Separation of healthy and early osteoarthritis by automatic quantification of cartilage homogeneity

Regenerative medicine for early osteoarthritis

The concept of early osteoarthritis (OA) is based on the expectation that if found and treated in the early stage, the progression of the disease might be arrested before affected joints are irreversibly destroyed. This notion of early OA detection can also bear meaning for regenerative medicine (RM) which is purposed to cure a disease by regenerating the damaged tissue. RM can be a category of disease-modifying osteoarthritis drugs (DMOADs) and provide an attractive treatment for OA, restoring structural damage incurred during the disease by repopulating cells and reconstituting. While cell therapy including the use of stem cells is conflated with RM, it may also comprise gene therapy, exosomes, and other cell or cell-free-derived products. Considering that not all early OA will become advanced OA and that RM has a characteristic of personalized medicine, it would be very important to foretell, even roughly, which patients will progress rapidly and who will favorably respond to regenerative treatment. Subclassification and comprehensive endotyping or phenotyping (E/P) can be very helpful in detecting the population who would benefit from RM as well as rapid progressors who need closer monitoring.

Magnetic resonance imaging as a structural refinement to the American College of Rheumathology clinical classification criteria for knee osteoarthritis

OBJECTIVE

To evaluate if fulfilment of the definition of osteoarthritis (OA) based on the American College of Rheumatology (ACR) clinical criteria corresponds to pathological knee findings evaluated by magnetic resonance imaging (MRI). To evaluate if any such criteria is associated with a specific MRI pattern.

METHODS

Forty-six consecutive patients aged 50 years or more referred by their general practitioners (GPs) to a radiology department because of non-traumatic knee pain underwent MRI using a dedicated low field (0.2 T) machine.

RESULTS

MRI results were compared against the ACR criteria for knee OA. Patients with knee pain fulfilling the ACR criteria showed more severe synovial fluid effusion (OR 6.2, 95% CI 2.02 to 19.1), cartilage lesions in the medial area (OR 2.4, 95% CI 1.2 to 5) and higher mean number of osteophytes (OR 2.3, 95% CI 1.1 to 4.5). The association between single criteria and MRI features was more difficult to establish. Nonetheless, crepitus at joint movement was associated with synovial fluid effusion (p=0.02); bone enlargement was more frequent in patients with lesions of the posterior cruciate ligament (p=0.0001); no palpable warmth was associated with cartilage lesions (p=0.02), and morning stiffness shorter than 30 minutes was associated with the surface of bone edema (p=0.02).

CONCLUSIONS

The ACR clinical criteria identify patients showing the most important features of OA. The association between individual clinical ACR criteria and OA pathology depicted by MRI may be difficult to explain on the basis of anatomical changes and needs further evaluation.

Interplay between cellular changes in the knee joint, circulating lipids and pain behaviours in a slowly progressing murine model of osteoarthritis

BACKGROUND

Synovial inflammation has known contributions to chronic osteoarthritis (OA) pain, but the potential role in transitions from early to late stages of OA pain is unclear.

METHODS

The slowly progressing surgical destabilization of the medial meniscus (DMM) murine OA model and sham control, was used in male C57BL/6J mice to investigate the interplay between knee inflammation, plasma pro- and anti-inflammatory oxylipins and pain responses during OA progression. Changes in joint histology, macrophage infiltration, chemokine receptor CX3CR1 expression, weight bearing asymmetry, and paw withdrawal thresholds were quantified 4, 8 and 16 weeks after surgery. Plasma levels of multiple bioactive lipid mediators were quantified using liquid chromatography with tandem mass-spectrometry (LC-MS/MS).

RESULTS

Structural joint damage was evident at 8 weeks post-DMM surgery onwards. At 16 weeks post-DMM surgery, synovial scores, numbers of CD68 and CD206 positive macrophages and pain responses were significantly increased. Plasma levels of oxylipins were negatively correlated with joint damage and synovitis scores at 4 and 8 weeks post-DMM surgery. Higher circulating levels of the pro-resolving oxylipin pre-cursor 17-HDHA were associated with lower weight bearing asymmetry at week 16.

CONCLUSIONS

The transition to chronic OA pathology and pain is likely influenced by both joint inflammation and plasma oxylipin mediators of inflammation and levels of pro-resolution molecules.

SIGNIFICANCE

Using a slow progressing surgical model of osteoarthritis we show how the changing balance between local and systemic inflammation may be of importance in the progression of pain behaviours during the transition to chronic osteoarthritis pain.

The effect of vitamin K insufficiency on histological and structural properties of knee joints in aging mice

Objective

While a role for vitamin K in maintaining joint tissue homeostasis has been proposed based on the presence of vitamin K dependent proteins in cartilage and bone, it is not clear if low vitamin K intake is causally linked to joint tissue degeneration. To address this gap, we manipulated vitamin K status in aging mice to test its effect on age-related changes in articular cartilage and sub-chondral bone.

Methods

Eleven-month old male C57BL6 mice were randomly assigned to a low vitamin K diet containing 120 mcg phylloquinone/kg diet (n = 32) or a control diet containing 1.5 mg phylloquinone/kg diet (n = 30) for 6 months. Knees were evaluated histologically using Safranin O and H&E staining, as well as using micro-CT.

Results

Eleven mice in the low vitamin K diet group and three mice in the control group died within the first 100 days of the experiment (p = 0.024). Mice fed the low vitamin K diet had higher Safranin-O scores, indicative of more proteoglycan loss, compared to mice fed the control diet (p ≤ 0.026). The articular cartilage structure scores did not differ between the two groups (p ≥ 0.190). The sub-chondral bone parameters measured using micro CT also did not differ between the two groups (all p ≥ 0.174).

Conclusion

Our findings suggest low vitamin K status can promote joint tissue proteoglycan loss in older male mice. Future studies are needed to confirm our findings and obtain a better understanding of the molecular mechanisms underlying the role of vitamin K in joint tissue homeostasis.

