An increased rate of falling leads to a rise in fracture risk in postmenopausal women with self-reported osteoarthritis: a prospective multinational cohort study (GLOW)

Prevalence and factors associated with falls in older adults in a Middle Eastern population: a retrospective cross-sectional study

OBJECTIVE

The main objective was to determine the prevalence of falls and associated factors in older adults living in Qatar.

STUDY DESIGN

Cross-sectional study.

METHODS

This is a cross-sectional study of older adults aged ≥60 years with at least one encounter with primary health care corporation (PHCC) in Qatar during the period 2017-2022. Data on documented falls, demographic variables, and medical comorbidities were extracted from all PHCCs in Qatar. Descriptive and inferential statistics were used to address the aim of the study.

RESULTS

A total of 68,194 older adults had at least one encounter with PHCC. The median age was 65.0 years, 58.9% were males, and 32.6% were Qatari nationality. A higher percentage of falls was found in individuals with hypertension (80%), diabetes (74.2%), and dyslipidemia (48.9%), which were also the most prevalent comorbidities. The prevalence of falls was 6.7% (95% CI 6.6-6.9). Compared to individuals aged 60-69 years, individuals aged 70-79, 80-89, and 90-99 had increased odds of falls by 1.6 (95% CI 1.5, 1.8), 2.5 (95% CI 2.2, 2.8), and 2.6 (95% CI 2.0, 3.3), respectively. Females and individuals of Qatari nationality had increased odds of fall by 1.5 (95% CI 1.4, 1.6) and 1.2 (95% CI 1.1, 1.3), respectively. Orthostatic hypotension, syncope, Parkinson's disease, and hip arthritis showed the strongest associations with falls.

CONCLUSIONS

Given the growing population of older adults in the Middle East and North African region, falls is a public health concern. The risk factors identified in this study suggest the need for proactive healthcare strategies tailored to the unique needs of older adult populations.

The test-retest reliability and concurrent validity of 360° turn test in patients with knee osteoarthritis

PURPOSE

The aim of this study is to determine whether the 360° turn test is a reliable and valid evaluator that can be used to assess dynamic balance in patients with early (radiographic grades I and II) and advanced (radiographic grades III and IV) knee osteoarthritis.

MATERIALS AND METHODS

This study is a methodological research. For the test time and step count of 360° turn test; test-retest reliability were determined by calculating the intraclass correlation coefficient and concurrent validity in patients with knee osteoarthritis was investigated by correlation with the timed up and go test time.

RESULTS

The final analysis was made on 117 participants. The intraclass correlation coefficient values for the test time and step count of 360° turn test in patients with early knee osteoarthritis are 0.931 and 0.902, respectively, while they are 0.923 and 0.943 in patients with advanced knee osteoarthritis. The Pearson correlation coefficients between the time and step count of 360° turn test and the test time of the timed up and go test in patients with early knee osteoarthritis, respectively; while they are 0.547 and 0.388, the correlation in patients with advanced knee osteoarthritis are 0.697 and 0.700, respectively (p < 0.01).

CONCLUSIONS

The 360° turn test is a evaluator that has excellent test-retest reliability and moderate to strong concurrent validity in patients with both early and advanced knee osteoarthritis and can be used in the assessment of dynamic balance in this population.

Radiographic knee osteoarthritis severity has no impact on fall risk: the locomotive syndrome and health outcomes in the aizu cohort study (LOHAS): a cross-sectional study

BACKGROUND

To investigate factors that have an impact on the risk of falls and determine whether radiographic knee osteoarthritis (KOA) is a factor involved in falls independent of knee pain, psychological factors, and physical function.

METHODS

A cross-sectional analysis was conducted on 1083 subjects for the 2009 Locomotive Syndrome and Health Outcomes in the Aizu Cohort Study (LOHAS). A logistic regression analysis was performed to examine the relationship between radiographic KOA and fall history.

RESULTS

Fall history was significantly associated with the severity of knee pain. Compared to subjects with no knee pain, the odds ratio (OR) was 1.53 times higher in the subjects with mild knee pain (95% confidence interval [CI]: 1.04-2.25), 1.69 times higher in those with moderate knee pain (95%CI: 1.03-2.79), and 2.98 times higher in those with severe knee pain (95%CI: 1.67-5.30). In subjects with depression, the OR was 1.91 (95%CI: 1.25-2.92), and in those with decreased mobility, the OR was 1.70 (95%CI: 1.08-2.69). Age, gender, knee crepitus, BMI, OLST, and sleeping pill use were not significantly associated with fall risk. In a multivariate analysis, radiographic KOA severity was not significantly associated with fall risk (OR 0.81, 95%CI 0.44-1.50 in mild OA; OR 1.10, 95%CI 0.57-2.14 in severe OA).

CONCLUSION

Knee pain, decreased mobility, and depression, but not the radiographic KOA severity, were significantly associated with a fall risk. Regardless of the individual's radiographic KOA severity, the risk of falls may be reduced by treating his/her knee pain, mobility problems, and/or psychological factors.

Individuals with knee osteoarthritis show few limitations in balance recovery responses after moderate gait perturbations

BACKGROUND

Knee osteoarthritis causes structural joint damage. The resultant symptoms can impair the ability to recover from unexpected gait perturbations. This study compared balance recovery responses to moderate gait perturbations between individuals with knee osteoarthritis and healthy individuals.

METHODS

Kinematic data of 35 individuals with end-stage knee osteoarthritis, and 32 healthy individuals in the same age range were obtained during perturbed walking on a treadmill at 1.0 m/s. Participants received anteroposterior (acceleration or deceleration) or mediolateral perturbations during the stance phase. Changes from baseline in margin of stability, step length, step time, and step width during the first two steps after perturbation were compared between groups using a linear regression model. Extrapolated center of mass excursion was descriptively analyzed.

FINDINGS

After all perturbation modes, extrapolated center of mass trajectories overlapped between individuals with knee osteoarthritis and healthy individuals. Participants predominantly responded to mediolateral perturbations by adjusting their step width, and to anteroposterior perturbations by adjusting step length and step time. None of the perturbation modes yielded between-group differences in changes in margin of stability and step width during the first two steps after perturbation. Small between-group differences were observed for step length (i.e. 2 cm) of the second step after mediolateral and anteroposterior perturbations, and for step time (i.e. 0.01-0.02 s) of first step after mediolateral perturbations and the second step after outward and belt acceleration perturbations.

INTERPRETATION

Despite considerable pain and damage to the knee joint, individuals with knee osteoarthritis showed comparable balance recovery responses after moderate gait perturbations to healthy participants.

Prevalence and risk factors for falls among community-dwelling adults in Riyadh area

Objectives

This study aimed to assess fall prevalence, identify related risk factors, and establish cut-off scores for fall risk measures among community-dwelling adults in Riyadh region of Saudi Arabia.

Methods

A cross-sectional study was conducted in community, Riyadh city, Saudi Arabia. A sample of 276 Saudi citizens aged ≥40 years who were able to read and write in Arabic. Fall history and number of falls in the past 12 months were determined via self-reports. Variables assessed included demographic information, self-reported chronic diseases, depressive symptoms, and back pain severity.

Results

Participants were classified as either fallers (n = 28, 10.14%) or non-fallers. Fallers were more likely to have arthritis (odds ratio [OR]: 7.60, p = 0.001), back pain (OR: 5.22, p = 0.002), and higher depressive symptom scores (OR: 1.09, p = 0.013) than non-fallers. The number of reported falls was significantly associated with an elevated body mass index (incidence rate ratio [IRR]: 1.09, p = 0.045), arthritis (IRR: 8.74, p < 0.001), back pain (IRR: 4.08, p = 0.005), neurological diseases (IRR: 13.75, p < 0.007), and depressive symptoms (IRR: 1.08, p = 0.005). Cut-off scores predictive of falls associated with back pain and depressive symptoms were 1.5 (sensitivity: 0.61; specificity: 0.79; area under the curve [AUC]: 0.70) and 11.5 score (sensitivity: 0.57; specificity: 0.76; AUC: 0.66), respectively.

Conclusions

The prevalence of falls was relatively low among the individuals considered in this study. Chronic conditions, back pain severity, and depressive symptoms were determined to be associated with falls among community-dwelling individuals in Saudi Arabia.

Classification of patients with osteoarthritis through clusters of comorbidities using 633 330 individuals from Spain

OBJECTIVES

To explore clustering of comorbidities among patients with a new diagnosis of OA and estimate the 10-year mortality risk for each identified cluster.

METHODS

This is a population-based cohort study of individuals with first incident diagnosis of OA of the hip, knee, ankle/foot, wrist/hand or 'unspecified' site between 2006 and 2020, using SIDIAP (a primary care database representative of Catalonia, Spain). At the time of OA diagnosis, conditions associated with OA in the literature that were found in ≥1% of the individuals (n = 35) were fitted into two cluster algorithms, k-means and latent class analysis. Models were assessed using a range of internal and external evaluation procedures. Mortality risk of the obtained clusters was assessed by survival analysis using Cox proportional hazards.

