2. How to define osteoarthritis
There are several "levels" of osteoarthritis: anatomical
(with presence of joint damage that is not always
detectable), radiological and symptomatic
Many people have radiologically
evident but asymptomatic
osteoarthritis
Osteoarthritis is not necessarily
synonymous with "pain"
Thus, of 100 people aged over 65:
2
Société Française de rhumatologie website:
http://www.rhumatologie.asso.fr/04-Rhumatismes/grandes-maladies/0B-dossier-arthrose/A0_definition.asp
INSERM (National medical research institute) web site:
http://www.inserm.fr/thematiques/circulation-metabolisme-nutrition/dossiers-d-information/arthrose
3. The hips and knees are not the joints
most commonly affected
The spine and fingers are the most commonly affected joints.
In the 65-75 year old age group, the incidence is as follows:
Cervical spine: 75%
Lumbar spine: 70%
Hands: 60%
Knee: 30%
Hip: 10%
It is most severe and debilitating when it affects the knees and hips,
both weight-bearing joints
The ankles, elbows and shoulders can be affected but this is less
common and generally occurs secondary to an earlier joint injury
3 Société Française de rhumatologie website:
http://www.rhumatologie.asso.fr/04-Rhumatismes/grandes-maladies/0B-dossier-arthrose/A0_definition.asp
4. 4
Cervical spine.
T2 MRI.
Erosive disc disease, different
stages, frontal view of lumbar
spine.
Hand and wrist MRI: coronal SE T1 and FSE T2 images with fat signal suppression.
Patellofemoral knee osteoarthritis.
Internal hip osteoarthritis
with deformation of the
reinforcement cup.
5. Pain: the main symptom of osteoarthritis
1. in the chronic phase
During the chronic phase, osteoarthritis
progresses very slightly or not at all
Osteoarthritis pain is described as
mechanical:
variable, mild to moderate pain that
changes only slowly over time
arises particularly during movement/usage
and is relieved by rest.
tends to become worse towards the end
of the day and evening
little night time pain
in the morning, stiffness lasts not more
than half an hour.
5 Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686
7. Pain: the main symptom of osteoarthritis
2. during the acute phase: an inflammatory flare
Recent change in pain intensity:
sudden increase in intensity over a few days
onset of night time pain which wakes the patient up
morning stiffness lasting more than 30 minutes
+/-mechanical pain as soon as any pressure is placed on the joint
Onset of joint effusion with a low cell count, i.e. containing less than
1500 elements per mm3
Sometimes, presence of signs of moderate local inflammation:
heat and swelling of the knee joint
7 Sellam J et Berenbaum F. Arthrose. Rev Prat. 2011; 61: 675-686
8. Examining the joint
Examination of the affected joint may show:
a decrease in range of movement
and/or pain when the joint is moved
(distributed through most of the range of movement)
course crepitus through much
of the range of movement
bony swelling
deformity/malalignment
joint-line tenderness +/- peri-articular
tenderness (hip/knee) due to secondary
peri-articular lesions
Between osteoarthritis flares:
the joint is neither swollen, nor warm
8
Site de la Société Française de rhumatologie :
http://www.rhumatologie.asso.fr/04-Rhumatismes/grandes-maladies/0B-dossier-arthrose/A1_pourquoi.asp
La Revue du Praticien, Arthrose et obésité. Jérémie Sellam and Francis Berenbaum, 2012; 62: 621-624
The examination must always be
comparative and, as far as the
leg joints are concerned, the patient must
also be examined in a standing position and
during walking.
