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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
J Magn Reson Imaging. Author manuscript; available in PMC 2011 April 1.
Published in final edited form as:
PMCID: PMC3069719
NIHMSID: NIHMS281234

ROUTINE THREE-DIMENSIONAL MAGNETIC RESONANCE IMAGING OF JOINTS

Richard Kijowki, M.D.1,3 and Garry E. Gold, M.D2

Abstract

Due to its high spatial resolution and excellent tissue contrast, magnetic resonance (MR) imaging has become the most commonly used imaging method to evaluate joints. Most musculoskeletal MR imaging is performed using two-dimensional fast spin-echo sequences. However, three-dimensional sequences have also been used for joint imaging and have the advantage of acquiring thin continuous slices through joints which reduces the effects of partial volume averaging. With recent advances in MR technology, three-dimensional sequences with isotropic resolution have been developed. These sequences allow high quality multi-planar reformat images to be obtained following a single acquisition, thereby eliminating the need to repeat sequences with identical tissue contrast in different planes. Preliminary results on the diagnostic performance of three-dimensional isotropic resolution sequences are encouraging. However, additional studies are needed to determine whether these sequences can replace currently used two-dimensional fast spin-echo sequences for providing comprehensive joint assessment in clinical practice.

Keywords: MRI, three-dimensional, isotropic resolution, musculoskeletal

Introduction

Magnetic resonance (MR) imaging is one of the most widely used imaging modality to evaluate patients with joint pain in clinical practice. Musculoskeletal MR protocols used at most institutions consist of two-dimensional fast spin-echo sequences repeated in multiple planes. These sequences have excellent tissue contrast and high in-plane spatial resolution. However, they have relatively thick slices and small gaps between slices which can obscure pathology secondary to partial volume averaging. Three-dimensional sequences can reduce partial volume averaging by acquiring thin, continuous slices through joints. Three-dimensional sequences can also be used to create multi-planar reformat images which allow joints to be evaluated in any orientation following a single acquisition. This article will review the clinical applications of three-dimensional sequences for musculoskeletal MR imaging.

Knee Joint Imaging

Cartilage Imaging

Three-dimensional sequences are most commonly used in clinical practice to evaluate the articular cartilage of the knee joint. Gradient-echo sequences were the first three-dimensional sequences used for cartilage imaging. Gradient-echo sequences can be divided into dark fluid sequences and bright fluid sequences based upon the signal intensity of synovial fluid. Dark fluid sequences include T1-weighted spoiled gradient recalled-echo (SPGR, GE Healthcare), fast low angle shot (FLASH, Siemens Medical System), and T1-fast field echo (T1-FFE, Philips Healthcare). Bright fluid sequences include T2*-weighted gradient recalled-echo acquired in the steady-state (GRASS, GE Healthcare), gradient recalled-echo (GRE, Siemens Medical System), and fast field-echo (FFE, Philips Healthcare). Fat suppression is typically added to gradient-echo sequences to reduce chemical shift artifact and to optimize the overall dynamic contrast range of the image. Frequency selective fat-saturation is the most commonly used method to suppress fat signal (14). However, gradient-echo images with higher cartilage signal-to-noise ratio (SNR) and higher contrast between cartilage and adjacent joint structures can be obtained using recently developed fat-suppression techniques such as water excitation (5, 6) and iterative decomposition of water and fat with echo asymmetry and least squares estimates (IDEAL) (79).

Dual-echo in the steady-state (DESS) and driven equilibrium fourrier transform (DEFT) are additional three-dimensional sequences which have been used to evaluate the articular cartilage of the knee joint. The DESS sequence acquires two gradient echoes separated by a refocusing pulse which are combined into a single image. Adding the two echoes enhances the T2*-weighting of the image and increases the signal intensity of both cartilage and synovial fluid (10). The DEFT sequence uses a −90 degrees tip-up pulse to return transverse magnetization to the z-axis which increases the signal intensity of synovial fluid and other tissues with long T1 relaxation times (1113). The DESS and DEFT sequences produce images of the knee joint with bright synovial fluid which creates an arthrogram-like effect that may increase the conspicuity of superficial cartilage lesions. A water excitation DESS sequence with 0.4 mm × 0.5 mm in-plane spatial resolution and 0.7 mm slice thickness is currently being used in the Osteoarthritis Initiative to provide detailed cartilage assessment (14).

