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Ge L, Zhang X, Zhu R, Cai G. Bone marrow lesions in osteoarthritis: biomarker or treatment target? A narrative review. Skeletal Radiol 2024:10.1007/s00256-024-04725-0. [PMID: 38877110 DOI: 10.1007/s00256-024-04725-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 06/05/2024] [Accepted: 06/05/2024] [Indexed: 06/16/2024]
Abstract
Osteoarthritis (OA) is a leading cause of pain, functional impairment, and disability in older adults. However, there are no effective treatments to delay and reverse OA. Magnetic resonance imaging (MRI) can assess structural abnormalities of OA by directly visualizing damage and inflammatory reactions within the tissues and detecting abnormal signals in the subchondral bone marrow region. While some studies have shown that bone marrow lesions (BMLs) are one of the early signs of the development of OA and predict structural and symptomatic progression of OA, others claimed that BMLs are prevalent in the general population and have no role in the progression of OA. In this narrative review, we screened and summarized studies with different designs that evaluated the association of BMLs with joint symptoms and structural abnormalities of OA. We also discussed whether BMLs may serve as an imaging biomarker and a treatment target for OA based on existing clinical trials.
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Affiliation(s)
- Liru Ge
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, 230032, Anhui, China
| | - Xiaoyue Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, 230032, Anhui, China
| | - Rui Zhu
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, 230032, Anhui, China
| | - Guoqi Cai
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, 230032, Anhui, China.
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, 7000, Australia.
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2
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Nielsen FK, Sørensen FB, Egund N, Boel LW, Holm C, Jurik AG. Bone marrow lesions in knee osteoarthritis assessed by dynamic contrast-enhanced MRI with histopathological correlations. Acta Radiol 2024:2841851241251639. [PMID: 38766869 DOI: 10.1177/02841851241251639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Bone marrow lesions (BMLs) in knee osteoarthritis (OA) have been assessed histopathologically and by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI); however, a direct comparison of the results has not been reported. PURPOSE To evaluate and compare the findings by DCE-MRI and histopathology of subchondral BMLs in knee OA. MATERIAL AND METHODS In total, 19 patients with medial tibiofemoral knee OA undergoing total knee arthroplasty were analyzed. Preoperative MRI, including a DCE sequence, was performed, and bone biopsies were obtained from the resected specimens corresponding to BML areas. The contrast enhancement by DCE-MRI was analyzed using semi-quantitative (area under the curve [AUC]), peak enhancement [PE]), and quantitative (Ktrans, Kep) methods. Enhancement in the medial OA compartment was compared with similar areas in a normal lateral compartment, and the DCE characteristics of BMLs were correlated with semi-quantitatively graded histopathological features. RESULTS AUC and PE were significantly higher in medial tibial and femoral BMLs compared with the values in the lateral condyles; Ktrans and Kep were only significantly higher in the tibial plateau. In the tibia, AUC and PE were significantly correlated with the grade of vascular proliferation, and PE also with the degree of marrow fibrosis. There was no significant correlation between AUC/PE and histopathological findings in the femur and no correlation between quantitative DCE parameters and histopathological findings. CONCLUSION BML characteristics by semi-quantitative DCE in the form of AUC and PE may be used as parameters for the degree of histopathological vascularization in the bone marrow whereas quantitative DCE data were less conclusive.
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Affiliation(s)
| | | | - Niels Egund
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | - Lene Warner Boel
- Department of Forensic Medicine, Aarhus University, Aarhus, Denmark
| | - Carsten Holm
- Department of Orthopaedic Surgery, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Anne Grethe Jurik
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
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3
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Ponnusamy R, Zhang M, Wang Y, Sun X, Chowdhury M, Driban JB, McAlindon T, Shan J. Automatic Segmentation of Bone Marrow Lesions on MRI Using a Deep Learning Method. Bioengineering (Basel) 2024; 11:374. [PMID: 38671795 PMCID: PMC11048083 DOI: 10.3390/bioengineering11040374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/04/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Bone marrow lesion (BML) volume is a potential biomarker of knee osteoarthritis (KOA) as it is associated with cartilage degeneration and pain. However, segmenting and quantifying the BML volume is challenging due to the small size, low contrast, and various positions where the BML may occur. It is also time-consuming to delineate BMLs manually. In this paper, we proposed a fully automatic segmentation method for BMLs without requiring human intervention. The model takes intermediate weighted fat-suppressed (IWFS) magnetic resonance (MR) images as input, and the output BML masks are evaluated using both regular 2D Dice similarity coefficient (DSC) of the slice-level area metric and 3D DSC of the subject-level volume metric. On a dataset with 300 subjects, each subject has a sequence of 36 IWFS MR images approximately. We randomly separated the dataset into training, validation, and testing sets with a 70%/15%/15% split at the subject level. Since not every subject or image has a BML, we excluded the images without a BML in each subset. The ground truth of the BML was labeled by trained medical staff using a semi-automatic tool. Compared with the ground truth, the proposed segmentation method achieved a Pearson's correlation coefficient of 0.98 between the manually measured volumes and automatically segmented volumes, a 2D DSC of 0.68, and a 3D DSC of 0.60 on the testing set. Although the DSC result is not high, the high correlation of 0.98 indicates that the automatically measured BML volume is strongly correlated with the manually measured BML volume, which shows the potential to use the proposed method as an automatic measurement tool for the BML biomarker to facilitate the assessment of knee OA progression.
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Affiliation(s)
- Raj Ponnusamy
- Department of Computer Science, Seidenberg School of CSIS, Pace University, New York City, NY 10038, USA; (R.P.); (Y.W.); (M.C.)
| | - Ming Zhang
- Department of Computer Science, Boston University, Boston, MA 02215, USA
| | - Yue Wang
- Department of Computer Science, Seidenberg School of CSIS, Pace University, New York City, NY 10038, USA; (R.P.); (Y.W.); (M.C.)
| | - Xinyue Sun
- School of Electronic Information and Electrical Engineering, Shanghai Jiao Tong University, Shanghai 200240, China;
| | - Mohammad Chowdhury
- Department of Computer Science, Seidenberg School of CSIS, Pace University, New York City, NY 10038, USA; (R.P.); (Y.W.); (M.C.)
| | - Jeffrey B. Driban
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA 01655, USA;
| | - Timothy McAlindon
- Division of Rheumatology, Allergy, and Immunology, Tufts Medical Center, Boston, MA 02111, USA;
| | - Juan Shan
- Department of Computer Science, Seidenberg School of CSIS, Pace University, New York City, NY 10038, USA; (R.P.); (Y.W.); (M.C.)
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4
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Smith SE, Bahouth SM, Duryea J. Quantitative bone marrow lesion, meniscus, and synovitis measurement: current status. Skeletal Radiol 2023; 52:2123-2135. [PMID: 36928478 DOI: 10.1007/s00256-023-04311-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 02/21/2023] [Accepted: 02/22/2023] [Indexed: 03/18/2023]
Abstract
Imaging plays a pivotal role in osteoarthritis research, particularly in epidemiological and clinical trials of knee osteoarthritis (KOA), with the ultimate goal being the development of an effective drug treatment for future prevention or cessation of disease. Imaging assessment methods can be semi-quantitative, quantitative, or a combination, with quantitative methods usually relying on software to assist. The software generally attempts image segmentation (outlining of relevant structures). New techniques using artificial intelligence (AI) or deep learning (DL) are currently a frequent topic of research. This review article provides an overview of the literature to date, focusing primarily on the current status of quantitative software-based assessment techniques of KOA using magnetic resonance (MR) imaging. We will concentrate on the imaging evaluation of three specific structural imaging biomarkers: bone marrow lesions (BMLs), meniscus, and synovitis consisting of effusion synovitis (ES) and Hoffa's synovitis (HS). A brief clinical and imaging background review of osteoarthritis evaluation, particularly relating to these three structural markers, is provided as well as a general summary of the software methods. A summary of the literature with respect to each KOA assessment method will be presented overall as well as with respect to each specific biomarker individually. Novel techniques, as well as future goals and directions using quantitative imaging assessment, will be discussed.
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Affiliation(s)
- Stacy E Smith
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Neil and Elise Wallace STRATUS Center for Medical Simulation, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sara M Bahouth
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey Duryea
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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5
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Driban JB, Price LL, LaValley MP, Lo GH, Zhang M, Harkey MS, Canavatchel A, McAlindon TE. Novel Framework for Measuring Whole Knee Osteoarthritis Progression Using Magnetic Resonance Imaging. Arthritis Care Res (Hoboken) 2022; 74:799-808. [PMID: 33202111 PMCID: PMC8631200 DOI: 10.1002/acr.24512] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 10/05/2020] [Accepted: 11/10/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE We developed and validated a set of composite scores that combine quantitative magnetic resonance imaging (MRI)-based measurements of hyaline cartilage damage, bone marrow lesions (BMLs), and effusion-synovitis into composite scores. METHODS We selected 300 participants (n = 100 for development cohort; n = 200 for validation cohort) from the Osteoarthritis Initiative with complete clinical, radiographic, and MRI data at baseline and 24 months. We used semiautomated programs to quantify tibiofemoral and patellar cartilage damage, BML volume, and whole-knee effusion-synovitis volume. The candidate composite scores were formed by summing changes from baseline to 24 months based on prespecified methods. We evaluated the candidate composite scores for 1) the ability to differentiate groups with and without knee osteoarthritis progression (17 radiographic and patient-reported definitions), 2) sensitivity to change (standardized response means), and 3) relative performance relating to legacy outcome measures of knee osteoarthritis progression. RESULTS Three of 13 developed composite scores qualified for testing in the validation cohort (ranked by sensitivity to change): whole-knee cumulative cartilage damage, unweighted total knee score, and BML plus effusion-synovitis volume. Change in cumulative cartilage damage associated with radiographic progression (Kellgren/Lawrence grade: odds ratio [OR] 1.84; joint space width progression: OR 2.11). Changes in the unweighted total knee score (OR 1.97) and BML plus effusion-synovitis score (OR 1.92) associated with Western Ontario and McMaster Universities Osteoarthritis Index knee pain progression. CONCLUSION Two composite scores emerged, reflecting discrete domains of knee osteoarthritis progression. First, cumulative damage, which is measured by a whole-knee cartilage damage score, reflects the damage accrued over time. Second, dynamic disease activity, which is measured by a BML plus effusion-synovitis score, relates to changes in a patient's state of disease and symptoms.