9. Standard x-rays
First and foremost, the imaging work-up for patients with suspected
osteoarthritis should include a comparative x-ray (for tibiofemoral
compartments weight-bearing films are required) study of the
symptomatic joint
In more complex cases, it will also help rule out other joint diseases
The main visible signs are:
reduction in joint space width (inter-osseous distance)
subchondral bone sclerosis (increased whiteness)
osteophyte (mainly marginal)
occasionally, the presence of lacunae called
bony cysts or geodes, and osteochondral
“loose” bodies
eventual development of bone attrition and deformity
sometimes the radiological signs can be very discrete and even absent
9 INSERM (National medical research institute) website:
http://www.inserm.fr/thematiques/circulation-metabolisme-nutrition/dossiers-d-information/arthrose
12. Beware of the possible lack of
correspondence between the radiological
findings and the clinical symptoms
There is no direct link between the extent of the lesions seen
on the x-ray and pain intensity
Up to 90% of subjects aged over 50 years old are thought to present
radiological modifications whilst only 30% have clinical symptoms and signs
Severe lesions may only cause occasional pain, whilst minimal damage
may be accompanied by intense pain
More information can be gleaned from monitoring the progress of the
lesions than from assessing radiological severity at any given time
If the patient continues to present with pain despite appropriate
treatment, the radiological work-up should be repeated to screen for
rapidly destructive osteoarthritis
12 Site de la Société Française de rhumatologie :
http ://www.rhumatologie.asso.fr/04-Rhumatismes/grandes-maladies/0B-dossier-arthrose/A0_definition.asp
13. CT and MRI scans: how useful are they?
A conventional x-ray is the gold standard examination
for the diagnosis and follow-up of osteoarthritis in
routine practice although it does not allow direct
visualisation of:
cartilage damage
fibrocartilage lesions (meniscus and fat pad)
intra-articular inflammation
These abnormalities are only screened
for during clinical trials
13
Loeuille D. Quand faut-il faire une IRM dans l’arthrose des membres inférieurs ? Rev Prat. 2012; 62: 625-629
Site de la Société Française de rhumatologie:
http://www.rhumatologie.asso.fr/04-Rhumatismes/grandes-maladies/0B-dossier-arthrose/A0_definition.asp
14. 14
Frontal FSE T2 image of internal femorotibial
osteoarthritis with stage 4 cartilage lesion of
plateau and condyle and edema of the tibial
plateau and condyle
Knee osteoarthritis, tibial edema and
synovial inflammation. FSE T2 sagittal
slices.
15. MRI as a second line examination
MRI can be performed as a second line examination
for an atypical presentation:
when a patient experiences mechanical pain in a joint that
appears normal on the x-ray which could potentially be an
indication of pre-radiological stage osteoarthritis or
epiphysial osteonecrosis
a subchondral fissure
Nonetheless, recourse to MRI
for osteoarthritis patients should
be exceptional
15 Chevalier X. Arthrose du genou et de la hanche. Rev Prat Med Gen. 2007; 21: 987-991
Loeuille D. Quand faut-il faire une IRM dans l’arthrose des membres inférieurs ? Rev Prat. 2012 ; 62 : 625-629
17. MRI, cartilage and bone
Used during clinical trials, MRI provides satisfactory exploration
of the knee hyaline cartilage which varies in thickness from 1.5 to 4 mm
(cartilage is thicker in men than women and varies according to height)
When used for diagnostic purposes, in 35% of cases MRI shows focal
cartilage lesions not evident on the x-ray
Bone damage may be found with - and sometimes even before - the loss
of cartilage. MRI has made a major contribution to the diagnosis of knee
osteoarthritis by making it possible to distinguish amongst the various types
of bony lesions, especially bone oedema which is not visible on standard
x-rays and which is correlated with pain in patients with knee osteoarthritis
MRI has made major contributions to the understanding of pain
mechanisms in patients with osteoarthritis
17 Loeuille D. Quand faut-il faire une IRM dans l’arthrose des membres inférieurs ? Rev Prat. 2012; 62: 625-629
18. Conclusion
A standard x-ray is the reference examination
for patients with suspected osteoarthritis
Early diagnosis of osteoarthritis could make it possible
to set up a number of preventive measures
It is also hoped that, in the future, the use of biomarkers
(for example type 2 collagen derivatives or hyaluronic
acid) may be used to detect the first cartilage changes at
an even earlier stage
18 Chevalier X. Arthrose du genou et de la hanche. Rev Prat Med Gen. 2007; 21: 987-991