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Radiographic Analysis ofKnee Arthritis
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> Valgus stress radiographs of the knee have been
described as a diagnostic option to assess the ability
to correct varus knee deformity in patients with
medial compartment osteoarthritis who may be can-
didates for medial unicompartmental knee arthro-
plasty (Argenson etal. 2002).
Similar to full-length standing radiographs, stress radiographs are not routinely obtained by all providers. To
obtain this view, a rm valgus force is applied through
the knee while the X-ray beam is shot from anterior to
posterior (Waldstein etal. 2013). The utility of valgus
stress radiographs is unknown as these radiographs do
not signicantly correlate to the amount of lateral compartment cartilage or the correctability of varus deformity (Waldstein etal. 2013). In theory, however, if the
lateral compartment was to collapse on a valgus stress
radiograph, the patient may not be an ideal candidate
for medial unicompartmental knee arthroplasty.
11.3 Radiographic Grading
While a number of grading systems are utilized to quantify the severity of knee osteoarthritis as seen on plain
radiographs, Kellgren–Lawrence (KL) is the most commonly used method to grade radiographic osteoarthritis
severity (Braun and Gold 2011; Kellgren and Lawrence
1957). The KL system was rst described in 1957 based
on AP knee radiographs.
. Table 11.1 Kellgren–Lawrence grading system for knee
osteoarthritis
Grade 0 No radiographic features of osteoarthritis are
present.
Grade 1 Doubtful joint space narrowing and possible
osteophyte formation
Grade 2 Denite osteophyte formation, possible joint
space narrowing
Grade 3 Multiple osteophytes, denite joint space
narrowing, sclerosis, possible deformity
Grade 4 Large osteophytes, marked joint space narrowing,
severe sclerosis, denite deformity
In addition to the Kellgren–Lawrence grading sys-
tem, a number of other radiographic grading systems
exist (.
Table 11.2). Each of the grading systems
assesses the degree of joint space narrowing as well as
other identiable characteristic osseous changes such as
osteophytes. In a recent study, the International Knee
Documentation Committee (IKDC) Classication had
the most favorable combination of reliability and correlation to the severity of osteoarthritis as seen during
arthroscopy (Wright etal. 2014).
11.4 Radiographic Assessment
ofNon-Osteoarthritic Arthritis
> The KL system combined their observed radiographic
features of OA which included: osteophytes on the
joint margin or tibial spines, narrowing of joint carti-
lage associated with sclerosis of subchondral bone, and
small pseudocystic areas with sclerotic walls situated in
subchondral bone (Kellgren and Lawrence 1957).
The system has become pervasive in orthopedic literature for research related to OA of many joints as well as
useful in guiding clinical decision-making and outcome
prediction. Even insurance companies will often require
documentation of aspects of the KL classication prior
to granting TKA and viscosupplementation injection
authorization.
The KL grading system is shown in .
Table 11.1.
Despite its wide adoption, studies have demonstrated a
wide range of interobserver reliability of the KL grading system ranging from 0.51 to 0.89 (Wright 2014).
Furthermore, a recent study found that the interclass
correlation coefcient (ICC) of the KL grading system
signicantly varied based on the type of image that was
being graded with a exed posteroanterior X-ray having
a higher ICC as compared to a fully extended anteroposterior X-ray (Wright etal. 2014).
While the majority of patients who present to the arthroplasty clinic will have primary osteoarthritis, it is important for the provider to be able to critically assess
radiographs to identify features that may suggest an
alternative cause to the patient’s arthritis such as an
inammatory process, trauma, or infection.
> The presence of bony erosions (Jacobson etal. 2008),
which are a hallmark of inammatory arthritis, can
readily allow a clinician to differentiate between
inammatory and primary osteoarthritis.
Bony erosions in the setting of inammatory arthritis
typically occur at the margin of an inamed joint in an
area that is devoid of hyaline cartilage. In addition to
bony erosions, inammatory arthritis is also characterized by uniform joint space narrowing since cartilage
destruction is uniform throughout the joint.
Rheumatoid arthritis is a common example of
inammatory arthritis. Radiographic features suggestive of rheumatoid arthritis include uniform joint space
loss, bony erosions, soft tissue swelling, and periarticular
osteopenia (. Fig. 11.3) (Jacobson et al. 2008).
