Zero Echo Time Musculoskeletal MRI: Technique, Optimization, Applications, and Pitfalls

Zero echo time (ZTE) imaging is an MRI technique that produces images similar to those obtained with radiography or CT. In ZTE MRI, the very short T2 signal from the mineralized trabecular bone matrix and especially cortical bone-both of which have a low proton density (PD)-is sampled in a unique sequence setup. Additionally, the PD weighting of the ZTE sequence results in less contrast between soft tissues. Therefore, along with gray-scale inversion from black to white and vice versa, ZTE imaging provides excellent contrast between cortical bone and soft tissues similar to that of radiography and CT. However, despite isotropic or near-isotropic three-dimensional (3D) imaging capabilities of the ZTE sequence, spatial resolution in this technique is still inferior to that of radiography and CT, and 3D volume renderings are currently time-consuming and require postprocessing software that features segmentation and manual contouring. Optimization of ZTE MRI mostly entails adjustments of bandwidth, flip angle, field of view, and image matrix. A wide range of structural abnormalities and disease or healing processes in the musculoskeletal system are well delineated with ZTE MRI, including conditions that involve bone-based morphometric analyses (which aid diagnosis, help prognostication, and guide surgery), impaction, avulsion and stress fractures, loose bodies or erosions in and around joints, soft-tissue calcifications and ossifications, and bone tumors (including treatment response). The pitfalls of ZTE imaging include mimics of foci of calcification or ossification such as intra-articular gas and susceptibility artifacts from surgical materials and hemosiderin deposition, which can be avoided in many instances by cross-referencing images obtained with other MRI sequences. Online supplemental material is available for this article. ©RSNA, 2022.