Comparative clinical and cost analysis between surgical and non-surgical intervention for knee osteoarthritis

Tuina on knee pain and functional decline of lower limbs for patients with mild-to-moderate knee osteoarthritis in Shanghai: protocol for a multicentre, assessor-blinded, randomised controlled trial

INTRODUCTION

Knee osteoarthritis (KOA) is one of the most common osteoarthritis, imposing substantial economic and medical burdens on both individuals and society. In China, Tuina has been selected as a complementary and alternative therapy to relieve knee pain and dysfunction symptoms. However, the current evidence is insufficient to support the efficacy of Tuina therapy in addressing knee pain and improving physical function. The trial aims to compare the effectiveness of Tuina with celecoxib, which is considered as the standard treatment, and to assess its potential as an alternative therapy through changes in outcome measures.

METHODS AND ANALYSIS

A total of 360 KOA patients aged between 40 and 70 years and classified as Kellgren and Lawrence grades I-II will be recruited from eight subcentral hospitals. The participants will be randomly assigned to either the treatment group (Tuina, Biw) or the control group (celecoxib, Qd), with both groups undergoing a 4-week intervention phase followed by an 8-week follow-up phase. The primary outcome is the change in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale at week 4 compared with baseline. Secondary outcomes including WOMAC stiffness and function subscales, WOMAC total score, 36-item Short-Form Health Survey, Timed Up and Go test, Short Physical Performance Battery, gait analysis parameters and pain medication records will be assessed at weeks 4, 8 and 12. Any adverse events that occur during the trial will be promptly recorded.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of Shanghai Municipal Hospital of Traditional Chinese Medicine (2023SHL-KY-16-01, 2023SHL-KY-16-02). Written informed consent will be obtained from all participants. Study results will be disseminated through peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

ChiCTR2300069416.

Systematic review and meta-analysis of single-stage versus two-stage revision for periprosthetic joint infection after knee arthroplasty: a call for a randomised trial

Purpose

Knee arthroplasty is an effective treatment for severe knee degeneration; however, periprosthetic joint infection (PJI) is one of its serious complications. Single- and two-stage revision are common treatments, but few studies have compared single- and two-stage revision for PJI after knee arthroplasty. This study aimed to compare the reinfection and reoperation rates of single- and two-stage revision through meta-analysis.

Methods

The review process was conducted according to the PRISMA guidelines. We searched the PubMed, Medline, Embase and Cochrane Central Register of Controlled Trials databases for trials comparing single- and two-stage revision for PJI after knee arthroplasty from the respective inception dates to April 2023. Two researchers individually screened the studies, performed the literature quality evaluation and data extraction and used Stata 17 software for data analysis.

Results

The meta-analysis showed that the reinfection rate was significantly lower in the single-stage revision group than in the two-stage revision group. While the reoperation rates demonstrated no statistically significant difference between the two groups. We presented descriptive results because the discrepancies in the knee function scores and data reported in the studies meant that these data could not be combined in the meta-analysis.

Conclusion

Based on the available research, single-stage revision is a reliable option for PJI after knee arthroplasty. However, when developing the best treatment strategy, it is still necessary to consider the individual circumstances and needs of the patient, as well as the risks of postoperative rehabilitation and complications.

Osteotomy Correction Angle Cut-off Points Can Guide the Operation to Prevent a Significant Decrease in Patella Height

OBJECTIVE

Patients who undergo a biplanar ascending medial open-wedge high tibial osteotomy with an excessive correction angle might experience patella infera and even knee pain after surgery. The purpose of this study was to identify the cut-off points for the degree of knee varus correction of open-wedge high tibial osteotomy, which is related to the symptomatic patellar position change.

METHODS

This retrospective study included 124 patients (mean age 61.69 ± 6.28 years; 78 women, 46 men) with varying degrees of varus knee osteoarthritis. All patients had undergone standard biplanar medial open-wedge high tibial osteotomy. They were divided into nine groups according to the change in hip-knee-ankle angle. Plain radiographs and three-dimensional CT images were obtained preoperatively and 18 months postoperatively. Patellar height was assessed using the Caton-Deschamps index, the Insall-Salvati index, and the Blackburne-Peel index. The patellofemoral index and patellar tilt were used to evaluate the degree of horizontal displacement of the patella. The varus correction, medial-proximal tibial angles, joint line convergence angles, and hip-knee-ankle angles were also measured. The subjective score was evaluated using the Western Ontario and McMaster Universities osteoarthritis index (WOMAC).

