Skeletal Radiology

, Volume 47, Issue 4, pp 511–517 | Cite as

The posterior–anterior flexed view is better than the anterior–posterior view for assessing osteoarthritis of the knee

  • Kilian Rueckl
  • Friedrich Boettner
  • Noor Maza
  • Armin Runer
  • Ulrich Bechler
  • Peter Sculco
Scientific Article
  • 66 Downloads

Abstract

Objective

The aim of this study is to determine whether the posterior–anterior (PA)-flexed view improves the radiographic assessment of patients with knee pain compared with the standard standing anterior–posterior radiograph.

Materials and methods

Three hundred and sixty-five patients with knee pain underwent anterior–posterior (AP), PA flexed, lateral, and Merchant radiographs of the knee. Knees were grouped as mild (Kellgren and Lawrence [K-L] 1–2) or severe (K-L 3–4) osteoarthritis (OA) and either varus (medial compartment), valgus (lateral compartment), or patellofemoral OA.

Results

In knees with mild valgus OA on AP view (K–L 1–2), the PA flexed view was more sensitive than the AP view. The measured lateral minimal joint space width (minJSW) decreased more than 2 mm in 68% of the patients, resulting in an increase in K–L grade (3 or 4). In patients with severe valgus OA and in all patients with varus and patellofemoral OA, there was no difference between AP and PA flexed view with regard to radiographic measurements or KL grade. Based on the Medicare reimbursement rate using the PA flexed view alone instead of both views reduced imaging costs by 47%.

Conclusion

The PA flexed view better classifies the severity of lateral compartment disease in patients with mild valgus OA and provides comparable diagnostic sensitivity for joint space narrowing in varus- and patellofemoral OA. Using the PA flexed view alone was more cost effective than using the combination of AP and PA flexed imaging.

Keywords

PA flexed view Assessment Osteoarthritis Cost Valgus 

Notes

Compliance with ethical standards

Conflicts of interest

Author Friedrich Boettner receives royalties from Smith&Nephew and Orthodevelopment and compensation from Smith&Nephew, Orthodevelopment, and DePuy. All other authors declare that they have no conflicts of interests.

