Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis

Treatment options for symptomatic knee osteoarthritis in adults

ABSTRACT

Knee osteoarthritis is a common medical condition in adults, especially among older adults. The incidence and prevalence of knee osteoarthritis are increasing, and many healthcare providers manage patients with symptomatic presentations. This article reviews the most common nonsurgical and surgical treatment options for knee osteoarthritis, emphasizing evidence-based and practical therapies.

Muscle strength and osteoarthritis of the knee: a systematic review and meta-analysis of longitudinal studies

OBJECTIVE

To evaluate the sex-specific association between low knee extensor and flexor muscle strength and the risk of knee structural worsening.

MATERIALS AND METHODS

Systematic searches in five databases identified longitudinal studies (≥ 1 year follow-up) reporting an association between knee extensor or flexor strength and structural decline in individuals with, or at risk of, knee osteoarthritis. Results were pooled for tibiofemoral and patellofemoral osteoarthritis worsening (and stratified by sex/gender where possible) using a random-effects meta-analysis estimating the risk ratio and 95% confidence interval or a best-evidence synthesis. Risk of bias and overall certainty of evidence were assessed.

RESULTS

Fourteen studies were included with participants (mean age 27-72 years) with osteoarthritis (n = 8), at risk of osteoarthritis (n = 3), or a combination with, or at risk of, osteoarthritis (n = 3). Low knee extensor strength was associated with an increased risk of worsening tibiofemoral (12 studies: RR 1.18, 95% CI 1.04 to 1.35) and patellofemoral osteoarthritis (4 studies: RR 1.62, 95% CI 1.01 to 2.61). Significant associations between low knee extensor strength and worsening tibiofemoral osteoarthritis were observed for women (4 studies: RR 1.25, 95% CI 1.04 to 1.51) but not men (4 studies: RR 1.10, 95% CI 0.87 to 1.39). Low knee flexor strength increased the risk of worsening tibiofemoral osteoarthritis (5 studies: RR 1.16, 95% CI 1.07 to 1.26). Ten studies were high risk of bias, and all estimates were graded as very low certainty of evidence.

CONCLUSION

Low knee extensor and flexor strength increased the risk of worsening tibiofemoral osteoarthritis. Low knee extensor strength increased the risk of worsening patellofemoral osteoarthritis. The relationship between low knee extensor strength and worsening tibiofemoral osteoarthritis may be modified by sex/gender.

Evaluation and Treatment of Knee Pain: A Review

Importance

Approximately 5% of all primary care visits in adults are related to knee pain. Osteoarthritis (OA), patellofemoral pain, and meniscal tears are among the most common causes of knee pain.

Observations

Knee OA, affecting an estimated 654 million people worldwide, is the most likely diagnosis of knee pain in patients aged 45 years or older who present with activity-related knee joint pain with no or less than 30 minutes of morning stiffness (95% sensitivity; 69% specificity). Patellofemoral pain typically affects people younger than 40 years who are physically active and has a lifetime prevalence of approximately 25%. The presence of anterior knee pain during a squat is approximately 91% sensitive and 50% specific for patellofemoral pain. Meniscal tears affect an estimated 12% of the adult population and can occur following acute trauma (eg, twisting injury) in people younger than 40 years. Alternatively, a meniscal tear may be a degenerative condition present in patients with knee OA who are aged 40 years or older. The McMurray test, consisting of concurrent knee rotation (internal or external to test lateral or medial meniscus, respectively) and extension (61% sensitivity; 84% specificity), and joint line tenderness (83% sensitivity; 83% specificity) assist diagnosis of meniscal tears. Radiographic imaging of all patients with possible knee OA is not recommended. First-line management of OA comprises exercise therapy, weight loss (if overweight), education, and self-management programs to empower patients to better manage their condition. Surgical referral for knee joint replacement can be considered for patients with end-stage OA (ie, no or minimal joint space with inability to cope with pain) after using all appropriate conservative options. For patellofemoral pain, hip and knee strengthening exercises in combination with foot orthoses or patellar taping are recommended, with no indication for surgery. Conservative management (exercise therapy for 4-6 weeks) is also appropriate for most meniscal tears. For severe traumatic (eg, bucket-handle) tears, consisting of displaced meniscal tissue, surgery is likely required. For degenerative meniscal tears, exercise therapy is first-line treatment; surgery is not indicated even in the presence of mechanical symptoms (eg, locking, catching).

Conclusions and Relevance

Knee OA, patellofemoral pain, and meniscal tears are common causes of knee pain, can be diagnosed clinically, and can be associated with significant disability. First-line treatment for each condition consists of conservative management, with a focus on exercise, education, and self-management.

Low-intensity pulsed ultrasound irradiation attenuates collagen degradation of articular cartilage in early osteoarthritis-like model mice

PURPOSE

Osteoarthritis (OA) is a combination of degeneration and destruction of articular cartilage due to mechanical stress, secondary synovitis, and bone remodelling. In recent years, early knee OA, a preliminary stage of structural failure in OA, has attracted attention as a potential target for therapy to prevent the onset of OA. Intra-articular administration of monoiodoacetic acid (MIA) induces OA-like symptoms, and low doses of MIA induce early OA like symptoms. In this experiment, a low-dose of MIA was induced to early OA model mice, which were then irradiated with low-intensity pulsed ultrasound (LIPUS) to examine whether LIPUS improves symptoms of early OA.

METHODS

After 4 weeks of LIPUS irradiation, articular cartilage was observed at 1 and 4 weeks. The Osteoarthritis Research Society International (OARSI) scores were calculated using Safranin-O staining results. Cartilage degeneration was detected using Denatured Collagen Detection Reagent (DCDR).

RESULTS

We observed a significant decrease in OARSI scores in the LIPUS irradiated group at week 4. The non-LIPUS group showed widespread areas of double positivity for Type II collagen and DCDR, whereas the LIPUS group showed only a small number of DCDR-positive areas. In addition, macrophage numbers counted in the articular capsule at week 1 showed a significant decrease in the LIPUS irradiated group. Lubricin detection showed that lubricin positive cell number was significantly increased by LIPUS irradiation at week 4.

CONCLUSIONS

These results suggest that LIPUS attenuates cartilage degeneration in early OA by relieving inflammation and enhancing the inhibitory effect of lubricin on cartilage degeneration.

Predictors of Outcomes After Lumbar Intra-Articular Facet Joint Injections and Medial Branch Blocks: A Scoping Review

STUDY DESIGN

A scoping review.

OBJECTIVE

We aimed to identify and describe the factors associated with the patient-reported response after lumbar intra-articular facet joint (FJ) injections or medial branch blocks (MBBs).

SUMMARY OF BACKGROUND DATA

FJ osteoarthritis is among the most common causes of chronic low back pain. Management often includes FJ intra-articular injection and MBBs (which may be followed by radiofrequency ablation of the nerves innervating these joints). However, the success of these approaches is variable, prompting interest in identifying patient characteristics (imaging features, clinical signs, and among others) associated with response to these types of facet injections.

MATERIALS AND METHODS

We performed a literature search on factors associated with patient-reported outcomes after lumbar FJ intra-articular injections or MBBs for patients with low back pain published in English or Spanish between 2000 and 2023. We excluded duplicate papers that did not describe factors associated with outcomes or those describing other interventions. We collected data on the association of these factors with patient-reported outcomes.

RESULTS

Thirty-seven studies met the inclusion criteria and were analyzed. These studies evaluated factors, such as age, depression, and single photon emission computed tomography (SPECT), and among variables. Age and imaging findings of facet arthropathy were the most frequently described factors. Imaging findings of FJ arthropathy and positive SPECT were often associated with positive results after intra-articular FJ injections or MBBs. In contrast, younger age and smoking were frequently associated with less favorable clinical outcomes.

CONCLUSION

Numerous factors were considered in the 37 studies included in this review. Imaging findings of facet arthropathy, duration of pain, and positive SPECT were consistently associated with favorable results after facet interventions.

Item development and pre-testing of an Osteoarthritis Conceptualisation Questionnaire to assess knowledge and beliefs in people with knee pain

Many people with osteoarthritis hold beliefs that physical activity is unhelpful or dangerous for their joints, despite high-level evidence suggesting otherwise. Recent advances in scientific understanding of osteoarthritis have led to new treatments that target an individual's understanding both of their condition and the importance of best-practice management strategies, such as physical activity. Conceptual change has been proposed as an important mechanism by which cognitive interventions, such as pain science education, may reduce pain and improve function. There are currently no specific assessments of osteoarthritis conceptualisation to determine the effectiveness of cognitive interventions in effecting conceptual change in people with knee osteoarthritis. Therefore, we aimed to develop an item bank, as the first phase of developing a questionnaire to assess people's conceptualisations about their knee osteoarthritis and the role of physical activity in managing their osteoarthritis. Using a guideline-informed mixed method design, a panel of experts identified domains relevant to conceptualisation about knee osteoarthritis and physical activity (knowledge, beliefs, understanding) based upon available evidence. The panel created 33 provisional items. Qualitative and quantitative pretesting were used to explore how people with knee osteoarthritis understood the provisional items. Eighteen people with knee osteoarthritis completed cognitive interviews about their comprehension of the wording/grammar of each provisional item. The provisional item bank was field tested with 100 people with knee osteoarthritis. Readability was adequate with a Flesch reading ease score of 57.7. Although 14.7% used the 'Strongly agree' response option, only 3.4% of responses used the 'Strongly disagree' option, suggesting possible response bias. Predictive quality testing identified relevant modifications to the questionnaire instructions. The panel of experts appraised the qualitative data to assess whether and how items should be modified to address the problems identified, resulting in a final item bank of 45 items that can be evaluated for psychometric properties in future research.

