Cartilage Imaging: Significance, Techniques, and New Developments

Cartilage Imaging

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Thomas M. Link Editor

Cartilage Imaging Significance, Techniques, and New Developments

Editor Thomas M. Link Department of Radiology and Biomedical Imaging University of California at San Francisco San Francisco, CA USA [email protected]

ISBN 978-1-4419-8437-1 e-ISBN 978-1-4419-8438-8 DOI 10.1007/978-1-4419-8438-8 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2011924334 © Springer Science+Business Media, LLC 2011 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not ­identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

Preface

One of the first systematic histological evaluations of the role of joint cartilage was published in 1843 by Ecker and was entitled “Ueber Abnuetzung und Zerstoerung des Gelenkknorpels” [1]. In 1942, Bennett et al. stated that degeneration of articular cartilage is the origin of osteoarthritis and that the degeneration is an inherent senescence of the cartilaginous tissue [2]. For many years, cartilage loss and degeneration were considered as inevitable, eventually leading to decrease in joint function, osteoarthritis, and immobility, with limited therapeutic options. Cartilage degeneration has been identified as a major threat to our aging society with substantial implications for health care and as a major socio-economic burden. Hence today, there is tremendous activity in developing strategies and treatments to prevent cartilage “Abnuetzung” (loss). These include injury prevention programs, cartilage repair, as well as oral and local treatments. While these therapies are clearly in their infancy, their development requires sensitive and reliable cartilage imaging and quantification techniques; these are indispensible to monitor the effects of new therapies and prevention strategies. Thus cartilage imaging gains a major and central role in the management of degenerative joint disease. The goal of this book was not simply to summarize currently available imaging techniques to assess cartilage, but also to provide clinical perspectives and an outlook on future developments. Major experts in this growing field contributed to this book, which is geared to radiologists, orthopedic surgeons, rheumatologists, and clinical and basic researchers. We believe that cartilage imaging and noninvasive quantification will be essential tools in preserving joint function and tackling the ever-increasing challenge of osteoarthritis in our society. I would finally like to acknowledge our developmental editor Michael Griffin’s hard work and support during the preparation of this book. San Francisco, CA, USA

Thomas M. Link, MD

References 1. Ecker A. Ueber Abnuetzung und Zerstoerung der Gelenkknorpel. Arch Physiol Heilk. 1843;2:235–48. 2. Bennett G, Waine H, Bauer W. Changes in the knee joint at various ages. New York: Commonwealth Fund; 1942.

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Contents

  1 Anatomy and Histology of Cartilage....................................................................... Andrew Horvai

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  2 Clinical Aspects: A Rheumatologist’s Perspective................................................. 11 David J. Hunter   3 Clinical Aspects: An Orthopedic Surgeon’s Perspective....................................... 19 Sunny Cheung and C. Benjamin Ma   4 Conventional Radiography as an Indirect Measure for Cartilage Pathology............................................................................................ 27 Daichi Hayashi, Jeffrey Duryea, Frank W. Roemer, and Ali Guermazi   5 Value of CT Arthrography in the Assessment of Cartilage Pathology................ 37 Patrick Omoumi, Bruno C. Vande Berg, and Frédéric E. Lecouvet   6 MRI of Cartilage: Standard Techniques................................................................ 49 Thomas M. Link   7 MRI of Cartilage: Pathological Findings................................................................ 67 Thomas M. Link   8 Scoring Systems to Semiquantitatively Grade Cartilage Pathology with MRI.................................................................................................. 93 Christoph Stehling   9 Atlas: Cartilage Abnormalities and Scores............................................................ 103 Hans Liebl and Thomas M. Link 10 Cartilage Segmentation............................................................................................ 117 Julio Carballido-Gamio and Thomas M. Link 11 Quantitative MR Imaging of Cartilage Morphology in Osteoarthritis............... 127 Felix Eckstein, Martin Hudelmaier, and Wolfgang Wirth 12 MR T2 Relaxation Time Measurements for Cartilage and Menisci.................... 145 Thomas Baum, Thomas M. Link, and Bernard J. Dardzinski 13 MR T 1r Relaxation Time Quantification in Cartilage........................................... 159 Xiaojuan Li

