The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 91, Issue Supplement 1

Section V: Knee Degeneration | February 01, 2009

Plain Radiography and Magnetic Resonance Imaging Diagnostics in Osteoarthritis: Validated Staging and Scoring

Ali Guermazi, MD¹; David J. Hunter, MD, PhD²; Frank W. Roemer, MD¹

¹ Section of Musculoskeletal Imaging, Department of Radiology, Boston Medical Center, FGH Building, 3rd Floor, 820 Harrison Avenue, Boston, MA 02118. E-mail address for A. Guermazi: guermazi@bu.edu
² Division of Research, New England Baptist Hospital, 125 Parker Hill Avenue, Boston, MA 02120

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2009 Feb 01;91(Supplement 1):54-62. doi: 10.2106/JBJS.H.01385

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Abstract

Osteoarthritis is the most common joint disorder worldwide, and it has an enormous socioeconomic impact both in the United States and throughout the world. Conventional radiography is the simplest and least expensive imaging method for assessing osteoarthritis of the knee. Radiography is able to directly visualize osseous features of osteoarthritis, including marginal osteophytes, subchondral sclerosis, and subchondral cysts, and it is used in clinical practice to confirm the diagnosis of osteoarthritis and to monitor progression of the disease. However, the assessment of joint-space width provides only an indirect estimate of cartilage thickness and meniscal integrity. Magnetic resonance imaging, with its unique ability to examine the joint as a whole organ, holds great promise with regard to the rapid advancement of knowledge about the disease and the evaluation of novel treatment approaches. Magnetic resonance imaging has been applied widely in quantitative morphometric cartilage assessment, and compositional measures have been introduced that evaluate chondral integrity. In addition, magnetic resonance imaging-based validated semiquantitative whole-organ scoring methods have been applied for cross-sectional and longitudinal joint evaluation. This review describes currently applied radiographic and magnetic resonance imaging staging and scoring methods for the assessment of osteoarthritis of the knee and focuses on the strengths and weaknesses of the two modalities with regard to their use in clinical trials and epidemiologic studies.

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Introduction

Introduction | Conventional Radiography | Magnetic Resonance Imaging | References

Osteoarthritis is an extremely prevalent disease with enormous socioeconomic impact both in the United States and throughout the world. Recent estimates suggest that symptomatic osteoarthritis of the knee occurs in 13% of persons sixty years of age and older¹. The prevalence of osteoarthritis is expected to increase even further as the population ages and as the prevalence of obesity rises. By 2020, the number of people with osteoarthritis may double¹. Current clinical research focuses on osteoarthritis of the knee due to the prevalence and morbidity of the disease in this joint and due to the fact that the knee exhibits the greatest physiologic cartilage thickness in the human body, which allows for relatively easy radiographic and magnetic resonance imaging assessment in comparison to that of other joints. Clinically, osteoarthritis of the knee is defined by the presence of pain plus additional symptoms and findings, such as stiffness, crepitus, osseous tenderness, and osseous enlargement².

Conventional radiography is the simplest and least expensive imaging method for assessing osteoarthritis of the knee. Radiography permits direct visualization of osseous features of osteoarthritis, including marginal osteophytes, subchondral sclerosis, and subchondral cysts, but an assessment of joint-space width provides only an indirect estimate of cartilage thickness and meniscal integrity. Radiography is used in clinical practice to confirm the diagnosis of osteoarthritis and to monitor progression of the disease.

Magnetic resonance imaging, with its unique ability to examine the joint as a whole organ, holds great promise with regard to the rapid advancement of knowledge about the disease and the evaluation of novel treatment approaches. Magnetic resonance imaging has been applied widely in quantitative morphometric cartilage assessment, and compositional measures have been introduced that evaluate chondral integrity^3-5. In addition, magnetic resonance imaging-based validated semiquantitative whole-organ scoring methods have been applied for cross-sectional and longitudinal joint evaluation^6-8. The aim of this review is to describe currently applied radiographic and magnetic resonance imaging staging and scoring methods for the assessment of osteoarthritis of the knee and to focus on the strengths and weaknesses of the two modalities with regard to their use in clinical trials and epidemiologic studies.

