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MENOUFIA MEDICAL JOURANL

MENOUFIA MEDICAL JOURNAL

Table of contents

Volume 35 NUMBER 1 January-March 2022

JANUARY-MARCH 2021
VOLUME 34 • NUMBER 1

Medical and Surgical Specialties

 Original article 157

Three‑dimensional versus two‑dimensional turbo‑spin‑echo

MRI for the detection of meniscal injuries with arthroscopic
correlation
Walaa Gouda, Rehab M. Habib, Rabab Yasin

Department of Radiology, Faculty of Medicine, Objectives

Menoufia University, Menoufia, Egypt
Correspondence to Rabab Yasin, MD,
Associate professor of Radiology, Faculty of
Medicine, Menofia University, Egypt
Postal code: 32519;
Tel: +20 100 174 1993/20 100 623 5708;
e‑mail: Rabab_yasin@outlook.com,
Rababyasin123@gmail.com,
Received 07 September 2021
Revised 12 October 2021
Accepted 18 October 2021
Published 18 April 2022
Menoufia Medical Journal 2022, 35:157–163
To compare three‑dimensional (3D) turbo‑spin‑echo (TSE) isotropic sequences with
two‑dimensional (2D) sequences in the detection of meniscal tears and compare it with
arthroscopic findings which was the gold standard method.
Background
MRI is the most common, noninvasive, and accurate imaging modality for knee injuries. The
purpose of the study was to compare 3D TSE isotropic sequences and conventional 2D TSE
at 3T MRI in the detection of meniscal tears.
Patients and methods
This study was a retrospective study on 95 patients [42 (44.2%) females and 53 (55.8%) males]
with suspected meniscal injury who had undergone knee 3 T MRI sequences, including a
series of 2D conventional sequences with additional 3D isotropic TSE sequence in the period
from April 2018 to March 2019.
Results
The sensitivity and specificity of 3D TSE is higher (100 and 100%) compared with 2D TSE
sequence (67 and 96%) with statistical significance (P<0.003) in radial tears. For other types
of meniscal tears, both 3D TSE and 2D TSE sequences had similar diagnostic accuracy with
nonstatistical significance between the sensitivity and specificity of both techniques.
Conclusion
We concluded that 3D TSE is a useful and reliable technique that has a diagnostic performance
like the routine 2D TSE MR protocol for detecting meniscal tears at 3 T with superior detection
of radial tears.

Keywords:
MRI, meniscal tear, three‑dimensional turbo‑spin‑echo

Menoufia Med J 35:157–163

© 2022 Faculty of Medicine, Menoufia University
1110‑2098

2D MRI sequences such as turbo‑spin‑echo (TSE)

Introduction
MRI of the knee is the most used cross‑sectional
imaging modality for the evaluation of knee pain
and injury due to excellent assessment of the knee
details including the ligaments, cartilage, menisci, and
periarticular soft tissue [1].
Meniscal injury increased sheer stress over the adjacent
articular cartilage with subsequent early degenerative
osteoarthritis. That is why early and correct estimation
of a meniscal tear is crucial for morbidity reduction
and treatment planning [2].
Different types of meniscal tears are described. The
diagnosis of the type, extent, and location of the
meniscal tear is sometimes difficult on MRI, and it is
important for preoperative decision [3].
methods have the advantages of high spatial
resolution, good contrast between tissues, and excellent
signal‑to‑noise. However, those sequences have some
limitations. They are performed with relatively thick
slices (2.0–4.0 mm) with slice gaps, which can give
partial volume artifacts. It is not possible to perform
multiplanar reformatted (MPR) images using the
2D sequences without significant impairment of the
quality. Also, it is difficult to assess oblique and small
structures such as ligaments and tendons that are
oriented obliquely [5].
Recently, using the three‑dimensional (3D) TSE
MRI with isotropic resolution techniques have
greatly improved the depiction of pathology through
decreasing the partial volume averaging and the