RESULTS

There were significant changes in patella indexes in each group after surgery, among which there was no significant difference in patellar height changes for Groups A to F (p > 0.05), which were significantly lower than those in Group G, H, and I (p < 0.001). The patellar tilt and patellofemoral index also followed the same trend. The improvement in WOMAC scores for Groups G, H, and I was also significantly less for Groups A to F (p < 0.001).

CONCLUSION

The patellar height, patellar tilt, and patellofemoral index all changed significantly in parallel with increasing degrees of osteotomy correction. The cut-off points for correction angle are 12.5° to 13.4°. When the correction angle is larger than this range, the patellar position can be significantly affected. Postoperative patellofemoral joint pain may be related to the changes in patella position.

Efficacy and Safety of Hyaluronic Acid and Platelet-Rich Plasma Combination Therapy Versus Platelet-Rich Plasma Alone in Treating Knee Osteoarthritis: A Systematic Review

Knee osteoarthritis (KOA) is a chronic degenerative disease of the joint characterized by biochemical and biomechanical alterations of articular cartilage, degradation of the joint edge, and subchondral bone hyperplasia. Nowadays, intra-articular hyaluronic acid (HA) or platelet-rich plasma (PRP) has become a popular treatment modality for treating KOA. Each treatment can be used independently or in combination. However, the efficacy and safety of combination treatment are still inconclusive, and there is a lack of high-quality level 1 studies that support using combination therapy over PRP alone. Consequently, we conducted a systematic review to examine the effectiveness and safety of combining HA and PRP therapy versus using PRP therapy alone in KOA patients. Based on the most up-to-date evidence, the dual approach of PRP and HA therapy yields outcomes similar to PRP therapy alone in the short term, up to 12 months. Nonetheless, when considering longer-term results, particularly in the 24-month follow-up, dual therapy holds the potential to produce superior outcomes compared to PRP alone therapy. Additionally, in terms of safety, dual therapy has been associated with slightly fewer adverse events.

Exploring patient treatment decision making for osteoarthritis in the UAE: a cross-sectional adaptive choice-based conjoint study

OBJECTIVE

To assess osteoarthritis (OA) patients' preferences for pharmaceutical treatment via Adaptive Choice-Based Conjoint (ACBC) method.

METHODS

A United Arab Emirates (UAE) based Patient and Public Involvement (PPI) group designed the ACBC questionnaire with 10 attributes and 34 levels. The questionnaire was developed using Sawtooth Software and analyzed through Hierarchical Bayesian (HB). Results were standardized using Z-score via SPSS.

RESULTS

Study participants were 1030 OA patients, 83.6% aged 50 or older and 83.4% female. The avoidance of medication's side effects accounted for 66% relative importance compared to 6% relative importance for the medication's benefits. The "way of taking the medicine" attribute had the highest coefficient of variation (70%) and the four side effect attributes "risk of gastric ulcer, addiction, kidney and liver impairment, and heart attacks and strokes" had a coefficient of variation from 18 to 21%.

CONCLUSIONS

Arab OA patients are similar to other ethnic groups in trading-off benefits and side effects and consistently prioritizing the avoidance of medications' side effects. Although the "Way of taking medicine" was the least important attribute it was associated with the highest variation amongst patients. OA patients also prefer prescribed medications to internet-purchased and over-the-counter options.

Costs and models used in the economic analysis of Total Knee Replacement (TKR): A systematic review

OBJECTIVES

The main objective of this review is to summarize the evidence on the core modelling specifications and methodology on the cost-effectiveness of TKR compared to non-surgical management. Another objective of this study is to synthesize evidence of TKR cost and compare it across countries using purchasing power parity (PPP).