Balanced steady-state free-precession (SSFP) sequences have also been used to evaluate the articular cartilage of the knee joint. Balanced SSFP sequences include commercially available sequences such as fast imaging employing steady-state acquisition (FIESTA, GE Healthcare), true fast imaging with steady-state precession (true-FISP, Siemens Medical Systems), and balanced fast-field echo imaging (balanced-FFE, Philips Healthcare) and variants such as fluctuating equilibrium magnetic resonance (FEMR) (15) and vastly undersampled isotropic projection steady-state free-precession (VIPR-SSFP) (16). Balanced SSFP sequences can be combined with various methods of fat-suppression such as water excitation (17), linear combination (18), intermittent frequency selective fat-saturation (19), phase detection (20), and IDEAL (21). These sequences produce images of the knee joint with T2/T1-weighted contrast and bright synovial fluid. Balanced SSFP sequences and their variants have higher cartilage SNR and higher contrast between cartilage and adjacent joint structures than two dimensional fast spin-echo and three-dimensional fat-saturated SPGR sequences (15, 2224). When combined with highly SNR efficient VIPR radial k-space trajectory and alternating repetition time fat-water separation, balanced SSFP images of the knee joint with 0.3 mm isotropic resolution can be obtained in as little as 8 minutes (Figure 1).

Figure 1
44 year old male volunteer with knee pain who was imaged at 3.0T. (a) Sagittal and (b) coronal balanced SSFP reformat images (0.3 mm isotropic resolution and 8 minute scan time) of the knee with VIPR radial k-space trajectory and alternating repetition ...

Recently, three-dimensional fast spin-echo sequences such as fast spin-echo Cube (FSE-Cube, GE Healthcare) (25) and sampling perfection with application oriented contrasts using different flip angle evolutions (SPACE, Siemens Medical System) (26) have become available for evaluating the articular cartilage of the knee joint. These sequences utilize long echo trains and parallel imaging to reduce scan time. Variable flip angle modulation is used to constrain T2 decay over an extended echo train which allows intermediate-weighted images of the knee joint to be acquired with minimal blurring. Three-dimensional fast spin-echo sequences have higher cartilage SNR but lower contrast between cartilage and synovial fluid when compared to two-dimensional fast spin-echo sequences (25, 26). Three-dimensional fast spin-echo sequences acquire volumetric datasets with isotropic resolution which allow articular cartilage to be evaluated in any orientation following a single acquisition. However, these sequences have lower in-plane spatial resolution when compared to other three-dimensional cartilage imaging sequences with similar acquisition times and have reduced magnetization transfer effect when compared to two-dimensional fast spin-echo sequences. Both factors may potentially reduce the conspicuity of superficial cartilage lesions.

Multiple studies with surgical correlation have evaluated the diagnostic performance of three-dimensional sequences for detecting cartilage lesions within the knee joint (3, 12, 2733). The results of these studies are summarized in Table 1. On 1.5T imaging systems, three-dimensional sequences have sensitivity values ranging between 85% for fat-saturated SPGR to 45% for water excitation true FISP with specificity values ranging between 78% and 97%. On 3.0T imaging systems, three-dimensional sequences have sensitivity values ranging between 66% for IDEAL-GRASS to 73% for fat-saturated intermediate-weighted FSE-Cube with specificity values ranging between 89% and 94%.

Table 1
Diagnostic performance of three-dimensional sequences for detecting cartilage lesions with the knee joint in clinical studies with arthroscopic correlation.

