SSSR. 1. Nov Ankle. Postoperative Imaging of Cartilage Repair. and Lateral Ligament Reconstruction
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1 Ankle Postoperative Imaging of Cartilage Repair and Lateral Ligament Reconstruction Andrea B. Rosskopf, MD University Hospital Balgrist
2 Imaging of Cartilage Repair Why? To assess the technical success of the procedure To evaluate the state of cartilage healing To identify potential complications Y. Choi et al./ RadioGraphics 2008; 28:
3 Imaging of Cartilage Repair Recommendations MR-Imaging: Same MR sequences as for the evaluation of native cartilage: High resolution images with extremity coils Intermediate- or T2-weighted FSE sequence 3D fat saturated gradient echo sequence Additionally fluid sensitive sequence for assessment of bone marrow edema (e.g. Stir-sequence) Y. Choi et al./ RadioGraphics 2008; 28: S. Marlovits et al. / European Journal of Radiology 57 (2006) S. Marlovits et al./the American J of Sports Medicine 2012, Vol. 40, No. 10
4 Imaging of Cartilage Repair Postoperative cartilage assessment : 1. Defect filling 2. Integration to border zone 3. Surface 4. Structure 5. Signal intensity 6. Subchondral bone S. Marlovits et al. / European Journal of Radiology 52 (2004)
5 Cartilage Assessment 1. Defect Filling complete hypertrophy S. Marlovits et al. / European Journal of Radiology 52 (2004) S.Trattnig et al. / European Journal of Radiology (2007)17:
6 Cartilage Assessment 1. Defect Filling incomplete < 50% incomplete > 50% S. Marlovits et al. / European Journal of Radiology 52 (2004) S.Trattnig et al. / European Journal of Radiology (2007)17:
7 Cartilage Assessment 2. Integration to border zone - complete or incomplete? - visible defect? incomplete with split like border incomplete with visible defect S. Marlovits et al. / European Journal of Radiology 52 (2004) S.Trattnig et al. / European Journal of Radiology (2007)17:
8 Cartilage Assessment 3. Surface - Intact Surface - Damaged Surface damaged surface with fibrillations, ulcerations and fissures S. Marlovits et al. / European Journal of Radiology 52 (2004) K. Lee et al. /Orthopedics 2011; Vol 34, No. 8
9 Cartilage Assessment 4. Structure - Homogenous - Inhomogenous or cleft formation inhomogenous structure of cleft formation S. Marlovits et al. / European Journal of Radiology 52 (2004) S.Trattnig et al. / European Journal of Radiology (2007)17:
10 Cartilage Assessment In the early postoperative period, the repair tissue may appear thin and indistinct The thickness of the repair tissue increases during 24 month 1 2 years postop the surface should appear smooth and well defined 8 month 18 month 23 month Y. Choi et al. / RadioGraphics 2008; 28: H. Tao et al. / Eur Radiol (2014) 24:
11 Cartilage Assessment before AMIC before AMIC 6 weeks after AMIC 47 years, female
12 Cartilage Assessment 5. Signal intensity: Early postop Late postop T2-TSE hyper-intense iso-intense 3D-GE-FS hypo-intense iso-intense S. Marlovits et al. / European Journal of Radiology 52 (2004)
13 Cartilage Assessment 5. Signal intensity R S S S 1 month N. 1 v o month 1 year The signal intensity of the reparative decreases as the tissue matures. S. Marlovits et al. / European Journal of Radiology 52 (2004)
14 Cartilage Assessment 6. Subchondral bone Subchondral lamina - Intact - Not intact broken subchondral lamina S. Marlovits et al. / European Journal of Radiology 52 (2004) S.Trattnig et al. / European Journal of Radiology (2007)17:
15 Cartilage Assessment 6. Subchondral bone - Normal bone marrow signal - Edema, granulation tissue, cysts, sclerosis subchondral alterations S. Marlovits et al. / European Journal of Radiology 52 (2004) S.Trattnig et al. / European Journal of Radiology (2007)17:
16 Cartilage Assessment 6. Subchondral bone: marrow edema - Frequent finding after surgery - Typically decreases with time 3 month 12 month H.Tao et al. /European Radiology 2014; 24:
17 Cartilage Assessment 6. Subchondral bone: marrow edema - Insufficient as independant factor for evaluation of repair quality Tao et al. / European Radiology 2014; 24:
18 Cartilage Assessment 6. Subchondral bone: marrow edema - Persistent bone marrow edema + incomplete filling of the defect + thin and irregular repair surface = indicative of treatment failure Y. Choi et al. / RadioGraphics 2008; 28:
19 MOCART-SCORE Sanghvi D. et al. / Indian J Radiol Imaging Jul-Sep; 24(3):
20 Imaging of Cartilage Repair Lee K. et al. / Orthopedics 2011 Aug 8;34(8):e
21 Imaging of Cartilage Repair Follow-up MR imaging: -At 3 6 postoperative months: assessment of the volume and the integration of repair tissue - And at 1 year: allows an evaluation of the maturation and identification of any complications Y. Choi et al./ RadioGraphics 2008; 28:
22 Imaging of Cartilage Repair T2-Mapping after Microfracturing 8 month 18 month 23 month T2-index (repair/native cartilage) decreases with increasing time after surgery Tao H. et al. / Eur Radiol (2014) 24:
23 Imaging of Cartilage Repair Diffusion-weighted-Imaging (DWI) after Chondrocyte Transplantation and Microfracturing To distinguish between different repair tissue qualities Apprich, S. et al. / Osteoarthritis and Cartilage 20 (2012) 703e711
24 Imaging of Cartilage Repair dgemric post AMIC Glycosaminoglycan content in repair tissue is lower than in normal hyaline cartilage Pre contrast T1 Post contrast T1 Wiwieworsky M. et al. / Clinical Radiology 68 (2013) 1031e1038
25 Ankle Postoperative Imaging of Cartilage Repair and Lateral Ligament Reconstruction Andrea B. Rosskopf, MD University Hospital Balgrist
26 Lateral Ankle Ligament Reconstruction Why postoperative MR imaging? 1. Assessment of ligament or reconstruction integrity: hypointense on T2-weighted MR images, in continuity 2. Assessment of related abnormalities: e.g. osteochondral defects and mechanical stress reactions 3. Assessment of complications: e.g. infection, impingement Y. Choi et al. / RadioGraphics 2008; 28: Zanetti et al. / SeminMusculoskelet Radiol 2010;14:
27 Preoperative Anterior talofibular ligament (ATFL): normal, diameter = 1.0 to 3.2 mm thickened, diameter > 3.2 mm thin or absent diameter < 1.0 mm direct ligament repair T. Kanamoto et al. / Bone Joint Res 2014;3: (Broström)
28 Lateral Ankle Ligament Reconstruction After Broström (=direct ligament repair): Y. Choi et al./ RadioGraphics 2008; 28:
29 Lateral Ankle Ligament Reconstruction After Broström: 34 years, male Y. Choi et al. / RadioGraphics 2008; 28:
30 Lateral Ankle Ligament Reconstruction After Broström: Prominent scar tissue 19 years, male, massive pain 1 year postop
31 Lateral Ankle Ligament Reconstruction After anatomical reconstruction: - anterior talofibular ligament (ATFL) calcaneofibular ligament (CFL) Penner M. / Practical Orthopaedic Sports Medicine & Arthroscopy 1st Edition, 2007
32 Lateral Ankle Ligament Reconstruction After anatomical reconstruction: 45 years, m, gracilis-tendon, 1 year postop
33 Lateral Ankle Ligament Reconstruction Extra-anatomical reconstructions: - Peroneus brevis tendon Re-Routing ATFL reconstruction tendon splitting above the ankle oblique vertical fibular tunnel Y. Choi et al./ RadioGraphics 2008; 28:
34 Peroneus brevis Tendon Rerouting 57 years, m, 20 years after operation
35 Peroneus brevis Tendon Extraanatomical reconstructions ATFL ATFL Loop Watson-Jones Chrisman-Snooke Y. Choi et al. / RadioGraphics 2008; 28: ATFL CFL
36 Peroneus brevis Tendon - follow the tendon from its insertion at the 5th metatarsal bone Y. Choi et al. / RadioGraphics 2008; 28:
37 Summary Cartilage Repair: - Best correlation with clinical outcome: Defect filling, surface of repair tissue - Bone marrow edeme is frequent and should not be interpreted as independent factor Lateral Ligament Reconstruction: - Knowledge about surgical technique is important - MRI : most important for assessment of complications - MRI can not assess instability
38 Thank you
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