Problems persist in reporting of methods and results for the WOMAC measure in hip and knee osteoarthritis trials

Patient-reported outcome measures offer little additional value two years after arthroplasty : a systematic review and meta-analysis

Aims

The use of patient-reported outcome measures (PROMs) to assess the outcome after total knee (TKA) and total hip arthroplasty (THA) is increasing, with associated regulatory mandates. However, the robustness and clinical relevance of long-term data are often questionable. It is important to determine whether using long-term PROMs data justify the resources, costs, and difficulties associated with their collection. The aim of this study was to assess studies involving TKA and THA to determine which PROMs are most commonly reported, how complete PROMs data are at ≥ five years postoperatively, and the extent to which the scores change between early and long-term follow-up.

Methods

We conducted a systematic review of the literature. Randomized controlled trials (RCTs) with sufficient reporting of PROMs were included. The mean difference in scores from the preoperative condition to early follow-up times (between one and two years), and from early to final follow-up, were calculated. The mean rates of change in the scores were calculated from representative studies. Meta-analyses were also performed on the most frequently reported PROMs.

Results

A total of 24 studies were assessed. The most frequently reported PROMs were the Oxford Knee Score (OKS) for TKA and the University of California, Los Angeles activity scale for THA. The mean rate of follow-up based on the number of patients available at final follow-up was 70.5% (39.2% to 91.0%) for knees and 82.1% (63.2% to 92.3%) for hips. The actual rates of collection of PROM scores were lower. For TKA, the mean OKS, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and transformed WOMAC changes were -16.3 (95% CI -17.5 to -15.2), 23.2 (95% CI 17.2 to 29.2), and -29.7 (95% CI -32.4 to -27.0) points for short-term follow-up. These decreased to 1.3 (95% CI -0.8 to 3.3), -3.4 (95% CI -7.0 to 0.3), and 4.7 (95% CI -1.5 to 10.9) points for the remaining follow-up. A similar meta-analysis was not possible for studies involving THA. We commonly observed that the scores plateaued after between one and two years, and that there was little or no change beyond this time.

Conclusion

The long-term PROMs for TKA and THA beyond one or two years are often incomplete and lose sensitivity at this time. Given the considerable resources, costs, and challenges associated with the collection of these scores, their clinical value is questionable. Therefore, consideration should be given to abandoning the requirement for the collection of long-term PROMs in favour of more robust and reliable measures of success that offer more clinical relevance and use.

Synergistic effect of Majoon-e-Suranjaan and isometric exercises in improving rheumatoid arthritis

OBJECTIVE

The study aimed to evaluate the synergistic effects of Majoon-e-Suranjaan with and without isometric exercises in patients with rheumatoid arthritis (RA).

METHODS

A prospective, pragmatic, community based, parallel group, single blinded randomized controlled trial conducted at Muhammad Physical Therapy and Rehabilitation Clinic and Rehabilitation Centre, Multan, from May to October 2023. The trial was approved and registered in the Iranian Registry of Clinical Trials (IRCT20230202057310N5). Ninety-five patients were randomly assigned to two groups. Group A received Majoon-e-Suranjaan (5 g orally, twice daily). Group B received the same dosage of Majoon-e-Suranjaan along with The isometric exercises. The exercise protocol for group B consisted of three weekly sessions, each lasting 40 minutes. Patients were evaluated at baseline and at the 24th week based on serological markers, including rheumatoid factor (RF), erythrocyte sedimentation rate (ESR), disease activity score (DAS), and C-reactive protein (CRP), as well as X-ray findings such as nodules and bone degeneration in affected joints. Pain, morning stiffness, and functional activities were assessed using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and the Numerical Pain Rating Scale (NPRS).

RESULTS

Of the 95 patients randomized, 90 completed the 24-week treatment. Among them, 60 (66.6%) were female, and 30 (33.3%) were male. Group B showed significantly greater improvements compared to Group A in in WOMAC activities of daily living (P=0.001), WOMAC stiffness (P=0.004), WOMAC pain and DAS (P=0.000), NPRS (P=0.001). Additionally, Group B demonstrated significant improvements in RF (P=0.001), ESR (P=0.002), and CRP (P=0.003) compared to group A.

CONCLUSIONS

This study demonstrated the synergistic effect of Majoon-e-Suranjaan and isometric exercises in RA patients, highlighting the potential for more effective RA treatment strategies.

Arthroscopic Debridement of Mild and Moderate Knee Osteoarthritis Results in Clinical Improvement at Short-Term Follow-Up: A Systematic Review

PURPOSE

To report the clinical outcomes of arthroscopic debridement for the treatment of Kellgren-Lawrence (KL) grade I and II (mild) and III (moderate) knee osteoarthritis (OA) at a minimum 1-year follow-up.

METHODS

A systematic review of primary literature was performed in concordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines using the Medline, Embase, and Cochrane databases for studies regarding arthroscopic debridement/chondroplasty for management of knee OA at a minimum 1-year follow-up. Studies were included if they included KL grades I to III or dichotomized clinical outcomes by KL grade. The primary outcome was patient-reported outcome measures (PROMs) at the final follow-up. Bias was assessed using the Methodological Index for Non-Randomized Studies (MINORS) score.

RESULTS

Eight studies including a total of 773 patients met inclusion criteria (range of patients in each study, 31-214). Mean age of patients ranged from 35.5 to 64 years, with most studies having a mean patient age of 55 to 65 years. Mean follow-up ranged from 1.5 to 10 years. Seven of the 8 (87.5%) studies reported good to excellent PROMs at a minimum 1- to 4-year follow-up after arthroscopic debridement. Improvements in PROMs were superior in patients with less severe knee OA (KL I-II) in comparison to KL III in most studies. Conversion to arthroplasty ranged from 7.6% to 50% in KL III patients compared with 0% to 4.5% in KL I-II patients after arthroscopic debridement. Two of the 3 studies with at least a 4-year clinical follow-up reported that clinical improvements diminished with time (improvements no longer significant in total Western Ontario and McMaster Universities Osteoarthritis Index score). The lone randomized controlled trial was the only investigation that did not find a benefit of arthroscopic debridement over quality nonoperative care. MINORS scores ranged from 6 to 10 (mean, 8.0) for the 5 nonrandomized studies without controls.

CONCLUSIONS

Arthroscopic debridement for the management of mild to moderate knee OA is effective at short-term follow-up in patients who have exhausted conservative care. There is limited evidence demonstrating the durability of improvement following arthroscopic debridement after 2 years.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I to IV studies.

A Single Surgeon Experience of Selective Patellar Resurfacing During Primary Total Knee Arthroplasty

Background

Routine patellar resurfacing remains controversial in primary total knee arthroplasty (TKA). This study reports the experience of a high-volume arthroplasty surgeon who stopped routinely resurfacing patellae for a 3-year period.

Methods

All primary TKAs performed by a single surgeon between January 2018 and September 2022 with minimum 1-year follow-up were retrospectively reviewed. Data were analyzed between cohorts-nonresurfaced and resurfaced patellae-and between phases-universal and selective resurfacing. Outcomes included reoperation, patellar complications, and patient-related outcome measure scores.

Results

Five hundred four primary TKAs, with mean 24-month follow-up, were included. Patellar resurfacing was performed in 77% of the overall cohort, including 58% in the selective and 100% in the universal phases. Reoperation (7.6% vs 0.3%; P < .001) and patellar complications (8.4% vs 1.3%; P < .001) were higher in the nonresurfaced vs resurfaced cohort. Eight of the 9 reoperations in the nonresurfaced group were for secondary resurfacing, and all were female (P = .017). Mean 12-Item Short Form Health Survey Physical Health (P = .037) and Western Ontario and McMaster Universities Arthritis Index Pain scores (P = .002) were better in the resurfaced cohort. Selective resurfacing demonstrated a higher reoperation rate (3.3% vs 0.4%; P = .022) and worse Western Ontario and McMaster Universities Arthritis Index Pain (P = .026) and Knee Society Knee Functional scores (P = .042).

Conclusions

Cessation of routine patellar resurfacing led to inferior clinical results and an unacceptably high early reoperation rate, specifically among women. The generalizability of these findings may be limited due to surgeon-specific factors; however, we urge caution in surgeons who consider similar changes in practice.

Level of Evidence

Level III.

Assessing the measurement properties of PROMIS Computer Adaptive Tests, short forms and legacy patient reported outcome measures in patients undergoing total hip arthroplasty

BACKGROUND

The commonly used ('legacy') PROMs evaluating outcomes of total hip arthroplasty (THA), have several limitations regarding their measurement properties and interpretation of scores. One innovation in PROMs is the use of Computerized Adaptive Testing (CAT). The Patient-Reported Outcomes Measurement Information System (PROMIS®) is a validated system of CATs. The aim of this study was to assess the measurement properties of PROMIS and legacy instruments in patients undergoing THA.

METHODOLOGY

Patients in this multicenter study filled out a questionnaire twice, including Dutch-Flemish PROMIS v1.2 Physical Function (PROMIS-PF) and v1.1 Pain Interference (PROMIS-PI) CATs and short forms, PROMIS v1.0 Pain Intensity, and legacy PROMs (Hip disability and Osteoarthritis Outcome Score (HOOS), HOOS-Physical function Shortform (HOOS-PS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Hip Score (OHS), and two numeric rating scales measuring pain). The reliability, measurement precision (Standard Error of Measurement (SEM)), smallest detectable change (SDC), and burden of PROMIS instruments were presented head-to-head to legacy PROMs. Furthermore, construct validity was assessed.