Only one previous study has directly compared various three-dimensional sequences for evaluating the articular cartilage of the knee joint. Duc and associates found similar sensitivity and specificity values for water excitation FLASH, water excitation DESS, and water excitation true FISP sequences for detecting surgically confirmed cartilage lesions in 30 patients at 1.5T (28). Additional studies with surgical correlation are needed to determine which three-dimensional sequence is best suited for evaluating the articular cartilage of the knee joint in clinical practice (Figure 2).

Figure 2
38 year old female volunteer with knee pain who was imaged at 3.0T. Corresponding sagittal (a) IDEAL-SPGR (0.4 mm × 0.6 mm × 1.0 mm resolution and 5 minute scan time), (b) IDEAL-GRASS (0.4 mm × 0.6 mm × 1.0 mm resolution ...

Comprehensive Joint Assessment

There has been much recent interest in developing three-dimensional sequences with isotropic resolution to provide comprehensive knee joint assessment. Current knee MR protocols are time consuming and typically consist of two-dimensional fast spin-echo sequences repeated in multiple planes. Three-dimensional sequences with isotropic resolution allow high quality multi-planar reformat images to be obtained following a single acquisition, thereby eliminating the need to repeat sequences with identical tissue contrast in different planes.

The use of three-dimensional isotropic resolution sequences in clinical practice could significantly decrease MR examination times which would improve patient comfort, reduce motion artifact, and increase the clinical efficiency of the MR scanner. The use of three-dimensional isotropic resolution sequences in musculoskeletal MR imaging has been limited by their long acquisition and post-processing times (34, 35). However, with the development of more SNR efficient imaging techniques and the availability of high-performance MR workstations, evaluating the knee joint using three-dimensional isotropic resolution sequences has become clinically feasible. Until recently, most three-dimensional sequences with isotropic resolution described in the literature were balanced SSFP sequences (30, 31, 34, 35). However, three-dimensional isotropic resolution fast spin-echo sequences have now been developed and are commercially available on many MR vendor platforms (25, 26, 32, 36, 37).

Two previous studies have shown that three-dimensional isotropic resolution balanced SSFP sequences can be used to provide rapid comprehensive knee joint assessment at 1.5T. In a preliminary study performed on 30 patients with surgical correlation, Duc and associated found that a 0.6 mm isotropic resolution water excitation true-FISP sequence with an acquisition time of 3:11 minutes had similar sensitivity and specificity as a routine MR protocol for detecting cartilage lesions, cruciate ligament tears, and meniscal tears (30). However, a larger study performed by Kijowski and associates on 95 patients with surgical correlation described potential limitations of the T2/T1-weighted tissue contrast of balanced SSFP sequences. In this study, a 0.5 mm isotropic resolution VIPR-SSFP sequence with an acquisition time of 5 minutes was found to have similar sensitivity and specificity as a routine MR protocol for detecting cartilage lesions, cruciate ligament tears, collateral ligament tears, and medial meniscal tears but significantly lower (p<0.05) sensitivity for detecting lateral meniscal tears and bone marrow edema lesions (Figure 3) (31).

Figure 3
19 year old male patient with a surgically confirmed anterior cruciate ligament tear and posterior horn lateral meniscal tear who was imaged at 1.5T. (a) Sagittal two-dimensional fat-saturated T2-weighted fast spin-echo image and (b) corresponding sagittal ...

Multiple recent studies have also shown that three-dimensional isotropic resolution fast spin-echo sequences can be used to provide rapid comprehensive knee joint assessment at 3.0T. Kijowski and associated compared a 0.7 mm isotropic resolution fat-saturated intermediate-weighted FSE-Cube sequence with an acquisition time of 5 minutes and a routine MR protocol for evaluating the knee joint in 100 patients with surgical correlation. FSE-Cube was found to have similar sensitivity and specificity as the routine MR protocol for detecting cartilage lesions, cruciate ligament tears, collateral ligament tears, meniscal tears, and bone marrow edema lesions (Figure 4). (32). Jung and associates also found that a 0.5 mm isotropic resolution intermediate-weighted fast spin-echo sequence with a 10 minute acquisition time had similar sensitivity and specificity as a routine MR protocol for detecting surgically confirmed cruciate ligament and meniscal tears in 85 patients (37). In another study performed by Notohamiprodjo and associates on 18 patients with surgical correlation, a 0.4 mm isotropic resolution fat-saturated intermediate-weighted SPACE sequence with an acquisition time of 10:35 minutes had similar sensitivity and specificity as a routine MR protocol for detecting cartilage lesions and meniscal tears (26).

