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Imaging of Osteoarthritis

Imaging plays a crucial role in understanding osteoarthritis (OA), with plain radiography being the most common method used in clinical practice despite its limitations. Magnetic resonance imaging (MRI) and ultrasonography offer more detailed assessments of joint structures and are valuable in research settings, while other imaging techniques have limited routine use. The document discusses the pathologic features of OA and how they correlate with radiographic findings, emphasizing the need for standardized imaging procedures to accurately evaluate the disease's progression.

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Imaging of Osteoarthritis

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185 Imaging of osteoarthritis

Andrew J. Barr • Claire Y.J. Wenham • Andrew J. Grainger • Philip G. Conaghan

Key Points In OA, subchondral sclerosis and osteophytosis are generally the earliest
■ Imaging has provided great insights into the pathogenesis of osteoarthritis (OA), but
radiographic features. They increase with time in both extent and size and
in routine practice, it is often not required because both the diagnosis and
precede radiographic joint space narrowing (JSN) (Fig. 185.2), which occurs
progression of peripheral joint OA are usually assessed clinically.
at a later stage of the disease.5-7
■ Plain radiography is the most feasible method of imaging of OA in clinical practice
and epidemiologic studies; despite limitations, it remains the regulatory standard for RADIOGRAPHIC PROCEDURES
trials of structure modification.
Radiographs are two-dimensional (2D) projection images of three-dimensional
■ Magnetic resonance imaging (MRI) visualizes the whole joint organ, improving
(3D) structures. Radiographs of the same joint may therefore vary in appearance
understanding of the multi-tissue pathologic processes and potential sources of pain
when weight bearing but also with minor variation in joint flexion or rotation,
in OA. It is highly important in the research environment and has provided improved
when repositioning a joint.8-10 Therefore in clinical trials, validated procedures
outcomes for clinical trials.
for the radiographic assessment of OA joints are necessary to standardize
■ Ultrasonography also provides multiplanar assessment of joints but is more limited assessment of the radiographic severity and progression of OA. Standardized
than MRI in the tissues it can evaluate. It does permit dynamic assessment of joints radiographic procedures minimize any distortion in the radiographic image
and differential diagnosis in the clinic; it also enables guided therapy. of the joint by positioning the joint so that the central ray of the x-ray beam
■ Other imaging modalities (radionucleotide scintigraphy, computed tomography, passes between the margins of the joint space (Fig. 185.3). The most reliable
positron emission tomography) may be used on a case-by-case basis but do not yet and reproducible method for imaging the tibiofemoral compartment of the
have a routine role in OA investigation or management. knee is the weight-bearing semiflexed view (≈20 degrees of fixed knee flexion)
with radioanatomic alignment of the medial tibial plateau. Alignment ensures
the center of the x-ray beam is parallel to the tibial plateau and is best
achieved with fluoroscopic guidance, which can be used to ensure correct
INTRODUCTION positioning before the radiograph is obtained (Fig. 185.4).11,12 Similar rec-
ommendations for hand repositioning have been described.10
Osteoarthritis (OA) is the commonest joint disease worldwide and is one of The patellofemoral compartment can be assessed using either a lateral
the leading causes of chronic pain, disability and socioeconomic burden. For or a “skyline” (axial) view (Fig. 185.5). In the axial view, the detector is
adults, an estimated 18% of women and 10% of men worldwide are affected placed on a step, and the knee is flexed to 30 degrees from the vertical. The
by OA.1 The prevalence of OA is increasing in our aging and increasingly axial view can give a false impression of the patellofemoral alignment if it
obese populations.2 Despite this enormous burden, there are few effective is undertaken without weight bearing.
and safe therapies, and these are currently limited to a moderate effect Hip radiographs are conventionally taken with the hip in 15 to 20 degrees
on symptoms.3 There is therefore a huge unmet need for therapies that of internal rotation. Unlike in knee examination, there is no advantage to
improve both symptoms and inhibit the structural deterioration characteristic obtaining the radiograph with the patient in a standing position. A lateral
of OA. oblique view may be used to detect anterior or posterior joint space loss.
The value of joint imaging depends on the clinical or research question The optimal view for imaging the hand is a dorsopalmar view with the
and the characteristics of the imaging modality. Conventional radiography fingers in line with the forearm when laid flat on the x-ray detector holder.
(CR) is not usually required for the routine clinical diagnosis of OA. Although
there are no licensed therapies that modify structural progression, current WHAT PATHOLOGIC FEATURES CAN CONVENTIONAL
OA treatment is symptomatic, and symptoms do not correlate well with the
severity of radiographic features of OA. CR therefore does not often assist
RADIOGRAPHY ASSESS IN OSTEOARTHRITIS?
in treatment decisions unless joint replacement or a differential diagnosis Osteophytes
of OA is being considered. OA is a syndrome that involves all the tissues Osteophytes (on 2D radiographs) have the appearance of outgrowths at
within the joint, including the cartilage, subchondral bone, synovium, and articular margins, capsular insertions, and central articular regions in the
periarticular tissues. 4 Therefore, modern imaging techniques, such as unloaded region of joints (Figs. 185.6 and 185.7). They form by endochondral
ultrasonography (US) and magnetic resonance imaging (MRI), are increasingly ossification and are initiated by vascular invasion of cartilage plates along
used to evaluate structural joint pathology, particularly in the research with increased bone turnover.13-15
environment.
Although MRI permits the assessment of multiple tissues, CR is the most Subchondral sclerosis, erosions, and cysts
studied and has the longest history of all joint imaging modalities in OA. Some of the early pathologic changes in OA occur in the subchondral bone
There is also a predominance of knee studies in the literature; this is reflected beneath the articular cartilage. Here the subchondral cortical plate thickens
in the more numerous and validated imaging assessment tools in knee OA. and subjacent bone trabeculae thicken with narrower spacing between
This chapter focuses on the common imaging modalities applied to OA, trabeculae as JSN progresses (see Fig. 185.2).16 This subchondral sclerosis
including what they can detect, and provides considerations for clinical and or “thickening” of the bone represents a failed repair mechanism of subchondral
research use. bone microfractures where increased bone turnover produces an excess of
hypomineralized osteoid bone, which is less capable of dissipating load than
healthy bone and is associated with cartilage degradation.17 Radiolucencies
CONVENTIONAL RADIOGRAPHY noted in the subchondral bone may be juxtaarticular erosions or subchondral
Plain radiography is widely available and inexpensive, and its images are cysts, which tend to occur in more advanced OA at sites of increased mechani-
easily interpreted. CR has limited utility in the clinical diagnosis and manage- cal load and frequently communicate with the articular surface.
ment of OA but may assist in excluding other diagnoses at the first presentation
of atypical joint pain. Joint space narrowing
Radiographic image quality is influenced by the sensitivity of the imaging The distance between bones in diarthrodial joints has traditionally been
system and the radiographic view. The latter is important because failure to assumed to represent articular cartilage thickness in weight-bearing joint
standardize the radioanatomic positioning of the joint between examinations radiographs. However, knee MRI studies have established that JSN is not
reduces the sensitivity of the technique to detection of changes over time just a measure of the loss of hyaline articular cartilage thickness but also a
(Fig. 185.1).5 composite of meniscal degeneration, extrusion, and loss of articular cartilage

1556
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CHAPTER 185 Imaging of osteoarthritis 1557

EVALUATION OF KNEE OA

a b

c d

FIG. 185.1 Differences in joint position at radiography affect joint space assessment.
With the knee extended (top row), radiography does not reveal joint space narrowing a
(JSN), but in the semiflexed position (bottom row) JSN is detected. With advanced
disease, lateral radiographs in the standing extended knee view (a) show the femoral
condyle resting on the anterior rim of the tibia, producing a gap visible as a joint
space in the anteroposterior (AP) view (b). Conversely, in the semiflexed view of the
same knee, the femoral condyle occupies the central region of the tibial plateau Film
(c) with no cartilage present. No joint space is visible in the AP view (d).