Conventional Radiography

Introduction | Conventional Radiography | Magnetic Resonance Imaging | References

The severity of osteoarthritis can be estimated by semiquantitative radiographic scoring systems. Several grading scales incorporating combinations of features have been developed. The two most widely employed systems are the Kellgren-Lawrence grading scheme and the Osteoarthritis Research Society International (OARSI) grading system^9,10 (Figs. 1-A and 1-B). Both systems have been applied widely in clinical trials and epidemiologic studies (Tables I and II). The Kellgren-Lawrence grading system is traditionally used to classify populations according to those who have osteoarthritis with a grade of =2. The individual radiographic features of the OARSI grading system have been widely used both in cross-sectional and observational epidemiologic studies, with joint-space narrowing as a surrogate measure of disease progression, although more recent studies have tended to use quantitative measures of joint-space width. Published atlases provide image examples that represent the specific grades¹⁰. Modifications have been introduced to these scoring systems, adding either complexity or simplification. Examples of Kellgren-Lawrence and OARSI modifications are summarized in Tables I and III, respectively.

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Fig. 1-A Fig. 1-B: Figs. 1-A and 1-B Examples of semiquantitative radiographic assessment with use of the Kellgren-Lawrence and Osteoarthritis Research Society International (OARSI) grading schemes. Fig. 1-A Kellgren-Lawrence grade 3. No lateral femoral and tibial osteophytes are seen (OARSI grade 0). A medial femoral osteophyte OARSI grade 1 (white arrow), a medial tibial osteophyte OARSI grade 2 (white arrowhead), lateral tibiofemoral joint-space width OARSI grade 0, and medial tibiofemoral joint-space narrowing OARSI grade 2 (black arrows) are depicted. Fig. 1-B Kellgren-Lawrence grade 2. A lateral femoral osteophyte OARSI grade 2 (white arrow), a lateral tibial osteophyte OARSI grade 2 (white arrowheads), a medial femoral osteophyte OARSI grade 3 (black arrows), a medial tibial osteophyte OARSI grade 2 (black arrowhead), a normal lateral tibiofemoral joint-space width (OARSI grade 0), and medial tibiofemoral joint-space width (OARSI grade 1) (gray arrows) are shown.

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TABLE I Description of Kellgren-Lawrence and Modified Kellgren-Lawrence Grading Systems

	Kellgren-Lawrence	Modified Kellgren-Lawrence
Grade 0	No feature of osteoarthritis	No feature of osteoarthritis
Grade 1	Doubtful joint-space narrowing and possible osteophytic lipping	Equivocal osteophyte
Grade 2	Definite osteophytes and possible joint-space narrowing	Unequivocal osteophyte
Grade 3	Moderate multiple osteophytes, definite joint-space narrowing, and some sclerosis and possible deformity of bone ends	Joint-space narrowing
Grade 4	Large osteophytes, marked joint-space narrowing, severe sclerosis, and definite deformity of bone ends	Bone-to-bone appearance

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TABLE I Description of Kellgren-Lawrence and Modified Kellgren-Lawrence Grading Systems

	Kellgren-Lawrence	Modified Kellgren-Lawrence
Grade 0	No feature of osteoarthritis	No feature of osteoarthritis
Grade 1	Doubtful joint-space narrowing and possible osteophytic lipping	Equivocal osteophyte
Grade 2	Definite osteophytes and possible joint-space narrowing	Unequivocal osteophyte
Grade 3	Moderate multiple osteophytes, definite joint-space narrowing, and some sclerosis and possible deformity of bone ends	Joint-space narrowing
Grade 4	Large osteophytes, marked joint-space narrowing, severe sclerosis, and definite deformity of bone ends	Bone-to-bone appearance

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TABLE II Osteoarthritis Research Society International (OARSI) Grading System

Features and Grading

Medial femoral osteophyte: Grade 0-3

Medial tibial osteophyte: Grade 0-3

Lateral femoral osteophyte: Grade 0-3

Lateral tibial osteophyte: Grade 0-3

Medial tibiofemoral joint-space narrowing: Grade 0-3

Lateral tibiofemoral joint-space narrowing: Grade 0-3

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TABLE II Osteoarthritis Research Society International (OARSI) Grading System

Features and Grading

Medial femoral osteophyte: Grade 0-3

Medial tibial osteophyte: Grade 0-3

Lateral femoral osteophyte: Grade 0-3

Lateral tibial osteophyte: Grade 0-3

Medial tibiofemoral joint-space narrowing: Grade 0-3

Lateral tibiofemoral joint-space narrowing: Grade 0-3

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TABLE III Modified Osteoarthritis Research Society International (OARSI) Grading System as Used for Radiographic Assessment in the Osteoarthritis Initiative Study

