Measures of Adult Knee Function

Patient-reported outcomes and return to pre-injury activities after surgical treatment of multi-ligamentous knee injuries in patients over 40-years-old: Average 5-years follow-up

BACKGROUND

Multi-ligamentous knee injuries (MLKI) are potentially devastating injuries, though existing prognostic research among older patients who sustain MLKI is limited. The purpose was to investigate clinical outcomes and rates of return to pre-injury activities following surgical treatment of MLKI in patients at least 40 years old.

METHODS

This study was a multi-center retrospective case series of patients who underwent surgical treatment for MLKI from 2013-2020 and were ≥ 40 years old at time of injury. Outcomes were assessed via e-mail and telephone using the International Knee Documentation Committee (IKDC) score, Lysholm score, Tegner activity scale, a satisfaction rating, and return to pre-injury sport and work surveys. Stepwise linear regression was used to assess the impact of preoperative characteristics on IKDC and Lysholm scores.

RESULTS

Of 45 patients eligible for inclusion, 33 patients (mean age: 48.6 years [range: 40-72]) were assessed at a mean follow-up of 59.1 months (range 24-133). The cohort reported a mean IKDC of 63.4 ± 23.5, Lysholm of 72.6 ± 23.6, and Tegner of 3.8 ± 2.0. There was a 41.2% rate of return to sports, and 82.1% returned to work. Documented knee dislocation was predictive of poorer IKDC (β:-20.05, p = 0.025) and Lysholm (β:-19.99, p = 0.030). Patients aged > 50 were more satisfied compared to those 40-50 years old (96.2 ± 4.9 vs 75.6 ± 23.3, p = 0.012).

CONCLUSIONS

Patients who sustained MLKI aged at least 40 at injury demonstrated fair clinical outcomes at a mean 5-year follow-up. Older patients who sustained MLKI reported a relatively high rate of return to work but were less likely to return to sports.

LEVEL OF EVIDENCE

IV, Case series.

Efficacy and Safety of Hyaluronic Acid and Platelet-Rich Plasma Combination Therapy Versus Platelet-Rich Plasma Alone in Treating Knee Osteoarthritis: A Systematic Review

Knee osteoarthritis (KOA) is a chronic degenerative disease of the joint characterized by biochemical and biomechanical alterations of articular cartilage, degradation of the joint edge, and subchondral bone hyperplasia. Nowadays, intra-articular hyaluronic acid (HA) or platelet-rich plasma (PRP) has become a popular treatment modality for treating KOA. Each treatment can be used independently or in combination. However, the efficacy and safety of combination treatment are still inconclusive, and there is a lack of high-quality level 1 studies that support using combination therapy over PRP alone. Consequently, we conducted a systematic review to examine the effectiveness and safety of combining HA and PRP therapy versus using PRP therapy alone in KOA patients. Based on the most up-to-date evidence, the dual approach of PRP and HA therapy yields outcomes similar to PRP therapy alone in the short term, up to 12 months. Nonetheless, when considering longer-term results, particularly in the 24-month follow-up, dual therapy holds the potential to produce superior outcomes compared to PRP alone therapy. Additionally, in terms of safety, dual therapy has been associated with slightly fewer adverse events.

Clinical aspects and outcomes in osteoarthritis

Osteoarthritis (OA) is the most prevalent type of arthritis worldwide, and its incidence significantly increases with age. It commonly affects the knees, hips, spine, big toes, and hands. OA can be identified through clinical examination, symptoms, and imaging methods. Its main symptoms include pain, stiffness, and limitations in joint movement. Examinations may reveal coarse crepitus, bony enlargement, and tenderness at the joint line. In severe cases of OA, rest pain, night pain, and deformity may occur. OA can lead to decreased physical activity, function, and quality of life due to symptoms such as pain and stiffness. To evaluate these impacts, patient-reported outcome measures (PROMs) are necessary. Various generic, disease-specific, and joint-specific PROMs have been developed and used in clinical practice to assess the outcomes of OA.

The influence of obesity on functional outcomes and patient satisfaction 8 weeks after total knee arthroplasty: results of the prospective FInGK study

OBJECTIVES

To investigate obese versus non-obese subjects´ knee joint function, stiffness, pain, expectations, and outcome satisfaction before and two months after total knee arthroplasty (TKA).