RESULTS

208 patients were included. All instruments had a sufficient test-retest reliability (range ICC: 0.83-0.96). The SEM of PROMIS CATs and short forms ranged from 1.8 to 2.2 T-score points, the SEM of legacy instruments 2.6-11.1. The SDC of PROMIS instruments ranged from 2.1 to 7.3 T-score points, the SDC of legacy instruments 7.2-30.9. The construct validity of PROMIS CAT and short forms were found sufficient, except for the PROMIS-PI short form. The burden of PROMIS CATs was smaller than PROMIS short forms (range 4.8-5.2 versus 8-20 items, respectively). The burden of legacy instruments measuring physical functioning ranged from 5 to 40 items.

CONCLUSIONS

The PROMIS-PF is less burdensome, with high measurement precision, and almost no minimal or maximal scores, and an equal reliability compared to legacy instruments measuring physical functioning in patients undergoing THA. The PROMIS Pain Intensity 1a is comparable to the legacy pain instruments in terms of burden, reliability and SDC. Measuring the construct Pain Interference may not have additional value in this population because of its high correlation with instruments measuring physical functioning. The SDC values presented in this study can be used for individual patient monitoring.

Does Robotic Assisted Technique Improve Patient Utility in Total Knee Arthroplasty? A Comparative Retrospective Cohort Study

BACKGROUND

Even if robotic assisted total knee arthroplasty (RATKA) is a widely used technique, there is still a gap of knowledge about whether this technology is effective in improving the patient utility. This measure is of paramount importance for conducting cost effectiveness analysis. The aim of this study was to compare the utility measure derived from self-reported outcomes questionnaires in patients who underwent RATKA compared to patients who underwent the manual surgery.

METHODS

We compared 72 patients operated with a robotic technique with 70 operated with traditional technique. The utility data were collected with the WOMAC (Western Ontario and McMaster University Osteoarthritis index) self-administrated questionnaire that investigates pain, stiffness and functionality of the patients, an then mapped to a utility value through a validated transforming function. We performed three surveys: the first one before the intervention (t0), the second one 1 year after the surgery (t1) and the third one at the 2 year follow up (t2).

RESULTS

we observed higher utility values in both groups. In detail, the mean utility score in the RATKA group increased from 0.37 to 0.71 (t1) and 0.78 (t2), while in the conventional group it increased from 0.41 to 0.78 (t1) and 0.78 (t2). The fixed effect coefficients of t1 and t2 were found to be 0.37 and 0.363 (p < 0.001 for both). The coefficient of the robotic technique, along with its interaction with the t1 and t2 time effect was non-significant.

CONCLUSIONS

Even if at t1 the utility of patient who underwent RATKA were lower, at longer follow up (t2) we found no significant difference compared to traditional technique, leaving the superiority of robotic assisted technique yet to be proved. Our results may be useful for calculating the gained or lost Quality Adjusted Life Years (QALYs), so that the health care system (or an insurance company) could make an appropriate decision whether to fund the robotic approach or not, after a careful assessment of the incremental costs incurred.

Clinical Assessment of Osteoarthritis Pain: Contemporary Scenario, Challenges, and Future Perspectives

The multifaceted nature of osteoarthritis (OA) pain presents a challenge in understanding and managing the condition. The diverse pain experiences, progression rates, individual responses to treatments, and complex disease mechanisms contribute to heterogeneity in the clinical studies outcomes. The lack of a standardized methodology for assessing and classifying OA pain challenges healthcare practitioners. This complicates the establishment of universally applicable protocols or standardized guidelines for treatment. This article explores the heterogeneity observed in clinical studies evaluating OA pain treatments, highlighting the necessity for refined methodologies, personalized patient categorization, and consistent outcome measures. It discusses the role of the multidimensional nature of OA pain, underlying pain mechanisms, and other contributing factors to the heterogeneity in outcome measures. Addressing these variations is crucial to establishing a more consistent framework for evidence-based treatments and advancing care of the patient with OA pain.

Safety and Efficacy of Hybrid Cooperative Complexes of Sodium Hyaluronate and Sodium Chondroitin for the Treatment of Patients with Symptomatic Knee Osteoarthritis

INTRODUCTION

Knee osteoarthritis (KOA) represents a widespread degenerative disease that causes pain and motor disability. Conservative treatments mainly focus on relieving symptoms, improving joint function, and trying to delay surgery. Safety and efficacy of hybrid cooperative complexes (2.4% sodium hyaluronate and 1.6% sodium chondroitin; HA-SC) for symptomatic KOA were investigated in a single-arm, prospective, pilot study.

METHODS

Patients with a visual analogue scale (VAS) pain score ≥ 4 and Kellgren-Lawrence Grade < 4 received a single intraarticular HA-SC injection. Patients with a VAS score change from baseline ≤ 1 received a second injection at day 30. Device-related adverse events (DR-AEs)/adverse events (AEs) were primary endpoints. Secondary endpoints included Western Ontario and McMaster Universities Osteoarthritis Index LK 3.1 (WOMAC LK 3.1), VAS, patient global assessment of disease status (PtGA), and patient proportion needing a second injection.

RESULTS

Of 83 patients with KOA (Kellgren-Lawrence Grade, 2-3), 34.9% had DR-AEs at day 7. No serious DR-AEs/AEs were reported. A significant (P < 0.0001) reduction over time in VAS pain score plus WOMAC pain, stiffness, physical function limitation, and total scores was reported. Median PtGA scores indicated a 'slight improvement' at most follow-up visits. Only 18.1% of patients required a second injection.

CONCLUSIONS

A single intraarticular HA-SC injection was safe, well-tolerated, and did not lead to major deterioration in terms of reducing knee pain, stiffness, and physical function limitation in patients with symptomatic KOA.

Association between Obesity and Short-Term Patient-Reported Outcomes following Total Knee Arthroplasty: A Retrospective Cohort Study in Japan

Background: This study investigated the association between obesity and short-term patient-reported outcomes after total knee arthroplasty (TKA). Methods: The primary outcomes were the Western Ontario and McMaster Universities Osteoarthritis Index's (WOMAC) pain and function scores. Data were collected preoperatively and 2 and 4 weeks after surgery. Patients were stratified into three groups based on body mass index (BMI): normal weight (BMI < 24.99 kg/m2), overweight (25 ≤ BMI < 29.99 kg/m2), and obese (BMI ≥ 30 kg/m2). The associations between BMI and the WOMAC pain and function scores were assessed using generalized linear mixed models. Results: Among the 102 patients (median age: 75.0, women [85.3%]), 29.4%, 48.0%, and 22.5% were normal weight, overweight, and obese, respectively. The mean pain and function scores at baseline were similar across the BMI-stratified groups (p = 0.727 and 0.277, respectively). The pain score significantly improved 2 weeks post-surgery (p = 0.001). The function score improved significantly 4 weeks post-surgery (p < 0.001). The group and group-by-time interaction effects lacked statistical significance. Conclusions: All patients statistically and clinically showed relevant pain reduction and functional improvement shortly after TKA, irrespective of their obesity status. These data may help healthcare professionals discuss the expectations of pain amelioration and functional improvement with TKA candidates.

Effectiveness of gonarthrosis treatment via intra-articular injections of linear vs. cross-linked hyaluronic acids

OBJECTIVES

The study aimed to compare the outcomes of single-dose cross-linked hyaluronic acid and the linear regimen of three doses of HA knee injections among patients with gonarthrosis.

PATIENTS AND METHODS

This single-center, retrospective study was conducted with 60 patients (47 females, 13 males; mean age: 57.9±4.29 years; range, 50 to 65 years) with Kellgren-Lawrence Grade 2 or 3 gonarthrosis between February 2020 and February 2022. Patients were either subjected to intra-articular cross-linked hyaluronic acid (n=30) or linear hyaluronic acid (n=30) injection treatments. Comprehensive assessments of the patients were conducted prior to the injections, as well as at three and six months after injection. The two injection groups were compared regarding the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Oxford Knee Score.

RESULTS

Both injections showed a statistically significant improvement from baseline in both WOMAC and Oxford Knee Score at three and six months (p<0.001). There was no notable distinction in the alteration of WOMAC knee scores between the two injection types. However, a notable discrepancy was observed in the elevation of Oxford Knee Score among patients who received cross-linked knee injections compared to those who underwent linear hyaluronic acid knee injections, signifying a significant increase in the former group (p<0.001).

CONCLUSION

The advantage of a single-dose administration of cross-linked HA knee injections, as opposed to the three-dose regimen required for linear hyaluronic acid, translates into reduced time and cost for the injection process. Moreover, this approach minimizes injection-associated discomfort for patients due to the singular dose administration.

