Luis Corrales, HMS III March, 2005

Gillian Lieberman, MD

MRI Assessment of
Osteonecrosis
Luis Corrales, Harvard Medical School
Year III
Gillian Lieberman, MD
 Luis Corrales, HMS III
Gillian Lieberman, MD
Introduction

Osteonecrosis used to describe spectrum of pathological and radiological
changes within bone due to ischemia.

Can occur in subarticular bone or epiphysis (ischemic bone, AVN, aseptic

necrosis), metaphysis and diaphysis (bone infarction).

Common condition affecting a relatively young population.

20-50 yrs (average age at Dx 40yrs)

Corticosteroids and excessive alcohol use reported to account for majority of

cases

If untreated eventually leads to articular collapse and secondary osteoarthritis.

In U.S. there are an estimated 10,000-20,000 new patients diagnosed per year

Responsible for roughly 18% of all total hip arthroplasties in U.S. 2

 Luis Corrales, HMS III
Gillian Lieberman, MD

Conditions and Risk Factors Associated with

Osteonecrosis

Trauma- Fracture, dislocation, vascular trauma, fat embolism, thermal

injury

Hemoglobinopathies- Sickle cell, polycythemia

Metabolic/Endocrine- Diabetes, Gauchers disease, Cushings,
pregnancy, chronic renal failure

Gastrointestinal- Pancreatitis, IBD

Vasculitides- SLE, RA, ankylosing spondylitis

Environmental- Alcoholism, smoking, decompression syndrome

Iatrogenic- Corticosteroids, radiotherapy, transplantation, hemodialysis

Idiopathic

In Children

Legg-Calve-Perthes

Slipped capital femoral epiphysis

Congenital hip dislocation
3
 Luis Corrales, HMS III
Gillian Lieberman, MD

Pathophysiology

Pathogenesis of atruamatic osteonecrosis is believed to

result from ischemic injury to bone and marrow

One or more of three mechanisms are believed to
occur:

1. Compromise of vessel wall integrity

2. Intraosseous vascular compression (increased

marrow pressure)

3. Intravascular occlusion

4
 Luis Corrales, HMS III
Gillian Lieberman, MD

Host response to bone ischemia and infarction

Body mounts an inflammatory and reparative response at margins of infarct which can be divided
into various ZONES

Hyperemic marrow appears on radiographs as area of osteoporosis

adjacent to viable bone

Progressive loss of mechanical support causes:

osteoblasticc reinforcement of adjacent viable trabecular
AVASCULAR bone
CELLS peripheral rim of sclerosis referred to as CREEPING
APPOSITION

Ischemic injury
Reactive hyperemia

Normal Bone

Acutely no radiographic abnormalities because initially only a marrow cellular phenomenon, and
mineralized bone remains unaltered.

Eventual mechanical instability causes microfracture of subchondral trabeculae (Crescent sign
on radiographs)

Subsequent articular collapse occurs and results in secondary osteoarthritis. 5
 Luis Corrales, HMS III
Gillian Lieberman, MD

Imaging Modalities

Convetional radographs

lack sensitivity in early disease

Only become diagnostic after subchondral fracture and

development of crescent sign.

Computed tomography (CT)

Most sensitive for detecting subchondral fractures

Bone Scan

Has sensitivity to detect early changes of osteonecrosis but
lacks specificity.

MRI

Has emerged as most accurate technique for detecting initial
changes of osteonecrosis

Sensitivity and specificity approach 100%
6
 Luis Corrales, HMS III
Gillian Lieberman, MD

Sites Osteonecrosis Can Affect

Femoral head most common

Humeral head

Femoral condyles

Carpal bones (especially scaphoid, and lunate)

Proximal tibia

Patella

Talus

Tarsal navicular

Vertebrae

Facial bones

7
 Luis Corrales, HMS III
Gillian Lieberman, MD

Staging Osteonecrosis

Staging The Association of Research Circulation Osseous (ARCO)
has recently developed a staging system.

Stage 0 -Asymptomatic, normal radiographs

Stage 1 -Plain radiographs normal, MRI positive and biopsy

positive.

Stage 2 -Radiographs positive (radiolucency and sclerosis) but no

collapse.

Stage 3 -Crescent sign, normal contour

Stage 4 -Flattening of femoral head, subchondral collapse

Stage5 Degenerate bone disease 8

 Luis Corrales, HMS III
Gillian Lieberman, MD

Imaging Features of Osteonecrosis on Plain Films

Crescent sign

Duke Medical. www.wheelessonline.com

Saini A, Saifuddin A. MRI of Osteonecrosis. Clin Radiology 2004; 59: 1079-1093

Subchondral lucent area

Areas of central lucency with
Represents subchondral collapse
sclerotic border due to medullary
Seen in advance stages of osteonecrosis
infarct
9
 Luis Corrales, HMS III
Gillian Lieberman, MD

MRI Appearance of Osteonecrosis

NECROTIC areas demonstrate

HYPOINTENCE SI on both T1W and T2W sequences

Patterns of abnormality

Homogenous pattern: well-defined area of HYPOintence SI confined to
subarticular region

Inhomogenous pattern: large irregular areas of decreased SI

Ring pattern: ring of decreased SI surrounding an area of relatively
normal intensity

Double line sign

Virtually diagnostic change on T2W sequences

Occurs at interface of viable and non-viable tissue.

