MRI PROCEDURE OF KNEE AND ANKLE JOINT

1. MRI PROCEDURE OF KNEE AND
ANKLE
Presenter :Sujan Karki
B.Sc. MIT 3RD Year
National Academy of Medical Sciences, Bir Hospital

2. WHY MRI ?????

3. Knee joint
• Complex hinge joint
• Formed by the two articulations
Patellofemoral(plane joint)
Tibiofemoral(synovial hinge
joint)
Largest and the most
stressed joint in the body.

4. Anterior Cruciate Ligament
• Origin : medial wall of lateral femoral
condyle
• Insertion: medial tibial condyle.
• Most commonly injured ligament.
• It should be stretched and should be
parallel to the intercondylar notch.
• ACL resist anterior translation and medial
rotation of the tibia .
• ACL injury occurs when bones of leg
twist in opposite directions under full
body weight.

5. Posterior Cruciate Ligament
• Origin: anterolateral aspect of medial femoral
condyle
• Insertion :posterior aspect of tibial plateau.
• Less commonly injured in comparison to ACL
• serves primarily to resist excessive posterior
translation of the tibia relative to the femur.
• PCL injury occurs due to the direct blow to the
knee while it is flexed.
Meniscofemoral ligaments

6. Ligaments of knee joint

7. Medial and lateral retinaculum ligaments

8. Coronary Ligaments
• Connects the periphery of
the meniscus to the tibia .
• They are the portion of
the capsule that is
stressed in rotary
movements of the knee

9. Bursae
• Bursae are extension of the
synovial membrane between
different anatomic structure.
• reduce friction between adjacent
moving structures
• As many as 13 bursae have been
described around knee joint.
• Four are anterior
• Four are lateral
• Five are medial

10. Fat Pads
• 3 fat pads are found in knee joint.
• Fat pads act as cushions, distributing your body
weight, absorbing shock, and protecting your bones
and joints.
• Fat pad are oblirated by inflammation
• Fat pad are displaced by tumors and masses

11. Meniscus
• Crescent shaped fibrocartilages.
• Wedge shaped on cross section
• Flexion and extension takes place at
the upper surface of the menisci
• Rotation occurs between the lower
surface of the menisci and the tibia

15. Ligament tear

16. Meniscal disorder (nondisplaced and displaced tears,
meniscal cysts)

17. Synovial based disorders (synovitis, bursitis, popliteal
cysts)

18. Congenital abnormalities (Agenesia, Blount disease,
Dysplasia)

19. Avulsion Fracture of the Intercondylar Eminence
• Excessive tension on ACL may result in an
interarticular avulsion fracture of the
intercondylar eminence of the tibia.
• In adults, the fracture most commonly
occurs secondary to an extreme
hyperextension.
• The role of MRI is to confirm the fracture
and to evaluate the ACL since partial or
complete tear of ACL is often associated
with this type of fracture

20. Marrow abnormalities (avascular necrosis, marrow
edema, stress fractures)

21. Muscle and tendon disorders (strains, partial and
complete tears, tendinitis)

22. Patient preparation
• Have the patient to micturate before the study
• Explain the procedure to the patient
• Offer the patient ear protectors or ear plugs
• Ask the patient to undress and offer hospital gown
• Ask the patient to remove anything containing metal (hearing aids, hairpins,
body jewelry, watch, etc.)
• Ask the patient about metallic implants , pacemaker ,denture etc.
• If possible ask pt., for previous radiographs

23. Patient Positioning
• Supine, feet first with leg extended.
• Place the knee coil straight at the center of the MR table.
• Position the knee in the knee coil and immobilize with
cushions.
• 10–15° external rotation to bring lateral femoral condyle
parallel to sagittal plane and demonstrate anterior cruciate
ligament.
• Give cushions under the ankle for extra comfort.
• Centre the laser beam localizer over the lower border of patella.
• Incase of any small palpable mass, vitamin E capsule may be
used as marker.

24. Contraindications
• Any electrically, magnetically, or mechanically activated implant (eg;
cardiac pacemaker, cochlear implant, insulin pump etc.)
• Pregnancy (risk VS benefit ratio to be assessed)
• Metallic foreign body in eye.
• Intracranial aneurysm clips .

