Osteoarthritis as a Public Health Problem

Gender Differences for Hip and Knee Arthroplasty: Complications and Healthcare Utilization

INTRODUCTION

The influence of patient gender on complications and healthcare utilization remains unexplored. The purpose of the present study was to determine if patient gender significantly affected outcomes following total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

Retrospective cohort study of THA and TKA patients was performed using the Nationwide Inpatient Sample from 2002 to 2011. Only patients who underwent elective procedures and those with complete perioperative data were included. Multivariate logistic regression was used to compare the rates of adverse events between male and female cohorts while controlling for baseline characteristics.

RESULTS

A total of 6,123,637 patients were included in the study (31.2% THA and 68.8% TKA). The cohort was 61.1% female. While males had a lower rate of any adverse event (odds ratio [OR] = 0.8, P < .001), urinary tract infection (OR = 0.4, P < .001), deep vein thrombosis/pulmonary embolism (OR = 0.9, P < .001), and blood transfusion (OR = 0.5, P < .001), male gender was associated with statistically significant increases in the rates of death (OR = 1.6, P < .001), acute kidney injury (OR = 1.6, P < .001), cardiac arrest (OR = 1.7, P < .001), myocardial infarction (OR = 1.6, P < .001), pneumonia (OR = 1.1, P < .001), sepsis (OR = 1.6, P < .001), surgical site infection (OR = 1.4, P < .001), and wound dehiscence (OR = 1.4, P < .001).

CONCLUSION

Males had increased rates of many individual adverse events. Females had higher rates of urinary tract infection, which translated to an overall higher rate of adverse events in females because of the rarity of the other individual adverse events.

An Observational 1-Month Trial on the Efficacy and Safety of Promerim for Improving Knee Joint

Objective:

This study was conducted to evaluate the efficacy and tolerability of the oral intake of promerim in the elimination of acute pain and discomfort associated with knee osteoarthritis (OA).

Methods:

Single-center, 1-month, prospective, observational clinical trial. A total of 92 patients not older than 70 years were included. Patients were offered to use 720-mg promerim for the first 15 days after admission after breakfast and then 360 mg for the second 15 days. All patients were analyzed with the visual analog scale (VAS) for pain, which ranges from 0 to 10, and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score before the start of treatment and 1 month after the start. Statistical analysis was performed by SPSS 15.0 software. An α level of P < .05 was assumed to be statistically significant.

Results:

This study comprised 92 patients (69 women and 23 men) with a mean age of 51.5 (range: 40-69) years. Before treatment, the mean VAS score was 5.6 ± 1.1, and after treatment, the mean VAS score was 2.6 ± 1.7. Treatment with promerim consistently showed a significant decrease in the VAS score (P < .001). The mean WOMAC score of the patients was 46.4 ± 8.2 before treatment. After treatment, the mean WOMAC score was 72.1 ± 14.4. Treatment with promerim consistently showed a significant increase in the WOMAC score (P < .001).

Conclusions:

The results of this single-center, open-label clinical study demonstrate that promerim is a viable natural treatment option for treating knee OA. We recommend that 720-mg promerim taken once daily for the first 15 days after admission and 360 mg taken once daily for the next 15 days significantly and rapidly reduced composite pain and stiffness in the knee OA within 1 month.

COMPARED EFFICACY OF INTRA-ARTICULAR INJECTION OF METHYLPREDNISOLONE AND TRIAMCINOLONE

Objective:

To compare the effect of two different corticosteroid types in bilateral and symmetrical knee osteoarthritis (OA).

Methods:

One hundred and twenty-six patients received injections of methylprednisolone acetate (MP) in one knee and triamcinolone hexacetonide (TH) in the contralateral knee. Patients were evaluated before injection and 2, 4, 8, 12, and 24 weeks after.

Results:

Mean patient age was 68.5±9 years. Mean BMI was 26.3±2.6 kg/m². At first admission, mean VAS score was 7.7±1.3 for the right side and 7.5±1.5 for the left side, and mean WOMAC score was 67.6±14.4. After bilateral intra-articular injection, VAS scores for both knees and WOMAC scores decreased significantly when initial scores were compared with 2, 4, 8, 12, and 24 weeks after injection (p<0.05). A statistically significant change was seen over time when VAS and WOMAC scores for 2, 4, 8, 12, and 24 weeks post-injection were compared to each other (p<0.05). No significant difference was seen between knee sides (p>0.05).

