and

present

Diagnosing osteoarthritisDiagnosing osteoarthritis

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 radiologicallyevident but asymptomaticosteoarthritis

Osteoarthritis is not necessarilysynonymous 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.aspINSERM (National medical research institute) web site:http://www.inserm.fr/thematiques/circulation-metabolisme-nutrition/dossiers-d-information/arthrose

The hips and knees are not the jointsmost 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

Cervical spine. T2 MRI.

Erosive disc disease, differentstages, frontal view of lumbarspine.

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.

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

6

According to Sellam 2012

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

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 secondaryperi-articular lesions

Between osteoarthritis flares: the joint is neither swollen, nor warm

8Site de la Société Française de rhumatologie : http://www.rhumatologie.asso.fr/04-Rhumatismes/grandes-maladies/0B-dossier-arthrose/A1_pourquoi.aspLa 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.

Standard x-raysFirst 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

10

Cystic hip osteoarthritis.Oblique image hip radiographs.

Fracture of the upper extremity of the femur

(pertrochanteric).

11

Advanced internal femorotibial knee osteoarthritis. Standard frontal x-ray.

Sample osteoarthritic knee x-ray

Advanced internal femorotibial knee osteoarthritis. Standard oblique x-ray

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 seenon 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

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 screenedfor during clinical trials

13Loeuille D. Quand faut-il faire une IRM dans l’arthrose des membres inférieurs ? Rev Prat. 2012; 62: 625-629Site de la Société Française de rhumatologie: http://www.rhumatologie.asso.fr/04-Rhumatismes/grandes-maladies/0B-dossier-arthrose/A0_definition.asp

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.

MRI as a second line examination

MRI can be performed as a second line examinationfor 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 MRIfor osteoarthritis patients shouldbe exceptional

15 Chevalier X. Arthrose du genou et de la hanche. Rev Prat Med Gen. 2007; 21: 987-991Loeuille D. Quand faut-il faire une IRM dans l’arthrose des membres inférieurs ? Rev Prat. 2012 ; 62 : 625-629

16

Rotator cuff rupture. MRI T2 images. External femoral condyle osteonecrosis, T1 MRI sequence,

frontal image.

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 lossof 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 standardx-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

Conclusion

A standard x-ray is the reference examinationfor patients with suspected osteoarthritis

Early diagnosis of osteoarthritis could make it possibleto 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