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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 34  |  Issue : 1  |  Page : 269-273

Early assessment of knee osteoarthritis using three-dimensional water-selective gradient-echo MRI technique


1 Department Diagnostic Radiology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Radiology, Faculty of Medicine, Mansoura University, Mansoura, Egypt

Date of Submission19-Aug-2019
Date of Decision09-Oct-2019
Date of Acceptance12-Oct-2019
Date of Web Publication27-Mar-2021

Correspondence Address:
Dalia W Elyamany
Nabroomm Mansoura, Dakahlia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_257_19

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  Abstract 


Objective
The aim was to evaluate the role of three-dimensional water-selective gradient-echo MRI technique (WATS) in early assessment of knee osteoarthritis (OA).
Background
OA is a degenerative joint disease occurring in older adults. The 3D WATS is the best imaging technique currently available for the assessment of articular cartilage.
Patients and methods
A prospective study was conducted on 25 patients with suspected knee joint disorder who were enrolled from the Rheumatology and Orthopedic Departments in Mansoura University Hospitals and Outpatient Clinic in Menoufia University Hospital from February 2017 to February 2018. Complete history, clinical examination, and imaging analysis using a knee coil in a 1.5T MRI scanner were done.
Results
Women were more affected with OA (68%) than men (32%). Cartilage defects were the most common MRI finding (76%). Osteophyte formation is represented by 12 (48%) cases. There were six cases with normal cartilage appearance and 19 cases have different grades of cartilage defect. Grade II cartilage defect was the most common finding (eight cases, 32%); 12 (48%) cases presented with osteophyte; 11 (44%) cases had osteophytes greater than 5 mm and one (4%) case had osteophyte of less than 5 mm.
Conclusion
Three-dimensional Gradient echo imaging is considered the standard technique for morphologic evaluations of knee cartilage. The 3D-WATS are proved to be more helpful in accurate assessment of cartilage thickness and volume, showing morphological changes of cartilage surface and internal cartilage signal changes. The 3D-WATS sequences cannot replace routine 2D sequences because they do not allow accurate assessment of other important joint structures.

Keywords: cartilage, defect, osteophyte, water-selective gradient-echo MRI technique


How to cite this article:
Maaly MA, Abd Ella TF, Elyamany DW. Early assessment of knee osteoarthritis using three-dimensional water-selective gradient-echo MRI technique. Menoufia Med J 2021;34:269-73

How to cite this URL:
Maaly MA, Abd Ella TF, Elyamany DW. Early assessment of knee osteoarthritis using three-dimensional water-selective gradient-echo MRI technique. Menoufia Med J [serial online] 2021 [cited 2021 May 8];34:269-73. Available from: http://www.mmj.eg.net/text.asp?2021/34/1/269/312035




  Introduction Top


Osteoarthritis (OA) is a degenerative joint disease occurring in older adults. It means arthritis is characterized by degeneration of the cartilage and the bone of joints [1]. Knee osteoarthritis (KOA) is the most prevalent OA subtype. It can lead to damage of the articular cartilage and abnormalities in the subchondral bone with pain and functional loss. The disease progresses rapidly in some patients, while in others it progresses very slowly. OA can affect the patellofemoral joint or/and the tibiofemoral joint [2]. MRI is one of the most widely used imaging modalities to evaluate patients with joint pain in clinical practice [3]. MRI study for articular cartilage should provide accurate assessment of cartilage thickness and volume, showing morphological changes of the cartilage surface, internal cartilage signal changes, and allow evaluation of the subchondral bone for signal abnormalities [4]. 3D sequences) can reduce partial volume averaging by acquiring thin, continuous slices through joints. It can be used to create multi-planer reformat images which allow joints to be evaluated in any orientation following a single acquisition. They are most commonly used in clinical practice to evaluate the articular cartilage of the knee [5]. The 3D T1-fast field echo with water excitation for cartilage (WATS-c) scan and the 3D water-selective fluid scan (WATS-f) are sequences that use water excitation for fat suppression, and they are similar to the water excitation 3D FlashScan [6]. The 3D gradient-echo MRI technique (WATS) is the best imaging technique currently available for the assessment of articular cartilage. It has the potential to provide morphological information, such as fissuring and the presence of partial or full thickness cartilage defect. In addition to this, it can provide biochemical and physiological information about the cartilage [7]. Therefore, the aim of this study was to evaluate the role of WATS in early assessment of KOA.


