The Effectiveness of Tai Chi for Knee Osteoarthritis: An Overview of Systematic Reviews

Background

Knee Osteoarthritis (KOA) has become a serious health issue for elderly patients. Several systematic reviews (SRs) have reported Tai Chi has widely been used in the treatment of KOA. However, the methodology and conclusions of these SRs are controversial. This overview aims to summarize and evaluate the available evidence for the efficacy and safety of Tai Chi for KOA.

Methods

Two independent researchers searched eight databases from the inception to April 30, 2022. The included SRs were assessed respectively by A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2, the Risk of Bias in Systematic Reviews (ROBIS) tool, and the Preferred Reporting Item for Systematic Review and Meta-analysis (PRISMA) statement. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool was used to assess the quality of the included SRs in terms of outcome indicators.

Results

Six SRs were finally included in this overview. The results of methodological quality, reporting quality, and risk of bias of the included SRs were generally unsatisfactory. The limitations were a lack of explaining the reasons for selection, a list of excluded literature, reporting bias assessment, and reporting the potential sources of conflict of interest. In addition, only 1 item was assessed as moderate quality by using the GRADE tool. Limitations were the most common downgraded factors.

Conclusion

Tai Chi is effective as a non-pharmacological intervention in the integrative treatment of KOA. However, the quality of evidence and methodological quality of SRs is generally unsatisfactory, suggesting that these results must be interpreted with caution.

Trial Registration/Protocol Registration

PROSPERO registration number: CRD42022315146.

Effective Treatment of Knee Osteoarthritis Using a Nano-Enabled Drug Acupuncture Technology in Mice

A nano-enabled drug delivery acupuncture technology (nd-Acu) is developed that is based on traditional acupuncture needles where the stainless-steel surface is designed to deliver various payload molecules. To create the nd-Acu platform, an electrochemistry procedure is used to attach methyl salicylate-modified cyclodextrin in which the sugar rings allow the encapsulation of structurally defined single or multiple payload molecules via an inclusion complexation process. Drug loading and release profile are first studied using fluorescent dyes abiotically and at intact animal level. nd-Acu allows more efficient dye loading and time-dependent release compared to pristine needles without cyclodextrin modification. Subsequently, a proof-of-principle efficacy study is conducted using the platform to load a local anesthetic, lidocaine, for the treatment of knee osteoarthritis (KOA) in mice. It is demonstrated that lidocaine-laden nd-Acu can effectively alleviate pain, reduce inflammation, and slow down KOA development biochemically and histologically. Hypothesis-driven and proteomic approaches are utilized to investigate the working mechanisms of lidocaine nd-Acu, indicating that the therapeutic outcome is attributed to the in vivo modulation of the HMGB1/TLR4 signaling pathway. The study also obtained preliminary evidence suggesting the involvement of mitochondria as well as small GTPase such as cdc42 during the treatment by lidocaine nd-Acu.

Home-Based Remote Rehabilitation Leads to Superior Outcomes for Older Women With Knee Osteoarthritis: A Randomized Controlled Trial

OBJECTIVES

To examine the effects of a home-based lower-extremity strengthening exercise program in community-dwelling older women with knee osteoarthritis.

DESIGN

Randomized controlled trial.

SETTING AND PARTICIPANTS

Women aged ≥60 years with knee osteoarthritis and Kellgren-Lawrence grade 1 or 2 on anteroposterior/lateral radiographs of both knee joints.

METHODS

Patients (n = 36) were randomly divided into experimental (EG) and control (CG) groups. The EG performed home-based remote rehabilitation lower-extremity strengthening exercises for 8 weeks, whereas the CG received no intervention. Assessment was performed at baseline and week 8. The primary outcome was the five-times sit-to-stand test (FTSST) result. Secondary outcomes included timed up-and-go (TUG) test results, knee extensor and flexor strength, quadriceps (rectus femoris) muscle activity, skeletal muscle index, blood pressure (BP), visual analog scale (VAS) scores, C-reactive protein level, and erythrocyte sedimentation rate.

RESULTS

A statistically significant difference in the FTSST times was observed between the groups after 8 weeks of intervention (EG: 7.95 ± 1.08 seconds, CG: 10.01 ± 2.03 seconds, P < .001). In the EG, the TUG test score decreased by 0.75 ± 0.80 seconds (P = .002), right and left knee flexor strength increased by 4.69 ± 6.05 kg (P = .007) and 3.98 ± 6.98 kg (P = .038), respectively, and the right knee extensor root mean square (RMS) ratio increased by 1.24 ± 0.39 (P = .027). Additionally, systolic and diastolic BP decreased by 9.50 ± 10.75 mm Hg (P = .005) and 4.25 ± 4.91 mm Hg (P = .003), respectively. In the CG, the VAS scores decreased by 9.10 ± 13.68 mm (P = .022).

CONCLUSIONS AND IMPLICATIONS

The home-based exercise program using a remote rehabilitation medical device was effective in improving lower extremity strength and function in community-dwelling older women with knee osteoarthritis. This finding suggests that the remote rehabilitation medical device may be used as an alternative to exercise interventions for patients with knee osteoarthritis.

Quadriceps Strength, Postural Stability, and Pain Mediation in Bilateral Knee Osteoarthritis: A Comparative Analysis with Healthy Controls

Bilateral knee osteoarthritis (OA) poses significant challenges to individuals' functional abilities, including quadriceps strength, postural stability, and pain perception. Understanding the complex relationships among these factors is crucial for enhancing knee OA management strategies. The primary objective of this research is to evaluate and draw comparisons between the strength of the quadriceps and the level of postural stability in two distinct groups: individuals afflicted with bilateral knee OA and those who are healthy. Furthermore, the study seeks to examine the potential correlation between the strength of the quadriceps and the level of postural stability in individuals with knee OA. In addition to this, an investigation into the potential mediating effect of pain on the relationship between these physiological factors will also be conducted. A total of 95 participants with bilateral knee OA and 95 healthy controls were recruited. Quadriceps strength was assessed using dynamometry and postural stability was evaluated through anterior-posterior and medial-lateral sway measurements along with the ellipse area using a force plate. Pain levels were measured using the Visual Analog Scale (VAS). Mediation analysis was employed to explore the role of pain in mediating the relationship between quadriceps strength and postural stability. Statistical analyses included t-tests, Pearson correlation coefficients, and mediation analysis. Knee OA participants exhibited significantly lower quadriceps strength (1.08 Nm/kg ± 0.54) compared to controls (1.54 Nm/kg ± 0.57, p < 0.001). They also demonstrated compromised postural stability with increased anterior-posterior sway (9.86 mm ± 3.017 vs. 2.98 mm ± 1.12, p < 0.001), medial-lateral sway (7.87 mm ± 2.23 vs. 3.12 mm ± 1.34, p < 0.001), and larger ellipse area (935.75 mm2 ± 172.56 vs. 436.19 mm2 ± 135.48, p < 0.001). Negative correlations were observed between quadriceps strength and postural stability variables (r = from -0.43 to -0.51, p < 0.001). Pain significantly mediated the relationship between quadriceps strength and postural stability variables (p < 0.05). This study highlights the associations between quadriceps strength, postural stability, and pain mediation in individuals with bilateral knee OA. Our findings emphasize the need for targeted interventions addressing quadriceps weakness and compromised postural stability. Additionally, the mediation effect of pain underscores the complexity of these relationships, offering insights for more effective management strategies.

Association of Sleep Disturbance With Catastrophizing and Knee Pain: Data From the Osteoarthritis Initiative

OBJECTIVE

To investigate the relationship between sleep disturbance, catastrophizing, and knee pain in middle-aged and older individuals.

METHODS

Data from the Osteoarthritis Initiative cohort from months 48 to 96 were used, where month 48 was treated as baseline. Knee pain (Western Ontario and McMaster Universities Osteoarthritis Index pain scale score ≥5 [range 0-20]), catastrophizing (extracted from Coping Strategies Questionnaire score ≥3 [range 0-6]), and sleep quality (extracted from Center for Epidemiologic Studies Depression Scale [range 1-4]) were assessed annually. We described the association of sleep disturbance with the presence and risk of knee pain and catastrophizing. The mediation effect of knee pain and catastrophizing on the sleep-catastrophizing and sleep-pain association was evaluated, respectively.

RESULTS

Catastrophizing and knee pain were reported in 346 (10%) and 917 (24%) of the 3,813 participants (mean 64.9 years, 58% female) at baseline. Participants with worse sleep disturbance were more likely to have knee pain (prevalence ratio [PR] 1.4-2.0, P for trend <0.001) and catastrophizing (PR 1.4-3.1, P for trend <0.001). Sleep disturbance at baseline predicted the risk of knee pain (risk ratio [RR] 1.1, P for trend <0.001) and catastrophizing (RR 1.2-1.7, P for trend <0.001) during follow-up. No statistically significant interactions between sleep disturbance and knee pain or catastrophizing were observed. Knee pain and catastrophizing mediated the sleep-catastrophizing and sleep-pain association, respectively, at baseline, and knee pain negatively mediated the sleep-catastrophizing association longitudinally.

CONCLUSION

Sleep disturbance was associated with the presence and risk of catastrophizing and knee pain. Sleep interventions may have a universal and independent effect in preventing incident knee pain.

The Efficacy of Electroacupuncture in the Treatment of Knee Osteoarthritis: A Systematic Review and Meta-Analysis

This study aims to evaluate the comparative efficacy of electroacupuncture (EA) and analgesics in treating knee osteoarthritis (KOA) and provide evidence-based medical support for EA for the treatment of KOA. Randomized controlled trials from January 2012 to December 2021 are included in electronic databases. The Cochrane risk of bias tool for randomized trials is used to assess the risk of bias in the included studies, while the Grading of Recommendations, Assessment, Development and Evaluation is used to assess the quality of evidence. Statistical analyses are performed using Review Manager V5.4. There are 1616 patients from 20 clinical studies, including 849 patients in the treatment group and 767 patients in the control group. The effective rate in the treatment group is significantly higher than in the control group (p < 0.00001). In the treatment group, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) stiffness scores are significantly improved as compared to the control group (p < 0.0001). However, EA is similar to analgesics in improving visual analog scale scores and WOMAC subitems such as pain and joint function. EA is effective in treating KOA because it can significantly improve clinical symptoms and quality of life in KOA patients.

