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The role of varus and valgus alignment in the initial development of knee cartilage damage by MRI: the MOST study
  1. Leena Sharma1,
  2. Joan S Chmiel2,
  3. Orit Almagor1,
  4. David Felson3,
  5. Ali Guermazi4,
  6. Frank Roemer4,5,
  7. Cora E Lewis6,
  8. Neil Segal7,
  9. James Torner8,
  10. T Derek V Cooke9,
  11. Jean Hietpas10,
  12. John Lynch10,
  13. Michael Nevitt10
  1. 1Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
  2. 2Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
  3. 3Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts, USA
  4. 4Department of Radiology, Boston University Medical Center, Boston, Massachusetts, USA
  5. 5Department of Radiology, Klinikum Augsburg, Augsburg, Germany
  6. 6Division of Preventive Medicine, University of Alabama, Birmingham, Alabama, USA
  7. 7Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, Iowa, USA
  8. 8Department of Epidemiology, University of Iowa, Iowa City, Iowa, USA
  9. 9School of Rehabilitation Therapy, Queens University, Kingston, ON, Canada, and OAISYS, Inc
  10. 10Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
  1. Correspondence to Leena Sharma, Division of Rheumatology, Feinberg School of Medicine, Northwestern University, 240 East Huron, McGaw M300, Chicago, IL 60611, USA; L-Sharma{at}


Objective Varus and valgus alignment are associated with progression of knee osteoarthritis, but their role in incident disease is less certain. Radiographic measures of incident knee osteoarthritis may be capturing early progression rather than disease development. The authors tested the hypothesis: in knees with normal cartilage morphology by MRI, varus is associated with incident medial cartilage damage and valgus with incident lateral damage.

Methods In MOST, a prospective study of persons at risk of or with knee osteoarthritis, baseline full-limb x-rays and baseline and 30-month MRI were acquired. In knees with normal baseline cartilage morphology in all tibiofemoral subregions, logistic regression was used with generalised estimating equations to examine the association between alignment and incident cartilage damage adjusting for age, gender, body mass index, laxity, meniscal tear and extrusion.

Results Of 1881 knees, 293 from 256 persons met the criteria. Varus versus non-varus was associated with incident medial damage (adjusted OR 3.59, 95% CI 1.59 to 8.10), as was varus versus neutral, with evidence of a dose effect (adjusted OR 1.38/1° varus, 95% CI 1.19 to 1.59). The findings held even excluding knees with medial meniscal damage. Valgus was not associated with incident lateral damage. Varus and valgus were associated with a reduced risk of incident lateral and medial damage, respectively.

Conclusion In knees with normal cartilage morphology, varus was associated with incident cartilage damage in the medial compartment, and varus and valgus with a reduced risk of incident damage in the less loaded compartment. These results support that varus increases the risk of the initial development of knee osteoarthritis.

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  • Funding Support for this project comes from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, R01 HD43500 (LS), and the National Institute on Ageing, U01 AG18820 (DF), U01 AG18832 (JT), U01 AG18947 (CEL) and U01 AG19069 (MN).

  • Competing interests None.

  • Ethics approval The study protocol was approved by each site's institutional review board.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.