Reference ball

Fluoroscopy
tube

a b

b
FIG. 185.2 Radiographic progression of osteoarthritis. Part of macroradiographs
(reduced) showing the medial compartment in osteoarthritic knees. (a) Early disease:
joint space width greater than 3 mm. (b) Definite disease: joint space width less
than 3 mm. With progressive joint space loss, note the increase in subchondral
cortical plate thickness and subjacent horizontal trabeculae, which results in a ladder-
FIG. 185.4 Reproducible radiographic methods for reliable evaluation in knee osteo-
arthritis (OA). (a) The patient stands in the semiflexed position; both knees are bent
like appearance that is enhanced by subarticular osteoporosis. Periarticular osteopenia
and in contact with the detector cassette, and the feet are slightly externally rotated
in (a) adjacent to the developing marginal osteophyte is not visible in (b) because
(≈15 degrees). The first metatarsophalangeal joint of each foot (arrow) is positioned
osteophytic growth appears to have halted. Osteophytes at the tibial spines appear
immediately below and in line with the front edge of the film cassette. The x-ray
as irregular outgrowths in (a) and (b). A marginal osteophyte is visible at the posterior
beam is directed midway between the knees, and the tube’s positioning light is
rim of the tibia in (b).
aligned with the horizontal plane of the joint. (b) The knee can also be positioned
reproducibly in the semiflexed view by using fluoroscopy to position the tibial plateau
horizontally and parallel to the x-ray beam. A metallic reference ball is used to correct
PLANE FOR MEASUREMENT OF MINIMUM JOINT WIDTH for radiographic magnification.

F F'
C
X-ray beam T T'

a b

FIG. 185.3 (a) For measurement of minimum joint space width in the tibiofemoral
compartment, the plane is taken in the middle of the joint, coincident with load
transmission (arrows), perpendicular to the central ray (c) of the x-ray beam and FIG. 185.5 Axial or skyline method for imaging the patellofemoral joint. The detector
parallel to the detector. (b) Arrowheads identify the corresponding site in the is placed on a step, and the knee is flexed to 30 degrees from the vertical. This
anteroposterior radiograph of an osteoarthritic knee. F, Femur; F′ and T′, their projec- view provides a reliable assessment of the interbone distances at the medial and
tions onto the x-ray detector; T, tibia. lateral compartments.

THE PATHOLOGIC FEATURES OF OA DETERMINE THE CHARACTERISTIC

RADIOGRAPHIC FEATURES

Radiology

Increased subchondral
cortical plate and
Pathology trabecular thickness

Increased activity of Increased subarticular

subchondral bone Early disease trabecular osteoporosis
b
Bone alters early in the disease
because of the blood supply Osteophytosis
Increased activity at
the articular margins
Later disease stage Remodeling of joint
Biomechanically weaker bone surfaces, cyst formation,
Altered bone and later altered joint
biochemistry alignment
Early disease stage
Altered articular Cartilage biomechanically weaker Narrowing of joint space
cartilage biochemistry caused by cartilage
compression
Later disease stage
Cartilage fissuring
Focal loss and removal of cartilage Loss of joint space
and rupture
a c

FIG. 185.6 (a) Pathologic changes in osteoarthritis and the corresponding characteristic radiographic features visualized in plain radiographs of joints with early- and late-stage
disease. (b) Radiograph of a healthy knee. (c) Radiograph of a knee with late disease showing most of the features listed in (a).

thickness.18 JSN on CR is also focal and not uniform, which reflects the Conventional radiography and osteoarthritis symptoms
asymmetry of articular cartilage loss within joints.5 This feature can prove Conventional radiography lacks utility in routine clinical practice because
useful in distinguishing OA from other arthritides such as rheumatoid arthritis. of the limited cross-sectional and longitudinal correlation of radiographic
Marked JSN is more typical of later stages of the disease (see Figs 185.1 and pathology and symptoms. Only 9% to 16% of hips with prevalent pain in
185.2, b).5 the Osteoarthritis Initiative (OAI) study and Framingham cohort had radio-
graphic evidence of OA, but only 21% to 24% of hips with radiographic OA
Bone remodeling and attrition had prevalent pain.25 A review of observational studies describing the cross-
Subchondral bone in established OA typically consists of an excess of sectional association of knee pain and radiographic OA reported a prevalence
hypomineralized osteoid with a reduced capacity to dissipate load compared of knee pain of 15% to 81% among knees with radiographic OA and a
to healthy bone. This is associated with subchondral bone attrition on CR, prevalence of radiographic OA of 15% to 76% among painful knees.26 This
which is a flattening of the bone surfaces, which may adversely affect joint inconsistency in knees may be partly explained by variation in the number
congruity (Fig. 185.8) and contribute to further stressing of the overlying of knee compartments investigated by CR. Earlier radiographic studies of
cartilage. Ensuing cartilage loss in load-bearing compartments and denudation OA, which excluded the patellofemoral joint, may have underestimated the
of the subchondral bone may be associated with further bone attrition (Fig. contribution of radiographic structural pathologic changes to pain and
185.8, b) and altered limb alignment. disability. Duncan and colleagues27 demonstrated that a posteroanterior view
of the tibiofemoral joint alone identifies around half of the cases of radiographic
Subchondral trabecular bone analysis OA in patients with knee pain; the proportion increased to 87% with two
Fractal signature analysis is a technique used on CR images in research to views and 98% with all three views (posteroanterior, supine skyline, and
characterize the morphometry of subchondral bone by providing a description supine lateral). Individual radiographic measures (e.g., JSN and osteophytes)
of trabecular subchondral bone microarchitecture and directional physical are also associated with the pain of hand28 and knee29 OA. However, in
properties from trabecular size, number, spacing, and cross-linking.16,19 longitudinal observational studies of radiographic knee OA, little change is
Buckland-Wright and colleagues observed that increasing severity of knee observed in knee pain over 6 years despite radiographic progression30 except
radiographic OA (ROA) and JSN was associated with thicker trabeculae with rarely when large increases in radiographic structural severity are observed.31
less space between trabeculae16 (Fig. 185.9). Alterations in knee trabecular Similarly, longitudinal studies of radiographic hand OA reported that
bone morphometry are associated with radiographic JSN, MRI-determined radiographic structural progression was not associated with self-reported
cartilage thinning, and joint replacement.20-22 Further validation is required symptomatic deterioration in hand OA.32,33 However, these studies assessed
before this can be used as an endpoint in clinical trials. symptoms at the level of the whole hand. When assessing the symptoms
and structure at the level of individual hand joints, there is a dose-dependent
Joint morphology association between structural severity and joint tenderness. There is also a
Abnormal or incongruent bone shape within diarthrodial joints has long substantive association between incident joint tenderness and incident
been recognized as a predisposing factor for adverse biomechanics and failure radiographic erosions.34
to dissipate load evenly. Femoroacetabular impingement is a pathologic
condition in which there is impingement between the acetabulum and the Conventional radiography and early osteoarthritis
femoral head during movement of the hip. The presence of an aspherical The concept of early OA is not currently well defined but there is a well-
femoral head (a cam deformity) creates an abnormally shaped junction recognized pre-radiographic phase. This is demonstrated by the symptoms
between the femoral head and neck, and this additional material may cause of OA typically preceding the incidence of radiographic OA by 25 to 39
impingement on the acetabulum (Figs. 185.10 and 185.11). As the asphericity months with a prodromal phase of activity-related pain.35 Structural pathology
of the femoral head increases, so does the alpha angle, which can be measured is also highly prevalent before radiographic OA is detected. By the time knee
on CR of the hip (see Fig. 185.11). This impingement is associated with ROA is detectable, 10% of knee hyaline articular cartilage is lost.36 The risk
delamination of the acetabular cartilage and confers up to a 10-fold greater of incident radiographic knee OA 2 years after baseline MRI is increased
risk of end-stage hip OA within 5 years.23 This asymmetry is also independently more with multiple than single structural abnormalities at baseline, including
associated with structural progression and total hip replacement.23,24 synovitis, bone marrow lesions (BMLs), and meniscal degeneration. 37