RESULTS

We identified 633 330 patients with a diagnosis of OA. Our proposed best solution used latent class analysis to identify four clusters: 'low-morbidity' (relatively low number of comorbidities), 'back/neck pain plus mental health', 'metabolic syndrome' and 'multimorbidity' (higher prevalence of all studied comorbidities). Compared with the 'low-morbidity' cluster, the 'multimorbidity' cluster had the highest risk of 10-year mortality (adjusted hazard ratio [HR]: 2.19 [95% CI: 2.15, 2.23]), followed by the 'metabolic syndrome' cluster (adjusted HR: 1.24 [95% CI: 1.22, 1.27]) and the 'back/neck pain plus mental health' cluster (adjusted HR: 1.12 [95% CI: 1.09, 1.15]).

CONCLUSION

Patients with a new diagnosis of OA can be clustered into groups based on their comorbidity profile, with significant differences in 10-year mortality risk. Further research is required to understand the interplay between OA and particular comorbidity groups, and the clinical significance of such results.

The test-retest reliability and concurrent validity of performance-based task tests in patients with knee osteoarthritis

BACKGROUND

The measurement tool used for an accurate balance assessment should produce valid and reliable results in the population in which it is used.

OBJECTIVES

To examine whether two performance-based task tests are a reliable and valid measurement test to assess balance in patients with early and advanced knee osteoarthritis (KO).

DESIGN

Reliability and concurrent validity research.

METHOD

Test-retest reliability by calculating the intraclass correlation coefficient (ICC) between the first and second trial periods of performance-based task tests (Alternate Step Test & Pen Pick up Test); their correlations with the Timed Up and Go Test (TUGT) were calculated and their concurrent validity in balance assessment were examined.

RESULTS

A total of 100 patients (75% women, 25% men, mean 59 ± 10 years) with KO, 50 early (54 ± 7 years, 34 women, 16 men) and 50 advanced (64 ± 9 years, 41 women, 9 men), participated in the study. The ICC values for the Alternate Step Test (AST) and Pen Pick up Test (PPT) in patients with early KO are 0.881 (0.747-0.939, 95% confidence intervals) and 0.815 (0.689-0.892, 95% confidence intervals), respectively, while it is 0.852 (0.752-0.913, 95% confidence intervals) and 0.861 (0.756-0.922, 95% confidence intervals) in patients with advanced KO. Pearson correlation coefficient between AST & PPT times and TUGT time in patients with early and advanced KO was in the range of 0.535-0.746 (p < 0.01).

CONCLUSIONS

Both task tests are reliable and valid clinical measurement tests that can be used to assess balance in patients with both early and advanced KO.

Effectiveness of Exercise in Patients with Overweight or Obesity Suffering from Knee Osteoarthritis: A Systematic Review and Meta-Analysis

OBJECTIVES

The main purpose of this study was to review the evidence about the effectiveness of exercise in patients with overweight or obesity suffering from knee osteoarthritis.

METHODS

Randomized clinical trials (RCTs) published between January 2002 and May 2022 were included.

RESULTS

A total of 64 articles were identified, of which six met the criteria for meta-analysis. The pain scale score was higher in the control group (mean difference 0.95; confidence interval 0.42-1.47; p < 0.001; I² = 44%). The physical function scale (lower scores indicate lower levels of symptoms or physical disability) presented a higher score in the control group (mean difference 3.74; confidence interval 0.85-6.53; p < 0.05; I² = 56%). Moreover, the intervention group achieved a greater distance (meters) walking in a 6 min interval (mean difference 38.18; confidence interval 20.01-56.35; p < 0.001; I² = 0%).

CONCLUSIONS

Exercise interventions seem effective in improving quality of life in people with overweight or obesity suffering from knee osteoarthritis, reducing pain and improving physical function.

Risk Factors Associated with Falls and Fractures Following Prescription of Opioids Among Privately Insured Patients with Osteoarthritis

Background: While prior research has shown that patients with osteoarthritis (OA) who are prescribed opioids have higher rates of falls and fractures following drug initiation, there is a limited body of work establishing a comprehensive model of factors that influence the risk of falls or fractures among these patients. Objective: Opioids are associated with negative clinical outcomes, including increased risk of falls and fractures. This study assessed the frequency, treatment characteristics, and risk factors associated with falls or fractures among patients with OA taking opioids. Methods: Optum Healthcare Solutions, Inc data (January 2012-March 2017) were used to identify patients over 18 with at least 2 diagnoses of hip and/or knee OA, and at least 90 days' supply of opioids. Patients with cancer were excluded. Falls or fractures outcomes were assessed in the 36-month follow-up period after the date of the first opioid prescription after first OA diagnosis. Demographic, treatment, and clinical characteristics associated with falls or fractures were assessed using logistic regression. Results: Of 16 663 patients meeting inclusion criteria, 3886 (23%) had at least 1 fall or fracture during follow-up. Of these 3886 patients, 1349 (35%) had at least 1 fall with an average of 3 fall claims, and 3299 (85%) patients had at least 1 fracture with an average of 8 claims during follow-up. Spine (15.8%) and hip (12.5%) fractures were most common. Median time to fall or fracture was 18.6 and 13.9 months, respectively. Significant (P<.05) risk factors associated with at least 1 fall or fracture during the follow-up period included alcohol use (odds ratio [OR], 3.41), history of falling (OR, 2.19), non-tramadol opioid use (OR, 1.31), age (OR, 1.03), benzodiazepine use (OR, 1.21), and at least 1 osteoporosis diagnosis (OR, 2.06). Discussion: This study is among only a few that clearly identifies the substantial impact and frequency of falls and fractures associated with prescribing non-tramadol opioids to patients with OA. Findings suggest that fall or fracture risks need to be considered when managing OA pain with opioids. Conclusion: Falls and fractures impose a major clinical burden on patients prescribed opioids for OA-related pain management. Falls or fracture risks should be an important consideration in the ongoing treatment of patients with OA.

Compensatory Responses During Slip-Induced Perturbation in Patients With Knee Osteoarthritis Compared With Healthy Older Adults: An Increased Risk of Falls?

Background: Functional impairment of the knee joint affected by osteoarthritis and loss of muscle strength leads to a significant increase in the number of falls. Nevertheless, little is known about strategies for coping with gait perturbations in patients with knee osteoarthritis (KOA). Thus, this study aimed to examine the compensatory strategies of patients with KOA in response to a backward slip perturbation compared with healthy older adults.

Methods: An automated perturbation program was developed by using D-Flow software based on the Gait Real-time Analysis Interactive Lab, and an induced backward slip perturbation was implemented on nine patients with severe KOA (68.89 ± 3.59 years) and 15 age-matched healthy older adults (68.33 ± 3.29 years). Step length, gait speed, range of motion, vertical ground reaction forces, lower extremity joint angles, and joint moments were computed and analyzed.

Results: Compared with older adults, patients with KOA had significantly lower step length, gait speed, and vertical ground reaction forces in both normal walking and the first recovery step following backward slip perturbations. Inadequate flexion and extension of joint angles and insufficient generation of joint moments predispose patients with KOA to fall. Hip extension angle and flexion moment, knee range of motion, and vertical ground reaction forces are key monitoring variables.

Conclusion: The risk of falls for patients with KOA in response to backward slip perturbations is higher. Patients with KOA should focus not only on quadriceps muscle strength related to knee range of motion but also on improving hip extensor strength and activation through specific exercises. Targeted resistance training and perturbation-based gait training could be better options.

Knee symptom but not radiographic knee osteoarthritis increases the risk of falls and fractures: results from the Osteoarthritis Initiative

OBJECTIVE

To describe the effect of knee symptoms and radiographic osteoarthritis (ROA) on the risk of falls, recurrent falls, and fractures.

DESIGN

Participants from the Osteoarthritis Initiative were classified as having 'no', 'unilateral' or 'bilateral' knee symptoms (≥19 on a 0-96 Western Ontario and McMaster Universities Osteoarthritis Index) and ROA (Kellgren-Lawrence grade ≥2) for each visit. Self-reported falls and fractures in the past 12 months were extracted at baseline and follow-up visits until month 96. Recurrent falls were defined as having ≥2 falls in the past 12 months. Hazard ratios (HR) with 95% confidence intervals (CI) were estimated using mixed-effects complementary log-log regression.