Conclusion:

MP and TH have similar efficacy in relieving pain and improving function. The efficacy of intra-articular corticosteroid injection peaks 2 weeks after injection and the effect continues until the 24^th week. Level of Evidence II, Comparative Prospective Study.

Levels of neuropeptide Y in synovial fluid relate to pain in patients with knee osteoarthritis

Background

The precise etiology of knee osteoarthritis (KOA) pain remains highly controversial and there is no known effective treatment. Due to the known and suggested effects of neuropeptide Y (NPY) on pain, we have sought to investigate the relationship between the concentration of NPY in synovial fluid of knee, pain of KOA, and structural severity of KOA.

Methods

One hundred KOA patients and twenty healthy participants (control group) were recruited. The pain and the radiographic grade of KOA were assessed separately by Hideo Watanabe’s pain score and Tomihisa Koshino’s scoring system. Synovial fluid of knee from all participants was collected with arthrocentesis. Radioimmunoassay was used to examine the concentration of NPY in synovial fluid of knee.

Results

Concentrations of NPY in synovial fluid were significantly higher in KOA patients (124.7 ± 33.4 pg/mL) compared with controls (64.8 ± 26.3 pg/mL) (p = 0.0297). According to Hideo Watanabe’s pain score, 100 KOA patients were divided into 5 subgroups: no pain (n = 12), mild pain (n = 25), moderate pain (n = 37), strong pain (n = 19) and severe pain (n = 7). Within the KOA group, significantly higher concentrations of NPY were found in each subgroup as pain intensified (no pain 81.4 ± 11.7 pg/mL, mild pain 99.1 ± 23.2 pg/mL, moderate pain 119.9 ± 31.5 pg/mL, strong pain 171.2 ± 37.3 pg/mL and severe pain 197.3 ± 41.9 pg/mL). Meanwhile, according to Tomihisa Koshino’s scoring system, 100 KOA patients were divided into 3 subgroups: early stage (n = 30), middle stage (n = 53), advanced stage (n = 17). Concentrations of NPY in middle and advanced stage groups of KOA patients were significant higher than early stage group of KOA patients (early stage 96.4 ± 27.1 pg/mL, middle stage 153.3 ± 16.9 pg/mL, advanced stage 149.5 ± 36.7 pg/mL) (p = 0.0163, p = 0.0352). Concentrations of NPY in advanced stage group of KOA patients has no significant difference compare with middle stage group of KOA patients (p = 0. 2175).

Conclusions

This study demonstrated the presence and variation of concentrations of NPY in the KOA joint fluid, suggesting a role for NPY as a putative regulator of pain transmission and perception in KOA pain.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-319) contains supplementary material, which is available to authorized users.

Perceived health status of women with knee osteoarthritis: a cross-sectional study of the relationships of age, body mass, pain and walking limitations

Persons with knee osteoarthritis (OA) often experience considerable physical disability. Although some studies suggest women with this condition suffer more than men, few have attempted to characterize the magnitude and that impact of this condition specifically among women with moderate knee osteoarthritis as well as the relationships that exist between their perceived health status and well established physical, emotional and perceptual factors found in this disease. This exploratory study strove to better understand factors that underpin the perceived impact of the condition, and to describe the extent of pain and function among women with mild to moderate knee osteoarthritis, and how this impacts this condition. The records of 20 women with the condition who had undergone multiple tests using a standardized protocols and validated instruments were examined. The primary outcome measure was the perceived impact of the disease using the Arthritis Impact Measurement Scale. Secondary outcome measures included six minute walking distance, fastest walking velocity, self-reported pain, pain and functional self-efficacy, body mass, and depression. The variables were subjected to t-tests, and correlational analyses. Results demonstrated pain is the clinical factor most consistently impacting the disease experience, along with deficiencies in walking ability (p <0.05). Important mediating variables of ambulatory capacity were body mass and pain self-efficacy.

