T2 mapping for the comparison of

treatment outcomes in osteochondral

lesions of the talus
Dane Brodke
UCSF School of Medicine
Case

• 26 yo male sustained severe inversion

sprain of right ankle while running
• Immediate sharp medial pain, able to
bear weight
• Persistent medial aching pain,
exacerbated by running, cycling
• Plain films unremarkable
• MRI demonstrates OLT on posteromedial
shoulder measuring 7mm in diameter
Background

• Osteochondral lesions of the talus (OLTs): “aseptic separation of a

fragment of articular cartilage, with or without attached subchondral
bone.”
• Uncertain natural history: rarely heal in adults, but not thought to
progress to OA in most cases
• Surgical treatment options have been modeled after experience with
osteochondral lesions of the knee, though outcomes in ankle must be
studied independently
 Operative treatment options
r Techniques
Optimal Use* Technique

tion Age ,40 years; focal contained defect (surrounded Arthroscopic introduction of micropenetration from defect surface to
by intact cartilage); femoral condyles; lesion the subchondral bone until visible bleeding. Resulting clot contains
size ,4 cm2 mesenchymal stem cells, which heal defect by forming fibrocartilage.
utograft Femoral lesions ,2.5 cm2 Grafts taken from the patient’s own nonweight-bearing cartilage
introduced into the chondral defect and underlying bone.
llograft Lesions with bone and cartilage loss; large, uncontained Grafts taken from a suitable deceased donor introduced into the chondral
lesions (ie, extend beyond the margin or the cartilage defect and underlying bone.
or deep into subchondral bone)
age allograft Focal articular cartilage defects Allograft articular cartilage from donors younger than 13 years that has
STATE OF THE ART: MR Imaging after Knee Cartilage Repair Surgery Guermazi et al
been cut into approximately 1-mm cubes. It is applied to cartilage
lesions in a monolayer and held in place with the use of fibrin sealant
during a single-step procedure. STATE OF THE ART: MR Imaging after Knee Cartilage Repair Surgery
ndrocyte Lesions .2 cm2 Two-part procedure. First, chondrocytes are harvested arthroscopically,
usually from tibial spines. They are cultured and multiplied ex vivo for
6–8 weeks, then implanted into the chondral defect.

6 and 35.

ent of the lesion to the

Figure 1 Figure 2 a complication, most often soon after host tissue. In clinical practice, the
recommended. The
one and peripherally to Figure 3
surgery (17,27–29). technique for particulated car tilage al-are used
techniques
cartilage margins. The
Osteochondral allograft—Because lografting is straightforward,and requiring
native cartilage.
one plate is then violated
abrasion or perforation allografts are not limited by the amount only a single surgery to effectolution of 0.3 mm
cartilage
mended to demonstr
subchondral bone mar- of donor tissue, defects larger than 4 cm repair (35). Posttherapy imag ing fol-
native cartilage surf
n, microfracture instru- in diameter, which require large grafts, low-up can be performed by resolution using MR is essentia
illing penetrate the plate can be repaired. Because the entire imaging to assess percentagethat defect
can fill
depict fiss
ral marrow progressively cartilage-bone unit is transplanted with and tissue microstructure (36). Overall,
plete cartilage repair
esultant bleeding fills the
osteochondral allografts, they can be clinical experience is limitedTypically, thus far, MR imagin
blood clot, facilitating the cartilage repair requi
luripotent marrow stem particularly useful for revision of previ- with short-term studies (up oftocartilage-sensitive 2-year
2–24). ously performed cartilage repair proce- follow-up) demonstrating the proce-
as fat-suppressed 3
row stimulation tech- dures—especially when the subchondral dure to be safe, feasible, and(GRE) effective,
and fluid-sen
e augmented with scaf- bone is damaged. The technique involves with improvements in subjective such as fat-suppresse
pa-
mers (eg, chitosan) that weighted, T2-weighte
harvesting cartilage from a cadaveric do- tient scores and MR imagingate-weighted evidence fast spin
lot (25). There are also
ed synthetic plugs avail-
nor; tissue matching is not thought to of good defect fill (36–40).The Although
3D GRE sequen
mote gradient ingrowth be necessary. In the United States, com- promising, prospective long-term pressionran-or water ex
ow cells into the porous mercial allograft suppliers are required domized controlled studies are accurate
needed depiction
and surface of cartil
oduce both a bone and a to adhere to the U.S. Food and Drug to refine the indications and contraindi-
aforementioned fast
Administration’s good tissue practices cations and to compare recovery quences times
outline the
of second-look arthros- Figure 3: Diagram shows steps oftesting.
autologous chondrocyte
Figure 1: Diagram shows steps of microfracture surgery. First, the defect is débrided to create stable Figure 2: Diagram shows osteochondral autograft and infectious disease A min- implantation. For the first arthroscopic
or postoperative proce-
activity levels with and ena
of cartilage
or near-normal macro- cartilage margin. Then, careful curettage of calcified cartilage layer is performed. Subchondral bone is pene- dure, cartilage is harvested from lower weight-bearing area separate from damaged cartilage site. Tissue is
transfer. Damaged cartilage is débrided to stable imum of 14 days are required to test for those of other techniques. focal cartilage defect
Arthroscopic marrow stimulation