Identification of antibodies against extracellular matrix proteins in human osteoarthritis

We investigated the presence of autoantibodies against the extracellular matrix proteins thrombospondin-4 (TSP-4), cartilage oligomeric matrix protein (COMP), C-type lectin domain family 3 member A (CLEC3A), collagen II, collagen VI, matrilin-3, and fibrillin-2 in the serum of osteoarthritis (OA) patients. We compared those results with the presence of such antibodies in rheumatoid arthritis (RA) patients and in healthy donors (HD). Our study examines whether antibodies against extracellular proteins can be used as potential biomarkers to support the clinical diagnosis of OA. 10 OA, 10 RA patients and 10 HD were enrolled in this explorative cross-sectional study. SDS-PAGE and immunoblot were used to investigate the presence of antibodies against extracellular matrix proteins. The serum of 5/10 OA patients but 0/10 HD exhibited TSP-4 IgG isotype antibodies (P = 0.033). The serum of 8/10 OA patients but only 1/10 HD exhibited IgG isotype antibodies against TSP-4 or COMP (P = 0.005). The serum of 9/10 OA patients but only 1/10 HD exhibited IgG isotype antibodies against TSP-4, COMP or CLEC3A (P = 0.005). We found strong evidence for the presence of IgG isotype autoantibodies against the cartilage extracellular matrix proteins TSP-4, COMP and CLEC3A in OA. The detection of IgG isotype autoantibodies against TSP-4, COMP and CLEC3A may support the clinical diagnosis of OA. OA with autoantibodies against cartilage extracellular matrix proteins defines a new OA subgroup suggesting that patients with high concentrations of autoantibodies may benefit from an immune suppressive therapy.

Noninvasive visualization of early osteoarthritic cartilage using targeted nanosomes in a destabilization of the medial meniscus mouse model

Background

Early stage osteoarthritis (OA) is clinically asymptomatic due to the avascular and the aneural nature of the cartilage tissue. Nevertheless, early detection of cartilage tissue is critical in order to impede the progression of OA. Hence, in order to develop effective preventive therapy for OA, diagnosis in the early stages is necessary.

Methods

To achieve this goal, we have developed targeted, fluorescent nanosomes conjugated with monoclonal anti-type II collagen antibodies (MabCII) for diagnosis of early OA. The MabCII-coated nanosomes (targeted-nanosomes) bind to the damaged cartilage explants in vitro and in vivo in an OA mouse model that mimics early stage OA. The OA mouse model was induced by destabilization of the medial meniscus (DMM) in 9–10 weeks old C57Bl/6 mice.

Results

The targeted-nanosomes enhanced the binding specificity to the cartilage tissue according to the severity of damage.

Conclusion

We show that MabCII-nanosomes can precisely detect early stage OA in the DMM mouse model. Thus, MabCII-nanosomes have the potential to be used as a non-invasive method for diagnosing the early osteoarthritic lesions.

Correlations of low-field NMR and variable-field NMR parameters with osteoarthritis in human articular cartilage under load

NMR experiments carried out at magnetic fields below 1 T provide new relaxation parameters unavailable with conventional clinical scanners. Contrast of T₁ generally becomes larger towards low fields, as slow molecular reorientation processes dominate relaxation at the corresponding Larmor frequencies. This advantage has to be considered in the context of lower sensitivity and frequently reduced spatial resolution. The layered structure of cartilage is one example where a particularly strong variation of T₁ across the tissue occurs, being affected by degenerative diseases such as osteoarthritis (OA). Furthermore, the presence of ¹ H-¹⁴  N cross-relaxation, leading to so-called quadrupolar dips in the ¹ H relaxation time dispersion, provide insight into the concentration and mobility of proteoglycans and collagen in cartilage, both being affected by OA. In this study, low-field imaging and variable-field NMR relaxometry were combined for the first time for tissue samples, employing unidirectional load to probe the mechanical properties. 20 human knee cartilage samples were placed in a compression cell, and studied by determining relaxation profiles without and with applied pressure (0.6 MPa) at 50 μm in-plane resolution, and comparing with volume-averaged T₁ dispersion. Samples were subsequently stored in formalin, prepared for histology and graded according to the Mankin score system. Quadrupolar dips and thickness change under load showed the strongest correlation with Mankin grade. Average T₁ and change of maximum T₁ under load, as well as its position, correlate with thickness and thickness change. Furthermore, T₁ (ω) above 25 mT was found to correlate with thickness change. While volume-averaged T₁ is not a suitable indicator for OA, its change due to mechanical load and its extreme values are suggested as biomarkers available in low-field MRI systems. The shape of the dispersion T₁ (ω) represents a promising access to understanding and quantifying molecular dynamics in tissue, pointing toward future in vivo tissue studies.

Effect of Matching or Overconstraining Knee Laxity During Anterior Cruciate Ligament Reconstruction on Knee Osteoarthritis and Clinical Outcomes: A Randomized Controlled Trial With 84-Month Follow-up

BACKGROUND

The "initial graft tension" applied at the time of graft fixation during anterior cruciate ligament (ACL) reconstruction surgery modulates joint contact mechanics, which in turn may promote posttraumatic osteoarthritis (OA).

PURPOSE/HYPOTHESES

The study objectives were to compare clinical, functional, patient-reported, and OA imaging outcomes between 2 different initial laxity-based graft tension cohorts and a matched uninjured control group as well as to evaluate the effects of laxity-based graft tension on OA development at 84-month follow-up. The 2 laxity-based tension protocols were (1) to restore normal anteroposterior (AP) laxity at the time of surgery relative to the contralateral uninjured knee (low-tension group) or (2) to overconstrain AP laxity by 2 mm relative to the contralateral uninjured knee (high-tension group). The hypotheses were that (1) the high-tension group would have improved outcomes and decreased OA compared with the low-tension group after 84 months, and (2) the outcomes for the high-tension group would be equivalent to those for an age-, sex-, race-, and activity-matched group of control participants with uninjured knees.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Patients had their ACLs reconstructed with either a bone-patellar tendon-bone or 4-stranded hamstring autograft, and outcomes were compared with a matched control group. Outcomes were evaluated preoperatively and at 60 and 84 months postoperatively and included clinical (KT-1000 arthrometer AP laxity measurement and International Knee Documentation Committee [IKDC] examination score), functional (1-legged hop for distance and knee extensor torque), patient-reported (Knee injury and Osteoarthritis Outcome Score [KOOS], Short Form-36 [SF-36], and patient satisfaction survey), and OA imaging (measurement of joint space width [JSW], Osteoarthritis Research Society International [OARSI] radiographic score, and Whole-Organ Magnetic Resonance Imaging Score [WORMS]) components. Repeated-measures analyses of variance were used to evaluate differences in outcomes between the treatment groups and the control group.

