NIH Public Access: Evolution of Semiquantitative Whole Joint Assessment of Knee OA: MOAKS (MRI Osteoarthritis Knee Score)

NIH Public Access
Author Manuscript
Osteoarthritis Cartilage. Author manuscript; available in PMC 2014 June 16.
Published in final edited form as:
NIH-PA Author Manuscript
Osteoarthritis Cartilage. 2011 August ; 19(8): 990–1002. doi:10.1016/j.joca.2011.05.004.
Evolution of semiquantitative whole joint assessment of knee

OA: MOAKS (MRI Osteoarthritis Knee Score)
David J Hunter1, Ali Guermazi2, Grace H Lo3, Andrew J Grainger4, Philip G Conaghan5,
Robert M Boudreau6, and Frank W. Roemer2,7
1Rheumatology Department, Royal North Shore Hospital and Northern Clinical School, University
of Sydney, Sydney, NSW Australia
2Quantitative
Imaging Center (QIC), Department of Radiology, Boston University School of
Medicine, Boston, MA USA
3Medical Care Line, Research Care Line, and Houston Health Services Research and
Development (HSR&D) Center of Excellence, Michael E. DeBakey Veterans Administration
Medical Center, Houston, TX; Department of Medicine, Section of Immunology, Allergy and
Rheumatology, Baylor College of Medicine, Houston, TX, USA
4Departmentof Radiology, Leeds Teaching Hospitals & NIHR Leeds Musculoskeletal Biomedical
Research Unit, Leeds, UK
5Sectionof Musculoskeletal Disease, University of Leeds & NIHR Leeds Musculoskeletal
Biomedical Research Unit, Leeds, UK
6Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh,
Pittsburgh, PA, USA
7Department of Radiology, Klinikum Augsburg, Augsburg, Germany
Abstract
Objective—In an effort to evolve semi-quantitative scoring methods based upon limitations
identified in existing tools, integrating expert readers’ experience with all available scoring tools
and the published data comparing the different scoring systems, we iteratively developed the MRI
Osteoarthritis Knee Score (MOAKS). The purpose of this report is to describe the instrument and
its reliability.
Methods—The MOAKS instrument refines the scoring of BMLs (providing regional delineation
and scoring across regions), cartilage (sub-regional assessment), and refines the elements of
Corresponding author for reprints: Dr. Hunter at Rheumatology Department and Northern Clinical School, Royal North Shore
Hospital, St Leonards, NSW 2065 Australia. University of Sydney, Sydney, AUSTRALIA. David.Hunter@sydney.edu.au.
Contributions
DJH conceived and designed the study, drafted the manuscript and takes responsibility for the integrity of the work as a whole, from
inception to finished article. All authors contributed to acquisition of the data. All authors critically revised the manuscript and gave
final approval of the article for submission.
Conflict of interest statement
The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for
publication.
Other authors declared no conflict of interest.
Hunter et al. Page 2
meniscal morphology (adding meniscal hypertrophy, partial maceration and progressive partial
maceration) scoring. After a training and calibration session two expert readers read MRIs of 20
knees separately. In addition, one reader re-read the same 20 MRIs 4 weeks later presented in
random order to assess intra-rater reliability. The analyses presented here are for both intra- and
inter-rater reliability (calculated using the linear weighted kappa and overall percent agreement).
Results—With the exception of inter-rater reliability for tibial cartilage area (kappa=0.36) and
tibial osteophytes (kappa=0.49); and intra-rater reliability for tibial BML number of lesions
(kappa=0.54), Hoffa-synovitis (kappa=0.42) all measures of reliability using kappa statistics were
very good (0.61-0.8) or reached near perfect agreement (0.81-1.0). Only intra-rater reliability for
Hoffa-synovitis, and inter-rater reliability for tibial and patellar osteophytes showed overall
percent agreement < 75%.
Conclusion—MOAKS scoring shows very good to excellent reliability for the large majority of
features assessed. Further iterative development and research will include assessment of its
validation and responsiveness.
Keywords
MRI; knee osteoarthritis; semi-quantitative score; reliability
Introduction
Magnetic resonance imaging (MRI) semi-quantitative scoring of knee osteoarthritis (OA)
has proven to be a valuable method for performing multi-feature joint assessment [1,2].
Such approaches score, in a semi-quantitative manner, a variety of features that are currently
believed to be relevant to the functional integrity of the knee and/or are potentially involved
in the pathophysiology of OA. These articular features include articular cartilage
morphology, subchondral bone marrow lesions (BMLs) and cysts, osteophytes, the menisci,
the anterior and posterior cruciate ligaments, the collateral ligaments, synovitis, joint
effusion, bone attrition, intra-articular loose bodies, and periarticular cysts / bursitis.
Several methods for semi-quantitative assessment of knee OA have been developed [3-5].
The first of the published instruments, the Whole-Organ Magnetic Resonance Imaging
Score (WORMS), was developed cognizant of the potential of MRI to provide a measure of
all potentially relevant knee OA structures [4]. After identifying some limitations with
WORMS [6,7], work was undertaken to develop the Boston Leeds Osteoarthritis Knee
Score (BLOKS) [5]. Both of these tools are in widespread use in various observational
studies and clinical trials.
Both WORMS and BLOKS have been widely disseminated and used, although the number
of direct comparisons of the two instruments to date was quite limited [5]. Recently the
validity and reliability of WORMS and BLOKS was compared [8-10]. This comparison has
been helpful in identifying the relative merits and weaknesses of these instruments with
regards to certain features assumed to be most relevant to the natural history of the disease
including cartilage, meniscus and bone marrow lesions. Both instruments had certain
limitations and if one were to use the extant literature on published semi-quantitative scoring

