AJR 2001; 177:905-909
© American Roentgen Ray Society
Effect of Chondrocalcinosis on the MR Imaging of Knee Menisci
Shaifali Kaushik1,2,
Joel K. Erickson3,
William E. Palmer3,
Carl S. Winalski1,
S. James Kilpatrick4 and
Barbara N. Weissman1
1
Department of Radiology, Brigham and Women's Hospital, 75 Francis St., Boston,
MA 02115.
2
Present address: Department of Radiology, Medical College of Virginia
Hospital, 401 N. 12th St., Rm. 3-407B, P. O. Box 980615, Richmond, VA
23298-0615.
3
Department of Radiology, Massachusetts General Hospital, 15 Parkman St., WACC
515, Boston, MA 02114.
4
Department of Biostatistics, Medical College of Virginia, P. O. Box 980032,
Richmond, VA 23298.
Received January 29, 2001;
accepted after revision March 22, 2001.
Address correspondence to S. Kaushik.
Abstract
OBJECTIVE. Our goal was to determine the influence of
chondrocalcinosis on MR imaging in the detection of meniscal tears.
MATERIALS AND METHODS. A retrospective review was performed of knee
MR imaging and arthroscopy records from two university hospitals between 1996
and 1998. Seventy individuals had radiographic evidence of chondrocalcinosis
and underwent knee MR imaging. Thirty-seven of these individuals had undergone
arthroscopy for further evaluation of their symptoms. MR imaging sensitivity
and specificity in the detection of medial and lateral meniscal tears were
calculated in these 37 patients who had radiographic evidence of
chondrocalcinosis and in a control group of 34 patients who underwent MR
imaging and arthroscopy but did not have knee chondrocalcinosis.
RESULTS. In the chondrocalcinosis group, MR imaging sensitivity,
specificity, and accuracy for meniscal tear were 78%, 71%, and 78%,
respectively, for the lateral meniscus, and 89%, 72%, and 81% for the medial
meniscus. The control group showed sensitivity, specificity, and accuracy of
93%, 100%, and 97%, respectively, for the lateral meniscus and 100% in all
cases for the medial meniscus. The MR imaging detection of meniscal tears in
both the lateral and medial compartments combined is significantly poorer in
the presence of chondrocalcinosis (p < 0.005).
CONCLUSION. MR imaging sensitivity and specificity for detection of
meniscal tear is decreased in the presence of meniscal chondrocalcinosis.
Chondrocalcinosis appeared as a high-signal-intensity region on T1-weighted,
intermediate-weighted, and inversion recovery sequences. The high signal of
chondrocalcinosis on inversion recovery sequence is an interesting observation
that to our knowledge has not been previously reported. Radiographic
correlation with the MR imaging examination can help prevent overdiagnosing
meniscal tears.
Introduction
Chondrocalcinosis refers to the calcification in the menisci or articular
cartilage due to the deposition of calcium pyrophosphate dihydrate crystal,
dicalcium phosphate dihydrate, calcium hydroxyapatite crystals, or a
combination of these [1,
2]. Calcium pyrophosphate
dihydrate crystal deposition disease is the most common crystalline
arthropathy [3]. Intraarticular
crystals were first described as weakly positive birefringent nonurate
crystals at polarized light microscopy in the joint fluid of patients who had
goutlike arthritis attacks [4,
5]. Zitnan and Sitaj
[6] first described the
radiographic manifestations of this entity, coining the term
"chondrocalcinosis polyarticularis." Punctate or linear
intraarticular calcifications are seen on the radiographs in classic calcium
pyrophosphate dihydrate crystal deposition disease
[7]. According to Yang et al.
[8], meniscal calcifications
are more frequent than hyaline cartilage calcifications, and meniscal
calcifications are considerably more prevalent in men.
Radiographic characteristics of chondrocalcinosis are well known
[9]. However, descriptions of
the MR appearance of meniscal chondrocalcinosis have been limited
[10]; and to our knowledge, no
MR arthroscopic correlation study has been reported. Articular cartilage
calcifications as seen on MR imaging and arthroscopy were evaluated by Beltran
et al. [11]. However, no
meniscal signal abnormality was noted in that study. The purpose of our study
was to determine whether the presence of radiographically detectable
calcification has an effect on MR imaging in the diagnosis of meniscal
tear.