RESULTS

There were significant differences between the 2 tension groups in 1 of 5 KOOS subscales (sports and recreation; P = .04) and 2 of 8 SF-36 subscales (vitality, mental health; P < .04) at 84 and 60 months, respectively. Both tension groups scored significantly worse than the control group in the IKDC examination (P < .001), 1-legged hop (P ≤ .017), KOOS quality of life and symptoms subscales (P < .03), and OARSI radiographic score (P ≤ .02) at 84 months. The low-tension group performed significantly worse than the control group on the KOOS pain subscale (P = .03), SF-36 general health and social functioning (P < .04), OARSI radiographic score (P < .001), and WORMS (P = .001), while the high-tension group had statistically different results than the control group in AP knee laxity (P < .001), radiographic JSW (P = .003), and OARSI radiographic score (P = .02) as well as significantly more subsequent knee injuries (P = .02) at 84 months.

CONCLUSION

The results do not support the hypotheses that the high-tension group would have improved outcomes when compared with the low-tension group after 84 months of healing or that the outcomes for the high-tension group would be equivalent to those for the matched control group. While there were minor differences in patient-reported outcomes between the 2 laxity-based tension groups, all other outcomes were similar.

REGISTRATION

NCT00434837.

Laterality of radiographic osteoarthritis of the knee

There are few reports of the laterality in radiological knee osteoarthritis (ROA). This study aimed to evaluate laterality in terms of the minimum joint space width (mJSW) and osteophyte areas (OFs) in a cross-sectorial general population screen and elucidate the association between laterality and risk of osteoarthritis. We enrolled 330 participants (mean age 64.6 years) and examined the presence of ROA (Kellgren-Lawrence grade ≧ 2) laterality in terms of the mJSW and OF on the medial tibia using auto-measuring software. Moreover, we examined the association between laterality and leg dominance. The right and left medial mJSWs were 4.02 ± 0.98 mm and 4.05 ± 1.01 mm, respectively, showing no laterality; the laterals were also similar. The participants who had osteophytes ≥1 mm² in the right, left, and bilateral knees were 15, 37, and 57 respectively, with osteophytes being significantly more common in the left knee. The OF was significantly larger in the left knee. Conversely, the medial and lateral mJSWs and OF did not differ according to leg dominance. The prevalence of ROA was higher and the OF was more pronounced in the left knee. However, the mJSW showed no laterality. Additionally, the mJSW and OF showed no differences according to leg dominance.

Feasibility of high-resolution one-dimensional relaxation imaging at low magnetic field using a single-sided NMR scanner applied to articular cartilage

Low field Nuclear Magnetic Resonance increases the contrast of the longitudinal relaxation rate in many biological tissues; one prominent example is hyaline articular cartilage. In order to take advantage of this increased contrast and to profile the depth-dependent variations, high resolution parameter measurements are carried out which can be of critical importance in an early diagnosis of cartilage diseases such as osteoarthritis. However, the maximum achievable spatial resolution of parameter profiles is limited by factors such as sensor geometry, sample curvature, and diffusion limitation. In this work, we report on high-resolution single-sided NMR scanner measurements with a commercial device, and quantify these limitations. The highest achievable spatial resolution on the used profiler, and the lateral dimension of the sensitive volume were determined. Since articular cartilage samples are usually bent, we also focus on averaging effects inside the horizontally aligned sensitive volume and their impact on the relaxation profiles. Taking these critical parameters into consideration, depth-dependent relaxation time profiles with the maximum achievable vertical resolution of 20 μm are discussed, and are correlated with diffusion coefficient profiles in hyaline articular cartilage in order to reconstruct T(2) maps from the diffusion-weighted CPMG decays of apparent relaxation rates.

T2 texture index of cartilage can predict early symptomatic OA progression: data from the osteoarthritis initiative

OBJECTIVE

There is an interest in using Magnetic Resonance Imaging (MRI) to identify pre-radiographic changes in osteoarthritis (OA) and features that indicate risk for disease progression. The purpose of this study is to identify image features derived from MRI T2 maps that can accurately predict onset of OA symptoms in subjects at risk for incident knee OA.

METHODS

Patients were selected from the Osteoarthritis Initiative (OAI) control cohort and incidence cohort and stratified based on the change in total Western Ontario and McMaster Universities Arthritis (WOMAC) score from baseline to 3-year follow-up (80 non-OA progression and 88 symptomatic OA progression patients). For each patient, a series of image texture features were measured from the baseline cartilage T2 map. A linear discriminant function and feature reduction method was then trained to quantify a texture metric, the T2 texture index of cartilage (TIC), based on 22 image features, to identify a composite marker of T2 heterogeneity.

RESULTS

Statistically significant differences were seen in the baseline T2 TIC between the non-progression and symptomatic OA progression populations. The baseline T2 TIC differentiates subjects that develop worsening of their WOMAC score OA with an accuracy between 71% and 76%. The T2 TIC differences were predominantly localized to a dominant knee compartment that correlated with the mechanical axis of the knee.

CONCLUSION

Baseline heterogeneity in cartilage T2 as measured with the T2 TIC index is able to differentiate and predict individuals that will develop worsening of their WOMAC score at 3-year follow-up.

Categorization of two-photon microscopy images of human cartilage into states of osteoarthritis

OBJECTIVE

The degeneration of articular cartilage is part of the clinical syndrome of osteoarthritis (OA) and one of the most common causes of pain and disability in middle-aged and older people(1). However, the objective detection of an initial state of OA is still challenging. In order to categorize cartilage into states of OA, an algorithm is presented which offers objective categorization on the basis of two-photon laser-scanning microscopy (TPLSM) images.