Clinical Outcomes after Computed Tomography-Based Total Knee Arthroplasty: A Minimum 3-Year Analyses

Computed tomography (CT) scan-based three-dimensional (3D) modeling operative technology has been shown to improve upon results of manual total knee arthroplasties (TKAs). Although there are many reports on superior precision of this CT-based technology, there has been continuing interest regarding extended clinical outcomes. The purpose of this study was to compare their clinical outcomes with manual TKAs at approximately 3-year follow-up. Specifically, we analyzed: (1) survivorship, (2) functional outcomes, (3) complications, and (4) radiographic outcomes (i.e., alignment, progressive radiolucencies). A total of 210 patients receiving CT-based TKAs performed by a single surgeon at a single center between July 1, 2016, and February 16, 2018, were compared with 210 manual TKAs completed by the same surgeon immediately preceding implementation of the CT-based technology. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) surveys were collected at ∼3 years postoperatively. Subgroup analyses of pain and physical function scores were performed. Follow-up radiographs were evaluated for alignment, loosening, and/or progressive radiolucencies. There was 100% survivorship at final follow-up. The postoperative mean pain scores for the CT-based cohort and manual cohort were 1 ± 2 (range, 0-14) and 2 ± 3 (range, 0-17), respectively (p < 0.05). The postoperative mean physical function scores for the CT-based cohort and manual cohort were 3 ± 4 (range, 0-18) and 5 ± 5 (range, 0-19), respectively (p < 0.05). The postoperative mean total WOMAC scores for the CT-based cohort and manual cohort were 5 ± 4 (range, 0-32) and 7 ± 8 (range, 0-35), respectively (p < 0.05). There were low numbers of postoperative complications at final follow-up in either cohort. None exhibited progressive radiolucencies by final follow-up. The 3-year postoperative clinical outcomes support excellent survivorship and radiographic outcomes, low complication rates, as well as improved pain, physical function, and total WOMAC scores for CT-based TKAs. Therefore, patients who undergo CT-based 3D modeling TKAs should expect to have superior long-term clinical outcomes.

Oral cannabidiol (CBD) as add-on to paracetamol for painful chronic osteoarthritis of the knee: a randomized, double-blind, placebo-controlled clinical trial

Background

Painful knee osteoarthritis (KOA) is common, pharmacological treatment, however, is often hampered by limited tolerability. Cannabidiol, which preclinically showed anti-inflammatory, analgesic activity, could supplement established analgesics, but robust clinical trials are lacking. The aim of our study was to investigate the effects of oral high-dose CBD administered over 8 weeks on pain, function and patient global assessment as an add-on to continued paracetamol in chronic symptomatic KOA.

Methods

Prospective, randomized, placebo-controlled, double-blind, parallel-group study. Single center, Outpatient Clinic, Department of Special Anaesthesia and Pain Therapy at Medical University of Vienna, Austria. Eligibility criteria included: age: 18-98 years; painful KOA; score ≥5 on the pain subscale of the Western Ontario and McMasters Universities Osteoarthritis (WOMAC) Index; KOA confirmed by imaging. Participants were on continued dosage of paracetamol 3 g/d and randomly assigned by web-based software 1:1 to oral cannabidiol 600 mg/d (n = 43) or placebo (n = 43). Study period: 8 weeks. Primary outcome: Change in WOMAC pain subscale scores (0 = no pain, 10 = worst possible pain) from baseline to week 8 of treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT04607603. Trial is completed.

Findings

The trial was conducted from October 1, 2020 to March 29, 2022. 159 patients screened, 86 randomized. Among 86 participants (mean age, 62.8 [SD 20.3] years; 60 females [69.8%]), 58 (67.4%) completed the trial. Mean baseline WOMAC pain subscale was 6.0 ± 1.1. Analysis: Intention-to-treat principal. Mean reduction in WOMAC pain subscale was 2.5 (95% CI: 1.8-3.3) in the cannabidiol group and 2.4 (95% CI: 1.7-3.2) in the placebo group with no significant group difference (p = 0.80). Adverse events were significantly more frequent with cannabidiol (cannabidiol: 135 [56%]; placebo: 105 [44%]) (p = 0.008). Rise above baseline of liver aminotransferases and gamma-glutamyltransferase was significantly more common in the cannabidiol (n = 15) than the placebo group (n = 5) (p = 0.02).

Interpretation

In KOA patients, oral high-dose add-on cannabidiol had no additional analgesic effect compared to adding placebo to continued paracetamol. Our results do not support the use of cannabidiol as an analgesic supplement in KOA.

Funding

Trigal Pharma GmbH.

Comparison of instrument-assisted soft tissue mobilization and proprioceptive neuromuscular stretching on hamstring flexibility in patients with knee osteoarthritis

Background

The association between hamstring tightness and knee osteoarthritis (KOA) is significant because tight hamstrings can put more strain on the knee joint, reduce its range of motion, and cause compensatory movements that worsen the KOA.

Objective

To compare the effects of instrument-assisted soft tissue mobilization (IASTM) and proprioceptive neuromuscular (PNF) on hamstring flexibility in patients with KOA.

Methods

Data for the randomized controlled trial (NCT05110326) was collected from n = 60 participants randomly divided into group A received IASTM and group B received PNF stretching. In group A, the therapist made 30 strokes gentle strokes with the tool from the origin to the insertion while holding the plane at a 45-degree angle over the treatment area. In group B, PNF stretching was done with three repetitions and 10 seconds rest between each, after isometric contraction of the hamstring muscle using approximately 50% of their maximum strength, holding it for 8 seconds, and then releasing it. A 30-minute session was given to each patient three times per week and was given for 6 weeks. Outcome measures were the visual analog scale (VAS) for pain intensity, the active knee extension test (AKET) for hamstring flexibility, and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) for the health status of KOA patients.

Results

The study found a significant interaction (p < 0.001) between interventions and time across several measurements. After 6 weeks, both interventions resulted in significant improvements (p < 0.001) across all dependent variables, with group A (IASTM) showing more significant improvement in hamstring flexibility, pain reduction, and health status (p < 0.001) compared to group B (PNF).

Conclusions

Both the IASTM technique and PNF stretching resulted in increased hamstring flexibility, decreased pain, and enhanced general health. The IASTM technique, however, showed potential benefits over PNF stretching in terms of flexibility, pain relief, and public health enhancement. Physical therapists and manual therapists may prioritize the usage of the IASTM technique for patients who want to make significant changes in these areas.

Quantifying Change in Perfusion after Genicular Artery Embolization with Parametric Analysis of Intraprocedural Digital Subtraction Angiograms

PURPOSE

To quantify perfusion changes during genicular artery embolization (GAE) with the qualitatively described "pruning" technique using parametric analysis.

MATERIALS AND METHODS

A total of 12 patients underwent unilateral GAE with a total of 36 vessels embolized. Among 34 of the 36 vessels embolized, regions of interest (ROIs) were placed on parent vessels (PVs) and hyperemic target vessels (TVs) before and after GAE. For each ROI, peak intensity (PI), time to arrival (TTA), and area under the curve (AUC) were computed and compared between PV and TV. Volume of embolic administered was correlated with adverse events.

RESULTS

No change was seen in PI, TTA, and AUC in the PV after GAE. Reduction in AUC (1,495.7 ± 521.5 vs 1,667.4 ± 574.0; P << .01) and PI (195.1 ± 43.8 vs 224.3 ± 49.2; P << .01) with increase in TTA (3.42 s ± 1.70 vs 1.92 s ± 1.45; P << .01) within the TV were observed after GAE. Median follow-up time was 89 days (range, 21-254 days). Reduction in clinical symptoms was also noted based on the Western-Ontario and McMaster Universities Arthritis Index total and pain scale at 1 month (total, 42.9% ± 23.0; pain, 54.4% ± 9.8; P << .01) and 3 months (total, 42.5% ± 14.9; pain, 57.8% ± 10.6; P << .01). Eight total mild adverse events (minor/self-limiting) were noted per Society of Interventional Radiology guidelines. A larger volume of embolic was observed in knees with skin changes (3.4 mL ± 0.4 vs 1.7 mL ± 0.4; P << .001). Furthermore, all skin changes were seen with embolic volumes >3.0 mL.

CONCLUSIONS

Quantification of intraprocedural perfusion changes with GAE demonstrated reduced flow to the TV with maintained flow in the PV and acceptable clinical outcomes. A potential relationship between embolic volume and nontarget embolization was also highlighted.

A scoping review of patient self-report measures of flare in knee and hip osteoarthritis (OA): A report from the OMERACT flares in OA working group

PURPOSE

We aimed to analyze the content validity/domain match and feasibility of self-report instruments that could measure flare in osteoarthritis (OA), by extending our 2017 literature review on the definition of flare in knee and hip OA.

METHOD

We searched PubMed (Medline), Web of Science and PsycInfo (Ebsco Host) databases for original articles reporting research about flare (or synonyms) in humans with knee and hip OA, between 2017 and 2023. Four experts worked independently, checking the records, and assessing content validity and feasibility, writing justification for exclusion.

RESULTS

At literature review phase, 575 papers were filtered. After experts' analysis, 59 studies were included, and 44 instruments associated with flare in OA were identified. Most were studies about pain in knee or hip OA (35 %), cultural adaptation of a measure (33 %) or studies investigating psychometric properties of full (16 %) or short form (4 %) instruments. The assessment of domain match and feasibility revealed that 15 instruments were assigned a label of 'yes' or 'uncertain' as to whether or not there was a good match with the domain concept or whether the instrument was considered feasible to use.

DISCUSSION

Most identified instruments considered different aspects of pain and the associated discomfort in performing daily activities but did not include the central aspects of flare in OA, i.e. the change of state, nor the additional Outcome Measures in Rheumatology (OMERACT) endorsed domains for OA flare namely stiffness, swelling, psychological aspects, impact of symptoms including fatigue and sleep disturbance. Although it is possible that the period specified to conduct this literature review may have led to some recognized instruments being excluded, this review demonstrates the need for the research community to reach consensus on the best way to measure self-reported flares in future clinical trials and observational studies.

Pinloc or Hansson pins: a multicenter, randomized controlled study of 439 patients treated for femoral neck fractures

Objectives

To compare the recently developed Hansson Pinloc system, which features 3 cylindrical parallel pins with hooks connected through a fixed-angle interlocking plate, with the Hansson Pin System (2 hook pins) for the treatment of femoral neck fractures.

