Bone Marrow Edema and Its Relation to Progression of Knee Osteoarthritis

  1. David T. Felson, MD, MPH;
  2. Sara McLaughlin, MPH;
  3. Joyce Goggins, MPH;
  4. Michael P. LaValley, PhD;
  5. M. Elon Gale, MD;
  6. Saara Totterman, MD;
  7. Wei Li, MBA;
  8. Catherine Hill, MD, MSc; and
  9. Daniel Gale, MD
  1. From Boston University and the Veterans Affairs Boston Health Care System, Boston, Massachusetts; and University of Rochester, Rochester, New York.

    Abstract

    Background: While factors affecting the course of knee osteoarthritis are mostly unknown, lesions on bone scan and mechanical malalignment increase risk for radiographic deterioration. Bone marrow edema lesions on magnetic resonance imaging correspond to bone scan lesions.

    Objective: To determine whether edema lesions in the subarticular bone in patients with knee osteoarthritis identify knees at high risk for radiographic progression and whether these lesions are associated with limb malalignment.

    Design: Natural history study.

    Setting: A Veterans Administration hospital in Boston, Massachusetts.

    Patients: Persons 45 years of age and older with symptomatic knee osteoarthritis.

    Measurements: Baseline assessments included magnetic resonance imaging of the knee and fluoroscopically positioned radiography. During follow-up at 15 and 30 months, patients underwent repeated radiography; at 15 months, long-limb films were obtained to assess mechanical alignment. Progression was defined as an increase over follow-up in medial or lateral joint space narrowing, based on a semi-quantitative grading. Generalized estimating equations were used to evaluate the relation of medial bone marrow edema lesions to medial progression and lateral lesions to lateral progression, before and after adjustment for limb alignment.

    Results: Of 256 patients, 223 (87.1%) participated in at least one follow-up examination. Medial bone marrow lesions were seen mostly in patients with varus limbs, and lateral lesions were seen mostly in those with valgus limbs. Twenty-seven of 75 knees with medial lesions (36.0%) showed medial progression versus 12 of 148 knees without lesions (8.1%) (odds ratio for progression, 6.5 [95% CI, 3.0 to 14.0]). Approximately 69% of knees that progressed medially had medial lesions, and lateral lesions conferred a marked risk for lateral progression. These increased risks were attenuated by 37% to 53% after adjustment for limb alignment.

    Conclusion: Bone marrow edema is a potent risk factor for structural deterioration in knee osteoarthritis, and its relation to progression is explained in part by its association with limb alignment.

    Article and Author Information

    • Acknowledgments: The authors thank field staff and study participants for generously giving their time. They also thank Dr. Kenneth Pritzker for valuable discussions on the pathology of bone marrow edema.

    • Grant Support: By the National Institutes of Health (AR47785) and by an Arthritis Foundation Clinical Sciences Grant.

    • Potential Financial Conflicts of Interest: None disclosed.

    • Requests for Single Reprints: David T. Felson, MD, MPH, Boston University School of Medicine, 715 Albany Street, A203, Boston, MA 02118.

    • Current Author Addresses: Drs. Felson, LaValley, and Hill and Ms. McLaughlin, Ms. Goggins, and Ms. Li: Boston University School of Medicine, 715 Albany Street, A203, Boston, MA 02118.

    • Drs. M.E. Gale and D. Gale: Radiology Department, Veterans Affairs Boston Health Care System, 150 Huntington Avenue, Boston, MA 02130.

    • Dr. Totterman: Department of Radiology, University of Rochester Medical Center, 601 Elmwood Avenue, PO Box 694, Rochester, NY 14624-8648.

    • Author Contributions: Conception and design: D.T. Felson.

    • Analysis and interpretation of the data: D.T. Felson, J. Goggins, M.P. LaValley, S. Totterman, W. Li.

    • Drafting of the article: D.T. Felson.

    • Critical revision of the article for important intellectual content: M.P. LaValley, C. Hill, D. Gale.

    • Final approval of the article: D.T. Felson.

    • Provision of study materials or patients: D.T. Felson, J. Goggins.

    • Statistical expertise: D.T. Felson, M.P. LaValley.

    • Obtaining of funding: D.T. Felson.

    • Administrative, technical, or logistic support: D.T. Felson, J. Goggins, M.P. LaValley, M.E. Gale, W. Li, D. Gale.

    • Collection and assembly of data: D.T. Felson, S. McLaughlin.

    Summary for Patients

    • Summaries for Patients:Association of Bone Marrow Changes with Worsening of Knee Osteoarthritis Ann Intern Med September 2, 2003 139:I-33
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    1. Ann Intern Med September 2, 2003 vol. 139 no. 5 Part 1 330-336
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