Screening for hand osteoarthritis (OA) using a postal survey

Factors associated with pain and osteoarthritis at the hip and knee in Great Britain's Olympians: a cross-sectional study

BACKGROUND

Knowledge of the epidemiology and potentially modifiable factors associated with musculoskeletal disease is an important first step in injury prevention among elite athletes.

AIM

This study investigated the prevalence and factors associated with pain and osteoarthritis (OA) at the hip and knee in Great Britain's (GB) Olympians aged 40 and older.

METHODS

This is a cross-sectional study. A survey was distributed to 2742 GB Olympians living in 30 countries. Of the 714 (26.0%) who responded, 605 were eligible for analysis (ie, aged 40 and older).

RESULTS

The prevalence of hip and knee pain was 22.4% and 26.1%, and of hip and knee OA was 11.1% and 14.2%, respectively. Using a multivariable model, injury was associated with OA at the hip (adjusted OR (aOR) 10.85; 95% CI 3.80 to 30.96) and knee (aOR 4.92; 95% CI 2.58 to 9.38), and pain at the hip (aOR 5.55; 95% CI 1.83 to 16.86) and knee (aOR 2.65; 95% CI 1.57 to 4.46). Widespread pain was associated with pain at the hip (aOR 7.63; 95% CI 1.84 to 31.72) and knee (aOR 4.77; 95% CI 1.58 to 14.41). Older age, obesity, knee malalignment, comorbidities, hypermobility and weight-bearing exercise were associated with hip and knee OA and/or pain.

CONCLUSIONS

This study detected an association between several factors and hip and knee pain/OA in retired GB Olympic athletes. These associations require further substantiation in retired athletes from other National Olympic Committees, and through comparison with the general population. Longitudinal follow-up is needed to investigate the factors associated with the onset and progression of OA/pain, and to determine if modulation of such factors can reduce the prevalence of pain and OA in this population.

Development and validation of self-reported line drawings of the modified Beighton score for the assessment of generalised joint hypermobility

Background

The impracticalities and comparative expense of carrying out a clinical assessment is an obstacle in many large epidemiological studies. The purpose of this study was to develop and validate a series of electronic self-reported line drawing instruments based on the modified Beighton scoring system for the assessment of self-reported generalised joint hypermobility.

Methods

Five sets of line drawings were created to depict the 9-point Beighton score criteria. Each instrument consisted of an explanatory question whereby participants were asked to select the line drawing which best represented their joints. Fifty participants completed the self-report online instrument on two occasions, before attending a clinical assessment. A blinded expert clinical observer then assessed participants’ on two occasions, using a standardised goniometry measurement protocol. Validity of the instrument was assessed by participant-observer agreement and reliability by participant repeatability and observer repeatability using unweighted Cohen’s kappa (k). Validity and reliability were assessed for each item in the self-reported instrument separately, and for the sum of the total scores. An aggregate score for generalised joint hypermobility was determined based on a Beighton score of 4 or more out of 9.

Results

Observer-repeatability between the two clinical assessments demonstrated perfect agreement (k 1.00; 95% CI 1.00, 1.00). Self-reported participant-repeatability was lower but it was still excellent (k 0.91; 95% CI 0.74, 1.00). The participant-observer agreement was excellent (k 0.96; 95% CI 0.87, 1.00). Validity was excellent for the self-report instrument, with a good sensitivity of 0.87 (95% CI 0.81, 0.91) and excellent specificity of 0.99 (95% CI 0.98, 1.00).

Conclusions

The self-reported instrument provides a valid and reliable assessment of the presence of generalised joint hypermobility and may have practical use in epidemiological studies.

Electronic supplementary material

The online version of this article (10.1186/s12874-017-0464-8) contains supplementary material, which is available to authorized users.

Involvement of different risk factors in clinically severe large joint osteoarthritis according to the presence of hand interphalangeal nodes

OBJECTIVE

To quantify the differences in risk factors influencing total hip replacement (THR) and total knee replacement (TKR) based on the presence versus absence of multiple interphalangeal nodes in 2 or more rays of the fingers of each hand in patients with large joint osteoarthritis (OA).

