Subchondral insufficiency fractures: overview of MRI findings from hip to ankle joint

Abstract

Background

Subchondral insufficiency fracture (SIF) represents a potentially severe condition that can advance to osteoarthritis, with collapse of the articular surface. SIF manifests as a fracture in bone weakened by non-tumorous disease, precipitated by repetitive physiological stress, without a clear history of major trauma. It is observed along the central weight-bearing region of the femoral condyle, with a higher incidence in the medial femoral condyle, but also in other large weight-bearing synovial joints, such as the femoral head, tibial plateau, or talus.

Method

A review of the literature from the past six years was performed by searching PubMed and ScienceDirect databases, using the keywords “subchondral insufficiency fracture” and “spontaneous osteonecrosis of the knee”. The inclusion criteria were scientific papers presented in the English language that reported on the magnetic resonance imaging (MRI) aspects of SIF of the lower limb.

Results and Conclusion

Detecting SIF at the level of the hip, knee, and ankle may present challenges both clinically and radiologically. The MRI appearance is dominated by a bone marrow edema-like signal and subchondral bone changes that can sometimes be subtle. Subchondral abnormalities are more specific than the pattern of bone marrow edema-like signal and are best shown on T2-weighted and proton-density-weighted MR images. MRI plays an important role in accurately depicting even subtle subchondral fractures at the onset of the disease and proves valuable in follow-up, prognosis, and the differentiation of SIF from other conditions.

Key Points

• Subchondral insufficiency fractures may affect the hip, knee, and ankle.

• Subchondral insufficiency fractures may heal spontaneously or progress to collapse.

• MRI is important for the detection, follow-up, and prognosis of subchondral insufficiency fractures.

• Differential diagnosis may include transient osteoporosis and osteonecrosis of systemic origin.

Citation Format

• Buturoiu MM, Ghiea S, Weber M. Subchondral insufficiency fractures: overview of MRI findings from hip to ankle joint. Fortschr Röntgenstr 2024; 196: 1143 – 1154

Zusammenfassung

Hintergrund

Die subchondrale Insuffizienzfraktur (SIF) stellt eine potenziell ernste Erkrankung dar, die zu einer Osteonekrose und oder einem Fortschreiten der Arthrose mit Kollaps der Gelenkoberfläche führen kann. SIF manifestiert sich als Fraktur im durch nicht-neoplastische Krankheiten geschwächten Knochen. Diese Fraktur wird ausgelöst durch wiederholten physiologischen Stress, jedoch ohne klare Anamnese eines schwerwiegenden Traumas. Sie tritt entlang der zentralen, gewichtstragenden Region der Femurkondyle auf, mit einer höheren Inzidenz im medialen Femurkondylus, aber auch in anderen großen, gewichtstragenden mit Synovia ausgekleideten Gelenken, wie dem Knie- und Sprunggelenk.

Methode

Es wurde eine retrospektive Literaturanalyse der letzten sechs Jahre durchgeführt, indem PubMed- und ScienceDirect-Datenbanken nach den Schlüsselwörtern „subchondrale Insuffizienzfraktur“ und „spontane Osteonekrose des Knies“ durchsucht wurden. Die Einschlusskriterien waren wissenschaftliche Arbeiten in englischer Sprache, die sich mit den magnetresonanztomografischen (MRT) Aspekten der SIF der unteren Extremität befassten.

Ergebnisse und Schlussfolgerung

Die Detektion von SIF im Bereich von Hüfte, Knie und Sprunggelenk kann sowohl klinisch als auch radiologisch herausfordernd sein. In der MRT zeigen sich Veränderungen, wie sie auch bei einem Knochenmarködem festzustellen sind. Außerdem zeigen sich subchondrale Knochenveränderungen, die manchmal auch nur subtil sein können. Subchondrale Abnormalitäten sind spezifischer als das eher unspezifische Knochenmarködem und werden am besten auf T2-gewichteten und Protonendichte-gewichteten MRT-Sequenzen dargestellt. Die MRT spielt eine wichtige Rolle dabei, auch subtile subchondrale Frakturen zu Beginn der Erkrankung genau darzustellen und erweist sich als wertvoll bei der Verlaufskontrolle, Prognose und Differenzierung von SIF zu anderen Pathologien.

Kernaussagen

• Subchondrale Insuffizienzfrakturen können spontan heilen oder zu einem Kollaps fortschreiten.

• MRT ist wichtig für die Erkennung, Nachsorge und Prognose von subchondralen Insuffizienzfrakturen.

• Die Differentialdiagnose kann transiente Osteoporose und Osteonekrose systemischen Ursprungs umfassen.

