Relationship of Joint Hypermobility with Ankle and Foot Radiographic Osteoarthritis and Symptoms in a Community-Based Cohort

Looking back on 30+ years of the Johnston County Osteoarthritis Project while looking forward with the Johnston County Health Study: A narrative review

Over the last 30 years, knowledge of the epidemiology of osteoarthritis (OA) has dramatically advanced, and Osteoarthritis and Cartilage has been on the forefront of disseminating research findings from large OA cohort studies, including the Johnston County OA Project (JoCoOA). The JoCoOA is a population-based, prospective longitudinal cohort that began roughly 30 years ago with a key focus on understanding prevalence, incidence, and progression of OA, as well as its risk factors, in a predominantly rural population of Black and White adults 45+ years old in a county in the southeastern United States. Selected OA results that will be discussed in this review include racial differences, lifetime risk, biomarkers, mortality, and OA risk factors. The new Johnston County Health Study will also be introduced. This new cohort study of OA and comorbid conditions builds upon current OA knowledge and JoCoOA infrastructure and is designed to reflect changes in demographics and urbanization in the county and the region.

A multi-professional survey of UK practice in the use of intra-articular corticosteroid injection for symptomatic first metatarsophalangeal joint osteoarthritis

BACKGROUND

The first metatarsophalangeal joint is the most common site of osteoarthritis (OA) in the foot and ankle. Intra-articular corticosteroid injections are widely used for this condition, but little is known about their use in practice. This study explored current practice within the UK National Health Service (NHS) relating to the administration of intra-articular corticosteroids for people with painful first metatarsophalangeal joint (MTPJ) OA.

METHODS

A cross-sectional survey using Qualtrics online survey platform (Qualtrics, Provo, UT, USA), distributed through professional bodies, special interest groups, and social media.

RESULTS

One hundred forty-four healthcare professionals responded, including podiatrists (53/144; 39%), orthopaedic surgeons (28/144; 19%), podiatric surgeons (26/144; 17%) and physiotherapists (24/144; 16%). Half of respondents administered up to 25 corticosteroid injections per year (67/136; 49%) but some administered more than fifty (21/136; 15%). Injections were administered across the healthcare system but were most common in hospital settings (64/136; 44%) followed by community (38/136; 26%), with less delivered in primary care (11/136; 8%). Half of respondents routinely used image-guidance, either ultrasound or x-ray/fluoroscopy (65/136; 48%) although over one third used none (52/136; 38%). Imaging guidance was more common amongst medical professionals (21/31; 68%) compared to non-medical health professionals (45/105; 43%). Overall, methylprednisolone acetate was the most common corticosteroid used. Medical professionals mostly injected methylprednisolone acetate (n = 15/27; 56%) or triamcinolone acetonide (n = 11/27; 41%), whereas premixed methylprednisolone acetate with lidocaine hydrochloride was the most common preparation used by non-medical health professionals (41/85; 48%). When injecting non premixed steroid, lidocaine hydrochloride (15/35; 43%) was the most common choice of local anaesthetic for non-medical health professionals but medical professionals showed more variation between lidocaine hydrochloride (8/23; 35%) levobupivacaine hydrochloride (9/23; 39%) and bupivacaine hydrochloride (5/23; 22%).

CONCLUSIONS

Multiple professional groups regularly administer intra-articular corticosteroids for symptomatic first MTPJ OA across a range of NHS healthcare settings. Overall, methylprednisolone acetate was the most commonly administered steroid and lidocaine hydrochloride the most common local anaesthetic. There was large variation in the use of imaging guidance, type and dose of steroid, local anaesthetic, and clinical pathways used in the intra-articular injection of corticosteroids for people with first MTPJ OA.

