Prevalence of intra-articular mineralization on knee computed tomography: the multicenter osteoarthritis study.

OBJECTIVE: The aim of this work was to report the prevalence of computed tomography (CT)-detected intra-articular mineralization. DESIGN: We included participants from the Multicenter Osteoarthritis (MOST) Study. At the 12th year visit of the MOST study, bilateral knee CTs were first obtained. All participants also had posteroanterior and lateral radiographs of bilateral knees and completed standard questionnaires. Knee radiographs were assessed for Kellgren & Lawrence grade (KLG) and radiographic evidence of intra-articular mineralization. CT images were scored using the Boston University Calcium Knee Score (BUCKS) for cartilage, menisci, ligaments, capsule, and vasculature. Prevalence of intra-articular mineralization was computed for the total sample, and stratified by age, sex, race, Body Mass Index (BMI), presence of frequent knee pain, and KLG. We also determined distribution of mineralization in the cartilage and meniscus, and co-localization. RESULTS: 4140 bilateral knees from 2070 participants were included (56.7% female, mean age 61.1 years, mean BMI: 28.8 kg/m2). On radiographs 240 knees (5.8%) had intraarticular mineralization, while CT-detected mineralization was present in 9.8% of knees. Prevalence of hyaline articular and meniscus mineralization increased with age and KL grade, and was similar by sex, BMI categories, and comparable in subjects with and without frequent knee pain. Mineralization tended to be ubiquitous in the joint, most commonly involving all three (medial/lateral tibiofemoral and patellofemoral) compartments (3.1%), while the patellofemoral compartment was the most involved compartment in isolation (1.4%). CONCLUSIONS: CT of the knee provides greater visualization of intra-articular mineralization than radiographs and allows better localization of the crystal deposition within the joint. Further studies should focus on the co-localization of intra-articular crystal deposition and corresponding magnetic resonance imaging (MRI)-features of knee osteoarthritis (OA).

Evidence that meniscus damage may be a component of osteoarthritis: the Framingham study.

OBJECTIVES: The etiology of degenerative meniscus tear is unclear but could be related to a generalized osteoarthritic disease process. We studied whether radiographic hand osteoarthritis (OA) is associated with meniscus damage. METHODS: We examined 974 persons aged 50-90 years drawn via census tract data and random-digit dialing from Framingham, Massachusetts, United States. One reader assessed bilateral hand radiographs (30 joints) and another read frontal knee radiographs, all according to the Kellgren-Lawrence (KL) scale. A third reader assessed right knee 1.5-T magnetic resonance imaging (MRI) scans for meniscus damage. We calculated the prevalence of medial and/or lateral meniscus damage in those with one to two and three or more finger joints with radiographic OA (KL grade ≥2) compared to those without radiographic hand OA with adjustment for age, sex, and body mass index. We also evaluated the above association in persons without evidence of radiographic OA (KL grade 0) in their knee (n = 748). RESULTS: The prevalence of meniscus damage in the knee of subjects with no, one to two, and three or more finger joints with OA was 24.9%, 31.7%, and 47.2%, respectively. The adjusted prevalence ratio (PR) of having meniscus damage was significantly increased in those who had three or more finger joints with OA (1.40 [95% confidence interval (CI) 1.11-1.77]). The estimate remained similar in persons without evidence of radiographic OA in their knee (PR, 1.42 [95% CI 1.03-1.97]). The association was more robust for medial meniscus damage. CONCLUSION: Results suggest a common non-age related etiologic pathway for both radiographic hand OA and meniscus damage.

Pre-radiographic osteoarthritic changes are highly prevalent in the medial patella and medial posterior femur in older persons: Framingham OA study.