METHODS

This study is a secondary analysis of data retrieved via a prospective single-centre cohort study investigating knee joint function and health care services utilization in patients undergoing TKA (FInGK Study). For the primary study, elective TKA patients were consecutively recruited between December 2019 and May 2021. Preoperative expectations, Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), surgery outcome satisfaction, and sociodemographic variables were assessed via self-reported questionnaires. In the current study, obese (Body Mass Index (BMI) ≥ 30 kg/m²) versus non-obese (BMI < 30 kg/m²) subjects' data were exploratively compared before and two months after TKA. Multivariable logistic regression assessed factors associated with TKA satisfaction two months postoperatively. Linear regression evaluated factors associated with higher WOMAC change two months postoperatively.

RESULTS

A total of 241 subjects participated (response: 85.2%). Eighty-seven were non-obese (mean age: 70.7 years, 63.2% female) and 154 were obese (mean age: 67.1 years, 57.8% female). Obese subjects reported inferior pre- and postoperative pain and knee joint function compared to non-obese subjects. Yet, WOMAC scores of obese and non-obese subjects significantly improved from preoperative means of 52.6 and 46.8 to 32.3 and 24.4 after surgery, respectively. The only significant TKA satisfaction predictor was subjects' smoking status. Non-obesity and worse preoperative WOMAC scores were predictive of higher WOMAC change scores after two months.

CONCLUSION

Both obese and non-obese subjects reported significant symptom improvements. However, as obese subjects' short-term outcomes were still inferior, more research on TKA rehabilitation measures adapted to the needs of this growing patient group is warranted to maximize their benefits from TKA.

Effectiveness of an Unsupervised Online Yoga Program on Pain and Function in People With Knee Osteoarthritis : A Randomized Clinical Trial

BACKGROUND

Yoga is a mind-body exercise typically done in groups in person, but this delivery method can be inconvenient, inaccessible, and costly. Effective online programs may increase access to exercise for knee osteoarthritis.

OBJECTIVE

To evaluate the effectiveness of an unsupervised 12-week online yoga program.

DESIGN

Two-group superiority randomized trial. (Australian New Zealand Clinical Trials Registry: ACTRN12620000012976).

SETTING

Community.

PARTICIPANTS

212 adults with symptomatic knee osteoarthritis.

INTERVENTION

Both groups received online osteoarthritis information (control). The yoga group also received access to an unsupervised online yoga program delivered via prerecorded videos over 12 weeks (1 video per week, with each session to be performed 3 times per week), with optional continuation thereafter.

MEASUREMENTS

Primary outcomes were changes in knee pain during walking (0 to 10 on a numerical rating scale) and physical function (0 to 68 on the Western Ontario and McMaster Universities Osteoarthritis Index) at 12 weeks (primary time point) and 24 weeks, analyzed using mixed-effects linear regression models. Secondary outcomes were self-reported overall knee pain, stiffness, depression, anxiety, stress, global change, quality of life, self-efficacy, fear of movement, and balance confidence. Adverse events were also collected.

RESULTS

A total of 195 (92%) and 189 (89%) participants provided 12- and 24-week primary outcomes, respectively. Compared with control at 12 weeks, yoga improved function (between-group mean difference in change, -4.0 [95% CI, -6.8 to -1.3]) but not knee pain during walking (between-group mean difference in change, -0.6 [CI, -1.2 to 0.1]), with more yoga participants than control participants achieving the minimal clinically important difference (MCID) for both outcomes. At 12 weeks, knee stiffness, quality of life, and arthritis self-efficacy improved more with yoga than the control intervention. Benefits were not maintained at 24 weeks. Adverse events were minor.

LIMITATION

Participants were unblinded.

CONCLUSION

Compared with online education, an unsupervised online yoga program improved physical function but not knee pain at 12 weeks in people with knee osteoarthritis, although the improvement did not reach the MCID and was not sustained at 24 weeks.

PRIMARY FUNDING SOURCE

National Health and Medical Research Council and Centres of Research Excellence.

The AktiWeb study: feasibility of a web-based exercise program delivered by a patient organisation to patients with hip and/or knee osteoarthritis

Background

Patient organisations may be an under-utilised resource in follow-up of patients requiring long-term exercise as part of their disease management. The purpose of this study was to explore the feasibility of a web-based exercise program delivered by a patient organisation to patients with hip and/or knee osteoarthritis (OA).