• Arthroscopic marrow stimulation is “gold standard” for small lesions with

an area less than 1.5 cm2
Arthroscopic marrow stimulation

• Good to excellent long term • Near 100% “success” with small

outcomes in 78% at 8-20 years lesions at 2.5 years
JBJS. 2013;95(6):519-525. Journal of Arthroscopic & Related Surgery. 2008;24(1):106-112.

Microfracture for Osteochondral Lesions of the Ankle:

Outcome Analysis and Outcome Predictors of 105 Cases

Bavornrit Chuckpaiwong, M.D., Eric M. Berkson, M.D., and George H. Theodore, M.D.
108 B. CHUCKPAIWONG ET AL.
Purpose: The purpose of this study was to identify outcomes and outcome predictors of arthroscopic
debridement with osteochondral bone stimulation (microfracture) for osteochondral lesions of the
10 T 1. Success of Lesions Distributed by Size
ABLEOne hundred five consecutive patients with osteochondral lesions of the ankle who
ankle. Methods:
(Average of Longitudinal and Transverse Diameter)
underwent ankle arthroscopy with microfracture were prospectively followed up for a mean of
31.6 ! 12.1 months. Study patients were evaluated at 6 weeks, 3 months, 6 months, 12 months, and
9 annually after surgery. Assessments via a visual analog scale for pain during daily activities and sport
activity, the Roles and Maudsley score, and the American Orthopaedic Foot & Ankle Society ankle
Size of Lesion
and hindfoot scoring systemSuccessful
were obtained at (neach
# 74) Unsuccessful
visit. Outcome predictors were (n # 31)
analyzed by
8 logistic regression model. Results: There were no failures of treatment with lesions smaller than 15
mm. In contrast, only 1 patient met the criteria for success in the group of lesions greater than 15 mm.
mm revealed that increasing46age, higher body mass index, history0of trauma, and
!5analysis
Statistical
7 presence of osteophytes negatively affected outcome. The presence of instability and the presence of
5-15 mm 27 0
anterolateral soft-tissue scar were correlated with a successful outcome. Conclusions: This study
6 15-20
found mm
a strong 1 and success across its entire population.
correlation between lesion size 7 For lesions
smaller than 15 mm, regardless of location, excellent results were obtained. In addition, increasing
$20 body
age, higher mmmass index, history of trauma,0 and presence of osteophytes24 negatively affect
outcome. The presence of instability and anterolateral soft-tissue scar correlated with a successful
5 outcome. Level of Evidence: Level IV, prognostic case series, prognostic study. Key Words:
NOTE. defect—Ankle
Osteochondral There were no failures in smaller lesions and only 1
arthroscopy—Microfracture—Ankle.
4 success in larger lesions.

2
O steochondral lesions of the ankle can be a chal-
tion, 5.7% of lesions were stage 1, 22.9% were stage
23 for the foot and ankle surgeon.
lenging problem
Ankle articular cartilage is distinctly different from
articular cartilage degeneration in the ankle.6 One
would expect that cartilage healing and responses to
surgical cartilage restoration procedures may be dif-
2, 43.8% were stage 3, and 27.6% were stage 4.
articular cartilage in the knee.1-4 Besides being mac- ferent as well.
Quality of repair tissue at follow-up?
The American Journal of Sports Medicine. 2009;37.
Non-invasive assessment of repair tissue

• A technique to non-invasively gauge the quality of repair tissue at long-

term follow up is needed to conclusively compare cartilage restoration
techniques

• Numerous MRI-based strategies have been proposed

• T2 mapping, one of the most validate techniques, takes advantage of the
fact that the constrained water present in articular cartilage has
characteristic spin-spin relaxation times of 35-45 msec
• Collagen bound water – 2 msec
• Proteoglycan bound water – 25 msec
• Water loosely associated with proteoglycan – 120 msec
 Non-invasive assessment of repair tissue
TABLE 4
Correlation between Cartilage T2 and WOMAC Score

