Use of Recommended Non-surgical Knee Osteoarthritis Management in Patients prior to Total Knee Arthroplasty: A Cross-sectional Study

Participants' perceived benefits from the GLA:D™ program for individuals living with hip and knee osteoarthritis: a qualitative study

BACKGROUND

The Good Life with osteoArthritis: Denmark (GLA:D™), an evidence-based education and exercise program designed for conservative management of knee and hip osteoarthritis (OA), has been shown to benefit participants by reducing pain, improving function, and quality of life. Standardized reporting in the GLA:D databases enabled the measurement of self-reported and performance-based outcomes. There is a paucity of qualitative research on the participants' perceptions of this program, and it is important to understand whether participants' perceptions of the benefits of the program align with reported quantitative findings.

METHODS

We conducted semi-structured telephone interviews with individuals who participated in the GLA:D program from January 2017 to December 2018 in Alberta, Canada. Data were analyzed using an interpretive description approach and thematic analysis to identify emergent themes and sub-themes associated with participants perceived benefits of the GLA:D program. We analyzed the data using NVivo Pro software. Member checking and bracketing were used to ensure the rigour of the analysis.

RESULTS

30 participants were interviewed (70% female, 57% rural, 73% knee OA). Most participants felt the program positively benefited them. Two themes emerged from the analysis: wellness and self-efficacy. Participants felt the program benefited their wellness, particularly with regard to pain relief, and improvements in mobility, strength, and overall well-being. Participants felt the program benefited them by promoting a sense of self-efficacy through improving the confidence to perform exercise and routine activities, as well as awareness, and motivation to manage their OA symptoms. Twenty percent of participants felt no benefits from the program due to experiencing increased pain and feeling their OA was too severe to participate.

DISCUSSION

The GLA:D program was viewed as beneficial to most participants, this study also identified factors (e.g., severe OA, extreme pain) as to why some participants did not experience meaningful improvements. Early intervention with the GLA:D program prior to individuals experiencing severe OA could help increase the number of participants who experience benefits from their participation.

CONCLUSION

As the GLA:D program expands across jurisdictions, providers of the program may consider recruitment earlier in disease progression and targeting those with mild and moderate OA.

Depression and Time to Knee Arthroplasty Among Adults Who Have Knee Osteoarthritis

BACKGROUND

Depression is common in osteoarthritis (OA) and is associated with poor outcomes following total knee arthroplasty (TKA). Depression can increase pain sensitivity and may be related to an increased likelihood of TKA.

METHODS

Nationally distributed electronic health record data from 2010 to 2018 were used to identify eligible patients (n = 9,466) who had knee OA and were 45 to 80 years of age. Cox proportional hazard models were computed to estimate the association between depression and incident TKA for all patients and by age group (45 to 54, 55 to 64, and 65 to 80 years of age). Confounding was controlled using entropy balancing. Sensitivity analyses determined if the association between depression and TKA differed when depression occurred in the 12 months occurring 90, 60, 30, and 0 days lag time before TKA.

RESULTS

The mean age of the sample was 63 (range, 45 to 80), 64.0% were women, 83.3% were White race, and approximately 50% resided in the Midwest. There was no association between depression and incident TKA (hazard ratio = 0.97; confidence interval = 0.81 to 1.16]). Results did not differ in age-stratified analyses. Sensitivity analyses revealed a higher percentage of TKA among depressed versus nondepressed patients (24.2 versus 21.6%; P = .028) when the patient's depression diagnosis was established in the 12 months with no lag time before TKA.

CONCLUSIONS

Patients who have knee OA and comorbid depression, compared to those who have only knee OA, do not have an increased likelihood of TKA. The multifactorial, complex decision to obtain TKA does not appear to be influenced by depression, but depression is a common comorbidity.

Total Hip Arthroplasty Versus Education and Exercise: A Propensity-Matched Analysis of 266 Patients Who Have Hip Osteoarthritis

BACKGROUND

Total hip arthroplasty (THA) for osteoarthritis (OA) is a major health system cost. Education and exercise (Edu + Ex) programs may reduce the number of THAs needed, but supporting data are limited. This study aimed to estimate the treatment effect of THA versus Edu + Ex on pain, function, and quality of life outcomes 3 and 12 months after treatment initiation for hip OA.

METHODS

Patients who had hip OA who underwent THA or an Edu + Ex program were included in this propensity-matched study. In 778 patients (Edu + Ex, n = 303; THA, n = 475), propensity scores were based on pretreatment characteristics, and patients were matched on a 1:1 ratio. Between-group treatment effects (pain, function, and quality of life) were estimated as the mean difference (MD) in change from pretreatment to 3-month and 12-month follow-up using linear mixed models.

RESULTS

The matched sample consisted of 266 patients (Edu + Ex, n = 133; THA, n = 133) who were balanced on all pretreatment characteristics except opioid use. At 12-month follow-up, THA resulted in significantly greater improvements in pain (MD 35.4; 95% confidence interval [CI] 31.4 to 39.4), function (MD 30.5; 95% CI 26.3 to 34.7), and quality of life (MD 33.6; 95% CI 28.8 to 38.4). Between 17% and 30% of patients receiving Edu + Ex experienced a surgical threshold for clinically meaningful improvement in outcomes, compared to 84% and 90% of THA patients.

CONCLUSIONS

A THA provides greater improvements in pain, function, and quality of life. A notable proportion of Edu + Ex patients had clinically meaningful improvements, suggesting Edu + Ex may result in THA deferral in some patients, but confirmatory trials are needed.

Predictive Tool Use and Willingness for Surgery in Patients With Knee Osteoarthritis: A Randomized Clinical Trial

Importance

Despite the increasing number of tools available to predict the outcomes of total knee arthroplasty (TKA), the effect of these predictive tools on patient decision-making remains uncertain.

Objective

To assess the effect of an online predictive tool on patient-reported willingness to undergo TKA.

Design, Setting, and Participants

This parallel, double-masked, 2-arm randomized clinical trial compared predictive tool use with treatment as usual (TAU). The study was conducted between June 30, 2022, and July 31, 2023. Participants were followed up for 6 months after enrollment. Participants were recruited from a major Australian private health insurance company and from the surgical waiting list for publicly funded TKA at a tertiary hospital. Eligible participants had unilateral knee osteoarthritis, were contemplating TKA, and had previously tried nonsurgical interventions, such as lifestyle modifications, physiotherapy, and pain medications.

Intervention

The intervention group was provided access to an online predictive tool at the beginning of the study. This tool offered information regarding the likelihood of improvement in quality of life if patients chose to undergo TKA. The predictions were based on the patient's age, sex, and baseline symptoms. Conversely, the control group received TAU without access to the predictive tool.

Main Outcomes and Measures

The primary outcome measure was the reduction in participants' willingness to undergo surgery at 6 months after tool use as measured by binomial logistic regression. Secondary outcome measures included participant treatment preference and the quality of their decision-making process as measured by the Knee Decision Quality Instrument.

Results

Of 211 randomized participants (mean [SD] age, 65.8 [8.3] years; 118 female [55.9%]), 105 were allocated to the predictive tool group and 106 to the TAU group. After adjusting for baseline differences in willingness for surgery, the predictive tool did not significantly reduce the primary outcome of willingness for surgery at 6 months (adjusted odds ratio, 0.85; 95% CI, 0.42-1.71; P = .64).

Conclusions and Relevance

Despite the absence of treatment effect on willingness for TKA, predictive tools might still enhance health outcomes of patients with knee osteoarthritis. Additional research is needed to optimize the design and implementation of predictive tools, address limitations, and fully understand their effect on the decision-making process in TKA.

Trial Registration

ANZCTR.org.au Identifier: ACTRN12622000072718.

'I do hope more people can benefit from it.': The qualitative experience of individuals living with osteoarthritis who participated in the GLA:D™ program in Alberta, Canada

INTRODUCTION

The Good Life with osteoArthritis: Denmark (GLA:DTM) is an evidence-based program designed for individuals with symptomatic hip and knee osteoarthritis (OA). This program has reported improvement in pain, quality of life and self-efficacy, as well as delays in joint replacement surgery for adults with moderate to severe hip or knee OA. Evaluations of GLA:DTM implementation in several countries have focused on effectiveness, training, and feasibility of the program primarily from the provider perspective. Our objective was to examine how the GLA:DTM program was perceived and experienced by individuals with hip and knee OA to inform on-going program refinement and implementation.

METHODS

Thirty semi-structured telephone interviews were conducted with participants who completed the GLA:DTM program in Alberta. An interpretive description approach was used to frame the study and thematic analysis was used to code the data and identify emergent themes and sub-themes associated with participants' experience and perception of the GLA:DTM program.

