Radiological imaging of osteoarthritis.

Dr/ ABD ALLAH NAZEER. MD.

Osteoarthritis (OA), or degenerative joint disease (DJD), is the most common of the arthritides.Osteoarthritis is a non-inflammatory, degenerative condition of joints, characterized by degeneration of articular cartilage and formation of new bone (osteophytes).Osteoarthritis is classified to primary and secondary osteoarthritis.Primary osteoarthritis is more common than secondary osteoarthritis, The cause is unknown, common in elderly and its mainly due to wear and tear changes occurring in old ages mainly in weight bearing joints.Secondary osteoarthritis is due to predisposing factor, such as injury to the joint, previous infection, hyperthyroidism, obesity and deformity.

Radiographic featuresGeneral imaging featuresThe hallmarks of DJD are joint space narrowing, sclerosis, and osteophytosis. If all three of these findings are not present on a radiograph, another diagnosis should be considered. Joint space narrowing is the least specific finding of the three, yet it is virtually always present in DJD. Unfortunately, it is also seen in almost every other joint abnormality.Joint space narrowing: characteristically in osteoarthritis is asymmetric whereas the joint space narrowing in inflammatory conditions is symmetric e.g. In the hip the narrowing occurs superiorly or sometimes axially in osteoarthritis.Sclerosis: should be present in varying amounts in all cases of DJD unless severe osteoporosis is present. Osteoporosis will cause the sclerosis to be diminished. For instance, in long-standing rheumatoid arthritis in which the cartilage has been destroyed, DJD often occurs with very little sclerosis.

Osteophytosis: will also be diminished in the setting of osteoporosis. Otherwise, sclerosis and osteophytosis should be prominent in DJD.Some osteophytes carry eponymous names such as at the proximal interphalangeal joint (Bouchard nodes). Primary osteoarthritis is a familial arthritis that affects middle-aged women almost exclusively and is seen only in the hands. It affects the distal interphalangeal joints (Heberden nodes), the proximal interphalangeal joints, and the base of the thumb in a bilaterally symmetric fashion. If it is not bilaterally symmetric, the diagnosis of primary osteoarthritis should be questioned.There are a few exceptions to the classic triad of findings seen in DJD (sclerosis, joint space narrowing, and osteophytes). Several joints also exhibit erosions as a manifestation of DJD: the temporomandibular joint, the acromioclavicular joint, the sacroiliac joints, and the symphysis pubis. When erosions are seen in one of these joints, DJD must be considered, or inappropriate treatment may be instituted.

Subchondral cyst or geode: often found in joints affected with DJD. Geodes are cystic formations that occur around joints in a variety of disorders (including, in addition to DJD, rheumatoid arthritis, calcium pyrophosphate dihydrate crystal deposition disease (CPPD) and avascular necrosis). Presumably, one method of geode formation takes place when synovial fluid is forced into the subchondral bone, causing a cystic collection of joint fluid. Another etiology is following a bone contusion, in which the contused bone forms a cyst. They rarely cause problems by themselves but are often misdiagnosed as something mores inister.

Primary Osteoarthritis ImagingRadiographyConventional radiographs remain the criterion standard for the imaging diagnosis of osteoarthritis. The diagnosis can be made with a high degree of confidence when joint narrowing, subchondral sclerosis, and osteophyte formation are seen. With the onset of osteoarthritis, articular cartilage loses its smooth texture and becomes coarsened. This change leads to a sharp increase in frictional forces. Subsequently, cracks and tears, which lead to cartilage softening and flaking, are noted histologically. The net loss of articular cartilage appears as a reduction of the joint space on radiographs. In major weight-bearing joints, a greater loss of joint space occurs at those areas subjected to the greatest pressures; this effect is in contrast to that of inflammatory arthritides, in which uniform joint-space narrowing is the rule. In the osteoarthritic knee, for example, one commonly observes the greatest loss of joint space in the medial femorotibial compartment (see the image below), although the lateral femorotibial compartment and patellofemoral compartment may also be affected. Collapse of the medial or lateral compartments may result in varus or valgus deformities, respectively. Hence, weight-bearing radiographs are preferred for evaluation of the osteoarthritic knee to depict such deformities, as well as to provide an accurate assessment of joint-space narrowing.