Cartilage
Compartment Function
WOMAC Score
Pain Stiffness Cartilage Volume Cartilage Thickness Opposing Volume* Opposing Thickness†
Radiology

Medial femur
R value 0.35 0.32 NA !0.30 !0.39 !0.33 !0.36
P value .013 .027 ".05 .027 .004 .013 .007

NA Musculoskeletal Imaging
Medial tibia
R value Radiology.
0.29 2004;232(2):592-598.
0.40 !0.38 !0.53 !0.45 !0.48 Radiology. 2008;247(1):154-161.
P value .042 .005 ".05 .004 #.001 #.001 #.001
Lateral femur
R value 0.31 NA NA NA NA NA !0.35
T2 ".05 Relaxation Time".05 of
Radiology

P value .028 C. Dunn,

Timothy ".05ScB ".05 ".05 .009
Lateral tibia
Ying Lu, PhD
R value
P value Hua
NA NA
Jin, PhD2 ".05
".05
NA
".05 Cartilage NA
".05 at .001
!0.43
MR Imaging: NA
".05
NA
".05
Michael D. Ries, MD
* Opposing volume is the volume of tibial cartilage Comparison
for femoral cartilage and the volumewith Severity
for tibial cartilage. of
Note.—NA $ notSharmila
applicable.
Majumdar, PhD
of femoral cartilage
1 for tibial cartilage.
Knee Osteoarthritis
† Opposing thickness is the volume of tibial cartilage for femoral cartilage and the thickness of femoral cartilage

Index terms:
Cartilage, MR, 452.121411
Knee, arthritis, 452.7
Knee, MR, 452.121411
Magnetic resonance (MR), tissue
characterization, 452.121411
Published online before print
10.1148/radiol.2322030976
Radiology 2004; 232:592–598
Abbreviations:
OA ! osteoarthritis
WOMAC ! Western Ontario and
McMaster University
1
From the Departments of Radiology
(T.C.D., Y.L., H.J., S.M.) and Ortho-
paedic Surgery (M.D.R., S.M.), Univer-
sity of California at San Francisco, 185
Berry St, Suite 350, San Francisco, CA
94107-1739. Received June 20, 2003;
revision requested August 29; final re-
vision received December 19; ac-
cepted January 13, 2004. Supported
by NIH grant R01 AR46905. Address
correspondence to T.C.D. (e-mail:
tcdunn@mrsc.ucsf.edu).
Current address:
2 relaxation time between healthy and diseased knees; however, no significant differ-
Department of Mathematics, South
China Normal University, Shipai, Guang-
zhou, China.
PURPOSE: To evaluate differences in T2 values in femoral and tibial cartilage at
magnetic resonance (MR) imaging in patients with varying degrees of osteoarthritis
(OA) compared with healthy subjects and to develop a mapping and display
method based on calculation of T2 z scores for visual grading and assessment of
cartilage heterogeneity in patients with OA.
MATERIALS AND METHODS: Knee cartilage was evaluated in 55 subjects who
were categorized with radiography as healthy (n ! 7) or as having mild OA (n ! 20)
or severe OA (n ! 28). Cartilage regions were determined with manual segmenta-
tion of an MR image acquired with spoiled gradients and fat suppression. The
segmentation was applied to a map of T2 relaxation time and was analyzed in four
knee cartilage compartments (ie, the medial and lateral tibia and femur). Differences
between cartilage compartment T2 values and subject groups were analyzed with
analysis of covariance. Correlations of cartilage T2 values with clinically reported
symptoms and cartilage thickness and volume were examined. Cartilage T2 values
were converted to z scores per voxel on the basis of normal population values in the
same cartilage compartment to better interpret cartilage heterogeneity and varia-
tion from normal.
RESULTS: Healthy subjects had mean T2 values of 32.1–35.0 msec, while patients
with mild and severe OA had mean T2 values of 34.4 – 41.0 msec. All cartilage
compartments except the lateral tibia showed significant (P " .05) increases in T2
ence was found between patients with mild and severe OA. Correlation of T2 values
with clinical symptoms and cartilage morphology was found predominantly in
medial compartments.
CONCLUSION: Femoral and medial tibial cartilage T2 values increase with the
severity of OA.
© RSNA, 2004