METHODS

A group of 3,800 patients with large joint OA who underwent total joint replacement (1,201 of whom had the nodal phenotype) and 1,906 control subjects from 2 case-control studies and a population-based cohort in the UK were studied. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated for the risk of total joint replacement in association with age, sex, body mass index (BMI), height, and prevalence of the T allele in the GDF5 rs143383 polymorphism. ORs for total joint replacement were compared between cases of nodal OA and cases of non-nodal OA and between patients who underwent TKR and those who underwent THR.

RESULTS

Age, sex, and BMI had significantly higher ORs for an association with total joint replacement in nodal OA cases than in non-nodal OA cases. The GDF5 polymorphism was significantly associated with THR in cases of nodal OA, but not in cases of non-nodal OA, and increased height was a risk factor for THR in non-nodal OA cases only. Female sex was a protective risk factor for TKR in non-nodal OA cases (OR 0.60, 95% CI 0.52-0.70) but was predisposing for TKR in the nodal form of OA (OR 1.83, 95% CI 1.49-2.26). The nodal phenotype was associated with a significantly higher risk of undergoing both THR and TKR (OR 1.46, 95% CI 1.09-1.94) and also a significantly higher risk of bilateral TKR (OR 1.70, 95% CI 1.37-2.11), but, paradoxically, was associated with a lower risk of bilateral THR (OR 0.72, 95% CI 0.56-0.91).

CONCLUSION

Nodal and non-nodal forms of large joint OA have significantly different risk factors and outcomes, indicating a different etiology for the 2 forms of OA. With regard to the likelihood of undergoing THR, this appears to be, at least in part, genetically determined.

Are hallux valgus and big toe pain associated with impaired quality of life? A cross-sectional study

Hallux valgus (HV) is common with a standardised prevalence of 28.4% in adults older than 40 years. It has been shown to associate with impaired quality of life (QOL) in small hospital based studies. Previous studies of association between HV, function and disability are based on the presence or absence of regional foot pain which may be due to other foot pathology and is not specific to HV. The objective of this study is to examine the association between self reported HV, big toe pain and impaired QOL in a primary care population. We hypothesise that presence of self-reported HV alone, big toe pain alone and both together will associate with progressively impaired QOL. This hypothesis is based on the known association of concurrent HV and foot pain with impaired physical function and the fact that foot pain and not foot deformity impairs functional status. Our study shows that concurrent HV and big toe pain but not isolated HV associates with impaired overall satisfaction with health and low score on the physical, psychological and social domains of World Health Organization Quality of Life-BREF (WHOQOL-BREF).

Development and validation of self-reported line drawings for assessment of knee malalignment and foot rotation: a cross-sectional comparative study

Background

For large scale epidemiological studies clinical assessments and radiographs can be impractical and expensive to apply to more than just a sample of the population examined. The study objectives were to develop and validate two novel instruments for self-reported knee malalignment and foot rotation suitable for use in questionnaire studies of knee pain and osteoarthritis.

Methods

Two sets of line drawings were developed using similar methodology. Each instrument consisted of an explanatory question followed by a set of drawings showing straight alignment, then two each at 7.5° angulation and 15° angulation in the varus/valgus (knee) and inward/outward (foot) directions. Forty one participants undertaking a community study completed the instruments on two occasions. Participants were assessed once by a blinded expert clinical observer with demonstrated excellent reproducibility. Validity was assessed by sensitivity, specificity and likelihood ratio (LR) using the observer as the reference standard. Reliability was assessed using weighted kappa (κ). Knee malalignment was measured on 400 knee radiographs. General linear model was used to assess for the presence of a linear increase in knee alignment angle (measured medially) from self-reported severe varus to mild varus, straight, mild valgus and severe valgus deformity.

Results

Observer reproducibility (κ) was 0.89 and 0.81 for the knee malalignment and foot rotation instruments respectively. Self-reported participant reproducibility was also good for the knee (κ 0.73) and foot (κ 0.87) instruments. Validity was excellent for the knee malalignment instrument, with a sensitivity of 0.74 (95%CI 0.54, 0.93) and specificity of 0.97 (95%CI 0.94, 1.00). Similarly the foot rotation instrument was also found to have high sensitivity (0.92, 95%CI 0.83, 1.01) and specificity (0.96, 95%CI 0.93, 1.00). The knee alignment angle increased progressively from self reported severe varus to mild varus, straight, mild valgus and severe valgus knee malalignment (p_trend <0.001).

