Guidelines for the medical management of osteoarthritis. Part I. Osteoarthritis of the hip. American College of Rheumatology

Plasma metabolites associated with biopsychosocial parameters in overweight/obese women with severe knee osteoarthritis

Introduction

Obesity aligned with quadriceps muscle weakness contributes to the high incidence of knee osteoarthritis (KOA), which is prevalent in women. Although molecular signatures of KOA have been suggested, the association between biopsychosocial responses and the plasma metabolomic profile in overweight/ obese women with KOA remains in its early stages of investigation. This study aims to associate the plasma metabolome with biopsychosocial parameters of overweight/obese women diagnosed with KOA.

Methods

Twenty-eight overweight/obese women (Control-n = 14; KOA-n = 14) underwent two visits to the laboratory. Functional tests and questionnaires assessing biopsychosocial parameters were administered during the first visit. After 48 h, the participants returned to the laboratory for blood collection. Specific to the KOA condition, the Numerical Pain Rating Scale (NPRS), Tampa Scale for Kinesiophobia (TSK), and Knee injury and Osteoarthritis Outcome Score (KOOS) were applied.

Results

Thirteen molecules were different between groups, and four correlated with KOA's biopsychosocial parameters. DG 22:4-2OH and gamma-Glutamylvaline were inversely associated with KOSS leisure and TSK score, respectively. LysoPE 18:0 and LysoPE 20:5 were positively associated with KOSS symptoms and TSK score, respectively.

Discussion

While the correlations of LysoPE 18:0 and gamma-Glutamylvaline are supported by existing literature, this is not the case for DG 22:4-2OH and LysoPE 20:5. Further studies are recommended to better elucidate these correlations before dismissing their potential involvement in the biopsychosocial factors of the disease.

Triptolide inhibits the proinflammatory potential of myeloid-derived suppressor cells via reducing Arginase-1 in rheumatoid arthritis

Triptolide (TPT) is widely used in the treatment of rheumatoid arthritis (RA). However, its regulatory mechanisms are not fully understood. This study demonstrated that Myeloid-derived suppressor cells (MDSCs) were expanded in both RA patients and arthritic mice. The frequency of MDSCs was correlated with RA disease severity and T helper 17 (Th17) responses. MDSCs from RA patients promoted the polarization of Th17 cells in vitro, which could be substantially attenuated by blocking arginase-1 (Arg-1). TPT inhibited the differentiation of MDSCs, particularly the monocytic MDSCs (M-MDSCs) subsets, as well as the expression of Arg-1 in a dose dependent manner. Alongside, TPT treatment reduced the potential of MDSCs to promote the polarization of IL-17+ T cell in vitro. Consistently, TPT immunotherapy alleviated adjuvant-induced arthritis (AIA) in a mice model, and reduced the frequency of MDSCs, M-MDSCs and IL-17+ T cells simultaneously. The presented data suggest a pathogenic role of MDSCs in RA and may function as a novel and effective therapeutic target for TPT in RA.

Effects of the combination of pulsed electromagnetic field with progressive resistance exercise on knee osteoarthritis: A randomized controlled trial

BACKGROUND

Knee osteoarthritis (OA) is a common and disabling disease among the elderly population. The optimal conservative treatment for knee OA is not well established.

OBJECTIVE

This study aimed to assess the effectiveness of pulsed electromagnetic field (PEMF) combined with progressive resistance exercise (PRE) in improving physical function and pain in patients with knee OA.

METHODS

Thirty-four patients with knee OA (17 in each group) participated in a single-blind randomized control study. Patients were randomly assigned to receive 24 sessions of either combined PEMF and PRE (treatment group) or PRE only (control group). Patients were evaluated at pre-treatment, post-treatment (2 months), and at 3-month and 6-month follow-ups using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Numeric Pain Rating Scale (NPRS); walking speed and 5-times chair stand test. Mixed ANOVA was used for statistical analysis with Bonferroni adjustments.

RESULTS

There was no significant group-by-time interaction for any outcome (P> 0.05). However, both groups scored significantly higher on the NPRS and KOOS at post-treatment, 3-, and 6-month follow-up compared to their baseline. Further, both groups completed the 5-times chair stand test and walking speed test with significantly less time at all post-treatment time points than the pre-treatment. None of the study outcomes (NPRS, KOOS, walking speed, and 5 times chair stand) were significantly different between groups at any of the time points.

CONCLUSION

Both treatment options, PRE only versus PRE with PEMF, were equally effective in decreasing pain and improving physical function in patients with knee OA. This would suggest that the optimal parameters for PEMF that may show beneficial effects for knee OA when added to PRE training need to be determined.

Clinical use of autologous adipose-derived stromal vascular fraction cell injections for hip osteoarthritis

Introduction

Currently, studies on adipose-derived stromal vascular fraction (SVF) cells are attracting increasing attention because they have the potential to differentiate into a subset of cell types, such as bone marrow-derived mesenchymal stromal cells (MSCs), and are easier to harvest than MSCs, thus making them easier to apply clinically. This study evaluated the short-term clinical outcomes of SVF cell therapy for hip osteoarthritis (OA).

Methods

Forty-two patients were enrolled in this study; these patients received a single injection comprising an average of 3.8 (standard deviation [SD], ±1.3) × 10⁷ SVF cells into the hip joint. All patients were followed-up for at least 6 months. The mean age of the patients was 60.2 years (SD, ±9.4 years). Kellgren-Lawrence (KL) grades II, III, and IV based on radiography were 13, 13, and 16 patients, respectively. SVF cells were obtained from the subcutaneous fat of the abdomen or breech using a Celution® 800/CRS system. The average cell viability of SVF cells was 90.8% (SD, ±2.8%). Clinical assessments were performed using the Harris Hip Score (HHS), Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) score, and visual analog scale (VAS) score to evaluate pain. Images were evaluated using radiography, and T2 mapping values were obtained using a 1.5-T magnetic resonance imaging system. These clinical and imaging assessments were followed from preoperatively to 6 months postoperatively.

Results

The HHS, JHEQ score, and VAS score improved significantly from 22.5 (SD, ±16.6), 26.6 (SD, ±11.3), and 75.5 (SD, ±15.8) preoperatively to 46.8 (SD, ±27.2), 39.4 (SD, ±19.7), and 46.5 (SD, ±27.9), respectively, at 6 months postoperatively. KL grade II showed significant improvement in clinical outcome from preoperative to postoperative, while KL grade IV showed slight or little improvement. The center edge angle, acetabular head index on the radiographs, and T2 mapping values did not change significantly from preoperatively to 6 months postoperatively.

Conclusions

SVF cell injection in the hip joint showed good short-term clinical efficacy for reducing hip OA symptoms. SVF cell therapy is thus an innovative and effective treatment for hip OA.

Comparing Intra-articular Platelet-Rich Plasma With Hyaluronic Acid for the Treatment of Hip Osteoarthritis: A Systematic Review and Meta-Analysis

Hip osteoarthritis (HOA), a prevalent condition among those aged 55 years and above, is a significant cause of joint pain and functional impairment and it contributes to the overall burden of chronic pain experienced by the elderly population. While platelet-rich plasma (PRP) and hyaluronic acid (HA) injections have emerged as innovative therapeutic approaches for managing osteoarthritis, their effectiveness in HOA remains a subject of contention. Therefore, the objective of this review was to assess the efficacy of PRP versus HA in terms of pain relief and functional outcomes for the management of HOA. We searched PubMed, Cochrane Library, and Google Scholar databases from 2013 to 2023 to identify pertinent randomized controlled trials (RCTs). A total of seven trials (478 participants) were included. The selected studies underwent quality assessment using the updated Cochrane risk of bias tool. The pain and functional outcomes were examined using measures of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scale, visual analog scale (VAS), and Harris hip score (HHS). In the meta-analysis, standard mean differences (SMDs) along with 95% confidence intervals (CIs) to estimate overall effect magnitudes for continuous outcomes were extracted. Statistical significance was determined using p-values below 0.05. At six months, the PRP group experienced a significantly lower standard mean WOMAC pain score (SMD = -0.38, CI = -0.64 - 0.13; p = 0.03). No significant differences in WOMAC pain scores were noted at one to two months (SMD = 0.09, CI = -0.24, 0.43; p = 0.59), and at 12 months (SMD = -0.85, CI = -1.81, 0.12; p = 0.09). Similarly, for VAS, patients on PRP showed a slight improvement in their VAS scores at six months (SMD = -0.50, CI = -0.89, -0.12; p < 0.01). However, no significant differences in VAS between the PRP groups and the HA groups were observed at one to two months (SMD = -0.22, CI = -0.49, 0.04; p = 0.10) and at 12 months (SMD = -0.22, CI: -0.63, 0.19; p = 0.29). In terms of hip dysfunction, there was no statistically significant standard mean difference in HHS between the PRP and HA groups at six months (SMD = 0.02, CI = -0.40, 0.44; p = 0.93), and at 12 months (SMD = -0.31, CI = -0.32, 0.22; p = 0.73). This review and meta-analysis provide insights into emerging treatments for HOA, especially considering that PRP shows potential benefits and safety for patients with HOA during mid-term follow-up in a 12-month period. Nevertheless, it is necessary to conduct research that includes high-quality designs and larger sample sizes to validate the comparative efficacy of these treatments.

