Superiority of the Lyon schuss view over the standing anteroposterior view for detecting joint space narrowing, especially in the lateral tibiofemoral compartment, in early knee osteoarthritis

The Association between Radiographic Features and the Duration of Effectiveness of a Single Injection of Extended-Release Hyaluronic Acid (HANOX-M-XL) in Patients with Knee Osteoarthritis: Preliminary Results of a Prospective Trial

BACKGROUND

Advanced radiological stage of knee osteoarthritis (OA) is predictive of poor response to viscosupplementation (VS). To date, the impact of x-ray features on the duration of effectiveness (DE) of VS has not been investigated.

OBJECTIVES

To investigate the radiological features associated with DE of VS in patients with knee OA.

METHODS

Cross-sectional study in patients with knee OA treated with 1 injection of cross-linked hyaluronic acid (HA). The primary outcome was DE, self-assessed by the patients in weeks of effectiveness. Radiological features (joint space narrowing-JSN topography and Kellgren-Lawrence [K-L] grade) associated with DE were studied.

RESULTS

Fifty-one patients-33 females (76 knees)-were analyzed. The average DE was 52.0 (24.7) weeks (range, 13-155 weeks). In the bivariate analysis, DE was 14 weeks longer in those with K-L grades 1 and 2 (62.6 ± 36.4 weeks) than in those with K-L 3 and 4 (48.9 ± 18.6) (P = 0.03). DE was not significantly different according to the involved compartment(s). It was significantly longer in men than in women (60 ± 31.4 vs. 47 ± 16 weeks; P = 0.035). In multivariate analysis, K-L grade (1-2 vs. 3-4) (P = 0.007), male gender (0.02), and older age (0.04) were independently associated with a longer DE.

CONCLUSION

DE of a single injection of extended-release HA is longer in K-L 1-2 than in K-L 3-4 OA knees, regardless of the JSN topography. However, even the patients with more advanced OA benefited from HANOX-M-XL injection for an average duration barely less than 1 year.

An assessment of the dose and image quality difference between AP and PA positioned adult radiographic knee examinations

INTRODUCTION

Knee X-rays are a standard examination to diagnose multiple conditions ranging from traumatic injuries, degeneration, and cancer. This study explores the differences between adult Anterior-Posterior (AP) and Posterior-Anterior (PA) weight-bearing knee examinations using absorbed radiation dose data and image quality.

METHODS

The study modelled and compared AP and PA knee X-ray radiation dose data using Monte-Carlo software, an Ion Chamber, and thermoluminescence dosemeters (TLDs) on a Rando phantom. Imaging parameters used were 66kVp, 4mAs, 100cm distance and 13 × 24cm collimation. The interval data analysis used a two-tailed t-test. The image quality of a sample of the AP and PA knee X-rays was assessed using Likert 5-point ordinal Image Quality Scoring (IQS) and the Wilcoxon matched pairs test.

RESULTS

Monte-Carlo modelling provided limited results; the Ion Chamber data for absorbed dose provided no variation between AP and PA positions but was similar to the AP TLD dose. The absorbed doses recorded with batches of TLDs demonstrated a 27.4% reduction (46.1μGy; p=0.01) in Skin Entrance Dose (ESD) and 9 - 58% dose reduction (1.6 - 16.4μGy; p=0.00-0.2) to the tissues and organs while maintaining diagnostic image quality (p=0.67).

CONCLUSION

The study has highlighted the various challenges of using different dosimetry approaches to measure absorbed radiation dose in extremity (knee) X-ray imaging. The Monte-Carlo simulated absorbed knee dose was overestimated, but the simulated body organ/tissue doses were lower than the actual TLD absorbed doses. The Ion Chamber absorbed doses did not differentiate between the positions. The TLD organ/tissue absorbed doses demonstrated a reduction in dose in the PA position compared to the AP position, without a detrimental effect on image quality. The study findings in laboratory conditions raise awareness of opportunities and potential to lower radiation dose, with further study replicated in a clinical site recommended.

Correlation of tibiofemoral joint-space width with the clinico-radiological scoring of knee osteoarthritis – a comparison between anteroposterior and lyon-schuss radiographic views

Background

The degree of joint space narrowing measured on radiographs provide a reliable estimate of the extent and severity of Osteoarthritis (OA) of the knee. While the standing antero-posterior (AP) view radiographs have been used traditionally, recent studies suggest that the Lyon-Schuss (LS) view is able to detect early OA changes better. The present study was, therefore, conducted to make an objective comparison between the two views with respect to their corelation with the patient's clinical and radiological scores.

Methods

Forty patients (80 knees) were included in this cross-sectional study. Medial as well as lateral tibiofemoral joint space widths (JSW) were measured using vernier callipers on printed, calibrated radiographic images. Knee Society Score (Function) (KSS-F) was used as the clinical outcome measure while Ahlbäck grade was used for determining radiological severity. JSW was correlated with KSS-F and the Ahlbäck grade using Spearman's rho correlation coefficient. Reproducibility of the method was assessed using the intra-class correlation coefficient (ICC).

Results

Average age of the participants was 60 ± 7.65 (range 50–78) years, with 18 males and 22 females. ICC for intraobserver reliability was 0.97 and for inter-observer reliability, was 0.91 (AP view) and 0.92 (LS view), respectively. Medial JSW measurements taken on the AP view were found to have a significantly higher degree of correlation with both KSS-F and Ahlbäck grade ( p  < 0.05) than those obtained from the LS view.

Conclusion

Although the LS view may be more sensitive for detecting early OA changes in knee, particularly in the lateral tibiofemoral compartment, the present study shows that AP view correlates better with the patient's overall clinical and radiological profile.