Conclusions

The two novel instruments appear to provide a valid and reliable assessment of self-reported knee malalignment and foot rotation, and may have a practical use in epidemiological studies.

Nonspherical femoral head shape (pistol grip deformity), neck shaft angle, and risk of hip osteoarthritis: a case-control study

OBJECTIVE

To determine whether 2-dimensional measures of femoral head shape and angle are associated with hip osteoarthritis (OA).

METHODS

We compared cases with symptomatic radiographic hip OA with asymptomatic controls with no radiographic hip OA. On anteroposterior pelvis radiographs, we measured "pistol grip deformity" for each hip (visually categorized as nonspherical, indeterminate, or spherical), the femoral head-to-femoral neck ratio as an interval measure of femoral head shape, and the femoral neck shaft angle. The relative risk of hip OA associated with each feature was estimated using odds ratios (ORs) and 95% confidence intervals (95% CIs), adjusted for possible confounders using a logistic regression model.

RESULTS

Of 1,007 cases, 965 had definite radiographic hip OA; of 1,123 controls, 1,111 had no radiographic OA. The prevalence of pistol grip deformity in at least 1 hip was 3.61% in controls and 17.71% in cases (OR 6.95 [95% CI 4.64-10.41]), and the prevalence of abnormal femoral head-to-femoral neck ratio in at least 1 hip was 3.70% in controls and 24.27% in cases (OR 12.08 [95% CI 8.05-18.15]). The risk of hip OA increased as the femoral head-to-femoral neck ratio decreased (P for trend<0.001) and with each extreme of neck shaft angle (P<0.05). In cases with unilateral hip OA, the prevalence of abnormal femoral head-to-femoral neck ratio in the unaffected hip was 2 times greater than that in controls (OR 1.82 [95% CI 1.07-3.07]); in contrast, an abnormally low, but not abnormally high, neck shaft angle was more common in unaffected hips than in controls (OR 1.79 [95% CI 1.03-3.14]).

CONCLUSION

Our findings indicate that pistol grip deformity is associated with hip OA. The increased prevalence of pistol grip deformity and an abnormally low neck shaft angle in unaffected hips of cases with unilateral OA suggests that they are risk factors for development of hip OA. However, both a nonspherical head shape and an increase in neck shaft angle may occur as a consequence of OA.

Prevalence and associations of hallux valgus in a primary care population

OBJECTIVE

To determine the population prevalence and examine factors associated with hallux valgus in a primary care population.

METHODS

A questionnaire was mailed to all adults age >30 years registered with 2 general practices. Validated instruments assessed self-reported hallux valgus, nodal osteoarthritis, and knee pain. The questionnaire also asked about big toe pain, joint replacement, and history of osteoarthritis and rheumatoid arthritis. Hallux valgus prevalence was calculated and standardized by the source population in terms of age, sex, knee pain, osteoarthritis, and rheumatoid arthritis. A nested case-control study was undertaken and age-sex adjusted odds ratios (ORs) were calculated between hallux valgus and age, sex, body mass index, nodal osteoarthritis, knee pain, big toe pain, joint replacement, self-reported osteoarthritis, and self-reported rheumatoid arthritis, using a binary logistic regression model.

RESULTS

A total of 13,684 questionnaires were mailed and 4,249 (32%) responses were received. The standardized prevalence of hallux valgus was 28.4%. Hallux valgus was associated with age (adjusted OR 1.61 per decade; 95% confidence interval [95% CI] 1.52-1.69), female sex (adjusted OR 2.64; 95% CI 2.26-3.08), nodal osteoarthritis (adjusted OR 1.66; 95% CI 1.26-2.17), knee pain (adjusted OR 1.96; 95% CI 1.65-2.32), big toe pain (adjusted OR 3.28; 95% CI 2.48-4.33), self-reported osteoarthritis (adjusted OR 1.41; 95% CI 1.15-1.72), and self-reported rheumatoid arthritis (adjusted OR 2.04; 95% CI 1.43-2.91).