Materials and Methods
A retrospective review of medical records from two university hospitals for
a 2-year period (1996-1998) identified 70 patients with radiographic evidence
of chondrocalcinosis who had undergone knee MR imaging within 6 months of the
radiographs. Knee pain was the most common indication for these examinations.
Of these patients, 37 (22 men and 15 women; 74 total menisci) underwent
arthroscopic examinations within 1 month of MR imaging; these patients formed
our study group. Their age range was 26-86 years (mean age, 48 years). Our
control group consisted of 34 patients (20 men and 14 women; 68 total menisci)
without radiographic evidence of chondrocalcinosis. These patients (age range,
28-79 years; mean age, 45 years) had undergone knee MR imaging and arthroscopy
for evaluation of knee pain and suspected internal derangement during the same
time (1996-1998). MR imaging interpretations were performed prospectively by
radiologists trained in musculoskeletal radiology. A clinical review of the MR
imaging and arthroscopy reports was performed in each group.
MR images were obtained with a 1.5-T system (General Electric Medical
Systems, Milwaukee, WI) with an extremity coil. The following imaging
sequences were acquired: sagittal and axial spin-echo T1-weighted (TR range/TE
range, 400-750/15-20; matrix size, 256 x 192), intermediate-weighted
(1800-3500/19-40; matrix size, 256 x 192), T2-weighted
(2500-3500/60-80), and inversion recovery (TR/TE, 4000/26 [approximately];
inversion time, 180 msec; matrix size, 256 x 192) sequences were
obtained in 20 patients. The evaluation of meniscal tear was based on
T1-weighted, intermediate-weighted, and T2-weighted sequences.
A cross-tabulation of MR imaging and arthroscopic findings was made for
each knee compartment (37 medial and 37 lateral). A meniscal tear was defined
as a linear region of increased signal within a meniscus communicating with
one of the articular surfaces on more than one image
[12,13,14].
T1-weighted coronal, intermediate-weighted, and T2-weighted spin-echo
sagittal images were used for meniscal assessment. Additional coronal
inversion recovery images were also reviewed (available in 20 patients) but
were not used primarily for the detection of meniscal tears. Correlation was
made with the presence and location of chondrocalcinosis on anteroposterior
and lateral knee radiographs to document whether the abnormal meniscal signal
(tear) occurred in the area of chondrocalcinosis. The sensitivity,
specificity, and accuracy of MR imaging to discover meniscal tears were
calculated for each compartment in the chondrocalcinosis and control
groups.
Results
Of the original 70 patients with meniscal calcification, none showed
articular calcifications on radiographs or MR imaging. As shown in Tables
1 and
2, the accuracy for the MR
imaging detection of meniscal tears in the chondrocalcinosis patients was
significantly lower than in the control group (p < 0.005). As
shown in Table 3, only one
misdiagnosis occurred—a false-negative lateral meniscal tear in the
control group. The patient was among the six judged by arthroscopy to have
medial and lateral tears. MR imaging correctly identified the 19 control
patients with medial meniscal tears and the nine with lateral meniscal
tears.
In the chondrocalcinosis group, two patients had medial and lateral tears
as shown on arthroscopy. All four tears were missed on MR imaging
(false-negative). Sixteen patients had a medial tear only. None of these were
missed on MR imaging. Seven patients had a lateral tear only. None of these
were missed on MR imaging. Among the 37 patients, 12 did not have a tear (as
judged by arthroscopy). All 12 of these were misdiagnosed (false-positive) on
MR imaging. These tears were equally divided between medial and lateral
compartments. In summary, 14 (38%) of the 37 patients with chondrocalcinosis
were misdiagnosed by MR imaging. The 95% confidence limit for this proportion
is 22-55%.
The accuracy of MR imaging in the detection of meniscal tears in patients
with chondrocalcinosis is 23 (62%) of 37, with 95% confidence limits of
45-78%.