Figure 4
23 year old male patient with a surgically confirmed anterior cruciate ligament tear and posterior horn medial meniscal tear who was imaged at 3.0T. (a) Sagittal two-dimensional fat-saturated T2-weighted fast spin-echo image and (b) corresponding sagittal ...

Preliminary results on the diagnostic performance of three-dimensional isotropic resolution fast spin-echo sequences are encouraging. However, a study performed by Ristow and associates described potential limitations of these sequences for evaluating the knee joint. In a detailed subjective comparison performed by three musculoskeletal radiologists, a 0.7 mm isotropic resolution fat-saturated intermediate-weighted FSE-Cube sequence with a 6:16 minute acquisition time was found to have significantly lower (p<0.05) image quality when compared to two-dimensional intermediate-weighted fast spin-echo sequences. In particular, a greater degree of image blurring and indistinctness of structural edges were noted on the FSE-Cube images. The authors concluded that FSE-Cube appears better suited for evaluating high contrast structures such as cartilage fissures and intra-articular loose bodies than low contrast structures such as meniscal tears and bone marrow edema lesions (36). Larger clinical studies with surgical correlation are needed to determine whether FSE-Cube and other three-dimensional isotropic resolution fast spin-echo sequences can replace currently used two-dimensional sequences for evaluating the knee joint in clinical practice.

Hip Joint Imaging

Accurate evaluation of the articular cartilage and labrum of the hip joint in patients undergoing MR imaging is clinically significant. During the past decade, conditions such as femoroacetabular impingement (3840) and acetabular dysplasia (41, 42) have been gaining increased attention as causes of premature osteoarthritis of the hip joint in young patients. Surgical interventions such as labral repair or debridement (4345) along with femoral and acetabular osteochondroplasty (43, 44) and acetabular osteotomy (4547) are currently available to treat these patients. However, performing these procedures before the development of advanced joint degeneration is essential for their long-term success (48, 49). Thus, early detection of cartilage and labral degeneration with MR imaging can help identify patients with hip pain who may best benefit from surgical intervention.

Non-contrast MR imaging with two-dimensional fast spin-echo sequences (50) and three-dimensional SPGR sequences (51, 52) has been used to evaluate the articular cartilage and labrum of the hip joint. However, most patients with hip pain in clinical practice are evaluated with MR arthrography using two-dimensional T1-weighted fast spin-echo sequences. MR arthrography has higher diagnostic performance for detecting labral tears than non-contrast MR imaging (51, 53, 54) with sensitivity values ranging between 92% and 97% and specificity values ranging between 90% and 100% in multiple studies with surgical correlation (5356). However, MR arthrography has much lower diagnostic performance for evaluating the articular cartilage of the hip joint. The sensitivity of MR arthrography for detecting surgically confirmed cartilage lesions range between 41% and 79% with specificity values ranging between 77% and 100% (53, 57). Furthermore, the sensitivity for detecting cartilage delamination in patients with femoroacetabular impingement is as low as 22% (58).

