OARSI Clinical Trials Recommendations: Design and conduct of clinical trials for primary prevention of osteoarthritis by joint injury prevention in sport and recreation

Recruitment and baseline characteristics of young adults at risk of early-onset knee osteoarthritis after ACL reconstruction in the SUPER-Knee trial

Objectives

The study aims to (1) report the process of recruiting young adults into a secondary knee osteoarthritis prevention randomised controlled trial (RCT) after anterior cruciate ligament reconstruction (ACLR); (2) determine the number of individuals needed to be screened to include one participant (NNS) and (3) report baseline characteristics of randomised participants.

Methods

The SUpervised exercise-therapy and Patient Education Rehabilitation (SUPER)-Knee RCT compares SUPER and minimal intervention for young adults (aged 18-40 years) with ongoing symptoms (ie, mean score of <80/100 from four Knee injury and Osteoarthritis Outcome Score subscales (KOOS4)) 9-36 months post-ACLR. The NNS was calculated as the number of prospective participants screened to enrol one person. At baseline, participants provided medical history, completed questionnaires (demographic, injury/surgery, rehabilitation characteristics) and underwent physical examination.

Results

1044 individuals were screened to identify 567 eligible people, from which 184 participants (63% male) enrolled. The sample of enrolled participants was multicultural (29% born outside Australia; 2% Indigenous Australians). The NNS was 5.7. For randomised participants, mean±SD age was 30±6 years. The mean body mass index was 27.3±5.2 kg/m2, with overweight (43%) and obesity (21%) common. Participants were, on average, 2.3 years post-ACLR. Over half completed <8 months of postoperative rehabilitation, with 56% having concurrent injury/surgery to meniscus and/or cartilage. The most affected KOOS (0=worst, 100=best) subscale was quality of life (mean 43.7±19.1).

Conclusion

Young adults post-ACLR were willing to participate in a secondary osteoarthritis prevention trial. Sample size calculations should be multiplied by at least 5.7 to provide an estimate of the NNS. The SUPER-Knee cohort is ideally positioned to monitor and intervene in the early development and trajectory of osteoarthritis.

Trial registration number

ACTRN12620001164987.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

ACTRN12620001164987.

State of art in intra-articular hip injections of different medications for osteoarthritis: a systematic review

BACKGROUND

Intra-articular hip injections for osteoarthritis represent a useful instrument to reduce pain and disability in the common clinical practice. Several medications can be injected locally with different level of evidence-based efficacy.

OBJECTIVE

The objective of this systematic review is to investigate the effectiveness of intra-articular injections of different medications or substances for the pain treatment and the management of disability in subjects affected by hip osteoarthritis.

METHODS

Two reviewers selected independently randomised controlled trials published in the last 10 years, using PubMed and Scopus databases. The risk of bias was evaluated with Cochrane library assessment tool.

RESULTS

12 randomised controlled trials have been selected. We found 8 papers comparing hyaluronic acid with platelet rich plasma, with corticosteroids and with saline solution; 1 paper compares two types of hyaluronic acid with different molecular weights; 3 papers study the effects of corticosteroids alone or compared to ketorolac or saline solution.

CONCLUSIONS

The studies reviewed were heterogeneous regarding sample size, level of osteoarthritis, evaluated with Kellegren-Lawrence score, medications used and follow up timings. However, we have observed that intra-articular injections of platelet-rich plasma seem to decrease pain at short term and disability at long term, in patients affected by hip osteoarthritis better than hyaluronic acid. The association of hyaluronic acid and corticosteroids could give better results compared to hyaluronic acid alone, while the use of intra-articular ketorolac and saline solution requires more studies.

