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  • Tolgay Şatana

Evaluation of MRI Efficiency in Cartilage Lesions in Terms of Arthroscopic Diagnosis

Joint pain is one of the main reasons for outpatient treatment for musculoskeletal problems. While MRI (Magnetic Resonance Imaging), one of the advanced diagnostic methods, increases the options for the treatment of joint cartilage lesions, its effect on the accuracy of the options and the decision of timing is limited. Early diagnosis and adequate treatment can prevent the irreversible loss of cartilage tissue.

Cartilage tissue is a metabolically active tissue. Except for superficial losses, it does not have the ability to repair itself. Since cartilage cells do not have regeneration capability, losses can only be covered up to 1 mm by cellular migration and matrix production.

In superficial losses, if the injury does not reach the subchondral tissue, there is no cellular migration. After hemorrhage in full-thickness injuries, we see that fibrin and mesenchymal cells play a role in shaping. In this case, the repair tissue becomes firocartilage like cicatricial tissue.

The hyaline cartilage provides a smooth and smooth surface as well as providing belt fluidity, one of the basic functions of cartilage. Fibrocartilage functions as a filler as a scar tissue and prepares the basis for the inflammatory response with PDGF, TGF- (3 mediators released from mesenchymal cells, which have an important place in arthritis physiopathology.

If the cartilage defect creates a mechanical obstacle and the arthroscopic treatment is delayed, the healing may result in the form of excess scar tissue. This will increase the friction and wear and make the treatment unsuccessful.

It is a hard osseous healing tissue caused by mesenchymal cells with pluripotent cell characteristics to increase osteophyte formations despite the relief of pain over time, therefore, in addition to acute inflammatory response, the problems in the late period will be in the form of a healing tissue that creates a mechanical obstacle and disrupts lubricity.

Viscosupplementation provides the migration of chondral cells and accelerates the formation of new cartilage as well as a mechanical effect in the closure of superficial defects. However, its application alone is controversial in cases where there is a mechanical obstacle.

Despite conservative options, the aim in arthroscopic surgery should be to provide acceptable lubricity of cartilage lesions without causing erosion on the opposite surface over time. In superficial cartilage lesions, this procedure can be applied to a simple debridement, and in more severe lesions, to cartilage transfer.

Simple debridement is based on cellular migration and matrix filling healing, unstable fragments, chondromalastic foci are cleaned and regeneration is given to healthy layers. Although the cartilage healing is hyaline, regional thinning develops and the irregularity continues. Although the belt-like mechanics of the injury area deteriorates due to thinning, the opposite surface wear is prevented.

Cartilage transfer is the process of removing cartilage osteochondral graft from a smooth area. When the healing is completed, the surface is covered with hyaline cartilage.

Correct treatment of timely, correctly defined cartilage lesion means preservation of long-term joint function. In the treatment, the right option should be determined immediately by targeting eradication. How sensitive and effective is MRI in this choice? Although the answer seems to be in favor of MRI with the developing technology, its sensitivity in superficial lesions is not yet sufficient.

Detection of cartilage lesions

The problem in diagnosing cartilage injuries or degenerations is that the main complaint and the way pain occurs during daily activity are quite similar to meniscal lesions.

Provocation maneuvers during physical examination can often be painful in condylar lesions. In case MRI examination and physical examination findings do not match, which is inevitable in differential diagnosis and treatment planning, the presence of a superficial cartilage lesion should be revealed by questioning the short-term conservative response. Arthroscopic joint examination of pain that does not decrease despite conservative treatment or recurs at the end of treatment is the gold standard in early detection of cartilage lesions.

Although rare, cartilage lesions can be reported as cruciate ligament injuries on MRI. In this case, if it cannot be distinguished due to the clinical painful knee, the large cartilage lesion can be missed by the decision of conservative ligament repair (Figure 1).

MRI methods and difficulties in the diagnosis of cartilage lesions

It is often seen that no special classification is used except for recording the presence of cartilage lesions, facial discontinuity and irregularity, and subchondral edema reported by MRI. Therefore, even if it is possible for the clinician to suspect the presence of a superficial cartilage lesion with a good physical examination, it may not be possible to confirm the lesion.

Clinically compatible results and sensitivity of MRI are reduced under 1 Tesla power. Sensitivity to cartilage lesions increases in proportion to magnet power.

Digital software support STIR imaging, spin echo T1 / T2 cartilage-specific sequence and gradient settings increase sensitivity, so a wide range of sensitivity between 18-80% is reported in the literature.

