Synovitis and bone marrow lesions associate with symptoms and radiographic progression in hand osteoarthritis: a systematic review and meta-analysis of observational studies

Bone marrow lesions and collateral ligament lesions are associated in interphalangeal joints with osteoarthritis: The Hand OSTeoArthritis in Secondary care cohort

OBJECTIVES

To investigate whether bone activity adjacent to collateral ligaments is present and results in collateral ligament lesions (CLLs) of the proximal and distal interphalangeal joints in patients with hand osteoarthritis (OA), and vice versa.

METHODS

We used data measured on baseline, year two and year four from the Hand OSTeoArthritis in Secondary care cohort. MR images of the right hand were scored at the radial and ulnar 1/3rd of each joint ("=joint side") for bone marrow lesions (BMLs) and CLLs (=non-visible or non-continuous ligament). Odds ratios (ORs) with 95% confidence intervals were used to quantify longitudinal associations at the same joint side, adjusted for patient effect.

RESULTS

In 261 patients (mean age 61 years, 84% women), BMLs were present at baseline in 113/4169 joint sides (3%), and at year four in 89/3356 (3%). Any CLL was present at baseline in 500/4169 joint sides (12%), and at year four in 559/3356 (17%). The presence of BMLs and CLL was cross-sectionally associated. In baseline joint sides without CLLs, BMLs were positively associated with CLL development in the corresponding joint side at year two and four (OR 3.7 (1.5;9.1) and 4.9 (2.3;10.7), respectively), compared with no BMLs. In baseline joint sides without BMLs, CLLs were positively associated with BMLs at the same side at year two and four (9.2 (3.9;22.1) and 11.0 (5.8;20.9) respectively), compared with no CLLs.

CONCLUSIONS

BMLs are rare yet associated with CLLs that are more common, both cross-sectionally and longitudinally, both adding to the OA process.

Osteoarthritis

Osteoarthritis is a heterogeneous disorder that is increasingly prevalent largely due to aging and obesity, resulting in a major disease burden worldwide. Knowledge about the underlying aetiology has improved, with increased understanding of the role of genetic factors, the microbiome, and existence of different pain mechanisms. However, this knowledge has not yet been translated into new treatment options. New evidence has questioned the efficacy of recommended treatments, such as therapeutic exercise programmes and the focus on weight loss, but managing obesity and maintaining activity remain important for the prevention and management of osteoarthritis. Approaches should consider individual and cultural preferences and resource availability to increase patient and community engagement, and optimise outcomes worldwide. Most of the focus has been on established osteoarthritis where management is primarily directed at relieving symptoms. The search for the much needed effective treatments that improve both symptoms and structure, often referred to as disease-modifying osteoarthritic drugs, is ongoing. Promising data indicate that targeting inflammation is effective in hand osteoarthritis.

Synovitis scoring in hand osteoarthritis with ultrasonography: the performance of the Global OMERACT/EULAR Ultrasound Synovitis Score (GLOESS) is comparable to synovial thickening alone

BACKGROUND

Inflammation is increasingly recognised as a treatment target in hand osteoarthritis, and therefore correct measurement of local inflammation is essential. This study aimed to assess ultrasound scoring of synovitis and the additional value of the Global OMERACT/EULAR Ultrasound Synovitis Score (GLOESS) in hand osteoarthritis.

METHODS

Data from the randomised, double-blinded Hand Osteoarthritis Prednisolone Efficacy (HOPE) trial were used. The HOPE trial included patients with painful, inflammatory hand OA, treated with prednisolone or placebo (1:1). Ultrasound was performed in 30 hand joints at weeks 0, 6 and 14. Effusion, synovial thickening and Doppler signal were measured, the GLOESS was calculated from the latter two. Joint tenderness on palpation was assessed semiquantitatively (0-3), soft swelling as present/absent. Changes in ultrasound scores, and their association with change in joint tenderness or soft swelling, were investigated using generalised estimating equations. Effect sizes were calculated.