FIG.185.9 Thicker and less well-spaced trabeculae. Part of a macroradiograph of a

knee joint with osteoarthritis showing subchondral sclerosis and trabeculae. These
are thicker and less well spaced than in normal bone. (From Buckland-Wright JC,
Lynch JA, Macfarlane DG. Fractal signature analysis measures cancellous bone
organisation in macroradiographs of patients with knee osteoarthritis. Ann Rheum
Dis 1996;55:749-55).16

a b

c d

FIG. 185.7 Radiographic changes in osteoarthritis (OA). (a) Hypertrophic OA of the

hip, with concentric joint space narrowing (JSN) and extensive osteophytosis and
subchondral sclerosis characteristic of the marked bony reaction. (b) Atrophic or c d
destructive OA of the hip, in which there is destruction of subchondral bone, with
a relative paucity of osteophyte formation associated with JSN. (c) Secondary OA of FIG.185.10 Radiographs of a normal hip and a hip with cam lesion. In a normal hip,
the hip, here caused by a dysplastic hip. The shallow acetabulum and uncovering the concavity of the femoral head-neck junction (green arrow) allows an extensive
of the head of the femur results in OA of the upper pole of the joint, with JSN, range of hip movement without impingement of the femur against the acetabular
subchondral sclerosis, cysts, and osteophytosis. (d) Erosive OA at a distal inter- rim. In cam lesion femoroacetabular impingement, the loss of this concavity at the
phalangeal joint: Apart from JSN, subchondral sclerosis, and osteophytosis, there anterosuperior head–neck junction (red arrow) results in impaction of the femur
are loss of the cortical margin, central erosions, and marked soft tissue swelling. against the acetabular rim. (From Glyn-Jones S, Palmer AJ, Agricola R, et al. Osteo-
arthritis. Lancet 2015;386:376-87.209).

Conventional radiography in advanced osteoarthritis

There are further limitations in the use of CR in the assessment of OA
structural progression in advanced knee OA. The highest Kellgren-Lawrence
(KL) grade of 4 refers to the most advanced structural radiographic severity.
a b In the longitudinal follow-up of knees with KL grade 4 at baseline, progressive
structural pathology was observed on serial MRI scans, including increasing
cartilage loss, synovitis, effusion, and bone pathology severity scoring.40 This
FIG. 185.8 Articular bone distortion and flattening in osteoarthritis (OA) caused by included knee compartments where the CR identified no joint space width
weaker bone. (a) OA of the knee in the standing extended view showing marked or “bone-on-bone” appearance.
subchondral sclerosis with tongue-and-groove corrugations on the femoral and tibial
articular surfaces of the medial compartment. (b) The same knee 21 months later. Quantification of pathology on conventional radiography
The corrugations visible in (a) are reduced or absent, which results in a flattened Radiographic grading systems
articular surface. The quantification of OA pathology on CR remains a research tool and is
not used in routine clinical practice. The KL grading system remains the
MRI-defined structural lesions of OA are also found in 89% of knees with most widely used scale to quantify radiographic OA lesions. The KL grade
no radiographic OA (with or without pain) in people older than the age of is determined by the presence and severity of osteophytes, joint space width,
50 years.38 Similarly, in a cross-sectional analysis of hips with chronic pain subchondral bone sclerosis, and deformity of bone contour.41 The KL system
but little or no radiographic evidence of OA, 26% had severe cartilage damage, is therefore a composite measure of global OA structural severity which is
and 57% had labral tears in the same joints.39 described on an ordinal scale of 0 to 4. The advantages of KL score are that

a b
Hip conventional radiography
For clinical trials in hip OA, semiquantitative scoring of hip OA on radiographs
is best done with KL grades or the OARSI Atlas based on validation, reproduc-
Cam ibility, and responsiveness. Automated methods for measuring quantitative
JSW may improve precision and improve responsiveness, which may shorten
the duration of clinical trials. However, currently, radiographic JSW is a
α
* recommended outcome measure for structure modification trials, acknowledg-
ing that trial duration may be long and the construct of JSW represents a
number of pathologies.53