OBJECTIVE: To determine which subregions of the knee joint have a high prevalence of pre-radiographic osteoarthritic changes, i.e., cartilage damage and osteophytes that can only be detected by magnetic resonance imaging (MRI), in radiographically normal knees. METHODS: Institutional Review Board approval and written informed consent from all participants was obtained. Data was collected from a community cohort in Framingham, MA, involving people aged 50-79. Participants underwent weight-bearing posteroanterior and lateral knee radiography with the fixed-flexion protocol, and 1.5 T MRI. Knees without radiographic osteoarthritis (Kellgren Lawrence grade 0 for the tibiofemoral joint and absence of any osteophytes or joint space narrowing in the patellofemoral joint) were included. The knee joint was divided into 14 subregions for cartilage and 16 subregions for osteophytes, and prevalence and severity of cartilage damage (grade 0-6) and osteophytes (grade 0-7) were semiquantitatively assessed using the Whole Organ Magnetic Resonance Imaging Score (WORMS). RESULTS: The mean age of 696 participants was 62.3 ± 8.4 years, and the mean body mass index was 27.9 ± 5.1 kg/m2. Women comprised 55.2% of the study sample (384/696). Prevalence of cartilage damage (grade ≥2) was 47.7% (332/696) in the medial patellar and 29.9% (208/696) in patellar lateral (PL) subregions, and 24.0% (167/696) in femoral medial anterior (FMA) and 26.5% (184/696) in femoral medial central (FMC) subregions. Prevalence of osteophytes (grade ≥2) was highest at 60.8% (423/696) in the medial femoral posterior subregion, followed by 34.0% (237/696) in PL and 24.6% (171/696) in patellar medial (PM) subregions. For all other subregions, prevalence of these lesions was lower than the aforementioned percentages. CONCLUSION: MRI-detected cartilage damage and osteophytes are highly prevalent in the medial patellofemoral and medial posterior tibiofemoral joints in radiographically normal knees in persons aged 50-79.

Physical activity, alignment and knee osteoarthritis: data from MOST and the OAI.

OBJECTIVE: To determine the effect of physical activity on knee osteoarthritis (OA) development in persons without knee injury and according to knee alignment. DESIGN: We combined data from Multicenter Osteoarthritis (MOST) and Osteoarthritis Initiative (OAI), studies of persons with or at high risk of OA. Subjects had long limb and repeated posteroanterior knee radiographs and completed the physical activity survey for the elderly (PASE). We studied persons without radiographic OA and excluded knees with major injury and without long limb films. We followed subjects 30 months (in MOST) and 48 months (in OAI) for one of two incident outcomes: (1) symptomatic tibiofemoral OA (radiographic OA and knee pain), or (2) tibiofemoral narrowing. 'Active' persons were those with PASE score in the highest quartile by gender. We examined risk of OA in active group using logistic regression adjusting for age, gender, body mass index (BMI), Western Ontario and McMaster Arthritis Index (WOMAC) pain score, Kellgren and Lawrence (KL) grade (0 or 1), and study of origin. We also analyzed knees from malaligned and neutrally aligned limbs. RESULTS: The combined sample comprised 2,073 subjects (3,542 knees) with mean age 61 years. The cumulative incidence of symptomatic tibiofemoral OA was 1.12% in the active group vs 1.82% in the others (odds ratio (OR) among active group 0.6, 95% confidence interval (CI) 0.3, 1.3). Joint space narrowing occurred in 3.41% of knees in the active group vs 4.04% in the others (OR among active group 0.9 (95% CI 0.5, 1.5)). Results did not differ by alignment status. CONCLUSIONS: Physical activity in the highest quartile did not affect the risk of developing OA.

Does cartilage volume or thickness distinguish knees with and without mild radiographic osteoarthritis? The Framingham Study.

OBJECTIVES: To examine whether the quantity of cartilage or semiquantitative scores actually differ in knees with mild radiographic osteoarthritis compared with knees without osteoarthritis. METHODS: Framingham Osteoarthritis Study participants had knee tibiofemoral magnetic resonance imaging-based measurements of cartilage. Using three-dimensional FLASH-water excitation sequences, cartilage volume, thickness and subregional cartilage thickness were measured and cartilage scored semiquantitatively (using the whole-organ magnetic resonance imaging score; WORMS). Using weight-bearing radiographs, mild osteoarthritis was defined as Kellgren/Lawrence (K/L) grade 2 and non-osteoarthritis as K/L grade 0. Differences between osteoarthritis and non-osteoarthritis knees in median cartilage measurements were tested using the Wilcoxon rank sum test. RESULTS: Among 948 participants (one knee each), neither cartilage volume nor regional thickness were different in mild versus non-osteoarthritis knees. In mild osteoarthritis, cartilage erosions in focal areas were missed when cartilage was quantified over large regions such as the medial tibia. For some but not all subregions of cartilage, especially among men, cartilage thickness was lower (p<0.05) in mild osteoarthritis than non-osteoarthritis knees. Because semiquantitative scores captured focal erosions, median WORMS scores were higher in mild osteoarthritis than non-osteoarthritis (all p<0.05). In moderate/severe osteoarthritis (K/L grades 3 or 4), osteoarthritis knees had much lower cartilage thickness and higher WORMS scores than knees without osteoarthritis. CONCLUSIONS: In mild osteoarthritis, the focal loss of cartilage is missed by quantitative measures of cartilage volume or thickness over broad areas. Regional cartilage volume and thickness (eg, medial tibia) are not different in mild osteoarthritis versus non-osteoarthritis. Subregional thickness may be decreased in mild osteoarthritis. Semiquantitative scoring that assesses focal cartilage damage differentiates mild osteoarthritis from non-osteoarthritis.