RESULTS

Of 92 included patients 79% were women, with mean (SD) age 63.9 (8.8) and body mass index 27.2 (4.6). Synovial thickening was the most prevalent. All ultrasound scores were strongly associated with joint tenderness and soft swelling cross-sectionally. There was no association of change in ultrasound scores with change in tenderness, but there was with change in soft tissue swelling. Synovial thickening and the GLOESS responded to treatment (effect size -0.39 (-0.72 to -0.07), -0.39 (-0.71 to -0.07), respectively).

DISCUSSION

Various ultrasound scores were associated with joint tenderness and soft swelling. The GLOESS and synovial thickening were both responsive to treatment, but GLOESS was not superior to synovial thickening alone.

Bidirectional association identified between synovitis and knee and hand osteoarthritis: a general population-based study

Background

Synovitis has long been considered a common and modifiable inflammatory feature of osteoarthritis (OA), but current disease-modifying anti-inflammatory treatments appear ineffective in OA clinical trials. Elucidating the temporal relationship between synovitis and OA could provide insight into the role of synovitis in OA.

Methods

We conducted a prospective cohort study based on the baseline and three-year follow-up data from the Xiangya Osteoarthritis (XO) Study. We assessed bidirectional associations between ultrasound-detected synovitis and radiographic and symptomatic OA at knee and hand sites using generalized estimating equations. Additionally, we performed bidirectional Mendelian randomization (MR) analyses to test these hypotheses utilising whole-genome sequencing data in the XO population. Age, sex, body mass index, smoking, alcohol consumption, educational level, physical activity, and joint injury history were adjusted for these analyses.

Findings

A total of 2211, 2420, 2280, and 2600 participants were enrolled for analyses of radiographic knee OA (RKOA), symptomatic knee OA (SKOA), radiographic hand OA (RHOA) and symptomatic hand OA (SHOA), respectively. The baseline synovitis (i.e., with synovitis vs. without synovitis) was associated with the incident RKOA (76/277 vs. 557/3674 knees), SKOA (49/387 vs. 287/4213 knees), RHOA (171/358 vs. 686/3664 hands) and SHOA (35/689 vs. 76/4327 hands), with adjusted odds ratio (aORs) of 2.2 (95% CI 1.7-3.1), 2.0 (1.3-2.9), 3.4 (2.7-4.4), and 2.4 (1.5-3.8), respectively. The baseline RKOA (with OA vs. without OA: 409/1246 vs. 481/3758 knees), SKOA (200/576 vs. 675/4356 knees), RHOA (192/778 vs. 410/3723 hands), and SHOA (41/162 vs. 548/4285 hands) were also associated with the incident synovitis, with aORs of 3.4 (95% CI 2.9-4.1), 2.7 (2.1-3.4), 2.3 (1.8-2.9) and 1.9 (1.2-2.8), respectively. These bidirectional associations were stronger when more active synovitis was compared with the reference group (all P < 0.05). MR analyses further supported bidirectional associations that synovitis significantly increased the odds of incident OA at both sites and vice versa (all ORs ranged from 1.2-1.7).

Interpretation

Our population-based cohort study found novel evidence of a bidirectional association between synovitis and OA, which was further validated through MR analysis and suggested that the bidirectional association is likely causal. Our findings indicated that synovitis is both a risk factor and a consequence of the OA rather than solely a risk factor.

Funding

The National Key Research and Development Plan, the National Natural Science Foundation of China, the Key Research and Development Program of Hunan Province, the Natural Science Foundation of Hunan Province, the Central South University Innovation-Driven Research Programme, and the Fundamental Research Funds for the Central Universities of Central South University.

Diabetes and Osteoarthritis: Exploring the Interactions and Therapeutic Implications of Insulin, Metformin, and GLP-1-Based Interventions

