Bernd Bittersohl

Cartilage damage in femoroacetabular impingement (FAI): preliminary results on comparison of standard diagnostic vs delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC)

OBJECTIVES To study the three-dimensional (3D) T1 patterns in different types of femoroacetabular impingement (FAI) by utilizing delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC) and subsequent 3D T1 mapping. We used standard grading of OA by Tonnis grade on standard radiographs and morphological grading of cartilage in MRI for comparative analysis. METHODS dGEMRIC was obtained from ten asymptomatic young-adult volunteers and 26 symptomatic FAI patients. MRI included the routine hip protocol and a dual-flip angle (FA) 3D gradient echo (GRE) sequence utilizing inline T1 measurement. Cartilage was morphologically classified from the radial images based on the extent of degeneration as: no degeneration, degeneration zone measuring <0.75 cm from the rim, >0.75 cm, or total loss. T1 findings were evaluated and correlated. RESULTS All FAI types revealed remarkably lower T1 mean values in comparison to asymptomatic volunteers in all regions of interest. Distribution of the T1 dGEMRIC values was in accordance with the specific FAI damage pattern. In cam-types (n=6) there was a significant drop (P<0.05) of T1 in the anterior to superior location. In pincer-types (n=7), there was a generalized circumferential decrease noted. High inter-observer (intra-observer) reliability was noted for T1 assessment using intra-class correlation (ICC):intra-class coefficient=0.89 (0.95). CONCLUSIONS We conclude that a pattern of zonal T1 variation does seem to exist that is unique for different sub-groups of FAI. The FA GRE approach to perform 3D T1 mapping has a promising role for further studies of standard MRI and dGEMRIC in the hip joint.

Feasibility of T2* mapping for the evaluation of hip joint cartilage at 1.5T using a three-dimensional (3D), gradient-echo (GRE) sequence: a prospective study.

This study defines the feasibility of utilizing three‐dimensional (3D) gradient‐echo (GRE) MRI at 1.5T for T  2* mapping to assess hip joint cartilage degenerative changes using standard morphological MR grading while comparing it to delayed gadolinium‐enhanced MRI of cartilage (dGEMRIC). MRI was obtained from 10 asymptomatic young adult volunteers and 33 patients with symptomatic femoroacetabular impingement (FAI). The protocol included T  2* mapping without gadolinium‐enhancement utilizing a 3D‐GRE sequence with six echoes, and after gadolinium injection, routine hip sequences, and a dual‐flip‐angle 3D‐GRE sequence for dGEMRIC T1 mapping. Cartilage was classified as normal, with mild changes, or with severe degenerative changes based on morphological MRI. T1 and T  2* findings were subsequently correlated. There were significant differences between volunteers and patients in normally‐rated cartilage only for T1 values. Both T1 and T  2* values decreased significantly with the various grades of cartilage damage. There was a statistically significant correlation between standard MRI and T  2* (T1) (P < 0.05). High intraclass correlation was noted for both T1 and T  2* . Correlation factor was 0.860 to 0.954 (T  2* ‐T1 intraobserver) and 0.826 to 0.867 (T  2* ‐T1 interobserver). It is feasible to gather further information about cartilage status within the hip joint using GRE T  2* mapping at 1.5T. Magn Reson Med, 2009.

T2∗ mapping of hip joint cartilage in various histological grades of degeneration

OBJECTIVE To evaluate T2* values in various histological severities of osteoarthritis (OA). METHOD Magnetic resonance imaging (MRI) and T2* mapping including a three-dimensional (3D) double-echo steady-state (DESS) sequence for morphological cartilage assessment and a 3D multiecho data image combination (MEDIC) sequence for T2* mapping were conducted in 21 human femoral head specimens with varying severities of OA. Subsequently, histological assessment was undertaken in all specimens to correlate the observations of T2* mapping with histological analyses. According to the Mankin score, four grades of histological changes were determined: grade 0 (Mankin scores of 0-4), grade I (scores of 5-8), grade II (scores of 9-10), and grade III (scores of 11-14). For reliability assessment, cartilage T2* measurements were repeated after 4 weeks in 10 randomly selected femoral head specimens. RESULTS T2* values decreased significantly with increasing cartilage degeneration (total P-values <0.001) ranging from 36.3 ± 4.3 ms in grade 0 regions to 22.8 ± 4.3 ms in regions with grade III changes. Pearson correlation analysis proved a fair correlation between T2* values and Mankin score (correlation coefficient = -0.362) that was statistically significant (P-value <0.001). Intra-class correlation (ICC) analysis demonstrated high intra-observer reproducibility for the T2* measurement (ICC: 0.949, P < 0.001). CONCLUSIONS Given the advantages of the T2* mapping technique with no need for contrast medium, high image resolution and ability to perform 3D biochemically sensitive imaging, T2* mapping may be a strong addition to the currently evolving era of cartilage biochemical imaging.