Psychological and neurological predictors of acupuncture effect in patients with chronic pain: a randomized controlled neuroimaging trial

ABSTRACT

Chronic pain has been one of the leading causes of disability. Acupuncture is globally used in chronic pain management. However, the efficacy of acupuncture treatment varies across patients. Identifying individual factors and developing approaches that predict medical benefits may promise important scientific and clinical applications. Here, we investigated the psychological and neurological factors collected before treatment that would determine acupuncture efficacy in knee osteoarthritis. In this neuroimaging-based randomized controlled trial, 52 patients completed a baseline assessment, 4-week acupuncture or sham-acupuncture treatment, and an assessment after treatment. The patients, magnetic resonance imaging operators, and outcome evaluators were blinded to treatment group assignment. First, we found that patients receiving acupuncture treatment showed larger pain intensity improvements compared with patients in the sham-acupuncture arm. Second, positive expectation, extraversion, and emotional attention were correlated with the magnitude of clinical improvements in the acupuncture group. Third, the identified neurological metrics encompassed striatal volumes, posterior cingulate cortex (PCC) cortical thickness, PCC/precuneus fractional amplitude of low-frequency fluctuation (fALFF), striatal fALFF, and graph-based small-worldness of the default mode network and striatum. Specifically, functional metrics predisposing patients to acupuncture improvement changed as a consequence of acupuncture treatment, whereas structural metrics remained stable. Furthermore, support vector machine models applied to the questionnaire and brain features could jointly predict acupuncture improvement with an accuracy of 81.48%. Besides, the correlations and models were not significant in the sham-acupuncture group. These results demonstrate the specific psychological, brain functional, and structural predictors of acupuncture improvement and may offer opportunities to aid clinical practices.

Acupuncture for Knee Osteoarthritis: A Systematic Review of Randomized Clinical Trials with Meta-Analyses and Trial Sequential Analyses

Background

Knee osteoarthritis (KOA) can cause chronic pain and seriously affect the quality of patient lives. The continued emergence of high-quality RCTS requires us to update the quality of evidence. This study aims to evaluate the efficacy of acupuncture for KOA patients and calculate the required information size (RIS) to determine whether further clinical studies are required.

Methods

We searched PubMed, Embase, WOS, CBM, CNKI, VIP, WHO ICTRP, ChiCTR, and Grey literature to collect randomized controlled trials (RCTs) of acupuncture for KOA from inception to December 2021. A meta-analysis was performed according to the Cochrane systematic review method by using Review Manager 5.4 and TSA 0.9.5.10 beta, and GRADE was used to evaluate the quality of the evidence. Trial sequential analysis was used to control random errors and calculate the required information size.

Results

Eleven RCTs with 2484 patients were included in our meta-analysis, meeting the inclusion criteria for the meta-analysis. The meta-analysis indicated that acupuncture had beneficial effect on knee osteoarthritis in reducing pain [n = 2387; SMD = -0.12, 95% CI (-0.20, -0.04); I 2 = 0%] and improved patients function activities [n = 2408; MD = -1.25, 95% CI (-1.97, -0.53); I 2 = 0%], but true acupuncture showed no significant effect in relieve patient's stiffness [n = 1337; MD = -0.07, 95% CI (-0.30, 0.15); I 2 = 0%]. We pooled the studies which found no significant difference in improving the quality life of mental [n = 1462; SMD = 0.02, 95% CI (-0.23, 0.27); I 2 = 78%] and patients physical health (SF-36 or SF-12) [n = 1745; SMD = 1.01, 95% CI (-0.08, 2.11); I 2 = 0%] compared with sham acupuncture. The pain and function TSA graphs indicated that cumulative Z-curves intersected with the traditional level of statistical favoring acupuncture, and more RCTs will required in the future studies.

Conclusion

Acupuncture has beneficial effect on pain relief and improves function activities, and this treatment can be recommended as a beneficial alternative therapy in patients with KOA, particularly for chronic patients and those currently undergoing long-term pain and help them increasing quality of life. But it should be further verified through more RCTs in function. Available studies suggested that acupuncture was superior to sham acupuncture in reduce pain and function as verified by TSA.

An anti-inflammatory diet intervention for knee osteoarthritis: a feasibility study

BACKGROUND

Knee osteoarthritis has an inflammatory component that is linked to pain and joint pathology, yet common non-surgical and non-pharmacological interventions (e.g., exercise, calorie restricting diets) do not typically target inflammation. We aimed to evaluate the feasibility of a telehealth delivered anti-inflammatory diet intervention for knee osteoarthritis.

METHODS

This 9-week single-arm feasibility study recruited participants aged 40-85 years with symptomatic knee osteoarthritis (inclusion criteria: average pain ≥4/10 or maximal pain ≥5/10 during past week). All participants received a telehealth-delivered anti-inflammatory dietary education intervention involving 1:1 consultations at baseline, 3- and 6-week follow-up. The diet emphasised nutrient-dense wholefoods and minimally processed anti-inflammatory foods and discouraged processed foods considered to be pro-inflammatory. The primary outcome of feasibility was assessed via: i) eligibility, recruitment and retention rates; ii) self-reported dietary adherence; iii) adverse events; and iv) treatment satisfaction. Post-intervention interviews evaluated the acceptability of the dietary intervention delivered via telehealth. Secondary outcomes included changes in self-reported body mass, Knee injury and Osteoarthritis Outcome Score (KOOS), health-related quality of life (EuroQoL-5D), analgesic use and global rating of change. Worthwhile effects were determined by the minimal detectable change (MDC) for all five KOOS-subscales (pain, symptoms, activities of daily living, sport/recreation, quality of life) being contained within the 95% confidence interval.

RESULTS

Forty-eight of seventy-three (66%) individuals screened were eligible and 28 enrolled over 2 months (82% female, mean age 66 ± 8 years, body mass index 30.7 ± 4.8 kg.m-2). Six participants withdrew prior to final follow-up (21% drop-out). Of those with final follow-up data, attendance at scheduled telehealth consultations was 99%. Self-reported adherence to diet during the 9-week intervention period: everyday = 27%, most of time = 68% and some of time = 5%. Two minor adverse events were reported. Change scores contained the MDC within the 95% confidence interval for all five KOOS subscales. Suggestions to improve study design and limit drop-out included an initial face-to-face consultation and more comprehensive habitual dietary intake data collection.

CONCLUSION

This study supports the feasibility of a full-scale randomised controlled trial to determine the efficacy of a primarily telehealth-delivered anti-inflammatory dietary education intervention in adults with symptomatic knee osteoarthritis.

TRIAL REGISTRATION

ACTRN12620000229976 prospectively on 25/2/2020.

Cardiovascular safety of celecoxib in rheumatoid arthritis and osteoarthritis patients: A systematic review and meta-analysis

OBJECTIVE

To assess the cardiovascular safety of celecoxib compared to non-selective non-steroid anti-inflammatory drugs or placebo.

METHODS

We included randomized controlled trials of oral celecoxib compared with a non-selective NSAID or placebo in rheumatoid arthritis and osteoarthritis patients. We conducted searches in EMBASE, Cochrane CENTRAL, MEDLINE, China National Knowledge Infrastructure, VIP, Wanfang, and Chinese Biomedical Literature Database. Study selection and data extraction were done by two authors independently. The risk of bias was assessed using Cochrane's risk-of-bias Tool for Randomized Trials. The effect size was presented as a risk ratio with their 95% confidence interval.

RESULTS

Until July 22nd, 2021, our search identified 6279 records from which, after exclusions, 21 trials were included in the meta-analysis. The overall pooled risk ratio for Antiplatelet Trialists Collaboration cardiovascular events for celecoxib compared with any non-selective non-steroid anti-inflammatory drugs was 0.89 (95% confidence interval: 0.80-1.00). The pooled risk ratio for all-cause mortality for celecoxib compared with non-selective non-steroid anti-inflammatory drugs was 0.81 (95% confidence interval: 0.66-0.98). The cardiovascular mortality rate of celecoxib was lower than non-selective non-steroid anti-inflammatory drugs (risk ratio: 0.75, 95% confidence interval: 0.57-0.99). There was no significant difference between celecoxib and non-selective non-steroid anti-inflammatory drugs or placebo in the risk of other cardiovascular events.

