 Okay, now just a quick short run about arthritis I'll be just discussing some salient points because arthritis in itself is a huge topic So just how to approach an x-ray when you get a knee x-ray of arthritis So the radiograph that you take in a knee arthritis is AP view obviously that's the most common view Standing or supine standing or a weight-bearing has more importance in arthritis because you can actually judge the joint space narrowing when the patient is standing Lateral view skyline view is not always taken But if you want to see the patellofemoral compartment that's when you can see Rosenberg view Now this is a weight-bearing or a standing radiograph which is done with 40 degree flexion of it And this is particularly important to diagnose early away because you can see the joint space very nicely So even mile narrowing in the joint space can be really picked up well on the Rosenberg view And the last thing is a scanogram which will be discussing about a bit later So what is the importance of an obliquity of the x-ray now normally whenever you take a AP view the central beam is actually placed About 1.5 centimeter Below the apex of the patella so just as you this is the apex of the patella and about Approximately 1.5 centimeter below is where you put your central beam now if Obviously you don't get the ideal x-rays every time and this is what happens when you don't get an ideal x-ray So this is a patient both the patients are normal But here you will see that here the medial femoral tibial space is very well visualized the lateral is also very well In this patient the lateral femoral tibial space is good, but the medial femoral tibial space is narrow So it so you know this is how it is So this is a nice big space and this is where you see that Someone may just reported that it's a moderate medial femoral tibial joint space now right now Why this is happening? So if you see here the medial tibial plateau is in profile Whereas here I can actually appreciate the entire medial tibial plateau like this So because of the obliquity of the medial tibial plateau you have a false appearance of the narrow joint space So whenever you see such radiographs with the obliquity be sure before you report them as Osteoarthrosis or a reduced joint space because often it won't be so you can just take a clue This is a very crude way But this is your medial femoral and this is which is your anterior margin of the medial femoral And this is the anterior margin of the medial tibia and this distance is actually maintained So when you get such obliquity x-rays make sure that you have a look at them properly before you report a joint space narrow What are the x-ray findings of osteoarthrosis and you can remember them by the term loss? So L stands for reduced joint space here You can see there is no obliquity and actually the joint space is very cheap O is for osteophytes. Just remember osteophytes does not mean that that particular compartment has cartilage loss The two don't go hand in hand here This patient has medial femoral tibial osteophytes, but this patient also has lateral femoral tibial osteophyte That does not mean that the patient has lateral femoral tibial compartment cartilage loss Subcontral sclerosis And subcontral cyst now all these loss of joint space is an indicator of some some form of cartilage loss And subcontral cyst is also an indicator of some form of cartilage loss because they usually develop after a cartilage whereas happen So osteophytes does not indicate cartilage loss in that particular compartment Whereas subcontral cyst and loss of joint space do indicate cartilage loss in that compartment So whenever you get the x-ray the first thing that should come to your mind is is this a typical degenerative osteoarthrosis or is this an Artificial osteoarthrosis which is there that because of some other reason Now it could be a early onset osteoarthrosis or anything of that sort So what are the things that should run in your mind whenever you see an x-ray? Is this a common age for o-ray? So if I see a patient having o-ray in 60 plus Yes, this is a common age for o-ray if I see an x-ray of a 30 year old with o-ray No, that's not a common age for o-ray. So your antenna should go up that why there is o-ray Second is this a common joint for o-ray now normally your hip and knee joints are your weight bearing joints And they are commonly associated with o-ray, but if you get o-ray in a shoulder and elbow joint That's not common. They are not weight bearing So it is secondary to probably a rotator cuff tear in the shoulder or a posterior lateral instability in the elbow Again for that knee is this a common compartment to get o-ray now normally because our knee is a slightly the way a Mechanical axis runs a medial femurotheal compartment Takes more load as compared to the lateral and as a result Medial femurotheal compartment always happens in a primary degenerative hole But if you get a primary lateral compartment o-ray, then you need to think of some cause for it And there are other features which go against a primary o-ray like there are erosion or if there is Symmetrical Try compartment with joint space narrowing and no osteophytes. No subfrontal cyst then that is what you need to think of some other pathology And other additional features which will be indicative of a early onset or a secondary o-ray like signs of ligament Is insufficiency so by now you know the signs of ligament is insufficiency if you see a sulcus terminalis depression