Andrew J Grainger Leeds, UK

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1 Andrew J Grainger Leeds, UK

2 Osteoarthri6s (OA) How do we diagnose OA of the knee at MRI? What associated features do we see? Why do they maeer? When is it not OA?

3 We think we have a clear understanding of what cons6tutes knee OA on conven6onal radiographs Current diagnoses based on clinical +/- radiographic findings ACR criteria Clinical & radiographic Altman et al 1986

4 Recognize OA involves mul6ple structures within the knee Bone Osteophyte Bone marrow lesions Car6lage Synovi6s Ligaments Menisci Unlike conven6onal radiographs we can see all these structures on MRI

5 Radiographs not sensi6ve to early changes in OA MRI shows greater sensi6vity to bone and sos 6ssue features Eckstein et al Conaghan et al Guermazi et al but what cons6tutes OA on a knee MRI? Car6lage damage & subchondral bone change common in the knee

6 How can we define knee OA on MRI Addressed by OARSI group Based on Delphi Exercise Expert group vo6ng on proposi6ons Hunter et al. 2007

7 Tibiofemoral OA Both group A features or 1 group A and 2 or more B features Hunter et al. 2007

8 How can we define knee OA on MRI Addressed by OARSI group Based on Delphi Exercise Expert group vo6ng on proposi6ons Hunter et al Not yet formally tested Key features used in defining criteria: Osteophytes Car6lage loss Subchondral marrow lesion & cysts Meniscal subluxa6on whole organ disease

9 What happens to the meniscus in OA? Meniscal extrusion Hunter. 2012

10 Occurs when there is disrup6on of the circumferen6al collagen bundles in the meniscus Meniscal root tears Large radial tear (more than 50% of meniscal width) Large complex tears (more than one cleavage plane through the meniscus) Costa et al Lerer et al. 2004

12 Meniscal extrusion contributes to joint space loss Adams et al Gale et al. 1999

13 There is a strong associa6on between presence of OA and meniscal tears Englund et al BhaCacharyya et al. 2003

14 Area of controversy Englund et al. 2009a Johnson et al Normal menisci rare in knee OA Englund et al BhaCacharyya et al Strong associa6on between presence of meniscal damage prior to car6lage loss and development of OA Englund et al. 2009b Altered biomechanics of the osteoarthri6c knee may contribute to meniscal damage, further accelera6ng OA

15 Par6al and total meniscectomy do not alter the progression to OA Englund et al Englund et al. 2009b We wait to judge benefit from: Meniscal repair Meniscal root repair Meniscal replacement

2000 Probably not influenced by reconstruc6on Øiestad

16 ACL rupture strongly associated with development of OA Gelber et al Probably not influenced by reconstruc6on Øiestad et al Kessler et al OA may cause injury to ACL Impingement Degenera6on Amin et al. 2008

17 MRI demonstrates abnormali6es in and around the MCL where there is no history of trauma Blankenbaker et al Bergin et al Wen et al. 2007

18 Some preliminary evidence to suggest changes in MCL may predate those in meniscus Blankenbaker et al In other joints we recognise ligament changes occur very early in the OA process McGonagle et al. 2008

19 OA of the knee is common & seen alongside other arthri6des OA is the endstage of many arthropathic processes

20 Synovi6s is common is OA and can be severe In itself not a help Seems to be an associa6on with pain Unusual signal characteris6cs can be helpful

21 Haemosiderin (blooming artefact with T2*) PVNS Haemophilia Also consider Amyloid deposi6on Fibrous synovium Chronic RA Gout

22 Haemosiderin (blooming artefact with T2*) PVNS Haemophilia Also consider Amyloid deposi6on Fibrous synovium Chronic RA Gout

23 Haemosiderin (blooming artefact with T2*) PVNS Haemophilia Also consider Amyloid deposi6on Fibrous synovium Chronic RA Gout

24 Fat signal synovi6s Seen in elderly with established osteoarthri6s Usually monoar6cular Some sugges6on cause of premature OA Al-Ismail et al. 2002