Osteoarthritis (OA) is an important health concern, as joint disease is the single largest
Figure 3. Representative z score conversion sagittal MR images obtained in six subjects (ie, two from each group)
Author contributions: cause of disability in elderly persons (1). Between 13% and 17% of Americans aged 55–74
(1,500/10 and 45; voxel size, 0.468 % 0.468 % 4 mm; examination time, 5 minutes 24 seconds; field of view, 12 cm;
Guarantors of integrity of entire study, years have pain and functional problems related to knee OA (2), and estimated economic
matrix, 256 % 256). Note the increase in area of regions of high z scores (indicated by yellow areas) in patients with
S.M., T.C.D.; study concepts and de- costs were $12.2 billion dollars in 1994 (3).
mild and severe OA. Note that these
sign, S.M., T.C.D.; literature research, are only single sections of the entire knee volume and may not reflect specific
Quantitative measures of T2 relaxation times may be useful in the characterization and
regions
T.C.D.; of disease that
experimental account
studies, S.M.; for OA grade.
long-term tracking of OA. Previous reports have demonstrated spatial variation of T2
data acquisition, S.M.; data analysis/
interpretation, all authors; statistical relaxation times in cartilage explants (4), healthy subjects (5), and substantial changes
analysis, Y.L., H.J.; manuscript prepa- with age (6), but we are unaware of reports that present T2 relaxation time variation with
ration, T.C.D.; manuscript definition OA in humans. Cartilage tissue analysis has shown increased water content in tissue that
decrease in variance of the
of intellectual measured
content, T2
S.M., T.C.D.; variation
has beenofdegraded
T2 values through
through the carti-
OA processes (7) andchondral
decreasedregion to the articulating
glycosaminoglycan concen- sur-
manuscript editing, T.C.D.; manu-
relaxation time with an increased num- lagetration
volumeandcould enhance
proteoglycan sizethe
in informa-
diseased tissueface.
(8,9).MR signal
These heterogeneity
findings across
support those of the
T2 mapping in the ankle European Journal of Radiology 81 (2012) 923–927

Contents lists available at ScienceDirect

European Journal of Radiology

journal homepage: www.elsevier.com/locate/ejrad

European Journal of Radiology. 2012;81(5):923-927.

Biochemical evaluation of articular cartilage in patients with osteochondrosis

dissecans by means of quantitative T2- and T2*-mapping at 3 T MRI: A feasibility
study
W. Marik a,∗ , S. Apprich b,1 , G.H. Welsch c,2 , T.C. Mamisch b,1 , S. Trattnig a,3
a
University of Vienna, Department of Radiology, MR-Centre of Excellence, Währinger Gürtel 18-20, A-1090 Wien, Austria
b
Universitätsklinik für Orthopädische Chirurgie, Universitätsspital Bern Inselspital, CH-3010 Bern, Switzerland
c
Unfallchirurgische Abteilung in der Chirurgischen Klinik, Universitätsklinikum Erlangen, Krankenhausstraße 12, 91054 Erlangen, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To perform an in vivo evaluation comparing overlying articular cartilage in patients suffering
Received 8 November 2010 from osteochondrosis dissecans (OCD) in the talocrural joint and healthy volunteers using quantitative
Received in revised form 17 January 2011 T2 mapping at 3.0 T.
Accepted 28 January 2011
Method and materials: Ten patients with OCD of Grade II or lower and 9 healthy age matched volunteers
were examined at a 3.0 T whole body MR scanner using a flexible multi-element coil. In all investigated
Keywords:
persons MRI included proton-density (PD)-FSE and 3D GRE (TrueFisp) sequences for morphological diag-
3T
nosis and location of anatomical site and quantitative T2 and T2* maps. Region of interest (ROI) analysis
MRI
T2 mapping
was performed for the cartilage layer above the OCD and for a morphologically healthy graded cartilage
Talus layer. Mean T2 and T2* values were then statistically analysed.
Osteochondrosis dissecans Results: The cartilage layer of healthy volunteers showed mean T2 and T2* values of 29.4 ms (SD 4.9)
and 11.8 ms (SD 2.7), respectively. In patients with OCD of grade I and II lesions mean T2 values were
40.9 ms (SD 6.6), 48.7 ms (SD 11.2) and mean T2* values were 16.1 ms (SD 3.2), 16.2 ms (SD 4.8). Therefore
statistically significantly higher mean T2 and T2* values were found in patients suffering from OCD
compared to healthy volunteers.
Conclusion: T2 and T2* mapping can help assess the microstructural composition of cartilage overlying
osteochondral lesions.
© 2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Cartilage is one of the most important structures involved in
traumatic and degenerative joint disease. Osteochondral lesions
of the talus are quite rare compared to larger joints like the knee,
but still they can cause severe problems for patients including
pain and disability [1]. Osteochondrosis dissecans (OCD) appears
as a special entity of osteochondral lesion in the ankle joint.
As the talus is the third most common site with 4% of all OCD’s
locations after knee and elbow its incidence is only 0.09% and its
prevalence 0.002% [2]. It most commonly affects patients in the 2nd
decade of life.
Different patho-ethological factors are discussed such as trau-
matic, vascular, genetic, endogen and infectious causes [2], but the
origin still remains unclear.
Over the last years cartilage assessment in preoperative diag-
T2 mapping in the ankle
Eur Radiol (2014) 24:1758–1767
DOI 10.1007/s00330-014-3196-8