Pre-radiographic MRI findings are associated with onset of knee symptoms: the most study.

OBJECTIVE: Magnetic resonance imaging (MRI) has greater sensitivity to detect osteoarthritis (OA) damage than radiographs but it is uncertain which MRI findings in early OA are clinically important. We examined MRI abnormalities detected in knees without radiographic OA and their association with incident knee symptoms. METHOD: Participants from the Multicenter Osteoarthritis Study (MOST) without frequent knee symptoms (FKS) at baseline were eligible if they also lacked radiographic features of OA at baseline. At 15 months, knees that developed FKS were defined as cases while control knees were drawn from those that remained without FKS. Baseline MRIs were scored at each subregion for cartilage lesions (CARTs); osteophytes (OST); bone marrow lesions (BML) and cysts. We compared cases and controls using marginal logistic regression models, adjusting for age, gender, race, body mass index (BMI), previous injury and clinic site. RESULTS: 36 case knees and 128 control knees were analyzed. MRI damage was common in both cases and controls. The presence of a severe CART (P=0.03), BML (P=0.02) or OST (P=0.02) in the whole knee joint was more common in cases while subchondral cysts did not differ significantly between cases and controls (P>0.1). Case status at 15 months was predicted by baseline damage at only two locations; a BML in the lateral patella (P=0.047) and at the tibial subspinous subregions (P=0.01). CONCLUSION: In knees without significant symptoms or radiographic features of OA, MRI lesions of OA in only a few specific locations preceded onset of clinical symptoms and suggest that changes in bone play a role in the early development of knee pain. Confirmation of these findings in other prospective studies of knee OA is warranted.

The relation of plasma homocysteine to radiographic knee osteoarthritis.

OBJECTIVE: Homocysteine has been implicated in multiple diseases that involve changes in structural tissue. In vitro studies have found that it alters the structure of collagen cross-linking thus affecting stability and mineralization such as that occurring in bone tissue. In the present study we considered the possible relationship between plasma homocysteine levels and the development and progression of knee osteoarthritis (OA). METHODS: The study question was posed in 691 men and 966 women from the original and offspring cohorts of the Framingham Osteoarthritis Study. We divided individuals into three groups according to plasma homocysteine levels and compared their risk for the development of new and progression of existing OA. We adjusted for potential confounders including age, body mass index, weight change, and physical activity. RESULTS: In the crude analysis, men in the middle homocysteine tertile were found to be at a greater risk than men in the lowest tertile for incident OA [odds ratios of 1.9 (1.1-3.5)]. This result persisted after adjusting for covariates [odds: 2.0, (1.1-3.8)]. No significant correlation was seen in women for the development of OA. In the evaluation of progression no significant trends were seen for both men and women. CONCLUSIONS: Although cellular and molecular studies of homocysteine-related pathophysiology suggest a possible correlation between plasma homocysteine levels and OA, the present clinical study did not conclusively demonstrate such an association. However, further research is needed to explore the role of homocysteine in specific aspects of OA etiopathogenesis.

Knee alignment differences between Chinese and Caucasian subjects without osteoarthritis.

OBJECTIVE: Despite the lower prevalence of obesity (a known risk factor for osteoarthritis (OA)), the prevalence of lateral tibiofemoral OA is higher in Chinese communities compared with Caucasian communities. One potential explanation is the difference in knee alignment between the two populations. We measured various knee alignment indices among Chinese and Caucasians and assessed whether these indices were different between the two racial groups. METHODS: We selected participants from the Framingham Osteoarthritis Study (FOA) and the Beijing Osteoarthritis Study (BOA), all without knee OA (Kellgren & Lawrence grade <2). Bilateral, fully extended anteroposterior knee radiographs were measured for the following angles in both knees: the anatomic axis (AA), the condylar angle (CA), the tibial plateau angle and the condylar-plateau angle (CP). We compared the mean of each measurement between the two racial groups adjusting for age and body mass index using linear regression and stratified by sex. RESULTS: The mean AA, CA and CP were significantly different in the BOA compared with the FOA. For women, the mean AA and CA were significantly more valgus in BOA subjects, while in men, the mean AA and CP were more valgus in BOA subjects. CONCLUSIONS: There are significant differences in knee morphology between Chinese and Caucasian cohorts, which result in a more valgus alignment of the distal femur in Chinese. This would serve to shift the mechanical loading towards the lateral compartment, and provide a possible explanation why Chinese have a higher prevalence of lateral tibiofemoral OA.