Three-dimensional sequences have been also been used to evaluate the articular cartilage and labrum of the hip joint during MR arthrography (5961). No previous study has directly compared MR arthrography using two-dimensional and three-dimensional sequences for evaluating the labrum perhaps due to the high diagnostic performance of currently used two-dimensional T1-weighted fast spin-echo sequences. However, two previous studies have compared two-dimensional and three-dimensional sequences for evaluating the articular cartilage of the hip joint during MR arthrography. Knuesel and associates compared a sagittal water excitation DESS sequence and a sagittal fat-saturated T1-weighted fast spin-echo sequence for detecting surgically confirmed cartilage lesions in 21 patients at 1.5T. Both sequences were found to have similar sensitivity and specificity for detecting cartilage lesions, but water excitation DESS had significantly greater (p<0.05) lesion conspicuity (62). In a larger study performed at 3.0T, Ulrich and associates compared an IDEAL-SPGR sequence and multi-planar fat-saturated T1-weighted fast spin-echo sequences for detecting surgically confirmed cartilage lesions within the hip joint in 80 patients. IDEAL-SPGR with multi-planar reformats was found to have significantly higher (p<0.05) sensitivity but significantly lower (p<0.05) specificity and accuracy than the T1-weighted fast spin-echo sequences for detecting cartilage lesions (Figure 5). The sensitivity for detecting superficial cartilage lesions in the study was extremely low with only 22% and 32% of grade 2A cartilage lesions identified using the two-dimensional and three-dimensional sequences respectively (63).

Figure 5
45 year old female patient with a surgically confirmed full thickness cartilage lesion on the posterior superior acetabulum who was imaged at 3.0T. (a) Sagittal fat saturated two-dimensional T1-weighted fast spin-echo image and (b) corresponding sagittal ...

The suboptimal diagnostic performance of two-dimensional and three-dimensional sequences for evaluating the articular cartilage of the hip joint during MR arthrography may be attributed to the thin articular cartilage and spherical surface geometry of the femoral head and acetabulum (64). The use of three-dimensional sequences with higher in-plane spatial resolution and decreased slice thickness may potentially improve the detection of small superficial cartilage lesions. Carballido-Gamio and associates reported the use a water excitation SPGR sequence with 0.3 mm × 0.3 mm in-plane spatial resolution and 1.5 mm slice thickness for evaluating the articular cartilage of the hip joint at 3.0T. While the high resolution SPGR sequence may be well suited for measuring cartilage volume in osteoarthritis research studies, the sequence had an acquisition time of 10 minute which would limit its use in clinical practice (65). Future development of more SNR efficient three-dimensional sequences and specialized multi-channel coils for hip imaging may allow higher resolution images to be obtained in clinically feasible scan times. Such improvements in MR technology may also allow the use of three-dimensional sequences with isotropic resolution to provide rapid assessment of the articular cartilage and labrum of the hip joint (Figure 6).

Figure 6
47 year old male patient with surgically confirmed labral tear and full thickness cartilage lesions on the anterior superior femoral head and acetabulum who was imaged at 3.0T. (a) Sagittal fat saturated two-dimensional T1-weighted fast spin-echo image ...

Ankle Joint Imaging

Accurate cartilage assessment in patients with ankle pain undergoing MR imaging is clinically significant. Early detection of cartilage degeneration in patients with chronic ankle instability may allow ligament reconstruction procedures to be performed before the development of advanced osteoarthritis (66, 67). Identification of cartilage surface damage in patients with osteochondral lesions of the talus is also important for proper staging and preoperative planning (68). However, achieving high diagnostic performance for detecting cartilage degeneration within the ankle joint is difficult due to the thin, incongruent articular surfaces of the distal tibia and talar dome (69, 70).