RESULTS

Of 4465 participants, 3145 (70%), 1681 (38%), and 806 (18%) experienced at least one fall, recurrent fall, and fracture, respectively, over 96 months. Compared to participants without symptomatic knee, unilateral and bilateral knee symptoms were associated with a 17% increased risk of falls and a 36-46% increased risk of recurrent falls, and bilateral knee symptoms increased the risk of fractures (HR 1.45, 95%CI 1.17 to 1.81). Compared to participants with no ROA in either knee, bilateral ROA was associated with a reduced risk of falls (HR 0.87, 95%CI 0.77 to 0.99) and fractures (HR 0.78, 95%CI 0.64 to 0.96). No statistically significant interactions between knee symptoms and ROA were observed.

CONCLUSIONS

This large population-based study showed that knee symptoms but not ROA increased the risk of falls, recurrent falls, and fractures, and that adults with bilateral ROA may have a lower risk of falls and fractures.

Determining the Profile of People with Fall Risk in Community-Living Older People in Algarve Region: A Cross-Sectional, Population-Based Study

One in three people aged 65 years or older falls every year. Injuries associated with this event among the older population are a major cause of pain, disability, loss of functional autonomy and institutionalization. This study aimed to assess mobility and fall risk (FR) in community-living older people and to determine reliable and independent measures (health, social, environmental and risk factors) that can predict the mobility loss and FR. In total, 192 participants were included, with a mean age of 77.93 ± 8.38. FR was assessed by EASY-Care (EC) Standard 2010, the Tinetti Test and the Modified Falls Efficacy Scale (MFES). An exploratory analysis was conducted using the divisive non-hierarchical cluster method, aiming to identify a differentiator and homogeneous group of subjects (optimal group of variables) and to verify if that group shows differences in fall risk. Individually, the health, social, environmental and risk factor categories were not found to be an optimal group; they do not predict FR. The most significant predictor variables were a mix of the different categories, namely, the presence of pain, osteoarthritis (OA), and female gender. The finding of a profile that allows health professionals to be able to quickly identify people at FR will enable a reduction in injuries and fractures resulting from falls and, consequently, the associated costs.

The Impact of Pain on Functionality, Postural Control and Fall Risk in Woman Aged 45 to 64 Years Old

BACKGROUND

Ageing in women is associated with chronic degenerative pain leading to a functional decrease and therefore increase fall risk. It is therefore essential to detect early functional decreases in the presence of pain related to osteoarthritis.

OBJECTIVE

This cross-sectional study aimed to assess the impact of pain on functionality, postural control and fall risk in women aged between 45 to 64 years old.

METHODS

Twenty-one (21) women aged 45 to 64 were evaluated by clinical and functional measures such as a pain questionnaire (Lequesne Index), functional tests (Stair Step Test, 5 times sit-to-stand, 6MWD, Timed-up and Go) and postural performance (under force platform). Women were classified into 2 groups from the Lequesne Pain Index (PI): low pain (score ≤ 9) and strong pain (score ≥ 10) for subsequent comparisons on functionality (physical and postural control performance).

RESULTS

A significant impact was observed between the pain index (strong PI) and 3 of the 4 functional tests carried out including Stair Step Test (p = 0.001; g = 1.44), walking distance (p = 0.003; g = 1.31) and Timed-up and Go (p = 0.04; g = -0.93). The group with a strong PI score reported further poor postural control under force platform compared to the weak pain group.

CONCLUSION

Pain and severity based on the PI index negatively modulate physical and postural control performance in women aged 45 to 64 years old.

Association between hip and knee osteoarthritis with falls: A systematic review and meta-analysis

OBJECTIVE

To examine the association between hip and knee osteoarthritis (OA) and falls. Potentially relevant articles that examine the association between hip, knee, radiological, and self-reported OA and falls were retrieved from PubMed, EMBASE, Scopus, and Web of Science up until March of 2020.

METHODS

The pooled risk ratios (RRs) as well as their related 95% confidence intervals (CIs) were calculated. Statistic and subgroup analyses were performed. A total of 21 studies involving 146 965 participants were included.

RESULTS

No association was found between hip OA and falls. The pooled RRs value suggested a higher prevalence of falls in knee OA patients (RR = 1.35, 95% CI: 1.20 to 1.51, P < .00001) and self-reported OA (RR = 1.33, 95% CI: 1.23 to 1.45, P < .00001) than in non-OA subjects. The pooled RR value suggested no difference between prevalence of falls in radiological OA patients compared to non-OA subjects (RR = 1.82, 95% CI: 0.89 to 3.73, P = .10). Both radiological and self-reported knee OA seem to be positively associated with falls, while no obvious association was found between hip OA and falls.

CONCLUSIONS

Therefore, knee OA is a risk factor for falls which should be closely monitored.

Risk of Osteoarthritis is Positively Associated with Vitamin D Status, but Not Bone Mineral Density, in Older Adults in the United States

OBJECTIVE

We examined the risk of osteoarthritis (OA) according to vitamin D status and bone mineral density (BMD) using a cross-sectional nationally representative database.

METHODS

National Health and Nutrition Examination Survey (NHANES) data from 2007 to 2010 were used to assess the relationship between OA and vitamin D status in adults aged ≥40 years (n = 2934). NHANES data from 2005 to 2010 and 2013 to 2014 were analyzed to investigate the association between OA and BMD (n = 5949). Vitamin D status was categorized as serum 25-hydroxyvitamin D (25OHD) <20 ng/mL or ≥20 ng/mL. Bone health was classified according to T-score (normal, osteopenia, or osteoporosis) and BMD tertile. Risk of OA was assessed using logistic regression and adjusted for covariates.

RESULTS

Participants with serum 25OHD <20 ng/mL had a 37% lower risk of OA (95% confidence interval (CI) [0.39-0.99], P = 0.046). When stratified by sex, the odds ratio for OA in men with lower vitamin D status was 0.35 (95% CI [0.15-0.81], P = 0.02). No association was found in women. The risk for OA did not differ according to BMD tertile or T-score classification.

CONCLUSIONS

The risk of OA is lower in older men with 25OHD less than 20 ng/mL but not in older women. Bone mineral density is not associated with OA risk in older adults in the United States.

Osteoarthritis and the incidence of fracture in the United Kingdom: a retrospective cohort study of 258,696 patients

OBJECTIVE

The goal of this study was to analyze the relationship between osteoarthritis and the incidence of fracture in men and women aged ≥18 years followed in general practices in the United Kingdom.

METHODS

This study included patients aged ≥18 years who had received an initial diagnosis of osteoarthritis in one of 256 general practices in the United Kingdom between January 1997 and December 2016 (index date). Patients without osteoarthritis were matched (1:1) to those with osteoarthritis by sex, age, index year, diabetes, dementia, corticosteroid therapy, and practice. For patients without osteoarthritis, the index date was a randomly selected visit date between 1997 and 2016. The association between osteoarthritis and the incidence of fracture was investigated using Kaplan-Meier curves and conditional Cox regression analyses.

RESULTS

This retrospective cohort study included 129,348 patients with osteoarthritis and 129,348 patients without osteoarthritis [60.1% women; mean (standard deviation) age 63.7 (14.0) years]. After 10 years of follow-up, 12.1% of individuals with osteoarthritis and 7.7% of those without osteoarthritis had suffered at least one fracture (log-rank P-value<0.001). There was a positive and significant association between osteoarthritis and fracture in the overall sample [hazard ratio (HR) = 1.55, 95% confidence interval (CI) = 1.50-1.60]. These findings were corroborated in all sex, age, and osteoarthritis joint site subgroups.

CONCLUSION

Intervention is urgently needed to reduce the risk of fracture in adults with osteoarthritis, and further research is warranted in order to gain more of an insight into the mediators involved in the relationship between osteoarthritis and fracture.

A systematic review and meta-analysis of fall incidence and risk factors in elderly patients after total joint arthroplasty

BACKGROUND

Falls in the elderly have become a serious social problem worldwide. Approximately a third of persons fall at least once in the year after total joint arthroplasty (TJA), but preventing and treating falls is still challenging in clinical practice. Until now, no formal systematic review or meta-analysis was performed to summarize the risk factors of falls after TJA. The present study aimed to quantitatively and comprehensively conclude the risk factors of falls after TJA in elderly patients.

METHODS

The electronic databases to be searched include CNKI, Embase, Medline, and Cochrane central database (all up to November 2018). All studies on the risk factors of falls after TJA in elderly patients without language restriction were reviewed. Process of evaluation of identified studies and extraction of data were independently conducted by 2 reviewers, qualities of included studies were assessed using the Newcastle-Ottawa Scale. Data were pooled and a meta-analysis completed. All analyses were performed by the software Stata 11.0.

RESULTS

A total of 14 studies were included, which altogether included 1284456 patients with TJA, of them 12879 cases of falls occurred after surgery, suggesting the accumulated incidence of 13.1% and the prevalence of in-hospital falls was 1.0%. This study has provided evidence for the preventing of falls in the elderly patients who were underwent TJA. Outcome measures include advanced age, female, Overweight (BMI≥25 kg/m), falls history, use of walking aid, diabetes, cardiac disease, hypertension, COPD and depressive symptoms. The ABC Scale was significantly negatively correlated with falls after lower extremity joint replacement.