CONCLUSION

Celecoxib is relatively safe in rheumatoid arthritis and osteoarthritis patients, independent of dose or duration. But it remains uncertain whether this would remain the same in patients treated with aspirin and patients with established cardiovascular diseases.

Cross-sectional Analysis of Recommendations for the Treatment of Hip and Knee Osteoarthritis in Clinical Guidelines

OBJECTIVE

To compare guideline recommendations for hip and knee osteoarthritis (OA) and their level of evidence.

DATA SOURCES

MEDLINE, Embase, the Cochrane Library, and websites of professional societies were searched in June 2020 using keywords such as knee or hip osteoarthritis, degenerative arthritis, guideline, and practice guideline.

STUDY SELECTION

General treatment guidelines for OA of the hip or knee published in English. After 461 abstracts were screened, 31 publications (17 guidelines from 10 professional societies) were included for analysis.

DATA EXTRACTION

Three reviewers assessed the quality of the guidelines according to the Appraisal of Guidelines for Research and Evaluation II tool. The rating of evidence and strength of recommendation was extracted and standardized into the Grading of Recommendations Assessment, Development, and Evaluation criteria.

DATA SYNTHESIS

Of the 17 guidelines included, 6 (35%) were of high quality, 10 (59%) of moderate quality, and 1 (6%) of low quality. Guidelines published after 2017 were of good quality. Although guidelines generally agreed on a nonsurgical multimodal concept, including patient education, exercise, and weight loss in obese, some recommendations remained vague and the level of evidence varied widely. In pharmacologic treatment, oral nonsteroidal anti-inflammatory drugs were the mainstay for pain management. Guidelines published after 2017 were more cautious in their recommendation for the use of paracetamol and strong opioids. Disagreement was observed for chondroitin sulfate, glucosamine, and intra-articular hyaluronic acid injections. Recommendations were conflicting for the use of insoles, braces, and transcutaneous electrical stimulation. The main indications for hip/knee arthroplasty were severe, persisting pain and loss of function despite nonsurgical treatment. No guideline defined a minimum time of conservative treatment before surgery.

CONCLUSIONS

We found a wide variation in evidence and strength of recommendations for OA treatment. Recommendations on when to refer patients for surgery remained unclear.

Knee-related disability was largely influenced by cognitive factors and disturbed body perception in knee osteoarthritis

The aim of this study was to explore the existence of subgroups in a cohort of people with knee osteoarthritis (OA) based upon data from multiple pain-related variables and to profile identified clusters according to levels of pain intensity and knee-related disability. Three hundred and three people with knee OA were recruited. Latent profile analysis was used to confirm the optimal number of knee OA subgroups. Body mass index, radiographic knee OA severity, pain catastrophizing, pain related self-efficacy, and knee specific self-perception, were incorporated into the model. Cluster, demographic and clinical variables were compared between the resulting classes. Four distinct classes were identified. Cluster 1 (28.7%) represented early radiographic OA, and moderate pain intensity, disability and cognitive and perceptual dysfunction. Cluster 2 (18.8%) showed advanced radiographic OA, and moderate pain intensity, disability and cognitive and perceptual dysfunction. Cluster 3 (34.3%) represented various levels of radiographic OA, and the lowest pain intensity, disability and cognitive and perceptual dysfunction. Cluster 4 (18.1%) represented various levels of radiographic OA, the highest disability and cognitive and perceptual dysfunction. Considering cognitive factors and disturbed body perception may help to explain the phenomenon of the discrepancy between the knee-related disability and the severity of radiographic knee OA.

Long non-coding RNA PCAT-1 regulates apoptosis of chondrocytes in osteoarthritis by sponging miR-27b-3p

BACKGROUND

Osteoarthritis (OA) is a non-inflammatory degenerative disease, with progressive damages on the articular cartilages. In recent years, researchers have paid many efforts in the diagnostics and treatments of OA. However, no effective therapeutic method has been revealed to help inhibit the development of OA. Herein, we studied the roles and associations of PCAT-1 and miR-27-3p in the pathogenesis OA.

METHODS

OA articular cartilages and healthy articular cartilages were isolated for investigation. The chondrocytes were isolated from articular cartilage samples. QRT-PCR and western blotting were used for the detection of expression of genes and proteins. cell Titer 96® AQueous one proliferation kit was applied for detect cell viability of Chondrocytes transfected with negative control vector, pcDNA3.1 PCAT-1 plasmid or siRNA against PCAT-1. RNA pull-down assays and Luciferase reporter assay were used to confirm the connection. SPSS 17.0 was employed for statistical analysis.

RESULTS

We found that the expressions of PCAT-1 were up-regulated in OA chondrocytes compared with normal chondrocytes. si-PCAT-1 suppressed apoptotic OA chondrocytes. Over-expression of PCAT-1 enhanced the apoptosis of normal chondrocytes. In addition, the online database and luciferase assay confirmed that PCAT-1 could directly target miR-27b-3p. PCAT-1 could promote the apoptosis of OA and normal chondrocytes through binding with miR-27b-3p.

CONCLUSIONS

Based on the comparisons and analysis, we could conclude that lncRNA PCAT-1 regulated the apoptosis of chondrocytes through sponging miR-27b-3p in OA. PCAT-1 has potential values to act as a new therapeutic target for OA patients.

Efficacy of Intensive Acupuncture Versus Sham Acupuncture in Knee Osteoarthritis: A Randomized Controlled Trial

OBJECTIVE

To assess the efficacy of intensive acupuncture (3 times weekly for 8 weeks) versus sham acupuncture for knee osteoarthritis (OA).

METHODS

In this multicenter, randomized, sham-controlled trial, patients with knee OA were randomly assigned to receive electroacupuncture (EA), manual acupuncture (MA), or sham acupuncture (SA) 3 times weekly for 8 weeks. Participants, outcome assessors, and statisticians were blinded with regard to treatment group assignment. The primary outcome measure was response rate, which is the proportion of participants who simultaneously achieved minimal clinically important improvement in pain and function by week 8. The primary analysis was conducted using a Z test for proportions in the modified intent-to-treat population, which included all randomized participants who had ≥1 post-baseline measurement.

RESULTS

Of the 480 participants recruited in the trial, 442 were evaluated for efficacy. The response rates at week 8 were 60.3% (91 of 151), 58.6% (85 of 145), and 47.3% (69 of 146) in the EA, MA, and SA groups, respectively. The between-group differences were 13.0% (97.5% confidence interval [97.5% CI] 0.2%, 25.9%; P = 0.0234) for EA versus SA and 11.3% (97.5% CI -1.6%, 24.4%; P = 0.0507) for MA versus SA. The response rates in the EA and MA groups were both significantly higher than those in the SA group at weeks 16 and 26.

CONCLUSION

Among patients with knee OA, intensive EA resulted in less pain and better function at week 8, compared with SA, and these effects persisted though week 26. Intensive MA had no benefit for knee OA at week 8, although it showed benefits during follow-up.

"I think we need to empower people to manage it better themselves": A qualitative interview study exploring UK healthcare practitioners' perspectives on treating young adults following a sport-related knee injury

OBJECTIVES

To elicit healthcare practitioners' views on treatment following sport-related knee injury in young adults (18-35) and the potential for individuals to self-manage joint health.

DESIGN

Semi-structured interviews were audio-recorded, transcribed and analysed systematically using an inductive approach.

SETTING

South West UK.

PARTICIPANTS

Twelve healthcare practitioners with experience of treating young adults.

MAIN OUTCOME MEASURES

Understanding how healthcare practitioners treat young adults following knee injury and to what extent individuals may be able to self-manage knee health.

RESULTS

Participants' perceptions were encapsulated in three consistent themes: [1] Treating patients; [2] Maintaining physical activity; and [3] Education and support. All participants described how staying physically active and maintaining a healthy weight were integral to conserving knee health, and that post-injury education was necessary to "empower" patients to self-manage knee health. A need for greater access to support, advice and guidance for patients was also articulated.

CONCLUSIONS

Healthcare practitioners should tailor their treatment to young adults to account for individual characteristics, aspirations for sport and exercise participation, and their emotional wellbeing. Fulfilment of individuals' educational and supportive needs is key to the establishment of self-management behaviours that may help to conserve knee health.

Acupotomy Therapy for Knee Osteoarthritis Pain: Systematic Review and Meta-Analysis

Methods

We performed a comprehensive search on PubMed, the Cochrane Library, EMBASE, and four Chinese databases for articles published prior to June 2020. We included only randomized controlled trials (RCTs) that used acupotomy therapy as the major intervention in adults with knee OA, were published in either Chinese and English, included more than 20 subjects in each group, and included pain and function in the outcome measures. Knee OA was defined by the American College of Rheumatology or Chinese Orthopedic Association criteria in all studies. We extracted the visual analogue scale (VAS) pain score, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score, the total effectiveness rate, the modified Japanese Orthopedic Association (JOA) activities of daily living score, and Lysholm's score. We calculated the mean difference (MD) or risk ratio (RR) for all relevant outcomes. Meta-analyses were conducted using random-effects models when appropriate.