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M. B. Zaid and J. Barry
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. Table 11.2 Alternative radiographic grading systems for knee osteoarthritis
11
Grading
system
IKDC A: No
Fairbank 0:
Brandt 0:< 25%
Ahlback 0:
Jager–
Wirth
IKDC International Knee Documentation Committee, JSN joint space narrowing
Grade and characteristics
B: Small osteophytes,
JSN
Normal
JSN
Normal
0:
Normal
slight sclerosis, > 4mm
joint space
1: Squaring of tibia 2: Flattening of
1:< 25% JSN with features
(sclerosis, osteophytes) or
25–50% JSN without
features
1: JSN without features 2: Obliteration of joint
1: Initial arthrosis,
minimal JSN, small
osteophytes
C: 2–4mm of joint
space
femoral condyles
2: 25–50% JSN with
features, 50–75% JSN
without features
space
2: Moderate arthrosis,
50% JSN
ab c
D:< 2mm joint space
3: Hypertrophic
changes, JSN or both
3: 50–75% JSN with
features, or>75% JSN
without features
3: Bone loss <5mm 4: Bone loss 5–10mm
3: Medium-grade
arthrosis
4: Increased severity of
all previously listed
characteristics
4:> 75% JSN with
features
4: Heavy-grade arthrosis
. Fig. 11.3 a–c Radiographs demonstrating the characteristic appearance of rheumatoid arthritis with symmetric joint space narrowing,
relatively minimal osteophyte formation, periarticular osteopenia, and cystic changes
Additionally, there tends to be a lack of bony proliferation (osteophyte formation) in patients with rheumatoid
arthritis which may help further differentiate it from primary osteoarthritis (Jacobson etal. 2008).
Similar to rheumatoid arthritis, arthritis as the
sequelae of a septic joint can be identied with uniform
joint space narrowing, soft tissue swelling, and bony erosions. History is typically helpful in differentiating
between rheumatoid and infectious arthritis as rheumatoid arthritis is polyarthritis while septic arthritis is typically monoarticular and the patient will describe a
history of an infection.
A plain radiograph can offer diagnostic findings
in addition to the standard patterns of wear.
Clinicians should also be able to determine patterns
of post- traumatic osteoarthritis of the knee on plain
radiographs or ACL-deficient knee patterns (Johnson
et al. 2017). Other diagnoses such as crystalline
deposit disorders (calcium pyrophosphate disease
[CPPD] or pseudogout and gout), retained hardware,
bony and soft tissue tumors, avascular necrosis,
osteochondral defects, vascular disease/calcifications,
and congenital deformities are all apparent on plain
radiographs.
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11.5 Correlation ofOA Severity andTKA
Outcomes
Although TKA unquestionably can improve pain and
function, there remains a subset of patients (up to 20%)
who remain dissatised after TKA (Nilsdotter et al.
2009; Woolhead etal. 2005; Beswick etal. 2012). This
group of unsatised patients remains an area of study
within the arthroplasty community as we strive to maximize the benet for our patients. Contributing factors
that have been found to affect satisfaction postoperatively include patient-related (psychosocial and medical
comorbidities), surgeon/healthcare-related (care access,
rehabilitation, expectation management, and intraoperative technique such as soft tissue balancing and alignment), and disease-related (type of arthritis, preoperative
severity, and deformity).
> Although there is a poor correlation between clinical
symptoms and radiographic severity of knee osteoarthritis (Bedson and Croft 2008), recent literature may
suggest that radiographic knee osteoarthritis severity
correlates to postoperative outcomes after TKA.
A recent meta-analysis concluded that patients with
worse radiographic preoperative knee osteoarthritis
were more likely to be satised after surgery at nal follow- up (Youlden etal. 2019). While patients with worse
radiographic osteoarthritis were more satised after
TKA, there was no signicant difference in the postoperative pain or function scores in patients with KL 4
arthritis versus KL<4 arthritis (Youlden etal. 2019).
Understanding this possible relationship may play a role
in counseling and the management of patient expectations following TKA. Additionally, a thorough preoperative evaluation of other possible pain generators and
trial of conservative management options should be had
with patients prior to undergoing TKA.
11.6 Radiographic Evaluation ofTKA
Radiographs following TKA are routinely obtained at
follow-up to assess implant position, wear, and xation.
A postoperative radiographic series is often similar to a
preoperative series though variations in practice exist.
For our practice, we typically obtain a standing AP, max
exion lateral, and patellofemoral view. For an accurate
assessment, the entire component must be visualized
including any augments or long stems.
> Images are individually assessed and compared to
prior lms for component alignment and position,
implant–cement and cement–bone interfaces, poly-
ethylene thickness, bone quality, and any progressive
lesions such as osteolytic defects (.
Fig.11.4).
