 Hello everyone. We welcome you to today's session of Radiology Journal Club by Indian Radiologist. We have been doing these sessions every month since last years and now you must be knowing this is all about going through a learning process together. In the busy schedule which we have these days, it's difficult to go through the recent articles. So this is the way we devised by which together with an expert we can go through the updates and imaging for one hour time and also we can revise these as this is going to be shared on the YouTube channel of Indian Radiologist afterwards. Thank you all for joining today on a Sunday morning and today's session will be taken by our expert Dr. Ankita Haaja. She is consultant radiologist at Innovation Imaging Mumbai and her key areas of interest are MSK imaging, neuroimaging and head and neck imaging. She is well known figure now for all those who are interested in MSK imaging specifically. Before we go ahead for today's session, I would just bring to your notice the upcoming programs which we have by Indian Radiologist. This is online edition of MRI teaching course. The on-site edition of the course we had in May this year and it was well taken. Thank you all for that. This is an international edition of the same MRI teaching course. It will be completely online and we earlier thought of doing it on three days that is 3rd, 4th and 5th of November but with great response which we received and support from our faculty members, we extended it to five-day program that is 28th and 29th of October and 3rd, 4th and 5th of November. Registrations are on and we will be sharing the links in the chat box today as well as you can visit the Indian Radiologist's website to get these links. We have over 70 plus international faculty members who are going to take MRI related topics specifically the advances in MRI techniques and what are new is coming up in the field of MR imaging. In this particular program, we will also have posters, papers for all our residents. So please do participate. We have case of the day which will be a good chance for you to participate in an interactive manner. All these speakers are going to be there with us. They will be live also for the Q&A session so you can participate and also interact with them as and when required. We'll have a complete session which will be headed by Dr. Dushyan Sahani sir and his team, entire team from University of Washington. So they will be taking an entire day of program and similarly we'll have a group of speakers from Mayo Clinic taking one entire day of MR imaging. So we are looking forward to this program and hope you join and take advantage of this online event. Also we'll have Onko Imaging Masterclass which is said you'll launch 16th and 17th of September and it's an extensive coverage of Onko Imaging related topic. As you can see we'll have it on today's Saturday which will start at 6 p.m and go up till 10 p.m and on Sunday it will be 9 a.m and straight it will be going ahead till 10 p.m again. So it's a good opportunity to update your Onko Imaging knowledge. Please do participate and the registration for this event also is on. Now we move ahead to today's journal club. As I mentioned Dr. Ankita Ahuja will be taking us through the topic today. She's consultant radiologist at Innovation Imaging and she has much more to her credit. She was ex assistant professor at Tata Memorial Hospital. She has finished her fellowship in musculoskeletal audiology and intervention. Also done observation at guys and St. Thomas Hospital London. She's one of the founder member of the well-known Cafe Ranjan associate editor for IJ MSR and very passionate educator with multiple online webinars and also she is faculty at various national level, state level and also international level conferences and also she has various publication to her credits. Thank you Ankita because you agreed to be with us today and she will be taking us through interpretation of catalyst damage at routine clinical MRI, how to match arthroscopic findings. Over to you Ankita. Thank you so much Mintusha for the invitation and kind introduction. It's a pleasure to be here. I'll just share my screen. Hope the screen has seen. Yes. Perfect. So like as Mintusha already highlighted what we are going to do today is to understand how to evaluate the cartilage on an MRI. So this is the most recent article which has come up which compares the car how to which depicts how to evaluate the cartilage on MRI and also tells us the correlation with the arthroscopic findings. So how can we match how to report on an MRI that it matches what we are seeing on arthroscopy and that is the motto for today. Why so what all we are going to do today is in next 40 to 45 minutes what we are going to do is to understand the normal appearance of the articular cartilage then we are going to understand if we see some variation from the normal how to label it what terminology to be sorry what terminology to be used and when. So that is the second most important thing that is how you're going to report it in your reports but why are you doing so much efforts why you want to use specific terminologies why you want to provide certain specific information so that is also we are going to understand that why we are doing so much efforts and how it impacts the management right so let's start from the first step articular cartilage so joints are lined by an articular cartilage that is your high line articular cartilage right what is articular cartilage composed of like all you can make out from the name it has some cartilage so it will have condos sides within but it is not like something which is really just densely packed with condos sides condos sides just account for 1 to 5% of the volume then in addition to condos sides what you have which actually form the bulk of the tissue is your extracellular matrix which is composed of water collagen and proteoglycans and in this following percentage so that's why the appearance of articular cartilage is there now let's understand and then we'll see simultaneously start to see radiological images so we have four layers in the articular cartilage superficial middle deep and a calcified zone through which I'm going to take you in a bit so we'll understand this image in a bit let's start with the layers so first of all can you all see this orange layer this is your superficial articular cartilage if you see these fibers are parallely arranged so it's again collagen fibers predominantly but which are parallel to the articular surface so they are running like a covering they are covering the articular surface the superficial most fibers and they are parallel to each other so once something is parallel and very well organized it should look bit dark on most of your sequences and you'll come and see that in a bit's time then the next layer is a middle zone and a deep zone so if you focus on middle zone and deep zone the fibers are perpendicular to the articular surface so they are organized in a columnar fashion so this is the arrangement of the fibers in this fibers also if you see the deeper fibers are very closely knit and organized but as you go towards the periphery they start to deviate from their path they're just diverging from their path and thus a little loose architecture is formed in the middle zone however deep zone is still well organized columnar fashion collagen fibers why these fibers so these fibers are kind of a protective fibers which are holding everything together that is your superficial layer however your middle and deep zone are arranged in a columnar fashion to hold