MRI can depict many of the same findings of osteoarthritis as radiographs do, including joint narrowing, subchondral osseous changes, and osteophytes, radiographs remain the imaging method of choice in the diagnosis of osteoarthritis because they are more cost-effective than other methods and because they can be obtained more readily and quickly.[

Fast spin-echo images (e.g, fast spin-echo T2-weighted fat-suppressed images) or gradient-echo images (e.g, T1-weighted 3-dimensional fat-suppressed images) can be used for the detection of cartilaginous ulceration, which is classically focal and located along the medial facet of the patella. For chondromalacia patellae, conventional radiographs provide little information. Although arthrography enables a more direct assessment of cartilaginous integrity, many consider MRI to be the initial imaging study of choice. Unlike radiography, MRI can depict articular cartilage directly; this feature of MRI has been the subject of multiple research studies over the past several years, particularly focusing on the cartilage of the knee (see the images below). A variety of pulse sequences have been described, but the most commonly used include spoiled gradient-recalled echo (SPGR) and fast spin-echo imaging.

CT is rarely used for the diagnosis of primary osteoarthritis, although it may be used for the diagnosis of malalignment of the patellofemoral joint or the foot and ankle joints. It may also be useful in evaluating the osseous detail of the vertebral column, particularly the facet joints.

Nuclear ImagingScintigraphic studies are of limited use for the diagnosis of osteoarthritis because increased uptake of the radiotracer can also be seen in several other hypervascular articular diseases. The image resolution of bone scintigraphy is much less than that of other imaging modalities. In joints affected with osteoarthritis, increased uptake of bone-seeking radiopharmaceuticals may be seen before any radiographic abnormalities are apparent. Tracer accumulation is concentrated in regions of bony eburnation and osteophyte formation.

Commonly affected joints.1- Hip joints.2- Knee joints.3- Feet.4- Spine.5- Hands(inter-phalngeal joints).

Uncommonly affected joints.1- Shoulder joint.2-Wrist joint.3-Elbow Joints.4-Metacarpophalangeal joints.5-Temporo-mandibular joint6- Sacro-iliac joint.7- Ankle joint.

Symptoms:Osteoarthritis symptoms often develop slowly and worsen over time. Signs and symptoms of osteoarthritis include:Pain. Your joint may hurt during or after movement.Tenderness. Your joint may feel tender when you apply light pressure to it.Stiffness. Joint stiffness may be most noticeable when you wake up in the morning or after a period of inactivity.Loss of flexibility. You may not be able to move your joint through its full range of motion.Grating sensation. You may hear or feel a grating sensation when you use the joint.Bone spurs. These extra bits of bone, which feel like hard lumps, may form around the affected joint.

Osteoarthritis of the hip joint:CausesOsteoarthritis has no single specific cause, but there are certain factors that may make you more likely to develop the disease, including:Increasing ageFamily history of osteoarthritisPrevious injury to the hip jointObesityImproper formation of the hip joint at birth, a condition known as developmental dysplasia of the hipEven if you do not have any of the risk factors listed above, you can still develop osteoarthritis.

SymptomsThe most common symptom of hip osteoarthritis is pain around the hip joint. Usually, the pain develops slowly and worsens over time, although sudden onset is also possible. Pain and stiffness may be worse in the morning, or after sitting or resting for a while. Over time, painful symptoms may occur more frequently, including during rest or at night. Additional symptoms may include:Pain in your groin or thigh that radiates to your buttocks or your kneePain that flares up with vigorous activityStiffness in the hip joint that makes it difficult to walk or bend"Locking" or "sticking" of the joint, and a grinding noise (crepitus) during movement caused by loose fragments of cartilage and other tissue interfering with the smooth motion of the hipDecreased range of motion in the hip that affects the ability to walk and may cause a limpIncreased joint pain with rainy weather

Conventional radiograph grading:grade 0: normalgrade 1: possible joint space narrowing and subtle osteophytesgrade 2: definite joint space narrowing, defined osteophytes and some sclerosis, especially in acetabular regiongrade 3: marked joint space narrowing, small osteophytes, some sclerosis and cyst formation and deformity of femoral head and acetabulumgrade 4: gross loss of joint space with above features plus large osteophytes and increased deformity of the femoral head and acetabulum MRI grading:grade 0: normalgrade 1: inhomogeneous high signal intensity in cartilage (T2WI)grade 2: inhomogeneity with areas of high signal intensity in articular cartilage (T2WI); indistinct trabaculae or signal intensity loss in femoral head & neck (T1WI)grade 3: criteria of Stage 1 & 2 plus indistinct zone between femoral head & acetabulum; subchondral signal loss due to bone sclerosisgrade 4: above criteria plus femoral head deformity.