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Affiliation(s)
| | - Lori Lyn Price
- Tufts University and Tufts Medical Center, Boston, Massachusetts
| | | | - Grace H Lo
- Baylor College of Medicine, Houston, Texas
| | - Ming Zhang
- Tufts Medical Center, Boston, Massachusetts
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6
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Fast quantitative bone marrow lesion measurement on knee MRI for the assessment of osteoarthritis. OSTEOARTHRITIS AND CARTILAGE OPEN 2022; 4:100234. [DOI: 10.1016/j.ocarto.2022.100234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/07/2021] [Accepted: 01/07/2022] [Indexed: 11/21/2022] Open
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7
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Juras V, Szomolanyi P, Schreiner MM, Unterberger K, Kurekova A, Hager B, Laurent D, Raithel E, Meyer H, Trattnig S. Reproducibility of an Automated Quantitative MRI Assessment of Low-Grade Knee Articular Cartilage Lesions. Cartilage 2021; 13:646S-657S. [PMID: 32988236 PMCID: PMC8808824 DOI: 10.1177/1947603520961165] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE The goal of this study was to assess the reproducibility of an automated knee cartilage segmentation of 21 cartilage regions with a model-based algorithm and to compare the results with manual segmentation. DESIGN Thirteen patients with low-grade femoral cartilage defects were included in the study and were scanned twice on a 7-T magnetic resonance imaging (MRI) scanner 8 days apart. A 3-dimensional double-echo steady-state (3D-DESS) sequence was used to acquire MR images for automated cartilage segmentation, and T2-mapping was performed using a 3D triple-echo steady-state (3D-TESS) sequence. Cartilage volume, thickness, and T2 and texture features were automatically extracted from each knee for each of the 21 subregions. DESS was used for manual cartilage segmentation and compared with automated segmentation using the Dice coefficient. The reproducibility of each variable was expressed using standard error of measurement (SEM) and smallest detectable change (SDC). RESULTS The Dice coefficient for the similarity between manual and automated segmentation ranged from 0.83 to 0.88 in different cartilage regions. Test-retest analysis of automated cartilage segmentation and automated quantitative parameter extraction revealed excellent reproducibility for volume measurement (mean SDC for all subregions of 85.6 mm3), for thickness detection (SDC = 0.16 mm) and also for T2 values (SDC = 2.38 ms) and most gray-level co-occurrence matrix features (SDC = 0.1 a.u.). CONCLUSIONS The proposed technique of automated knee cartilage evaluation based on the segmentation of 3D MR images and correlation with T2 mapping provides highly reproducible results and significantly reduces the segmentation effort required for the analysis of knee articular cartilage in longitudinal studies.
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Affiliation(s)
- Vladimir Juras
- High-Field MR Centre, Department of
Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna,
Austria,Institute of Measurement Science, Slovak
Academy of Sciences, Bratislava, Slovakia,Vladimir Juras, High-Field MR Centre,
Department of Biomedical Imaging and Image-Guided Therapy, Medical University of
Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria.
| | - Pavol Szomolanyi
- High-Field MR Centre, Department of
Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna,
Austria,Institute of Measurement Science, Slovak
Academy of Sciences, Bratislava, Slovakia
| | - Markus M. Schreiner
- Department of Orthopedics and Trauma
Surgery, Medical University of Vienna, Vienna, Austria
| | - Karin Unterberger
- Department of Orthopedics and Trauma
Surgery, Medical University of Vienna, Vienna, Austria
| | - Andrea Kurekova
- High-Field MR Centre, Department of
Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna,
Austria
| | - Benedikt Hager
- High-Field MR Centre, Department of
Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna,
Austria,CD Laboratory for Clinical Molecular MR
Imaging, Vienna, Austria
| | - Didier Laurent
- Novartis Institutes for Biomedical
Research, Department of Translational Medicine, Basel, Switzerland
| | | | | | - Siegfried Trattnig
- High-Field MR Centre, Department of
Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna,
Austria,CD Laboratory for Clinical Molecular MR
Imaging, Vienna, Austria,Austrian Cluster for Tissue
Regeneration, Vienna, Austria
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8
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Noorveriandi H, Parkes MJ, Callaghan MJ, Felson DT, O'Neill TW, Hodgson R. Assessment of bone marrow oedema-like lesions using MRI in patellofemoral knee osteoarthritis: comparison of different MRI pulse sequences. Br J Radiol 2021; 94:20201367. [PMID: 34233484 PMCID: PMC8523191 DOI: 10.1259/bjr.20201367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 06/18/2021] [Accepted: 06/21/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To compare bone marrow oedema-like lesion (BML) volume in subjects with symptomatic patellofemoral (PF) knee osteoarthritis (OA) using four different MRI sequences and to determine reliability of BML volume assessment using these sequences and their correlation with pain. METHODS 76 males and females (mean age 55.8 years) with symptomatic patellofemoral knee OA had 1.5 T MRI scans. PD fat suppressed (FS), STIR, contrast-enhanced (CE) T1W FS, and 3D T1W fast field echo (FFE) sequences were obtained. All sequences were assessed by one reader, including repeat assessment of 15 knees using manual segmentation and the measurements were compared. We used random-effects panel linear regression to look for differences in the log-transformed BML volume (due to positive skew in the BML volume distribution) between sequences and to determine associations between BML volumes and knee pain. RESULTS 58 subjects had PF BMLs present on at least one sequence. Median BML volume measured using T1W FFE sequence was significantly smaller (224.7 mm3, interquartile range [IQR] 82.50-607.95) than the other three sequences. BML volume was greatest on the CE sequence (1129.8 mm3, IQR 467.28-3166.02). Compared to CE sequence, BML volumes were slightly lower when assessed using PDFS (proportional difference = 0.79; 95% confidence interval [CI] 0.62, 1.01) and STIR sequences (proportional difference = 0.85; 95% CI 0.67, 1.08). There were strong correlations between BML volume on PDFS, STIR, and CE T1W FS sequences (ρs = 0.98). Correlations were lower between these three sequences and T1W FFE (ρs = 0.80-0.81). Intraclass correlation coefficients were excellent for proton density fat-suppressed, short-tau inversion recovery, and CE T1W FS sequences (0.991-0.995), while the ICC for T1W FFE was good at 0.88. We found no significant association between BML volumes assessed using any of the sequences and knee pain. CONCLUSION T1W FFE sequences were less reliable and measured considerably smaller BML volume compared to other sequences. BML volume was larger when assessed using the contrast enhanced T1W FS though not statistically significantly different from BMLs when assessed using PDFS and STIR sequences. ADVANCES IN KNOWLEDGE This is the first study to assess BMLs by four different MRI pulse sequences on the same data set, including different fluid sensitive sequences and gradient echo type sequence.
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Affiliation(s)
- Henry Noorveriandi
- Division of Musculoskeletal & Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester, United Kingdom
| | - Matthew J Parkes
- Division of Population Health, Health Services Research & Primary Care, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | | | | | | | - Richard Hodgson
- Division of Informatics, Imaging & Data Sciences, School of Health Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
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9
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Driban JB, Davis JE, Lu B, Price LL, Ward RJ, MacKay JW, Eaton CB, Lo GH, Barbe MF, Zhang M, Pang J, Stout AC, Harkey MS, McAlindon TE. Accelerated Knee Osteoarthritis Is Characterized by Destabilizing Meniscal Tears and Preradiographic Structural Disease Burden. Arthritis Rheumatol 2019; 71:1089-1100. [PMID: 30592385 DOI: 10.1002/art.40826] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/20/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine whether accelerated knee osteoarthritis (KOA) is preceded by, and characterized over time by, destabilizing meniscal tears or other pathologic changes. METHODS We selected 3 sex-matched groups of subjects from the first 48 months of the Osteoarthritis Initiative, comprising adults who had a knee without KOA (Kellgren/Lawrence [K/L] radiographic grade <2) at baseline. Subjects in the accelerated KOA group developed KOA of K/L grade ≥3, those with typical KOA showed increased K/L radiographic scores, and those with no KOA had the same K/L grade over time. An index visit was the visit when the radiographic criteria for accelerated KOA and typical KOA were met (the no KOA group was matched to the accelerated KOA group). The observation period was up to 2 years before and after an index visit. Radiologists reviewed magnetic resonance (MR) images of the index knee and identified destabilizing meniscal tears (root tears, radial tears, complex tears), miscellaneous pathologic features (acute ligamentous or tendinous injuries, attrition, subchondral insufficiency fractures, other incidental findings), and meniscal damage in >2 of 6 regions (3 regions per meniscus: anterior horn, body, posterior horn). In addition, bone marrow lesions (BMLs) and cartilage damage on MR images were quantified. Linear mixed regression models were performed to analyze the results. RESULTS At 1 year before the index visit, >75% of adults with accelerated KOA had meniscal damage in ≥2 regions (odds ratio 3.19 [95% confidence interval 1.70-5.97] versus adults with typical KOA). By the index visit, meniscal damage in ≥2 regions was ubiquitous in adults with accelerated KOA, including 42% of subjects having evidence of a destabilizing meniscal tear (versus 14% of subjects with typical KOA). These changes corresponded to findings of larger BMLs and greater cartilage loss in the accelerated KOA group. CONCLUSION Accelerated KOA is characterized by destabilizing meniscal tears in a knee compromised by meniscal damage in >2 regions, and also characterized by the presence of large BMLs and greater cartilage loss.
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Affiliation(s)
| | | | - Bing Lu
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lori Lyn Price
- Tufts Medical Center and Tufts University, Boston, Massachusetts
| | | | - James W MacKay
- University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Charles B Eaton
- Alpert Medical School of Brown University, Pawtucket, Rhode Island
| | - Grace H Lo
- Baylor College of Medicine and Michael E. DeBakey VAMC, Houston, Texas
| | - Mary F Barbe
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Ming Zhang
- Tufts Medical Center, Boston, Massachusetts
| | | | | | - Matthew S Harkey
- Tufts Medical Center, Boston, Massachusetts, and University of Massachusetts Medical School, Worcester
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10
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Nielsen FK, Boesen M, Jurik AG, Bliddal H, Nybing JD, Ellegaard K, Bartholdy C, Bandak E, Henriksen M. The effect of intra-articular glucocorticosteroids and exercise on symptoms and bone marrow lesions in knee osteoarthritis: a secondary analysis of results from a randomized controlled trial. Osteoarthritis Cartilage 2018; 26:895-902. [PMID: 29499289 DOI: 10.1016/j.joca.2018.02.900] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 02/18/2018] [Accepted: 02/20/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate if the relative volume of bone marrow lesions (BMLs) changed in patients with knee osteoarthritis (OA) during a therapeutic study. DESIGN This study is a sub-study to a larger clinical trial which compared the clinical effects of intra-articular corticosteroid injection in knee OA to placebo injection, both given prior to exercise therapy. Clinical assessment using the Knee injury and Osteoarthritis Outcome Score (KOOS) and magnetic resonance imaging (MRI) examinations with BML assessments were performed at baseline and follow-up after 14 weeks and 26 weeks, respectively. The BML volume was determined using a computer assisted method focusing on participants with valid baseline and follow-up MRI examinations. Any changes in BML and KOOS were analyzed and investigated for associations. RESULTS Fifty participants received steroid and placebo injection, respectively, of which 41 and 45 had complete MRI examinations at week 14, and 36 and 33 at week 26, respectively. All participants received 12 weeks of exercise. A significant change in relative BML volume was observed between the corticosteroid group and the placebo group after 14 weeks [-1.1% vs 2.7%; between-group difference, 3.8% (95% CI 0.5-7.0)] but not after 26 weeks [0.8% vs 1.6%; between-group difference, 0.8% (95% CI -2.8 to 4.4)]. No significant association was found between changes in relative BML volume and KOOS. CONCLUSIONS Despite the statistically significant difference in BML volume at 14 weeks after corticosteroid injection and 12 weeks exercise therapy compared to placebo injection and exercise, there is very little evidence on a relationship between corticosteroids and BML volume. EU CLINICAL TRIALS REGISTER EudraCT number: 2012-002607-18.
