High-grade bone edema identified by MRI is common in patients with rheumatoid arthritis (RA) undergoing orthopedic surgery, according to a report in the December Annals of the Rheumatic Diseases. High-grade bone edema identified by MRI is common in patients with rheumatoid arthritis (RA) undergoing orthopedic surgery, according to a report in the December Annals of the Rheumatic Diseases.

"This is one more piece of evidence (and there are now epidemiological, clinical, imaging, and histological data) to show that MRI bone edema in the setting of inflammatory arthritis is a sign of aggressive disease with bone-eroding potential - and is a 'red flag' to alert the clinician that active and aggressive management is required," Dr. Fiona M. McQueen from University of Auckland, New Zealand told Reuters Health.

Dr. McQueen and colleagues investigated whether MRI bone edema was present at the site of surgery in 11 RA patients undergoing joint replacement or fusion and whether it corresponded with the presence of osteitis in resected subchondral bone specimens.

More surgical than nonsurgical sites showed bone edema (60 versus 38 per cent), erosions (75 versus 41 per cent), and synovitis (70 versus 31 per cent), the authors report, and higher degrees of each were found at surgical compared with nonsurgical bone sites.

In several patients, the investigators say, extensive bone edema exactly matched the site of intended surgery on the preoperative MRI scan.

Bone edema scores correlated with pain scores and C-reactive protein levels, the report indicates, and there was complete concordance between bone edema and subchondral osteitis in four of seven bone samples.

"We have presented compelling evidence that MRI bone edema in RA patients is associated with an inflammatory cellular infiltrate (osteitis) involving subchondral bone," the authors conclude. "We suggest that this osteitic lesion is painful and possibly associated with ongoing bony destruction, and that is the reason for its over-representation within the surgical field for patients undergoing reparative orthopedic surgery."

"If a patient with early RA has evidence of florid bone edema, e.g., at the wrist, I would regard this as a sign of aggressive disease and intensify management," Dr. McQueen said. "This would very rarely occur in an asymptomatic patient, as intense bone edema usually goes with other evidence of active disease such as pain, synovitis and, often, (after a while) joint erosion.

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