Knee-xRAI: An Explainable AI Framework for Automatic Kellgren-Lawrence Grading of Knee Osteoarthritis

Radiographic grading of knee osteoarthritis (KOA) with the Kellgren-Lawrence (KL) system is limited by inter-reader variability and the opacity of current deep learning approaches, which predict KL grades directly from images without decomposing structural features. We present Knee-xRAI, a modular framework that independently quantifies the three cardinal radiographic features of KOA (joint space narrowing [JSN], osteophytes, and subchondral sclerosis) and integrates them into an explainable KL grade classification. The pipeline combines U-Net++ segmentation for contour-based JSN measurement, an SE-ResNet-50 network for per-site osteophyte grading (OARSI scale), and a hybrid texture-CNN classifier for binary sclerosis quantification. The resulting 50-dimensional structured feature vector feeds two complementary classification paths. An XGBoost path supports SHAP-based feature attribution. A ConvNeXt hybrid path combines the structured vector with a full-image encoder for enhanced predictive performance. Evaluated on 8,260 radiographs from an OAI-derived dataset, the JSN module achieved a Dice coefficient of 0.8909 and an mJSW intraclass correlation of 0.8674 against manual annotations. The ConvNeXt hybrid path reached a test quadratic weighted kappa (QWK) of 0.8436 and AUC of 0.9017. The transparent XGBoost path achieved a test QWK of 0.6294 with full feature-level audit capability. Ablation confirmed JSN as the dominant predictor (QWK = 0.6103 alone), with osteophyte features providing consistent incremental gain (+0.0183) and sclerosis contributing marginally. Inference-time ablation of Path B confirmed the structured pathway contributes materially beyond the image encoder, with QWK drops of 0.098 (feature zeroing) and 0.284 (feature-image permutation). Knee-xRAI explicitly quantifies all three KL-defining radiographic features within a single auditable pipeline.