CONCLUSION

Hallux valgus is prevalent in the community and is associated with age, female sex, and components of generalized osteoarthritis such as nodal osteoarthritis, knee pain, big toe pain, and self-reported osteoarthritis.

Index to ring finger length ratio and the risk of osteoarthritis

OBJECTIVE

To determine the relationship between the index to ring finger (2D:4D) length ratio and the risk of knee and hip osteoarthritis (OA).

METHODS

We conducted a case-control study, in which cases with persistent symptoms and radiographic evidence of knee or hip OA were compared with controls with no symptoms and no radiographic evidence of knee or hip OA. Hand radiographs were visually classified as type 1 (index finger longer than the ring finger), type 2 (index finger equal to the ring finger), or type 3 (index finger shorter than the ring finger). The 2D:4D phalangeal and metacarpal length ratios were measured separately. The odds ratio (OR) and 95% confidence interval (95% CI) were calculated and adjusted for possible confounding factors using a logistic regression model.

RESULTS

Of 2,049 cases, 1,013 had radiographic evidence of knee OA and 995 had hip OA. Of 1,123 controls, 836 had no knee OA and 1,050 had no hip OA. The type 3 finger pattern was associated with knee OA (OR 1.94, 95% CI 1.54-2.44), and the risk was greater in women (OR 3.05, 95% CI 2.08-4.47) than in men (OR 1.45, 95% CI 1.08-1.95). There was a dose-response relationship between both 2D:4D phalangeal and metacarpal length ratios and the risk of knee OA. The risk of hip OA was inconsistent.

CONCLUSION

Compared with types 1 and 2, the type 3 "male" pattern 2D:4D length ratio is associated with OA, especially knee OA. The risk is independent of other major OA risk factors.

The Clinical Assessment Study of the Hand (CAS-HA): a prospective study of musculoskeletal hand problems in the general population

BACKGROUND

Pain in the hand affects an estimated 12-21% of the population, and at older ages the hand is one of the most common sites of pain and osteoarthritis. The association between symptomatic hand osteoarthritis and disability in everyday life has not been studied in detail, although there is evidence that older people with hand problems suffer significant pain and disability. Despite the high prevalence of hand problems and the limitations they cause in older adults, little attention has been paid to the hand by health planners and policy makers. We plan to conduct a prospective, population-based, observational cohort study designed in parallel with our previously reported cohort study of knee pain, to describe the course of musculoskeletal hand problems in older adults and investigate the relative merits of different approaches to classification and defining prognosis.

METHODS/DESIGN

All adults aged 50 years and over registered with two general practices in North Staffordshire will be invited to take part in a two-stage postal survey. Respondents to the survey who indicate that they have experienced hand pain or problems within the previous 12 months will be invited to attend a research clinic for a detailed assessment. This will consist of clinical interview, hand assessment, screening test of lower limb function, digital photography, plain x-rays, anthropometric measurement and brief self-complete questionnaire. All consenting clinic attenders will be followed up by (i) general practice medical record review, (ii) repeat postal questionnaire at 18-months, and (iii) repeat postal questionnaire at 3 years.

DISCUSSION

This paper describes the protocol for the Clinical Assessment Study of the Hand (CAS-HA), a prospective, population-based, observational cohort study of community-dwelling older adults with hand pain and hand problems based in North Staffordshire.

Utility of digital photographs of the hand for assessing the presence of hand osteoarthritis

OBJECTIVES

Nodal osteoarthritis of the hand (hand OA) is a subset of OA with a strong heritable component. Multiple genetic analyses of this condition have been performed and are underway. Highest yield from any genetic study depends upon a clear clinical phenotype for case definition. Radiographs may provide the most detail about the nature of the lesion. Physical examination is an imperfect means of evaluating each patient, particularly when hundreds or thousands of patients are required for study. Our study evaluated the accuracy, relative to a radiograph, of a digital photograph of the hands for the presence of OA in a particular joint, as well as for the diagnosis of nodal hand OA.