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Affiliation(s)
- F K Nielsen
- Department of Radiology, Aarhus University Hospital, Noerrebrogade 44, 8000 Aarhus, Denmark; The Parker Institute, Copenhagen University Hospital Bispebjerg-Frederiksberg, Ndr. Fasanvej 57, 2000 Frederiksberg, Denmark.
| | - M Boesen
- Department of Radiology, Bispebjerg and Frederiksberg Hospital, Ndr. Fasanvej 57, 2000 Frederiksberg, Denmark.
| | - A G Jurik
- Department of Radiology, Aarhus University Hospital, Noerrebrogade 44, 8000 Aarhus, Denmark; Institute of Clinical Medicine, Aarhus University, Denmark.
| | - H Bliddal
- The Parker Institute, Copenhagen University Hospital Bispebjerg-Frederiksberg, Ndr. Fasanvej 57, 2000 Frederiksberg, Denmark.
| | - J D Nybing
- Department of Radiology, Bispebjerg and Frederiksberg Hospital, Ndr. Fasanvej 57, 2000 Frederiksberg, Denmark.
| | - K Ellegaard
- The Parker Institute, Copenhagen University Hospital Bispebjerg-Frederiksberg, Ndr. Fasanvej 57, 2000 Frederiksberg, Denmark.
| | - C Bartholdy
- The Parker Institute, Copenhagen University Hospital Bispebjerg-Frederiksberg, Ndr. Fasanvej 57, 2000 Frederiksberg, Denmark; The Department of Physical and Occupational Therapy, Copenhagen University Hospital Bispebjerg-Frederiksberg, Bispebjerg Bakke 23, 2400 København NV, Denmark.
| | - E Bandak
- The Parker Institute, Copenhagen University Hospital Bispebjerg-Frederiksberg, Ndr. Fasanvej 57, 2000 Frederiksberg, Denmark.
| | - M Henriksen
- The Parker Institute, Copenhagen University Hospital Bispebjerg-Frederiksberg, Ndr. Fasanvej 57, 2000 Frederiksberg, Denmark; The Department of Physical and Occupational Therapy, Copenhagen University Hospital Bispebjerg-Frederiksberg, Bispebjerg Bakke 23, 2400 København NV, Denmark.
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11
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Hafezi-Nejad N, Guermazi A, Demehri S, Roemer FW. New imaging modalities to predict and evaluate osteoarthritis progression. Best Pract Res Clin Rheumatol 2018; 31:688-704. [PMID: 30509414 DOI: 10.1016/j.berh.2018.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 04/17/2018] [Accepted: 04/25/2018] [Indexed: 12/18/2022]
Abstract
In this narrative review, we discuss the role of different imaging methods for the evaluation of progression of structural osteoarthritis. We will focus on the role of less commonly applied imaging modalities and imaging biomarkers that were introduced in recent years or on established methods that have evolved into more prominent positions in recent years. We will highlight findings from longitudinal studies that focused on structural osteoarthritis progression as their outcome of interest. Imaging modalities discussed include plain radiography (including novel approaches of joint space width assessment and fractal signature analysis), ultrasonography (including the assessment of synovitis), magnetic resonance imaging (including semiquantitative, quantitative, and compositional evaluation), and positron emission tomography.
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Affiliation(s)
- Nima Hafezi-Nejad
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, 601 N Caroline St, JHOC 4240, Baltimore, MD 21287 USA
| | - Ali Guermazi
- Department of Radiology, Boston University School of Medicine, 820 Harrison Avenue, FGH Building 3rd Floor, Boston, MA 02118, USA
| | - Shadpour Demehri
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, 601 N Caroline St, JHOC 4240, Baltimore, MD 21287 USA
| | - Frank W Roemer
- Department of Radiology, Boston University School of Medicine, 820 Harrison Avenue, FGH Building 3rd Floor, Boston, MA 02118, USA; Department of Radiology, University of Erlangen-Nuremberg, Maximiliansplatz 3, 91054 Erlangen, Germany.
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12
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Stout AC, Barbe MF, Eaton CB, Amin M, Al-Eid F, Price LL, Lu B, Lo GH, Zhang M, Pang J, McAlindon TE, Driban JB. Inflammation and glucose homeostasis are associated with specific structural features among adults without knee osteoarthritis: a cross-sectional study from the osteoarthritis initiative. BMC Musculoskelet Disord 2018; 19:1. [PMID: 29304778 PMCID: PMC5755424 DOI: 10.1186/s12891-017-1921-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 12/22/2017] [Indexed: 12/11/2022] Open
Abstract
Background Greater age and body mass index are strong risk factors for osteoarthritis (OA). Older and overweight individuals may be more susceptible to OA because these factors alter tissue turnover in menisci, articular cartilage, and bone via altered glucose homeostasis and inflammation. Understanding the role of inflammation and glucose homeostasis on structural features of early-stage OA may help identify therapeutic targets to delay or prevent the onset of OA among subsets of adults with these features. We examined if serum concentrations of glucose homeostasis (glucose, glycated serum protein [GSP]) or inflammation (C-reactive protein [CRP]) were associated with prevalent knee bone marrow lesions (BMLs) or effusion among adults without knee OA. Methods We conducted a cross-sectional study using baseline data from the Osteoarthritis Initiative. We selected participants who had no radiographic knee OA but were at high risk for knee OA. Blinded staff conducted assays for CRP, GSP, and glucose. Readers segmented BML volume and effusion using semi-automated programs. Our outcomes were prevalent BML (knee with a BML volume > 1 cm3) and effusion (knee with an effusion volume > 7.5 cm3). We used logistic regression models with CRP, GSP, or glucose concentrations as the predictors. We adjusted for age, sex, body mass index (BMI), and Physical Activity Scale for the Elderly (PASE) scores. Results We included 343 participants: mean age = 59 ± 9 years, BMI = 27.9 ± 4.5 kg/m2, PASE score = 171 ± 82, and 64% female. Only CRP was associated with BML prevalence (odds ratio [OR] = 1.43, 95% confidence interval [CI] = 1.09 to 1.87). For effusion, we found an interaction between BMI and CRP: only among adults with a BMI <25 kg/m2 was there a significant trend towards a positive association between CRP and effusion (OR = 1.40, 95% CI = 1.00 to 1.97). We detected a U-shaped relationship between GSP and effusion prevalence. Fasting glucose levels were not significantly associated with the presence of baseline effusion or BML. Conclusions Among individuals without knee OA, CRP may be related to the presence of BMLs and effusion among normal weight individuals. Abnormal GSP may be associated with effusion. Future studies should explore whether inflammation and glucose homeostasis are predictive of symptomatic knee OA.
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Affiliation(s)
- Alina C Stout
- Division of Rheumatology, Tufts Medical Center, 800 Washington Street, Box #406, Boston, MA, 02111, USA
| | - Mary F Barbe
- Department of Anatomy and Cell Biology, Temple University School of Medicine, 3500 North Broad Street, Philadelphia, PA, 19140, USA
| | - Charles B Eaton
- Center for Primary Care and Prevention, Alpert Medical School of Brown University, 111 Brewster Street, Pawtucket, RI, 02860, USA
| | - Mamta Amin
- Department of Anatomy and Cell Biology, Temple University School of Medicine, 3500 North Broad Street, Philadelphia, PA, 19140, USA
| | - Fatimah Al-Eid
- Division of Rheumatology, Tufts Medical Center, 800 Washington Street, Box #406, Boston, MA, 02111, USA
| | - Lori Lyn Price
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street, Box #63, Boston, MA, 02111, USA.,Tufts Clinical and Translational Science Institute, Tufts University, 800 Washington Street, Box #63, Boston, MA, 02111, USA
| | - Bing Lu
- Brigham & Women's Hospital and Harvard Medical School, 75 Francis Street PBB-B3, Boston, MA, 02115, USA
| | - Grace H Lo
- Medical Care Line and Research Care Line, Houston Health Services Research and Development (HSR&D) Center of Excellence Michael E. DeBakey VAMC, 2002 Holcombe Blvd, Houston, TX, 77030, USA.,Section of Immunology, Allergy, and Rheumatology, Baylor College of Medicine, 1 Baylor Plaza, BCM-285, Houston, TX, 77030, USA
| | - Ming Zhang
- Division of Rheumatology, Tufts Medical Center, 800 Washington Street, Box #406, Boston, MA, 02111, USA
| | - Jincheng Pang
- Department of Electrical Engineering, Tufts University, 161 College Avenue, Medford, MA, 02155, USA
| | - Timothy E McAlindon
- Division of Rheumatology, Tufts Medical Center, 800 Washington Street, Box #406, Boston, MA, 02111, USA
| | - Jeffrey B Driban
- Division of Rheumatology, Tufts Medical Center, 800 Washington Street, Box #406, Boston, MA, 02111, USA.