  Patients and methods Top


A prospective study was conducted on 25 patients with suspected knee joint disorder (eight men and 17 women). Their ages ranged from 20 to 70 years. All patients were enrolled from the Rheumatology and Orthopedic Departments in Mansoura University Hospitals and Outpatient Clinic in Menoufia University Hospital. Cases were selected during the study period from February 2017 to February 2018.

Ethical consideration

The study was approved by the Ethics Committee of Menoufia Faculty of Medicine and Mansoura University and an informed consent was obtained from all participants guardian before the start of the study.

Selection criteria for the patients

The participants included in this study were selected according to the inclusion and exclusion criteria. Inclusion criteria: patients who were complaining of knee pain, swelling, difficulty in walking or slipping of the joint with positive clinical tests suggestive of internal derangement of knee and patients with no previous major surgery in the knee joint. Exclusion criteria: patients with contraindication to MRI like intracerebral aneurysmal clips, cardiac pacemaker, metallic foreign body in the eye, implants in the middle ear, uncooperative patients with excessive motion, and patients with severe claustrophobia and bad general condition. All cases were subjected to the following: first, full history taking including present, past, and family history such as age, relative parents, consanguinity, and drug history; second, clinical examination: with special emphasis on particular symptoms such as pain, swelling, and limitation of movement was done in the orthopedic or the rheumatology clinic; third, technique of examination: knees were imaged using a dedicated knee coil in a 1.5T MRI scanner (Version VA 12 A; Magnetom Symphony, Siemens, Germany). The patient is positioned supine, with the affected extremity in the knee coil. The head is outside the magnet. The extremity is in slight external rotation of ∼15°. Each examination: Sagittal T1-weighted fast-spin-echo (FSE) images (with repetition time (TR) 600 ms and echo time (TE) 15 ms). Axial T2-weighted fast-spin-echo (FSE) images (with TR 4000 ms and TE 90 ms). Coronal (STIR) short time inversion recovery images (with TR over 4000 ms and TE 120 ms). 3D-WATS-c images are fat-suppressed/water excitation gradient-echo pulse sequences (with TR 20 ms and TE 8 ms) in axial, sagittal, and coronal planes. Slice thickness: Slice thickness was 2 mm in the Philips 3D WATS-c (Philips Medical Systems, Best, Netherlands) sequence and 4.0 mm in all other sequences. Interslice gap 1 mm. Field of view: 14–16 cm depending on the size of the patient. Matrix: 2256 × 256, flip angle = 25°, and the total scanning time was 15 min. Imaging analysis: normal menisci appear as homogeneously black with no intrameniscal signal. Degenerated: appear as intrameniscal signal that did not communicate with an articular margin. Tear: appear as linear or complex signal intensity that communicated with an articular margin. An articular margin was defined as the superior or inferior surface of the meniscus directly facing the articular cartilage of the femur or the tibia. Normal anterior cruciate ligament: seen as low signal intensity band running from the posteromedial aspect of the lateral femoral condyle just posterior to the intercondylar roof and then fanning out distally to insert onto the tibia. Torn: when there was a fluid filling the gap between the fibers or avulsion in its femoral or tibial attachment, it was assigned as complete tear. Normal posterior cruciate ligament: seen as a broad band of low T1-weighted and T2-weighted signal, near the midline of the knee, extending from the femoral intercondylar notch to the posterior tibial plateau. Torn: seen as a focus of increased T2-weighted signal within the continuous ligamentous band. Normal medial collateral ligament: appear as low signal intensity band conformal attached to the medial tibial plateau. Grade I injury: appear as intact ligament with the presence of preligamentous edema separating it from the medial tibial plateau. Grade II: it shows partial tear with the surrounding edema. Grade III: when it appeared as a complete tear, it was assigned as grade III injury. Synovial joint effusion: no joint effusion was assumed to be present when a small, physiological sliver of synovial fluid was observed. Mild effusion: when a small amount of fluid distended one or two of the joint recesses. Moderate effusion: when more than two joint recesses were partially distended. Marked effusion: when there was full, marked distention of all the joint recesses. Articular cartilage: in our study, we used 3D-WATS-c which is a T1 fast-field echo with water excitation gradient-echo pulse sequence that allows excellent image acquisition of the articular cartilage of the knee joint (reduce the partial volume averaging by acquiring thin, continuous slice through the joint). von Engelhardt 2010 (74) classify the articular cartilage defect as the following: Grade 0: defined as cartilage with a normal intrinsic signal and a normal surface contour on MRI. Grade I: there is signal heterogeneities within the cartilage in the presence of a smooth surface. Grade II: there is fibrillation or erosion composing less than 50% of the cartilage thickness. Grade III: defects of more than 50% of the cartilage thickness occur with or without small bone ulcerations. Grade IV: full cartilage thickness defect. Subchondral cyst-like lesions: appear as well-defined foci of high signal intensity on T2-weighted images, in the cancellous bone underlying the joint cartilage. Bone marrow lesions: assessed as an ill-defined area in the subchondral cancellous bone, extending away from the articular surface over a variable distance that are hypointense onT1-weighted images and hyperintense onT2-weighted fat-suppressed. Osteophytes: they are considered present if there were bony projections that form along different margins of the tibiofemoral joint of the knee. They were evaluated in the central and posterior margins of the femoral condyles and tibial plateaus, and along the medial, lateral, superior, and inferior margins of the patella.