CircSLC7A2 protects against osteoarthritis through inhibition of the miR-4498/TIMP3 axis

Objectives

Circular RNAs (circRNAs) are noncoding RNAs that compete against other endogenous RNA species, such as microRNAs, and have been implicated in many diseases. In this study, we investigated the role of a new circRNA (circSLC7A2) in osteoarthritis (OA).

Materials and Methods

The relative expression of circSLC7A2 was significantly lower in OA tissues than it was in matched controls, as shown by real‐time quantitative polymerase chain reaction (RT‐qPCR). Western blotting, RT‐qPCR and immunofluorescence experiments were employed to evaluate the roles of circSLC7A2, miR‐4498 and TIMP3. The in vivo role and mechanism of circSLC7A2 were also conformed in a mouse model.

Results

circSLC7A2 was decreased in OA model and the circularization of circSLC7A2 was regulated by FUS. Loss of circSLC7A2 reduced the sponge of miR‐4498 and further inhibited the expression of TIMP3, subsequently leading to an inflammatory response. We further determined that miR‐4498 inhibitor reversed circSLC7A2‐knockdown‐induced OA phenotypes. Intra‐articular injection of circSLC7A2 alleviated in vivo OA progression in a mouse model of anterior cruciate ligament transection (ACLT).

Conclusions

The circSLC7A2/miR‐4498/TIMP3 axis of chondrocytes catabolism and anabolism plays a critical role in OA development. Our results suggest that circSLC7A2 may serve as a new therapeutic target for osteoarthritis.

Contemporary knee arthroplasty: one fits all or time for diversity?

INTRODUCTION

Total knee arthroplasty (TKA) has historically been the preferred solution for any type of knee osteoarthritis, independently of the number of compartments involved. In these days of patient-specific medicine, mono-compartmental disease could also be approached with a more individualized treatment, such as partial knee arthroplasty (PKA). Off-the-shelf (OTS) implants are often the compromise of averages and means of a limited series of anatomical parameters retrieved from patients and the pressure of cost control by limited inventory. Personalized medicine requires respect and interest for the individual shape and alignment of each patient.

MATERIALS AND METHODS

A Pubmed and Google Scholar search were performed with the following terms: "patient-specific knee" and "arthroplasty" and "custom implant" and "total knee replacement" and "partial knee replacement" and "patellofemoral knee replacement" and "bicompartmental knee replacement". The full text of 90 articles was used to write this narrative review.

RESULTS

Unicondylar, patellofemoral and bicompartmental knee arthroplasty are successful treatment options, which can be considered over TKA for their bone and ligament sparing character and the superior functional outcome that can be obtained with resurfacing procedures. For TKA, where compromises dominate our choices, especially in patients with individual variations of their personal anatomy outside of the standard, a customized implant could be a preferable solution.

CONCLUSION

TKA might not be the only solution for every patient with knee osteoarthritis, if personalized medicine wants to be offered. Patient-specific mono-compartmental resurfacing solutions, such as partial knee arthroplasty, can be part of the treatment options proposed by the expert surgeon. Customized implants and personalized alignment options have the potential to further improve clinical outcome by identifying the individual morphotype and respecting the diversity of the surgical population.

Fixed-flexion view X-ray of the knee superior in detection and follow-up of knee osteoarthritis

A fixed flexion view (FFV) is useful for evaluating joint space when assessing the severity of osteoarthritis (OA) of the knee. We analyzed changes in joint space revealed by standing extended view (SEV) and FFV over a mean 4 years, to compare both views on their capacity to measure joint space width accurately at particular time points during follow-up.SEV and FFV images were acquired in patients with knee OA. The 81 patients (157 knees) followed up for ≥24 months were selected as study subjects. Medial joint space widths (MJSW), Kellgren-Lawrence (KL) grades, and reductions in MJSW on SEV (ΔSEV) and FFV (ΔFFV) were compared in knees evaluated by SEV and FFV.At both time-points, mean MJSW was significantly lower by FFV than by SEV. Mean MJSW was significantly lower at follow-up than at first examination by both SEV and FFV. At both time-points, the KL grade was higher by FFV than by SEV group. The ΔFFV was significantly greater than the ΔSEV. ΔSEV did not differ significantly among KL grades, but ΔFFV was significantly greater in patients with KL grade II than in patients with other KL grades.FFV is not only useful for evaluating joint space in knees with OA, but also for accurately evaluating the progression of OA. The risk of rapid progression of knee OA may be higher in patients with KL grade II, as determined by FFV. FFV may be superior to SEV in determining appropriate treatment strategies for knee OA.

EULAR recommendations for the use of imaging in the clinical management of peripheral joint osteoarthritis

The increased information provided by modern imaging has led to its more extensive use. Our aim was to develop evidence-based recommendations for the use of imaging in the clinical management of the most common arthropathy, osteoarthritis (OA). A task force (including rheumatologists, radiologists, methodologists, primary care doctors and patients) from nine countries defined 10 questions on the role of imaging in OA to support a systematic literature review (SLR). Joints of interest were the knee, hip, hand and foot; imaging modalities included conventional radiography (CR), MRI, ultrasonography, CT and nuclear medicine. PubMed and EMBASE were searched. The evidence was presented to the task force who subsequently developed the recommendations. The strength of agreement for each recommendation was assessed. 17 011 references were identified from which 390 studies were included in the SLR. Seven recommendations were produced, covering the lack of need for diagnostic imaging in patients with typical symptoms; the role of imaging in differential diagnosis; the lack of benefit in monitoring when no therapeutic modification is related, though consideration is required when unexpected clinical deterioration occurs; CR as the first-choice imaging modality; consideration of how to correctly acquire images and the role of imaging in guiding local injections. Recommendations for future research were also developed based on gaps in evidence, such as the use of imaging in identifying therapeutic targets, and demonstrating the added value of imaging. These evidence-based recommendations and related research agenda provide the basis for sensible use of imaging in routine clinical assessment of people with OA.

