A comparison of the semiflexed (MTP) view with the standing extended view (SEV) in the radiographic assessment of knee osteoarthritis in a busy routine X-ray department

Objective. To compare the reproducibility of the standing extended view (SEV) (also known as the standing anteroposterior view) with the semiflexed, postero-anterior view [the 'metatarsophalangeal' (MTP)] view for assessing joint space width (JSW) and osteophytes in osteoarthritis of the knee when used in a busy routine X-ray department. Methods. Forty-seven patients (24 men) had both SEV and MTP views taken on the same day in a busy National Health Service radiography department. Repeat views were taken as entirely separate procedures some time over the following 2 weeks, in the same department and with no special arrangements for the selection of radiographers, time of day, or X-ray machine. The first 24 patients had second views in the SEV position whilst the remaining 23 had second MTP views. Radiographs were read independently by two experienced observers who measured JSW with a transparent ruler to the nearest 0.5 mm at the narrowest point in both medial and lateral compartments of the tibiofemoral joint in both knees. Osteophytes were graded 0-2 according to a standard atlas. Ten SEV and 10 MTP radiographs selected randomly were re-read by one observer. Results. Mean (95% confidence interval) JSW in the medial compartment measured on SEV radiographs was 3.54 mm (3.08, 3.99) and on MTP radiographs it was 2.80 mm (2.37, 3.23); in the lateral compartment it was 6.04 mm (5.71, 6.37) when measured on SEV radiographs and 5.47 mm (5.09, 5.85) on MTP radiographs. The estimated variances for the medial compartment were 2.0 mm(2) for SEV and 0.2 mm(2) for MTP (P<0.001) and for the lateral compartment 1.4 mm(2) for SEV and 0.5 mm(2) for MTP (P<0.001). The proportion of radiographs for which there was disagreement between observers regarding osteophyte grade was not statistically different between SEV and MTP views (SEV, medial 40%, lateral 44%; MTP, medial 39%, lateral 39%). Conclusions. Even when radiographs are taken in a busy National Health Service radiography department, measurement of JSW from the MTP view is more reproducible than from the SEV view, the MTP view gives a slightly lower measurement of JSW, and there is no advantage in using either view in recording osteophyte grade. We recommend the wider adoption of the MTP method.