25. Localizer image

26. AXIAL PLANNING(T2 axial)
• CORONAL : ANGLE THE POSITION BLOCK PARALLEL TO THE FEMORAL
CONDYLES.
• SAGITTAL : PERPENDICULAR TO THE LINE OF FEMUR AND TIBIA
• AXIAL : COVER THE KNEE JOINT
TR TE FA SL SG MATRIX PHASE NXA
4000-
5000
110 90 5 10% 324X360 L-R

27. CORONAL PLANNING(T2 coronal)
• AXIAL : POSITION BLOCK PARALLEL TO THE FEMORAL CONDYLES.
• SAGITTAL : PARALLEL TO THE MIDLINE OF FEMUR AND TIBIA
• CORONAL : COVER THE KNEE JOINT
TR TE FA SL SG MATRIX NXA
4500-5000 108 90 4 10% 384X384

28. CORONAL PLANNING(T2 STIR coronal)
• AXIAL : POSITION BLOCK PARALLEL TO THE FEMORAL
CONDYLES.
• SAGITTAL : PARALLEL TO THE MIDLINE OF FEMUR AND TIBIA
• CORONAL : COVER THE KNEE JOINT
TR TE FA SL SG MATRI
X
PHASE NXA
5500-
6000
108 90 4 10% 216X216 H-F

29. SAGITTAL PLANNING( T1)
• AXIAL : POSITION BLOCK PARALLEL TO THE ANTERIOR CRUCIATE
LIGAMENT.
• CORONAL : PARALLEL TO THE MIDLINE OF FEMUR AND TIBIA
• SAGITTAL : COVER THE KNEE JOINT
TR TE FA SL SG MATRI
X
PHASE NXA
360 20 90 5 10% 384X38
4
H-F

30. SAGITTAL PLANNING( T2)
• AXIAL : POSITION BLOCK PARALLEL TO THE ANTERIOR
CRUCIATE LIGAMENT.
• CORONAL : PARALLEL TO THE MIDLINE OF FEMUR AND TIBIA
• SAGITTAL : COVER THE KNEE JOINT
TR TE FA SL SG MATRIX PHASE NXA
4500-5000 108 90 5 10% 384X384 H-F

31. SAGITTAL PLANNING( PD)
• AXIAL : POSITION BLOCK PARALLEL TO THE ANTERIOR CRUCIATE
LIGAMENT.
• CORONAL : PARALLEL TO THE MIDLINE OF FEMUR AND TIBIA
• SAGITTAL : COVER THE KNEE JOINT
TR TE FA SL SG MATRIX PHASE NXA
1800 19 90 5 10% 334X334 H-F

32. Kinematic(dynamic imaging) imaging
• A real time gradient echo sequence depicts
functional details during motion.
• Muhle et al. showed dynamic MRI was
significantly better than static imaging for the
demonstration of patellar tilt angle, particularly at
the critical angle of patellar instability between 30
degree and o degree flexion.
• Appropriate and customized patient setup and coil
installation inside the MR bore are functional for
the exploration of joint motion.
• Generally balanced steady state free precession,
RF spoiled sequences and ultrafast gradient echo
sequences are used.

34. ANKLE JOINT

35. CHOPART AND LISFRANC JOINT

36. Tendons in ankle joint

38. Ligaments in ankle joint( Lateral Collateral Ligaments)

39. Medial collateral ligament (deltoid ligament)

40. Syndesmotic ligaments

41. INDICATIONS
• Tendons – tears, tenosynovitis
• Masses – soft tissue, osseous
• Bone pathology – occult fracture, OCL, infections, tumors.

42. Tendons – tears, tenosynovitis

43. Masses – soft tissue, osseous

44. Bone pathology – occult fracture, OCL,
infections, tumors.

45. Patient positioning
• Supine with feet first, and ankle in neutral position or
mid plantar flexion (for fore foot ,prone with foot in
plantar flexion)
• Custom cushioned inserts can be used to keep the
heel immobilized and centered in the coil
• a marker is placed over the sight of maximal
tenderness or near a non healing ulcer
• vitamin E or docusate sodium (Colace) are often used

46. • Type of coil: extremity coil use a dedicated foot and ankle coil that
incorporates a chimney-like extension so that the toes can be included
in the FOV
• Topogram position center of coil
• Mode of scaning:2D or 3D
• Scout :T1 axial
• Slice thickness : 2-4 mm
• Slice interval: 0-0.5
• Contrast administration :nil

47. Localizer

48. AXIAL PLANNING (PD TSE AXIAL 4mm)
• CORONAL : POSITION THE BLOCK PARALLEL TO THE MORTISE JOINT
• SAGITTAL: PLACE THE BLOCK PARALLEL TO THE JOINT
• AXIAL : COVER THE ANKLE JOINT FROM 4 SLICE ABOVE THE
TIBIOTALAR JOINT TO THE PLANTER ASPECT OF FOOT
TR TE FATSAT SL SG MATRI
X
FOV PHASE NXA
3000-
4000
15-20 OFF 4 10% 320X256 150-170 A-P 2