RESULTS

Most participants had a positive experience of the GLA:DTM program and particularly enjoyed the group format, although some participants felt the group format prevented one-on-one support from providers. Three emergent themes related to acceptability were identified: accessible, adaptable, and supportive. Participants found the program to be accessible in terms of location, cost, and scheduling. They also felt the program was adaptable and allowed for individual attention and translatability into other settings. Finally, most participants found the group format to be motivating and fostered connections between participants.

CONCLUSION

The GLA:DTM program was perceived as acceptable by most participants, yet the group format may not be useful for all individuals living with OA. Recommended improvements included adapting screening to identify those suited for the group format, providing program access earlier in the disease progression trajectory, modifying educational content based on participants' knowledge of OA and finally, providing refresher sessions after program completion.

Implementing lifestyle-related treatment modalities in osteoarthritis care: Identification of implementation strategies using the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change matching tool

AIMS

Despite recommendations in international clinical guidelines, lifestyle-related treatment modalities (LRTMs) are currently underutilised in the conservative treatment of patients with hip and/or knee osteoarthritis. This study aimed to identify implementation strategies in order to address barriers to implementing LRTMs from the perspective of healthcare professionals (HCPs).

METHODS

The Consolidated Framework for Implementation Research (CFIR)-Expert Recommendations for Implementing Change (ERIC) Implementation Strategy Matching Tool was applied. First, previously identified influencing factors among primary and secondary HCPs were mapped onto the corresponding CFIR constructs/subconstructs by two researchers. Second, the CFIR-based barriers relevant for all HCPs were entered into the tool. Third, the CFIR-based barriers specific to one or more subgroups of HCPs served as additional input for the tool. Finally, a selection of ERIC implementation strategies was made based on the tool's output.

RESULTS

Fourteen implementation strategies were selected. The strategy most endorsed by the tool was 'build a coalition'. Eight of the selected strategies belonged to the ERIC cluster 'develop stakeholder interrelationships'. Other strategies were part of the clusters 'use evaluative and iterative strategies' (n = 3), 'utilise financial strategies' (n = 2), and 'engage consumers' (n = 1).

CONCLUSIONS

The findings emphasise the importance of an interdisciplinary approach when addressing the implementation of LRTMs in osteoarthritis care. The final selection of implementation strategies forms the basis for a tailored implementation plan. Future work should focus on further operationalising the implementation strategies and evaluating the effectiveness of the resulting implementation plan.

Usage of guideline-adherent core treatments for knee osteoarthritis before and after consulting an orthopaedic surgeon: A prospective cohort study

Objective

To describe 1) the proportion of patients with knee osteoarthritis (OA) undergoing guideline-adherent core treatments until six months after primary referral to an orthopaedic surgeon, 2) which specific treatment pathways these patients undertake and 3) the characteristics of patients choosing different treatment pathways.

Design

This prospective cohort study consecutively invited patients referred to an orthopaedic surgeon due to knee OA at two Danish hospitals from October 2018 to December 2020. Before and six months after consulting the surgeon, patients answered a questionnaire reporting which treatments they had received for knee OA. The proportion receiving the combination of guideline-adherent treatments (i.e., exercise, education, and dietary weight management if needed) was determined. We evaluated the specific treatment usage before and until six months after the consultation and investigated characteristics of patients undertaking different pathways.

Results

Out of 5251 eligible patients, 2574 (49%) had complete data and were included in analyses. 23% received guideline-adherent treatments, 10% had no treatment. Patients underwent 1143 unique treatment pathways, 62% including treatments not recommended/recommended against. Those who underwent guideline-adherent pathways had similar characteristics to those who did not but tended to be females, retired, had longer-lasting knee problems, have comorbidities, and higher education levels.

Conclusions

Only one in four patients with knee OA received treatment adhering to clinical guidelines before and six months after consulting the surgeon. Patients used many different treatment pathways. There is a need for a structured effort to increase the use of guideline-adherent core treatments.

Trial Identifiers

Registration: NCT03746184, Protocol: PMID: 34233992.

Efficacy and safety of Gutong Patch compared with NSAIDs for knee osteoarthritis: A real-world multicenter, prospective cohort study in China

The Gutong Patch (GTP) is common in clinical practice for bone diseases. This study compared the efficacy and safety of GTP and nonsteroidal anti-inflammatory drugs (NSAIDs) for KOA patients from 35 medical centers assigned to GTP, selective COX-2 inhibitor (SCI), GTP + SCI, non-selective COX-2 inhibitor (NSCI), and GTP + NSCI groups. The visual analog scale (VAS) pain score, EuroQol-VAS, EuroQol 5D-3 L, time to articular pain relief / disappearance, and joint motion recovery were the efficacy assessments. Safety assessments included contact dermatitis, gastrointestinal disorders, etc. The p-value < 0.05 was considered statistically significant. After statistical analysis, the SCI and GTP + SCI groups showed better improvement of VAS than the GTP group; the time to articular pain relief in the NSCI group was shorter than that in GTP and SCI group; the time to joint motion recovery in the GTP + NSCI group was longer than that in the SCI group. Additionally, the improvement of the quality of life in all groups was significant after treatments. While the incidence of gastrointestinal adverse events in the NSAIDs group was higher than that in the GTP and GTP + NSAIDs groups. GTP and NSAIDs are effective for KOA patients, and GTP is more suitable for KOA patients with cardiovascular and gastrointestinal comorbidities. This study was approved by the Ethics Committee at Peking Union Medical College Hospital (HS-1766) and registered in the Chinese Clinical Trial Registry (ChiCTR2100046391).

Recommendations for the management of hip and knee osteoarthritis: A systematic review of clinical practice guidelines

OBJECTIVES

Guideline adherence for hip and knee osteoarthritis management is often poor, possibly related to the quality and/or inconsistent recommendations. This systematic review of hip and knee osteoarthritis guidelines aimed to appraise the quality and consistency in recommendations across higher-quality guidelines.

METHODS

Eight databases, guideline repositories, and professional associations websites were searched on 27/10/2022. Guideline quality was appraised using the Appraisal of Guidelines for Research and Evaluation II (AGREE II tool) (six domains). Higher quality was defined as scoring ≥60% for domains 3 (rigour of development), 6 (editorial independence), plus one other. Consistency in recommendations across higher-quality guidelines was reported descriptively. This review was registered prospectively (CRD42021216154).

RESULTS

Seven higher-quality and 18 lesser-quality guidelines were included. AGREE II domain scores for higher-quality guidelines were > 60% except for applicability (average 46%). Higher-quality guidelines consistently recommended in favour of education, exercise, and weight management and non-steroidal anti-inflammatory drugs (hip and knee), and intra-articular corticosteroid injections (knee). Higher quality guidelines consistently recommended against hyaluronic acid (hip) and stem cell (hip and knee) injections. Other pharmacological recommendations in higher-quality guidelines (e.g., paracetamol, intra-articular corticosteroid (hip), hyaluronic acid (knee)) and adjunctive treatments (e.g., acupuncture) were less consistent. Arthroscopy was consistently recommended against in higher-quality guidelines. No higher-quality guidelines considered arthroplasty.

CONCLUSION

Higher-quality guidelines for hip and knee osteoarthritis consistently recommend clinicians implement exercise, education, and weight management, alongside consideration of Non-Steroidal Anti-Inflammatory Drugs and intra-articular corticosteroid injections (knee). Lack of consensus on some pharmacological options and adjunctive treatments creates challenges for guideline adherence. Future guidelines must prioritise providing implementation guidance, considering consistently low applicability scores.

Barriers and facilitators for implementing lifestyle-related treatment modalities in osteoarthritis: A cross-sectional study among primary and secondary healthcare professionals

PURPOSE

To identify barriers and facilitators as perceived by primary and secondary healthcare professionals (HCPs) when implementing lifestyle-related treatment modalities (LRTMs) in patients with hip/knee osteoarthritis (OA).

METHODS

A cross-sectional study. A Dutch online survey was distributed among eight different disciplines of primary and secondary HCPs. Potential barriers and facilitators were identified based on participants' responses to 32 research-derived statements on implementing LRTMs, and presented as factors with "major agreement" (≥75%), "minor agreement" (60-75%) or "no agreement" (<60%).