A controlled double blind study comparing the effects of strong Burst Mode TENS and High Rate TENS on painful osteoarthritic knees

This double blind, controlled study compared the changes in pain, stiffness, circumference and range of movement, produced by one 30 minute application of High Rate TENS, or strong Burst Mode TENS on chronic osteoarthritic knees. Both TENS applications were applied at strong, tolerable intensities for 30 minutes, over four acupuncture points around the knee. Pain, stiffness, circumference, and range of movement measurements were recorded immediately before and after the TENS applications. Length of continuation of pain relief and alteration in stiffness was reported by subjects. The study aimed to establish whether strong Burst Mode TENS produced significantly greater and longer lasting changes than those produced by High Rate TENS. The only significant change produced by strong Burst Mode when compared with High Rate TENS was on knee circumference.

Effect of music on anxiety and pain during joint lavage for knee osteoarthritis

Joint lavage for knee osteoarthritis is an invasive procedure that can be stressful and painful. We aimed to assess the impact of music therapy on perioperative anxiety, pain and tolerability of the procedure in patients undergoing joint lavage performed with two needles. We randomized all patients diagnosed with knee osteoarthritis and undergoing joint lavage in our department from November 2009 to October 2010 to an experimental group listening to recorded music or a control group receiving no music intervention. Perioperative anxiety and pain related to the procedure were self-reported on a visual analogic scale (0-100 mm visual analog scale [VAS]), and heart rate and blood pressure were measured during the procedure. Tolerability was assessed on a four-grade scale directly after the procedure. We included 62 patients (31 in each group). Mean age was 68.8 ± 12.6 years (72% females). As compared with the control group, the music group had lower levels of perioperative anxiety (40.3 ± 31.1 vs. 58.2 ± 26.3 mm; p = 0.046) and pain related to the procedure (26.6 ± 16.2 vs. 51.2 ± 23.7 mm; p = 0.0005). Moreover, heart rate was lower in the music group (69.5 ± 11.4 vs. 77.2 ± 13.2; p = 0.043) but not diastolic or systolic blood pressure. Tolerability was higher in the music group (p = 0.002). Music is a simple and effective tool to alleviate pain and anxiety in patients undergoing joint lavage for knee osteoarthritis.

Understanding pain in osteoarthritis

The majority of patients with osteoarthritis present to orthopaedic surgeons seeking relief of pain and associated restoration of function. Although our understanding of the physiology of pain has improved greatly over the last 25 years there remain a number of unexplained pain-related observations in patients with osteoarthritis. The understanding of pain in osteoarthritis, its modulation and treatment is central to orthopaedic clinical practice and in this annotation we explore some of the current concepts applicable. We also introduce the concept of the ‘phantom joint’ as a cause for persistent pain after joint replacement.

Translation and validation of Moroccan Western Ontario and McMaster Universities (WOMAC) osteoarthritis index in knee osteoarthritis

The aim of this study is to assess the reliability and validity of the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) in Moroccan patients with knee osteoarthritis. The WOMAC was translated and back translated to and from dialectal Arabic, pre-tested and reviewed by a committee following the Guillemin criteria. The Moroccan version of the WOMAC was administered twice during a 24-48 h interval to 71 Moroccan patients with symptomatic knee osteoarthritis, fulfilling the revised criteria of the American College of Rheumatology. The test-retest reliability was assessed using intra-class correlation coefficient, and the Bland and Altman method. Internal consistency was assessed by Cronbach's alpha coefficient. Construct validity was tested by correlating the WOMAC subscales with visual analogic scale (VAS) of pain, VAS of handicap, maximum distance walked and clinical characteristics. The Moroccan version of the WOMAC showed good reliability, with ICC values of the three dimensions: pain, stiffness and physical function being 0.80, 0.77 and 0.89, respectively. Bland and Altman analysis showed that means of differences did not differ significantly from 0 and that no systematic trend was observed. Internal consistency with Cronbach's alpha for pain was found to be 0.76, and its equivalents for stiffness and physical function subscales were evaluated at 0.76, 0.90, respectively. Construct validity showed statistically significant correlation with all WOMAC subscales and VAS of pain (rho=0.38, 0.42, 0.63 respectively, P<0.01). Correlation between VAS handicap (rho=0.38 P<0.001) and maximum distance walked (rho=-0.40, P<0.01) was observed with physical function subscale. There was no correlation between age, duration of disease, BMI and severity of pain and physical function in knee OA. The Moroccan version of the WOMAC is a comprehensible, reliable, and valid instrument to measure outcome in patients with knee OA.