You see a second fracture and you see lateral compartment o-ray You know that it is ac linsufficiency that is causing the lateral compartment If you see heat lateral T will that the fractures then obviously the The articular surface is uneven and such a patient will go into lateral compartment o-ray So just whenever you get an x-ray run these five points in your mind And you will come to a conclusion whether it's a primary degenerative o-ray or whether it is an artificial o-ray So here 65 year old female knee pain on the medial aspect Looks like a primary o-ray to me. You have osteophytes You have everything and the age matches the compartment matches the joint matches In this particular case a 35 year old male with knee pain and swelling So if you see first of all 35 is a young bitch to develop o-ray Second thing this patient has a uniform joint space or a symmetric joint space narrowing involving medial and lateral tumourage with compartments Third thing to note is there is a lot of soft tissue density. So here you'll see there is a lot of soft tissue density There is a large effusion Okay, so there is a large density here as well So this patient is probably having something else than just a primary o-ray It's a secondary o-ray which could be secondary for some inflammatory or infective pathology This was the MR of the patient where you can see that medial compartment cartilage loss was there and the lateral compartment cartilage is intact So again, what I told you before presence of osteophytes does not mean that there is a cartilage loss in that particular compartment This patient had lateral hemorrhageal osteophytes, but the lateral cartilage was good. So those two don't go to the And here in this patient you can see that there is diffuse narrowing Okay, there is really no significant meniscus that's left and there is a lot of synovial technique So this patient was actually an advanced inflammatory osteopathy with advanced secondary osteostasis 40 year old female with knee pain laterally So you can see that there is a lateral compartment o-ray, but the medial compartment is good. So this is obviously obliquity Okay, here you can see that If I'll say this is my at tbl Latu but if I'll see the anterior margin of the tbl and the anterior margin of female space is very good Right. So this is a predominantly lateral compartment. Now, as I told you lateral compartment o-rays are not common Because normally the weight bearing is the medial compartment. So when you get such x-rays call up the patient and get Some more information get more history because normally you don't get histories for x-rays and you just tend to report and send them off You have to be a clinical radiologist So call up these patients and get a good history and what the patient gave the history was There was a history of partial lateral meniscus. Okay, so what happens is whenever there is a partial lateral meniscus Meniscus act as shock absorbers for the cartilage Once you remove the meniscus, there is increased chances of cartilage wear and therefore this patient Though she was young she was only 40. She landed up into lateral compartment o-ray. So here you can see this was the MR of the patient You can see that there is cartilage loss here. There is cartilage loss here The medial compartment cartilage is good. You cannot see any lateral meniscus You cannot see any lateral meniscus here also and there is a cartilage loss So secondary to partial lateral meniscaectomy the patient had landed up into an early lateral compartment o-ray So, what are the causes of isolated lateral compartment o-ray? ACL deficiency, lateral meniscactomy, prior trauma that is Shaskov fracture or lateral tibial platelet fracture Which may cause irregularity of the arterial surface and hence resultant o-ray What are the causes of o-ray in a young patient? Post-infective, post-inflammatory, post-traumatic. Post-traumatic can again be any of these three Right, so whenever you get something out of the normal just run those five points in your mind of age Joint compartment any other features that you are seeing which is against a primary o-ray any features suggestive of a prior trauma So just whenever you get something which doesn't fit into these five your antennas should go up and you should start looking for the cause of o-ray Now, what are the role of x-ray with the management of o-rays? We've discussed about the diagnosis. Now, what about management? So joint space narrowing particularly when it is in terms of management You want a weight-bearing x-ray and weight-bearing MRI is not possible. So obviously the information will get from a weight-bearing x-ray So you can obviously subjectively classify the o-ray as mild moderate senior depending upon the joint space narrowing And second thing the most important is to know the alignment of the knee Which is again not possible or an MRI because it is not a weight-bearing MRI So you need weight-bearing scanograms for alignment of the knees So this patient again, this is a patient with very mild See, there is no obliquity, but there is reduction in the joint space There is a mild reduction in joint space and if you say there is tiny tibial intercondylar eminence osteophytes tiny osteophyte here as well So this was a patient with a mild early o-ray This is a patient where there is moderate joint space narrowing moderate osteophytes bilaterally Okay, meaning medial and lateral and also added to that you see subcontinuous sclerosis And in this patient besides