Structural predictors of response to intra-articular steroid injection in symptomatic knee osteoarthritis

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Abstract

Background

The aim was to examine if structural factors could affect response to intra-articular steroid injections (IASI) in knee osteoarthritis (OA).

Method

Persons with painful knee OA participated in an open-label trial of IASI where radiographic joint space narrowing (JSN) and Kellgren-Lawrence (KL) grade, whole-organ magnetic resonance imaging (MRI) scores (WORMS) and quantitative assessment of synovial tissue volume (STV) were assessed on baseline images. Participants completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) and a question about knee pain with a visual analogue scale for pain during nominated activity (VAS _NA), and Outcome Measures in Rheumatology (OMERACT)-Osteoarthritis Research Society International (OARSI) criteria were used to assess responder status within 2 weeks (short term) and 6 months (longer term). Regression models were used to examine predictors of short and longer term response to IASI.

Results

Subjects ( n = 207) attended and had IASI. Information on responder status was available on 199 participants. Of these, 188 subjects, mean age 63.2 years (standard deviation (SD) 10.3), 97 (51.6%) female, had x-rays and 120 had MRI scans available. Based on the OMERACT-OARSI criteria, 146 (73.4%) participants responded to therapy and 40 (20.1%) were longer term responders. A few factors were associated with a reduced KOOS-pain and VAS _NA response though none were associated with OMERACT-OARSI responder status in the short term. Higher MRI meniscal damage (odds ratio (OR) = 0.74; 95% CI 0.55 to 0.98), increasing KL maximal grade (OR = 0.43; 95% CI 0.23 to 0.82) and joint space narrowing (JSN) maximal score (OR = 0.60; 95% CI 0.36 to 0.99) were each associated with a lower odds of longer term responder status. Baseline synovitis was not associated with treatment response. The predicted probability of longer term response decreased from 38% to 12% as baseline maximal JSN increased from grade 0 to 3.

Conclusion

Compared with those who have mild structural damage, persons with more severe knee damage on either MRI or x-ray are less likely to respond to knee IASI.

Trial registration

ISRCTN.com, ISRCTN07329370. Registered 21 May 2010. Retrospectively registered

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Most cited references 24

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Whole-Organ Magnetic Resonance Imaging Score (WORMS) of the knee in osteoarthritis.

C Peterfy, A Guermazi, S Zaim … (2004)

To describe a semi-quantitative scoring method for multi-feature, whole-organ evaluation of the knee in osteoarthritis (OA) based on magnetic resonance imaging (MRI) findings. To determine the inter-observer agreement of this scoring method. To examine associations among the features included in the scoring method. Nineteen knees of 19 patients with knee OA were imaged with MRI using conventional pulse sequences and a clinical 1.5 T MRI system. Images were independently analyzed by two musculoskeletal radiologists using a whole-organ MRI scoring method (WORMS) that incorporated 14 features: articular cartilage integrity, subarticular bone marrow abnormality, subarticular cysts, subarticular bone attrition, marginal osteophytes, medial and lateral meniscal integrity, anterior and posterior cruciate ligament integrity, medial and lateral collateral ligament integrity, synovitis/effusion, intraarticular loose bodies, and periarticular cysts/bursitis. Intraclass correlation coefficients (ICC) were determined for each feature as a measure of inter-observer agreement. Associations among the scores for different features were expressed as Spearman Rho. All knees showed structural abnormalities with MRI. Cartilage loss and osteophytes were the most prevalent features (98% and 92%, respectively). One of the least common features was ligament abnormality (8%). Inter-observer agreement for WORMS scores was high (most ICC values were >0.80). The individual features showed strong inter-associations. The WORMS method described in this report provides multi-feature, whole-organ assessment of the knee in OA using conventional MR images, and shows high inter-observer agreement among trained readers. This method may be useful in epidemiological studies and clinical trials of OA.

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Atlas of individual radiographic features in osteoarthritis, revised.

R D Altman, G E Gold (2007)

Develop a radiographic atlas of osteoarthritis (OA) to be used as a template and guide for grading radiographs of osteoarthritic lesions of the hand, hip and knee. The 1995 atlas was reviewed for the images most useful for clinical trials. Replacement images were selected from the Stanford University Radiology Department Picture Archive and Communications System by reviewing consecutive radiographs obtained from patients. Selected images were downloaded without patient identification information. Images were organized by hand, hip and knee. They were reviewed for findings of OA and images grouped into image files by individual findings and degree of change. Both investigators individually selected the most promising images. Final images were selected by consensus. Original electronic images were then cropped and placed in sequence. Individual radiographic features (e.g., osteophytes, joint space narrowing) were recorded for hand (distal interphalangeal joint, proximal interphalangeal joint, trapeziometacarpal joint), hip (acetabular, femoral) and knee (medial compartment, lateral compartment, tibial, femoral); they were also sequenced for normal, 1+, 2+, and 3+ change. Images were made available in print and electronic formats. An updated atlas of radiographic images was produced to assist in grading individual radiographic features of the hand, hip and knee for clinicians and for use in clinical trials.

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Increase in bone marrow lesions associated with cartilage loss: a longitudinal magnetic resonance imaging study of knee osteoarthritis.