(Left) In this x-ray of a normal hip, the space between the ball and socket indicates healthy cartilage. (Right) This x-ray of an arthritic hip shows severe loss of joint space and bone spurs.

Bilateral Hip Osteoarthritis – Pelvis radiograph reveals severe bilateral hip osteoarthritis characterized by joint spaced narrowing, cystic changes and severe osseous productive changes and remodeling of the femoral head and acetabulum.

CT-Arthrography shows superior and anterior joint space narrowing (blue circle) with denuded chondral surface (yellow arrow), subchondral cysts and sclerosis. No

femoroacetabular impingement or associated labral tear. Normal mineralization.

Marginal osteophytes in a left hip with moderate osteoarthritis as seen with a coronal T1 sequence (A), a coronal proton

density fat saturation sequence (B), and plain radiography (C).

MRI demonstrating osteoarthritis with severe joint space narrowing and cyst formation right hip.

Osteoarthritis of the hip. Bone marrow edema is subchondral in location. Joint narrowing, subchondral cysts and joint effusion also appear

Osteoarthritis of the knee joint:Osteoarthritis is the most common form of arthritis in the knee. It is a degenerative, "wear-and-tear" type of arthritis that occurs most often in people 50 years of age and older, but may occur in younger people, too.In osteoarthritis, the cartilage in the knee joint gradually wears away. As the cartilage wears away, it becomes frayed and rough, and the protective space between the bones decreases. This can result in bone rubbing on bone, and produce painful bone spurs.Osteoarthritis develops slowly and the pain it causes worsens over time.

SymptomsA knee joint affected by arthritis may be painful and inflamed. Generally, the pain develops gradually over time, although sudden onset is also possible. There are other symptoms, as well:The joint may become stiff and swollen, making it difficult to bend and straighten the knee.Pain and swelling may be worse in the morning, or after sitting or resting.Vigorous activity may cause pain to flare up.Loose fragments of cartilage and other tissue can interfere with the smooth motion of joints. The knee may "lock" or "stick" during movement. It may creak, click, snap or make a grinding noise (crepitus).Pain may cause a feeling of weakness or buckling in the knee.Many people with arthritis note increased joint pain with rainy weather.

(Left) In this x-ray of a normal knee, the space between the bones indicates healthy cartilage (arrows). (Right) This x-ray of an arthritic knee shows severe loss of joint space.

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Osteoarthritis: Radiographic Progression, Left Knee

Synovial chondromatosis of the knee secondary to osteoarthritis in a 50-year-old woman. CT scan shows osteophytes and narrowing of joint spaces, consistent with osteoarthritis.

Notice the variable sized ossified intra-articular loose bodies (arrows in c and d).

MRI image of osteoarthritis.

A) Coronal proton-density-weighted fat-saturated image showing a large bone marrow lesion (BML) in the central part of the medial femur (ill-defined area of hyperintensity indicated by arrows). A large BML is also depicted in the medial tibial plateau (asterisk). (B) Fast low-angle shot (FLASH) image. Although commonly used for cartilage segmentation due to the excellent contrast between cartilage and subchondral bone and high resolution acquisition, the FLASH image depicts the femoral BML poorly compared with the proton density-weighted image (arrow)

MRI image of osteoarthritis.

Arthritis of the Foot and Ankle:Arthritis is inflammation of one or more of your joints. It can cause pain and stiffness in any joint in the body, and is common in the small joints of the foot and ankle.There are more than 100 forms of arthritis, many of which affect the foot and ankle. All types can make it difficult to walk and perform activities you enjoy. Although there is no cure for arthritis, there are many treatment options available to slow the progress of the disease and relieve symptoms. With proper treatment, many people with arthritis are able to manage their pain, remain active, and lead fulfilling lives. Symptoms:Pain with motionPain that flares up with vigorous activityTenderness when pressure is applied to the jointJoint swelling, warmth, and rednessIncreased pain and swelling in the morning, or after sitting or restingDifficulty in walking due to any of the above symptoms.