instruments the discerning investigator would need to choose from a complex array of
measures from these two different instruments. For example, WORMS meniscal scoring
method mixes multiple different constructs and for BLOKS, application of the BML scoring
system was cumbersome and complex and parts of it seemed redundant.
Both of these tools have also undergone unpublished iterations that have made it difficult for
the naïve reader to determine the differences between the original instruments description
and that which has been used in published research. To facilitate appraisal it is important
that iterative developments be made public.
A number of large epidemiologic studies and clinical trials are maturing to the point where
large scale scoring is commencing, and it is important that iterative evolution of existing
instruments occur with past research findings in mind. In an effort to evolve semi-
quantitative scoring methods based upon limitations identified in existing tools, integrating
expert readers’ experience with all available scoring tools and the published data comparing
the different scoring systems, we iteratively developed the MRI Osteoarthritis Knee Score
(MOAKS). The purpose of this report is to describe the instrument and its reliability.
Methods
Upon recognition of the limitations in existing scoring methods iterations were made to
elements of the original instruments. The experts (DJH, AG, GHL, AJG, PGC, FR, DG)
involved met to consider the limitations of the existing scoring for each pathological feature:
Bone marrow lesions (BMLs) and meniscal abnormalities were the most important areas for
revision. The focus of the current exercise was therefore to refine the scoring of BMLs, to
include sub-regional assessment, to omit some areas of redundancy in cartilage and BML
scoring, and to refine the elements of meniscal morphology. After consensus was reached on
the new definitions, a intra- and inter-rater reliability exercise was undertaken.
Description of MOAKS
The MOAKS instrument was developed and tested on images obtained on a 3.0 T MRI
system with a dedicated peripheral knee coil. Other systems with different field strengths
will need to be evaluated.
Delineation of subregional divisions—Osteoarthritis can affect one or multiple

compartments in the knee. In MOAKS the knee is divided into 14 articular subregions for
scoring articular cartilage and BMLs and in addition the subspinous region is added for
BML scoring:
1. The patella is divided into 2 subregions, the medial and lateral patella on the axial
view (see Figure 1). The patellar crista (also called apex) is allocated to the medial
subregion.
2. The femur is divided into 6 subregions- medial and lateral trochlea, medial and
lateral central femur, and the medial and lateral posterior femur. Method of
dividing the subregions (see Figure 2):

i. Trochlea is defined as the femoral articular surface of the PF joint For the
division between the trochlea and central regions, on the sagittal image a line
is drawn tangentially to the anterior aspect of the proximal tibia (at the
margin of the tibial plateau) until it intersects the femoral surface. The
division between the central femur and the posterior femur is a line
constructed vertically from the posterior aspect of the tibia. (The rationale
for choosing these divisions, as opposed to choosing the meniscal
boundaries, was the concern that meniscal subluxation and degeneration
would introduce variability into this delineation if used).
ii. Anterior and posterior tibial margins are defined irrespective of the presence
of osteophytes
iii. The femoral notch is defined as being part of the medial femur.
iv. The superior border of the femur is the physeal line. The posterior border of
the trochlea region is the anterior 50% of this region (as measured along the
length of the epiphyseal line) (see figure 2)
3. The tibia is divided into 3 medial (anterior, central and posterior) and 3 lateral
(anterior, central and posterior) subregions covered by articular cartilage, and the
subspinous subregion (SS-region delineated by the tibial spines (Figure 3)).
4. For the anterior, central and posterior divisions the tibia is divided into equal thirds
excluding the presence of osteophytes.
Special considerations for scoring in any region: If a lesion spans more than one
subregion, the lesion needs to be scored in all subregions, especially as the MOAKS system
is modified into a volume-oriented approach and not lesional. Also, if a feature occurs
within the subspinous region, but extends also into one or more of the medial or lateral tibial
subregions, the lesion will be scored in the subspinous region but also in the additional tibial
subregions separately.
Description of scoring for individual features—Each feature is scored separately.

We have chosen a number of commonly recognized features based on their likely relevance
to pain and structural damage or progression of OA. The scoring for BMLs and articular
cartilage described is by subregions as outlined above. Scoring of osteophytes will be

performed at defined locations or sites.
For each joint morphologic feature, we have listed the number (if there are multiple
abnormalities), its location and grade. For BML and cartilage which are scored by region the
score is assigned for the region. We have also described preferred pulse sequences to
delineate each feature.
1 Bone Marrow Lesions (BMLs) and cysts- include areas of presumed bone
marrow lesion (BML) (areas of ill-delineated signal within the trabecular bone
that are hypointense on T1-weighted images and hyperintense on T2-weighted
fat-suppressed images) and associated subarticular bone marrow cysts (defined

as well-delineated lesions of fluid equivalent signal directly adjacent to the

subchondral plate).
BMLs will be scored based on the standardized regions outlined previously (p

4-5). Multiple BMLs can occur within each region. Each region will generate a
single grade for size inclusive of all BMLs into one score, the number of BMLs
per subregion will be counted and % of lesions that is BML as distinct from cyst
will be coded (see Table 1).
a. Each subregion will be graded for BML (including ill-defined lesion and
cysts) size in regard to the total volume of the subregion occupied by
BML(s) (see Figure 4). Consequently, a BML in a smaller subregion will
be smaller when compared to a BML that is assigned the same grade but
is present in a larger subregion, or two BMLs of the same absolute size
might be assigned different grades if present in subregions with differing
volume.
b. Percentage of the volume of each BML that is BML (as distinct from
cyst) is graded as; grade 0= none, grade 1 <33%, grade 2= 33-66% and
grade 3 >66%.
c. If a cyst is present without an associated bone marrow lesion, then cysts

will be scored as a 0 for size % of lesion that is BML. The scoring for
size should be identical to that for bone marrow lesions (Table 1). In
contrast, if a BML does not include any portion of a cyst, the % of the
lesion that is BML v. cyst score would be 3.
d. Do not score marrow signal within osteophytes, however if the lesion

