The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study

Therapeutic Review of Methylprednisolone Acetate Intra-Articular Injection in the Management of Osteoarthritis of the Knee - Part 1: Clinical Effectiveness

Intra-articular (IA) corticosteroid injections are a common approach in the management of osteoarthritis (OA) of the knee. The effectiveness of injections and particular injection products is often discussed and debated in clinical arenas. The following therapeutic review examines the evidence for intra-articular methylprednisolone acetate (MPA) injections in the management of OA knee. A review of research evidence, published guidelines and clinical literature was undertaken following an electronic database and relevant literature search. The review found that there is limited evidence which indicates that a single dose intra-articular MPA injection can provide short to medium term benefits for pain, with less evidence for beneficial effects on function or stiffness. There is heterogeneity across studies and until recently, most studies had only short to medium term follow-up periods, thus limiting the evidence available on longer term benefit. There was also evidence indicating equivalent overall efficacy of MPA to that of other corticosteroid products. Most guideline recommendations concerning IA injections for OA knee have drawn on evidence from pooled data for several corticosteroid products. The review also found there was limited reporting of the incidence of adverse events in most studies. Overall, MPA shows efficacy for symptom relief in OA knee. At an individual management level, evidence for a limited duration of effect needs consideration in injections decisions. Furthermore, consensus across clinical guidelines suggests that the management of OA knee should be individualized to a person's clinical history, degree of disability, risk factors, quality of life and personal preferences, whereby injecting involves a shared decision and forms part of a multimodal approach. Copyright © 2016 John Wiley & Sons Ltd.

Transglutaminase 2 in cartilage homoeostasis: novel links with inflammatory osteoarthritis

Transglutaminase 2 (TG2) is highly expressed during chondrocyte maturation and contributes to the formation of a mineralised scaffold by introducing crosslinks between extracellular matrix (ECM) proteins. In healthy cartilage, TG2 stabilises integrity of ECM and likely influences cartilage stiffness and mechanistic properties. At the same time, the abnormal accumulation of TG2 in the ECM promotes chondrocyte hypertrophy and cartilage calcification, which might be an important aspect of osteoarthritis (OA) initiation. Although excessive joint loading and injuries are one of the main causes leading to OA development, it is now being recognised that the presence of inflammatory mediators accelerates OA progression. Inflammatory signalling is known to stimulate the extracellular TG2 activity in cartilage and promote TG2-catalysed crosslinking of molecules that promote chondrocyte osteoarthritic differentiation. It is, however, unclear whether TG2 activity aims to resolve or aggravate damages within the arthritic joint. Better understanding of the complex signalling pathways linking inflammation with TG2 activities is needed to identify the role of TG2 in OA and to define possible avenues for therapeutic interventions.

Logistical challenges and design considerations for studies using acute anterior cruciate ligament injury as a potential model for early posttraumatic osteoarthritis

Anterior cruciate ligament (ACL) injuries are common and lead to posttraumatic osteoarthritis (PTOA) in a high percentage of patients. Research has been ineffective in identifying successful treatment options for people suffering from symptomatic PTOA resulting in a shift of focus toward the young, ACL injured patients at risk of developing PTOA. Randomized clinical trials examining the very early phase after ACL injury are ideal to study this population; however, these trials face significant challenges regarding recruitment as well as reproducibility of patient-reported outcomes (PROs) and inflammatory and/or chondrodegenerative biomarkers associated with early PTOA. The aim of this work was to develop an approach to allow for early recruitment into an RCT for early treatment following ACL injury and to analyze the variability of commonly used measures and biomarkers at various time points after injury. This paper reports the study design and data related to the first month of treatment for the placebo group of an ongoing 2-year clinical trial to evaluate the effect of an early intra-articular intervention after ACL injury. The results of this study suggest that acute ACL injury results in early changes of both inflammatory and chondrodegenerative biomarkers. These results also provide vital information for researchers to consider when developing future protocols, both related to the logistics of early patient enrollment as well as the appropriate timing of biomarker and patient-reported outcome collection. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:641-650, 2017.

Proliferative injection therapy for osteoarthritis: a systematic review

PURPOSE

To systematically analyse randomised controlled trials (RCTs) about efficacy and safety of proliferative injection therapy (prolotherapy) for treatment of osteoarthritis (OA).

METHODS

CENTRAL, Embase and MEDLINE were searched. Two reviewers independently conducted screening and data extraction. RCTs were assessed with the Cochrane risk of bias tool. Type of treatment, study design, dosing, efficacy outcomes and safety outcomes were analysed. The protocol was registered in PROSPERO (CRD42016035258).

RESULTS

Seven RCTs were included, with 393 participants aged 40-75 years and mean OA pain duration from three months to eight years. Follow-up was 12 weeks to 12 months. Studies analysed OA of the knee joint (n = 5), first carpometacarpal joint (n = 1) and finger joints (n = 1). Various types of prolotherapy were used; dextrose was the most commonly used irritant agent. All studies concluded that prolotherapy was effective treatment for OA. No serious adverse events were reported. The studies had considerable methodological limitations.

DISCUSSION

Limited evidence from low-quality studies indicates a beneficial effect of prolotherapy for OA management. The number of participants in these studies was too small to provide reliable evidence.

CONCLUSIONS

Current data from trials about prolotherapy for OA should be considered preliminary, and future high-quality trials on this topic are warranted.

Latin-American challenges and opportunities in rheumatology

The importance of diseases to mankind is very similar worldwide. However, social and environmental issues, not to mention political and individual aspects, affect the prevalence and management of diseases and their outcomes. I present a brief and tentative comment to illustrate that the Latin-American rheumatology community, despite relevant gains in recent years, has some challenges to face in order to improve patient care in our region.

Musculoskeletal disorders as underlying cause of death in 58 countries, 1986-2011: trend analysis of WHO mortality database

Background

Due to low mortality rate of musculoskeletal disorders (MSK) less attention has been paid to MSK as underlying cause of death in the general population. The aim was to examine trend in MSK as underlying cause of death in 58 countries across globe during 1986–2011.

Methods

Data on mortality were collected from the WHO mortality database and population data were obtained from the United Nations. Annual sex-specific age-standardized mortality rates (ASMR) were calculated by means of direct standardization using the WHO world standard population. We applied joinpoint regression analysis for trend analysis. Between-country disparities were examined using between-country variance and Gini coefficient. The changes in number of MSK deaths between 1986 and 2011 were decomposed using two counterfactual scenarios.