MUSCULOSKELETAL
Eur Eur Radiol2014;24(8):1758-1767.
Radiol. (2014) 24:1758–1767 1765

Quantitative
A Themagnetic
correlation of thickness
resonance imaging index(MRI) and AOFAS evaluation that filling degree positively correlated with clinical outcome
of cartilage score
repair after microfracture (MF) treatment for adult
120 [48, 49]. Domayer et al. [29] found the T2 index correlated
unstable osteochondritis dissecans (OCD) in the ankle: Eur Radiolwith (2014) 24:1758–1767
outcome of the Lysholm score and the IKDC subjective
1763
100
correlations with clinical outcome
AOFAS score

80 kneeA evaluation form. And postoperative B BME was found to C

Hongyue Tao & Xiliang Shang & Rong Lu & Hong Li &
60 correlate with clinical outcome in the study by Cuttica et al.
Yinghui Hua & Xiaoyuan Feng & Shuang Chen
40 [39]. All these findings correspond well with the results of our
r=0.416 study, in which the MF was performed for ankle OCD. Thus,
Received: 22 November 2013 / Revised: 20 March 2014 / Accepted: 22 April 2014 / Published online: 10 May 2014
20
# European Society of Radiology 2014 P=0.003
0
we can conclude that with the increase of filling thickness, the
Abstract Key Points
0 0.2 0.4
Objectives To quantitatively evaluate cartilage repair after
0.6 0.8 1 decrease of T2 value and subchondral BME, the patient’s
• Patients with unstable ankle OCD had satisfactory clinical
microfracture (MF) for ankle osteochondritis Thickness
dissecans index outcome after MF. clinical outcome will be improved.
(OCD) using MRI and analyse correlations between MRI • Quantitative MRI correlates with clinical outcome after MF
and clinical outcome. for ankle OCD. BME is the main factor which initiated pain sensation, not
B 120Forty-eightThe
Methods correlation
patients were recruited andof T2 index
underwent • Theand AOFAS
reduction score
of subchondral BME will improve the patient’s
the cartilage injury. The AOFAS score system emphasizes the
MR imaging, including 3D-DESS, T2-mapping and T2-STIR clinical outcome.
sequences, and completed American Orthopaedic Foot and
100 (AOFAS) scoring. Thickness index, T2 index
Ankle Society over time.
patient’s perception of function and pain (50 function, 40
• Quantitative MRI can monitor the process of cartilage repair

of repair tissue (RT) and volume of subchondral bone marrow pain),

D which partly explains the Ereason why BME was nega- F
AOFAS score

oedema (BME)
80 were calculated. Subjects were divided into Keywords MRI . Microfracture . Ankle . Osteochondritis
two groups: group A (3–12 months post-op), and group B
dissecans (OCD) . Bone marrow edema (BME)
tively correlated with AOFAS score. However, BME was not
(12–24 months post-op). Student’s t test was used to compare
60
the MRI and AOFAS score between two groups and Pearson’s correlated with thickness index or T2 index. The filling
correlation coefficient to analyse correlations between them.
40
Results Thickness index and AOFAS score of group B were
Abbreviations
ACI Autologous chondrocyte implantation
thickness and biochemical properties are the most important
higher than group A (P<0.001, P<0.001). T2 index and BME AOFAS Americanr=-0.475 predicators
Orthopaedic Foot and Ankle Society to evaluate the repair quality. Therefore, subchondral
of group 20B were lower than group A (P<0.001, P=0.012). AP Anteroposterior
P=0.001
Thickness index, T2 index and BME were all correlated with BMI Body mass index BME was an insufficient independent predicator to evaluate
AOFAS score 0 (r=0.416, r=−0.475, r=−0.353), but BME was BME Bone marrow oedema
correlated with0 neither thickness index
0.5 nor T2 index. 1 CC Craniocaudal
1.5
the repair quality. BME could serve as an assisted predictor
2
Conclusions Significant improvement from MF can be
expected on the basis of the outcomes of quantitative T2MRI index
3D-DESS Three-dimensional double echo steady tostateevaluate the repair quality when combined with thickness
sequence
and AOFAS score. MRI was correlated with AOFAS score. dGEMRIC Delayed gadolinium-enhanced MRI ofindex cartilage and T2 index. However, BME was negatively corre-
BMEC The correlation
is insufficient as an independentof subchondral
predictor to evaluate
repair quality, but reduction of BME can improve the patient’s
BME and
DWI AOFAS imaging
Diffusion-weighted score lated3D-DESS
Fig. 3 Sagittal with AOFAS score,
image (a) and which
T2-mapping imageindicated
(d) of a 31- thatA timely
according inter-
to the corresponding colour bar (right). The RT of group A
FOV Field of view
clinical120
outcome. year-old patient in group A (8 months after MF). The sagittal 3D-DESS was arranged in an irregular manner according to colour. The sagittal 3D-
GAG Glycosaminoglycan
vention and reduction of BME could improve the patient’s
 T2 mapping in the ankle Osteoarthritis and Cartilage 20 (2012) 829e836