Hand conventional radiography

For hand OA trials, study-specific training should be received by the site
technologists, and quality control should be verified centrally with regular
feedback. Reading of imaging should be centrally performed by two independ-
c d ent readers and adjudicated. Furthermore, the images for each participant
should be measured simultaneously with the readers blinded to chronologic
order and treatment allocation.10
FIG.185.11 (a) and (b) A spherical femoral head provides the hip with a wide range Standardized radiographic imaging of the hands with consistent beam-
of motion. (c) and (d) A cam abnormality (asterisk) can cause impingement (arrow) centering, reproducible positioning, and exposure are critical for hand OA
against the acetabular rim, especially during flexion and internal rotation of the hip. trials. Image acquisition should involve using a positioning frame.
The α angle is indicated in a and c. (From Agricola R, Waarsing JH, Arden NK, The scoring methods for hand radiographs should be consistent with the
et al. Cam impingement of the hip: a risk factor for hip osteoarthritis. Nat Rev consensus statement from Outcome Measures in Rheumatology Clinical
Rheumatol 2013;9:630-4.210) Trials (OMERACT) 12 (Budapest 2014), using the best validated methods
(i.e., KL, OARSI atlas, Verbruggene Veys, or Kallman method) for preliminary
instruments for structural damage.10
it incorporates the severity of structural pathology in more than one tissue
in this multi-tissue whole-joint disorder. It is well known and widely used Knee conventional radiography
and has even been validated using trained nonclinicians compared with The most commonly used outcome measure in clinical trials is the minimum
experienced radiologists.42 JSW. However, the smallest detectable difference in minimum knee JSW is
The KL grade has a number of limitations. A KL grade of 2 defines the 0.2 mm.9,54 This is relatively large considering the mean rate of annual knee
incidence of radiographic knee OA, and this is heavily dependent on the JSN is 0.13 ± 0.15 mm/year, with change occurring in only a small group
detection of osteophytes, which can change with minor rotation of the knee. of “progressors.”12,55 This highlights the relatively poor responsiveness
This limitation highlights the importance of joint repositioning. KL grade of JSN.
2 has been inconsistently defined in longitudinal studies, which has led to Despite restricted access to fluoroscopic facilities, fluoroscopic positioning
some heterogeneity in definitions of OA that include the presence of osteo- and semiflexed views improve responsiveness. Radiographic JSW remains a
phytes but may or may not include JSN.43 The KL grade is also not an interval recommended outcome measure for structural modification trials, while
variable and is therefore less sensitive to detecting progression than measures acknowledging that the construct of JSW narrowing represents a number of
such as continuous JSN.6,7 For this reason, Felson and colleagues have proposed pathologies, and trial duration may be long. This confers the requirement
distinguishing “KL grade 2 with osteophytes only” and “KL grade 2 with for studies to be 12 to 24 months in duration. The use of automated methods
osteophytes and JSN.”7 for assessing JSW may improve precision and hence responsiveness.52
The Osteoarthritis Research Society International (OARSI) atlas classifica-
tion grades the severity of radiographic OA of the knee, hip, and hand. It
provides distinct scoring systems for each joint and describes JSN; osteophytes
MAGNETIC RESONANCE IMAGING
with a semiquantitative ordinal score (0–3); and the presence or absence of Magnetic resonance imaging offers excellent soft tissue contrast in a tomo-
subchondral sclerosis, cysts, and attrition but also joint malalignment.44 In graphic presentation and covers the entire joint three dimensionally in one
the knee, the features are identified by their presence in the medial and examination. It provides sections in any plane prescribed by the operator.
lateral tibiofemoral compartments. These individual features can be used to MRI allows visualization of structural pathology of the hyaline articular
measure progression, but scoring may be more time consuming than the KL cartilage, fibrocartilage (e.g., the menisci), synovium, bone shape, bone
grade. marrow, and ligaments regardless of their location.56 MRI abnormalities are
Scoring systems for hand OA also include the semiquantitative Kallman seen more frequently with increasing radiographic OA severity. However, as
scale, the Verbruggen numerical scoring system, and a global scoring system mentioned, MRI detects OA structural pathologies in the pre-radiographic57
in which 32 joints in the hands are scored yes/no for features of radiographic and radiographic58 phases of OA.
OA. These scoring methods have demonstrated similar reliability and may Magnetic resonance imaging applies a magnetic field and then uses different
be used to detect radiologic progression in hand OA over time.45 pulse sequences to visualize the tissues within joints. After a radiowave
Joint space width (JSW) can be measured manually using calipers or a pulse, the protons within different tissues (e.g., fat, fluid, and muscle) are
graduated ruler and a micrometric eyepiece or with semiautomated computer aligned and then resume a state of equilibrium by which they can be measured
software.46,47 JSW measurements include minimum JSW, mean JSW, joint as T1 and T2 relaxation signals. The protons in each tissue have different
space area, and JSW at fixed locations.48,49 T1 and T2 relaxation times, and this provides soft tissue contrast based on
Software analysis of digital knee radiographs has been shown to be the different signal sizes coming from each tissue. Bone marrow lesions and
comparable to cartilage morphometry analysis using MRI in detection of focal defects of the articular cartilage are better assessed through fast spin
OA progression.49 fluid-sensitive echo sequences (e.g., T2 weighted or proton density weighted)

with fat suppression.59,60 MRI also provides tomographic visualization of There is also increasing use of modern MRI sequences that detect com-
joints in any section in any plane but also can be truly 3D when the undulating positional changes in cartilage that precede the macroscopic degeneration
surfaces of the whole joint are visualized. of cartilage. These techniques enable the examination of cartilage “quality”
by using the properties of glycosaminoglycan concentration and collagen
WHAT PATHOLOGIC FEATURES CAN MAGNETIC RESONANCE fibril orientation within the cartilage. A range of techniques such as delayed
gadolinium-enhanced MRI of cartilage (dGEMRIC),61 diffusion-weighted
IMAGING ASSESS IN OSTEOARTHRITIS? imaging, and T2 and T1ρ mapping procedures can provide information on
Cartilage abnormalities the composition and structure of the cartilage matrix.62-65 Currently, these
The reliability and accuracy of detection of cartilage morphologic abnormalities remain largely research tools and are often difficult to standardize (Fig.
is improving with increasing sophistication of available MRI sequences and 185.14),66,67 and further validation is required before these can be used as
improved spatial resolution of modern scanners (Figs 185.12 and 185.13). validated endpoints in DMOAD trials.
In large cohorts of knees at risk of knee OA, MRI-determined knee cartilage
damage is associated with incident radiographic knee OA after 12 months Synovitis and joint effusion
of follow-up, and there is a dose-response association between worsening Modern imaging with its more precise detection of synovial effusion and
cartilage damage and subsequent incidence of radiographic OA.57 Worsening hypertrophy has highlighted that the prevalence of inflammation in OA
cartilage damage is also associated with incidence and persistence of knee joints is far greater than first thought.68 Contrast-enhanced MRI remains the
pain in the same study. gold standard for assessing synovial hypertrophy, with studies demonstrating
that the prevalence of definite synovitis in the OA knee in large cohorts is
80% to 90%.69,70 Studies of hand OA using contrast-enhanced MRI noted
synovitis in more than half of the distal interphalangeal and proximal
interphalangeal joints (Fig. 185.15).71 Joint effusion is best detected on
fat-suppressed proton density–weighted or T2-weighted fast-spin echo
sequences.

FIG. 185.12 Axial T2-weighted fat-suppressed magnetic resonance image of the knee
demonstrating cartilage loss over the crista and medial facet of the patella FIG. 185.14 T2-mapped magnetic resonance image of the knee demonstrating early
(arrowhead). intrasubstance degeneration of the patellar cartilage seen as prolonged T2 signal.

FIG. 185.13 Coronal oblique T1-weighted fat-suppressed magnetic resonance

arthrogram of the shoulder with intraarticular gadolinium demonstrating a large
osteophyte (black arrow) and areas of cartilage damage to both the glenoid and FIG. 185.15 Coronal magnetic resonance image of a distal phalangeal joint demonstrat-
humeral head (white arrows). ing synovitis (after gadolinium contrast administration).

*
*
*

*
*

FIG. 185.17 Coronal T2-weighted fat-suppressed magnetic resonance image of the

knee demonstrating bone marrow lesion and cartilage loss on both sides of the
medial joint. The medial meniscus is markedly degenerated with maceration and
FIG. 185.16 Axial T1-weighted fat-suppressed magnetic resonance image of the knee abnormally increased signal (straight arrow) compared with the normal lateral meniscus
with gadolinium contrast. The high-signal synovitis is well demonstrated in the (curved arrow). Abnormally increased signal is also seen on both sides of the medial
suprapatellar pouch and intercondylar notch (asterisks). Osteophytes are also seen collateral ligament (arrowheads).
(arrows).