'Highlighting a gap in radiographers' pain knowledge: A letter to the editor on 'Radiographers' decision-making processes in the movement of pain-afflicted adult trauma patients in planar diagnostic imaging''

This letter to the editor highlights a crucial knowledge gap within the radiography profession-a modern understanding of pain. The outdated belief that pain is directly correlated to tissue injury or pathology is misleading and potentially harmful, as it could lead to the stigmatisation and invalidation of patients with pain. Radiographers are urged to listen to their patients in order to truly understand their pain, and to embrace the opportunity to develop their knowledge and enhance the experience of patients in the imaging department.

Hip rotation muscle strength is implicated in the progression of early post-traumatic osteoarthritis: A longitudinal evaluation up to 5 years following ACL reconstruction

INTRODUCTION

Following ACL reconstruction (ACLR), deficits in hip muscle strength and relationships to future outcomes are unknown.

METHODS

111 participants one year after ACLR, completed hip external rotation (ER) and internal rotation (IR) strength assessment. At 1 (n = 111) and 5 (n = 74) years post-ACLR, participants completed a battery of functional, symptomatic (Knee Osteoarthritis Outcome Score (KOOS)) and structural assessments (radiography, magnetic resonance imaging (MRI)). Cartilage health of the patellofemoral and tibiofemoral compartments was assessed with the semiquantitative MRI Osteoarthritis Knee Score. Hip rotation strength was compared between-limbs, and relationships between hip strength at 1 year and functional, symptomatic and cartilage outcomes at 1 and 5 years were investigated with regression models.

RESULTS

The index (ACLR) limb had weaker hip ER (but not IR) strength compared to the contralateral side (standardised mean difference ER = -0.33 (95%CI -0.60, -0.07; IR = -0.11 (95%CI -0.37, 0.15). Greater hip ER and IR strength was associated with superior function at 1 and 5 years, and better KOOS-Patellofemoral symptoms at 5 years. Greater hip ER strength was associated with lower odds of worsening tibiofemoral cartilage lesions at 5 years (odds ratio 0.01, 95%CI 0.00, 0.41).

CONCLUSION

Hip rotation strength may play a role in worsening function, symptoms and cartilage health after ACLR.

The burden of osteoarthritis due to high Body Mass Index in Iran from 1990 to 2019

High BMI related burden of knee and hip osteoarthritis (OA) is on a significant rise worldwide. OA not only causes joint pain and stiffness, but it also leads to disability. This study investigated the trend and burden of OA attributable to high body mass index (BMI) in Iran. The age-standardized disability-adjusted life years (DALYs) rates of knee and hip OA due to high BMI, were estimated using data from the Global Burden of Disease 2019. We evaluated DALYs rate trend of high BMI related OA by sex and age in span of 30 years from 1990-2019 across the 31 provinces of Iran. The age-standardized prevalence trend of OA in the knee and hip showed an increase from 1990 to 2019. In 2019 there were 29.92 (95% CI: 10.98-64.92) and 42.50 (95% CI: 16.32-97.37) DALYs/100,000 related to OA from high BMI in men and women, respectively. 2019 saw the greatest DALYs/100,000 rate in the 65-79 age group. From 2005 to 2019, men and women saw DALYs/100,000 rate changes of 24.87 and 17.43 percent, respectively. The burden of knee OA was significantly higher than that of hip OA. DALYs rate of OA due to high BMI was found to be positively associated with the Socio-demographic Index (SDI). The burden of knee and hip OA due to high BMI has increased significantly in recent years in Iran among all age groups of both men and women. It is recommended that health policymakers develop weight control strategies to reduce the burden of OA and implement them at the national level.

Bone marrow lesions in osteoarthritis: From basic science to clinical implications

Osteoarthritis (OA) is the most prevalent musculoskeletal disease characterized by multiple joint structure damages, including articular cartilage, subchondral bone and synovium, resulting in disability and economic burden. Bone marrow lesions (BMLs) are common and important magnetic resonance imaging (MRI) features in OA patients. Basic and clinical research on subchondral BMLs in the pathogenesis of OA has been a hotspot. New evidence shows that subchondral bone degeneration, including BML and angiogenesis, occurs not only at or after cartilage degeneration, but even earlier than cartilage degeneration. Although BMLs are recognized as important biomarkers for OA, their exact roles in the pathogenesis of OA are still unclear, and disputes about the clinical impact and treatment of BMLs remain. This review summarizes the current basic and clinical research progress of BMLs. We particularly focus on molecular pathways, cellular abnormalities and microenvironmental changes of subchondral bone that contributed to the formation of BMLs, and emphasize the crosstalk between subchondral bone and cartilage in OA development. Finally, potential therapeutic strategies targeting BMLs in OA are discussed, which provides novel strategies for OA treatment.

Development of machine learning models aiming at knee osteoarthritis diagnosing: an MRI radiomics analysis

BACKGROUND

To develop and assess the performance of machine learning (ML) models based on magnetic resonance imaging (MRI) radiomics analysis for knee osteoarthritis (KOA) diagnosis.

METHODS

This retrospective study analysed 148 consecutive patients (72 with KOA and 76 without) with available MRI image data, where radiomics features in cartilage portions were extracted and then filtered. Intraclass correlation coefficient (ICC) was calculated to quantify the reproducibility of features, and a threshold of 0.8 was set. The training and validation cohorts consisted of 117 and 31 cases, respectively. Least absolute shrinkage and selection operator (LASSO) regression method was employed for feature selection. The ML classifiers were logistic regression (LR), K-nearest neighbour (KNN) and support vector machine (SVM). In each algorithm, ten models derived from all available planes of three joint compartments and their various combinations were, respectively, constructed for comparative analysis. The performance of classifiers was mainly evaluated and compared by receiver operating characteristic (ROC) analysis.

RESULTS

All models achieved satisfying performances, especially the Final model, where accuracy and area under ROC curve (AUC) of LR classifier were 0.968, 0.983 (0.957-1.000, 95% CI) in the validation cohort, and 0.940, 0.984 (0.969-0.995, 95% CI) in the training cohort, respectively.

CONCLUSION

The MRI radiomics analysis represented promising performance in noninvasive and preoperative KOA diagnosis, especially when considering all available planes of all three compartments of knee joints.

Pain neuroscience education, blended exercises and booster sessions as an effective therapy for pain, functional and psychological factors in patients with knee osteoarthritis: a study protocol for a single-blind randomised controlled trial with 22 factorial design during 6-month follow-up

INTRODUCTION

This study aims to investigate whether a pain neuroscience education (PNE) combined with a blended exercises programme including aerobic, resistance, neuromuscular, breathing, stretching and balance exercises and diet education provides greater pain relief and improvement in functional and psychological factors than PNE and blended exercises alone and whether 'exercise booster sessions (EBS)' approach may improve outcomes and increase adherence in patients with knee osteoarthritis (KOA) (by telerehabilitation (TR)).

METHODS AND ANALYSIS

In this single-blind randomised controlled trial, 129 patients (both genders; age >40) diagnosed with KOA will be randomly assigned to one of the 22 treatment combinations as: (1) blended exercises alone (36 sessions over 12 weeks), (2) PNE alone (three sessions over 2 weeks), (3) combination of PNE with blended exercises (exercise three times a week for 12 weeks combined with three sessions of PNE) and (4) a control group. Outcome assessors will be blinded towards group allocation. The primary outcome variables are the visual analogue scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis index in knee osteoarthritis (WOMAC) score. Secondary outcomes include Pain Self-Efficacy Questionnaire (PSEQ), Depression, Anxiety and Stress Scale (DASS), Tampa Scale for Kinesiophobia (TSK), Short Falls Efficacy Scale International (FES-I), Pain Catastrophising Scale (PCS), Short Form Health Survey (SF-12) and Exercise Adherence Rating Scale (EARS), 30 s sit-to-stand test (30CST), Timed Up and Go (TUG), lower limbs' muscle strength and lower limb joints' active range of motion (AROM) will be performed at baseline, 3 and 6 months' postinterventions. The primary and secondary outcomes will assess at baseline, 3 months and 6 months postinterventions.The findings will be useful in establishing an effective treatment strategy covering multiple aspects behind KOA. The study protocol is conducted in clinical settings, thereby enhancing the possibility of future implementation of the treatments in the healthcare systems and self-care management. Results in comparison between groups will help to clarify the most effective of mixed-method TR (blended exercise, PNE, EBS with diet education) on more improvement in pain, functional and psychological factors in patients with KOA. This study will combine some of the most critical interventions, to be able to introduce a 'gold standard therapy' in the treatment of KOA.

ETHICS AND DISSEMINATION

The trial has been approved by the ethics committee for research involving human subjects of the Sport Sciences Research Institute of Iran (IR.SSRC.REC.1401.021). The study findings will be published in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

IRCTID: IRCT20220510054814N1.

Use of Decision-Analytic Modelling to Assess the Cost-Effectiveness of Diagnostic Imaging of the Spine, Shoulder, and Knee: A Scoping Review

BACKGROUND

Limited evidence is available on the cost-effectiveness of diagnostic imaging for back, neck, knee, and shoulder complaints. Decision analytic modelling may be an appropriate method to synthesise evidence from multiple sources, and overcomes issues with trial-based economic evaluations.