Prevalence and Characteristics of Knee Osteoarthritis Among the General Public in Saudi Arabia

Background Knee osteoarthritis (OA) is a chronic and progressive knee joint condition that is influenced by multiple factors. This research aims to examine the prevalence and characteristics of knee OA among the general public in Saudi Arabia. Methodology This cross-sectional online survey was conducted in September 2023 in Saudi Arabia. This research used a previously developed questionnaire to validate the diagnosis of OA, which was performed in accordance with the diagnostic criteria established by the American College of Rheumatology (ACR). The Western Ontario and McMaster Universities Arthritis Index questionnaire (WOMAC) was used to examine the severity and characteristics of knee OA patients. A binary logistic regression analysis was conducted to determine the variables that influence the severity of knee OA and the likelihood of developing OA. Results A total of 1,019 individuals participated in this study. Around one-third of the participants (34.5%) fulfilled the ACR criteria for knee OA diagnosis. Overall, the mean WOMAC score was 34.1 (18.8) out of 96, which represents 35.5% of the maximum obtainable score and demonstrates a low degree of knee OA severity. The mean pain sub-scale score was 7.4 (3.8) out of 20, which represents 37.0% of the maximum obtainable score and demonstrates a low level of pain intensity. The mean stiffness sub-scale score was 2.7 (1.8) out of 8, which represents 33.8% of the maximum obtainable score and demonstrates a low degree of stiffness in joints. The mean physical function sub-scale score was 24.0 (14.0) out of 68, which represents 35.3% of the maximum obtainable score and demonstrates a low level of physical function difficulty. Females, older participants (above 40 years), those with high body mass index (28.8 kg/cm2 and higher), non-smokers, those with comorbidities, those who did not practice daily physical activity, those who had a family history of knee OA, and those who suffered from flat feet, rheumatoid arthritis, gout, lupus, or back or hip pain were more likely to develop knee OA and have severe OA (p < 0.05). Conclusions The findings of this study demonstrated a significant prevalence rate of knee OA and highlighted a discrepancy between the rates obtained by diagnostic criteria and those determined through clinical diagnosis. Several significant factors that contribute to the development of OA encompass lifestyle choices such as food and exercise, familial predisposition, genetic influences, and the presence of comorbidities. To effectively tackle this intricate matter, it is imperative to adopt a patient-centered strategy and prioritize early intervention.

The Viability of an Artificial Intelligence/Machine Learning Prediction Model to Determine Candidates for Knee Arthroplasty

BACKGROUND

The purpose of this study is to assess the viability of a knee arthroplasty prediction model using 3-view X-rays that helps determine if patients with knee pain are candidates for total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), or are not arthroplasty candidates.

METHODS

Analysis was performed using radiographic and surgical data from a high-volume joint replacement practice. The dataset included 3 different X-ray views (anterior-posterior, lateral, and sunrise) for 2,767 patients along with information of whether that patient underwent an arthroplasty surgery (UKA or TKA) or not. This resulted in a dataset including 8,301 images from 2,707 patients. This dataset was then split into a training set (70%) and holdout test set (30%). A computer vision model was trained using a transfer learning approach. The performance of the computer vision model was evaluated on the holdout test set. Accuracy and multiclass receiver operating characteristic area under curve was used to evaluate the performance of the model.

RESULTS

The artificial intelligence model achieved an accuracy of 87.8% on the holdout test set and a quadratic Cohen's kappa score of 0.811. The multiclass receiver operating characteristic area under curve score for TKA was calculated to be 0.97; for UKA a score of 0.96 and for No Surgery a score of 0.98 was achieved. An accuracy of 93.8% was achieved for predicting Surgery versus No Surgery and 88% for TKA versus not TKA was achieved.

CONCLUSION

The artificial intelligence/machine learning model demonstrated viability for predicting which patients are candidates for a UKA, TKA, or no surgical intervention.

Investigation of Vitamin D Status, Age, and Body Mass Index as Determinants of Knee Osteoarthritis Severity Using the Kellgren-Lawrence Grading System in a Saudi Arabian Cohort: A Cross-Sectional Study

Background Knee osteoarthritis (OA) is a common and disabling condition affecting millions worldwide. This cross-sectional study endeavors to investigate the relationship between vitamin D status, age, body mass index (BMI), and knee OA in a cohort of individuals in Saudi Arabia. Methods In this cross-sectional study, we assessed vitamin D serum levels, conducted knee radiographs, and evaluated the severity of knee OA using the Kellgren-Lawrence grading system (KLGS). The analysis incorporated both descriptive and inferential statistics, including chi-square tests and a regression model to investigate the relationship between KLGS grades as indicators of knee OA severity and vitamin D levels, considering demographics as covariants. Results The study included 93 participants with suspected knee OA, of which a substantial portion of the sample population presented with knee OA (58 [62.4%]). Knee OA exhibited a higher prevalence among females, comprising 47 (50.54%) of the total, while 11 (11.83%) were male. The largest age group with knee OA was those older than 58 years, 27 (29.03%), followed by the age group of 48-58 years, 19 (20.43%). Obesity was a prevalent factor among knee OA patients (36 [38.7%]), with grade 2 (17 [18.3%]) and grade 3 (24 [25.8%]) being the most frequent. Vitamin D deficiency was prevalent in 54 (58%) of patients. Among knee OA cases, bilateral involvement was predominant in 46 (79%), with a substantial portion, 36 (62%), presenting deficient vitamin D levels. The regression model revealed that age (95% CI: 0.54-1.03, p < 0.001) and BMI (95% CI: 0.01-0.60, p = 0.04) significantly predict higher KLGS grades, indicating that increasing age and higher BMI are associated with higher KLGS grades. However, Vitamin D levels did not show a significant impact on the severity of knee OA. Conclusions The findings from this study highlight the importance of monitoring and maintaining adequate vitamin D levels to potentially reduce the risk of knee OA and the need for early detection and intervention to manage knee OA, particularly in females, older poplulation, and obese adults. They may guide healthcare providers in developing comprehensive approaches to reduce the risk of this condition.

Efficacy and safety of diacerein and celecoxib combination therapy for knee osteoarthritis: A double-blind, randomized, placebo-controlled prospective study

BACKGROUND

Osteoarthritis is a degenerative disease with a growing burden in South Korea. Corresponding drugs are commonly used for pain relief and joint function improvement. Specifically, symptomatic slow-acting drugs for osteoarthritis are frequently used, with diacerein being the most common symptomatic slow-acting drugs for osteoarthritis in South Korea. In this study, we evaluated the efficacy and safety of diacerein and celecoxib combination therapy in patients with osteoarthritis.

METHODS

A total of 71 subjects were randomly assigned to group 1 (diacerein and celecoxib), 2 (diacerein and placebo), or 3 (celecoxib and placebo). The primary outcome measure was the change in the visual analog scale (VAS) score 12 weeks after treatment.

RESULTS

The combination therapy group exhibited a significant decrease in the VAS score, alongside the other control monotherapy groups. Although there was no significant difference between the groups, the combination therapy group exhibited a greater decrease in the absolute value of the VAS score than the other groups. Four weeks after treatment, the combination therapy group showed significantly higher improvement in the stiffness and physical function categories of the Western Ontario and McMaster Universities Osteoarthritis Index than the other groups. Additionally, no serious adverse events occurred following combination therapy, with most adverse events being mild and resolving without specific treatment.

CONCLUSIONS

Diacerein and celecoxib combination therapy is as safe and effective as corresponding monotherapies. A relatively early improvement in stiffness and physical function following treatment with this combination therapy indicates that physicians should consider this for the early-stage treatment of patients with symptomatic osteoarthritis.

Research progress on the treatment of knee osteoarthritis combined with osteoporosis by single-herb Chinese medicine and compound

Knee osteoarthritis (KOA) is a degenerative disease with synovial inflammation, articular surface cartilage degeneration, meniscus degeneration, ligament and muscle changes, subchondral bone changes, and osteophyte formation around the joint as the main pathological changes. Osteoporosis (OP) is a disease characterized by low bone mass and deterioration of the microstructure of bone tissue. KOA and OP are both geriatric diseases, and the incidence of KOA combined with OP is high, but there is a lack of specific drugs, and the major treatments are limited to drug therapy. Most traditional Chinese medicine (TCM) treatments use plant-based natural products, and they help patients obtain good clinical benefits and at the same time provide researchers with ideas to study the mechanism of disease occurrence and the relationship between the two diseases. This article summarizes the research progress of TCM monomers and TCM compounds that are frequently used to treat KOA combined with OP to provide ideas for future clinical treatments and related basic research.

How to Choose the Appropriate Posterior Slope Angle Can Lead to Good Knee Joint Function Recovery in Total Knee Arthroplasty?

Objective

In this study, we aim to examine the effects of osteotomy under varying posterior slope angles on knee joint function recovery following knee arthroplasty.

Methods

We conducted a retrospective analysis from September 2015 to September 2018 on 240 patients who underwent knee arthroplasty three years previously. The study participants were categorized based on changes in the angle of the posterior slope before and after surgery: Group 1, > 5°; Group 2, 3°-5°; Group 3, 0°-3°; Group 4, -3°-0°; Group 5, < -3°. All participants were affected with knee osteoarthritis. The Knee Society Clinical Rating System (KSS) knee function score, Western Ontario and McMaster Universities Arthritis Index (WOMAC) knee function score, Visual Analogue Scale (VAS) pain score, and postoperative complications were measured 3 years after surgery.

Results

The level of pain experienced by the patients decreased significantly than before, with pain scores ranging from 1.0-3.0, and there was a statistical difference between groups (H = 93.400, P < 0.001). The KSS score increased, with group 5 having the lowest median score of 78.0 and group 2 having the highest median score of 97.0, and there was a statistical difference between groups (H = 164.460, P < 0.001). The WOMAC score was reduced, with the median score being 24.0, 11.0, 14.0, 20.0, and 26.0, in the five groups, respectively. Group 5 had the highest score, while Group 2 had the lowest score, and there was a statistically significant difference between groups (H = 164.223, P < 0.001). No symptoms such as periprosthetic femoral fracture, prosthetic loosening, or pad wear were detected in patients postoperatively.

Conclusion

Osteotomy at various posterior slope angles in total knee arthroplasty impacts postoperative knee function rehabilitation. An excessive increase or decrease in angle can have an impact on the postoperative recovery of knee function.

Efficacy and safety of flurbiprofen cataplasms versus loxoprofen sodium cataplasms in knee osteoarthritis: a randomized controlled trial

BACKGROUND

Clinical trial evidence is limited to identify better topical non-steroidal anti-inflammatory drugs (NSAIDs) for treating knee osteoarthritis (OA). We aimed to compare the clinical efficacy and safety of flurbiprofen cataplasms (FPC) with loxoprofen sodium cataplasms (LSC) in treating patients with knee OA.

METHODS

This is an open-label, non-inferiority randomized controlled trial conducted at Peking University Shougang Hospital. Overall, 250 patients with knee OA admitted from October 2021 to April 2022 were randomly assigned to FPC and LSC treatment groups in a 1:1 ratio. Both medications were administered to patients for 28 days. The primary outcome was the change of pain measured by visual analog scale (VAS) score from baseline to day 28 (range, 0-10 points; higher score indicates worse pain; non-inferiority margin: 1 point; superiority margin: 0 point). There were four secondary outcomes, including the extent of pain relief, the change trends of VAS scores, joint function scores measured by the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), and adverse events.