Consists of a LOW SI outer rim (sclerotic bone) with an adjacent inner
rim of HIGH SI (corresponding to vascularized granulation tissue)

On T1W images double line appears as a single LOW SI band

10
 Luis Corrales, HMS III
Gillian Lieberman, MD

Diffential Diagnosis

Ill-defined marrow area of Low SI on T1W and
intermediate of high SI intensity on T2W (Bone
marrow edema pattern) at epiphysis

Osteonecrosis

Posttraumatic or stress fractures

Transient osteoporosis

Reactive changes of degenerative articular disease

Transient bone marrow edema syndrome

Infection

Infiltrative neoplasm
11
 Luis Corrales, HMS III
Gillian Lieberman, MD

Variable appearance of Osteonecrosis on Sagittal

TIW image of Distal Femoral Condyle
Inhomogeneous area of
Hypointense SI
Med Femoral Condyle Serpiginous subchondral
pattern

Homogeneous band of
Hypointense SI subchondral
pattern

Ant. Horn of Post. Horn of

Med. Meniscus Med. Meniscus

Saini A, Saifuddin A. MRI of Osteonecrosis. Clin Radiology 2004; 59: 1079-1093

12
Tibia Articular Cartilage
 Luis Corrales, HMS III
Gillian Lieberman, MD

Double Line Sign on MRI

Sagittal T2W image

Distal femoral and proximal

tibial metaphysial bone
infarcts
Inner rim of HIGH SI-
edema/hypervascular granulation tissue

Outer rim of LOW SI- Sclerotic bone

Saini A, Saifuddin A. MRI of Osteonecrosis. Clin Radiology 2004; 59: 1079-1093

13
 Luis Corrales, HMS III
Gillian Lieberman, MD

Osteonecrosis of Femoral Head

Most common site affected by osteonecrosis

Susceptability

Large area covered by articular cartilage which limits
arterial inflow and venous outflow

Venous outflow from femoral head is restricted at
the much narrower metaphyseal neck and
predisposes to increased intramedullary pressure.

Has large weight bearing stresses which lead to local
high marrow pressure

Vascular supply susceptible to traumatic interruption
14
 Luis Corrales, HMS III
Gillian Lieberman, MD

Patient 1

Hx:

30 year old female with history of sarcoid and
corticosteroid treatment.

15
Luis Corrales, HMS III
Gillian Lieberman, MD

Patient 1 Frontal Radiograph

Courtesy of Dr. Hall

No definite abnormality
16
Luis Corrales, HMS III
Gillian Lieberman, MD

Patient 1- Frog Leg View Left Hip

Flattening of Femoral
head
Secondary to
subchondral fracture
and collapse

Courtesy of Dr. Hall

17
 Luis Corrales, HMS III
Gillian Lieberman, MD

Patient 1 MRI T1W Coronal images

Psoas M.

Iliacus M.

Gluteus
Minimus M.

Acetabulum M.
Subchondral
band of
Hypointense SI

Obturator
Externus M.
Courtesy of Dr. Hall

Pectenius M.

18
Luis Corrales, HMS III
Gillian Lieberman, MD

Patient 1 MRI T1W Coronal images

Ring pattern
of
Hypointense
Courtesy of Dr. Hall
SI

19
Luis Corrales, HMS III
Gillian Lieberman, MD

Patient 1 MRI T1W Coronal images

Courtesy of Dr. Hall

20
 Luis Corrales, HMS III
Gillian Lieberman, MD

Osteonecrosis of Femoral condyles

Spontaneus (Idiopathic) osteonecrosis of knee

Occurs in elderly- typically women > 60yrs

Presents with spontaneous onset of severe pain

Typically affects only the medial femoral condyle

Secondary osteonecrosis of knee

Younger population

Presents with vague onset of knee pain

More commonly bilateral and multifocal

Equal involvement of medial and lateral condyles

Osteonecrosis in hemopoietic cell transplantation

Presence of graft versus host disease and duration of
corticosteroid use are risk factors
21
 Luis Corrales, HMS III
Gillian Lieberman, MD

Index Patient

Hx:

45 year old female with history of AML s/p bone
marrow transplant, chemotherapy, corticosteroid
treatment, and graft versus host disease.