OBJECTIVE

The aim was to describe the reporting of methods and objectives utilised in existing decision analytic modelling studies that assess the cost-effectiveness of diagnostic imaging for back, neck, knee, and shoulder complaints.

METHODS

Decision analytic modelling studies investigating the use of any imaging modality for people of any age with back, neck, knee, or shoulder complaints were included. No restrictions on comparators were applied, and included studies were required to estimate both costs and benefits. A systematic search (5 January 2023) of four databases was conducted with no date limits imposed. Methodological and knowledge gaps were identified through a narrative summary.

RESULTS

Eighteen studies were included. Methodological issues were identified relating to the poor reporting of methods, and measures of effectiveness did not incorporate changes in quantity and/or quality of life (cost-utility analysis in only ten of 18 studies). Included studies, particularly those investigating back or neck complaints, focused on conditions that were of low prevalence but have a serious impact on health (i.e. cervical spine trauma, cancer-related back pain).

CONCLUSIONS

Future models should pay particular attention to the identified methodological and knowledge gaps. Investment in the health technology assessment of these commonly utilised diagnostic imaging services is needed to justify the current level of utilisation and ensure that these services represent value for money.

Let's talk about sex (and gender) after ACL injury: a systematic review and meta-analysis of self-reported activity and knee-related outcomes

OBJECTIVE

Investigate sex/gender differences in self-reported activity and knee-related outcomes after anterior cruciate ligament (ACL) injury.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Seven databases were searched in December 2021.

ELIGIBILITY CRITERIA

Observational or interventional studies with self-reported activity (including return to sport) or knee-related outcomes after ACL injury.

RESULTS

We included 242 studies (n=123 687, 43% females/women/girls, mean age 26 years at surgery). One hundred and six studies contributed to 1 of 35 meta-analyses (n=59 552). After ACL injury/reconstruction, very low-certainty evidence suggests females/women/girls had inferior self-reported activity (ie, return to sport, Tegner Activity Score, Marx Activity Scale) compared with males/men/boys on most (88%, 7/8) meta-analyses. Females/women/girls had 23%-25% reduced odds of returning to sport within 1-year post-ACL injury/reconstruction (12 studies, OR 0.76 95% CI 0.63 to 0.92), 1-5 years (45 studies, OR 0.75 95% CI 0.69 to 0.82) and 5-10 years (9 studies, OR 0.77 95% CI 0.57 to 1.04). Age-stratified analysis (<19 years) suggests female athletes/girls had 32% reduced odds of returning to sport compared with male athletes/boys (OR 0.68, 95% CI 0.41 to 1.13, I² 0.0%). Very low-certainty evidence suggests females/women/girls experienced inferior knee-related outcomes (eg, function, quality of life) on many (70%, 19/27) meta-analyses: standardised mean difference ranging from -0.02 (Knee injury and Osteoarthritis Outcome Score, KOOS-activities of daily living, 9 studies, 95% CI -0.05 to 0.02) to -0.31 (KOOS-sport and recreation, 7 studies, 95% CI -0.36 to -0.26).

CONCLUSIONS

Very low-certainty evidence suggests inferior self-reported activity and knee-related outcomes for females/women/girls compared with males/men/boys after an ACL injury. Future studies should explore factors and design targeted interventions to improve outcomes for females/women/girls.

PROSPERO REGISTRATION NUMBER

CRD42021205998.

Magnetic resonance imaging evidence for subclinical joint bleeding in a Dutch population of people with severe hemophilia on prophylaxis

BACKGROUND

Previous studies suggest that subclinical bleeding occurs in persons with hemophilia.

OBJECTIVES

The aim of this study was to investigate whether patients with lifelong access to prophylaxis showed signs of previous subclinical bleeding on magnetic resonance imaging (MRI) in joints without a history of joint bleeding.

METHODS

This single-center cross-sectional study included persons with severe hemophilia A on prophylaxis, aged 16 to 33 years, with lifetime bleeding records available. Per participant, 1 index joint without a history of joint bleeding was evaluated with 3-Tesla MRI, including hemosiderin sensitive sequences. MRI scans were reviewed according to the International Prophylaxis Study Group (IPSG) additive MRI scale (range, 0-17/joint). Hemosiderin deposits with/without synovial hypertrophy were considered signs of previous subclinical bleeding. Additionally, physical examination was performed, followed by ultrasound examination according to the Hemophilia Early Arthropathy Detection with Ultrasound protocol.

RESULTS

In 43 patients with a median age of 23.5 years, 43 joints (16 elbows, 13 knees, 14 ankles) without reported bleeds were evaluated with MRI. The median IPSG MRI score was 1 (range, 0-9). Signs of previous subclinical bleeding were observed in 7 of 43 joints (16%; 95% CI, 7-30): 7 of 7 joints showed hemosiderin deposits, with concomitant synovial hypertrophy in 2 of 7 joints. MRI changes were accompanied by swelling and ultrasound-detected synovial hypertrophy in 1 ankle only. None of the other joints showed abnormalities at physical examination and ultrasound.

CONCLUSION

In this study, 16% of the joints without reported bleeds showed signs of previous subclinical bleeding, providing evidence for subclinical bleeding in people with severe hemophilia with lifelong access to prophylaxis.

Effectiveness of Rehabilitation for Knee Osteoarthritis Associated With Isolated Meniscus Injury: A Scoping Review

Meniscus tear is the most common type of injury to the meniscus and occurs more frequently on the medial compartments than the lateral compartments. Further, it is often caused by trauma or degenerative processes and can occur anywhere on either the meniscus, anterior horn, posterior horn, or midbody. Treatment of meniscus injuries is likely to greatly impact the evolution of osteoarthritis (OA) as meniscus injuries can gradually progress to knee OA. Hence, treatment of these injuries is important for managing the progression of OA. While the types of meniscus injuries and symptoms have been reported previously, the effectiveness of rehabilitation according to the degree of meniscus injury (e.g., vertical, longitudinal, radial, and posterior horn tears) remains unknown. In this review, we aimed to investigate whether rehabilitation for knee OA associated with isolated meniscus injuries varies with the degree of injury and determine the effects of rehabilitation on outcomes. We searched PubMed, Cumulative Index to Nursing and Allied Health Literature, Web of Science, and Physiotherapy Evidence Database for studies published before September 2021. Studies on ≥40-year-old patients with knee OA and isolated meniscus injury were included for analysis. The types of meniscus injury were classified as longitudinal, radial, transverse, flap, combined, or avulsion of the anterior and posterior roots of the medial meniscus, and assigned knee arthropathy grades of 0-4 according to the Kellgren-Lawrence classification. The exclusion criteria were meniscus injury, combined meniscus and ligament injury, and knee OA associated with combined injury in patients <40 years of age. There were no restrictions on the region, race, or gender of participants, or language or research format of the studies. The outcome measures were the Knee Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index Score, Visual Analog Scale or Numeric Rating Scale, Western Ontario Meniscal Evaluation Tool, International Knee Documentation Committee Score, Lysholm Score, 36-Item Short-Form Health Survey, one-leg hop test, timed up and go test, and re-injury and muscle strength. A total of 16 reports met these criteria. In studies that did not classify or distinguish degrees of meniscus injury, the effects of rehabilitation were generally favorable in the medium-to-long term. In cases where the intervention was not sufficiently effective, patients were recommended either arthroscopic partial meniscectomy or total knee replacement. Studies on medial meniscus posterior root tear did not confirm the effectiveness of rehabilitation due to the short intervention period. Further, Knee Osteoarthritis Outcome Score cut-offs, clinically important differences in Western Ontario and McMaster Universities Osteoarthritis Index, and minimum important changes in patient-specific functional scales were reported. Of the 16 studies reported in this review, nine met the definition. This scoping review has a few limitations such as the effect of rehabilitation alone could not be examined, and the intervention effectiveness differed at short-term follow-up. In conclusion, there was a gap in evidence regarding the rehabilitation of knee OA after isolated meniscus injury due to differences in intervention duration and methods. In addition, on short-term follow-up, intervention effects varied across studies.

Soluble and EV-Associated Diagnostic and Prognostic Biomarkers in Knee Osteoarthritis Pathology and Detection

Osteoarthritis (OA) is the most common degenerative disease of the connective tissue of the human musculoskeletal system. Despite its widespread prevalence, there are many limitations in its diagnosis and treatment. OA diagnosis currently relies on the presence of clinical symptoms, sometimes accompanied by changes in joint X-rays or MRIs. Biomarkers help not only to diagnose early disease progression but also to understand the process of OA in many ways. In this article, we briefly summarize information on articular joints and joint tissues, the pathogenesis of OA and review the literature about biomarkers in the field of OA, specifically inflammatory cytokines/chemokines, proteins, miRNA, and metabolic biomarkers found in the blood, synovial fluid and in extracellular vesicles.

Unilateral tests of lower-limb function as prognostic indicators of future knee-related outcomes following anterior cruciate ligament injury: a systematic review and meta-analysis of 13 150 adolescents and adults

OBJECTIVE

To investigate the prognostic capacity of individual hop tests, hop test batteries and other unilateral functional performance tests following anterior cruciate ligament (ACL) injury.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Six databases searched up to June 2021.