RESULTS

Among 250 randomized patients (One patient without complete baseline record in the flurbiprofen cataplasms was excluded; age, 62.8 ± 10.5 years; 61.4% [153/249] women), 234 (93.6%) finally completed the trial. In the intention-to-treat analysis, the decline of the VAS score for the 24-h most intense pain in the FPC group was non-inferior, and also superior to that in the LSC group (differences and 95% confidence interval, 0.414 (0.147-0.681); P <0.001 for non-inferiority; P = 0.001 for superiority). Similar results were observed of the VAS scores for the current pain and pain during exercise. WOMAC scores were also lower in the FPC group at week 4 (12.50 [8.00-22.50] vs . 16.00 [11.00-27.00], P = 0.010), mainly driven by the dimension of daily activity difficulty. In addition, the FPC group experienced a significantly lower incidence of adverse events (5.6% [7/124] vs . 33.6% [42/125], P <0.001), including irritation, rash and pain of the skin, and sticky hair uncovering pain.

CONCLUSIONS

This study suggested that FPC is superior to LSC for treating patients with knee OA in pain relief, joint function improvement, and safety profile.

Efficacy of Transcutaneous 4.4 MHz Radiofrequency Diathermy versus Therapeutic Ultrasound for Pain Relief and Functional Recovery in Patients with Knee Osteoarthritis: A Randomized Controlled Study

Knee osteoarthritis (KOA) is a prevalent common cause of disability and pain among adults. Transcutaneous radiofrequency (RF) diathermy and therapeutic ultrasound (US) are commonly employed treatments for addressing musculoskeletal conditions. This study aims to evaluate and compare the clinical effectiveness of transcutaneous 4.4 MHz RF diathermy and therapeutic US therapy in individuals diagnosed with KOA. A total of 108 patients with KOA were randomly assigned to either the RF or US groups. Each participant underwent a series of 10 treatment sessions over four weeks and was evaluated at different time points. The assessments included physical evaluations, vital sign measurements, the Numeric Rating Scale (NRS) for pain, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, the Lequesne index, gait analysis, the 36-Item Short Form Health Survey (SF-36), and analysis of adverse responses. Both groups showed significant differences in NRS, WOMAC scores, and Lequesne index compared to baseline values at both the 10th treatment session and the one-month follow-up assessment. However, no significant disparities were observed between the two groups at each assessment point. In the gait analysis, following the 10th treatment, the RF group showed significant changes in stride length and stride velocity compared to baseline. Four weeks after the completion of treatment, both groups exhibited significant alterations in stride length and stride velocity when compared to baseline measurements. However, regarding cadence, only the RF group exhibited a significant difference compared to baseline. The findings suggest that transcutaneous 4.4 MHz RF diathermy displays a comparable effectiveness to therapeutic US in reducing pain and enhancing functional capacity among individuals with KOA. Further research endeavors are warranted to advance the efficacy of noninvasive treatments for KOA.

Does total knee arthroplasty affect pelvic movements? A prospective comparative study

OBJECTIVE

Pathology in any segment of the spine-pelvis-lower extremity may impair the global postural balance, leading to compensatory alterations in other parts. The aim of this study was to compare the pelvic movements of patients suffering from knee osteoarthritis with patients who underwent total knee arthroplasty and healthy controls.

METHODS

This study was performed at the Department of Orthopedics and Traumatology Clinic of a Cankiri State Hospital between April 2021 and February 2022. This study included 84 participants. Of them, 31 patients who underwent total knee arthroplasty between 2018 and 2020 years were selected as the total knee arthroplasty group, while 28 patients with knee osteoarthritis were selected as the knee osteoarthritis group. In the control group, there were 25 healthy individuals. Exclusion criteria from the study included any kind of neurological disease, an inability to walk a distance of 100 m unassisted, or a history of surgery to the lower limb. Pelvic movements (i.e., tilt, rotation, and obliquity) and gait parameters (i.e., "gait velocity," "cadence," and "stride length") were assessed using a wireless tri-axial accelerometer.

RESULTS

Total knee arthroplasty and control groups had decreased minimum anterior tilt of the pelvis, decreased maximum anterior tilt, and decreased oblique range of the pelvis compared with the knee osteoarthritis group. In comparison with the control group, gait velocity and length of stride during gait were remarkably lower in both knee osteoarthritis and total knee arthroplasty groups.

CONCLUSION

In this study, total knee arthroplasty was found to affect pelvic movements. It was thought that total knee arthroplasty changed these variables, probably owing to the frontal and sagittal plane alignment correction through surgery.

A Bidirectional Mendelian Randomization Study of Sarcopenia-Related Traits and Knee Osteoarthritis

Background

With the development of population aging worldwide, sarcopenia and knee osteoarthritis (KOA), two age-related diseases, will continue to impose increasing medical and economic burdens on the society. Previous studies have discovered an association between the two, but the causality remains controversial, and it is difficult to eliminate confounding factors. Therefore, a Mendelian randomization (MR) study was conducted to overcome these confounding factors and investigate the causal relationship between sarcopenia and KOA.

Objective

The present work focused on assessing the causality between KOA and sarcopenia, so as to provide new strategies to prevent and treat these two conditions in clinic.

Methods

We registered the title with PROSPERO (ID: CRD42023421096). The two-sample bidirectional MR analysis was conducted in two steps, with sarcopenia being the exposure whereas KOA being the outcome in the first step, and vice versa in the second step. Genome-wide association studies (GWAS) data on low hand-grip strength (n=256,523), walking pace (n=459,915), appendicular lean mass (ALM, n=450,243), and KOA (n=403,124) were obtained from the UK Biobank. Methods such as the inverse variance weighted (IVW) and weighted median were utilized for assessing the causality of KOA with sarcopenia, and sensitivity analyses were also conducted.

Results

In the main MR analysis using the IVW method, evidence suggested that low hand-grip strength, walking pace, and ALM had adverse effects on KOA (p-value 0.0001, odds ratio (OR) 1.4569, 95% confidence interval (CI) 1.2007-1.7677 for low hand-grip strength; p-value 0.0003, OR 1.1500, 95% CI 1.050-1.183 for ALM; p-value 5.29E-19, OR 0.0932, 95% CI 0.0553-0.1572 for walking pace). However, there was no causality of KOA with sarcopenia in the opposite direction.

Conclusion

Our study suggests an obvious unidirectional causality of KOA with sarcopenia, and supports the notion that patients with sarcopenia are more susceptible to the development of KOA.

The efficacy of the leg swing and quadriceps strengthening exercises versus platelet-rich plasma and hyaluronic acid combination therapy for knee osteoarthritis: A retrospective comparative study

The aim of this was to investigate the efficacy of physical exercise (leg swing and quadriceps strengthening exercises) versus platelet-rich plasma (PRP) and hyaluronic acid (HA) combination therapy. From January 2020 to August 2021, 106 patients with Kellgren-Lawrence Grade I-III knee osteoarthritis were divided into leg swing and quadriceps strengthening exercises (Group A) and intra-articular combination injections of PRP and HA (Group B) according to the treatment strategies. Patients in Group A received regular leg swing and quadriceps strengthening exercises for 3 months. Patients in Group B received 2 intra-articular combination injections of PRP (2 mL) and HA (2 mL) every 2 weeks. The primary outcome measures were the Visual Analogue Scale (VAS) and the Western Ontario and McMaster Universities (WOMAC) score. Secondary outcomes included single leg stance test and functional activity by 2-minute walk test and time up and go test. All outcomes were evaluated at baseline and again 1, 3, 6, and 12 months. The VAS and WOMAC scores were similar in both groups at 1 and 3 months after treatment (P > .05); however, Group A patients had significantly superior VAS and WOMAC scores than Group B patients at 6 and 12 months after treatment. For the single leg stance test, 2-minute walk test, and time up and go test, Group A patients were significantly superior to Group B throughout follow-up (P < .001). The leg swing and quadriceps strengthening exercises resulted in a significantly better clinical outcomes than the combined PRP and HA therapy, with a sustained lower pain score and improved quality of life, balance ability, and functional activity within 12 months.

Efficacy of acupotomy combined with sodium hyaluronate versus sodium hyaluronate alone in the treatment of knee osteoarthritis: A meta-analysis

BACKGROUND

The efficacy of acupotomy combined with hyaluronic sodium acid in the treatment of knee osteoarthritis (KOA) is unclear. Therefore, this meta-analysis aims to evaluate the efficacy of acupotomy combined with hyaluronic sodium acid compared with hyaluronic sodium acid alone in the treatment of KOA.

METHODS

Studies from 8 Online databases were searched on KOA treatment using acupotomy combined with sodium hyaluronate until May 2022. The primary outcome indicator was clinical effectiveness, and the secondary outcome indicators included the visual analogue scale scores and Lysholm scores. We calculated the weighted mean difference (WMD) or relative risk for all relevant outcomes.

RESULTS

Nine studies were identified, involving 644 cases. The results showed that acupotomy combined with intra-articular sodium hyaluronate injection for KOA was superior to sodium hyaluronate injection alone in terms of clinical effectiveness (relative risk = 1.17, 95% confidence interval [CI]: 1.09-1.25, P < .001) and visual analogue scale (WMD = -2.1, 95% CI: -2.25 to 1.95, P < .001), Lysholm score (WMD = 13.83, 95% CI: 3.47-24.19, P = .009).

CONCLUSION

Acupotomy combined with intra-articular sodium hyaluronate injection for KOA is superior to sodium hyaluronate injection alone. Limited by the number and quality of included studies, this conclusion still needs to be verified by more high-quality Research.

INPLASY REGISTRATION NUMBER

INPLASY202350029.

Economic Evaluation of Glucosamine in Knee Osteoarthritis Treatments in Vietnam

Osteoarthritis (OA) is the degeneration of cartilage in joints that results in bones rubbing against each other; it causes uncomfortable symptoms such as pain, swelling, and stiffness and can lead to disability. It usually occurs in the elderly and causes a large medical burden. The aim of this study is to evaluate the cost-effectiveness between the standard treatment for osteoarthritis and standard treatment with added crystalline glucosamine sulfate at various stages. Markov analysis modeling was applied to evaluate the effect of both adding glucosamine compared to standard treatment from a societal perspective during whole patients' lifetimes. Data input was collected from reviews in previous studies. The outcome was measured in quality-adjusted life years (QALYs), and the Incremental Cost-Effectiveness Ratio (ICER) from a societal perspective was applied with 3% and discounted for all costs and outcomes. One-way analysis via the Tornado diagram was performed to investigate the change in factors in the model. In general, adding glucosamine into the standard treatment proved to be more cost-effective compared to the standard treatment. Particularly, the early-stage addition of glucosamine in the treatment was cost-effective compared to the post-stage addition of glucosamine. The addition of supplementing crystalline glucosamine sulfate to the whole regimen at any stage was cost-effective at the willingness-to-pay (WTP) threshold.