Radiographic Measurement of Joint Space Width Using the Fixed Flexion View in 1,102 Knees of Japanese Patients with Osteoarthritis in Comparison with the Standing Extended View

Purpose

The fixed flexion view (FFV) of the knee is considered useful for evaluating the joint space when assessing the severity of osteoarthritis (OA) of the knee. To clarify the usefulness of FFV for evaluation of the joint space and severity of knee OA, this study evaluated changes in the joint space on the FFV and standing extended view (SEV) in patients with knee OA.

Materials and Methods

The SEV and FFV images were acquired in 567 patients (1,102 knees) who visited the hospital with a chief complaint of knee joint pain. Medial joint space width (MJSW) and Kellgren-Lawrence (K-L) classification assessed using the SEV and FFV images were compared.

Results

Mean MJSW was significantly smaller when assessed on the FFV than on the SEV (3.02±1.55 mm vs. 4.31±1.30 mm; p<0.001). The K-L grade was the same or higher on the FFV than on the SEV.

Conclusions

The FFV is more useful than the SEV for evaluating the joint space in OA knees. Treatment strategies in patients with knee OA should be determined based on routinely acquired FFV images.

A new quantitative measure for radiologic osteoarthritis of the lateral knee compartment distinguishes patients with longstanding lateral meniscectomy from non-pathological knees

PURPOSE

Common radiologic scores to evaluate knee osteoarthritis (OA) have been widely used but are descriptive and may lack objectivity. The aim of this study was to develop a quantitative and objective radiologic measure for the evaluation of lateral knee compartment OA. Furthermore, we tested the reliability of this new measure and its correlation to well-accepted radiologic scores.

METHODS

This retrospective study was performed within the context of a multi-centre long-term follow-up (15-25 years) of a patient cohort after partial or total lateral meniscectomy (n = 36 knees). In addition, 99 radiographs of clinically and radiologically normal knees were obtained from a control group. Anteroposterior weight-bearing views (0°) and Schuss (45°) views were analysed. The joint height of the lateral knee compartment was measured on the lateral border (lateral joint space height) and in the centre (central joint space height, CJSH) and normalized with respect to the width of the lateral compartment (X). All measurements were taken independently by two observers, allowing for inter- and intra-observer reliability assessments. The results of the two groups were compared using an analysis of covariance. Finally, the correlations between the results and the Fairbank and Kellgren & Lawrence scores were determined using a Spearman ρ rank order correlation.

RESULTS

The normalized joint space height in the centre of the compartment on the Schuss view (CJSH/X) showed the highest intra- (ICC = 0.980) and inter-observer reliability (ICC = 0.982). There was a significant difference in CJSH/X between the control (0.19 ± 0.05) and the meniscectomized knees (0.08 ± 0.07) (p < 0.001). CJSH/X showed a significant decline of 11 % per 10 years in the meniscectomy group. A negative correlation could be found between CJSH/X and the Fairbank (ρ = -0.751; p < 0.001) and Kellgren & Lawrence scores (ρ = -0.712; p < 0.001). A cut-off value of 0.14 of CJSH/X was defined-representing one standard deviation below the mean of the control group-from which measurements were considered as pathologic.

CONCLUSION

The normalized joint space height measured in the centre of the lateral knee compartment from a Schuss view, CJSH/X, was highly reproducible and showed a significant correlation to established radiologic scores. This new measure has the advantage of being objective and dimensionless and thus independent of the size of the radiograph. The normative values provided by our healthy control knees are useful to help establish an early diagnosis of radiologic lateral knee compartment OA.

LEVEL OF EVIDENCE

Retrospective diagnostic study, Level III.

The Combination of the Tunnel View and Weight-Bearing Anteroposterior Radiographs Improves the Detection of Knee Arthritis

Imaging used for the evaluation of knee pain has historically included weight-bearing anteroposterior (AP), lateral, and sunrise radiographs. We wished to evaluate the utility of adding the weight-bearing (WB) posteroanterior (PA) view of the knee in flexion. We hypothesize that (1) the WB tunnel view can detect radiographic osteoarthritis (OA) not visualized on the WB AP, (2) the combination of the AP and tunnel view increases the radiographic detection of OA, and (3) this may provide additional information to the clinician evaluating knee pain. We retrospectively reviewed the WB AP and tunnel view radiographs of 100 knees (74 patients) presenting with knee pain and analyzed for evidence of arthritis. The combination of the WB tunnel view and WB AP significantly increased the detection of joint space narrowing in the lateral (p < 0.001) and medial (p = 0.006) compartments over the AP view alone. The combined views significantly improved the identification of medial subchondral cysts (p = 0.022), sclerosis of the lateral tibial plateau (p = 0.041), and moderate-to-large osteophytes in the medial compartment (p = 0.012), intercondylar notch (p < 0.001), and tibial spine (p < 0.001). The WB tunnel view is an effective tool to provide additional information on affected compartments in the painful knee, not provided by the AP image alone.

Femoro-tibial knee osteoarthritis: One or two X-rays? Results from a population-based study

OBJECTIVE

Our objective was to compare the use of both anteroposterior (AP) extended-knee X-ray and semi-flexed X-ray (current gold standard) versus the use of semi-flexed X-ray alone to detect femoro-tibial osteoarthritis (OA).