Quantitative MRI markers of synovitis include synovial membrane thick- BMLs, and they manifest as ill-defined high-signal area seen on fat-suppressed
ness, synovial fluid volume, and the rate of synovial enhancement after T2-weighted or short tau inversion recovery (STIR) sequences. They are
intravenous injection of contrast agent (Fig. 185.16). Contrast enhancement more frequently identified at sites of greater mechanical load. This includes
improves the certainty of detecting inflamed synovium.72 However, accurate overloading of subchondral bone as a consequence of meniscal degeneration,
quantification of synovitis can be achieved without using contrast agents,73,74 malalignment, cruciate ligament tear, and obesity.94-100 Subchondral bone
and recent concerns over the potential toxicity of gadolinium-based contrast cysts are also frequently observed in knees with OA and are a hallmark
agents in patients with severe renal impairment means that such methods feature of OA on CR. On MRI, they may be seen to develop with time within
warrant further development. an existing bone marrow lesion and are well-defined, rounded areas of fluidlike
The presence of knee synovitis and effusion is associated with pain,69,75,76 intensity (Fig. 185.18).101,102 These are not pure cysts because they lack an
and extensive synovitis is strongly associated with knee pain.69 Synovitis in epithelial lining and histologically represent bone trauma with necrosis and
knee OA is associated with longitudinal structural and pain progression77 increased bone turnover.103,104 Their prevalence increases with the severity
and joint replacement.78 Synovitis in hand OA is associated with longitudinal of radiographic knee OA.105
structural progression.79,80 Furthermore, fluctuations in synovitis over time Subchondral BMLs are the most frequently studied subchondral bone
have been associated with change in symptoms.76,81,82 MRI feature in OA. In the knee, BMLs are independently associated with
longitudinal structural progression and longitudinal change in pain severity
Fibrocartilage and ligament abnormalities but also joint replacement. BMLs in hand OA are associated with structural
Meniscal tears, degeneration, and extrusion are common in knee OA and progression.79,106 BMLs have also been used in clinical trials as clinical endpoints
can be detected on MRI (Fig. 185.17). Meniscal extrusion and degeneration and tissue targets with bisphosphonates in knee OA. In a randomized controlled
are major contributors to radiographic JSN,18 and the prevalence of MRI- (RCT) trial, zolendronic acid conferred a sustained reduction in size of BMLs
detected meniscal tears increases with increasing KL grade. Meniscal damage but only a temporary reduction in pain.107 More recently, an RCT of the
has also been associated with the incidence or enlargement of BMLs over bisphosphonate neridronate in painful knee OA conferred a sustained reduction
time.83 Degeneration and tearing of the fibrocartilage in other joints such as in pain and BML size.108 Subchondral bone cysts have no independent
the labrum of the shoulder, the hip, and the triangular fibrocartilage of the association with structural progression or pain.
wrist can also be detected with MRI.
Studies have suggested that ligament abnormalities seen on MRI may be Bone attrition
an early feature of the disease.84 The association of anterior cruciate ligament Within the femorotibial compartment, meniscal degeneration and malalignment
(ACL) tears and subsequent development and progression of radiographic have been associated with increased prevalence of bone attrition.109,110 Attrition
OA is well described. A high incidence of ACL changes has been reported is commonly seen in conjunction with BMLs, which are strongly associated
in MRI studies of OA patients, with the occurrence of complete ACL tear with the incidence of bone attrition in longitudinal studies.111 Attrition is
reported in up to 20% of one cohort.85 typically seen in advanced OA112 and is independently associated with greater
Magnetic resonance imaging studies to investigate the association of pain overlying cartilage loss,113 but it might occur in milder OA and earlier in
with meniscal tears have yielded conflicting results. However, in large cohort the disease than previously thought.112
analyses, meniscal degeneration is associated with longitudinal articular Subchondral bone attrition has no independent association with structural
cartilage thickness loss,86 pain progression, and BML volume.87 Studies of progression or pain. In hand OA, MRI-detected bone attrition has recently
ACL tears in OA have shown no association with pain.88 However, ACL tears been demonstrated to be associated with joint tenderness.71
occurring in younger adults expedite the incidence of OA and confer an
increased lifetime risk of need for total knee replacement.89 Osteophytes
Similar to other subchondral bone pathologies, osteophytes develop in
Subchondral bone marrow lesions and cysts association with increased mechanical load such as that seen with meniscal
The most commonly detected subchondral bone abnormality on MRI is the degeneration,114,115 ACL tear,116 malalignment,110,117 and cartilage damage.118
BML. They are commonly associated with damage in the overlying articular Although marginal osteophytes may be visualized with CR, central osteophytes
cartilage90,91 and represent bone microfracture, necrosis, fibrosis, and remod- are more easily detected with MRI. MRI studies have also demonstrated that
eling.92,93 They have a similar appearance to “bone marrow edema” seen in osteophytes are common in people with no knee symptoms even in the
inflammatory arthritides, which histologically are very different and represent absence of CR changes. MRI-determined osteophytes are independently
inflammatory osteitis. MRI is the only imaging modality that can identify associated with knee OA structural progression but not with pain.106

Three-dimensional bone shape

The shape of bones in the knee have a physiological “starting” shape that
is determined by height, age, weight.124 Osteoarthritis represents a failure to
effectively dissipate load within the joint tissues, and Wolff’s law describes
how bone shape readily changes in response to mechanical forces acting on
it.125,126 In particular, the articulating regions of knee bones typically expand
in 3D with structural progression of OA.127 The ACL, menisci, and normal
knee alignment are involved in effectively dissipating load within knees. It
is therefore interesting that in a 2-year longitudinal study of 117 patients
with knee OA, baseline extrusion of the medial meniscus was independently
associated with a longitudinal expansion of the medial tibial bone area.128
Malalignment is independently associated with a larger tibial bone area change
in the compartment with greater biomechanical load conferred by the
malalignment,129,130 and in normal knees of young healthy adults after ACL
tear, the 3D shape of the femur, tibia, and patella expands more rapidly than
in control participants without radiographic knee OA in the subsequent 5
years.131 These findings support the role of load in bone remodeling in the
pathogenesis of OA. Furthermore, bone shape is independently associated
with the outcome of total knee replacement,132 incident radiographic knee
OA,133 and pain and structural progression.134
a
Muscle
Quadriceps strengthening exercises are a recognized therapy for knee
OA that confers pain relief.135-137 More recent studies have attempted to
quantify the independent muscle imaging risk factors for OA structural
progression and these include low area and higher proportion of fat in the
muscle.138

QUANTIFICATION OF MAGNETIC RESONANCE IMAGING

PATHOLOGIC CHANGES
Magnetic resonance imaging of joint pathology can essentially be divided
into semiquantitative and quantitative outcomes and tissues can be assessed
by morphology or composition.