More detailed evaluation for aseptic loosening can be
found in 7 Chap. 52. Briey, however, the greatest tool
is the evaluation of serial radiographs to look for a
change in implant position or progression of radiolucent lines (. Fig.11.5).
a b
. Fig. 11.4 a, b Standing PA and lateral views demonstrating a well-placed and well-xed cemented TKA with an appropriate cement
mantel
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. Fig. 11.5 A Series of standing PT and lateral X-rays of a
cemented TKA demonstrating progressive loosening and failure.
The immediate postoperative image on the left side demonstrates a
well-xed arthroplasty; subsequent images demonstrate the formation of radiolucent lines at the bone–implant interface indicative of
loosening and then subsequent varus collapse
Unfortunately, there is a relative lack of standardization
in the radiographic assessment of total knee implants
postoperatively (Elmallah etal. 2015). Although classication systems were proposed in 1989 such as the Knee
Society Total Knee Arthroplasty Roentgenographic
Evaluation and Scoring System (Ewald 1989), many
revision articles typically only report coronal, sagittal,
and axial alignment and then bone loss at the time of
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revision. A more recent updated Knee Society scoring
system has been created, which we encourage readers to
utilize for standardization.
> The Modern Knee Society scoring system (Meneghini
etal. 2015) provides a structured framework to evaluate the integrity of total knee prosthesis xation.
Weight-bearing AP, lateral, and patellofemoral views
are examined for radiolucent lines at cement–bone and
implant–cement interfaces. Additionally, the signicance of these radiolucencies depends on whether they
are stable or progressive on serial imaging and if they
involve the entire contact interface or just part of it. The
Modern Knee Society scoring system assesses loosening
of a cemented component by breaking the tibia and
femur into ve distinct zones and looking for the cumulative amount of radiolucency at the prosthetic interface
(.
Table 11.3) (Meneghini et al. 2015). Additionally,
component alignment and position are evaluated on
each radiographic view. On the weight-bearing PA view,
the coronal alignment can be evaluated relative to the
anatomic axis of the femur; the coronal alignment of
the tibial component can be judged by measuring the
angle between the baseplate and the mechanical axis of
the tibia. The lateral radiographs are used to evaluate
the sagittal alignment of the component. Sagittal tibial
component alignment can be determined by measuring
the angle between the baseplate and the tibial shaft while
the sagittal femoral component position can be measured from the angle between the femoral shaft and a
line perpendicular to the most distal xation point of
the femoral component. Finally, patellofemoral component position is assessed by examining subluxation and
tilt in the trochlear groove as seen on the Merchant view.
While cement xation remains the gold standard for
total knee arthroplasty, interest in cementless implants
has been increasing.
> Overall, postoperative evaluation of cementless
implants is similar to that of cemented implants; pro-
viders should assess serial radiographs for signs of
implant loosening such as progressive migration or
radiolucencies.
The appearance of a well-functioning cemented total
knee implant may be signicantly different than a wellfunctioning cementless implant; it is important that the
provider be able to recognize these differences as cementless implants become more common. A recent series of
modern cementless total knee implants demonstrated
that all patients demonstrated peri-implant radiolucencies at the 6-week follow-up with the majority of these
on the tibial side. These radiolucencies can persist as
long as 1year (the nal follow-up in the study) and are
typically small (<2mm), incomplete, and nonprogressive (Costales etal. 2020).
11.7 Cross-Sectional andAdvanced
Imaging
11.7.1 Computed Tomography
Routine use of cross-sectional imaging techniques such
as computed tomography and magnetic resonance imaging are not typically used for the diagnosis of knee
osteoarthritis as X-ray can consistently provide a diagnosis in most cases and is more readily available and
affordable at less radiation risk to the patient.
. Table 11.3 Modern Knee Society radiographic grading
Zone
Tibial component Femoral component
AP XR
1 Medial baseplate Anterior baseplate Anterior ange Medial
2 Lateral baseplate Posterior baseplate Posterior ange Lateral
3 Central keel/stem
4 Revision TKA stem
extension
5 Inferior aspect of keel/stem Inferior aspect of keel/stem Superior aspect of revision TKA
a
Can further be denoted with M (medial) and L (lateral)
b
Can further be denoted with A (anterior) and P (posterior),
c
can further be denoted with A (anterior chamfer) and P (posterior chamfer) if visible
a
Patellofemoral
component
Lateral XR Lateral and AP XR
a
Central keel/stem
Revision TKA stem
extension
b
b
Central box/pegs/distal xation
c
region
Revision TKA stem extension
stem
PF XR
Central peg/baseplate
a
b
–
–
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Conventional CT scans offer no signicant benet over
plain radiographs as cartilage is not readily visualized
(Blackburn etal. 1996). To overcome this, arthrography
with an iodized-based injection may be done to allow for
improved visualization of intraarticular structures
including cartilage (Carrillon 2008). With this technique,
focal cartilage defects and thinning can readily be identied in each of the compartments. Little evidence exists
in the current literature examining the efcacy of CT
scans in the diagnosis of knee osteoarthritis.
