Unravelling the knee-hip-spine trilemma from the CHECK study

Association between severe lumbar disc degeneration and end-stage hip or knee osteoarthritis requiring joint replacement surgery: a population-based cohort study with a 26-year follow-up

INTRODUCTION

An association between intervertebral disc degeneration (IDD) and osteoarthritis (OA) of the hip and knee has been found previously. However, studies using MRI-evaluated IDD grades with large sample sizes are lacking. Total hip and knee arthroplasty (THA and TKA) can be considered an indicator of clinically evident end-stage OA.

MATERIALS AND METHODS

The study population consisted of 1,153 postmenopausal Finnish women with clinical back problems, of whom 166 had THA and 295 had TKA during the 26-year follow-up. The study was based on the prospective OSTPRE cohort established in 1989 and Finnish Arthroplasty Register data. The IDD severity was graded from T2-weighted lumbar MRI images using the five-grade Pfirrmann classification. Five intervertebral levels (L1-L2 to L5-S1) were studied (5,765 discs). Cox regression with a time-dependent covariate was used to calculate hazard ratios (HRs) for THA and TKA to account for exposure time for severe degeneration.

RESULTS

A higher hazard for THA was observed in women with severe IDD at the L1-L2 (HR 2.66, 95% CI 1.48-4.80), L2-L3 (HR 1.97, CI 1.15-3.38), L5-S1 (HR 1.69, 95% CI 1.16-2.46) and the L1-S1 (HR 2.19, 95% CI 1.53-3.15) intervertebral levels. Adjustment with potential confounders did not alter the results. Women with severe IDD had an elevated hazard for TKA at the L1-S1 mean degeneration (HR 1.50, CI 1.11-2.02) analysis. However, in the adjusted model, the statistical significance of this association was lost (HR 1.34, 95% CI 0.98-1.84). Higher BMI increased the hazard for both THA and TKA; however, the effect was more substantial for TKA.

CONCLUSIONS

The present study supports the association between lumbar IDD and hip OA. A weak association between lumbar IDD and knee OA was observed. Further research is needed to investigate the causality of the relationship between IDD and OA.

Relationship between paravertebral muscle function, pelvic incidence, and health-related quality of life in patients with degenerative spinal deformity

BACKGROUND

Patients with degenerative spinal deformity often experience symptoms that seriously affect their quality of life, such as low back pain and dysfunction. This study aimed to investigate the relationship between paravertebral muscle function and pelvic incidence (PI) and their effect on health-related quality of life (HRQL) in patients with degenerative spinal deformity.

METHODS

A total of 112 patients with degenerative spinal deformity in Southwest Hospital (Chongqing, China) were enrolled. They were divided into groups according to PI angle: high (PI > 60°, n = 37), normal (PI 50°-60°, n = 31), and low (PI < 50°, n = 44). Paravertebral muscle strength and endurance were assessed using the prone external fixation test frame. The sagittal vertical axis (SVA) was measured on X-rays of the spine in an anterolateral position, and all subjects were assessed with the Oswestry Disability Index (ODI), Roland-Morris questionnaire (RMQ), and 36-Item Short Form Health Survey (SF-36). Pearson or Spearman coefficients were used to assess the relationship of paravertebral muscle function with SVA, PI, and health-related quality of life.

RESULTS

Maximal voluntary exercise (MVE) in the high-PI group was significantly lower than the MVE of both the normal- and low-PI groups (p < 0.05). There was no significant difference in MVE between the normal- and low-PI groups (p > 0.05). There was no significant difference in endurance time, SVA, ODI, RMQ, and SF-36 among the three groups. Paravertebral muscle MVE was negatively correlated with PI, SVA, ODI, and RMQ (r = - 0.193, - 0.210, - 0.283, - 0.277, p < 0.05). Endurance time of paravertebral muscle was also negatively correlated with SVA, ODI, and RMQ (r =  - 0.200, - 0.420, - 0.348, p < 0.05) and positively correlated with SF-36 (r = 0.245, p < 0.05). In addition, paravertebral muscle MVE was positively correlated with the physical functioning score of the SF-36 (r = 0.251, p < 0.05), and the endurance time of paravertebral muscle was positively correlated with the physical functioning, physical role, bodily pain, and social function scores of the SF-36 (r = 0.342, 0.230, 0.209, 0.256, p < 0.05).