The established MRI knee protocols used for clinical
practice often use the two‑dimensional (2D) sequences,
acquired in the three orthogonal planes: axial, sagittal,
and coronal [4].
This is an open access journal, and articles are distributed under the terms
of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0
License, which allows others to remix, tweak, and build upon the work
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1110-2098 © 2022 Faculty of Medicine, Menoufia University DOI: 10.4103/mmj.mmj_164_21

158 Menoufia Medical Journal, Volume 35 | Number 1 | January‑March 2022
time efficiency of the MRI used in musculoskeletal
applications [6–10].
3D TSE also can create multiplanar reconstructions,
good tissue contrast in different planes, and faster
acquisition compared with the 2D TSE protocol
especially in evaluating complex and small structures
with variable orientation directions [11].
But the 3D technique is more liable to the motion
artifact because of its longer acquisition time than
the 2D technique. The quality of the images acquired
may be affected when trying to decrease the time of
acquisition for 3D techniques [11].
Shortly, gradient‑echo imaging was used for
generating 3D isotropic sequences because of its
short time of repetition (TR); however, accentuated
magnetic susceptibility and lack of tissue contrast
between abnormal and normal tissue were considered
the major drawbacks for this sequence [8,9]. TSE
sequences using different flip angle refocusing
and extremely long echo‑train length have been
recently commercialized allowing the acquisition of
3D isotropic images based on TSE with reasonable
acquisition time [12–14].
We aimed in our study to compare 3D TSE isotropic
with 2D sequences in the detection of meniscal tears
and compare it with arthroscopic findings, which was
the gold standard method.
Patients and methods
The study protocol was approved by the local Ethics
Committee. All patients provided a written informed
consent. This study was a retrospective study on
95 patients [42 (44.2%) females and 53 (55.8%)
males, mean age was 43.47 ± 16.24 years, age range
was 17.0–58.0 years) with suspected meniscal injury
who had undergone knee 3 T MRI sequences,
including a series of 2D conventional sequences with
additional 3D isotropic TSE sequence in the period
from April 2018 to March 2019. All patients had been
referred for knee arthroscopy. Of the 46 patients had
a history of trauma (recent in 21 patients and remote
in 25 patients); the remainder had chronic symptoms
such as swelling, pain, or instability in the affected knee
joint. An informed written consent was given for all
patients.
A 3 T MR scanner (Skyra, Siemens, Erlangen,
Germany) a 20‑channel receiver and a dedicated knee
coil was used for all examinations. 2D conventional
sequences were performed in sagittal and coronal planes
with intermediate‑weighted images and then 3D
PD (proton density)‑SPACE isotropic fat‑suppressed
sagittal sequence was generated. The parameters of
each sequence are demonstrated in Table 1. From the
3D TSE SPACE, coronal and axial reformat images
were then obtained with 0.6 mm slice thickness and
without an interslice gap.
The 2D conventional and 3D TSE SPACE images
were interpreted by two radiologists (who had an
experience of 18 years for MRI knee), who were blinded
to all MRI clinical information. The 2D images were
assessed first with a 3‑week delay for the 3D image
assessment to decrease the risk of recall bias.
A meniscal tear was recorded if there is either meniscal
distortion or high signal intensity involving the
meniscal articular surface on at least two consecutive
sagittal or coronal images. We did not consider the
intrameniscal signal abnormalities as meniscal tears.
The meniscal tears were categorized into eight
types (longitudinal, horizontal, root, radial, flap,
oblique, complex, and bucket‑handle tears):
(1) A horizontal tear ran parallel to the tibial plateau
and divided the meniscus into upper and lower
parts.
(2) A longitudinal tear (Fig. 1) was vertically oriented
and propagated along the meniscal circumferential
axis.
(3) A radial tear (Fig. 2) was a vertical tear that
Figure 1
a b c
d e
A 45-year male on sagittal and coronal 3D TSE sequence (a and c).
There was a small vertical tear of the body of the lateral meniscus
reaching the superior articular surface. On the 2D PD FS sequence
(b), the tear was not detected. This was confirmed on arthroscopic
correlation (d and e) to be a small longitudinal tear of the body of the
lateral meniscus. 2D, two-dimensional; 3D, three dimensional; PD,
proton density; TSE, turbo-spin-echo.
 3D MRI in meniscal injuries Gouda et al. 159