Results

We identified 1317 potentially relevant studies, thirty-two of which met the eligibility criteria and were conducted in China between 2007 and 2020. A total of 3021 knee OA patients (62.96% female, median age: 57 years, and median disease duration: 33 months) were included. The treatment duration ranged from 1 week to 5 weeks (median: 3 weeks). The typical acupotomy treatment involved releasing soft tissue adhesions and was performed once a week for 1–5 weeks until the pain was relieved. The control group treatments included acupuncture (8 studies), electroacupuncture (10 studies), sodium hyaluronate (8 studies), radiofrequency electrotherapy (1 study), and nonsteroidal anti-inflammatory drugs (NSAIDs, 5 studies). The results from the meta-analysis showed that acupotomy led to superior improvements in the VAS pain score (MD = −1.11; 95% confidence interval (CI), −1.51 to −0.71; p < 0.00001) and WOMAC pain score (MD = −2.32; 95% CI, −2.94 to −1.69; p < 0.00001), a higher total effectiveness rate (RR = 1.15; 95% CI, 1.09–1.21; p < 0.00001), and superior improvements in the JOA score (MD = 6.39; 95% CI, 4.11–9.76; p < 0.00001) and Lysholm's score (MD = 12.75; 95% CI, 2.61–22.89; p = 0.01) for overall pain and function. No serious adverse events were reported.

Conclusion

Chinese acupotomy therapy may relieve pain and improve function in patients with knee OA. Furthermore, rigorously designed and well-controlled RCTs are warranted.

Knee joint biomechanics of patients with unilateral total knee arthroplasty during stationary cycling

Stationary cycling is typically recommended following total knee arthroplasty (TKA) operations. However, knee joint biomechanics during cycling remains mostly unknown for TKA patients. Biomechanical differences between the replaced and non-replaced limb may inform applications of cycling in TKA rehabilitation. The purpose of this study was to examine the knee joint biomechanics of TKA patients during stationary cycling. Fifteen TKA participants cycled at 80 revolutions per minute and workrates of 80 W and 100 W while kinematics (240 Hz) and pedal reaction forces using a pair of instrumented pedals (1200 Hz) were collected. A 2x2 (limb × workrate) repeated measures ANOVA was run with an alpha of 0.05. Peak knee extension moment (KEM, p = 0.034) and vertical pedal reaction force (p = 0.038) were significantly reduced in the replaced limbs compared to non-replaced limbs by 21.3% and 5.3%, respectively. Peak KEM did not change for TKA patients with the increased workrate (p = 0.750). However, both peak hip extension moment (p = 0.009) and ankle plantarflexion moment (p = 0.017) increased due to increased workrate. Patients following TKA showed similar decreases in peak KEM and vertical pedal reaction force in their replaced compared to non-replaced limbs, as previously seen in gait. Patients of TKA may rely on their hip and ankle extensors to increases in workrate. Increasing intensity by 20 W did not exacerbate any inter-limb differences for peak KEM and vertical PRF.

TLR-4, TLR-5 and IRF4 are diagnostic markers of knee osteoarthritis in the middle-aged and elderly patients and related to disease activity and inflammatory factors

Expression and diagnostic value of serum toll-like receptor-4 (TLR-4), Toll-like receptor-5 (TLR-5) and interferon regulatory factor 4 (IRF4) in middle-aged and elderly patients with knee osteoarthritis (KOA) and their correlation with Interleukin 1β (IL-1β), interleukin-6 (IL-6), matrix metalloproteinase-1 and tumor necrosis factor-α (TNF-α) were investigated. Sixty-eight middle-aged and elderly patients with KOA in Puyang Hospital of Traditional Chinese Medicine were selected as the study group and 49 healthy people receiving physical examination were the control group. Levels of serum TLR-4, TLR-5, IRF4, IL-1β, IL-6, MMP-1 and TNF-α were measured by enzyme linked immunosorbent assay (ELISA). Correlation between the expression levels of serum TLR-4, TLR-5, IRF4 and K-L grades was determined by Spearman correlation analysis. The diagnostic efficacy of serum TLR-4, TLR-5 and IRF4 for KOA was analyzed by the receiver operator characteristics analysis (ROC). Expression of serum TLR-4, TLR-5 and IRF4 in the study group was significantly higher than those in the control group. The sensitivity and specificity of TLR-4 in the diagnosis of KOA were, respectively, 76.47 and 93.88%, those of TLR-5 were 73.29 and 87.76%, those of IRF4 were 72.06 and 95.92%, and those of TLR-4, TLR-5 and IRF4 were 94.12 and 97.96%. Expression of serum TLR-4, TLR-5 and IRF4 was significantly higher in the severe group than in the moderate group, and significantly higher in the moderate group than those the in mild group, and significantly higher in the mild group than those in the suspected mild group. Expression of TLR-4, TLR-5 and IRF4 in serum was positively correlated with the concentration of IL-1β, IL-6, MMP-1 and TNF-α, respectively (P<0.001). The combined detection of TLR-4, TLR-5 and IRF4 can be used for early diagnosis of KOA, and they are positively correlated with IL-1β and IL-6, MMP-1 and TNF-α.

Comparison of the Efficiency and Safety of Total Ankle Replacement and Ankle Arthrodesis in the Treatment of Osteoarthritis: An Updated Systematic Review and Meta-analysis

While osteoarthritis is a common degenerative disease, ankle osteoarthritis is a subdivision that has received little attention. Two effective ways to treat osteoarthritis of the ankle are total ankle replacement (TAR) and ankle arthrodesis (AAD). Whether TAR or AAD is more beneficial for treatment is controversial. The purpose of this meta‐analysis was to compare the efficiency (clinical outcome and patient satisfaction) and safety (complications and survival) of these two procedures. The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement was performed as a guideline for this study. Three electronic databases, PubMed, Web of Science, and Cochrane Library, were searched up to May 2019, with no language restrictions. Prospective or retrospective comparative studies were identified. The outcomes included clinical outcome, patient satisfaction, complications, and survival. Review Manager (Revman) 5.3 software was used to conduct the data analysis. We only selected literature from the past 5 years (no earlier than 2015). Seven comparative studies were included. There were six cohort studies and one cross‐sectional study. The Newcastle–Ottawa Scale (NOS) was used to assess the quality of cohort studies, and The Agency for Healthcare Research and Quality (AHRQ) checklist was chosen to assess the quality of cross‐sectional studies. No significant difference was observed for efficiency and safety. Clinical outcome was included in five studies with four different scoring systems. Two of them used the American Orthopaedic Foot & Ankle Society (AOFAS) questionnaire scores to assess the two procedures (mean difference, −4.26; 95% confidence interval [CI], −11.37–2.85; P = 0.24; I² = 1%). Patient satisfaction (risk ratio [RR], 0.96; 95% CI, 0.65–1.40; P = 0.82; I² = 54%), complications (RR, 1.15; 95% CI, 0.16–8.21; P = 0.89; I² = 84%), and survival (RR, 1.91; 95% CI, 0.33–11.08; P = 0.47; I² = 90%) showed no significant difference between the TAR group and the AAD group. This meta‐analysis showed no statistically significant difference between TAR and AAD in clinical outcome, patient satisfaction, complications, and survival. This revealed that TAR and AAD could appear to have similar results in these aspects. Therefore, the present results are not sufficient to conclude which of these two methods is better. Further studies are needed to obtain more clues.

Economic Outcomes Related to Persistence and Dosing of Celecoxib in Patients with Osteoarthritis (OA) Using a Retrospective Claims Database Analysis

Objective

This study describes treatment patterns, healthcare resource utilization (HCRU), and costs associated with persistence, switching, and dosing of branded celecoxib in osteoarthritis (OA) patients.

Methods

This retrospective claims database analysis used MarketScan^® Commercial Claims and Encounters (MarketScan) data from 2009 to 2013. Included patients were adult (≥ 18 years), incident celecoxib users with ≥ 1 OA claim. The treatment switch analysis analyzed outcomes in patients persistent on celecoxib versus switched to a generic nonsteroidal anti-inflammatory drug (NSAID). The dosing analysis stratified patients as under-dose (<200 mg per day) and standard dose (≥200 mg per day). HCRU, costs, and treatment duration were compared in persistent versus switched and standard dose versus under-dose patients using descriptive, multivariate logistic regression, and Kaplan–Meier analysis.