Supercritical carbon dioxide decellularized porcine cartilage graft with PRP attenuated OA progression and regenerated articular cartilage in ACLT-induced OA rats

Knee osteoarthritis (OA) is a common degenerative articular disorder and considered one of the primary causes of pain and functional disability. Knee OA is prevalent in 10% of men and 13% of women aged 60 years above. The study aims to use cartilage tissue engineering that combines the triads of decellularized porcine cartilage graft as "scaffold," plasma rich platelet (PRP) as "signal" and chondrocytes from rat as "cell" to attenuate ACLT-induced OA progression and regenerate the knee cartilage in rats. Decellularization of the porcine cartilage was characterized by hematoxylin and eosin, 4,6-Diamidino-2-phenylindole staining, scanning electron microscopy and residual DNA quantification. The protective effect of decellularized porcine cartilage graft (dPCG) was evaluated by intra-articular administration in surgically induced anterior cruciate ligament transection (ACLT) rat osteoarthritis (OA) model. Supercritical carbon dioxide technology completely decellularized the porcine cartilage. Intra-articular administration of dPCG with or without PRP significantly reduced the ACLT-induced OA symptoms and attenuated the OA progression. Pain-relief by dPCG with or without PRP was assessed by capacitance meter and improved articular cartilage damage in the rat knee was characterized by X-ray and micro-CT. Besides, the histological analysis depicted cartilage protection by dPCG with or without PRP. The repairation and attenuation effect by dPCG with or without PRP in the articular knee cartilage damage were also explored by safranin-O, type II collagen, aggrecan and SOX-9 immuno-staining. To conclude, intra-articular administration of dPCG with or without PRP is efficient in repairing the damaged cartilage in the experimental OA model.

Elevation of Pro-Inflammatory Cytokine Levels Following Intra-Articular Fractures-A Systematic Review

Introduction: Intra-articular fractures are a major cause of post-traumatic osteoarthritis (PTOA). Despite adequate surgical treatment, the long-term risk for PTOA is high. Previous studies reported that joint injuries initiate an inflammatory cascade characterized by an elevation of synovial pro-inflammatory cytokines, which can lead to cartilage degradation and PTOA development. This review summarizes the literature on the post-injury regulation of pro-inflammatory cytokines and the markers of cartilage destruction in patients suffering from intra-articular fractures. Methods: We searched Medline, Embase, and Cochrane databases (1960-February 2020) and included studies that were performed on human participants, and we included control groups. Two investigators assessed the quality of the included studies using Covidence and the Newcastle-Ottawa Scale. Results: Based on the surveyed literature, several synovial pro-inflammatory cytokines, including interleukins (IL)-1β, IL-2, IL-6, IL-8, IL-12p70, interferon-y, and tumor necrosis factor-α, were significantly elevated in patients suffering from intra-articular fractures compared to the control groups. A simultaneous elevation of anti-inflammatory cytokines such as IL-10 and IL-1RA was also observed. In contrast, IL-13, CTX-II, and aggrecan concentrations did not differ significantly between the compared cohorts. Conclusions: Overall, intra-articular fractures are associated with an increase in inflammation-related synovial cytokines. However, more standardized studies which focus on the ratio of pro- and anti-inflammatory cytokines at different time points are needed.

Posttraumatic osteoarthritis: what have we learned to advance osteoarthritis?

PURPOSE OF REVIEW

Current thinking in the study of posttraumatic osteoarthritis (PTOA) is overviewed: the osteoarthritis which follows acute joint injury. The review particularly highlights important publications in the last 18 months, also reflecting on key older literature, in terms of what have we have we learned and have yet to learn from PTOA, which can advance the osteoarthritis field as a whole.

RECENT FINDINGS

PTOA is a mechanically driven disease, giving insight into mechanical drivers for osteoarthritis. A mechanosensitive molecular tissue injury response (which includes activation of pain, degradative and also repair pathways) is triggered by acute joint injury and seen in osteoarthritis. Imaging features of PTOA are highly similar to osteoarthritis, arguing against it being a different phenotype. The inflammatory pathways activated by injury contribute to early joint symptoms. However, later structural changes appear to be dissociated from traditional measures of synovial inflammation.

SUMMARY

PTOA remains an important niche in which to understand processes underlying osteoarthritis and seek interventional targets. Whether PTOA has true molecular or clinical differences to osteoarthritis as a whole remains to be understood. This knowledge is important for a field where animal modelling of the disease relies heavily on the link between injury and osteoarthritis.