the compressive load just imagine your knee if you're trying to stand then what do you see then these columnar fibers or the middle and deep zone is the fiber which is going to take the load so the load hits over here like this and then it is taken out by this articular cartilage so this is the main layer which takes the load of the body right so these are the three important layers and beneath this layer is your calcified zone so there is this purple zone which you can see over here in this row is your calcified layer and below that is your subconvial bone so because it is in close proximity to the subconvial bone so the deeper layer starts to get calcified right but the story doesn't end over here so now till now you've understood that there are four layers just to revise the superficial layer arranged parallel to the articular surface then your middle and deep layer arranged perpendicular and below it is your calcified layer but the distinction between the calcified layer and deep zone there is a mark which comes up which is called as your tide mark as you can read over here now just hold back a minute and imagine you are at a beach once the wave of water comes to you it leaves a tide mark that's what this tide mark is so it's not like a smooth line it's just like a wave which is coming and holding over here so your calcified layer is going in between the deep zone and creating a mark which is called as the tide mark why are why am I so much emphasizing on this term as tide mark so if you would have understood till here you have collagen fibers and here the matrix is getting calcified so there is a difference in the shearing forces of the boat so this is still loser as compared to the calcified zone so whenever there is an injury or an impact then there might have sheer injury at the level of tide mark and that's why this is called as deep zone is also called as radial zone and in the radial zone this is the level where the radial force shearing injuries are most common correct so this is something which is really important just going back to this slide for a minute so this is your superficial zone of very well arranged fibers and as you can see it looks a comparatively hypo intense then as you move down to the middle and deep zones the fibers are columnarly arranged or perpendicularly arranged with deviation towards the middle zone that's why middle zone has a little brighter signal as compared to your deeper zone in which very high resolution MRI you might be able to see this pattern as well and then deep down you have a calcified layer and below it you have your bone plate right and in between these two zones you have your tide mark which is coming up right so this is how your normal articular cartilage is now let's see how it looks like on an MRI so if you try to analyze so these are your this is your pd fat suppressed image and this is your pd without fat suppression image right so in this if you try and see that you have a superficial hypo intense band so this would be your superficial fibers deep to it there are very few fibers which are little brighter as compared to the rest of the zone so this is your middle zone and this is your deep zone with this being your subcontrail bone with the calcified layer similarly it might be little difficult to distinguish the superficial most zone on this but your deep and middle zone are very well distinguished from rest of the fluid joint fluid so you use basically both the two sequences but as the article states that in a routine MRI when you're doing you either obtain these three kind of images what is the advantages and what are the disadvantages of each and particular sequence which we are going to see now so this is the quotation from the same article which states that your T1 weighted MRI image has joint fluid which will be hypo intense and cartilage surface also which will be hypo intense so if there is something which is happening on the surface of the legion articular cartilage it will not be possible to make it out on an T1 weighted MRI so T1 weighted MRI are not the most useful sequences unless and until you're using art programs right then next sequence which you do in your routine practice is your T2 weighted sequence in T2 weighted sequence the joint fluid and cartilage surface will be seen well but then the further depth of the cartilage will be really homogeneous will not have a good internal cartilage intensity differentiation so it will be difficult to make out anything which is happening to the middle and deep zone however your superficial lesions you might be able to pick up then your third sequence which you use usually for the joints and in my practice we use only the sequence mostly is your PD weighted image right which can be a fat suppressed or a non-fat suppressed image in both the images you get a very high resolution of the articular cartilage and you also get a good distinction between the cartilage and the joint fluid so you can pick up superficial as well as deep lesions really well so PD weighted images are well suited for evaluation of the articular cartilage and there are some places also do an intermediate weighted MRI sequences which have a T2 component to it and they are almost like a PD weighted image with a little bit more of T2 component to it thus making them even ideal for the evaluation of the articular cartilage but in routine practice like every one of us would be having always have your PD weighted sequences whenever you are doing joints because they provide you great information about the articular cartilage so till now what we have understood is how a normal cartilage looks like then the second step we understood is that which sequence should be used to evaluate the articular cartilage now let's start to understand that how do we describe the various abnormalities so this is again from the same article which beautifully quotes the various terms which are being used for articular cartilage and going forward I'm going to show you each and every kind of a cartilage image so first of all let's just go through the terms once before we go into the images there are two things which you need to understand a process cartilage injury can be an acute injury or a chronic degenerative kind of an injury or a thing happening to the articular cartilage so whenever it is acute you call it you might have a finding which is called as a control fracture right but if you have something which is just you cannot describe that what is going on with the articular cartilage you use the term damage although it is not really often used because you can usually put them into one of these categories right then let's go on to the terms I'll show you these terms as and when we are going to the case but I'm just touching upon the names you have a control defect you have control degeneration control delamination control fibrillation fissure figuring you usually put them all together then you have control flap you have hyper intense control lesion or you have might have a hyper intense control lesion then you may have control loss and osteoarthritis and lastly two distinct terms which are osteocondrial lesion and osteocondritis desiccants this is to touch upon the name don't worry about it I'm going to show you each and everything separately so acute and chronic as I was trying to say how can you differentiate usually seeing an MRI whether this would be an acute related stuff or is it a chronic thing so acute injuries to the cartilage usually have very linear margins so if you see this is the articular surface and you see linear clear defect lines then like a fracture