Features	Grading
Osteophyte (anywhere on the tibia or femur)	Grade 0: No osteophyte, OARSI grade 0
	Grade 1: Equivocal, minute, OARSI grade 0-1
	Grade 2: Definite, OARSI grade 1-3
Joint-space grade (medial and lateral tibiofemoral)	Grade 0: Normal, OARSI grade 0
	Grade 1: Narrowed, OARSI grade 1-2
	Grade 2: Severe, OARSI grade 3 or <0.5 mm

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TABLE III Modified Osteoarthritis Research Society International (OARSI) Grading System as Used for Radiographic Assessment in the Osteoarthritis Initiative Study

Features	Grading
Osteophyte (anywhere on the tibia or femur)	Grade 0: No osteophyte, OARSI grade 0
	Grade 1: Equivocal, minute, OARSI grade 0-1
	Grade 2: Definite, OARSI grade 1-3
Joint-space grade (medial and lateral tibiofemoral)	Grade 0: Normal, OARSI grade 0
	Grade 1: Narrowed, OARSI grade 1-2
	Grade 2: Severe, OARSI grade 3 or <0.5 mm

One of the major drawbacks of these grading systems is their lack of sensitivity to change¹¹. Joint-space width is a crude measure of indirect assessment of articular cartilage, and cartilage is only one contributor to physiologic joint-space width. Meniscal pathology (including position and morphology) accounts for a substantial proportion of observed change in joint-space width¹². In addition, expected annual rates of cartilage loss are minimal, as has been shown by quantitative magnetic resonance imaging morphometry¹³. Furthermore, visually detectable minor changes in osteophyte shape and joint-space width do not necessarily translate into a change in grading when radiographic grading systems are used (Figs. 2-A through 3-B). For this reason, some researchers have introduced half-grades to account for subtle longitudinal change, although this approach has not been well validated.

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Fig. 2-A Fig. 2-B: Figs. 2-A and 2-B Example of progressive joint-space narrowing and the insensitivity of radiographic scoring systems to change. Fig. 2-A Baseline anteroposterior radiograph of the right knee, showing normal joint-space width in the lateral tibiofemoral compartment and OARSI grade-2 joint-space narrowing in the medial tibiofemoral compartment at baseline. The Kellgren-Lawrence grade is 3. Fig. 2-B Follow-up radiograph of the same knee after six months, showing normal joint-space width in the lateral compartment and unequivocally progressive medial tibiofemoral joint-space narrowing at the time of follow-up. However, according to the OARSI and Kellgren-Lawrence scoring systems, there is no change in grade.

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Fig. 3-A Fig. 3-B: Figs. 3-A and 3-B Example of the limitations of the Kellgren-Lawrence scoring system. Fig. 3-A Baseline anteroposterior radiograph of the right knee. Kellgren-Lawrence grade 3 was determined by the presence of definite lateral joint-space narrowing. Fig. 3-B Follow-up radiograph of the same knee after six months. Obvious narrowing of the medial tibiofemoral joint-space width from baseline to follow-up is observed (OARSI grades 0 to 1), but there is no change in the Kellgren-Lawrence grade (grade 3) because no progressive narrowing of the lateral tibiofemoral joint-space width is observed.

When compared with magnetic resonance imaging as the reference standard, radiography has shown an excellent specificity with regard to the detection of longitudinal cartilage loss. However, the reported sensitivity is low¹¹. Methods of measuring joint-space width either can be manual, with use of calipers or a simple graduated ruler and a micrometric eyepiece, or semiautomated, with use of computer software¹⁴. The smallest standard deviation of the difference between test-retest measurements of minimum joint-space width in pairs of radiographs reaches about 0.1 mm in the most reproducible methods, indicating a smallest detectable difference of at least 0.2 mm, which remains relatively large considering the 0.10 to 0.15-mm expected average annual joint-space narrowing of osteoarthritic knee joints¹⁵. Furthermore, conventional radiography does not visualize additional key structures that are important to the development and/or progression of osteoarthritis, such as subchondral bone marrow, menisci, ligaments, and synovial tissue.

Lastly, reproducibility of positioning in longitudinal studies and large multicenter trials is still problematic, and the variability of joint-space width due to the positioning protocol adds to the weaknesses of conventional radiography. Several nonfluoroscopic radiographic protocols have been developed to reliably and accurately assess joint-space loss in multicenter longitudinal studies of progression and treatment of osteoarthritis of the knee. Examples of these protocols are the metatarsophalangeal protocol, the fixed flexion protocol, and the modified Lyon-Schuss protocol^16,17.

