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Morphological MRI of knee cartilage: repeatability and reproducibility of damage evaluation and correlation with gross pathology examination

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To assess the performance of a morphological evaluation, based on a clinically relevant magnetic resonance imaging (MRI) protocol, in scoring the severity of knee cartilage damage. Specifically, to evaluate the reproducibility, repeatability, and agreement of MRI evaluation with the gross pathology examination (GPE) of the tissue.


MRI of the knee was performed the day before surgery in 23 patients undergoing total knee arthroplasty. Osteochondral tissue resections were collected and chondral defects were scored by GPE according to a semi-quantitative scale. MR images were independently scored by four radiologists, who assessed the severity of chondral damage according to equivalent criteria. Inter- and intra-rater agreements of MRI evaluations were assessed. Correlation, precision, and accuracy metrics between MRI and GPE scores were calculated.


Moderate to substantial inter-rater agreement in scoring cartilage damage by MRI was found among radiologists. Intra-rater agreement was higher than 96%. A significant positive monotonic correlation between GPE and MRI scores was observed for all radiologists, although higher correlation values were obtained by radiologists with expertise in musculoskeletal radiology and/or longer experience. The accuracy of MRI scores displayed a spatial pattern, characterized by lesion overestimation in the lateral condyle and underestimation in the medial condyle with respect to GPE.


Evaluation of knee cartilage morphology by MRI is a reproducible and repeatable technique, which positively correlates with GPE. Clinical expertise in musculoskeletal radiology positively impacts the evaluation reliability. These findings may help to address limitations in MRI evaluation of knee chondral lesions, thus improving MRI assessment of knee cartilage.

Key Points

• MRI evaluation of knee cartilage shows moderate to strong correlation with gross pathology examination.

• MRI evaluation overestimates cartilage damage in the lateral condyle and underestimates it in the medial condyle.

• Education and experience of the radiologist play a role in MRI evaluation of knee chondral lesions.

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Absolute difference


Fast spin echo


Gross pathology examination


Magnetic resonance


Magnetic resonance imaging


Relative difference


Total knee arthroplasty


Three-dimensional true fast imaging with steady-state free precession


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The authors are grateful to the technical staff of the Division of Diagnostic Radiology at Rovereto Hospital for assistance in collecting MR data.


The study has been supported in part by the Healthcare Research and Innovation Program (IRCS) of the Autonomous Province of Trento (Healthcare Research and Innovation Program IRCS-HTA 2016) and by the Fondazione Cassa di Risparmio di Trento e Rovereto (EviVa project, 2011).

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Correspondence to Francesco Tessarolo.

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The scientific guarantor of this publication is Dr. Sabino Walter Della Sala.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors (MR) has significant statistical expertise (got a PhD in biomedical statistics).

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Written informed consent was obtained from all subjects in this study.

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Institutional Review Board approval was obtained.


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Marinetti, A., Tessarolo, F., Ventura, L. et al. Morphological MRI of knee cartilage: repeatability and reproducibility of damage evaluation and correlation with gross pathology examination. Eur Radiol (2020). https://doi.org/10.1007/s00330-019-06627-5

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  • Magnetic resonance imaging
  • Articular cartilage
  • Knee