RESULTS

213 participants completed the survey. Seven "barriers" and 20 "facilitators" were identified. There were three "major agreement barriers": organization of Dutch healthcare system, audits within organization, and lifestyle climate in Dutch society. The top three "major agreement facilitators" were: health effects on patients, safety of increasing physical activity, and personal attitude. The total number of "barriers" differed per HCP discipline, with the highest number (12) among orthopedic surgeons (or in-training) and the lowest number (4) among dieticians, physiotherapists, and lifestyle counselors.

CONCLUSIONS

The findings suggest that implementing LRTMs within OA care could be improved by focusing on societal rather than individual HCP factors. National preventive policies on health promotion could counteract the expected increase in healthcare demand and costs due to OA and other chronic diseases. Future research is needed to match relevant implementation strategies to all barriers identified.

Exploring appropriateness criteria for informing the total knee arthroplasty decision-making process: An interpretive descriptive study

RATIONAL

The Hawker appropriateness criteria for total knee arthroplasty (TKA) are: osteoarthritis symptoms impacting quality of life, evidence of osteoarthritis, trial of conservative treatments, patient's realistic expectations, patient/surgeon agree benefits outweigh risks, and readiness for surgery. Little is known about the barriers and facilitators of using the Hawker et al. appropriateness criteria for TKA in clinical practice.

AIMS AND OBJECTIVES

Explore the barriers and facilitators to using appropriateness criteria for TKA in making decisions for adults with knee osteoarthritis.

METHODS

Interpretive descriptive qualitative study at an academic hospital. Purposive sampling aimed to recruit: (1) healthcare team members at all levels influencing care delivery, and (2) adults with TKA assessed at the hospital clinic. Semi-structured interviews asked about the barriers/facilitators to using the Hawker appropriateness criteria. Data analysis consisted of inductive thematic analysis with themes mapped to the Consolidated Framework for Implementation Research domains.

RESULTS

Nine healthcare professionals and 14 adults with TKA participated and identified common barriers to using the Hawker appropriateness criteria: (a) intervention characteristics domain: difficulty to assess criteria, patients expecting healthcare professionals to decide, limited accessibility to conservative treatments; (b) individuals characteristics domain: no need to change current TKA process, clinical judgement limited to OA severity/age, implicit assessment of subjective criteria; (c) inner setting domain: TKA information received after decision made; and (d) outer setting domain: no timely access to TKA. A facilitator of use was evidence/buy-in fosters programme changes.

CONCLUSION

Barriers to using the criteria relevant to clinical practice and the healthcare system were identified while only one facilitator was revealed. Interventions tailored to these barriers are needed to support the use of the Hawker appropriateness criteria in TKA decision-making.

Use of non-surgical treatments on the journey to knee replacement in patients with knee osteoarthritis: a 10-year population-based case-control study

AIM

To investigate temporal trends in primary care visits, physiotherapy visits, dispensed non-steroidal anti-inflammatory drugs (NSAIDs) and opioids in knee osteoarthritis (OA) patients who have and have not undergone knee replacement.

METHODS

We analysed 5665 OA patients from the Skåne Healthcare Register, Sweden, who underwent knee replacement between 2015 and 2019. Controls were OA patients without knee replacement, matched 1:1 by sex, age, time and healthcare level of initial OA diagnosis, and assigned a pseudo-index date corresponding to their case's knee replacement date. Annual prevalence and prevalence ratio of primary care and physiotherapy visits, dispensed NSAIDs and opioids (all for any cause) in the 10 years before knee replacement were estimated using Poisson regression.

RESULTS

The annual prevalence of all-cause primary care visits, physiotherapy visits and opioid use was similar between cases and controls until 3 years before the index date when it started to increase among the cases. The year before the index date, the prevalence ratio (cases vs controls) for physiotherapy use was 1.8 (95% CI 1.7, 1.8), while for opioid use 1.6 (1.5, 1.7). NSAID use was consistently higher among cases, even 10 years before the index date when the prevalence ratio versus controls was 1.3 (1.2, 1.3), increasing to 1.8 (1.7, 1.9) in the year preceding the index date.

CONCLUSIONS

Management of OA patients who have and have not undergone knee replacement appears largely similar except for higher use of NSAIDs in knee replacement cases. Symptomatic treatments start to increase a few years before the surgery in knee replacement cases.

Core Recommendations for Osteoarthritis Care: A Systematic Review of Clinical Practice Guidelines

OBJECTIVE

To evaluate the quality of clinical practice guidelines (CPGs) for interventions in management of osteoarthritis (OA) and to provide a synthesis of high-quality CPG recommendations.

METHODS

Five databases (OvidSP Medline, Cochrane, Cumulative Index to Nursing and Allied Health Literature [CINAHL], Embase, and the Physiotherapy Evidence Database [PEDro]) and 4 online guideline repositories were searched. CPGs for the management of OA were included if they were 1) written in English and published from January 2015 to February 2022, focused on adults age ≥18 years, and met the criteria of a CPG as defined by the Institute of Medicine; and 2) were rated as high quality on the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. CPGs for OA were excluded if they were available via institutional access only, only addressed recommendations for the system/organization of care and did not include interventional management recommendations, and/or included other arthritic conditions.

RESULTS

Of 20 eligible CPGs, 11 were appraised as high quality and included in the synthesis. Of interest were the hip, knee, hand, and glenohumeral joints and/or polyarticular OA. Consistent recommendations were that care should be patient centered and include exercise, education, and weight loss (where appropriate). Nonsteroidal antiinflammatory drugs and surgical interventions were recommended for disabling OA that had not improved with nonsurgical care. Hand orthoses should be recommended for patients with hand OA.

CONCLUSION

This synthesis of high-quality CPGs for OA management offers health care providers with clear, simple guidance of recommended OA care to improve patient outcomes.

The GLA:D® Canada program for knee and hip osteoarthritis: A comprehensive profile of program participants from 2017 to 2022

BACKGROUND

The Good Life with osteoArthritis in Denmark (GLA:D®) program was implemented in Canada in 2017 with the aim of making treatment guideline-recommended care available to the 4 million Canadians with knee and hip osteoarthritis (OA). This report describes the GLA:D® Canada program, registry and data collection procedures, and summarizes the sociodemographic and clinical profile of participants with knee and hip OA to inform the scientific research community of the availability of these data for future investigations and collaborations.

METHODS

The GLA:D® program consists of three standardized components: a training course for health care providers, a group-based patient education and exercise therapy program, and a participant data registry. Patients seeking care for knee or hip OA symptoms and enrolling in GLA:D® are given the option to provide data to the GLA:D® Canada registry. Participants agreeing to provide data complete a pre-program survey and are followed up after 3-, and 12-months. Data collected on the pre-program and follow-up surveys include sociodemographic factors, clinical characteristics, health status measures, and objective physical function tests. These variables were selected to capture information across relevant health constructs and for future research investigations.

RESULTS

At 2022 year-end, a total of 15,193 (11,228 knee; 3,965 hip) participants were included in the GLA:D® Canada registry with 7,527 (knee; 67.0%) and 2,798 (hip; 70.6%) providing pre-program data. Participants were 66 years of age on average, predominately female, and overweight or obese. Typically, participants had knee or hip problems for multiple years prior to initiating GLA:D®, multiple symptomatic knee and hip joints, and at least one medical comorbidity. Before starting the program, the average pain intensity was 5 out of 10, with approximately 2 out of 3 participants using pain medication and 1 in 3 participants reporting a desire to have joint surgery. Likewise, 9 out 10 participants report having previously been given a diagnosis of OA, with 9 out 10 also reporting having had a radiograph, of which approximately 87% reported the radiograph showed signs of OA.

CONCLUSION

We have described the GLA:D® Canada program, registry and data collection procedures, and provided a detailed summary to date of the profiles of participants with knee and hip OA. These individual participant data have the potential to be linked with local health administrative data registries and comparatively assessed with other international GLA:D® registries. Researchers are invited to make use of these rich datasets and participate in collaborative endeavours to tackle questions of Canadian and global importance for a large and growing clinical population of individuals with hip and knee OA.

Variation in the utilisation of physiotherapy in patients with advanced knee osteoarthritis prior to total knee arthroplasty a systematic review

INTRODUCTION

Due to demographic changes and increasing knee osteoarthritis (KOA) prevalence, the incidence of total knee arthroplasties (TKA) is constantly rising. Clinical practice guidelines for the treatment of KOA unanimously recommend non-surgical interventions such as exercise, education, and weight reduction in overweight patients. The aim of this systematic review is to determine the proportion of patients with end-stage KOA who attended physiotherapy (PT) prior to TKA.