ELIGIBILITY CRITERIA

Studies reporting associations between unilateral lower-limb function (eg, hop tests) following ACL injury and future (≥3 months) knee-related outcomes.

RESULTS

Of 42 included studies (13 150 participants), all assessed the single-forward hop test and 32 assessed a repeated-forward hop test (crossover hop, triple hop, 6m-timed hop), mostly within a year after ACL injury/reconstruction. Results of meta-analyses indicated that higher single-forward and repeated-forward hop limb symmetry were associated with higher odds of return-to-sport 1-3 years post-ACL reconstruction (OR 2.15; 95% CI 1.30 to 3.54; OR 2.11; 95% CI 1.23 to 3.60, respectively). Higher single-forward and repeated-forward hop limb symmetry was associated with better self-reported symptoms and function 1-37 years after ACL injury (OR 2.51; 95% CI 1.62 to 3.88; OR 4.28; 95% CI 1.65 to 11.08, respectively). Higher limb symmetry on a repeated-forward hop does not appear to be associated with higher odds of successful rehabilitation without ACL reconstruction (OR 1.51; 95% CI 0.94 to 2.44). Achieving ≥90% limb symmetry on the single-forward hop was associated with reduced odds of knee osteoarthritis 5-37 years after ACL injury (OR 0.46; 95% CI 0.23 to 0.94).

CONCLUSION

Very low certainty evidence suggests single-forward and repeated-forward hop tests are prognostic indicators for important knee-related outcomes in individuals after ACL injury and may help stratify individuals at risk of poor outcomes to target rehabilitation interventions.

PROSPERO REGISTRATION NUMBER

CRD42018092197.

SUpervised exercise-therapy and Patient Education Rehabilitation (SUPER) versus minimal intervention for young adults at risk of knee osteoarthritis after ACL reconstruction: SUPER-Knee randomised controlled trial protocol

INTRODUCTION

Anterior cruciate ligament injury and reconstruction (ACLR) is often associated with pain, functional loss, poor quality of life and accelerated knee osteoarthritis development. The effectiveness of interventions to enhance outcomes for those at high risk of early-onset osteoarthritis is unknown. This study will investigate if SUpervised exercise-therapy and Patient Education Rehabilitation (SUPER) is superior to a minimal intervention control for improving pain, function and quality of life in young adults with ongoing symptoms following ACLR.

METHODS AND ANALYSIS

The SUPER-Knee Study is a parallel-group, assessor-blinded, randomised controlled trial. Following baseline assessment, 184 participants aged 18-40 years and 9-36 months post-ACLR with ongoing symptoms will be randomly allocated to one of two treatment groups (1:1 ratio). Ongoing symptoms will be defined as a mean score of <80/100 from four Knee injury and Osteoarthritis Outcome Score (KOOS4) subscales covering pain, symptoms, function in sports and recreational activities and knee-related quality of life. Participants randomised to SUPER will receive a 4-month individualised, physiotherapist-supervised strengthening and neuromuscular programme with education. Participants randomised to minimal intervention (ie, control group) will receive a printed best-practice guide for completing neuromuscular and strengthening exercises following ACLR. The primary outcome will be change in the KOOS4 from baseline to 4 months with a secondary endpoint at 12 months. Secondary outcomes include change in individual KOOS subscale scores, patient-perceived improvement, health-related quality of life, kinesiophobia, physical activity, thigh muscle strength, knee function and knee cartilage morphology (ie, lesions, thickness) and composition (T2 mapping) on MRI. Blinded intention-to-treat analyses will be performed. Findings will also inform cost-effectiveness analyses.

ETHICS AND DISSEMINATION

This study is approved by the La Trobe University and Alfred Hospital Ethics Committees. Results will be presented in peer-reviewed journals and at international conferences.

TRIAL REGISTRATION NUMBER

ACTRN12620001164987.

Osteoarthritis today: Lost in translation?

Osteoarthritis (OA) is a highly prevalent joint disease that is associated with pain, loss of function, and high direct and indirect economic costs. The current therapeutic options are inadequate, providing only a moderate symptom relief without the possibility of disease modification. While treatment options and personalized medicines are increasing for many complex diseases, OA drug development has been impeded by the advanced state of disease at the time of diagnosis and intervention, heterogeneity in both symptoms and rates of progression, and a lack of validated biomarkers and relevant outcome measures. This review article summarizes the OA landscape, including therapies in development as potential OA treatments, potential biomarkers undergoing evaluation by the US Food and Drug Administration, and a summary of current OA treatment guidelines, with a particular focus on the knee OA.

Accuracy and Reliability of MRI Reports in Diagnosing the Symptomatic Knee in Patients Who Had Bilateral MRI

Background

Newly symptomatic chronic musculoskeletal illness is often misinterpreted as new pathology, particularly when symptoms are first noticed after an event. In this study, we were interested in the accuracy and reliability of identifying the symptomatic knee based on bilateral MRI reports.

Methods

We selected a consecutive sample of 30 occupational injury claimants, presenting with unilateral knee symptoms who had bilateral MRI on the same date. A group of blinded musculoskeletal radiologists dictated diagnostic reports, and all members of the Science of Variation Group (SOVG) were asked to indicate the symptomatic side based on the blinded reports. We compared diagnostic accuracy in a multilevel mixed-effects logistic regression model, and calculated interobserver agreement using Fleiss' kappa.

Results

Seventy-six surgeons completed the survey. The sensitivity of diagnosing the symptomatic side was 63%, the specificity was 58%, the positive predictive value was 70%, and the negative predictive value was 51%. There was slight agreement among observers (kappa= 0.17). Case descriptions did not improve diagnostic accuracy (Odds Ratio: 1.04; 95% CI: 0.87 to 1.3; P=0.65).

Conclusion

Identifying the more symptomatic knee in adults based on MRI is unreliable and has limited accuracy, with or without information about demographics and mechanism of injury. When there is a dispute concerning the extent of the injury to a knee in a litigious, medico-legal setting such as Workers' Compensation, consideration should be given to obtaining a comparison MRI of the uninjured, asymptomatic extremity.

Addition of tDCS and TENS to an education and exercise program in subjects with knee osteoarthritis: A study protocol

BACKGROUND

Knee osteoarthritis often leads to chronic pain that frequently becomes disabling.Osteoarthritis has been linked to maladaptive plasticity in the brain, which can contribute to chronic pain. Therapies including neuromodulation and peripheral electrical stimulation are used to counteract the maladaptive plasticity of the brain.

OBJECTIVE

To determine the efficacy of the addition of tDCS and TENS to an education and exercise program in reducing pain.

METHODS

Over a 2-week study period, 60 participants will complete an exercise and educational intervention. Eligible participants accepting to participate will be subsequently randomized into one of the three treatment groups: 1) Active Transcranial Direct Current Stimulation (tDCS) and active Transcutaneous Electrical Nerve Stimulation (TENS); 2) Active tDCS and sham TENS; 3) Sham tDCS and sham TENS.

RESULTS

The primary outcome will be subjective pain intensity.

SECONDARY OUTCOMES

quality of life, physical function, central sensitization, and pain adjuvants (uncertainty, catastrophizing kinesiophobia, adverse events).

CONCLUSION

This clinical trial will provide data on the effect that the addition of tDCS and/or TENS to an education and exercise program may have to counteract maladaptive plastic changes and improve the benefits of exercises, and whether the combination of both neuromodulator techniques may have a higher magnitude of effect.

The Efficacy of the Mulligan Concept to Treat Meniscal Pathology: A Systematic Review

Background

Meniscal pathologies are common knee injuries and arthroscopic surgery is the current accepted gold standard for treatment. However, there is evidence to support the use of the Mulligan Concept (MC) Mobilization with Movement (MWM) for meniscal pathologies including the 'Squeeze' technique, tibial internal rotation (IR), and tibial external rotation (ER).

Hypothesis/Purpose

The purpose of this systematic review was to critically appraise the literature to investigate the effectiveness of MC MWMs for meniscal lesions on patient reported pain, function, and multi-dimensional health status in patients with clinically diagnosed meniscal pathologies.

Study Design

Systematic Review.

Methods

A literature search was completed across multiple databases using combinations of the words "knee, function, mobilization with movement, MWM, mulligan concept, MC, meniscal pathology, meniscal derangement, and meniscal tear." Studies written within the prior 10 years that examined MC MWM techniques to treat knee meniscal injury were included. Articles that met the inclusion criteria (used MC MWM 'Squeeze' technique, tibial IR, or tibial ER for treatment of clinically diagnosed meniscal pathologies; Patient reported outcome [PRO] measures had to be used in the assessment of knee pain or function) were analyzed for quality. Randomized control trials were analyzed using the PEDro scale and the Downs & Black (D&B) checklist, case series were analyzed using the Joanna Briggs Institute (JBI) checklist, and case reports were analyzed using the CARES checklist.

Results

Six articles met the inclusion criteria and were included in this review, two randomized controlled studies, two case series, and two case reports consisting of 72 subjects. All six papers included reports of improvements in pain and function that were either statistically significant or met the minimal clinically important difference (MCID). Five studies reported the Disablement in the Physically Active (DPA) scale that also demonstrated statistically significant differences or met the MCID. The MC MWM 'Squeeze' technique, tibial IR, or tibial ER demonstrated the ability to reduce pain, improve function, and improve patient perceived disability following treatment of a clinically diagnosed meniscal pathology. These studies demonstrated short term results lasting from one week to 21 weeks.