right so you see a clear fracture line or a clear line then you know that this is a acute injury however if you have something going on like this rounded kind of a morphology and there is a gradation from completely lost to thin to thicker then you know that this is something which is happening over years or over a period of time so that is a chronic thing so this is the first thing which you need to understand I'll show you a few examples from the articular from the article itself so that we complete the article in a way so I'm showing you the article images as well and then I show you the images which I have from my routine practice right so in this case you see the articular cartilage is looking like this and then there is this focal area of signal hyperintensity over here so this area sometimes when we see during reporting we ignore it but this should not be no this is signal hyperintensity and on arthroscopy it may correspond to cartilage softening so when the arthroscopic went inside he saw that there is some area of signal the area of signal hyperintensity on the MRI was corresponding to the cartilage softening when he was trying to probe so when they try to probe they feel that this cartilage is not really that healthy and there might be an internal derangement within the articular cartilage which is happening so when you see this kind of a signal change that is bright then the normal articular cartilage we call it conval softening then the other example shown in the article is your partial thickness cartilage fishery so these are CT arthrogram images this is MRI image and this is arthroscopy image when you see over here the cartilage is looking very smooth and on CT you very beautifully identify the fissure but I feel in a country like India we always cannot go ahead for arthroscopic sorry the arthrograms and MRI also if you look very carefully you can see a little fissure and I'll show you on my cases you can really on pd weighted images really pick up these fissures on MRI as well so these are the conval fissuring and similarly it was corresponding to the arthrography where you saw a little bit of superficial conval fissuring so this is one spectrum which you can see then there can be something fissuring which is going into deep so this is a deep fissure which is extending along the radial zone like we discussed so this is this would be calcified cartilage and this delamination so what is happening there is a fissure which is dissecting into the articular cartilage like this and giving rise to a conval flap so we are having a conval flap which is over here because of the delamination which is happening within the articular cartilage so just to repeat on this sequence so you see that the cartilage has got bone superficially over here and then this bone cartilage is intersecting into the rest of the middle and deep zones up to the radial zone giving rise to what is called as conval delamination and the resultant cartilage which is left is attached only at one point so it is like a flap which is just moving right so this is just attached over here I'll just switch on my video so that I can show you guys so it is like something is going into the cartilage and then it is dissecting into the cartilage so the remaining bit is free and it is moving like this over here so this is like a conval flap which is much more prone to injury because any force which happens can lead to further avulsion of this flap which is really free and moving over here so this is your deep in the deep fissure which has led to further into the delamination and the resultant conval flap over here then you have a then you can have a full thickness cartilage defect as you can see over here so you can see here you can see the cartilage over here and then you see a big defect over here which corresponded to the arthroscopy now before going on to the arthroscopy and how you can correlate things let's go through the examples and make things really simple in life so this patient has acute trauma if you go and see over here this patient has discrete defects along the articular cartilage so these are the cases which we see on a day to day basis so this patient has acute trauma there are clear defects which you can see over here and over here so you see how the linear margins of the cartilage are and you clearly know that this conval part is missing from here so there are two conval bits which are missing from here and if you look carefully you start to see one bit which is lying over here and clearly you see the two both the bits larger and smaller lying over here so this patient had a acute trauma and there were conval defects which was happening and the conval body was lying somewhere so this is the first term which we will read so it's a defect some people might call it erosion and ulceration which is not the very correct term you may use conval fracture also because there is an acute injury so acute fracture of the cartilage usually with a displaced fragment so this case because of acute trauma will fit into conval fracture but your conval defect would also look like this so that is any abnormality of the articular cartilage with localized loss of height so these two conditions only differ depending upon the history and if you have associated features of trauma then you definitely know that this is the conval fracture you can label it as conval fracture you do not get that history classically then you call it as a conval defect that is a particular conval loss with defect in the height of the articular cartilage in that location right so this is your first term depending upon the acuteness of the situation or the associated findings you can call it conval fracture or a conval defect then we move on to the next case and from here I'll show you a spectrum that how the cartilage can go into degeneration right if you see over here this is how your normal cartilage should look like a little hypo intent because we saw that the middle and deep zones are really not that bright they're a little hypo intent but you see if you start to see over here everything looks really bright really bright in the sense brighter than what it should be unusual so there is lateral patello femoral conval softening which is happening over here and similarly you can see that which is seen on this sagittal pd weighted image also so this is the first step which is called as conval softening people even describe it as a hyper intense lesion like we saw that focal one published in the article so focal high signal intensity without surface abnormality it indicates possible softening or partial thickness degeneration right so we don't know what is happening within the medial middle and deep zones I'm sorry so what is happening within the middle and deep zones but we know that definitely there is nothing which is happening on the surface and surface is really well intact just we saw a little increased signal so usually we label it as conval softening which might depict an inside partial thickness degeneration happening and it is called as hyper intense lesion as well then moving on to the next term if you see over here then this cartilage is a little bright no this cartilage looks normal so you have a hyper intense little bright and a little darker zones as we discussed in the normal anatomy so this looks perfectly bright but if you see there is some dark zone which is coming up within this bright normal looking cartilage so this is little more darker than usual and it is standing out from the rest of the articular cartilage so this is something new and this is called as hypo intense lesion