Multiple tissue evaluation

Trained readers can semiquantitatively describe the severity of OA structural
pathology on MRI, typically using an ordinal scale (e.g., 0,1, 2 and 3). There
are a variety of different semiquantitative scoring systems for the knee,139-142
hip,39,143-145 and hand146 that assess multiple tissues in this joint with OA.
b However, some semiquantitative scoring systems focus a single tissue such
as cartilage structural damage,147 BMLs,148 ligaments,149 meniscus,150 and
FIG. 185.18 Sagittal T2-weighted fat-suppressed magnetic resonance images of the synovitis.151
knee. (a) Bone marrow lesions (BMLs) with an edematous pattern (arrow) are apparent For evaluating multiple tissue features of knee OA, MRI semiquantitative
on the anterior lateral trochlea. (b) Image taken 6 months later shows that these scoring systems include the Boston Leeds Osteoarthritis Knee Score (BLOKS),
lesions have become cystic in nature (arrows). Note also the articular cartilage loss the Whole-Organ MRI Score (WORMS), the Knee Osteoarthritis Scoring
overlying the BMLs. System (KOSS),139,140 and more recently the MRI Osteoarthritis Knee Score
(MOAKS).142 Each of these measurement tools divides the knee into various
anatomical subregions and uses ordinal scales to describe the structural
severity of multiple tissues within these subregions.152
Reliable, responsive, and validated semiquantitative scoring systems such
as MOAKS and WORMS have been applied to multicenter, large-scale, cross-
Bone erosion sectional, and longitudinal observational epidemiologic studies.153 These
Bone erosions are typically considered a feature of primary inflammatory systems have been used by researchers to understand associations of structural
arthritides. However, an inflammatory hand OA phenotype with swollen tissue pathologies with pain57,106 and structural progression77 and to evaluate
joints and radiographic erosions is well described, although it is not clear the effects of therapies on structural progression in several clinical trials in
if this represents a distinct subset of hand OA or part of the spectrum of OA.154,155 Semiquantitative systems specifically for scoring synovitis, which
severity. Erosive hand OA (EHOA) has been associated with the metabolic have been validated against the more time-consuming gold standard of synovial
syndrome, which may confer a distinct etiopathogenesis. However, imaging volumetric analysis, have also been described.151,156 Training sets, teaching
studies suggest it may be part of a spectrum of severity. EHOA has been atlases, and an electronic template overlying MRI scans can improve reader
distinguished from nonerosive hand OA (NEHOA) by the presence or absence reliability.157
of interphalangeal joint radiographic OA erosions in the context of hand The Oslo Hand Osteoarthritis MRI (OHOA-MRI) score was developed
OA. MRI and US evidence indicates that erosions may be present even in as a semiquantitative scoring system assessing multiple tissue pathologies
NEHOA,119,120 with MRI detecting approximately twice as many joints with in the proximal and distal interphalangeal joints and excluded metacar-
erosions compared with CR.121 Furthermore, when comparing radiographic pophalangeal (MCP) and carpometacarpal (CMC) joints.146 Despite good
EOA and NEHOA with US and MRI imaging, inflammatory structural features reliability and validity for the assessment of inflammatory and structural
such as synovitis, effusions, and erosions were frequently detected in both features in HOA,158 it was time consuming and included features such as
groups.120 When comparing the frequency of OA symptoms in joints with collateral ligament pathology and flexor tenosynovitis that are uncommon,
and without radiographic erosive hand OA, the frequency of joint OA with lower reliability and no relation to pain. It has been subsequently itera-
symptoms are comparable to joints with moderate to severe radiographic tively modified by OMERACT methodology into the Hand Osteoarthritis
OA (KL score ≥3) and more common than in milder forms of structural MRI scoring system (HOAMRIS).159
radiographic OA severity (KL score ≥2).122 In longitudinal analyses, EHOA In 2011, Roemer and a multidisciplinary consensus committee published
has more frequent and severe synovitis, pain, and radiographic structural the semiquantitative Hip OA MRI Scoring system (HOAMS).39 This incorporates
progression compared with NEHOA.79,123 These analyses suggest that erosive 14 structural pathologies scored within subregions of the hip joint. The
OA sits on the severe end of the spectrum of symptomatic and structural subregional division varies according to which MRI structural feature is
severity of hand OA. being assessed. The Hip Inflammation MRI Scoring System (HIMRISS)

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1564 SECTION 16 Osteoarthritis
subregional joint scoring of OA was designed to emphasize evidence of active
inflammation and does not incorporate the measurement of untreatable and
HAND MAGNETIC RESONANCE IMAGING
established structural pathology.160 It is more complex than HOAMS scoring Hand MRI should include the fingers, especially the proximal interphalangeal
despite only focusing on “inflammation” features (bone marrow lesions and (PIP) and distal interphalangeal (DIP) joints and possibly the first CMC. It
a composite of synovitis and effusion). is critically important to use an acrylic positioning frame and biplanar slice
Compared with quantitative measures, semiquantitative systems use a alignment to ensure the tomography is reproducible. The ideal sections to
simpler and quicker process for assessing structural pathology than segmenta- read are triplanar but if restricted by feasibility, coronal and possibly sagittal
tion of tissues, but the ordinal scales may not be interval variables and may sections should be acquired. Furthermore, STIR and high-resolution, fat-
be less sensitive to change.161 As a consequence, the measurement of longi- suppressed 3D gradient echo should be included in the pulse sequences
tudinal structural change with semiquantitative measures has evolved to with or without postcontrast T1-weighted sequences. The HOAMRIS is the
incorporate “within-grade” scoring changes to improve longitudinal sensitivity most developed method for reading hand MRIs and therefore this is recom-
to change.162,163 A meta-analysis of the responsiveness and reliability of mended for its use in MRI trials.10
semiquantitative and quantitative measures of BMLs and cartilage in knee
OA found that the pooled standardized response means for both methods
were adequate to good and comparable.164
KNEE MAGNETIC RESONANCE IMAGING
Magnetic resonance imaging–determined cartilage morphometry assessment
is recommended as an outcome measure for clinical trials in light of existing
QUANTITATIVE IMAGING ANALYSIS evidence for construct and predictive validity, with good evidence for reliability
Quantitative imaging analysis of structural lesions in joints with OA involves and responsiveness. Measuring change in MRI knee cartilage morphometry
the segmentation of tissues, which is usually performed manually or using is accurate and feasible over 12 months in trials of OA structure modification.
semiautomated methods. The segmentation of tissues permits the quantification By including BMLs or meniscal extrusion, higher KL grades and maligned
of tissue characteristics such as cartilage thickness,165 cartilage volume,166 knees, at baseline, the study population of a trial can be “enriched” to
bone marrow lesion volume,167 synovial volume,168 muscle area,138 and even increase the rate of cartilage loss. The role of MRI semiquantitative and
3D bone shape.132 Serial measurements of cartilage volume or thickness compositional measures of cartilage in OA trials is currently uncertain.52
provide quantitative data with which to monitor structural progression of
OA.150,169 The natural rate of change in osteoarthritic joint tissues may be
very slow and detecting structural progression (cartilage loss) and therefore
ULTRASONOGRAPHY
requires great reliability and accuracy in the segmentation process. This Ultrasonography is a real-time imaging modality that permits dynamic mul-
typically requires labor-intensive methods, expert analysis, specialized tiplanar assessment of joints and provides a 3D aspect that is not achieved
computer software, special training of segmenters, and quality control with plain radiography. US is a noninvasive, cost-effective, and widely
procedures. The imaging sequences required for quantitative measures differ available “bedside” technique that minimizes inconvenience and discomfort
from semiquantitative grading because the precise distinction of the osteo- to the patient and involves no radiation. This improves the feasibility of the
chondral interface and cartilage surface is essential, and spatial resolution evaluation of multiple joints in a single sitting and the repeated evaluation
is of greater importance.170 A subset of core measures that comprehensively of peripheral joints. If injections or aspirations are required, US guidance
describes cartilage morphology, and its longitudinal change has been can improve the accuracy of needle placement.173 The ultrasonic waves that
described.171 are used for generating US images are elastic mechanical waves that require
The responsiveness and reliability of semiquantitative and quantitative elastic or viscoelastic medium for propagation in a similar manner to sound.
measures of BMLs and cartilage in knee OA have been good using trained Therefore, US cannot visualize structures beneath or within tissues that are
readers.52,164 not viscoelastic (e.g., bone) or that are sufficiently deep to the skin for the
echo to be detected (e.g., cartilage in the center of the knee). US imaging is
operator dependent and is therefore also limited by the proficiency of the
CONSIDERATIONS FOR RESEARCH ultrasonographer.
Magnetic resonance imaging–determined quantitative and semiquantitative The majority of work assessing the validity of US has been based on
measurements of joint tissue in OA have started to be used as clinical outcome inflammatory arthritis. US has been shown to be more accurate than CR at
measures in structure-modification DMOAD trials. This reflects the opinion detecting cortical erosions in inflammatory arthritis and comparable to MRI.174
of the OARSI working group that recommend MRI cartilage morphology US detects structural pathology in three dimensions.
assessment be used as a primary structural endpoint in clinical trials which
also acknowledged the rapid evolution of quantitative MRI assessments of WHAT PATHOLOGIC FEATURES CAN ULTRASONOGRAPHY
subchondral bone and synovium.52,172
The cost and technical demands of performing clinical trials with endpoints
ASSESS IN OSTEOARTHRITIS?
defined by CR and MRI might favor CR based on cost and accessibility. Ultrasonography can demonstrate a wide spectrum of structures, including
However, although CR is inexpensive and easily accessible, the relative the bony cortex, tendons, ligaments, bursae, and peripheral aspect of the
insensitivity and poor responsiveness confers the need for large numbers of menisci. US has been used to assess hand OA, with studies largely in people
participants with long duration (>2 years) compared with MRI bone and with erosive OA; effusions and gray-scale synovitis were noted in up to half
cartilage imaging biomarkers. The additional expense of MRI and image of the DIP and PIP joints assessed.175,176 Synovitis and effusion were particularly
analysis is likely to be offset by the substantial reduction in trial size and prevalent in those with erosive OA rather than nonerosive OA.177
duration, which may ultimately facilitate the development of prospective
DMOADs Synovitis
The OARSI group has recently published expert opinion, consensus-driven In OA, a major advantage of US over CR is that it can detect synovial
recommendations to provide detail on how to apply hip, knee, and hand pathology. This includes synovial fluid effusion (Fig. 185.19), synovitis (Fig.
imaging in disease-modifying clinical trials of OA.10,52,53 185.20), and increased vascularity or power Doppler signal. Synovitis and
effusion are commonly detected in patients with OA, with between 47% and
100% of patients having synovitis or effusion on US examination of a
HIP MAGNETIC RESONANCE IMAGING symptomatic knee.178 US detection of gray-scale synovitis has been validated
For hip OA, change in cartilage morphometry over 12 to 18 months can be against arthroscopic biopsy results and MRI detection of synovitis in large-
feasibly and accurately measured using MRI. Therefore, the use of MRI for joint OA.
assessing cartilage morphometry in trials of OA structure modification is Reliable synovitis scoring methods have been established in rheumatoid
recommended. arthritis179 and more recently developed in knee OA.180
Current assessment of quantitative hip cartilage morphometry (e.g., In OA, US generally demonstrates low-grade synovitis, but more severe
cartilage volume) with MRI requires improved responsiveness and better synovitis (indicated by the presence of synovitis with power Doppler signal)
assessment of the sensitivity and specificity before it is recommended as an was associated with the appearance of new bone erosions,181 and radiographic
outcome measure. However, semiquantitative evaluation of cartilage mor- structural progression182,183 in hand OA.
phometry is recommended as an outcome measure in OA trials. In knee OA US-detected knee synovial effusion (synovitis) is associated
Although OA affects all of the tissues within the joint, noncartilage with Western Ontario McMaster University Osteoarthritis Index (WOMAC)
pathology measures may be developed as potential structural outcome scores in knee OA cross-sectional analysis,184 and in longitudinal studies,
measures, but further assessments of their validity is required.53 US-detected synovial effusion in knee OA is associated with joint replacement