CONCLUSIONS

Related prophylaxis strategies should be implemented in elderly patients involved with above-mentioned risk factors to prevent falls after TJA.

Global, regional prevalence, incidence and risk factors of knee osteoarthritis in population-based studies

BACKGROUND

Knee osteoarthritis (OA) is a major cause of disability in the elderly, however, there are few studies to estimate the global prevalence, incidence, and risk factors of knee OA.

METHODS

For this study, we searched PUBMED, EMBASE and SCOPUS from inception to April 4, 2020, without language restriction. We identified eligible studies with information on the prevalence or incidence of knee OA in population-based observational studies and extracted data from published reports. We did random-effects meta-analysis to generate estimates. This study was registered with PROSPERO (CRD42020181035).

FINDINGS

Out of 9570 records identified, 88 studies with 10,081,952 participants were eligible for this study. The pooled global prevalence of knee OA was 16⋅0% (95% CI, 14⋅3%-17⋅8%) in individuals aged 15 and over and was 22⋅9% (95% CI, 19⋅8%-26⋅1%) in individuals aged 40 and over. Correspondingly, there are around 654⋅1 (95% CI, 565⋅6-745⋅6) million individuals (40 years and older) with knee OA in 2020 worldwide. The pooled global incidence of knee OA was 203 per 10,000 person-years (95% CI, 106-331) in individuals aged 20 and over. Correspondingly, there are around annual 86⋅7 (95% CI, 45⋅3-141⋅3) million individuals (20 years and older) with incident knee OA in 2020 worldwide. The prevalence and incidence varied substantially between individual countries and increased with age. The ratios of prevalence and incidence in females and males were 1⋅69 (95% CI, 1⋅59-1⋅80, p<0⋅00) and 1⋅39 (95% CI, 1⋅24-1⋅56, p<0⋅00), respectively.

INTERPRETATION

Our study provides the global prevalence (16⋅0% [95% CI, 14⋅3%-17⋅8%]) and incidence (203 per 10,000 person-years [95% CI, 106-331]) of knee OA. These findings can be used to better assess the global health burden of knee OA. Further prospective cohort studies are warranted to identify modifiable risk factors for providing effectively preventive strategies in the early stages of the disease.

FUNDING

This work was supported by grants from the National Natural Science Foundation of China (nos. 81772384 and 81572174).

Incidence of postoperative complications and non- periprosthetic fractures after total hip arthroplasty: A more than 10-year follow-up retrospective cohort study

OBJECTIVE

Postoperative complications and non-periprosthetic fractures (NPPFs), which was defined as a fracture existing non- periprosthetic implant, after total hip arthroplasty (THA) have a negative effect on the patients' ability to perform activities of daily living. Thus, investigating these incidences of patients after THA will be valuable as it lead to a more strategic physical therapy interventions and advanced research to prevent these problems. The purpose of this study was to investigate the incidence of postoperative complications related to implants and NPPFs in patients after THA, a more than 10-year follow-up.

METHODS

This is a retrospective cohort study. A total 892 patients with hip osteoarthritis who underwent primary THA were analyzed (age at surgery was 45-79 years; 805 women; the average follow-up period was 12.4-year). The postoperative complications related to implants and NPPFs were calculated using data from their medical records.

RESULTS

The postoperative complications occurred in 37 patients, and NPPFs occurred in 72 patients, who were significantly older, and hip and knee OA diagnosis, compared to patients without NPPFs ( p <.05). The most common cause of NPPFs was minor trauma. In patients aged ≧ 65 years, significantly more NPPFs occurred during the first year after surgery( p <.05).

CONCLUSION

More than 10-year after THA, the incidence of NPPFs was higher than that of postoperative complications related to implants. Older patients who had hip and knee OA were a significantly higher risk of developing NPPFs due to falls within the first year after surgery.

Coexistent Osteoarthritis and Parkinson's Disease: Data from the Parkinson's Foundation Outcomes Project

BACKGROUND

The impact of concurrent osteoarthritis on mobility and mortality in individuals with Parkinson's disease is unknown.

OBJECTIVE

We sought to understand to what extent osteoarthritis severity influenced mobility across time and how osteoarthritis severity could affect mortality in individuals with Parkinson's disease.

METHODS

In a retrospective observational longitudinal study, data from the Parkinson's Foundation Quality Improvement Initiative was analyzed. We included 2,274 persons with Parkinson's disease. The main outcomes were the effects of osteoarthritis severity on functional mobility and mortality. The Timed Up and Go test measured functional mobility performance. Mortality was measured as the osteoarthritis group effect on survival time in years.

RESULTS

More individuals with symptomatic osteoarthritis reported at least monthly falls compared to the other groups (14.5% vs. 7.2% without reported osteoarthritis and 8.4% asymptomatic/minimal osteoarthritis, p = 0.0004). The symptomatic group contained significantly more individuals with low functional mobility (TUG≥12 seconds) at baseline (51.5% vs. 29.0% and 36.1%, p < 0.0001). The odds of having low functional mobility for individuals with symptomatic osteoarthritis was 1.63 times compared to those without reported osteoarthritis (p < 0.0004); and was 1.57 times compared to those with asymptomatic/minimal osteoarthritis (p = 0.0026) after controlling pre-specified covariates. Similar results hold at the time of follow-up while changes in functional mobility were not significant across groups, suggesting that osteoarthritis likely does not accelerate the changes in functional mobility across time. Coexisting symptomatic osteoarthritis and Parkinson's disease seem to additively increase the risk of mortality (p = 0.007).

CONCLUSION

Our results highlight the impact and potential additive effects of symptomatic osteoarthritis in persons with Parkinson's disease.

Incidence and risk factors for falls among community-dwelling elderly subjects on a 1-year follow-up: a prospective cohort study from Ernakulam, Kerala, India

OBJECTIVES

There is limited knowledge regarding epidemiology and risk of falls among the elderly living in low-income and middle-income countries. In this situation, the current study aims to report the incidence of falls and associated risk factors among free living elderly population from Kerala, India.

DESIGN

Prospective cohort study with stratified random cluster sampling.

SETTING

The study location was Ernakulam, Kerala, India, and we collected information via house visits using a questionnaire. During the research, the subjects were followed up prospectively for 1 year by phone at intervals of 3 months and missing subjects were contacted by house visits.

PARTICIPANTS

Community-dwelling elderly above 65 years of age.

RESULTS

We recruited a total of 1000 participants out of which a total of 201 (20.1%) subjects reported a fall during the follow-up. The incidence rate of falls was 31 (95% CI 27.7 to 34.6) per 100 person-years. Female sex (OR 1.48, 95% CI 1.05 to 2.10, p=0.027), movement disorders including Parkinsonism (OR 2.26, 95% CI 1.00 to 5.05, p=0.048), arthritis (OR 1.48, 95% CI 1.05 to 2.09, p=0.026), dependence in basic activities of daily living (OR, 3.49, 95% CI 2.00 to 6.09, p<0.001), not using antihypertensive medications (OR, 1.53, 95% CI 1.10 to 2.13, p=0.012), living alone during daytime (OR 3.27, 95% CI 1.59 to 6.71, p=0.001) and a history of falls in the previous year (OR, 2.25, 95% CI 1.60 to 3.15, p<0.001) predicted a fall in the following year.

CONCLUSIONS

One in five community-dwelling senior citizen fall annually and one in four who fall are prone to fall again in the following year. Interventions targeting falls among the elderly need to focus on modifiable risk factors such as living alone during daytime, movement disorders, arthritis and dependence on basic activities of daily living.

Triaging Total Hip Arthroplasty During the COVID-19 Pandemic

Purpose of Review

The purpose of this review was to evaluate the available literature to determine what may be considered urgent indications for total hip arthroplasty, in the unprecedented setting of the worldwide COVID-19 pandemic.

Recent Findings

SARS-CoV-2 is a novel coronavirus currently presenting in the form of a global pandemic, referred to as COVID-19. In this setting, multiple states have issued executive orders prohibiting “elective” surgery, including arthroplasty, in order to preserve healthcare resources. However, during this unprecedented reduction in elective surgery, there is likely to be some controversy as to what constitutes a purely “elective” procedure, versus an “urgent” procedure, particularly regarding hip arthroplasty. We reviewed the available literature for articles discussing the most commonly encountered indications for primary, conversion, and revision hip arthroplasty. Based upon the indications discussed in these articles, we further stratified these indications into “elective” versus “urgent” categories.