within the cartilage so some people also describe it like cart dark cartilage lesion or a black line sign so you see focal low signal intensity without surface abnormality and it indicates a partial thickness degeneration right so you see the cartilage surface is very well maintained but there is a focal hypo intensity within so what happened when they were looking at these cases on arthroscopy they figured out when they were going to poke this area which was looking hypo intense it was not great quality inside so it had degeneration inside and it just opened up for them very easily so this lesion is also significant not only bright but dark area is also significant because it indicates that there is an underlying degeneration which is happening over there okay then moving on to the next term which is delamination so if you see carefully over here that you see this is the overlying articular cartilage and deep down you see this bright zone which is also at the radial zone because radial zone is the most common area to get delaminated by the shearing force people even call it radial zone shearing so similarly if you see over here there is this bright signal which is tracking up but still the surface is preserved right so this also again may happen with the acute shearing force and because this is the zone of literally soft to comparatively harder area so the shear forces are maximum over in this zone and this leads to delamination so this is something which is called as delamination delamination may communicate up by a fissure and then you see delamination tracking deep down over here or you may just have a radial zone shearing and radial zone delamination without a communicating fissure depending upon the mechanism of injury it happened so delamination is also referred to as a wave sign or carpet lesion if not surfacing like I mentioned so separation if there is separation into the layers mostly between the calcified and the uncalcified layers this we have already discussed and I hope it is clear that this will happen at the radial zone deep where there is a junction between the calcified and the uncalcified layers then moving on to the next term which is condor flap so we have moved condor softening when there is just diffuse brightening then they can be hyper intense lesion that there is sudden black zone then there can be a control delamination control flap and control fissure which can happen as a stepwise thing or it can happen separate entities as well so we are discussing all the three entities right now out of which we discussed control delamination moving on to the control flap like I showed you in the case from the article as well what happens that there is an defect which has happened over here and then this delamination happened deep along the radial zone into the articular cartilage leaving a condor thing which is attached at only at one point to the bone or the sub condor bone plate resulting in what we call as a control flap so just removing my lines you can see that there was a fissure which happened over here and then this led into delamination over here and a resultant flap this body which is only communicating at one point with the bone is called as a control flap so some people even call it as unstable edge so it's a piece of cartilage pinched on one side which if removed would yield a defect clear so if you remove this entire control flap we'll have a defect over here so this is your next term and then there is something which is called as phissuring which can lead to delamination and control flaps as well so what do you mean by phissuring so phissuring means you have some irregularities so it is seen best over here so this is your articular cartilage and you see something like a squirrel has eaten it kind of an appearance to it like so it's like so there are thin linear fissures within it so that is something which we call as phissuring in this case in addition to phishing there is like a diffuse control thinning also you can compare it with the posterior cartilage which is relatively thick compared to this this cartilage has got thinner so there is a diffuse thinning in addition to your phissuring so how do you defy is describe phissuring so you describe it as a crack or a cleavage tear and you see thin clefs if you have it superficial you call it fibrillation which is like a superficial phissuring so something which has been cracked or there are a lot of cleavage or something like a eaten by a squirrel kind of a thing so that is what you call as phishing so to make it simpler over here so you may have a fissure which may lead to delamination and result in control flap and if this progresses it may lead to a control defect so you try to understand everything fall can fall into one piece as well but you can have these entities occurring separately also then moving on to the next entity which we call as control loss and as you all can see in this case there is a diffuse control loss you do not see any articular cartilage this posterior medial tibial articular cartilage is relatively preserved and maybe inner one third cartilage is relatively preserved and rest of the articular cartilage is completely gone so you have this is called as a control loss so you have complete loss of the articular cartilage so how do you describe it it is thin denuded if full thickness chronic disease in cartilage thickness so this is something which will happen over a period of time it is hugely gone and it is kind of a chronic process indicator right then we have one more important thing to understand is the other two terms which are left at the bottom that is your osteocondrial lesion and osteocondritis desiccants so your osteocondrial lesion is something any of normality of the articular cartilage and the underlying bone so I'm going to tell you that over here so what do you mean by osteocondrial defect so till now we saw conral defect in which only the articular cartilage has come on if it comes off along with the bone along with the subconral bone then we call it as an osteocondrial defect so it is nothing difficult in conral defect if you add oscius then it becomes osteocondrial defect so the name itself tells you so conral if you add an oscius component to it then it is called as osteocondrial defect so if you can see clearly a bony defect also then you label it as an osteocondrial defect and in such cases if you see a body displaced that will also have that bony component to it so that will be an osteocondrial body rather than just a conral body right then there is another entity especially being discussed with the me is osteocondritis desiccants so what do you mean by osteocondritis desiccants sometimes these two are used exchangeably it is not a right thing so the pathophysiology between osteocondritis desiccants is that you are having your knee especially adolescent knees we see it so especially you are having a constant repetitive trauma to the articular cartilage as a result the cartilage and these underlying bone are injured so you see injury to the underlying bone you see cystic change you see marrow edema in the early phases with the overlaying articular cartilage changes but eventually because of constantly going on repetitive trauma the osteocondrial unit will become unstable and move out from its base and then you can have an osteocondrial body or an osteocondrial defect associated with it so osteocondrial defect can be the last stage of osteocondritis desiccants but osteocondritis desiccant in itself is a big spectrum in which you can just see subconral cystic changes just see conral associated with conral