Osteophytes
Ultrasonography can detect early bone changes in OA as a hyperechoic signal
in the area of the attachment of the joint capsule to the bony cartilaginous
margin. This corresponds with the eventual appearance of osteophytes seen
on the conventional radiograph.192 US can detect established osteophytes in
OA joints.193 However, pathologic changes deep to the cortex such as sub-
chondral bone changes (e.g., BMLs) cannot be visualized.
Ultrasonography has excellent reliability in the assessment of osteo-
phytes in the hand, hip, and knee.180,184,191 US is more sensitive than CR in
detecting osteophytes in hand OA,194 especially at the MCP joints,195 and
knee OA.187
Eff In cross-sectional analyses of knee OA, US-determined osteophytes cor-
related well with CR-detected osteophytes187 arthroscopically determined
cartilage pathology196 and with symptomatic severity (WOMAC) in knee
OA.184 Further validation is required before considering US-determined
osteophytosis as an outcome measure in clinical trials.

Menisci
Existing analyses of US-determined meniscal degeneration in the knee indicate
a good reliability of assessment.180,184,197 Although MRI has established the
importance of meniscal degeneration in the pathogenesis of OA, further
validation of US-determined meniscal assessment is required before considering
its utility in clinical trials. One advantage of US over MRI is in the imaging
of extruded meniscus. The measurement of this is more feasible with US
while weight bearing.198

Quantification of ultrasound imaging pathologic changes

FIG. 185.19 Sonogram of the knee joint (taken longitudinally through the suprapatellar To date, most US quantification systems have been semiquantitative. Keen
pouch). The anterior cortex of the femur is shown (black arrowheads). A knee joint and colleagues developed a scoring system for hand OA features on US. This
effusion (Eff) and synovitis are apparent in the suprapatellar pouch (white arrows). evaluated power Doppler and gray-scale synovitis in 15 joints in the hands.
These features were scored (if present) using an ordinal semiquantitative
scale (0–3) with moderately good reliability.199 A global hand OA semiquantita-
tive system measuring cartilage damage and osteophytes in DIP, PIP, and
MCP joints has also been described.191 In knee OA, semiquantitative scoring
has been used to quantify synovitis, cartilage damage, medial meniscal damage,
and osteophytes with fair to good reliability.180

CONSIDERATIONS FOR RESEARCH

The progression of radiographic JSN is slow and only occurs in a small
proportion of patients even in carefully selected cohorts; hence, large numbers
of patients need to be followed for a minimum of 2 years in DMOAD studies.
With modern imaging techniques, short-term changes of novel outcome
measures may better reflect long-term changes in patient outcomes and thus
make randomized trials more feasible. Although US-determined structural
outcome measures are not recommended as primary outcome measures in
clinical trials, the latest OARSI Task Force review of clinical trial recommen-
dations for hand OA supports the use of ultrasonography to assess exploratory
Tib outcomes and assess structural damage as well as joint inflammatory
activity.200