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13
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Carotti M, Salaffi F, Di Carlo M, Giovagnoni A. Relationship between magnetic resonance imaging findings, radiological grading, psychological distress and pain in patients with symptomatic knee osteoarthritis. Radiol Med 2017; 122:934-943. [DOI: 10.1007/s11547-017-0799-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 08/04/2017] [Indexed: 01/20/2023]
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14
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Collins JE, Losina E, Nevitt MC, Roemer FW, Guermazi A, Lynch JA, Katz JN, Kent Kwoh C, Kraus VB, Hunter DJ. Semiquantitative Imaging Biomarkers of Knee Osteoarthritis Progression: Data From the Foundation for the National Institutes of Health Osteoarthritis Biomarkers Consortium. Arthritis Rheumatol 2017; 68:2422-31. [PMID: 27111771 DOI: 10.1002/art.39731] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 04/19/2016] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To determine the association between changes in semiquantitative magnetic resonance imaging (MRI) biomarkers over 24 months and radiographic and pain progression over 48 months in knees with mild-to-moderate osteoarthritis (OA). METHODS We undertook a nested case-control study as part of the Foundation for the National Institutes of Health Biomarkers Consortium Project. We used multivariable logistic regression models to examine the association between change over 24 months in semiquantitative MRI markers and radiographic and pain progression in knee OA. MRIs were read according to the MRI OA Knee Score system. We focused on changes in cartilage, osteophytes, meniscus, bone marrow lesions, Hoffa-synovitis, and effusion-synovitis. RESULTS The most parsimonious model included changes in cartilage thickness and surface area, effusion-synovitis, Hoffa-synovitis, and meniscal morphology (C statistic 0.740). Compared with no worsening, worsening in cartilage thickness in ≥3 subregions was associated with 2.8-fold (95% confidence interval [95% CI] 1.3-5.9) greater odds of being a case, and worsening in cartilage surface area in ≥3 subregions was associated with 2.4-fold (95% CI 1.3-4.4) greater odds of being a case. Worsening of meniscal morphology in any region was associated with 2.2-fold (95% CI 1.3-3.8) greater odds of being a case. Worsening effusion-synovitis and Hoffa-synovitis were also associated with a greater odds of being a case (odds ratios 2.7 and 2.0, respectively). CONCLUSION Twenty-four-month changes in cartilage thickness, cartilage surface area, effusion-synovitis, Hoffa-synovitis, and meniscal morphology were independently associated with OA progression, suggesting that these factors may serve as efficacy biomarkers in clinical trials of disease-modifying interventions for knee OA.
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Affiliation(s)
- Jamie E Collins
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Elena Losina
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Frank W Roemer
- Boston University School of Medicine and Quantitative Imaging Center, Boston, Massachusetts, and University of Erlangen-Nuremberg, Erlangen, Germany
| | - Ali Guermazi
- Boston University School of Medicine and Quantitative Imaging Center, Boston, Massachusetts
| | | | - Jeffrey N Katz
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - C Kent Kwoh
- University of Arizona College of Medicine, Tucson
| | | | - David J Hunter
- Royal North Shore Hospital, Kolling Institute of Medical Research, and University of Sydney, New South Wales, Sydney, Australia
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15
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Abstract
With technologic advances and the availability of sophisticated computer software and analytical strategies, imaging plays an increasingly important role in understanding the disease process of osteoarthritis (OA). Radiography has limitations in that it can visualize only limited features of OA, such as osteophytes and joint space narrowing, but remains the most commonly used modality for establishing an imaging-based diagnosis of OA. This article describes the roles and limitations of different imaging modalities and discusses the optimum imaging protocol, imaging diagnostic criteria of OA, differential diagnoses, and what the referring physician needs to know.
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16
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Nielsen FK, Egund N, Jørgensen A, Peters DA, Jurik AG. Assessment of subchondral bone marrow lesions in knee osteoarthritis by MRI: a comparison of fluid sensitive and contrast enhanced sequences. BMC Musculoskelet Disord 2016; 17:479. [PMID: 27852298 PMCID: PMC5112734 DOI: 10.1186/s12891-016-1336-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 11/09/2016] [Indexed: 01/29/2023] Open
Abstract
Background Bone marrow lesions (BMLs) in knee osteoarthritis (OA) can be assessed using fluid sensitive and contrast enhanced sequences. The association between BMLs and symptoms has been investigated in several studies but only using fluid sensitive sequences. Our aims were to assess BMLs by contrast enhanced MRI sequences in comparison with a fluid sensitive STIR sequence using two different segmentation methods and to analyze the association between the MR findings and disability and pain. Methods Twenty-two patients (mean age 61 years, range 41–79 years) with medial femoro-tibial knee OA obtained MRI and filled out a WOMAC questionnaire at baseline and follow-up (median interval of 334 days). STIR, dynamic contrast enhanced-MRI (DCE-MRI) and fat saturated T1 post-contrast (T1 CE FS) MRI sequences were obtained. All STIR and T1 CE FS sequences were assessed independently by two readers for STIR-BMLs and contrast enhancing areas of BMLs (CEA-BMLs) using manual segmentation and computer assisted segmentation, and the measurements were compared. DCE-MRIs were assessed for the relative distribution of voxels with an inflammatory enhancement pattern, Nvoxel, in the bone marrow. All findings were compared to WOMAC scores, including pain and overall symptoms, and changes from baseline to follow-up were analyzed. Results The average volume of CEA-BML was smaller than the STIR-BML volume by manual segmentation. The opposite was found for computer assisted segmentation where the average CEA-BML volume was larger than the STIR-BML volume. The contradictory finding by computer assisted segmentation was partly caused by a number of outliers with an apparent generally increased signal intensity in the anterior parts of the femoral condyle and tibial plateau causing an overestimation of the CEA-BML volume. Both CEA-BML, STIR-BML and Nvoxel were significantly correlated with symptoms and to a similar degree. A significant reduction in total WOMAC score was seen at follow-up, but no significant changes were observed for either CEA-BML, STIR-BML or Nvoxel. Conclusions Neither the degree nor the volume of contrast enhancement in BMLs seems to add any clinical information compared to BMLs visualized by fluid sensitive sequences. Manual segmentation may be needed to obtain valid CEA-BML measurements. Electronic supplementary material The online version of this article (doi:10.1186/s12891-016-1336-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Flemming K Nielsen
- Department of Radiology, Aarhus University Hospital, Noerrebrogade 44, 8000, Aarhus, Denmark.
| | - Niels Egund
- Department of Radiology, Aarhus University Hospital, Noerrebrogade 44, 8000, Aarhus, Denmark
| | - Anette Jørgensen
- Department of Rheumatology, Aarhus University Hospital, Noerrebrogade 44, 8000, Aarhus, Denmark
| | - David A Peters
- Department of Biomedical Engineering, Aarhus University Hospital, Noerrebrogade 44, 8000, Aarhus, Denmark
| | - Anne Grethe Jurik
- Department of Radiology, Aarhus University Hospital, Noerrebrogade 44, 8000, Aarhus, Denmark
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17
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Duryea J, Cheng C, Schaefer L, Smith S, Madore B. Integration of accelerated MRI and post-processing software: a promising method for studies of knee osteoarthritis. Osteoarthritis Cartilage 2016; 24:1905-1909. [PMID: 27296293 PMCID: PMC7608695 DOI: 10.1016/j.joca.2016.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 04/30/2016] [Accepted: 06/04/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Magnetic resonance imaging (MRI) is a widely used imaging modality for studies of knee osteoarthritis (OA). Compared to radiography, MRI offers exceptional soft tissue imaging and true three-dimensional (3D) visualization. However, MRI is expensive both due to the cost of acquisition and evaluation of the images. The goal of our study is to develop a new method to address the cost of MRI by combining innovative acquisition methods and automated post-processing software. METHODS Ten healthy volunteers were scanned with three different MRI protocols: A standard 3D dual-echo steady state (DESS) pulse sequence, an accelerated DESS (DESSAcc), acquired at approximately half the time compared to DESS, and a multi-echo time DESS (DESSMTE), which is capable of producing measurements of T2 relaxation time. A software tool was used to measure cartilage volume. Accuracy was quantified by comparing DESS to DESSAcc and DESSMTE and precision was measured using repeat readings and acquisitions. T2 precision was determined using duplicate DESSMTE acquisitions. Intra-class correlation coefficients (ICCs), root-mean square standard deviation (RMSSD), and the coefficient of variation (CoV) were used to quantify accuracy and precision. RESULTS The accuracies of DESSAcc and DESSMTE were CoV = 3.7% and CoV = 6.6% respectively, while precision was 3.8%, 3.0%, and 3.1% for DESS, DESSAcc and DESSMTE. T2 repositioning precision was 5.8%. CONCLUSION The results demonstrate that accurate and precise quantification of cartilage volume is possible using a combination of substantially faster MRI acquisition and post-processing software. Precise measurements of cartilage T2 and volume can be made using the same acquisition.
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Affiliation(s)
- J. Duryea
- Address correspondence and reprint requests to: J.
Duryea, Radiology, Brigham and Women’s Hospital, Harvard Medical School,
75 Francis Street, Boston, MA 02115, USA,
(J. Duryea)
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18
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Ruoff CM, Eichelberger BM, Pool RR, Griffin JF, Cummings KJ, Pozzi A, Padua A, Saunders WB. THE USE OF SMALL FIELD-OF-VIEW 3 TESLA MAGNETIC RESONANCE IMAGING FOR IDENTIFICATION OF ARTICULAR CARTILAGE DEFECTS IN THE CANINE STIFLE: AN EX VIVO CADAVERIC STUDY. Vet Radiol Ultrasound 2016; 57:601-610. [PMID: 27629105 DOI: 10.1111/vru.12420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 06/29/2016] [Accepted: 07/30/2016] [Indexed: 11/28/2022] Open
Abstract
Noninvasive identification of canine articular cartilage injuries is challenging. The objective of this prospective, cadaveric, diagnostic accuracy study was to determine if small field-of-view, three tesla magnetic resonance imaging (MRI) was an accurate method for identifying experimentally induced cartilage defects in canine stifle joints. Forty-two canine cadaveric stifles (n = 6/group) were treated with sham control, 0.5, 1.0, or 3.0 mm deep defects in the medial or lateral femoral condyle. Proton density-weighted, T1-weighted, fast-low angle shot, and T2 maps were generated in dorsal and sagittal planes. Defect location and size were independently determined by two evaluators and compared to histologic measurements. Accuracy of MRI was determined using concordance correlation coefficients. Defects were identified correctly in 98.8% (Evaluator 1) and 98.2% (Evaluator 2) of joints. Concordance correlation coefficients between MRI and histopathology were greater for defect depth (Evaluator 1: 0.68-0.84; Evaluator 2: 0.76-0.83) compared to width (Evaluator 1: 0.30-0.54; Evaluator 2: 0.48-0.68). However, MRI overestimated defect depth (histopathology: 1.65 ± 0.94 mm; Evaluator 1, range of means: 2.07-2.38 mm; Evaluator 2, range of means: 2-2.2 mm) and width (histopathology: 6.98 ± 1.32 mm; Evaluator 1, range of means: 8.33-8.8 mm; Evaluator 2, range of means: 6.64-7.16 mm). Using the paired t-test, the mean T2 relaxation time of cartilage defects was significantly greater than the mean T2 relaxation time of adjacent normal cartilage for both evaluators (P < 0.0001). Findings indicated that MRI is an accurate method for identifying cartilage defects in the cadaveric canine stifle. Additional studies are needed to determine the in vivo accuracy of this method.