Table 1 MRI parameters for the two‑dimensional and three‑dimensional tubro‑spin‑echo SPACE sequences
3D PD SPACE PD FS (fat T1 sagittal T2 sagittal PD FS PD FS T2 coronal
sagittal suppressed) sagittal axial coronal oblique
TR (time of repetition) 1200 ms 4090 ms 750 ms 4000 ms 3500 ms 3760 ms 3500 ms
TE (time of echo) 28 ms 27 ms 11 ms 70 ms 36 ms 27 ms 70 ms
Slices 160 30 25 25 25 25 20
Slice thickening 0.6 mm 3 mm 3 mm 3 mm 5 mm 3 mm 2 mm
FOV (field of view) read 160 mm 140 mm 140 mm 140 mm 130 mm 140 mm 140 mm
FOV (field of view) phase 78.8% 100% 100% 100% 100% 100% 100%
Matrix 256 320 320 320 320 320 320
Acquisition time 7:50 4:40 2:12 3:34 2:15 3:43 2:39
Average 1 1 1 1 1 1 1
3D, three dimensional; PD, proton density.

Figure 2 Figure 3

a b a b

c d e c
A 59-year-male patient on the sagittal 2D PD FS sequence (a)
There was an abnormal high signal involving both horns of the
lateral meniscus with a small parameniscal cyst anteriorly (arrow).
On the 3D TSE SPACE sequence (b-d), a small radial tear is seen
at the body of the lateral meniscus, which was not seen on 2D
sequences (arrows). This was confirmed on arthroscopic correlation
(e) to be a small partial small radial tear with parameniscal cysts.
2D, two-dimensional; 3D, three dimensional; PD, proton density;
TSE, turbo-spin-echo.
d e
A 65-year-female patient. On the 2D PD FS sequence, sagittal and
coronal (a-c); there was a posterior root tear of the medial meniscus
at its junction with the posterior horn with a ghost meniscus sign and
consequent medial meniscal extrusion (arrows). The same finding
was confirmed on the 3D TSE SPACE sequence with no other
additional finding detected on the 3D sequence. This was confirmed
on arthroscopic correlation (e) to be posterior root radial tear of the
medial meniscus. 2D, two-dimensional; 3D, three dimensional; PD,
proton density; TSE, turbo-spin-echo.

extends perpendicular to the inner margin of the
meniscus.
(4) A root tear (Fig. 3) was a radial tear at the root of
the meniscus, which differs from the usual radial
tear in its clinical implication.
(5) A flap tear showed a displaced flap to the
horizontal or the vertical direction.
(6) An oblique tear was considered as a vertical tear
that extends obliquely without displacement.
(7) A complex tear was a combination of two or more
tears in more than one plane.
(8) A bucket‑handle tear (Fig. 4) was a displaced
vertical tear with a centrally displaced fragment.
All arthroscopies were done at our institution by an
experienced orthopedic surgeon within 30 days after
the MRI for detection of meniscal tears.
Statistical analysis
The sensitivity, specificity, and accuracy were calculated
separately for each of the MRI protocols for the
diagnosis of meniscal tears and the arthroscopic
findings were used as our reference standard. Kappa
statistics were used to measure the interobserver
agreement between the two methods and arthroscopy,
values of P value less than 0.05 being considered
statistically significant. The statistical analysis was done
with the Statistical Package for the Social Sciences,
version 17.0.2 (SPSS Inc., Chicago, Illinois, USA).
Results
This study was a retrospective study on
95 patients [42 (44.2%) females and 53 (55.8%) males,
mean age was 43.47 ± 16.24 years, age range was
17.0–58.0 years) with suspected meniscal injury who
had undergone knee 3 T MRI sequences, including a
series of 2D conventional sequences with additional
3D isotropic TSE sequence in the period from April
2018 to March 2019. All patients had been referred for
knee arthroscopy.
The positive findings (tears) noticed in each MRI
technique for both readers as well as the number
160 Menoufia Medical Journal, Volume 35 | Number 1 | January‑March 2022

