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Imaging of osteoarthritis (OA): What is new?

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Abstract

In daily clinical practice, conventional radiography is still the most applied imaging technique to supplement clinical examination of patients with suspected osteoarthritis (OA); it may not always be needed for diagnosis. Modern imaging modalities can visualize multiple aspects of the joint, and depending on the diagnostic need, radiography may no longer be the modality of choice. Magnetic resonance imaging (MRI) provides a complete assessment of the joint and has a pivotal role in OA research. Computed tomography (CT) and nuclear medicine offer alternatives in research scenarios, while ultrasound can visualize bony and soft-tissue pathologies and is highly feasible in the clinic. In this chapter, we overview the recent literature on established and newer imaging modalities, summarizing their ability to detect and quantify the range of OA pathologies and determining how they may contribute to early OA diagnosis. This accurate imaging-based detection of pathologies will underpin true understanding of much needed structure-modifying therapies.

Introduction

While osteoarthritis (OA) has traditionally been considered a noninflammatory disease with much of the focus being on hyaline cartilage degeneration, new imaging modalities such as magnetic resonance imaging (MRI) and ultrasound have expanded our knowledge on its pathogenesis, showing that all structures of the joint are commonly involved [1]. The pathogenesis is complex, with loss of articular cartilage, synovial hypertrophy and inflammation, meniscal damage, subchondral bone remodeling with formation of osteophytes, and bone marrow lesions as well as muscle and ligament abnormalities. Conventional radiography (CR) can only visualize bone and indirectly cartilage by the inter-bone distance, whereas modern modalities offer additional 3-dimensional (3D) perspectives on the joint (Table 1).

Despite this increased knowledge on the detailed pathology of OA, there are currently no licensed pharmacological disease-modifying OA drugs (DMOADs), and the relevant pathological processes or phenotypes to target have not been identified. Difficulties in demonstrating treatment effects in clinical trials may be in part due to limitations of the methods to measure and quantify OA progression, as radiographic joint-space narrowing (JSN) is the current regulatory standard for treatment response [2]. The progression of radiographic JSN is slow and occurs only in a small proportion of patients, even in carefully selected cohorts; hence, large numbers of patients need to be followed up for a minimum of 2 years in DMOAD studies. Using modern imaging techniques, short-term changes in novel outcome measures may be identified, which may better reflect long-term changes in patient outcomes, thus making randomized trials more feasible. An important step was the inclusion of ultrasound and/or MRI in the recent 2015 OARSI Clinical Trials Recommendations for knee, hip, and hand trials of structural modification therapy ∗[3], ∗[4], ∗[5], and we present here the most favorable outcome measures for each modality.

Current treatment options are limited to symptomatic therapies: analgesics and anti-inflammatory agents, with weak-to-moderate benefits, in combination with patient education, exercise, physical therapy, and devices [6]. In people with severe symptoms, surgical interventions such as joint replacement, osteotomy, or trapezectomy may be considered. At present, with the exception of joint replacement, imaging outcomes are not included in clinical algorithms, as they have not been demonstrated to direct therapeutic choices. Choosing the most appropriate strategy through a more targeted and personalized approach could optimize effectiveness, in which imaging modalities may play an important role.

Section snippets

Review criteria

To complement existing reviews on imaging in OA, this narrative review focuses on and summarizes studies from the past 3 years. We performed an extended PubMed search of the literature with the following search terms applied in various arrangements: “radiography,” “magnetic resonance imaging,” “ultrasound,” “computed tomography,” “optical imaging,” “PET,” “osteoarthritis,” “semi-quantitative scoring,” “knee,” “hand,” “hip,” and “osteoarthritis”. Because of the large amount of publications, we

Conventional radiography

OA is a clinical diagnosis based on the presence of joint pain and characteristic clinical features such as weight-bearing pain, stiffness, bony enlargement, and joint swelling. However, laboratory tests and CR may be used to distinguish OA from other joint diseases where there is diagnostic uncertainty. Being widely available, economical, and well accepted by patients, radiography remains the cornerstone in obtaining an image-based OA diagnosis. It can detect bony features related to OA,

Magnetic resonance imaging (MRI)

MRI is usually not required in clinical practice, because the relevant information for the diagnosis and management of patients with OA are obtained from the history and clinical examination. However, in daily clinical practice, MRI may be helpful in individual patients, especially in large joints when the diagnosis is unclear. It is worth noting that in a large series of people over the age of 50 years with and without knee pain, but with normal, weight-bearing knee X-ray report, almost 90%

Ultrasound

Ultrasound is a highly sensitive imaging modality, where use of high frequency probes provides a resolution up to about 0.1 mm. The method uses sound waves, has no known side effects, and offers opportunity for scanning of multiple musculoskeletal regions in a single sitting. The major limitation of ultrasound in assessing OA is that only tissues superficial to bone may be examined, and subchondral BMLs and cysts can therefore not be detected.

Ultrasound is a “bed-side” imaging modality that may

Computed tomography (CT)

In rheumatology, CT is often used for the brain and lung in people with connective tissue diseases, and is often limited to bone abnormalities in the axial skeleton or other joints in which radiographs are unclear and MRI is contraindicated or not available.

CT has some advantages. The acquisition is so fast that motion is rarely a problem, as opposed to MRI, and thus, the technique is well accepted by patients. With superior images of the bony cortex and soft-tissue calcification, CT may serve

Nuclear medicine – SPECT and PET

Nuclear medicine imaging is based on radioactive isotopes, often injected intravenously or taken orally. It provides a whole body examination and identifies tissues with high metabolic activity. The most common modalities are Single Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET) scans, and the latter has been applied to OA patients in small trials.

The potential advantages of PET depend on markers targeting specific tissues, of which bone remodeling and

Optical imaging

Optical spectral transmission (OST) and fluorescence optical imaging (FOI) are new imaging modalities for the assessment of joint inflammation, currently limited to the hands. The principals are similar to those employed in pulse oximetry: light of specific wavelengths are measured quantitatively, and vascular enhancement, i.e., inflammation, reduces the transmission of light. OST measures the change in transmission of light before and after impeding the venous return of blood from the

Use of imaging in therapeutic decisions

Imaging features are not included in current clinical recommendations for the diagnosis of OA [6], where patient history and clinical examination are sufficient for the diagnosis in the majority of people. Imaging may, however, add value where there is a need for differential diagnosis, and there may be cases where imaging could be used to identify subgroups of patients who are more or less likely to benefit from interventions. This was explored in a recent study by Knoop et al. using MRI to

Summary

This review discussed the potential benefits of applying new imaging modalities to people with OA, both in a clinical and research setting. Imaging offers a potential supplement to the clinical evaluation of patients with suspected OA, but the choice of correct modality is becoming more complex with newer modalities. Radiography will continue to be a cornerstone in diagnosing OA, while MRI provides a more complete assessment of the joint and may be helpful in individuals when symptoms are not

Conflict of interest

MAC received speaking fees and grants for clinical studies from Alfa Wasserman, Janssen, Menarini, MSD, Pfizer, Roche, and UCB, and is president of ANIMAREUM srl, a University spin-off providing image analysis services to academia and to pharmaceutical industry.

HBH has received honoraria and/or speaking fees from AbbVie, BMS, MSD, Novartis, Pfizer, Roche, and UCB.

IKH has received honoraria and/or speaking fees from Abbott/AbbVie and Roche.

PGC is on the speaker's bureau of and has acted as a

Role of the funding source

No funding received.

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