Results

A total of 65,530 patients met the inclusion criteria. During follow-up, 83% discontinued celecoxib without switching, 10% were persistent, and 5% switched to a generic NSAID. Ninety percent received a standard dose of celecoxib. Switched (versus persistent) patients had significantly higher all-cause hospital admissions, length of stay, emergency room (ER) visits, and office visits per person year (PPY), all P <0.001; and under-dosed (versus standard dose) patients had significantly higher hospital admissions (P<0.001), length of stay (P<0.001), and ER visits (P= 0.021) PPY. Persistent versus switched patients had lower mean total all-cause costs PPY ($20,378 vs $23,949, P<0.001). Standard dose versus under-dose patients had lower mean total all-cause costs ($23,680 vs $26,955 PPY, P<0.001), and not statistically significant higher mean total OA-related costs ($5698 vs $5524 PPY, P=0.441).

Conclusion

Patients that switched from branded celecoxib to a generic NSAID or received an under-dose of branded celecoxib had higher average overall HCRU and costs. OA-related inpatient and outpatient cost savings may offset the higher drug cost of celecoxib for persistent patients.

Recommendation Rates for Physical Therapy, Lifestyle Counseling, and Pain Medications for Managing Knee Osteoarthritis in Ambulatory Care Settings: A Cross-Sectional Analysis of the National Ambulatory Care Survey (2007-2015)

OBJECTIVE

To describe and compare triennial rates of physicians' recommendations for physical therapy (PT), lifestyle counseling, and pain medication for knee osteoarthritis (OA) and to identify patient, physician, and practice factors associated with each treatment recommendation.

METHODS

We conducted a cross-sectional analysis examining data between 2007 and 2015 from the National Ambulatory Medical Care Survey. Visits to orthopedists and primary care physicians for knee OA were identified and assessed for the following: PT referral, lifestyle counseling, nonsteroidal antiinflammatory drug (NSAID) prescriptions, and narcotics prescriptions. Triennial rates for each treatment were calculated. We examined associations between patient (e.g., race, insurance), physician, and practice factors (e.g., ownership, location) and treatments prescribed using multivariate logistic regression that accounted for complex sampling design.

RESULTS

A total of 2,297 physician visits related to knee OA (~67 [±4] million weighted visits) were identified. For visits to orthopedists, PT and lifestyle recommendation rates declined (158 to 88 of 1,000 visits and 184 to 86 of 1,000 visits, respectively), while NSAID and narcotics prescriptions increased (132 to 278 of 1,000 visits and 77 to 236 of 1,000 visits, respectively) over time (P < 0.05). For visits to primary care physicians, there were no significant changes in rates of PT, lifestyle counseling, and narcotics prescriptions over time, while NSAIDs prescriptions increased (221 to 498 of 1,000 visits; P < 0.05). Treatment recommendations were associated with nonclinical factors, including practice type, location, and type of provider.

CONCLUSION

In patients with knee OA, PT and lifestyle counseling seem underutilized, while pain medication prescriptions increased during the investigated timeframe. Variation in treatment choices were associated with nonclinical factors. Future research is necessary to examine ways to improve PT and lifestyle utilization and reduce variation in care for knee OA.

Potential Therapeutic Effects of Mg/HCOOH Metal Organic Framework on Relieving Osteoarthritis

This study was designed to explore the potential therapeutic effects of Mg-based metal organic frameworks (MOFs) in osteoarthritis (OA) and to broaden the application field of MOFs. Mg/HCOOH-MOF was introduced and characterized by using SEM, XRD, TGA, and FTIR. ICP-MS results proved that Mg/HCOOH-MOF is stable in various physiological media and can maintain the release of Mg²⁺ ions for a long time. In vitro experiments were carried out to evaluate its potential application in attenuating OA. Mg/HCOOH-MOF was successfully synthesized, and results of MTT assays showed that it is biocompatible and can promote cell proliferation. qPCR results suggested that it can significantly regulate the expression of OCN, Axin2, iNOS and IL-1β, which indicated its activity in anti-inflammation and bone protection. We believe that Mg/HCOOH-MOF could benefit OA therapy.

Analgesic Herbal Medicines in the Treatment of Knee Osteoarthritis: A Systematic Review

Background:

Osteoarthritis (OA) is a type of progressive rheumatoid disease, which leads to the degeneration of the articular cartilage, synovium, subchondral bone, tendons, and the surrounding ligaments.There are various treatments for knee OA, including pharmaceutical, nonpharmaceutical, and surgical treatments. Considering the chronic nature of the disease as well as the necessity for the long-term use of chemical medications, various side effects could occur that include gastrointestinal bleeding, hypertension, congestive heart failure, hyperkalemia, and kidney failure. Therefore, suitable treatments with fewer side effects should be recommended. Recent investigations suggest increased tendency in people to use Complementary and Alternative Medicine (CAM) for knee OA treatment.

Objective:

This systematic review aimed to assess the effectiveness and safety of herbal preparations for the treatment of OA.

Methods:

The searched databases were Cochrane, Scopus, and PubMed. All the selected papers pertained to randomized controlled trials until August 8, 2017 in English in which one or several specific herbs had been used in knee OA treatment.

Results:

We included 24 randomized trials (involving 2399 women and men). There were several different herbal medicines used within the included trials.

Conclusion:

The results show that the methods used in these trials may reduce symptoms and the extent of NSAID consumption and enhance the quality of life. Additional trials are suggested to investigate the safety and efficacy of herbs for the treatment of patients with OA.

Comparative study of the effect of Thymus daenensis gel 5% and diclofenac in patients with knee osteoarthritis

Background: Osteoarthritis is a syndrome characterized by joint pain and reduced performance and efficien- cy in patient. Thymus daenensis has been used since old times for the treatment of bone and joint deformities and pain in traditional medicine.

Purpose: This study was conducted to examine traditional usages and pharmacological features of T. daen- ensis with respect to the effect of the plant in patients with osteoarthritis.

Methods: 120 patients with osteoarthritis were divided into 3 groups. Patients in each group were treated by 5% Thymus daenensis gel, 1% diclofenac gel, or placebo for 6 weeks, along with oral celecoxib capsules. Patients were assessed in different intervals, based on the VAS score for assessment of pain in the joint and different dimensions of WOMAC questionnaire.

Results: Pain level (P < 0.005), stiffness during the day (P < 0.05), morning stiffness (P < 0.05) and physi- cal performance (P < 0.05) were significantly different among the groups.

Conclusions: Thymus daenensis gel improves the symptoms in patients equal and without significant difference than diclofenac group. It can be argued that its use can produce a satisfactory effect on patients with osteoarthritis due to its low cost, easy access, the plant’s natively occurring in Iran.

Appropriateness of clinical criteria for the use of SYmptomatic Slow-Acting Drug for OsteoArthritis (SYSADOA). A Delphi Method Consensus initiative among experts in Italy

BACKGROUND

Osteoarthritis (OA) is a theme currently representing an emerging topic for its increasing incidence. It is well known that it is a chronic disease that could lead to important long-lasting disability; this generates increasing costs for the health care system. OA treatment options vary: localization, etiology, grading and symptomatology should be considered before choosing the most adequate therapy. Currently, a modern approach to managing OA involves SYmptomatic Slow-Acting Drug for OsteoArthritis (SYSADOAs). However, while all preparations may claim to deliver a therapeutic level of glucosamine or chondroitin, not all of them are supported by clinical evidence. Recently the European Society for Clinical and Economic aspects of Osteoporosis, Osteoarthritis and musculoskeletal diseases (ESCEO), produced an evidenced based document providing practitioners with the latest clinical and economic information, thereby allowing them to optimize the management of knee OA. According to this report, only crystalline glucosamine sulphate and the pharmaceutical-grade chondroitin sulphate are considered as effective in the first line approach to treating knee OA as an alternative drug to acetaminophen. However, some OA guidelines do not agree are not concordant in recommending the use of SYSADOA, perhaps because they are generally considered as a class and distinctions among formulations are not made.

AIM

Aim of this study was to identify the main aspects involved in patient selection, the choice of therapeutic agents and the safety profile in using SYSADOA.

DESIGN

Delphi method Consenus Statement.

POPULATION

Italian Physicians having expertise in Osteoarthritis management.

METHODS

A committee of 11 experts from Italian universities, public hospitals, territorial services, research institutes and patient associations was set up. Sixty-three clinicians from a large number of Italian medical centers specialized in osteoarthritis management took part in a Delphi process which was aimed at obtaining consensus statements among the participants.

RESULTS

Large consensus was obtained for statements grouped under the following main themes: treatment indications; drug/medical devices choice; treatment efficacy.