extends beyond the osteophyte then it should be scored.
Pulse sequences:
Suggested pulse sequences to evaluate BMLs are turbo spin echo T2-/intermediate- or
proton-density-weighted fat-saturated or Short TI Inversion Recovery (STIR) sequences
in the axial, coronal, and sagittal planes [11]. T1-weighted fat suppressed images after
intravenous administration of a gadolinium-based contrast agent may be used
alternatively [12]. 3D turbo spin echo (TSE) sequences such as Cube (GE), XETA
(eXtended Echo Train Acquisition) or SPACE (Sampling Perfection with Application

optimized Contrasts using different flip angle Evolution, Siemens) might possibly be of
use for BML assessment in the future [13-15].
Gradient echo-type sequences, even with robust fat suppression or water excitation, are
notoriously insensitive to bone marrow abnormalities due to trabecular magnetic
susceptibility of T2* effects, which may result in underestimation of the size of non-
cystic BMLs [16,17]. Recent studies have demonstrated that these sequences are also
less sensitive in the detection of non-cystic BMLs when using fluid-sensitive FSE
sequences as the reference standard [16,18-21]. We do not recommend the use of these
sequences for scoring BMLs.
2 Articular Cartilage

Although many joint structures are affected in OA, articular cartilage is one of
the main tissues involved in the disease process. The rationale for the cartilage
score was to provide separate scores for the size (i.e. area affected) and depth of
cartilage damage in each of the subregions.
Each articular cartilage region (except the subspinous region) is graded for size
of any cartilage loss (including partial and full thickness loss) as a % of surface
area as related to the size of each individual region surface (see figure 5) and %
of loss in this subregion that is full-thickness loss (table 2 and figure 5).
Description of morphology at individual sites is not to be used to create
cumulative scores of the knee as histopathology is unclear and this scale is not
necessarily linear.
Pulse Sequences:
Optimal pulse sequences to evaluate cartilage are still undergoing extensive review. We
refer to current state of the art reviews of imaging of articular cartilage [22]. For
assessment of early OA commonly used gradient-echo sequences such as spoiled
gradient recalled acquisition(SPGR), Fast Low Angle Shot Water Excitation (FLASH),
dual echo steady state (DESS) or similar are not suitable as these depict focal defects in
an inferior manner when compared to standard T2-/IW (Intermediate Weighted)- or PD
(Proton Density)-w fat suppressed turbo-spin echo sequences [23-26].
3 Osteophytes
Osteophytes are osteo-cartilaginous protrusions growing at the margins of
osteoarthritic joints from a process that involves endochondral ossification.
Previous radiographic studies have highlighted this feature as a hallmark of
disease [27].
For MOAKS, osteophytes are scored in each of the 12 locations or sites outlined
below (Table 3, Figure 6) and graded according to size where: Grade 0= none;
Grade 1=small; Grade 2= medium; Grade 3= large.
Osteophytes along the trochlea, central and posterior margins of the femoral
condyles and tibial plateaus, and along the medial, lateral, superior and inferior
margins of the patella (see Figure 6). Posterior femoral osteophytes are assessed
peripherally and centrally. The larger osteophyte for either, peripheral or central,
location will be scored (Fig 6).
a. Size of osteophyte should reflect protuberance (how far the osteophyte

extends from the joint) rather than total volume of osteophyte (see Figure
7).
b. Score the largest osteophyte within a given location

Pulse sequences:
Optimal pulse sequences to evaluate osteophytes are standard non-fat-suppressed short

TE-weighted (preferably T1 over proton density) or gradient- echo-type such as SPGR,

FLASH, DESS etc. images in the axial, coronal, and sagittal planes. They may also be
assessed on fat suppressed water-sensitive sequences [17].
4 Hoffa’s Synovitis and Synovitis - Effusion

Synovitis and effusion are frequently present in OA and in some studies this
feature correlated with pain and other clinical outcomes although the literature is
conflicting [28-30]. Quantitative MRI markers of synovitis include thickness (or
volume) of synovial tissue and the rate of synovial enhancement following
intravenous injection of contrast material [31].
As commonly employed contrast-enhanced sequences are not available in large
OA studies due to cost concerns and possible side reactions, a surrogate of
signal changes in Hoffa’s fat pad has been applied that has been shown on
biopsy to represent mild chronic synovitis [32]. This abnormality is best
described as diffuse hyperintense signal on T2/PD/IW-w ft suppressed
sequences within the fat pad. It has to be noted that in addition to synovitis these
signal changes could also be attributed to other etiologies such as post-
arthroscopic changes or Hoffa’s disease [33]. Despite this non-specificity these
signal changes are referred to as “Hoffa-synovitis” in MOAKS.
i. Hoffa-synovitis score (on sagittal image) (one single score for assessment
of degree of hyperintensity in Hoffa’s fat pad) based on the region
highlighted in Figure 8. Score is based on size: 0= normal; 1= mild, 2=
moderate, 3= severe.
Pulse sequences:
Suggested pulse sequences to evaluate regions for Hoffa-synovitis are T2/IW- or PD-
weighted fat-saturated images in the mid-slices of the sagittal plane [28,29].
Effusions occur frequently in OA. Recent studies suggest that large synovial effusions
may be associated with pain and stiffness in patients with OA [28]. It is important to
note that “effusion” (fluid equivalent signal within the joint cavity) on T2/IW/PD w
images includes synovitis and effusion [34]. Thus, this imaging measure should
preferably referred to as “effusion-synovitis”.
Scores (Table 4) should be obtained from axial views (Figure 9). Paraarticular cysts and
ganglia should not be included in this score as they are considered separately. Pulse
Sequences: True amount of joint effusion may be assessed as intraarticular
hypointensity on T1w images after i.v. contrast administration. T2/IW/PDw images
show intraarticular hyperintensity that represents a composite of effusion and synovitis
[34].
5 Meniscus
The meniscus has many functions in the knee, including load bearing, shock
absorption, stability enhancement and lubrication [35]. Degenerative meniscal
lesions such as horizontal cleavages, oblique or complex tears are associated
with older age [36]. By the time radiographic disease develops, the
overwhelming majority of persons have meniscal lesions [36,37]. The studies

that have explored the relationship between the meniscus and risk of disease
progression in OA provide a clear indication of the increased risk inherent with
damage to this vital tissue [38,39]. Changes in position (also termed subluxation
or extrusion) and meniscal morphologic change manifest as tears or loss of

substance have both been shown to predispose to cartilage loss. We chose a
scoring system that delineated both of these items and provided detail on what
the abnormality was and where in the meniscus this occurred.
a. Extrusion: Four areas where extrusion is scored:
1. Medial Meniscus: Medial extrusion relative to medial tibial margin