METHODS

Consecutive patients were evaluated as part of the I-NODAL study (Investigation of Nodal Osteoarthritis to Detect an Association with Loci encoding Interleukin-1 [IL-1]). Evaluation included a physical examination by a trained rheumatologist, a postero-anterior radiograph of the hands, and a digital photograph of each hand. Radiographs were read by one trained observer using the Kellgren-Lawrence scale. Photographs were taken by one individual and were analyzed by an experienced rheumatologist. Kappa statistics were determined for each modality and accuracy was assessed using radiographic readings as a gold standard.

RESULTS

Intra-reader reliability for radiograph interpretation was good for the overall diagnosis of hand OA (kappa0.76 [0.45,1.07]), but varied widely for the presence or absence of K-L grades 2-4 in individual joints (median kappa0.70, range 0.49-0.87 for ACR index joints). Distal interphalangeal joint (DIP) nodes on physical examination were sensitive (median 96.27, 93.94-100), but not specific for radiographic hand OA in the corresponding joint (median 33.0, 17.24-42.86). Physical examination evidence of OA in the 1st carpo-metacarpal (CMC) and proximal interphalangeal (PIP) joints provided only moderate sensitivity and specificity. However, the negative predictive value of the examination of individual joints was good (median negative predictive value was 82.58 for IP joints with a range 68.29-100.00), particularly in the DIP joints. Specificity of a node visualized on hand photograph was variable (median for all IP joints and 1st CMC 83.77, range 53.37-96.97), with greatest specificity for radiographic OA in the corresponding joint found in the 1st CMC and the PIP joints. Clinical hand OA was sensitive, but not specific for the radiographic diagnosis of hand OA; while, photographic OA was moderately specific, but insensitive.

CONCLUSION

The visualization of a node on a digital photograph of the hand provides fair to moderate specificity for radiographic hand OA in the corresponding joint, with generally poor sensitivity. A photograph has limited value as a screening tool for the diagnosis of radiographic hand OA.

The Knee Clinical Assessment Study--CAS(K). A prospective study of knee pain and knee osteoarthritis in the general population

BACKGROUND

Knee pain affects an estimated 25% of the adult population aged 50 years and over. Osteoarthritis is the most common diagnosis made in older adults consulting with knee pain in primary care. However, the relationship between this diagnosis and both the current disease-based definition of osteoarthritis and the regional pain syndrome of knee pain and disability is unclear. Expert consensus, based on current evidence, views the disease and the syndrome as distinct entities but the clinical usefulness of these two approaches to classifying knee pain in older adults has not been established. We plan to conduct a prospective, population-based, observational cohort study to investigate the relative merits of disease-based and regional pain syndrome-based approaches to classification and prognosis of knee pain in older adults.

METHODS

All patients aged 50 years and over registered with three general practices in North Staffordshire will be invited to take part in a two-stage postal survey. Respondents to this survey phase who indicate that they have experienced knee pain within the previous 12 months will be invited to attend a research clinic for a detailed assessment. This will consist of clinical interview, physical examination, digital photography, plain x-rays, anthropometric measurement and a brief self-complete questionnaire. All consenting clinic attenders will be followed up by (i) general practice medical record review, (ii) repeat postal questionnaire at 18-months.

Assessment of a genetic contribution to osteoarthritis of the hip: sibling study

OBJECTIVES

To study the influence of genetics on the development of hip osteoarthritis as determined by structural change on plain radiographs.

DESIGN

Sibling study.

SETTING

Nottinghamshire, England.

PARTICIPANTS

392 index participants with hip osteoarthritis of sufficient severity to warrant total hip replacement, 604 siblings of the index participants, and 1718 participants who had undergone intravenous urography.

MAIN OUTCOME MEASURE

Odds ratios for hip osteoarthritis in siblings.

RESULTS

The age adjusted odds ratios in siblings were 4.9 (95% confidence interval, 3.9 to 6.4) for probable hip osteoarthritis and 6.4 (4.5 to 9.1) for definite hip osteoarthritis. These values were not significantly altered by adjusting for other risk factors.

CONCLUSION

Siblings have a high risk of hip osteoarthritis as shown by structural changes on plain radiographs. One explanation is that hip osteoarthritis is under strong genetic influence.