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Affiliation(s)
- Catherine M Ruoff
- Department of Large Animal Clinical Sciences, Texas A&M University, College Station, TX, 77843.
| | - Bunita M Eichelberger
- Department of Large Animal Clinical Sciences, Texas A&M University, College Station, TX, 77843
| | - Roy R Pool
- Department of Veterinary Pathobiology, Texas A&M University, College Station, TX, 77843
| | - John F Griffin
- Department of Large Animal Clinical Sciences, Texas A&M University, College Station, TX, 77843
| | - Kevin J Cummings
- Department of Veterinary Integrative Biosciences, Texas A&M University, College Station, TX, 77843
| | - Antonio Pozzi
- Department of Small Animal Clinical Sciences, University of Zurich, 8057 Zurich, Switzerland
| | - Abraham Padua
- Siemens Research and Development, Houston, TX, 77095
| | - W Brian Saunders
- Department of Small Animal Clinical Sciences, Texas A&M University, College Station, TX, 77843
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19
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Muratovic D, Cicuttini F, Wluka A, Findlay D, Wang Y, Otto S, Taylor D, Humphries J, Lee Y, Labrinidis A, Williams R, Kuliwaba J. Bone marrow lesions detected by specific combination of MRI sequences are associated with severity of osteochondral degeneration. Arthritis Res Ther 2016; 18:54. [PMID: 26912313 PMCID: PMC4766616 DOI: 10.1186/s13075-016-0953-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 02/09/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Bone marrow lesions (BMLs) are useful diagnostic and prognostic markers in knee osteoarthritis (OA), but what they represent at the tissue level remains unclear. The aim of this study was to provide comprehensive tissue characterization of BMLs detected using two specific MRI sequences. METHODS Tibial plateaus were obtained from 60 patients (29 females, 31 males), undergoing knee arthroplasty for OA. To identify BMLs, MRI was performed ex vivo using T1 and PDFS-weighted sequences. Multi-modal tissue level analyses of the osteochondral unit (OCU) were performed, including cartilage volume measurement, OARSI grading, micro-CT analysis of bone microstructure, routine histopathological assessment and quantitation of bone turnover indices. RESULTS BMLs were detected in 74 % of tibial plateaus, the remainder comprising a No BML group. Of all BMLs, 59 % were designated BML 1 (detected only by PDFS) and 41 % were designated BML 2 (detected by both PDFS + T1). The presence of a BML was related to degeneration of the OCU, particularly within BML 2. When compared to No BML, BML 2 showed reduced cartilage volume (p = 0.008), higher OARSI scores (p = 0.004), thicker subchondral plate (p = 0.002), increased trabecular bone volume and plate-like structure (p = 0.0004), increased osteoid volume (p = 0.002) and thickness (p = 0.003), more bone marrow oedema (p = 0.03), fibrosis (p = 0.002), necrosis (p = 0.01) and fibrovascular cysts (p = 0.04). For most measures, BML 1 was intermediate between No BML and BML 2. CONCLUSIONS BMLs detected by specific MRI sequences identify different degrees of degeneration in the OCU. This suggests that MRI characteristics of BMLs may enable identification of different BML phenotypes and help target novel approaches to treatment and prevention of OA.
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Affiliation(s)
- Dzenita Muratovic
- Discipline of Orthopaedics and Trauma, The University of Adelaide, Adelaide, Australia. .,Bone and Joint Research Laboratory, SA Pathology, Frome Road, Adelaide, 5000, Australia.
| | - Flavia Cicuttini
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia.
| | - Anita Wluka
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia.
| | - David Findlay
- Discipline of Orthopaedics and Trauma, The University of Adelaide, Adelaide, Australia.
| | - Yuanyuan Wang
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia.
| | - Sophia Otto
- Anatomical Pathology, SA Pathology, Adelaide, Australia.
| | - David Taylor
- Department of Radiology, Royal Adelaide Hospital, Adelaide, Australia.
| | - Julia Humphries
- Bone and Joint Research Laboratory, SA Pathology, Frome Road, Adelaide, 5000, Australia.
| | - Yearin Lee
- Bone and Joint Research Laboratory, SA Pathology, Frome Road, Adelaide, 5000, Australia.
| | - Agatha Labrinidis
- Adelaide Microscopy, The University of Adelaide, Adelaide, Australia.
| | - Ruth Williams
- Adelaide Microscopy, The University of Adelaide, Adelaide, Australia.
| | - Julia Kuliwaba
- Discipline of Orthopaedics and Trauma, The University of Adelaide, Adelaide, Australia. .,Bone and Joint Research Laboratory, SA Pathology, Frome Road, Adelaide, 5000, Australia.
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20
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Conventional and novel imaging modalities in osteoarthritis: current state of the evidence. Curr Opin Rheumatol 2015; 27:295-303. [PMID: 25803224 DOI: 10.1097/bor.0000000000000163] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Imaging modalities are currently an inseparable part of osteoarthritis diagnosis. In this review, we describe the current state of evidence regarding conventional and novel imaging modalities in evaluation of osteoarthritis. Modalities including radiography (qualitative and semi-quantitative assessments), ultrasonography, computed tomography [CT; conventional multidetector CT (MDCT), cone-beam CT (CBCT) and four-dimensional CT (4DCT)], MRI (MRI; semi-quantitative, quantitative and compositional) and PET and their applications are reviewed. RECENT FINDINGS Radiography is the modality of choice for initial assessment of osteoarthritis. However, due to its low sensitivity and specificity, numerous recent investigations have proposed MRI as a powerful addition to detect and grade osteoarthritis features, which are not apparent in radiography. Semi-quantitative MRI measurements are feasible to perform in routine clinical practice. Quantitative and compositional MRI measurements have extended the amount of information an MRI examination can provide regarding the three-dimensional shape and tissue composition of articular cartilage. 4DCT and CBCT are introduced as imaging examinations that may reveal biomechanical cartilage abnormalities in osteoarthritis joint by dynamic and weight-bearing evaluations, respectively. Recent PET studies may unveil the underlying metabolic activities that can be associated with osteoarthritis. SUMMARY In addition to the established role of radiographs, MRI is the advanced modality of choice for detection and quantification of various osteoarthritis features. 4DCT and CBCT may have specified applications when diagnosis of underlying motion abnormality or dynamic changes in weight-bearing situation is suspected. Future studies should elucidate the specific clinical applications of ultrasonography and PET.
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21
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Hakky M, Jarraya M, Ratzlaff C, Guermazi A, Duryea J. Validity and responsiveness of a new measure of knee osteophytes for osteoarthritis studies: data from the osteoarthritis initiative. Osteoarthritis Cartilage 2015; 23:2199-2205. [PMID: 26187573 DOI: 10.1016/j.joca.2015.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 06/03/2015] [Accepted: 07/07/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To validate a novel quantitative MRI method to measure osteophyte volume. METHODS 90 subjects were selected from the Progression Cohort of the Osteoarthritis Initiative (OAI) at baseline and 48 months, and analyzed using a semi-automated software tool. Marginal osteophyte volume was calculated for four compartments of the central weight-bearing region of the tibiofemoral joint. Standardized response mean (SRM) for change in volume was used to quantify responsiveness. Concurrent validity was assessed via a comparison with MRI Osteoarthritis Knee Score (MOAKS) using Kruskal-Wallis analysis and Spearman's correlation coefficient. Intra- and inter-reader reliability was assessed on a subset of 20 knees using intra-class correlation coefficients (ICCs) and the root mean square standard deviation (RMSSD). RESULTS The average change in osteophyte volume (ΔV) was 196 mm(3) (SD = 272 mm(3)), and the baseline to 48-month SRM was 0.72. An increase in osteophyte volume was observed for 84% (76/90) of the subjects. Kruskal-Wallis analysis across the four MOAKS osteophyte categories was significant for medial and lateral compartments of both the tibia and femur (P < 0.001 for all). The intra-reader ICC was 0.98, and RMSSD was 82 mm(3), while inter-reader ICC was 0.97 and RMSSD was 91 mm(3). A statistically significant positive correlation was observed between osteophyte volume and several MOAKS cartilage and BML scores. The reader time was approximately 10 min per knee. CONCLUSIONS The method is responsive, efficient, and precise, making it practical for use in large cohort studies and observational research.
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Affiliation(s)
- M Hakky
- Lahey Hospital and Medical Center, Burlington MA, USA
| | - M Jarraya
- Boston University Medical Center, Boston MA, USA; Mercy Catholic Medical Center, Darby PA, USA
| | - C Ratzlaff
- Brigham and Women's Hospital, Boston MA, USA
| | - A Guermazi
- Boston University Medical Center, Boston MA, USA
| | - J Duryea
- Brigham and Women's Hospital, Boston MA, USA.
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Nielsen FK, Egund N, Peters D, Jurik AG. Measurement of bone marrow lesions by MR imaging in knee osteoarthritis using quantitative segmentation methods--a reliability and sensitivity to change analysis. BMC Musculoskelet Disord 2014; 15:447. [PMID: 25528153 PMCID: PMC4364568 DOI: 10.1186/1471-2474-15-447] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 12/16/2014] [Indexed: 12/27/2022] Open
Abstract
Background Longitudinal assessment of bone marrow lesions (BMLs) in knee osteoarthritis (KOA) by MRI is usually performed using semi-quantitative grading methods. Quantitative segmentation methods may be more sensitive to detect change over time. The purpose of this study was to evaluate and compare the validity and sensitivity to detect changes of two quantitative MR segmentation methods for measuring BMLs in KOA, one computer assisted (CAS) and one manual (MS) method. Methods Twenty-two patients with KOA confined to the medial femoro-tibial compartment obtained MRI at baseline and follow-up (median 334 days in between). STIR, T1 and fat saturated T1 post-contrast sequences were obtained using a 1.5 T system. The 44 sagittal STIR sequences were assessed independently by two readers for quantification of BML. The signal intensities (SIs) of the normal bone marrow in the lateral femoral condyles and tibial plateaus were used as threshold values. The volume of bone marrow with SIs exceeding the threshold values (BML) was measured in the medial femoral condyle and tibial plateau and related to the total volume of the condyles/plateaus. The 95% limits of agreement at baseline were used to determine the sensitivity to change. Results The mean threshold values of CAS and MS were almost identical but the absolute and relative BML volumes differed being 1319 mm3/10% and 1828 mm3/15% in the femur and 941 mm3/7% and 2097 mm3/18% in the tibia using CAS and MS, respectively. The BML volumes obtained by CAS and MS were significantly correlated but the tissue changes measured were different. The volume of voxels exceeding the threshold values was measured by CAS whereas MS included intervening voxels with normal SI. The 95% limits of agreement were narrower by CAS than by MS; a significant change of relative BML by CAS was outside the limits of -2.0%-4.7% whereas the limits by MS were -6.9%-8.2%. The BML changed significantly in 13 knees using CAS and in 10 knees by MS. Conclusion CAS was a reliable method for measuring BML and more sensitive to detect changes over time than MS. The BML volumes measured by the two methods differed but were significantly correlated. Electronic supplementary material The online version of this article (doi:10.1186/1471-2474-15-447) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | - Anne Grethe Jurik
- Department of Radiology, Aarhus University Hospital, Noerrebrogade 44, 8000 Aarhus, Denmark.