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14 Cartilage Matrix Assessment Using dGEMRIC.................................................... 171 Martha L. Gray and Deborah Burstein 15 Imaging of Cartilage Repair.................................................................................... 185 Goetz H. Welsch, Stephan Domayer, Vladimir Juras, Tallal C. Mamisch, and Siegfried Trattnig 16 Cartilage as a Biomarker......................................................................................... 205 Thomas M. Link 17 Frontiers in Molecular Imaging of Cartilage: Future Developments.................. 213 Ravinder Reddy, Arijitt Borthakur, Walter R.T. Witschey, and J. Bruce Kneeland 18 Future Perspective and Significance of Cartilage Imaging and Quantification.................................................................................................... 229 Thomas M. Link and Sharmila Majumdar Index................................................................................................................................... 239

Contents

Contributors

Thomas Baum, MD Department of Radiology and Biomedical Imaging, Musculoskeletal and Quantitative Imaging Research Group, University of California, San Francisco, CA, USA and Department of Radiology, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany Arijitt Borthakur, PhD Department of Radiology, Center for Magnetic Resonance and Optical Imaging, School of Medicine, University of Pennsylvania, Philadelphia, PA, USA Deborah Burstein, PhD Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA Julio Carballido-Gamio, PhD Grupo Tecnológico Santa Fe, S.A. de C.V., Mexico City, Mexico and Department of Radiology and Biomedical Imaging, University of California at San Francisco, San Francisco, CA, USA Sunny Cheung, MD Division of Orthopedic Sports Surgery, Mission Bay Orthopedic Institute, University of California, San Francisco, CA, USA Bernard J. Dardzinski, PhD Exploratory and Translational Sciences – Imaging, University of Pennsylvania, Merck & Co., Inc., Children’s Hospital of Pennsylvania, West Point, PA, USA Stephan Domayer, MD Department of Orthopaedics, Medical University of Vienna, Vienna, Austria Jeffrey Duryea, PhD Department of Radiology, Brigham and Women’s Hospital, Boston, MA, USA Felix Eckstein, MD Institute of Anatomy & Musculoskeletal Research, Paracelsus Medical University, Salzburg, Austria and Chondrometrics GmbH, Ainring, Germany

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Martha L. Gray, PhD Department of Electrical Engineering and Computer Science, MIT, Harvard-MIT Division of Health Sciences and Technology (HST), New England Baptist (NEB) Bone and Joint Center, BIDMC, Cambridge, MA, USA Ali Guermazi, MD Department of Radiology, Boston University, Quantitative Imaging Center (QIC), Boston, MA, USA Daichi Hayashi, MBBS, BSc Department of Radiology, Boston University School of Medicine, Boston, MA, USA Andrew Horvai, MD, PhD Department of Pathology, University of California, San Francisco, CA, USA Martin Hudelmaier, MD Paracelsus Medical University, Institute of Anatomy and Musculoskeletal Research, Salzburg, Austria David J. Hunter, MBBS, PhD, FRACP Division of Research, New England Baptist Hospital, Boston, MA, USA and Rheumatology Department, Royal North Shore Hospital, University of Sydney, Australia Vladimir Juras, PhD Department of Radiology, MR Center, General Hospital of Vienna, Medical University of Vienna, Vienna, Austria J. Bruce Kneeland, MD Department of Radiology, Center for Magnetic Resonance and Optical Imaging, School of Medicine, University of Pennsylvania, Philadelphia, PA, USA Frédéric E. Lecouvet, MD, PhD Department of Radiology and Medical Imaging, Cliniques Universitaires Saint-Luc – UC Louvain, Brussels, Belgium Xiaojuan Li, PhD Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA Hans Liebl Medical School, Technical University of Munich, Munich, Germany Thomas M. Link, MD Department of Radiology and Biomedical Imaging, University of California at San Francisco, San Francisco, CA, USA C. Benjamin Ma, PhD Sports Medicine and Shoulder Service, Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, USA Sharmila Majumdar, PhD Department of Radiology and Biomedical Imaging, University of California at San Francisco, San Francisco, CA, USA