Statistical analysis

Results were tabulated and statistically analyzed by on a personal computer using Microsoft Excel 2016 and SPSS v. 21 (SPSS Inc., Chicago, Illinois, USA). Statistical analysis was done using: descriptive, for example, percentage, mean, and SD.


  Results Top


The current study included 25 patients complaining of joint pain, swelling, and difficulty in walking. Age of the studied patients ranged from 20 to 70 years old, with a mean age of 48 years. Also, women were more affected (68%) than men (32%) [Table 1]. In the current study, cartilage defects were the most common MRI finding, it was present in 19 (76%) cases and absent in six (24%) cases, while osteophyte formation was present in 12 (48%) cases and absent in 13 (52%) cases [Table 2]. In the present study, there were six cases with normal cartilage appearance and 19 cases had different grades of cartilage defect [Figure 1] and [Figure 2]. Partial-thickness defect of less than 50% (grade II cartilage defect) was the most common finding (eight cases, 32%), followed by signal intensity change (grade I) in five (20%) cases and partial-thickness defect of more than or equal to 50% (grade III) in four (16%) cases, then full thickness defect (grade IV) in two (8%) cases [Table 3]. According to the presence of osteophyte, it was found that 13 (52%) cases had no osteophyte and 12 (48%) cases presented with osteophyte, 11 (44%) cases had osteophyte of size greater than 5 mm and one (4%) case had osteophyte of size less than 5 mm [Table 4].
Table 1: Age and sex distribution among the studied patients

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Table 2: Summary of MRI water excitation for cartilage finding of osteoarthritis in the studied patients (n=25)

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Figure 1: A female patient of 47 years old, presented with knee pain and swelling. (a) T1WI: Degenerated posterior horn medial meniscus. (b) STIR image shows grade I joint effusion. (c) 3D-WATS image shows grade II osteophyte formation. (d) 3D WATS shows signal intensity changes in the cartilage grade I (arrow). Narrowing in the tibiofemoral joint space (arrowhead).

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Figure 2: A male patient of 52 years old, presented with left knee pain and swelling. (a) STIR image shows minimal joint effusion. (b) 3D-WATS image shows grade I cartilage defect in the tibial side (arrowhead) and grade II cartilage defect in the femoral side (arrow).