49. AXIAL PLANNING(T2 STIR AXIAL 4mm)
• CORONAL : POSITION THE BLOCK PARALLEL TO THE MORTISE
JOINT
• SAGITTAL: PLACE THE BLOCK PARALLEL TO THE JOINT
• AXIAL : COVER THE ANKLE JOINT FROM 4 SLICE ABOVE THE
TIBIOTALAR JOINT TO THE PLANTER ASPECT OF FOOT
TR TE FA SL SG MATRI
X
TI PHASE NXA
4000-
5000
110 130 4 10% 256X256 130 R-L 2

50. SAGITTAL PLANNING (T1 SAGITTAL 3mm)
• AXIAL: POSITION THE BLOCK PARALLEL TO MEDIAL AND LATERAL
MALLEOLUS.
• CORONAL : PLACE THE BLOCK PARALLEL TO TIBIA
• SAGITTAL: COVER THE ANKLE JOINT FROM OUTER BORDER OF
MEDIAL MALLEOLUS TO OUTER BORDER OF LATERAL MALLEOLUS.
TR TE FA SL SG MATRI
X
FOV PHASE NXA
400-600 15-25 150 4 10% 320X32
0
160-170 A-P 2

51. SAGITTAL PLANNING (T2 STIR SAGITTAL 4mm)
• AXIAL: POSITION THE BLOCK PARALLEL TO MEDIALAND LATERAL
MALLEOLUS.
• CORONAL : PLACE THE BLOCK PARALLEL TO TIBIA
• SAGITTAL: COVER THE ANKLE JOINT FROM OUTER BORDER OF MEDIAL
MALLEOLUS TO OUTER BORDER OF LATERAL MALLEOLUS.
TR TE FA SL SG MATRIX FOV TI PHASE NXA
4000-
5000
110 130 4 10% 256X256 150-170 130 A-P 2

52. CORONAL PLANNING( PD FATSAT CORONAL 4mm)
AXIAL: PLACE THE BLOCK PERPENDICULAR TO THE MEDIAL AND
LATERAL MALLEOLUS.
SAGITTAL: POSITION THE BLOCK PARALLEL TO THE TIBIA.
CORONAL: COVER THE ANKLE JOINT FROM ACHILLES TENDON TO
MIDFOOT.
TR TE SL SG FATSAT FOV MATRIX PHASE NXA
3000-4000 15-20 4 10% ON 160-170 320X320 A-P 2

53. MAGIC ANGLE ARTEFECT
• when collagen is oriented at 55° to the main
magnetic field, resulting in a prolongation of T2
relaxation time.
• Magic angle effect is particularly notable with
short TE sequences such as T1-weighted, proton
density-weighted, or T2*-weighted (which is based
on a gradient-recalled echo sequence using a low
flip angle) sequences
• Magic angle effect can be avoided by using a long
TE. Therefore, if magic angle effect is seen in T2*-
weighted images, it can be eliminated by using SE
sequences with a long TE or T2-weighted FSE
sequences

54. Sinus Tarsi Syndrome
• Fat
• Nerve
• Vessels
• Ligaments
cervical ligament
interosseous ligament

55. Tarsal Coalition
• complete or partial union between two or
more bones in the midfoot and hindfoot.
• Most subtype are talocalcaneal and
calcaneonavicular.

56. BIR HOSPITAL KNEE AND ANKLE PROTOCOL
• PDW SPAIR sagittal
• PDW SPAIR axial
• PDW SPAIR coronal
• T1 TSE sagittal
• T2 coronal
Post contrast
• T1 FS axial
• T1 FS coronal
• T1 FS sagittal
 T1 W SAGITTAL
 PDW FATSUPPRESSED SAGITTAL
 PDW FATSUPPRESSED CORONAL
 T2W TSE CORONAL
 PDW FATSUPPRESSED AXIAL
 T2W TSE AXIAL
 T1W TSE AXIAL

57. References
• POSTERIOR CRUCIATE LIGAMENT INJUR by Dr Chang Haw Chong on
July 1, 2010
• MarGarry E. Gold,1 Christina A. Chen1 Seungbum Koo,2 Brian
Hargreaves,1 and Neal K. Bangerter Recent Advances in MRI of Articular Cartilage
• Garetier et.al Dynamic MRI for articulating joint evaluation on 1.5 T and 3.0 T
scanners: setup, protocols, and real-time sequences.
• CT and MRI of the whole body by JR Haaga
• MRI Parameters
• MRI Masters
• Handbook of MRI
• Radiology key

59. Questions for discussion
• Why do you think proton density weighted sequence in important in
musculoskeletal system?
• Although ligaments are seen in all three plains, which plane is best for
the visualization of major types of knee ligaments?
• What are the tendons of ankle joint ?
• What do you understand by chopart’s and Lisfranc joint ?