Diabetes mellitus (DM) and osteoarthritis (OA) are prevalent chronic conditions with shared pathophysiological links, including inflammation and metabolic dysregulation. This study investigates the potential impact of insulin, metformin, and GLP-1-based therapies on OA progression. Methods involved a literature review of clinical trials and mechanistic studies exploring the effects of these medications on OA outcomes. Results indicate that insulin, beyond its role in glycemic control, may modulate inflammatory pathways relevant to OA, potentially influencing joint health. Metformin, recognized for its anti-inflammatory properties via AMPK activation, shows promise in mitigating OA progression by preserving cartilage integrity and reducing inflammatory markers. GLP-1-based therapies, known for enhancing insulin secretion and improving metabolic profiles in DM, also exhibit anti-inflammatory effects that may benefit OA by suppressing cytokine-mediated joint inflammation and supporting cartilage repair mechanisms. Conclusions suggest that these medications, while primarily indicated for diabetes management, hold therapeutic potential in OA by targeting common underlying mechanisms. Further clinical trials are warranted to validate these findings and explore optimal therapeutic strategies for managing both DM and OA comorbidities effectively.

Hand osteoarthritis: A fresh look

Hand osteoarthritis (OA) has been the subject of numerous publications in recent years, particularly in the fields of imaging and therapeutics. The imaging studies revealed a good correlation between the presence of synovitis and/or subchondral edema and arthritic joint pain. Several randomized controlled trials (RCTs) have assessed the efficacy of biologics and conventional DMARDs in patients with symptomatic hand OA. No less than six RCTs have evaluated the symptomatic and, in some cases, structural efficacy of anti-IL-1, anti-TNF or anti-IL-6 drugs. Overall, the results of these trials were disappointing - none of them demonstrated superiority over placebo. There were also two negative trials with hydroxychloroquine. In the end, the only trial that was positive evaluated 10mg oral prednisone versus placebo for 6 weeks in patients with flares of hand OA and synovitis visible on ultrasound. While that trial confirms the role of inflammation in hand OA, it should obviously not encourage the long-term use of corticosteroids as a symptomatic treatment.

Erosive Hand Osteoarthritis: Recent Advances and Future Treatments

PURPOSE OF THE REVIEW

Erosive hand osteoarthritis (EHOA) is an aggressive form of hand osteoarthritis that leads to significant disability, and recent data suggests that it is increasing in prevalence. This review provides an update of our current understanding of epidemiology, genetic associations, biomarkers, pathogenesis, and treatment of EHOA, with particular focus on studies published within the last 5 years.

RECENT FINDINGS

New studies of EHOA have identified new genetic loci associated with disease, including variants in genes involved in inflammation and bone remodeling. Preclinical studies implicate pathways of innate immunity, including some that may be causal in the condition. Recent novel studies showed that inflammatory features identified by ultrasound and MRI are associated with development of erosive lesions over time on conventional radiography. In the future, these imaging modalities may be useful in identifying patients at risk of adverse outcomes. Promising new findings in genetics, biomarkers, and treatment targets will hopefully allow for future therapeutic options for this debilitating condition.

Synovial inflammation in osteoarthritis. A treatable target?

Synovial inflammation is present in osteoarthritis and associated with pain and structural damage, so it is hypothesized that anti-inflammatory drugs might be of use in osteoarthritis. However, nine randomized clinical trials targeting pro-inflammatory cytokines, especially IL-1 and TNFα, did not show an effect on short-term pain relief (as primary end-points). These results were rather disappointing. The questions is whether the results reflect a true lack of effect of anti-inflammatory drugs in osteoarthritis, or whether there are alternative explanations. Currently, we lack insight in the pathobiology of the synovitis-driven endotype and in cross-talk between tissues in the osteoarthritic joint, complicating identification of the appropriate patients for trials and of the best outcome measures. Furthermore we lack classification criteria to define inflammatory osteoarthritis complicating selection of patients. We do know that anti-inflammatory corticosteroids alleviate pain in osteoarthritis, warranting further investigation of other mediators than IL-1 and TNFα. Now, trials are set up with short follow-up aiming for short-term pain alleviation. For investigation of pain alleviation in the context of disease modification, trials with at least one year follow-up should be performed.

Intra-Arterial Injection of Temporary Embolic Material Through a Needle Inserted into the Radial or Ulnar Artery for Distal and Proximal Interphalangeal Joint Osteoarthritis: A Retrospective Study of 92 Patients

PURPOSE

To assess the efficacy and safety of intra-arterial injection of imipenem/cilastatin sodium (IPM/CS) via a needle placed into the radial artery or ulnar artery (RA/UA) for distal interphalangeal and proximal interphalangeal joint osteoarthritis (DIP/PIP-OA).