Results

The number of MSK deaths increased by 67% between 1986 and 2011 mainly due to population aging. The mean ASMR changed from 17.2 and 26.6 per million in 1986 to 18.1 and 25.1 in 2011 among men and women, respectively (median: 7.3% increase in men and 9.0% reduction in women). Declines in ASMR of 25% or more were observed for men (women) in 13 (19) countries, while corresponding increases were seen for men (women) in 25 (14) countries. In both sexes, ASMR declined during 1986–1997, then increased during 1997–2001 and again declined over 2001–2011. Despite decline over time, there were substantial between-country disparities in MSK mortality and its temporal trend.

Conclusions

We found substantial variations in MSK mortality and its trends between countries, regions and also between sex and age groups. Promoted awareness and better management of MSK might partly explain reduction in MSK mortality, but variations across countries warrant further investigations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1428-1) contains supplementary material, which is available to authorized users.

Outcome Assessment in Total Knee Arthroplasty: A Systematic Review and Critical Appraisal

BACKGROUND

The Outcome Measures in Rheumatology (OMERACT) initiative developed a core outcome set (COS) of domains to assess effectiveness of interventions for knee osteoarthritis. These domains (pain, physical function, patient global assessment, imaging at 1 year) should be assessed in every trial to make research evidence meaningful and comparable. We systematically evaluated and critically appraised the use of measurement instruments and outcome domains in prospective studies evaluating patients with knee osteoarthritis undergoing total knee arthroplasty (TKA) and assessed their accordance with the OMERACT COS.

METHODS

Literature search was performed until August 26, 2014, in Medline and Embase. Clinical trials and prospective observational studies with ≥50 participants and a follow-up of ≥1 year were included. We collected general study characteristics, comprehensive information on measurement instruments, and corresponding domains used.

RESULTS

This systematic review identified low accordance of used outcome domains with the OMERACT COS of domains published in 1997. Only 4 of 100 included studies included all recommended core domains. Pain (85% of studies) and physical function (86%) were assessed frequently, whereas patient global assessment (21%) and joint imaging (≥1 year; 27%) were rarely assessed. There was substantial heterogeneity in the use of measurement instruments (n = 111) investigating TKA.

CONCLUSION

More efforts are required to implement the existing COS. In addition, a more consistent use of adequate measurement instruments is important to make research evidence on TKA more relevant, better comparable, and thus more useful for guideline developers and clinical decision makers.

Clinical Characterization of Patients With Autosomal Dominant Short Stature due to Aggrecan Mutations

CONTEXT

Heterozygous mutations in the aggrecan gene (ACAN) cause autosomal dominant short stature with accelerated skeletal maturation.

OBJECTIVE

We sought to characterize the phenotypic spectrum and response to growth-promoting therapies.

PATIENTS AND METHODS

One hundred three individuals (57 females, 46 males) from 20 families with autosomal dominant short stature and heterozygous ACAN mutations were identified and confirmed using whole-exome sequencing, targeted next-generation sequencing, and/or Sanger sequencing. Clinical information was collected from the medical records.

RESULTS

Identified ACAN variants showed perfect cosegregation with phenotype. Adult individuals had mildly disproportionate short stature [median height, -2.8 standard deviation score (SDS); range, -5.9 to -0.9] and a history of early growth cessation. The condition was frequently associated with early-onset osteoarthritis (12 families) and intervertebral disc disease (9 families). No apparent genotype-phenotype correlation was found between the type of ACAN mutation and the presence of joint complaints. Childhood height was less affected (median height, -2.0 SDS; range, -4.2 to -0.6). Most children with ACAN mutations had advanced bone age (bone age - chronologic age; median, +1.3 years; range, +0.0 to +3.7 years). Nineteen individuals had received growth hormone therapy with some evidence of increased growth velocity.

CONCLUSIONS

Heterozygous ACAN mutations result in a phenotypic spectrum ranging from mild and proportionate short stature to a mild skeletal dysplasia with disproportionate short stature and brachydactyly. Many affected individuals developed early-onset osteoarthritis and degenerative disc disease, suggesting dysfunction of the articular cartilage and intervertebral disc cartilage. Additional studies are needed to determine the optimal treatment strategy for these patients.

Osteoarthritis Year in Review 2016: biomarkers (biochemical markers)

PURPOSE

The aim of this "Year in Review" article is to summarize and discuss the implications of biochemical marker related articles published between the Osteoarthritis Research Society International (OARSI) 2015 Congress in Seattle and the OARSI 2016 Congress in Amsterdam.

METHODS

The PubMed/MEDLINE bibliographic database was searched using the combined keywords: 'biomarker' and 'osteoarthritis'. The PubMed/MEDLINE literature search was conducted using the Advanced Search Builder function (http://www.ncbi.nlm.nih.gov/pubmed/advanced).

RESULTS

Over two hundred new biomarker-related papers were published during the literature search period. Some papers identified new biomarkers whereas others explored the biological properties and clinical utility of existing markers. There were specific references to several adipocytokines including leptin and adiponectin. ADAM Metallopeptidase with Thrombospondin Type 1 motif 4 (ADAMTS-4) and aggrecan ARGS neo-epitope fragment (ARGS) in synovial fluid (SF) and plasma chemokine (CeC motif) ligand 3 (CCL3) were reported as potential new knee biomarkers. New and refined proteomic technologies and novel assays including a fluoro-microbead guiding chip (FMGC) for measuring C-telopeptide of type II collagen (CTX-II) in serum and urine and a novel magnetic nanoparticle-based technology (termed magnetic capture) for collecting and concentrating CTX-II, were described this past year.

CONCLUSION

There has been steady progress in osteoarthritis (OA) biomarker research in 2016. Several novel biomarkers were identified and new technologies have been developed for measuring existing biomarkers. However, there has been no "quantum leap" this past year and identification of novel early OA biomarkers remains challenging. During the past year, OARSI published a set of recommendations for the use of soluble biomarkers in clinical trials, which is a major step forward in the clinical use of OA biomarkers and bodes well for future OA biomarker development.

Barriers for guideline adherence in knee osteoarthritis care: A qualitative study from the patients' perspective

RATIONALE, AIMS AND OBJECTIVES

Guidelines for patients with knee osteoarthritis (OA) are suboptimally implemented in clinical care. To improve guideline adherence, patients' perceived barriers and facilitators in current care were investigated.

METHODS

Eleven patients with knee OA were extensively interviewed using a semistructured script based on quality indicators. Directed content analysis, within the framework of Grol and Wensing, was performed to describe barriers and facilitators in 6 domains: guideline, health care professional, patient, social environment, organization, and financial context. Data were analyzed using NVIVO 10 software.

