Evaluation of the X- ray Presentation of Osteoarthritis of Knee in - - PDF document

Evaluation of the X- ray Presentation of Osteoarthritis of Knee in Diabetic and Non Diabetic Subject

SHARMISTHA DEY1, MAHBUBA HOSSAIN2, FAHMIDA YESHMINE3, TOWHIDUR RAHMAN4, AS MOHIUDDIN5

1.Assistant Professor, Department of Radiology & Imaging, BIRDEM 2. Junior Consultant, Department of Radiology & Imaging, BIRDEM. 3. Associate Professor, Department of Radiology & Imaging, BIRDEM 4. Assistant Professor, Department of Radiology & Imaging, BIRDEM and 5. Professor & Head, Department of Radiology and Imaging, BIRDEM, Dhaka.

Abstract Introduction: This cross-sectional study was carried out in the Department of Radiology and Imaging of BIRDEM during 1st June 2014 to 30th may 2015, to compare the difference between the x-ray presentation of osteoarthritis of knee in diabetic & non diabetic subjects. A total of 160 patients clinically diagnosed as osteoarthritis of knee of diabetic and non diabetic subjects were enrolled in the study. Duration of pain in

• steoarthritic joint, Joint space narrowing, severity
• f osteophytosis, sclerosis and sub-chondral cyst

formation was analyzed. Results: Joint space narrowing was absent in 04(3.6%), mild/moderate in 69(62%) and severe in 37(33.6%) patients of diabetic group. Joint space narrowing was absent in 02(4%), mild/moderate in 30(60%) and severe in 18(36%) patients of non-diabetic group. Osteophytes was absent in 20(18.2%), mild/ moderate in 54(49.1%) and severe in 36(32.7%) patients of diabetic group. In non-diabetic group absence of osteophyte formation was not found, 22(44%) had mild/moderate and 28(56%) had severe osteophyte formation in this group. Sclerosis was absent in 42(38.2%), mild/moderate in 52(47.3%) and severe in 16(14.5%) patients of diabetic group. In non-diabetic group sclerosis was absent in18(36%), mild/moderate in 22(44%) and severe in 10(20%) patients. Subchondral cysts formation was absent in 70(63.6%), mild/moderate in 38(34.5%) and severe in 02(1.83%) patients of diabetic group. In non-diabetic group sub-chondral cyst formation was absent in 28(56%), mild/ moderate in 20(40%) and severe in 02(4%) of

• patients. Conclusion: Osteophytes formation were

statistically significant (p<0.05) between diabetic and non-diabetic group. However, joint space narrowing, sclerosis and subchondral cysts formation were not statistically significant (p>0.05). Introduction: Osteoarthritis is a progressive, degenerative joint disease characterized by chronic inflammation of the joint lining. It is a joint disease that mostly affects cartilage. Cartilage is the slippery tissue that covers the ends of bones in a joint. Healthy cartilage allows bones to glide over each other. It also helps absorb shock of movement. In

• steoarthritis, the top layer of cartilage breaks

down and wears away. This allows bones under the cartilage to rub together. The rubbing causes pain, swelling, and loss of motion of the joint. Over time, the joint may lose its normal shape. Also, bone spurs may grow on the edges of the joint.1 Among over 100 types of arthritis conditions, OA is the most common condition. In a study Haq et al, it has been found that the prevalence of

• steoarthritis in Bangladesh is 7.5% in rural, 9.2%

in urban slum, 10.6% in urban affluent community.2 Osteoarthritis may be of two types — (a) Primary

• r idiopathic osteoarthritis and (b) Secondary
• steoarthritis .Primary OA is mostly related to
• aging. With aging the water content of cartilage

increases and protein made up of cartilage

• degenerates. Secondary osteoarthritis may be

caused by various causes like- trauma, congenital

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cause, metabolic, endocrine, gout and pseudogout, neuropathic (charcot joint).3 Among the endocrine causes Diabetes mellitus, growth hormonal disorders are also associated with early cartilage wear and secondary OA4. Although the Cardinal pathological feature of osteoarthritis is a progressive loss of articular cartilage,

• steoarthritis is not disease of only the cartilage

but a disease of an organ, the synovial joint, in which all of tissue are affected. The most morphological changes in osteoarthritis are usually seen in load bearing areas of the articular