> In the postoperative setting, CT scan is most often
used to assess component rotation or to evaluate for
fractures around the implant.
11.7.2 Magnetic Resonance Imaging
Similar to computed tomography, magnetic resonance
imaging does not play a signicant role in the routine
diagnosis of knee osteoarthritis. Although unlike CT
scans and plain radiographs, MRI is able to visualize
cartilage, it is less readily available, relatively expensive,
and does not offer signicant benet for routine diagnosis. Typically, cartilage is visualized on T2 weighted
images with fat suppression where it appears grey in
color and can readily be distinguished from subchondral
bone which is dark, and synovial uid, which is bright.
> Magnetic resonance imaging may play a role in pre-
operative planning for unicompartmental knee
replacements where the clinician will need to determine if the patient truly has arthritis isolated to a
single compartment and whether or not they have an
intact anterior cruciate ligament.
Radiographic assessment of knee osteoarthritis is typically
performed on plain radiographs. For the majority of cases,
the standard osteoarthritis X-rays series should be sufcient enough to make a diagnosis and aid in presurgical
planning. Advanced cross- sectional imaging techniques
such as computed tomography and magnetic resonance
imaging should be used sparingly and for specic cases.
11.7.3 Nuclear Medicine
Nuclear medicine studies including three-phase
Technetium- 99m bone scans and tagged white blood cell
(WBC) scans are alternative diagnostic tools for implant
loosening and infection that are typically used in con-
junction with history, physical exam, and serologies in
difcult diagnostic cases.
Technetium-99m is a sensitive marker of bone turnover, however, since increased bone turnover is seen in
cases of implant loosening, tumor, infection, and metabolic bone disease, the test is relatively non-specic
(Hofmann etal.
1990; Rosenthall etal. 1987; Hill etal.
2019). A recent retrospective study found that
Technetium- 99m bone scans had a positive predictive
value of 2.5%, a negative predictive value of 100%, a
specicity of 33%, and a sensitivity of 100%, making it
relatively poor stand-alone test (Hill et al. 2019).
Additionally, increased radionuclide uptake can persist
for a year or even longer after an index procedure in
patients who are completely asymptomatic (Rosenthall
etal. 1987). This is especially true in cementless TKA.
> It has been demonstrated that in asymptomatic
patients, increased Technetium-99m take-up can be
seen at the bone–implant interface in cementless total
knees for up to 4years following the index procedure;
however, rates of uptake typically decrease as time
progresses (Rubello etal. 1996).
Given the excellent negative predictive value of the
bone scan, this tool can be useful in ruling out infection
or implant loosening if it is negative.
Take-Home Messages
5 Knee osteoarthritis is a clinical diagnosis that is
conrmed on plain radiographs consisting of a
series of a exed weight-bearing PA views, lateral views, and patellofemoral views.
5 Full-length standing radiographs may be useful
for presurgical planning in patients with lower
extremity deformity.
5 Radiographic osteoarthritis severity poorly cor-
relates to pain; however, preoperative radiographic osteoarthritis severity inversely
correlates to postoperative TKA outcomes.
5 Serial radiographs to check for changes in
implant position or radiolucencies at the bone–
cement or cement–implant interface can be useful for the diagnosis of implant loosening.
Peri-implant radiolucency is common in cementless TKA; these lucencies can be persistent and
asymptomatic.
5 Technetium-99m bone scans have poor specic-
ity but high sensitivity for diagnosing loosening
and possibly infection.