Osteoarthritis in the metatarsophalangeal joint of the big toe. Joint space narrowing (black arrow) and bone spurs (white arrows) can be seen.

The X-ray shows complete obliteration of the big toe joint in a case of severe arthritis.

Erosive OA of feet; arrow heads show erosions in interphalangeal joints of feet.

CT and MRI images for OA of ankle and feet; arrow.

Osteoarthritis of the hands usually happens as part of nodal osteoarthritis (a form of osteoarthritis that runs in families). This mainly affects women and often starts in your 40s or 50s, around the menopause (the time when menstruation ends and it’s no longer possible to have children). Osteoarthritis of the hands usually affects the base of your thumb and the joints at the ends of your fingers, although other finger joints can also be affected. At times these joints become swollen and tender, especially when the condition first appears. Over several years, firm knobbly swellings form on the finger joints. These are caused by osteophytes and are known as Heberden’s nodes when they’re at the end joints of your fingers or Bouchard’s nodes when they’re at the mid-finger joints. Once the nodes are fully formed, the pain and tenderness often improve. Although the fingers are knobbly and sometimes slightly bent, they usually still work well. Arthritis at the base of your thumb may cause longer-lasting problems.

Osteoarthritis of the hands.

Erosive Osteoarthritis. (Above). Frontal radiograph of the hand demonstrates an arthritis which affects mainly the DIP and PIP joints (white arrows) and carpal-metacarpal joint of thumb (yellow arrow). There are small osteophytes and erosions (white circle). (Below) The characteristic lesion of erosive osteoarthritis is shown in close-up. There is a central erosion of the proximal part of joint (yellow arrow) and bone overgrowth peripherally (white arrows) resembling a seagull's wings.

Erosive osteoarthritis.

MRI scans showing typical features of hand OA.

Osteoarthritis of the SpineOsteoarthritis (OA) is the degenerative form of joint arthritis. It is a progressive joint disease associated with aging. In the spine, OA can affect the facet joints, the intervertebral discs, and the ligaments supporting the spine.SymptomsBack pain is the typical symptom associated with OA of the spine. The pain is typically felt deep in the muscles. Being upright aggravates the pain, and lying down typically helps. The first symptom of spine OA is intermittent low back pain that is usually most severe in the morning or after inactivity. Other symptoms depend on the disease stage and may include: stiffness and limited motion of the lumbar spine; pain and limited chest expansion; arthritis involving the shoulders, hips, and knees; kyphosis (curvature of the spine) in advanced stages, sometimes caused by the tendency for these patients to assume a stooping posture in an attempt to reduce their symptoms; hip deformity with limited range of motion; and tenderness over the inflammation site. These symptoms progress unpredictably, and the disease can disappear temporarily or permanently at any time.DiagnosisPhysical examination is typically not very specific in this illness. X-rays and MRIs show narrowed or collapsed disc spaces, and sometimes there is forward slip of one vertebra versus the other. The MRI sometimes shows a tear in the outer layer of the disc and may even show edema in the bone adjacent to the arthritic level.

CT for osteoarthritis of the facet joints.

Osteoarthritis of the Uncovertebral joints.

CT images for osteoarthritis of the right facet Uncovertebral joints.

Osteoarthritis of the Shoulder:The shoulder is made up of two joints, the acromioclavicular (AC) joint and the glenohumeral joint. The AC joint is the point where the collarbone, or clavicle, meets the acromion, which is the tip of the shoulder blade. The glenohumeral joint is the point where the top of the arm bone, or humerus, meets the shoulder blade, or scapula. Osteoarthritis is more commonly found in the AC joint. Symptoms of Shoulder Osteoarthritis:As with most types of osteoarthritis, pain is a key symptom. A person with shoulder arthritis is likely to have pain while moving the shoulder and after moving the shoulder. The person can even have pain while sleeping.Another symptom may be a limited range of motion. This limitation can be seen when you are trying to move your arm. It can also be evident if someone is moving your arm to assess range of motion. Moving the shoulder might also produce a clicking or creaking noise.

Severe osteoarthritis of the glenohumeral joint.

Osteoarthritis of the glenohumeral and AC joint.

X-Ray and CT images for osteoarthritis of the shoulder joint.

(Glenohumeral Joint) Osteoarthritis.