RESULTS

In total, 38 barriers, at all 6 domains, were identified. The most frequently mentioned barriers were in the domains of the patient and the health care professional, namely, patients' disagreement with guidelines recommendations, negative experience with drugs, patients' limited comprehension of the disease process, and poor communication by the health care professional. The patients' disagreement with recommendations is further explained by the following barriers: "insistence on medical imaging," "fear that physiotherapy aggravates pain," and "perception that knee OA is not a priority health issue". Patients also reported 20 facilitators, all of which are listed as opposing barriers.

CONCLUSIONS

Patients indicate that both personal factors and factors related to health care professionals play an important role in nonadherence. An interview script, based on quality indicators, was a significant aid to structurally formulate barriers and facilitators in the perceived knee OA care. Future guideline implementation strategies should take the identified barriers and facilitators into account.

The role for arthroscopic partial meniscectomy in knees with degenerative changes: a systematic review

AIMS

Patients with osteoarthritis of the knee commonly have degenerative meniscal tears. Arthroscopic meniscectomy is frequently performed, although the benefits are debatable. Recent studies have concluded that there is no role for arthroscopic washout in osteoarthritis of the knee. Our aim was to perform a systematic review to assess the evidence for the efficacy of arthroscopic meniscectomy in patients with meniscal tears and degenerative changes in the knee.

PATIENTS AND METHODS

A literature search was performed, using the PubMed/MEDLINE database, for relevant articles published between 1975 and 2015. A total of six studies, including five randomised controlled trials and one cross-sectional study of a prospective cohort, met the inclusion criteria. Relevant information including study design, operations, the characteristics of the patients, outcomes, adverse events and further operations were extracted.

RESULTS

The degree of osteoarthritis in the patients who were included and the rate of cross over from one form of treatment to another varied in the studies. Two randomised controlled trials showed a benefit of arthroscopic surgery in patients with limited degenerative joint disease, compared with conservative treatment. One cross-sectional study showed that patients with less severe degenerative changes had better outcomes.

CONCLUSION

Patients with symptomatic meniscal tears and degenerative changes in the knee can benefit from arthroscopic meniscectomy, particularly if the osteoarthritis is mild. A trial of conservative management may be effective and should be considered, especially in patients with moderate osteoarthritis. Cite this article: Bone Joint J 2016;98-B:934-8.

Accuracy of injection and short-term pain relief following intra-articular corticosteroid injection in knee osteoarthritis - an observational study

Background

Intra-articular corticosteroid injections (IACI) are effective treatments for pain in knee osteoarthritis (KOA) but treatment response varies. There is uncertainty as to whether structural factors such as accurate placement of IACI affect outcome. We examined this question in a pragmatic observational study, using ultrasound (US) to verify accuracy of IACI.

Methods

105 subjects with KOA (mean age 63.1 years, 59% female) routinely referred for IACI underwent assessment of demographic factors, x-ray and US of the knee before aspiration and IACI (based on clinical landmarks) with 40 mg triamcinolone acetonide with lignocaine plus a small amount of atmospheric air by an independent physician. US demonstration of intra-articular mobile air, i.e. a positive air arthrosonogram, was used to determine accurate placement of injection. Both patients and injecting physicians were blind to the US findings. Pain at baseline, three and nine weeks post injection was assessed using the 500 mm WOMAC pain subscale and response defined as ≥ 40% reduction in pain from baseline. Inter-observer reliability of air-arthrosonogram assessment was good: κ 0.79 (three raters).

Results

Sixty-three subjects (60.6%) were responders at three weeks and 43 (45.7%) at nine weeks. Seventy-four subjects (70.5%) had a positive arthrosonogram. A positive air arthrosonogram did not associate with a higher rate of response to treatment (p 0.389 at three weeks, p 0.365 at nine weeks). There was no difference in US effusion depth, power Doppler signal or radiographic grade between responders and non-responders to the injection, but female gender associated with response at 3 weeks and previous injection with non-response at 9 weeks.

Conclusions

Accurate intra-articular injection of corticosteroid results did not result in superior outcome in terms of pain compared to inaccurate injection in symptomatic knee OA.

The Effects of Traditional Chinese Exercise in Treating Knee Osteoarthritis: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Traditional Chinese exercise (TCE) includes a variety of exercise, which is being accepted by more and more people in the treatment of knee osteoarthritis (OA) from different countries. With the attendant, many clinical reports focus on it. Our meta-analysis aimed to systematically assess the effects of traditional Chinese exercise on pain, stiffness, physical function, quality of life, mental health and adverse events in people with knee osteoarthritis.

METHODS

PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), the Web of Science, and Chinese Biomedical Literature Database (CBM) were searched from the time of their inception through April 2016 and risk of bias was independently assessed by two authors. Outcome measures included pain, physical functional, joint stiffness, quality of life, mental health and safety. For pooled outcomes, standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated.

RESULTS

Eight randomized controlled trials with a sample size of 375 cases met the criteria to be included in the study indicating that high quality literature is lacking in this field. Results of the meta-analysis showed that short-term TCE could relieve pain (SMD: -0.77;95% CI: -1.13 to -0.41; P<0.0001), improve physical function (SMD -0.75; 95% CI: -0.98 to -0.52; P<0.00001), and alleviate stiffness (SMD: -0.56; 95%: CI -0.96 to -0.16; P<0.006), but had no significant effect on quality of life (SMD: 0.57; 95% CI: 0.17 to 0.97; P = 0.005), and mental health (SMD 4.12; 95% CI: -0.50 to 8.73; P = 0.08). Moreover, TCE was not associated with serious adverse events.

CONCLUSIONS

Our systematic review revealed that short-term TCE was potentially beneficial in terms of reducing pain, improving physical function and alleviating stiffness. These results may suggest that TCE could prove useful as an adjuvant treatment for patients with knee OA. Further studies are urgently needed to confirm these results.

Health enhancing physical activity in patients with hip or knee osteoarthritis - an observational intervention study

Background

Osteoarthritis is one of the leading causes of inactivity worldwide. The recommended level of health enhancing physical activity (HEPA) is at least 150 min of moderate intensity physical activity per week. The purpose of this study was to explore how the proportion of patients, who reached the recommended level of HEPA, changed following a supported osteoarthritis self-management programme in primary care, and to explore how reaching the level of HEPA was influenced by body mass index (BMI), gender, age and comorbidity.