Musculoskeletal findings in obese children

AIM

A cross-sectional study was conducted to explore osteoarticular alterations in obese children.

METHODS

Twenty-five boys and 24 girls (mean age: 10.8+/-2.07 years) with a body mass index (BMI) above the 95th percentile were compared with 28 boys and 19 girls (controls, mean age: 10.4+/-2.3 years) with a BMI below the 80th percentile.

RESULTS

A higher frequency of at least one osteoarticular manifestation was observed in obese patients (55%) compared with the control group (23%) (P=0.001). A statistically significant association was also found between obesity and lower back pain, genu valgum, genu recurvatum and tight quadriceps. Fibromyalgia tender points (=11) were present at similar frequency in both groups (obese: 3/38 (9%) vs. control: 1/48 (2%)).

CONCLUSION

The present data suggest that obesity has a negative impact on osteoarticular health by promoting biomechanical changes in the lumbar spine and lower extremities.

Comorbid Conditions in the AMICA Study Patients: Effects on the Quality of Life and Drug Prescriptions by General Practitioners and Specialists

OBJECTIVE

Osteoarthritis (OA) has been identified as the disease with the highest rate of comorbidities, which may increase the likelihood of disability. The AMICA study evaluated how the presence of a coexistent disease and/or its chronic pharmacological treatment influenced the prescription of pharmacological and nonpharmacological therapy in patients with OA.

PATIENTS AND METHODS

The 2764 general practitioners (GPs) and 316 specialists (98 rheumatologists, 166 orthopedic surgeons, 52 physical medicine specialists) participating in the study were asked to enroll 10 consecutive patients with OA diagnosed according to the American College of Rheumatology clinical criteria. Information was collected regarding demographics, the clinical characteristics of OA, and previous diagnostic and therapeutic interventions. Pain intensity was assessed using a 100-mm visual analog scale (VAS); the patients were also asked to report on their quality of life and joint function, as well as the presence of any concomitant disease and/or therapy. The influence of comorbidities on the quality of life, pain, and drug prescription was evaluated.

RESULTS

A total of 29,132 evaluable patients was observed (25,589 recruited by GPs and 3543 by specialists). The most frequent comorbidities were hypertension (52%), osteoporosis (21%), type II diabetes mellitus (15%), and chronic obstructive pulmonary disease (12%); myocardial infarction and/or angina pectoris were present in 6% and peptic ulcer was present in 5%. Comorbidities were more frequent in older patients and, except in the case of hypertension, were closely related to more intense pain and a decreased quality of life; they were also generally associated with worsened joint function. The presence of peptic ulcer was associated with a reduction in the prescription of nonsteroidal antiinflammatory drugs (NSAIDs) (odds ratio (OR) 0.61; confidence intervals (CI) 0.53 to 0.69) and the more frequent use of Coxibs (OR 1.15; CI 1.03 to 1.28) and simple analgesics (OR 1.42; CI 1.26 to 1.61), as well as with greater use of physical therapy. Hypertension was associated with a reduction in the prescription of physical therapy. NSAIDs and Coxibs were less frequently prescribed if the patients were on anticoagulant therapy (NSAIDs: OR 0.86; CI 0.70 to 1.06; Coxibs: OR 0.77; CI 0.64 to 0.93). Gastroprotective therapy was more frequently used in patients treated with NSAIDs, Coxibs, and analgesics, with GPs giving greater preference to proton pump inhibitors than specialists.

CONCLUSIONS

Comorbidities decrease the quality of life and worsen the joint function in OA patients. Comorbidities and their treatment generally do not influence the physician's choice of OA treatment, with the exception of peptic ulcer and anticoagulant therapy, both of which were associated with a reduction in the prescription of antiinflammatory drugs. There was a preferential use of Coxibs in patients with peptic ulcer, and an underuse of gastroprotective measures in OA patients treated with NSAIDs.