Chinese guidelines for the rehabilitation treatment of knee osteoarthritis: An CSPMR evidence-based practice guideline

BACKGROUND

Knee osteoarthritis (KOA) is the most common degenerative joint disease in China, causing a huge economic burden on patients, families, and society. Standardized KOA rehabilitation treatment is an important means to prevent and treat the disease and promote the development of high-quality medical services. This guideline is updated on the basis of the 2016 and 2019 editions.

METHODS

Clinical questions regarding rehabilitation assessment and treatment were selected through clinical questions screening and deconstruction, and multiple rounds of Delphi questionnaire consultation. The International Classification of Functioning, Disability and Health (ICF) was used as the theoretical framework, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was used to grade the quality of evidence and recommendations.

RESULTS

The reporting of this guideline followed the standard of Reporting Items for Practice Guidelines in Healthcare (RIGHT). Taking into account patients' preferences and values and the needs of Chinese clinical practice, a total of 11 clinical questions and 28 recommendations were established. The clinical questions were grouped into two categories: KOA assessment (body function, body structure, activity and participation, quality of life, and environmental factors and clinical outcomes assessment, resulting in 9 recommendations) and KOA treatment (health education, therapeutic exercise, therapeutic modalities, occupational therapy, assistive devices, and regenerative rehabilitation approaches, resulting in 19 recommendations).

CONCLUSION

This is the first evidence-based guideline for KOA rehabilitation in China utilizing the ICF framework. This guideline provides key guidance for developing systematic, standardized, and precise rehabilitation protocols for KOA across various healthcare settings.

The effectiveness of peroneal nerve stimulation combined with neuromuscular electrical stimulation in the management of knee osteoarthritis: A randomized controlled single-blind study

Objectives

This study aimed to compare the effectiveness of neuromuscular electrical stimulation (NMES) combined with peroneal nerve stimulation (PNS) on muscle strength around the knee, proprioception, pain, functional status, and quality of life in patients with knee osteoarthritis (OA).

Patients and methods

The prospective, randomized, single-blinded, controlled trial included 63 patients with clinical and radiological diagnoses of knee OA between December 2019 and March 2020. The patients were divided into two groups: Group 1 (NMES+PNS, n=31) and Group 2 (NMES, n=32). The patients were followed up at two and six weeks. Main outcome measures were the Visual Analog Scale, Western Ontario and McMaster Universities Arthritis Index, Nottingham Health Profile, and 100-m walking test, quadriceps muscle strength, hamstring muscle strength (HMS), and joint position sense were evaluated using a computer-controlled isokinetic dynamometer at 60°/sec, 90°/sec, and 120°/sec angular velocities. The proprioception was evaluated at 30° and 60° flexion angles using the same device.

Results

Two patients from Group 1 and two patients from Group 2 were excluded from the study after they failed to show up for the six-week control. As a result, the study was completed with 59 patients (30 females, 29 males; 55.9±6.1 years; range, 40 to 65 years). There was a significant difference between the two groups in the 100-m walking test parameter at the six-week control in favor of Group 1 (p<0.05). There was a significant difference in favor of Group 1 in the parameters of proprioception (30° and 60°) and HMS (60° and 90°) in both the two-week evaluation and six-week controls (p<0.05). The HMS 120° parameter showed a significant difference in favor of Group 1 at the six-week control (p<0.05).

Conclusion

In patients with knee OA, we believe that PNS combined with NMES may be more effective than NMES treatment alone in terms of proprioception, HMS, and functional status.

Relationship between knee osteophytes and calcitonin gene-related peptide concentrations of serum and synovial fluid in knee of osteoarthritis

To explore the relationship between knee osteophytes of osteoarthritic knee and calcitonin gene-related peptide (CGRP) concentrations of serum and synovial fluid (SF). 65 patients with knee medial compartment osteoarthritis (OA) were recruited and examined with weight-bearing radiographs of the entire lower limb. The concentrations of CGRP in serum/SF were also detected in surgery. The relationship between the concentrations of CGRP in serum/SF and osteophyte scores were detected with Spearman rank correlation coefficient. CGRP concentrations in serum and SF were significantly correlated with osteophyte score of overall knee respectively (R = 0.462, P < .001; R = 0.435, P < .001). In addition, a correlation tended to be observed about the relationship between CGRP concentrations in serum and SF and osteophyte scores of medial compartment (R = 0.426, P < .001; R = 0.363, P = .003), and osteophyte scores of lateral compartment (R = 0.429, P < .001; R = 0.444, P < .001). In this study, the relationship between CGRP in serum/SF and knee osteophyte scores in different subregions were explored, which showed significant positive correlations, that possibly reflecting the contribution of CGRP influencing osteophyte formation. Positive correlations between osteophyte scores and CGRP suggest that CGRP promote the growth of osteophyte formation. It has the potential to be selected as a biomarker for the assessment of severity in knee OA patients and predict the progression of knee OA. It also provides a potential therapeutic target to delay the progression and relieve the symptom of OA.

Developing a common metric using current scales for assessing functioning in patients with knee osteoarthritis

Objectives

Various scales exist to assess different domains of functioning in knee osteoarthritis (OA). This study aimed to explore whether it is possible to develop a common metric (CM) from the frequently used scales to assess functioning in knee OA.

Patients and methods

The methodological study evaluated 411 patients (81 males, 330 females; mean age: 61.8±10.5 years; range, 41 to 88 years) with knee OA. Data from the Health Assessment Questionnaire, Oxford Knee Score, Medical Outcomes Study Short Form 36, Knee Injury and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Arthritis Index, and the Nottingham Health Profile were used, and the items focusing on self-care, mobility, and domestic activity domains based on the activities and participation component of the International Classification of Functioning, Disability, and Health were included. Concurrent calibration was performed to combine the items of the scales. The CM parameters were estimated using the Rasch measurement model. Reliability was assessed using the person separation index. The CM was utilized to generate a transformation table to convert the scale scores to each other based on the reference metric score.

Results

Each scale fitted the Rasch model. Item invariance was achieved for the CM (p=0.775). The CM had a person separation index of 0.827. Age, sex, and disease duration did not cause difference in item functions. The CM satisfied the assumptions of unidimensionality and local independence.

Conclusion

A reliable CM was created from the commonly used scales to measure functioning in individuals with knee OA. Thus, clinicians and researchers can refer to the transformation table to directly compare scores of those scales and use them interchangeably.

The relationship between inadequate response to physical therapy and central sensitization in patients with knee osteoarthritis: A prospective cohort study

Objectives: This study aims to investigate the relationship between physical therapy response and the presence of central sensitization (CS) in patients with painful knee osteoarthritis (OA). Patients and methods: Between May 2019 and March 2020, a total of 84 patients with knee OA (12 males, 72 females; mean age: 60.7±7.7 years; range 50 to 74 years) and 30 age and sex-matched controls (6 males, 24 females; mean age: 59.2±8.9 years; range 50 to 75 years) were included in this study. Knee pain and functional status were evaluated by Visual Analog Scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Structural damage was assessed by knee radiography. The Central Sensitization Inventory (CSI), Beck Depression Inventory (BDI), Insomnia Severity Index (ISI), Pain Catastrophizing Scale (PCS), and PainDETECT Questionnaire (PDQ) were applied at baseline. Pain pressure thresholds (PPTs) of the patients were measured and compared with the control group. All patients underwent a total of 15 sessions of physical therapy program for five sessions/weekly. After treatment, the patients were divided into two groups as responders and non-responders according to the Osteoarthritis Research Society International (OARSI) criteria. Results: The CSI score of the patients in non-responder group was significantly higher compared to the responder group (p=0.004). Using a cut-off value of ≥40, the proportion of patients with CSI scores of ≥40 was significantly lower in the responder group compared to non-responder group (p=0.021). The PPT measurement values were significantly lower in the non-responder group compared to the responder and control groups (p <0.01). There was a significant difference in the frequency of hyperalgesia between the groups (p=0.021). Central sensitization and depression were the most significant predictors of non-response to physical therapy (p=0.045 and p=0.024, respectively). Conclusion: Our study results suggest the presence of CS and depression may result in an inadequate response to physical therapy in patients with knee OA. Clinicians should consider the findings of CS and depression in treatment planning.

Medial and lateral knee contact forces during walking, stair ascent and stair descent are more affected by contact locations than tibiofemoral alignment in knee osteoarthritis patients with varus malalignment

Introduction: Knee OA progression is related to medial knee contact forces, which can be altered by anatomical parameters of tibiofemoral alignment and contact point locations. There is limited and controversial literature on medial-lateral force distribution and the effect of anatomical parameters, especially in motor activities different from walking. We analyzed the effect of tibiofemoral alignment and contact point locations on knee contact forces, and the medial-lateral force distribution in knee OA subjects with varus malalignment during walking, stair ascending and stair descending. Methods: Fifty-one knee OA subjects with varus malalignment underwent weight-bearing radiographs and motion capture during walking, stair ascending and stair descending. We created a set of four musculoskeletal models per subject with increasing level of personalization, and calculated medial and lateral knee contact forces. To analyze the effect of the anatomical parameters, statistically-significant differences in knee contact forces among models were evaluated. Then, to analyze the force distribution, the medial-to-total contact force ratios were calculated from the fully-informed models. In addition, a multiple regression analysis was performed to evaluate correlations between forces and anatomical parameters. Results: The anatomical parameters significantly affected the knee contact forces. However, the contact points decreased medial forces and increased lateral forces and led to more marked variations compared to tibiofemoral alignment, which produced an opposite effect. The forces were less medially-distributed during stair negotiation, with medial-to-total ratios below 50% at force peaks. The anatomical parameters explained 30%-67% of the variability in the knee forces, where the medial contact points were the best predictors of medial contact forces. Discussion: Including personalized locations of contact points is crucial when analyzing knee contact forces in subjects with varus malalignment, and especially the medial contact points have a major effect on the forces rather than tibiofemoral alignment. Remarkably, the medial-lateral force distribution depends on the motor activity, where stair ascending and descending show increased lateral forces that lead to less medially-distributed loads compared to walking.

Medial Meniscus Posterior Root Repair Reduces but Does Not Avoid Histologic Progression of Osteoarthritis: Randomized In Vivo Experimental Study in a Rabbit Model

BACKGROUND

The optimal treatment option for meniscus root tears is still challenging, and whether the meniscus root repair ultimately can arrest or delay osteoarthritic changes is still a concern.

PURPOSE/HYPOTHESIS

The purpose of this study was 2-fold: (1) to describe and compare histopathologic findings of 3 different therapeutic options for medial meniscus posterior root tear: nonoperative management, partial meniscectomy, and meniscus root repair; and (2) to test the hypothesis that meniscus root tears treated nonoperatively predispose to a lower risk of osteoarthritic progression compared with partial meniscectomy.

STUDY DESIGN

Controlled laboratory study.