Methods

In this pre–post feasibility study, patients aged 40–80 years with hip and/or knee OA were recruited from Diakonhjemmet Hospital. The 12-week intervention was delivered through a patient organisation’s digital platform. Feasibility was evaluated by proportion of eligible patients enrolled, proportion of enrolled patients who provided valid accelerometer data at baseline, and proportion completing the cardiorespiratory exercise test according to protocol at baseline and completed follow-up assessments. Patient acceptability was evaluated for website usability, satisfaction with the initial exercise level and comprehensibility of the exercise program. Change in clinical outcomes were assessed for physical activity, cardiorespiratory fitness and patient-reported variables.

Results

In total, 49 eligible patients were identified and 35 were enrolled. Thirty (86%) of these attended baseline assessments and provided valid accelerometer data and 18 (51%) completed the maximal cardiorespiratory exercise test according to protocol. Twenty-two (63%) patients completed the follow-up questionnaire, and they rated the website usability as ‘acceptable’ [median 77.5 out of 100 (IQR 56.9, 85.6)], 19 (86%) reported that the initial exercise level was ‘just right’ and 18 (82%) that the exercise program was ‘very easy’ or ’quite easy’ to comprehend. Improvement in both moderate to vigorous physical activity (mean change 16.4 min/day; 95% CI 6.9 to 25.9) and cardiorespiratory fitness, VO_2peak (mean change 1.83 ml/kg/min; 95% CI 0.29 to 3.36) were found in a subgroup of 8 patients completing these tests. Across all patient-reported outcomes 24–52% of the patients had a meaningful improvement (n = 22).

Conclusion

A web-based exercise program delivered by a patient organisation was found to be feasible and acceptable in patients with hip and/or knee OA.

Trial registration

ClinicalTrials.gov, NCT04084834 (registered 10 September 2019). The Regional Committee for Medical and Health Research Ethics south-east, 2018/2198. URL: Prosjekt #632074 - Aktiv med web-basert støtte. - Cristin (registered 7 June 2019).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01110-3.

Fundamentals of osteoarthritis: outcome evaluation with patient-reported measures and functional tests

Evaluating outcome in osteoarthritis (OA) clinical research and practice requires reliable, valid and responsive patient-reported outcome measures (PROMs) and functional tests that reflect important problems experienced by people with OA. The goal of this work is to provide information to start to guide the reader in selecting measures for people with OA. In this narrative review, we begin by providing an overview of measurement properties that can help clinicians and researchers in making decisions about whether a measure might be appropriate for use in their research or clinical context. We then report evidence supporting the use of measures of pain (e.g., Pain Visual Analogue (VAS), Numeric Pain Rating Scale (NPRS), Intermittent and Constant Osteoarthritis Pain, PROMIS Pain Interference, and, for screening in research, the painDETECT and the Self-report Leeds Assessment of Neuropathic Symptoms and Signs) and fatigue (e.g., PROMIS-Fatigue) at a group level in clinical research. Several multi-dimensional joint-specific measures (e.g., Western Ontario McMaster Universities' Osteoarthritis Outcomes Scale, Knee/Hip Injury and Osteoarthritis Outcome Score, Oxford Hip/Knee Scale) also have evidence for group-level use. Functional tests (e.g., timed walk tests, 30 Second Chair Stand, Timed Up and Go, etc.) have measurement properties supporting their use at the group level in clinical research and at the individual patient level as do the pain VAS and NPRS. Other generic and disease-specific PROMs have been used in or could be used in OA studies but their measurement properties require further evaluation in people with OA.

Prevalence of Early Knee Osteoarthritis Illness Among Various Patient-Reported Classification Criteria After Anterior Cruciate Ligament Reconstruction

OBJECTIVE

To compare the prevalence of participants meeting different patient-reported criteria for early osteoarthritis (OA) illness after anterior cruciate ligament reconstruction (ACLR).