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11
Patient-Reported Outcomes
https://t.me/medicina_free
inTotal Knee Arthroplasty
AnasSaleh andDenisNam
Contents
12.1 Introduction – 124
12.2 General Health Outcome Measures – 124
12.2.1 Medical Outcomes Study Short-Form (SF-36 andSF-12) – 124
12.2.2
EuroQOL 5-Dimension Score (EQ-5D) – 125
The Patient-Reported Outcomes Measurement Information System
12.2.3
(PROMIS) – 127
12.2.4 Press Ganey – 129
12.2.5 Prediction Model forPatient Satisfaction (PMPS) – 130
123
12
12.3 Joint-Specic Outcome Measures – 130
12.3.1 Western Ontario andMcMaster Universities Osteoarthritis Index
(WOMAC) – 130
12.3.2 Knee Injury andOsteoarthritis Outcome Score (KOOS) – 130
12.3.3 Oxford Knee Score (OKS) – 131
12.3.4 Knee Society Score – 131
References – 131
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
E. Hansen, K.-D. Kühn (eds.), Essentials of Cemented Knee Arthroplasty,
https://doi.org/10.1007/978-3-662-63113-3_12
124
https://t.me/medicina_free
A. Saleh and D. Nam
12
12.1 Introduction
Recent emphasis on demonstrating treatment outcomes
and “value-based care” in total knee arthroplasty (TKA)
has led to the development of multiple outcome measures and scoring systems. These may include
performance- based objective assessments, patientreported assessments, or both. As a result of honoring
the relative importance of patient satisfaction as compared to surgeon satisfaction with treatment results,
there has been a shift in orthopedic literature toward
patient-reported outcomes (Wright 2009). These patientreported outcome measures can be generic measures of
quality of life or joint-specic. The general health measures evaluate a range of physical and mental parameters. A joint-specic measure is focused on issues that
are related to a specic joint or injury.
> Most epidemiologists believe that studies should
include general health outcomes in addition to jointspecic ones (Vangsness etal. 1995).
In general, a practical outcome measure should be easy
to administer, reliable, valid, and responsive to clinical
change (Roos etal. 1998).
5 Reliability refers to the test’s ability to give consistent
and reproducible results under similar testing conditions.
5 Validity is the ability of an outcome measure to eval-
uate what it is designed to measure.
5 Responsiveness is the ability to detect change in con-
dition when it occurs.
5 The minimal clinically important difference (MCID)
of an outcome measure is the smallest change in an
outcome score that corresponds to a signicant
change in a patient’s condition (Beaton etal. 2002;
Smith etal. 2012).
The purpose of this chapter is to examine the more common patient-reported outcomes in TKA, including both
general health outcome measures and knee-specic measures. It will also serve as an update on some of the newly
developed outcome measures. Knowledge of these various patient-reported outcomes is critical for both
researchers involved in designing clinical studies and clinicians evaluating the literature on TKA outcomes.
12.2 General Health Outcome Measures
The advantage of a general health outcome measure is
that it can be used to compare diseases and conditions
across the medical spectrum. This allows researchers to
compare the relative impact of treatment on patients
despite completely different diagnoses. Patients and cli-
nicians may believe that the general health measure is
less relevant to the disease condition in question and that
any such measure should be combined with diseasespecic outcome measures that have more content and
validity for that specic condition (Giesinger etal. 2014).
12.2.1 Medical Outcomes Study
Short-Form (SF-36 andSF-12)
The Medical Outcomes Study 36-Item Short-Form (SF-
36)is one of the most popular general health outcome
measures (Ware and Sherbourne 1992). It was developed to assist in health policy development, clinical
practice, research, and general population surveys. The
SF-36 has been extensively used in numerous publications to measure outcomes of over 130 diseases and conditions (Ware 2000).
This questionnaire consists of 35 questions in 8 subscale domains (4physical health domains and 4 mental
health domains), and one general overall health status
question (.
weighted, and transformed to fall between 0 (worst possible health and severe disability) and 100 (best possible
health, no disability). This was designed so that an average US citizen would score 50 on a subscale. The SF-36
has been validated for a variety of ages and languages,
and for patients aged 75 years and older (Weinberger
et al. 1991; Jenkinson et al. 1994; Lyons et al. 1994;
Perneger etal. 1995; Sullivan etal. 1995).
While the SF-36 has proved to be useful for a variety
of diseases, it is too long for inclusion in some largescale health measurements. Subsequently, the 12-Item
Short-Form (SF-12) was developed (. Table 12.1)
(Ware etal. 1996). This represented a “downsizing” of
the SF-36, including 12 items that reproduced more
than 90% of the variance in SF-36 physical health and
mental health components, and accurately reproduced
the average scores of these measures. The length of this
questionnaire reduced the original SF-36 to one to two
pages, so that it is sufcient for self-administration in
2minutes or less. In choosing between forms, Ware etal.
recommended the use of SF-36 for smaller studies due
to its reliability in measuring more levels of health,
whereas the SF-12 is recommended in studies with large
sample sizes having constraints on questionnaire length
and in studies focusing on patient-based assessments of
physical and mental health (Ware etal. 1996).
> Webster et al. compared the performance of SF-12
and SF-36in 407 patients who underwent TKA and
found a signicant correlation between both versions
for preoperative and 1-year postoperative measures
(Webster and Feller 2016). The change in score from
pre- to postoperative was also highly correlated.
Table12.1). Each subscale score is totaled,
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