Conclusion

Treatment interventions incorporating MC MWM techniques demonstrated reduction of pain and improvement in function in the short term in patients with clinically diagnosed meniscal pathologies.

Level of Evidence

2a.

Test reliability and comparability of paper and Chinese electronic version of the western Ontario and McMaster University osteoarthritis index: protocol for a randomised controlled clinical trial

INTRODUCTION

The Western Ontario and McMaster University osteoarthritis index (WOMAC) is the most commonly used indicator of disease-specific outcome in knee osteoarthritis for its convenience and reliability. It has two formats the paper-based WOMAC (p-WOMAC) and the electronic WOMAC (e-WOMAC). In China, the p-WOMAC has been widely used though e-WOMAC is yet untested. This study aims to test whether e-WOMAC is consistent with the p-WOMAC before and after the intervention.

METHODS AND ANALYSIS

A total of 70 patients from Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine will be randomly assigned in two groups, named, group A and group B. This study is divided into three stages. In the first stage, patients in group A will be evaluated first by p-WOMAC and then by e-WOMAC. Patients in group B will be evaluated by e-WOMAC and then by p-WOMAC. In the second stage of the study, drug interventions will be implemented. 200 mg celecoxib will be administered orally once a day starting from the second day of enrolment for a period of 21 days. In the third stage, postintervention evaluation will be conducted after administration. Patients in group A will be evaluated first by e-WOMAC and then by p-WOMAC. Patients in group B will be evaluated first by p-WOMAC and then by e-WOMAC. In order to avoid the possible bias because of patients' potential memory, e-WOMAC and p-WOMAC will be taken for each patient at 15 min apart. The primary outcome of the study is the mean score difference in WOMAC, and the secondary outcomes are the score differences in WOMAC subscales: pain, stiffness and physical function.

ETHICS AND DISSEMINATION

The protocol has been approved by the Independent Review Board of SGH (approval number: 2020-814-21-01). The results of the trial will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ChiCTR2100050914.

Preoperative Veterans Rand-12 Mental Composite Score of < 40 Leads to Increased Healthcare Utilization and Diminished Improvement After Primary Knee Arthroplasty

BACKGROUND

Adverse outcomes after total knee arthroplasty (TKA) have been associated with preoperative psychological disorders and poor mental health. We aimed to investigate and quantify the association between preoperative mental health and 1) postoperative 90-day health care utilization; and 2) 1-year patient-reported outcomes after primary TKA.

METHODS

Retrospective review of prospectively collected data of patients who underwent primary elective TKA (n = 7,476) was performed. Preoperative mental health was evaluated using Veterans Rand-12 Mental Composite Scores (VR-12 MCS). Outcomes included prolonged length of stay (>2-days), nonhome discharge, 90-day readmissions, emergency department visits, and reoperation. Improvement in Knee Injury and Osteoarthritis Outcome Score (KOOS) and Patient Acceptable Symptom State (PASS) achievement were evaluated at 1-year. Multivariable regression was implemented to explore associations between preoperative VR-12 MCS and outcomes of interest.

RESULTS

A total of 5,402 (72.3%) completed 1-year follow-up. Lower preoperative VR-12 MCS was associated with higher odds of prolonged length of stay (MCS 20-39: odds ratio (OR): 1.46;P < .001), and nonhome discharge disposition (MCS 20-39: OR: 1.92;P < .001), but not 90-day readmission or reoperation (MCS20-39; P = .12 and P = .64). At 1-year, patients with a lower MCS were less likely to attain a substantial clinical benefit in KOOS-pain (MCS 0-19; OR: 0.25; P < .001) and less likely to achieve PASS (MCS20-39; OR: 0.74; P = .002). Patients with an MCS >60 were more likely to be discharged home (OR: 1.42; P = .008), achieve substantial clinical benefit in their KOOS-JR (OR: 1.16; P = .027),-Pain (OR: 1.220; P = .007) and PASS at 1-year (OR: 1.28; P = .008).

CONCLUSIONS

Lower VR-12 MCS is associated with increased postoperative health care utilization and worse patient-reported outcome measures at 1-year post-TKA. These findings suggest that a VR-12 MCS ≤40 could be used to designate increased risk, guide the preoperative discussion and potential interventions.

Natural biopolymer scaffold for meniscus tissue engineering

Meniscal injuries caused by trauma, degeneration, osteoarthritis, or other diseases always result in severe joint pain and motor dysfunction. Due to the unique anatomy of the human meniscus, the damaged meniscus lacks the ability to repair itself. Moreover, current clinical treatments for meniscal injuries, including meniscal suturing or resection, have significant limitations and drawbacks. With developments in tissue engineering, biopolymer scaffolds have shown promise in meniscal injury repair. They act as templates for tissue repair and regeneration, interacting with surrounding cells and providing structural support for newly formed meniscal tissue. Biomaterials offer tremendous advantages in terms of biocompatibility, bioactivity, and modifiable mechanical and degradation kinetics. In this study, the preparation and composition of meniscal biopolymer scaffolds, as well as their properties, are summarized. The current status of research and future research prospects for meniscal biopolymer scaffolds are reviewed in terms of collagen, silk, hyaluronic acid, chitosan, and extracellular matrix (ECM) materials. Overall, such a comprehensive summary provides constructive suggestions for the development of meniscal biopolymer scaffolds in tissue engineering.

Long-term quality of life, work limitation, physical activity, economic cost and disease burden following ACL and meniscal injury: a systematic review and meta-analysis for the OPTIKNEE consensus

OBJECTIVE

Determine the long-term health-related quality-of-life (HRQoL), work limitation, physical activity, health/economic cost and disease burden of traumatic ACL and/or meniscal injury. Findings will inform OPTIKNEE evidence-based consensus recommendations.

DESIGN

Random-effects meta-analysis evaluated HRQoL (SF-36/SF-12/VR-12 Physical Component Scores (PCS) and Mental Component Scores (MCS), EuroQol-5D (EQ-5D)) stratified by time postinjury, and pooled mean differences (95% CI) between ACL-injured and uninjured controls. Other outcomes were synthesised descriptively. Risk-of-bias (RoB) and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation) were assessed.

DATA SOURCES

MEDLINE, EMBASE, CENTRAL, SPORTDiscus, CINAHL searched inception: 22 November 2021.

ELIGIBILITY

Studies reporting HRQoL, work limitations, physical activity levels, health/economic costs or disease burden, ≥2 years post-ACL and/or meniscal injury.

RESULTS

Fifty studies were included (10 high-RoB, 28 susceptible-to-some-bias and 12 low-RoB). Meta-analysis (27 studies, very low certainty of evidence) estimated a pooled mean (95% CI) PCS of 52.4 (51.4 to 53.4) and MCS of 54.0 (53.0 to 55.0) 2-14 years post-ACL injury. Pooled PCS scores were worse >10 years (50.8 (48.7 to 52.9)) compared with 2-5 years (53.9 (53.1 to 54.7)) postinjury. Excluding high-RoB studies, PCS scores were worse in ACL-injured compared with uninjured controls (-1.5 (-2.9 to -0.1)). Six studies (low certainty of evidence) informed a pooled EQ-5D score of 0.83 (0.81 to 0.84). Some individuals experienced prolonged work absenteeism and modified activities ≥2 years post-ACL injury. ACL injury was associated with significant direct and indirect costs, and early ACL reconstruction may be less cost-effective than rehabilitation. Only three studies evaluated meniscal injury outcomes (all evaluated HRQoL).

CONCLUSION

There is a very-low certainty of evidence that PCS scores ≥2 years post-ACL injury are worse than uninjured controls and decline over time, whereas MCS scores remain high. ACL injury can result in prolonged work absenteeism and high health/economic costs. Further studies are needed to determine the long-term burden of traumatic meniscal injury.

Application of Low-Dose CT and MRI in the Evaluation of Soft Tissue Injury in Tibial Plateau Fractures

Objective

To explore the application value of low-dose CT and MRI in the evaluation of soft tissue injury in tibial plateau fractures.

Methods

This study included 89 patients with high suspicion of TPF and KI admitted to our hospital from July 2015 to May 2021. After arthroscopy, 81 patients were diagnosed with FTP combined with KI. The Schatzker classification based on X-ray and CT plain scan combined with three-dimensional reconstruction was recorded, and the soft tissue injury was recorded according to the MRI examination of the affected knee joint.

Results

With the results of pathological examination and arthroscopic surgery as the gold standard, the results of MRI and pathological examination and arthroscopic examination were in good agreement (Kappa = 0.857, 0.844), and CT was moderately in agreement (Kappa = 0.697, 0.694). In KI examination, CT and MRI had no difference in the evaluation of ligament injury and bone injury (P > 0.05), but MRI had better diagnostic effect on meniscus injury (P < 0.05). Finally, the satisfaction survey showed that patients in the CT group were more satisfied with clinical services (P < 0.05).

Conclusion

Both CT and MRI have certain diagnostic value for occult tibial plateau fractures, among which CT examination is more advantageous for trabecular bone fractures, MRI examination is more advantageous for cortical bone fractures, and MRI examination can improve occult tibial plateau fracture inspection accuracy.

A Genome-Wide Association Study Reveals Two Genetic Markers for Chondromalacia

OBJECTIVE

It is unknown why some athletes develop chondromalacia and others do not, even when accounting for similar workloads between individuals. Genetic differences between individuals may be a contributing factor. The purpose of this work was to screen the entire genome for genetic markers associated with chondromalacia.

