Journal of the Association of Physicians of India
JAPI
Editor : Dr. Siddharth N. Shah
Journal of the Association of Physicians of India
JAPI
Editor : Dr. Siddharth N. Shah
Current Issue • July 2018 • Vol. 66
Original Article
Osteoarthritis: Clinical and Radiological Correlation
Shilpa P Karande1, Seema Kini1*
1Associate Professor, Department of Medicine,
T.N. Medical College and Nair Hospital, Mumbai,
Maharashtra; *
Corresponding Author
Received: 03.10.2016; Accepted: 16.04.2018
Abstract
Background: Osteoarthritis (OA) is a slowly progressive degenerative joint
disease, characterized by pain and functional disability. Various outcome
measures for radiographic and clinical OA are described in studies. A limitation
of radiographic evaluation is that, except for the direct evaluation of bone, the
tissues involved in the OA process are either evaluated indirectly (cartilage) or
not at all (synovium). In evaluation of clinical OA, the scores for pain, stiffness and
function are commonly used outcome measures. The objective of this study was
to co-relate the clinical status with activity and radiological score in osteoarthritis
of various joints.
Materials and Methods: A Cross-sectional study was conducted including
100 consecutive patients of osteoarthritis of various joints. A thorough
clinical examination of affected joint was performed and relevant laboratory
investigations and radiology of the affected joint was done in all patients. Grading
of severity of osteoarthritis was assessed by following clinical indices: Knee/ Hip
by Lequesne, Articular Index of Doyle for osteoarthritis and modified WOMAC
index – KGMC index. Radiological indices used were: Kellgren and Lawrence
global grading scheme for the severity of osteoarthritis of the knee, hip, lumbar
disc degeneration and apophyseal joints of the cervical spine, Kallman grading
scale for individual features of the hand and Individual radiographic features
assessed in radiographs of the hip and lumbar spine.
Results:Knee joint was commonly involved (89%), followed by lumbar spine
(49%). Knee joint tenderness was significantly co-relating with KGMC and
radiological index. Lequesne and KGMC Indian index were co-relating positively
with each other for knee joint. All clinical indices showed significant co-relation
with radiological indices for knee joint. Clinical and radiological indices were also
co-relating positively in cervical and lumbar spine. Visual analogue scale (VAS)
co-related significantly with Lequesne and Indian KGMC index with respect to
knee joint, but showed no co-relation with Doyle index. Also for hands, cervical
and lumbar spine VAS and clinical indices did not co-relate.
Conclusion: KGMC index is best applicable to assess the osteoarthritis knee joint.
Radiological progression in OA co-relates well with all clinical indices including
KGMC index. This study highlights the usefulness of visual analogue scale and
various radiological and clinical indices to assess osteoarthritis especially for
knee joint.
Introduction
Osteoarthritis (OA) is the most
common joint disease of mankind
and is also the leading cause of chronic
disability in developed countries.1
It
is a slowly progressive degenerative
joint disease, characterized by pain
and functional disability. The larger
joints are commonly affected and
specifically involvement of the hip and
knee joint has a great health (care) and
economic burden. Diagnosis of OA is
usually based on symptoms (clinical
OA) and is confirmed by radiography.2
An inconsistent association between
radiographic and clinical OA hampers
diagnosis however.3,4
In clinical practice expression of
disease varies significantly between
p a t i e n t s , p o s s i b l y i m p l y i n g t h e
existence of different types of OA.
Despite this inconsistency and the
development of magnetic resonance imaging, with which a relation between
pain and structural damage like bone
marrow lesions and bone attrition was
found,5,6 radiographs are still the gold
standard for demonstrating structural
changes since image acquisition is noninvasive,
cheap, fast, and generally
available.7,8
Various outcome measures for
radiographic and clinical OA are
described in studies. Common outcomes
for radiographic OA are Kellgren
and Lawrence grading (KL)9 and in
recent years actual measurement of
joint space width (JSW) has been
increasingly applied.10,11 A limitation of
radiographic evaluation is that, except
for the direct evaluation of bone, the
tissues involved in the OA process are
either evaluated indirectly (cartilage)
or not at all (synovium). In evaluation
of clinical OA the visual analogue
scale (VAS) for pain, and the Western
Ontario and McMaster Universities OA
Index (WOMAC)12,13 scores for pain,
stiffness and function are validated
and commonly used outcome measures.
The objective of this study was to
correlate the clinical status with activity
and radiological score in osteoarthritis
of various joints.
Materials and Methods
A C r o s s - s e c t i o n a l s t u d y wa s conducted at Department of Medicine of a tertiary care hospital, Mumbai after approval from institutional ethics committee. We studied 100 consecutive patients of osteoarthritis of various joints over a period of one year either attending OPD or admitted for various reasons.
Inclusion Criteria
1. Primary osteoarthritis of various
joints in either sex.
2. Those who gave informed consent.
Exclusion Criteria
1. P a t i e n t s w i t h s e c o n d a r y
osteoarthritis due to trauma,
RA, congenital or developmental
defect, metabolic, endocrine,
inflammatory neuropathic and
endemic diseases.
2. Patients less than 12 years of age.
A thorough clinical examination of affected joint was performed and relevant laboratory investigation like ESR, CRP, IgM rheumatoid factor and radiology of the affected joint was done in all patients, which is the standard of care. Grading of severity of osteoarthritis was assessed by following indices:
Clinical Indices
1. Knee / Hip by Lequesne et al.14-16
2. Articular Index of Doyle et al. for
Osteoarthritis (the higher the score
the worse the osteoarthritis)17
3. Modified WOMAC index – KGMC
index18
Radiological Indices
1. Kellgren and Lawrence global grading scheme for the severity
of osteoarthritis of the knee, hip, lumbar disc degeneration and apophyseal joints of the cervical spine.19
2. K a l l m a n g r a d i n g s c a l e f o r
individual features of the hand.19
3. Individual radiographic features
assessed in radiographs of the hip
and lumbar spine.20
Statistical Analysis of data was done by using SPSS software ver. 21. The association of clinico-radiological association was assessed by unpaired `t’ test, chi square test and Pearson’s co-efficient of correlation.
