RADIOLOGICAL ASSESSMENT

OF OSTEOARTHRITIS

Dr OMAR HUSSEIN
Professor of Radiology
Ain Shams University
 Osteoarthritis ???
 
 Os Is one of the most prevalent and disabling
chronic conditions affecting older adults and a
significant public health problem among adults of
working age.
 Worldwide, osteoarthritis is the most common
form of arthritis, noninflammatory, nonsystemic
disease
 Pain and limitation of motion restrict the
independence of older adults by impairing their
performance of activities of daily
living.
 older adults
Women Men

53% 37%
©2002 Pfizer Inc. All rights reserved.

 Prevalence increases exponentially beyond the age

of 50 with about 80-90% of both sexes having
osteoarthritis by age 65;
 Before age 50: Men more affected than women.
 After age 50: Incidence greater in women.
 It affects over 1/3 of men (37%) and just over half of
women (53%) in this age group.
 Osteoarthritis

 Affects one or more weight-bearing joints

 Hand, wrist, lower cervical spine, lumbar spine and
sacroiliac, hip, knees, ankles, feet
 Aches and stiffness
 Symptoms increase with activity; diminish with rest
 Usually no redness of adjacent tissues
 Sometimes nocturnal pain – may be referred

4
Aetiology and Pathogenesis of Osteoarthritis

 Primary Osteoarthritis.
 Secondary Osteoarthritis.
OA: Pattern of Joint Involvement

Neck

Lower Back
DIPs
Hips

CMCs Knees
PIPs

Base of
big toe
Pathology of Osteoarthritis

Joint = Bone + Cartilage +

Synovial Fluid

©2002 Pfizer Inc. All rights reserved.

 Osteoarthritis

 Pathological characteristics:
 Erosion of the articular cartilage
 Sclerosis of subchondral bone
 Formation of bone spurs or osteophytes

 Synovial membrane is indirectly affected

 Fragments of fibrocartilage cause inflammation –pain
 Fibrous repair of joint capsule restricts motion
 Osteophytes form – pain and loss of motion

8
Early changes may be arrested
or .……delayed
 Structural changes with Osteoarthritis

 Early
Cartilage softens.
 Moderate
Cartilage thinner.
bone ends hypertrophy and spurs.
 Advanced
Cartilage destruction.
Secondary inflammation of synovial membrane.
Late ankylosis.
Current assessment tools
 Clinical

 Laboratory markers

 Imaging

 Thermography

 Arthroscopy
 Imaging Objectives
 DIAGNOSIS:
 Plain radiography
 US
 MRI
 CT
 Scintigraphy

 MONITORING:
 X-ray findings
 Joint space narrowing , asymmetrical, may be only
finding in early disease
 Subchondral bone sclerosis
 Subchondral cysts
 Osteophytes
 Central bone erosions occur in distal
interphalangeal joints of fingers
 Deformities
 Heberden (osteophytes at DIJ ) and Bouchard
(osteophytes at PIJ ) nodes.
 Subluxation
Plain X-Ray of the shoulder and wrist joints show osteophytes.
Radiographic grading of OA: Kellgren-Lawrence (KL) scale 

 The KL scale is a standard radiologic grading

system for osteoarthritis .

 Features considered evidence of osteoarthritis

are osteophytes in the joint margins, narrowing
of joint spaces, and subchondral sclerosis.
 KL scale
On the basis of these features, the following KL scores
were defined :
 0 no features of osteoarthritis;
 1 doubtful osteoarthritis, with minute osteophytes of
doubtful importance;
 2 minimal osteoarthritis, with definite osteophytes
but unimpaired joint space;
 3 moderate osteoarthritis, with osteophytes and
moderate diminution of joint space; and
 4 severe osteoarthritis, with greatly impaired joint
space and sclerosis of subchondral bone.
Score 1 score 2 score 3 score 4

Link T M et al. Radiology 2003;226:373-381

 Limitation
 X-rays of osteoarthritis do not detect early
cartilage abnormalities.
 Also, x-rays can show mild osteoarthritis while
a patient may be experiencing severe
symptoms.
 Conversely, an x-ray may show changes
indicative of advanced or severe osteoarthritis
while a patient may have few or no symptoms. 
 Ultrasound
Shoulder

 From head to toe :- Wrist

Hip

Knee

Ankle
 Advantages of The Ultrasound

 There is NO contraindication.
 Non-invasive.
 It is able to visualise the examined part
together with surrounding structures.
 Early detection cartilage and synovium and
effusion.