Table 2 Overall combined sensitivity, specificity, accuracy, and agreement (kappa) for two‑dimensional and three dimensional
turbo‑spin‑echo SPACE MRI protocols in the detection of meniscal tears
Type Validity Area under the curve κ agreement between each technique and arthroscopy
2D 3D TSE SPACE 2D 3D TSE SPACE 2D 3D TSE SPACE
Horizontal
Sensitivity 71 77 0.785 0.840 0.569 0.686
Specificity 86 91
Accuracy 81 86 P=0.507
Longitudinal
Sensitivity 75 88 0.718 0.763 0.472 0.544
Specificity 96 95
Accuracy 95 95 P=0.285
Radial
Sensitivity 67 100 0.811 1.00 0.667 1.00
Specificity 96 100
Accuracy 87 100 P=0.003
Root
Sensitivity 68 84 0.826 0.913 0.706 0.859
Specificity 97 99
Accuracy 89 95 P=0.265
Flap
Sensitivity 38 62 0.674 0.777 0.415 0.554
Specificity 96 94
Accuracy 88 89 P=0.542
Oblique
Sensitivity 33 33 0.667 0.661 0.484 0.420
Specificity 100 99
Accuracy 96 95 P=0.984
Complex
Sensitivity 60 80 0.675 0.900 0.405 0.871
Specificity 95 100
Accuracy 89 97 P=0.105
Bucket
Sensitivity 83 91 0.702 0.857 0.515 0.714
Specificity 99 96
Accuracy 97 96 P=0.322
2D, two‑dimensional; 3D, three dimensional; κ, kappa agreement; TSE, turbo‑spin‑echo. <0, less than chance agreement. 0.01‑0.20,
slight agreement. 0.21‑0.40, fair agreement. 0.41‑0.60, moderate agreement. 0.61‑0.80, substantial agreement. 0.81‑0.99, almost perfect
agreement. P<0.05 was considered statistically significant.

Figure 4 for the detection of tears and the interobserver

agreement.

The combined MR techniques detected a total 70

a b c d
A 36-year-male patient. On sagittal 2D PD FS (a), double PCL sign
(arrow) is seen with displaced longitudinal medial meniscal tear
where the inner part is displaced centrally (bucket-handle). The same
finding was seen on the 3D TSE sequence (b and c) with no other
additional finding detected on the 3D sequence (arrows). This was
confirmed on arthroscopic correlation (d) to be a bucket-handle tear
of the posterior horn of the medial meniscus. 2D, two-dimensional;
3D, three dimensional; PD, proton density; TSE, turbo-spin-echo.
of positive findings noticed by arthroscopy are
displayed in Table 2, representing the overall
combined sensitivity, specificity, and accuracy
medial and 67 lateral meniscal tears with more than
one tear among the total of 95 pairs of menisci.
Regarding the type of meniscal tears, 31 horizontal,
eight longitudinal, 27 radial, 25 root, 13 flap, six
oblique, 15 complex, and 12 bucket‑handle tears were
revealed on arthroscopy.
The sensitivity and specificity of 3D TSE is higher (100
and 100%) compared with the 2D TSE sequence (67
and 96%) with statistical significance (P˂0.003) in
radial tears. For other types of meniscal tears, both 3D
TSE and 2D TSE sequences had similar diagnostic
accuracy with no statistical significance between the
sensitivity and specificity of both techniques (Table 2).