Prevalence of radiographic ankle osteoarthritis in different subgroups of patients referred for ankle radiography

BACKGROUND

Ankle osteoarthritis(OA) has detrimental effects on physical health and has a relatively early disease onset compared to OA in other joints. However, the prevalence of radiographic ankle OA in different subgroups of patients referred for ankle radiography remains unknown. Therefore, we aimed to determine the prevalence of radiographic talocrural, subtalar and talonavicular OA(Kellgren-Lawrence scale ≥2) in a population referred for ankle radiography. Moreover, we aimed to identify differences in prevalence between specific subgroups of patients i.e. Body Mass Index (BMI), sex, age and reason for referral.

METHODS

A cross-sectional study was conducted at a radiology department serving primary and secondary care. Patients completed a questionnaire before radiography. Features of radiographic ankle OA were assessed for subgroups of patients, including; BMI, sex, age and reason for referral (chronic vs (sub)acute complaints). To examine the difference in (features of) radiographic OA for subgroups, multinomial and logistic regression were used to calculate Odds Ratios (ORs), with adjustment for age, sex and BMI.

RESULTS

Data from 893 patients that visited the radiology department across 16 months in 2017 or 2018 were included for analysis. Prevalence of radiographic ankle OA was 9.2%, 0.4% and 7.0%, for the talocrural, subtalar and talonavicular joint, respectively. Obesity was associated with radiographic talonavicular OA (adjusted OR 2.16, 95%CI:1.09; 5.26). Radiographic talocrural and talonavicular OA were both positively associated with male sex [(adjusted OR 4.64, 95%CI:276; 7.81) and (adjusted OR 1.95, 95%CI:1.13; 3.35), respectively].

CONCLUSION

Radiographic ankle OA was more common in men and obese patients that were referred to radiology.

Early Detection of First Carpometacarpal Joint Osteoarthritis Using Magnetic Resonance Imaging Assessment in Women With High Hypermobility Scores

OBJECTIVE

The aim of this study was to explore association between hypermobility and osteoarthritis (OA) at the first carpometacarpal (CMC) joint, using magnetic resonance imaging (MRI) to identify early change in women at high risk of developing OA but without yet established diagnoses.

METHODS

For this observational study, 33 women (aged 30-50 years) with self-reported history of maternal hand OA but without personal diagnoses of OA were recruited. Participants completed a 5-point hypermobility questionnaire. The 20 participants with 2 or more positive responses were categorized with "high hypermobility scores." The remaining 13 were categorized with "low hypermobility scores." Data collection included functional index, hand pain measure, parity, smoking status, and body mass index. Each participant underwent dominant hand radiographic and MRI examination. Imaging studies were interpreted by assessors blinded to hypermobility score categorization.

RESULTS

No significant differences in age, body mass index, parity, functional index, or pain scores were observed between higher and lower hypermobility score groups. Similarly, there were no significant differences between groups for radiographic changes. However, significantly higher proportions of women with higher hypermobility scores were observed on MRI to have abnormalities of trapezium cartilage (75% vs. 38%), metacarpal cartilage (80% vs. 38%), and trapezium bone (70% vs. 31%); p < 0.05 for all.

CONCLUSIONS

First CMC joint structural abnormalities were more frequently observed in women with higher hypermobility scores. Identification of early preradiographic changes in this group supports the concept that early-life joint laxity may contribute to future OA predisposition. Magnetic resonance imaging may be a preferred imaging test for detection of early cartilage changes in people at high risk of CMC joint OA.

Kinematic alterations of the ankle in subjects with generalized joint hypermobility compared with the controls: A cross-sectional study

INTRODUCTION

Generalized joint hypermobility (GJH) is a hereditary connective tissue disease in which the range of motion (ROM) of multiple joints exceeds the normal range, and the ROM varies with age, gender, and ethnicity. At present, the six-degree-of-freedom (6-DOF) of ankle kinematics among people with GJH have not been studied. To investigate the kinematic characteristics in the ankle during treadmill gait of university students with generalized joint hypermobility compared to normal participants. We hypothesized that compared to the participants in the control group, those with GJH would exhibit kinematic characteristics of poorer active motion stability in the ankle during treadmill gait.