changes with a little fluid cleft tracking without any discrete defect or anything such and eventually it may lead to a osteocondrial defect per se which is another topic in itself as such so if you read this line osteocondritis desiccants may progress from subconral edema like signal intensity that is only subconral changes to an osteocondrial defect if it is not treated or not healed then it may lead to a osteocondrial defect so let's see an example if you see over here this is a young patient who had an osteocondrial defect but this was a sequel to osteocondritis desiccants because it's a young me so you know that this patient was constantly complaining of pain for many years and if you would have previous MRI you may see that body just lying over here itself but in this case you just see that there is something that cartilage is missing for sure so you do not see any cartilage you see that there is a missing bone and if you try and look for carefully you see a missing bone with a missing articular cartilage lying together over here in the lateral supra-patellar recess so at this stage it is an osteocondrial defect with body but depending upon the history you know that this patient has an osteocondritis desiccants which has eventually led to osteocondrial body right so these are the terms which you need to understand and use in your reporting every day so you can follow that chart that chart is beautifully they have compiled and highlighted all the important terms which you need to use now how does your term make a difference to them at arthroscopy so this chart is again really beautiful that's why I've kept it over here so like we kept on talking we see hyper intensity with intact surface what were we calling it we were calling it as softening so I wish you guys could have answered in the chat box but I don't know if everybody is viewing it through the zoom or some people might be viewing it on youtube as well so those who so ever have logged in through zoom I would request you guys to answer in the chat so any hyper intensity with intact surface right now the answer is conral softening so whenever you see conral softening or you label something as conral softening it actually turned out softening at arthroscopy and it is just grade one according to the orthoscopy picture so this corresponds just to grade one which they're not going to do any ruckus about it is going to be left alone right then you can have hyper intensity within the intact surface so for us hyper intensity is just like a really minor thing on radiology but when they went to arthroscopy what they figured out that it corresponded to almost a partial thickness damage so kind of middle and deep zones were injured or damaged so this depending upon how bad the damage is was corresponding to one two or three so mentioning about hyper intensity would also be relevant and maybe after reading this article I have incorporated that in my reporting so it corresponds it on arthroscopy it may correspond to grade one grade to a grade three so whenever you will mention this in your report and arthroscopic is going arthroscopist is going into the knee they would be well prepared then in this area I can find any lesion which can be any deeper right so it can range from grade one to a three then when we call on MRI superficial partial thickness so we call only partial thickness so previously we used to be very pissed about this much percentage this much but right now if you say less than 50% more than 50% thickness of the articular cartilage that is more than sufficient that's what they really need to treat the patient and that also I'm going to come up on in a bit so when we call it partial thickness superficial fibers that usually corresponds to them for less than 50% and it corresponds to grade two on arthroscopy but when we call something as deep partial thickness like more than 50% of the fibers that corresponds to more than 50% so you can use this term or you can directly say that we feel that there is more than 50% thickness articular cartilage involvement and that actually corresponds to grade three and they might need to think to do something so if we label something as this they go inside and find something like this then they know what they're going to treat it with right which we are going to come on in a little bit more time then if you have a full thickness damage they can see the bone plate along with it then that corresponds to literally grade four so basically your findings and arthroscopic findings can correspond at all the levels from softening to less than 50% to more than 50% to full thickness what is important and new which we figured out with this study was that if you see hypo intensity within the articular cartilage that is also relevant and that might suggest a partial thickness cartilage damage right so that is also relevant to be mentioned in your reports then all of you should be aware that sometimes patient may not come to you for a glitch problem you start to look at the knee patient is a little early and you just see a diffuse mild thinning of the articular cartilage ideally in pathologic term it might be pathologic so it in literally it might be pathologic but that might not be the cause of patient symptoms right so cartilage volume as a person ages usually decreases why is it decreasing because of the changes in hydration which are happening so it is not truly a if we look at pathologically it is a degenerative process which is happening but that might really not be because of patient symptoms so we need to be a little carefully when evaluating things right so usually with age if you try to see and compare a 20 year old me with a 60 year old me who is healthy and not having any problems then you may say 20 year old has a thick cartilage whereas 60 year old might have a little thinner cartilage than that but that's a process which happens with age right then the next thing which we need to understand and from here I'll try to highlight how it affects the management is that you should not equate something as a focal point of normality to osteoarthritis so I'm also quoting the article within so if you go through this you might not need to literally go through the article because I've covered all the key points which the article was trying to highlight so the management of a focal control abnormality like a focal control defect and osteoarthritis are literally different and osteoarthritis might not undergo much treatment it might be just going for a physiotherapy and if required we go for a UKR or a TKR that means any arthroplasty surgery but if you have a focal control abnormality then that is really important to be mentioned because they can treat it they can really fix that problem and we'll see how so this is just the same thing if you have severe focal cartilage defect you should not call it as a severe osteoarthritis so sometimes I'll give you a literally a clinical picture which we face in everyday life you open a NEMRA and you feel the cartilage is medial cartilage is looking thinned out but if you see within that cartilage there is a focal defect like I was just telling you a 60 year old me the cartilage is slightly thinned out so we should not leave it like a diffuse cartilage thinning if there is still a focal control defect over there because that focal control defect might be the cause of patient symptoms and that mild diffuse thinning might not be the cause of patient symptoms and if they go ahead and treat this focal control abnormality the symptoms might get relieved and this patient doesn't need an arthro plastic so your management