Methods

An observational study was conducted using data from a National Quality Registry in which 6810 patients in primary care with clinically verified hip or knee osteoarthritis with complete data at baseline, 3 and 12 months follow-up before December 31^st 2013 were included. HEPA was defined as self-reported physical activity of at least moderate intensity either a) at least 30 min per day on four days or more per week, or b) at least 150 min per week. HEPA was assessed at baseline, and again at 3 and 12 months follow-up. Cochran’s Q test was used to determine change in physical activity over time. The association between reaching the level of HEPA and time, age, BMI, gender, and Charnley classification was investigated using the generalized estimation equation (GEE) model.

Results

The proportion of patients who reached the level of HEPA increased by 345 patients, from 77 to 82%, from baseline to 3 months follow-up. At 12 months, the proportion of patients who reached the level of HEPA decreased to 76%. Not reaching the level of HEPA was associated with overweight, obesity, male gender and Charnley category C, i.e. osteoarthritis in multiple joint sites (hip and knee), or presence of any other disease that affects walking ability.

Conclusions

Following the supported osteoarthritis self-management programme there was a significant increase in the proportion of patients who reached the recommended level of HEPA after 3 months. Improvements were lost after 12 months. To increase physical activity and reach long-lasting changes in levels of physical activity, more follow-up sessions might be needed.

Musculoskeletal Health Conditions Represent a Global Threat to Healthy Aging: A Report for the 2015 World Health Organization World Report on Ageing and Health

Persistent pain, impaired mobility and function, and reduced quality of life and mental well-being are the most common experiences associated with musculoskeletal conditions, of which there are more than 150 types. The prevalence and impact of musculoskeletal conditions increase with aging. A profound burden of musculoskeletal disease exists in developed and developing nations. Notably, this burden far exceeds service capacity. Population growth, aging, and sedentary lifestyles, particularly in developing countries, will create a crisis for population health that requires a multisystem response with musculoskeletal health services as a critical component. Globally, there is an emphasis on maintaining an active lifestyle to reduce the impacts of obesity, cardiovascular conditions, cancer, osteoporosis, and diabetes in older people. Painful musculoskeletal conditions, however, profoundly limit the ability of people to make these lifestyle changes. A strong relationship exists between painful musculoskeletal conditions and a reduced capacity to engage in physical activity resulting in functional decline, frailty, reduced well-being, and loss of independence. Multilevel strategies and approaches to care that adopt a whole person approach are needed to address the impact of impaired musculoskeletal health and its sequelae. Effective strategies are available to address the impact of musculoskeletal conditions; some are of low cost (e.g., primary care-based interventions) but others are expensive and, as such, are usually only feasible for developed nations. In developing nations, it is crucial that any reform or development initiatives, including research, must adhere to the principles of development effectiveness to avoid doing harm to the health systems in these settings.

Diabetes mellitus and the risk of total knee replacement among Chinese in Singapore, the Singapore Chinese Health Study

Association between diabetes mellitus (diabetes) and risk of knee osteoarthritis (KOA) is confounded by high body mass index (BMI), a strong risk factor for both conditions. We evaluated the association between diabetes and incidence of total knee replacement (TKR) due to severe KOA in the Singapore Chinese Health Study, a prospective cohort of 63,257 Chinese men and women, aged 45-74 years at recruitment in 1993-1998, and re-interviewed in 1999-2004. Height, weight, lifestyle factors and history of diabetes were obtained through in-person interviews at recruitment and re-interview. Incident cases of TKR were identified via record linkage with nationwide hospital discharge database. Subjects with/without prevalent diabetes had comparable BMI (24.0 kg/m² versus 23.0 kg/m²). After an average of 14-years, 1,973 subjects had TKR attributable to KOA. Compared to subjects without diabetes, hazard ratio (HR) of TKR for subjects with diabetes was 0.63 [95% confidence interval (CI), 0.52-0.75] after controlling for BMI and other risk factors. An inverse association was also observed between incident diabetes at re-interview and subsequent risk of TKR (HR = 0.74; 95% CI = 0.58-0.94). The inverse diabetes-TKR risk association was similar by gender and across three categories of BMI. Our study does not support diabetes as a risk factor of KOA.

Effects of different omega-3 sources, fish oil, krill oil, and green-lipped mussel against cytokine-mediated canine cartilage degradation

Our purpose was to evaluate the protective effect of three marine omega-3 sources, fish oil (FO), krill oil (KO), and green-lipped mussel (GLM) against cartilage degradation. Canine cartilage explants were stimulated with either 10 ng/mL interleukin-1β (IL-1β) or IL-1β/oncostatin M (10 ng/mL each) and then treated with various concentrations of docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA; 3 and 30 μg/mL), FO, KO, or GLM (250, 500, and 1000 μg/mL) for 28 days. Gene expression was then investigated in primary canine chondrocytes. Our results showed that DHA and EPA as well as omega-3 sources could suppress matrix degradation in cytokine-induced cartilage explants by significantly reducing the increase of sulfated glycosaminoglycans (s-GAGs) and preserving uronic acid and hydroxyproline content (except GLM). These agents were not able to reduce IL-1β-induced IL1B and TNFA expression but were able to down-regulate the expression of the catabolic genes MMP1, MMP3, and MMP13 and up-regulate the anabolic genes AGG and COL2A1; FO and KO were especially effective. Our findings indicated that FO and KO were superior to GLM for their protective effect against proteoglycan and collagen degradation. Hence, FO and KO could serve as promising sources of chondroprotective agents.

Knee Cartilage Regeneration with Umbilical Cord Mesenchymal Stem Cells Embedded in Collagen Scaffold Using Dry Arthroscopy Technique

Articular cartilage injuries lead to progressive degeneration of the joint with subsequent progression to osteoarthritis, which currently becomes a serious health and economic issue. Due to limited capability for self-regeneration, cartilage repair remains a challenge for the present-day orthopedics. Currently, available therapeutic methods fail to provide satisfactory results. A search for other strategies that could regenerate a hyaline-like tissue with a durable effect and adequate mechanical properties is underway. Tissue engineering strategies comprise the use of an appropriately chosen scaffold in combination with seeding cells. Mesenchymal stem cells (MSC) provide an interesting new option in regenerative medicine with solid preclinical data and first promising clinical results. They act not only through direct cartilage formation, but also due to paracrine effects, such as releasing trophic factors, anti-inflammatory cytokines, and promoting angiogenesis. The MSC can be applied in an allogeneic setting without eliciting a host immune response. Out of the various available sources, MSC derived from Wharton's jelly of an umbilical cord seem to have many advantages over their counterparts. This article details a novel, single-staged, and minimally invasive technique for cartilage repair that involves dry arthroscopic implantation of scaffold-embedded allogenic mesenchymal stem cells isolated from umbilical cord Wharton's jelly.