(coronal image)
2. Medial Meniscus: Anterior extrusion (sagittal image) – where

extrusion is maximum
3. Lateral Meniscus: Lateral extrusion relative to lateral tibial margin

(coronal image)
4. Lateral Meniscus: Anterior extrusion (sagittal image) where

extrusion is maximum
Grading for extrusion: Grade 0:<2mm; Grade 1: 2 to 2.9mm,

Grade 2: 3-4.9mm; Grade 3: >5mm.
Note: we wanted to capture anterior extrusion to see if this is

independently predictive of cartilage loss/pain/etc compared with
medial or lateral extrusion. For each measurement the reference
will be the edge of the tibial plateau (excluding any osteophytes).
b. Morphology: (scored on medial and lateral meniscus for the anterior,

body and posterior horn). The anterior and posterior horn regions are
scored using the sagittal sequences and the body is scored using the
coronal sequences. Morphologic features scored:
i. Signal (not extending through meniscal surface i.e. not a tear): Y/N
a. Signal is defined as above as compared with “tears” which

are defined as high signal extending to an articular surface
on at least 2 slices
ii. Vertical tear (includes radial and longitudinal tears) – must extend
to both the femoral and tibial surfaces: Y/N
iii. Horizontal and radial tear: – must extend from the periphery of the
meniscus to either a femoral or tibial surface. Y/N
iv. Complex tear: as defined by high signal that extends to both the
tibial and femoral surfaces and ≥ 3 points on those surfaces). Y/N
v. Root tear (posterior horn): - Y/N

vi. Partial maceration: as defined by loss of morphological substance

of the meniscus and with or without associated increased signal in
the remaining meniscal tissue. Y/N
vii. Progressive partial maceration: Progressive partial maceration as

compared to the previous visit. Y/N
viii. Complete maceration: No meniscal substance is visible. Y/N
ix. Meniscal cyst: Y/N
x. Meniscal hypertrophy is defined as definite increase in meniscal

volume in given subregion when compared to normal : Y/N
Pulse sequences:
Optimal sequences to evaluate menisci are T1, T2w or proton density fat-saturated
images in both coronal and sagittal planes [40,41]. As for BMLs, newly developed 3D
FSE sequences might alternatively be used for meniscal assessment [42].
6 Ligaments/Tendon
Anterior cruciate ligament tears will be recorded as either absent or present.

Partial tears are infrequent and reportedly prone to poor reliability on
interpretation [43]. Thus, partial tears are scored as “normal” in MOAKS. Only
definite complete tears will be scored.
a. Anterior Cruciate Ligament (ACL): Score: normal (0) / complete tear (1)
i. Associated with BML/cyst at site of insertion or origin?: Y/N
ii. ACL Repair: Y/N
b. Posterior Cruciate Ligament (PCL): Score: normal (0) / complete tear (1)
i. Associated with BML/cyst at site of insertion or origin?: Y/N
c. Patellar tendon: Score: 0: no signal abnormality/ 1: signal abnormality

present
Pulse Sequences:
Optimal sequences to evaluate the aforementioned ligaments are coronal, axial and
sagittal, PD or intermediate-weighted, fat Turbo Spin Echo (TSE) images, while 3D
sequences also appear promising [17,44,45]. Additional paracoronal T2-w sequences
might be helpful to differentiate partial from full thickness tears [46].
7 Periarticular features
a. Pes anserine bursitis – absent / present
This is a bursa that lies anterior and inferior to the medial tibial plateau
and is a potential source of pain around the knee. If there is increased
signal in this bursa, bursitis is scored as being present.
b. Iliotibial band (ITB) signal – absent / present

The iliotibial band is a strong, dense, broad layer of fascia that is part of
the fascia lata. The iliotibial band encases the tensor fasciae lata which
helps to steady the trunk on the thigh. ¾ of the gluteus maximus inserts
into the iliotibial tract and the distal end inserts at the lateral tibial
plateau. High signal between the iliotibial band and the femoral cortex
may represent irritation of the iliotibial band and is common in medial
OA. However, this is also a non-specific finding and often asymptomatic
[47]. If there is high signal in this structure, ITB signal should be scored
as being present.
c. Popliteal cyst-absent/ present
Popliteal cysts are not true cysts and represent fluid in the
semimembranosus–medial gastrocnemius bursa. The communication
between the joint space and gastrocnemius–semimembranosus bursa
allows intraarticular joint fluid to communicate with this bursa [48]. If
there is any fluid in this region, this feature should be scored as being
present.
Pulse sequence: Optimal sequences for evaluating popliteal cysts are

Proton density or T2-weighted axial images.
d. Infrapatellar bursa signal – absent / present
This is a bursa located inferior to Hoffa’s fat pad adjacent to the patellar
tendon and is a potential source of pain around the knee. If there is high
signal in this bursa, this feature should be scored as being present.
e. Prepatellar bursa signal – absent / present
This is a bursa that lies anterior to the patella and is a potential source of
pain around the knee. High signal anterior to the patella tendon is a very
common non-specific finding of often no clinical relevance. True bursitis
is characterized by well demarcated fluid equivalent signal within this
structure; only then should this feature be scored as being present.
f. Ganglion cyst
i. Associated with the tibio-fibular joint: present/absent
ii. Associated with PCL and ACL: present/absent
iii. Other: present/absent