Summary

In patients presenting with hip arthroplasty indications, the decision to proceed urgently with surgery should be based upon (a) the potential harm incurred by the patient if the surgery was delayed and (b) the potential risk incurred by the patient in the context of COVID-19 if surgery was performed. The authors present a decision-making algorithm for determining surgical urgency in three patients who underwent surgery in this context. Urgent total hip arthroplasty in the setting of the COVID-19 pandemic is a complex decision-making process, involving clinical and epidemiological factors. These decisions are best made in coordination with a multidisciplinary committee of one’s peers. Region-specific issues such as hospital resources and availability of PPE may also inform the decision-making process.

Risk for hip fracture before and after total knee replacement in Sweden

We studied the risk for hip fracture before and after total knee replacement (TKR) in the entire population in Sweden. Women and men had a low risk for hip fracture before TKR but an increased risk the first year after TKR.

PURPOSE

It is known that osteoarthritis is associated with high bone mass. We therefore studied the risk of hip fracture before and after total knee replacement (TKR), risk of different hip fracture types, and risk subdivided in genders and age groups.

METHODS

We followed the total Swedish population born between 1902 and 1952 (n = 4,258,934) during the period 1987-2002 and identified all patients with TKR due to primary OA (n = 39,291), and all patients with hip fracture (n = 195,860) in the Swedish National Inpatient Register. The risk time analyses were based on Poisson regression models.

RESULTS

The hazard ratio (HR) for hip fracture the last year before TKR was 0.86 (95% CI 0.74 to 1.00) and the first year after 1.26 (95% CI 1.11 to 1.42) compared to individuals without TKR. The HR for femoral neck fracture 0-10 years after TKR was 0.95 (95% CI 0.89 to 1.01) and for trochanteric fracture was 1.13 (95% CI 1.06 to 1.21). The HR for hip fracture in the age group 50-74 was 1.28 (95% CI 1.14 to 1.43) and in the age group 75-90 years was 0.99 (95% CI 0.94 to 1.04) 0-10 years after TKR, compared to individuals without TKR.

CONCLUSION

Individuals had a low risk for hip fracture before TKR but an increased risk the first year after TKR. The risk in individuals below age 75 years and for trochanteric fractures was increased after TKR. Possible explanations include changed knee kinematics after a TKR, physical activity level, fall risk, and other unknown factors.

Task-Specific Perturbation Training Improves the Recovery Stepping Responses by Women With Knee Osteoarthritis Following Laboratory-Induced Trips

Trip-specific training improves the kinematics of trip-specific compensatory stepping response (CSR) in the laboratory and reduces prospectively measured trip-related fall-rate of middle age and older women. We examined whether one session of trip-specific perturbation training could improve recovery step kinematics in women with knee osteoarthritis (OA), a condition known to increase fall risk. Seventeen women with self-reported symptomatic knee OA (age 61.1 ± 7.7 years, body mass index [BMI] 29.7 ± 5.9 kg/m2 ) and 22 control women (age 59.5 ± 6.8 years, BMI 28.4 ± 6.2 kg/m2 ) completed a brief training protocol consisting of 20 trials of treadmill-delivered trip-specific perturbations. We assessed pre- and post-training recovery step length and trunk kinematics at the instant of recovery step completion. Repeated-measures analysis of variance was used to determine the significance of between-group differences following the training protocol, and to evaluate the significance of within-group pre-to-post changes in the variables of interest. The group by training interaction effects for step length (p = 0.466), trunk flexion angle (p = 0.751), and trunk angular velocity (p = 0.413) were not significant and the pre-to-post changes in step length were not significant (p = 0.286). However, pre-to-post trunk flexion angle improved by 26% and 34% in the OA and control groups, respectively (p < 0.001) and trunk flexion angular velocity decreased by 193% in the OA group and by 32% in the control group, respectively (p < 0.001), often reflecting a transition to the direction of extension. The results suggest that trip-specific training can improve CSR kinematics in women with knee OA. It is important to determine, the effectiveness of trip-specific training in decreasing trip-specific fall-rate by women with knee OA. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:663-669, 2020.

Clinical osteoarthritis of the hip and knee and fall risk: The role of low physical functioning and pain medication

OBJECTIVE

Several studies have found an increased fall risk in persons with osteoarthritis (OA). However, most prospective studies did not use a clinical definition of OA. In addition, it is not clear which factors explain this risk. Our objectives were: (1) to confirm the prospective association between clinical OA of the hip and knee and falls; (2) to examine the modifying effect of sex; and (3) to examine whether low physical performance, low physical activity and use of pain medication are mediating these relationships.

METHODS

Baseline and 1-year follow-up data from the European Project on OSteoArthritis (EPOSA) were used involving pre-harmonized data from five European population-based cohort studies (ages 65-85, n = 2535). Clinical OA was defined according to American College of Rheumatology (ACR) criteria. Falls were assessed using self-report.

RESULTS

Over the follow-up period, 27.7% of the participants fell once or more (defined as faller), and 9.8% fell twice or more (recurrent faller). After adjustment for confounding, clinical knee OA was associated with the risk of becoming a recurrent faller (relative risk=1.55; 95% confidence interval: 1.10-2.18), but not with the risk of becoming a faller. No associations between clinical hip OA and (recurrent) falls were observed after adjustment for confounding. Use of opioids and analgesics mediated the associations between clinical OA and (recurrent) falls, while physical performance and physical activity did not.

CONCLUSION

Individuals with clinical knee OA were at increased risk for recurrent falls. This relationship was mediated by pain medication, particularly opioids. The fall risk needs to be considered when discussing the risk benefit ratio of prescribing these medications.

Subchondral bone dysplasia mediates susceptibility to osteoarthritis in female adult offspring rats induced by prenatal caffeine exposure

Our previous studies confirmed that prenatal caffeine exposure (PCE) could induce susceptibility to osteoarthritis in adult offspring rats due to poor chondrocyte differentiation, but its mechanism remains to be further investigated. This study aimed to explore whether subchondral bone dysplasia mediates susceptibility to osteoarthritis in adult offspring rats induced by PCE. Pregnant Wistar rats were treated with caffeine (120 mg/kg.d) or saline from gestational day (GD) 9 to 20. The female offspring were euthanized to collect femurs at GD20, postnatal week (PW) 6, and PW28 (non-ovariectomy and ovariectomy groups) to detect osteoarthritis-like phenotype, subchondral bone mass, ossification center development, and other evidence. The results showed that PCE increased the Mankin score of pathological articular cartilage, but decreased articular cartilage thickness and subchondral bone mass, which were more obvious after ovariectomy. Meanwhile, the correlation analysis results demonstrated that the Mankin score of articular cartilage was significantly negatively correlated with subchondral bone mass, and the thickness of articular cartilage was significantly positively correlated with subchondral bone mass. Further, the length and area of the primary and secondary ossification centers, the number of osteoblasts, and the related genes' expression of osteogenic differentiation (e.g., Runx2, BSP, ALP, and OCN) were all significantly decreased in the PCE group before and after birth. Taken together, PCE induced susceptibility to osteoarthritis in adult female offspring, which was likely related to the subchondral bone dysplasia and reduction of subchondral bone mass production due to developmental disorder of primary and secondary ossification centers caused by osteoblast differentiation disability before and after birth.

Lifetime risk of knee and hip replacement following a GP diagnosis of osteoarthritis: a real-world cohort study

OBJECTIVE

The aim of this study was to estimate lifetime risk of knee and hip replacement following a GP diagnosis of osteoarthritis and assess how this risk varies with patient characteristics.

METHODS

Routinely collected data from Catalonia, Spain, covering 2006 to 2015, were used. Study participants had a newly recorded GP diagnosis of knee or hip osteoarthritis. Parametric survival models were specified for risk of knee/hip replacement and death following diagnosis. Survival models were combined using a Markov model and lifetime risk estimated for the average patient profile. The effects of age at diagnosis, sex, comorbidities, socioeconomic status, body mass index (BMI), and smoking on risk were assessed.

RESULTS

48,311 individuals diagnosed with knee osteoarthritis were included, of whom 2,561 underwent knee replacement. 15,105 individuals diagnosed with hip osteoarthritis were included, of whom 1,247 underwent hip replacement. The average participant's lifetime risk for knee replacement was 30% (95% CI: 25-36%) and for hip replacement was 14% (10-19%). Notable patient characteristics influencing lifetime risk were age at diagnosis for knee and hip replacement, sex for hip replacement, and BMI for knee replacement. BMI increasing from 25 to 35 was associated with lifetime risk of knee replacement increasing from 24% (20-28%) to 32% (26-37%) for otherwise average patients.

CONCLUSION

Knee and hip replacement are not inevitable after an osteoarthritis diagnosis, with average lifetime risks of less than a third and a sixth, respectively. Patient characteristics, most notably BMI, influence lifetime risks.

