2021 6th St SE, Minneapolis, MN 55455; and Complex Knee and Sports Medicine Surgery, The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colo (R.F.L.)
| | - Bradley J Nelson
- From the Department of Radiology and Center for Magnetic Resonance Research (J.E., C.P.J., L.W.) and Department of Orthopaedic Surgery (J.A.M., B.J.N.), University of Minnesota Medical Center, 2021 6th St SE, Minneapolis, MN 55455; and Complex Knee and Sports Medicine Surgery, The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colo (R.F.L.)
| | - Robert F LaPrade
- From the Department of Radiology and Center for Magnetic Resonance Research (J.E., C.P.J., L.W.) and Department of Orthopaedic Surgery (J.A.M., B.J.N.), University of Minnesota Medical Center, 2021 6th St SE, Minneapolis, MN 55455; and Complex Knee and Sports Medicine Surgery, The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colo (R.F.L.)
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“Weak Links” of the Pediatric Skeleton: Common Foci for Disease and Trauma. Part 1: The Link Between Bone and Cartilage. CURRENT RADIOLOGY REPORTS 2016. [DOI: 10.1007/s40134-015-0134-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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