CONCLUSIONS

Results from the Italian consensus on appropriateness of OA therapies in osteoarthritis seems to be in line with the stepwise approach proposed by the ESCEO algorithm, where crystalline glucosamine sulphate shows greater clinical efficacy than other glucosamine-based formulations, according to several independent meta-analyses.

CLINICAL REHABILITATION IMPACT

This study may be used as a practical reference tool to help Italian physicians treat osteoarthritis patients using SYSADOA.

Pharmacokinetic Profile of Intra-articular Fluticasone Propionate Microparticles in Beagle Dog Knees

OBJECTIVE

The objective of this pilot study was to determine time point(s) at which maximum concentration of fluticasone propionate (Cmax) occurs in synovial fluid and plasma in Beagle dog knees after intra-articular injection of EP-104IAR.

DESIGN

EP-104IAR is composed of fluticasone propionate drug crystals coated with heat-treated polyvinyl alcohol (PVA) to result in extended release properties. Thirty-two Beagle dogs had an injection of EP-104IAR into the knee joint at 2 different dose levels (0.6 mg and 12 mg). Outcome measures included plasma, synovial fluid, and articular cartilage fluticasone propionate concentrations as well as histological analysis of cartilage and synovium at a variety of time points up to 58 days postdosing.

RESULTS

Intra-articular administration of 0.6 and 12 mg EP-104IAR was well tolerated. Early minor abnormalities found on microscopy resolved by the end of the study. There were no quantifiable concentrations of fluticasone propionate in plasma of animals administered 0.6 mg at any of the sampling time points. Highest concentrations in plasma following 12 mg administration occurred 1 day postdose and declined with a half-life of approximately 45 days. Highest concentrations of fluticasone propionate in synovial fluid and cartilage generally occurred 5 days postdose in both dose groups and declined with a half-life of approximately 11 to 14 days.

CONCLUSIONS

EP-104IAR is capable of providing a safe and prolonged local exposure to a corticosteroid in the synovial joint while minimizing systemic exposure, with peak exposures occurring within a matter of days after dosing before declining in all tissues in a predictable manner.

An open-label, prospective, multicenter, clinical study to evaluate efficacy of Ayuartis capsules in patients suffering from osteoarthritis of the knee(s)

Background

The management of chronic degenerative joint disorders such as osteoarthritis (OA) with ayurvedic medicines provides a safe and effective alternative. Ayurvedic medicines possess analgesic, anti-inflammatory, anti-oxidant and immunomodulator activities.

Aims

The main aim of the study was to assess the efficacy of Ayuartis capsule in patients suffering from OA of the knee(s).

Materials and Methods

Thirty-one patients suffering from OA knee(s) were recruited after evaluating them as per inclusion/exclusion criteria. Patients were advised to take two Ayuartis capsules twice daily orally for 90 days. Knee joint(s) pain was assessed on the Visual Analog Scale. Patients' joint pain, stiffness, and physical functions were assessed on the Western Ontario McMaster University Osteoarthritis (WOMAC) index. Quality of life (QOL) and the time required to walk 50 feet was evaluated. Patients were called for follow-up visits on every 15^th day till 90 days. Adverse events and vitals were recorded at every visit. Safety laboratory investigations were done before and after the completion of trial.

Statistical Analysis

Data describing quantitative measures are expressed as mean ± standard deviation. The comparison of variables representing categorical data was performed using pair t-test.

Results

The mean joint pain reduced significantly by 53.82% on day 90. The mean WOMAC combined score, pain score, stiffness score and difficulty score reduced significantly by 50.88%, 54.96%, 58.76% and 49.02%, respectively on day 90. A significant improvement was observed in mean QOL of patients. A significant reduction in mean time required to walk 50 feet was observed. Majority of the patients had shown good overall improvement and excellent tolerability to the trial drug.

Conclusion

Ayuartis capsule is a safe and effective medicine for the treatment of OA of the knee(s).

Model-based roentgen stereophotogrammetric analysis using elementary geometrical shape models: 10 years results of an uncemented acetabular cup component

Background

Non-cemented acetabular cup components demonstrated different clinical performance depending on their surface texture or bearing couple. However, clinical osseointegration needs to be proved for each total joint arthroplasty (TJA) design. Aim of this study was to detect the in vivo migration pattern of a non-cemented cup design, using model-based roentgen stereophotogrammetric analysis with elementary geometrical shape models (EGS-RSA) to calculate early cup migration.

Methods

Interchangeable applicability of the model-based EGS-RSA method next to gold standard marker-based RSA method was assessed by clinical radiographs. Afterwards, in vivo acetabular cup migration for 39 patients in a maximum follow up of 120 months (10 years) was calculated using model-based EGS-RSA.

Results

For the axes with the best predictive capability for acetabular cup loosening, mean (±SD) values were calculated for migration and rotation of the cup. The cup migrated 0.16 (±0.22) mm along the cranio-caudal axis after 24 months and 0.36 (±0.72) mm after 120 months, respectively. It rotated − 0.61 (±0.57) deg. about the medio-lateral axis after 24 months and − 0.53 (±0.67) deg. after 120 months, respectively.

Conclusions

Interchangeable applicability of model-based EGS-RSA next to gold standard marker-based RSA method could be shown. Model-based EGS-RSA enables an in vivo migration measurement without the necessity of TJA specific surface models. Migration of the investigated acetabular cup component indicates significant migration values along all the three axes. However, migration values after the second postoperative year were within the thresholds reported in literature, indicating no risk for later aseptic component loosening of this TJA design.

Physical Impairments in Adults With Ankle Osteoarthritis: A Systematic Review and Meta-analysis

Study Design Systematic review with meta-analysis. Background Lower-limb osteoarthritis (OA) is associated with pain and reduced function. Most research focuses on hip and knee OA- related impairments; consequently, impairments that characterize ankle OA are not well understood. Objective To systematically review available evidence of physical impairments in individuals with ankle OA. Methods A comprehensive search of electronic databases was conducted from their inception to July 2017. Studies were screened using predefined inclusion/exclusion criteria. Studies that compared physical measures (excluding gait) between individuals with ankle OA and healthy controls or the unaffected ankle were included. Two reviewers rated studies for quality. Meta-analyses with random effects were conducted when appropriate. Results Of 4565 identified studies (563 participants), 8 satisfied the inclusion criteria and 3 studies were included in meta-analyses. All studies evaluated a range of impairments at end-stage OA, and exhibited poor reporting of missing data, assessor blinding, and measurement validity. Meta-analyses revealed large impairments of ankle sagittal plane motion and strength. Evidence from single studies indicated large deficits of ankle frontal plane motion and strength, talar translation and rotation on arthrometry, balance, and electromyography of ankle joint muscles. There were also abnormal bony alignments and greater fatty infiltrate in all calf muscle compartments. Conclusion The results of this literature review suggest significant ankle motion, strength, and functional impairments in individuals with ankle OA. The strength of the conclusions is limited, due to the small number and methodological limitations of published studies. Level of Evidence Symptom prevalence, level 1a. J Orthop Sports Phys Ther 2018;48(6):449-459. Epub 7 Apr 2018. doi:10.2519/jospt.2018.7569.

Changes in Physical Activity After Total Hip or Knee Arthroplasty: A Systematic Review and Meta-Analysis of Six- and Twelve-Month Outcomes

OBJECTIVE

Little is known about the extent to which physical activity (PA) levels change following total knee or hip joint replacement relative to pain, physical function, and quality of life. Our objective was to conduct a systematic review and meta-analysis on changes in PA relative to pain, quality of life, and physical function after total knee or hip joint replacement.

METHODS

We searched the PubMed (Medline), Embase, and CINAHL databases for peer-reviewed, English-language cohort studies measuring PA with an accelerometer from presurgery to postsurgery. Random-effects models were used to produce standardized mean differences (SMDs) for PA, quality of life, pain, and physical function outcomes. Heterogeneity was assessed using I² .

RESULTS

Seven studies (336 participants) met the eligibility criteria. No significant increase in PA was found at 6 months (SMD 0.14 [95% confidence interval (95% CI) -0.05, 0.34]; I² = 0%) and a small to moderately significant effect was found for increasing PA at 12 months (SMD 0.43 [95% CI 0.22, 0.64]; I² = 0%). Large improvements were found at 6 months in physical function (SMD 0.97 [95% CI 0.12, 1.82]; I² = 92.3%), pain (SMD -1.47 [95% CI -2.28, -0.65]; I² = 91.6%), and quality of life (SMD 1.02 [95% CI 0.30, 1.74]; I² = 83.2%).

CONCLUSION

Physical activity did not change at 6 months, and a small to moderate improvement was found at 12 months postsurgery, despite large improvements in quality of life, pain, and physical function. Reasons for the lack of increased PA are unknown but may be behavioral in nature, as a sedentary lifestyle is difficult to change. Changing sedentary behavior should be a future focus of research in this subgroup.