Loose bodies: Scale: absent/present
Table 5 provides a summary of the changes in the new score (MOAKS) from older
instruments including BLOKS [5] and WORMS [4].
Study Images for Reliability Exercise: The images for the reliability exercise were chosen
at random from MRI scans undertaken within the National Institutes of Health (NIH)
Osteoarthritis Initiative (OAI, http://www.oai.ucsf.edu). The OAI is a multi-center,

longitudinal, prospective observational study of knee OA. The overall aim of the OAI is to
develop a public domain research resource to facilitate the scientific evaluation of
biomarkers for osteoarthritis as potential surrogate endpoints for disease onset and
progression. The OAI database provides an unparalleled state-of-the-art database showing

both the natural progression of the disease and information on imaging and biochemical
biomarkers and outcome measures.
From 329 participants in the OAI Progression subcohort within OAI Group C (those
enrolled through 4/30/2005) with MRI performed on both knees at baseline, all knees with
K&L grade 2 or 3 were identified (n=339). A 2×2 factorial design was formed incorporating
the factors of side (left vs. right knee) and KL grade (2 or 3). For subjects with both knees
having K&L grade 2 or 3, only one knee was randomly selected for potential inclusion. The
final 2×2 factorial random sample of 20 knees for the reliability study included 5 randomly
selected knees in each of the four cells. A computerized uniform random number between 0
and 1 was assigned to each knee, sorted, then the 5 knees in each cell with the lowest
assigned numbers comprised the randomly selected knees in each cell (e.g. n=5 of 90 knees
in cell “left knee with K&L grade=3” were randomly selected, etc.).
MRI Acquisition: MRI of both knees was performed on 3 T systems (Siemens Trio,
Erlangen, Germany). MRIs were acquired with a USAI quadrature transmit/ receive knee
coil. The coronal intermediate-weighted (IW) 2D turbo spin-echo, a sagittal 3D dual echo
steady state (DESS) sequence, coronal and axial multiplanar reformations of the 3D DESS
and a sagittal IW fat-suppressed (fs) fast spin-echo (FSE) sequence were used for
scoringMOAKS. Details of the full OAI pulse sequence protocol and the sequence
parameters have been published in detail recently [49]. The sagittal T2 mapping and coronal
3D T1-weighted Fast Low Angle Shot Water Excitation (FLASH WE) sequences were not
used for semi-quantitative assessment.
Assessment of Reliability: After an initial training and calibration session on 10 cases that
were not included in the reliability exercise, two expert readers with 10 and 8 years
experience in semi-quantitative MRI assessment of knee OA respectively, (AG, FR)
independently read MRIs of the 20 knees from the OAI. In addition, one reader (FR) re-read
the same 20 MRIs 4 weeks later presented in random order to assess intra-rater reliability.
The analyses presented here are for both intra- and inter-rater reliability (calculated using the
linear weighted kappa (95%CI)) and the percent agreement of the scoring exercise.
Results
The reliability of the instrument was assessed on 20 subjects with a mean age of 57.8 years
(SD 9.8) and a mean BMI of 31.4 kg/m2 (SD 5.0). Fifty-five percent (n=11) were female. Of
the 20 knees that were assessed their Kellgren and Lawrence Grades were K&L=2 in 10
knees, K&L=3 in 10 knees. The reliability for the features described above is reported in
Table 6.

With the exception of inter-rater reliability for tibial cartilage surface area (kappa=0.36),
tibial osteophytes (kappa=0.49) and intercondylar synovitis (kappa=0.49); and intra-rater
reliability for tibial BML number of lesions (kappa=0.54), infrapatellar synovitis
(kappa=0.42) and intercondylar synovitis (kappa=0.57) all measures of reliability were very
good (0.61-0.8) or reached near-perfect agreement (0.81-1.0) according to the criteria
developed by Landis and Koch [50]. The low prevalence of certain features in certain sub-
regions may have adversely affected the kappa results hence the percent agreement was also
calculated. The majority of features were scored with overall percent agreement above 75%
for both, the intra- and inter-reader exercise. Only intra-rater reliability for Hoffa-synovitis
(55%), and inter-rater reliability for tibial (55%) and patellar (65%) osteophytes showed
overall percent agreement < 75%.
Discussion
The structural determinants of mechanical dysfunction and pain in arthritis are presently not
well understood, but probably involve a multitude of interactive pathways characterized by
changes in structure and function of the whole joint [51]. The current practice of monitoring
only a few of these features (usually radiographically-assessed joint-space narrowing and
osteophytes) provides only a restricted view of the disease process and lessens the utility of
such assessments. Semi-quantitative MRI scoring will continue to provide important insights
into the etiopathogenesis of disease as well as structure-function relationships. As new
insights continue to develop the field, this scoring instrument, used to assess structural
change in knee OA will similarly need to evolve.
This report provides data on the reliability of structural features scored using MOAKS: a
semi-quantitative scoring instrument for MRI assessment of knee OA that builds on the prior
experiences of BLOKS and other semi-quantitative scoring tools. The MOAKS instrument
refines the scoring of BMLs (providing regional delineation and scoring across regions),
cartilage (sub-regional assessment), and refines the elements of meniscal morphology
(adding meniscal hypertrophy, partial maceration and progressive partial maceration) and
subluxation scoring. In addition we decided to omit some areas of redundancy including the
second cartilage scoring method that was part of the original BLOKS instrument and
assessed cartilage at defined locations in a specific image and also omitted BML adjacency
to subchondral plate scoring.
The timing of this work is relevant as large scale scoring exercises are about to commence in
a number of studies including the Osteoarthritis Initiative. Importantly, the measurement
properties (including construct and predictive validity and the responsiveness) of these
modifications will need to be assessed to ensure their credibility.
The reliability of most of the features that were scored in this exercise was substantial or
almost perfect agreement according to Landis and Koch criteria [50]. Some of the features
however had only moderate agreement when using kappa statistics including intra-rater
reliability for femoral and tibial cystic portions of BMLs, count of tibial BMLs, and Hoffa
synovitis, and inter-rater reliability for tibial cartilage area and tibial osteophytes. For some

