A systematic review of the sex differences in risk factors for knee osteoarthritis

Sex-Specific Associations Between Body Mass Index and Knee Flexion Kinematics and Kinetics in Individuals With Anterior Cruciate Ligament Reconstruction

CONTEXT

Anterior cruciate ligament reconstruction (ACLR) is a common surgical procedure after injury. However, ACLR contributes to aberrant biomechanical movement patterns that influence secondary injury or joint degeneration. Higher body size may influence gait and landing biomechanics differently between males and females. The purpose of this study was to investigate the influence of sex on the association between body mass index (BMI) and knee biomechanics long-term after ACLR recovery.

DESIGN

Sixteen female (BMI: 27.7 [5.4]) and 14 male (BMI: 24.2 [5.5]) participants who had a history of ACLR performed walking and drop vertical jump tasks.

METHODS

The knee-flexion angle (KFA), external knee flexion moment, knee abduction moment (landing), and knee adduction moment (gait) were measured using 3D motion capture. Body fat percentage was assessed using a BOD POD. Moderated regression evaluated the influence of sex on the association between BMI and biomechanical outcomes after adjusting for body fat percentage.

RESULTS

There was a significant interaction between sex and BMI on the KFA at heel contact (P = .01), peak KFA (P = .04), and peak external knee flexion moment (P = .05) during gait and on the KFA at ground contact during landing (P = .04). Higher BMI was associated with smaller KFAs at heel contact (P = .03), smaller peak KFAs during gait (P = .02), and smaller external knee flexion moments (P = .01) but only in females. Similarly, a higher BMI was associated with a smaller KFA at ground contact during landing (P = .03) but only in females. There was no sex by BMI interaction on the knee adduction moment during gait (P = .657) or on the knee abduction moment during landing (P = .643). Moreover, sex and BMI were not independent predictors of the knee adduction moment during gait or the knee abduction moment during landing (all P > .05).

CONCLUSIONS

The association between sex and BMI may have implications for posttraumatic knee osteoarthritis and ACL reinjury, and female sex and high BMI should be considered when designing individualized rehabilitation programs. These findings suggest that females with high BMI may benefit from interventions to improve knee flexion during landing and gait.

Sex Differences in Obesity and Its Treatment

PURPOSE OF REVIEW

Researchers and clinicians have increasingly recognized the importance of investigating and considering sex differences in obesity treatment. In this narrative review, we first summarized sex differences in select obesity-related conditions that have been the focus of studies of second-generation anti-obesity medications (i.e., semaglutide and tirzepatide) including type 2 diabetes, obstructive sleep apnea, knee osteoarthritis, and heart failure. We next described sex differences related to obesity treatments with a focus on the second-generation anti-obesity medications, semaglutide and tirzepatide.

RECENT FINDINGS

Type 2 diabetes, obstructive sleep apnea, knee osteoarthritis, and heart failure demonstrated sex-specific pathways influenced by factors such as hormones and body composition. Lifestyle modification, on average, resulted in larger weight losses in males. In contrast, second-generation AOMs produced higher mean weight losses among females. Females reported more adverse events (e.g., nausea, vomiting) with second-generation anti-obesity medications. The few studies that have performed analyses of changes in obesity-related comorbidities stratified by sex have shown consistent improvements between males and females in heart failure and cardiovascular outcomes. Studies are needed to evaluate the effect of sex on the efficacy of anti-obesity medications including on mental health, investigate the mechanisms underlying these effects, and develop interventions to improve the availability and access of these medications.

Radial extracorporeal shock wave therapy for pain and function in adults with knee osteoarthritis: protocol for a placebo-controlled, randomized clinical trial

BACKGROUND

Knee osteoarthritis (KOA) is the most common degenerative joint disease. It is characterized by pain, stiffness, reduced joint motion, and muscle weakness. It also has the potential for long-term disability. Radial extracorporeal shock wave therapy (rESWT) is a noninvasive therapeutic modality widely used for the treatment of musculoskeletal disorders. However, the role of rESWT in the treatment of knee osteoarthritis remains controversial in previous clinical trials. This trial will investigate the efficacy of rESWT in improving the symptoms, function, and bone metabolic status of participants with knee osteoarthritis.

METHODS

The study is a randomized, double-blind, controlled trial. Thirty participants with knee osteoarthritis will be randomized to receive either rESWT or sham rESWT on the affected knee once per week for 4 weeks. All participants will undergo professional physiotherapy once a week during the treatment period. The primary outcome is the visual analogue scale score for pain. Secondary outcomes include the Western Ontario and McMaster Universities Osteoarthritis Index score, knee range of motion, the 10-m walk test results, and bone metabolism biochemical indicators. Outcomes will be measured at baseline (T0), 5 weeks post-intervention (T1), and 8 weeks post-intervention (T2).