References

  1. 1.
    Leach RE, Gregg T, Siber FJ. Weight-bearing radiography in osteoarthritis of the knee. Radiology. 1970;97(2):265–8.CrossRefPubMedGoogle Scholar
  2. 2.
    Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis. 1957;16(4):494–502.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Altman RD, Gold GE. Atlas of individual radiographic features in osteoarthritis, revised. Osteoarthritis Cartilage. 2007;15(Suppl A):A1–56.CrossRefPubMedGoogle Scholar
  4. 4.
    Mancuso CA, Ranawat CS, Esdaile JM, Johanson NA, Charlson ME. Indications for total hip and total knee arthroplasties. Results of orthopaedic surveys. J Arthroplast. 1996;11(1):34–46.CrossRefGoogle Scholar
  5. 5.
    UniCare. Clinical UM guideline #: CG-SURG-54. 2017. https://www.unicare.com/medicalpolicies/guidelines/gl_pw_c187157.htm. Accessed 7 October 2017.
  6. 6.
    Cicuttini F, Hankin J, Jones G, Wluka A. Comparison of conventional standing knee radiographs and magnetic resonance imaging in assessing progression of tibiofemoral joint osteoarthritis. Osteoarthritis Cartilage. 2005;13(8):722–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Kijowski R, Blankenbaker DG, Stanton PT, Fine JP, Smet AAD. Radiographic findings of osteoarthritis versus arthroscopic findings of articular cartilage degeneration in the tibiofemoral joint. Radiology. 2006;239(3):818–24.CrossRefPubMedGoogle Scholar
  8. 8.
    Messieh SS, Fowler PJ, Munro T. Anteroposterior radiographs of the osteoarthritic knee. J Bone Joint Surg Br. 1990;72(4):639–40.PubMedGoogle Scholar
  9. 9.
    Peterfy C, Li J, Zaim S, Duryea J, Lynch J, Miaux Y, et al. Comparison of fixed-flexion positioning with fluoroscopic semi-flexed positioning for quantifying radiographic joint-space width in the knee: test-retest reproducibility. Skeletal Radiol. 2003;32(3):128–32.CrossRefPubMedGoogle Scholar
  10. 10.
    Guermazi A, Niu J, Hayashi D, Roemer FW, Englund M, Neogi T, et al. Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham osteoarthritis study). BMJ. 2012;345:e5339.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Kijowski R, Blankenbaker D, Stanton P, Fine J, De Smet A. Arthroscopic validation of radiographic grading scales of osteoarthritis of the tibiofemoral joint. AJR Am J Roentgenol. 2006;187(3):794–9.CrossRefPubMedGoogle Scholar
  12. 12.
    Buckland-Wright JC, Wolfe F, Ward RJ, Flowers N, Hayne C. Substantial superiority of semiflexed (MTP) views in knee osteoarthritis: a comparative radiographic study, without fluoroscopy, of standing extended, semiflexed (MTP), and schuss views. J Rheumatol. 1999;26(12):2664–74.PubMedGoogle Scholar
  13. 13.
    Michael Johnson J, Mahfouz MR. Cartilage loss patterns within femorotibial contact regions during deep knee bend. J Biomech. 2016;49(9):1794–801.CrossRefPubMedGoogle Scholar
  14. 14.
    Buckland-Wright JC, Macfarlane DG, Williams SA, Ward RJ. Accuracy and precision of joint space width measurements in standard and macroradiographs of osteoarthritic knees. Ann Rheum Dis. 1995;54(11):872–80.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Hellio Le Graverand MP, Mazzuca S, Duryea J, Brett A. Radiographic-based grading methods and radiographic measurement of joint space width in osteoarthritis. Radiol Clin N Am. 2009;47(4):567–79.CrossRefPubMedGoogle Scholar
  16. 16.
    Piperno M, Hellio Le Graverand MP, Conrozier T, Bochu M, Mathieu P, Vignon E. Quantitative evaluation of joint space width in femorotibial osteoarthritis: comparison of three radiographic views. Osteoarthritis Cartilage. 1998;6(4):252–9.CrossRefPubMedGoogle Scholar
  17. 17.
    Mazzuca SA, Brandt KD, Dieppe PA, Doherty M, Katz BP, Lane KA. Effect of alignment of the medial tibial plateau and X-ray beam on apparent progression of osteoarthritis in the standing anteroposterior knee radiograph. Arthritis Rheum. 2001;44(8):1786–94.CrossRefPubMedGoogle Scholar
  18. 18.
    Vignon E, Brandt KD, Mercier C, Hochberg M, Hunter D, Mazzuca S, et al. Alignment of the medial tibial plateau affects the rate of joint space narrowing in the osteoarthritic knee. Osteoarthritis Cartilage. 2010;18(11):1436–40.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Kothari M, Guermazi A, von Ingersleben G, Miaux Y, Sieffert M, Block JE, et al. Fixed-flexion radiography of the knee provides reproducible joint space width measurements in osteoarthritis. Eur Radiol. 2004;14(9):1568–73.CrossRefPubMedGoogle Scholar
  20. 20.
    Neumann G, Hunter D, Nevitt M, Chibnik LB, Kwoh K, Chen H, et al. Location specific radiographic joint space width for osteoarthritis progression. Osteoarthritis Cartilage. 2009;17(6):761–5.CrossRefPubMedGoogle Scholar
  21. 21.
    Reichmann WM, Maillefert JF, Hunter DJ, Katz JN, Conaghan PG, Losina E. Responsiveness to change and reliability of measurement of radiographic joint space width in osteoarthritis of the knee: a systematic review. Osteoarthritis Cartilage. 2011;19(5):550–6.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Botha-Scheepers S, Kloppenburg M, Kroon HM, Hellio Le Graverand MP, Breedveld FC, Ravaud P, et al. Fixed-flexion knee radiography: the sensitivity to detect knee joint space narrowing in osteoarthritis. Osteoarthritis Cartilage. 2007;15(3):350–3.CrossRefPubMedGoogle Scholar
  23. 23.
    Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G*power 3.1: tests for correlation and regression analyses. Behav Res Methods. 2009;41(4):1149–60.CrossRefPubMedGoogle Scholar
  24. 24.
    Hellio Le Graverand MP, Mazzuca S, Duryea J, Brett A. Radiographic grading and measurement of joint space width in osteoarthritis. Rheum Dis Clin N Am. 2009;35(3):485–502.CrossRefGoogle Scholar
  25. 25.
    Segal NA, Frick E, Duryea J, Nevitt MC, Niu J, Torner JC, et al. Comparison of tibiofemoral joint space width measurements from standing CT and fixed flexion radiography. J Orthop Res. 2017;35(7):1388–95.CrossRefPubMedGoogle Scholar

Copyright information

© ISS 2017

Authors and Affiliations

  • Kilian Rueckl
    • 1
  • Friedrich Boettner
    • 1
  • Noor Maza
    • 1
    • 2
  • Armin Runer
    • 1
  • Ulrich Bechler
    • 1
  • Peter Sculco
    • 1
  1. 1.Hospital for Special SurgeryNew YorkUSA
  2. 2.Icahn School of Medicine at Mount SinaiNew YorkUSA

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