Level of physical activity and the risk of radiographic and symptomatic knee osteoarthritis in the elderly: the Framingham study.

PURPOSE: Because osteoarthritis may be caused by "wear and tear," we examined the association between level of physical activity and risk of knee osteoarthritis in the elderly. SUBJECTS AND METHODS: Eligible subjects were participants in the Framingham Heart Study cohort who had radiographically normal knees at biennial exam 18 (1983-1985) and who also completed a physical activity questionnaire at exam 20 (1988-1989). Follow-up knee radiographs were obtained at biennial exam 22 (1992-1993). The study outcomes were the development of incident radiographic or symptomatic knee osteoarthritis between the baseline and follow-up exams. RESULTS: The number of hours per day of heavy physical activity was associated with the risk of incident radiographic knee osteoarthritis (odds ratio = 1.3 per hour, 95% confidence limits 1.1-1.6, P for trend = 0.006). Adjustment for age, sex, body mass index, weight loss, knee injury, health status, total calorie intake, and smoking strengthened this association (eg, odds ratio for > or = 4 hours heavy physical activity/day compared with no heavy physical activity = 7.0, 95% confidence limits 2.4-20, P for trend = 0.0002). Risk was greatest among individuals in the upper tertile of body mass index (odds ratio for > or = 3 hours/day of heavy physical activity = 13.0, 95% confidence limits 3.3-51). For incident symptomatic knee osteoarthritis, the results were similar, although the number of cases was small. No effects on these outcomes were observed from moderate and light physical activity, number of blocks walked, or number of flights of stairs climbed daily. CONCLUSIONS: Heavy physical activity is an important risk factor for the development of knee osteoarthritis in the elderly, especially among obese individuals. Light and moderate activities do not appear to increase risk.

Gastric uptake of gallium-67 in AIDS.

We describe gastric localization of 67Ga in 13 patients with acquired immunodeficiency syndrome (AIDS) among 148 referred primarily to rule out Pneumocystis carinii pneumonia (PCP). Endoscopic biopsies in five of the patients indicated cytomegalovirus (CMV) infection in one, gastritis in two, and normal tissue in two. Other associated, but nongastric, infections in these 13 patients included esophageal candidiasis, PCP, Mycobacterium avium-intracellulare (MAI) complex, coccidioidomycosis, toxoplasmosis and Isospora belli. Only six of the patients exhibited gastric symptoms, and even fewer proved to have gastric pathology. Although gastric 67Ga uptake in a patient with AIDS may not require specific treatment, opportunistic infections as a possible cause of gastritis should be considered.

Hip arthrography, aspiration, block, and bursography.

Hip arthrography in children with Legg-Calvé-Perthes disease is used to determine the optimal position of the femoral head for immobilization during the process of epiphyseal healing and in developmental dysplasia of the hip as a guide to operative treatment. In adult hips, arthrography and aspiration are useful techniques for demonstration of prosthetic implant loosening and infection. Aspiration of the hip joint and culture of aspirated fluid helps to diagnose septic arthritis. Anesthetic hip arthrography helps to distinguish between pain originating from the hip and radicular pain from the spine. Iliopsoas bursography may be used to diagnose bursal enlargement and its cause.

The fate of acetabular allografts after bipolar revision arthroplasty of the hip. A radiographic review.

We reviewed the radiographs of thirty-one patients (thirty-two hips) who had had revision of the acetabular component of a total hip arthroplasty with a bipolar socket supplemented by allograft and were followed for twenty-four to forty-eight months. The grafts were categorized according to their consistency (solid or crushed bone), the location of the acetabular defect (peripheral [rim] or central), and the extent of the acetabular defect (contained--the medial part of the acetabular wall was intact, or non-contained--it was deficient). We recorded the time to incorporation of the graft, the amount of migration of the socket in the superior and medial axes, and the percentage of graft remaining at the time of the most recent follow-up. The time to healing was similar for all categories of grafts. The central, contained, solid grafts had less resorption than did the central, contained, crushed-bone grafts, as evidenced by less migration of the socket during follow-up. The non-contained grafts, in both peripheral and central locations, were associated with high rates of migration and of instability of the socket.