Michael LaValley, D Felson, Joyce Goggins … (2006)

Although bone marrow lesions (BMLs) are powerful predictors of joint space loss as visualized on radiographs, the natural history of these lesions, their relationship to cartilage loss, and the association between change in these lesions and cartilage loss are unknown. These questions were tested using longitudinal magnetic resonance imaging (MRI) data in a natural history study of symptomatic knee osteoarthritis (OA). MRI of the knee was performed at baseline, 15 months, and 30 months in 217 patients with primary knee OA (122 men, 95 women; mean +/- SD age 66.4 +/- 9.4 years). To assess mechanical alignment, long-limb films were obtained at 15 months. Subchondral bone marrow abnormalities, graded in the medial and lateral tibiofemoral joints, were defined as poorly marginated areas of increased signal intensity in the marrow on fat-suppressed, T2-weighted images. Cartilage morphologic features in the medial and lateral tibiofemoral joints were scored at all time points using a semiquantitative scale. For each of the medial and lateral compartments, generalized estimating equations were used to evaluate the longitudinal relationship of tibiofemoral BMLs to the tibiofemoral cartilage score, with adjustment for malalignment. Fifty-seven percent of knees had BMLs at baseline, of which 99% remained the same or increased in size at followup. Knee compartments with a higher baseline BML score had greater cartilage loss. An increase in BMLs was strongly associated with further worsening of the cartilage score. Enlarging or new BMLs occurred mostly in malaligned limbs, on the side of the malalignment (e.g., new medial BMLs in varus-aligned knees). The association of BML change with medial tibiofemoral cartilage loss was not significant after adjusting for alignment. Lesions of the bone marrow are unlikely to resolve and often get larger over time. Compared with BMLs that stay the same, enlarging BMLs are strongly associated with more cartilage loss. Furthermore, any change in BML is mediated by limb alignment.

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Author and article information

Contributors

Nasimah Maricar: nasimah.maricar@manchester.ac.uk

Matthew J. Parkes: matthew.parkes@manchester.ac.uk

Michael J. Callaghan: michael.callaghan@manchester.ac.uk

Charles E. Hutchinson: c.e.hutchinson@warwick.ac.uk

Andrew D. Gait: Andrew.gait@manchester.ac.uk

Richard Hodgson: Richard.hodgson@manchester.ac.uk

David T. Felson: david.felson@manchester.ac.uk

Terence W. O’Neill: terence.o'neill@manchester.ac.uk

Journal

Journal ID (nlm-ta): Arthritis Res Ther

Journal ID (iso-abbrev): Arthritis Res. Ther

Title: Arthritis Research & Therapy

Publisher: BioMed Central (London )

ISSN (Print): 1478-6354

ISSN (Electronic): 1478-6362

Publication date (Electronic): 8 May 2017

Publication date PMC-release: 8 May 2017

Publication date (Print): 2017

Volume: 19

Electronic Location Identifier: 88

Affiliations

[1 ]ISNI 0000000121662407, GRID grid.5379.8, Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, , University of Manchester, ; Manchester, UK

[2 ]GRID grid.454377.6, , NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, ; Manchester, UK

[3 ]ISNI 0000 0000 8535 2371, GRID grid.415721.4, Department of Physiotherapy, , Salford Royal Hospital NHS Foundation Trust, ; Manchester, UK

[4 ]ISNI 0000 0001 0790 5329, GRID grid.25627.34, Department of Health Professions, , Manchester Metropolitan University, ; Manchester, UK

[5 ]ISNI 0000 0000 8809 1613, GRID grid.7372.1, , Imaging Sciences, University of Warwick, Warwick Medical School, ; Coventry, UK

[6 ]ISNI 0000000121662407, GRID grid.5379.8, Centre for Imaging Sciences, Institute of Population Health, , The University of Manchester, ; Manchester, UK

[7 ]ISNI 0000 0004 0367 5222, GRID grid.475010.7, Clinical Epidemiology Unit, , Boston University School of Medicine, ; Boston, MA USA

[8 ]Department of Rheumatology, Salford Royal Hospital NHS Foundation Trust, Manchester, UK

Article

Publisher ID: 1292

DOI: 10.1186/s13075-017-1292-2

PMC ID: 5423020

PubMed ID: 28482926

SO-VID: 1471f5aa-a965-422e-9667-53ab313da716

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 2 October 2016

Date accepted : 7 April 2017

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100000341, Arthritis Research UK;

Award ID: 18676

Custom metadata

ScienceOpen disciplines: Orthopedics

Keywords: knee osteoarthritis,clinical trial,intra-articular steroid injection,predictors of response

Data availability:

ScienceOpen disciplines: Orthopedics

Keywords: knee osteoarthritis, clinical trial, intra-articular steroid injection, predictors of response

Structural predictors of response to intra-articular steroid injection in symptomatic knee osteoarthritis

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Abstract

Background

Method

Results

Conclusion

Trial registration

Related collections

Orthopedics

Most cited references 24

Whole-Organ Magnetic Resonance Imaging Score (WORMS) of the knee in osteoarthritis.

Atlas of individual radiographic features in osteoarthritis, revised.

Increase in bone marrow lesions associated with cartilage loss: a longitudinal magnetic resonance imaging study of knee osteoarthritis.

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