MR-arthrography is useful in detecting the suspicious lesion after a good physical examination, which is not frequently used, but has not found its place in practice. Detection of superficial erosions is difficult, and the possibility of focal focuses outside of the sections is quite strong.

Reaching the surface in the presence of MRI subchondral edema

Some side lesions may reveal false positivity in 14%. In addition, false-negative rate has been reported to be higher (16-30%), although it varies depending on sensitivity.

When degenerative cartilage lesions are widespread and superficial, they may not be demonstrated by MRI even though they are responsible for a significant part of the findings (Figure 2).

Although MRI sensitivity is claimed to be 100% in full-thickness lesions, it may not give any MRI findings (Figure 3). Cartilage in small joints such as ankles

Detection of dac lesions can be much more misleading. A full-thickness lesion cannot be detected on MRI scans, and extensive talus edema may be false negative (Figure 4).

Fragmented flap-style cartilage injuries, which are clinically extremely noisy, often do not show MRI findings (Figure 5).

Similarly, extensive-superficial chronic subchondral inflammation can be missed in lesions whose process is over (Figure 6).

  • 54-year-old female patient, diffuse superficial degenerated cartilage loss and softening

  • 43-year-old male patient with complete focal cartilage lesion without MRI findings and peripheral meniscal separation in return

  • 41-year-old male patient, a full-thickness cartilage lesion on the articular surface of the ankle tibia distal end without MRI findings

  • 34-year-old female patient with MRI findings non-giving flap-style cartilage defect

  •  A 34-year-old female patient, an explosive superficial chronic cartilage lesion in the medial femoral condyle.

Arthroscopy efficacy

Arthroscopic diagnostic approach should be among the options of the clinician under the guidance of physical examination in cases of joint pain that does not resolve despite conservative treatment. Arthroscopic diagnosis can explain the clinic by revealing the cartilage softening with dynamic examination as well as video imaging, even if there is no superficial loss.

Arthroscopic classifications of cartilage lesions should reveal the topography of the lesion as a focal, large or kissing lesion and should be able to convey sufficient information depending on whether its depth is superficial, moderate or full. However, we could not use a practical and generally accepted classification that defines both features in our clinic. Surface changes Maintaining the habit of defining Outerbridge's popularized cartilage lesions at 4 degrees, we preferred to characterize them topographically as focal, large and kissing lesions.


Irle et al. He found 100% efficiency and sensitivity of MRI in injuries extending to the subchondral region, but insufficient in superficial lesions. Similarly, Ochi et al. Increasingly determined the sensitivity in softening, fragmentation, erosion and full thickness lesions as 14.3%, 57.3%, 75% and 100%.

Potter et al., In a series of 600 cases, obtained more sensitive results by using the MRI spin echo technique in arthroscopic images according to the Outerbridge classification. In this study, sensitivity was 87%, specificity was 94% and accurate diagnosis was 92%. On the other hand, they found false positive 15% and false negativity 14%. Spiers et al. A prospective study of 58 patients found inadequate physical examination efficacy in terms of MRI in terms of meniscal lesions. In this series, it is significant to emphasize that MRI reduces diagnostic arthroscopy by 29% at the stage of diagnosis and the sensitivity is reported as 68%. Bradella et al. Reported a sensitivity of 64-80% in cartilage lesions.

Although Friemert et al found increased sensitivity with the STIR technique in addition to the spin echo technique, the increase in sensitivity in superficial cartilage lesions is not significant.

In the study of Macarini et al, it is highly specific to emphasize that the sensitivity may change according to the localization of the cartilage lesion. The similarity between the cartilage injury in the medial femoral condyle and the anterior cruciate ligament rupture in our series is a good example of this study.

Emphasizing that the sensitivity may change to magnet power and echo-gradient choices, these studies reveal the importance of clinical evaluation.


Treatment of superficial cartilage losses, whether traumatic or degenerative, should relieve pain and increase functional capacity by creating a slippery joint surface. In conservative treatment, symptoms rapidly regress as long as the lesion remains within the regeneration limits of the tissue. If there is no significant improvement in functional capacity despite conservative treatment, the findings in the MRI examination should be considered false negative. Otherwise, arthroscopy performed after false positive is not a loss. Subchondral edema in joint contusion that occurs after trauma may mislead the extent of the lesion reaching the surface. False positivity is extremely low compared to false negative results in all series. Therefore, arthroscopy should not be avoided at an acceptable rate.

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