The quality-of-life burden of knee osteoarthritis in New Zealand adults: A model-based evaluation

BACKGROUND

Knee osteoarthritis is a leading global cause of health-related quality of life loss. The aim of this project was to quantify health losses arising from knee osteoarthritis in New Zealand (NZ) in terms of quality-adjusted life years (QALYs) lost.

METHODS

The Osteoarthritis Policy Model (OAPol), a validated Monte Carlo computer simulation model, was used to estimate QALYs lost due to knee osteoarthritis in the NZ adult population aged 40-84 over their lifetimes from the base year of 2006 until death. Data were from the NZ Health Survey, NZ Burden of Diseases, NZ Census, and relevant literature. QALYs were derived from NZ EQ-5D value set 2. Sensitivity to health state valuation, disease and pain prevalence were assessed in secondary analyses.

RESULTS

Based on NZ EQ-5D health state valuations, mean health losses due to knee osteoarthritis over people's lifetimes in NZ are 3.44 QALYs per person, corresponding to 467,240 QALYs across the adult population. Average estimated per person QALY losses are higher for non-Māori females (3.55) than Māori females (3.38), and higher for non-Māori males (3.34) than Māori males (2.60). The proportion of QALYs lost out of the total quality-adjusted life expectancy for those without knee osteoarthritis is similar across all subgroups, ranging from 20 to 23 percent.

CONCLUSIONS

At both the individual and population levels, knee osteoarthritis is responsible for large lifetime QALY losses. QALY losses are higher for females than males due to greater prevalence of knee osteoarthritis and higher life expectancy, and lower for Māori than non-Māori due to lower life expectancy. Large health gains are potentially realisable from public health and policy measures aimed at decreasing incidence, progression, pain, and disability of osteoarthritis.

Validated Measures of Illness Perception and Behavior in People with Knee Pain and Knee Osteoarthritis: A Scoping Review

OBJECTIVE

To identify validated measures that capture illness perception and behavior and have been used to assess people who have knee pain/osteoarthritis.

METHODS

A scoping review was performed. Nine electronic databases were searched for records from inception through April 19, 2015. Search terms included illness perception, illness behavior, knee, pain, osteoarthritis, and their related terms. This review included English language publications of primary data on people with knee pain/osteoarthritis who were assessed with validated measures capturing any of 4 components of illness perception and behavior: monitor body, define and interpret symptoms, take remedial action, and utilize sources of help. Seventy-one publications included relevant measures. Two reviewers independently coded and analyzed each relevant measure within the 4 components.

RESULTS

Sixteen measures were identified that capture components of illness perception and behavior in the target population. These measures were originally developed to capture constructs that include coping strategies/skills/styles, illness belief, illness perception, self-efficacy, and pain behavior. Coding results indicated that 5, 11, 12, and 5 of these measures included the monitor body, define and interpret symptoms, take remedial action, and utilize sources of help components, respectively.

CONCLUSIONS

Several validated measures were interpreted as capturing some components, and only 1 measure was interpreted as capturing all of the components of illness perception and behavior in the target population. A measure that comprehensively captures illness perception and behavior could be valuable for informing and evaluating therapy for patients along a continuum of symptomatic knee osteoarthritis.

Hand-related physical function in rheumatic hand conditions: a protocol for developing a patient-reported outcome measurement instrument

INTRODUCTION

There is no consensus about what constitutes the most appropriate patient-reported outcome measurement (PROM) instrument for measuring physical function in patients with rheumatic hand conditions. Existing instruments lack psychometric testing and vary in feasibility and their psychometric qualities. We aim to develop a PROM instrument to assess hand-related physical function in rheumatic hand conditions.

METHODS AND ANALYSIS

We will perform a systematic search to identify existing PROMs to rheumatic hand conditions, and select items relevant for hand-related physical function as well as those items from the Patient Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) item bank that are relevant to patients with rheumatic hand conditions. Selection will be based on consensus among reviewers. Content validity of selected items will be established through the use of focus groups. If patients deem necessary, we will develop new items based on the patients' input. We will examine whether it is valid to score all selected and developed items on the same scale as the original items from the PROMIS PF item bank. Our analyses will follow the methods used for calibrating the original PROMIS PF item bank in US samples, which were largely based on the general PROMIS approach.

ETHICS AND DISSEMINATION

This study will be carried out in accordance with the Helsinki Declaration. Ethics approvals will be obtained where necessary, and signed informed consent will be obtained from all participants. We aim to disseminate the results of the study through publication in international peer-reviewed journals and at international conferences.

Factors associated with functional limitations in the daily living activities of Japanese hip osteoarthritis patients

AIM

As society ages, there is a vast number of elderly people with locomotive syndrome. In this study, the factors associated with functional limitations in daily living activities evaluated by female hip osteoarthritis (OA) patients were investigated.

METHODS

This study was a cross-sectional study. The subjects were 353 female patients who were newly diagnosed with hip OA at an orthopedic clinic with no history of hip joint surgery. Outcome indices were functional limitations in two daily living activities obtained from a questionnaire completed by the patients: (i) standing up (standing from a crouched position) and (ii) stair-climbing (climbing and/or descending stairs). The odds ratios (ORs) and 95% confidence intervals (CIs) were computed for explanatory variables using the proportional odds model in logistic regression to evaluate their associations with functional limitations.

RESULTS

Functional limitations in standing up were associated with heavy weight (third tertile vs. first tertile: 1.91, 1.11-3.27), participation in sports at school (0.62, 0.40-0.98), parity (vs. nullipara: 1.96, 1.08-3.56), old age and OA stage. Associations with functional limitations in stair-climbing were seen with short height (< 151.0 cm vs. ≥ 156.0 cm: 2.05, 1.02-4.12), bilateral involvement (vs. unilateral: 1.71, 1.01-2.88), old age and OA stage.

CONCLUSION

Old age, OA stage, heavy weight, parity, shorter height and bilateral OA were associated with functional limitations in standing up and/or stair-climbing, whereas participation in sports such as club activities in school maintained standing up.

Health-related quality of life in midlife women in Qatar: relation to arthritis and symptoms of joint pain

OBJECTIVE

The prevalence of osteoarthritis (OA) and rheumatoid arthritis (RA) has been poorly documented in the Middle East and North African region, including the State of Qatar. Given that musculoskeletal pain is commonly reported among midlife women, we evaluated the association between self-report of either OA or RA and health-related quality of life (HRQoL) among midlife women in Qatar. In addition, HRQoL among women in Qatar was compared with that of women in the Study of Women's Health Across the Nation (SWAN).