Development and evaluation of an osteoarthritis risk model for integration into primary care health information technology

BACKGROUND

We developed and evaluated a prognostic prediction model that estimates osteoarthritis risk for use by patients and practitioners that is designed to be appropriate for integration into primary care health information technology systems. Osteoarthritis, a joint disorder characterized by pain and stiffness, causes significant morbidity among older Canadians. Because our prognostic prediction model for osteoarthritis risk uses data that are readily available in primary care settings, it supports targeting of interventions delivered as part of clinical practice that are aimed at risk reduction.

METHODS

We used the CPCSSN (Canadian Primary Sentinel Surveillance Network) database, which contains aggregated electronic health information from a cohort of primary care practices, to develop and evaluate a prognostic prediction model to estimate 5-year osteoarthritis risk, addressing contextual challenges of data availability and missingness. We constructed a retrospective cohort of 383,117 eligible primary care patients who were included in the cohort if they had an encounter with their primary care practitioner between 1 January 2009 and 31 December 2010. Patients were excluded if they had a diagnosis of osteoarthritis prior to their first visit in this time period. Incident cases of osteoarthritis were observed. The model was constructed to predict incident osteoarthritis based on age, sex, BMI, previous leg injury, and osteoporosis. Evaluation of the model used internal 10-fold cross-validation; we argue that internal validation is particularly appropriate for a model that is to be integrated into the same context from which the data were derived.

RESULTS

The resulting prediction model for 5-year risk of osteoarthritis diagnosis demonstrated state-of-the-art discrimination (estimated AUROC 0.84) and good calibration (assessed visually.) The model relies only on information that is readily available in Canadian primary care settings, and hence is appropriate for integration into Canadian primary care health information technology.

CONCLUSIONS

If the contextual challenges arising when using primary care electronic medical record data are appropriately addressed, highly discriminative models for osteoarthritis risk may be constructed using only data commonly available in primary care. Because the models are constructed from data in the same setting where the model is to be applied, internal validation provides strong evidence that the resulting model will perform well in its intended application.

Ipriflavone attenuates the degeneration of cartilage by blocking the Indian hedgehog pathway

BACKGROUND

To determine if ipriflavone, a novel and safe inhibitor of Indian hedgehog (Ihh) signaling, can attenuate cartilage degeneration by blocking the Ihh pathway.

METHODS

Human chondrocytes were used to evaluate Ihh signaling, cell proliferation, apoptosis, gene, and protein expression of chondrocytes by cell proliferation and apoptosis assays, real-time qPCR, and Western blotting at 48 h after ipriflavone treatment. Human cartilage explants were further used to validate the cell culture results. The effects of ipriflavone on cartilage degeneration in vivo were assessed using the rat ACLT OA model. Two-month-old male SD rats were randomized into 3 groups (n = 75): (1) sham, (2) ACLT alone, and (3) ACLT+ ipriflavone. Ipriflavone was administered intragastrically at 24 h after ACLT for 6 weeks. The extent of OA progression was evaluated by the OARSI score and immunohistochemistry at 12 weeks after surgery. The Ihh signaling pathway and OA-related genes were quantified by real-time PCR.

RESULTS

Cell proliferation in the cells treated with ipriflavone was increased to 36.40% ± 1.32% (5 μM) and 28.54% ± 0.74% (10 μM) from 11.99% ± 0.35% (DMSO) (P < 0.001), and apoptosis was decreased to 12.64% ± 3.7% (5 μM) and 15.18% ± 3.13% (10 μM) from 25.76% ± 5.1% (DMSO) (P < 0.05). Ipriflavone blocked Runx-2 mainly through the Smo-Gli2 pathway. A similar result was found in the cartilage explant culture. Ihh signaling in vivo was inhibited in animals treated with ipriflavone. Safranin-O staining revealed a less cartilage damage with lower OARSI scores (P < 0.05) in the ipriflavone-treated animals compared with untreated animals. The gene expression of Smo and Gli2 was inhibited significantly by ipriflavone (P < 0.05). The OA-related gene and protein type X, MMP-13, and type II collagen-C fragment were reduced, while type II collagen and Agg were increased in the ipriflavone-treated animals (P < 0.05).

CONCLUSIONS

Catabolic genes were disrupted by blocking the Ihh pathway. This finding suggests that disruption of Ihh signaling with ipriflavone provides chondral protection in rat posttraumatic OA.

