Imaging of osteoarthritis

1. Radiological imaging of osteoarthritis.
Dr/ ABD ALLAH NAZEER. MD.

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

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

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

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

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

7. MRI can depict many of the same findings of osteoarthritis as radiographs
do, including joint narrowing, subchondral osseous changes, and
osteophytes, radiographs remain the imaging method of choice in the
diagnosis of osteoarthritis because they are more cost-effective than other
methods and because they can be obtained more readily and quickly.[
Fast spin-echo images (e.g, fast spin-echo T2-weighted fat-suppressed
images) or gradient-echo images (e.g, T1-weighted 3-dimensional fat-
suppressed images) can be used for the detection of cartilaginous ulceration,
which is classically focal and located along the medial facet of the patella.
For chondromalacia patellae, conventional radiographs provide little
information. Although arthrography enables a more direct assessment of
cartilaginous integrity, many consider MRI to be the initial imaging study of
choice.
Unlike radiography, MRI can depict articular cartilage directly; this feature
of MRI has been the subject of multiple research studies over the past
several years, particularly focusing on the cartilage of the knee (see the
images below). A variety of pulse sequences have been described, but the
most commonly used include spoiled gradient-recalled echo (SPGR) and fast
spin-echo imaging.

8. CT is rarely used for the diagnosis of primary osteoarthritis,
although it may be used for the diagnosis of malalignment
of the patellofemoral joint or the foot and ankle joints. It
may also be useful in evaluating the osseous detail of the
vertebral column, particularly the facet joints.
Nuclear Imaging
Scintigraphic studies are of limited use for the diagnosis of
osteoarthritis because increased uptake of the radiotracer can
also be seen in several other hypervascular articular diseases. The
image resolution of bone scintigraphy is much less than that of
other imaging modalities. In joints affected with osteoarthritis,
increased uptake of bone-seeking radiopharmaceuticals may be
seen before any radiographic abnormalities are apparent. Tracer
accumulation is concentrated in regions of bony eburnation and
osteophyte formation.

9. Commonly affected joints.
1- Hip joints.
2- Knee joints.
3- Feet.
4- Spine.
5- Hands(inter-phalngeal joints).
Uncommonly affected joints.
1- Shoulder joint.
2-Wrist joint.
3-Elbow Joints.
4-Metacarpophalangeal joints.
5-Temporo-mandibular joint
6- Sacro-iliac joint.
7- Ankle joint.

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

14. Osteoarthritis of the hip joint:
Causes
Osteoarthritis has no single specific cause, but there are
certain factors that may make you more likely to develop
the disease, including:
Increasing age
Family history of osteoarthritis
Previous injury to the hip joint
Obesity
Improper formation of the hip joint at birth, a condition
known as developmental dysplasia of the hip
Even if you do not have any of the risk factors listed above,
you can still develop osteoarthritis.

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

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

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

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

20. CT-Arthrography shows superior and anterior joint space narrowing (blue circle) with
denuded chondral surface (yellow arrow), subchondral cysts and sclerosis. No
femoroacetabular impingement or associated labral tear. Normal mineralization.

21. Marginal osteophytes in a left hip with moderate osteoarthritis
as seen with a coronal T1 sequence (A), a coronal proton
density fat saturation sequence (B), and plain radiography (C).

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

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

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

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

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

28. Osteoarthritis: Radiographic Progression, Left Knee

31. Synovial chondromatosis of the knee secondary to osteoarthritis in a 50-year-old woman.
CT scan shows osteophytes and narrowing of joint spaces, consistent with osteoarthritis.
Notice the variable sized ossified intra-articular loose bodies (arrows in c and d).

32. MRI image of osteoarthritis.

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

34. MRI image of osteoarthritis.

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

36. Osteoarthritis in the metatarsophalangeal joint of
the big toe. Joint space narrowing (black arrow)
and bone spurs (white arrows) can be seen.
The X-ray shows complete obliteration of
the big toe joint in a case of severe arthritis.

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

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

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

41. Osteoarthritis of the hands.

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

43. Erosive osteoarthritis.

45. MRI scans showing typical features of hand OA.

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

47. CT for osteoarthritis of the facet joints.

48. Osteoarthritis of the Uncovertebral joints.

49. CT images for osteoarthritis of the right facet Uncovertebral joints.

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

52. Severe osteoarthritis of the glenohumeral joint.

53. Osteoarthritis of the glenohumeral and AC joint.

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

55. (Glenohumeral Joint) Osteoarthritis.

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

57. X-Ray images for elbow arthritis.

58. X-Ray images for elbow arthritis.

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

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

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

62. Wrist with osteoarthritis.

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

64. MRI with osteoarthritis at distal radio-ulnar joints.

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

66. Panoramic
film with
TMJ arthritis.

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

68. Temporomandibular joint osteoarthritis with prominent osteophytes

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

70. Osteoarthritis of the sacro-iliac joint:
The SI joints, like any other joint in the body, are covered and protected by
cartilage. So they too can fall victim to the effects of osteoarthritis. When this
happens, the many nerves surrounding the SI joint may begin to send pain
signals to the brain. Osteoarthritis is usually a condition that occurs gradually,
over time. While getting older is the most significant contributing factor
associated with this disorder, there are others that can put a person at
greater risk for developing it. These include:
Overweight or obesity
Extreme stress on the joints from sports or certain job duties
Traumatic Injury to the affected joint
Malformed joints as the result of a birth defect or other anatomical condition
Genetically defective joint cartilage.
Symptoms of Osteoarthritis in the SI Joint:
Mild-to-severe low back pain on one or both sides, below L5
Pain on one or both sides of the buttocks that may radiate into the groin or
back of the thigh
Pain on one side that may radiate down one leg in particular
Increased pain with certain activities – prolonged sitting or standing, bending
or twisting or climbing stairs.

71. Osteoarthritis of the Sacroiliac (SI) Joint

72. Sacroiliitis
on CT.

73. Findings
of acute
sacroiliitis
on MRI

74. Chronic
sacroiliitis
on MRI

75. Thank You.