METHODS

Individuals 40 to 75 years of age with symptomatic hip and/or knee OA (Kellgren/Lawrence [KL] score≥2) were recruited using a multiregional prevalence survey in France. Both AP and schuss X-rays were performed and read; two years later, the same examiner, blinded to the results of the first reading, performed a second reading of the schuss X-ray. We compared the KL stages of each knee and analyzed osteophyte detection and localization, joint space narrowing (JSN), and the relationship to obesity.

RESULTS

The analysis included 350 participants with OA of various stages. Comparing the two readings showed that a higher proportion of patients had KL≥2 when the two X-ray views were combined (right knee: P<0.0001; left knee: P<0.001). There were no differences when using the schuss X-ray alone versus in combination with an AP X-ray in terms of detecting JSN, osteophytes. A comparison of schuss X-ray alone versus AP X-ray alone demonstrated the superiority of the schuss view for evaluating JSN (P=0.0001 and P=0.0001) and no difference in osteophyte detection.

CONCLUSION

Our study shows that the schuss view alone was sufficient for detecting knee osteophytes and JSN. Using one X-ray rather than two will reduce medical costs and irradiation burden. Using two views seems preferable for epidemiological studies.

Minimal Preoperative Degenerative Arthritis May Not Predict Poor TKA Outcome

Although most orthopedic surgeons presume that patients with more severe degenerative osteoarthritis are better candidates for total knee arthroplasty (TKA), few data have compared outcomes based on the extent of radiographic osteoarthritis. The authors tested the hypothesis that patients with minimal radiographic osteoarthritis would have worse outcomes compared with a matched cohort with severe osteoarthritis. The authors identified 29 patients (31 knees) with minimal degenerative changes who underwent TKA between 2000 and 2004. The authors identified a matched cohort with severe osteoarthritis. Mean follow-up was 5 years (range, 2-10 years). Preoperative knee scores were 63 and 59 in patients with minimal osteoarthritis and severe osteoarthritis, respectively. Postoperative knee scores were 89 and 93, respectively. Preoperative function scores were 57 and 56 in patients with minimal osteoarthritis and severe osteoarthritis, respectively. Postoperative function scores increased to 79 and 72, respectively. Of 31 patients in the minimal osteoarthritis group, 26 (84%) had mild or no pain at the time of last follow-up, whereas 5 (16%) had moderate or severe pain. In the group with severe osteoarthritis, 25 of 31 patients (81%) had mild or no pain at the time of last follow-up, whereas 6 (19%) had moderate or severe pain. In the group with minimal osteoarthritis, 6 of 31 knees (19%) had a complication. Only 1 of 31 knees (3.1%) in the matched cohort had a complication. Fewer than 1% of patients undergoing TKA at the authors' institution had minimal preoperative radiographic osteoarthritis. These patients had a higher risk of complications, but similar pain relief, function, and overall satisfaction compared with a matched group with severe arthritis.

Is end-stage lateral osteoarthritic knee always valgus? Mechanical alignment analysis and radiographic severity assessment

Background

We hypothesized that not all persons with end-stage lateral osteoarthritis (OA) have valgus malalignment and that full extension radiographs may underreport radiographic disease severity. The purpose of this study was to examine the demographic and radiographic features of end-stage lateral compartment knee OA.

Materials and methods

We retrospectively studied 133 knees in 113 patients who had undergone total knee arthroplasty between June 2008 and August 2010. All patients had predominantly lateral idiopathic compartment OA according to the compartment-specific Kellgren–Lawrence grade (KLG). The mechanical axis angle (MAA), compartment-specific KLG and joint space narrowing (JSN) of the tibiofemoral joint at extension and 30° of knee flexion, tibia vara angle, tibial slope angle, body mass index, age, and sex were surveyed.

Results

End-stage lateral compartment knee OA has varus (37.6 %), neutral (22.6 %), and valgus (39.8 %) MAA on both-leg standing hip-knee-ankle radiographs. KLGs at 30° of knee flexion (fKLG) were grades 3 and 4 in all patients. However, for KLGs at full extension (eKLG), 54 % of all patients had grades 3 and 4. The others (46 %) showed grades 1 and 2. We observed significant differences in lateral compartment eKLG/eJSN (2.3/2.3 mm in varus, 2.5/1.9 mm in neutral, 2.9/1.6 mm in valgus, p = 0.01 and 0.03, respectively), tibia vara angle (4.9° in varus, 4.1° in neutral, 3.0° in valgus, p < 0.01), and medial compartment eKLG/eJSN (2.1/3.1 mm in varus, 2.0/3.4 mm in neutral, 1.8/4.3 mm in valgus, p < 0.01 and 0.01, respectively) between MAA groups, except for the tibial slope angle (9.7° in varus, 10.1° in neutral, 9.8° in valgus, p = 0.31).

Conclusion

Varus alignment was paradoxically shown in approximately one-third of those with end-stage lateral knee OA on both-leg standing hip-knee-ankle radiographs. Films taken in full extension underreported the degree of OA radiographic severity.

Level of evidence

Level IV, observational study.