Keywords

Subchondral insufficiency fracture - Hip - Knee - ankle - Magnetic resonance imaging

Publication History

Received: 12 January 2024

Accepted after revision: 04 June 2024

Article published online:
19 July 2024

• References

• 1 Gorbachova T, Melenevsky Y, Cohen M. et al. Osteochondral Lesions of the Knee: Differentiating the Most Common Entities at MRI. Radiographics 2018; 38: 1478-1495 DOI: 10.1148/rg.2018180044.
• 2 Lee S, Saifuddin A. Magnetic resonance imaging of subchondral insufficiency fractures of the lower limb. Skeletal Radiol 2019; 48: 1011-1021 DOI: 10.1007/s00256-019-3160-4.
• 3 Chen M, Wang X, Takahashi E. et al. Current Research on Subchondral Insufficiency Fracture of the Femoral Head. Clin Orthop Surg 2022; 14: 477-485 DOI: 10.4055/cios22175.
• 4 Kiuru MJ, Pihlajamaki HK, Ahovuo JA. Fatigue stress injuries of the pelvic bones and proximal femur: evaluation with MR imaging. Eur Radiol 2003; 13: 605-611 DOI: 10.1007/s00330-002-1562-4.
• 5 Thierfelder KM, Gerhardt JS, Langner S. et al. Spezielle Aspekte bei Stressfrakturen. Radiologe 2020; 60: 506-513 DOI: 10.1007/s00117-020-00657-7.
• 6 Ahlbäck S, Bauer GC, Bohne WH. Spontaneous osteonecrosis of the knee. Arthritis Rheum 1968; 11: 705-733 DOI: 10.1002/art.1780110602.
• 7 Lecouvet FE, van de Berg BC, Maldague BE. et al. Early irreversible osteonecrosis versus transient lesions of the femoral condyles: prognostic values of subchondral bone and marrow changes on MR imaging. AJR Am J Roentgenol 1998; 170: 71-77 DOI: 10.2214/ajr.170.1.9423603.
• 8 Lecouvet FE, Malghem J, Maldague BE. et al. MR imaging of epiphyseal lesions of the knee: current concepts, challenges, and controversies. Radiol Clin North Am 2005; 43: 655-672 DOI: 10.1016/j.rcl.2005.02.002.
• 9 Yamamoto T, Bullough PG. Spontaneous osteonecrosis of the knee: the result of subchondral insufficiency fracture. J Bone Joint Surg Am 2000; 82: 858-866 DOI: 10.2106/00004623-200006000-00013.
• 10 Takeda M, Higuchi H, Kimura M. et al. Spontaneous osteonecrosis of the knee: histopathological differences between early and progressive cases. J Bone Joint Surg Br 2008; 90: 324-329 DOI: 10.1302/0301-620X.90B3.18629.
• 11 Hatanaka H, Yamamoto T, Motomura G. et al. Histopathologic findings of spontaneous osteonecrosis of the knee at an early stage: a case report. Skeletal Radiol 2016; 45: 713-716 DOI: 10.1007/s00256-016-2328-4.
• 12 Sayyid S, Younan Y, Sharma G. et al. Subchondral insufficiency fracture of the knee: grading, risk factors, and outcome. Skeletal Radiol 2019; 48: 1961-1974 DOI: 10.1007/s00256-019-03245-6.
• 13 Husain R, Nesbitt J, Tank D. et al. Spontaneous osteonecrosis of the knee (SONK): The role of MR imaging in predicting clinical outcome. J Orthop 2020; 22: 606-611 DOI: 10.1016/j.jor.2020.11.014.
• 14 Gorbachova T, Amber I, Beckmann NM. et al. Nomenclature of Subchondral Nonneoplastic Bone Lesions. AJR Am J Roentgenol 2019; 213: 963-982 DOI: 10.2214/AJR.19.21571.
• 15 Palmer W, Bancroft L, Bona F at al. Glossary of terms for musculoskeletal radiology. Skeletal Radiol 2020; 49: 1-33 DOI: 10.1007/s00256-020-03465-1.
• 16 Malghem J, Lecouvet F, Vande Berg B. et al. Subchondral insufficiency fractures, subchondral insufficiency fractures with osteonecrosis, and other apparently spontaneous subchondral bone lesions of the knee-pathogenesis and diagnosis at imaging. Insights Imaging 2023; 14: 164 DOI: 10.1186/s13244-023-01495-6.