Current trends in sport injury prevention

Participation in sport and recreation has important positive implications for public health across the lifespan; however, the burden of sport-related musculoskeletal injury is significant, with the greatest risk being in youth and young adults. Moving upstream to primary prevention of injury is a public health priority that will have significant implications for reducing the long-term consequences of musculoskeletal injury including early post-traumatic osteoarthritis. The primary targets for the prevention of musculoskeletal injury in sport include neuromuscular training (NMT), rule modification, and equipment recommendations. Currently, there is significant high-quality evidence to support the widespread use of NMT warm up programs in team and youth sport, with an expected significant impact of reducing the risk of musculoskeletal injury by over 35%. Policy disallowing body checking in youth ice hockey has led to a >50% reduction in injuries, and rules limiting contact practice in youth American football has significant potential for injury prevention. There is evidence to support the use of bracing and taping in elite sport to reduce the risk of recurrent ankle sprain injury but not for use to prevent the primary injury, and wrist guards are protective of sprain injuries in snowboarding. Future research examining the maintenance of NMT programs across real-world sport and school settings, optimization of adherence, additional benefit of workload modification, and evaluation of rule changes in other sports is needed.

Towards prevention of post-traumatic osteoarthritis: report from an international expert working group on considerations for the design and conduct of interventional studies following acute knee injury

OBJECTIVE

There are few guidelines for clinical trials of interventions for prevention of post-traumatic osteoarthritis (PTOA), reflecting challenges in this area. An international multi-disciplinary expert group including patients was convened to generate points to consider for the design and conduct of interventional studies following acute knee injury.

DESIGN

An evidence review on acute knee injury interventional studies to prevent PTOA was presented to the group, alongside overviews of challenges in this area, including potential targets, biomarkers and imaging. Working groups considered pre-identified key areas: eligibility criteria and outcomes, biomarkers, injury definition and intervention timing including multi-modality interventions. Consensus agreement within the group on points to consider was generated and is reported here after iterative review by all contributors.

RESULTS

The evidence review identified 37 studies. Study duration and outcomes varied widely and 70% examined surgical interventions. Considerations were grouped into three areas: justification of inclusion criteria including the classification of injury and participant age (as people over 35 may have pre-existing OA); careful consideration in the selection and timing of outcomes or biomarkers; definition of the intervention(s)/comparator(s) and the appropriate time-window for intervention (considerations may be particular to intervention type). Areas for further research included demonstrating the utility of patient-reported outcomes, biomarkers and imaging outcomes from ancillary/cohort studies in this area, and development of surrogate clinical trial endpoints that shorten the duration of clinical trials and are acceptable to regulatory agencies.

CONCLUSIONS

These considerations represent the first international consensus on the conduct of interventional studies following acute knee joint trauma.

Intervention Strategies Used in Sport Injury Prevention Studies: A Systematic Review Identifying Studies Applying the Haddon Matrix

BACKGROUND

Prevention of sport injuries is crucial to maximise the health and societal benefits of a physically active lifestyle. To strengthen the translation and implementation of the available evidence base on effective preventive measures, a range of potentially relevant strategies should be considered.

OBJECTIVE

Our aim was to identify and categorise intervention strategies for the prevention of acute sport injuries evaluated in the scientific literature, applying the Haddon matrix, and identify potential knowledge gaps.

METHODS

Five electronic databases were searched (PubMed, EMBASE, SPORTDiscus, CINAHL, Cochrane) for studies that evaluated the effect of interventions on the occurrence of acute sport injuries. Studies were required to include a control group/condition, prospective data collection, and a quantitative injury outcome measure.

RESULTS

A total of 155 studies were included, mostly randomised controlled trials (43%). The majority of studies (55%) focussed on strategies requiring a behavioural change on the part of athletes. Studies predominantly evaluated the preventive effect of various training programmes targeted at the 'pre-event' phase (n = 73) and the use of equipment to avoid injury in the 'event phase' (n = 29). A limited number of studies evaluated the preventive effect of strategies geared at rules and regulations (n = 14), and contextual modifications (n = 18). Studies specifically aimed at preventing re-injuries were a minority (n = 8), and were mostly related to ankle sprains (n = 5).