METHODS

Posteromedial meniscus root tears were carried out in 39 New Zealand White rabbits. Animals were randomly assigned into 3 experimental groups: partial meniscectomy after root tear (PM; n = 13), root tears treated conservatively (CT; n = 13), and transtibial root repair (RR; n = 13). Contralateral limbs were used as healthy controls. The animals were euthanized at 16 weeks postoperatively; tissue samples of femoral and tibial articular cartilage were collected and processed for macro- and microscopic assessment to detect signs of early osteoarthritis (OA). Each sample was histopathologically assessed using the Osteoarthritis Research Society International grading and staging system.

RESULTS

Osteoarthritic changes were the hallmark in all 3 experimental groups. The RR group had the lowest scores for cartilage damage (mean, 2.5; range, 2-3), and the PM group exhibited higher and more severe signs of OA (mean, 16; range, 9-16) compared with the CT group (mean, 5; range, 4-6). The between-group comparison revealed significant differences, as the PM group showed a significantly higher rate of macro- and microscopic osteoarthritic changes compared with the RR (P < .001) and CT (P < .001) groups. The weightbearing area of the medial femoral condyle was the most severely affected, and tidemark disruption was evident in all tissue samples.

CONCLUSION

Meniscus root repair cannot completely arrest the histopathologic progression of knee OA but leads to significantly less severe degenerative changes than partial meniscectomy and nonoperative treatment. Partial meniscectomy leads to the most severe osteoarthritic progression, while stable radial tears left in situ have lower progression compared with partial meniscectomy.

CLINICAL RELEVANCE

Histologic assessment is an essential tool and metric for guiding and understanding osteoarthritic features, providing insight into the disease development and progression. This study provides histopathologic evidence on osteoarthritic progression after medial meniscus posterior root repair. This knowledge can help to set more realistic expectations and can lead to the future development of augmented techniques.

Decreased Elastic Modulus of Knee Articular Cartilage Based on New Macroscopic Methods Accurately Represents Early Histological Findings of Degeneration

OBJECTIVE

Ex vivo nanoindentation measurement has reported that elastic modulus decreases as cartilage degenerates, but no method has been established to macroscopically evaluate mechanical properties in vivo. The objective of this study was to evaluate the elastic modulus of knee joint cartilage based on macroscopic methods and to compare it with gross and histological findings of degeneration.

DESIGN

Osteochondral sections were taken from 50 knees with osteoarthritis (average age, 75 years) undergoing total knee arthroplasty. The elastic modulus of the cartilage was measured with a specialized elasticity tester. Gross findings were recorded as International Cartilage Repair Society (ICRS) grade. Histological findings were graded as Mankin score and microscopic cartilage thickness measurement.

RESULTS

In ICRS grades 0 to 2 knees with normal to moderate cartilage abnormalities, the elastic modulus of cartilage decreased significantly as cartilage degeneration progressed. The elastic modulus of cartilage was 12.2 ± 3.8 N/mm for ICRS grade 0, 6.3 ± 2.6 N/mm for ICRS grade 1, and 3.8 ± 2.4 N/mm for ICRS grade 2. Similarly, elastic modulus was correlated with Mankin score (r = -0.51, P < 0.001). Multiple regression analyses showed that increased Mankin score is the most relevant factor associated with decreased elastic modulus of the cartilage (t-value, -4.53; P < 0.001), followed by increased histological thickness of the cartilage (t-value, -3.15; P = 0.002).

CONCLUSIONS

Mechanical properties of damaged knee cartilage assessed with new macroscopic methods are strongly correlated with histological findings. The method has potential to become a nondestructive diagnostic modality for early cartilage damage in the clinical setting.

A comparison between hypertonic dextrose prolotherapy and conventional physiotherapy in patients with knee osteoarthritis

The aim of the present study was to compare the efficacy of hypertonic dextrose prolotherapy (HDP) with conventional physiotherapy (CPT) in improving symptoms in females with knee osteoarthritis (OA). The present study included 60 patients with a diagnosis of knee OA. The patients were randomly assigned to the HDP (n=30) and CPT (n=30) groups. The patients in the HDP group were treated with a dextrose injection into the knee joint (25% dextrose) and around the knee (15% dextrose) in two sessions for 1 month, while those in the CPT group received a hot pack, transcutaneous electrical nerve stimulation and therapeutic ultrasound in five sessions a week for 4 weeks. Prior to commencing the treatment, and at 1 and 3 months post-treatment, all the patients were evaluated using the visual analog scale (VAS), Western Ontario and McMaster Osteoarthritis Index (WOMAC), the goniometric measurement of active knee range of motion (ROM), a 50-m walking test and isokinetic knee muscle strength measurements. There were no statistically significant differences between the two groups as regards the demographic characteristics at pre-treatment (P>0.05). However, at 1 and 3 months post-treatment, the scores of all the outcome parameters were significantly improved in the HDP group compared with the CPT group (P<0.05 for all). In both groups, a significant improvement was observed in the VAS scores, WOMAC total values and ROM following the treatments, with the greatest improvement observed in the HDP group (P<0.001). The isokinetic quadriceps peak torque measurements were increased in both groups following treatment. All the scores exhibited a statistically significant improvement in the HDP group at both 1 and 3 months post-treatment. On the whole, the results of the present study demonstrate that both HDP and CPT are effective treatment modalities to relieve pain, and increase functionality and strength in patients with knee OA. However, greater improvements in pain and functionality can be achieved with prolotherapy.

Effectiveness and Adherence Rate of S-flurbiprofen Plaster for the Pain Management of Patients With Moderate and End-Stage Knee Osteoarthritis

BACKGROUND

S-flurbiprofen plaster (SFPP) is highly skin permeable and represents a new conservative treatment for knee osteoarthritis (KOA) that can attain considerably higher concentrations in the synovium than topical flurbiprofen. To date, no study has investigated the efficacy and adherence rate of SFPP in patients with end-stage KOA. This study aimed to compare the effectiveness and adherence rate of SFPP for pain management in patients with moderate and end-stage KOA.

METHODS

This retrospective study included a total of 118 patients with KOA (Kellgren-Lawrence classification grades II (n = 29), III (n = 32), and IV (n = 57)). The difference in SFPP use rate, adverse drug reactions rate, whether 50% pain relief occurred, and the percentage of patients who underwent surgical treatment were calculated.

RESULTS

The overall SFPP use rate at one year was 61.0% (88.1% at less than one month, 79.7% at three months, and 61.0% at six months), with no significant differences among Kellgren-Lawrence grade II, III, and IV groups (p = 0.538). Adverse drug reactions such as skin rash (n = 23), skin irritation (n = 8), and gastrointestinal disorders (n = 2) were observed. The one-year SFPP use rate was significantly lower in patients in whom these side effects occurred but did not decrease in patients in whom only a skin rash occurred. Overall, 19 patients underwent surgery after discontinuation of SFPP use. Surgery was statistically selected more by the "over 71 years of age" group (p = 0.038) and the "ineffective" group (p = 0.007).

CONCLUSION

SFPP exerts a comparable therapeutic effect even in end-stage KOA and may be an effective treatment option. Even if patients have end-stage KOA, there are cases in which the patient's background does not allow for surgery positively, such as high perioperative risk or desire for conservative treatment. In such cases, SFPP may be an effective treatment option worth trying.

Comparison of Neuromuscular Joint Facilitation and Quadriceps Strengthening Exercise in Knee Osteoarthritis: a Randomized Controlled Trial

Objectives

To compare the effect of neuromuscular joint facilitation (NJF) and quadriceps strengthening exercises on pain, physical function, static posture, and balance control in subjects with knee osteoarthritis.

Design

Randomized controlled trial.

Setting

Department of Physiotherapy, Manipal Hospitals, Bangalore.

Participants

Subjects diagnosed with knee osteoarthritis according to the American College of Sports Medicine criteria. The mean age of subjects in the control group was 63.12 ± 8.08 years; in the experimental group was 61.77 ± 8.46 years.

Interventions

The intervention group received NJF treatment twice a week for six weeks, and the control group received quadriceps strengthening exercises. Standard knee exercises were given as a home program to both groups.

Outcome Measures

Numeric Pain Rating Scale (NPRS), 30-second chair stand (30s-CST), and single leg stance (SLS) were used to assess physical function, static posture, and balance control, respectively, at the end of the sixth week.

Results

Sixty subjects were randomly allocated to intervention and control groups. The experimental and control group showed a mean difference of 3.89 and 4.17 in NPRS, 4.19 and 4.17 in 30s-CST, 6.81 and 5.71 in SLS at the end of six weeks. This change was significant within both groups (p value .000) and not significant between groups (NPRS p value .303; 30s-CST p value .09; SLS p value .525) at the end of six weeks.

Conclusions

NJF and quadriceps strengthening exercises effectively reduced pain and improved physical function, static posture, and balance control in subjects with knee osteoarthritis. Both groups had the same effect on all clinical variables at six weeks of follow-up. Hence, further studies with long term follow-up are warranted.

[Cangxi Tongbi Capsules promote chondrocyte autophagy by regulating circRNA＿0008365/miR-1271/p38 MAPK pathway to inhibit development of knee osteoarthritis]

To investigate the mechanism by which Cangxi Tongbi Capsules promote chondrocyte autophagy to inhibit knee osteoarthritis(KOA) progression by regulating the circRNA＿0008365/miR-1271/p38 mitogen-activated protein kinase(MAPK) pathway. The cell and animal models of KOA were established and intervened with Cangxi Tongbi Capsules, si-circRNA＿0008365, si-NC, and Cangxi Tongbi Capsules combined with si-circRNA＿0008365. Flow cytometry and transmission electron microscopy were employed to determine the level of apoptosis and observe autophagosomes, respectively. Western blot was employed to reveal the changes in the protein levels of microtubule-associated protein light chain 3(LC3)Ⅱ/Ⅰ, Beclin-1, selective autophagy junction protein p62/sequestosome 1, collagen Ⅱ, a disintegrin and metalloproteinase with thrombospondin motifs 5(ADAMTS-5), and p38 MAPK. The mRNA levels of circRNA＿0008365, miR-1271, collagen Ⅱ, and ADAMTS-5 were determined by qRT-PCR. Hematoxylin-eosin staining was employed to reveal the pathological changes of the cartilage tissue of the knee, and enzyme-linked immunosorbent assay to measure the levels of interleukin-1β(IL-1β) and tumor necrosis factor-alpha(TNF-α). The chondrocytes treated with IL-1β showed down-regulated expression of circRNA＿0008365, up-regulated expression of miR-1271 and p38 MAPK, lowered autophagy level, increased apoptosis rate, and accelerated catabolism of extracellular matrix. The intervention with Cangxi Tongbi Capsules up-regulated the expression of circRNA＿0008365, down-regulated the expression of miR-1271 and p38 MAPK, increased the autophagy level, decreased the apoptosis rate, and weakened the catabolism of extracellular matrix. However, the effect of Cangxi Tongbi Capsules was suppressed after interfering with circRNA＿0008365. The in vivo experiments showed that Cangxi Tongbi Capsules dose-dependently inhibited the p38 MAPK pathway, enhanced chondrocyte autophagy, and mitigated articular cartilage damage and inflammatory response, thereby inhibiting the progression of KOA in rats. This study indicated that Cangxi Tongbi Capsules promoted chondrocyte autophagy by regulating the circRNA＿0008365/miR-1271/p38 MAPK pathway to inhibit the development of KOA.