METHODS

Healthy university student volunteers aged 18-24 (excluding those with a history of ankle trauma, etc.) were recruited and divided into a control group (50 volunteers) and a GJH group (Beighton score ≥4, 50 volunteers). Data of the 6-DOF kinematics of ankle was collected using a 3D gait analysis system. Variables were evaluated using independent t-tests and Wilcoxon signed-rank tests.

RESULTS

In the proximal/distal parameter, proximal displacement was significantly increased in the GJH group compared with the control group during 4-9% and 96-97% of the gait phase (loading response and terminal swing phase), with an increase of (0.1-0.2 cm, p < .05). Regarding the proximal/distal, internal/external, plantarflexion/dorsiflexion, and anterior/posterior parameters, the participants with GJH exhibited greater ROM than those in the control group throughout the gait cycle (0.24 ± 0.22 cm vs. 0.19 ± 0.15 cm, p = 0.047, 5.56 ± 2.90° vs. 4.48 ± 3.30°, p = .020, 23.05 ± 5.75° vs. 20.36 ± 4.91°, p < .001, 0.65 ± 0.30 cm vs. 0.55 ± 0.27 cm, p = .018). However, ROM of inversion/eversion translation was found to be decreased in the GJH group compared to the control group (8.92 ± 1.59° vs. 9.47 ± 1.37°, p = .009). In addition, there was no statistical difference between the GJH group and the control group in ROM of medial/lateral translation (0.05 ± 0.06 cm vs. 0.04 ± 0.05 cm, p = .131).

CONCLUSION

Our results confirm that our hypothesis is not valid. Although there were a few differences in each gait parameter of the ankle between the GJH group and the control group, the difference was not significant. These results indicate that the presence of GJH has less effect on ankle kinematics and enhance our knowledge of the relationship between GJH and 6-DOF of ankle kinematics.

International Foot and Ankle Osteoarthritis Consortium review and research agenda for diagnosis, epidemiology, burden, outcome assessment and treatment

OBJECTIVE

To summarise the available evidence relating to the diagnosis, epidemiology, burden, outcome assessment and treatment of foot and ankle osteoarthritis (OA) and to develop an agenda to guide future research.

METHOD

Members of the International Foot and Ankle Osteoarthritis Consortium compiled a narrative summary of the literature which formed the basis of an interactive discussion at the Osteoarthritis Research Society International World Congress in 2021, during which a list of 24 research agenda items were generated. Following the meeting, delegates were asked to rank the research agenda items on a 0 to 100 visual analogue rating scale (0 = not at all important to 100 = extremely important). Items scoring a mean of 70 or above were selected for inclusion.

RESULTS

Of the 45 delegates who attended the meeting, 31 contributed to the agenda item scoring. Nineteen research agenda items met the required threshold: three related to diagnosis, four to epidemiology, four to burden, three to outcome assessment and five to treatment.

CONCLUSIONS

Key knowledge gaps related to foot and ankle OA were identified, and a comprehensive agenda to guide future research planning was developed. Implementation of this agenda will assist in improving the understanding and clinical management of this common and disabling, yet relatively overlooked condition.

Comparative Reliability of a Novel Electromechanical Device and Handheld Ruler for Measuring First Ray Mobility

BACKGROUND

Quantifying first ray mobility is crucial to understand aberrant foot biomechanics. A novel device (MAP1^st) that can perform measurements of first ray mobility in different weightbearing conditions, foot alignments, and normalization was tested. The reliability of these measurement techniques was assessed in comparison to a handheld ruler considered representative of the common clinical examination.