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Driban JB, Price L, Lo GH, Pang J, Hunter DJ, Miller E, Ward RJ, Eaton CB, Lynch JA, McAlindon TE. Evaluation of bone marrow lesion volume as a knee osteoarthritis biomarker--longitudinal relationships with pain and structural changes: data from the Osteoarthritis Initiative. Arthritis Res Ther 2014; 15:R112. [PMID: 24020939 PMCID: PMC3978948 DOI: 10.1186/ar4292] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 04/15/2013] [Accepted: 09/10/2013] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Bone marrow lesion (BML) size may be an important imaging biomarker for osteoarthritis-related clinical trials and reducing BML size may be an important therapeutic goal. However, data on the interrelationships between BML size, pain, and structural progression are inconsistent and rarely examined in the same cohort. Therefore, we evaluated the cross-sectional and longitudinal associations of BML volume with knee pain and joint space narrowing (JSN). METHODS A BML volume assessment was performed on magnetic resonance images of the knee collected at the 24- and 48-month Osteoarthritis Initiative visits from a convenience sample of 404 participants in the progression cohort. During the same visits, knee pain was assessed with WOMAC pain scores and knee radiographs were acquired and scored for JSN. BML volume was summed to generate a total knee volume and an index tibiofemoral compartment volume (compartment with greater baseline JSN). Primary analyses included multiple linear regressions (outcome = pain, predictor = total knee BML volume) and logistic regressions (outcome = JSN, predictor = index tibiofemoral compartment BML volume). RESULTS This sample was 49% female with a mean age of 63 (9.2 standard deviation (SD)) years, and 71% had radiographic osteoarthritis in the study knee. Larger baseline BMLs were associated with greater baseline knee pain (P = 0.01), the presence of JSN at baseline (odds ratio (OR) = 1.50, 95% confidence interval (CI) = 1.23 to 1.83), and JSN progression (OR = 1.27, 95%CI = 1.11 to 1.46). Changes in total knee BML volume had a positive association with changes in knee pain severity (P = 0.004) and this association may be driven by knees that were progressing from no or small baseline BMLs to larger BMLs. In contrast, we found no linear positive relationship between BML volume change and JSN progression. Instead, regression of medial tibiofemoral BML volume was associated with JSN progression compared to knees with no or minimal changes in BML volume (OR = 3.36, 95%CI = 1.55 to 7.28). However, follow-up analyses indicated that the association between JSN progression and BML volume change may primarily be influenced by baseline BML volume. CONCLUSION Large baseline BMLs are associated with greater baseline knee pain, the presence of JSN at baseline, and disease progression. Additionally, BML regression is associated with decreased knee pain but not a reduced risk of concurrent JSN progression.
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Roemer FW, Eckstein F, Hayashi D, Guermazi A. The role of imaging in osteoarthritis. Best Pract Res Clin Rheumatol 2014; 28:31-60. [PMID: 24792944 DOI: 10.1016/j.berh.2014.02.002] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Osteoarthritis (OA) is the most prevalent joint disorder with no approved disease-modifying treatment available. The importance of imaging in assessing all joint structures involved in the disease process, including articular cartilage, meniscus, subarticular bone marrow, and synovium for diagnosis, prognostication, and follow-up, has been well recognized. In daily clinical practice, conventional radiography is still the most commonly used imaging technique for the evaluation of a patient with known or suspected OA and radiographic outcome measures are still the only approved end point by regulatory authorities in clinical trials. The ability of magnetic resonance imaging (MRI) to visualize all joint structures in three-dimensional fashion including tissue ultrastructure has markedly deepened our understanding of the natural history of the disease. This article describes the roles and limitations of different imaging modalities for clinical practice and research in OA, with a focus on radiography and MRI and an emphasis on the knee joint.
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Affiliation(s)
- Frank W Roemer
- Department of Radiology, Quantitative Imaging Center (QIC), Boston University School of Medicine, 820 Harrison Avenue, FGH Building, 3rd Floor, Boston, MA 02118, USA; Department of Radiology, University of Erlangen-Nuremberg, Maximiliansplatz 1, 91054 Erlangen, Germany; Department of Radiology, Klinikum Augsburg, Augsburg, Stenglinstr 2, 86156 Augsburg, Germany.
| | - Felix Eckstein
- Institute of Anatomy, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria.
| | - Daichi Hayashi
- Department of Radiology, Quantitative Imaging Center (QIC), Boston University School of Medicine, 820 Harrison Avenue, FGH Building, 3rd Floor, Boston, MA 02118, USA; Department of Radiology, Bridgeport Hospital, Yale University School of Medicine, 267 Grant Street, Bridgeport, CT 06610, USA.
| | - Ali Guermazi
- Department of Radiology, Quantitative Imaging Center (QIC), Boston University School of Medicine, 820 Harrison Avenue, FGH Building, 3rd Floor, Boston, MA 02118, USA.
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Roemer FW, Guermazi A, Trattnig S, Apprich S, Marlovits S, Niu J, Hunter DJ, Welsch GH. Whole joint MRI assessment of surgical cartilage repair of the knee: cartilage repair osteoarthritis knee score (CROAKS). Osteoarthritis Cartilage 2014; 22:779-99. [PMID: 24685525 DOI: 10.1016/j.joca.2014.03.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 12/23/2013] [Accepted: 03/19/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To develop a magnetic resonance imaging (MRI) scoring system for follow-up of knee cartilage repair procedures integrating assessment of the repair site and the whole joint called Cartilage Repair OsteoArthritis Knee Score (CROAKS), and to assess its reliability. DESIGN MRI examinations of 20 patients that had undergone matrix-associated autologous chondrocyte transplantation (MACT) of the knee 12 months before were semi-quantitatively assessed for the repair site using features of the magnetic resonance observation of cartilage repair tissue (MOCART) system and for the whole joint based on experiences with the MRI Osteoarthritis Knee Score (MOAKS) instrument. Intra- and inter-observer reliability was calculated using weighted (w) kappa statistics for plates (medial/lateral tibia, medial/lateral femur, trochlea, patella), compartments (medial tibio-femoral, lateral tibio-femoral, patello-femoral) and the whole joint. For certain features with low prevalence the overall percent agreement was calculated in addition. RESULTS For cartilage, reliability on a plate level ranged between 0.48 (lateral femur) and 1.00 (medial femur). BML assessment showed comparable results ranging on a plate level between 0.46 and 1.00 with overall percent agreement between 83.3% and 100%. Meniscal morphology assessment ranged between 0.62 and 0.94. For repair site assessment reliability ranged from 0.41 (signal intensity inter-observer) to 1.00 (several features). Overall percent agreement was above 80% for 17 of 22 features assessed (intra- and inter-observer results combined). CONCLUSIONS Combined scoring of the repair site and whole joint assessment for common osteoarthritis features using CROAKS, which is based on experience with two established semi-quantitative scoring tools, is feasible and may be performed with good to excellent reliability.
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Affiliation(s)
- F W Roemer
- Department of Radiology, University of Erlangen-Nuremberg, Erlangen, Germany; Quantitative Imaging Center (QIC), Department of Radiology, Boston University School of Medicine, Boston, MA, USA.
| | - A Guermazi
- Quantitative Imaging Center (QIC), Department of Radiology, Boston University School of Medicine, Boston, MA, USA
| | - S Trattnig
- MR Center of Excellence, Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - S Apprich
- MR Center of Excellence, Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - S Marlovits
- Department of Traumatology, Medical University of Vienna, Vienna, Austria
| | - J Niu
- Clinical Epidemiology Training and Research Unit, Boston University School of Medicine, Boston, MA, USA
| | - D J Hunter
- Institute of Bone and Joint Research and Kolling Institute, University of Sydney, Sydney, Australia
| | - G H Welsch
- Department of Trauma Surgery, University of Erlangen-Nuremberg, Erlangen, Germany.
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Ratzlaff C, Guermazi A, Collins J, Katz JN, Losina E, Vanwyngaarden C, Russell R, Iranpour T, Duryea J. A rapid, novel method of volumetric assessment of MRI-detected subchondral bone marrow lesions in knee osteoarthritis. Osteoarthritis Cartilage 2013; 21:806-14. [PMID: 23518154 PMCID: PMC3701435 DOI: 10.1016/j.joca.2013.03.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 02/13/2013] [Accepted: 03/08/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess reliability and validity of a semi-automated quantitative method for osteoarthritis (OA)-related bone marrow lesion (BML) assessment in the femur and tibia. METHODS In a cross-sectional study of subjects with knee OA, we examined concurrent criterion and clinical validation of a novel method of semi-automated quantitative BML measurement. The primary outcome was total segmented BML volume in femoral and tibial medial and lateral knee compartments. Criterion validation was examined through comparison of BML volumes with Whole-Organ Magnetic Resonance Imaging Score (WORMS) scoring. Clinical validation was examined via associations of tibial and femoral BML volume with the Western Ontario and McMaster University OA Index weight-bearing pain questions. RESULTS Among the 115 subjects, mean age was 62 years, mean BMI 30.4 (kg/m(2)), 84% were white and 52% male. The intra-class correlation coefficients (ICC) for intra-reader reliability was 0.96 and 0.97 for inter-reader reliability. Significant Spearman's correlations were found between segmented BML volume and WORMS BML scoring for tibial medial (0.75) and lateral (0.73) compartments, and for femoral medial (0.72) and lateral (0.88) compartments. Significant positive associations were found between weight-bearing pain and total femoral BML volume (P < 0.003), but not total tibial BML (P < 0.101). CONCLUSION We have documented a moderately strong correlation between a novel measurement method of femoral and tibial BML volume and semi-quantitative WORMS scores, providing evidence of criterion validity. The hypothesis that weight-bearing pain was associated with BML volume was confirmed for total femoral BML volume but not total tibial BML volume. The lack of association between tibial BML volume and pain requires further investigation.
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Affiliation(s)
- C Ratzlaff
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA 2115, USA.
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Osteoarthritis: a review of strengths and weaknesses of different imaging options. Rheum Dis Clin North Am 2013; 39:567-91. [PMID: 23719076 DOI: 10.1016/j.rdc.2013.02.001] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Slowing of radiographic joint space narrowing represents the only recommended imaging-based outcome measure to assess structural disease progression in osteoarthritis (OA) clinical trials. There are no effective disease-modifying OA drugs. The ability of magnetic resonance (MR) to image structures within the knee and to visualize cartilage morphology and composition gives MR imaging a critical role in understanding the natural history of the disease and in the search for therapies. In this article, the roles and limitations of conventional radiography and MR imaging, focusing on knee OA, and the use of other modalities in clinical practice and OA research are described.