Magnetic Resonance Imaging

Introduction | Conventional Radiography | Magnetic Resonance Imaging | References

Magnetic resonance imaging offers several advantages over conventional radiography. It is a tomographic imaging technique that can directly visualize articular cartilage, synovium, menisci, and other intra-articular structures important to the functional integrity of joints. There is no radiation involved. For research purposes, magnetic resonance imaging may be used for quantitative analysis and cartilage volume morphometry^12,18 (Fig. 4), or semiquantitative whole-joint assessment^7,8,19. Due to standardized placement of the knee in the center of the dedicated knee coil, the above-mentioned shortcomings of reproducible joint positioning that apply to radiography are not relevant to magnetic resonance imaging, which is an advantage especially for multicenter studies. Disadvantages of magnetic resonance imaging include the high price of the examination when compared with conventional radiography, the length of time required to acquire the images, and a few contraindications to the procedure, especially patients who have pacemakers or are claustrophobic. Magnetic resonance imaging equipment is expensive to purchase, maintain, and operate; therefore the technique is still not readily available.

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Fig. 4: Three-dimensional cartilage morphometry. Each chondral plate is depicted in a different color (yellow, medial aspect of femur; blue, medial aspect of tibial plateau; red, lateral aspect of femur; and green, lateral aspect of tibial plateau). (Courtesy of Felix Eckstein, MD)

Semiquantitative magnetic resonance imaging scoring assesses the joint as a whole organ. In addition to evaluation of articular cartilage morphology, other important structures are being scored—the menisci, osteophytes, subchondral bone attrition, subchondral bone-marrow lesions and cysts, the cruciate and collateral ligaments, the synovium, the joint fluid and any effusion, and additional periarticular features. Three magnetic resonance imaging scoring systems have been developed for semiquantitative analysis of osteoarthritis of the knee: the Whole-Organ Magnetic Resonance Imaging Score (WORMS)⁸, the Knee Osteoarthritis Scoring System (KOSS)¹⁹, and the Boston Leeds Osteoarthritis Knee Score (BLOKS)⁷. A comparative study of the different systems has not been performed, and superiority of one system over the others will probably not be shown as not all features are scored by all three systems. When estimating the time needed to apply any of these semiquantitative systems, the imaging protocol (especially the number of sequences and individual images) as well as the quality of images and the degree of joint abnormalities due to osteoarthritis must be taken into account. Time needed for scoring cross-sectionally will differ from longitudinal scoring, and the number of time points to be assessed also needs to be considered. Finally, reader experience and documentation of the scoring (manually or electronically) are very important factors to be considered. Suggestions for useful magnetic resonance imaging protocols for whole-organ assessment of osteoarthritis of the knee have been published^20,21 (Figs. 5-A and 5-B). An overview of the characteristics of the three different systems is presented in Table IV. Whole-organ semiquantitative scoring systems have been applied in several cross-sectional and longitudinal epidemiologic studies and clinical trials. The findings of these studies have tremendously increased our knowledge of the pathophysiology and natural history of the disease^6,22,23.

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Fig. 5-A Fig. 5-B: Figs. 5-A and 5-B Relevance of sequence selection for semiquantitative assessment of osteoarthritic features. Fig. 5-A Sagittal dual-echo steady-state T1-weighted gradient-echo magnetic resonance image showing normal patellar and trochlear cartilage surface morphology. Note discrete hypointense signal alteration in retropatellar cartilage (white arrow). Fig. 5-B Sagittal intermediate-weighted fast-spin-echo magnetic resonance image at the same level, showing a definite focal partial-thickness cartilage defect of the patella (arrow). An associated subchondral bone-marrow lesion is depicted, with its full extent only appreciable on the intermediate-weighted magnetic resonance image (white arrowheads).