METHODS

A systematic literature search was carried out in the medical databases MEDLINE (via Pubmed), PEDro, and EBSCO in August of 2022. Studies were included regardless of their design, if they reported the proportion of patients with a diagnosis of primary KOA, who participated in PT prior to undergoing TKA. Study quality assessment was performed by two independent authors using the Joanna Briggs Institutes Checklist for studies reporting prevalence data. Results were presented by using a narrative synthesis.

RESULTS

Eighteen studies, comprising 579,718 patients, were identified in this systematic review. PT utilisation prior to TKA ranged from 10% to 73% for patients with advanced KOA. Only two studies showed PT utilisation rates of 60% or higher. Female gender, higher income, better socioeconomic status, higher education levels, older age were associated with PT utilisation. Data for other predicting factors was conflicting.

DISCUSSION

This review shows substantial variation in the utilisation of PT in patients with end-stage KOA. This is concerning, considering the uniform recommendation from clinical practice guidelines for non-surgical treatments like exercise and education in patients with KOA, which are mostly provided by physiotherapists.

Exercise Therapy for Knee and Hip Osteoarthritis: Is There An Ideal Prescription?

Purpose of review

Exercise therapy is the first line treatment for patients with knee and hip osteoarthritis (OA) but is consistently underutilized. In this review, we aim to provide health care professionals with an overview of the latest evidence in the areas of exercise therapy for OA, which can serve as a guide for incorporating the ideal exercise therapy prescription in the overall management plan for their patients with OA.

Recent findings

Evidence continues to be produced supporting the use of exercise therapy for all patients with knee or hip OA. Ample evidence exists suggesting exercise therapy is a safe form of treatment, for both joint structures and the patient overall. Several systematic reviews show that exercise therapy is likely to improve patient outcomes, regardless of disease severity or comorbidities. However, no single type of exercise therapy is superior to others.

Summary

Health care practitioners and patients should be encouraged to incorporate exercise therapy into treatment plans and can be assured of the safety profile and likelihood of improvement in important patient outcomes. Since no single exercise therapy program shows vastly superior benefit, patient preference and contextual factors should be central to the shared decision-making process when selecting and individualising appropriate exercise therapy prescriptions.

"I Often Feel Conflicted in Denying Surgery": Perspectives of Orthopaedic Surgeons on Body Mass Index Thresholds for Total Joint Arthroplasty: A Qualitative Study

BACKGROUND

Use of a patient body mass index (BMI) eligibility threshold for total joint arthroplasty (TJA) is controversial. A strict BMI criterion may reduce surgical complication rates, but over-restrict access to effective osteoarthritis (OA) treatment. Factors that influence orthopaedic surgeons' use of BMI thresholds are unknown. We aimed to identify and explore orthopaedic surgeons' perspectives regarding patient BMI eligibility thresholds for TJA.

METHODS

A cross-sectional, online qualitative survey was distributed to orthopaedic surgeons who conduct hip and/or knee TJA in the United States. Survey questions were open-ended, and responses were collected anonymously. Survey data were coded and analyzed in an iterative, systematic process to identify predominant themes.

RESULTS

Forty-five surveys were completed. Respondents were 54.3 ± 12.4 years old (range, 34 to 75 years), practiced in 22 states, and had 21.2 ± 13.3 years (range, 2 to 44 years) of surgical experience. Twelve factors influencing BMI threshold use by orthopaedic surgeons were identified: (1) evidence interpretation, (2) personal experiences, (3) difficulty of surgery, (4) professional ramifications, (5) ethics and biases, (6) health-system policies and performance metrics, (7) surgical capacity and resources, (8) patient body fat distribution, (9) patient self-advocacy, (10) control of decision-making in the clinical encounter, (11) expectations for demonstrated weight loss, and (12) research and innovation gaps.

CONCLUSIONS

Multilevel, complex factors underlie BMI threshold use for TJA eligibility. Addressing identified factors at the patient, surgeon, and health-system levels should be considered to optimally balance complication avoidance with improving access to life-enhancing surgery.

CLINICAL RELEVANCE

This study may influence how orthopaedic surgeons think about their own practices and how they approach patients and consider surgical eligibility.

Bioinformatics analysis based on crucial genes of endothelial cells in rheumatoid

Objectives: Synovial neovascularization is an early and remarkable event that promotes the development of rheumatoid arthritis (RA) synovial hyperplasia. This study aimed to find potential diagnostic markers and molecular therapeutic targets for RA at the mRNA molecular level. Method: We download the expression profile dataset GSE46687 from the gene expression ontology (GEO) microarray, and used R software to screen out the differentially expressed genes between the normal group and the disease group. Then we performed functional enrichment analysis, used the STRING database to construct a protein-protein interaction (PPI) network, and identify candidate crucial genes, infiltration of the immune cells and targeted molecular drug. Results: Rheumatoid arthritis datasets included 113 differentially expressed genes (DEGs) including 104 upregulated and 9 downregulated DEGs. The enrichment analysis of genes shows that the differential genes are mainly enriched in condensed chromosomes, ribosomal subunits, and oxidative phosphorylation. Through PPI network analysis, seven crucial genes were identified: RPS13, RPL34, RPS29, RPL35, SEC61G, RPL39L, and RPL37A. Finally, we find the potential compound drug for RA. Conclusion: Through this method, the pathogenesis of RA endothelial cells was further explained. It provided new therapeutic targets, but the relationship between these genes and RA needs further research to be validated in the future.

Impact of an online, individualised, patient reported outcome measures based patient decision aid on patient expectations, decisional regret, satisfaction, and health-related quality-of-life for patients considering total knee arthroplasty: Results from a randomised controlled trial

RATIONALE

Total knee arthroplasty is a common surgical procedure but not appropriate for all patients with knee osteoarthritis. Patient decision aids (PtDAs) can promote shared decision making and enhance understanding and expectations of procedures among patients, resulting in better discussions between patients and healthcare providers about whether total knee arthroplasty is the most appropriate option.

AIMS AND OBJECTIVES

Evaluate impact of an individualised PtDA for osteoarthritis patients considering total knee arthroplasty 1 year after baseline assessment.

METHODS

Prospective, randomised controlled trial comparing an intervention arm (IA) and routine care arm (RCA). The IA included an online individualised patient reported outcome measures (PROMs) based PtDA and one-page summary report for the surgeon. We report secondary outcomes from the final assessment: patient expectations, decisional regret, patient satisfaction with outcomes of knee replacement, health-related quality-of-life (HRQOL) and depression. We report changes in HRQOL between baseline and final assessments, study arms, and surgical versus non-surgical patients. Descriptive statistics were used to describe participant characteristics and continuous variables. Dichotomous outcomes (expectations, decisional regret, satisfaction) were analyzed using logistic regression and continuous outcomes (HRQOL, depression) were modelled using linear regression.

RESULTS

Overall, 140 participants completed all study assessments (IA: n = 69, RCA: n = 71); n = 108 underwent surgery (IA: n = 49, RCA: n = 59). Regardless of study arm, most participants reported expectations were met, minimal decisional regret, satisfaction with outcomes of knee replacement, and had improvements in HRQOL. While no significant differences in study outcomes were found between study arms, IA results were in the direction hypothesised in favour of the PtDA.

CONCLUSIONS

Although we were not able to detect statistically significant benefits associated with implementing this PROMs-based PtDA, there was no apparent negative effect on these outcomes 1 year after baseline. We anticipate there may be benefit to implementing this PtDA earlier in the osteoarthritis care pathway where patients have more opportunities to manage their disease non-surgically.

Hip and Knee Total Joint Arthroplasty Online Resources for Patients and Health Care Professionals: A Canadian Environmental Scan

Purpose:

To appraise the quality of publicly available online Canadian resources for patients with hip or knee osteoarthritis considering total joint arthroplasty (TJA) and health care professionals participating in TJA decision-making processes.

Method:

An environmental scan. Two independent authors appraised: a) patient resources against the International Patient Decision Aids Standards (IPDAS) criteria and the Patient Education Material Evaluation Tool (PEMAT); and b) health care professional resources against six appropriateness criteria for TJA and eight elements of shared decision-making. Analysis was descriptive.

Results:

Of 84 included resources, 71 were for patients, 11 for health care professionals, and 2 for both. For patient resources, the median number of IPDAS defining criteria met was 2 of 7, median PEMAT understandability score was 83%, and median PEMAT actionability score was 60%. For health care professional resources, the median number of appropriateness criteria was 3 of 6, and the median number of shared decision-making elements was 3 of 8.

Conclusions:

Only four of 73 patient resources were structured to help patients consider their options and reach a decision based on their preferences. Health care professional resources were limited to traditional criteria for determining TJA appropriateness (evidence of osteoarthritis, use of conservative treatments) and poorly met key elements of shared decision-making.