METHODS

The study included 25 participants (50 feet). Two independent raters performed baseline, test-retest, and remove-replace measurements of first ray mobility with MAP1^st and the handheld device. The effects of non-, partial, and full weightbearing in subtalar joint neutral and the resting calcaneal stance position were assessed. Measurement normalization relative to foot size was also investigated. Intra- and interclass correlation coefficients (ICCs) were calculated for each device between the 2 raters. In addition, Bland-Altman plots were constructed to determine if fixed biases or substantial outliers were present.

RESULTS

Similar intrarater ICC values were found for both devices (≥0.85). However, interrater ICC values were substantially improved by MAP1^st compared with the handheld device (0.58 vs 0.06). Bland-Altman plots demonstrated biases of 1.27 mm for the handheld ruler, and 2.88 to 0.05 mm and -1.16 to 0.00 for linear and normalized MAP1^st measurements, respectively. Improved reliability was achieved with MAP1^st for normalized assessments of first ray mobility while the foot was placed in partial- and full-weightbearing resting calcaneal stance positions.

CONCLUSION

MAP1^st provided reliable assessments of partial- and full-weightbearing first ray mobility. It should help investigators to explore the potential relationships between first ray function and aberrant foot biomechanics in future research.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

ISB recommendations for skin-marker-based multi-segment foot kinematics

The foot is anatomically and functionally complex, and thus an accurate description of intrinsic kinematics for clinical or sports applications requires multiple segments. This has led to the development of many multi-segment foot models for both kinematic and kinetic analyses. These models differ in the number of segments analyzed, bony landmarks identified, required marker set, defined anatomical axes and frames, the convention used to calculate joint rotations and the determination of neutral positions or other offsets from neutral. Many of these models lack validation. The terminology used is inconsistent and frequently confusing. Biomechanical and clinical studies using these models should use established references and describe how results are obtained and reported. The International Society of Biomechanics has previously published proposals for standards regarding kinematic and kinetic measurements in biomechanical research, and in this paper also addresses multi-segment foot kinematics modeling. The scope of this work is not to prescribe a particular set of standard definitions to be used in all applications, but rather to recommend a set of standards for collecting, calculating and reporting relevant data. The present paper includes recommendations for the overall modeling and grouping of the foot bones, for defining landmarks and other anatomical references, for addressing the many experimental issues in motion data collection, for analysing and reporting relevant results and finally for designing clinical and biomechanical studies in large populations by selecting the most suitable protocol for the specific application. These recommendations should also be applied when writing manuscripts and abstracts.

Joint hypermobility and its association with self-reported knee health: A cross-sectional study of healthy Australian adults

AIM

The primary aim of this study was to determine the association between generalized joint hypermobility (GJH), knee-specific hypermobility (KSH) and self-reported knee health in an Australian population. Secondary aims included elucidating ethnic/gender differences in GJH/KSH prevalence and knee health, and identifying KSH using a novel knee extension range of motion cut-off method.

METHOD

Knee extension range, Beighton score, and 5 domains of the Knee Injury and Osteoarthritis Outcome Score (KOOS) were collected from adults aged 18-101 years self-identifying as healthy, and were grouped by ethnicity and gender. Two established Beighton score criteria and 1 novel knee extension range cut-off method were used to determine GJH and KSH respectively. Point-biserial correlation tested the associations between GJH/KSH and KOOS. Differences in GJH/KSH prevalence and knee health between ethnic/gender groups were determined with the Chi-squared test.

RESULTS

Of 732 participants (50% male), 80.3% were Caucasian. No correlations were found between GJH and KOOS while a very weak correlation was found between KSH and 1 KOOS domain (r > -.30; P = .04). Prevalence of GJH was higher in non-Caucasians (17.4% vs 5.6%, P < .001) and females (4.4% vs 1.1%, P = .007). Prevalence of KSH between ethnic and gender groups was not significantly different (P = .50 and P = .69 respectively). Non-Caucasians scored higher (better) in all KOOS domains than Caucasians (all P < .05).

CONCLUSION

Those who met the age- and gender-specific criteria for GJH/KSH did not report worse knee health than their non-hypermobile counterparts. Clinicians can assure individuals who exhibit GJH/KSH that these are not associated with lower knee health and function.