Reproducibility of dGEMRIC in assessment of hip joint cartilage: a prospective study

To investigate the reproducibility of dGEMRIC in the assessment of cartilage health of the adult asymptomatic hip joint.

Delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC), after slipped capital femoral epiphysis

OBJECTIVE The aim of this study was to assess the glycosaminoglycan (GAG) content in hip joint cartilage in mature hips with a history of slipped capital femoral epiphysis (SCFE) using delayed gadolinium-enhanced MRI of cartilage (dGEMRIC). METHODS 28 young-adult subjects (32 hips) with a mean age of 23.8 ± 4.0 years (range: 18.1-30.5 years) who were treated for mild or moderate SCFE in adolescence were included into the study. Hip function and clinical symptoms were evaluated with the Harris hip score (HHS) system at the time of MRI. Plain radiographic evaluation included Tonnis grading, measurement of the minimal joint space width (JSW) and alpha-angle measurement. The alpha-angle values were used to classify three sub-groups: group 1=subjects with normal femoral head-neck offset (alpha-angle <50°), group 2=subjects with mild offset decrease (alpha-angle 50°-60°), and group 3=subjects with severe offset decrease (alpha-angle >60°). RESULTS There was statistically significant difference noted for the T1(Gd) values, lateral and central, between group 1 and group 3 (p-values=0.038 and 0.041). The T1(Gd) values measured within the lateral portion were slightly lower compared with the T1(Gd) values measured within the central portion that was at a statistically significance level (p-value <0.001). HHS, Tonnis grades and JSW revealed no statistically significant difference. CONCLUSION By using dGEMRIC in the mid-term follow-up of SCFE we were able to reveal degenerative changes even in the absence of joint space narrowing that seem to be related to the degree of offset pathology. The dGEMRIC technique may be a potential diagnostic modality in the follow-up evaluation of SCFE.

T2* mapping for articular cartilage assessment: principles, current applications, and future prospects

With advances in joint preservation surgery that are intended to alter the course of osteoarthritis by early intervention, accurate and reliable assessment of the cartilage status is critical. Biochemically sensitive MRI techniques can add robust biomarkers for disease onset and progression, and therefore, could be meaningful assessment tools for the diagnosis and follow-up of cartilage abnormalities. T2* mapping could be a good alternative because it would combine the benefits of biochemical cartilage evaluation with remarkable features including short imaging time and the ability of high-resolution three-dimensional cartilage evaluation—without the need for contrast media administration or special hardware. Several in vitro and in vivo studies, which have elaborated on the potential of cartilage T2* assessment in various cartilage disease patterns and grades of degeneration, have been reported. However, much remains to be understood and certain unresolved questions have become apparent with these studies that are crucial to the further application of this technique. This review summarizes the principles of the technique and current applications of T2* mapping for articular cartilage assessment. Limitations of recent studies are discussed and the potential implications for patient care are presented.

T2* mapping of acetabular and femoral hip joint cartilage at 3 T: a prospective controlled study.