METHODS

The algorithm is based on morphological characteristics of the images and results in a topographical visualization. This paper describes the algorithm and shows the result of a categorization of human cartilage samples.

RESULTS

The resulting map of the analysis of TPLSM images can be divided into areas which correspond to the grades of the Outerbridge-Categorization. The algorithm is able to differentiate the samples in coincidence with the macroscopic impression.

CONCLUSION

The method is promising for early OA detection and categorization. In order to achieve a higher benefit for the physician the method must be transferred to an endoscopic setup for an application in surgery.

Analysis of knee flexion characteristics and how they alter with the onset of knee osteoarthritis: a case control study

Background

The purpose of this study was to examine the differences in gait profile between patients with knee osteoarthritis (OA) and healthy control and to create motion characteristics that will differentiate between them.

Methods

Twenty three patients diagnosed with knee OA and 21 healthy matched controls underwent a gait test using a sensor system (gaitWALK). Gait parameters evaluated were: stride duration, knee flexion range of motion (ROM) in swing and stance. T-Test was used to evaluate significant differences between groups (P < 0.05).

Results

Patients with knee OA had significant lower knee flexion ROM (10.3° ± 4.0°) during stance than matched controls (18.0° ± 4.0°) (p < 0.001). Patients with knee OA had significant lower knee flexion ROM (54.8° ± 5.5°) during swing than matched controls (61.2° ± 6.1) (p = 0.003). Patients with knee OA also had longer stride duration (1.12 s ± 0.09 s) than matched controls (1.06 s ± 0.11 s), but this was not statistically significant (p = 0.073). Motion characteristics differentiate between a patient with knee OA and a healthy one with a sensitivity of 0.952 and a specificity of 0.783.

Conclusions

Significant differences were found in the gait profile of patients with knee OA compared to matched control and motion characteristics were identified. This test might help clinicians identify and evaluate a knee problem in a simple gait test.

UTE-T2∗ mapping detects sub-clinical meniscus injury after anterior cruciate ligament tear

OBJECTIVE

Meniscus tear is a known risk factor for osteoarthritis (OA). Quantitative assessment of meniscus degeneration, prior to surface break-down, is important to identification of early disease potentially amenable to therapeutic interventions. This work examines the diagnostic potential of ultrashort echo time-enhanced T2∗ (UTE-T2∗) mapping to detect human meniscus degeneration in vitro and in vivo in subjects at risk of developing OA.

DESIGN

UTE-T2∗ maps of 16 human cadaver menisci were compared to histological evaluations of meniscal structural integrity and clinical magnetic resonance imaging (MRI) assessment by a musculoskeletal radiologist. In vivo UTE-T2∗ maps were compared in 10 asymptomatic subjects and 25 ACL-injured patients with and without concomitant meniscal tear.

RESULTS

In vitro, UTE-T2∗ values tended to be lower in histologically and clinically normal meniscus tissue and higher in torn or degenerate tissue. UTE-T2∗ map heterogeneity reflected collagen disorganization. In vivo, asymptomatic meniscus UTE-T2∗ values were repeatable within 9% (root-mean-square average coefficient of variation). Posteromedial meniscus UTE-T2∗ values in ACL-injured subjects with clinically diagnosed medial meniscus tear (n=10) were 87% higher than asymptomatics (n=10, P<0.001). Posteromedial menisci UTE-T2∗ values of ACL-injured subjects without concomitant medial meniscal tear (n=15) were 33% higher than asymptomatics (P=0.001). Posterolateral menisci UTE-T2∗ values also varied significantly with degree of joint pathology (P=0.001).

CONCLUSION

Significant elevations of UTE-T2∗ values in the menisci of ACL-injured subjects without clinical evidence of subsurface meniscal abnormality suggest that UTE-T2∗ mapping is sensitive to sub-clinical meniscus degeneration. Further study is needed to determine whether elevated subsurface meniscus UTE-T2∗ values predict progression of meniscal degeneration and development of OA.

Automatic analysis of trabecular bone structure from knee MRI

We investigated the feasibility of quantifying osteoarthritis (OA) by analysis of the trabecular bone structure in low-field knee MRI. Generic texture features were extracted from the images and subsequently selected by sequential floating forward selection (SFFS), following a fully automatic, uncommitted machine-learning based framework. Six different classifiers were evaluated in cross-validation schemes and the results showed that the presence of OA can be quantified by a bone structure marker. The performance of the developed marker reached a generalization area-under-the-ROC (AUC) of 0.82, which is higher than the established cartilage markers known to relate to the OA diagnosis.

Low-field one-dimensional and direction-dependent relaxation imaging of bovine articular cartilage

The structure of articular cartilage is separated into three layers of differently oriented collagen fibers, which is accompanied by a gradient of increasing glycosaminoglycan (GAG) and decreasing water concentration from the top layer towards the bone interface. The combined effect of these structural variations results in a change of the longitudinal and transverse relaxation times as a function of the distance from the cartilage surface. In this paper, this dependence is investigated at a magnetic field strength of 0.27 T with a one-dimensional depth resolution of 50 μm on bovine hip and stifle joint articular cartilage. By employing this method, advantage is taken of the increasing contrast of the longitudinal relaxation rate found at lower magnetic field strengths. Furthermore, evidence for an orientational dependence of relaxation times with respect to an axis normal to the surface plane is given, an observation that has recently been reported using high-field MRI and that was explained by preferential orientations of collagen bundles in each of the three cartilage zones. In order to quantify the extent of a further contrast mechanism and to estimate spatially dependent glycosaminoglycan concentrations, the data are supplemented by proton relaxation times that were acquired in bovine articular cartilage that was soaked in a 0.8 mM aqueous Gd++ solution.