DISCUSSION

This study will investigate the effects of rESWT on pain, physical function, and bone metabolism biochemical indicators in participants with knee osteoarthritis, which is expected to reduce the pain of participants, improve the function of participants, and improve bone metabolism biochemical indicators. The information obtained will enhance our understanding of rESWT for the treatment of knee osteoarthritis and may be used to standardize clinical treatment protocols for knee osteoarthritis.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2300069997. Registered on 30 March 2023.

Aortic, musculoskeletal and organ characteristics on computed tomography in knee osteoarthritis - an explorative study in the IMI-APPROACH cohort

The systemic associations with knee osteoarthritis (KOA) are incompletely understood. This study explores aortic disease, musculoskeletal and organ findings in patients with KOA in relation to their symptoms or radiographic abnormalities. Full body computed tomography (CT) scans of 255 IMI-APPROACH participants were investigated using an automated analysis of multislice CT (Voronoi Health Analytics) that extracts aortic size and calcifications, and volumes and densities of bones, muscles, fat compartments and thoracic and abdominal organs. The CT measurements were primarily related to KOA as measured with Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual scores and automated knee radiograph analysis of osteophytes, bone sclerosis and joint space width. The median age was 67 years, body mass index (BMI) 26.8 kg/m2 and 78% were female. About half had Kellgren-Lawrence grade ≥ 2. Larger knee osteophyte area was associated with a larger aortic volume (RSpearman=0.21,P = 0.001), which can be due to elongation or dilatation. We observed an association between more symptoms and increased psoas (RSpearman=-0.23,P < 0.001) and lower leg (RSpearman=-0.23,P < 0.001) muscle density, suggesting less microscopic muscle fat. Symptomatic KOA was associated with substantially lower lung volume (771 ml difference between 50% worst and 50% best WOMAC), but not with visible lung disease. Lung volume and density were significantly associated with the physical functioning WOMAC component. These associations remained significant after adjustment for age, sex and BMI. KOA is associated with significant systemic changes, including altered aortic and organ volumes. These correlations suggest that KOA's impact may extend beyond the joints. Future research should explore the causal relationships and therapeutic implications associations.

Efficacy and Safety of Intra-Articular Therapy with Cross-Linked Hyaluronic Acid in Patients with Knee Osteoarthritis

Background/Objectives: Knee osteoarthritis (OA) is a degenerative chronic disease characterized by a reduction in articular cartilage, as well as pain and functional limitations. We evaluated both the efficacy and safety of cross-linked high-molecular-weight hyaluronic acid in patients with knee OA. Methods: In this observational prospective single-arm study, a cross-linked high-molecular-weight hyaluronic acid (DIART ONE 90 mg in 3 mL) was administered in single injections to 50 patients aged 18-65 years, with a follow-up at 3, 6, and 12 months. Several scores were evaluated, including the Knee Injury and Osteoarthritis Outcome Score as the primary outcome measure and the Visual Analogue Scale, Timed Up and Go Test, Six-Minute Walking Test, General Health Assessment with 36-Item Short Form Health Survey, Zung's Self-Rating Anxiety Scale, and Zung's Self-Rating Depression Scale as secondary outcome measures. Both physicians and patients knew the kind of treatment they received. Results: During the follow-ups, we observed a statistically significant improvement in clinical scores at 3 and 6 months, with a decrease in clinical benefit at 12 months. Functional and psychological benefits were significant at 3, 6, and 12 months. No side effects were described except pain associated with the site of injection. Conclusions: In conclusion, we documented that cross-linked high-molecular-weight hyaluronic acid (DIART ONE 90 mg in 3 mL) represents an effective option in the management of mild-moderate osteoarthritis.

Sexually dimorphic metabolic effects of a high fat diet on knee osteoarthritis in mice

BACKGROUND

Women have a higher risk of developing osteoarthritis (OA) than men, including with obesity. To better understand this disparity, we investigated sex differences in metabolic and inflammatory factors associated with OA using a diet-induced mouse model of obesity. We hypothesized that 20 weeks of high-fat diet (HFD) would induce sexually dimorphic changes in both systemic and local risk factors of knee OA.

METHODS

Male and female C57BL/6J mice were fed Chow or HFD from 6 to 26 weeks of age (n = 12 per diet and sex). We performed broad metabolic phenotyping, 16 S gut microbiome analysis, targeted gene expression analysis of synovium-infrapatellar fat tissue, targeted gene expression and proteomic analysis of articular cartilage, chondrocyte metabolic profiling, and OA histopathology. Two-way ANOVA statistics were utilized to determine the contribution of sex and diet and their interaction on outcomes.