CONCLUSIONS

Valuable insight into the extent of the evidence base of sport injury prevention studies was obtained for 20 potential intervention strategies. This approach can be used to monitor potential gaps in the knowledge base on sport injury prevention.

Sports Biostatistician: a critical member of all sports science and medicine teams for injury prevention

Sports science and medicine need specialists to solve the challenges that arise with injury data. In the sports injury field, it is important to be able to optimise injury data to quantify injury occurrences, understand their aetiology and most importantly, prevent them. One of these specialty professions is that of Sports Biostatistician. The aim of this paper is to describe the emergent field of Sports Biostatistics and its relevance to injury prevention. A number of important issues regarding this profession and the science of sports injury prevention are highlighted. There is a clear need for more multidisciplinary teams that incorporate biostatistics, epidemiology and public health in the sports injury area.

Prevention of Ankle Sprain Injuries in Youth Soccer and Basketball: Effectiveness of a Neuromuscular Training Program and Examining Risk Factors

OBJECTIVES

The primary objective of this study was to examine the effectiveness of a neuromuscular training (NMT) warm-up program in reducing the risk of ankle sprain injury (ASI) in youth soccer and basketball. The secondary objective included the evaluation of risk factors for ASI.

STUDY DESIGN

Secondary analysis of pooled data from 5 studies.

PARTICIPANTS

Male and female youth (11-18 years) soccer and basketball players (n = 2265) in Alberta, Canada.

OUTCOME MEASURES

Ankle sprain injury was the primary outcome and was recorded using a validated prospective injury surveillance system consistent in all studies. The primary exposure of interest was NMT warm-up, which included aerobic, strength, agility, and balance components. Multivariable Poisson regression, controlling for clustering by team and offset for exposure hours, was used to estimate incidence rate ratios (IRRs) with 95% confidence intervals (CIs), with considerations for confounding and effect modification and evaluating all covariates as potential risk factors.

RESULTS

A total of 188 ASIs were reported in 171 players. Neuromuscular training significantly reduced the risk of ASI [IRR = 0.68 (95% CI; 0.46-0.99)]. Independent risk factors for ASI included previous ASI [IRR = 1.98 (95% CI; 1.38-2.81)] and participation in basketball versus soccer [IRR = 1.83 (95% CI; 1.18-2.85)]. Sex, age, body mass index, and previous lower extremity injury (without previous ASI) did not predict ASI (P > 0.05).

CONCLUSIONS

Exposure to an NMT program is significantly protective for ASI in youth soccer and basketball. Risk of ASI in youth basketball is greater than soccer, and players with a history of ASI are at greater risk.

Anti-osteoarthritic effects of ChondroT in a rat model of collagenase-induced osteoarthritis

Background

Previously, we reported that ChondorT showed significant anti-arthritis and anti-inflammatory effects. ChondroT, a new herbal medication, consists of the water extracts of Osterici Radix, Lonicerae Folium, Angelicae Gigantis Radix, Clematidis Radix, and Phellodendri Cortex (6:4:4:4:3). The objective of this study was to investigate the effects of ChondroT in collagenase-induced osteoarthritis rat model.

Methods

Osteoarthritis was induced by the injection of collagenase into the right knee joint cavity of rats. The samples were divided into seven groups [intact (n = 6), control (n = 6), indomethacin (n = 6), Joins tab (n = 6), ChondroT50 (n = 6), ChondroT100 (n = 6), and ChondroT200 (n = 6)]. The control group was administered normal saline, indomethacin group was administered indomethacin (2 mg/kg), and Joins tab group was administered Joins Tab (20 mg/kg). The ChondroT50, ChondroT100, and ChondroT200 groups were administered 50, 100, and 200 mg/kg of ChondroT, respectively. All oral administrations were initiated 7 days after the induction of arthritis and were continued for a total of 12 days. At the end of the experiment, serum aminotransferase, albumin, blood urea nitrogen, creatinine, leukocyte, and inflammatory cytokines [tumor necrosis factor (TNF)-α, interleukin (IL)-1β, and IL-6] were analyzed. Hematoxylin and eosin (H&E) and safranin O-fast green staining of the articular structures of the knee joint were performed.