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TABLE IV Comparison of Three Different Semiquantitative Scoring Systems of Knee Osteoarthritis*

	Scoring Systems
	BLOKS	KOSS	WORMS
MRI protocol of original publication (all publications used 1.5-tesla systems)	Sag/cor T2w FS, sag T1 SE, axial/cor 3D FLASH	Cor/sag T2w and PDw, sag 3D SPGR, axial PD, and axial T2w FS	Axial T1 SE, cor T1 SE, sag T1 SE, sag T2 FS, sag 3D SPGR
Subregional division of knee	9 subregions: medial and lateral aspect of patella, medial and lateral aspect of trochlea, medial and lateral weight-bearing aspect of femur, medial and lateral weight-bearing aspect of tibia, subspinous aspect of tibia	9 subregions: medial aspect of patella, patellar crest, lateral aspect of patella, medial and lateral aspect of trochlea, medial and lateral aspect of femoral condyle, medial and lateral aspect of tibial plateau	15 subregions: medial and lateral aspect of patella, medial and lateral aspect of femur (anterior, central, or posterior parts), medial and lateral aspect of tibia (anterior, central, or posterior parts), subspinous aspect of tibia
Cartilage	Two different scores. Score 1: subregional approach. Score 2: site-specific approach. Scoring of cartilage thickness at 11 specific locations (not subregions) from 0 (none) to 2 (full-thickness loss)	Subregional approach: focal and diffuse defects are differentiated. Depth of lesions is scored from 0 to 3. Diameter of lesions is scored from 0 to 3	Subregional approach: scores from 0 to 6, depending on depth and extent of cartilage loss. Intrachondral cartilage signal additionally scored as present or absent
Bone-marrow lesions	Scoring of individual lesions. 3 different aspects of BMLs are scored: a. size of BML scored from 0 to 3. b. percentage of surface area adjacent to subchondral plate. c. percentage of BML that is noncystic	Scoring of individual lesions from 0 to 3 with regard to maximum diameter of lesion	Summed BML size and volume for subregion from 0 to 3 with regard to percentage of subregional bone volume
Subchondral cysts	Scored together with BMLs	Scoring of individual lesions from 0 to 3 with regard to maximum diameter of lesion	Summed cyst size and volume for subregion from 0 to 3 with regard to percentage of subregional bone volume
Osteophytes	Scored at 12 sites from 0 to 3	Scored from 0 to 3	Scored at 16 sites from 0 to 7
Bone attrition	Not scored	Not scored	Scored in 14 subregions from 0 to 3
Effusion	Scored from 0 to 3	Scored from 0 to 3	Scored from 0 to 3
Synovitis	Scoring of size of signal changes in Hoffa fat pad	Synovial thickening scored as present or absent	Combined effusion and synovitis score
Meniscal status	Anterior horn, body, and posterior horn scored separately in medial and lateral meniscus	No subregional division of meniscus described	Anterior horn, body, and posterior horn scored separately in medial and lateral meniscus from 0 to 4
Meniscal extrusion	Scored as medial and lateral extrusion on coronal image and anterior extrusion for medial and lateral meniscus on sagittal image from 0 to 3	Scored on coronal image from 0 to 3	Not scored
Ligaments	Cruciate ligaments scored as normal or complete tear. Associated insertional BMLs are scored in tibia and in femur	Not scored	Cruciate ligaments and collateral ligaments scored as intact or torn
Periarticular features	Patellar tendon: signal normal or abnormal. Pes anserine bursitis, iliotibial band signal, popliteal cyst, infrapatellar bursa, prepatellar bursa, ganglion cysts of the TFJ, meniscus, ACL, PCL, and others are scored as present or absent	Only popliteal cysts scored from 0 to 3	Popliteal cysts, anserine bursitis, semimembranosus bursa, meniscal cyst, infrapatellar bursitis, prepatellar bursitis, tibiofibular cyst scored from 0 to 3
Loose bodies	Scored as absent or present	Not scored	Scored from 0 to 3

BLOKS = Boston Leeds Osteoarthritis Knee Score, KOSS = Knee Osteoarthritis Scoring System, WORMS = Whole-Organ Magnetic Resonance Imaging Score, MRI = magnetic resonance imaging, BML = bone-marrow lesion, Sag = sagittal, Cor = coronal, T2w FS = T2-weighted fat-suppressed sequence, T1 SE = T1-weighted spin-echo sequence, 3D FLASH = three-dimensional fast low-angle shot sequence, PDw = proton density-weighted, 3D SPGR = three-dimensional spoiled gradient-echo sequence, TFJ = tibiofemoral joint, ACL = anterior cruciate ligament, and PCL = posterior cruciate ligament.(Reprinted in adapted form, from: Guermazi A, Burstein D, Conaghan P, Eckstein F, Hellio Le Graverand-Gastineau M-P, Keen H, Roemer FW. Imaging in osteoarthritis. Rheum Dis Clin North Am. 2008;34:645-87; with permission from Elsevier.)