Clinical Impact of the Fracture Risk Assessment Tool on the Treatment Decision for Osteoporosis in Patients with Knee Osteoarthritis: A Multicenter Comparative Study of the Fracture Risk Assessment Tool and World Health Organization Criteria

Background: To compare the frequency of high-risk osteoporotic fracture in patients with knee OA (OA) using the fracture risk assessment tool (FRAX) and the bone mineral density (BMD). Methods: We retrospectively assessed 282 Korean patients with knee OA who visited five medical centers and 1165 healthy controls (HCs) aged ≥50 years without knee OA. After matching for age, sex, and body mass index, 478 subjects (239 patients with knee OA and 239 HCs) were included. Results: Based on the BMD, the frequency of osteoporosis was 40.2% in patients with knee OA and 36.4% in HCs. The predicted mean FRAX major osteoporotic fracture probabilities calculated with or without femur neck BMD differed significantly between the knee OA and HCs (6.9 ± 3.8% versus 6.1 ± 2.8%, p = 0.000 and 8 ± 3.6% versus 6.8 ± 2.3%, p < 0.001, respectively). The mean FRAX hip fracture probabilities calculated with or without femur neck BMD differed significantly in the knee OA and HCs (2.1 ± 2.4% versus 1.7 ± 1.8%, p = 0.006 and 3 ± 2.3% versus 2.4 ± 1.6%, p < 0.001, respectively). Conclusion: Our study suggests that FRAX may have a clinical impact on treatment decisions to reduce osteoporotic facture in patients with knee OA.

Genome-wide analyses using UK Biobank data provide insights into the genetic architecture of osteoarthritis

Osteoarthritis is a common complex disease imposing a large public-health burden. Here, we performed a genome-wide association study for osteoarthritis, using data across 16.5 million variants from the UK Biobank resource. After performing replication and meta-analysis in up to 30,727 cases and 297,191 controls, we identified nine new osteoarthritis loci, in all of which the most likely causal variant was noncoding. For three loci, we detected association with biologically relevant radiographic endophenotypes, and in five signals we identified genes that were differentially expressed in degraded compared with intact articular cartilage from patients with osteoarthritis. We established causal effects on osteoarthritis for higher body mass index but not for triglyceride levels or genetic predisposition to type 2 diabetes.

Analgesic Use and Risk for Acute Coronary Events in Patients With Osteoarthritis: A Population-based, Nested Case-control Study

PURPOSE

Recent controversies on the safety profiles of opioids and paracetamol (acetaminophen) have led to changes in clinical guidance on osteoarthritis (OA) management. We studied the existing association between the use of different OA drug therapies and the risk for acute coronary events.

METHODS

A cohort of patients with clinically diagnosed OA (according to ICD-10 codes) was identified in the SIDIAP database. Within the cohort, cases with incident acute coronary events (acute myocardial infarction or unstable angina) between 2008 and 2012 were identified using ICD-10 codes and data from hospital admission. Controls were matched 3:1 to acute coronary event-free patients matched by sex, age (±5 years), geographic area, and years since OA diagnosis (±2 years). Linked pharmacy dispensation data were used for assessing exposure to drug therapies. Multivariate conditional logistic regression models were fitted to estimate adjusted odds ratios of acute coronary events.

FINDINGS

Totals of 5663 cases and 16,989 controls were studied. Previous morbidity and cardiovascular risk were higher in cases than in controls, with no significant differences in type or number of joints with OA. Multivariate adjusted analyses showed increased risks (odds ratio; 95% CI) related to the use of diclofenac (1.16; 1.06-1.27), naproxen (1.25; 1.04-1.48), and opioid analgesics (1.13; 1.03-1.24). No significant associations were observed with cyclooxygenase-2 selective NSAIDs, topical NSAIDs, glucosamine, chondroitin sulfate, paracetamol, or metamizole.

IMPLICATIONS

In patients with clinically diagnosed OA, the use of nonselective NSAIDs or opioid analgesics is associated with an increased risk for acute coronary events. These risks should be considered when selecting treatments of OA in patients at high cardiovascular risk.

Pre-operative predictors of post-operative falls in people undergoing total hip and knee replacement surgery: a prospective study

INTRODUCTION

Pain and disability often persist following hip (THR) and knee replacement (TKR) surgery predisposing patients to increased risk of falling. This study identified pre-operative predictors for post-operative falls in TKR and THR patients, and the incidence and circumstances of falls in the 12 months post-surgery.

MATERIALS AND METHODS

A survey was undertaken of patients before THR and TKR, and was repeated 12 months post-operation. The survey included (1) medical history and medications usage, (2) pain and function, (3) health-related and physical activity and (4) fear of falls and history of falls questionnaires. Patients were classified as 'fallers' (≥1 fall) or 'non-fallers' based on prospectively documented falls in the 12 months post-surgery. Binary logistic regression was conducted to identify independent pre-operative predictors of incident falls status.

RESULTS

Eighty-two of the 243 participants (33.7%) reported ≥1 fall in the 12 months post-operatively [60 (34.1%) patients following TKR and 22 (32.8%) following THR]. The logistic regression model was statistically significant, χ ² = 24.731, p < 0.001, the model explaining 22% of the variance in falls, and correctly classifying 73.7% of cases as fallers or non-fallers. Reduced SF-36v2 general health sub-scale, increased planned physical activity and previous falls in the preceding year were predictors of falls. Those reporting ≥1 fall pre-operatively were three times more likely to fall post-operatively.

CONCLUSION

People awaiting hip or knee joint replacement surgery might present with complex conditions that predispose them to greater risk of falling post-operation. Review of general health and history of falling is recommended pre-operatively to identify patients at risk.

Older men with severe disc degeneration have more incident vertebral fractures-the prospective MINOS cohort study

OBJECTIVE

Data on the relationship between disc degeneration (DD) and fragility fractures in men are limited. The aim of this study was to prospectively analyse the risk of vertebral and non-vertebral fractures in men with thoracolumbar DD according to the severity of its radiological signs: disc space narrowing (DSN), osteophytes and endplate sclerosis.

METHODS

Men >50 years of age (n = 765) had lateral spine radiographs and DXA and were monitored prospectively. We analysed the risk of incident vertebral (7.5 years) and non-vertebral fractures (10 years) in men according to the severity of DD.

RESULTS

After adjustment for age and weight, BMD increased with increasing total DSN score, endplate sclerosis and osteophytosis. Over 7.5 years, 28 incident vertebral fractures occurred in 27 men. After adjustment for age, BMI, spine BMD, prior fractures and abdominal aortic calcifications, the vertebral fracture risk was 3-fold higher in the upper DSN quartile vs men without DSN. After adjustment for the same confounders, vertebral fracture risk was also nearly 3-fold higher in the upper DSN quartile vs the three lower quartiles combined. Over 10 years, 61 men sustained non-vertebral fragility fractures. After adjustment for age, BMI, hip BMD, abdominal aortic calcifications and prior falls and fractures, the non-vertebral fracture risk decreased with increasing DSN score. The risk of non-vertebral fracture was half as high in men above the median total DSN score vs men below the median.

CONCLUSION

In older men, severe DD is associated with higher BMD. Multilevel severe DSN is associated with higher vertebral fracture risk and lower non-vertebral fracture risk.

Obesity and the Relative Risk of Knee Replacement Surgery in Patients With Knee Osteoarthritis: A Prospective Cohort Study

OBJECTIVE

It is unclear what impact obesity has on the progression of knee osteoarthritis (OA) from diagnosis to knee replacement surgery. This study was undertaken to examine the relative risk of knee replacement surgery in overweight and obese patients who were newly diagnosed as having knee OA in a community setting.

METHODS

Subjects were selected from the Information System for Development of Primary Care Research database, which compiles comprehensive clinical information collected by health care professionals for >5.5 million people in Catalonia, Spain (80% of the population). Patients newly diagnosed as having knee OA in primary care between 2006 and 2011 were included. Knee replacement was ascertained using International Classification of Diseases, Ninth Revision, Clinical Modification codes from linked hospital admissions data. Multivariable Cox regression models were fitted for knee replacement according to body mass index (BMI), and were adjusted for relevant confounders. Population proportional attributable risk was calculated.

RESULTS

A total of 105,189 participants were followed up for a median of 2.6 years (interquartile range 1.3-4.2). Of these patients, 7,512 (7.1%) underwent knee replacement. Adjusted hazard ratios and 95% confidence intervals (95% CIs) for knee replacement for the World Health Organization BMI categories were 1.41 (95% CI 1.27-1.57) for overweight, 1.97 (95% CI 1.78-2.18) for obese I, 2.39 (95% CI 2.15-2.67) for obese II, and 2.67 (95% CI 2.34-3.04) for obese III compared to normal weight. The effect of BMI on risk of knee replacement was stronger among younger participants. The population attributable risk of obesity for knee OA-related knee replacement was 31.0%.