The role of osteoarthritis severity, BMI and age on clinical efficacy of bone marrow aspirate concentrate in the treatment of knee osteoarthritis

Aim: The aim of this study was to assess whether BMI, severity of knee osteoarthritis, age and gender have any influence on the final clinical results of bone marrow aspirate concentrate injection. Method: A total of 111 study participants with painful knee osteoarthritis and different characteristics concerning before mentioned factors underwent bone marrow aspirate concentrate (BMAC) therapy and were followed up for 1 year. Result: Significant pain and functional improvement were observed in all participant groups. Participants' age and BMI did not influence the clinical outcome, but there was an influence of OA severity, especially among older patients. Conclusion: This study shows that BMAC therapy is effective. Younger patients with milder OA changes could be better candidates for long-lasting and more efficient BMAC therapy. Clinical Trial Registration: NCT03825133 (ClinicalTrials.gov).

The Role of Matrix Metalloproteinase 13 and Vitamin D in Osteoarthritis: A Hospital-Based Observational Study

Introduction Osteoarthritis (OA) is the most common form of degenerative joint disease characterized by the progressive degeneration of articular cartilage, osteophyte formation, and joint space narrowing. Matrix metalloproteinases (MMPs) are potential biomarkers for osteoarthritis. Aims and objective The study's aim is the estimation of serum and synovial fluid matrix metalloproteinase (MMP) 13 and serum vitamin D levels in the grade 3 and grade 4 stages of osteoarthritis according to the Kellgren and Lawrence (KL) system of classification. Materials and methods A total of 100 subjects were included; of them, 25 patients with grade 3 and 25 patients with grade 4 knee osteoarthritis diagnosed clinically and radiologically according to the Kellgren and Lawrence criteria have been enrolled in the study, and 50 patients with knee pain having a diagnosis other than degenerative OA of the knee were taken as controls. Venous blood and synovial fluid have been collected from all of them for the estimation of MMP-13 and vitamin D. The enzyme-linked immunosorbent assay (ELISA) and chemiluminescent microparticle immunoassay (CMIA) methods were used for the estimation of MMP-13 and vitamin D, respectively. Results The mean value of synovial fluid MMP-13 was found to be elevated in grade 4 as compared to grade 3 and the control group, whereas the mean value of serum MMP-13 was found to be elevated in grade 3 as compared to grade 4 and control. The level of serum vitamin D was found deficient in OA patients as compared to control. The Kruskal-Wallis test was performed to compare these groups, and there was a significant difference between these groups (p-value of <0.05). Summary and conclusion High synovial and serum MMP-13 is associated with knee structural abnormalities in patients with knee OA as compared to the control group suggesting that MMP-13 can be a biomarker in knee OA, whereas the decreased level of vitamin D may be associated with an increased risk for the progression of OA; hence, serum vitamin D may be a good indicator for the prediction of the initiation of OA.

Increase in Postoperative Body Mass Index in Patients After Total Knee Arthroplasty

Objectives The aim of this is to investigate the changes in body mass index (BMI) following knee arthroplasty and to evaluate their impact on patient-reported outcomes and functional evaluations. Methods This observational study included 90 patients who underwent total knee arthroplasty (TKA) and were followed up for a median period of 2.6 years. BMI measurements were recorded before and after surgery, and patient-reported outcomes and functional evaluations were assessed using standardized scales and tests. Results Following TKA, BMI increased statistically significantly (Wilcoxon signed-rank test, p < 0.000). In addition, half of the patients experienced an increase in BMI, with 32% moving up in their BMI category. However, there were no clinically significant differences in patient-reported outcomes or functional evaluations between the group that gained BMI and the group that maintained or lost BMI. Conclusion This study reveals that patients tend to have increased BMI following TKA. However, these BMI changes do not significantly impact patient-reported outcomes or functional evaluations. It underscores the importance of patient education regarding healthy lifestyle habits, including diet and physical activity, to address postoperative weight gain effectively.

Bilateral Knee Osteoarthritis Treated With Medial Open-Wedge High Tibial Osteotomy Using Two Types of β-Tricalcium Phosphate With Differing Placements in Each Knee: A Report of Two Cases

In medial open-wedge high tibial osteotomy (MOWHTO) for knee osteoarthritis, synthetic bone is commonly used as a replacement material for the opening gap. Unidirectional porous β-tricalcium phosphate (UDPTCP) and spherical porous β-tricalcium phosphate (SPTCP) have been widely used in this regard. In general, the two prostheses are placed parallel to the osteotomy opening gap. In this report, we discuss two cases involving a 63-year-old woman and a 51-year-old man who underwent MOWHTO for bilateral knee osteoarthritis. Both patients had experienced bilateral knee pain. In both patients, UDPTCP was placed anteriorly and SPTCP was placed posteriorly in one knee, with the placement reversed in the other knee. The remodeling of each type of β-TCP was evaluated using CT immediately after the surgery and one year postoperatively. The postoperative corrective loss and clinical outcomes were also evaluated. Remodeling with β-TCP was found to be faster with UDPTCP than with SPTCP, even though the anteroposterior placement differed laterally in each patient. Furthermore, there was no correction loss, and the clinical outcomes were comparable, regardless of the placement of β-TCP.

Association of Medial Meniscus Root Tears and Nonroot Tears With Worsening of Radiographic Knee Osteoarthritis

Background

Medial meniscus root tears (RTs) are associated with the development and worsening of knee osteoarthritis (OA), but little is known about their progression when compared with meniscal tears that spare the root (nonroot tears; NRTs).

Purpose

To compare radiographic worsening of OA in knees with RTs versus NRTs and to identify factors associated with radiographic worsening of OA in knees with RTs.

Study Design

Cohort study; Level of evidence, 3.

Methods

Using the Osteoarthritis Initiative database, we included knees with medial meniscus RTs and NRTs present at the baseline visit (baseline tears) and new RTs and NRTs observed at 12- to 48-month annual follow-up visits (incident tears). Worsening of radiographic OA was defined for baseline tears as an increase in Kellgren-Lawrence grade (KLG) during the subsequent 12 months of follow-up; for incident tears, worsening was defined as either concurrent (increase in KLG over the 12 months preceding tear appearance on magnetic resonance imaging) or subsequent (increase in KLG during the 12 months after tear appearance). Odds ratios (ORs), adjusted for covariates, were calculated for the association of worsening by type of tear.

Results

Included were 39 knees with baseline RTs, 633 knees with baseline NRTs, 33 knees with incident RTs, and 234 knees with incident NRTs. Radiographic OA worsening subsequent to meniscal tear identification was no different for baseline RTs (15%) or baseline NRTs (14%; adjusted OR, 1.34; 95% CI, 0.52-3.47), nor did subsequent worsening differ for incident RTs (19%) versus incident NRTs (18%; adjusted OR, 0.52; 95% CI, 0.15-1.83). Concurrent radiographic OA worsening was seen at a significantly higher rate for incident RTs (64%) versus incident NRTs (21%; adjusted OR, 3.00; 95% CI, 1.21-7.47). Incident RTs in knees without radiographic OA (KLG 0-1) before the tear had a high rate of worsening (94%, n = 16) and were more likely to worsen than those in knees with radiographic OA (KLG ≥2) present before the tear.

Conclusion

Compared with NRTs, incident RTs were associated with a significantly increased risk of worsening radiographic OA over a 12-month period concurrent with the appearance of the tear. Incident RTs in knees without radiographic OA at baseline had a high rate of worsening.

Incidence and risk factors for surgical site infection after medial opening-wedge high tibial osteotomy using a locking T-shape plate

Medial opening-wedge high tibial osteotomy (MOWHTO) is a well-established surgical method for treatment of isolated medial compartment osteoarthritis with varus deformity, but the surgical outcomes may be compromised by surgical site infection (SSI). This study aimed to investigate the incidence and the risk factors for SSI after MOWHTO. This retrospective study included consecutive patients who underwent MOWHTO for isolated medial compartment osteoarthritis with varus deformity in two tertiary referral hospitals from January 2019 and June 2021. Patients who developed SSI within 12 months of surgery were identified by inquiring the medical records for index hospitalisation, notes of after-discharge outpatient visits, or records of readmission for treatment of SSI. Univariate comparisons were performed to detect the differences between SSI and non-SSI groups, and multivariate logistic regression analysis was used to identify the independent risk factors. Six hundred sixteen patients with 708 procedures were included and 30 (4.2%) cases of SSI occurred, with 0.6% rate for deep SSI and 3.6% for superficial. Univariate analyses showed significant difference between groups in terms of morbidity obesity (≥32 kg/m2 ) (20.0% vs 8.9%), comorbid diabetes (26.7% vs 11.1%), active smoking (20.0% vs 6.3%), time from admission to operation (5.2 ± 4.0 vs 4.1 ± 3.0), size of osteotomy ≥12 mm (40.0% vs 20.0%), type of bone grafting and lymphocyte count (2.1 ± 0.5 vs 1.9 ± 0.6). However, in the multivariate analysis, only active smoking (OR, 3.4; 95% CI, 1.4-10.2), size of osteotomy ≥12 mm (OR, 2.8; 95% CI, 1.3-5.9) and allogeneic/artificial vs no bone grafting (OR, 2.4; 95% CI, 1.0-10.8) remained significant. SSI was not uncommon after MOWHTO, but the majority was superficial. The identified three independent factors, including smoking, size of osteotomy ≥12 mm and allogeneic/artificial bone grafting would help risk assessment and stratification, target risk factor modification and clinical surveillance, and inform patient counselling.