Osteoarthritis and Cartilage. 2012;20(8):829-836.

Cartilage repair of the ankle: first results of T2 mapping at 7.0 T after microfracture
and matrix associated autologous cartilage transplantation
S.E. Domayer y *, S. Apprich z, D. Stelzeneder z, C. Hirschfeld y, M. Sokolowski y, C. Kronnerwetter z,
C. Chiari y, R. Windhager y, S. Trattnig z
y Department of Orthopedics, Medical University of Vienna, Austria S.E. Domayer et al. / Osteoarthritis and Cartilage 20 (2012) 829e836 833
z MR Center of Excellence, Department of Radiology, Medical University of Vienna, Austria

832 S.E. Domayer et al. / Osteoarthritis and Cartilage 20 (2012) 829e836

a r t i c l e i n f o s u m m a r y

Article history: Background: Both microfracture (MFX) and matrix associated autologous cartilage transplantation
Received 26 October 2011 (MACT) are currently used to treat cartilage defects of the talus. T2 mapping of the ankle at 7 T has the
Accepted 19 April 2012 potential to assess the collagen fibril network organization of the native hyaline cartilage and of the
repair tissue (RT). This study provides first results regarding the properties of cartilage RT after MFX
Keywords: (mean follow-up: 113.8 months) and MACT (65.4 months).
T2 mapping
Methods: A multi-echo spin-echo sequence was used at 7 T to assess T2 maps in 10 volunteer cases, and
Microfracture
in 10 cases after MFX and MACT each. Proton weighted morphological images and clinical data were used
Matrix assisted autologous cartilage
transplantation
to ensure comparable baseline criteria.
Ankle joint Results: A significant zonal variation of T2 was found in the volunteers. T2 of the superficial and the deep
7T layer was 39.3 ! 5.9 ms and 21.1 ! 3.1 ms (zonal T2 index calculated by superficial T2/deep T2: 1.87 ! 0.2,
P < 0.001). In MFX, T2 of the reference cartilage was 37.4 ! 5.0 ms and 25.3 ! 3.5 ms (1.51 ! 0.3,
P < 0.001). In the RT, T2 was 43.4 ! 10.5 ms and 36.3 ! 7.7 ms (1.20 ! 0.2, P ¼ 0.009). In MACT, T2 of the
reference cartilage was 39.0 ! 9.1 ms and 27.1 ! 6.6 ms (1.45 ! 0.2, P < 0.001). In the RT, T2 was
44.6 ! 10.4 ms and 38.6 ! 7.3 ms (1.15 ! 0.1, P ¼ 0.003). The zonal RT T2 variation differed significantly
from the reference cartilage in both techniques (MFX: P ¼ 0.004, MACT: P ¼ 0.001).
(b). Both ROIsT2
Conclusion:
Fig. 2. Example of the ROI setting in a case after MACT in the repair site (a) and the reference are mapping at orientation
set at the same 7 T allows for
to the themagnetic
static quantitative
field. The assessment
deep (1) of the collagen network organi-
and superficial (2) ROIs are indicated by the white boxes. This case shows T2 values in the zation of thethat
repair tissue talus. MACT and
are comparable MFX
to the yielded
articular RT both
cartilage within comparable
the deep and theT2 properties.
superficial layer.
! 2012 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.
Fig. 3. Boxplots of the T2 values after MFX and matrix associated autologous chondrocyte implantation (MACT) in cartilage RT and reference cartilage. Both treatment groups show
a significant increase of T2 in the superficial layer of the RT similar to the hyaline reference cartilage (blue and green boxes), however, T2 of the deep layers differs significantly
between RT and reference cartilage (blue boxes). In contrast, T2 of the superficial layers is comparable between RT and reference cartilage (green boxes). The P-values refer to
Results In the volunteers, we observed a highly significant increase from
Student’s t-tests.
deep to superficial T2 (21.1 ! 3.1 ms vs 39.3 ! 5.9 ms, P < 0.001,
The morphological outcome was comparable in both groups zonal T2 index ¼ 1.87).
(see Table I for details). The majority of cases had complete defect The reference cartilage both of the MFX and of the MACT cases
significant differences between the superficial layers (MFX: a deterioration of clinical outcomes at 71 months, and Hunt and
Introduction various techniques have been used in the ankle, however, the
filling and good integration of the RT, however, interestingly almost yielded comparable ranges of T2 and a highly significant variation
P ¼ 0.159; MACT: P ¼ 0.155). In contrast, both patient groups had Sherman found 54% of the cases had fair or poor results at 66
microfracture technique (MFX) is considered the most effective
all cases had alteration of the subchondral bone. of T2, however, we found small, yet significant differences between
significantly
4 (MFX: P ¼ 0.004; MACT: P ¼ 0.001) increased T2 in the months34. Also, first second-look arthroscopy findings indicate that
 the repair tissue; (5) subchondral bone alterations; (6) with the treatment outcomes (1 = excellent, 2 = very good,
signal intensity of the repair tissue; and (7) effusion. Dis- 3 = good, 4 = fair, and 5 = poor), also asking patients if

