title: New view on the initial development site and radiographic classification system of osteoarthritis of the knee based on radiographic analysis.
abstract: BACKGROUND
  Radiographic pathology of severe osteoarthritis of the knee (OAK) such as severe osteophyte at tibial spine (TS), compartment narrowing, marginal osteophyte, and subchondral sclerosis is well known. Kellgren-Lawrence grading system, which is widely used to diagnose OAK, describes narrowing-marginal osteophyte in 4-grades but uses osteophyte at TS only as evidence of OAK without detailed-grading. However, kinematically the knee employs medial TS as an axis while medial and lateral compartments carry the load, suggesting that early OAK would occur sooner at TS than at compartment. Then, Kellgren-Lawrence system may be inadequate to diagnose early-stage OAK manifested as a subtle osteophyte at TS without narrowing-marginal osteophyte. This undiagnosed-OAK will deteriorate becoming a contributing factor in an increasing incidence of OAK.
  
  
  METHODS
  This study developed a radiographic OAK-marker based on both osteophyte at TS and compartment narrowing-marginal osteophyte and graded as normal, mild, moderate, and severe. With this marker, both knee radiographs of 1,728 patients with knee pain were analyzed.
  
  
  RESULTS
  Among 611 early-stage mild OAK, 562 or 92% started at TS and 49 or 8% at compartment. It suggests the initial development site of OAK, helping develop new site-specific radiographic classification system of OAK accurately to diagnose all severity of OAK at early, intermediate, or late-stage. It showed that Kellgren-Lawrence system missed 92.0% of early-stage mild OAK from diagnosis.
  
  
  CONCLUSIONS
  A subtle osteophyte at TS is the earliest radiographic sign of OAK. A new radiographic classification system of OAK was suggested for accurate diagnosis of all OAK in severity and at stage.
authors.affiliation: Department of Orthopedic Surgery, Interfaith Medical Center, 1545 Atlantic Ave, Brooklyn, NY, USA.
authors.forename: Ki-Ho
authors.initials: KH
authors.lastname: Moon
keywords: axis of the knee; initial development site of knee osteoarthritis; knee kinematics; narrowing of compartment and marginal osteophyte; osteoarthritis of the knee; osteophyte at tibial spine; radiographic classification system of knee osteoarthritis