Efficacy and safety of combined Chinese and Western medicine in the treatment of knee osteoarthritis: a prospective, multicenter cohort study

Purpose: To conduct a real-world evaluation of the efficacy and safety of combined Chinese and Western medicine in treating knee osteoarthritis (KOA). Methods: A multicenter, prospective cohort study design was employed, enrolling 450 KOA patients (Kellgren-Lawrence score of 3 or less). The patients were divided into a Western medicine treatment group (WM group) and a combined Western and traditional Chinese medicine treatment group (WM-CM group). A 6-week treatment plan was administered, and follow-up visits occurred at 2 weeks, 4 weeks, and 6 weeks after initiating treatment. The primary outcome indicator was the total Western Ontario and McMaster Universities Arthritis Index (WOMAC) score after 6 weeks of treatment. Secondary outcome indicators included WOMAC subscales for pain, stiffness, and joint function, visual analogue scale (VAS) score, physical component summary (PCS), mental component summary (MCS), and clinical effectiveness. The incidence of drug-related adverse events was used as a safety evaluation indicator. Results: A total of 419 patients were included in the final analysis: 98 in the WM group and 321 in the WM-CM group. The baseline characteristics of the two groups were comparable, except for the incidence of stiffness symptoms and stiffness scores. After 6 weeks of treatment, the WM-CM group exhibited superior results to the WM group in improving the total WOMAC score (24.71 ± 1.38 vs. 16.36 ± 0.62, p < 0.001). The WM-CM group also outperformed the WM group in WOMAC pain and joint function scores, VAS score, PCS score, MCS score, and clinical effectiveness (p < 0.05), which was consistent with the findings of the main evaluation index. Subgroup analysis indicated that the combined Chinese and Western medicine treatment showed more pronounced benefits in patients under 65 years of age and in those with a Kellgren-Lawrence (K-L) classification of 0-I. Throughout the study, no adverse effects were observed in either group. Conclusion: The combination of Chinese and Western medicine demonstrated superiority over Western medicine alone in relieving knee pain symptoms, improving knee function, and enhancing the quality of life for KOA patients with a K-L score of 3 or less. Moreover, the treatment exhibited a good safety profile. Clinical Trial Registration: (https://www.chictr.org.cn/), identifier (ChiCTR1900027175).

A comparison of the burden of knee osteoarthritis attributable to high body mass index in China and globally from 1990 to 2019

Background

Excess body mass index (BMI) plays a key role in the onset and progression of knee osteoarthritis (knee OA). However, the burden of knee OA attributable to high BMI at the global, Chinese, and regional levels have received far too little attention. The aim of this study is to provide evidence to support the design of policy by investigating long-term trends of years lived with disability (YLDs) for knee OA.

Methods

To illustrate the trends of YLDs for knee OA attributable to high BMI and the temporal trends of the YLDs rate by age, period, and cohort, Joinpoint regression software and age-period-cohort (APC) were used to analyze the YLDs data of knee OA from the Global Burden of Disease (GBD) 2019.

Results

In China, there were 549,963.5 YLDs for knee OA attributable to high BMI in 2019, which had increased by 460.7% since 1990. From 1990 to 2019, age-standardized disability-adjusted life year rate (ASDR) of knee OA attributable to high BMI trended upwards. The average annual percent change (AAPC) of knee OA attributable to high BMI in China and globe were 3.019, 1.419%, respectively. The longitudinal age curve of the APC model showed that the YLDs rates of knee OA due to high BMI increased with age, and YLDs rates were higher among females than males. The period rate ratios (RRs) of knee OA due to high BMI increased significantly. The cohort RRs of knee OA due to high BMI increased among those born between 1900 and 1970. The net drifts of knee OA attributable to high BMI in China and globe were above 1. Compared with global condition, the net drift values of knee OA attributable to high BMI in China was higher. Compared with females, males had higher net drift value. Countries with high socio-demographic index (SDI) have a much higher burden of knee OA caused by high BMI than countries with low SDI.

Conclusion

In China, high BMI is a substantial cause of knee OA, the incidence of which has been increasing since 1990. In addition, women and the elderly are more vulnerable to knee OA caused by high BMI. The Chinese government must take the long-term impact of high BMI on knee OA into account and implement effective public health policies and resort to interventions to reduce the burden as soon as possible.

Tai Chi exercise reduces circulating levels of inflammatory oxylipins in postmenopausal women with knee osteoarthritis: results from a pilot study

Background

Tai Chi (TC) controls pain through mind-body exercise and appears to alter inflammatory mediators. TC actions on lipid biomarkers associated with inflammation and brain neural networks in women with knee osteoarthritic pain were investigated.

Methods

A single-center, pre- and post-TC group (baseline and 8 wk) exercise pilot study in postmenopausal women with knee osteoarthritic pain was performed. 12 eligible women participated in TC group exercise. The primary outcome was liquid chromatography tandem mass spectrometry determination of circulating endocannabinoids (eCB) and oxylipins (OxL). Secondary outcomes were correlations between eCB and OxL levels and clinical pain/limitation assessments, and brain resting-state function magnetic resonance imaging (rs-fMRI).

Results

Differences in circulating quantitative levels (nM) of pro-inflammatory OxL after TC were found in women. TC exercise resulted in lower OxL PGE1 and PGE2 and higher 12-HETE, LTB4, and 12-HEPE compared to baseline. Pain assessment and eCB and OxL levels suggest crucial relationships between TC exercise, inflammatory markers, and pain. Higher plasma levels of eCB AEA, and 1, 2-AG were found in subjects with increased pain. Several eCB and OxL levels were positively correlated with left and right brain amygdala-medial prefrontal cortex functional connectivity.

Conclusion

TC exercise lowers pro-inflammatory OxL in women with knee osteoarthritic pain. Correlations between subject pain, functional limitations, and brain connectivity with levels of OxL and eCB showed significance. Findings indicate potential mechanisms for OxL and eCB and their biosynthetic endogenous PUFA precursors that alter brain connectivity, neuroinflammation, and pain.

Clinical Trial Registration

ClinicalTrials.gov, identifier: NCT04046003.

The Effects of the Combination of Rhein and Platelet-Rich Plasma on Human Articular Chondrocytes

BACKGROUND

The presence of side effects and low bioavailability of rhein has limited its use in the treatment of osteoarthritis. We aimed to evaluate the in vitro response of human articular chondrocytes to the presence of the combination of platelet-rich plasma (PRP) and rhein.

METHODS

Solutions of rhein were prepared to assess solubility and select a working concentration. A stimulus with interleukin-1β (IL-β, 10 ng/mL) was induced for 24 h on human chondrocytes. Five treatment groups were established: control, IL-β control, PRP, rhein, and PRP + rhein. Cell viability, cell migration, nitric oxide (NO) production, tumor necrosis factor-α (TNF-α), and gene expression analyses were carried out.

RESULTS

A concentration of 50 mg/L was selected after a dose-response curve assay. Both NO and tumor TNF-α production significantly decreased after PRP and PRP + rhein treatments at 24 and 48 h. The wound healing assay revealed a significant stimulation of migration after 72 h with the PRP and PRP + rhein treatments. Expression of IL-1β, IL-6, MMP-13, and ADAMTS-5 was significantly downregulated, particularly after treatment with the combination of PRP + rhein.

CONCLUSIONS

Much of the determinations denoted a better performance of the combination of PRP and rhein in decreasing the levels of the different targets evaluated; however, this was not great enough to detect a significant difference in comparison with the PRP treatment alone.

Complex-Type N-Glycans Are Associated with Cartilage Degeneration within Different Loading Sites of the Tibial Plateau for Knee Osteoarthritis Patients

Abnormal N-glycosylation has been shown to play an important role in the pathogenesis of multiple diseases. However, little is known about the relationship between N-glycosylation and knee osteoarthritis (KOA) progression at the tissue level. Thus, the aim of this study was to quantify the cartilage histomorphometric changes in formalin-fixed paraffin-embedded (FFPE) tissue collected from the lateral and medial compartments of the tibial plateau KOA patients (n = 8). Subsequently, N-glycans were analyzed by matrix-assisted laser desorption/ionization mass spectrometry imaging (MALDI-MSI) followed by in situ MS/MS fragmentation. Overall, the Osteoarthritis Research Society International (OARSI) histological grade and cartilage surface fibrillation index were significantly higher, and chondrocyte size in the superficial zone was much larger, for the medial high-loaded cartilage compared to the lateral less-loaded cartilage. Among 92 putative N-glycans observed by MALDI-MSI, 3 complex-type N-glycans, (Hex)4(HexNAc)3, (Hex)4(HexNAc)4, and (Hex)5(HexNAc)4, and 1 oligomannose-type N-glycan, (Hex)9(HexNAc)2, were significantly higher in intensity in the medial cartilage compared to the lateral cartilage, whereas 2 tetra-antennary fucosylated-type N-glycans, (Hex)3(HexNAc)6(Fuc)2 and (Hex)3(HexNAc)6(Fuc)3, were significantly higher in intensity in the lateral cartilage than the medial cartilage. Our findings indicate that complex-type N-glycans are associated with higher severity of cartilage degeneration and may influence the cellular processes of KOA.

Relationship between 25-hydroxy vitamin D and knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trials

Objective

In order to examine the relationship between 25-hydroxyl vitamin D and knee osteoarthritis (KOA), a meta-analysis of 8 randomized controlled trials (RCTs) publications was hereby performed.

Methods

For the purpose of finding pertinent research, the databases of PubMed, Embase and the Cochrane Library were searched. Factors including tibial cartilage volume, joint space width (JSW), synovial fluid volume, and Western Ontario and McMaster Universities Arthritis Index (WOMAC) were correspondingly evaluated, and the results were expressed using SMD and 95% confidence intervals (CI).

Results

The present meta-analysis evaluated the effects of vitamin D supplementation in patients with knee osteoarthritis, with 3,077 patients included. The results showed that vitamin D administration had a statistically significant impact on the amount of synovial fluid, Visual Analog Scale (VAS) and tibial cartilage. The pain and function scales of the WOMAC scale presented a statistically significant difference, and there was no discernible difference between the vitamin D and placebo groups in the stiffness scale. Additionally, bone marrow lesions and alterations in the diameter of the joint space were not influenced by the administration of vitamin D, and according to a subgroup study, a daily vitamin D supplement containing more than 2,000 IU significantly slowed the development of synovial tissue.

Conclusion

Vitamin D supplementation did benefit those suffering from knee discomfort and knee dysfunction.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022332033, identifier: CRD42022332033.

Statistical Fragility of Randomized Controlled Trials Evaluating Platelet-Rich Plasma Use for Knee Osteoarthritis: A Systematic Review

Background

Numerous studies have been published on the use of platelet-rich plasma (PRP) for knee osteoarthritis (OA), with conflicting results.

Purpose

To determine the fragility index (FI) and fragility quotient (FQ) of randomized controlled trials (RCTs) that evaluated the use of PRP to treat knee OA.

Study Design

Systematic review.

Methods

RCTs evaluating the efficacy of PRP injections for knee OA from 2000 to 2020 were included for analysis according to PRISMA guidelines. The FI was determined by calculating the number of outcome event reversals required to change the statistical significance. The associated FQ was determined by dividing the FI by the sample size.

Results

Our initial search resulted in 41,149 studies, of which 8 RCTs (678 patients, 72 outcome events) were included in the analysis. One study failed to report PRP formulation details, whereas 87.5% of studies reported using either leukocyte-rich or leukocyte-poor PRP. The platelet concentration was reported in 25% of the included trials. The overall FI of the 72 outcome events was 8.5. Accounting for sample size, the associated FQ was determined to be 0.14, suggesting that the reversal of 14% of outcome events was required to change outcome significance. There were 51 statistically significant outcomes, of which the FI and FQ were 12 and 0.164, respectively.