Instruments to assess appropriateness of hip and knee arthroplasty: a systematic review

OBJECTIVE

To assess criteria and psychometric properties of instruments for assessing appropriateness of elective joint arthroplasty (JA) for adults with primary hip and knee osteoarthritis (OA).

METHODS

A systematic review guided by Cochrane methods and PRISMA guidelines. Studies were searched in five databases. Eligible articles include all study designs developing, testing, and/or using an instrument to assess JA appropriateness. Two independent reviewers screened and extracted data. Instruments were compared with Hawker et al. JA consensus criteria. Psychometric properties of instruments were described and appraised guided by Fitzpatrick's and COSMIN approaches.

RESULTS

Of 55 instruments included, none met all Hawker et al. JA consensus criteria. Criteria the most met were pain (n = 50), function (n = 49), quality of life (n = 33), and radiography (n = 24). Criteria the least met were clinical evidence of OA (n = 18), expectations (n = 15), readiness for surgery (n = 11), conservative treatments (n = 8), and patient/surgeon agree benefits outweigh risks (n = 0). Instrument by Arden et al. met the most criteria (6 of 9). The most tested psychometric properties were appropriateness (n = 55), face/content validity (n = 55), predictive validity (n = 29), construct validity and feasibility (n = 24). The least tested psychometric properties were intra-rater reliability (n = 3), internal consistency (n = 5), and inter-rater reliability (n = 13). Instruments by Gutacker et al. and Osborne et al. met the most psychometric properties (4 of 10).

CONCLUSION

Most instruments included traditional criteria for assessing JA appropriateness but did not include a trial of conservative treatments or shared decision-making elements. There was limited evidence on psychometric properties.

A survey of patient and medical professional perspectives on implementing osteoarthritis management programs for hip and knee osteoarthritis

BACKGROUND

Strategies are needed to improve referral into, and uptake of, osteoarthritis (OA) management programs. This survey investigated and compared patients' and medical professionals' views around hip and knee OA management and factors impacting implementation of an osteoarthritis management program.

METHODS

As part of a mixed-methods program of research, patients with hip or knee OA and medical professionals routinely involved in the management of OA, were invited to complete a comprehensive online survey. All data were analysed descriptively or using chi squared tests. Survey findings for factors perceived to impact implementation of an OA management programme were triangulated with previously reported qualitative data.

RESULTS

Fifty-three patients (38 females, 15 males) and 32 medical professionals (orthopaedic surgeons, sports physicians, rehabilitation physicians, rheumatologists and general practitioners) completed the survey. Twenty-eight patients (53%) had prior participation in the OA management programme (GLA:D^® ) and 19 medical professionals (59%) had previously referred patients to the programme. Of the participants with prior exposure, 21 patients (75%) and 15 medical professionals (79%) agreed the programme was beneficial. A higher proportion of medical professionals, compared to patients, believed weight loss (100% vs. 67%), injection therapy (50% vs. 21%), hip replacement (100% vs. 62%) and knee replacement (97% vs. 62%) were effective treatments, with no differences for all other treatments. The barriers and enablers identified for referral into, and participation in, an OA management programme mostly aligned to factors identified in previous related qualitative research. Divergent factors in the survey included patients concerns about doing exercise-therapy with 81% (higher than expected) not reporting any concerns about exercising, and 19% (lower than expected) concerned about their OA joint, such as making their pain worse.

CONCLUSIONS

This study has extended our understanding of barriers and enablers for referral into, and participation in, an OA management programme with a lower than expected number of patients being concerned about exercising due to their OA joint. Patients and medical professionals had positive views relating to the quality of the programme delivery, patient satisfaction and programme effectiveness. Medical professionals were more likely than patients to consider weight loss, injections and joint replacement as effective treatment options.

Improving diagnosis and treatment of knee osteoarthritis in persons with type 2 diabetes: development of a complex intervention

BACKGROUND

Symptomatic knee osteoarthritis (OA) commonly co-occurs in people with type 2 diabetes (T2DM) and increases the risk for diabetes complications, yet uptake of evidence-based treatment is low. We combined theory, stakeholder involvement and existing evidence to develop a multifaceted intervention to improve OA care in persons with T2DM. This was done in partnership with Arthritis Society Canada to leverage the existing infrastructure and provincial funding for community arthritis care.

METHODS

Each step was informed by a User Advisory Panel of stakeholder representatives, including persons with lived experience. First, we identified the target groups and behaviours through consulting stakeholders and current literature. Second, we interviewed persons living with T2DM and knee OA (n = 18), health professionals (HPs) who treat people with T2DM (n = 18) and arthritis therapists (ATs, n = 18) to identify the determinants of seeking and engaging in OA care (patients), assessing and treating OA (HPs) and considering T2DM in OA treatment (ATs), using the Theoretical Domains Framework (TDF). We mapped the content to behavioural change techniques (BCTs) to identify the potential intervention components. Third, we conducted stakeholder meetings to ascertain the acceptability and feasibility of intervention components, including content and modes of delivery. Fourth, we selected intervention components informed by prior steps and constructed a programme theory to inform the implementation of the intervention and its evaluation.

RESULTS

We identified the barriers and enablers to target behaviours across a number of TDF domains. All stakeholders identified insufficient access to resources to support OA care in people with T2DM. Core intervention components, incorporating a range of BCTs at the patient, HP and AT level, sought to identify persons with knee OA within T2DM care and refer to Arthritis Society Canada for delivery of evidence-based longitudinal OA management. Diverse stakeholder input throughout development allowed the co-creation of an intervention that appears feasible and acceptable to target users.

CONCLUSIONS

We integrated theory, evidence and stakeholder involvement to develop a multifaceted intervention to increase the identification of knee OA in persons with T2DM within diabetes care and improve the uptake and engagement in evidence-based OA management. Our partnership with Arthritis Society Canada supports future spread, scalability and sustainability. We will formally assess the intervention feasibility in a randomized pilot trial.

Making the current non-surgical treatments for knee osteoarthritis more effective: Solutions from a diverse patient group

OBJECTIVE

To examine patient perceived solutions to barriers to effective non-surgical knee osteoarthritis (OA) treatments in a diverse racial/ethnic group.

METHODS

Nominal groups were conducted with consecutive patients with knee OA at a medical center clinic, oversampling for African Americans with knee OA. Participants discussed potential solutions and rank-ordered their concerns.

RESULTS

Thirteen nominal groups with 46 knee OA patients were conducted with mean age, 60.8 years (standard deviation [sd], 10.0) and knee OA duration, 8.1 years (sd, 5.4); 22% were men, and 56% were African American. The following solutions were in the top three ranked solutions in 13 NGTs: (A) more research, effective and/or safer new medications/treatments, and joint cartilage restoration (8 groups; 15% votes [43/276]); (B) early diagnosis (2 groups; 7% votes [20/276]); (C) better and more effective communication (5 groups; 10% votes [29/276]); (D) public and patient education (4 groups; 8% votes [22/276]); (E) motivation and behavioral modification (4 groups; 9% votes [26/276]); (F) team approach (1 group; 1% votes [2/276]); (G) personalized medicine (6 groups; 8% votes [24/276]); (H) cheaper and more affordable medications and treatments (3 groups; 5% votes [15/276]).

CONCLUSIONS

A diverse group of participants with knee OA identified several solutions to barriers to the effectiveness of current knee OA treatments. This new knowledge can inform the development and implementation of future interventions to improve the outcomes of people with knee OA.

Osteoarthritis management care pathways are complex and inefficient: A qualitative study of physiotherapist perspectives from specialised osteoarthritis services

OBJECTIVE

Hip and knee osteoarthritis guidelines internationally provide consistent first-line care recommendations. However, uptake of these recommendations remains suboptimal. This qualitative study explores factors influencing guideline-based care from the perspectives of physiotherapists working in specialised osteoarthritis services across different models of care.

METHODS

Nineteen semi-structured interviews were conducted with physiotherapists working in specialist osteoarthritis services across three different Australian models of care (OsteoArthritis Hip and Knee Service n = 10; OsteoArthritis Chronic Care Programme n = 4; Orthopaedic Physiotherapy Screening Clinics and Multidisciplinary Services n = 5). Interviews were audio recorded and transcribed verbatim. Data were coded and analysed inductively using thematic analysis.

RESULTS

The overarching theme to emerge was that accessing first-line osteoarthritis care is complex and difficult, regardless of model of care. Subthemes indicated that: (i) services are either unavailable or inadequately funded, (ii) referral pathways are labyrinthine and lengthy, (iii) patients and other health professionals often believe that surgery is the only/best option and (iv) managing patient co-morbidities is challenging.