Design

One hundred fourteen patients with displaced femoral neck fractures and 325 patients with nondisplaced fractures from 9 orthopaedic centers were randomized to either Hansson Pinloc system or Hansson Pin System and followed for 2 years or until death. Age at inclusion was 50 years or older.

Main Outcome Measurements

The primary outcome was failure (defined as early displacement, nonunion, symptomatic avascular necrosis, or deep infection). Secondary outcomes included revision surgery, Timed Up and Go (TUG) test and patient-reported outcome measures (PROMs: EQ-5D and WOMAC).

Results

For nondisplaced fractures, the incidence of failure was 14% (23/169) in the Pinloc group and 16% (25/156) in the Hansson group. For displaced fractures, the analysis was stratified by age. Patients aged 50-69 years with displaced fractures showed a 2-year failure rate of 44% (17/39) in the Pinloc group versus 44% (16/36) in the Hansson group. For patients 70 years or older with displaced fractures, 33% (7/21) in the Pinloc group versus 22% (4/18) in the Hansson group failed. At 3 and 12 months, no clinically significant differences between treatment groups were found for EQ-5D-3L, WOMAC, or for the TUG in any fracture type or age group.

Conclusions

There were no advantages for Pinloc in any of the studies aspects.

Level of evidence

1.

Efficacy and safety of platelet-rich plasma combined with Tai Chi for knee osteoarthritis: study protocol for a placebo-controlled randomized trial

BACKGROUND

No definitive treatment methods of curative for knee osteoarthritis (KOA). The combined therapies that into account both the biochemical and biomechanical may provide potential opportunities for treat KOA, and previous studies have demonstrated that the platelet-rich plasma of intra-articular injection (IAI-PRP) and exercise treatments afford more benefits than do their corresponding monotherapies. The absence of a specific exercise plan and detailed explanation renders the aforementioned study results questionable. Furthermore, Tai Chi (TC) with moderate-intensity, whole body movements and good adherence may prove to be more effective for treating KOA. However, few studies examined the effectiveness and safety of combined IAI-PRP and TC for KOA.

METHODS

This study protocol will be a placebo-controlled, assessor-blinded randomized trial involving 12-week intervention and 1-year follow-up. The stratified randomization will be used to randomly assign the 212 participants to four groups: group A (placebo IAI); group B (PRP IAI); group C (TC and placebo IAI); group D (TC and PRP IAI). Injection will be performed once a week, three consecutive times as a course, after a week of rest to continue the next course, a total of 3 courses (12 week). Additionally, the TC interventions will be carried out 3 days per week for a total of 12 weeks. The primary outcome measures will include the efficacy (Western Ontario and McMaster Universities Osteoarthritis Index), acceptability and safety of these interventions. The secondary outcome measures will include physical function (Timed Up and Go test), walking function (Gait Analysis), inflammatory factor levels (e.g., Interleukin-1 β, interleukin-6, vascular endothelial growth factor), quality of life (36-Item Short Form Health Survey), volume of patellofemoral cartilage and effusion-synovitis (MRI). Two-way of variance with repeated measures will be applied to examine the main effects of the group and the time factor and group-time interaction effects for all outcome measures.

DISCUSSION

This trial will be first one to propose an integrated scheme combing IAI-PRP and TC for treatment of KOA, based on the consideration of the biochemical and biomechanical pathogenesis of KOA. These results of the study will provide evidence with high quality for integrated IAI-PRP and TC to treatment KOA. Trial Registration Chinese Clinical Trial Registry ChiCTR2300067559. Registered on 11 January 2023.

Patient-Reported Outcomes in Calcium Pyrophosphate Deposition Disease Compared to Gout and Osteoarthritis

OBJECTIVE

Calcium pyrophosphate deposition (CPPD) disease prevalence is similar to that of gout and osteoarthritis (OA), yet CPPD outcomes research greatly lags behind research in these other forms of arthritis. We compared validated patient-reported outcome measures in patients with CPPD vs gout and OA.

METHODS

Patients with CPPD were recruited from Brigham and Women's Hospital from 2018 to 2022. Presence of CPPD manifestations (acute calcium pyrophosphate [CPP] crystal arthritis, chronic CPP inflammatory arthritis, and/or OA with CPPD) was confirmed by medical record review. Baseline surveys included the Gout Assessment Questionnaire version 2.0, modified to ask about "pseudogout" rather than "gout"; Routine Assessment of Patient Index Data 3 (RAPID-3); and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). We compared responses in patients with CPPD against published gout and OA cohort studies.

RESULTS

Among 47 patients with CPPD, the mean age was 71.9 years and 51% were female. Sixty-eight percent had at least 1 episode of acute CPP crystal arthritis, 40% had chronic CPP inflammatory arthritis, and 62% had OA with CPPD. Pain visual analog scale scores during a flare were similar in CPPD (mean 6.8 [SD 1.9]) and gout (mean 6.7 [SD 2.6]; P = 0.78). Patients with CPPD reported significantly greater unmet treatment need than patients with gout (P = 0.04). RAPID-3 scores in CPPD (mean 8.1 [SD 5.6]) were lower than in gout (mean 12.1 [SD 6.2]; P < 0.01) and similar in OA (mean 6.8 [SD 6.1]; P = 0.30). Patients with CPPD had significantly worse WOMAC stiffness scores than patients with mild OA, and significantly better WOMAC function scores than patients with severe OA.

CONCLUSION

Patients with CPPD may experience pain comparable to that in gout and OA and reported substantial unmet treatment needs.

Adaptation of the WOMAC for Use in a Patient Preference Study

OBJECTIVES

To adapt a patient-reported outcome (PRO) measure, the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC), into efficacy attributes for a discrete choice experiment (DCE) survey designed to quantify the relative importance of endpoints commonly used in knee osteoarthritis (KOA) trials.

METHODS

The adaptation comprised four steps: (1) selecting domains of interest; (2) determining presentation and framing of selected attributes; (3) determining attribute levels; and (4) developing choice tasks. This process involved input from multiple stakeholders, including regulators, health preference researchers, and patients. Pretesting was conducted to evaluate if patients comprehended the adapted survey attributes and could make trade-offs among them.

RESULTS

The WOMAC pain and function domains were selected for adaption to two efficacy attributes. Two versions of the discrete choice experiment (DCE) instrument were created to compare efficacy using (1) total domain scores and (2) item scores for "walking on a flat surface." Both attributes were presented as improvement from baseline scores by levels of 0%, 30%, 50%, and 100%. Twenty-six participants were interviewed in a pretest of the instrument (average age 60 years; 58% female; 62% had KOA for ≥ 5 years). The participants found both versions of attributes meaningful and relevant for treatment decision-making. They demonstrated willingness and ability to tradeoff improvements in pain and function separately, though many perceived them as inter-related.

CONCLUSIONS

This study adds to the growing literature regarding adapting PRO measures for patient preference studies. Such adaptation is important for designing a preference study that can incorporate a clinical trial's outcomes with PRO endpoints.

The short-to-midterm outcomes of geniculate artery embolization for mild-to-moderate osteoarthritis of the knee: a systematic review

Background

Geniculate Artery Embolization (GAE) is a novel, minimally-invasive treatment for mild to moderate Osteoarthritis (OA) associated with musculoskeletal pain.

Purpose

To investigate the outcomes of GAE in patients with mild to moderate OA of the knee using a Quantitative-analysis of the available literature.

Methods

The PubMed, EMBASE and Cochrane databases were searched for GAE-related studies. Qualitative and quantitative analyses were performed following PRISMA-guidelines. Quantitative-analysis was performed using windows based 'MedCalc-Statistical-Software version 19.6.1 (2020). Statistical analysis was performed in Stata-IC-13.1(Stata corp-USA). Quantitative-analysis was done using the random-effects model, and the Standardized-Mean-Differences (SMD) were calculated.

Results

After a full-text review, 13 studies with 399 knees (345-patients) were included in the qualitative synthesis, 10 were included in the quantitative synthesis. The total WOMAC score improved by a [SMD (95% CI)] of 3.46 points (1.27, 5.65), 3.50 (1.28, 5.71), 3.77 (0.58, 6.96), 5.46 (1.59, 9.33), 2.96 (-0.93, 6.85) compared to baseline at 1, 3, 6, 12, 24 months respectively. The VAS score improved by 2.06 (1.35, 2.76), 2.13 (1.39, 2.87), 2.36 (1.85, 2.90), 2.09 (0.91, 3.28) compared to baseline at 1, 3, 6, 12 months respectively. The Pain WOMAC score improved by SMD 2.97 (0.51, 5.43), 3.77 (0.58, 6.96), 2.27 (0.31, 4.22), 2.27 (0.31, 4.22) compared to baseline at 1, 3, 12, 24 months, respectively.

Conclusion

There was a statistically significant change from baseline in all outcome measures after GAE. GAE is a safe and effective method for pain control in mild to moderate OA-associated knee pain in the short and medium term.

Partial Two-Stage Exchange for Infected Total Hip Arthroplasty: A Treatment to Take into Account

INTRODUCTION

Two-stage revision is the gold standard for chronic periprosthetic joint infection (PJI). The removal of well-fixed implants, especially the femoral component, can be extremely difficult and additional osteotomies may be needed, which is time-consuming and results in bone stock loss. When the femoral stem is osseointegrated, there is no clear indication for the use of partial two-stage revision. The primary objective was to assess infection eradication after surgery.