Costs and outcomes associated with alternative discharge strategies following joint replacement surgery: analysis of an observational study using a propensity score

We estimated the impact of alternative discharge strategies, following joint replacement (JR) surgery, on acute care readmission rates and the total cost of a continuum of care. Following surgery, patients were discharged to one of four destinations. Propensity scores were used to adjust costs and outcomes for potential bias in the assignment of discharge destinations. We demonstrated that the use of rehabilitation hospitals may lower readmission rates, but at a prohibitive incremental cost of each saved readmission, that patients discharged with home care had longer acute care stays than other patients, that the provision of home care services increased health system costs, and that acute care readmission rates were greatest among patients discharged with home care. Our study should be seen as one important stepping stone towards a full economic evaluation of the continuum of care for patients.

The economic cost of musculoskeletal disorders in Canada

OBJECTIVE

This study estimated the total cost of musculoskeletal disorders for Canadians in 1994 and assessed the sensitivity of these cost estimates to variations in the definition of musculoskeletal disorders.

METHODS

Disease-related costs, from a societal perspective, were measured using a prevalence-based analysis. First, direct treatment costs, including expenditures on hospitals and other institutions, physicians and other health professionals, drugs, research, and other items were assessed. Second, indirect costs associated with lost (or foregone) productivity due to disability and premature mortality were evaluated using the human capital approach.

RESULTS

The total cost of musculoskeletal disorders in Canada was $25.6 billion (in 1994 Canadian dollars, $1.00 CDN approximately $0.75 US) or 3.4% of the gross domestic product. Direct and indirect costs were estimated at $7.5 billion and $18.1 billion, respectively. Lower and upper bound estimates of the total cost of musculoskeletal disorders, derived from the sensitivity analysis, were $19.9 billion and $30.8 billion, respectively. Wide variations were reported in the total cost of various musculoskeletal disorder subcategories, with the highest costs reported for injuries ($10.7 billion), back and spine disorders ($8.1 billion), and arthritis and rheumatism ($5.9 billion).

CONCLUSIONS

The economic cost of musculoskeletal disorders was substantial and was sensitive to the definition of musculoskeletal disorders and other underlying assumptions. The hallmark of this study was the variation between subcategories in their cost, pattern of health resource use, and sequelae. The cost estimates may provide guidance in setting priorities for research and prevention activities.

The experience of knee arthritis in athletic young and middle-aged adults: an heuristic study

OBJECTIVE

To gain a better understanding of the experience of living with tibiofemoral osteoarthritis (OA) as young and middle-aged adults.

METHODS

Heuristic qualitative research methods were used. Four informants between the ages of 25 and 45 years diagnosed with tibiofemoral OA were purposively sampled. Informants were white, college educated, middle class, and physically active. Informants were interviewed for 4 hours. Interviews were transcribed verbatim and analyzed according to a van Kaam method modified by Moustakas.

RESULTS

Living with tibiofemoral OA involved pain, fear, isolation, helplessness, and loss of function, identity, and perceived control. The informants struggled with adapting to their pathology. Behavior change and activity modification were difficult and seemed to be related to the physical, sociologic, and psychologic aspects of pathology.

CONCLUSIONS

A biopsychosocial model of chronic pathology was developed that may guide health professionals in treating and developing interventions for younger adults with arthritis.

Osteoarthritis: how to make exercise part of your treatment plan

The idea of exercising with swollen, painful joints and weakened muscles may seem counterintuitive. But increasingly research shows that the vicious cycle of immobility and dependence initiated by osteoarthritis can be interrupted by making exercise part of therapy. A well-designed program of aerobic and resistance training and whole-body flexibility and joint mobility exercise should join other interventions such as weight loss, medication, physical therapy, joint protection, and surgery to improve symptoms and reduce the impact of osteoarthritis on patients' lives.

Intra-articular triamcinolone hexacetonide in knee osteoarthritis: factors influencing the clinical response

OBJECTIVE

To assess the efficacy of a single intra-articular injection of triamcinolone hexacetonide (THA) in knee osteoarthritis (OA) and examine factors which may relate to treatment efficacy.

METHODS

Eighty four patients with clinical and radiographic evidence of knee OA were recruited and randomly allocated to receive either THA (20 mg in 1 ml) or placebo (0.9% normal saline, 1 ml). Follow up assessments evaluated the following outcome variables: patient opinion of overall change in the treated knee, visual analogue pain score (VAS), distance walked in one minute (WD), and Health Assessment Questionnaire modified for lower limb function (HAQ).