Contributors

Contributors

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Tallal C. Mamisch, MD Department of Orthopaedic Surgery, University of Bern, Bern, Switzerland and Department of Radiology, MR Center, General Hospital of Vienna, Medical University of Vienna, Vienna, Austria Patrick Omoumi, MD Department of Radiology and Medical Imaging, Saint-Luc University Hospital – UC Louvain, Brussels, Belgium Ravinder Reddy, PhD Department of Radiology, School of Medicine, University of Pennsylvania, Philadelphia, PA, USA Frank W. Roemer, MD Department of Radiology, Klinikum Augsburg, Augsburg, Germany; Department of Radiology, Boston University, Quantitative Imaging Center (QIC), Boston, MA, USA Christoph Stehling, MD Department of Clinical Radiology, University of Muenster, Muenster, Germany Siegfried Trattnig, MD Department of Radiology, MR Center, Medical University of Vienna, General Hospital of Vienna, Vienna, Austria Bruno C. Vande Berg, MD, PhD Department of Radiology and Medical Imaging, Saint-Luc University Hospital – UC Louvain, Brussels, Belgium Goetz H. Welsch, MD Department of Radiology, MR Center, General Hospital of Vienna, Medical University of Vienna, Vienna, Austria and Department of Trauma Surgery, University of Erlangen-Nuremberg, Erlangen, Germany Wolfgang Wirth, PhD Institute of Anatomy and Musculoskeletal Research, Paracelsus Medical University, Salzburg, Austria Walter R.T. Witschey, PhD Department of Radiology, Center for Magnetic Resonance and Optical Imaging, School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

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Chapter 1

Anatomy and Histology of Cartilage Andrew Horvai

Keywords  Anatomy • Histology • Cartilage • Matrix ­composition • Osteoarthritis • Neoplasia • Fibrocartilage

Introduction Cartilage is a connective tissue structure that is composed of a collagen and proteoglycan-rich matrix and a single cell type: the chondrocyte. Cartilage is unique among connective tissues in that it lacks blood vessels and nerves and receives its nutrition solely by diffusion [1]. In fetal life, cartilage forms the template for the majority of the skeleton but persists in selected locations into adulthood including articular surfaces, ribs, ears, and the tracheobronchial tree. Structurally, cartilage provides a firm material which, depending on subtype, is adapted to resist and damp compressive and tensile forces. Functionally, it plays important roles in skeletal development, growth and repair, joint articulation, lubrication, and patency of the respiratory tract. Although the mechanical properties of cartilage are functions of the extracellular matrix, it is the chondrocyte that directs the synthesis and composition of the matrix. Though few in number, chondrocytes also mediate critical pathways of regeneration and growth by highly regulated signal transduction pathways that are now becoming better understood [2, 3]. Most pathology of cartilage involves degenerative ­diseases, particularly osteoarthritis. However, cartilage neoplasms, especially the benign forms, are among the most common primary tumors of bone and illustrate the close association between radiologic and pathologic findings.