METHODS

Retrospective study of specific case series. A total of eight patients with a chronic uncemented PJI, in the setting of complex revision surgeries, were treated with partial two-stage revision, which included selective retention of the well-fixed femoral component and complete acetabular removal. Stem retention was carried out regardless of the bacteria or associated comorbidities.

RESULTS

All patients were re-revision cases with at least two previous surgeries (range, 2-4). Complex revisions were performed in five cases (non-articulated spacer) and simple revisions in three cases (articulated spacer). The minimum follow-up time was 24 months (range, 24-132 months). The infection eradication rate at final follow-up was 100%.

CONCLUSION

Partial two-stage reconstruction is a promising technique for the treatment of chronic PJI in patients with a well-fixed stem and complex re-revision acetabular procedures. Further prospective studies and prolonged follow-ups are required to confirm our results.

Bipolar radiofrequency ablation of the superomedial (SM), superolateral (SL) and inferomedial (IM) genicular nerves for chronic osteoarthritis knee pain: a randomized double-blind placebo-controlled trial with 12-month follow-up

BACKGROUND

Variability in anatomy in the knees supports the use of aggressive lesioning techniques such as bipolar-radiofrequency ablation (RFA) to treat knee osteoarthritis (KOA). There are no randomized controlled trials evaluating the efficacy of bipolar-RFA.

METHODS

Sixty-four patients with KOA who experienced >50% pain relief from prognostic superomedial, superolateral and inferomedial genicular nerve blocks were randomly assigned to receive either genicular nerve local anesthetic and steroid injections with sham-RFA or local anesthetic and steroid plus bipolar-RFA. Participants and outcome adjudicators were blinded to allocation. The primary outcome was Visual Analog Scale pain score 12 months postprocedure. Secondary outcome measures included Western Ontario and McMaster Universities Arthritis (WOMAC) and Patient Global Improvement-Indexes (PGI-I).

RESULTS

Both groups experienced significant reductions in pain, with no significant differences observed at 12 months (reduction from 5.7±1.9 to 3.2±2.6 in the RFA-group vs from 5.0±1.4 to 2.6±2.4 in the control-group (p=0.40)) or any other time point. No significant changes were observed between groups for WOMAC and PGI-I at the primary endpoint, with only the control group experiencing a significant improvement in function at 12-month follow-up (mean reduction from 91.2±38.2 to 67.1±51.9 in the RFA-group (p=0.06) vs from 95.8±41.1 to 60.6±42.8 in the control group (p=0.001); p=0.85 between groups).

CONCLUSION

Our failure to find efficacy for genicular nerve RFA, coupled with evidence showing that a plenitude of nerves supply the knee joint and preliminary studies indicating superiority of lesioning strategies targeting more than three nerves, suggest controlled trials using more aggressive lesioning strategies are warranted.

TRIAL REGISTRATION NUMBER

TCTR20170130003.

Impact of soft tissue around the knee on the efficacy of extracorporeal shockwave therapy in knee osteoarthritis

Knee osteoarthritis (KOA) is the leading cause of knee pain in middle-aged and older individuals. Extracorporeal shockwave therapy (ESWT) has been applied to treat patients with KOA to reduce pain and improve function. Patients (n = 123) diagnosed with KOA who received ESWT were selected to participate in this study, and were grouped according to their body mass index (BMI). The treatment parameters were as follows: 8000 pulses, 2.0 bar, 0.25 mJ/mm2, and 6 Hz/s once per week for 8 weeks. The visual analog scale (VAS), Lequesne index, and Western Ontario and McMaster University Osteoarthritis Index (WOMAC) were measured to assess knee pain and functional recovery according to BMI groups. Radiographs were used to measure the richness of the soft tissue around the knee joint. The correlation between the distribution of tissue, pain, and functional improvement was analyzed using the receiver operator characteristic curve. All the patients showed a reduction in pain after treatment compared to that before treatment (P < .01). As measured by the VAS, the Lequesne and WOMAC indexes, after the intervention, the pain and functional index of the overweight and above BMI group improved to a greater extent than that of the normal or below normal BMI group (P < .01). The area under the curve showed, with VAS as the demarcation criterion, when the tibial plateau soft tissue ratio, femoral intercondylar apex soft tissue ratio, and medial tibial soft tissue ratio exceeded 1.538, 1.534, and 1.296, respectively, the patient's pain relief was more pronounced the ESWT treatment was better. With pain in WOMAC as the demarcation criterion, the tibial plateau soft tissue ratio, femoral intercondylar apex soft tissue ratio, and medial tibial soft tissue ratio also are positively correlated with pain relief in patients. When the Lequesne and WOMAC scores were the demarcation criteria, the patients' function improved significantly when the patella apical soft tissue ratio exceeded 2.401 and 2.635, respectively. ESWT can effectively alleviate pain and improve knee function in patients with KOA, and the soft tissue around the knee joint should also be an important reference factor in KOA treatment.

Effect of extracorporeal shock wave therapy on pain and function in patients with knee osteoarthritis: a systematic review with meta-analysis and grade recommendations

Objective

To investigate extracorporeal shock wave therapy effect on knee osteoarthritis compared to a sham or kinesiotherapy by a systematic review and meta-analysis of randomized clinical trials.

Data Sources

The search was performed in: Cochrane Library, PubMed, PEDro, Web of Science, EMBASE, Scopus, LILACS, and Scielo.

Review methods

We performed the online search until October, 2022. The following terms were used (Osteoarthritis) AND (“knee joint”) AND (“Extracorporeal Shockwave Therapy”). Eligibility criteria: (1) randomized clinical trials; (2) effects comparison of shockwave therapy to a sham or kinesiotherapy in individuals with knee osteoarthritis; (3) pain and physical function as outcome variables. Risk of bias assessed using the PEDro scale. PROSPERO registration (CRD42021235597).

Results

We identified 4217 studies, and 12 were included in the qualitative synthesis and the meta-analysis, totaling 403 individuals submitted to the intervention and 331 control individuals. Compared to sham, shockwave was favored in short-term for the function outcome (SMD = −1.93; 95%CI: [−2.77; −1.09]; I² = 83%; P < 0.01). For the pain outcome, the shockwave was favored in the short (MD = −2.05; 95%CI: [−2.59; −1.51]; I² = 84%; P < 0.01), medium (MD = −3.46; 95%CI: [−4.03; −2.89]; I² = 0%; P < 0.01) and long-term (MD = −2.01; 95%CI: [−3.36; −0.65]; I² = 98%; P < 0.01). The association with kinesiotherapy was favored in the short term for the function outcome (SMD = -1.88; 95%CI: [−2.98; −0.78]; I² = 94%; P < 0.01) and favored for the pain outcome in the short (MD = −1.44; 95%CI: [−1.81; −1.07]; I² = 37%; P = 0.14), medium (MD = −1,31; 95%CI: [−1.76; −0,85]; I² = 0%; P = 0.41), and long terms (MD = −1.63; 95%CI: [−1.73; −1.52]; I² = 0%; P = 0.43).

Conclusion

Shockwave therapy may improve functionality in patients with knee osteoarthritis in the short term and pain in all follow-up moments, compared with sham. When associated to kinesiotherapy, it may improve function in the short term and pain in all follow-up time points, although improvement in pain may not be clinically significant.

The Impact of Chronic Pain, Stiffness and Difficulties in Performing Daily Activities on the Quality of Life of Older Patients with Knee Osteoarthritis

Osteoarthritis causes a number of physical ailments, which result in the deterioration of a persons' general health and reduction of their ability to move freely. This cross-sectional study was designed to assess the impact of physical ailments in the course of knee osteoarthritis (KOA) on the quality of life (QoL) of patients in early old age. An anonymous survey was conducted by the use of the recognized research tools: Western Ontario scale and McMaster Osteoarthritis Index (WOMAC), The Index of Severity for Knee Disease (ISK) and World Health Organization Quality of Life-BEFF (WHOQOL-BREF). The study involved 300 people aged between 60 and 75 years old, including 150 patients diagnosed with gonarthrosis and 150 people without lower limb complaints. The significant intensification of the symptoms of knee osteoarthritis was associated with a worse assessment of health (p < 0.001), overall quality of life (p < 0.001) and in the following domains: physical (p < 0.001), mental (p < 0.001) and environmental (p < 0.001) in a group of patients with KOA. These findings suggest that taking measures to reduce knee pain and improve function may have an impact on improving the overall quality of the life of people in their early old age.

Evaluation of the effects of dexamethasone iontophoresis, galvanic current, and conservative treatment on pain and disability in patients with knee osteoarthritis and Baker's cyst

Objectives

This study aims to evaluate the effectiveness of galvanic current and dexamethasone iontophoresis in the treatment of knee osteoarthritis and Baker's cyst (BC).

Patients and methods

This prospective, randomized, controlled, single-blind study included 37 patients (9 males, 28 females; mean age: 57.8+10.3 years; range 40 to 75 years) with knee osteoarthritis and BC, between January and August 2020. The patients were randomized into three groups: the iontophoresis group (n=13), the galvanic current group (n=11), and the control group (n=13). The numerical rating scale (NRS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores and ultrasonographic measurements of BC were recorded at baseline, two weeks, and six weeks. All groups received the same physiotherapy program. Dexamethasone iontophoresis and galvanic current therapy were administered to the patients in the iontophoresis and galvanic current groups, respectively, with a galvanic current at an intensity of 0.1-0.2 mA/cm2 for 10 days.