Presents with left knee pain

Outside plain films show sclerosis of femoral

condyles

22
Luis Corrales, HMS III
Gillian Lieberman, MD

Sagittal MRI T1W Images of Knee

Semimembranosus M.

Quadraceps M.

BIDMC
23
Luis Corrales, HMS III
Gillian Lieberman, MD

Sagittal MRI T1W Images of Knee

Med. Femoral condyle

Tibia

BIDMC

24
Luis Corrales, HMS III
Gillian Lieberman, MD

Sagittal MRI T1W Images of Knee

Inhomogenous
subchondral
hypointense SI pattern

Normal Normal appearing

appearing Post. Horn of Med. Meniscus
Ant. Horn
of Med.
Normal Articular cartilage BIDMC
Meniscus
25
Luis Corrales, HMS III
Gillian Lieberman, MD

Sagittal MRI T1W Images of Knee

Osteonecrosis extending to
articular surface
BIDMC

26
Luis Corrales, HMS III
Gillian Lieberman, MD

Sagittal MRI T1W Images of Knee

Area of Hypointense
SI within Tibial
Plateu
BIDMC

27
Luis Corrales, HMS III
Gillian Lieberman, MD

Sagittal MRI T1W Images of Knee

Serpingenous pattern of
Hypointense SI

BIDMC

28
Luis Corrales, HMS III
Gillian Lieberman, MD

Sagittal MRI T1W Images of Knee

Cortical Bone
Quadriceps Tendon

PCL
Patella

Intrapatellar fat pad

BIDMC

29
Luis Corrales, HMS III
Gillian Lieberman, MD

Sagittal MRI T1W Images of Knee

Lateral femoral condyle

Area of inhomogenous low SI

BIDMC

30
Luis Corrales, HMS III
Gillian Lieberman, MD

Sagittal MRI T1W Images of Knee

BIDMC

31
Luis Corrales, HMS III
Gillian Lieberman, MD

T2W Coronal Images of Knee

Anterior View

Med. Femoral Condyle

Band of Hypointense SI
adjacent to band of High SI

BIDMC
32
Luis Corrales, HMS III
Gillian Lieberman, MD

T2W Coronal Images of Knee

Homogenous area of low

SI in Medial condyle

BIDMC

33
Luis Corrales, HMS III
Gillian Lieberman, MD

T2W Coronal Images of Knee

BIDMC

34
Luis Corrales, HMS III
Gillian Lieberman, MD

T2W Coronal Images of Knee

Double line sign

BIDMC

35
 Luis Corrales, HMS III
Gillian Lieberman, MD

T2W Coronal Images of Knee

Osteonecrosis
extending into
posterior aspect of
femoral condyles

Double line sign

BIDMC

36
Luis Corrales, HMS III
Gillian Lieberman, MD

STIR Image

STIR(Short T1 inversion recovery)

images

Detects bone edema

Suppresses marrow fat signal

Strong signal for granulation tissue
and joint fluid

37
 Luis Corrales, HMS III
Gillian Lieberman, MD

Index Patient STIR image

Serpiginous High SI margin with central Fat SI

Typical appearance of
Osteonecrosis on STIR images

BIDMC

38
 Luis Corrales, HMS III
Gillian Lieberman, MD

Summary

Corticosteroid use is a common cause of osteonecrosis

MRI is the most sensitive and specific imaging
technique for detecting osteonecrosis

Necrotic tissue has hypointense SI on T1W and T2W
images

Double line sign on T2W MR images is diagnostic

STIR images show bone edema, and hypervascularized
granulation tissue has High SI, while fat has low SI.

39
 Luis Corrales, HMS III
Gillian Lieberman, MD

References

Gillespy III T, Genant H, Helms CA. Radiologic Clinics of North America 1986; Vol. 24,
No.2: 193-208.

Lecouver FE, Vande Berg BC, Maldague BE, et al. Early Irreversible Osteonecrosis
Verusus Transient Lesions of the Femoral Condyles: Prognostic Value of Subchondral
Bone and Marrow Changes on MR Imaging. American Journal of Roentgenology 1998; Vol
170, No 1: 71-77.

Lufkin RB. Magnetic Resonance Imaging of Joints and Extremities. Hurley, editor. The
MRI Manual Second Edition. USA: Mosby; 1998. 407-423.

Saini A, Saifuddin A. MRI of Osteonecrosis. Clin Radiology 20004; 59: 1079-1093

Stevens K, Tao C, Lee S, et al. Subchondral Fractures in Osteonecrosis of the Femoral
Head: Comparison of Radiography, CT, and MRI Imaging. American Journal of
Roentgenology 2003; 180: 363-368

40
 Luis Corrales, HMS III
Gillian Lieberman, MD

Acknowledgements

Ferris Hall, MD

Eric Niendorf, MD

Gillian Lieberman, MD

Pamela Lepkowski

Larry Barbaras

41