RESULTS

Seventy eight percent of THA and 49% of placebo treated patients reported overall improvement at week 1 (p < 0.05). At week 6, improvement was reported in 57% and 55% of patient groups, respectively. VAS improved in both groups at week 1 (THA, p < 0.001; placebo, p < 0.05) and week 6 (both p < 0.01). Improvement in VAS was significantly greater among THA treated patients at week 1 only (p < 0.01). Subgroup analysis of THA treated patients revealed greater improvement in VAS among patients with clinical evidence of an effusion (p < 0.05), and those who had synovial fluid successfully aspirated at the time of injection (p < 0.01). WD improved in THA treated patients at week 1 (p < 0.001), and in both groups at week 6 (THA, p < 0.001; placebo, p < 0.01). Improvements in HAQ were seen in THA patients only at weeks 1 and 6 (p < 0.05). Regression analysis did not identify any additional clinical, radiographic, or synovial fluid characteristics which influenced the response.

CONCLUSIONS

THA provided short term pain relief in knee OA. Increased benefit was associated with both clinical evidence of joint effusion and successful aspiration of synovial fluid at the time of injection.

Sensitivity versus specificity of phonoarthrography as an indicator for cartilage degeneration

In an attempt to update the idea of recording knee sounds, 400 osteoarthritic (OA) knees, 100 knees from a young age group (18-31 years) and 100 knees from an age-matching group (45-60 years) were recorded by a computerized device using a special program that enabled the conversion of sounds--recorded in a fixed lapse of time--to waves which were then analysed in terms of frequency/second and average amplitude. Radiological grading was done for all groups in order to compare both parameters. Reproducibility of the recordings for each knee was confirmed statistically. Phonoarthrography was found to be 100% sensitive for radiological changes and for clinically felt crepitus, simultaneously diagnosing early OA in 32.5% of subjects with no radiological changes and in 7.5% of subjects with no clinically felt crepitus. From the work it can be deduced that computerized phonoarthrography can diagnose early cases of OA and is excellent for assessing and following up cases. It may be regarded as an indicator for cartilage degeneration.

Prediction of the progression of joint space narrowing in osteoarthritis of the knee by bone scintigraphy

OBJECTIVES

To test the hypothesis that bone scintigraphy will predict the outcome of osteoarthritis (OA) of the knee joint.

METHODS

Ninety four patients (65 women, 29 men; mean age 64.2 years) with established OA of one or both knee joints were examined in 1986, when radiographs and bone scan images (early and late phase) were also obtained. The patients were recalled, re-examined, and had further radiographs taken in 1991. Paired entry and outcome radiographs were read by a single observer, blinded to date order and other data. Scan findings and other entry variables were related to outcome. Progression of OA of the knee was defined as an operation on the knee or a decrease in the tibiofemoral joint space of 2 mm or more.

RESULTS

Over the five year study period 10 patients died and nine were lost to follow up. Fifteen had an operation on one or both knees (22 knees). Of the remaining 120 knees (60 patients) analysed radiographically, 14 (12%) had progressed in the manner defined. Of 32 knees with severe scan abnormalities, 28 (88%) showed progression, whereas none of the 55 knees with no scan abnormality at entry progressed. The strong negative predictive power of scintigraphy could not be accounted for by disease severity or any combination of entry variables. Pain severity predicted a subsequent operation, but age, sex, symptom duration, and obesity had no predictive value.

CONCLUSIONS

Scintigraphy predicts subsequent loss of joint space in patients with established OA of the knee joint. This is the first description of a powerful predictor of change in this disease. The finding suggests that the activity of the subchondral bone may determine loss of cartilage.

The role of cartilage-derived antigens, pro-coagulant activity and fibrinolysis in the pathogenesis of osteoarthritis

Superficial fraying, splitting and fibrillation of articular cartilage as a consequence of ageing or mechanical injury is not always associated with joint pain. However, similar cartilage lesions accompanied by synovitis and engorgement of the subchondral vasculature generally is; the disorder being known as osteoarthritis (OA). In this hypothesis it is contended that the progression of early cartilage fibrillation to symptomatic OA arises as a consequence of the antigenic nature of cartilage components which when released into synovial fluid and the circulation can stimulate leukocytes (to a varying degree) to produce a number of factors some of which promote blood coagulation. While it is known that with ageing hyper-coagulation and plaque deposition is increased, the augmentation of this process by factors released by activated leukocytes is considered to exacerbate the problem. These haematological events may be particularly relevant in individuals whose leukocytes are hypersensitive to the cartilage-derived antigens, and whose fibrinolytic system is less capable of mobilizing the thrombi deposited in synovial tissues and the subchondral vascular tree.