all the findings you also begin to see that there are Subcontinuous which have started to develop right? So this was a very much advanced Now coming to scanogram scanogram is mainly done to evaluate the alignment Whether a patient has a valgus or a barous mild alignment or it's a neutral alignment So barous is where the discol bone goes away from the midline To be like in simple terms. It is nothing but bone Okay, whether you get a bowing of the knees valgus is where the discol bone comes Away from the midline and again in simple terms. It is nothing but a knock. So knock me is valgus bow knee is your varus This is how you take you take three x-rays and then you stitch them together to get this x-ray now Key thing to remember and this is very very very important Your patella should be facing forwards whenever you take an x-ray You need to tell this to your technician because if the patella is not facing forwards You will not get the right values A neutral alignment x-ray may appear like a mild alignment and the patient will land up with a wrong surgeon Why wrong surgery? I'll let you know in the next few slides So it is very important for the orthophore also that the patella are facing forwards. So this is a normal scanogram Okay Now whenever you get a scanogram What you need to Understand is this is something called as the mechanical axis of the lower limb going from the center of the femoral head Up to the center of the medial valulus of the tia. Okay So this is your mechanical axis and normally the mechanical axis passes just lateral to the tbl spine Normally an individual has a slightly valgus Okay, so it passes just lateral to the tbl spine Which is called as the milkylix point in this other leg if you see the mechanical axis has shifted medial So this patient this knee the right knee is going into varus Again some more examples. This is bow knees You can classically appreciate the bow and this is nothing but varus mal alignment Whereas in this patient you can see there is a valgus mal alignment So normally your line should have passed from here just lateral to the tbl spine But it is passing way too much lateral and this is nothing but the valgus mal alignment on a scanogram There are some angles that you need to measure and put on the scanogram But this is beyond today's session. So I'm not discussing them. You can read them up So let's go. I've just put it you get it on the google what is an LDF and MPTL angle and how to measure And now this is what you need to understand about the scanogram The management and why scanogram or x-rays is important So here you can see that if the patient has a tricompartmental OA the patient will be going for a TTR But what happens if the patient has only medial compartment OA on an x-ray? In such cases patient goes for an MRI to assess the lateral and particular femoral cartilage If it is good, which means that patient has only unique compartmental Now if the biological age by biological age, obviously I mean that if the patient is a runner Yet if the patient is 80 years old, but patient is a runner when his biological age is less actually So if the biological age is 55 to 60 then you do a scanogram Okay, or less than 55 you do a scanogram to look for the alignment If it's a neutral alignment and the ACL is intact patient will go for a unique compartment replacement Which is nothing but the medial compartment replacement But if the patient has a virus or a valgus mal alignment The patient will go for a HTO and DF So this is where we as radiologists play a role This is where they get a scanogram done And we need to inform the orthobox whether the patient has a mal alignment or it's a neutral one Whereas if the lateral or the patella comodal compartment cartilage is bad Then the patient will land up into your TTR So again no more investigation such patients don't require a scanogram But the gray zone is the biological age more than 60 Now if the rest of the cartilage is good and the biological age is more than 60 Some orthos prefer to do a unique compartment way Some orthos prefer to directly go for a totally replacement So it is there is it's a gray zone whether you want to do a unique compartment replacement Or a totally replacement for a elderly patients with good lateral and patella comodal cartilage You don't have to remember this algorithm The whole idea to show this algorithm was You need to start thinking when you're reporting an x-ray that what all stuff you need to put in the report So whenever you get a scanogram what all stuff you need to put in the report Whether there is a mal alignment which compartment is involved Similarly on the knee x-ray MC middle compartment OA is there great But you need to see if there is a lateral compartment OA You need to see if there is a patella femoral area Because that's when your management plan will change So this is just to make you understand that what stuff needs to be put in the report So take home points, have a format to read any radiograph Look at the review areas before reporting a radiograph as normal So avoid satisfaction of search In case of doubt please call up the patient Call up the referring doctor and find out the clinical history I'm telling you your life will be very easy to do that Are the knee x-rays really useful? So by now I hope you've understood that Yes knee x-rays are very useful in today's practice Even in today's practice when you have MRI And that depends upon how well you understand these x-rays and how well you report them