CONCLUSION

Physiotherapists working in specialised osteoarthritis services perceive multiple and complex factors influencing adherence to first-line care. Barriers occur at various levels in all models of care, including patient and health professional beliefs, health service, and system levels. These results suggest improving healthcare for people with osteoarthritis requires urgent system reform.

Barriers and enablers to health care providers assessment and treatment of knee osteoarthritis in persons with type 2 diabetes mellitus: A qualitative study using the Theoretical Domains Framework

Objectives

Symptomatic knee osteoarthritis (OA) commonly co-exists in persons with Type 2 diabetes (T2DM) and may impede diabetes self-management. Yet, OA is often underdiagnosed and undertreated due to competing health care demands. We sought to determine healthcare providers' (HCPs') perceptions of the barriers and enablers to assessing and treating knee OA in persons with T2DM.

Design

We conducted 18 semi-structured telephone interviews with HCPs who manage persons with T2DM (family physicians, endocrinologists, diabetes educators). Interviews were analyzed deductively using Theoretical Domains Framework (TDF), a framework developed to comprehensively identify behavioural determinants. Within relevant domains, data were thematically analyzed to generate belief statements, and these were compared across the different HCP disciplines.

Results

Six TDF domains influenced HCPs behaviour to assess and treat knee OA in persons with T2DM. For all HCPs, important barriers included not seeing assessment/treatment of joint pain as a priority for their patients (intention), and insufficient access to required resources such as physiotherapy to treat OA (environmental context and resources). Endocrinologists and diabetes educators perceived having insufficient knowledge and skills to identify and manage OA (knowledge, skills), did not consider it within their professional role to do so (professional role and identity), and perceived other physicians would not want to receive a referral for OA care (social influences).

Conclusions

We identified barriers and enablers encountered by diabetes HCPs to assessing and treating knee OA in persons with T2DM involving multiple domains of the TDF. These will help inform development of a complex intervention to improve health outcomes.

Factors That Patients Consider in Their Choice of Non-Surgical Management for Hip and Knee Osteoarthritis: Formative Qualitative Research for a Discrete Choice Experiment

BACKGROUND

Approximately half of patients with hip and knee osteoarthritis have tried non-surgical management before surgical consultation. Understanding the many factors affecting the uptake of recommended strategies is important to inform future development of such management strategies.

OBJECTIVES

The aim of this study was to explore and identify factors that patients with osteoarthritis consider when choosing non-surgical management for hip and knee osteoarthritis, as formative research for a study of patient preferences for non-surgical management programs for osteoarthritis.

METHODS

A qualitative research design was used. Participants were recruited using a combination of stratified and convenience sampling. Interviews were conducted, using a semi-structured interview guide, with English-speaking patients who had self-reported hip and/or knee osteoarthritis and at least one joint that had not undergone replacement surgery. Data were thematically analyzed.

RESULTS

Thirteen patients participated in these interviews. Sixteen factors that participants considered when choosing non-surgical osteoarthritis management were identified. Eleven were extrinsic, relating to features of programs and services, and are categorized as types of interventions, general program and service details, and program-specific details. Five were intrinsic to the individual and influenced how decisions for osteoarthritis management were approached and the options available to choose from. Three novel factors included participants' desire for further management, their views about joint replacement surgery, and whether they felt personal choice was available in osteoarthritis management strategies.

CONCLUSION

Key factors were identified that patients considered when making decisions about non-surgical management for their osteoarthritis that will be used to inform a discrete choice experiment (DCE) that aims to measure preferences for these factors.

Construction of an Administrative Osteoarthritis Severity Index

OBJECTIVE

Electronic health record (EHR) databases are a powerful resource to investigate clinical trajectories of osteoarthritis (OA). There are no existing EHR tools to evaluate risk for knee arthroplasty (KA). We developed an OA severity index (OASI) using EHR data and demonstrate the index's association with time to KA.

METHODS

This retrospective cohort study used 2010-2018 nationally distributed Optum EHR data. Eligible patients were 45 to 80 years old with a new diagnosis of knee OA in 2011-2012 and no prior KA. The OASI was a sum of first instance of x-ray imaging, advanced imaging, intra-articular injection, nonsteroidal anti-inflammatory drugs, and opioids. Principal components analysis index (PCI) score was also explored. Extended Cox proportional hazard models assessed time-dependent OASI and time to KA.

RESULTS

Among 16,675 eligible patients, 12.7% underwent KA. Median follow-up time was 72 months. Adjusted OASI models showed each additional event almost doubled the risk for KA (adjusted hazard ratio = 1.80, 95% confidence interval: 1.75-1.86). Similar results were observed for PCI.

CONCLUSION

The sum OASI performs well identifying patients who would undergo KA and offers simplicity versus the PCI. Although replication in other cohorts is recommended, the OASI appears to be a novel and valid means to measure clinical OA severity in research studies using large EHR-based cohorts.

Factors associated with physician-reported treatment status of patients with osteoarthritis pain

BACKGROUND

Osteoarthritis (OA) is typically associated with pain, but many patients are not treated.

METHODS

This point in time study explored factors associated with treatment status, using logistic regression of data from the Adelphi OA Disease Specific Programme conducted in the United States. Patients' treatment status was based on physician-reported, current: 1) prescription medication for OA vs. none; and 2) physician treatment (prescription medication and/or recommendation for specified nonpharmacologic treatment for OA [physical or occupational therapy, acupuncture, transcutaneous electrical nerve stimulation, or cognitive behavior therapy/psychotherapy]) vs. self-management (no prescription medication or specified nonpharmacologic treatment).

RESULTS

The 841 patients (including 57.0% knee OA, 31.9% hip OA) reported mild (45.4%) or moderate or severe (54.6%) average pain intensity over the last week. The majority were prescribed medication and/or recommended specified nonpharmacologic treatment; 218 were not prescription-medicated and 122 were self-managed. Bivariate analyses showed less severe patient-reported pain intensity and physician-rated OA severity, fewer joints affected by OA, lower proportion of joints affected by knee OA, better health status, lower body mass index, and lower ratings for cardiovascular and gastrointestinal risks, for those not prescribed medication (vs. prescription-medicated). Multivariate analyses confirmed factors significantly (p < 0.05) associated with prescription medication included (odds ratio): physician-rated current moderate OA severity (vs. mild, 2.03), patient-reported moderate OA severity 6 months ago (vs. mild, 1.71), knee OA (vs. not, 1.81), physician-recommended (0.28) and patient-reported (0.43) over-the-counter medication use (vs. not), prior surgery for OA (vs. not, 0.37); uncertain income was also significant. Factors significantly (p < 0.05) associated with physician treatment included (odds ratio): physician-recommended nonpharmacologic therapy requiring no/minimal medical supervision (vs. not, 2.21), physician-rated current moderate OA severity (vs. mild, 2.04), patient-reported over-the-counter medication use (vs. not, 0.26); uncertain time since diagnosis was also significant. Patient-reported pain intensity and most demographic factors were not significant in either model.

CONCLUSIONS

Approximately 1 in 4 patients were not prescribed medication and 1 in 7 were self-managed, although many were using over-the-counter medications or nonpharmacologic therapies requiring no/minimal medical supervision. Multiple factors were significantly associated with treatment status, including OA severity and over-the-counter medication, but not pain intensity or most demographics.

Minimal clinically important difference for improvement in six-minute walk test in persons with knee osteoarthritis after total knee arthroplasty

BACKGROUND

The interpretability of the six-minute walk test (6MWT) in individuals with knee osteoarthritis (OA) is unclear. We aimed to determine the minimal clinically important difference (MCID) for improvement in 6MWT in persons with knee OA at 12 months after total knee arthroplasty (TKA), and if it differed by baseline walking ability.

METHODS

Participants with knee OA were assessed 1 month pre- and 12 months post-TKA, including completion of 6MWT. At 12 months, participant-perceived change in walking ability was assessed on an 8-point Likert scale ranging from "extremely worse" to "extremely better". Using logistic regression, ROC curves examined the ability of change in 6MWT distance to discriminate those who perceived walking was improved. MCID was selected overall and then by quartile of baseline 6MWT distance using the Youden method.

RESULTS

Two hundred seventy-eight participants were included: mean age 67 years (SD 8.5), 65.5% female, mean pre-TKA 6MWT distance 323.1 (SD 104.7) m, and mean 12-mo 6MWT distance 396.0 (SD 111.9) m. The overall MCID was 74.3 m (AUC 0.65). Acceptable model discrimination (AUC > 0.70) was achieved for individuals in the lowest quartiles of baseline 6MWT distance: Quartile 1: MCID 88.63 m (AUC 0.73); Quartile 2: MCID 84.47 m (AUC 0.72).