MR imaging of arthritides of the cervical spine.

Indications for MR imaging have broadened with the development of multiplanar capability, superb soft tissue contrast, and high sensitivity for detecting pathologic alterations. These developments are especially valuable in the analysis of the spine, where multiple anatomic structures reside, each with varying physical properties. MR imaging is unsurpassed in demonstrating early structural and proliferative changes that occur in inflammatory and related arthritides, and in evaluating complications that can cause significant morbidity, and even death. The role of MR imaging in the evaluation of cervical spinal arthritis continues to evolve, as its role in identifying patients for surgical intervention becomes clearer.

Improving the patient evaluation process in a cardiovascular and interventional radiology department.

Brigham & Women's Hospital (BWH) has adopted total quality management (TQM) to increase productivity and efficiency and to improve the quality of patient care services. This article reports on a quality improvement project in the department of radiology designed to improve the process of pre-procedure workup of patients referred for cardiovascular and interventional radiology (CVIR) procedures. The project was initiated, led, and conducted by a physician.

Long-term follow-up of residual mediastinal-hilar Ga-67 uptake after treatment for Hodgkin's and non-Hodgkin's lymphomas: what degree of Ga-67 uptake is significant?

PURPOSE: Ga-67 planar and SPECT images of 85 patients after treatment for mediastinal-hilar (M-H) lymphoma were reviewed retrospectively. Forty-seven patients had Hodgkin's disease and 38 patients had non-Hodgkin's lymphoma. The entire period was 7 years after diagnosis. The main goal was visual assessment of the significance of mild (grades 1 or 2) Ga-67 uptake in the M-H area as compared with Ga-67 uptake in bone marrow. METHODS: Residual Ga-67 mediastinal uptake after a complete course of chemotherapy or other treatments was defined as normal (no residual) M-H uptake, borderline (M-H residual uptake with intensity less than that or equal to the sternum, spine, or both), and abnormal (M-H residual uptake with intensity greater than that of the sternum or spine). RESULTS: Among the 38 patients (45%) with no residual M-H uptake, four (one Hodgkin's disease and three non-Hodgkin's lymphoma) experienced recurrence: two in the mediastinum and two in the abdomen. Among the 45 patients (53%) with borderline M-H uptake, five experienced recurrence: two in the mediastinum and three in other sites. The two patients (2%) with abnormal (M-H) uptake never responded to treatment. No significant statistical difference in tumor recurrence was found between no residual and borderline uptake (P = 0.21). CONCLUSIONS: Visual assessment of M-H Ga-67 uptake (without quantification) could be useful to differentiate active residual tumor from nonactive residual uptake.

Gastric Ga-67 uptake in patients with lymphoma.

Gastric accumulation of Ga-67 greater than that seen in the liver was observed in 16 of 162 (9.8%) patients with lymphoma. Endoscopic biopsies in six patients showed one instance each of histiocytic lymphoma, mixed cellularity Hodgkin's disease, adenocarcinoma, and hiatal hernia with mucosal deformity, as well as two instances of benign gastric ulcer. All six patients had chronic gastric symptoms, as well as persistent radiogallium accumulation on sequential examinations of 2 years duration. The remaining 10 patients exhibited transient radiotracer gastric uptake and only two has gastric symptoms. Persistent gastric Ga-67 accumulation is not common in lymphoma and warrants endoscopy when accompanied by prolonged symptoms.

Chronic osteomyelitis: the relative roles of scintigrams, plain radiographs, and transmission computed tomography.

We evaluated the relative contribution of transmission computed tomograms (CT), plain radiographs, and bone/gallium scans in the diagnosis of 27 patients with suspected active chronic osteomyelitis. All patients were imaged with all modalities and had surgical proof of the presence or absence of disease. At surgery, osteomyelitis was shown to be active in 20 patients, 15 of whom had sequestra, and inactive in the remaining seven. CT depicted all 15 sequestra, but was falsely positive in three patients, all of whom had bone remodeling only and had negative bone/gallium scintiscans. Plain radiographs had a limited value; they detected sequestra, which was the only findings to indicate the presence of active disease, in 5 patients out of the 15 with surgical proof thereof. The authors conclude that, considering the shortcoming of other modalities with regard to depicting sequestra, scintigraphy is helpful in confirming the presence or absence of active disease and therefore in preventing unnecessary surgery.