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Guermazi A, Hayashi D, Eckstein F, Hunter DJ, Duryea J, Roemer FW. Imaging of Osteoarthritis. Rheum Dis Clin North Am 2013; 39:67-105. [DOI: 10.1016/j.rdc.2012.10.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Pang J, Driban JB, Destenaves G, Miller E, Lo GH, Ward RJ, Price LL, Lynch JA, Eaton CB, Eckstein F, McAlindon TE. Quantification of bone marrow lesion volume and volume change using semi-automated segmentation: data from the osteoarthritis initiative. BMC Musculoskelet Disord 2013; 14:3. [PMID: 23281825 PMCID: PMC3637109 DOI: 10.1186/1471-2474-14-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 12/23/2012] [Indexed: 11/28/2022] Open
Abstract
Background To determine the validity of a semi-automated segmentation of bone marrow lesions (BMLs) in the knee. Methods Construct validity of the semi-automated BML segmentation method was explored in two studies performed using sagittal intermediate weighted, turbo spine echo, fat-suppressed magnetic resonance imaging sequences obtained from the Osteoarthritis Initiative. The first study (n = 48) evaluated whether tibia BML volume was different across Boston Leeds Osteoarthritis Knee Scores (BLOKS) for tibia BMLs (semiquantitative grades 0 to 3). In the second study (n = 40), we evaluated whether BML volume change was associated with changes in cartilage parameters. The knees in both studies were segmented by one investigator. We performed Wilcoxon signed-rank tests to determine if tibia BML volume was different between adjacent BLOKS BML scores and calculated Spearman correlation coefficients to assess the relationship between 2-year BML volume change and 2-year cartilage morphometry change (significance was p ≤ 0.05). Results BML volume was significantly greater between BLOKS BML score 0 and 1 (z = 2.85, p = 0.004) and BLOKS BML scores 1 and 2 (z = 3.09, p = 0.002). There was no significant difference between BLOKS BML scores 2 and 3 (z = −0.30, p = 0.77). Increased tibia BML volume was significantly related to increased tibia denuded area (Spearman r = 0.42, p = 0.008), decreased tibia cartilage thickness (Spearman r = −0.46, p = 0.004), increased femur denuded area (Spearman r = 0.35, p = 0.03), and possibly decreased femur cartilage thickness (Spearman r = −0.30, p = 0.07) but this last finding was not statistically significant. Conclusion The new, efficient, and reliable semi-automated BML segmentation method provides valid BML volume measurements that increase with greater BLOKS BML scores and confirms previous reports that BML size is associated with longitudinal cartilage loss.
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Affiliation(s)
- Jincheng Pang
- Department of Electrical and Computer Engineering, Tufts University, 216 Halligan Hall, Medford, MA 02155, USA
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Felson D, Parkes M, Marjanovic E, Callaghan M, Gait A, Cootes T, Lunt M, Oldham J, Hutchinson C. Bone marrow lesions in knee osteoarthritis change in 6-12 weeks. Osteoarthritis Cartilage 2012; 20:1514-8. [PMID: 22944524 PMCID: PMC3526790 DOI: 10.1016/j.joca.2012.08.020] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Revised: 07/12/2012] [Accepted: 08/22/2012] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Knee osteoarthritis (OA) is thought to be a slowly evolving disease with glacial changes in cartilage morphology necessitating trials of potential treatments lasting 1-2 years with evidence that over 6 months change in cartilage is not detectable. In contrast to cartilage, bone has the capacity to adapt rapidly, such as after fracture. We tested whether bone marrow lesions (BMLs) change in volume in 6 and 12 weeks, suggesting they may provide evidence of short term fluctuations of joint damage. METHODS In 62 patients with patellofemoral knee OA (mean age 55.7 years, 59.7% women, mean BMI 31.0), we obtained baseline, 6 and 12 week knee MRIs with contrast enhancement. Of those with BMLs at baseline, we assessed BML volume on the axial proton density fat saturated (FS) images and postcontrast sagittal T1 weighted FS images. We manually segmented BML volumes, testing repeatability of BML volumes in knees remeasured. Using the standard deviation of the difference between repeated measurements to calculate Bland-Altman Limits of Agreement, we determined how much BML volume change represented a change greater than due to chance. RESULTS Fifty-two patients had BMLs at baseline. Test-retest reliability for BML volume was high (ICC 0.89, 95% CI 0.80-0.97). All knees showed at least some change in BML volume by 6 and 12 weeks. On the axial view at 6 weeks, 20/49 (40.8%) knees showed BML volume changes greater than the limits of agreement with similar results at 12 weeks. BML changes were evenly divided among knees with enlarging and shrinking BMLs. 63.3% of the knees had more than 50% change in BML volume at either 6 or 12 weeks on the axial view and 48.7% on the sagittal view. CONCLUSIONS Knee BML volumes change in several weeks in many persons with knee OA. To the extent that they could be regarded as treatment targets, trials testing BML effects could avoid the usual prolonged structure modification trials.
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Affiliation(s)
- D.T. Felson
- Address correspondence and reprint requests to: D.T. Felson, Arthritis Research UK Epidemiology Unit, University of Manchester, Manchester, UK.
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Driban JB, Tassinari A, Lo GH, Price LL, Schneider E, Lynch JA, Eaton CB, McAlindon TE. Bone marrow lesions are associated with altered trabecular morphometry. Osteoarthritis Cartilage 2012; 20:1519-26. [PMID: 22940708 PMCID: PMC3478500 DOI: 10.1016/j.joca.2012.08.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 08/07/2012] [Accepted: 08/22/2012] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Bone marrow lesions (BMLs) are a common magnetic resonance (MR) feature in patients with osteoarthritis, however their pathological basis remains poorly understood and has not been evaluated in vivo. Our aim was to evaluate the trabecular structure associated with the presence and size of BMLs present in the same regions of interest (ROI) using quantitative MR-based trabecular morphometry. DESIGN 158 participants in the Osteoarthritis Initiative (OAI) were imaged with a coronal 3D fast imaging with steady state precession (FISP) sequence for trabecular morphometry in the same session as the OAI 3 T MR knee evaluation. The proximal medial tibial subchondral bone in the central weight-bearing ROI on these knee 3D FISP images were quantitatively evaluated for apparent bone volume fraction, trabecular number, spacing, and thickness. BMLs were also evaluated in the subchondral bone immediately adjacent to the articular cartilage. BML volume was also evaluated within the same trabecular morphometry ROI and semi-quantitatively classified as none, small, or large. Kruskal-Wallis test was used to determine if mean apparent bone volume fraction, trabecular number, spacing, or thickness differed by BML score. RESULTS Compared to knees with ROIs containing no BMLs, knees with small or large BMLs had statistically higher apparent bone volume fraction (P < 0.01), trabecular number (P < 0.01), and thickness (P = 0.02), and lower trabecular spacing (P < 0.01). CONCLUSIONS Compared to knees with ROIs containing no BMLs, knees with ROIs containing small or large BMLs had higher apparent bone volume fraction, trabecular number and thickness, but lower trabecular spacing. These findings may represent areas of locally increased bone remodeling or compression.
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Affiliation(s)
- Jeffrey B Driban
- Division of Rheumatology, Tufts Medical Center, 800 Washington Street, Box #406, Boston, MA 02111
| | - Anna Tassinari
- Division of Rheumatology, Tufts Medical Center, 800 Washington Street, Box #406, Boston, MA 02111
| | - Grace H Lo
- Medical Care Line and Research Care Line; Houston Health Services Research and Development (HSR&D) Center of Excellence Michael E. DeBakey VAMC, Houston, TX. Section of Immunology, Allergy, and Rheumatology, Baylor College of Medicine, Houston, TX. 1 Baylor Plaza, BCM-285, Houston, TX 77030
| | - Lori Lyn Price
- Biostatistics Research Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street, Box #63, Boston, MA 02111
| | - Erika Schneider
- Imaging Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue HB6, Cleveland, OH 44195
| | - John A Lynch
- Department of Epidemiology and Biostatistics, University of California at San Francisco, 185 Berry Street, Lobby 5, Suite 5700, San Francisco, CA 94107
| | - Charles B. Eaton
- Departments of Family Medicine and Epidemiology, Alpert Medical School of Brown University, Center for Primary Care and Prevention, Second Floor, Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI 02864
| | - Timothy E. McAlindon
- Division of Rheumatology, Tufts Medical Center, 800 Washington Street, Box #406, Boston, MA 02111
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Hunter DJ, Guermazi A. Imaging Techniques in Osteoarthritis. PM R 2012; 4:S68-74. [DOI: 10.1016/j.pmrj.2012.02.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 02/01/2012] [Indexed: 10/28/2022]
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Xu L, Hayashi D, Roemer FW, Felson DT, Guermazi A. Magnetic resonance imaging of subchondral bone marrow lesions in association with osteoarthritis. Semin Arthritis Rheum 2012; 42:105-18. [PMID: 22542276 DOI: 10.1016/j.semarthrit.2012.03.009] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 03/13/2012] [Accepted: 03/18/2012] [Indexed: 01/16/2023]
Abstract
OBJECTIVES This nonsystematic literature review provides an overview of magnetic resonance imaging (MRI) of subchondral bone marrow lesions (BMLs) in association with osteoarthritis (OA), with particular attention to the selection of MRI sequences and semiquantitative scoring systems, characteristic morphology, and differential diagnosis. Histologic basis, natural history, and clinical significance are also briefly discussed. METHODS PubMed was searched for articles published up to 2011, using the keywords bone marrow lesion, osteoarthritis, magnetic resonance imaging, bone marrow edema, histology, pain, and subchondral. RESULTS BMLs in association with OA correspond to fibrosis, necrosis, edema, and bleeding of fatty marrow as well as abnormal trabeculae on histopathology. Lesions may fluctuate in size within a short time and are associated with the progression of articular cartilage loss and fluctuation of pain in knee OA. The characteristic subchondral edema-like signal intensity of BMLs should be assessed using T2-weighted, proton density-weighted, intermediate-weighted fat-suppressed fast spin echo or short tau inversion recovery. Several semiquantitative scoring systems are available to characterize and grade the severity of BMLs. Quantitative approaches have also been introduced. Differential diagnoses of degenerative BMLs include a variety of traumatic or nontraumatic pathologies that may appear similar to OA-related BMLs on MRI. CONCLUSIONS Subchondral BMLs are a common imaging feature of OA with clinical significance and typical signal alteration patterns, which can be assessed and graded by semiquantitative scoring systems using sensitive MRI sequences.