• cartilage. Remodeling and hypertrophy of bone are

major features of osteoarthritis, appositional bone growth in the subchondrial region, leading to the bone ‘sclerosis’ seen radiographically. Growth of bone at the joint margins leads to osteophytes (spur) which alter the contour of the joint and may restrict movement. Periarticular muscle wasting is common and may play a major role in symptoms and as indicated above, in disability.5 Diabetes Mellitus is a metabolic disorder the prevalence of which is increasing day by day throughout the world. It can be noted that 95% diabetic subjects have type 2 disease. In 2000, Bangladesh had 3.2 million people with Diabetes mellitus and was listed at 10, which will occupy the 7th position with 11.1 million in 2030. As estimated on the basis of present prevalence rates

• f diabetes (Type-2-5.2% and IGT-12.5%), in the

projected population more then 10 million Bangladeshi will suffer from the disease on the year 2010.6 suggested that prevalence of OA is higher in young and middle aged diabetic subjects than in non- diabetic subjects.7 Insulin has been demonstrated to stimulate cartilage growth and proteoglycan biosynthesis. These effects are likely to be mediated through somatostatin (Insulin like growth factor-I) (Husni et al., 2007).7 It is suggested that the diminished availability of insulin at the cellular level or diabetic micro-vascular disease attenuates the chondro and osteogenesis required for osteophyte formation in the joints of patients with

• steoarthritis.8 Since insulin is a potent growth

factor for connective tissue, the study is designed to investigate the difference between x-ray presentations of osteoarthritis of knee in diabetic and non-diabetic subjects Materials & Methods: This cross sectional study was performed in the Department of Radiology and Imaging, BIRDEM from June 2014 to May 2015, who were referred from medicine out patients Department, BIRDEM, for plain x-ray both knee joints AP view. 200 patients were collected consecutively, out of them 15 having decreased bone density, 10 having H/0 trauma, 10 having neuropathic joint and another 5 with deformity of the joints were excluded from the study. Ultimately a total of 160 patients were included in this study. Out of them 110 were diabetic and 50 were non diabetic. The objective of the study was to find out the difference between the x-ray presentation of

• steoarthritis of knee in diabetic & non diabetic
• subjects. Demographic information was

prospectively recorded and substantiated by means of inspection of medical record. Information included the subject’s age, sex, followed by plain x-ray knee joint AP view. The x-ray both knee joint AP view was performed by an efficient technician under observation of the investigator herself. For evaluation the investigator herself and two radiologists did interpretation of the films without knowing the two groups (diabetic and non-diabetic) to get unbiased reports. Observation and Results: The study was conducted in the department of radiology and imaging at BIRDEM from June 2014 to May 2015. The main objective of the study was to find out the comparison between x-ray presentation of osteoarthritis of knee in diabetic and non-diabetic subjects. A total of 160 subjects were included in the study. All the subjects underwent X-ray of both knee joints AP view. The findings derived from the data analysis are furnished below. The study included 160 patients with

• steoarthritis were divided into three groups

according to their duration of osteoarthritis (OA), which were <5 years, 6-10 years and >10 years. The severity of osteophytosis and subchondral sclerosis was analyzed in relation to the duration

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• f pain in the osteoarthritic knee. Knee OA had

been symptomatic for at least 11 years were considered, marked osteophyte formation was noted in only 4 of the 19 with diabetic (21.1%), but in 14 of the 18 (77.8%) in non diabetic. The duration

• f clinically apparent OA influence the severity of
• steophytes formation in non diabetic. Table-I

below showing the severity of Osteophytes and sclerosis according to the duration of osteoarthritis (OA) diabetic and non-diabetic subjects. Severity of radiographic features of osteoarthritis in diabetic and non-diabetic subjects (n=160) are summarized in Table-II. Results in this category showed that osteophytes formation were statistically significant (p<0.05) between diabetic and non-diabetic group and Joint space narrowing, Sclerosis and Subchondral cysts formation were not statistically significant (p>0.05) in chi square test. Table I DM NDM Years of OA Years of OA < 5 yrs 6-10 yrs >10 yrs < 5 yrs 6-10 yrs >10 yrs n % n % n % n % n % n % Osteophytosis Absent 08 11.9 08 33.3 04 21.1 00 00 00 00 00 0.0 Mild/moderate 31 46.3 12 50.0 11 57.8 16 80 02 16.7 04 22.2 Marked 28 41.8 04 16.7 04 21.1 04 20 10 83.3 14 77.8 Sclerosis Absent 24 35.8 14 58.4 04 21.1 02 10 10 83.3 06 33.3 Mild/moderate 29 43.3 08 33.3 15 78.9 16 80 02 16.7 04 22.2 Marked 14 20.9 02 08.3 00 0.00 02 10 00 0.0 08 44.5