CONCLUSIONS

In persons with knee OA 12 months post-TKA, 6MWT MCID is dependent on baseline walking ability. Poor model discrimination for those in the highest (best) quartiles of baseline walking ability raise questions about 6MWT use across the full spectrum of walking ability. Further research is needed to better understand use of 6MWT as a performance-based measure of physical function for persons with knee OA.

Use of Physiotherapy Prior to Total Knee Arthroplasty—Results of the Prospective FInGK Study

Background: Data regarding physiotherapy (PT) utilization prior to total knee arthroplasty (TKA) are insufficient. Therefore, this study aims to examine which percentage of patients receive PT within 12 months prior to TKA and which factors are associated with its use. Methods: Consecutive patients (≥18 years) undergoing primary or revision TKA in a German university hospital were recruited. A questionnaire including information on PT utilization, demography, and socioeconomics was collected one day prior to surgery and linked to medical hospital records. Multivariable logistic regression was conducted to determine variables associated with the use of PT. Results: A total of 241 out of 283 (85%) patients participated (60% female; mean age: 68.4 years). Overall, 41% received PT at least once during 12 months prior to TKA, women more frequently than men (48% vs. 29%). Although high disease burden was associated with increased utilization, about one in two in this condition did not receive PT. Multivariable logistic regression showed that age 75+ years, low education level, and moderate-to-severe depressive symptoms were associated with decreased PT utilization. Conclusions: We found low use of recommended PT management in patients prior to TKA. This potential underuse was even higher in some vulnerable subgroups, indicating inequalities. Prescribers as well as patients should integrate PT more consistently into osteoarthritis management.

Patient beliefs about who and what influences their hip and knee osteoarthritis symptoms and progression

BACKGROUND

Osteoarthritis management aims to reduce pain and improve function. Many factors affect whether patients follow recommended strategies. Locus of control refers to individual beliefs around who and what influences health. Locus of control is related to the treatment strategies patients prefer. Currently, no studies explore locus of control in non-surgical management of osteoarthritis.

OBJECTIVES

To explore patients' beliefs about the influences on their osteoarthritis symptoms and disease progression.

METHODS

Semi-structured interviews were conducted with individuals experiencing self-reported hip and/or knee osteoarthritis who had at least one joint that had not undergone replacement surgery. We used a qualitative description approach and the Braun and Clarke method for thematic analysis. Participants' locus of control classifications-internal, chance, doctors, or other people-were based on the Multidimensional Health Locus of Control (MHLC) Scales Form C score.

RESULTS

Locus of control was discussed in relation to aetiology, progression, and symptoms. Participants' opinions varied on whether their osteoarthritis progression could be influenced. 46% of participants attributed control to other people. Most participants believed that a previous injury had caused their osteoarthritis and that both themselves and others had some influence over their osteoarthritis symptoms, regardless of their locus of control classification.

CONCLUSION

This research highlights the need for education about: the aetiology of osteoarthritis, the link between management and progression, and patient management of osteoarthritis. Further research is required to discern why expected patterns were not observed between participants' beliefs and locus of control classifications.

Emerging and New Treatment Options for Knee Osteoarthritis

Osteoarthritis (OA) is the most prevalent type of arthritis worldwide, resulting in pain and often chronic disability and a significant burden on healthcare systems globally. Non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, intra-articular corticosteroid injections are of little value in the long term, and opioids may have ominous consequences. Radiotherapy of knee OA has no added value. Physical therapy, exercises, weight loss, and lifestyle modifications may give pain relief, improve physical functioning and quality of life. However, no single treatment has regenerating potential for damaged articular cartilage. Due to a better understanding of osteoarthritis, innovative new treatment options have been developed. In this narrative review, we focus on emerging OA knee treatments, relieving symptoms, and regenerating damaged articular cartilage that includes intra-articular human serum albumin, conventional disease-modifying anti-rheumatic drugs (DMARDs), lipid-lowering agents (statin), nerve growth factors antagonists, bone morphogenetic protein, fibroblast growth factors, Platelet-Rich Plasma (PRP), Mesenchymal Stem Cells (MSC), exosomes, interleukin-1 blockers, gene-based therapy, and bisphosphonate.

Identification and validation of hub genes of synovial tissue for patients with osteoarthritis and rheumatoid arthritis

Background

Osteoarthritis (OA) and rheumatoid arthritis (RA) were two major joint diseases with similar clinical phenotypes. This study aimed to determine the mechanistic similarities and differences between OA and RA by integrated analysis of multiple gene expression data sets.

Methods

Microarray data sets of OA and RA were obtained from the Gene Expression Omnibus (GEO). By integrating multiple gene data sets, specific differentially expressed genes (DEGs) were identified. The Gene Ontology (GO) functional annotation, Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways and protein–protein interaction (PPI) network analysis of DEGs were conducted to determine hub genes and pathways. The “Cell Type Identification by Estimating Relative Subsets of RNA Transcripts (CIBERSORT)” algorithm was employed to evaluate the immune infiltration cells (IICs) profiles in OA and RA. Moreover, mouse models of RA and OA were established, and selected hub genes were verified in synovial tissues with quantitative polymerase chain reaction (qPCR).

Results

A total of 1116 DEGs were identified between OA and RA. GO functional enrichment analysis showed that DEGs were enriched in regulation of cell morphogenesis involved in differentiation, positive regulation of neuron differentiation, nuclear speck, RNA polymerase II transcription factor complex, protein serine/threonine kinase activity and proximal promoter sequence-specific DNA binding. KEGG pathway analysis showed that DEGs were enriched in EGFR tyrosine kinase inhibitor resistance, ubiquitin mediated proteolysis, FoxO signaling pathway and TGF-beta signaling pathway. Immune cell infiltration analysis identified 9 IICs with significantly different distributions between OA and RA samples. qPCR results showed that the expression levels of the hub genes (RPS6, RPS14, RPS25, RPL11, RPL27, SNRPE, EEF2 and RPL19) were significantly increased in OA samples compared to their counterparts in RA samples (P < 0.05).

Conclusion

This large-scale gene analyses provided new insights for disease-associated genes, molecular mechanisms as well as IICs profiles in OA and RA, which may offer a new direction for distinguishing diagnosis and treatment between OA and RA.

Early-stage symptomatic osteoarthritis of the knee - time for action

Osteoarthritis (OA) remains the most challenging arthritic disorder, with a high burden of disease and no available disease-modifying treatments. Symptomatic early-stage OA of the knee (the focus of this Review) urgently needs to be identified and defined, as efficient early-stage case finding and diagnosis in primary care would enable health-care providers to proactively and substantially reduce the burden of disease through proper management including structured education, exercise and weight management (when needed) and addressing lifestyle-related risk factors for disease progression. Efforts to define patient populations with symptomatic early-stage knee OA on the basis of validated classification criteria are ongoing. Such criteria, as well as the identification of molecular and imaging biomarkers of disease risk and/or progression, would enable well-designed clinical studies, facilitate interventional trials, and aid the discovery and validation of cellular and molecular targets for novel therapies. Treatment strategies, relevant outcomes and ethical issues also need to be considered in the context of the cost-effective management of symptomatic early-stage knee OA. To move forwards, a multidisciplinary and sustained international effort involving all major stakeholders is required.

Utilisation of outpatient physiotherapy in patients following total knee arthroplasty - a systematic review

OBJECTIVE

Data on the utilisation of outpatient physiotherapy (PT) in patients following total knee arthroplasty (TKA) are scarce, and available studies have not been systematically synthesised. This study aims to summarise the existing literature on outpatient PT following TKA as well as to identify factors associated with its use.

METHODS

A systematic literature search in MEDLINE (via PubMed), CINAHL, Scopus and PEDro was conducted in July 2020 without language restrictions. Two authors independently selected studies, extracted data and assessed study quality. The primary outcome was the proportion being treated with at least one session of outpatient PT (land- or water-based treatments supervised/provided by a qualified physiotherapist) during any defined period within 12 months following TKA. Furthermore, predictors for the use of PT were assessed. Studies including only revision surgeries or bilateral TKA were excluded.

RESULTS

After screening 1934 titles/abstracts and 56 full text articles, 5 studies were included. Proportions of PT utilisation ranged from 16.7 to 84.5%. There were large variations in the time periods after hospital discharge (4 weeks to 12 months) and in the reporting of PT definitions. Female sex was associated with higher PT utilisation, and compared to patients after total hip arthroplasty, utilisation was higher among those following TKA.

