Radiographic diagnosis of osteoarthritis

Diagnostic criteria

Osteoarthritis of the limbs

The radiographic diagnosis of osteoarthritis is based on 4 signs which may be isolated or associated with each other:

  • Joint space pinching , which is localised and generally asymmetric. It essentially reflects a reduction in the thickness of the cartilage and its deterioration. It is necessary to assess its location and extent.
  • Marginal osteophytosis
  • Epiphyseal osteocondensation
  • Epiphyseal or ‘hyperpressure’ geodes are round or oval in shape. They are most often found in the zone of epiphyseal osteocondensation of the subchondral bone.

The first 2 signs are sufficient to confirm a diagnosis that is often clinically suspected. In the case of pinching without osteophytes, the diagnosis may be more difficult and require additional imaging examinations.

Spinal osteoarthritis

Discarthrosis is revealed by global or focal pinching of the intervertebral disc, subchondral condensation and osteophytosis of the vertebral plates. Zygapophyseal osteoarthritis is revealed by condensation of the articular facets, articular pinching on three-quarter views, osteophytosis, remodelling and horizontalisation of the articular surfaces, sometimes responsible, with disc degeneration, for degenerative spondylolisthesis.

In the vast majority of cases, standard radiography remains the most appropriate tool for diagnosing osteoarthritis.

Other benefits of standard radiography

Searching for aetiological factors in osteoarthritis

X-rays can be used to look for aetiological factors in arthroses such as hip dysplasia, joint chondrocalcinosis, traumatic sequelae, etc., as well as signs of complications such as secondary synovial osteochondromatosis.

O: Osteophyte – P: Pinch
G: Geode – C: Condensation

Major form of centric omarthrosis with stage IV omohumeral pinch, exuberant osteophyte of the lower pole of the humeral head and the neck of the scapula, osteocondensation and osteochondromas.
Lyon Sud Hospital – Prof. Vignon, Dr. Conrozier and Dr. Mathieu
Monitoring structural evolution

Standard X-rays can also be used to monitor structural changes, which is one of the factors in the prognosis of osteoarthritis disease. Structural monitoring is carried out by X-ray every 18 to 24 months. The joint space is measured to assess pinching.

Iterative inflammatory flare-ups of osteoarthritis in the lower limbs may be associated with rapid chondrolysis. Close radiological monitoring may then be necessary.

In standard radiography, several scores can be used to classify patients according to the severity of their disease. These scores are mainly used in clinical research. The Kellgren and Lawrence score is the most widely used. It is an index that takes into account osteophytes and joint space narrowing.
It comprises 4 grades: doubtful, minimal, definite and advanced osteoarthritis.

A grade 0 corresponds to a normal X-ray and a grade 4 to complete disappearance of the cartilage. This type of score can be used to assess the progression of osteoarthritis and can be applied to many joints.

Main principles of standard radiography

There are a few main principles of standard osteoarticular radiography:

Always X-ray the 2 symmetrical joints in order to compare the pathological side with the asymptomatic side presumed to be healthy.

In fact, when the X-ray reveals an abnormal image, if it is bilateral, it may be an anomaly of no clinical significance. On the other hand, X-rays of the 2 symmetrical joints can sometimes reveal bilateral pathological damage that is asymptomatic on one side. This is relatively common, for example, in coxarthrosis.

For the lower limbs (especially the knee), images should be taken in a stress position, preferably under load. When the patient is standing, the joint space becomes more compressed as a result of the stress imposed on the skeleton by the weight of the body. Any pinching may disappear completely when the patient is unloaded, leading to a misdiagnosis.

X-rays should always be taken at several different angles in order to get a better spatial view of the joint, but only at the angles that are really essential, in order to minimise the dose of exposure to the patient. In addition to the frontal view in extension and the profile, a schuss view is essential in the assessment of a gonarthrosis in order to judge any posterior pinching.

O: Osteophyte – P: Pinch
C: Condensation

Bilateral digital osteoarthritis affecting the IPD and bilateral rhizarthrosis
Pitié-Salpétrière University Hospital – Dr. Gibert

Limitations of standard radiography

Radiological signs are generally present from the first clinical manifestations of osteoarthritis, but radiographs may be normal or subnormal at an early stage of the disease due to the slow progression of radiographic signs.
The clinician can then make use of modern imaging techniques, which can provide lesion and structural information and enable appropriate early treatment.

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