DESIGN

Genome-wide association (GWA) analyses were performed utilizing data from the Kaiser Permanente Research Board (KPRB) and the UK Biobank. Chondromalacia cases were identified based on electronic health records from KPRB and UK Biobank. GWA analyses from both cohorts were tested for chondromalacia using a logistic regression model adjusting for sex, height, weight, age of enrollment, and race/ethnicity using allele counts for single-nucleotide polymorphisms (SNPs). The data from the 2 GWA studies (KPRB and UK Biobank) were combined in a meta-analysis.

RESULTS

There were a total of 3,872 combined cases of chondromalacia from the KPRB and the UK Biobank cohorts. Genome-wide significant associations with chondromalacia were found for rs144449054 in the ARHGAP15 gene (OR = 3.70 [2.32-5.90]; P = 1.4 × 10^-8) and rs188900564 in the MAGEC2 (OR = 2.07 [1.61-2.65]; P = 3.7 × 10^-9).

CONCLUSIONS

Genetic markers in ARHGAP15 and MAGEC2 appear to be associated with chondromalacia and are potential risk factors that deserve further validation regarding molecular mechanisms.

Magnetic Resonance Imaging-Defined Osteoarthritis Features and Anterior Knee Pain in Individuals With, or at Risk for, Knee Osteoarthritis: A Multicenter Study on Osteoarthritis

OBJECTIVE

The lack of strong association between knee osteoarthritis (OA) structural features and pain continues to perplex researchers and clinicians. Evaluating the patellofemoral joint in addition to the tibiofemoral joint alone has contributed to explaining this structure-pain discordance, hence justifying a more comprehensive evaluation of whole-knee OA and pain. The present study, therefore, was undertaken to evaluate the association between patellofemoral and tibiofemoral OA features with localized anterior knee pain (AKP) using 2 study designs.

METHODS

Using cross-sectional data from the Multicenter Osteoarthritis Study, our first approach was a within-person, knee-matched design in which we identified participants with unilateral AKP. We then assessed magnetic resonance imaging (MRI)-derived OA features (cartilage damage, bone marrow lesions [BMLs], osteophytes, and inflammation) in both knees and evaluated the association of patellofemoral and tibiofemoral OA features to unilateral AKP. In our second approach, MRIs from 1 knee per person were scored, and we evaluated the association of OA features to AKP in participants with AKP and participants with no frequent knee pain.

RESULTS

Using the first approach (n = 71, 66% women, mean ± SD age 69 ± 8 years), lateral patellofemoral osteophytes (odds ratio [OR] 5.0 [95% confidence interval (95% CI) 1.7-14.6]), whole-knee joint effusion-synovitis (OR 4.7 [95% CI 1.3-16.2]), and infrapatellar synovitis (OR 2.8 [95% CI 1.0-7.8]) were associated with AKP. Using the second approach (n = 882, 59% women, mean ± SD age 69 ± 7 years), lateral and medial patellofemoral cartilage damage (prevalence ratio [PR] 2.3 [95% CI 1.3-4.0] and PR 1.9 [95% CI 1.1-3.3], respectively) and lateral patellofemoral BMLs (PR 2.6 [95% CI 1.5-4.7]) were associated with AKP.

CONCLUSION

Patellofemoral but not tibiofemoral joint OA features and inflammation were associated with AKP.

Effectiveness of exercise versus arthroscopic partial meniscectomy plus exercise in the management of degenerative meniscal tears at 5-year follow-up: a systematic review and meta-analysis

INTRODUCTION

There are no meta-analytical data in the long term for comparing surgery and exercise for meniscal tear. The aim of this study is to compare the effectiveness of exercise versus arthroscopic partial meniscectomy (APM) plus exercise for degenerative meniscal tears (DMT) in knee function at 5-year follow-up.

MATERIALS AND METHODS

A systematic search of Medline, EMBASE, Web of Science, SciELO, SPORTDiscus, Scopus, and Cochrane Library was performed. The studies were included if they were randomized controlled trials performed in patients aged ≥ 18 years with DMT, that compared physical therapy to APM at 5-year follow-up, and reported at least one outcome measure of knee function/disability. Risk of bias was analyzed with the Cochrane RoB-2 tool and certainty of evidence with GRADE recommendations. A random effects model meta-analysis was performed.

RESULTS

3743 articles were identified and 4 met the criteria. Three had low risk of bias and one had some concerns. There were no significant between-group differences, in within-group changes from baseline to 5-year, on the Knee Injury and Osteoarthritis Outcome Score pain (- 2.28; 95% CI - 5.41 to 0.84), symptoms (- 0.24; 95% CI - 4.13 to 3.64), activities of daily living (- 2.16; 95% CI - 6.16 to 1.83) and quality of life (- 3.98; 95% CI - 9.05 to 1.10). There was a significant difference in support of APM plus exercise for sport/recreation (- 9.28; 95% CI - 18.28 to - 0.29). Leave-one-out sensitivity analysis revealed a non-significant difference in sport/recreation (- 5.05; 95% CI - 12.04 to 1.94). There were no differences in other patient-reported outcome measures.

CONCLUSION

Moderate certainty of evidence suggests that the addition of APM to an exercise program adds no benefits in knee function at 5-year follow-up.

Strain sonoelastography in asymptomatic individuals and individuals with knee osteoarthritis: an evaluation of quadriceps and patellar tendon

An advanced ultrasound imaging technique, sonoelastography (SE) is used to evaluate tissue elasticity. To determine SE potential to detect pathological-related changes, and characteristics related to tendon pathology we aimed to (1) compare quadriceps and patellar tendon findings in individuals with knee osteoarthritis (KOA) and asymptomatic older adults (AC), and (2) explore associations between SE, participant characteristics (age, BMI, and leg circumference) and KOA status. 84 participants (47; KOA and 37; asymptomatic older adults) underwent SE examination of quadriceps (distal) and patellar (distal, proximal) tendon in a supine position with the knee bent at 30°. Colour score (CS) and Elasticity Ratio (ER) analysis were performed by a blinded experienced operator using Esaote Mylab 70 XVG Ultrasound equipment. Significantly reduced elasticity in the distal quadriceps (median (IQR) 2(2), 3(1), p = 0.033 for KOA and AC, respectively) and proximal patellar (3(1), 3(0), p = 0.001) tendons and more elastic distal patellar (1.50 (0.55), 1.87 (0.72), p = 0.034) tendons were observed in the KOA group. Significant associations) were identified between SE and participant BMI (Rs = − 0.249–0.750, p < 0.05) and leg circumference (Rs = − 0.260–0.903, p < 0.05). Age, BMI and KOA status, were independent explanatory variables of SE CS findings at the distal quadriceps tendon patellar tendon, proximal patellar tendon and distal patellar tendon, explaining 66%, 81% and 64% of variance, respectively. Age, BMI and KOA status were independent explanatory variables of SE ER findings at the distal patellar tendon explaining 19% of variance. Potentially clinically relevant altered tendon stiffness were observed between individuals with KOA and asymptomatic controls. Key KOA risk factors and participant characteristics explained variance in tendon stiffness. Findings provide context for future studies to investigate the potential for targeted SE detected early clinical management based on associated participant characteristics.

Trans-Posterior Cruciate Ligament All-Inside Root Repair Versus Partial Meniscectomy for Medial Meniscus Posterior Root Tears: Comparison of Semiquantitative and Quantitative MRI Outcomes in Cartilage Degeneration and Osteoarthritic Progression

OBJECTIVE

To perform conventional, morphological, and T2 mapping compositional MRI imaging to assess the cartilage degeneration and osteoarthritic progression in patients with medial meniscus posterior root tears (MMPRTs) who underwent trans-posterior cruciate ligament (PCL) all-inside repair or partial meniscectomy.

DESIGN

Patients with MMPRTs after trans-PCL all-inside repair (group AR) or partial meniscectomy (group PM) between 2015 and 2018 were retrospectively identified. Preoperative and postoperative conventional MRI were collected to assess medial meniscus extrusion (MME) and the whole-organ magnetic resonance imaging score (WORMS). Postoperative morphological MRI and T2 mapping compositional MRI were collected to evaluate the quantitative cartilage thickness/volume and cartilage composition.

RESULTS

The final cohort consisted of 21 patients in group AR and 22 patients in group PM, with no differences in demographic data and baseline patient characteristics between the 2 groups. Group AR demonstrated less progression of articular cartilage wear (P < 0.05) and decreased meniscal extrusion (P = 0.008) than group PM at the final follow-up. In addition, group AR demonstrated less extracellular matrix degeneration in the cartilage subregion of the medial compartment (P < 0.05) than group PM with lower T2 relaxation times in the superficial layer of the articular cartilage.

CONCLUSION

Trans-PCL all-inside repair of MMPRTs could delay the initial cartilage deterioration and morphological cartilage degeneration compared with partial meniscectomy. However, the amount of residual meniscal extrusion is clinically important, and an improved root repair fixation method should be investigated.