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TABLE IV Comparison of Three Different Semiquantitative Scoring Systems of Knee Osteoarthritis*

	Scoring Systems
	BLOKS	KOSS	WORMS
MRI protocol of original publication (all publications used 1.5-tesla systems)	Sag/cor T2w FS, sag T1 SE, axial/cor 3D FLASH	Cor/sag T2w and PDw, sag 3D SPGR, axial PD, and axial T2w FS	Axial T1 SE, cor T1 SE, sag T1 SE, sag T2 FS, sag 3D SPGR
Subregional division of knee	9 subregions: medial and lateral aspect of patella, medial and lateral aspect of trochlea, medial and lateral weight-bearing aspect of femur, medial and lateral weight-bearing aspect of tibia, subspinous aspect of tibia	9 subregions: medial aspect of patella, patellar crest, lateral aspect of patella, medial and lateral aspect of trochlea, medial and lateral aspect of femoral condyle, medial and lateral aspect of tibial plateau	15 subregions: medial and lateral aspect of patella, medial and lateral aspect of femur (anterior, central, or posterior parts), medial and lateral aspect of tibia (anterior, central, or posterior parts), subspinous aspect of tibia
Cartilage	Two different scores. Score 1: subregional approach. Score 2: site-specific approach. Scoring of cartilage thickness at 11 specific locations (not subregions) from 0 (none) to 2 (full-thickness loss)	Subregional approach: focal and diffuse defects are differentiated. Depth of lesions is scored from 0 to 3. Diameter of lesions is scored from 0 to 3	Subregional approach: scores from 0 to 6, depending on depth and extent of cartilage loss. Intrachondral cartilage signal additionally scored as present or absent
Bone-marrow lesions	Scoring of individual lesions. 3 different aspects of BMLs are scored: a. size of BML scored from 0 to 3. b. percentage of surface area adjacent to subchondral plate. c. percentage of BML that is noncystic	Scoring of individual lesions from 0 to 3 with regard to maximum diameter of lesion	Summed BML size and volume for subregion from 0 to 3 with regard to percentage of subregional bone volume
Subchondral cysts	Scored together with BMLs	Scoring of individual lesions from 0 to 3 with regard to maximum diameter of lesion	Summed cyst size and volume for subregion from 0 to 3 with regard to percentage of subregional bone volume
Osteophytes	Scored at 12 sites from 0 to 3	Scored from 0 to 3	Scored at 16 sites from 0 to 7
Bone attrition	Not scored	Not scored	Scored in 14 subregions from 0 to 3
Effusion	Scored from 0 to 3	Scored from 0 to 3	Scored from 0 to 3
Synovitis	Scoring of size of signal changes in Hoffa fat pad	Synovial thickening scored as present or absent	Combined effusion and synovitis score
Meniscal status	Anterior horn, body, and posterior horn scored separately in medial and lateral meniscus	No subregional division of meniscus described	Anterior horn, body, and posterior horn scored separately in medial and lateral meniscus from 0 to 4
Meniscal extrusion	Scored as medial and lateral extrusion on coronal image and anterior extrusion for medial and lateral meniscus on sagittal image from 0 to 3	Scored on coronal image from 0 to 3	Not scored
Ligaments	Cruciate ligaments scored as normal or complete tear. Associated insertional BMLs are scored in tibia and in femur	Not scored	Cruciate ligaments and collateral ligaments scored as intact or torn
Periarticular features	Patellar tendon: signal normal or abnormal. Pes anserine bursitis, iliotibial band signal, popliteal cyst, infrapatellar bursa, prepatellar bursa, ganglion cysts of the TFJ, meniscus, ACL, PCL, and others are scored as present or absent	Only popliteal cysts scored from 0 to 3	Popliteal cysts, anserine bursitis, semimembranosus bursa, meniscal cyst, infrapatellar bursitis, prepatellar bursitis, tibiofibular cyst scored from 0 to 3
Loose bodies	Scored as absent or present	Not scored	Scored from 0 to 3