Individuals with chondrocalcinosis and meniscal tear on arthroscopy showed
a hyperintense intermediate-weighted, T1-weighted, and T2-weighted inversion
recovery intrameniscal signal, always extending to at least one articular
surface. Individuals with chondrocalcinosis
(Fig. 1A) and false-positive
meniscal tear (positive MR imaging, negative arthroscopy) showed similar
meniscal signal abnormalities (Figs.
1B,
1C, and
1D), as described earlier,
reaching to at least one articular surface. Of the false-positive meniscal
tears, only one showed arthroscopic evidence of minimal fraying. The presence
of chondrocalcinosis was seen on a knee radiograph
(Fig. 2A) in another patient
with false-positive meniscal tear (positive MR imaging, negative arthroscopy).
The MR imaging was compatible with a lateral meniscal tear (Figs.
2B,
2C, and
2D). Hyperintense meniscal
signal was noted on T2-weighted (Fig.
2E) and inversion recovery
(Fig. 2F) sequences. No
meniscal tear was detected on arthroscopy.
View larger version (133K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B. —48-year-old man who presented with knee pain. Sagittal
T1-weighted spin-echo MR image (TR/TE, 500/20) shows high signal intensity in
lateral meniscus with extension to superior articular surface (anterior horn)
and inferior articular surface (posterior horn), interpreted as meniscal tear
(arrows). No meniscal tear was found on arthroscopy.
|
|
View larger version (71K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C. —48-year-old man who presented with knee pain. Coronal
T1-weighted spin-echo MR image (550/20) shows central high-signal-intensity
region in lateral meniscus (arrow) extending to inferior articular
surface, suggestive of meniscal tear.
|
|
View larger version (152K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2A. —64-year-old man who was evaluated for knee pain.
Anteroposterior knee radiograph shows significant lateral meniscal
calcifications (arrow). Moderate medial compartment osteoarthritis is
also seen.
|
|
View larger version (179K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2C. —64-year-old man who was evaluated for knee pain. Sagittal
intermediate-weighted MR image (2300/20) shows high-signal-intensity region in
lateral meniscus body extending to inferior articular surface
(arrow).
|
|
View larger version (161K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2D. —64-year-old man who was evaluated for knee pain. Sagittal
intermediate-weighted MR image (2300/20) shows high signal intensity in
lateral meniscus posterior horn extending to superior articular surface
(arrow).
|
|
View larger version (205K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2E. —64-year-old man who was evaluated for knee pain. Sagittal
T2-weighted MR image (2300/80) shows hyperintense signal in lateral meniscus
posterior horn (arrow) corresponding to abnormalities in
A-D.
|
|
Discussion
The prevalence of chondrocalcinosis is reported to be 5.0-14.6% and
increases with age [15,
16]. In one study
[15], chondrocalcinosis was
seen on radiographs in 9.6% of patients 50 years old or older. In Spain,
Sanmarti et al. [16] reported
an estimated prevalence of chondrocalcinosis of 10%. Yang et al.
[8] found meniscal
calcifications to be more frequent than hyaline cartilage calcifications. A
multitude of conditions and mechanisms are implicated in the pathogenesis of
chondrocalcinosis [17,
18]. In our patients, the
radiographic appearance of meniscal calcification was the same regardless of
the causes of the chondrocalcinosis.
Our results show decreased sensitivity, specificity, and accuracy of MR
imaging for diagnosing meniscal tear in the presence of chondrocalcinosis.
Twelve (32%) of the 37 patients with radiographic evidence of
chondrocalcinosis had an MR imaging diagnosis of meniscal tear that was not
confirmed at arthroscopy. No false-positive tears were found in the control
group of patients without chondrocalcinosis. An increased number of
false-positives for meniscal tear in the chondrocalcinosis group resulted from
the MR imaging appearance of high meniscal signal reaching the articular
surface.
Confirmed meniscal tears were more common in the medial meniscus
[19]. However, this may be a
result of the small number of lateral meniscal tears. Although the total
number of false-negative meniscal tears was lower than false-positive meniscal
tears in the chondrocalcinosis group, a false-negative MR imaging result for
meniscal tear has more serious implications than a false-positive result. It
is possible that a large area of meniscal signal abnormality as a result of
chondrocalcinosis decreases the sensitivity to detect abnormal signal
extension to the meniscal surface, thus obscuring the diagnosis of a meniscal
tear on MR imaging in false-negative cases. The diagnostic accuracy of MR
imaging for meniscal tears in both compartments (medial and lateral) was
affected by the presence of chondrocalcinosis. MR imaging sensitivity and
specificity for meniscal tear detection in the control group were within the
previously reported range
[20].