A Population-Level Summary of Health Care Utilization for the Management of Patellar Tendinopathy in the Military Health System

Patellar tendinopathy (PT) is a common nontraumatic orthopaedic disorder of the knee suffered by many service members. Understanding the make-up of usual care for PT at the system level can better frame current clinical gaps and areas that need improvement. Exercise therapy is recommended as a core treatment for PT, but it is unclear how often it is used as a part of usual care for PT within the Military Health System (MHS). The purpose of the study was to identify interventions used in the management of PT and the timing of these interventions. A secondary purpose was to determine if exercise therapy use was associated with reduced recurrence of knee pain. In total, 4,719 individuals aged 17 to 50 years in the MHS diagnosed with PT between 2010 and 2011 were included. Pharmacological and nonpharmacological interventions, visits to specialty providers, and imaging services were captured. Descriptive statistics were used to report the findings. Interventions were further categorized as being part of initial care (within the first 7 days), the initial episode of care (within the first 60 days), or the 2-year time period after diagnosis. Linear regression assessed the relationship between the number of exercise therapy visits in the initial episode of care and recurrences of knee pain. In total, 50.6% of this cohort had no more than one medical visit total for PT. Exercise therapy (18.2%) and nonsteroidal anti-inflammatory drugs (4.3%) were the two most used interventions in the initial episode of care. Radiographs were ordered for 23.1% of the cohort in the initial episode of care. The number of exercise therapy visits a patient received during the initial episode of care was not associated with recurrences of knee pain. Half of the individuals received no further care beyond an initial visit for the diagnosis of PT. Exercise therapy was the most common intervention used during the initial episode of care, but exercise therapy did not influence the recurrence of knee pain.

Surgical therapy in osteoarthritis

OBJECTIVE

To provide an evidence-based overview of the different surgical procedures in osteoarthritis (OA).

DESIGN

This narrative review reports on surgical therapies (1) for severe, end stage OA and (2) of surgical options aiming to possibly reduce OA development earlier in the course of the disease.

RESULTS

Surgical practice guidelines provide evidence-based recommendations to assist in the clinical decision-making. Total joint arthroplasty represents the only valuable, established surgical option for severe, end stage OA. For hip and knee OA, it is by far the most common surgical procedure and provides considerable pain relief, functional restoration, and improved quality of life. Surgical therapy aiming to postpone OA essentially addresses extra- or intraarticular pre-osteoarthritic deformities, defined as congenital or acquired disturbances of the joint structure that adversely affect its function. Approaches in this category include osteotomies and different cartilage repair procedures such as osteochondral autograft and allograft transfer, marrow stimulation techniques, and autologous chondrocyte implantation. However, they are not only less commonly performed than arthroplasty, but the scientific clinical evidence in favour of this type of surgery to reduce the long-term risk of developing OA is considerably reduced.

CONCLUSION

Total knee and hip arthroplasty are two of the most successful procedures in all of medicine. As the progression of this insidious disease is often asymptomatic and slow, it is imperative to judge reparative procedures at their potential to reduce OA development at long-term, besides their primary clinical outcomes. Evidence-based guidelines provide a valuable tool for high-quality surgical decision making in OA.

The Effect of Lesion Size on Pain and Function in Patients Scheduled for Cartilage Surgery of the Knee

OBJECTIVE

Despite an increased interest in treatment options for cartilage lesions of the knee, the relationship between lesion characteristics and the symptoms they elicit is not well understood. We evaluated the relationship between lesion characteristics and the patient-reported outcome measures (PROMs) and compared this with symptoms reported by patients scheduled for knee ligament reconstruction and knee arthroplasty.

DESIGN

Preoperative data, including Lysholm score and The Knee Injury and Osteoarthritis Outcome Score (KOOS), in 90 consecutive patients scheduled for surgery for symptomatic isolated cartilage lesions were prospectively collected.

RESULT

The patients had a mean age of 33.2 years. There were 62 (69%) males. There was no statistically significant difference in PROMs between patients with cartilage lesions smaller or larger than 2 cm², except for the KOOS subscale symptoms, with patients with smaller lesions reporting higher scores, 62.8 (95% confidence interval [CI] 58.3-67.3) vs. 51.9 (95% CI 45.5-58.4), P = 0.005. There was a small correlation between lesion size and Lysholm score. However, when adjusted for age, sex, body mass index, and lesion localization, this effect was not statistically significant. The International Cartilage Regeneration & Joint Preservation Society grade did not affect preoperative PROMs. Cartilage patients reported worse preoperative symptoms than patients scheduled for knee ligament reconstruction, and approaching the symptoms reported by patients scheduled for knee arthroplasty.

CONCLUSION

The size, depth, and location of cartilage lesions have little impact on the symptoms experienced by the patients. Cartilage patients have comparable symptoms to patients scheduled for knee arthroplasty.

Experiences of How Health and Lifestyle among Individuals with Knee Pain Have Been Influenced during the COVID-19 Pandemic, a HALLOA Study

The COVID-19 pandemic has affected the health and lifestyles of both the general population and of vulnerable groups. Individuals with knee pain are recommended to lead an active lifestyle to relieve pain but find it difficult to maintain health and lifestyle compared to the general population due to the cause of chronic pain, impaired physical function, and a diminished quality of life. This study aimed to explore experiences of how health and lifestyle among individuals with knee pain have been influenced during the COVID-19 pandemic. Interviews (n = 19) were conducted in 2021 and analysed with qualitative content analysis. The results showed how individuals with knee pain adjusted their behaviour and revalued their life to maintain health and lifestyle during COVID-19. Adjusted behaviours emerged, such as spending more time at home, becoming digital, and spending more time outdoors, while revaluing life emerged as having a positive outlook on life and sharing responsibility. In conclusion, behaviour was adjusted, and life revalued to manage health and lifestyle during the pandemic. However, the findings are probably similar to the general population, i.e., individuals with knee pain live similar lives as the general population despite knee pain. The results may contribute to alternative ways of maintaining health and lifestyle in various vulnerable groups and may be applied in situations other than the pandemic.

Rehabilitation after anterior cruciate ligament and meniscal injuries: a best-evidence synthesis of systematic reviews for the OPTIKNEE consensus

OBJECTIVE

Synthesise evidence for effectiveness of rehabilitation interventions following ACL and/or meniscal tear on symptomatic, functional, clinical, psychosocial, quality of life and reinjury outcomes.

DESIGN

Overview of systematic reviews with Grading of Recommendations Assessment, Development and Evaluation certainty of evidence.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, SPORTDiscus and Cochrane Library.

ELIGIBILITY CRITERIA

Systematic reviews of randomised controlled trials investigating rehabilitation interventions following ACL and/or meniscal tears in young adults.

RESULTS

We included 22 systematic reviews (142 trials of mostly men) evaluating ACL-injured individuals and none evaluating isolated meniscal injuries. We synthesised data from 16 reviews evaluating 12 different interventions. Moderate-certainty evidence was observed for: (1) neuromuscular electrical stimulation to improve quadriceps strength; (2) open versus closed kinetic chain exercises to be similarly effective for quadriceps strength and self-reported function; (3) structured home-based versus structured in-person rehabilitation to be similarly effective for quadriceps and hamstring strength and self-reported function; and (4) postoperative knee bracing being ineffective for physical function and laxity. There was low-certainty evidence that: (1) preoperative exercise therapy improves self-reported and physical function postoperatively; (2) cryotherapy reduces pain and analgesic use; (3) psychological interventions improve anxiety/fear; and (4) whole body vibration improves quadriceps strength. There was very low-certainty evidence that: (1) protein-based supplements improve quadriceps size; (2) blood flow restriction training improves quadriceps size; (3) neuromuscular control exercises improve quadriceps and hamstring strength and self-reported function; and (4) continuous passive motion has no effect on range of motion.

CONCLUSION

The general level of evidence for rehabilitation after ACL or meniscal tear was low. Moderate-certainty evidence indicates that several rehabilitation types can improve quadriceps strength, while brace use has no effect on knee function/laxity.

Higher risk of knee arthroplasty during ten-year follow-up if baseline radiographic osteoarthritis involves the patellofemoral joint: a CHECK Cohort Study

Background

Patellofemoral OA is a strong risk factor for progression to generalized whole knee OA, but it is unknown whether involvement of the patellofemoral joint in early radiographic OA (ROA) is associated with risk of undergoing future knee arthroplasty. This is clinically relevant because patellofemoral OA likely requires a different treatment approach than tibiofemoral OA, and identifying prognostic factors for future arthroplasty might assist clinicians with prioritizing and guiding early interventions that could improve long-term outcomes. Therefore, we evaluated association of baseline patellofemoral or tibiofemoral ROA with undergoing knee arthroplasty over 10 years.

Methods

Using the multicenter Cohort Hip and Cohort Knee (CHECK) study, we acquired three views of radiographs in both knees of individuals aged 45–65 years with complaints of knee symptoms in at least one knee. From baseline radiographs, we categorized each knee as having one of four patterns of ROA: no ROA, isolated patellofemoral ROA, isolated tibiofemoral ROA, or combined ROA. We evaluated the 10-year relative hazard for undergoing going arthroplasty, based on baseline ROA pattern, using Cox proportional hazard models, adjusting for age, sex body mass index, and pain severity.

Result

Our sample (n = 842) included 671 (80%) women and had mean (SD) age 56 (5) years, and BMI 26.3 (4.0) kg/m². Arthroplasties were undertaken in 44/1678 knees. In comparison to having no ROA at baseline, adjusted hazard ratios (aHR) for arthroplasty were highest for combined ROA (aHR 14.2 [95% CI 5.8, 34.6]) and isolated patellofemoral ROA (aHR 12.7 [5.6, 29.0]). Isolated tibiofemoral ROA was not significantly associated with arthroplasty (aHR 2.9 [0.6, 13.6]).