Advances in imaging of osteoarthritis and cartilage

Osteoarthritis (OA) is the most frequent form of arthritis, with major implications for individual and public health care without effective treatment available. The field of joint imaging, and particularly magnetic resonance (MR) imaging, has evolved rapidly owing to technical advances and the application of these to the field of clinical research. Cartilage imaging certainly is at the forefront of these developments. In this review, the different aspects of OA imaging and cartilage assessment, with an emphasis on recent advances, will be presented. The current role of radiography, including advances in the technology for joint space width assessment, will be discussed. The development of various MR imaging techniques capable of facilitating assessment of cartilage morphology and the methods for evaluating the biochemical composition of cartilage will be presented. Advances in quantitative morphologic cartilage assessment and semiquantitative whole-organ assessment will be reviewed. Although MR imaging is the most important modality in imaging of OA and cartilage, others such as ultrasonography play a complementary role that will be discussed briefly.

Systematic review of the concurrent and predictive validity of MRI biomarkers in OA

OBJECTIVE

To summarize literature on the concurrent and predictive validity of MRI-based measures of osteoarthritis (OA) structural change.

METHODS

An online literature search was conducted of the OVID, EMBASE, CINAHL, PsychInfo and Cochrane databases of articles published up to the time of the search, April 2009. 1338 abstracts obtained with this search were preliminarily screened for relevance by two reviewers. Of these, 243 were selected for data extraction for this analysis on validity as well as separate reviews on discriminate validity and diagnostic performance. Of these 142 manuscripts included data pertinent to concurrent validity and 61 manuscripts for the predictive validity review. For this analysis we extracted data on criterion (concurrent and predictive) validity from both longitudinal and cross-sectional studies for all synovial joint tissues as it relates to MRI measurement in OA.

RESULTS

Concurrent validity of MRI in OA has been examined compared to symptoms, radiography, histology/pathology, arthroscopy, CT, and alignment. The relation of bone marrow lesions, synovitis and effusion to pain was moderate to strong. There was a weak or no relation of cartilage morphology or meniscal tears to pain. The relation of cartilage morphology to radiographic OA and radiographic joint space was inconsistent. There was a higher frequency of meniscal tears, synovitis and other features in persons with radiographic OA. The relation of cartilage to other constructs including histology and arthroscopy was stronger. Predictive validity of MRI in OA has been examined for ability to predict total knee replacement (TKR), change in symptoms, radiographic progression as well as MRI progression. Quantitative cartilage volume change and presence of cartilage defects or bone marrow lesions are potential predictors of TKR.

CONCLUSION

MRI has inherent strengths and unique advantages in its ability to visualize multiple individual tissue pathologies relating to pain and also predict clinical outcome. The complex disease of OA which involves an array of tissue abnormalities is best imaged using this imaging tool.

Responsiveness and reliability of MRI in knee osteoarthritis: a meta-analysis of published evidence

OBJECTIVE

To summarize literature on the responsiveness and reliability of MRI-based measures of knee osteoarthritis (OA) structural change.

METHODS

A literature search was conducted using articles published up to the time of the search, April 2009. 1338 abstracts obtained with this search were preliminarily screened for relevance and of these, 243 were selected for data extraction. For this analysis we extracted data on reliability and responsiveness for every reported synovial joint tissue as it relates to MRI measurement in knee OA. Reliability was defined by inter- and intra-reader intra-class correlation (ICC), or coefficient of variation, or kappa statistics. Responsiveness was defined as standardized response mean (SRM) - ratio of mean of change over time divided by standard deviation of change. Random-effects models were used to pool data from multiple studies.

RESULTS

The reliability analysis included data from 84 manuscripts. The inter-reader and intra-reader ICC were excellent (range 0.8-0.94) and the inter-reader and intra-reader kappa values for quantitative and semi-quantitative measures were all moderate to excellent (range 0.52-0.88). The lowest value (kappa=0.52) corresponded to semi-quantitative synovial scoring intra-reader reliability and the highest value (ICC=0.94) for semi-quantitative cartilage morphology. The responsiveness analysis included data from 42 manuscripts. The pooled SRM for quantitative measures of cartilage morphometry for the medial tibiofemoral joint was -0.86 (95% confidence intervals (CI) -1.26 to -0.46). The pooled SRM for the semi-quantitative measurement of cartilage morphology for the medial tibiofemoral joint was 0.55 (95% CI 0.47-0.64). For the quantitative analysis, SRMs are negative because the quantitative value, indicating a loss of cartilage, goes down. For the semi-quantitative analysis, SRMs indicating a loss in cartilage are positive (increase in score).

CONCLUSION

MRI has evolved substantially over the last decade and its strengths include the ability to visualize individual tissue pathologies, which can be measured reliably and with good responsiveness using both quantitative and semi-quantitative techniques.

Analysis of synovial fluid in knee joint of osteoarthritis:5 proteome patterns of joint inflammation based on matrix-assisted laser desorption/ionization time-of-flight mass spectrometry

PURPOSE

The purpose of this study was to use matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF-MS) in osteoarthritis research. Our aim was to find differentially expressed disease-related and condition-specific peptide in synovial fluid in the knee joint of patients suffering from osteoarthritis (OA), and to develop and validate the peptide classification model for OA diagnosis.

METHODS

Based on the American College of Rheumatology criteria, 30 OA cases and ten healthy donors were enrolled and underwent analysis. Magnetic beads-based weak cation exchange chromatography (MB-WCX) was performed for sample processing, and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF-MS) was conducted for peptide profile. ClinProt software 2.2 was used for data analysis and a genetic algorithm was created for class prediction.

RESULTS

Two peptide peaks were found which may be characterised as the potential diagnostic markers for OA. Two other significantly different peptide peaks were found in OA patients at a medium stage compared to the early and late stages. A genetic algorithm (GA) was used to establish differential diagnosis models of OA. As a result, the algorithm models marked 100% of OA, and of 97.92% of medium-stage OA.

CONCLUSION

This study demonstrated that use of proteomics methods to identify potential biomarkers of OA is possible, and the identified potential biomarkers may be potential markers for diagnosis and monitoring the progression of OA.