Although calcifications are typically of low signal on all MR imaging pulse
sequences, descriptions of high-signal-intensity calcium deposits in the brain
[21,
22] and lumbar intervertebral
disks [23] have been reported.
Beltran et al. [11] described
articular cartilage calcifications on spin-echo intermediate-weighted,
T2-weighted, inversion recovery, and T2-weighted gradient-recalled echo
sequences as hypointense foci with a surrounding hyperintense halo, thought to
be a result of magnetic susceptibility artifact. No meniscal calcifications
were noted in that study. In another report
[9], a hyperintense meniscal
signal abnormality on intermediate-weighted, T1-weighted, and T2-weighted
sequences in a patient with chondrocalcinosis, initially suspected to be a
meniscal tear, was not found on subsequent arthroscopy. Eustace et al.
[24] described linear high
signal intensity in the meniscus on MR imaging in a patient with
hemochromatosis and radiographic evidence of chondrocalcinosis. However, in
this patient, the abnormal meniscal signal did not extend to the articular
surface. Only one previous abstract
[25] has reported high
intrameniscal T2-weighted spin-echo signal in the presence of
chondrocalcinosis.
No single theory has satisfactorily explained the cause of high signal
intensity related to calcifications on certain MR imaging sequences. Increased
T1- and T2-weighted MR imaging intervertebral disk signal in the presence of
calcifications on radiography has been thought to be caused by the
concentration of the calcium crystals
[21]. Henkelman et al.
[22] found high MR imaging
signal on T1-weighted images to be associated with T1 shortening due to
calcified crystals.
In our study, high intrameniscal inversion recovery signal (Figs.
1E and
2F) corresponded to the
hyperintense intermediate-weighted, T1-weighted, and T2-weighted meniscal
signal in individuals with radiographic evidence of chondrocalcinosis. It did
not show the "halo" type of hyperintense signal that has been
described previously in the literature
[11].
View larger version (149K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1E. —48-year-old man who presented with knee pain. Coronal
inversion recovery MR image (4250/19; inversion time, 180 msec) shows central
high-signal-intensity area in lateral meniscus (arrow), corresponding
to high signal in figures B and C, and chondrocalcinosis in
A.
|
|
Our results show the confounding effect that chondrocalcinosis has on the
MR imaging diagnosis of meniscal tear. These results reinforce the need for
correlation of MR imaging with radiography to avoid errors in diagnosing
meniscal tears. Radiologists must be aware of this potential pitfall and know
that they can benefit from radiographic correlation.
References
-
Jensen PS. Chondrocalcinosis and other calcifications.
Radiol Clin North Am
1988;26:1315
-1325[Medline]
-
Villiaumey J, Avouac B. Role of radiology in the diagnosis of joint
chondrocalcinosis: the so-called atypical symptomatic aspects. J
Radiol 1994;75:339
-361[Medline]
-
Brower AC, Flemming DJ. Arthritis in black and
white, 2nd ed. Philadelphia: Saunders, 1997:343
-
McCarthy DJ, Hollander JL. Identification of urate crystals in
gouty synovial fluid. Ann Intern Med
1961;54:452
-460
-
McCarthy DJ, Kohn NN, Fairs JS. The significance of calcium
pyrophosphate crystals in the synovial fluid of arthritis patients: the
"pseudogout" syndrome. Ann Intern Med
1962;56:711
-737
-
Zitnan D, Sitaj S. Chondrocalcinosis articularis: clinical and
radiological study. Ann Rheum Dis
1963;22:142
-
El-Khoury GY, Foucar E, Blair WF, Strottman MP, Malvitz TA, Smoker
WRK. Case report 364: massive calcium pyrophosphate dihydrate crystal
deposition disorder (MCPDD) involving thumb. Skeletal
Radiol 1986;15:312
-315
-
Yang BY, Sartoris DJ, Resnick D, Clopton P. Calcium pyrophosphate
dihydrate deposition disease: frequency of tendon calcification about the
knee. J Rheumatol
1996;23:883
-888[Medline]
-
Resnick D, Niwayama G, Georgen T, et al. Clinical, radiographic and
pathologic abnormalities in calcium pyrophosphate dihydrate deposition disease
(CPPD) pseudogout. Radiology
1977;122:1
-15[Abstract]
-
Burke BJ, Escobedo EM, Wilson AJ, Hunter JC. Chondrocalcinosis
mimicking a meniscal tear on MR imaging. AJR
1998;170:69
-70[Free Full Text]
-
Beltran J, Marty-Delfaut E, Bencardino J, et al. Chondrocalcinosis
of the hyaline cartilage of the knee: MR imaging manifestations.