is changing from just treating a focal defect to an arthroplasty which is not right so you should even correlate with radiographs in such cases right because radiographs provide you weight bearing radiographs provide you a good insight about the joint space so whenever you are describing a control of normality if it is focal it has to be clearly labeled as a focal right if not then you can go ahead and say whether it's a medium size large size or diffuse right so in our practice how do we report like I'll tell you a simple basic example if you have a medial joint space narrowing and only the anterior cartilage is involved so we would write it in two ways some of us write like anterior one third of the weight bearing articular cartilage is involved or some people even go right and 30 percent of the articular cartilage is involved right because 70 percent is normal basically the posterior everything is normal so we need to be very careful and the most important thing is whenever you see something focal please give sizes because measurements really help them they know once you are putting in measurement they know you're dealing with something focal and something which is not really diffuse right if it is diffuse they're going to treat the patient with love tender loving care and if required some surgical management but if it is focal like defects and delamination and you give size they know that oh really the orthopedician will alarm will click in here okay the radiologist has specified sizes so I think I might need to go and look into it if I need to do something for this local thing and on the same note I would also like to say if it is really diffuse you don't need to mention the size because you're not going to add on anything and they're not going to do any focal procedure so you don't mention the size or a measurement for a diffuse thing that's perfectly normal but if there is a focal thing a focal defect or delamination please please mention these sizes right so why I'm seeing so much and how it impacts we are going to see over here so first of all just go through the boxes ignore something which is outside the box so if there are focal cartilage lesions right maybe there is just softening or partial thickness or if there are partial thickness lesions actually the box sizes have got smaller so text is coming out so just ignore that part please so there are focal cartilage lesions right and then what what do you mean by focal cartilage lesion you're just being softening or you're seeing just partial thickness featuring or smaller things then you need to mention focal lesion which is just softening or a partial thickness thing then either the authorization would ignore and do nothing for it and if at all he needs to treat it it would be just by controplasty so they go in like this showed you on the arthroscopic a little fig tree so they'll smoothen the margin of that cartilage they'll make that cartilage again look smooth and homogeneous and that little touching up of it will help us to smoothen the surface so that it doesn't progress to a further badder lesion right so they just go in smoothen that lesion and just come out however in place of that if you have focal full thickness lesions right we are talking about depth in along with the focal lesions so these are focal lesions which are literally softening or very small tiny tiny things but if there is focal something which is involving the full thickness then the sizes are really important why because if it's a smaller lesion then you may think of planning and doing one of the procedures like marrow stimulation controsight implantation or osteocondrial grafts right osteocondrial grafts are also more not really common because they are predominantly preferred for larger lesions so just imagine that there is a control defect so what would somebody like to do they might do an ores procedure they might like to take some cartilage from somewhere else and put it on over here or they might create some micro fractures in the underlying bone so that the healing starts and it is replaced by the fibro cartilage however if there are larger regions this micro fracturing and abrasion techniques don't help so they have only one choice left if a larger control defect is there then they need to put autologous grafts over there or they might try some rarely they might try some micro fracture but it really doesn't help that much but it varies from orthopedician to orthopedician what is our responsibility over here is to give the size so that they have an idea of what they want to do for this particular patient if you see a focal full thickness lesions right then in addition to the cartilage when you're looking at the cartilage you also look at the subcontral bone in subcontral bone what all you can find you can find either there is marrow edema in the subcontral bone or there are cystic lesions in the subcontral bone so both are really important and our clue that the overlying cartilage is affected so when they went in for arthroscopy sometimes the quality was not great and the subcontral bone was showing marrow edema but the articular cartilage was not showing anything but when the cartilage was having some amount of damage which might or might not be seen on the MRI right so mentioning about the subcontral marrow edema and cystic change is very important if you see those findings only then you might you would like to mention them because that might be the cause of pain as well as the cause of symptoms so subcontral bone is a structure which is really well innervated so there is a good nerve supply over there so it is the cause of patient's pain and the overlying cartilage can be better evaluated on the arthroscopy if you're not finding anything so these are just examples again from the articular article itself so you see over your subcontral cystic changes with adjoining marrow edema if you look carefully you see overlying cartilage fissuring over here so if you would have just come and try to see the articular cartilage you might have missed but once you see the subcontral cystic change and the marrow edema you know that you will get something or the other in the overlying articular cartilage similarly this is another example in which you have you can see that this is the articular cartilage defect but eventually if you try to look carefully the cartilage defect is also being filled in by a little bit of articular cartilage which is coming up eventually which is the result of the micro fractures and as a result the marrow edema which you were seeing over here is starting to resolve so marrow edema is giving you a clue that what you're looking at this is another case in which you could see marrow edema over here but the cartilage evaluation in this area was really difficult it looked like it might be thin but on arthroscopy they found out that this area had a counter defect overlying so just mentioning about the marrow edema also helps them during arthroscopy to figure out if there is something abnormal going on so if you see what are the importance of talking about the subcontral lesions if you see larger subcontral lesions you are mentally prepared during arthroscopy that you're going to get a higher grade of control defect and eventually if you're comparing like you're doing sequential MRIs and if you see enlarging subcontral lesions then you know that there is overlaying cartilage loss which is also progressing right so subcontral bone is giving you an indirect clue that what is happening to the articular cartilage and if you see more of cystic appearance like not only marrow edema