􀁑 ALSO Allows for aspiration and injection

procedures
Hand Sonography shows synovitis of the 2nd MP joint
Hand Sonography shows Carpometacarpal
osteoarthritis of the thumb
Ankle Sonography shows joint effusion and synovitis
between navicular and cuniform bones.
Hip Sonography examination shows peritrochanteric
joint effusion
Knee Sonography shows osteophtes and protrusion of medial
mensicus and MCL associated with effusion.
Limitation of US

• Operator Dependence
• Difficult through Bone, air/gas
• Obesity
 C.T .
With AGAINST

 Ionizing radiation
 Now Available
 Inexpensive relatively
 Patient cooperation
 Excellent visualization of
bony details
 In secondary OA
 Skeletal evaluation in cases of
trauma.
 Congenital anomalies.
 MSCT :-
Give more details by
Reformatting images and
3-D reconstruction
Plain X-ray and CT of the hip shows bony fragments
Ankle CT shows osteophytes, subchondral sclerosis
and diminished joint space.
Hip CT-Arthrography shows superior and anterior joint
space narrowing (blue circle) with denuded chondral
surface (yellow arrow), subchondral cysts and sclerosis.
CT knee arthrography shows Loose bodies (arrow).
 MRI
With
 Multi-planar scanning.
 Non ionizing radiation.
 Safer contrast agent.
 The best joint and soft
tissue characterization .
 Can detect early bone
change (bone “edema”).
AGAINST
 ?? Availability.
 Expensive??????
 Require more time
 Patient cooperation
 Sedation required
Contraindications for MR
 Cranial Metal (Head, Brain,
Orbit).
 Pacemaker (sensing).
 Prosthesis.
 Claustrophobia.
 MRI

 Conventional

 Advanced
 MRI grading of OA

 Cartilage lesions

 Bone marrow edema

 Osteophyte
 A. Cartilage lesion grading
 Grade I lesions as having areas of
inhomogeneous signal intensity of cartilage
 Grade IIa lesions, as cartilage defects
involving less than half of the articular
cartilage thickness
 Grade IIb lesions, as cartilage defects involving
more than half of the cartilage but less than full
thickness
 Grade III lesions, as cartilage defects exposing
the bone.
 B. Bone Marrow Edema grading
 Bone marrow edema pattern is defined as
diffuse subchondral low signal intensity on T1-
weighted images and high signal intensity on
T2-weighted images.
 Edema pattern is mild when it is less than 1 cm
in diameter in the long axis on fat-suppressed
T2-weighted images.
 Moderate when its diameter is 1–2 cm
 Severe when its diameter is larger than 2 cm in
the long axis. 
 C. Osteophytes grading
 Osteophytes are classified as mild when they
were located in the joint margins and were less
than 0.5 cm in diameter when measured from
the base to the tip on T1-weighted images;

 when osteophytes were larger than 0.5 cm in

diameter, they were defined as severe.

Link T M et al. Radiology 2003;226:373-381

 KL 1, cart. KL 2, cart. Thinning KL 3, G III KL 4 ,G III
thinning G II tibia

KL 1, osteophytes KL 2, cart.
KL 3 BM KL 4, BM
Thinning, edema,effusion
edema,
G III
effusion
A central osteophyte
(arrow) in a patient with
advanced osteoarthritis
with cartilage defects
(arrowhead) at the
femur and tibia

Link T M et al. Radiology 2003;226:373-381

Link T M et al. Radiology 2003;226:373-381
 KL 1 Grade II lesion Effusion

Link T M et al. Radiology 2003;226:373-381

 Subchond.cyst, destruction
KL score 4 Grade III cartilage
of med.meniscus, effusion

Link T M et al. Radiology 2003;226:373-381

Shoulder MR-Arthrography, SE T1-weighted sequences in axial
planes shows inferior osteophytes (blue arrows) with carilage loss
of the humeral head (yellow arrows).
Ankle MRI shows Posterior subtalar joint arthritis with bone marrow
oedema.
 Advanced MRI

 Delayed Contrast Enhanced MRI of Cartilage

(dGEMRIC) is a new MRI technique

 It provides a 3 D image of the joint that

measures the volume of cartilage which may
identify early change in cartilage metabolism

Magn Reson Med 49:488–492, 2003. Wiley-Liss, Inc

dGEMRIC of the knee joint
dGEMRIC MRI of left
Knee OA
Sagittal T2 map
shows areas with
markedly increased
T2 values at weight-
bearing and
posterior aspect of
medial femoral
condyle that are
yellow and red
 Colour Map MRI
The end of the femur is eroded
and jagged; cracks causing
weakening in both bones are
also visible. 
 Bone scintigraphy
 Radionuclide scanning shows increased
activity during the bone phase in the
subarticular region of any affected joint.
 These changes are apparent years before the
typical radiographic changes appear and reflect
the vascular reaction and osteoblastic activity
that are present even in the early stages of
cartilage loss.
 Scintigraphy , although sensitive, lacks
specificity
Symmetrical increased isotope
accumulation in the knees and shoulders
 Finally,
Which modality …
……………….select ?
 In early OA
 Ultrasonography.
 MRI and dGEMRIC.
 Bone scan (Scintigraphy).
 In moderate OA
computed tomography (CT) scan .
X-rays .

 In Advanced OA
 X-rays .
Thanks for your
PET Scans andattention
the Thyroid Nodule