of these features low frequencies of non-zero scores are accountable for these kappa values.
Overall percent agreement was good to perfect for almost all features.
Some of the features listed are exploratory in nature and warrant further investigation,
including measures of meniscal extrusion. The magnitude of the meniscal extrusion is the
same that we have previously used in BLOKS and that has been used in prior analyses
[39,52,53]. The extent of analysis in the research literature describing the importance of
anterior or posterior extrusion is limited. In our previous analyses anterior extrusion has
been associated with an increased risk of cartilage loss [39].
In conclusion, we have refined an existing scoring instrument and assessed its reliability.
MOAKS demonstrates reasonable reliability. Further iterative development and research
will include assessment of its validation and responsiveness for use in both clinical trials and
epidemiological studies. This will allow determination of the significance of specific
features to determine if there are subsets that can be consolidated or eliminated to simplify
the instrument.
Acknowledgments
Dr Hunter is supported by an Australian Research Council Future Fellowship. We would like to acknowledge the
support of Dr Daniel Gale who contributed to BLOKS and the initial development of MOAKS.
Funding: The image analysis of this study was funded by a contract with the University of Pittsburgh (Pivotal OAI
MRI Analyses POMA: NIH/NHLBI Contract No. HHSN2682010000 21C), and in part by a vendor contract from
the OAI coordinating center at University of California, San Francisco (N01-AR-2-2258). The statistical data
analysis was funded by a contract with the University of Pittsburgh (Pivotal OAI MRI Analyses POMA: NIH/
NHLBI Contract No. HHSN2682010000 21C) and the University of Pittsburgh Multidisciplinary Clinical Research
Center (MCRC) for Rheumatic and Musculoskeletal Diseases (P60 AR054731).
David Hunter receives research or institutional support from AstraZeneca, DonJoy, Lilly, Merck, NIH, Pfizer,
Stryker and Wyeth.
Ali Guermazi receives research or institutional support from NIH and GE Healthcare. He is consultant to
MerckSerono, Stryker, Genzyme and Novartis. He is President of BICL (Boston Imaging Core Lab), LLC, a
company providing radiologic image assessment services.
Frank Roemer is shareholder of Boston Imaging Core Lab (BICL) LLC., a company providing radiologic image
assessment services.
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Figure 1.
Subregional division of the patella in the axial plane. Axial T2w image shows the medial
(M) and lateral (L) portions of the patella as divided in MOAKS. Note that the patellar apex
is part of the medial subregion (arrow).

Figure 2.
Anatomical delineation of femur into trochlea (T), central (C) and posterior (P) regions on
sagittal projection. Sagittal projection depicts delineation of the tibia into anterior, central
and posterior subregions, which is divided into equal thirds.

Figure 3.
Coronal IW image shows anatomical delineation of the tibia into medial, subspinous (SS)
and lateral subregions. The femur is divided into the medial and lateral femoral condyle. The
intercondylar notch is considered to be part of the medial femur.

Figure 4.
BML grading. Grade 0= none, grade 1 <33% of subregional volume, grade 2= 33-66% of
subregional volume and grade 3 >66% of subregional volume. A. Coronal T2 w image
shows small grade 1 BML in central subregion of medial tibia. B. A grade 2 BML is
depicted in central subregion of medial femur. C. Grade 3 BMLs in the central subregions of
the medial femur (arrows) and central medial tibia (arrowheads). D. Coronal image shows
BML consisting of non-cystic/ill-defined portion (arrowheads) and cystic (arrow) part.

Figure 5.
Grade for size of any cartilage loss as a % of surface area as related to the size of each
individual region. Grade 0= none, grade 1 < 10% of region of cartilage surface area, grade
2= 10-75% of region of cartilage surface area and grade 3 >75% of region of cartilage
surface area. (Drawing courtesy of Daichi Hayashi, MD)

Figure 6.
Locations for osteophytes scoring. A. Coronal plane. Osteophytes are scored at the marginal
locations of the medial and lateral femur and tibia, respectivel (arrowheads). B. Sagittal
plane. Osteophytes are scored at the superior and inferior patellar pole (arrowheads). C.
Axial plane. Osteophytes are scored at yhe medial and lateral patella poles (arrowheads), at
the anterior medial and lateral femur (black arrows) and the posterior femur medial and
lateral (white arrows). Note that there are two locations medially and laterally for
osteophytes scoring at the posterior femur, the central and peripheral location. Only the
larger osteophyte for either the central or peripheral location will be scored.

Figure 7.
Scoring of osteophytes. Grade 0= none, grade 1=small, grade 2= medium and grade 3=
large. A. Grade 1 osteophyte medial femur. B. Grade 2 osteophyte lateral femur. C. Grade 3
osteophyte lateral femur. Size of osteophyte should reflect protuberance (how far the
osteophyte extends from the joint) rather than total volume of osteophyte

Figure 8.
Hoffa-synovitis. Sagittal T2w image shows grade 2 hyperintense signal changes in Hoffa’s
fat pad consistent with Hoffa-synovitis.

Figure 9.
Effusion-synovitis. Hyperintensity within the articular cavity represents a composite of
effusion and synovial thickening that cannot be distinguished from each other in the absence
of contrast. Grade 0= none, grade 1=small, grade 2= medium and grade 3= large.
A. Grade 0 effusion-synovitis. Normal intraarticular hyperintensity is depicted. B. Grade 1
effusion-synovitis. C. Grade 2 effusion synovitis. D. Grade 3 effusion-synovitis.