signal intensity but you are seeing cyst like features then you know that you're dealing with something chronic because it is something which is an indicator of chronic process so your subcontral marrow edema subcontral cystic changes are important to be mentioned in your reports because they are an indirect clue that there is something wrong going on with the articular cartilage then lastly you get osteophytes which are again a clue that you might be looking at something which is happening to the cartilage so your osteophytes can be central they can be marginal or they can be along the synovial linings most commonly with conical conical things you see central cartilage defects which I think I just the image is not there but in the article they show you a beautiful image and in your practice every day you will see the image that when there is a conical loss you see the subcontral bone forming the subcontral bone oscious prominence kind of a thing happens which is kind of a central osteophyte at the region of defect and lastly you can see interarticular bodies which we saw in two cases during the discussion so which can be seen in the synovial fluid they can be stable or unstable so basically synovial bodies they are floating in the synovial fluid if they are loose or they may get impacted somewhere but what synovial fluid is there now it is kind of a food for the synovial bodies the synovial bodies are really flourishing and enjoying themselves in the synovial fluid as well so if you see today you see this big synovial body but if you do an MRI an ear later and the synovial body has increased in size that's perfectly normal it's just eating and growing and that normally happens and at this stage after an ear stage you might think this might not have come from this defect because this looks much bigger but that's not the truth because they grow in size with period of time so it's perfectly fine if you see conical bodies which are larger than your conical defects because they grow from the synovial fluid and sometimes they also get centrally ossified so you may call it them as osteo conical bodies as well so before we come on to the summing up of these points I'll just show you one or two cartilage cases just give me some one second I'll just show you one live case at least so that we get an idea that how we need to approach the cases I hope you guys can see my screen with case over here so this was the case which I showed you for the conical body so if you start to evaluate the cartilage so you should evaluate in me I'm showing you examples of me because that is something which is really more common so you should evaluate all the compartments so let's start and evaluate all the compartments so your medial opening both the PDs next to each other so your medial compartment cartilage looks fine on both these sequences no featuring surfaces also look fine and everything look fine moving on to the lateral one so here is your lateral one it looks perfectly fine you see antero lateral thyroid demon you know you're dealing with a case of a tailor in stability and if you see over here this was an acute event of instability and you see those what we do call them what are these control somebody around can't reply in the chat box defect perfect thank you Satya Lakshmi so yes now everybody has started applying so that makes it more interesting so this is something which is just a control defect so there you can see the sub control bone which is really well maintained only defects which you see here with very nice margin so you know these are control defects whenever you see control or osteocondrol defects try and look for control bodies so control body one body is definitely you can see lying over here here itself and if you go and search the other one one more is lying over here and another one is lying over here so you see much more control bodies if you see go back over here in this impacted zone again there is this control defect over here right so there is this cartilage which has gone from here as well we go and see over here so this is this bit of cartilage which is gone from here so more the number of control body and this area would have been missed so the importance is of sub control marrow edema it gives you a clue go back and look at your articular cartilage right so sub control bone is very important for you guys right you might see control defects directly sometimes you might not be able to see them at certain curved surfaces so marrow edema is helpful marrow edema gives you a clue that go back and look at your articular cartilage then this is another case okay we'll just go quickly through the medial and lateral cartilage wherever you see the abnormality just quickly say out so this is medial and lateral sorry I'm scrolling fast because I think I'm about to finish the time so medial and lateral articular cartilage seen over here beautifully then let's see the patello femoral articular cartilage okay somebody saw something which is hypo I think I should put it over here again scrolling it for you on this plane as well okay I'll just focus it on pd fat that's so you guys anything abnormal yes I agree with you I see hypo intensity but what is happening adjoining the hypo intensity you have picked the hypo intensity well anything happening adjoining the hypo intensity can you see this fluid kind of a signal over here yes so your hypo intensity like the arthroscopus feel that when you see hypo intensity there is the kind of injury which is happening to the articular cartilage and in this case adjoining the hypo intensity you can clearly see this delamination radial zone delamination which is happening over here so don't ignore your hypo intensities and picking up delaminations might be difficult in the earlier phase but what I would suggest that look at your subcontral bone region carefully because that is the most common location where you're going to have your delaminations and just quickly the last case okay so again what do you think is happening over here medial femorrhutibial all okay so in this medial femorrhutibial there is diffused cartilage loss you can call this as osteoarthritis it is not going to make a change in the management because this might be treated with u kr because as I see over here the lateral cartilage is completely preserved so this is condryl loss right this falls into condryl loss which is diffuse I'll just show you the patellofemoral as well so what do you think is happening in the patellofemoral I'm talking about this area so again if you see would be able to see cartilage over here but then you see subchondrocystic changes and marrow edema so you realize that I need to revisit this area right so this lateral patello articular cartilage is also thinned out if you compare it with the rest of the articular cartilage it's thinned out so there is thinning of this cartilage and cystic changes are a clue that this might be happening for a longer period so this is also part of osteoarthritis and as somebody correctly pointed medial patellofemoral cartilage is almost gone so again this is a case of diffuse condryl loss and articular and osteoarthritis right so this is condryl loss which is diffuse so moving just I think I opened the wrong bit yeah so just moving on to the teaching point over here so what all do we learn from this article is just a second I'm trying to get the yeah so what we also learned and was a very important and interesting point any increase and decrease in the signal intensity of the articular cartilage corresponds to cartilage degeneration and arthroscopy and which may on subsequent