Results

There was no significant dissimilarity in demographic and clinical characteristics, basal NRS (resting and exercise) and WOMAC scores, and basal cyst volumes between groups. A significant temporal change was found in three groups for resting NRS, exercise NRS, and WOMAC scores and cyst volumes, except for the cyst volume in the control group. There was a notable difference in terms of improvement in cyst volumes between baseline and the second week in the iontophoresis group compared to the galvanic current group (p=0.046). There was a significant improvement in resting NRS and exercise NRS scores between baseline and the second week in the galvanic current group compared to the control group (p=0.015 and p=0.002, respectively). Additionally, a significant improvement was observed in resting NRS and exercise NRS scores between baseline and the second week in the iontophoresis group compared to the control group (p=0.009 and p=0.001, respectively).

Conclusion

A significant clinical and functional improvement was detected with dexamethasone iontophoresis in the treatment of patients with knee osteoarthritis and BC.

Validation and interval scale transformation of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) in patients undergoing knee arthroplasty, using the Rasch model

Objectives

Interval scale reduce measurement bias compared to ordinal scale. We aimed to evaluate the fit of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) to the Rasch model and derive the transformation table for interval scale measurement.

Methods

Data from osteoarthritis patients listed for knee arthroplasty (KA) pre-operatively, and at 6- and 12- months post-operative was used. WOMAC was calibrated for fit to the Rasch model for monotonicity, homogeneity, local item independence and absence of differential item functioning (DIF) in a randomly selected 900 patients, 300 from each time point; parameter estimates were then imported into the full data set. Responsiveness was reported through Standard Error of Measurement (SEM); Smallest Detectable Difference (SDD), %SDD and effect sizes (ES) between baseline and 6-months. WOMAC was transformed from ordinal to interval values.

Results

1136 patients (mean age 65.9 years, 69.9% female) were included. WOMAC pain (0-20), function (0-68) and total scores (0-96) had adequate fit to Rasch model with good reliability (Person Separation Index: 0.76, 0.80 and 0.79). No item deletion was required. The SEM, SDD, %SDD and ES of WOMAC total were 4.4, 6.9, 10.1, and 1.97. No significant DIF was seen for age, sex, body mass index, type of KA, languages, and education level. WOMAC pain, function and total scores were transformed to interval scales.

Conclusion

WOMAC total, pain and function scales had adequate fit to the Rasch model, providing unidimensional measure with good reliability and responsiveness. Transformation of WOMAC to interval scale measurement is applicable to other studies.

A systematic review on the potential value of synovial fluid biomarkers to predict clinical outcomes in cartilage repair treatments

OBJECTIVE

Multiple biochemical biomarkers have been previously investigated for the diagnosis, prognosis and response to treatment of articular cartilage damage, including osteoarthritis (OA). Synovial fluid (SF) biomarker measurement is a potential method to predict treatment response and effectiveness. However, the significance of different biomarkers and their correlation to clinical outcomes remains unclear. This systematic review evaluated current SF biomarkers used in investigation of cartilage degeneration or regeneration in the knee joint and correlated these biomarkers with clinical outcomes following cartilage repair or regeneration interventions.

METHOD

PubMed, Institute of Science Index, Scopus, Cochrane Central Register of Controlled Trials, and Embase databases were searched. Studies evaluating SF biomarkers and clinical outcomes following cartilage repair intervention were included. Two researchers independently performed data extraction and Quality Assessment of Diagnostic Accuracy Score 2 (QUADAS-2) analysis. Biomarker inclusion, change following intervention and correlation with clinical outcome was compared.

RESULTS

9 studies were included. Study heterogeneity precluded meta-analysis. There was significant variation in sampling and analysis. 33 biomarkers were evaluated in addition to microRNA and catabolic/anabolic ratios. Five studies reported on correlation of biomarkers with six biomarkers significantly correlated with clinical outcomes following intervention. However, correlation was only demonstrated in isolated studies.

CONCLUSION

This review demonstrates significant difficulties in drawing conclusions regarding the importance of SF biomarkers based on the available literature. Improved standardisation for collection and analysis of SF samples is required. Future publications should also focus on clinical outcome scores and seek to correlate biomarkers with progression to further understand the significance of identified markers in a clinical context.

REGISTRATION NUMBER

PROSPERO CRD42022304298. Study protocol available on PROSPERO website.

Evaluation of mindfulness based stress reduction in symptomatic knee or hip osteoarthritis patients: a pilot randomized controlled trial

Background

To evaluate the efficacy for symptomatic knee and hip osteoarthritis (OA) patients of a mindfulness-based stress reduction (MBSR) program versus usual care.

Methods

Randomized, physician-blind, clinical trial in a monocentric prospective pilot study. Adult participants with symptomatic knee or hip OA were randomized into either intervention or control groups. The intervention group completed the MBSR program for a two-and-a-half-hour weekly session for 8 weeks. Usual care management was similar in both groups. All patients were evaluated at baseline, 3 months and 6 months. The primary objective was to evaluate the change in WOMAC pain score between baseline and 3 months in the MBSR group compared to usual care group. Secondary objectives were to evaluate changes in pain VAS, WOMAC scores, quality of life (SF-36), HAD scores between baseline and 3/6 months.

Results

Forty patients were enrolled in the study. No differences in the WOMAC pain score between the two groups were observed in the different time points. A similar pattern was found for the other assessment outcomes. However, a significant pain VAS reduction in favor of the MBSR group between baseline and 6 months (− 29.6 ± 26.6 vs − 9.3 ± 27.3; p = 0.03) has been reached.

Conclusions

Our pilot RCT found contrasting results with no benefit on WOMAC pain and function and a delayed but long-term efficacy in pain VAS following a MBSR program in symptomatic knee or hip OA patients. Future studies with larger sample size are mandatory to confirm these preliminary results.

Trial registration The study was registered in ClinicalTrials.gov (NCT03644615, 23/08/2018).

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-022-00277-9.

Comparing dextrose prolotherapy with other substances in knee osteoarthritis pain relief: A systematic review

The objective of this study is to compare the effectiveness of dextrose-prolotherapy with other substances for pain relief in patients with primary knee osteoarthritis. The literature screening was done in January 2021 through Medline (PubMed), EMBASE, and Database of the National Institute of Health based on the following criteria: randomized clinical trials that subjected patients with primary knee osteoarthritis who underwent treatment with dextrose-prolotherapy and other substances for pain relief. Paired reviewers independently identified 3381 articles and included 8 trials that met the eligibility criteria. According to the findings of this review, participants that underwent dextrose-prolotherapy showed improvements between baseline and posterior assessments and when compared to saline injections, but when compared to other substances, the results were not clear. Although dextrose-prolotherapy is a useful treatment method by itself, it is still not possible to clearly affirm that it is superior or inferior to its counterparts. There is an urgent need for further studies to bring more evidence to the field.

Wearable transcutaneous electrical nerve stimulation (actiTENS®) is effective and safe for the treatment of knee osteoarthritis pain: a randomized controlled trial versus weak opioids

INTRODUCTION

Despite their poor tolerance, especially in the elderly, weak opioids (WO) remain commonly prescribed for patients with knee osteoarthritis (KOA). We compared the efficacy and safety of a new wearable transcutaneous electrical nerve stimulation (W-TENS) device with WO for the treatment of moderate-to-severe, nociceptive KOA chronic pain.

METHODS

The study was a non-inferiority, multicentric, prospective, randomized, single-blind, controlled, 2-parallel groups Trial. A total of 110 patients with KOA were included (Kellgren-Lawrence radiographic grade ⩾2; American College of Rheumatology criteria), with chronic moderate-to-severe nociceptive pain (mean 8-day pain intensity (PI) ⩾ 4 on an 11-point numerical rating scale), in failure to non-opioid analgesics, including nonsteroidal anti-inflammatory drugs (NSAIDs). Patients with neuropathic pain were excluded. The co-primary endpoints were mean PI at 3 months (M3) and number of potentially treatment-related adverse events (TRAEs). Secondary outcomes included Western Ontario MAC Master University function subscale (range, 0-68), additional pain and quality of life measures, and responder rates.

RESULTS

The non-inferiority of W-TENS was demonstrated in both the per protocol (PP) and intent-to-treat (ITT) populations. At M3, PI in PP population was 3.87 (2.12) compared with 4.66 (2.37) [delta: -0.79 (0.44); 95% CI (-1.65, 0.08)] in W-TENS and WO groups, respectively. A planned superiority analysis showed a significant superiority of W-TENS over WO on PI at M3 (p = 0.0124). The number of TRAEs was significantly lower in the W-TENS group (n = 7) than in the WO group (n = 36) (p < 0.001). Other secondary outcomes also favored W-TENS.

CONCLUSION

W-TENS was more effective and better tolerated than WO in the treatment of chronic nociceptive KOA pain and offers an interesting non-pharmacological analgesic alternative in the management of KOA.Trial Registration: ClinicalTrials.gov: NCT03902340.

Does obesity affect patient-reported outcomes following total knee arthroplasty?

Background

There is an existing perception that obesity has a negative impact on complications following total knee arthroplasty (TKA). However, data on the impact of obesity levels on patient-reported outcomes (PROMs) is sparse. We investigated the association between different obesity classes with PROMs among patients who underwent TKA.

Methods

We performed retrospective secondary analyses on data extracted from the total joint replacement data repository (Alberta, Canada) managed by the Alberta Bone and Joint Health Institute (ABJHI). Patients had WOMAC and EQ5D scores measured at baseline in addition to 3 and/or 12 months following TKA. Patients were stratified according to the World Health Organization (WHO) classification, into five body mass index (BMI) groups of normal, overweight, BMI class I, BMI class II, and BMI class III. The association between BMI and mean changes in WOMAC subscales (pain, function, and stiffness) and EQ-5D-5L index over the time intervals of baseline to 3 months and 3 to 12 months following TKA was assessed. Linear mixed-effects models were used, and the models were adjusted for age, sex, length of surgery, comorbidities, year of surgery, and geographical zone where the surgery was performed.