DM= diabetes mellitus NDM= non diabetes mellitus

Table-II DM NDM P -value n % n % Joint space narrowing Absent 04 3.6 02 04 Mild/moderate 69 62.0 30 60 0.946 NS Marked 37 33.6 18 36 Osteophytosis Absent 20 18.2 00 00 Mild/moderate 54 49.1 22 44 0.001 S Marked 36 32.7 28 56 Sclerosis Absent 42 38.2 18 36 Mild/moderate 52 47.3 22 44 0.686 NS Marked 16 14.5 10 20 Subchondai cysts Absent 70 63.6 28 56 Mild/moderate 38 34.5 20 40 0.531 NS Marked 02 1.83 02 04

DM = Diabetes mellitus, NDM= Non Diabetes mellitus, S= significant, NS= Not significant, P= Value reached from chi square test.

Evaluation of the X- ray Presentation of Osteoarthritis of Knee in Diabetic and Non Diabetic Subject Sharmistha Dey et al

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Discussion: The radiographic features that characterize

• steoarthritis (OA) are the result of articular

cartilage degeneration and concomitant repair activity of bone and cartilage. Major features of

• steoarthritis are irregular joint space narrowing,

marginal sclerosis, osteophytes formation and subchondral cysts. Joint fusions, mal-alignment and subluxation may occur but are less common. Mineralization is usually maintained9. This cross sectional study was carried out with an objective to compare the difference between the x-ray presentation of osteoarthritis of knee in diabetic & non-diabetic subjects. A total of 160 patients age ranged from 40 to 79 years clinically diagnosed as osteoarthritis of knee

• f diabetic and non diabetic subjects were included

in the study, who were referred in the department

• f Radiology and Imaging of BIRDEM during 1st

June 2014 to 30th May 2015. The present study findings were discussed and compared with previously published relevant

• studies. In the present study 160 patients with
• steoarthritis were enrolled and they were divided

into three groups according to their duration of

• steoarthritis (OA), which were < 5 years, 6-10

years and >10 years. According to severity of

• steophytosis and subchondral sclerosis was

analyzed in relation to the duration of pain in the

• steoarthritic knee. Osteophyte formation was

noted in only 04 of the 19 diabetic (21.1%), but in 14 of the 18 (77.8%) non-diabetic patients. The duration of clinically apparent OA influence the severity of subchondral sclerosis in non diabetic. Knee Osteoarthrosis (OA) tends to be progressive reported by Massardo et al.10 The severity of osteophytosis and of subchondral sclerosis was analyzed by Horn et al8 with the duration of pain in the osteoarthritic knee. Although there were too few patients in each subgroup and marked osteophyte formation was noted in only 02(28.0%) of the 07 with DM, but in 08(62.0%) of the 13 controls. The results obtained in the present study closely resemble the work of above authors. Fig.-1: Anterio-posterior radiograph of the knee

• steoarthritis without diabetes mellitus showing

joint space narrowing in the medial compartment with minimal osteophytosis. Fig.-2: Anterio-posterior radiograph of the knee

• steoarthritis without diabetes mellitus showing

joint space narrowing in the medial compartment with marked osteophytosis.