Incidence and progression of ankle osteoarthritis: The johnston county osteoarthritis project

OBJECTIVE

To determine the incidence and progression of ankle osteoarthritis (OA) and associated risk factors in a community-based cohort of African Americans and whites.

METHODS

Data were from 541 participants who had standardized lateral and mortise radiography of the ankles in weight bearing at baseline (2013-2015) and follow-up (2017-2018). Incident radiographic ankle OA (rAOA) was defined as a Kellgren-Lawrence grade (KLG) ≥ 1 at follow-up among ankles with baseline KLG < 1; progressive rAOA was a ≥ 1 KLG increase at follow-up among ankles with KLG ≥ 1 at baseline. Symptoms were assessed using self-reported pain, aching, and stiffness (PAS) on most days and the Foot and Ankle Outcome Score (FAOS) symptoms subscale. Ankle-level logistic regression models were used to assess associations of ankle outcomes with covariates (age, sex, race, body mass index [BMI], smoking, number of symptomatic joints, comorbidities, prior ankle injury, and knee or foot OA).

RESULTS

Among ankles without rAOA at baseline, 28% developed incident rAOA, 37% had worsening FAOS symptoms, and 7% had worsening PAS. Incident rAOA and worsening ankle symptoms were associated with higher BMI and symptoms in other joints. Among ankles with baseline rAOA, 4% had progressive rAOA, 35% had worsening of FAOS symptoms, and 9% had worsening PAS. rAOA progression was associated with ankle injury and concomitant knee or foot OA; worsening of symptoms was associated with higher BMI and other symptomatic joints.

CONCLUSIONS

Not all ankle OA is post-traumatic. Smoking prevention/cessation, a healthy weight, and injury prevention may be methods for reducing the incidence and progression of rAOA.

Joint hypermobility is not positively associated with prevalent multiple joint osteoarthritis: a cross-sectional study of older adults

BACKGROUND

This cross-sectional study evaluated associations of joint hypermobility and multiple joint osteoarthritis (MJOA) in a community-based cohort of adults 45+ years of age.

METHODS

MJOA and joint hypermobility data were from 1677 participants (mean age 69 years, 68% women) who completed research clinic visits during 2003-2010. Prevalent MJOA was defined in four ways. Radiographic OA (rOA) was defined as Kellgren-Lawrence (KL) > 2 at any included study joint; symptomatic OA (sxOA) required both symptoms and rOA in a joint. Joint hypermobility was defined as a Beighton score of > 4. Separate logistic regression models were used to estimate odds ratios (OR) between joint hypermobility and each MJOA definition, adjusting for age, sex, race, body mass index, and baseline visit.

RESULTS

In this cohort, 4% had Beighton score > 4 and 63% met any definition of MJOA. Joint hypermobility was associated with significantly lower odds of radiographic and symptomatic MJOA-1 (multiple joint OA-definition 1: involvement of > 1 IP (interphalangeal) nodes and > 2 sites of hip, knee, and spine; 74 and 58% lower, respectively). However, for the other MJOA definitions (i.e., MJOA-2:involvement of > 2 IP joints, > 1 carpometacarpal [CMC] joints, and knee or hip sites; MJOA-3: involvement of > 5 joint sites from among distal interphalangeal, proximal interphalangeal, CMC, hip, knee, or spine sites; and MJOA-4:involvement of > 2 lower body sites (hip, knee, or spine), there were no statistically significant associations. For associations between site-specific hypermobility and any MJOA definition, most adjusted ORs were less than one, but few were statistically significant.

CONCLUSIONS

Overall, joint hypermobility was not positively associated with any definition of prevalent MJOA in this cohort, and an inverse association existed with one definition of MJOA. Longitudinal studies are needed to determine the contribution of hypermobility to the incidence and progression of MJOA outcomes.