Imaging of cartilage and bone: promises and pitfalls in clinical trials of osteoarthritis

Imaging in clinical trials is used to evaluate subject eligibility, and/or efficacy of intervention, supporting decision making in drug development by ascertaining treatment effects on joint structure. This review focusses on imaging of bone and cartilage in clinical trials of (knee) osteoarthritis. We narratively review the full-text literature on imaging of bone and cartilage, adding primary experience in the implementation of imaging methods in clinical trials. Aims and constraints of applying imaging in clinical trials are outlined. The specific uses of semi-quantitative and quantitative imaging biomarkers of bone and cartilage in osteoarthritis trials are summarized, focusing on radiography and magnetic resonance imaging (MRI). Studies having compared both imaging methodologies directly and those having established a relationship between imaging biomarkers and clinical outcomes are highlighted. To make this review of practical use, recommendations are provided as to which imaging protocols are ideal for capturing specific aspects of bone and cartilage tissue, and pitfalls in their usage are highlighted. Further, the longitudinal sensitivity to change, of different imaging methods is reported for various patient strata. From these power calculations can be accomplished, provided the strength of the treatment effect is known. In conclusion, current imaging methodologies provide powerful tools for scoring and measuring morphological and compositional aspects of most articular tissues, capturing longitudinal change with reasonable to excellent sensitivity. When employed properly, imaging has tremendous potential for ascertaining treatment effects on various joint structures, potentially over shorter time scales than required for demonstrating effects on clinical outcomes.

Rapid chondrolysis following an unoperated lateral meniscus tear in a young professional rugby player

Rapid chondrolysis following a lateral meniscectomy is a rare complication. We present the first reported case of rapid chondrolysis of the lateral compartment, which developed 6 months after a meniscus tear that was not surgically treated in a young 18-year-old professional rugby player. The possible hypotheses to explain this complication are presented, and certain previously published causes were excluded (iatrogenic during surgery, undiagnosed increased rotatory instability, chondrotoxicity of bupivacaine). Overloading of the cartilage surface of the lateral compartment from meniscal extrusion can cause cartilage necrosis.

[Quantitative analysis for narrowing of radiographic joint space in knee osteoarthritis]

Conventional radiography is first performed in the evaluation of knee osteoarthritis (OA). In view of diagnostic accuracy and reproducibility, joint space narrowing that is a typical feature of knee OA should be evaluated quantitatively based on the image findings, because it has been evaluating subjectively. We measured joint space widths and joint space areas on knee radiographs to analyze joint space narrowing quantitatively and investigated the usefulness in classification of the severity of knee OA. Radiographs of 35 no OA knees (normal group) and 46 OA knees (OA group) were analyzed in this study. Medial and lateral joint space width and joint space area were measured manually using ImageJ i.e., a public domain image processing program. Measured values were corrected for the physical size with the length of epicondylar line, and statistically significant differences between the normal group and OA group were investigated. The results showed that medial joint space width was significantly smaller and lateral joint space width was significantly larger in the OA group than in the normal group. Furthermore, joint space area in the OA group decreased significantly compared that in normal group. We conclude that joint space widths and joint space area are important parameters to classify the severity of knee OA.

Direct comparison of fixed flexion, radiography and MRI in knee osteoarthritis: responsiveness data from the Osteoarthritis Initiative

OBJECTIVE

Minimum radiographic joint space width (mJSW) represents the Food and Drug Administration (FDA) standard for demonstrating structural therapeutic benefits for knee osteoarthritis (KOA), but only shows moderate responsiveness (sensitivity to change). We directly compare the responsiveness of magnetic resonance imaging (MRI)-based cartilage thickness and JSW measures from fixed-flexion radiography (FFR) and explore the correlation of region-matched changes between both methods.

METHODS

Nine hundred and sixty-seven knees of Osteoarthritis Initiative participants with radiographic KOA were studied: 445 over 1 year with coronal FLASH MRI and FFR, and 375/522 over 1/2 years with sagittal DESS MRI and FFR. Standardized response means (SRM) of cartilage thickness and mJSW were compared using the sign-test.

RESULTS

With FLASH MRI, SRM was -0.28 for medial femorotibial compartment (MFTC) cartilage loss vs -0.15 for mJSW, and -0.32 vs -0.22 for the most sensitive MRI subregion (central MFTC) vs the most sensitive fixed-location JSW(x = 0.25). With DESS MRI, 1-year SRM was -0.34 for MFTC vs -0.22 for mJSW and -0.44 vs -0.28 for central MFTC vs JSW(x = 0.225). Over 2 years, the SRM was significantly greater for MFTC than for mJSW (-0.43 vs -0.31, P = 0.017) and for central MFTC than for JSW(x = 0.225) (-0.51 vs -0.44, P < 0.001). Correlations between changes in spatially matched MRI subregions and fixed-location JSW were not consistently higher (r = 0.10-0.51) than those between non-matched locations (r = 0.15-0.50).

CONCLUSIONS

MRI displays greater responsiveness in KOA than JSW FFR-based JSW, with the greatest SRM observed in the central medial femorotibial compartment. Fixed-location radiographic measures appear not capable of determining the spatial distribution of femorotibial cartilage loss.

Doxycycline for osteoarthritis of the knee or hip

BACKGROUND

Osteoarthritis is a chronic joint disease that involves degeneration of articular cartilage. Pre-clinical data suggest that doxycycline might act as a disease-modifying agent for the treatment of osteoarthritis, with the potential to slow cartilage degeneration. This is an update of a Cochrane review first published in 2009.

OBJECTIVES

To examine the effects of doxycycline compared with placebo or no intervention on pain and function in people with osteoarthritis of the hip or knee.

SEARCH METHODS

We searched CENTRAL (The Cochrane Library 2008, issue 3), MEDLINE, EMBASE and CINAHL up to 28 July 2008, with an update performed at 16 March 2012. In addition, we checked conference proceedings, reference lists, and contacted authors.