METHODS

A cross-sectional study was conducted among 841 women 40 to 60 years recruited from primary care centers in Qatar. Face-to-face interviews were conducted and included measures of self-reported OA and RA, health-related symptom experience, and HRQoL using the SF-36 health survey.

RESULTS

Most women were obese (75.5%) and reported being bothered by aches and stiffness in joints (71.6%). Prevalence of self-reported OA and RA was 4.8% and 4.3%, respectively. OA was significantly associated with reduced physical function (adjusted odds ratio [OR], 2.97; P=0.003). RA was also significantly related to reduced physical function (adjusted OR, 2.94; P = 0.01) and role physical (adjusted OR, 2.67; P = 0.01). When compared with women from the SWAN, women from the current study had significantly lower mean scores for bodily pain (53.0 vs. 68.9, P = 0.0001) and for vitality (49.9 vs. 54.8, P = 0.0001).

CONCLUSIONS

Self-report of OA or RA was associated with significant disability in our sample. Because symptoms of aches and stiff joints were so frequently reported, arthritis may be under-diagnosed, especially given the high rates of obesity observed.

Extracellular vesicles in the pathogenesis of rheumatoid arthritis and osteoarthritis

Osteoarthritis (OA) and rheumatoid arthritis (RA) are both debilitating diseases that cause significant morbidity in the US population. Extracellular vesicles (EVs), including exosomes and microvesicles, are now recognized to play important roles in cell-to-cell communication by transporting various proteins, microRNAs (miRNAs), and mRNAs. EV-derived proteins and miRNAs impact cell viability and cell differentiation, and are likely to play a prominent role in the pathophysiology of both OA and RA. Some of the processes by which these membrane-bound vesicles can alter joint tissue include extracellular matrix degradation, cell-to-cell communication, modulation of inflammation, angiogenesis, and antigen presentation. For example, EVs from IL-1β-stimulated fibroblast-like synoviocytes have been shown to induce osteoarthritic changes in chondrocytes. RA models have shown that EVs stimulated with inflammatory cytokines are capable of inducing apoptosis resistance in T cells, presenting antigen to T cells, and causing extracellular damage with matrix-degrading enzymes. EVs derived from rheumatoid models have also been shown to induce secretion of COX-2 and stimulate angiogenesis. Additionally, there is evidence that synovium-derived EVs may be promising biomarkers of disease in both OA and RA. The characterization of EVs in the joint space has also opened up the possibility for delivery of small molecules. This article reviews current knowledge on the role of EVs in both RA and OA, and their potential role as therapeutic targets for modulation of these debilitating diseases.

Cost utility modeling of early vs late total knee replacement in osteoarthritis patients

Given the dramatic increase in the number of total knee replacement (TKR) surgeries in developed countries, the issue of the best time for surgery needs to be addressed from an economic perspective.

OBJECTIVE

To assess, from the perspective of the healthcare payer, the cost-utility of two surgical strategies in which knee replacement is performed at the early or late stage of the disease in patients with knee osteoarthritis (OA).

DESIGN

Patient data and evidence from published literature on economic costs and outcomes in OA, including utilities, non-pharmacological, pharmacological and surgical options, combined with population life tables were entered in a Markov model of OA. The model represented the lifetime experience of a cohort of patients following their therapeutic management, discounting costs (euros) and utilities (quality-adjusted life-years) at 4% annually.

RESULTS

In the base-case scenario, early TKR cost €6,624 more than late TKR (€76,223 vs €69,599) with a 0.15 gain in QALYs (18.675 vs 18.524). This yielded an incremental cost-utility ratio (ICUR) of 43,631 €/QALY. Sensitivity analyses of the most influential uncertain parameters were performed and did not modify the direction of the conclusions: early TKR cost between €3,655 and €7,194 more than late TKR with a gain in QALYs between 0.15 and 0.39. The ICUR ranged from 17,131 €/QALY to 48,241 €/QALY.

CONCLUSION

Our data do not support the early TKR strategy over the late TKR strategy in knee OA patients from a medico-economic perspective.

Associations Between Fat Mass, Lean Mass, and Knee Osteoarthritis: The Fifth Korean National Health and Nutrition Examination Survey (KNHANES V)

As little is known about the associations between body composition (fat mass and lean mass) and knee OA, especially regarding body parts (upper body and lower limbs), the purpose of this study was to identify the association between the former and the prevalence of the latter according to body parts. This study was designed as a cross-sectional analysis, with 4194 people (1801 men and 2393 women) from the fifth Korean National Health and Nutrition Examination Survey (KNHANES V, 2010-2011) included. Body composition (fat mass and lean mass) was measured by using dual-energy X-ray absorptiometry, and knee OA was diagnosed based on the level of Kellgren-Lawrence grade. In multivariate logistic regression analysis, upper body composition was not significantly correlated with radiographic knee OA (P > 0.05), while participants with higher lean mass of lower limbs were less likely to have radiographic knee OA (aOR 0.57; 95 % CI 0.32-0.99). In stratified analysis, participants with higher lean mass of lower limbs were less likely to have a radiographic knee OA in 40-54 kg (P for trend = 0.05) and 55-70 kg stratum (P for trend = 0.03), while this trend slightly attenuated in 70-85 kg stratum (P for trend = 0.15). In conclusion, the increase in lean mass of lower limbs is inversely related to the prevalence of knee OA while upper body composition is not. This study suggests that the lean mass of lower limbs might be associated with reduction in the risk of knee OA.

Number of Persons With Symptomatic Knee Osteoarthritis in the US: Impact of Race and Ethnicity, Age, Sex, and Obesity

OBJECTIVE

The prevalence of symptomatic knee osteoarthritis (OA) has been increasing over the past several decades in the US, concurrent with an aging population and the growing obesity epidemic. We quantify the impact of these factors on the number of persons with symptomatic knee OA in the early decades of the 21st century.

METHODS

We calculated the prevalence of clinically diagnosed symptomatic knee OA from the National Health Interview Survey 2007-2008 and derived the proportion with advanced disease (defined as Kellgren/Lawrence grade 3 or 4) using the Osteoarthritis Policy Model, a validated simulation model of knee OA. Incorporating contemporary obesity rates and population estimates, we calculated the number of persons living with symptomatic knee OA.