Three-dimensional sequences can potentially improve the detection of cartilage lesions due to their ability to acquire thin continuous slices through the ankle joint with high in-plane spatial resolution. However, Bauer and associates compared two-dimensional fat-saturated intermediate-weighted fast spin-echo, fat-saturated SPGR, and fat-saturated FIESTA sequences for detecting artificially created cartilage lesions in human cadaver ankle joints at 1.5T and 3.0T. Sensitivity values for detecting cartilage lesions ranged between 33% for fat-saturated SPGR and 49% for fat-saturated intermediate-weighted fast spin-echo at 1.5T and between 42% for fat-saturated SPGR and 71% for fat-saturated intermediate-weighted fast spin-echo at 3.0T. The authors attributed the lower diagnostic performance of the three-dimensional sequences to increased artifacts secondary to the challenging magnetic field environment and high spatial resolution requirements associated with ankle joint imaging (69). However, Welsch and associates recently described the use of a water excitation true-FISP sequence with 0.3 mm isotropic resolution for evaluating the articular cartilage of the ankle joint at 3.0T. The authors reported no degradation of image quality associated with the use of the balanced SSFP sequence. The high in-plane spatial resolution, thin slices, and multi-planar capability of the true-FISP sequence would make it ideal for detecting cartilage lesions within the ankle joint. However, the sequence had an acquisition time of 10 minutes which would significantly limit its use for routine ankle joint imaging (71).

There has also been recent interest in using three-dimensional isotropic resolution fast spin-echo sequences to provide rapid comprehensive assessment of the ankle joint (72, 73). Stevens and associates performed a quantitative and qualitative comparison of image quality of a 0.6 mm isotropic resolution intermediate-weighted FSE-Cube sequence with an acquisition time of 6 minutes and two dimensional intermediate-weighted fast spin-echo sequence for ankle joint imaging. The FSE-Cube sequence was found to have significantly higher (p<0.05) SNR efficiency of cartilage, synovial fluid, and muscle when compared to the two dimensional fast spin-echo sequences. While blurring was significantly greater (p<0.05) for FSE-Cube, there was no significant difference between the two-dimensional and three-dimensional sequences in overall image quality and artifact (73). Additional studies are needed to determine whether the thin, continuous slices of three-dimensional fast spin-echo sequences and their ability to view the complex anatomy of the ankle joint in oblique and curved planes may improve the detection of ankle joint pathology (Figure 7).

Figure 7
24 year old male volunteer who was imaged at 3.0T. (a) Coronal oblique intermediate-weighted FSE-Cube reformat image (0.6 mm isotropic resolution with 6 minute scan time) of the ankle shows the thin calcaneofibular ligament in its entirety (arrow). (b) ...

Shoulder Joint Imaging

In the past, three-dimensional T2*-weighted gradient-echo sequences have been used to evaluate the shoulder joint with similar sensitivity and specificity values for detecting rotator cuff and labral tears as two-dimensional spin-echo sequences and much shorter acquisition times (7476). However, over the past decade, the use of fast spin-echo sequences have significantly reduced the time required to obtain images with intermediate-weighted and T2-weighted contrast. Thus, two-dimensional fast spin-echo sequences are currently the sequences of choice for evaluating the shoulder joint during non-contrast MR imaging (7779). However, three-dimensional sequences such as DESS and true-FISP are being used at many institutions for shoulder MR arthrography. Previous studies with surgical correlation have shown that these sequences are more sensitive than two-dimensional T1-weighted fast spin-echo sequences for detecting cartilage lesions and labral tears within the shoulder joint (80).

There has been recent interest in using three-dimensional isotropic resolution fast spin-echo sequences to decrease the time required to evaluate the shoulder joint during non-contrast MR imaging. Hill and associates compared a 0.6 mm isotropic resolution fat-saturated T2-weighted FSE-Cube sequence with an acquisition time of 7:27 minutes and multi-planar two-dimensional fast spin-echo sequences for evaluating the rotator cuff tendon in 19 patients at 3.0T. The FSE-Cube sequence was found to have fair to good agreement and similar confidence level for grading the rotator cuff tendon as two-dimensional fast spin-echo sequences (Figure 8). The authors also described a novel reformat plane called the radial oblique coronal plane which could be acquired from the volumetric FSE-Cube source data. Using this curved oblique plane, thin continuous reformat images perpendicular to each portion of the rotator cuff tendon could be obtained which reduces the effect of partial volume averaging (Figure 9) (81). Additional studies are needed to determine whether three-dimensional isotropic resolution fast spin-echo sequences have similar diagnostic performance as two-dimensional sequences for evaluating the shoulder joint during non-contrast MR imaging.

