RADIOLOGICAL FEATURES OF

OSTEOARTHRITIS

DR. SHILPA DEVAKAR

ASSOCIATE PROFESSOR AND INCHARGE HEAD
DEPARTMENT OF RADIODIAGNOSIS AND IMAGING
RAICHUR INSTITUTE OF MEDICAL SCIENCES
DEFINITION

Inflammation of joint
 Arthros-- Joint
 Itis– Inflammation
Osteoarthritis (OA), also known as degenerative joint disease
(DJD), is the most common form of arthritis, being widely
prevalent with high morbidity
WHY IMAGE IN OSTEOARTHRITIS

Diagnosis Staging Prognosis

Efficacy
Follow up of
treatment
 RADIOGRAPHY

ULTRASONOGRAPHY
IMAGING
MODALITIES
CT SCAN

MRI SCAN

RADIONUCLIDE SCAN
RADIOGRAPHY

 Plain radiographs are the workhorse of imaging including follow-up,

although there is a poor correlation between radiographic findings
and clinical symptoms.
 Simplest imaging technique First Line
 Still the most widely used investigation
 Skeletal survey- disease distribution
 Treatment monitoring
 Not sensitive for early disease
 Gives only indirect measure of chondral thickness/meniscal integrity

On radiographs one critical assessment is differentiating inflammatory

arthritis from a degenerative process because the treatment options are
quite different
Correlation between x-ray and symptoms is variable:

Knee x-ray correlates with symptoms - 85%

Hand and wrist x-ray correlates with symptoms - 80%
Hip x-ray correlates with symptoms - 75%
ULTRASOUND

 Ultrasound is not routinely used in osteoarthritis.

 The assessment of the bony structure and deep joint
structures using this modality is impossible.
 Joint effusion
 Synovial thickening and hypervascularity
 Erosions
 Monitor disease activity and progression
 Guided aspiration and injections
COMPUTED TOMOGRAPHY

Limited role
 Images of CV junction
 Better demonstration of new bone formation and Bony
ankylosis
MAGNETIC RESONANCE IMAGING

 Not routine clinical initial assessment

 Not routine for follow up in OA
 Useful in early stage OA
 Visualisation of pathologies not detected on X-ray
 Particularly Mechanical intra-articular issues
 Useful in abnormal clinical presentation (i.e. tumour/AVN)
 Gold standard for synovial imaging
 Detection of active synovitis
 Bone marrow changes
 Scoring
 Early detection of erosions (MRI erosions progress to radiographical erosions within 2
years)
 MRI studies have strongly associated pain with the presence of synovitis
and BML (bone marrow lesions)
RADIONUCLIDE SCANNING

Radiolabelled polyclonal human Ig

 Highly sensitive detection of inflammatory changes
 Poor specificity
CLASSIFICATION

• Primary (Idiopathic)
• Absence of an antecedent insult
• Strong genetic component with the disease primarily affecting
middle-aged women
• Secondary
• Abnormal mechanical forces (e.g. occupational stress, obesity)
• Previous joint injury
• Post-traumatic osteoarthritis
• Major cause in young adults
• Prior surgery
• Crystal deposition (e.g. gout, CPPD)
• Inflammatory arthritis (e.g. rheumatoid arthritis, seronegative spondylarthritis)
• Hemochromatosis
DISTRIBUTION

Osteoarthritis can affect both the axial and

appendicular skeleton.
The most common peripheral joints affected
include
• hands
• knee
• hip
Correlation between x-ray and symptoms is
variable:

Knee x-ray correlates with symptoms - 85%

Hand and wrist x-ray correlates with symptoms - 80%
Hip x-ray correlates with symptoms - 75%
KNEE OA
X-RAY VIEWS

 AP VIEW
 LATERAL VIEW
 SKYLINE VIEW
 ROSENBERG VIEW
 Plain radiographs are the workhorse of imaging including follow-up,
although there is a poor correlation between radiographic findings
and clinical symptoms.
ROSENBERG
VIEW
NORMAL X-RAY KNEE
 Non-uniform narrowing of joint
space
Subchondral bony sclerosis