Results
Out of 100 patients of osteoarthritis, 73% were females and rest were males with mean age of 54.2 and 57.3 years respectively. Knee joint was commonly involved (89%) followed by lumbar spine (49%), cervical spine (31%) and hand (26%) (Table 1).
Knee joint swelling and tenderness
had significant positive co-relation with
each other. However no co-relation was
observed between swelling and VAS,
clinical indices (Lequesne, KGMC,
Doyle) and radiological index. Knee
joint tenderness was significantly corelating
with KGMC and radiological
index while no co-relations was
observed between tenderness and VAS,
Lequesne and Doyle index (Table 2).
Knee joint’s clinical and radiological
indices co-relation showed that,
Lequesne and KGMC Indian index were
co-relating positively with each other
but Lequesne and Doyle index in this
study were not co-relating. Lequesne,
KGMC and Doyle’s Index, all showed
significant co-relation with radiological
indices suggesting that clinical and
radiological indices for knee joint
co-relate with each other (Table 3).
On observing co-relation of hand,
cervical and lumbar spine, we found
that clinical and radiological indices
were co-relating positively in cervical
and lumbar spine. Movement restriction
and tenderness were also co-relating
with each other in lumbar spine (Table
4).
When severity of illness by visual
analogue scale as assessed by the
patients and other clinical indices were
co-related with each other, results
obtained suggested that for knee joints
visual analogue scale and clinical
indices (Lequesne and KGMC) were
co-related positively, however visual
analogue scale and Doyle index did
not co-relate. For hands, cervical spine
and lumbar spine visual analogue scale
and clinical indices did not co-relate
(Table 5).
Discussion
Several studies have been conducted all over the world to note various p a r a m e t e r s o f O A w i t h s p e c i a l emphasis on the knee joint as it is the most commonly involved joint. Present study is an attempt to find out the co-relation between clinical and radiological indices in osteoarthritis of various joints.
H u n d r e d p a t i e n t s o f p r i m a r y o s t e o a r t h r i t i s f o l l o w i n g u p i n rheumatology and medical OPD of a tertiary care hospital were studied. Most commonly involved joint was knee joint (89%). Both Indian and Western literature shows that knee is the most commonly affected joint in mono or pauciarticular pattern.21 The results are also attributed to habit of squatting in Indian population during day to day activity. The second common involvement was lumbar spine (49%) which can be attributed to lifting heavy weights on heads, manual labor which is common in Indian population. Spine osteoarthritis is seen in areas of maximum spinal motion in middle aged and elderly best manifested by pain on bending backwards. In the present study, hand affection was seen in 26% patients. In Indian scenario of vibratory tools in industries, and other occupations attributes to hand involvement as osteoarthritis. Hip joint involvement was seen in 7% patients. In India, hip joint involvement was found in one study in Karnataka described as Handigodu disease. 22 Hip joint involvement is not commonly seen in India as compared with Western countries which are still unexplained.
I n p r e s e n t s t u d y , we t r i e d t o co-relate various disease parameters viz. visual analogue scale, clinical profile, clinical indices and radiological indices with each other for various joints to find out their reliability in assessing the status of osteoarthritis. In case of osteoarthritis of knee cases the association between swelling and tenderness was significant. Knee joint tenderness co-relates with KGMC clinical index and radiological index suggesting that tenderness can be a reliable indicator of knee osteoarthritis. Knee joint clinical indices like Lequesne co-relate with Indian KGMC index and radiological index positively, however, the same is not true for Doyle’s index, suggesting that Indian KGMC index for assessing severity of knee osteoarthritis is reliable. 18 Worldwide WOMAC scale is being use to assess knee joint osteoarthritis, but, we did not find it applicable in Indian population. KGMC scale is modified WOMAC scale which is best applicable in Indian scenario. The positive co-relation between KGMC scale and radiological indices further validates the reliability of KGMC score that it can be used to assess the progression of osteoarthritis of knee. Doyle index was not co-relating with KGMC and Lequesne, thus should not be advocated in Indian population.
I n t h e p r e s e n t s t u d y , h a n d osteoarthritis and clinical indices didn’t not co-relate with each other. Doyle’s clinical and radiological indices of cervical and lumbar spine co-relates well with each other and can thus be taken as a good marker for assessment of clinico-radiological presentation in patients. Movement restriction and tenderness were also co-relating well with each other in lumbar spine.
Visual analogue scale (VAS) as given by patients at the time of presentations in outpatients department when corelated with clinical indices suggested that it had a good co-relation in knee joint only. VAS co-related significantly with Lequesne and Indian KGMC index with respect to knee joint, but showed no co-relation with Doyle index. Also for hands, cervical and lumbar spine, VAS and clinical indices did not corelate. Hence there is a need to study the clinical indices for other joints like hands, wrist, cervical and lumbar spine in Indian population.
Conclusion
We thus conclude that KGMC index is best applicable to assess the osteoarthritis knee joint followed by Lequesne index while Doyle index is not suited. Radiological progression in OA co-relates well with all clinical indices including KGMC index. This study highlights the usefulness of visual analogue scale and various radiological and clinical indices to assess osteoarthritis especially for knee joint.
References
© Journal of the Association of Physicians of India 2011
Site Designed @ URVI COMPUGRAPHICS