The kappa agreement between the two methods and
arthroscopic results were ranging from 0.405 to 0.871
with higher interobserver agreements on 3D TSE
SPACE than 2D sequences for radial, root, complex,
and bucket‑handle tears.
Discussion
MRI is the most accurate and noninvasive imaging
modality of choice in the assessment of meniscal injuries
of the knee. 2D fast spin‑echo (FSE) sequence is the
routinely used sequence in MRI of the knee with high
spatial resolution and good tissue contrast by 1.5 T and
3 T MRI. However, it is sometimes difficult to decide if
the intrameniscal abnormal signal reaches the articular
surface or not due to partial volume averaging caused
by a slice thickness of 2–4 mm in 2D sequences. This
is in addition to the inability to perform MPR in 2D
sequences for better evaluation of meniscal injury [15].
3D sequences of high‑isotropic or near‑isotropic
resolution have many advantages with MPR and
eliminating the effects of partial volume averaging.
Although, 3D sequences are beneficial, suboptimal
images due to higher noise, long echo‑train length
with blurred image, and lower spatial resolution are
considered as disadvantages of 3D sequences [16].
Several 3D isotropic‑type gradient‑echo sequences
namely: double‑echo steady‑state; spoiled
gradient‑recalled echo; fast low‑angle shot; driven
equilibrium Fourier transform; and balanced
steady‑state free precession has been previously
experienced in the articular cartilage pathology [17].
However, routine 2D TSE cannot be totally replaced
by the 3D gradient‑echo acquisition protocols because
they are time consuming with less accurate assessment
of the ligaments and subchondral bone changes [18].
Recently, 3D TSE MRI techniques of isotropic or nearly
isotropic resolution can detect meniscal, ligamentous,
and cartilaginous lesions with good diagnostic
performance using the 3.0 T magnet. The acquisition
of the 3D protocol source images was also significantly
faster than the triplanar 2D TSE protocol [12].
Pass et al. [1] stated that the ability of 3D sequence
to perform MPRs in nonorthogonal planes is a
major advantage of a 3D sequence but 3D TSE has
disadvantages of reduced reporting accuracy. 3D
sequence has another advantage of reducing acquisition
time, 7 min 55 s for the 3D sequence versus 13 min
4 s for the standard 3 PD sequences, which reduce
the costs and improve patient experience with a time
3D MRI in meniscal injuries Gouda et al. 161
saving of 5 min 9 s per scan but if 3D sequence had to
be repeated due to excessive motion artifacts, it takes
longer time than the standard 3 PD sequences.
Notohamiprodjo et al. [19] and Gold et al. [20]
reported that the 3D‑SPACE using 3 T MRI had
higher contrast and signal when compared with 2D
FSE especially in evaluating the articular cartilage and
fluid.
In our study, the 3D TSE SPACE sequence showed
a statistically higher sensitivity and specificity for the
detection of radial meniscal tear compared with the 2D
sequence (Fig. 2) with statistical significance (P˂0.003).
There was almost perfect substantial intraobserver and
interobserver agreement between 3D and arthroscopic
results for radial tears (Table 2).
This agreed with Lim et al. [21] who did a study on
23 patients to compare FS 3D MRI versus 2D MRI in
evaluating radial and root meniscal tears. They found
that 3D FS MRI had higher sensitivity, specificity, and
accuracy with excellent interobserver agreement for
detecting meniscal tears. They concluded that the FS
3D Volume ISotropic TSE Acquisition (VISTA) is
very useful in the diagnosis of radial and root meniscal
tears with better diagnostic performance than 2D MRI
sequences.
While Jung et al. [3] concluded in their study that the
3D TSE SPACE sequence has higher specificity in
diagnosing flap meniscal tear when compared with 2D
conventional sequences, but for other types of meniscal
tears, there were no statistical significance between
both sequences. The flap tear can be displaced into
places that are difficult to be identified on arthroscopy
if not diagnosed preoperative properly. They also
concluded that 3D isotropic images with thin‑slice
thickness can help for better understanding of the
configuration of the meniscal tear with its complexity
than 2D sequences [3].
Although in our results, the 3D TSE sequence had
higher sensitivity than 2D sequence for the detection of
horizontal tear (77 and 71%, respectively), longitudinal
tear (88 and 75%, respectively), root tear (84 and 68%,
respectively), flap tear (62 and 38%, respectively),