26 Fibrinous 6ssue Shed infarcted synovium Think RA but also TB sepsis

27 Recognize bone marrow lesions (edema like signal) as a feature of arthri6s Significance poorly understood in OA Pain associa6on Predicts progression Hunter Associa6on with meniscal pathology Englund et al. 2010

28 Edema like and Cysts Baseline + 6 weeks + 12

29 Significance beeer understood in inflammatory arthri6s Pre-erosive in RA Feature of enthesi6s in seronega6ve arthri6s

30 Look for entheseal paeerns of marrow lesions Think seronega6ve

32 Feature of inflammatory arthri6s Less commonly seen than in small joints Tibia more common than femur Poleksic et al Par6cularly difficult to see on conven6onal radiographs in large joints

33 Gout Knee a common site Erosive change Patella very common Cys6c, Punched out Associated sos 6ssue changes Tendon and peritendinous

34 Gout Knee a common site Erosive change Patella very common Cys6c, Punched out Associated sos 6ssue changes Tendon and peritendinous Popliteus

35 Gout Knee a common site Erosive change Patella very common Cys6c, Punched out Associated sos 6ssue changes Tendon and peritendinous Popliteus

36 Osteoarthri6s Diagnosis Menisci Extrusion & Tear Role in pathogenesis of OA Ligaments Hunter et al. 2007

37 Osteoarthri6s Diagnosis Menisci Extrusion & Tear Role in pathogenesis of OA Ligaments

38 Osteoarthri6s Diagnosis Menisci Extrusion & Tear Role in pathogenesis of OA Ligaments

39 When is it not OA? Unusual paeerns of synovi6s PaEerns of bone marrow lesion Erosions Tendon & sos 6ssue changes

40 When is it not OA? Unusual paeerns of synovi6s PaEerns of bone marrow lesion Erosions Tendon & sos 6ssue changes

41 When is it not OA? Unusual paeerns of synovi6s PaEerns of bone marrow lesion Erosions Tendon & sos 6ssue changes

42 When is it not OA? Unusual paeerns of synovi6s PaEerns of bone marrow lesion Erosions Tendon & sos 6ssue changes

43 Adams JG, McAlindon T, Dimasi M, Carey J, Eustace S (1999) Contribution of meniscal extrusion and cartilage loss to joint space narrowing in osteoarthritis. Clin Radiol 54: Al-Ismail K, Torreggiani WC, Al-Sheikh F, Keogh C, Munk PL (2002) Bilateral lipoma arborescens associated with early osteoarthritis. Eur Radiol 12: Altman R, Asch E, Bloch D, et al. (1986) Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum 29: Amin S, Guermazi A, Lavalley MP, et al. (2008) Complete anterior cruciate ligament tear and the risk for cartilage loss and progression of symptoms in men and women with knee osteoarthritis. Osteoarthritis Cartilage 16: Bergin D, Keogh C, O'Connell M, et al. (2002) Atraumatic medial collateral ligament oedema in medial compartment knee osteoarthritis. Skeletal Radiol 31:14-18 Bhattacharyya T, Gale D, Dewire P, et al. (2003) The clinical importance of meniscal tears demonstrated by magnetic resonance imaging in osteoarthritis of the knee. J Bone Joint Surg Am 85-A:4-9 Blankenbaker DG, De Smet AA, Fine JP (2005) Is intra-articular pathology associated with MCL edema on MR imaging of the non-traumatic knee? Skeletal Radiol 34: Conaghan PG, Felson D, Gold G, Lohmander S, Totterman S, Altman R (2006) MRI and noncartilaginous structures in knee osteoarthritis. Osteoarthritis Cartilage 14 Suppl A:A87-94 Costa CR, Morrison WB, Carrino JA (2004) Medial meniscus extrusion on knee MRI: is extent associated with severity of degeneration or type of tear? AJR Am J Roentgenol 183:17-23 Eckstein F, Burstein D, Link TM (2006) Quantitative MRI of cartilage and bone: degenerative changes in osteoarthritis. NMR in biomedicine 19: Englund M, Guermazi A, Gale D, et al. (2008) Incidental meniscal findings on knee MRI in middle-aged and elderly persons. The New England journal of medicine 359: Englund M, Guermazi A, Lohmander LS (2009a) The meniscus in knee osteoarthritis. Rheumatic diseases clinics of North America 35: Englund M, Guermazi A, Roemer FW, et al. (2009b) Meniscal tear in knees without surgery and the development of radiographic osteoarthritis among middle-aged and elderly persons: The Multicenter Osteoarthritis Study. Arthritis Rheum 60: Englund M, Guermazi A, Roemer FW, et al. (2010) Meniscal pathology on MRI increases the risk for both incident and enlarging subchondral bone marrow lesions of the knee: the MOST Study. Annals of the rheumatic diseases 69: Englund M, Lohmander LS (2004) Risk factors for symptomatic knee osteoarthritis fifteen to twenty-two years after meniscectomy. Arthritis Rheum 50: Gale DR, Chaisson CE, Totterman SM, Schwartz RK, Gale ME, Felson D (1999) Meniscal subluxation: association with osteoarthritis and joint space narrowing. Osteoarthritis Cartilage 7:

44 Gelber AC, Hochberg MC, Mead LA, Wang NY, Wigley FM, Klag MJ (2000) Joint injury in young adults and risk for subsequent knee and hip osteoarthritis. Ann Intern Med 133: Guermazi A, Hunter DJ, Roemer FW, et al. (2007) Magnetic resonance imaging prevalence of different features of knee osteoarthritis in persons with normal knee X-rays [abstract]. Arthritis & Rheumatism 56:S128 Hunter D (2012) Degeneration of the meniscus and progression of osteoarthritis. HSS journal : the musculoskeletal journal of Hospital for Special Surgery 8:13-14 Hunter DJ (2009) Insights from imaging on the epidemiology and pathophysiology of osteoarthritis. Radiol Clin North Am 47: Hunter DJ, Arden N, Conaghan PG, et al. (2011) Definition of osteoarthritis on MRI: results of a Delphi exercise. Osteoarthritis Cartilage 19: Johnson VL, Giuffre BM, Hunter DJ (2012) Osteoarthritis: what does imaging tell us about its etiology? Semin Musculoskelet Radiol 16: Kessler MA, Behrend H, Henz S, Stutz G, Rukavina A, Kuster MS (2008) Function, osteoarthritis and activity after ACL-rupture: 11 years follow-up results of conservative versus reconstructive treatment. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 16: Lerer DB, Umans HR, Hu MX, Jones MH (2004) The role of meniscal root pathology and radial meniscal tear in medial meniscal extrusion. Skeletal Radiol 33: McGonagle D, Tan AL, Grainger AJ, Benjamin M (2008) Heberden's nodes and what Heberden could not see: the pivotal role of ligaments in the pathogenesis of early nodal osteoarthritis and beyond. Rheumatology (Oxford) 47: Oiestad BE, Engebretsen L, Storheim K, Risberg MA (2009) Knee osteoarthritis after anterior cruciate ligament injury: a systematic review. The American journal of sports medicine 37: Poleksic L, Zdravkovic D, Jablanovic D, Watt I, Bacic G (1993) Magnetic resonance imaging of bone destruction in rheumatoid arthritis: comparison with radiography. Skeletal Radiol 22: Wen DY, Propeck T, Kane SM, Godbee MT, Rall KL (2007) MRI description of knee medial collateral ligament abnormalities in the absence of trauma: edema related to osteoarthritis and medial meniscal tears. Magnetic resonance imaging 25:

Medial Knee Osteoarthritis Precedes Medial Meniscal Posterior Root Tear with an Event of Painful Popping

Medial Knee Osteoarthritis Precedes Medial Meniscal Posterior Root Tear with an Event of Painful Popping Dhong Won Lee, M.D, Ji Nam Kim, M.D., Jin Goo Kim, M.D., Ph.D. KonKuk University Medical Center