SELECTION CRITERIA

We included studies if they were randomised or quasi-randomised controlled trials that compared doxycycline at any dosage and any formulation with placebo or no intervention in people with osteoarthritis of the knee or hip.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate. We contacted investigators to obtain missing outcome information. We calculated differences in means at follow-up between experimental and control groups for continuous outcomes and risk ratios (RR) for binary outcomes.

MAIN RESULTS

We identified one additional trial (232 participants) and included two trials (663 participants) in this update. The methodological quality and the quality of reporting were considered moderate. At end of treatment, clinical outcomes were similar between the two treatment groups, with an effect size of -0.05 (95% confidence interval (CI) -0.22 to 0.13), corresponding to a difference in pain scores between doxycycline and control of -0.1 cm (95% CI -0.6 to 0.3 cm) on a 10-cm visual analogue scale, or 32% versus 29% improvement from baseline (difference 3%; 95% CI -5% to 10%). The effect size for function was -0.07 (95% CI -0.25 to 0.10), corresponding to a difference between doxycycline and control of -0.2 (95% CI -0.5 to 0.2) on the Western Ontario and McMaster Universities Arthritis Index (WOMAC) disability subscale with a range of 0 to 10, or 24% versus 21% improvement (difference 3%; 95% CI -3% to 10%). The difference in changes in minimum joint space narrowing assessed in one trial was in favour of doxycycline (-0.15 mm; 95% CI -0.28 to -0.02 mm), which corresponds to a small effect size of -0.23 standard deviation units (95% CI -0.44 to -0.02). More participants withdrew from the doxycycline group compared with placebo due to adverse events (RR 2.28; 95% CI 1.06 to 4.90). There was no evidence that participants in the doxycycline group experienced more serious adverse events than those in the placebo group, but the estimate was imprecise (RR 1.07; 95% CI 0.68 to 1.68).

AUTHORS' CONCLUSIONS

In this update, the strength of evidence for effectiveness outcomes was improved from low to moderate and we confirmed that the symptomatic benefit of doxycycline is minimal to non-existent, while the small benefit in terms of joint space narrowing is of questionable clinical relevance and outweighed by safety problems. The CIs of the summary estimates now exclude any clinically relevant difference in improvement of symptoms and the small benefit in terms of joint space narrowing does not outweigh the harms.

Cartilage repair and joint preservation: medical and surgical treatment options

BACKGROUND

Articular cartilage defects are most often caused by trauma and osteoarthritis and less commonly by metabolic disorders of the subchondral bone, such as osteonecrosis and osteochondritis dissecans. Such defects do not heal spontaneously in adults and can lead to secondary osteoarthritis. Medications are indicated for symptomatic relief. Slow-acting drugs in osteoarthritis (SADOA), such as glucosamine and chondroitin, are thought to prevent cartilage degeneration. Reconstructive surgical treatment strategies aim to form a repair tissue or to unload compartments of the joint with articular cartilage damage.

METHODS

In this article, we selectively review the pertinent literature, focusing on original publications of the past 5 years and older standard texts. Particular attention is paid to guidelines and clinical studies with a high level of evidence, along with review articles, clinical trials, and book chapters.

RESULTS

There have been only a few randomized trials of medical versus surgical treatments. Pharmacological therapies are now available that are intended to treat the cartilage defect per se, rather than the associated symptoms, yet none of them has yet been shown to slow or reverse the progression of cartilage destruction. Surgical débridement of cartilage does not prevent the progression of osteoarthritis and is thus not recommended as the sole treatment. Marrow-stimulating procedures and osteochondral grafts are indicated for small focal articular cartilage defects, while autologous chondrocyte implantationis mainly indicated for larger cartilage defects. These surgical reconstructive techniques play a lesser role in the treatment of osteoarthritis. Osteotomy near the knee joint is indicated for axial realignment when unilateral osteoarthritis of the knee causes axis deviation.

CONCLUSION

Surgical reconstructive techniques can improve joint function and thereby postpone the need for replacement of the articular surface with an artificial joint.

Osteoarthritis: an update with relevance for clinical practice

Osteoarthritis is thought to be the most prevalent chronic joint disease. The incidence of osteoarthritis is rising because of the ageing population and the epidemic of obesity. Pain and loss of function are the main clinical features that lead to treatment, including non-pharmacological, pharmacological, and surgical approaches. Clinicians recognise that the diagnosis of osteoarthritis is established late in the disease process, maybe too late to expect much help from disease-modifying drugs. Despite efforts over the past decades to develop markers of disease, still-imaging procedures and biochemical marker analyses need to be improved and possibly extended with more specific and sensitive methods to reliably describe disease processes, to diagnose the disease at an early stage, to classify patients according to their prognosis, and to follow the course of disease and treatment effectiveness. In the coming years, a better definition of osteoarthritis is expected by delineating different phenotypes of the disease. Treatment targeted more specifically at these phenotypes might lead to improved outcomes.

Cross-sectional comparison of extended anteroposterior and posteroanterior fixed flexion positioning to assess radiographic osteoarthritis at the knee: the Johnston County Osteoarthritis Project

OBJECTIVE

To compare values for Kellgren/Lawrence (K/L) scale grade, joint space narrowing (JSN), and osteophytes in anteroposterior (AP) extended and fixed flexion posteroanterior (PA) radiographs obtained during a single clinic visit (the first followup of the Johnston County Osteoarthritis Project).

METHODS

All films (n = 1,664 bilateral knees) were read by an experienced musculoskeletal radiologist. For each subject, AP and PA fixed flexion films were read in one sitting. K/L scale grades (range 0-4) and JSN and osteophytes (ranges 0-3) were assessed using standard atlases. Descriptive statistics were calculated for demographic and clinical variables. AP and PA fixed flexion results were compared by contingency table methods to obtain frequencies for K/L scale, JSN, and osteophyte grades using percent agreement and kappa coefficients. Results from the right and left knees were similar; data for the right knee are presented.