Osteoarthritis of the ElbowCauseOsteoarthritis of the elbow occurs when the cartilage surface of the elbow is damaged or becomes worn. This can happen because of a previous injury such as elbow dislocation or fracture. It may also be the result of degeneration of the joint cartilage from age. Osteoarthritis usually affects the weight-bearing joints, such as the hip and knee. The elbow is one of the least affected joints because of its well matched joint surfaces and strong stabilizing ligaments. As a result, the elbow joint can tolerate large forces across it without becoming unstable. SymptomsThe most common symptoms of elbow arthritis are:Pain.Loss of range of motion.

X-Ray images for elbow arthritis.

X-Ray images for elbow arthritis.

CT scan for elbow arthritis showed marked narrowing of the joint space with excessive bone formation in and around the elbow joint.

Coronal STIR MR image reveals osteoarthritis of the radiohumeral joint, with subchondral cysts, loss of cartilage and narrowing of the joint space.

Osteoarthritis of the wrist can be idiopathic, but it is mostly seen as a post-traumatic condition. There are different types of post-traumatic osteoarthritis. Scapholunate Advanced Collapse (SLAC) is the most common form, followed by Scaphoid Non-union Advanced Collapse (SNAC). Other post-traumatic causes such as intra-articular fractures of the distal radius or ulna can also lead to wrist osteoarthritis, but are less common. Signs and symptoms:The most common initial symptom of wrist osteoarthritis is joint pain. The pain is brought on by activity and increases when there is activity after resting. Other signs and symptoms, as with any joint affected by osteoarthritis, include:Morning stiffness, which usually lasts less than 30 minutes. This is also present in patients with rheumatoid arthritis, but in those patients this typically lasts for more than 45 minutes.Swelling of the wrist.Crepitus (crackling), which is felt when the hand is moved passively.Joint locking, where the joint is fixed in an extended position.Joint instability.

Wrist with osteoarthritis.

Osteoarthritis with destruction of the wrist joint (radio-carpal) (aspect on Rx and CT Scan).

MRI with osteoarthritis at distal radio-ulnar joints.

TMJ Osteoarthritis The TMJ may be affected, usually in people > 50 yr. Occasionally, patients complain of stiffness, grating, or mild pain. Crepitus results from a hole worn through the disk, causing bone to grate on bone. Joint involvement is generally bilateral. X-rays or CT may show flattening and lipping of the condyle, suggestive of dysfunctional change. Treatment is symptomatic. A mouth guard worn during the night or day may help alleviate pain and reduce grating sounds in patients with missing teeth (which can cause their jaws to come closer together when biting). Symptoms:Jaw discomfort or soreness (often most prevalent in the morning or late afternoon)HeadachesPain spreading behind the eyes, in the face, shoulder, neck, and/or backEaraches or ringing in the ears (not caused by an infection of the inner ear canal)Clicking or popping of the jawLocking of the jawLimited mouth motionsClenching or grinding of the teethDizzinessSensitivity of the teeth without the presence of an oral health diseaseA change in the way the upper and lower teeth fit together.

Panoramic film with

TMJ arthritis.

CT slice of the left temporomandibular joint with arthritis and ankylosis.

Temporomandibular joint osteoarthritis with prominent osteophytes

CT and MRI images of temporomandibular joint osteoarthritis with prominent osteophytes.

Osteoarthritis of the sacro-iliac joint:The SI joints, like any other joint in the body, are covered and protected by cartilage. So they too can fall victim to the effects of osteoarthritis. When this happens, the many nerves surrounding the SI joint may begin to send pain signals to the brain. Osteoarthritis is usually a condition that occurs gradually, over time. While getting older is the most significant contributing factor associated with this disorder, there are others that can put a person at greater risk for developing it. These include:Overweight or obesityExtreme stress on the joints from sports or certain job dutiesTraumatic Injury to the affected jointMalformed joints as the result of a birth defect or other anatomical conditionGenetically defective joint cartilage. Symptoms of Osteoarthritis in the SI Joint:Mild-to-severe low back pain on one or both sides, below L5Pain on one or both sides of the buttocks that may radiate into the groin or back of the thighPain on one side that may radiate down one leg in particularIncreased pain with certain activities – prolonged sitting or standing, bending or twisting or climbing stairs.

Osteoarthritis of the Sacroiliac (SI) Joint

Sacroiliitis on CT.

Findings of acute sacroiliitis on MRI

Chronic sacroiliitis

on MRI

Thank You.