CONCLUSIONS

High PI may serve as a risk factor for decreased paraspinal muscle strength in patients with degenerative spinal deformities. Early and targeted exercises focusing on paraspinal muscle strength and endurance could potentially be of positive significance in slowing down the progression of sagittal imbalance, alleviating functional disorders, and increasing health-related quality of life in patients with degenerative spinal deformity.

Unravelling the hip-spine dilemma from the CHECK-cohort: is sagittal pelvic morphology linked to radiographic signs of femoroacetabular impingement?

INTRODUCTION

To date the aetiology of femoroacetabular impingement (FAI) is still not completely understood. There are mechanical theories that suggest symptomatic FAI is linked to sagittal pelvic morphology and spinopelvic-femoral dynamics. The aim of this study is to evaluate the relation of sagittal pelvic morphology and orientation to radiographic signs of FAI. Additionally, we test whether the relation between FAI and spinopelvic parameters differs in osteoarthritic hips.

METHODS

From a prospective, observational cohort study, 1002 patients between 45 and 65 years old with a first episode of knee or hip pain were followed for 8 years. All patients who had lateral lumbar radiographs and clinical and radiographic follow-up of the hips were included in the present study. Range of internal rotation of the hip as well as radiographic signs of FAI (alpha and Wiberg angle) and presence of hip osteoarthritis (Kellgren and Lawrence) were systematically measured at baseline. Pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS)) were measured at 8-year follow-up. Associations between PI, PT, SS and FAI parameters were tested using generalised estimating equations.

RESULTS

421 subjects, 842 hips, were included. No significant relations between PI, PT or SS and alpha or Wiberg angle were found. Comparison of hips with and without radiological sign(s) of FAI showed no differences in PI, PT or SS. There was no relation between range of internal rotation of the hip and spinopelvic parameters.

CONCLUSION

Sagittal pelvic morphology and orientation are not related to the presence of radiological signs of FAI in this study population.

Revealing the Effect of Spinopelvic Alignment on Hip Disorders

Background

Hip osteoarthritis (HOA) is a growing burden and one of the leading causes of hip pain. The relationship between the HOA and the alignment of the spinopelvic region has been intensively studied, however the issue remains controversial. Spinopelvic imbalance, HOA, and dysplasia were investigated in relation to sagittal spinopelvic parameters in this study.

Methods

We collected computerized tomography (CT) topograms of the pelvis or abdomen from 380 patients. In antero-posterior (AP) topograms, Tonnis grading, center-edge angle (CEA) and Sharp's acetabular angle (AA) measurements were performed on each patient. Lateral topograms were used to evaluate the following spinopelvic parameters for each patient: pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), sacral table angle (STA), lumbar lordosis (LL), proximal lumbar lordosis (PLL), distal lumbar lordosis (DLL), and PI-LL difference. Initially, the cohort was divided into two subgroups based on whether or not they had HOA. Then, they were divided into two subgroups based on whether or not they had dysplasia. Ultimately, it was divided in half based on the PI-LL imbalance. Statistical analyses were conducted to determine the likely correlations between the spinopelvic parameters of these subgroups. In addition, the correlations between spinopelvic parameters were investigated.

Results

There were 380 patients evaluated. We found no association between HOA or dysplasia and spinopelvic parameters. In addition, there was no association between PI-LL imbalance and HOA or dysplasia.

Conclusion

There was no difference in constant PI and STA angle, besides other variable parameters, between groups having HOA and dysplasia or not. PI-LL imbalance has no effect on HOA and dysplasia.

Biomechanical and clinical relationships between lower back pain and knee osteoarthritis: a systematic review

BACKGROUND

Osteoarthritis (OA) and lower back pain (LBP) are most common health problems which lead to pain and disability. This study aimed to systematically review the evidence to find any relationship between knee osteoarthritis (KOA) and LBP or any potential causation.

METHODS

The databases of Scopus, MEDLINE, and Embase were searched from inception to 01 October 2022. Any study published in English assessing live humans over 18 years with KOA and LBP was eligible to be included. Studies were independently screened by two researchers. Data of the included studies were extracted based on the participants, outcomes related to knee and lumbar spine, reported association or causation between LBP and KOA, and study design. Data were narratively analyzed and presented as graphs and table. Methodology quality was assessed.

RESULTS

Of 9953 titles and abstracts, duplicates were removed, and 7552 were screened. Altogether, 88 full texts were screened, and 13 were eligible for the final inclusion. There were some biomechanical and clinical causations were observed for the concurrent presence of LBP and KOA. Biomechanically, high pelvic incidence is a risk factor for development of spondylolisthesis and KOA. Clinically, knee pain intensity was higher in KOA when presents with LBP. Less than 20% of studies have justified their sample size during the quality assessment.