X-RAY Marginal osteophyte formation

FINDINGS
Subchondral Cyst formation

Gross deformity in advanced

cases
JOINT SPACE NARROWING
SUBCHONDRAL
CYSTS
INTRA-ARTICULAR LOOSE BODIES
 Effusion and synovial
thickening / synovitis
Subchondral bone marrow
MRI edema and/or cysts
(ADDITIONAL
FINDINGS ON Cartilaginous defects
MRI) (partial or full-thickness)
Bursitis
SYNOVITIS AND EFFUSION
BONE MARROW LESIONS (BMLS)
FOCAL CHONDRAL PATHOLOGY
MENISCAL PATHOLOGY
EXTRA-ARTICULAR PATHOLOGY
GRADING

• Kellgren and Lawrence system

• Ahlbäck classification system
• MRI Osteoarthritis Knee Score (MOAKS)
 Grade 0 (none): definite absence of x-ray changes of osteoarthritis
THE KELLGRE Grade 1 (doubtful): doubtful joint space narrowing and possible osteophytic

N AND lipping

LAWRENCE Grade 2 (minimal): definite osteophytes and possible joint space narrowing

SYSTEM Grade 3 (moderate): moderate multiple osteophytes, definite narrowing of joint

space and some sclerosis and possible deformity of bone ends

Grade 4 (severe): large osteophytes, marked narrowing of joint space, severe

sclerosis and definite deformity of bone ends
 Grade 1: joint space narrowing (less than 3 mm)

AHLBÄCK Grade 2: joint space obliteration

CLASSIFICATION Grade 3: minor bone attrition (0-5 mm)

SYSTEM Grade 4: moderate bone attrition (5-10 mm)

Grade 5: severe bone attrition (more than 10 mm)
MRI OSTEOARTHRITIS KNEE SCORE (MOAKS)

 MRI Osteoarthritis Knee Score (MOAKS) is a semi-

quantitative scoring tool that was developed from
the Whole Organ Magnetic Resonance Imaging
Score (WORMS) and Boston Leeds Osteoarthritis
Knee Score (BLOKS) scoring tools.
 MOAKS has been shown to have very good to
excellent reliability.
 Subregions-
Fourteen subregions
• Medial patella (including median patellar ridge)
Patella (axial view) • Lateral patella

• Medial and lateral trochlea

Femur • Medial and lateral central femur
• Medial and lateral posterior femur

• Anterior, central and posterior medial articular cartilage

Tibia • Anterior, central and posterior lateral articular cartilage
• Subspinous region (tibial spines)
Individua Bone marrow lesions and cysts
l features Articular cartilage
Osteophytes
Hoffa's synovitis and synovitis-effusion
Meniscus
Ligaments/tendons
Periarticular features
 Unicompartmental Knee Osteoarthritis
 Bicompartmental Knee Osteoarthritis
 Tricompartmental Knee Osteoarthritis
OA HIP
  AP radiograph of the hip
PLAIN  Cross-table lateral or frog-leg

RADIOGRAPH lateral view

RADIOGRAPHIC FEATURES
PATTERN OF HIP MIGRATION
HIP JOINT SPACE

 The minimal
joint space
width is
measured
between the
femoral head
and the nearest
part of
the acetabular
sourcil (represen
ting the weight-
bearing surface).
ULTRASOUND

Ultrasound can depict

 Joint effusions
 Synovitis
 Increased synovial vascularization
 Can detect osteophytes
 Image-guided injections
CT

Computed tomography provides information on the

 3D assessment of acetabular and proximal femoral
anatomy
 surgicalplanning in cases of femoroacetabular
impingement (FAI) or acetabular dysplasia
 to assess the amount of bone stock
MRI