METHODS

Participants completed the Knee Injury and Osteoarthritis Outcomes Score (KOOS) at a single time point 5.0-7.9 months post-ACLR. We used established KOOS subscale criteria (i.e., Luyten original and Englund original) to define patient-reported early OA illness. A two-by-two contingency table and McNemar's test were used to compare the prevalence of participants who met the Luyten original versus Englund original KOOS criteria for early OA illness. These analyses were repeated using KOOS subscale thresholds based on established population-specific patient acceptable symptom state (PASS) within the Luyten and Englund KOOS criteria (i.e., Luyten PASS and Englund PASS).

RESULTS

A greater prevalence of participants with ACLR met the Luyten original criteria (n = 165 [54%]) compared to those who met the Englund original criteria (n = 128 [42%]; χ2  = 19.3, P < 0.001). When using the KOOS subscale PASS as thresholds, a significantly greater prevalence of participants with ACLR met the Luyten PASS criteria (n = 133 [43%]) compared to those who met the Englund PASS criteria (n = 85 [28%]; χ2  = 48.0, P < 0.001). When combining the Luyten and Englund KOOS criteria and using the original/PASS subscale thresholds, respectively, 40%/57% of participants met neither, 24%/15% met only 1, and 36%/28% met both KOOS criteria.

CONCLUSION

Regardless of the classification criteria used to define early OA illness, it is concerning that 28-54% of patients report considerable symptoms ~6 months post-ACLR. Our findings will improve the classification criteria to define early OA illness, which may raise awareness for the need of population-specific criteria.

Comparing Video-Based, Telehealth-Delivered Exercise and Weight Loss Programs With Online Education on Outcomes of Knee Osteoarthritis : A Randomized Trial

BACKGROUND

Scalable knee osteoarthritis programs are needed to deliver recommended education, exercise, and weight loss interventions.

OBJECTIVE

To evaluate two 6-month, telehealth-delivered exercise programs, 1 with and 1 without dietary intervention.

DESIGN

3-group, parallel randomized (5:5:2) trial. (Australian New Zealand Clinical Trials Registry: ACTRN12618000930280).

SETTING

Australian private health insurance members.

PARTICIPANTS

415 persons with symptomatic knee osteoarthritis and a body mass index between 28 and 40 kg/m2 who were aged 45 to 80 years.

INTERVENTION

All groups received access to electronic osteoarthritis information (control). The exercise program comprised 6 physiotherapist consultations via videoconference for exercise, self-management advice, and behavioral counseling, plus exercise equipment and resources. The diet and exercise program included an additional 6 dietitian consultations for a ketogenic very-low-calorie diet (2 formulated meal replacements and a low-carbohydrate meal daily) followed by a transition to healthy eating, as well as nutrition and behavioral resources.

MEASUREMENTS

Primary outcomes were changes in knee pain (numerical rating scale [NRS] of 0 to 10, higher indicating worse) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]; scale, 0 to 68, higher indicating worse) at 6 months (primary time point) and 12 months. Secondary outcomes were weight, physical activity, quality of life, mental health, global change, satisfaction, willingness to have surgery, orthopedic appointments, and knee surgery.

RESULTS

A total of 379 participants (91%) provided 6-month primary outcomes, and 372 (90%) provided 12-month primary outcomes. At 6 months, both programs were superior to control for pain (between-group mean difference in change on NRS: diet and exercise, -1.5 [95% CI, -2.1 to -0.8]; exercise, -0.8 [CI, -1.5 to -0.2]) and function (between-group mean difference in change on WOMAC: diet and exercise, -9.8 [CI, -12.5 to -7.0]; exercise, -7.0 [CI, -9.7 to -4.2]). The diet and exercise program was superior to exercise (pain, -0.6 [CI, -1.1 to -0.2]; function, -2.8 [CI, -4.7 to -0.8]). Findings were similar at 12 months.

LIMITATION

Participants and clinicians were unblinded.

CONCLUSION

Telehealth-delivered exercise and diet programs improved pain and function in people with knee osteoarthritis and overweight or obesity. A dietary intervention conferred modest additional pain and function benefits over exercise.

PRIMARY FUNDING SOURCE

Medibank, the Medibank Better Health Foundation Research Fund, and a National Health and Medical Research Council Centre of Research Excellence.