Tal
OTHER IMAGING MODALITIES
FIG. 185.20 Sonogram taken longitudinally across the anterior ankle joint. Severe SCINTIGRAPHY
synovitis is filling the anterior joint space (arrowheads). Tal, Talus; Tib, tibia. Bone scintigraphy is an imaging modality that reflects alterations in the
metabolic activity of bone through the use of radiopharmaceutical agents,
in knee OA.185 Intraarticular corticosteroid therapy reduced US-detected commonly technetium 99m–labeled methylene diphosphonate (MDP). This
synovial thickening, effusion, and power Doppler signal in knee OA.186 compound accumulates rapidly in bone by adsorption to the mineral phase
of bone. Imaging with a gamma camera detects areas of isotope accumulation
Cartilage representing points of high skeletal bone turnover.
The validity of US to assess OA varies according to the joint being imaged. Early studies using scintigraphy in nodal hand OA demonstrated increased
Superficial articular cartilage can be identified using US. However, US cannot activity in the subchondral bone before any typical radiographic changes
“see” through bone structures because of the limited acoustic window. were seen in OA. A later study involving patients with chronic knee pain
Therefore, in the knee, superficial regions of cartilage can be reliably evaluated compared scintigraphy findings with MRI findings and demonstrated good
by US,180 but it is not feasible to visualize the central load-bearing regions correlation between MRI-detected subchondral bone lesions and isotope
of the joint which typically degenerate in OA. In cross-sectional analysis, uptake.201 Scintigraphy (likely through detection of BMLs seen on MRI) has
US-detected cartilage pathology of the knee is associated with the existing predicted disease progression in OA. Normal bone scan findings at baseline
construct of radiographic JSN187 and knee OA symptoms (WOMAC score).184 in individuals with established OA were highly predictive of a lack of radio-
Measuring cartilage thickness by US in the hand requires perpendicular graphic disease progression (as determined by measurement of joint space
assessment of the cartilage plates. Oblique rather than perpendicular insonation width) at 5 years.202
of cartilage plates may overestimate cartilage thickness.188 Osteophytes typically Scintigraphy is inexpensive and readily clinically available; however, despite
hinder the acoustic window in DIP and PIP joints. Although MCP cartilage the sensitivity of the technique, it shows low specificity and is associated
is more feasible for assessment, conflicting reports of adequate189,190 and with a significant radiation dose. For these reasons, it has limited clinical
inadequate191 reliability for this assessment have been reported. applicability in OA.

COMPUTED TOMOGRAPHY AND COMPUTED progression on OA severity. When imaging is required, CR is the first-line
choice before other modalities. To optimize the detection of OA features with
TOMOGRAPHIC ARTHROGRAPHY CR, the radiographic view is important. This is particularly true for the knee
Computed tomography (CT) is a cross-sectional digital imaging method when weight-bearing and patellofemoral views are recommended. To make
based on advanced radiographic technology. It is particularly effective at additional diagnoses, bone is best imaged with CT or MRI, and soft tissues
depicting cortical bone and may be useful when detailed presurgical planning are best imaged with US or MRI. Based on existing evidence, imaging features
is required or when validation of MRI imaging is required for subchondral of OA do not predict clinical response to medical (nonsurgical) therapies,
bone pathology. CT has an established role in assessing facet joint OA of and therefore imaging is not recommended to predict treatment response.
the spine. CT arthrography, using a contrast medium, has the ability to Finally, the accuracy of administering intraarticular corticosteroids may be
clearly image the articular surface of a joint, and this technique is comparable improved using imaging guidance. The decision to use imaging guidance
to MRI for qualitative assessment of knee cartilage. This may be particularly should be determined by the skill of the medical practitioner and the technical
useful when MRI is unavailable or contraindicated. CT has low soft tissue difficulty of the joint injection. This may be greater because difficulty in
contrast and therefore gives no information on the intrinsic structure of the obtaining intraarticular access (e.g., the hip joint, joints in obese patients,
cartilage. CT also confers the highest radiation dose of any imaging modality. or where joints are deformed). These recommendations have recently been
CT therefore has no established role in OA trials or clinical practice. presented.208
Currently, 3D CT scanning has been used in hip OA and has described
the co-localization of posterior osteophytes and JSN.203 This may be relevant
to future research in defining OA phenotypes and accurate structural disease
CONSIDERATIONS FOR FUTURE RESEARCH
assessment. A future research agenda should include methodologically robust studies to
describe the additional value of any modality of imaging to the differential
diagnosis and clinical diagnosis of OA and in describing imaging features
POSITRON EMISSION TOMOGRAPHY that may predict response to specific therapies. Imaging studies should also
Positron emission tomography (PET) demonstrates metabolic changes in be used to attempt to identify subgroups or phenotypes with different tra-
target tissues and reflects glucose metabolism in different tissues.18 Fluoro- jectories to facilitate targeted therapy based on these subgroups. Further
deoxyglucose (FDG)-PET can identify sites of synovitis and BMLs in OA.204 imaging studies are required to determine if serial imaging biomarkers can
The role of PET in assessing OA is not yet established, and limitations be used to measure response to therapy and if this is associated with any
include its poor anatomical resolution, cost, and exposure to ionizing radiation. clinical benefit. For example, novel imaging technologies may sensitively
However, a cross-section of individuals with or at risk of radiographic hip detect change in relevant joint structures, but their relationship with clinical
OA had MRI and PET imaging. PET signal was associated with increasing response should be explored. The potential advantages of imaging-guided
radiographic severity, but longitudinal analyses are required to further explore or -delivered therapy should be explored in case it improves the efficacy of
this association.205,206 the therapy. Most imaging studies for OA focus on the knee, but the benefits
of imaging less commonly studied OA sites (e.g., the foot and shoulder)
should be considered. The added value of weight-bearing compared with
CONSIDERATIONS FOR CLINICAL PRACTICE207 non–weight-bearing CR for hip OA should also be explored.
Recent European League Against Rheumatism evidence-based recommen-
dations, informed by meta-analyses, for the use of joint imaging in clinical
practice for the management of OA have been described.208 First, joint imaging
SUMMARY
is not necessary to diagnose OA in patients with a typical presentation of Radiography is still a useful imaging investigation for evaluating a person
OA. This includes activity-related pain, with a short duration of morning with suspected OA because of its low cost and widespread availability and
stiffness, which affects one or a few joints in individuals older than 40 the ease of interpreting the results. The ability of MRI to evaluate the knee
years. However, joint imaging is recommended to confirm the diagnosis as a whole organ and to assess cartilage composition has made it invaluable,
of OA or alternative or additional diagnoses with atypical presentations both for understanding the natural history of the disease and for guiding
of OA. Routine or serial imaging in OA follow-up is not recommended future treatments. US can play an important role in diagnosing OA and in
unless a change in clinical characteristics or an unexpected rapid progression monitoring synovitis and response to treatment. The other modalities discussed
of symptoms occurs. In this context, further imaging (e.g., US or MRI) may be used on a case-by-case basis but do not have a routine role in OA
may help distinguish if this change relates to an additional diagnosis or investigation or management.

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Imaging of Osteoarthritis

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Imaging of Osteoarthritis

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185 Imaging of osteoarthritis

Andrew J. Barr • Claire Y.J. Wenham • Andrew J. Grainger • Philip G. Conaghan

THE PATHOLOGIC FEATURES OF OA DETERMINE THE CHARACTERISTIC

Increased activity of Increased subarticular

FIG.185.9 Thicker and less well-spaced trabeculae. Part of a macroradiograph of a

FIG. 185.7 Radiographic changes in osteoarthritis (OA). (a) Hypertrophic OA of the

Conventional radiography in advanced osteoarthritis

Hand conventional radiography

FIG. 185.13 Coronal oblique T1-weighted fat-suppressed magnetic resonance

FIG. 185.17 Coronal T2-weighted fat-suppressed magnetic resonance image of the

Three-dimensional bone shape

QUANTIFICATION OF MAGNETIC RESONANCE IMAGING

Multiple tissue evaluation

Quantification of ultrasound imaging pathologic changes

CONSIDERATIONS FOR RESEARCH

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