Quantitative cartilage imaging in knee osteoarthritis

Quantitative measures of cartilage morphology (i.e., thickness) represent potentially powerful surrogate endpoints in osteoarthritis (OA). These can be used to identify risk factors of structural disease progression and can facilitate the clinical efficacy testing of structure modifying drugs in OA. This paper focuses on quantitative imaging of articular cartilage morphology in the knee, and will specifically deal with different cartilage morphology outcome variables and regions of interest, the relative performance and relationship between cartilage morphology measures, reference values for MRI-based knee cartilage morphometry, imaging protocols for measurement of cartilage morphology (including those used in the Osteoarthritis Initiative), sensitivity to change observed in knee OA, spatial patterns of cartilage loss as derived by subregional analysis, comparison of MRI changes with radiographic changes, risk factors of MRI-based cartilage loss in knee OA, the correlation of MRI-based cartilage loss with clinical outcomes, treatment response in knee OA, and future directions of the field.

Automatic human knee cartilage segmentation from 3D magnetic resonance images

This study aimed at developing a new automatic segmentation algorithm for human knee cartilage volume quantification from magnetic resonance images (MRI). Imaging was performed using a 3T scanner and a knee coil, and the exam consisted of a DESS sequence which contrasts cartilage and soft tissues including the synovial fluid. The algorithm was developed on MRI 3D images in which the bone-cartilage interface for the femur and tibia was segmented by an independent segmentation process, giving a parametric surface of the interface. Firstly, the MR images are resampled in the neighborhood of the bone surface. Secondly, by using texture analysis techniques optimized by filtering, the cartilage is discriminated as a bright and homogeneous tissue. This process of excluding soft tissues enables the detection of the external boundary of the cartilage. Thirdly, a technology based on a Bayesian decision criterion enables the automatic separation of the cartilage and synovial fluid. Finally, the cartilage volume and changes in volume for an individual between visits was assessed using the developed technology. Validation included first, for nine knee osteoarthritis patients, a comparison of the cartilage volume and changes over time between the developed automatic system and a validated semi-automatic cartilage volume system, and second, for five knee osteoarthritis patients, a test-retest procedure. Data revealed excellent Pearson correlations and Dice Similarity Coefficients (DSC) for the global knee (r=0.96, p<0.0001, median DSC=0.84), for the femur (r=0.95, p<0.0001, median DSC=0.85) and the tibia (r=0.83, p<0.0001, median DSC=0.84). Very good similarity between the automatic and semi-automatic methods in regard to cartilage loss was also found for the global knee (r=0.76, p=0.016) as well as for the femur (r=0.79, p=0.011). The test-retest revealed an excellent measurement error of -0.3?1.6% for the global knee and 0.14?1.7% for the femur. In conclusion, the newly developed fully automatic method described herein provides accurate and precise quantification of knee cartilage volume and will be a valuable tool for clinical follow-up studies.

Magnetic resonance imaging-based semiquantitative and quantitative assessment in osteoarthritis

Whole organ magnetic resonance imaging (MRI)-based semiquantitative (SQ) assessment of knee osteoarthritis (OA), based on reliable scoring methods and expert reading, has become a powerful research tool in OA. SQ morphologic scoring has been applied to large observational cross-sectional and longitudinal epidemiologic studies as well as interventional clinical trials. SQ whole organ scoring analyzes all joint structures that are potentially relevant as surrogate outcome measures of OA and potential disease modification, including cartilage, subchondral bone, osteophytes, intra- and periarticular ligaments, menisci, synovial lining, cysts, and bursae. Resources needed for SQ scoring rely on the MRI protocol, image quality, experience of the expert readers, method of documentation, and the individual scoring system that will be applied. The first part of this article discusses the different available OA whole organ scoring systems, focusing on MRI of the knee, and also reviews alternative approaches. Rheumatologists are made aware of artifacts and differential diagnoses when applying any of the SQ scoring systems. The second part focuses on quantitative approaches in OA, particularly measurement of (subregional) cartilage loss. This approach allows one to determine minute changes that occur relatively homogeneously across cartilage structures and that are not apparent to the naked eye. To this end, the cartilage surfaces need to be segmented by trained users using specialized software. Measurements of knee cartilage loss based on water-excitation spoiled gradient recalled echo acquisition in the steady state, fast low-angle shot, or double-echo steady-state imaging sequences reported a 1% to 2% decrease in cartilage thickness annually, and a high degree of spatial heterogeneity of cartilage thickness changes in femorotibial subregions between subjects. Risk factors identified by quantitative measurement technology included a high body mass index, meniscal extrusion and meniscal tears, knee malalignment, advanced radiographic OA grade, bone marrow alterations, and focal cartilage lesions.

A framework for optimizing measurement weight maps to minimize the required sample size

We propose a fully automatic statistical framework for identifying the non-negative, real-valued weight map that best discriminate between two groups of objects. Given measurements on a spatially defined grid, a numerical optimization scheme is used to find the weight map that minimizes the sample size required to discriminate the two groups. The weight map produced by the method reflects the relative importance of the different areas in the objects, and the resulting sample size reduction is an important end goal in situations where data collection is difficult or expensive. An example is in clinical studies where the cost and the patient burden are directly related to the number of participants needed for the study. In addition, inspection of the weight map might provide clues that can lead to a better clinical understanding of the objects and pathologies being studied. The method is evaluated on synthetic data and on clinical data from knee cartilage MRI. The clinical data contain a total of 159 subjects aged 21-81 years and ranked from zero to four on the Kellgren-Lawrence osteoarthritis severity scale. Compared to a uniform weight map, we achieve sample size reductions up to 58% for cartilage thickness measurements. Based on quantifications from both morphometric and textural based imaging features, we also identify the most pathological areas in the articular cartilage.

Spatial analysis of magnetic resonance T1rho and T2 relaxation times improves classification between subjects with and without osteoarthritis

PURPOSE

Studies have shown that functional analysis of knee cartilage based on magnetic resonance (MR) relaxation times is a valuable tool in the understanding of osteoarthritis (OA). In this work, the regional spatial distribution of knee cartilage T1rho, and T2 relaxation times based on texture and laminar analyses was studied to investigate if they provide additional insight compared to global mean values in the study of OA.