CONCLUSION

Despite using a broad search strategy, we found only 5 studies assessing the utilisation of PT after hospital discharge in patients with TKA. These studies showed large heterogeneity in PT utilisation, assessed time periods and PT definitions. Clearly, more studies from different countries with uniform PT definitions are needed to address this relevant public health question.

Association Between Knee Joint Muscle Activation and Knee Joint Moment Patterns During Walking in Moderate Medial Compartment Knee Osteoarthritis: Implications for Secondary Prevention

OBJECTIVE

To determine associations between knee moment features linked to osteoarthritis (OA) progression, gait muscle activation patterns, and strength.

DESIGN

Cross-sectional secondary analysis.

SETTING

Gait laboratory.

PARTICIPANTS

Convenience sample of 54 patients with moderate, medial knee OA (N=54).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Knee moments and quadriceps and hamstrings activation were examined during walking. Knee extensor and flexor strength were measured. Waveform patterns were extracted using principal component analysis. Each measured waveform was scored against principal components (PCs) that captured overall magnitude (PC1) and early to midstance difference (PC2) features, with higher PC2 scores interpreted as greater moment differential and more prolonged muscle activity. Correlations were calculated between moment PC scores and muscle PC and strength scores. Regression analyses determined moment PC score variance explained by muscle PC scores and strength.

RESULTS

All correlations for knee adduction moment difference feature (KAMPC2) and prolonged muscle activity (PC2) were significant (r=-0.40 to -0.54). Knee flexion moment difference feature (KFMPC2) was significantly correlated with all quadriceps and medial hamstrings PC2 scores (r=-0.47 to -0.61) and medial hamstrings magnitude feature (PC1) (r=-0.52). KAMPC2 was significantly correlated with knee flexor strength (r=0.43), and KFMPC2 was significantly correlated with knee extensor (r=0.60) and flexor (r=0.55) strength. Regression models including muscle PC2 scores and knee flexor strength explained 46% of KAMPC2 variance, whereas muscle PC2 scores and knee extensor strength explained 59% of KFMPC2 variance.

CONCLUSIONS

Muscle activation patterns and strength explained significant variance in moment difference features, highest for the knee flexion moment. This supports that exercises such as neuromuscular training, focused on appropriate muscle activation patterns, and strengthening have the potential to alter dynamic loading gait patterns associated with knee OA clinical progression.

Comorbidities do not limit improvement in pain and physical function after total knee arthroplasty in patients with knee osteoarthritis: the BEST-Knee prospective cohort study

OBJECTIVE

To assess the relationship between comorbidities and amount of improvement in pain and physical function in recipients of total knee arthroplasty (TKA) for knee osteoarthritis (OA).

DESIGN

Prospective cohort study.

SETTING

Two provincial central intake hip and knee centres in Alberta, Canada.

PARTICIPANTS

1051 participants (278 in 6-minute walk test (6MWT) subset), ≥30 years of age with primary knee OA referred for consultation regarding elective primary TKA; assessed 1 month prior and 12 months after TKA.

PRIMARY AND SECONDARY OUTCOME MEASURES

Pre-post TKA change in knee OA pain (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)), physical function (Knee injury and Osteoarthritis Outcome Score (KOOS) Physical Function Short-Form) and 6MWT walking distance; and the reporting of an acceptable symptom state (Patient Acceptable Symptom State (PASS)) at 12 months after TKA.

RESULTS

Mean participant age was 67 years (SD 8.8), 59% were female and 85% reported at least one comorbidity. Individuals with a higher number of comorbidities had worse pre-TKA and post-TKA scores for pain, physical function and 6MWT distance. At 12-month follow-up, mean changes in pain, function and 6MWT distance, and proportion reporting a PASS, were similar for those with and without comorbidities. In multivariable regression analysis, adjusted for potential confounders and clustering by surgeon, no specific comorbidities nor total number of comorbidities were associated with less improvement in pain, physical function or 6MWT distance at 12 months after TKA. Patients with diabetes (OR 0.64, 95% CI 0.44 to 0.94) and a higher number of lower extremity troublesome joints (OR 0.85, 95% CI 0.76 to 0.96) had lower odds of reporting a PASS.

CONCLUSION

For individuals with knee OA, comorbid conditions do not limit improvement in pain, physical function or walking ability after TKA, and most conditions do not impact achieving an acceptable symptom state.

Understanding the Impact of Sex and Gender in Osteoarthritis: Assessing Research Gaps and Unmet Needs

Osteoarthritis (OA) affects more than 300 million individuals globally, with higher prevalence in women than in men. In addition, OA affects women and men differently, with women demonstrating both increased disease severity and disability. The Society for Women's Health Research (SWHR) convened an interdisciplinary group of expert researchers and clinicians for a roundtable meeting to review the current state of the science on OA and to identify knowledge gaps in the scientific literature, especially as they relate to the topics of sex and gender. The current review summarizes discussions from the roundtable and prioritizes areas of need that warrant further attention in OA research, diagnosis, care, and education. Improvements in basic and clinical research, clinical practice, patient education, and policy are needed to allow for better understanding as to the pathogenesis of sex- and gender-related disparities in OA.

A critical review of weight loss recommendations before total knee arthroplasty

OBJECTIVE

Increased infection risk after total knee arthroplasty (TKA) in patients with a higher body mass index (BMI), particularly a BMI ≥40kg/m², suggests that BMI reduction (through weight loss) prior to TKA may be important. However, the impact of weight loss on TKA risk reduction is unclear. Furthermore, weight loss could have detrimental consequences with respect to muscle loss and development of sarcopenic obesity, whereby a potential weight loss paradox in adults with advanced knee OA and obesity may be present. Using a critical review approach, we examined the current evidence supporting weight loss in adults with obesity and advanced knee osteoarthritis (OA). We focused on three key areas: (1) TKA complication risk with severe obesity compared to obesity (BMI ≥40kg/m² versus 30.0-39.9kg/m²); (2) weight loss recommendations for individuals with advanced knee OA; and (3) TKA outcomes after pre-surgical weight loss.

METHODS

Medline and CINAHL databases were examined from Jan 2010 to May 2020 to identify high-level and/or clinically-influential evidence (systematic reviews, meta-analyses and clinical practice guidelines).

RESULTS

The literature does not show a clear relationship between weight loss and reduction in TKA complications, and no indication that a patients' individual risk is lowered by reducing their BMI from a threshold of ≥40kg/m² to ≤39.9kg/m². Studies that have found a benefit of weight loss for knee OA have not included patients with higher BMIs (≥40kg/m²) or more advanced knee OA. Furthermore, there is unclear evidence of a benefit of pre-surgical weight loss on TKA outcomes. These are important evidence gaps, suggesting that recommendations for BMI reduction prior to TKA should be tempered by the current uncertainty in the literature.

CONCLUSION

Evidence to support a benefit of weight loss prior to TKA is lacking. Until knowledge gaps are clarified, it is recommended that practitioners consider individual patient needs and risk before recommending weight loss (and therefore BMI reduction).

What You Should Know About Osteoarthritis Rehabilitation: A Bibliometric Analysis of the 50 Most-Cited Articles

Background:

Osteoarthritis is a degenerative disease that commonly occurs in middle-aged and elderly people. High-quality articles in the field of osteoarthritis rehabilitation have not been studied in detail.

Objective:

To identify and conduct a qualitative and quantitative analysis of the 50 most-cited articles on osteoarthritis rehabilitation and provide valuable scientific information for researchers.

Methods:

Fifty articles related to the rehabilitation of individuals with osteoarthritis were retrieved from the Web of Science Core Collection. Basic information, such as the authors, title, number of citations, year of publication, journal, country/territory, and research type, was extracted. CiteSpace was used to visualize the keywords.

Results:

The average number of citations per article was 244.54. The top 50 articles were published in 27 journals and published by 262 authors. Most of the top 50 articles were published in the United States. The top 50 articles included 23 randomized controlled trials, 21 cohort studies, 2 case series, and 4 expert opinion articles. The most commonly studied topics in osteoarthritis rehabilitation included rehabilitation for pain, gait abnormalities, muscle strength deficiencies, and other functional impairments caused by osteoarthritis in elderly people.

Conclusions:

The top articles in the field of osteoarthritis rehabilitation have a high level of evidence. Collaboration between authors was high for highly-cited articles. Moreover, the eminent articles can provide important information for the education of doctors and therapists specializing in osteoarthritis rehabilitation.