In addition to the above-mentioned features the MRI shows:

 chondral and labral morphology including, attrition, labral
hypertrophy and paralabral cysts
 subchondral bone marrow edema like signal
 joint effusion, synovitis
 intraarticular loose bodies
 acetabular and femoral head-neck morphology
 ligamentous abnormalities including signs of insertional tendonitis or
greater trochanteric bursitis
GRADING OF HIP OA

 Kellgren and Lawrence score-- apparently the most reliable

 Croft score
 Tönnis classification
 Another semi-quantitative method--OARSI atlas.
 Recommended scoring systems are the Kellgren and Lawrence
score and the OARSI atlas
Tönnis classification for osteoarthritis of the hip
• Grade 0: no signs of osteoarthritis
• Grade 1: minor joint space narrowing, subchondral sclerosis of the
femoral head and/or acetabulum, small osteophytes
• Grade 2: moderate joint space narrowing, small subchondral cysts of
the femoral head and/or acetabulum, moderate loss of sphericity of
the femoral head
• Grade 3: severe joint space narrowing or obliteration, large
subchondral cysts, severe deformity of the femoral head
 MRI
• grade 0: normal
• grade 1: inhomogeneous high signal intensity in cartilage (T2WI)
• grade 2: inhomogeneity with areas of high signal intensity in articular
cartilage (T2WI); indistinct trabeculae or signal intensity loss in femoral
head and neck (T1WI)
• grade 3: criteria of grade 1 and 2 plus indistinct zone between femoral
head and acetabulum; subchondral signal loss due to bone sclerosis
• grade 4: above criteria plus femoral head deformity
MRI-based semi-quantitative scoring systems are the
 HOAMS
 HIMRISS (hip inflammation MRI scoring system)
 SHOMRI systems
The semiquantitative MRI scoring systems are
primarily used in clinical trials and are rather labour-
intensive due to many features and subregions.
 The HOAMS score assesses a variety of features of the hip joint such
as chondral lesions, bone marrow lesions, subchondral cysts,
osteophytes, labral lesions, synovitis and joint effusion as well as
attrition, dysplasia, intraarticular bodies, labral hypertrophy,
paralabral cysts, femoral herniation pit, insertional greater
trochanteric tendonitis and/or bursitis
 The SHOMRI score assesses fewer features including, chondral loss,
bone marrow edema pattern, subchondral cysts, labral abnormalities
as well as paralabral cysts, intraarticular loose bodies, joint
effusion or synovitis and ligamentum teres abnormalities.
 For the evaluation of active disease HIMRISS (hip inflammation MRI
scoring system) has been described, which focuses on the active
inflammatory aspect of osteoarthritis and measures only three
features of the disease, being bone marrow lesions, effusion and
synovitis.
 Quantitative MRI techniques,
 subject to clinical research and are not used in
clinical routine
 Include assessment of cartilage composition with
mapping techniques as dGEMRIC, T1rho, T2 and T2*
YOU CAN REFER IT LATER

 Atlas of individual radiographic features in osteoarthritis

 The atlas of individual radiographic features in osteoarthritis
(OARSI atlas) are publications about radiographic features
of osteoarthritis in different joints. They provide a grading scheme for
those features illustrated by imaging examples
DEGENERATIVE DISC DISEASE –
C-SPINE X-RAY

• Reduction of
height of the
intervertebral
discs
• Osteophytes
• Vertebral body
endplates are
sclerotic and
irregular
(compare with
the normal
endplates more
superiorly)
DEGENERATIVE DISC DISEASE –
LS-SPINE X-RAY

Reduction of disc height

Vertebral body osteophytes
Cortical irregularity of the facet joints is a sign of
facet joint arthrosis
Note: The intervertebral disc spaces are not
synovial joints and so osteoarthritis is an incorrect
term for degenerative disc disease.
However, the facet joints are synovial joints and
so are susceptible to osteoarthritis – often referred
to as ‘arthrosis’.
 Degenerative disc disease – L-
Spine X-ray
• The disc spaces are narrow due to
reduction of disc height
• Prominent vertebral body osteophytes
have formed anteriorly
• Cortical irregularity of the facet joints
is a sign of facet joint arthrosis
• Note: The intervertebral disc spaces
are not synovial joints and so
osteoarthritis is an incorrect term for
degenerative disc disease. However,
the facet joints are synovial joints and
so are susceptible to osteoarthritis –
often referred to as ‘arthrosis’.
• (Same patient as MRI below)
MRI
 Thank you
 PHYSICAL AND CHEMICAL FORCES