Etoricoxib improves osteoarthritis pain relief, joint function, and quality of life in the extreme elderly

Etoricoxib is a selective cyclooxygenase-2 inhibitor, with a lower risk of gastrointestinal toxicity compared to traditional nonsteroidal anti-inflammatory drugs (NSAIDs). We evaluated the effectiveness and tolerability of etoricoxib in extremely elderly patients with chronic pain due to osteoarthritis (OA). A prospective, single-center, single-arm study was conducted, enrolling 19 extremely elderly men with OA (mean age 85.9, range 79-96 years), who responded inadequately to NSAIDs or other analgesics. Patients were switched to etoricoxib, 60 mg once daily for 4 weeks, without prior medication washout. Data were recorded before and after etoricoxib treatment. The primary endpoint was improvement in pain, assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) after the 4-week treatment. Other endpoints included the Brief Pain Inventory Short Form (BPI-SF), Treatment Satisfaction Questionnaire for Medication (TSQM), Short Form 36 (SF36), and European Quality of Life-5 Dimensions (EQ-5D). Safety and tolerability were assessed by collecting adverse events data. Pain and disability scores measured by WOMAC index were lower after treatment (pain, p ≤ 0.001; disability, p = 0.020). BPI-SF showed a significant improvement in joint function when walking and performing normal work (walking, p = 0.021; normal work, p = 0.030). SF36 scores improved for 7 out of 11 items after etoricoxib treatment (#1, p = 0.032; #4, p = 0.026; #5, p = 0.017; #6, p = 0.008; #7, p = 0.009; #8, p = 0.013; and #10, p = 0.038). EQ-5D showed a significant improvement in visual analogue scale scores (p = 0.036). TSQM results demonstrated a higher patient perception of overall satisfaction. No adverse events were reported. Pain relief, joint function, quality of life, and treatment satisfaction improved significantly in elderly patients with OA after etoricoxib administration.

Synovial and systemic pharmacokinetics (PK) of triamcinolone acetonide (TA) following intra-articular (IA) injection of an extended-release microsphere-based formulation (FX006) or standard crystalline suspension in patients with knee osteoarthritis (OA)

OBJECTIVE

Intra-articular (IA) corticosteroids relieve osteoarthritis (OA) pain, but rapid absorption into systemic circulation may limit efficacy and produce untoward effects. We compared the pharmacokinetics (PK) of IA triamcinolone acetonide (TA) delivered as an extended-release, microsphere-based formulation (FX006) vs a crystalline suspension (TAcs) in knee OA patients.

METHOD

This Phase 2 open-label study sequentially enrolled 81 patients who received a single IA injection of FX006 (5 mL, 32 mg delivered dose, N = 63) or TAcs (1 mL, 40 mg, N = 18). Synovial fluid (SF) aspiration was attempted in each patient at baseline and one post-IA-injection visit (FX006: Week 1, Week 6, Week 12, Week 16 or Week 20; TAcs: Week 6). Blood was collected at baseline and multiple post-injection times. TA concentrations (validated LC-MS/MS, geometric means (GMs)), PK (non-compartmental analysis models), and adverse events (AEs) were assessed.

RESULTS

SF TA concentrations following FX006 were quantifiable through Week 12 (pg/mL: 231,328.9 at Week 1; 3590.0 at Week 6; 290.6 at Week 12); post-TAcs, only two of eight patients had quantifiable SF TA at Week 6 (7.7 pg/mL). Following FX006, plasma TA gradually increased to peak (836.4 pg/mL) over 24 h and slowly declined to <110 pg/mL over Weeks 12-20; following TAcs, plasma TA peaked at 4 h (9628.8 pg/mL), decreased to 4991.1 pg/mL at 24 h, and was 149.4 pg/mL at Week 6, the last post-treatment time point assessed. AEs were similar between groups.

CONCLUSION

In knee OA patients, microsphere-based TA delivery via a single IA injection prolonged SF joint residency, diminished peak plasma levels, and thus reduced systemic TA exposure relative to TAcs.

Effectiveness of rehabilitation after a total hip arthroplasty: a protocol for an observational study for the comparison of usual care in the Netherlands versus Germany

INTRODUCTION

Osteoarthritis is the most common joint disorder worldwide. Total hip arthroplasty (THA) is considered one of the most effective treatments for end-stage hip osteoarthritis. The number of THAs is expected to increase dramatically in the coming decades. Usual postoperative rehabilitation after primary THA differs between the German and the Dutch system. In the Netherlands, patients undergo fast-track surgery and are discharged into their home environment within a few days without receiving any aftercare. In Germany, patients stay in the hospital for about 12 days before being transferred to a rehabilitation centre for a period of 3 weeks. The superficially more cost-effective Dutch system of usual care after THA is judged critically in both countries due to suboptimal rehabilitation outcomes. The aim of this study is therefore to compare the Dutch with the German usual care rehabilitation after primary THA. It is hypothesised that the German procedure is more effective in terms of functional outcomes and patient satisfaction than the Dutch procedure and that in the long run the German approach is more cost-effective than the Dutch system.

METHODS AND ANALYSIS

Medical effectiveness will be assessed at four different time points by means of patient self-reported questionnaires and functional tests. Assessments include the Hip disability and Osteoarthritis Outcome Score, Patient Acceptable Symptom State, Short Form 36, EuroQol 5 Dimensions 3 Level Questionnaire, Timed Up & Go Test and Five Times Sit-to-Stand Test. Additionally, long-term economic aspects in both countries will be assessed from a societal perspective, to get a first impression on whether cutting costs for rehabilitation, as practised in the Netherlands, really disburdens the healthcare system efficiently.

ETHICS AND DISSEMINATION

The study is approved by the Institutional Review Boards of both University Medical Center Groningen (METc2015/483) and Hannover Medical School (no 2874-2015) and will be conducted according to the principles of the Declaration of Helsinki (64th, 2013). The results of the study will be published in international peer-reviewed scientific journals. Patient data will be presented anonymously in any publication or scientific journal.

TRIAL REGISTRATION NUMBER

DRKS00011345; Pre-results.

Cross-cultural adaptation and psychometric analysis of the Arabic version of the oxford knee score in adult male with knee osteoarthritis

BACKGROUND

There are varieties of self-assessment questionnaire used for the evaluation of pain, functional disability, and health related quality of life in individuals with knee osteoarthritis (OA). The present study intended to adapt and translate the oxford knee score into the Arabic and investigated its psychometric properties in adult male with knee OA.

METHODS

Ninety-seven adult male (mean age 57.55 ± 11.49 years) with knee OA participated. Patients were requested to complete the adapted Arabic version of the Oxford knee score (OKS-Ar), reduced "Western Ontario and McMaster Universities Index (WOMAC)", and the Visual analogue scale (VAS). Patients were requested to complete 2^nd form of OKS-Ar at least 1 week apart to assess the reproducibility of the score. The OKS was adapted and translated into Arabic by two independent Arabic native speakers (one rehabilitation professional having experience of knee OA patients and another one a trained translator) according to the international guidelines.

RESULTS

All the participants completed the 2^nd form of OKS-Ar (Response rate 100%). Reliability and internal consistency was high with an ICC of 0.97, and the Cronbach's alpha coefficient of 0.987, respectively. A significant relationship between the OKS-Ar and the WOMAC and VAS scores confirmed the construct validity (p < 0.001). The standard error of measurement (SEM) and the minimum detectable change (MDC) were 2.2 and 6.2, respectively.

CONCLUSIONS

The adapted Arabic version of the OKS demonstrated acceptable psychometric properties, including reliability, internal consistency, and the validity. The present study indicates that the OKS-Ar is a suitable questionnaire to measure pain and physical function in the Arabic speaking adult male patients with knee OA.

Acetylsalicylic acid combined with diclofenac inhibits cartilage degradation in rabbit models of osteoarthritis

The present study aimed to investigate the effect of different concentrations of acetylsalicylic acid combined with diclofenac on the articular cartilage of a rabbit model of osteoarthritis (OA). A total of 40 New Zealand white rabbits were divided into 5 groups. Group A was a sham-operated control group, which was treated with normal saline. Groups B-E were OA models and were treated with normal saline and acetylsalicylic acid combined with diclofenac at concentrations of 5, 10 and 20 mg/kg, respectively. A cartilage macroscopic examination and a pathological observation were performed to analyze the structure of the articular cartilage in all of the treated groups. The nitric oxide (NO) content and interleukin 1β (IL-1β) levels were detected by an enzyme-linked immunosorbent assay. In addition, the protein expression of matrix metalloproteinase 3 (MMP)-3 and MMP-13 were detected by western blot analysis. The mRNA expression of tissue inhibitor of metalloproteinases 1 (TIMP1) was detected by polymerase chain reaction (PCR). The results revealed that different concentrations of the drugs significantly reduced the scores of cartilago articularis, the NO and IL-1β levels and the protein expression of MMP-3 and MMP-13. Furthermore, PCR revealed that the mRNA expression of TIMP1 was significantly upregulated, and the effects increased with increasing drug concentration. Thus, the administration of different concentrations of acetylsalicylic acid combined with diclofenac demonstrates preventive or therapeutic effects against OA progression.

