Staging of Osteochondral Lesions of the Talus: MRI and Cone Beam CT

Magdalena Posadzy, Julie Desimpel, Filip Vanhoenacker, Magdalena Posadzy, Julie Desimpel, Filip Vanhoenacker

Abstract

Osteochondral lesions (OCL) of the talus involve both articular cartilage and subchondral bone of the talar dome. This term refers to a wide spectrum of pathologies including mild bone marrow contusion as well as severe osteoarthritis resulting from long standing disease. Although Magnetic Resonance Imaging (MRI) at 1.5 Tesla is the leading cross-sectional modality for detection and staging of OCL, lack of spatial resolution hampers accurate assessment of thin articular cartilage. Cone Beam Computed Tomography (CBCT) arthrography is better suited for precise staging of cartilage lesions. The purpose of this pictorial review is to illustrate the strength of each imaging method.

Keywords: Arthrography; Cone Beam CT (CBCT); Magnetic Resonance Imaging (MRI); Musculoskeletal bone; Musculoskeletal joint; Trauma.

Figures

Figure 1
Figure 1
Location of the OCL according to the mechanism of trauma. Schematic drawing of talocrural joint injury in pronation (a) results in sprain of the medial collateral ligaments (brown) and lateral-sided OCL of the talar dome and/or kissing tibial lesion (orange zones), whereas injury in supination (b) causes sprain of the lateral ligaments and medial-sided OCL of the talar dome and/or kissing lesions at the tibia (orange zones). The red arrow indicates the direction of the applied force. The articular cartilage layer of the talocrural joint is indicated in blue.
Figure 2
Figure 2
Anatomy of the talocrural joint. Schematic drawing of the normal talocrural joint (a). Articular cartilage covering the articular surfaces (blue), cortical bone (black), normal bone marrow (yellow) and ligaments (brown). Conventional radiography, Mortise View (b). Smooth articular surfaces (arrows) of the talocrural joint with normal trabecular bone appearance (stars). MRI coronal PD fat suppressed image (1.5 Tesla equipment) of the talocrural joint (c) with normal appearance of the thin cartilage layer (arrows) of intermediate signal, low signal of subchondral bone and homogenous bone marrow signal (stars). CBCT-Arthrography (CBCT-A) of the talocrural joint, coronal reformatted image (d) showing smooth cartilage lining covering the normal subchondral bone of the talus (arrow) and tibia (arrowhead). The presence of intraarticular contrast and high spatial resolution improves visualization of the cartilage surfaces compared to routine MRI on 1.5 Tesla.
Figure 3
Figure 3
Example of understaging of the cartilage defect of an OCL on MRI compared to CBCT arthrography. Coronal fat suppressed T2-WI (intermediate weighting) showing BME (white asterisk) at the lateral corner of the talar dome (a). There is slight irregular delineation of the cartilage (white arrow). Sagittal fat suppressed T2-WI (intermediate weighting) showing BME (white asterisk) at the lateral corner of the talar dome (b). There is slight irregular delineation of the cartilage (white arrow). On a corresponding sagittal reformatted CBCT-A (c), there is almost complete detachment of the cartilage at the superolateral aspect of the talar dome (black arrow).
Figure 4
Figure 4
Example of improved visualization of communication of subchondral cysts with the joint through deep articular cartilage lesions on CBCT arthrography. Sagittal (a) and coronal (b) fat suppressed T2-WI showing multilocular subchondral cysts (black arrowheads) at the medial aspect of the talar dome. The cartilage at the talar dome is slightly irregularly delineated (white arrow). Coronal (c, d) reformatted CBCT-A clearly shows an extensive cartilage lesion down to bone with adjacent cartilage flap (black arrow). Note also partial filling of the subchondral cyst (black arrowhead) with contrast as an indirect sign of joint communication through a cartilage lesion.
Figure 5
Figure 5
Example of accurate staging of the status of the articular cartilage in paediatric OCL. Coronal (a) and sagittal (b) fat suppressed T2-WI show adjacent kissing areas of bone marrow edema (white arrowheads) at the distal tibia and talar dome. The overlying cartilage is difficult to assess on MRI. Coronal (c) and sagittal (d) reformatted CBCT-A show a focal bony lesion with peripheral sclerosis in the distal tibia and talus. The overlying cartilage is intact at the talus, whereas there is subtle cartilage lesion at the distal tibia (arrow).
Figure 6
Figure 6
Schematic drawings of OCL classification according to Anderson.
Figure 7
Figure 7
Stage 1 lesion according to Anderson classification. Sagittal PD fat suppressed MRI image (a) showing BME (star) at the posteromedial part of the talar dome. Coronal PD fat suppressed MRI image (b) revealing BME (star) in the posteromedial part of the talar dome.
Figure 8
Figure 8
Stage 3 according to Anderson classification. Coronal PD fat suppressed coronal image (a) showing an OCL fragment completely detached from talar dome without displacement (arrow), bone marrow oedema (star) of adjacent part of the talus. Coronal reformatted CBCT-A (b) demonstrates more clearly the OCL fragment (arrow) separated from the adjacent talus by thin rim of surrounding contrast (arrowheads).
Figure 9
Figure 9
Down staging of an OCL on CBCT compared to MRI. Coronal (a) fat suppressed T2-WI show adjacent BME (white asterisk) at the superolateral aspect of the talar dome. The overlying cartilage is difficult to assess on MRI but seems to be slightly inhomogeneous (white arrow). Coronal (b) and sagittal (c) reformatted CBCT-A show subtle subchondral sclerosis (black arrow) at the superolateral aspect of the talar dome, but the overlying cartilage is intact.
Figure 10
Figure 10
Modification of the Outerbridge classification of cartilage defects.
Figure 11
Figure 11
Alternative diagnosis on CBCT compared to MRI. Sagittal (a) fat suppressed T2-WI show a subchondral band-like area of low signal at the subchondral cortex (white arrow) with surrounding BME (white asterisk). Coronal proton density (b) shows focal hypointense thickening of the talar dome (arrow). Coronal reformatted CBCT-A (c) barely shows subtle subchondral sclerosis at the superolateral aspect of the talar dome and intact overlying cartilage. Based on the combination of MRI and CBCT findings the diagnosis of a subchondral insufficiency fracture (SIF) was made.

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