Results

TNF-α and IL-1β decreased in the ChondroT100 and ChondroT200 groups compared with those in the control group. IL-6 and aspartate aminotransferase decreased in the ChondroT50, ChondroT100, and ChondroT200 groups compared with that in the control group. Albumin, WBC and lymphocytes decreased in the ChondroT100 and ChondroT200 groups compared with those in the control group. In H&E stain, synoviocytes, cartilage lacunae, and chondrocytes were well preserved in the ChondroT100 and ChondroT200 groups, and safranin O-fast staining showed a clear reaction of proteoglycans in the ChondroT100 and ChondroT200 groups.

Conclusions

Based on these results, it can be proposed that ChondroT has anti-osteoarthritic effects on collagenase-induced rat model.

Comparison of Regenerative Tissue Quality following Matrix-Associated Cell Implantation Using Amplified Chondrocytes Compared to Synovium-Derived Stem Cells in a Rabbit Model for Cartilage Lesions

Known problems of the autologous chondrocyte implantation motivate the search for cellular alternatives. The aim of the study was to test the potential of synovium-derived stem cells (SMSC) to regenerate cartilage using a matrix-associated implantation. In an osteochondral defect model of the medial femoral condyle in a rabbit, a collagen membrane was seeded with either culture-expanded allogenic chondrocytes or SMSC and then transplanted into the lesion. A tailored piece synovium served as a control. Rabbit SMSC formed typical cartilage in vitro. Macroscopic evaluation of defect healing and the thickness of the regenerated tissue did not reveal a significant difference between the intervention groups. However, instantaneous and shear modulus, reflecting the biomechanical strength of the repair tissue, was superior in the implantation group using allogenic chondrocytes (p < 0.05). This correlated with a more chondrogenic structure and higher proteoglycan expression, resulting in a lower OARSI score (p < 0.05). The repair tissue of all groups expressed comparable amounts of the collagen types I, II, and X. Cartilage regeneration following matrix-associated implantation using allogenic undifferentiated synovium-derived stem cells in a defect model in rabbits showed similar macroscopic results and collagen composition compared to amplified chondrocytes; however, biomechanical characteristics and histological scoring were inferior.

The Role of Athletic Trainers in Preventing and Managing Posttraumatic Osteoarthritis in Physically Active Populations: a Consensus Statement of the Athletic Trainers' Osteoarthritis Consortium

OBJECTIVE

  To provide athletic trainers with a fundamental understanding of the pathogenesis and risk factors associated with the development of posttraumatic osteoarthritis (PTOA) as well as the best current recommendations for preventing and managing this condition.

BACKGROUND

  Posttraumatic osteoarthritis, or osteoarthritis that develops secondary to joint injury, accounts for approximately 5.5 million US cases annually. A young athlete with a joint injury is at high risk for PTOA before the age of 40, which could lead to the patient living more than half of his or her life with a painful and disabling disorder. Given our frequent contact with physically active people who often sustain traumatic joint injuries, athletic trainers are in a unique position to help prevent and manage PTOA. We can, therefore, regularly monitor joint health in at-risk patients and implement early therapies as necessary.

RECOMMENDATIONS

  The recommendations for preventing and managing PTOA are based on the best available evidence. Primary injury prevention, self-management strategies, maintenance of a healthy body weight, and an appropriate level of physical activity should be encouraged among those at risk for PTOA after acute traumatic joint injury. Education of athletic trainers and patients regarding PTOA is also critical for effective prevention and management of this disease.