Figure 8
43 year old male patient with a surgically confirmed partial thickness supraspinatus tendon tear who was imaged at 3.0T. (a) Coronal and (c) sagittal two-dimensional fat-saturated T2-weighted fast spin-echo images and corresponding (b) coronal and (d) ...
Figure 9
48 year male patient with shoulder pain who was imaged at 3.0T. (a) To create radial oblique coronal reformat images of the shoulder, a series of lines are drawn parallel to the rotator cuff (black lines) on a sagittal oblique fat-saturated T2-weighted ...

Three-dimensional T1-weighted isotropic resolution sequences have also been used to provide rapid comprehensive shoulder joint assessment during MR arthrography. In a study performed on 36 patients undergoing indirect MR arthrography at 3.0T, Oh and associates found that a 0.6 mm isotropic resolution fat-saturated SPGR sequence with an acquisition time of 5:32 minutes had similar sensitivity and specificity as multi-planar two-dimensional fat-saturated T1-weighted fast spin-echo sequences for detecting surgically confirmed rotator cuff and labral tears (82). Magee compared the diagnostic performance of a 0.6 mm isotropic resolution fat-saturated SPGR sequence with an acquisition time of 2:46 minutes and multi-planar two-dimensional fat-saturated T1-weighted fast spin-echo sequences for evaluating the shoulder joint during direct MR arthrography in 59 patients at 3.0T (Figure 10) (83). The three-dimensional isotropic resolution sequence was found to have similar diagnostic performance as the two-dimensional fast spin-echo sequences for detecting surgically confirmed rotator cuff and labral tears. In another study performed on 33 patients undergoing direct MR arthrography at 3.0T, Jung and associates also found that a 0.6 mm isotropic resolution fat-saturated SPGR sequence with an acquisition time of 5:32 minutes had similar sensitivity and specificity for detecting surgically confirmed labral tears as multi-planar two-dimensional fat-saturated T1-weighted fast spin-echo sequences (84).

Figure 10
46 year old male patient with a surgically confirmed full-thickness supraspinatus tendon tear and superior labral tear who was imaged with MR arthography at 3.0T. (a) Sagittal fat saturated two-dimensional T1-weighted fast spin-echo image and (b) corresponding ...

Elbow Joint Imaging

Three-dimensional T2*-weighted gradient-echo sequences have been used to evaluate the ulnar collateral ligament (85, 86) and lateral collateral ligament (87) of the elbow joint during non-contrast MR imaging. Three-dimensional sequences can acquire much thinner slices through the elbow join than two-dimensional sequences which allow for better visualization of the collateral ligaments in the coronal plane. Three-dimensional sequences can also be used to obtain multi-planar reformat images which allow the collateral ligaments to be evaluated in any orientation. This is especially important when assessing the ulnar band of the lateral collateral ligament which can be best visualized in its entirety by using a 20 degrees posterior oblique coronal plane (Figure 11) (88). While there are many potential advantages of using three-dimensional sequences for evaluating the collateral ligaments of the elbow joint, no previous study has directly compared two-dimensional and three-dimensional sequences for detecting surgically confirmed ligament tears in symptomatic patients. Thus, the clinical benefits of using three-dimensional sequences for evaluating the collateral ligaments remain unknown.

Figure 11
40 year old male patient who was imaged with MR arthrography at 3.0T. Coronal oblique fat-saturated intermediate-weighted FSE-Cube reformat image (0.6 mm isotropic resolution with 5minute scan time) of the elbow shows the ulnar band of the lateral collateral ...