ObjectivesThe aim of this study was to identify the pattern of T2* values in acetabular and femoral head cartilage in morphologically normal and abnormal zones at 3 T. Materials and MethodsTwenty-nine patients (mean [SD] age, 30.8 [8.8] years) with symptomatic femoroacetabular impingement and suspected cartilage damage (study group) and 35 healthy, asymptomatic volunteers (mean [SD] age, 24.9 [2.1] years) with no obvious history of hip diseases or abnormalities (control group) were included. Magnetic resonance imaging was performed at 3 T using a 3-dimensional (3D) double-echo steady-state sequence for grading cartilage morphologically and a 3D multiecho data image combination sequence for T2* assessment. Statistical assessment included the Student t test to reveal differences between mean T2* values of the study group and the control group. One-way analysis of variance was used to identify any statistically significant differences between the T2* values in various grades (modified Outerbridge score system) of cartilage damage within the study group. ResultsSignificant differences were noted between the T2* values in the study group and the control group (P < 0.001). We also noted a significant drop in T2* in accordance with the morphologic damage in the study group (P < 0.001). The largest drop in T2* was found between morphologically normal-appearing cartilage (grade 0; T2*, 25.2 milliseconds) and grade I changes (T2*, 18.1 milliseconds) (P < 0.001). ConclusionsIn combination with a 3-T system, T2* mapping offers unique advantages such as high image resolution and the ability of 3D biochemically sensitive cartilage evaluation in the hip joint without the need for contrast medium. Given these advantages, we believe that T2* mapping is another welcome addition to the rapidly evolving era of hip cartilage biochemical imaging. Further studies are necessary that involve a diagnostic histological analysis as gold standard for comparison.

Delayed gadolinium-enhanced magnetic resonance imaging (dGEMRIC) of hip joint cartilage in femoroacetabular impingement (FAI): Are pre- and postcontrast imaging both necessary?

The purpose of this study was to assess if delayed gadolinium MRI of cartilage using postcontrast T1 (T1Gd) is sufficient for evaluating cartilage damage in femoroacetabular impingement without using noncontrast values (T10). T1Gd and ΔR1 (1/T1Gd − 1/T10) that include noncontrast T1 measurements were studied in two grades of osteoarthritis and in a control group of asymptomatic young‐adult volunteers. Differences between T1Gd and ΔR1 values for femoroacetabular impingement patients and volunteers were compared. There was a very high correlation between T1Gd and ΔR1 in all study groups. In the study cohort with Tonnis grade 0, correlation (r) was −0.95 and −0.89 with Tonnis grade 1 and −0.88 in asymptomatic volunteers, being statistically significant (P < 0.001) for all groups. For both T1Gd and ΔR1, a statistically significant difference was noted between patients and control group. Significant difference was also noted for both T1Gd and ΔR1 between the patients with Tonnis grade 0 osteoarthritis and those with grade 1 changes. Our results prove a linear correlation between T1Gd and ΔR1, suggesting that T1Gd assessment is sufficient for the clinical utility of delayed gadolinium MRI of cartilage in this setting and additional time‐consuming T10 evaluation may not be needed. Magn Reson Med, 2009.

Magnetic resonance imaging of the hip at 3 Tesla: clinical value in femoroacetabular impingement of the hip and current concepts.

Magnetic resonance imaging (MRI) is the most promising noninvasive modality for hip joint evaluation, but it has limitations in diagnosing cartilage lesion and acetabular labrum changes, especially in early stages. This is significant due to superior outcome results of surgery intervention in hip dysplasia or femoroacetabular impingement in patients not exceeding early degeneration. This emphasizes the need for accurate and reproducible methods in evaluating cartilage structure. In this article, we discuss the impact of the most recent technological advance in MRI, namely the advantage of 3-T imaging, on diagnostic imaging of the hip. Limitations of standard imaging techniques are shown with emphasis on femoroacetabular impingement. Clinical imaging examples and biochemical techniques are presented that need to be further evaluated.

Cord blood-an alternative source for bone regeneration.

Bone regeneration is one of the best investigated pathways in mesenchymal stromal cell (MSC) biology. Therfore strong efforts have been made to introduce tissue engineering and cell therapeutics as an alternative treatement option for patients with bone defects. This review of the literature gives an overview of MSC biology aiming for clinical application including advantages but also specific challenges and problems which are associated with cord blood derived stromal cell (CB-MSC) as a source for bone regeneration. The use of postnatal CB-MSC is ethically uncomplicated and requires no invasive harvesting procedure. Moreover, most data document a high osteogenic potential of CB-MCS and also low immunoreactivity compared with other MSC types. The expression profile of CB-MSC during osteogenic differentiation shows similarities to that of other MSC types. Within the umbilical cord different MSC types have been characterized which are potent to differentiate into osteoblasts. In contrast to a large number of in vitro investigations there are only few in vivo studies avaiable so far.