METHODOLOGY

The electronic databases used for this review were MEDLINE (PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), HTAIn repository, Cost effectiveness Analysis (CEA) registry, and Google Scholar. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) was used to assess the validity of the methods and transparency in reporting the results. The Quality of Health Economic Studies (QHES) was used to check the quality of economic evaluation models of the studies included. The cost of TKR surgery from high income and low- or middle-income countries were extracted and converted to single USD ($) using purchasing power parities (PPP) method.

RESULT

Thirty-two studies were included in this review, out of which eight studies used Markov model, five used regression model, one each reported Marginal structure model, discrete simulation model, decision tree and Osteoarthritis Policy Model (OAPol) respectively to assess the cost-effectiveness of TKR. For PPP, twenty-six studies were included in the analysis of TKR cost. The average cost of TKR surgery was the lowest in developing country-India ($3457) and highest in USA ($19568).

CONCLUSION

The findings of this review showed that the Markov model was most widely used in the analysis of the cost effectiveness of TKR. Our review also concluded that the cost of TKR was higher in the developed countries as compared to the developing countries.

Advances in Mesenchymal Stem Cell Therapy for Osteoarthritis: From Preclinical and Clinical Perspectives

The prevalence of osteoarthritis (OA), a degenerative disorder of joints, has substantially increased in recent years. Its key pathogenic hallmarks include articular cartilage destruction, synovium inflammation, and bone remodeling. However, treatment outcomes are unsatisfactory. Until recently, common therapy methods, such as analgesic and anti-inflammatory treatments, were aimed to treat symptoms that cannot be radically cured. Mesenchymal stem cells (MSCs), i.e., mesoderm non-hematopoietic cells separated from bone marrow, adipose tissue, umbilical cord blood, etc., have been intensively explored as an emerging technique for the treatment of OA over the last few decades. According to existing research, MSCs may limit cartilage degradation in OA by interfering with cellular immunity and secreting a number of active chemicals. This study aimed to examine the potential mechanism of MSCs in the treatment of OA and conduct a thorough review of both preclinical and clinical data.

Effect of a PA-led arthritis center on hip and knee osteoarthritis care

OBJECTIVE

To evaluate the effect of an arthritis center on patient care and operational throughput.

METHODS

A single-institution, retrospective review was conducted of patients with hip or knee osteoarthritis from January 2016 to October 2019. Our physician assistant (PA) led arthritis center opened in November 2017, and manages nonoperative treatment of osteoarthritis by formulating individualized treatment plans. Descriptive and inferential statistics comparing operational measures, treatment patterns, and patient satisfaction pre- and postcenter opening were performed.

RESULTS

Overall patient volume, new patient volume, and the proportion of new patients seen increased after the arthritis center opened. Encounters per patient and clinicians seen per patient decreased, while the rate of injections and surgery increased. Patient satisfaction improved after opening of the arthritis center.

CONCLUSIONS

The establishment of a dedicated PA-led arthritis center is associated with improved access to care, operational efficiency, and patient satisfaction in patients with hip and knee osteoarthritis.

Burden, Treatment Patterns and Unmet Needs of Osteoarthritis in Dubai: a Retrospective Analysis of the Dubai Real-World Claims Database

Introduction

Osteoarthritis (OA) is a degenerative joint disease that impacts 3.3–3.6% of population globally with significant health and societal impact. The current study assessed the disease burden, treatment patterns, and healthcare resource utilisation (HCRU) and costs in patients with OA and subgroups of hip and/or knee OA, in Dubai, United Arab Emirates (UAE).

Methodology

This retrospective longitudinal case–control study collected OA-related data from January 1, 2014 to May 31, 2020 from the Dubai Real-World Claims Database (DRWD). Adults aged at least 18 years old with OA diagnosis and at least two claims and continuous enrolment during the study period were included in the study. The patients with OA were 1:1 matched with individuals without OA. The patients with OA were divided into four cohorts on the basis of an a priori algorithm: OA of the hip and/or knee (cohort 1) and (difficult-to-treat) subsets of patients with moderate-to-severe OA of the hip and/or knee (cohort 2), inadequate response or inability to tolerate at least three pain-related medications (cohort 3), and contraindications to nonsteroidal anti-inflammatory drugs (NSAIDs) (cohort 4).