RESULTS

There was substantial agreement between AP and PA fixed flexion reads for radiographic osteoarthritis, defined as a K/L scale grade ≥ 2 (89% agreement; κ = 0.73, 95% confidence interval 0.69-0.76). Substantial agreement was also seen for tibial osteophytes and medial JSN; slightly lower kappa values were observed for femoral osteophytes and lateral JSN.

CONCLUSION

The requirements of large observational cohort studies are different than those of clinical trials, and sensitivity is less of an issue because of longer followup times. In cohort studies such as the Johnston County Osteoarthritis Project, there is substantial agreement by K/L scale grade for AP and PA fixed flexion radiographs, allowing incorporation of older films in longitudinal analyses.

Spatial patterns of cartilage loss in the medial femoral condyle in osteoarthritic knees: data from the Osteoarthritis Initiative

The objective of this study was to develop a technique for analyzing spatial patterns of cartilage loss in the medial femoral condyle (MF), and to study MF cartilage loss in participants of the Osteoarthritis Initiative. Using a 0.7 mm sagittal double echo at steady state (DESS) sequence, 160 osteoarthritic knees from 80 participants with varying degrees of medial joint space narrowing were imaged at baseline and 1-year follow-up. MF cartilage was segmented and cartilage loss determined. Rate of change varied significantly (P = 0.0067) along the anterior-posterior extension of the MF, with the greatest changes (-45 microm, -2.7%) observed 30-60 degrees posterior to the trochlear notch. The rate was greater in the central MF after excluding peripheral aspects of the MF from analysis. Sensitivity to change was greatest at 45-75 degrees (standardized response mean = -0.32) but was minimally affected by medial-lateral trimming. In conclusion, the greatest sensitivity to change was achieved when analyzing the posterior aspect of the central, weight-bearing MF.

Magnitude and regional distribution of cartilage loss associated with grades of joint space narrowing in radiographic osteoarthritis--data from the Osteoarthritis Initiative (OAI)

OBJECTIVE

Clinically, radiographic joint space narrowing (JSN) is regarded a surrogate of cartilage loss in osteoarthritis (OA). Using magnetic resonance imaging (MRI), we explored the magnitude and regional distribution of differences in cartilage thickness and subchondral bone area associated with specific Osteoarthritis Research Society International (OARSI) JSN grades.

METHOD

Seventy-three participants with unilateral medial JSN were selected from the first half (2678 cases) of the OA Initiative cohort (45, 21, and 7 with OARSI JSN grades 1, 2, and 3, respectively, no medial JSN in the contra-lateral knee). Bilateral sagittal baseline DESSwe MRIs were segmented by experienced operators. Intra-person between-knee differences in cartilage thickness and subchondral bone areas were determined in medial femorotibial subregions.

RESULTS

Knees with medial OARSI JSN grades 1, 2, and 3 displayed a 190 microm (5.2%), 630 microm (18%), and 1560 microm (44%) smaller cartilage thickness in weight-bearing medial femorotibial compartments compared to knees without JSN, respectively. The weight-bearing femoral condyle displayed relatively greater differences than the posterior femoral condyle or the medial tibia (MT). The central subregion within the weight-bearing medial femur (cMF) of the femoral condyle (30-75 degrees ), and the external and central subregions within the tibia displayed relatively greater JSN-associated differences compared to other medial femorotibial subregions. Knees with higher JSN grades also displayed larger than contra-lateral femorotibial subchondral bone areas.

CONCLUSIONS

This study provides quantitative estimates of JSN-related cartilage loss, with the central part of the weight-bearing femoral condyle being most strongly affected. Knees with higher JSN grades displayed larger subchondral bone areas, suggesting that an increase in subchondral bone area occurs in advanced OA.

Radiographic grading and measurement of joint space width in osteoarthritis

The progression of osteoarthritis is traditionally measured using radiographic joint space width (JSW). Numerous knee radiograph protocols have been developed with various levels of complexity and performance as it relates to detecting JSW loss (ie, joint space narrowing). Sensitivity to joint space narrowing is improved when radioanatomic alignment of the medial tibial plateau is achieved. Semiautomated software has been developed to improve the accuracy of JSW measurement over manual methods. JSW measurements include minimum JSW, mean JSW or joint space area, and JSW at fixed locations.

Risk stratification for knee osteoarthritis progression: a narrative review

OBJECTIVE

A narrative review describing the assessment of osteoarthritis (OA) progression, and more specifically the risk factors which assist in delineating strata of individuals at greatest risk for more rapid progression.

DESIGN

A narrative review based on selected recent medical literature.

RESULTS

With little currently available in the treatment of this disease, better understanding of responsive and valid endpoints is essential to identifying potential new interventions for treatment of OA. Efforts to stratify those at greatest risk for progression can use a number of systemic or local risk factors that may assist in delineating populations at greater risk for progression.

CONCLUSIONS

Current data suggests that stratification of risk is feasible to ascertain those at risk for rapid progression using a number of different metrics including knee alignment, meniscal damage, bone marrow lesions and late stage disease. Identifying persons at greatest risk for progression has important implications for clinical trial planning and can enhance study efficiency.

Doxycycline for osteoarthritis of the knee or hip

BACKGROUND

Osteoarthritis is a chronic joint disease that involves degeneration of articular cartilage. Pre-clinical data suggest that doxycycline might act as a disease-modifying agent for the treatment of osteoarthritis, with the potential to slow cartilage degeneration.