Conclusions

In a sample of middle-aged individuals with complaints in one or both knees, the 10-year relative hazard for undergoing arthroplasty, compared to no ROA, was increased when OA involved the patellofemoral joint, regardless of whether it was isolated to the patellofemoral joint or occurred in combination with tibiofemoral OA. Further research is needed to confirm this association and to clarify the causal mechanism of this relationship. However, our results provide preliminary evidence that identifying patellofemoral ROA may be a clinically useful prognostic indicator in early knee OA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05549-6.

Intelligent Algorithm-Based Magnetic Resonance for Evaluating the Effect of Platelet-Rich Plasma in the Treatment of Intractable Pain of Knee Arthritis

The application of intelligent algorithms in the treatment of intractable pain of patients with platelet-rich plasma (PRP) knee osteoarthritis by magnetic resonance was investigated. The automatic diagnosis of magnetic resonance knee osteoarthritis was established with multiple intelligent algorithms, including gray projection algorithm, adaptive binarization algorithm, and active shape model (ASM). The difference between automatic magnetic resonance detection indexes of the patients with knee osteoarthritis and artificial measurement results was analyzed. The included patients received PRP treatment. Knee osteoarthritis MRI osteoarthritis knee scores (KOA MOAKS) and Western Ontario and McMaster Universities arthritis index (WOMAC) before and after treatment were compared. The results showed that the results of knee osteoarthritis scores, inferior angle of femur, superior angle of tibia, and tibiofemoral angle (TFA) by automatic magnetic resonance diagnostic model were entirely consistent with artificial detection results. After the treatment, the total scores of knee lateral area, interior area, central area, and patellar area were all remarkably lower than those before the treatment (P < 0.05). After the treatment, knee KOA MOAKS scores and WOMAC scores were both lower than those before the treatment (P < 0.05). Visual analogue scale (VAS) scores 1 week, 2 weeks, and 3 weeks after the treatment were decreased compared with those before the treatment (P < 0.05). Relevant studies indicated that intelligent algorithm-based automatic magnetic resonance diagnostic knee osteoarthritis model showed good utilization values, which could provide the reference and basis for the treatment of the patients with knee osteoarthritis.

Assessing functional recovery following total knee replacement surgery using objective classification of level gait data and patient-reported outcome measures

BACKGROUND

Patient recovery can be quantified objectively, via gait analysis, or subjectively, using patient reported outcome measures. Association between these measures would explain the level of disability reported in patient reported outcome measures and could assist with therapeutic decisions.

METHODS

Total knee replacement outcome was assessed using objective classification and patient-reported outcome measures (Knee Outcome Survey and Oxford Knee Scores). A classifier was trained to distinguish between healthy and osteoarthritic characteristics using knee kinematics, ground reaction force and temporal gait data, combined with anthropometric data from 32 healthy and 32 osteoarthritis knees. For the osteoarthritic cohort, classification of 20 subjects quantified changes at up to 3 timepoints post-surgery.

FINDINGS

Osteoarthritic classification was reduced for 17 subjects when comparing pre- to post-operative assessments, however only 6 participants achieved non-pathological classification and only 4 of these were classified as non-pathological at 12 months. In 15 cases, the level of osteoarthritic classification did not decrease between every post-operative assessment. For an individual's recovery, classification outputs correlated (r > 0.5) with knee outcome survey for 75% of patients and oxford knee score for 78% of patients (based on 20 and 9 subjects respectively). Classifier outputs from all visits of the combined total knee replacement sample correlated moderately with knee outcome survey (r > 0.4) and strongly with oxford knee score (r > 0.6).

INTERPRETATION

Biomechanical deficits existed in most subjects despite improvements in Patient Reported Outcome Measures, with larger changes reported subjectively as compared to measured objectively. Objective Classification provides additional insight alongside Patient Reported Outcomes when reporting recovered outcomes.

Joint status of patients with nonsevere hemophilia A

BACKGROUND

Joint bleeding in hemophilia may eventually lead to joint damage. In nonsevere hemophilia, joint bleeds occur infrequently. Currently, knowledge on the joint status of patients with nonsevere hemophilia using objective imaging is limited.

OBJECTIVE

To investigate the joint status in patients with nonsevere hemophilia A.

METHODS

This cross-sectional study included patients with nonsevere hemophilia A aged 24-55 years. Joint status was assessed by magnetic resonance imaging (MRI) of the elbows, knees, and ankles and International Prophylaxis Study Group (IPSG) scores were calculated. Lifetime joint bleeding history was collected from medical files. The contribution of factors to joint outcome was explored using multivariable linear regression analysis.

RESULTS

In total, 51 patients were included, of whom 19 (37%) had moderate and 32 (63%) had mild hemophilia. Patients had a median age of 43 years (interquartile range [IQR] 32-50), a median factor VIII activity of 10 IU/dl (IQR 4-16) and a median annual joint bleeding rate (AJBR) of 0.0 (IQR 0.0-0.2). Soft-tissue changes (IPSG subscore > 0) in the elbows, knees, and ankles were present in 19%, 71%, and 71% of patients, respectively. Osteochondral changes (IPSG subscore > 0) in the elbows, knees, and ankles were present in 0%, 20%, and 35% of patients, respectively. In 14% of bleed-free joints, hemosiderin depositions were observed. Age and AJBRs were most strongly associated with the IPSG score.

CONCLUSION

This study demonstrates that a substantial proportion of adults with nonsevere hemophilia has joint changes on MRI despite low joint bleeding rates.

Association between knee pain location and abnormal imaging or arthroscopic findings: A systematic review

BACKGROUND

Assessment of pain location is an essential component of the differential diagnosis of knee pain because pain location is thought to indicate pathology. Previous studies have questioned whether abnormal imaging findings are related to the presence of pain, but none has systematically reviewed the association between knee pain location and the location of abnormal imaging or arthroscopic findings.

OBJECTIVE

To systematically review the association between the location of knee pain and the location of abnormal imaging or arthroscopic findings.

METHODS

Databases were searched up to November 2021 for articles in English that investigated the association between pain location reported using pain mapping and the location of abnormal imaging or arthroscopic findings. Risk of bias was assessed with the modified Newcastle-Ottawa scale. Results were sub-grouped by pathology and data analysis was performed as appropriate.

RESULTS

Among 7730 articles identified, 10 (n = 2034 participants) met the inclusion criteria. Three sub-pathologies were evaluated: patellar tendinopathy (n = 2), knee osteoarthritis (n = 7), and degenerative meniscal tears (n = 1). The primary analysis found poor sensitivity and specificity of patellar tendon hypoechogenic areas and local patellar tendon pain in adult (n = 55) and adolescent athletes (n = 114). The location of pain and the location of abnormal imaging findings was associated in 2 studies of knee osteoarthritis (n = 166). Five articles reported no relationship (n = 1563). No association was reported between the location of pain and the location of arthroscopic findings in degenerative meniscus tears (n = 193). All articles included were rated at low risk of bias.

CONCLUSION

Sensitivity and specificity of the presence of patellar tendon hypoechogenic areas and localised patellar tendon pain was poor. Pain location was not associated with the location of abnormal imaging findings in knee osteoarthritis or to abnormal arthroscopic findings in degenerative meniscus tears.

Editorial Commentary: Intraoperative Platelet-Rich Plasma Injections for Open-Wedge High Tibial Osteotomies Effectively Improve Clinical Outcomes and Minimal Medial Joint Space Width: An Orthobiologic Application

Osteoarthritis is a significant cause of morbidity and mortality involving the knee joint, and high tibial osteotomy is becoming more commonly used to treat severe knee osteoarthritis. In addition, the best management and therapies to mitigate osteoarthritis symptoms and progression may include biologic injections, as we focus on more than just structural abnormalities but also on the inflammatory environment in the joint. These therapies include platelet-rich plasma, bone marrow aspirate concentrate, cell-based therapies, adipose-derived stromal cells, and amniotic suspension allografts. Recent research supports a promising therapy: combined high tibial osteotomy and intraoperative, intraarticular platelet-rich plasma injection.

Implementing the 27 PRISMA 2020 Statement items for systematic reviews in the sport and exercise medicine, musculoskeletal rehabilitation and sports science fields: the PERSiST (implementing Prisma in Exercise, Rehabilitation, Sport medicine and SporTs science) guidance

Poor reporting of medical and healthcare systematic reviews is a problem from which the sports and exercise medicine, musculoskeletal rehabilitation, and sports science fields are not immune. Transparent, accurate and comprehensive systematic review reporting helps researchers replicate methods, readers understand what was done and why, and clinicians and policy-makers implement results in practice. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement and its accompanying Explanation and Elaboration document provide general reporting examples for systematic reviews of healthcare interventions. However, implementation guidance for sport and exercise medicine, musculoskeletal rehabilitation, and sports science does not exist. The Prisma in Exercise, Rehabilitation, Sport medicine and SporTs science (PERSiST) guidance attempts to address this problem. Nineteen content experts collaborated with three methods experts to identify examples of exemplary reporting in systematic reviews in sport and exercise medicine (including physical activity), musculoskeletal rehabilitation (including physiotherapy), and sports science, for each of the PRISMA 2020 Statement items. PERSiST aims to help: (1) systematic reviewers improve the transparency and reporting of systematic reviews and (2) journal editors and peer reviewers make informed decisions about systematic review reporting quality.