Results

Disease burden of OA in Dubai and HCRU and treatment costs in patients with OA were evaluated from January 1, 2014 to May 31, 2021. Patients were compared with matched controls in 1:1 ratio. The overall cohort comprised 11,651 patients with a median age of 48 years and predominantly male population (61.6%). HCRU was calculated for each cohort and it was highest (United States dollar [USD] 11,354.39) in cohort 4 (patients with contraindication to NSAIDS); in cohort 3 (inability to respond to at least three pain-related medications), USD 495.30 and USD 765.14 were spent on medication and procedures, respectively. Highest cost burden was seen in cohort 4, USD 3120.49 on consumables and USD 228.18 on services.

Conclusion

Osteoarthritis imposes a substantial healthcare and economic burden in the UAE. The study findings elucidate the unmet need among patients with difficult-to-treat OA and inform development of new therapeutics to alleviate their burden.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00391-z.

The influence of posterior tibial slope on the mid-term clinical effect of medial-pivot knee prosthesis

OBJECTIVE

To evaluate the effect of posterior tibial slope (PTS) on the mid-term clinical outcome following a medial-pivot (MP) prosthesis.

METHOD

Two hundred thirty-three patients from The Affiliated Hospital of Qingdao University, who had undergone a total knee arthroplasty (TKA) with MP prosthesis between January 2015 and December 2015, were retrospectively included in this study. They were divided into 3 groups according to postoperative PTS: A ≤ 5°; B 5-7°; and C ≥ 7°. Multiple assessments were made on the patient postoperatively and recorded in the three groups, the measurements of this study included: the range of motion (ROM), knee scoring system (KSS), Western Ontario and McMaster universities osteoarthritis index (WOMAC), posterior condylar offset (PCO), joint line height, and postoperative complications.

RESULTS

The average post-operative ROM for groups B and C were 108° and 110° respectively; this was significantly higher than that of group A (98°, P < 0.001). The WOMAC scores of patients in group C were significantly lower than those in groups A and B (P < 0.05). However, there were no significant differences in KSS, PCO, and joint line height among the 3 groups (P > 0.05). Only 2 cases of postoperative complications occurred in group C, these were ameliorated after operation.

CONCLUSION

With an increase to PTS, the postoperative ROM can be significantly increased for the patient. However, the knee joint function will not be significantly improved, and the stability of knee joint will not be affected when within the limits of appropriate PTS.

Healthcare Utilization and Knee Osteoarthritis Symptoms among Urban Older Malaysian

Knee osteoarthritis (OA) is a prevalent chronic disorder in the older population. While timely management is important to minimize the consequences of knee OA, information on the utilization of healthcare services among this population remains limited. Therefore, the objectives of this study were to determine the healthcare utilization and its associated factors in older persons with knee OA. Cross-sectional data from 1073 participants aged 60 years and above from the Malaysian Elders Longitudinal Research (MELoR) study were included. The utilization rate of healthcare services was quantified. Factors related to the utilization of healthcare services were determined using logistic regression analysis. Healthcare utilization among participants with knee OA was significantly higher than those without knee OA (p < 0.01). Outpatient usage was higher (p < 0.01) in comparison to inpatient and pharmacotherapy. Being married and having an income were significantly associated with seeking outpatient care (OR: 11.136, 95% CI: 1.73–52.82, p < 0.01) and pharmacotherapy (OR: 10.439, 95% CI: 1.187–91.812, p < 0.05), while females were less likely to utilize inpatient care services (OR: 0.126, 95% CI: 0.021–0.746, p < 0.05). The higher rate of healthcare utilization among older persons with knee OA indicates the increased healthcare needs of this population, who are commonly assumed to suffer from a benign disease.

Changes in patellar height and posterior tibial slope angle following uniplanar medial opening wedge high tibial osteotomy using a novel wedge-shaped spacer implanation concurrent with proximal partial fibulectomy

PURPOSE

The purpose of this study was to evaluate changes of patellar height and posterior tibial slope angle following uniplanar medial opening wedge high tibial osteotomy using a novel wedge-shaped spacer implanation concurrent with proximal partial fibulectomy.

