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CT-like MRI: a qualitative assessment of ZTE sequences for knee osseous abnormalities

Skeletal Radiology Aims and scope Submit manuscript



To qualitatively evaluate the utility of zero echo-time (ZTE) MRI sequences in identifying osseous findings and to compare ZTE with optimized spoiled gradient echo (SPGR) sequences in detecting knee osseous abnormalities.

Materials and methods

ZTE and standard knee MRI sequences were acquired at 3T in 100 consecutive patients. Three radiologists rated confidence in evaluating osseous abnormalities and image quality on a 5-grade Likert scale in ZTE compared to standard sequences. In a subset of knees (n = 57) SPGR sequences were also obtained, and diagnostic confidence in identifying osseous structures was assessed, comparing ZTE and SPGR sequences. Statistical significance of using ZTE over SPGR was characterized with a paired t-test.


Image quality of the ZTE sequences was rated high by all reviewers with 278 out of 299 (100 studies, 3 radiologists) scores ≥ 4 on the Likert scale. Diagnostic confidence in using ZTE sequences was rated “very high confidence” in 97%, 85%, 71%, and 73% of the cases for osteophytosis, subchondral cysts, fractures, and soft tissue calcifications/ossifications, respectively. In 74% of cases with osseous findings, reviewer scores indicated confidence levels (score ≥ 3) that ZTE sequences improved diagnostic certainty over standard sequences. The diagnostic confidence in using ZTE over SPGR sequences for osseous structures as well as abnormalities was favorable and statistically significant (p < 0.01).


Incorporating ZTE sequences in the standard knee MRI protocol was technically feasible and improved diagnostic confidence for osseous findings in relation to standard MR sequences. In comparison to SPGR sequences, ZTE improved assessment of osseous abnormalities.

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Correspondence to Upasana Upadhyay Bharadwaj.

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Bharadwaj, U.U., Coy, A., Motamedi, D. et al. CT-like MRI: a qualitative assessment of ZTE sequences for knee osseous abnormalities. Skeletal Radiol 51, 1585–1594 (2022).

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