In comparison to radiography, magnetic resonance imaging visualizes cartilage directly, and focal as well as diffuse cartilage damage can be scored cross-sectionally and longitudinally with good reliability^7,8 (Figs. 6-A and 6-B). Subchondral bone-marrow lesions are a hallmark of osteoarthritis on magnetic resonance images and have raised a lot of interest in recent years. Large baseline bone-marrow lesions and progression of bone-marrow lesions are strongly associated with an increased risk of cartilage loss²⁴. An increase in the size of bone-marrow lesions is associated with incident knee pain⁶. Bone-marrow lesions, unlike cartilage, are one of the highly variable features of osteoarthritis, as they may undergo possible regression or complete resolution but also perhaps progression over time²⁴. Semiquantitative as well as quantitative methods have been applied to measure and score size and location of bone-marrow lesions^7,8. Attrition is another feature of osteoarthritis and is defined as flattening and depression of the subchondral bone contour. Bone attrition may occur in milder osteoarthritis and at earlier stages of disease than previously thought²⁵. Attrition is associated independently with the presence of knee pain.

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Fig. 6-A Fig. 6-B: Figs. 6-A and 6-B Sensitivity of visual assessment of progressive cartilage loss over a six-month period. Fig. 6-A Baseline coronal three-dimensional double-echo steady-state T1-weighted gradient-echo image showing diffuse partial-thickness defects of the medial femoral and tibial cartilage. Fig. 6-B A six-month follow-up magnetic resonance image in the same patient shows increasing medial femoral and tibial cartilage loss (white arrows). Note the presence of large osteophytes at the joint margins, and medial meniscal subluxation (black arrows).

The menisci are important structures that are of interest in understanding the natural history of disease. Menisci are buffers for the knee joint and play a role in the distribution of axial load and the protection of adjacent articular cartilage. An association between meniscal damage and subsequent development of frequent knee pain was recently shown²⁶. Meniscal damage and malposition are associated with an increased risk of cartilage loss. The ligaments are also important structures for preserving joint stability. Incident complete anterior cruciate ligament tears in patients with radiographic evidence of osteoarthritis are associated with an increased risk for cartilage loss²². A recent study on periarticular cysts showed that moderate-to-large popliteal cysts are associated with incident radiographic osteoarthritis and that the presence of a lateral meniscal cyst increases the risk of incident frequent knee pain²⁷. Lastly, synovitis and synovial effusion are becoming central to our understanding of both pain and structural progression in osteoarthritis. Change in the degree of synovitis is correlated with change in the severity of knee pain²³. A majority of patients with early stage osteoarthritis show evidence of low-grade synovial inflammation, and synovial activation might also play an important role in preradiographic osteoarthritis²⁸.

In conclusion, radiographically detected joint-space narrowing is the only structural end point currently accepted by the regulatory bodies in the United States (U.S. Food and Drug Administration [FDA]) and Europe (European Medicines Agency [EMEA]) to prove efficacy of disease-modifying drugs targeting osteoarthritis in phase-III clinical trials. However, radiographic assessment of joint-space narrowing has several limitations. The most important drawback is its insensitivity to change. Radiography does not visualize cartilage directly and consequently is nonspecific. Meniscal damage and subluxation contribute to radiographic joint-space width and may also account for longitudinal joint-space narrowing. Exact reproducibility of positioning is challenging, which is of relevance especially in multicenter and longitudinal studies. However, radiography is still an important tool for subject inclusion and stratification. Magnetic resonance imaging offers a multitude of advantages over conventional radiography. Magnetic resonance imaging permits direct visualization of cartilage. Semiquantitative methods have been introduced as a way of scoring morphology, and quantitative analytic approaches are available to reliably assess volumetric morphometry. Compositional integrity, surface smoothness, coverage, and distribution of changes are other cartilage parameters that can be analyzed by magnetic resonance imaging. Semiquantitative whole-organ scoring methods have been introduced for the assessment of additional key structures that are important to the development and/or progression of osteoarthritis, such as bone marrow, synovitis, menisci, ligaments, osteophytes, and other soft tissues. Magnetic resonance imaging offers the advantage of being reproducible in multicenter studies and detects preradiographic osteoarthritic features with high sensitivity²⁹. Image Not Available

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Introduction | Conventional Radiography | Magnetic Resonance Imaging | References

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Topics

cartilage ; exostoses ; osteoarthritis ; osteoarthritis, knee ; vibration ; articular space

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Ali Guermazi, David J. Hunter, Frank W. Roemer; Plain Radiography and Magnetic Resonance Imaging Diagnostics in Osteoarthritis: Validated Staging and Scoring. The Journal of Bone & Joint Surgery. 2009 Feb;91(Supplement_1):54-62.

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