Altered chondrocyte function

Altered ground function (loss of chondroitin sulfate)

Fibrillation Fissures
Flaking Vascularization
Loss of joint space

Secondary changes

Subchondral Subchondr Articular Synovial Subluxatio

Sclerosis al Cysts deformity hypertrophy n
MRI OSTEOARTHRITIS KNEE SCORE (MOAKS)

 MRI Osteoarthritis Knee Score (MOAKS) is a semi-quantitative

scoring tool that was developed from the
Whole Organ Magnetic Resonance Imaging Score (WORMS) and
Boston Leeds Osteoarthritis Knee Score (BLOKS) scoring tools. MOAKS
has been shown to have very good to excellent reliability.
 Scoring
 Subregions
 Fourteen subregions are defined for scoring of articular cartilage and bone marrow lesions 1:
• patella (axial view)
• medial patella (including median patellar ridge)
• lateral patella
• femur
• medial and lateral trochlea
• medial and lateral central femur
• medial and lateral posterior femur
• tibia
• anterior, central and posterior medial articular cartilage
• anterior, central and posterior lateral articular cartilage
• subspinous region (tibial spines)
 N.B. lesions crossing two subregions are scored in both subregions
 Individual features
 Bone marrow lesions and cysts
• bone marrow lesion: ill-defined trabecular bone signal that is low on T1 and high on T2FS weighted imaging
• cyst: well-defined regions of fluid signal adjacent to the subchondral bone plate
• multiple bone marrow lesions in one subregion are collated into one percentage
• scoring
• subregional volume of bone marrow lesion (including cysts)
• grade 0: none
• grade 1: <33%
• grade 2: 33-66%
• grade 3: >66%
• % of lesion that is bone marrow lesion vs cyst
• grade 0: none
• grade 1: <33%
• grade 2: 33-66%
• grade 3: >66%
 Articular cartilage
 Articular cartilage is graded for lesion size (any cartilage loss) and degree of full-
thickness loss:
• size of cartilage loss as a percentage of subregion size
• grade 0: none
• grade 1: <10%
• grade 2: 10-75%
• grade 3: >75%
• percentage of full-thickness cartilage loss in subregion
• grade 0: none
• grade 1: <10%
• grade 2: 10-75%
• grade 3: >75%
 Osteophytes
 Osteophytes are graded in 12 regions as none (grade 0), small (grade
1), medium (grade 2) or large (grade 3):
• anterior femur (trochlea): medial and lateral (sagittal/axial)
• posterior femur: medial and lateral (sagittal/axial)
• central femur: medial and lateral (coronal)
• patella: superior, inferior (sagittal) and medial, lateral (axial)
• tibia: medial and lateral (coronal)
 Hoffa's synovitis and synovitis-effusion
 Mild chronic synovitis in MOAKS is described as diffuse high signal on T2/PD FS
sequences within Hoffa's fat pad. It is scored on the sagittal view as:
• grade 0: normal
• grade 1: mild
• grade 2: moderate
• grade 3: severe
 Effusion-synovitis is scored on the axial view as:

• grade 0: physiological volume

• grade 1: small - fluid continuous in the retropatellar space
• grade 2: medium - slight convexity of the suprapatellar bursa
• grade 3: large - evidence of capsular distension
 Meniscus
 Meniscal position and morphology are graded. Meniscal extrusion is
graded as <2 mm (grade 0), 2-2.9 mm (grade 1), 3-4.9 mm (grade 2),
and >5 mm (grade 3) and scored in four locations:
• medial meniscus
• medial extrusion relative to medial tibial margin (coronal)
• maximal anterior extrusion (sagittal)
• lateral meniscus
• lateral extrusion relative to lateral tibial margin (coronal)
• maximal anterior extrusion (sagittal)
 Morphology is scored at the anterior and posterior horns (sagittal) and body (coronal) for
both medial and lateral menisci. The following features are scored as present (yes) or absent
(no):
• signal not extending through to meniscal surface on at least two slices
• vertical tear (radial and longitudinal): must extend to both femoral and tibial surfaces
• horizontal and radial tear: must extend from the periphery to either femoral or tibial surface
• complex tear: ≥3 point involvement of the tibial and femoral surfaces
• root tear
• partial maceration
• progressive partial maceration'
• complete maceration
• meniscal cyst
• meniscal hypertrophy
 Ligaments/tendons
 The following are scored:

• anterior cruciate ligament

• normal vs complete tear
• associated bone marrow lesion/cyst at site of insertion or origin
• anterior cruciate ligament repair
• posterior cruciate ligament
• normal vs complete tear
• associated bone marrow lesion/cyst at site of insertion or origin
• patellar tendon
• normal signal vs signal abnormality
 Periarticular features
 The following structures are defined as being absent or present:
• pes anserine bursitis
• iliotibial band signal
• popliteal (Baker's) cyst
• infrapatellar bursa signal
• prepatellar bursa signal
• ganglion cyst
• associated with the tibio-fibular joint
• associated with the cruciate ligaments
• other
• loose bodies
 Figure 1

 Illustration of hip joint subregion subdivisions with color coding. (A)

Acetabulum joint surface subregions seen from lateral aspect. (B) Femur
joint surface subregions seen from medial aspect. Foveal attachment is noted
in the medial center of femoral head. Dotted crescent line represents outline
of acetabular fossa. (C) Femur joint surface subregions seen from anterior
aspect. (D) Femur joint surface subregions seen from posterior aspect
 Figure 2

 Hip MRI images with subregion subdivision illustration. (A) Sagittal MR

images were used to evaluate the acetabular anterior (AA), femoral anterior
(FA) and acetabular posterior (AP) and femoral posterior (FP) subregions.
White line outlines the anterior and posterior 1 cm division. (B) Coronal MR
images were used to evaluate acetabular superolateral (ASL), acetabular
superomedial (ASM), and femoral lateral (FL), femoral superolateral (FSL),
femoral superomedial (FSM) and femoral inferior (FI) subregions. Two white
lines extend from center of the femoral head, one a vertical line dividing
acetabular and femoral superolateral and superomedial subregions and the
other extending to the lateral edge of acetabulum dividing superolateral and
lateral subregion of femur
 Examples of SHOMRI grading. (A) On the coronal MR image, a small partial thickness
articular cartilage loss is noted at the femoral superomedial subregion (white arrow), which
would be scored as 1. (B) On the sagittal MR image, a full thickness large articular cartilage
lesion is noted at femoral anterior and superomedial subregions with white arrows
denoting the anterior-posterior extent. As full thickness cartilage loss is greater than 1 cm, it
is scored in both subregions, a score of 2 in each subregion. (C) On the axial MR image, a
labral tear with labrocartilage separation is demonstrated at the anterior aspect (white
arrow), which is scored as 3. (D) The sagittal MR image demonstrates bone marrow edema
pattern with a size larger than 0.5 cm and smaller than 1.5 cm, that was scored as 2 in the
femoral anterior subregion (large arrow head), a subchondral cyst larger than 0.5 cm that
was scored as 2 (arrow) in the superomedial subregion and a labrum maceration in the
anterosuperior region, that was scored as 5 (small arrowhead). Full thickness articular
cartilage loss is also noted in the acetabular and femoral anterior subregions that was
scored as 2 in each subregion. (E) The sagittal MR image shows a paralabral cyst (arrow)
with a score of 1 at the anterosuperior aspect of the labrum. (F) An intraarticular body and
effusion, both scored as1 each, are shown on the axial MR image
EXTRA SLIDES
WEIGHT BEARING ANKLE X-RAY
 This process tends to involve specific joints during specific decades of a person’s life and depends
in part on the patient’s body habitus and level of physical activity.
 For example, one of the first joints that may demonstrate osteoarthritis is the acromioclavicular
joint, where minimal osteophyte formation may be seen in the 4th decade of life and beyond,
owing to the stresses that occur at this joint (Fig 4). Another site of typical osteoarthritis is the first
carpometacarpal joint, often beginning after the 5th decade of life, owing in part to stresses related
to constant use of opposing thumbs or joint laxity (Fig 5a) (3).
 Osteoarthritis also characteristically involves the interphalangeal joints of the hands after the 4th or
5th decades of life; this is related in part to degree of use and overuse (Fig 5b) (4).
 Involvement of the metacarpophalangeal joints is not infrequently associated with osteoarthritis of
the interphalangeal joints, although this type of involvement is usually of lesser severity. Unlike in
larger joints, joint space narrowing of the interphalangeal and metacarpophalangeal joints in
osteoarthritis may be symmetric. Osteoarthritis of the first metatarsophalangeal joint is common
beginning in the 5th decade of life (Fig 6) and may be associated with hallux valgus deformity.
RADIOGRAPHIC FEATURES
• Can detect OA-associated bony features: Marginal osteophytes Subchondral sclerosis Subchondral cysts.
Joint space width (JSW) - an indirect surrogate of cartilage thickness and meniscal integrity.Joint space
narrowing (JSN) is the key end point currently for interventional studies
• Joint space narrowing
• Characteristically asymmetric