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Affiliation(s)
- Li Xu
- Department of Radiology, Boston University School of Medicine, Boston, MA, USA
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Driban JB, Lo GH, Lee JY, Ward RJ, Miller E, Pang J, Price LL, McAlindon TE. Quantitative bone marrow lesion size in osteoarthritic knees correlates with cartilage damage and predicts longitudinal cartilage loss. BMC Musculoskelet Disord 2011; 12:217. [PMID: 21961433 PMCID: PMC3190349 DOI: 10.1186/1471-2474-12-217] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Accepted: 09/30/2011] [Indexed: 11/10/2022] Open
Abstract
Background Bone marrow lesions (BMLs), common osteoarthritis-related magnetic resonance imaging findings, are associated with osteoarthritis progression and pain. However, there are no articles describing the use of 3-dimensional quantitative assessments to explore the longitudinal relationship between BMLs and hyaline cartilage loss. The purpose of this study was to assess the cross-sectional and longitudinal descriptive characteristics of BMLs with a simple measurement of approximate BML volume, and describe the cross-sectional and longitudinal relationships between BML size and the extent of hyaline cartilage damage. Methods 107 participants with baseline and 24-month follow-up magnetic resonance images from a clinical trial were included with symptomatic knee osteoarthritis. An 'index' compartment was identified for each knee defined as the tibiofemoral compartment with greater disease severity. Subsequently, each knee was evaluated in four regions: index femur, index tibia, non-index femur, and non-index tibia. Approximate BML volume, the product of three linear measurements, was calculated for each BML within a region. Cartilage parameters in the index tibia and femur were measured based on manual segmentation. Results BML volume changes by region were: index femur (median [95% confidence interval of the median]) 0.1 cm3 (-0.5 to 0.9 cm3), index tibia 0.5 cm3 (-0.3 to 1.7 cm3), non-index femur 0.4 cm3 (-0.2 to 1.6 cm3), and non-index tibia 0.2 cm3 (-0.1 to 1.2 cm3). Among 44 knees with full thickness cartilage loss, baseline tibia BML volume correlated with baseline tibia full thickness cartilage lesion area (r = 0.63, p< 0.002) and baseline femur BML volume with longitudinal change in femoral full thickness cartilage lesion area (r = 0.48 p< 0.002). Conclusions Many regions had no or small longitudinal changes in approximate BML volume but some knees experienced large changes. Baseline BML size was associated to longitudinal changes in area of full thickness cartilage loss.
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Affiliation(s)
- Jeffrey B Driban
- Division of Rheumatology, Tufts Medical Center, 800 Washington Street, Box #406, Boston, MA 02111, USA.
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Hayashi D, Guermazi A, Kwoh CK, Hannon MJ, Moore C, Jakicic JM, Green SM, Roemer FW. Semiquantitative assessment of subchondral bone marrow edema-like lesions and subchondral cysts of the knee at 3T MRI: a comparison between intermediate-weighted fat-suppressed spin echo and Dual Echo Steady State sequences. BMC Musculoskelet Disord 2011; 12:198. [PMID: 21906292 PMCID: PMC3182962 DOI: 10.1186/1471-2474-12-198] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Accepted: 09/09/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Choice of appropriate MR pulse sequence is important for any research studies using imaging-derived data. The aim of this study was to compare semiquantitative assessment of subchondral bone marrow edema-like lesions and subchondral cysts using intermediate-weighted (IW) fat-suppressed (fs) spin echo and Dual Echo Steady State (DESS) sequences on 3 T MRI. METHODS Included were 201 subjects aged 35-65 with frequent knee pain. 3T MRI was performed with the same sequence protocol as in the Osteoarthritis Initiative (OAI). In a primary reading subchondral bone marrow edema-like lesions were assessed according to the WORMS system. Two hundred subregions with such lesions were randomly chosen. The extent of subchondral bone marrow edema-like lesions was re-evaluated separately using sagittal IW fs and DESS sequences according to WORMS. Lesion size and confidence of the differentiation between subchondral bone marrow edema-like lesions and subchondral cysts located within or adjacent to them was rated from 0 to 3. Wilcoxon signed-rank tests and chi-square statistics were used to examine differences between the two sequences. RESULTS Of 200 subchondral bone marrow edema-like lesions detected by IW fs sequence, 93 lesions (46.5%) were not depicted by the DESS sequence. The IW fs sequence depicted subchondral bone marrow edema-like lesions to a larger extent than DESS (p < 0.0001), and the opposite was true for subchondral cysts. Confidence scores for differentiation of the two types of lesions were not significantly different between the two sequences. CONCLUSIONS In direct comparison the IW fs sequence depicts more subchondral bone marrow edema-like lesions and better demonstrate the extent of their maximum size. The DESS sequence helps in the differentiation of subchondral bone marrow edema-like lesions and subchondral cysts. The IW fs sequence should be used for determination of lesion extent whenever the size of subchondral bone marrow edema-like lesions is the focus of attention.
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Affiliation(s)
- Daichi Hayashi
- Quantitative Imaging Center, Department of Radiology, Boston University School of Medicine, Boston, MA 02118, USA.
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Current world literature. Curr Opin Rheumatol 2011; 23:497-503. [PMID: 21844756 DOI: 10.1097/bor.0b013e32834a96c0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Roemer FW, Hunter DJ, Winterstein A, Li L, Kim YJ, Cibere J, Mamisch TC, Guermazi A. Hip Osteoarthritis MRI Scoring System (HOAMS): reliability and associations with radiographic and clinical findings. Osteoarthritis Cartilage 2011; 19:946-62. [PMID: 21550411 DOI: 10.1016/j.joca.2011.04.003] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Revised: 03/01/2011] [Accepted: 04/03/2011] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To develop a semiquantitative MRI-based scoring system (HOAMS) of hip osteoarthritis (OA) and test its reliability and validity. DESIGN Fifty-two patients with chronic hip pain were included. 1.5T magnetic resonance imaging (MRI) was performed on all patients. Pelvic radiographs were scored according to the Kellgren-Lawrence (KL) system. Clinical outcomes were assessed by the hip osteoarthritis outcome score (HOOS). MRIs were analyzed using a novel whole-joint MRI score that incorporated 13 articular features. Reliability was determined on a random subset of 15 cases. Weighted-kappa statistics and overall agreement were used as a measure of intra- and inter-observer reliability. Associations between MRI features and radiographic OA severity were calculated using Cochran-Armitage test for trend. Ordinal logistic regression was used to assess associations between MRI features and severity of pain and functional limitation. RESULTS Distribution of radiographic grading was: KL 0=12 (27%), KL 1=11 (25%), KL 2=14 (32%), KL 3=5 (11%) and KL 4=2 (5%). Intra-reader reliability for the different features ranged from 0.18 (cysts) to 0.85 (cartilage). Inter-reader reliability ranged between 0.15 (cysts) and 0.85 (BMLs). Low kappas were due to low frequencies of some features as overall percent agreement was good to excellent (83.8% and 83.1%). There was a strong association between MRI-detected lesions and radiographic severity (P=0.002). Non-significant trends were observed between MRI features and clinical outcomes. CONCLUSION MRI-based semiquantitative assessment of the hip shows adequate reliability. Presence of more severe MRI-detected intraarticular pathology shows a strong association with radiographic OA. The results suggest possible associations between MRI-detected pathology and clinical symptoms.
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Affiliation(s)
- F W Roemer
- Quantitative Imaging Center, Department of Radiology, Boston University Medical Center, 820 Harrison Avenue, Boston, MA 02118, USA.
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Hunter DJ, Guermazi A, Lo GH, Grainger AJ, Conaghan PG, Boudreau RM, Roemer FW. Evolution of semi-quantitative whole joint assessment of knee OA: MOAKS (MRI Osteoarthritis Knee Score). Osteoarthritis Cartilage 2011; 19:990-1002. [PMID: 21645627 PMCID: PMC4058435 DOI: 10.1016/j.joca.2011.05.004] [Citation(s) in RCA: 630] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Revised: 04/07/2011] [Accepted: 05/11/2011] [Indexed: 02/07/2023]
Abstract
OBJECTIVE In an effort to evolve semi-quantitative scoring methods based upon limitations identified in existing tools, integrating expert readers' experience with all available scoring tools and the published data comparing the different scoring systems, we iteratively developed the magnetic resonance imaging (MRI) Osteoarthritis Knee Score (MOAKS). The purpose of this report is to describe the instrument and its reliability. METHODS The MOAKS instrument refines the scoring of bone marrow lesions (BMLs) (providing regional delineation and scoring across regions), cartilage (sub-regional assessment), and refines the elements of meniscal morphology (adding meniscal hypertrophy, partial maceration and progressive partial maceration) scoring. After a training and calibration session two expert readers read MRIs of 20 knees separately. In addition, one reader re-read the same 20 MRIs 4 weeks later presented in random order to assess intra-rater reliability. The analyses presented here are for both intra- and inter-rater reliability (calculated using the linear weighted kappa and overall percent agreement). RESULTS With the exception of inter-rater reliability for tibial cartilage area (kappa=0.36) and tibial osteophytes (kappa=0.49); and intra-rater reliability for tibial BML number of lesions (kappa=0.54), Hoffa-synovitis (kappa=0.42) all measures of reliability using kappa statistics were very good (0.61-0.8) or reached near-perfect agreement (0.81-1.0). Only intra-rater reliability for Hoffa-synovitis, and inter-rater reliability for tibial and patellar osteophytes showed overall percent agreement <75%. CONCLUSION MOAKS scoring shows very good to excellent reliability for the large majority of features assessed. Further iterative development and research will include assessment of its validation and responsiveness.
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Affiliation(s)
- David J Hunter
- Rheumatology Department, Royal North Shore Hospital and Northern Clinical School, University of Sydney, Sydney, NSW Australia
| | - Ali Guermazi
- Quantitative Imaging Center (QIC), Department of Radiology, Boston University School of Medicine, Boston, MA USA
| | - Grace H Lo
- Medical Care Line, Research Care Line, and Houston Health Services Research and Development (HSR&D) Center of Excellence, Michael E. DeBakey Veterans Administration Medical Center, Houston, TX; Department of Medicine, Section of Immunology, Allergy and Rheumatology, Baylor College of Medicine, Houston, TX, USA
| | - Andrew J Grainger
- Department of Radiology, Leeds Teaching Hospitals & NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Philip G Conaghan
- Section of Musculoskeletal Disease, University of Leeds & NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Robert M Boudreau
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Frank W. Roemer
- Quantitative Imaging Center (QIC), Department of Radiology, Boston University School of Medicine, Boston, MA USA,Department of Radiology, Klinikum Augsburg, Augsburg, Germany
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