T2 mapping in the ankle

crepancies in interpretation were settled by consensus. they would undergo the procedure again and if they would
recommend this procedure. Institutional review board
approval (ID 5791) was obtained from the ethical committee
of Hannover Medical School prior to the study.
2408 Knee Surg Sports Traumatol Arthrosc (2015) 23:2406–2412
Statistical analysis
was done at the repair tissue (RT) and at the native adjacent Score outcome measures
Knee Surg Sports
healthy cartilage (RC) Traumatol Arthroscreference
as an internal (2015) 23:2406–2412
using two Descriptive statistics were calculated (mean, range, and
DOI 10.1007/s00167-014-2913-9
consecutive representative coronal and sagittal images Data collection was performed at the follow-up
standard examination
deviation values). To determine differences
following Aearlier
NKLE published protocols [26]. The ROIs were and according to the patient records. Rating of
between the T2the results wasa two-sided independent Student’s
values,
drawn Knee Surgery,
manually, carefully Sports Traumatology,
excluding the subchondral Arthroscopy.
bone April 2015:1-7.
performed with the Hannover Scoring System
t test (HSS)
was used forconfirming
after the normality of the variances
and synovial fluid. The data of all measurements were then ankle [7, 24] and the American Orthopaedicof the T2Foot and Ankle
values by the Kolmogorov–Smirnov test. The
analysed to calculate mean RT T2 and RC T2. Society (AOFAS) hind-foot score [18]. The HSS was
nonparametric modi-
Mann–Whitney test was used to confirm the
T2-mapping
The classification system forat cartilage
3 T after repair bymicrofracture
Marlo- inofthe
fied because treatment
the lack of access to standard preoperative
t test result. Correlationsand between the T2 values, MOCART
vits et al.of osteochondral
(MOCART) [20] was useddefects
to assess the ofcartilage
the talus at an average
post-operative plain film radiographs. score,Theandmaximum scorebetween the clinical scores as well
associations
repair andfollow-up of 8 years
joint status comprising the following variables: was therefore adjusted to 100 %, and the scores were reported
as defect size, age, and the follow-up time were assessed
(1) degree of defect repair and filling; (2) integration
Fig. 1 Coronal to spinasecho
T1-weighted a percentage
image with T2 of map
the maximum
and an [6, 8].theSatisfaction
using was
Pearson coefficient of correlation. Inter-observer
border zone; (3) surface of the repair illustration of the
tissue; (4) region-of-interest
structure of (ROI) analysis
evaluated of a 28-year-old
by a questionnaire that rated the general satisfaction
Christoph Becher • David female Zühlke5.4 • Christian Plaas •
reliability was evaluated using the intra-class correlation
years post-operatively.
the repair tissue; (5) subchondral bone alterations; (6) withThe
the RT (repair tissue) was
treatment outcomes (1 = excellent,
coefficient 2= very good,
(ICC). SPSS 18.0 (SPSS Inc., Chicago, IL,
Marc Ewig • Tilman Calliess 40.3• ms, and the Stukenborg-Colsman
Christina RC (healthy cartilage) was
• 38.8 ms. The defect is
signal intensity of the repair tissue; and (7) effusion.
completely covered Dis- repair
with 3 =tissue
good, that
4 = appears
fair, andslightly
5 = poor), also was
USA) askingusedpatients
for if analyses. A P value B0.05 was
all
Hajo Thermann
crepancies in interpretation were settled by consensus.
hypertrophic they would undergo the procedure consideredagain and ifsignificant.
they would
recommend this procedure. Institutional review board
approval (ID 5791) was obtained from the ethical committee
Received: 2 July 2013 / Accepted: 9 February 2014 / Published online: 23 February 2014
! Springer-Verlag Berlin Heidelberg 2014
of Hannover Medical School prior to the study.