Results

Mean age was 65.5 years (SD = 8.7). Postoperatively, there was a significant improvement (p < 0.001) in WOMAC subscales of patient-reported pain, function, and stiffness, as well as EQ-5D-5L regardless of BMI group. Although, patients in BMI class II and class III reported significantly improved pain 3 months after TKA compared to those with normal BMI, all BMI groups attained similar level of pain reduction at 12 months after TKA. The greatest improvement in all WOMAC subscales, as well as EQ5D index, occurred between baseline and 3 months (adjusted p < 0.0001).

Conclusion

The findings indicate that patients reported improved pain, function, and stiffness across all BMI groups following TKA. Patients with BMI classified as obese reported similar benefits to those with BMI classified as normal weight. These results may help health care providers to discuss expectations regarding the TKA recovery in terms of pain, function, and quality of life improvements with their TKA candidates.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-04997-4.

Efficacy and safety of radiofrequency treatment for improving knee pain and function in knee osteoarthritis: a meta-analysis of randomized controlled trials

Background

The clinical utility of radiofrequency (RF) in patients with knee osteoarthritis (OA) remains unclear. We conducted a meta-analysis to systematically evaluate the efficacy and safety of RF treatment in patients with knee OA.

Methods

Searches of the PubMed, Web of Science, EMBASE, Cochrane Library, China National Knowledge Infrastructure, and Wanfang Data databases were performed through August 30, 2021. The major outcomes from published randomized controlled trials (RCTs) involving patients with knee OA were compared between RF and control groups, including Visual Analogue Scale (VAS) or Numerical Rating Scale (NRS) scores, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), Global Perceived Effect (GPE) scale, and adverse effects at available follow-up times.

Results

Fifteen RCTs involving 1009 patients were included in this meta-analysis, and the results demonstrated that RF treatment correlated with improvements in pain relief (VAS/NRS score, all P < 0.001) and knee function (WOMAC, all P < 0.001) at 1–2, 4, 12, and 24 weeks after treatment as well as patients’ degree of satisfaction with treatment effectiveness (GPE scale, 12 weeks, P < 0.001). OKSs did not differ significantly between the two groups. Moreover, treatment with RF did not significantly increase adverse effects. Subgroup analysis of knee pain indicated that the efficacy of RF treatment targeting the genicular nerve was significantly better than intra-articular RF at 12 weeks after treatment (P = 0.03).

Conclusions

This meta-analysis showed that RF is an efficacious and safe treatment for relieving knee pain and improving knee function in patients with knee OA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02906-4.

Management of Osteoarthritis: Expert Opinion on NSAIDs

Osteoarthritis (OA) is a leading cause of disability among older adults worldwide. Treatment aims are to alleviate inflammatory pain and improve physical function through non-pharmacological and pharmacological interventions. Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line therapy. However, selection is challenged by patient age, comorbidities and polypharmacy, and by the drug's benefit/risk balance, all of which together influence the risk of cardiovascular (CV), gastrointestinal (GI) and renal adverse events (AEs). While the efficacy profile of the various NSAIDs is delineated, the differences in their safety profile are not straightforward. This narrative review provides practical indications by a multidisciplinary Italian expert panel for general practitioners and specialists managing OA patients with chronic inflammatory pain; the goal is to maximize therapy efficacy while reducing untoward effects caused by inappropriate NSAID use. The discussion on the best approach to NSAIDs spanned the following topics: (1) patient evaluation: investigate pain origin, duration and components together with possible risk factors for CV, GI and renal AEs; (2) non-pharmacological interventions: the physiatrist provides a person-centered, holistic approach accounting for all patient aspects; (3) pharmacological interventions: patient profile and drugs' pharmacological properties affect NSAID selection, which drugs to be used in combination or to be avoided, formulation and therapy duration; (4) the pharmacologist's, general practitioner's and pain therapist's points of view; (5) NSAID safety: the individual baseline risk and the drug's safety profile are major determinants of CV, GI and renal risk; consider possible drug-drug interactions; (6) periodical re-evaluation of treatment response and adherence, using scales to assess pain and function.

Association between changes in the knee adduction moment and changes in knee pain and function in response to non-surgical biomechanical interventions for medial knee osteoarthritis: a systematic review

There is lack of understanding of the relationship between knee adduction moment (KAM) reductions and improvements in pain or function in patients with knee osteoarthritis (KOA). Moreover, there is no systematic review describing the longitudinal relationship between KAM changes and subsequent changes in pain and/or physical function. We aimed (1) to investigate the relationship between changes in KAM induced by non-surgical biomechanical interventions and consecutive changes in pain and/or physical function in patients with medial KOA and (2) to compare this relationship for different interventions. We considered eligible all RCTs using biomechanical interventions aimed to reduce KAM in KOA patients, that measured pain/function. We used Cohen's d effect size to quantify outcome measurements. 14 papers reporting 11 studies were identified. Braces were tested in 6 studies, insoles in 5 studies, shoes in 3 studies and gait retraining in 2 studies. Methodological differences were large among studies. Large effect sizes (≥0.8) changes in pain/function were observed with interventions having at least a small KAM effect size (≥0.2), suggesting an association between KAM and pain/function changes. A linear trend was observed between inter-intervention KAM and VAS pain effect sizes, based on 4 studies. No firm conclusions could be drawn for the different intervention types. There was a trend toward larger KAM reductions leading to larger improvements in pain/function in non-surgical biomechanical interventions. Additional high-quality RCT with consistent methodology are needed to fully characterize the association between KAM and pain/function changes.

Heterotopic Ossification Following Arthroplasty for Femoral Neck Fracture

BACKGROUND

Heterotopic ossification (HO) is a frequent complication following hip surgery. Using data from the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial, we aimed to (1) determine the prevalence of HO following total hip arthroplasty (THA) for femoral neck fracture in patients ≥50 years of age, (2) identify whether HO is associated with an increased risk of revision surgery within 24 months after the fracture, and (3) determine the impact of HO on functional outcomes.

METHODS

We performed a multivariable Cox regression analysis using revision surgery as the dependent variable and HO as the independent variable. We compared Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores between participants with and those without HO at 24 months.

RESULTS

Of 1,441 participants in the study, 287 (19.9%) developed HO within 24 months. HO was not associated with subsequent revision surgery. Grade-III HO was associated with statistically significant and clinically relevant deterioration in the total WOMAC score, which was mainly related to the function component of the score, compared with grade I or II.

CONCLUSIONS

The impact of grade-III HO on the functional outcomes and quality of life after THA for hip fracture is clinically important, and HO prophylaxis for selected high-risk patients may be appropriate.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Targeting Nerve Growth Factor for Pain Management in Osteoarthritis-Clinical Efficacy and Safety

Nerve growth factor (NGF) is a neurotrophin that mediates pain sensitization in pathologic states, including osteoarthritis. In clinical trials, antibodies to NGF reduce pain and improve physical function due to osteoarthritis of the knee or hip and have a long duration of action. Rapidly progressive osteoarthritis is a dose-dependent adverse event with these agents, and additional joint safety signals, such as subchondral insufficiency fractures and increased rates of total joint replacement, are reported. The effects on pain and potential mechanisms behind these joint events both are of considerable importance in the consideration of future use of anti-NGF therapies for osteoarthritis.

Evaluation of the effect of a three-color ladder management model for knee osteoarthritis in the community

OBJECTIVE

To explore the application effect of a three-color ladder management system for knee osteoarthritis in the community.

METHODS

Eighty-six patients with knee osteoarthritis in our community were obtained for study and randomly grouped. The control group received routine management, while the research group received three-color ladder management for 12 months. The knee joint function (WOMAC score), pain degree (VAS score), joint flexibility, health-related behavior score, self-care ability scale (exercise of self-care agency scale (ESCA) score), quality of life (knee osteoarthritis quality of life scale (AIMS2-SF) score) and knee replacement rate were compared between the two groups before and after management, and the changes of patients' visits and treatment costs before and after management were observed.

RESULTS

After 12 months, the scores of WOMAC and VAS in the research group were significantly lower than those of the control group (P<0.05), while the scores of joint flexibility and extension, cognition, behavior and condition of Omaha System health-related behaviors, ESCA and AIMS2-SF were significantly higher than those of the control group (P<0.05). After 12 months, the monthly visits and expenses of green cards, yellow cards and red cards in the research group were significantly lower than those before entering the group (P<0.05). After 12 months, the knee replacement rate was 20.93% (9/43) in the research group, while it was 27.91% (12/43) in the control group, with no significant difference between the two groups (P>0.05).

CONCLUSION

The three-color ladder management system for knee osteoarthritis patients in the community can reduce the number of doctor visits and overall expenses, improve knee joint function, reduce pain, improve self-management ability and quality of life, and it has high community popularization.

Sample-size estimation is not reported in 24% of randomised controlled trials of inflammatory bowel disease: A systematic review

BACKGROUND

Sample-size estimation is an important factor in designing a clinical trial. A recent study found that 65% of Cochrane systematic reviews had imprecise results.

OBJECTIVE

This study set out to review the whole body of inflammatory bowel disease (IBD) randomised controlled trials systematically in order to identify the reporting of sample-size estimation.