Table 1
Scoring system for bone marrow lesions

Size of BML (including volume of any associated cysts) by volume No. of BMLs % of lesion that is bone marrow lesion (v.
counted cyst)
0: none 0: none
1: < 33% of subregional volume 1: < 33%
2: 33 – 66% of subregional volume 2: 33 – 66%
3: > 66% of subregional volume 3: > 66%


Table 2
Delineation of grading for Cartilage

Size of any cartilage loss (including partial and full thickness loss) as a % of surface % full thickness cartilage loss of the region
area as related to the size of each individual region
0: none 0: none
1: < 10% of region of cartilage surface area 1: < 10% of region of cartilage surface area
2: 10 – 75% of region of cartilage surface area 2: 10 – 75% of region of cartilage surface area
3: > 75% of region of cartilage surface area 3: > 75% of region of cartilage surface area

Table 3
Sites for osteophyte scoring

Osteophyte Location Slice Orientation

Anterior femur (trochlea) Medial Sagittal/ Axial
Lateral
Posterior Femur Medial Sagittal/ Axial
Lateral
Central Femur Medial Coronal
Lateral
Patella Superior Sagittal
Inferior
Medial Axial
Lateral
Tibia Medial Coronal
Lateral

Table 4
Delineation of grading for Effusion-synovitis

Size of effusion-synovitis
0: physiologic amount
1: small – fluid continuous in the retropatellar space
2: medium – with slight convexity of the suprapatellar bursa
3: large – evidence of capsular distention


Table 5
Features that are scored in MOAKS in comparison to the original BLOKS instrument and WORMS Score. We
used BLOKS as the starting point, and the alterations in MOAKS reflect deviation from BLOKS
MRI feature Original BLOKS score Original WORMS score Alteration in MOAKS
BML size Score of 0-3 applied for BML Summed BML size/volume for subregion Modify thresholds from
volume in 9 different articular from 0 to 3 in regard to percentage of 10-85% to 33-66%. Instead of
subregions. Each BML within a subregional bone volume scoring EACH BML, the entire
subregion receives an individual subregion receives one size
size score. score based on the threshold
listed above. Grade for regions-
use same sub-regions as
proposed for cartilage – with
the addition of the subspinous
region. Count no. of lesions.
BML % area Score of 0-3 applied for % - Omitted from new scoring
surface area adjacent to system.
subchondral plate
% of lesion BML Score of 0-3 for % of lesion that Summed cyst size/volume for subregion No change
rather than cyst is bone marrow lesion as distinct from 0 to 3 in regard to percentage of
from cyst subregional bone volume
Cartilage 1 Score of 0-3 for size of loss and Subregional approach:Scores from 0 to 6 Further subdivision of the
% of loss in region that is full depending on depth and extent of cartilage medial and lateral tibial region
thickness loss. Intrachondral cartilage signal into anterior, central and
additionally scored as present/absent posterior and subdivision of the

weight-bearing femur into
central and posterior
Cartilage 2 Extent of any cartilage loss at - Omitted from new scoring

specified points system.
Osteophyte Score of 0-3 applied for Score of 0-7 applied for osteophyte size at No change
osteophyte size in12 locations 16 sites.
Synovitis Score of 0-3 applied for synovial Combined effusion/synovitis score. Score of 0-3 applied to signal
volume changes in Hoffa’s fat pad.
Feature renamed as “Hoffa-
synovitis”
Effusion Score of 0-3 applied for size of Score of 0-3 applied for size of effusion Feature renamed to “Effusion-
effusion synovitis”Scoring parameters
are unchanged.
Meniscal extrusion Score of 0-3 applied for amount Not scored No change
of extrusion in 4 locations
Meniscal signal Scored as present or absent in 6 Not scored No change

regions.
Meniscus tear Type of tear or degenerative Anterior horn, body, posterior horn scored Add meniscal hypertrophy,
process scored as present or separately in medial/lateral meniscus from 0 partial maceration and
absent in 6 regions. to 4: progressive partial maceration

1 minor radial or parrot beak tear
2 non-displaced tear or prior
surgical repair
3 displaced tear or partial
resection
4 complete maceration/
destruction or complete
resection
Ligaments Presence/ absence of tear Presence/ absence of tear No change
Periarticular features Presence/ absence Presence/ absence No change

NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Table 6
The reliability for reading of MOAKS features (weighted kappa and percent agreement)
MOAKS Feature Region Intra-rater Inter-rater

Hunter et al.
Weighted kappa (95%CI) Percent agreement Weighted kappa (95%CI) Percent agreement
Cartilage Area Femoral 0.92(0.77-1.00) 0.95 0.62(0.27-0.98) 0.80
Tibial 0.73(0.47-1.00) 0.80 0.36(0.05-0.67) 0.70
Patella 0.71(0.43-0.99) 0.75 0.71(0.42-0.99) 0.75
Cartilage Depth Femoral 0.95(0.85-1.00) 0.95 0.79(0.60-0.98) 0.80
Tibial 0.83(0.69-0.96) 0.80 0.73(0.52-0.94) 0.75
Patella 0.92(0.82-1.00) 0.90 0.85(0.72-0.98) 0.80
BML Size Femoral 0.85(0.69-1.00) 0.85 0.82(0.69-0.95) 0.80
Tibial 0.76(0.55-0.98) 0.75 0.96(0.86-1.00) 0.95
Patella 1.00(1.00-1.00) 1.00 0.87(0.74-1.00) 0.85
Subspinous 0.79(0.60-0.99) 0.80 0.76(0.57-0.94) 0.75
BML, %cyst Femoral 0.57(0.18-0.95) 0.85 0.74(0.40-1.00) 0.90
Tibial 0.50(0.23-0.97) 0.80 0.74(0.46-1.00) 0.85
Patella 0.88(0.73-1.00) 0.90 1.00(1.00-1.00) 1.00
Subspinous 0.70(0.36-1.00) 0.85 0.65(0.36-0.93) 0.75
BML, No. of lesions Femoral 0.84(0.68-1.00) 0.85 0.78(0.64-0.92) 0.75
Tibial 0.54(0.30-0.77) 0.65 0.82(0.62-1.00) 0.85
Patella 0.90(0.77-1.00) 0.90 0.93(0.82-1.00) 0.90
Subspinous 0.80(0.63-0.97) 0.80 0.72(0.51-0.93) 0.75