• 17 Ochi J, Nozaki T, Nimura A. et al. Subchondral insufficiency fracture of the knee: review of current concepts and radiological differential diagnoses. Jpn J Radiol 2022; 40: 443-457 DOI: 10.1007/s11604-021-01224-3.
• 18 Wilmot AS, Ruutiainen AT, Bakhru PT. et al. Subchondral insufficiency fracture of the knee: a recognizable associated soft tissue edema pattern and a similar distribution among men and women. Eur J Radiol 2016; 85: 2096-2103 DOI: 10.1016/j.ejrad.2016.08.016.
• 19 Farrell TP, Deely DM, Zoga AC. et al. Lateral femoral condyle insufficiency fractures: imaging findings, demographics, and analysis of outcomes. Skeletal Radiol 2021; 50: 189-199 DOI: 10.1007/s00256-020-03548-z.
• 20 Iwasaki K, Yamamoto T, Nakashima Y. et al. Subchondral insufficiency fracture of the femoral head after liver transplantation. Skeletal Radiol 2009; 38: 925-928 DOI: 10.1007/s00256-009-0706-x.
• 21 Yamamoto T, Schneider R, Iwamoto Y. et al. Subchondral insufficiency fracture of the femoral head in a patient with systemic lupus erythematosus. Ann Rheum Dis 2006; 65: 837-838 DOI: 10.1136/ard.2005.041095.
• 22 Fotiadou A, Karantanas A. Acute nontraumatic adult knee pain: the role of MR imaging. Radiol Med 2009; 114: 437-447 DOI: 10.1007/s11547-009-0380-z.
• 23 Wilson AJ, Murphy WA, Hardy DC. et al. Transient osteoporosis: transient bone marrow edema?. Radiology 1988; 167: 757-760 DOI: 10.1148/radiology.167.3.3363136.
• 24 Kosaka H, Maeyama A, Nishio J. et al. Histopathologic evaluation of bone marrow lesions in early stage subchondral insufficiency fracture of the medial femoral condyle. Int J Clin Exp Pathol 2021; 14: 819-826
• 25 Eriksen EF, Ringe JD. Bone marrow lesions: a universal bone response to injury?. Rheumatol Int 2012; 32: 575-584 DOI: 10.1007/s00296-011-2141-2.
• 26 Musbahi O, Waddell L, Shah N. et al. Subchondral Insufficiency Fractures of the Knee: A Clinical Narrative Review. JBJS Rev 2023; 11 DOI: 10.2106/JBJS.RVW.23.00084.
• 27 Reddy AS, Frederick RW. et al. Evaluation of the intraosseous and extraosseous blood supply to the distal femoral condyles. Am J Sports Med 1998; 26: 415-419 DOI: 10.1177/03635465980260031201.
• 28 Björkengren AG, AlRowaih A, Lindstrand A. et al. Spontaneous osteonecrosis of the knee: value of MR imaging in determining prognosis. AJR Am J Roentgenol 1990; 154: 331-336 DOI: 10.2214/ajr.154.2.2105026.
• 29 Yamamoto T, Bullough PG. et al. The role of subchondral insufficiency fracture in rapid destruction of the hip joint: a preliminary report. Arthritis Rheum 2000; 43: 2423-2427
• 30 Iwasaki K, Yamamoto T, Motomura G. et al. Common site of subchondral insufficiency fractures of the femoral head based on three-dimensional magnetic resonance imaging. Skeletal Radiol 2016; 45: 105-113 DOI: 10.1007/s00256-015-2258-6.
• 31 Boutry N, Paul C, Leroy X. et al. Rapidly destructive osteoarthritis of the hip: MR imaging findings. AJR Am J Roentgenol 2002; 179: 657-663 DOI: 10.2214/ajr.179.3.1790657.
• 32 Woertler K, Neumann J. Atraumatic Bone Marrow Edema Involving the Epiphyses. Semin Musculoskelet Radiol 2023; 27: 45-53 DOI: 10.1055/s-0043-1761498.
• 33 Ikemura S, Yamamoto T, Motomura G. et al. MRI evaluation of collapsed femoral heads in patients 60 years old or older: Differentiation of subchondral insufficiency fracture from osteonecrosis of the femoral head. AJR Am J Roentgenol 2010; 195: W63-W68 DOI: 10.2214/AJR.09.3271.
• 34 Ikemura S, Mawatari T, Matsui G. et al. The depth of the low-intensity band on the T1-weighted MR image is useful for distinguishing subchondral insufficiency fracture from osteonecrosis of the collapsed femoral head. Arch Orthop Trauma Surg 2018; 138: 1053-1058 DOI: 10.1007/s00402-018-2948-3.