Clinical assessment of osteoarthritis of the knee

The repeatability of physical signs used to assess osteoarthritis of the knee has not been systematically examined. The within and between observer variation of 10 commonly used physical signs to determine osteoarthritis of the knee has been assessed here. The results obtained show variation in the repeatability of these signs. For those examining the tibiofemoral joints the repeatability was greater than for those examining the patellofemoral joint. It would therefore seem vital to take note of the repeatability of physical signs in determining the number of subjects to be studied in epidemiological studies and therapeutic studies in osteoarthritis.

Anatomy and physiology of the cervical spine

Although the lumbar spine was extensively studied from 1934 to the present, the cervical spine has received far less attention. Anatomic, physiological, biochemical, and biomechanical characteristics of the lumbar spine are often presumed to apply to the cervical spine. The differences are far too extensive to warrant such an assumed correlation. Beginning in 1955, the authors have collected 171 whole human spines and studied them anatomically, physiologically, and histologically. Reported in this article are clinically important anatomic characteristics of the nucleus pulposus, the uncinate process, nerve root exit sites, position of the motor (anterior) nerve root, relation of spinal cord volume to size and shape of the spinal canal, anatomy of the anterior and posterior spinal canal, menisci of the zygapophyseal joints, and the anatomy and clinical significance of the autonomic nervous system in the cervical spine.

Estrogen use and radiographic osteoarthritis of the knee in women. The Framingham Osteoarthritis Study

Female participants of the Framingham Osteoarthritis Study (n = 831, mean age 73, age range 63-93) were evaluated for osteoarthritis with weight-bearing radiographs of the knee during 1983-1985. At each biennial examination (1963-1981), the women were asked about their use of estrogen during the previous 2 years. We categorized estrogen use as no use reported, use reported at 1 examination, or use reported at 2 or more examinations. We found no positive association of estrogen use with radiographic knee osteoarthritis after controlling for age, body mass index, age at menopause, physical activity, history of knee injury, and smoking. In fact, a modest but nonsignificant protective effect for both radiographic osteoarthritis (odds ratio 0.71, 95% confidence interval 0.42, 1.20) and severe radiographic osteoarthritis (odds ratio 0.66, 95% confidence interval 0.33, 1.32) was seen in women who reported estrogen use at 2 or more examinations. Subgroup analyses also showed no association between estrogen use and radiographic knee osteoarthritis. We conclude that estrogen use in women is not associated with an increased risk of radiographic knee osteoarthritis.

Osteoarthritis of the knee joint: an eight year prospective study

Thirty one patients (25 women, six men, mean age 71.7 years) with established osteoarthritis (OA) of the knee were examined clinically and radiologically on two occasions, eight years apart. Four patients thought they had got better, two of whom had striking functional improvement. Seven remained the same and 20 patients got worse, two needing knee surgery and many developing severe disabilities. Most of the patients had a history of slow acquisition of OA at new joint sites, hand disease emerging as the commonest other site of involvement. Changes in symptoms, disability, and radiographs did not correlate. Three of the four patients who improved symptomatically lost range of motion at the knee and developed more severe changes on their radiographs. Chondrocalcinosis of the knee was seen in five patients, including two of those who improved.

MRI in osteoarthritis of the hip: gradations of severity

In a prospective study, 10 patients with well-documented osteoarthritis (O.A.) of the hips were imaged using spin-echo pulse sequences (TR = 0.5 to 1.5 s and TE = 28 to 60 ms). After analyzing the changes observed, an MR grading system for assessing severity of O.A. in the hips was developed. Using this grading system and an established grading system for osteoarthritis using roentgenograms (both systems use grades 0-4), two radiologists independently graded the MR studies and plain films separately, twice. The roentgenogram grading system was more accurate in predicting symptoms in the more severe cases, whereas the MR grading system was slightly more useful in the less severe cases. Our results show that MR can demonstrate a spectrum of changes of O.A. in the hips. Its ability to directly image articular cartilage makes it a powerful research and clinical tool.