Intra-Articular Injection of Cross-Linked Hyaluronic Acid-Dexamethasone Hydrogel Attenuates Osteoarthritis: An Experimental Study in a Rat Model of Osteoarthritis

Cross-linked hyaluronic acid hydrogel (cHA gel) and dexamethasone (Dex) have been used to treat knee osteoarthritis (OA) in clinical practice owing to their chondroprotective and anti-inflammatory effects, respectively. The aim of the present study was to compare the treatment effects of the cHA gel pre-mixed with/without Dex in a surgery-induced osteoarthritis model in rats. Anterior cruciate ligament transection (ACLT) surgery was performed on the right knee of rats to induce OA. Male 2-month-old Sprague-Dawley rats were randomly divided into five groups (n = 10/per group): (1) ACLT + saline; (2) ACLT + cHA gel; (3) ACLT + cHA-Dex (0.2 mg/mL) gel; (4) ACLT + cHA-Dex (0.5 mg/mL) gel; (5) Sham + saline. Intra-joint injections were performed four weeks after ACLT in the right knee. All animals were euthanized at 12 weeks post-surgery. Cartilage damage and changes in the synovial membrane were assessed by micro X-ray, Indian ink articular surface staining, Safranin-O/Fast Green staining, immunohistochemistry, hematoxylin and eosin staining of the synovial membrane, and quantitative reverse transcription-polymerase chain reaction for changes in gene expression. Micro X-ray revealed that the knee joint treated with the cHA-Dex gel was wider than those treated with cHA gel alone or saline. The cHA-Dex gel group had less Indian ink staining (indicator of cartilage fibrillation) than the cHA gel or saline injection groups. Safranin-O/Fast Green staining indicated that increased proteoglycan staining and less cartilage damage were found in the cHA-Dex gel group compared with the cHA gel or saline injection groups. Quantification of histology findings from saline, cHA gel, cHA-Dex (0.2 mg/mL) gel, cHA-Dex (0.5 mg/mL) gel, and sham groups were 5.84 ± 0.29, 4.50 ± 0.87, 3.00 ± 1.00, 2.00 ± 0.48, and 0.30 ± 0.58 (p < 0.05), respectively. A strong staining of type II collagen was found in both the cHA-Dex gel groups compared with saline group or cHA alone group. Similar result was found for the mRNA level of aggrecan and opposite result for type X collagen. Hematoxylin and eosin staining in the synovial membrane showed less synovial lining cell layers and reduced inflammatory cell infiltration in cHA-Dex gel-treated animals compared with saline or cHA only groups. Altogether, cHA-Dex gel has better chondroprotective and anti-inflammatory effects in rat surgery-induced osteoarthritis than cHA alone.

A multicenter randomised, 1-year comparative effectiveness, parallel-group trial protocol of a physical therapy approach compared to corticosteroid injection on pain and function related to knee osteoarthritis (PTA Trial)

INTRODUCTION

Corticosteroid injections (CSIs) are commonly used as an initial or a primary intervention for knee osteoarthritis (OA). Consistent evidence indicates CSIs offer symptom relief with conflicting reports regarding long-term efficacy. Physical therapy (PT) offers a non-invasive alternative. There is moderate evidence suggesting short-term and long-term symptom relief and functional improvement with PT interventions. Patients with knee OA are more commonly prescribed CSI than PT prior to total joint replacement. UnitedHealthcare and Military Health System data show substantially more total knee replacement patients receive preoperative CSI than PT. There are no studies comparing CSI to a PT approach in individuals with knee OA. The primary objective of this study is to compare the effectiveness of CSI to PT in individuals with knee OA at 1, 2 and 12 months.

METHODS AND ANALYSIS

We plan to recruit 156 participants meeting established knee OA criteria. Following informed consent, participants will be randomised to receive either CSI or PT. All participants will receive instruction on recommended exercise and weight control strategies plus usual medical care. The CSI intervention consisting of 3 injections and the PT intervention consisting of 8-12 sessions will be spaced over 12 months. Measures of the dependent variables (DVs) will occur at baseline, 4 weeks, 8 weeks, 6 months and 12 months post enrolment. This pragmatic, randomised clinical trial will be a mixed-model 2×5 factorial design. The independent variables are treatment (CSI and PT) and time with five levels from baseline to 1 year. The primary DV is the Western Ontario & McMaster Universities Arthritis Index (WOMAC). We will also compare healthcare utilisation between the 2 groups.

ETHICS AND DISSEMINATION

The protocol was approved by the Madigan Army Medical Center Institutional Review Board. The authors intend to publish the results in a peer-reviewed source.

TRIAL REGISTRATION NUMBER

NCT01427153.