Skeletal Radiol
1998;27:369
-374[Medline]
-
Stoller DW, Martin C, Crues JV III, Kaplan L, Mink JH. Meniscal
tears: pathologic correlation with MR imaging.
Radiology
1987;163:731
-735[Abstract/Free Full Text]
-
Munk PL, Helms CA, Genant HK, Holt RH. MR imaging of the knee:
current status, new directions. Skeletal Radiol
1989;18:569
-577[Medline]
-
DeSmet AA, Norris MA, Yandow DR, Quintana FA, Graf BK, Keene JS. MR
diagnosis of meniscal tears of the knee: importance of high signal in the
meniscus that extends to the surface. AJR
1993;161:101
-107[Abstract/Free Full Text]
-
Ellman MH, Brown NL, Levin B. Prevalence of knee chondrocalcinosis
in hospital and clinic patients aged 50 or older. J Am Geriatr
Soc 1981;29:189
-192[Medline]
-
Sanmarti R, Panella D, Brancos MA, Canela J, Collado A, Brugues J.
Prevalence of articular chondrocalcinosis in elderly subjects in a rural area
of Catalonia. Ann Rheum Dis
1993;52:418
-422[Abstract/Free Full Text]
-
Nyulassy S, Stefanovic J, Sitaj S, Zitnan D. HLA system in
articular chondrocalcinosis. Arthritis Rheum
1976;200:1
-9
-
Steinbach LS, Resnick D. Calcium pyrophosphate dihydrate crystal
deposition disease revisited. Radiology
1996;200:1
-9[Free Full Text]
-
Baker BE, Peckham AC, Pupparo F, Sanborn JC. Review of meniscal
injury and associated sports. Am J Sports Med
1985;13:1
-4[Abstract/Free Full Text]
-
Muellner T, Weinstabi R, Schabus R, Vecsei V, Kainberger F. The
diagnosis of meniscal tears in athletes: a comparison of clinical and magnetic
resonance imaging investigations. Am J Sports Med
1997;25:7
-12[Abstract/Free Full Text]
-
Dell L, Brown M, Orrison W, Eckel C, Matwiyoff N. Physiologic
intracranial calcifications with hyperintensity on MR imaging: case report and
experimental models. AJR
1988;9:1145
-1148
-
Henkelman R, Watts J, Kucharczyk W. High signal intensity in MR
images of calcified brain tissue. Radiology
1991;179:199
-206[Abstract/Free Full Text]
-
Major NM, Helms CA, Genant HK. Calcification demonstrated as high
signal intensity on T1-weighted MR images of the disks of the lumbar spine.
Radiology
1993;189:494
-496[Abstract/Free Full Text]
-
Eustace S, Buff B, McCarthy C, MacMathuana P, Gilligan P, Ennis J.
Magnetic resonance imaging of hemochromatosis arthropathy. Skeletal
Radiol 1994;23:547
-549[Medline]
-
Gale DR, Gianturco LE, Gale ME, Totterman M. MR characteristics of
chondrocalcinosis of the knee. (abstr) Radiology
1996;201:332
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
C. A. Helms
The Meniscus: Recent Advances in MR Imaging of the Knee
Am. J. Roentgenol.,
November 1, 2002;
179(5):
1115 - 1122.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