METHODS

Knee cartilage of 36 subjects, 19 healthy controls and 17 with mild OA, was divided into 16 compartments. T1rho and T2 relaxation times were studied with first order statistics, eight texture parameters with four different orientations using gray-level co-occurrence matrices and by subdividing each compartment into two different layers: Deep and superficial. Receiver operating characteristic curve analysis was performed to evaluate the potential of each technique to correctly classify the populations.

RESULTS

Although the deep and superficial cartilage layers had in general significantly different T1rho and T2 relaxation times, they performed similarly in terms of subject discrimination. The subdivision of lateral and medial femoral compartments into weight-bearing and non-weight-bearing regions did not improve discrimination. Also it was found that the most sensitive region was the patella and that T1rho discriminated better than T2. The most important finding was that with respect to global mean values, laminar and texture analyses improved subject discrimination.

CONCLUSIONS

Results of this study suggest that spatially assessing MR images of the knee cartilage relaxation times using laminar and texture analyses could lead to better and probably earlier identification of cartilage matrix abnormalities in subjects with OA.

Spatial distribution and relationship of T1rho and T2 relaxation times in knee cartilage with osteoarthritis

T(1rho) and T(2) relaxation time constants have been proposed to probe biochemical changes in osteoarthritic cartilage. This study aimed to evaluate the spatial correlation and distribution of T(1rho) and T(2) values in osteoarthritic cartilage. Ten patients with osteoarthritis (OA) and 10 controls were studied at 3T. The spatial correlation of T(1rho) and T(2) values was investigated using Z-scores. The spatial variation of T(1rho) and T(2) values in patellar cartilage was studied in different cartilage layers. The distribution of these relaxation time constants was measured using texture analysis parameters based on gray-level co-occurrence matrices (GLCM). The mean Z-scores for T(1rho) and T(2) values were significantly higher in OA patients vs. controls (P < 0.05). Regional correlation coefficients of T(1rho) and T(2) Z-scores showed a large range in both controls and OA patients (0.2-0.7). OA patients had significantly greater GLCM contrast and entropy of T(1rho) values than controls (P < 0.05). In summary, T(1rho) and T(2) values are not only increased but are also more heterogeneous in osteoarthritic cartilage. T(1rho) and T(2) values show different spatial distributions and may provide complementary information regarding cartilage degeneration in OA.

Identification of progressors in osteoarthritis by combining biochemical and MRI-based markers

Introduction

At present, no disease-modifying osteoarthritis drugs (DMOADS) are approved by the FDA (US Food and Drug Administration); possibly partly due to inadequate trial design since efficacy demonstration requires disease progression in the placebo group. We investigated whether combinations of biochemical and magnetic resonance imaging (MRI)-based markers provided effective diagnostic and prognostic tools for identifying subjects with high risk of progression. Specifically, we investigated aggregate cartilage longevity markers combining markers of breakdown, quantity, and quality.

Methods

The study included healthy individuals and subjects with radiographic osteoarthritis. In total, 159 subjects (48% female, age 56.0 ± 15.9 years, body mass index 26.1 ± 4.2 kg/m²) were recruited. At baseline and after 21 months, biochemical (urinary collagen type II C-telopeptide fragment, CTX-II) and MRI-based markers were quantified. MRI markers included cartilage volume, thickness, area, roughness, homogeneity, and curvature in the medial tibio-femoral compartment. Joint space width was measured from radiographs and at 21 months to assess progression of joint damage.

Results

Cartilage roughness had the highest diagnostic accuracy quantified as the area under the receiver-operator characteristics curve (AUC) of 0.80 (95% confidence interval: 0.69 to 0.91) among the individual markers (higher than all others, P < 0.05) to distinguish subjects with radiographic osteoarthritis from healthy controls. Diagnostically, cartilage longevity scored AUC 0.84 (0.77 to 0.92, higher than roughness: P = 0.03). For prediction of longitudinal radiographic progression based on baseline marker values, the individual prognostic marker with highest AUC was homogeneity at 0.71 (0.56 to 0.81). Prognostically, cartilage longevity scored AUC 0.77 (0.62 to 0.90, borderline higher than homogeneity: P = 0.12). When comparing patients in the highest quartile for the longevity score to lowest quartile, the odds ratio of progression was 20.0 (95% confidence interval: 6.4 to 62.1).

Conclusions

Combination of biochemical and MRI-based biomarkers improved diagnosis and prognosis of knee osteoarthritis and may be useful to select high-risk patients for inclusion in DMOAD clinical trials.

Early detection of aging cartilage and osteoarthritis in mice and patient samples using atomic force microscopy

The pathological changes in osteoarthritis--a degenerative joint disease prevalent among older people--start at the molecular scale and spread to the higher levels of the architecture of articular cartilage to cause progressive and irreversible structural and functional damage. At present, there are no treatments to cure or attenuate the degradation of cartilage. Early detection and the ability to monitor the progression of osteoarthritis are therefore important for developing effective therapies. Here, we show that indentation-type atomic force microscopy can monitor age-related morphological and biomechanical changes in the hips of normal and osteoarthritic mice. Early damage in the cartilage of osteoarthritic patients undergoing hip or knee replacements could similarly be detected using this method. Changes due to aging and osteoarthritis are clearly depicted at the nanometre scale well before morphological changes can be observed using current diagnostic methods. Indentation-type atomic force microscopy may potentially be developed into a minimally invasive arthroscopic tool to diagnose the early onset of osteoarthritis in situ.

Increased urinary excretion of C-telopeptides of type II collagen (CTX-II) predicts cartilage loss over 21 months by MRI

OBJECTIVE

Osteoarthritis (OA) is characterized by increased bone and cartilage metabolism leading to joint damage. The urinary excretion of C-telopeptides of type II collagen (CTX-II) has earlier predicted progression in radiographic OA (ROA)--useful for participant selection in clinical studies of potential disease modifying OA drugs (DMOADs). We investigated the longitudinal interrelationship between CTX-II and knee cartilage volume quantified from magnetic resonance imaging (MRI).