Statistical analysis
Abstract respectively; intra-class correlation coefficient = 0.94;
Purpose To compare repaired cartilage with native car- confidence interval 0.84–0.99, P B 0.001). Despite C50 %
Descriptive statistics were calculated (mean, range, and
tilage, and inter-observer reliability, using T2 mapping at defect filling in all patients, subchondral bone changes
3 T for assessing cartilage repair in osteochondral defectsstandard deviation values).
were considerable. The HSSToat the determine
follow-updifferences
revealed a
of the talus after the microfracture technique. between
mean score of 87 ± 12 (range 51–97), and theStudent’s
the T2 values, a two-sided independent AOFAS-
Methods We enrolled eight females and seven malest testScore was used
was 90after confirming
± 13 normality of the variances
(range 59–100).
undergoing arthroscopic microfracture for osteochondralof the T2 values 3byT the
Conclusions Kolmogorov–Smirnov
T2 maps were similar in repairedtest. The
and
defects of the talus at an average follow-up ofnonparametric Mann–Whitney
native cartilage test was usedreliability.
with good inter-observer to confirm the
7.9 ± 2.2 years (range 5–13 years). Cartilage tissue wast testLevel result.
ofCorrelations
evidence IV. between the T2 values, MOCART
assessed using a 3-T magnetic resonance imaging unit withscore, and associations between the clinical scores as well
an 8-channel phased array foot and ankle coil (gradientas defect Keywords Ankle
size, age, and! Microfracture
the follow-uptechnique
time were ! assessed
strength,
Fig. 1 Coronal 50 mT/m;spin
T1-weighted slew Fig.
rate,
echo image 2 Sagittal
200 T2 and
T/m/s).
with T2coronal
map maps
and T1-weighted
an were spin echo
Osteochondral image
defect !
with T2
T2 appears
mapping slightly
using the Pearson coefficient of correlation. Inter-observer hypertrophic. b The T2 value of the majority of the
illustrationthen
of the region-of-interest
calculated. Three (ROI)mapanalysis
and an illustration
independent of of the ROI analysis a of a 23-year-old female
a 28-year-old
boarded specialists repair tissue appears comparable to that of the adjacent native
6.5 RT
years(repair
post-operatively.
reliability was evaluated using the intra-class correlation
female 5.4 years post-operatively.
evaluated the images, andThemagnetic tissue)
resonance wasThe RT was 41.8 ms, and the RC was
observation cartilage. However, although integration appears complete, the
40.3 ms, and the RC (healthy cartilage)43.3 was ms.
38.8The
ms. defect is completely
The defect is coefficient (ICC).
covered with repairSPSS
tissue 18.0
that (SPSS Inc.,zone
integration Chicago,
displays IL,
higher T2 properties
of cartilage repair tissue scores was used to assess the Introduction
completely covered with repair tissue that appears slightly USA) was used for all analyses. A P value B0.05 was
hypertrophiccartilage and joint status. Clinical results were assessed
considered significant.
using the Hannover Scoring System (HSS) for the ankle
123 Arthroscopic debridement and bone marrow stimulation
Summary and future directions

• Summary
• Research on treatments for OLTs needs a method to non-invasively follow the
quality of repair tissue
• T2 mapping may be a feasible MRI-based method for use in these studies

• Remaining challenges
• Needs extensively validation through correlation with clinical and histologic
outcomes
• It remains to be used in high quality comparative studies in a standardized manner
• 7T MRI may be essential for validity in the ankle
• Will have to automated
Case conclusion

• Underwent debridement and microfracture of posteromedial lesion

• Lesion dimensions 5x8mm with probe measurement
• Postop placed in soft dressing and to remain non weight-bearing for
4-6 weeks