Conclusion

Comprehensive fragility analysis suggested that the published literature evaluating the efficacy of PRP use for knee OA may lack statistical stability. We recommend the reporting of both an FI and FQ in addition to P value analysis to provide a clear and thorough understanding of the statistical integrity of studies reporting on PRP use for knee OA.

The Reliability of the Divergence Angle for Evaluating Rotational Implant Positioning in Medial Unicompartmental Knee Replacement

Background Unicompartmental knee arthroplasty (UKA) is a highly effective surgical procedure used to treat patients with osteoarthritis affecting a single knee compartment. UKA has gained significant popularity, accompanied by an expansion of its surgical indications. This increasing trend can be attributed to the consistently excellent clinical outcomes associated with UKA, which rival those achieved with total knee arthroplasty (TKA). However, despite these advancements, implant rotation malposition remains a prevalent factor contributing to early failure in UKA cases. The aim of this study is to analyze the rotational positioning of femorotibial implants in UKA and to identify an appropriate angle formed by the femoral component and the tibial component using a newly described angle. Methods This was a retrospective study of patients' data of 40 medial UKA cases of 33 patients who were operated on in our hospital between October 1998 and March 2019. The study introduces a new angle called the "divergence angle." This angle is formed between the lateral portion of the femoral component and the lateral part of the tibial component, as measured on a patellofemoral Merchant view at 30 degrees of knee flexion. The divergence angle was evaluated through radiographic assessment by two independent reviewers. Results According to statistical analysis, the divergence angle was highly reliable with both intra- and inter-observer reproducibility. Intra-observer reproducibility was excellent with an intra-class correlation coefficient (ICC) between 0.901 and 0.933 (p < 0.001). The inter-observer reproducibility was excellent with an ICC of 0.92 (p < 0.001). The Gaussian curve confirmed the normal distribution of the divergence angle values with moderate dispersion of values. The majority of the angles of divergence (85%) measured between the femoral and tibial components were less than 10 degrees (n = 34), with a mean angle of 6.3 ± 4.5°. Conclusion The divergence angle between the femoral and tibial components, measured at 30 degrees of knee flexion using the Merchant view, is an easily accessible, reliable, and reproducible method. This technique enables the assessment of the optimal rotational positioning of implants in medial UKA.

Clinical and radiological efficacy of single-dose intra-articular high-molecular-weight hyaluronic acid in knee osteoarthritis

Context

While visco-supplementation is being used for the treatment of knee osteoarthritis (OA), the published reports vary widely in benefits afforded by this treatment. It was therefore proposed to assess the objective parameters along with subjective outcomes.

Aims

Our study assessed the radiological and clinical efficacy of single-dose high-molecular-weight intra-articular hyaluronic acid (HMW-IAHA) injection in knee OA.

Settings and Design

This interventional cohort study was conducted in a calculated sample size of 44 patients with knee OA.

Materials and Methods

Visual analog scale (VAS) and knee OA and outcome score (KOOS) were used for clinical assessment, and whole organ magnetic resonance imaging score (WORMS) for radiological assessment. The subjects were given a single dose of HMW-IAHA injection, 90 mg/3 ml, and were assessed on day 0 and day 90.

Statistical Analysis

Statistical Package for Social Sciences (SPSS) software was used.

Results

At the day 90 follow-up, there was an improvement in mean ± standard deviation values of VAS score (day 0: 8.53 ± 0.81, day 90: 5.97 ± 0.87), KOOS score (day 0: 27.33 ± 15.18, day 90: 57.26 ± 14.26), and the cartilage signal and morphology in the medial femorotibial joint (day 0: 11.02 ± 6.26 and day 90: 10.91 ± 6.22) and patellofemoral joint (day 0: 10.35 ± 4.36 and day 90: 10.28 ± 4.39) compartments. There was a decrease in synovitis score from 2.3 ± 1.61 to 1.3 ± 1.3 in the medial femorotibial joint compartment and total WORMS score (day 0: 66.57 ± 36.06, day 90: 65.14 ± 35.62).

Conclusions

A single dose of intra-articular injection with high-molecular-weight hyaluronic acid produces improvement in the clinical symptoms and quality of life as well as is effective in maintaining the articular cartilage integrity and reducing synovial inflammation.

Relationship between Motor Corticospinal System, Endogenous Pain Modulation Mechanisms and Clinical Symptoms in Patients with Knee Osteoarthritis: New Perspectives on an Old Disease

Knee osteoarthritis (OA) is a painful condition characterized by joint and bone changes. A growing number of studies suggest that these changes only partially explain the pain experienced by individuals with OA. The purpose of the current study was to evaluate if corticospinal and bulbospinal projection measurements were interrelated in patients with knee OA, and to explore the relationship between these neurophysiological measures and temporal summation (excitatory mechanisms of pain) on one hand, and clinical symptoms on the other. Twenty-eight (28) patients with knee OA were recruited. Corticospinal projections were measured using transcranial magnetic stimulation, while bulbospinal projections were evaluated with a conditioned pain modulation (CPM) protocol using a counter-irritation paradigm. Validated questionnaires were used to document clinical and psychological manifestations. All participants suffered from moderate to severe pain. There was a positive association between corticospinal excitability and the effectiveness of the CPM (rs = 0.67, p = 0.01, n = 13). There was also a positive relationship between pain intensity and corticospinal excitability (rs = 0.45, p = 0.03, n = 23), and between pain intensity and temporal summation (rs = 0.58, p = 0.01, n = 18). The results of this study highlight some of the central nervous system changes that could be involved in knee OA and underline the importance of interindividual variability to better understand and explain the semiology and pathophysiology of knee OA.

Dynamic interaction of obesity, age, MCP-1 Level, and ACE-1 gene with the severity of knee osteoarthritis: a cross-sectional study

The risk factors most strongly associated with knee osteoarthritis (OA) are old age and obesity. However, few studies have evaluated the interaction between aging and obesity in conjunction with inflammatory markers and knee OA severity as part of a complete assessment of knee OA management. Therefore, this study aims to evaluate the interaction between obesity, age, inflammation [including the I/D polymorphism of angiotensin converting enzyme-1 (ACE-1)], and the severity of knee OA.

METHODS

A total of 80 knee OA patients were included in this cross-sectional study. The severity of knee OA was determined based on the Kellgren-Lawrence system. All patients underwent physical and radiological examination; monocyte chemoattractant protein 1 (MCP-1) markers were measured. The parameters of the ACE-1 gene were examined with sequencing DNA.

RESULTS

There was a significant relationship between age and severity of knee OA (P=0.007), with subjects aged greater than or equal to 65 having a 3.56-fold higher risk of developing moderate to severe OA than subjects aged less than 65. There was a significant difference between body weight and knee OA severity (P=0.026), in which subjects weighing greater than or equal to 60 kg had 3.14 times the risk of experiencing severe knee OA. Multivariate regression analysis indicated that age was the strongest independent variable for knee OA severity compared with body weight. MCP-1 levels were significantly higher in mild knee OA than in moderate to severe knee OA. The DD genotype of the ACE-1 gene increases the risk of severe knee OA by four times in subjects aged greater than or equal to 65 compared to subjects aged less than 65. However, the DD genotype of the ACE-1 gene does not increase the risk of severe knee OA in subjects weighing greater than or equal to 60 kg.

CONCLUSION

While obesity and age were found to be associated with the severity of knee OA, age emerged as the independent risk factor for knee OA severity. Furthermore, MCP-1 levels were significantly higher in cases of mild knee OA compared to severe knee OA. It was observed that the DD genotype of the ACE-1 gene increases the risk of severe knee OA in individuals aged 65 years or older.

Utilising a non-surgical intervention in the knee osteoarthritis care pathway: a 6-year retrospective audit on NHS patients

Background

Knee osteoarthritis (OA) is a chronic, debilitating, musculoskeletal condition that affects millions. The increase in prevalence and its economic impact on healthcare and society raise the need for additional non-surgical interventions.

Objective

To assess the referral rates to secondary care consultation and clinical outcomes in patients with severe knee OA treated with a home-based, non-surgical intervention.

Design

This was a retrospective audit on 571 patients with knee OA who met the clinical criteria for total knee replacement (TKR) and received the service between October 2015 and March 2020.

Methods

Patients were treated with a non-surgical, home-based, biomechanical intervention that aims to reduce pain and improve function, involving a foot-worn device for gait rehabilitation. The device is adjusted to the patient based on their gait patterns and clinical symptoms. Patients are advised to use the device at home or work and continue their routine. Patients are also advised to return to follow-up appointments to readjust the device and treatment plan. The primary outcome measure was the referral rates to secondary care consultation. Secondary outcomes included patient-reported outcome measures to assess pain and function and a computerised gait test. Follow-up time was between 1 and 6 years post-treatment initiation with a mean follow-up time of 1308.1 (SD = 473.4) days (i.e. 3.5 years.).

Results

There were 65 (11.4%) referrals for secondary consultation with an average follow-up of 3.5 years. The mean days to referral was 480.9 (SD = 399.2) days. Of all referrals, 48% (n = 31) occurred during the first year of treatment, and 32% (n = 21) occurred during the second year. The rest were after more than 2 years of treatment.Significant improvements were seen in all clinical outcomes, including a reduction in pain and an improvement in function and gait patterns (p < 0.05 for all).

Conclusion

Utilising this intervention as a non-surgical option for patients with knee OA who met the clinical criteria for TKR led to a significant reduction in pain and improvement in function after 3 months that was maintained for up to 3 years. Most patients (89%) did not proceed to secondary care consultation during their time in treatment for up to 6 years.

Obesity-Related Knee Osteoarthritis-Current Concepts

The knee is the joint most frequently involved in osteoarthritis and represents a significant contributor to patient morbidity and impaired functional status. Major risk factors include genetics, age, sex, mechanical load and obesity/metabolic syndrome. Recent studies highlighted the role of obesity and metabolic syndrome in the pathogenesis of knee osteoarthritis not simply through increased mechanical loading but the systemic effects of obesity-induced inflammation. The current concept of knee osteoarthritis is that of a 'whole joint disease', which highlights the involvement not only of articular cartilage but also the synovium, subchondral bone, ligaments and muscles. Obesity and metabolic syndrome are associated with higher levels of pro-inflammatory cytokines, increased production of adipokines with both protective and destructive effects on articular cartilage, an up-regulation of proteolytic enzymes such as matrix metalloproteinases and aggrecanases and an increase in free fatty acids and reactive oxygen species induced by dyslipidemia. These findings underscore that the adequate management of knee osteoarthritis needs to include an optimization of body weight and a beneficial mobility regimen. The possible introduction of pharmacological therapy targeting specific molecules involved in the pathogenesis of obesity-related osteoarthritis will likely also be considered in future therapeutic strategies, including personalized treatment approaches.