DISCUSSION

Development and progression of KOA in patients with degenerative spondylolisthesis may be induced by significantly greater mismatches of lumbo-pelvic sagittal alignment. Elderly patients with degenerative lumbar spondylolisthesis and severe KOA reported a different pelvic morphology, increased sagittal malalignment with a lack of lumbar lordosis due to double-level listhesis, and greater knee flexion contracture than in patients with no to mild and moderate KOA. People with concurrent LBP and KOA have reported poor function with more disability. Both LBP and lumbar kyphosis indicate functional disability and knee symptoms in patients with KOA.

CONCLUSIONS

Different biomechanical and clinical causations were revealed for the concurrent existence of KOA and LBP. Therefore, careful assessment of both back and knee joints should be considered when treating KOA and vice versa.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022238571.

Spinopelvic mismatch is associated with patient-reported outcome measures after total knee arthroplasty at a mean follow-up of 15 years

BACKGROUND

Total knee arthroplasty (TKA) is widely performed; yet, up to 25% of patients are dissatisfied with outcomes. Our aim was to evaluate the association between a spinopelvic mismatch and patient-reported outcomes after TKA.

METHODS

This was a retrospective study of 101 TKAs performed for osteoarthritis, at a mean 14.6 (range, 10.0-18.0) years post-surgery. Postoperative knee joint perception was evaluated as 'artificial', with or without restrictions, or 'natural'. Age, sex and the spinopelvic mismatch were compared between the 'artificial' (n = 54) and 'natural' (n = 47) perception groups. Multiple logistic regression analysis was used to identify predictive factors of an artificial perception, with a receiver operating characteristic curve to identify cut-off values for significant factors.

RESULTS

A spinopelvic mismatch, defined as a pelvic incidence minus lumbar lordosis (PI-LL) ≥ 10°, was associated with an artificial perception (odds ratio, 1.57; 95% confidence interval, 1.29-3.22; P = 0.023). An artificial joint perception was related to lower Knee Injury and Osteoarthritis Outcome Score-Joint Replacement (KOOS-JR, P = 0.021) and EuroQol 5-Dimension (EQ-5D, P = 0.025) scores. The cut-off PI-LL of 11° differentiated the groups with a sensitivity of 87.0% and specificity of 91.9%. Postoperative KOOS-JR (P < 0.001), EQ-5D (P = 0.014), satisfaction (P = 0.015), knee extension angle (P = 0.024), and perception (P = 0.032) differed between the groups when the PI-LL threshold was set at 10°.

CONCLUSION

A spinopelvic mismatch (PI-LL ≥ 10°) is associated with a risk of artificial perception of function after TKA. Measurement of the PI-LL could assist patients and surgeons to predict TKA outcomes.

Pelvic incidence is not associated with the development of hip osteoarthritis

AIMS

Pelvic incidence (PI) is considered an important anatomical parameter for determining the sagittal balance of the spine. The contribution of an abnormal PI to hip osteoarthritis (OA) remains controversial. In this study, we aimed to investigate the relationship between PI and hip OA, and the difference in PI between hip OA without anatomical abnormalities (primary OA) and hip OA with developmental dysplasia of the hip (DDH-OA).

METHODS

In this study, 100 patients each of primary OA, DDH-OA, and control subjects with no history of hip disease were included. CT images were used to measure PI, sagittal femoral head coverage, α angle, and acetabular anteversion. PI was also subdivided into three categories: high PI (larger than 64.0°), medium PI (42.0° to 64.0°), and low PI (less than 42.0°). The anterior centre edge angles, posterior centre edge angles, and total sagittal femoral head coverage were measured. The correlations between PI and sagittal femoral head coverage, α angle, and acetabular anteversion were examined.

RESULTS

No significant difference in PI was observed between the three groups. There was no significant difference between the groups in terms of the category distribution of PI. The DDH-OA group had lower mean sagittal femoral head coverage than the other groups. There were no significant correlations between PI and other anatomical factors, including sagittal femoral head coverage, α angle, and acetabular anteversion.

CONCLUSION

No associations were found between mean PI values or PI categories and hip OA. Furthermore, there was no difference in PI between patients with primary OA and DDH-OA. From our evaluation, we found no evidence of PI being an independent factor associated with the development of hip OA. Cite this article: Bone Joint J 2021;103-B(11):1656-1661.