CONCLUSION

Overweight and obese patients are at >40% and 100% increased risk of knee replacement surgery, respectively, compared to patients with normal weight. This association is even stronger in younger patients. Weight reduction strategies could potentially reduce the need for knee replacement surgery by 31% among patients with knee OA.

Association Between Overweight and Obesity and Risk of Clinically Diagnosed Knee, Hip, and Hand Osteoarthritis: A Population-Based Cohort Study

OBJECTIVE

Studies of previous cohorts have demonstrated an association between a status of overweight/obesity and the presence of knee and hand osteoarthritis (OA). However, no data on the effect of these factors on the OA burden are available. The aim of the present study was to analyze the effect of being overweight or obese on the incidence of routinely diagnosed knee, hip, and hand OA.

METHODS

The study was conducted in a population-based cohort using primary care records from the Sistema d'Informació per al Desenvolupament de l'Investigació en Atenció Primària database (>5.5 million subjects, covering >80% of the population of Catalonia, Spain). Participants were subjects ages ≥40 years who were without a diagnosis of OA on January 1, 2006 and had available body mass index (BMI) data. All subjects were followed up from January 1, 2006 to December 31, 2010 or to the time of loss to follow-up or death. Measures included the World Health Organization categories of BMI (exposure), and incident clinical diagnoses of knee, hip, or hand OA according to International Classification of Diseases, Tenth Revision codes.

RESULTS

In total, 1,764,061 subjects were observed for a median follow-up period of 4.45 years (interquartile range 4.19-4.98 years). Incidence rates (per 1,000 person-years at risk) of knee, hip, and hand OA were 3.7 (99% confidence interval [99% CI] 3.6-3.8), 1.7 (99% CI 1.7-1.8), and 2.6 (99% CI 2.5-2.7), respectively, among subjects in the normal weight category, and 19.5 (99% CI 19.1-19.9), 3.8 (99% CI 3.7-4.0), and 4.0 (99% CI 3.9-4.2), respectively, in those with a classification of grade II obesity. Compared to subjects with normal weight, being overweight or obese increased the risk of OA at all 3 joint sites, especially at the knee. A status of overweight, grade I obesity, and grade II obesity increased the risk of knee OA by a factor of 2-fold, 3.1-fold, and 4.7-fold, respectively.

CONCLUSION

Being overweight or obese increases the risk of hand, hip, and knee OA, with the greatest risk in the knee, and this occurs on a dose-response gradient of increasing BMI.

Biomechanical balance response during induced falls under dual task conditions in people with knee osteoarthritis

OBJECTIVE

People with knee osteoarthritis (OA) are at twice the risk of falling compared to older people without knee OA, however the mechanism for this is poorly understood. This study investigated the biomechanical response of the trunk and lower limb joints during a forward induced fall under different task conditions in people with and without knee OA.

METHOD

Twenty-four participants with OA (68.6±6.2 years) and 15 asymptomatic controls (72.4±4.8 years) participated in the study. Forward fall was induced by releasing participants from a static forward leaning position. Participants were required to recover balance during three conditions: normal, physical (obstacle clearance) and cognitive dual tasks (counting backwards). Spatiotemporal parameters, lower limb joint kinematics and kinetics of the recovery limb were compared between the two groups and across the three task conditions.

RESULTS

The OA group demonstrated slower spatio-temporal characteristics and reduced hip and knee flexion angles, joint moments/powers and reduced muscle negative work at the knee and ankle (p<0.05). Cognitive dual task resulted in reduced centre of mass velocity and step length (p=0.03) compared to the physical dual task condition. Reduced knee (p=0.02) and hip joint powers (p=0.03) were demonstrated in the OA group in the physical task condition.

CONCLUSION

When simulating a forward fall, participants with OA demonstrated difficulty in absorbing the impact and slowing down the forward momentum of the body during a recovery step. Moreover, poor dynamic postural control was demonstrated as task complexity increased.

Knee osteoarthritis negatively affects the recovery step following large forward-directed postural perturbations

The reasons for higher fall risk of people with osteoarthritis (OA) compared to people without OA are not known. It is possible that following a loss of balance OA may negatively affect the recovery stepping response. Stepping responses have not been reported for people with knee OA. Here, we compared recovery step kinematics following laboratory-induced trip and following a large treadmill-delivered perturbation simulating a trip between a group of women with and without self-reported knee OA. We hypothesized that knee OA would significantly impair recovery step kinematics compared to those of a control group. Following the laboratory-induced trip, step length and trunk flexion velocity at recovery step completion of women with OA were significantly impaired and more so for the women who fell. Following the treadmill-delivered perturbation, the recovery step kinematics of women with OA were not significantly impaired. For both perturbations, the women who fell had significantly impaired recovery step kinematics compared to those who did not fall, regardless of OA. The results are consistent with previous work on healthy middle aged and older women and suggest that the same biomechanical risk factors for trip-related falls are shared by middle age and older women regardless of the presence of knee OA. The results support the need to determine whether training protocols which have been shown to improve recovery step kinematics and reduce prospective falls by healthy older women can have similar outcomes for people with knee OA.

Socio-economic status and the risk of developing hand, hip or knee osteoarthritis: a region-wide ecological study

OBJECTIVE

To determine the association between socio-economic status (SES) and risk of hand, hip or knee osteoarthritis (OA) at a population level.

DESIGN

Retrospective ecological study using the System for the Development of Research in Primary Care (SIDIAP) database (primary care anonymized records for >5 million people in Catalonia (Spain)). Urban residents >15 years old (2009-2012) were eligible.

OUTCOMES

Validated area-based SES deprivation index MEDEA (proportion of unemployed, temporary workers, manual workers, low educational attainment and low educational attainment among youngsters) was estimated for each area based on census data as well as incident diagnoses (ICD-10 codes) of hand, hip or knee OA (2009-2012). Zero-inflated Poisson models were fitted to study the association between MEDEA quintiles and the outcomes.

RESULTS

Compared to the least deprived, the most deprived areas were younger (43.29 (17.59) vs 46.83 (18.49), years (Mean SD), had fewer women (49.1% vs 54.8%), a higher percentage of obese (16.2% vs 8.4%), smokers (16.9% vs 11.9%) and high-risk alcohol consumption subjects (1.5% vs 1.3%). Compared to the least deprived, the most deprived areas had an excess risk of OA: age-sex-adjusted Incidence Rate Ratio (IRR) 1.26 (1.11-1.42) for hand, 1.23 (1.17-1.29) hip, and 1.51 (1.45-1.57) knee. Adjustment for obesity attenuated this association: 1.06 (0.93-1.20), 1.04 (0.99-1.09), and 1.23 (1.19-1.28) respectively.

CONCLUSIONS

Deprived areas have higher rates OA (hand, hip, knee). Their increased prevalence of obesity accounts for a 50% of the excess risk of knee OA observed. Public health interventions to reduce the prevalence of obesity in this population could reduce health inequalities.

Annual consultation incidence of osteoarthritis estimated from population-based health care data in England

OBJECTIVES

To estimate the consultation incidence of OA using population-based health care data in England and compare OA incidence figures with those derived in other countries.

METHODS

A population-based health care database (Consultations in Primary Care Archive) in England was used to derive the consultation incidence of OA (overall and by joint site) using the maximum available run-in period method. These estimates, and their distribution by age and sex, were compared with those published from population-based health care databases in Canada, the Netherlands and Spain. A novel age-stratified run-in period method was then used to investigate whether the consultation incidence has been increasing over time in younger adults.

RESULTS

The annual consultation incidence of OA (any joint) was 8.6/1000 persons ≥15 years of age (95% CI 7.9, 9.3) [6.3 (95% CI 5.5, 7.1) in men and 10.8 (95% CI 9.8, 12.0) in women]. Incidence increased sharply between 45 and 64 years of age, peaking at 75-84 years. The joint-specific incidence was 1.4 (95% CI 1.1, 1.7), 3.5 (95% CI 3.1, 3.9) and 1.3 (95% CI 1.1, 1.6) for hip OA, knee OA and hand OA, respectively. The estimates and their distribution by age and sex were broadly consistent with international estimates. Between 2003 and 2010, incidence in those aged 35-44 years increased from 0.3 to 2.0/1000 persons.

CONCLUSION

Newly diagnosed cases of OA in England occur in 9 in 1000 at-risk adults each year, similar to other international estimates. Although lower, the consultation incidence proportion in younger adults appears to have increased in the past decade.

Lower-extremity osteoarthritis and the risk of falls in a community-based longitudinal study of adults with and without osteoarthritis

OBJECTIVE

Knee and hip osteoarthritis (OA) are known risk factors for falls, but whether they together additionally contribute to falls risk is unknown. This study utilizes a biracial cohort of men and women to examine the influence of lower-extremity OA burden on the risk for future falls.