Clinical phenotype and musculoskeletal characteristics of patients with aggrecan deficiency

Aggrecan is a proteoglycan within the physeal and articular cartilage. Aggrecan deficiency, due to heterozygous mutations in the ACAN gene, causes dominantly inherited short stature and, in many patients, early-onset osteoarthritis and degenerative disc disease. We aimed to further characterize this phenotypic spectrum with an emphasis on musculoskeletal health. Twenty-two individuals from nine families were enrolled. Histories and examinations focused on joint health, gait analysis, joint specific patient reported outcomes, and imaging studies were performed. All patients had dominantly inherited short stature, with the exception of a de novo mutation. Short stature was worse in adults versus children (median height -3.05 SD vs. -2.25 SD). ACAN mutations were not always associated with bone age advancement (median advancement +1.1 years, range 0 to +2 years). Children had subtle disproportionality and clinically silent joint disease-25% with osteochondritis dissecans (OD). Adults had a high prevalence of joint symptomatology-decline in knee function, disability from spinal complaints, and lower physical activity on outcome measures. Osteoarthritis (OA) and OD was detected in 90% of adults, and orthopedic surgeries were reported in 60%. Aggrecan deficiency leads to short stature with progressive decline in height SD, mild skeletal dysplasia, and increasing prevalence of joint pathology over time. Optimal musculoskeletal health and quality of life can be attained with timely identification of pathology and intervention.

Exergames to improve Rehabilitation after Anterior Cruciate Ligament Injury: Systematic review and GRADE evidence synthesis

INTRODUCTION

Exergames are a fun, engaging, and interactive form of exercise that has been used in rehabilitation. This systematic review aimed to evaluate the effectiveness of exergames compared to usual rehabilitation after anterior cruciate ligament reconstruction.

METHOD

We performed a Systematic Review and GRADE evidence synthesis. The PRISMA guidelines for systematic reviews were followed. MEDLINE® (Medical Literature Analysis and Retrieval System Online), CINAHL® (Cumulative Index to Nursing and Allied Health Literature), SPORTDiscus, SCOPUS, SciELO (Scientific Electronic Library Online), Cochrane Central Register of Controlled Trials, and PEDro (Physiotherapy Evidence Database) were searched from their first record to May 2021. Randomised controlled trials using exergames as an intervention were included.

RESULTS

Initial literature searches yielded 794 non-duplicated records. After exclusion based on title, abstract, and full text review, five articles were included for analysis. Compared with the control group, the participants in the exergames group showed differences in proprioception and flexion angle difference.

CONCLUSION

Although there is no conclusive evidence that favours exergames over traditional rehabilitation, they did not aggravate the effects of rehabilitation. Nonetheless, exergames can be safe and motivating.

High-Intensity Interval Training for Knee Osteoarthritis: A Pilot Study

OBJECTIVE

To assess the feasibility and changes in outcomes of a 12-week high-intensity interval training (HIIT) program in individuals with symptomatic knee osteoarthritis (OA).

METHODS

The single-arm trial included 29 participants (mean ± SD age 63 ± 7 years; 66% women; 66% obese). Measures of participant flow, adherence, and tolerability were collected. Pain, function, and balance were assessed at baseline, 6 weeks, and 12 weeks using the Western Ontario and McMaster Universities Osteoarthritis Index, 20-m fast-paced walk test, 30-second chair-stand test, stair-climb test, timed up and go test, and single leg stance. Cardiorespiratory fitness, strength, and body composition were evaluated using peak oxygen consumption (VO2 peak), isometric knee extensor/flexor strength, and dual-energy x-ray absorptiometry, respectively. HIIT was completed two times/week (cycling or treadmill) and consisted of 10 repetitions of 1-minute bouts at 90% VO2 peak, with 1-minute rest periods. Separate multivariable-adjusted linear mixed models were fit for each outcome with fixed effects of time, age, sex, body mass index, and random effects of baseline values to estimate mean changes and 95% confidence intervals (CIs) between baseline and 12-week assessments.

RESULTS

Recruitment aligned with the anticipated enrollment rate, adherence was 70%, and no adverse events were reported. At 12 weeks, improvements were observed for most outcomes, with notable mean changes for the 20-m fast-paced walk (-1.13 [95% CI -1.61 to -0.64] seconds), 30-second chair-stand (2.6 [1.8-3.4] stands), and VO2 peak (0.14 [0.03-0.24] liters/minute).

CONCLUSION

In this 12-week pilot study, HIIT improved multiple aspects of health in individuals with knee OA; larger studies are needed.