• 35 Miyanishi K, Kaminomachi S, Hara T. et al. A subchondral fracture in transient osteoporosis of the hip. Skeletal Radiol 2007; 36: 677-680 DOI: 10.1007/s00256-006-0248-4.
• 36 Miyanishi K, Yamamoto T, Nakashima Y. et al. Subchondral changes in transient osteoporosis of the hip. Skeletal Radiol 2001; 30: 255-261 DOI: 10.1007/s002560100350.
• 37 Karantanas AH, Nikolakopoulos I, Korompilias AV. et al. Regional migratory osteoporosis in the knee: MRI findings in 22 patients and review of the literature. Eur J Radiol 2008; 67: 34-41 DOI: 10.1016/j.ejrad.2008.01.054.
• 38 Moosikasuwan JB, Miller TT, Math K. et al. Shifting bone marrow edema of the knee. Skeletal Radiol 2004; 33: 380-385 DOI: 10.1007/s00256-004-0783-9.
• 39 Lotke PA, Nelson CL, Lonner JH. Spontaneous osteonecrosis of the knee: tibial plateaus. Orthop Clin N Am 2004; 35: 365-370 DOI: 10.1016/j.ocl.2004.02.009.
• 40 Hussain ZB, Chahla J, Mandelbaum BR. et al. The Role of Meniscal Tears in Spontaneous Osteonecrosis of the Knee: A Systematic Review of Suspected Etiology and a Call to Revisit Nomenclature. Am J Sports Med 2019; 47: 501-507 DOI: 10.1177/0363546517743734.
• 41 Yamagami R, Taketomi S, Inui H. et al. The role of medial meniscus posterior root tear and proximal tibial morphology in the development of spontaneous osteonecrosis and osteoarthritis of the knee. Knee 2017; 24: 390-395 DOI: 10.1016/j.knee.2016.12.004.
• 42 Yao L, Stanczak J, Boutin RD. Presumptive subarticular stress reactions of the knee: MRI detection and association with meniscal tear patterns. Skelet Radiol 2004; 33: 260-264 DOI: 10.1007/s00256-004-0751-4.
• 43 Hashimoto S, Terauchi M, Hatayama K. et al. Medial meniscus extrusion as a predictor for a poor prognosis in patients with spontaneous osteonecrosis of the knee. Knee 2021; 31: 164-171 DOI: 10.1016/j.knee.2021.06.003.
• 44 Barras LA, Pareek A, Parkes CW. et al. Post-arthroscopic Subchondral Insufficiency Fractures of the Knee Yield High Rate of Conversion to Arthroplasty. Arthroscopy 2021; 37: 2545-2553 DOI: 10.1016/j.arthro.2021.03.029.
• 45 Allam E, Boychev G, Aiyedipe S. et al. Subchondral insufficiency fracture of the knee: unicompartmental correlation to meniscal pathology and degree of chondrosis by MRI. Skeletal Radiol 2021; 50: 2185-2194 DOI: 10.1007/s00256-021-03777-w.
• 46 Vidoni A, Shah R, Mak D. et al. Metaphyseal burst sign: A secondary sign on MRI of subchondral insufficiency fracture of the knee. J Med Imaging Radiat Oncol 2018; 62: 764-768 DOI: 10.1111/1754-9485.12781.
• 47 Breitenseher MJ, Kramer J, Mayerhoefer ME. et al. Differenzialdiagnosen des Knochenmarködems am Kniegelenk. Radiologe 2006; 46: 46-54 DOI: 10.1007/s00117-005-1304-0.
• 48 Rios AM, Rosenberg ZS, Bencardino JT. et al. Bone marrow edema patterns in the ankle and hindfoot: distinguishing MRI features. AJR Am J Roentgenol 2011; 197: W720-W729 DOI: 10.2214/AJR.10.5880.
• 49 Long NM, Zoga AC, Kier R. et al. Insufficiency and nondisplaced fractures of the talar head: MRI appearances. AJR Am J Roentgenol 2012; 199: W613-W617 DOI: 10.2214/AJR.11.7313.
• 50 Bonadio MB, Filho AGO, Helito CP. et al. Bone Marrow Lesion: Image, Clinical Presentation, and Treatment. Magn Reson Insights 2017; 10: 1-6 DOI: 10.1177/1178623x17703382.
• 51 Sibilska A, Góralczyk A, Hermanowicz K. et al. Spontaneous osteonecrosis of the knee: what do we know so far? A literature review. Int Orthop 2020; 44: 1063-1069 DOI: 10.1007/s00264-020-04536-7.