METHODS

We followed 158 subjects [48% females, 36 with knee ROA at baseline (BL)] for 21 months. The Kellgren and Lawrence (KL) index and joint space width were assessed from radiographs (acquired load-bearing, semi-flexed). MRI scans were acquired from a 0.18 T Esaote scanner (40 degrees flip angle (FA), TR 50 ms, TE 16 ms, scan time 10 min, resolution 0.7 mm x 0.7 mm x 0.8 mm) and medial tibial and femoral cartilage volume was quantified. Radiographs and MRI were acquired at BL and follow-up. Fasting morning urine samples (second void) were collected for BL CTX-II measurement.

RESULTS

CTX-II was 56% higher in ROA subjects (P=0.0001). In addition, elevated BL CTX-II was associated with radiographic progression (by KL or joint space narrowing) although not statistically significant. Contrarily, elevated BL CTX-II predicted longitudinal cartilage loss by MRI (middle/high tertiles had odds ratios 4.0/3.9, P<0.01) corresponding to 3.1% increased yearly cartilage loss.

CONCLUSION

Prognostic markers in study selection criteria must ensure that placebo-treated participants progress to enable efficacy demonstration. And efficacy markers must allow progression detection within the study period. Our results support applying CTX-II for selection of high risk subjects and applying the fully automatic MRI-based framework for quantification of cartilage loss.

New techniques for cartilage magnetic resonance imaging relaxation time analysis: texture analysis of flattened cartilage and localized intra- and inter-subject comparisons

MR relaxation time measurements of knee cartilage have shown potential to characterize knee osteoarthritis (OA). In this work, techniques that allow localized intra- and inter-subject comparisons of cartilage relaxation times, as well as cartilage flattening for texture analysis parallel and perpendicular to the natural cartilage layers, are presented. The localized comparisons are based on the registration of bone structures and the assignment of relaxation time feature vectors to each point in the bone-cartilage interface. Cartilage flattening was accomplished with Bezier splines and warping, and texture analysis was performed with second-order texture measures using gray-level co-occurrence matrices (GLCM). In a cohort of five normal subjects the performance and reproducibility of the techniques were evaluated using T1rho maps of femoral knee cartilage. The feasibility of creating a mean cartilage relaxation time map is also presented. Successful localized intra- and inter-subject T1rho comparisons were obtained with reproducibility similar to that reported in the literature for regional T2. Improvement of the reproducibility of GLCM features was obtained by flattening the T1rho maps. The results indicate that the presented techniques have potential in longitudinal and population studies of knee OA at different stages of the disease.

Quantitative MR imaging using "LiveWire" to measure tibiofemoral articular cartilage thickness

OBJECTIVE

To assess the reliability and accuracy of manual and semi-automated segmentation methods for quantifying knee cartilage thickness. This study employed both manual and LiveWire-based semi-automated segmentation methods, ex vivo and in vivo, to measure tibiofemoral (TF) cartilage thickness.

METHODS

The articular cartilage of a cadaver knee and a healthy volunteer's knee were segmented manually and with LiveWire from multiple 3T MR images. The cadaver specimen's cartilage thickness was also evaluated with a 3D laser scanner, which was assumed to be the gold standard. Thickness measurements were made within specific cartilage regions. The reliability of each segmentation method was assessed both ex vivo and in vivo, and accuracy was assessed ex vivo by comparing segmentation results to those obtained with laser scanning.

RESULTS

The cadaver specimen thickness measurements showed mean coefficients of variation (CVs) of 4.16%, 3.02%, and 1.59%, when evaluated with manual segmentation, LiveWire segmentation, and laser scanning, respectively. The cadaver specimen showed mean absolute errors versus laser scanning of 4.07% and 7.46% for manual and LiveWire segmentation, respectively. In vivo thickness measurements showed mean CVs of 2.71% and 3.65% when segmented manually and with LiveWire, respectively.

CONCLUSIONS

Manual segmentation, LiveWire segmentation, and laser scanning are repeatable methods for quantifying knee cartilage thickness; however, the measurements are technique-dependent. Ex vivo, the manual segmentation error was distributed around the laser scanning mean, while LiveWire consistently underestimated laser scanning by 8.9%. Although LiveWire offers repeatability and decreased segmentation time, manual segmentation more closely approximates true cartilage thickness, particularly in cartilage contact regions.

Efficient segmentation by sparse pixel classification

Segmentation methods based on pixel classification are powerful but often slow. We introduce two general algorithms, based on sparse classification, for optimizing the computation while still obtaining accurate segmentations. The computational costs of the algorithms are derived, and they are demonstrated on real 3-D magnetic resonance imaging and 2-D radiograph data. We show that each algorithm is optimal for specific tasks, and that both algorithms allow a speedup of one or more orders of magnitude on typical segmentation tasks.

The feasibility of characterizing the spatial distribution of cartilage T(2) using texture analysis

OBJECTIVE

The purpose of this study was (1) to characterize the spatial distribution of cartilage T(2) in postmenopausal osteoarthritis (OA) patients and age-matched healthy subjects using second order texture measures at baseline, and (2) to analyze changes in the texture of cartilage T(2) after 9 months.

METHODS

3.0T-MRI of the knee was performed in 8 mild OA patients and 10 age-matched controls at baseline and after 9 months. Cartilage T(2), volume, and average thickness were calculated in all patients. Texture analysis, based on the gray level co-occurrence matrix, was performed on the cartilage T(2) maps. Texture parameters, including entropy and angular second moment, were calculated at 0 degrees (corresponding to the anterior-posterior axis) and at 90 degrees (corresponding to the superior-inferior axis), with pixel offsets ranging from 1 to 3 pixels.

RESULTS

Least square means analysis showed that mean T(2) values, their standard deviation (SD), and their entropy were greater (P<0.05) in OA patients than in controls. Over 9 months, the SD and entropy of cartilage T(2) significantly (P<0.05) decreased in OA patients, while no significant changes were evident in cartilage thickness or volume.

CONCLUSION

The mean cartilage T(2) values, their SD, and their entropy were greater in OA patients than in controls, indicating that the T(2) values in osteoarthritic cartilage are not only elevated, but also more heterogeneous than those in healthy cartilage. The longitudinal results demonstrate that changes in texture parameters of cartilage T(2) may precede morphological changes in thickness and volume in the progression of OA.