METHODS

All patients who underwent uniplanar medial opening wedge high tibial osteotomy using a novel wedge-shaped spacer implanation concurrent with proximal partial fibulectomy between January 2017 and February 2019 were included and assessed retrospectively. Radiological assessment was made in terms of the changes in patellar height and posterior tibial slope angle between pre-operative and post-operative radiographs.

RESULTS

Thirty-five patients (9 males and 26 females) with a mean age of 57.3 years (range 50.8-64.2 years) were enrolled in this study protocol and demonstrated decreased posterior tibial slope angle post-operatively (9.7° ± 2.5° pre-operatively and 7.3° ± 1.8° post-operatively, P < 0.001). Patellar height was unchanged significantly post-operatively (Caton-Deschamps: 0.83 ± 0.12 pre-operatively and 0.82 ± 0.09 post-operatively, P > 0.05).

CONCLUSIONS

Uniplanar medial opening wedge high tibial osteotomy using a novel wedge-shaped spacer implanation concurrent with proximal partial fibulectomy can decrease posterior tibial slope and maintain the patellar height.

Effects of bushen huoxue method for knee osteoarthritis: A protocol for systematic review and meta-analysis

BACKGROUND

Knee osteoarthritis (KOA) is a common progressive joint disorder in old people. Bushen huoxue (BSHX) is a classical method of TCM in treating KOA. However, there is no systematic review related to BSHX for KOA. The purpose of this study is to provide a comprehensive and reliable evaluation of the clinical evidence of BSHX in the treatment of KOA.

METHODS

We searched relevant studies on BSHX for KOA from the databases of PubMed, Embase, MEDLINE, Cochrane Library Central Register of Controlled Trials, China national knowledge infrastructure database (CNKI), Wan fang database, Chongqing VIP information, and SinoMed from their inception to May 2020. Two researchers will select and evaluate qualified studies independently. The primary outcomes of this review will focus on pain intensity. The meta-analyses will be performed by using the RevMan 5.3.

RESULTS

The study will provide a comprehensive evaluation of the efficacy and safety of the BSHX method for patients with KOA.

CONCLUSION

The results of this systematic review will provide evidence to judge whether BSHX is an effective intervention for patients with KOA.

Does the medial pivot knee improve the clinical and radiographic outcome of total knee arthroplasty? A single centre study on two hundred and ninety seven patients

PURPOSE

Total knee arthroplasty (TKA) is a cost-effective surgery with a survival rate higher than 90% after 15 years. Nevertheless, patients are unsatisfied in more than 15% of cases. Medial pivot (MP) prosthetic designs were introduced in late 90's with the aim to reproduce natural knee kinematics. The purpose of this study is to evaluate the survivorship and clinical outcomes of a novel design of MP knee with a minimum follow-up of five years.

METHODS

This is a retrospective review of all patients who underwent primary TKA using the K-Mod dynamic congruence implant (Gruppo Bioimpianti, Peschiera Borromeo, Milan, Italy) between 2012 and 2013 at a single institution. A total of 339 patients (351 knees) were included with a mean age of 74 years (range 41-89). The Knee Society score, the global range of movement, the Western Ontario and McMaster Universities Osteoarthritis score, Forgotten Joint score, and the short-term form 12 health survey were collected. FJS and SF-12 were collected only post-operatively. Radiographic outcomes were evaluated according to the Knee Society's roentgenographic evaluation system. Kaplan-Meyer (KM) curves were performed to evaluate implant survivorship. A two-tailed paired t test was performed to evaluate the differences between pre-operative and post-operative score.

RESULTS

A total 297 patients (315 knees) were available for clinical and radiographic analysis, and the mean follow-up was 66.4 months. A total of 17 patients (17 knees 5.4%) experienced a post-operative complication, and a reoperation was performed in five patients (5 knees 1.6%). Four patients had a periprosthetic joint infection, and two patients had a post-traumatic periprosthetic femoral fracture. The KM survivorship at five years was 98.2% (95% CI 0.96 to 0.99) for revision for any reason. There was a statistically significant improvement (p < 0.05) in all the objective and subjective outcomes measured.

CONCLUSION

The K-Mod dynamic congruence design has shown an excellent clinical, radiographic, and patient-reported outcome in primary TKAs.