RESULTS

We estimate that approximately 14 million persons had symptomatic knee OA, with advanced OA comprising more than half of those cases. This includes more than 3 million persons of racial/ethnic minorities (African American, Hispanic, and other). Adults younger than 45 years of age represented nearly 2 million cases of symptomatic knee OA and individuals between 45 and 65 years of age comprised 6 million more cases.

CONCLUSION

More than half of all persons with symptomatic knee OA are younger than 65 years of age. As many of these younger persons will live for 3 decades or more, there is substantially more time for greater disability to occur, and policymakers should anticipate health care utilization for knee OA to increase in the upcoming decades. These data emphasize the need for the deployment of innovative prevention and treatment strategies for knee OA, especially among younger persons.

The contribution of leg press and knee extension strength and power to physical function in people with knee osteoarthritis: A cross-sectional study

The purposes of this study were to 1) determine the additional contributions of leg press and knee extensor power, over and above that of strength, to the performance of physical function tasks in people with knee osteoarthritis, and 2) compare the ability of bilateral leg press to unilateral knee extensor strength and power to predict functional task performance.

METHODS

A cross-sectional, exploratory study of 40 individuals with tibiofemoral knee osteoarthritis resulting in moderate impairments in physical function was conducted. Physical function (Get-up and Go, timed stair climb and descent, and five time chair rise) and muscle performance (leg press and knee extension strength and power) were assessed.

RESULTS

After controlling for covariates and strength, leg press, but not knee extensor, power explained additional variance in physical function (11% and 21%). Conversely, adding strength to regression models including covariates and power did not consistently improve the prediction of physical function. Additionally, leg press power consistently explained more variance in physical function (44 to 57%) than involved (24 to 34%) or uninvolved (28 to 48%) knee extension power.

CONCLUSIONS

Leg press power may be a more functionally relevant measure of muscle performance than knee extension strength in this population. Future studies should investigate the effectiveness of interventions specifically designed to improve leg press power in people with knee osteoarthritis.

Content and Evaluation of the Benefits of Effective Exercise for Older Adults With Knee Pain Trial Physiotherapist Training Program

OBJECTIVE

To explore whether participating in the Benefits of Effective Exercise for knee Pain (BEEP) trial training program increased physiotherapists' self-confidence and changed their intended clinical behavior regarding exercise for knee pain in older adults.

DESIGN

Before/after training program evaluation. Physiotherapists were asked to complete a questionnaire before the BEEP trial training program, immediately after, and 12 to 18 months later (postintervention delivery in the BEEP trial). The questionnaire included a case vignette and associated clinical management questions. Questionnaire responses were compared over time and between physiotherapists trained to deliver each intervention within the BEEP trial.

SETTING

Primary care.

PARTICIPANTS

Physiotherapists (N=53) who completed the BEEP trial training program.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Self-confidence in the diagnosis and management of knee pain in older adults; and intended clinical behavior measured by a case vignette and associated clinical management questions.

RESULTS

Fifty-two physiotherapists (98%) returned the pretraining questionnaire, and 44 (85%) and 39 (74%) returned the posttraining and postintervention questionnaires, respectively. Posttraining, self-confidence in managing older adults with knee pain increased, and intended clinical behavior regarding exercise for knee pain in older adults appeared more in line with clinical guidelines. However, not all positive changes were maintained in the longer-term.

CONCLUSIONS

Participating in the BEEP trial training program increased physiotherapists' self-confidence and changed their intended clinical behavior regarding exercise for knee pain, but by 12 to 18 months later, some of these positive changes were lost. This suggests that brief training programs are useful, but additional strategies are likely needed to successfully maintain changes in clinical behavior over time.

Symptom-modifying effects of oral avocado/soybean unsaponifiables in routine treatment of knee osteoarthritis in Poland. An open, prospective observational study of patients adherent to a 6-month treatment

OBJECTIVES

Observational studies provide insights into real-life situations. Therefore, we assessed the effects of oral avocado/soybean unsaponifiable (ASU) capsules on pain relief and functional ability in patients, while they were receiving a routine treatment for knee osteoarthritis (OA).

MATERIAL AND METHODS

An open, prospective, observational 6-month study was conducted in 99 centers in Poland in a group of 4822 patients with symptomatic knee OA receiving one 300 mg ASU capsule/day as a routine medication. The patients had no diagnoses of other rheumatic diseases and were not treated with other symptomatic slow-acting drugs for osteoarthritis (SYSADOAs). Data on OA symptoms and therapy were collected from the initiation of ASU treatment (visit 0) and during 3 consecutive control visits performed every 2 months (visits 1-3). Functional Lequesne index, severity of joint pain of one symptomatic knee (Laitinen index and VAS), use of analgesics and non-steroidal anti-inflammatory drugs (NSAIDs), adherence to treatment and adverse events were evaluated and recorded using electronic Case Report Forms.

RESULTS

Four thousand one hundred and eighty-six patients (86.8%) attended all 4 visits. In 94.2% of patients (mean age 60.7 ±11.6 years SD, 73.4% female) at least one OA risk factor was identified. There was a significant improvement in functional ability between the last and baseline visits as evidenced by the median Lequesne index decreasing from 8 to 4 points (p < 0.001). Measures of pain intensity also fell significantly (p < 0.001) throughout the study: median Laitinen score decreased from 6 to 3 points, median pain at rest VAS - from 1.8 to 0 cm and median pain during walking VAS - from 5.6 to 1.9 cm. The significant differences were also noted between consecutive visits. The proportion of patients using analgesics and NSAIDs declined from 58.8% at the baseline visit to 24.9% at the last visit 3 (p < 0.001). Defined daily dose of NSAIDs decreased significantly from 1 at the baseline visit to 0.67 at the visit 3. Severe adverse events associated with ASU treatment were not observed.

CONCLUSIONS

It was the first observational study in Poland evaluating the effects of routine knee OA treatment with oral ASU. Only a small group of patients (13.2%) treated with ASU discontinued the study. The majority of patients adherent to the ASU treatment for 6 months showed gradual alleviation of joint pain, improvement in functional ability and a significant reduction in NSAIDs intake.

Clinical settings in knee osteoarthritis: Pathophysiology guides treatment

Osteoarthritis (OA) is the most common chronic joint disorder and its prevalence increases rapidly during midlife. Complex interactions of genetic alterations, sex hormone deficit, and aging with mechanical factors and systemic inflammation-associated metabolic syndrome lead to joint damage. Thus, the expression of a clinical phenotype in the early stages of OA relies on the main underlying pathway and predominant joint tissue involved at a given time. Moreover, OA often coexists with other morbidities in the same patient, which in turn condition the OA process. In this scenario, an appropriate identification of clinical phenotypes, especially in the early stages of the disease, may optimize the design of individualized treatments in OA. An ESCEO-EUGMS (European Union Geriatric Medicine Society) working group has recently suggested possible patient profiles in OA. Hereby, we propose the existence of 4 clinical phenotypes - biomechanical, osteoporotic, metabolic and inflammatory - whose characterization would help to properly stratify patients with OA in clinical trials or studies. Further research in this field is warranted.