Meniscus Morphology Medial 1.00(1.00-1.00) 1.00 0.97(0.89-1.00) 0.95
Lateral 0.91(0.77-1.00) 0.90 0.95(0.86-1.00) 0.95
Meniscal extrusion Medial 0.82(0.67-0.98) 0.80 0.66(0.46-0.86) 0.60
Lateral 0.89(0.75-1.00) 0.90 0.79(0.67-0.91) 0.80
Osteophytes Femoral 0.64(0.36-0.92) 0.75 0.80(0.58-1.00) 0.95
Tibial 0.70(0.50-0.91) 0.75 0.49(0.24-0.74) 0.55
Patella 0.84(0.67-1.00) 0.85 0.64(0.39-0.89) 0.65
Hoffa-Synovitis 0.42(0.14-0.70) 0.55 0.70(0.47-0.93) 0.75

Page 31
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
MOAKS Feature Region Intra-rater Inter-rater
Weighted kappa (95%CI) Percent agreement Weighted kappa (95%CI) Percent agreement
Effusion-Synovitis 0.90(0.78-1.00) 0.90 0.72(0.52-0.92) 0.70
Hunter et al.

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NIH Public Access: Evolution of Semiquantitative Whole Joint Assessment of Knee OA: MOAKS (MRI Osteoarthritis Knee Score)

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Osteoarthritis Cartilage. 2011 August ; 19(8): 990–1002. doi:10.1016/j.joca.2011.05.004.

Evolution of semiquantitative whole joint assessment of knee

Osteoarthritis Cartilage. Author manuscript; available in PMC 2014 June 16.

system was cumbersome and complex and parts of it seemed redundant.

Delineation of subregional divisions—Osteoarthritis can affect one or multiple

Osteoarthritis Cartilage. Author manuscript; available in PMC 2014 June 16.

Description of scoring for individual features—Each feature is scored separately.

cartilage described is by subregions as outlined above. Scoring of osteophytes will be

Osteoarthritis Cartilage. Author manuscript; available in PMC 2014 June 16.

as well-delineated lesions of fluid equivalent signal directly adjacent to the

BMLs will be scored based on the standardized regions outlined previously (p

c. If a cyst is present without an associated bone marrow lesion, then cysts

d. Do not score marrow signal within osteophytes, however if the lesion

(eXtended Echo Train Acquisition) or SPACE (Sampling Perfection with Application

Osteoarthritis Cartilage. Author manuscript; available in PMC 2014 June 16.

cartilage damage in each of the subregions.

a. Size of osteophyte should reflect protuberance (how far the osteophyte

b. Score the largest osteophyte within a given location

Optimal pulse sequences to evaluate osteophytes are standard non-fat-suppressed short

Osteoarthritis Cartilage. Author manuscript; available in PMC 2014 June 16.

4 Hoffa’s Synovitis and Synovitis - Effusion

Osteoarthritis Cartilage. Author manuscript; available in PMC 2014 June 16.

or extrusion) and meniscal morphologic change manifest as tears or loss of

a. Extrusion: Four areas where extrusion is scored:

1. Medial Meniscus: Medial extrusion relative to medial tibial margin

2. Medial Meniscus: Anterior extrusion (sagittal image) – where

3. Lateral Meniscus: Lateral extrusion relative to lateral tibial margin

4. Lateral Meniscus: Anterior extrusion (sagittal image) where

Grading for extrusion: Grade 0:<2mm; Grade 1: 2 to 2.9mm,

Note: we wanted to capture anterior extrusion to see if this is

b. Morphology: (scored on medial and lateral meniscus for the anterior,

a. Signal is defined as above as compared with “tears” which

v. Root tear (posterior horn): - Y/N

Osteoarthritis Cartilage. Author manuscript; available in PMC 2014 June 16.

vi. Partial maceration: as defined by loss of morphological substance

vii. Progressive partial maceration: Progressive partial maceration as

viii. Complete maceration: No meniscal substance is visible. Y/N

ix. Meniscal cyst: Y/N

x. Meniscal hypertrophy is defined as definite increase in meniscal

Anterior cruciate ligament tears will be recorded as either absent or present.

i. Associated with BML/cyst at site of insertion or origin?: Y/N

ii. ACL Repair: Y/N

i. Associated with BML/cyst at site of insertion or origin?: Y/N

c. Patellar tendon: Score: 0: no signal abnormality/ 1: signal abnormality

a. Pes anserine bursitis – absent / present

b. Iliotibial band (ITB) signal – absent / present

Osteoarthritis Cartilage. Author manuscript; available in PMC 2014 June 16.

c. Popliteal cyst-absent/ present

Pulse sequence: Optimal sequences for evaluating popliteal cysts are

Proton density or T2-weighted axial images.

d. Infrapatellar bursa signal – absent / present

e. Prepatellar bursa signal – absent / present

i. Associated with the tibio-fibular joint: present/absent

ii. Associated with PCL and ACL: present/absent

iii. Other: present/absent

Osteoarthritis Cartilage. Author manuscript; available in PMC 2014 June 16.

progression. The OAI database provides an unparalleled state-of-the-art database showing

Osteoarthritis Cartilage. Author manuscript; available in PMC 2014 June 16.

Osteoarthritis Cartilage. Author manuscript; available in PMC 2014 June 16.

Osteoarthritis Cartilage. Author manuscript; available in PMC 2014 June 16.

Osteoarthritis Cartilage. Author manuscript; available in PMC 2014 June 16.

abnormalities of the knee: prospective clinical evaluation of a 3D water-excitation true FISP