MRIs may progress to morphological defects right so you if you see any increase and decrease in the signal which you feel is abnormal needs to be reported and if you do a repeat MRI try and keep an eye if that same patient has a repeat MRI in those areas you might start to see some morphologic changes as well then the next important point which we learn is sequence parameters affecting grading of cartilage damage because they affect delineation of the articular cartilage and the underlying bone plate so what we are trying to learn is that we need to identify the underlying bone plate because we know above all that would be the articular cartilage and till this much thickness you need to evaluate to look for a partial thickness versus a full thickness control changes right so what we learned is that we need to make distinction between a partial thickness and a full thickness cartilage lesion by identifying the bone plate because there is a difference in management between partial thickness and full thickness but we don't need to really die out for partial thickness lesions grading no no this is only one percent is only two percent it doesn't make a difference they are going to treat that patient if it is partial thickness they're going to treat that patient in a similar manner so you don't need to lose your sweep over trying to grade your partial thickness lesions then what we learned is subcontral bone marrow is very helpful to help us identify the underlying articular cartilage damage and it can also help us in reassessing the lesion like if the cystic change is progressing cartilage worsening is progressing if it is marrow edema has subsided it might be that the cartilage lesion is in a bit better state right and this was also very interesting so damage cartilage in one compartment so like usually I also observe it in my clinical practice but I'm just highlighting it over here so you usually see medial femorotibial articular cartilage is completely lost but you see osteophytes are more prominent in the lateral compartment that's perfectly normal that they also saw in this study so damage cartilage in one compartment may cause marginal osteophyte at another compartment which has intact articular cartilage why is this happening because they share a joint common joint cavity so the friction forces are over there as well and you might see the osteophytes on the other compartment thank you so much I hope you guys would look into cartilage more nicely and try to keep these points in your mind before reporting the cartilage and use the standard terminologies thank you so much thank you Dr. Ankita you have taken it really wonderfully systematically through the article and added your experience to it which really added a lot of value there are few questions in the Q&A section I think you have covered most of these things but if you can just revise them so they just want with sequence for cartilage mapping I think you are muted oops sorry yeah I'll keep on reading and answering the question so the first question is with sequence to see the cartilage so as I discussed and as this article also again clearly mentioned is that you need to use pd weighted images or some intermediate weighted images to assess the articular cartilage because that provides you a better evaluation of the matrix of the cartilage so that is important so you depend upon pd weighted images can you please explain the normal appearance of cartilage on MRI which best sequence to see so again I think this is a repeat question so cartilage I hope all of you have understood it has four layers superficial middle deep and a calcified layer you evaluate the cartilage on pd weighted images and you can make the distinction between the layers if not so very beautifully but you can still make out what is important is to identify the calcified layer or the subcontral bone plate and see whether the control lesions are reaching up to that level or not to differentiate a full thickness from a partial thickness lesion so in our practice we use pd weighted images without fat suppression along with pd weighted images with fat suppression to completely assess the articular cartilage but in my personal experience pd weighted images without fat separations are really helpful and they provide you a beautiful understanding of the cartilage then next question is again a repeat question focal cartilage defect with marrow edema in femoral contile what to write and what's the treatment so it all depends upon what the causes like just now I show you an example in which lateral femoral also had a control defect and there was a control body also if it's a young patient they might go back and fix it right so it matters so you whenever you see a focal control defect you need to start looking for a control body and you need to describe where the control body is lying and how big the defect is the measurements matter for a change I always don't believe too much in measurements but whenever there is a focal conrelation measurements matter so do mention about the measurements of focal control defects because if they're really big enough the management would be only or a osteocontrol grafting but if they're smaller enough then they might if it is very like just like softening then you leave it but if it's a small conrel defect they can fix it back if you can see a healthy control body along or they might go for other procedures like micro trauma or abrasion conroplasty right so talking about the management is again another big topic in itself but what we learn from today's talk is that we need to understand whenever you see a focal conrelation you need to give the size of it right unless it's diffuse you can avoid and ignore anything focal give the sizes do we need to grade cartilage injury yes that was the motto of today so you need to grade in the sense you need to describe what cartilage pattern of damage you are seeing whether it's just featuring delamination conrel flap conrel defect or maybe a diffuse conrel loss right but you need to use the correct term if you guys have want to go through the article once again just go through the articles those two charts and they will give you a much better insight it will kind of a revision for you guys okay so the question is should we grade cartilage injury or just describe the lesion so with these terms you are kind of a grading them so if there is a focal full thickness defect you are giving the size as well so kind of you have graded it with the description so if both the things go hand in hand I think with Usha with that I yeah we have covered yes yes so thank you Ankita once again and I hope with this we learn more about cartilage interest like earlier it was just a generalized description but now we have more specific description to our reports for these cartilage defects and cartilage damage areas thank you once again all of you and if you want to revise this entire session will also be shared on our YouTube channel so you can go through it and with this we come to an end of today's journal club again reminding you about the upcoming conferences by Indian radiologist you can visit our website and register for all these events so international edition online this is completely online of MRI teaching course and there will be 70 plus international speakers going through important MRI related topics and similarly we'll have our ongoing majoring masterclass which will be happening on 16th and 17th of September so registrations are still on request you to visit Indian radiologist website and register for all these courses thank you once again thank you all