Role of physical activity in cartilage damage progression of subjects with baseline full-thickness cartilage defects in medial tibiofemoral compartment: data from the Osteoarthritis Initiative

OBJECTIVE

To assess the association between physical activity and cartilage damage progression in medial tibiofemoral compartment (MTFC) using 2-year follow-up magnetic resonance imaging (MRI) in subjects with denuded areas of subchondral bone (dABs) at the central weight-bearing medial femur (cMF) at baseline MRI examination.

METHODS

One hundred subjects from the Osteoarthritis Initiative (OAI) progression cohort with dABs at the cMF at 3T MRI at baseline (51% men; mean age 62.2 years, range 45-79) were included. Sagittal 3D dual-echo steady-state with water excitation images were used to assess 2-year MTFC cartilage change. Associations between 2-year average Physical Activity Scale for the Elderly (PASE) and 2-year MTFC cartilage change were assessed by linear regression analysis. Subgroup analyses were performed.

RESULTS

No associations between PASE and 2-year MTFC cartilage change were observed in the entire cohort. Similarly, in the subgroup with cartilage loss during the 2 years, the non-refuted confidence intervals for the regression coefficients were tightly clustered around the null value (regression coefficients for: mean cMF.ThCtAB = -0.00059; 98.75% CI: -0.00130 to 0.00012), cMF.dAB% = 0.02176; 98.75% CI: -0.02514 to 0.06865, Mean MT.ThCtAB = -0.00013; 98.75% CI: -0.00064 to 0.00038, MT.dAB% = 0.02543; 98.75% CI: -0.01485 to 0.06571.

CONCLUSION

In the entire group of subjects with dABs at the cMF at baseline, no association between physical activity and 2-year MTFC cartilage change was detected. Due to the limited sample size of our study, small-sized effects may not have been detected in our study.

Predictors of Exercise Adherence in Patients With Meniscal Tear and Osteoarthritis

OBJECTIVE

To identify predictors of poor exercise adherence in patients with osteoarthritis (OA) and meniscal tear.

DESIGN

Secondary analysis of data gathered over the first 12 weeks in the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial, a multicenter, randomized controlled trial.

SETTING

Seven referral centers.

PARTICIPANTS

Most of the patients in the MeTeOR trial (N=325 of 351) were included in the analysis, each of whom was aged ≥45 years and had a meniscal tear and osteoarthritic changes on imaging studies; 26 were excluded because of missing data from which to derive the primary outcome variable.

INTERVENTIONS

All patients received a structured, supervised exercise program focused on strengthening, along with prescribed home exercises; half were randomly assigned to also receive arthroscopic partial meniscectomy.

MAIN OUTCOME MEASURE

Poor exercise adherence through 12 weeks, defined as performing <50% of prescribed exercise.

RESULTS

Thirty-eight percent of the MeTeOR cohort showed poor exercise adherence. In the multivariate model, adjusting for treatment group, those who earned ≤$29,000 per year had 1.64 times the risk of nonadherence (95% confidence interval [CI], 1.10-2.43) than those who earned >$100,000 per year; and those without baseline pain with pivoting and twisting had 1.60 times greater risk of nonadherence than those with these symptoms (95% CI, 1.14-2.25).

CONCLUSIONS

Low income was associated with poor exercise adherence among patients aged ≥45 years with OA and a meniscal tear, as was absence of pain with pivoting and twisting. Our findings highlight the need for further research into exercise adherence and for interventions to enhance adherence among those with low incomes.

Defining an International Standard Set of Outcome Measures for Patients With Hip or Knee Osteoarthritis: Consensus of the International Consortium for Health Outcomes Measurement Hip and Knee Osteoarthritis Working Group

OBJECTIVE

To define a minimum Standard Set of outcome measures and case-mix factors for monitoring, comparing, and improving health care for patients with clinically diagnosed hip or knee osteoarthritis (OA), with a focus on defining the outcomes that matter most to patients.

METHODS

An international working group of patients, arthroplasty register experts, orthopedic surgeons, primary care physicians, rheumatologists, and physiotherapists representing 10 countries was assembled to review existing literature and practices for assessing outcomes of pharmacologic and nonpharmacologic OA therapies, including surgery. A series of 8 teleconferences, incorporating a modified Delphi process, were held to reach consensus.

RESULTS

The working group reached consensus on a concise set of outcome measures to evaluate patients' joint pain, physical functioning, health-related quality of life, work status, mortality, reoperations, readmissions, and overall satisfaction with treatment result. To support analysis of these outcome measures, pertinent baseline characteristics and risk factor metrics were defined. Annual outcome measurement is recommended for all patients.

CONCLUSION

We have defined a Standard Set of outcome measures for monitoring the care of people with clinically diagnosed hip or knee OA that is appropriate for use across all treatment and care settings. We believe this Standard Set provides meaningful, comparable, and easy to interpret measures ready to implement in clinics and/or registries globally. We view this set as an initial step that, when combined with cost data, will facilitate value-based health care improvements in the treatment of hip and knee OA.

Osteoarthritis

Osteoarthritis (OA) is the most common joint disorder, is associated with an increasing socioeconomic impact owing to the ageing population and mainly affects the diarthrodial joints. Primary OA results from a combination of risk factors, with increasing age and obesity being the most prominent. The concept of the pathophysiology is still evolving, from being viewed as cartilage-limited to a multifactorial disease that affects the whole joint. An intricate relationship between local and systemic factors modulates its clinical and structural presentations, leading to a common final pathway of joint destruction. Pharmacological treatments are mostly related to relief of symptoms and there is no disease-modifying OA drug (that is, treatment that will reduce symptoms in addition to slowing or stopping the disease progression) yet approved by the regulatory agencies. Identifying phenotypes of patients will enable the detection of the disease in its early stages as well as distinguish individuals who are at higher risk of progression, which in turn could be used to guide clinical decision making and allow more effective and specific therapeutic interventions to be designed. This Primer is an update on the progress made in the field of OA epidemiology, quality of life, pathophysiological mechanisms, diagnosis, screening, prevention and disease management.