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Osteophytes were common in both groups. However, radiographs of 16% of the DM patients and only 2% of the non-diabetic group, showed no evidence of osteophyte formation, which was significant (P<0.05). Furthermore, among those in whom osteophytes were present, spurring was somewhat less likely to be “marked” in the diabetic patients than in those without diabetes (32% and 44%, respectively; (P > 0.05). The summed

• steophyte severity score for the index knee of the

patients with DM averaged 4.1 and that for the nondiabetic patients averaged 5.1 (P<0.05). Subchondral sclerosis also tended to be somewhat less prevalent and less severe in the patients with DM. Horn et al8 have found no significant differences between two of patients with respect to the degree

• f JSN or geode formation. The result obtained in

the above study is similar with the present study, where in this current study it was observed that according to joint space narrowing 04(3.6%) absent, 69(62%) mild/moderate and 37(33.6%) severe in diabetic group. In non-diabetic group 02(4%) absent, 30(60%) mild/ moderate and 18(36%) severe. Osteophytes was 20(18.2%) absent, 54(49.1%) mild/moderate and 36(32.7%) severe in diabetic group. In non diabetic group absent was not found, 22(44%) mild/moderate and 28(56%) severe. Sclerosis was 42(38.2%) absent, 52(47.3%) mild/moderate and 16(14.5%) severe in diabetic group. In non-diabetic group 18(36%) absent, 22(44%) mild/moderate and 10(20%)

• severe. Sub-chondral cysts formation was

70(63.6%) absent, 38(34.5%) mild/moderate and 2(1.83%) severe in diabetic group. In non-diabetic group 28(56%) absent, 20(40%) mild/ moderate and 02(4%) severe. Osteophytes formation were statistically significant (p<0.05) between diabetic and non diabetic. However, joint space narrowing, sclerosis and Sub-chondral cysts formation were almost similar in both groups. Conclusion In this study it was observed that osteoarthritis, particularly of knee which is the most common form of joint disease in the community, has strong association with diabetes mellitus with earlier

• nset and greater severity of the disease. The

study concludes that radiographic appearances

• f osteoarthritis of knee in diabetics differ from

those of non diabetics as osteophyte formation is impaired in diabetic subjects in comparison to non diabetic subjects. However other radiographic changes of osteoarthritis e.g. joint space narrowing, marginal sclerosis and subchondral cysts formation are almost similar in two groups. References 1. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) Nov 2014 2. Haq SA, Darmawan J, Islam MN, Uddin MN, DAS BB, Rahman F, et al. 2000 “Prevalence

• f rheumatic diseases & associated outcomes

in rural & urban communities in Bangladesh COPCORD study”, Done by rheumatology wing, Department of Medicine, BSMMU Dhaka. 3. Doherty M, Lanyon P, Raltson SH 2006, Musculoskeletal disorders; Nicholas A Boon, Nicki R. Colledge, Brian R Walker, Jhon AA. Hunter; Davidson’s Principles and Practice

• f Medicine, 20th Edition, pp.1065- 1144

4. Islam LN 2002, Infection and Inflammatory response in diabetes; Dash RJ, vol. I; New Vistas in type-11 diabetes, p. 290. 68. 5. Brandt KD 2005, Osteoarthritis, In: Kasper, Braunwald, Fauci, Hauser, Longo, Jameson editors, Harrisons Principles of Internal Medicine; 15th edition, Medical publishing division, USA, pp. 2036-2045. 6. Sayeed MA 2007, Epidemiology of Diabetes mellitus, In: Mahatab H. Latif Z A, Pathan

• MF. Diabetes mellitus hand book for

professionals, 4th edition, Diabetic Association of Bangladesh, pp. 24-29. 7. Husni ME, Kroop SF & Simon LS 2005, Joint & Bone Manifestations of Diabetes Mellitus,

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In: Kahn CR, Weir GC, King GL, Moses AC, Smith RJ editors, In Joslin’s Diabetes Mellitus, 14th edition, Lippincott Williams and Wilkins, Philadelphia, pp. 1061-1068. 8. Horn CA, Bradly JD, Brandt KD, Kreipke DL, Slowman SD, Kalasanski LA 1992, “Impairment of Osteophyte formation in hyperglycemic patients with type 2 diabetes mellitus and knee arthritis”, Arthritis and Rheumatism, vol. 35(3), pp. 336-342. 9. Murphy WA and Preston BJ 2001, Joint disease, In: Grainger RG, Alison DJ, Adam A, Dixon AK (editors), A text book of medical imaging, 4th edition, vol. 3, Churchill Livingstone, London, pp. 2016-2020. 10. Massardo L, Watt I, Cushnaghan J, Dieppe P 1989, “Osteoarthritis of the knee: an eight year prospective study”, Ann Rheum Dis, vol. 48, pp. 893-897.

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