• Least specific: present in many other pathological processes

• Subchondral sclerosis
• Sclerotic changes occur at joint margins

• Frequently seen unless severe osteoporosis is present

• Osteophytosis
• i.e. development of osteophytes

• Common degenerative joint disease finding

• Will also be diminished in the setting of osteoporosis

• Some osteophytes carry eponymous names, e.G. Heberden nodes, bouchard nodes
• Joint erosions
• several joints may exhibit degenerative erosions 1:
• temporomandibular joint
• acromioclavicular joint
• sacroiliac joints
• symphysis pubis
• Subchondral cysts
• also known as geodes
• cystic formations that occur around joints in a variety of disorders, including, rheumatoid
arthritis, calcium pyrophosphate dihydrate crystal deposition disease (CPPD), and avascular necrosis
• Bone marrow lesions 14,16
• visible on MRI as bone marrow edema-like lesions, often adjacent to areas of cartilage damage - likely
representing early osteoarthritis changes
• have been shown to correlate with joint pain and progression of cartilage loss
• may progress to subchondral cysts
• Synovitis
• a non-specific finding, present also in other diseases, including inflammatory and infectious conditions
• present in up to 50% of patients with osteoarthritis 14
• according to some authors it may be correlated with pain, disease severity and progression
 Unicompartmental Knee Osteoarthritis – When a single compartment of the joint is
affected. This could involve either the lateral or medial tibiofemoral compartment, or the
patellofemoral compartment. Osteoarthritis of the medial tibiofemoral compartment can also
lead to bone-spurs (small fragments of bone) near the affected area which can lead to a varus
deformity (commonly referred to as bow-leggedness). A similar process can occur in the
lateral compartment which leads to a valgus deformity (knock-kneed).
 Bicompartmental Knee Osteoarthritis – When two compartments of the joint are affected.
This could be both tibiofemoral compartments, or a single tibiofemoral compartment and the
patellofemoral compartment. Bicompartmental osteoarthritis occurs more commonly in the
patellofemoral compartment and a tibiofemoral compartment that it does in both tibiofemoral
compartments.
 Tricompartmental Knee Osteoarthritis – This is when all three compartments of the joint
are affected. It is relatively common and most osteoarthritis knee braces are not designed to
help with this condition.