Whole Joint Imaging of Osteoarthritis with Morphological & Quantitative MRI
Ashley Williams1,2

1Stanford University, Stanford, CA, United States, 2Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States

Synopsis

Imaging tools are needed to detect and stage joint status early enough in the disease process that osteoarthritis modifying interventions might have a chance. The purpose of this talk is to introduce MRI methods for morphologic and quantitative evaluation of osteoarthritis of the knee. Compositional MRI measures of OA will also be discussed.

Target Audience

Healthcare professionals and MRI researchers with interests in musculoskeletal (MSK) studies and osteoarthritis disease processes.

Objectives

Audience members will be introduced to MRI methods for morphologic and quantitative evaluation of osteoarthritis of the knee.

Highlights

  • MRI is a key research tool for imaging osteoarthritis (OA) because it can assess structures not visualized by conventional x-ray radiography: articular cartilage, menisci, ligaments, synovium, synovitis and effusions and bone marrow.
  • MRI permits visualization of OA-induced tissue changes potentially early enough in the disease process to intervene with disease modifying therapies.
  • Semi-quantitative morphologic and quantitative compositional measures are needed to detect subtle but clinically meaningful changes in tissues.
  • Comprehensive and fast whole-joint MRI acquisition and evaluation remains elusive.

Purpose

There is no cure for advanced OA and total joint replacement is not a good option for many patients. By the time conventional x-ray radiography detects joint space narrowing and bone degeneration, it is likely too late in the disease process to stave off the functional deficits and pain that are associated with advanced OA. Hence, imaging tools are needed to detect and stage joint status early enough in the OA process that disease modifying interventions might have a chance.

Methods & Results

MRI can be used to visualize joint changes before and beyond the gross changes to bone and joint space observable with radiography. Importantly, morphologic and quantitative (or semi-quantitative) MRI techniques provide whole-joint evaluation of osteoarthritis. Salient features of progressive OA that can be seen by morphologic MRI include: cartilage surface disruption, extracellular matrix degeneration and lesions; meniscus maceration, extrusion and tear; bone inflammation (bone marrow lesions (BMLs)), osteophytes, and subchondral thickening; synovitis & effusions with cysts and synovial thickening; ligament damage; loose bodies and, by geometric inference, muscle insufficiency. Many of these morphologic features of OA can also be quantitated or semi-quantitated using scoring systems designed for that specific purpose: for the knee: WORMS1, BLOKS2, MOAKS3, KIMRISS4; CROAKS5; ACLOAS6; for the hand: OMERACT HOAMRIS7, TOMS8; for the hip: SHOMRI9; HAOMS10. Additionally, quantitative cartilage morphometry is widely applied in OA studies to assess cartilage thickness and volume with more sensitivity than the indirect clinical standard of radiographic joint space narrowing11; 12. MRI has also been used for 3-D quantitative volumetric measures of BMLs13 and synovitis14. Very recently, metabolic abnormalities in subchondral bone have been identified via co-localization of positron emission tomography (PET) uptake of 18F-flouride with degenerative bone and cartilage changes on morphologic MRI15.

Sequences for Morphologic OA assessment: Whole-joint evaluation of OA requires appropriate pulse sequence selections. Cartilage morphology, cartilage lesions, meniscus integrity and BMLs are best observed with fluid-sensitive, fat-saturated T2-weighted, intermediate-weighted or proton density-weighted sequences acquired in 3 orthogonal planes16. 3-D FSE intermediate-weighted fat-suppressed sequences with isotropic or nearly isotropic resolution (e.g. Cube (GE), XETA, SPACE (Siemens)) provide a time-efficient assessment of these and other joint structures17. For cartilage morphometry, where clear delineation of both bone-cartilage and bone-synovium interfaces are required, T1-weighted fat-suppressed gradient-echo sequences with thin slices and close to isotropic resolution such as spoiled gradient recalled acquisition (SPGR), fast low angle shot water excitation (FLASH) and dual echo steady state (DESS) provide good boundary contrasts11; 18. Osteophytes, bone attrition and ligaments are better assessed with non-fat-saturated short echo time-weighted sequences (e.g. T1-W or gradient echo SPGR FLASH, DESS) so that bony interfaces can be visualized3. Synovitis-effusions can be seen with non-contrast, fat-saturated T2-W, I-W, PD-W images, but dynamic contrast-enhancement (DCE)-MRI permits differentiation of fluid pockets from thickened synovial capsular membranes14. Cross-sectional thigh muscle diameters may be measured from axial T1-W images19.

Compositional MRI: Compositional imaging strategies permit visualization of changes to the biochemical properties of joint tissues due to OA. The most prominent compositional MRI techniques to spatially map properties of cartilage include T2 for hydration and collagen extracellular matrix integrity and organization20; 21; delayed gadolinium enhanced MRI of cartilage (dGEMRIC) for relative proteoglycan distribution22; 23; and T1ρ for proteoglycan content although the specificity of this measure remains controversial at the low spin-lock frequencies used clincally24-26. Adiabatic T1ρ and T2ρ changes in cartilage, which have the potential to be more sensitive to slow molecular interactions, have also been explored as biomarkers for OA27. Newer but promising techniques to further assess collagen organization of joint tissues with an abundance of short-T2 species like tendons, ligaments, menisci and deep and calcified articular cartilage include ultrashort-echo (UTE) imaging28; 29 and UTE-T2* mapping30. Though not yet optimized for use at typical clinical field strengths of 1.5T and 3T, MRI strategies to measure cartilage glycosaminoglycan content with Na+ imaging31 and gagCest (chemical-exchange-dependent saturation transfer)32 have also been examined. Finally, diffusion-weighted33 and diffusion tensor imaging (DTI)34 techniques can be used to indirectly evaluate collagen architecture and proteoglycan content by assessment of anisotropic water motions.

Discussion & Conclusion

Despite the existing range and depth of morphologic, quantitative and compositional MRI techniques with which to examine OA changes throughout the joint, time-efficient methods to capture and analyze this information remain lacking. Recent efforts to reduce the time to acquire17, quantitatively segment35, and analyze composition36 are beginning to address this. However, until scantimes and post-processing efforts are reduced, quantitative and compositional MRI evaluations of OA will likely remain tools of OA research, while clinical OA evaluations will remain focused on morphologic assessment.

Acknowledgements

No acknowledgement found.

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Proc. Intl. Soc. Mag. Reson. Med. 26 (2018)