Assessment of readiness to change in patients with osteoarthritis. Development and application of a new questionnaire

Objective: To develop a self-report measure for assessment of the stage of change in patients with osteoarthritis, in order to identify patients who would benefit from a self-management programme.

Methods: According to the ‘stages of change’ model a questionnaire was developed with three groups of items corresponding to the precontemplation stage (Pre), the contemplation (Cont) and the action (Act) stage. Internal consistency and factor structure of this questionnaire were investigated by assessing Cronbach's alphas and by performing factor analysis.

Subjects and setting: The questionnaire was offered to 273 patients who entered a randomized clinical trial on self-management in a general health care setting.

Results: Factor analysis revealed that most items corresponded to the a priori described groups, while some items were not loading on the presumed factor. In each subgroup some items were deleted, resulting in a 15-item questionnaire. After this item reduction Cronbach's alphas were 0.72 (Pre), 0.76 (Cont) and 0.79 (Act) and all factor loadings were satisfactory (above 0.35). Classification revealed some differences between parts of the total group, for example in the proportion of patients in the preparation stage (recruited by general practitioner 33.6%; advertisement 49.2%).

Conclusions: The Stages of Change Questionnaire in Osteoarthritis, a 15-item questionnaire to assess the ‘stage of change’ of a patient with osteoarthritis showed good internal consistency and adequate factor structure. These findings warrant further studies on validity and applicability in a clinical context.

Computer Hexapod-Assisted Orthopaedic Surgery for the Correction of Tibial Deformities

We describe the intraoperative use of the Taylor Spatial Frame to correct complex multiplanar deformities of the tibia before definitive internal stabilization using minimally invasive techniques. Thirteen consecutive procedures were performed in 12 patients. All deformities of the tibia were assessed with standardized radiographs allowing estimation of the center of rotation of angulation (CORA) or multiple CORA for multiplanar deformities. The cause of the deformity included both posttraumatic and metabolic conditions. A wide range of deformities was deemed appropriate for correction with this technique. All underwent acute intraoperative correction through single or multiple osteotomies mediated by the Taylor Spatial Frame before definitive internal stabilization using a locked intramedullary nail. Deformity correction and restoration of the tibial mechanical axis was achieved in all cases. There were no cases of nonunion. There was only one superficial infection necessitating removal of implants following union of the osteotomies. Two patients developed a common peroneal nerve palsy, 1 had full recovery at 18 months and 1 had partial recovery. Another patient developed a tibial artery pseudoaneurysm treated successfully with a percutaneous stent. This series demonstrates the use of the Taylor Spatial Frame for acute intraoperative correction of complex tibial deformities and definitive internal stabilization.

Long-term efficacy and safety of oxycodone-naloxone prolonged release in geriatric patients with moderate-to-severe chronic noncancer pain: a 52-week open-label extension phase study

BACKGROUND

Two-thirds of older people suffer from chronic pain and finding valid treatment options is essential. In this 1-yearlong investigation, we evaluated the efficacy and safety of prolonged-release oxycodone-naloxone (OXN-PR) in patients aged ≥70 (mean 81.7) years.

METHODS

In this open-label prospective study, patients with moderate-to-severe noncancer chronic pain were prescribed OXN-PR for 1 year. The primary endpoint was the proportion of patients who achieved ≥30% reduction in pain intensity after 52 weeks of treatment, without worsening bowel function. The scheduled visits were at baseline (T0), after 4 weeks (T4), and after 52 weeks (T52).

RESULTS

Fifty patients completed the study. The primary endpoint was achieved in 78% of patients at T4 and 96% at T52 (P<0.0001). Pain intensity, measured on a 0-10 numerical rating scale, decreased from 6.0 at T0 to 2.8 at T4 and to 1.7 at T52 (P<0.0001). Mean daily dose of oxycodone increased from 10 to 14.4 mg (T4) and finally to 17.4 mg (T52). Bowel Function Index from 35.1 to 28.7 at T52. No changes were observed in cognitive functions (Mini-Mental State Examination evaluation), while daily functioning improved (Barthel Index from 53.1 to 61.0, P<0.0001). The Screener and Opioid Assessment for Patients with Pain-Revised score at 52 weeks was 2.6 (standard deviation 1.6), indicating a low risk of aberrant medication-related behavior. In general, OXN-PR was well tolerated.

CONCLUSION

This study of the long-term treatment of chronic pain in a geriatric population with OXN-PR shows satisfying analgesic effects achieved with a stable low daily dose, coupled with a good safety profile and, in particular, with a reduction of constipation, often present during opioid therapy. Our findings support the indications of the American Geriatrics Society, suggesting the use of opioids to treat pain in older people not responsive to acetaminophen or nonsteroidal anti-inflammatory drugs.

Diagnosis and management of knee osteoarthritis: Chinese medicine expert consensus (2015)

Literature review shows that Chinese medicine and other related treatment are still the main stream treatment of knee osteoarthritis. Currently, there is short of handbook guiding Chinese medicine from evidence-based medical evidence, so it is a top priority to develop a clinical guideline from the expert consensus. After several rounds of discussion during the conference and examination by letter, which has collected opinions from nearly one hundred experts, consensus was reached. Nonpharmacologic interventions include health education, medical exercise, acupuncture, massage, acupotomology, and physiotherapy. Pharmacological interventions are as follows. Topical application includes fumigation, application, hot compressed, ironing and iontophoresis with Chinese herbs, etc. Chinese patent medicine for external use includes plaster, ointment, etc. Western medicine for external use mainly includes emulsion, ointment, plaster and embrocation containing nonsteroidal anti-inflammatory drugs (NSAIDs). Intraarticular injection mainly includes sodium hyaluronic acid, chitosan (for injection) with prudent use of glucocorticoid. Chinese herbal medicine and Chinese patent medicine can be taken referring to syndrome differentiation which mainly includes syndromes of qi stagnation and blood stasis, cold dampness, deficiency of Gan (Liver) and Shen (Kidney), deficiency of qi and blood. Western medicine mainly includes analgesic, NSAIDs, diseases modifying drugs. Surgery procedures mainly include joint irrigation, arthroscopic surgery, osteotomy, arthroplasty, etc.

Effects of Osteoarthritis on Quality of life in Elderly Population of Bhubaneswar, India: A Prospective Multicenter Screening and Therapeutic Study of 2854 Patients

Introduction:

Osteoarthritis (OA) is the most common age-related joint disease affecting >80% people beyond 55 years of age. It is a leading cause of elderly visit to outpatient departments and accounts for almost half of all nonsteroidal anti-inflammatory drug prescriptions. The burden and impact of knee OA in Indian population and extent of public health services usage by people with OA are not known.

Methods:

We performed a prospective blinded multicenter screening and therapeutic study from June 2013 to June 2014 at 3 centers to screen patients >55 years with knee OA to assess quality of life, functional disability, and limitation of functions and to compare the effectiveness of hip and leg strengthening exercise programs in these patients. Functional disability was assessed by Western Ontario and McMaster’s Universities OA index (WOMAC), Friedman, and Wyman Scores; locomotor function was assessed by walking status, Visual Analog Scale (VAS), and 30-second timed chair stand tests; and quality of life was assessed by Short Form-36 (SF-36).

Results:

Of 2854 patients screened, 2054 (72%) patients had OA (male:female-1.9:1) with mean age of 63 years and standard deviation of 8. Of 2054 patients, 226 patients were randomly selected for therapeutic study. In remaining 1828 patients, baseline 10-meter walk test (10MWT) was 0.3 m/s, mean SF-36 Physical Component Score (PCS) was 31.3, and Mental Component Score (MCS) was 34.2. At 3 months, 79% patients were comfortable with significant VAS, WOMAC, Friedman-Wyman Scores, 10MWT, and timed chair test improvements in patients who performed lifestyle modifications and exercises (P = .04). Short Form-36 improved, mean PCS was 43.6, and MCS was 54.2. At 3 months, 274 (15%) patients were unsatisfied among whom 26% and 74% were treated with arthroscopic procedures and arthroplasty, respectively. Isolated hip and leg strengthening exercise programs similarly improved knee pain, function, and quality of life.

Conclusion:

Motivation and counseling with hip and leg strengthening exercises should be incorporated with pharmacotherapy in each OA prescription. Physical fitness and weight reduction should be promoted as first-line management of OA.