complex tear (80 and 60%, respectively) and
bucket‑handle tear (91 and 83%, respectively). There
was no statistically significant difference between both
2D and 3D sequences as regards the detection of the
other types of meniscal tears (Table 2).
Shakoor et al. [15] performed a study on the 3D FSE
MRI sequence in the knee and concluded that the
3D FSE can replace the standard MRI protocol for
162 Menoufia Medical Journal, Volume 35 | Number 1 | January‑March 2022
the evaluation of meniscal injuries of the knee. But
in suspecting other knee pathology as ligamentous or
cartilaginous pathologies, 3D FSE is still the subject
for further investigation.
Our results agreed with studies by Kijowski et al. [4]
and Jung et al. [22] who stated that the 3D sequence
had promising results in the assessment of meniscal
tear with no statistical difference in the evaluation
of surgically confirmed meniscal tears except in the
detection of root tears in the posterior horn of the
lateral meniscus with Kijowski et al. [4] reporting that
3D FSE sequences had only lower sensitivity than the
2D sequence in the root tear of the lateral meniscus.
Sandhu et al. [23] demonstrated that the 3D‑SPACE
sequence had an excellent statistically significant
intrarater agreement for the detection of suspected
meniscal tears with MPR, high spatial resolution,
and shorter acquisition time. They recommended
replacement of the standard 2D sequence with the
3D‑SPACE when evaluating meniscal tear.
Ai et al. [10] found that the 3D TSE sequence is better
than 2D imaging in the detection of knee injuries and
they predicted that 3D TES can replace 2D imaging
protocols for the evaluation of knee injuries.
Van Dyck et al. [8] concluded that 3D TSE may be
a valuable element at the 3.0 T MRI knee protocol,
yet it cannot totally replace routine MRI 2D in the
assessment of the knee.
However Pass et al. [1] concluded in their study that
the 3D FSE sequence at 1.5 T had less diagnostic
accuracy in the detection of meniscal tears as well as
articular cartilage lesions when compared with the
standard 2D imaging in the three planes. They did not
agree for replacing 2D standard MRI sequences with
the reconstructed 3D sequence.
This agreed also with Ristow et al. [24] and Jung et al. [9]
who did studies using 3‑T systems and demonstrated
that 3D sequences had similar or even lower diagnostic
accuracy in comparison with conventional 2D imaging.
Subhas et al. [25] found that at 3 T MRI, the 3D FSE
SPACE sequence is inferior to conventional 2D FSE
acquisitions in the evaluation of menisci, while both
sequences had the same accuracy in the evaluation of
knee ligaments. Stevens et al. [26] stated that 3D FSE
sequences had a more blurred image due to their long
echo‑train.
Jung et al. [3] found the 3D TSE SPACE sequence missed
more horizontal and root tears than on 2D sequences
compared with other types of meniscal tears. They
explained that both types of tears are mostly associated
with meniscal degeneration, which is more pronounced
on the 3D TSE SPACE. Also long echo‑train length in
3D FSE isotropic sequences causes more image blurring
that affects the conspicuity of the root tears.
Chagas‑Neto et al. [11] found no statistical significance
between 2D and 3D in the detection of meniscal tears
with 0.89 kappa agreement between the two methods
for the medial meniscus and 0.74 for the lateral
meniscus.
There were some limitations in our study. We did not
include the ligamentous and the articular cartilage
evaluation within our study. Furthermore, we did not
categorize in detail the locations of the meniscal tears.
On the basis of our results in the current study, we
cannot recommend that radiologists totally replace the
routine 2D TSE technique with the 3D TSE protocol
for knee MRI. However, the results of this study
represent an important step toward the implementation
of this technique in the clinical practice in diagnosing
radial meniscal tears.
Conclusion
We concluded that 3D TSE is a useful reliable
technique and has a diagnostic performance like that
of the routine 2D TSE MR protocol for detecting
meniscal tears at 3 T with a superior detection of radial
tears.
Acknowledgements
Authors’ contributions: equal sharing between authors
as regards writing of the manuscript, collection and
analysis of data, and revising the final manuscript. All
authors have read and approved the manuscript.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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