MATERIALS AND METHODS

This is a retrospective single-arm cohort study. Ninety-two patients [92% women, mean (SD) age 55(8.3) years] with a primary DIP/PIP-OA meet the American College of Rheumatology criteria for hand osteoarthritis with pain ≥ 4 on the 0-10 numeric rating scale (NRS) were enrolled. All procedures were performed by injecting IPM/CS through a 24-gauge needle percutaneously inserted into the RA/UA. Two procedures were planned; the second procedure was scheduled 1-2 months after the first. NRS, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, Patient Global Impression of Change (PGIC) scale, and procedure-related adverse events were evaluated.

RESULTS

Technical success, defined as injection of IPM/CS into the RA/UA, was achieved in all patients. Clinical success, defined as a reduction of 2 points or more in the NRS at 12 months, was 77% (95% confidence interval 68-85%). The NRS improved from the baseline to 3, 6, and 12 months (7.8 ± 1.6 vs. 3.8 ± 2.6, 3.9 ± 2.7, and 4.0 ± 2.8, respectively, all p < 0.001). The QuickDASH score improved from the baseline to 12 months (27 ± 15 vs. 19 ± 17, p < 0.001) respectively. No major adverse events were observed.

CONCLUSIONS

Intra-arterial injection of IPM/CS is a feasible treatment option for DIP/PIP-OA.

An update on the use of conventional and biological disease-modifying anti-rheumatic drugs in hand osteoarthritis

Osteoarthritis (OA) is a highly prevalent condition worldwide associated with pain, progressive disability, reduced participation in social activities, and impaired quality of life. Despite its growing burden, the therapeutic options are still limited and almost exclusively addressed to symptoms' management, while no disease-modifying OA drugs able to prevent or retard disease progression are actually available. For these reasons, in the last decades, relevant efforts to find new potential therapeutic targets in OA have been made and a number of existing conventional and biological disease-modifying anti-rheumatic drugs (DMARDs), including hydroxychloroquine (HCQ), methotrexate (MTX), tumor necrosis factor (TNF)-α, interleukin (IL)-1, and IL-6 inhibitors, commonly used to treat inflammatory rheumatic diseases, have been repurposed for the treatment of OA and explored also in hand osteoarthritis (HOA). The current narrative review was aimed to provide a comprehensive and updated understanding of the possibilities and the criticisms related to the treatment of HOA with conventional and biological DMARDs. Unfortunately, therapy with conventional and biologic drugs in HOA has not achieved the expected success, despite a rationale for their use exists. Thus, our findings outline the urgent need to enhance the exploration of HOA basic molecular mechanisms to find new potential therapeutic targets, personalized for each patient, and appropriate for the different subsets of HOA and for the different phases of disease.

Bone in osteoarthritis: imaging and interventions

PURPOSE OF REVIEW

To review the recent literature on bone in osteoarthritis (OA), with a focus on imaging and intervention studies.

RECENT FINDINGS

Most studies focused on knee OA; hip and hand studies were uncommon. Bone shape studies demonstrated that shape changes precede radiographic OA, predict joint replacement, and have demonstrated high responsiveness. Novel quantitative 3D imaging markers (B-score) have better characterized OA severity, including preradiographic OA status. The addition of computerized tomography-derived 3D metrics has improved the prediction of hip joint replacement when compared to radiographs alone.Recent studies of bisphosphonates for knee OA have reported no benefits on pain or bone marrow lesion (BML) size. A meta-analysis on Vitamin D supplementation in knee OA suggested minimal symptom improvement and no benefits on the structure. Cathepsin K inhibition demonstrated reduction in OA bone change progression, but with no symptom benefit. Studies of injections of bone substitutes into BMLs (subchondroplasty) have generally been small and potential benefits remain unclear.

SUMMARY

Subchondral bone features are associated with pain, incidence and progression of OA. Recent studies have validated quantitative bone shape as a biomarker for OA trials. Trials of bone-targeted OA therapies have been disappointing although cathepsin K inhibition may slow structural progression.