METHODS

We conducted a comprehensive hand search of the Cochrane Library and Cochrane IBD Specialized Trials Register. We extracted information on relevant features and the results of the included studies. We produced descriptive statistics for our results.

RESULTS

A total of 242 randomised controlled trials were included from 44 Cochrane systematic reviews. About 25% of the studies failed to report on sample-size estimation. Of those that did report on sample-size estimation, 33% failed to recruit their target sample size.

CONCLUSIONS

Around half of the randomised controlled trials in IBD either do not report sample-size estimation or reach their recruitment target with the level of detail in reporting being limited.

Targeting Cartilage Degradation in Osteoarthritis

Osteoarthritis is a common, degenerative joint disease with significant socio-economic impact worldwide. There are currently no disease-modifying drugs available to treat the disease, making this an important area of pharmaceutical research. In this review, we assessed approaches being explored to directly inhibit metalloproteinase-mediated cartilage degradation and to counteract cartilage damage by promoting growth factor-driven repair. Metalloproteinase-blocking antibodies are discussed, along with recent clinical trials on FGF18 and Wnt pathway inhibitors. We also considered dendrimer-based approaches being developed to deliver and retain such therapeutics in the joint environment. These may reduce systemic side effects while improving local half-life and concentration. Development of such targeted anabolic therapies would be of great benefit in the osteoarthritis field.

Preoperative cognitive-behavioral therapy for reducing pain catastrophizing and improving pain outcomes after total knee replacement: a randomized clinical trial

INTRODUCTION

Cognitive-behavioral therapy (CBT) can reduce preoperative pain catastrophizing and may improve postsurgical pain outcomes. We hypothesized that CBT would reduce pain catastrophizing more than no-CBT controls and result in improved pain outcomes.

METHODS

The study was a randomized controlled trial of patients undergoing elective total knee arthroplasty between January 2013 and March 2020. In phase 1, the change in pain catastrophizing scores (PCS) among 4-week or 8-week telehealth, 4-week in person and no-CBT sessions was compared in 80 patients with a PCS >16. In phase 2, the proportion of subjects that achieved a 3-month decrease in Western Ontario and McMaster Universities Osteoarthritis (WOMAC) pain subscale >4 following 4-week telehealth CBT with no-CBT controls were compared in 80 subjects.

RESULTS

In phase 1, 4-week telehealth CBT had the highest completion rate 17/20 (85%), demonstrated an adjusted median reduction in PCS of -9 (95% CI -1 to -14, p<0.01) compared with no-CBT and was non-inferior to 8-week telehealth CBT at a margin of 2 (p=0.02). In phase 2, 29 of 35 (83%) in the 4-week telehealth CBT and 26 of 33 (79%) subjects in the no-CBT demonstrated a decrease in the WOMAC pain subscale >4 at 3 months, difference 4% (95% CI -18% to 26%, p=0.48), despite a median decrease in the PCS for the 4-week CBT and no-CBT group of -6 (-10 to -2, p=0.02).

CONCLUSIONS

Our findings demonstrate that CBT interventions delivered prior to surgery in person or via telehealth can reduced PCS scores; however, this reduction did not lead to improved 3-month pain outcomes.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT01772329, registration date 21 January 2013).

Voluntary step execution in patients with knee osteoarthritis: Symptomatic vs. non-symptomatic legs

BACKGROUND

Individuals with osteoarthritis fall at a greater rate than the general population, likely as a result of weakness, pain, movement limitations, and a decline in balance. Due to the high prevalence of osteoarthritis in the population, understanding the mechanisms leading to greater fall risk is an important issue to better understand.

RESEARCH QUESTION

What is the influence of unilateral knee osteoarthritis on the characteristics of performing a voluntary step (i.e., similar to that performed to avoid a fall after a perturbation), compared to healthy age-matched controls?

METHODS

Case-control study performed in a Health maintenance organization physical therapy clinic. The research group consisted of a referred sample of 21 patients with unilateral knee osteoarthritis. The control group consisted of 22 age-matched healthy individuals. All participants were over 65 years of age. Participants were excluded if they had a surgical procedure to back or lower limb within one year before testing, oncological or neurological disease or a deficit in tactile sense. Movements were performed with and without dual tasking.

MEASUREMENTS

Duration of the initiation phase (cue to step initiation), preparatory phase (step initiation to foot off) and swing phase (foot off to foot contact).

RESULTS

In the preparatory phase and swing phase, the osteoarthritis group moved more slowly than the control group, and these differences were larger for forward compared to backward movements. Dual-tasking slowed responses in the pre-movement initiation stage across groups.

SIGNIFICANCE

The differences in basic parameters, and the slower movements in the osteoarthritis group, are consistent with known features of osteoarthritis, being a disease commonly regarded as primarily "mechanical", and are likely to increase fall risk. These response deficits suggest we should take advantage of advanced rehabilitation techniques, including cognitive loading, to help prevent falls in older adults with osteoarthritis.

TKA patients experience less improvement than THA patients at 3 and 12 months after surgery. A retrospective observational cohort study

PURPOSE

To investigate whether WOMAC scores changes after THA or TKA are gender and joint specific.

METHODS

Retrospective cohort study. The data of 855 THA and 684 TKA patients were analyzed.

RESULTS

Follow-up time (p < 0.001), gender (p < 0.001), joint (p < 0.001), and interaction FU by joint (p < 0.001) had significant effects on WOMAC total and sub-scores. Patients after TKA perceived less improvement in all dimensions in comparison to THA patients (p < 0.001).

CONCLUSION

WOMAC score changes after THA or TKA are joint-specific. Patients after TKA perceived less improvement. These results can be used to adjust patients' expectations.

An update on joint-specific outcome measures in total hip replacement

This is the latest review of joint-specific tools used to evaluate patients undergoing total hip replacement (THR) surgery, which is an effective treatment for end-stage osteoarthritis. Due to the large number and multitude of scales and their variants used, a critical assessment of the available tools is necessary. In the article, we briefly describe six different clinical tools: the Western Ontario and McMaster Universities Osteoarthritis Index, the Hip Disability and Osteoarthritis Outcome Score, the Harris Hip Score, the Oxford Hip Score, the Mayo Hip Score, and the Rheumatoid and Arthritis Outcome Score. We present the advantages and constraints of the different outcome measures, providing a helpful resource of information for clinical trials and for everyday routine evaluation.

Identification of knee osteoarthritis disability phenotypes regarding activity limitation: a cluster analysis

Background

Studies have reported the subtypes of individuals with knee osteoarthritis (OA) attempting to cluster this heterogonous condition. Activity limitations are commonly used to set goals in knee OA management and better identify subgroups based on level of disability in this patient population. Therefore, the objective of this study was to identify those activity limitations which could classify the disability phenotypes of knee OA. The phenotypes were also validated by comparing impairments and participation restrictions.

Methods

Participants comprised individuals with symptomatic knee OA. They were interviewed and undertook physical examination according to a standard evaluation forms based on the International Classification of Functioning, Disability and Health (ICF) model. Cluster analysis was used to determine those activity limitations which could best classify the phenotypes of knee OA. To validate the clustered variables, comparisons and regression analysis were performed for the impairments consisting of pain intensity, passive range of motion and muscle strength, and the participation restrictions included the difficulty level of acquiring goods and services and community life.

Results

In all, 250 participants with symptomatic knee OA were enrolled in the study. Three activity limitations identified from data distribution and literature were used as the cluster variables, included the difficulty level of maintaining a standing position, timed stair climbing and 40-m self-paced walk test. The analysis showed four phenotypes of individuals with knee OA according to the levels of disability from no to severe level of disability. All parameters of impairment and participation restrictions significantly differed among phenotypes. Subgroups with greater disability experienced worse pain intensity, limited range of motion (ROM), muscle power and participation restriction levels. The variance accounted for of the subgroups were also greater than overall participants.

Conclusion

The results of this study emphasized the heterogeneous natures of knee OA. Three activity limitations identified could classify the individuals with symptomatic knee OA to homogeneous subgroups from no to severe level of disability. The management plan, based on these homogeneous subgroups of knee OA, could be designated by considering the levels of impairments and participation restrictions.

Autologous conditioned serum: clinical and functional results using a novel disease modifying agent for the management of knee osteoarthritis

Objective: The purpose of this study was to investigate the potential ability of autologous conditioned serum (ACS) to decrease pain and improve joint functionality in patients affected by knee osteoarthritis (OA). Methods: Fifteen patients with clinical and radiological signs of OA of the knee were recruited for this study. Each patient received 4 injections of ACS (Orthokine; orthogen, Dusseldorf, Germany) at the site of OA once per week for 4 weeks. Clinical and functional evaluation was performed using the VAS scale for pain, WOMAC scale and KSS functional and clinical scores before the first injection, at one week, at two weeks, at three weeks, at one month and at six months. Statistical analysis was done with the Wilcoxon Signed-Rank Test. Results: Our results show an improvement of all the evaluation scales at 6 months follow-up. Particularly, VAS scales among all patients decreased by 35.8% (p = .00148), KSS functional scores improved by 38.2% (p = .00148), KSS clinical scores improved by 28.9% (p = .00236) and WOMAC scores were reduced by 19.8% (p = .00188). Few adverse effects were observed in our sample. The most common complaint was pain and swelling in the subsequent days after performing the intra-articular injection. Only one patient reported rigidity following the injection of the ACS. Conclusion: Our results, in conjunction with preexisting studies in the medical literature regarding ACS, demonstrate the viability of this therapy for the treatment of knee OA, showing positive influence on pain and joint function without significant adverse effects.