OBJECTIVES

To examine the effects of doxycycline compared with placebo or no intervention on pain and function in patients with osteoarthritis of the hip or knee.

SEARCH STRATEGY

We searched CENTRAL ( The Cochrane Library 2008, issue 3), MEDLINE, EMBASE and CINAHL up to 28 July 2008, checked conference proceedings, reference lists, and contacted authors.

SELECTION CRITERIA

We included studies if they were randomised or quasi-randomised controlled trials that compared doxycycline at any dosage and any formulation with placebo or no intervention in patients with osteoarthritis of the knee or hip.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate. We contacted investigators to obtain missing outcome information. We calculated differences in means at follow-up between experimental and control groups for continuous outcomes and risk ratios for binary outcomes.

MAIN RESULTS

We found one randomised controlled trial that compared doxycycline with placebo in 431 obese women. After 30 months of treatment, clinical outcomes were similar between the two treatment groups, with a mean difference of -0.20 cm (95% confidence interval (CI) -0.77 to 0.37 cm) on a visual analogue scale from 0 to 10 cm for pain and -1.10 units (95% CI -3.86 to 1.66) for function on the WOMAC disability subscale, which ranges from 17 to 85. These differences correspond to clinically irrelevant effect sizes of -0.08 and -0.09 standard deviation units for pain and function, respectively. The difference in changes in minimum joint space narrowing was in favour of doxycycline (-0.15 mm, 95% CI -0.28 to -0.02 mm), which corresponds to a small effect size of -0.23 standard deviation units. More patients withdrew from the doxycycline group compared with placebo due to adverse events (risk ratio 1.69, 95% CI 1.03 to 2.75).

AUTHORS' CONCLUSIONS

The symptomatic benefit of doxycycline is minimal to non-existent. The small benefit in terms of joint space narrowing is of questionable clinical relevance and outweighed by safety problems. Doxycycline should not be recommended for the treatment of osteoarthritis of the knee or hip.

Subregional femorotibial cartilage morphology in women--comparison between healthy controls and participants with different grades of radiographic knee osteoarthritis

OBJECTIVE

To identify subregional differences in femorotibial cartilage morphology between healthy controls and women with different grades of radiographic knee osteoarthritis (OA).

DESIGN

158 women aged > or =40 years were studied. Weight-bearing extended anterior-posterior (AP) and Lyon schuss radiographs were obtained and the Kellgren Lawrence grade (KLG) determined. 97 women had a body mass index (BMI)< or =28, no symptoms, and were AP KLG0. 61 women had a BMI> or =30, symptoms in the target knee, and mild (KLG2=31) to moderate (KLG3=30) medial femorotibial radiographic OA in the AP views. Coronal spoiled gradient echo water excitation sequences were acquired at 3.0 Tesla. Total plate and regional measures of cartilage morphology of the weight-bearing femorotibial joint were quantified.

RESULTS

KLG2 participants displayed, on average, thicker cartilage than healthy controls in the medial femorotibial compartment (particularly anterior subregion of the medial tibia (MT) and peripheral [external, internal] subregions of the medial femur), and in the lateral femur. KLG3 participants displayed significantly thinner cartilage than KLG0 participants in the medial weight-bearing femur (central subregion), in the external subregion of the MT, and in the internal subregion of the lateral tibia. These differences were generally unaffected when possible effects of demographic covariates were considered.

CONCLUSIONS

The results indicate that in femorotibial OA regional cartilage thickening and thinning may occur, dependent on the (radiographic) disease status of the joint. These changes appear to display a heterogeneous spatial pattern, where certain subregions are more strongly affected than others.

Radiologic markers of osteoarthritis progression

PURPOSE OF REVIEW

To review radiographic and MRI developments in measuring osteoarthritis progression in the tibiofemoral compartment of the knee.

RECENT FINDINGS

Standardized techniques for measuring joint space width in the medial tibiofemoral compartment, using standardized radiographic protocols, have become accepted for quantifying changes in tibiofemoral in knee osteoarthritis. In addition, there is a significant body of supporting data on the longitudinal change in MRI-derived cartilage morphology (thickness, volume) as an end point to reflect osteoarthritis progression/cartilage loss.

SUMMARY

This review appraises the current methods of measurement of osteoarthritis progression and limitations with regards their interpretation and further development.

Osteoarthritis: current role of imaging

Osteoarthritis (OA) is the most prevalent joint disease; it is increasingly common in the aging population of Western society and has a major health economic impact. Despite surgery and symptom-oriented approaches there is no efficient treatment. Conventional radiography has played a role in the past in confirming diagnosis and demonstrating late bony changes and joint space narrowing. MRI has become the method of choice in large research endeavors and may become important for individualized treatment planning. This article focuses on radiography and MRI, with insight into other modalities, such as ultrasound, scintigraphy, and CT. Their role in OA diagnosis, follow-up, and research is discussed.

Evaluation of a dynamic bayesian belief network to predict osteoarthritic knee pain using data from the osteoarthritis initiative

The most common cause of disability in older adults in the United States is osteoarthritis. To address the problem of early disease prediction, we have constructed a Bayesian belief network (BBN) composed of knee OA-related symptoms to support prognostic queries. The purpose of this study is to evaluate a static and dynamic BBN--based on the NIH Osteoarthritis Initiative (OAI) data--in predicting the likelihood of a patient being diagnosed with knee OA. Initial validation results are promising: our model outperforms a logistic regression model in several designed studies. We can conclude that our model can effectively predict the symptoms that are commonly associated with the presence of knee OA.