METHODS

A longitudinal analysis was performed using data from 2 time points of a large cohort. The outcome of interest was falls at followup. Covariates included age, sex, race, body mass index, a history of prior falls, symptomatic OA of the hip and/or knee, a history of neurologic or pulmonary diseases, and current use of narcotic medications. Symptomatic OA was defined as patient-reported symptoms and radiographic evidence of OA in the same joint. Logistic regression analyses were used to determine associations between covariates and falls at followup.

RESULTS

The odds of falling increased with an increasing number of lower-extremity symptomatic OA joints: those with 1 joint had 53% higher odds, those with 2 joints had 74% higher odds, and those with 3-4 OA joints had 85% higher odds. When controlling for covariates, patients who had symptomatic knee or hip OA had an increased likelihood of falling (adjusted odds ratio [aOR] 1.39, 95% confidence interval [95% CI] 1.02-1.88 and aOR 1.60, 95% CI 1.14-2.24, respectively).

CONCLUSION

This study reveals the risk for falls increases with additional symptomatic OA lower-extremity joints and confirms that symptomatic hip and knee OA are important risk factors for falls.

Increased hip fracture and mortality in chronic kidney disease individuals: the importance of competing risks

BACKGROUND

Many studies have shown a correlation between chronic kidney disease (CKD) and fracture. However, increased mortality in CKD patients is a competing risk scenario not accounted for in previous studies. Our aim was to investigate the true impact of CKD on hip fracture after accounting for a competing risk with death.

METHODS

We conducted a population-based cohort study to determine the impact of CKD on hip fractures in individuals aged ≥50years old registered in the SIDIAP(Q) database (representative of 1.9 million people in Catalonia, Spain). Cox regression was used to estimate hazard ratio (HR) for death and hip fracture according to CKD status. A competing risk (Fine and Gray) model was fitted to estimate sub-HR for hip fracture in CKD or CKD-free patients accounting for differential mortality.

RESULTS

A total of 873,073 (32,934 (3.8%) CKD) patients were observed for 3 years. During follow-up, 4,823 (14.6%) CKD and 36,328 (4.3%) CKD-free participants died (HR, 1.83 [95% CI, 1.78-1.89]), whilst 522 (1.59%) and 6,292 (0.75%) sustained hip fractures, respectively. Adjusted Cox models showed a significantly increased risk of hip fractures for the CKD group (HR, 1.16 [1.06-1.27]), but this association was attenuated in competing risk models accounting for mortality (SHR, 1.14 [1.03-1.27]).

CONCLUSIONS

Both death and hip fracture rates are increased (by 83% and 16%, respectively) in CKD patients. However, the association between CKD and hip fractures is attenuated when an excess of mortality is taken into account. A competing risk with death must be considered in future analyses of association between CKD and any health outcomes.

Osteoporotic fracture rate among women with at least 1 year of adherence to osteoporosis treatment

PURPOSE

In clinical trials, bisphosphonate therapy reduces but does not eliminate the risk of fracture. The objective of this retrospective observational study was to examine fracture rates among women who were adherent to bisphosphonate therapy for at least 1 year.

METHODS

We studied outcomes for women ≥50 years old who received their first osteoporosis therapy as an oral bisphosphonate during 2002-2008 and were enrolled in a large claims database for ≥3 consecutive years, including a baseline year before and 2 years after the index prescription (thus, the full study period was 2001-2010). Adherence during the first year of therapy was defined as a medication possession ratio (MPR) ≥80% (total number of days' supply/365 days × 100%).

RESULTS

Of the 62,446 women who met the eligibility criteria, 26,852 (43%) had an MPR ≥80% for osteoporosis therapy during year 1. In year 2, the fracture rate was 52/1000 patient-years. Fragility fractures were recorded for 1292 patients (4.8%) during the baseline year (before initiating therapy); for 1051 patients (3.9%) during year 1 (adherence year); and for 871 patients (3.2%) during year 2. Significant predictors of fracture in year 2 were older age, higher comorbidity score, comorbid inflammatory joint disease, and prior fragility fracture during the baseline year or first year of treatment. The primary limitation of these results is the scope of the claims database, which did not provide information on bone mineral density, supplemental use of calcium or vitamin D, or reasons for initiating oral bisphosphonates.

CONCLUSIONS

Despite being adherent to bisphosphonate treatment for 1 year, 3.2% of women experienced a fracture in the subsequent year. These results suggest an unmet need in patients with osteoporosis and an opportunity for newer therapies to help address this need.

Socioeconomic status and its association with the risk of developing hip fractures: a region-wide ecological study

PURPOSE

To determine the association between socioeconomic deprivation (SES) and hip fracture risk.

METHODS

Retrospective cohort study using a population-based database (primary care records) of over 5 million people. Eligibility: all living subjects registered during the period 2009-2012 and resident in an urban area.

MEASURES

a validated SES composite index (proportion of unemployed, temporary workers, manual workers, low educational attainment and low educational attainment among youngsters) estimated for each area based on census data.

OUTCOME

incident hip fracture rates as coded in medical records using ICD-10 codes.

STATISTICS

zero-inflated Poisson models fitted to study the association between SES quintiles and hip fracture risk, adjusted for age, sex, obesity, smoking and alcohol consumption.

RESULTS

Compared to the most deprived, wealthy areas had a higher hip fracture incidence (age- and sex-adjusted incidence 38.57 (37.14-40.00) compared to 34.33 (32.90-35.76) per 10,000 person-years). Similarly, most deprived areas had a crude and age- and sex-adjusted lower risk of hip fracture, RR of 0.71 (0.65-0.78) and RR of 0.90 (0.85-0.95), respectively, compared to wealthiest areas. The association was attenuated and no longer significant after adjustment for obesity: RR 0.96 (0.90-1.01). Further adjustment for smoking and high alcohol consumption did not make a difference.

CONCLUSION

Wealthiest areas have an almost 30% increased risk of hip fracture compared to the most deprived. Differences in age-sex composition and a higher prevalence of obesity in deprived areas could explain this higher risk.

Medication use before and after hip fracture: a population-based cohort and case-control study

BACKGROUND

Osteoporosis, together with age, is the main risk factor for hip fracture, the incidence of which has also been associated with an increased risk of falling or co-morbidities and related pharmacological treatments.

OBJECTIVES

The aim of this study was to investigate changes in concomitant pharmacological treatments prescribed before and after hip fracture in elderly patients compared with treatments prescribed to a matched cohort of subjects without hospitalisation for fractures.

METHODS

Data relating to the study population were extracted from a large population-based administrative database of the Italian National Health Authorities. A retrospective analysis was conducted involving female patients (6,431) aged ≥65 years and hospitalised for a hip fracture. The control group comprised age-matched subjects (38,586) not hospitalised for fracture. Changes in drug prescriptions 1 year before and 1 year after hip fracture and differences versus controls were compared.

RESULTS

Prior to the fracture, patients were taking more anti-Parkinson medications, antidepressants, medications for chronic obstructive pulmonary disease (COPD), bisphosphonates and calcium-vitamin D supplements, although the intake of the routinely monitored drug classes was significantly infrequent. Polypharmacy was less frequent in fractured women before fracture than in controls (22 vs. 25 %, respectively; P < 0.001), but it was more frequent (30 %, P < 0.001) post-fracture. The incidence of fracture was associated with a significant increase in the use of a number of drug classes: insulin, NSAIDs or analgesics, gastroprotectants, loop diuretics, β-blockers, antidepressants, antiparkinson drugs, antiepileptics and drugs for COPD.

CONCLUSION

Our study confirms a strong association between the use of some drugs (antidepressants, antiparkinson drugs, drugs for COPD) and the risk of hip fracture, but drug use is globally less common than in controls. Hip fracture is associated with a significant increase in drug use, suggesting a global deterioration of health conditions.

Osteoarthritis and bone mineral density: are strong bones bad for joints?

Osteoarthritis (OA) is a common and disabling joint disorder affecting millions of people worldwide. In OA, pathological changes are seen in all of the joint tissues including bone. Although both cross-sectional and longitudinal epidemiological studies have consistently demonstrated an association between higher bone mineral density (BMD) and OA, suggesting that increased BMD is a risk factor for OA, the mechanisms underlying this observation remain unclear. Recently, novel approaches to examining the BMD-OA relationship have included studying the disease in individuals with extreme high bone mass, and analyses searching for genetic variants associated with both BMD variation and OA, suggesting possible pleiotropic effects on bone mass and OA risk. These studies have yielded valuable insights into potentially relevant pathways that might one day be exploited therapeutically. Although animal models have suggested that drugs reducing bone turnover (antiresorptives) may retard OA progression, it remains to be seen whether this approach will prove to be useful in human OA. Identifying individuals with a phenotype of OA predominantly driven by increased bone formation could help improve the overall response to these treatments. This review aims to summarise current knowledge regarding the complex relationship between BMD and OA.