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Table 3: Grades of cartilage defect by MRI in the studied patients (n=25)

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Table 4: Grades of osteophyte by MRI in the studied patients (n=25)

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  Discussion Top


OA describes a common age-related group of disorders characterized by focal areas of loss of articular cartilage in synovial joints [1]. MRI is a sensitive, noninvasive diagnostic test for detecting abnormalities of the knee. It is considered as an accurate means of detecting and grading cartilage lesions in the knee joint [7]. Adding 3D cartilage imaging sequences to a routine MRI protocol is clinically advantageous and can improve the detection and characterization of cartilage lesions within the knee joint. 3D sequences acquire thin continuous slices through the knee joint, which reduces the effects of partial volume averaging. In addition, the volumetric source data can be used to create multiplanar reformat images that allow articular cartilage to be evaluated in any orientation after a single acquisition [5]. The aim of our study was to evaluate the role of 3D WATS in patients with KOA. The current study included 25 patients who were complaining of joint pain, swelling, and difficulty in walking. Age of the studied patients ranged from 20 to 70 years, with a mean age of 48 years. The most common age groups affected with OA are those in the sixth decade of life, which represent 32% patients. These results agreed with Loeser et al. [8] who stated that the prevalence of OA rises directly with age and it was the most common cause of chronic disability in older adults. They also added that the prevalence of the disease increases dramatically among persons older than 50 years, likely because of age-related alternation in collagen and proteoglycans that decrease the tensile strength of the joint cartilage and because of a diminished nutrient supply to the cartilage. Also, results of the current study were confirmed by Chu and Andriacchi [9], who described that aging was the main risk factor for OA. Age-related changes occur in the cartilage matrix and contributing to OA development. MRI studies showed that knee cartilage thins during aging, suggesting a gradual loss of cartilage matrix with age. This could be due to reduced growth factor activity as well as water content. In the current study, it was noticed that women were more affected with OA (68%) than men (32%) and this result was confirmed by Hafez and Mohammed [10], who reported that women had a greater risk for developing KOA compared with men. Women with OA had greater levels of knee pain and lower function. In the present study, 3D-WATS was used that allows excellent image acquisition of the articular cartilage of the knee joint. It was found that the most common grade was grade II represented by eight (32%) cases, followed grade I by five (20%) cases and grade III by four (16%) cases, then grade IV by two (8%) cases, and this result was in disagreement with van Dyck et al. [11], who found that 20 cases had cartilage defect, 35% of them was of grade II and 65% was of grade III. Regarding the presence of osteophyte, in the present study osteophytic formation was found in 12 (48%) cases. This result disagreed with Guermazi et al. [12] who studied 710 patients aged more than 50 years and all of them underwent MRI of the knee and found that 74% of the knees had osteophyte. In the current study, 76% of cases had different grades of cartilage defects and 48% of cases had multiple osteophyte formations. This result was confirmed by Suri and Walsh [13] who found that cartilage changes and osteophytes formation were the most prominent features in patients with knee OA. Also, McAlindon et al. [14] stated that the high prevalence of joint effusion was present in patients with knee OA who had knee pain, and this agreed with the current study. In contrast with the present study, Pouders et al. [15] reported that subchondral cysts were a common finding in patients with knee OA, while in the current study there was no cases who had subchondral cysts.


  Conclusion Top


3D GRE imaging is considered the standard technique for morphologic evaluations of knee cartilage. The 3D-WATS are proved to be more helpful in accurate assessment of cartilage thickness and volume, showing morphological changes of cartilage surface and internal cartilage signal changes. The 3D-WATS sequences cannot replace routine 2D sequences because they do not allow accurate assessment of other important joint structures such as the menisci, ligaments, and the subchondral bone.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M, et al. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. JAMA 2017; 317:1967–1975.  Back to cited text no. 14
    
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Pouders C, De Maeseneer M, Van Roy P, Gielen J, Goossens A, Shahabpour M. Prevalence and MRI-anatomic correlation of bone cysts in osteoarthritic knees. Am J Roentgenol 2008; 190:17–21.  Back to cited text no. 15
    


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