A. Horvai (*) Department of Pathology, University of California, 1600 Divisadero Street, B220, San Francisco, CA 94115, USA e-mail: [email protected]

Anatomy Grossly, cartilage consists of a translucent pale-blue to ­yellow-white (depending on subtype and collagen content) rubbery tissue (Fig. 1.1). Perichondrium is a layer of dense fibrous tissue that covers cartilage in most locations except the articular surfaces. No neurovascular structures penetrate beyond the perichondrium. Consequently, all nutrition arrives by diffusion, limiting the thickness of cartilage surfaces to a few centimeters - a rule that manifests in even the largest animals. As cartilage ages, it transforms from bluewhite to yellowish and opaque, which may be related to dehydration and age-related pigment deposits [4]. Cartilage is attached to the underlying bone by means of radial collagen fibers that penetrate from bone into the cartilage over a complex three-dimensional interface. However, the specialized collagen fibers of cartilage do not extend into subchondral bone. Hyaline (from the Greek hyalos meaning “glass or transparent stone”) cartilage is the predominant type in the human body and forms all diarthrotic articular surfaces, the most peripheral part of the nucleus pulposus of the intervertebral disk, portions of the ribs, and tracheobronchial tree. A specialized type of hyaline cartilage is also present in the epiphyseal plate (growth plate). Fibrocartilage is present in the temporomandibular and sternoclavicular joints and the annulus fibrosus of the intervertebral disk as well as the meniscus at the knee and the labrum of the shoulder. Finally, elastic cartilage is largely restricted to the external ear and a few other sites. All cartilage is ideally suited to resist compressive forces. However, the presence of type I collagen and elastin in fibrocartilage and elastocartilage, respectively, also allows these tissues to resist tension. The anatomic and functional differences of the three major cartilage subtypes are summarized in Table 1.1. Although the anatomy of cartilage differs somewhat depending on subtype, articular cartilage is the most common and best studied in terms of biochemical and histologic features.

T.M. Link (ed.), Cartilage Imaging: Significance, Techniques, and New Developments, DOI 10.1007/978-1-4419-8438-8_1, © Springer Science+Business Media, LLC 2011

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A. Horvai

Fig.  1.1  Gross appearance of cartilage. Hyaline cartilage, in young patients, can be seen in the articular surface and growth plate (a) and is usually a translucent blue-white rubbery material (a). With aging, the

articular surface becomes more opaque and yellow-white (b). Fibrocartilage of the intervertebral disk (c) has a dense, fibrous off-white appearance with concentric layers of fibers in the annulus fibrosus

Table 1.1  Summary of three main cartilage types Type Mechanical function Locations

Unique components

Hyaline Fibro

Compression Tension

Collagen type I

Elasto

Tension

Articular, growth plate Temporomandibular joint, sternoclavicular joint, annulus fibrosus, meniscus, labrum External ear, ligamentum flavum, epiglottis

Elastin

Matrix Composition

Table 1.2  Approximate fractional composition of hyaline cartilage Component Fraction (%)

The cartilage matrix consists predominantly of extracellular water (66–78%) with the remaining (dry) weight composed of proteoglycans, collagen, and additional specialized proteins [5]. The approximate distribution of components of hyaline cartilage is outlined in Table 1.2. In articular cartilage, water is unevenly distributed such that the highest concentration is present at the articular surface [6]. The constant diffusion and tidal movement of water in and out of the cartilage matrix with joint compression allow nutrients to reach the chondrocytes. Proteo­ glycans, discussed in more detail below, are directly responsible for the high water content of cartilage. Proteoglycans are composed of high molecular weight proteins with carbohydrate side chains resulting in large, charged molecules that attract water thereby increasing their volume dramatically. Collagen represents ~50% of the dry weight of the matrix. In cartilage, type II collagen (encoded by the COL2A1 gene) predominates and confers the tensile stiffness and strength to the matrix [7, 8]. The expansive pressure of water within the matrix is opposed by the collagen cross-links that restrict expansion and result in a steady-state turgor pressure. This turgor pressure is critical to maintain the viscoelastic properties of the matrix. Type II collagen is composed of three identical aI polypeptide chains to form a triple helix. The aI monomer is produced as a propeptide with large N- and C-terminal regions that are required for assembly in the chondrocyte. Specific proteases in the extracellular matrix, ADAMTS-3 and BMPI, cleave the N- and C-terminal domains, respectively

Water Collagen type II Proteoglycans Other cartilage-specific collagens (IX, X, XI) Other proteins Inorganic salts

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