Newly developed three-dimensional isotropic resolution fast spin-echo sequences may also be used to evaluate the collateral ligaments of the elbow joint. These sequences produce multi-planar images of the elbow joint with intermediate-weighted contrast. Previous studies performed by Carrino and associates using cadaveric elbow joints have shown that intermediate-weighted fast spin-echo sequences have higher sensitivity for detecting surgically created tears of the ulnar collateral ligament (89) and lateral collateral ligament (90) than T2*-weighted gradient-echo images of similar slice thickness. Thus, three-dimensional isotropic resolution fast spin-echo sequences combine the most optimal tissue contrast with the ability to acquire thin continuous slices through the elbow joint which may improve the detection of collateral ligament tears. The intermediate-weighted tissue contrast and multi-planar capabilities of these sequences may also be useful for evaluating the tendons, muscles, and osseous structures of the elbow joint, especially when combined with fat-suppression to improve fluid sensitivity (Figure 12). Additional studies are needed to assess the ability of three-dimensional isotropic resolution fast spin-echo sequences to detect elbow joint pathology.

Figure 12
35 year old male volunteer who was images at 3.0T. (a) Coronal oblique fat-saturated intermediate-weighted FSE-Cube reformat image (0.6 mm isotropic resolution with 5 minute scan time) of the elbow shows the common flexor tendon origin in its entirety ...

Wrist Joint Imaging

Three-dimensional T2*-weighted gradient-echo (9194) and DESS sequences (95) have been used to evaluate the articular cartilage, ligaments, and triangular fibrocartilage complex of the wrist joint during non-contrast MR imaging. Three-dimensional T1-weighted gradient-echo sequences have also been used during MR arthrography to evaluate the wrist joint (95, 96). These sequences acquire thin continuous slices with high in-plane spatial resolution which are well suited for assessing the thin articular cartilage and small ligaments and fibrocartilage structures of the wrist joint. No previous study with surgical correlation has directly compared two-dimensional and three-dimensional sequences for evaluating wrist joint pathology. However, in a meta-analysis performed by Hobby and associates, the diagnostic performance of non-contrast MR imaging for detecting carpal ligament and triangular fibrocartilage complex tears was significantly higher at institutions which included three-dimensional T2*-weighted gradient-echo sequences in their MR protocols (97).

Studies have shown that MR arthrography is superior to non-contrast MR imaging for detecting surgically confirmed carpal ligament and triangular fibrocartilage complex tears (97, 98). However, newly developed three-dimensional isotropic resolution fast spin-echo sequences may improve the diagnostic performance of non-contrast MR imaging for evaluating the wrist joint. These sequences acquire thinner slices through the wrist joint than currently used two-dimensional and three-dimensional sequences which reduces the effects of partial volume averaging. In addition, oblique reformat images through the carpal ligaments and triangular fibrocartilage complex can be obtained which may improve the detection of subtle tears (Figure 13) (99). Additional studies are needed to determine whether three-dimensional isotropic resolution fast spin-echo sequences are superior to currently used two-dimensional and three-dimensional sequences for evaluating the wrist joint during non-contrast MR imaging.

Figure 13
35 year old male volunteer who was imaged at 3.0T. (a) Coronal intermediate-weighted FSE-Cube image (0.6 mm isotropic resolution with 5:35 minute scan time) of the wrist shows the scapholunate ligament (white arrow) and triangular fibrocartilage complex ...

Conclusion

Three-dimensional sequences have many important clinical applications in musculoskeletal MR imaging. These sequences acquire thin continuous slices through joints with high in-plane spatial resolution which minimizes the effects of partial volume averaging. While three-dimensional sequences have used for years to evaluate the musculoskeletal system, few studies have directly compared two-dimensional and three-dimensional sequences for detecting joint pathology. For this reason, the clinical benefits of using three-dimensional sequences remain unknown. With recent improvements in MR technology, three-dimensional sequences with isotropic resolution have become available for use in musculoskeletal MR imaging. These sequences allow high quality multi-planar reformat images to be obtained following a single acquisition, thereby eliminating the need to repeat sequences with identical tissue contrast in different planes. Additional studies are needed to determine whether three-dimensional isotropic sequences resolution can be used to provide rapid comprehensive joint assessment in clinical practice.

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