RESULTS

Mice fed HFD weighed 1.76-fold (p < 0.0001) and 1.60-fold (p < 0.0001) more than male and female Chow cohorts, respectively, with both sexes reaching similar body fat levels (male: 43.9 ± 2.2%; female: 44.1 ± 3.8%). HFD caused greater cartilage pathology (p < 0.024) and synovial hyperplasia (p < 0.038) versus Chow in both sexes. Cartilage pathology was greater in male versus female mice (p = 0.048), and only male mice developed osteophytes with HFD (p = 0.044). Both sexes exhibited metabolic inflexibility on HFD, but only male mice developed glucose intolerance (p < 0.0001), fatty liver (p < 0.0001), and elevated serum amylase (p < 0.0001) with HFD versus Chow. HFD treatment caused sex-dependent differences in gut microbiota beta diversity (p = 0.01) and alteration in specific microbiome clades, such as a HFD-dependent reduction in abundance of Bifidobacterium only in male mice. In knee synovium and infrapatellar fat tissue, HFD upregulated the expression of pro-inflammatory and pro-fibrotic genes predominantly in female mice. In cartilage, lipid metabolism proteins were more abundant with HFD in male mice, whereas proteins involved in glycolysis/gluconeogenesis and biosynthesis of amino acids were greater in cartilage of female mice. Sex-dependent metabolic differences were observed in cartilage from young, healthy mice prior to pubertal maturation, but not in primary juvenile chondrocytes studied in vitro.

CONCLUSIONS

HFD induced numerous sex differences in metabolic and inflammatory outcomes, especially in joint tissues, suggesting that sex-specific cellular processes are involved during development of early-stage OA with obesity.

Effectiveness of Meniscus Root Tear Repair Versus Conservative Therapy and Adjunct Therapies: A Systematic Review

The meniscus plays a vital role in knee biomechanics, particularly in load distribution and stability. Meniscus root tears (MRTs) compromise these functions, resulting in biomechanical alterations and knee osteoarthritis. The effectiveness of different MRT treatments is not yet well defined. This study aimed to compare the effectiveness of MRT repair versus conservative therapy and conservative therapy versus multimodal or adjunct therapy in patients with MRTs. A systematic review of clinical studies was performed using electronic searches of PubMed, CENTRAL, CINAHL, and PEDro databases. Two reviewers independently conducted screening, data extraction, risk of bias assessment, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). The database search identified 3,837 articles, of which 11 (three randomized controlled trials [RCTs] and eight cohort studies) were relevant. MRT repair surgery and conservative treatment improved the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales for activities of daily living (ADL) and quality of life (QOL). Multimodal or adjunct therapies also enhanced KOOS subscales for ADL and QOL. In the bias risk assessment, three RCTs were of high risk, five cohort studies were of high quality, and three were of moderate quality. Additionally, the certainty of evidence was very low for all comparisons in GRADE. Therefore, the effectiveness of MRT repair, conservative therapy, and multimodal therapy remains unclear owing to the risk of bias and low certainty of evidence. Whether MRT repair versus conservative therapy and conventional versus multimodal or adjunct therapy are more effective in improving ADL and QOL remains unclear. Future treatment decisions require long-term, high-quality research including controlled and randomized trials with large sample sizes.

Osteoarthritis year in review 2024: Epidemiology and therapy

This "Year in Review" presents a curated selection of research themes and individual studies within the clinical osteoarthritis (OA) field, focusing on epidemiology and therapy. The search was conducted in electronic database MEDLINE from March 4, 2023, to March 31, 2024, specifically targeting English-language articles involving human participants. Inclusions were based on perceived importance and relevance to identifying risk factors or advancing OA treatments. A total of 6539 studies were screened by the 5 authors, resulting in 157 studies considered for potential inclusion. Ultimately, 44 studies were selected, uncovering six key OA-related themes: i) the burden of OA (mostly from Global Burden of Disease studies), ii) pain drivers and trajectories, iii) impacts of sex/gender, iv) OA risk factors, and treatments for v) hand and vi) knee OA. The prevalence of OA continues to rise, particularly affecting women, with unclear distinctions in risk factors and treatment responses between sexes. Associations with atopy were demonstrated in two significant databases. Notably, the authors were particularly interested in recent high-quality methodology randomized controlled trials focusing on hand (methotrexate, denosumab, colchicine, topical betamethasone) and knee OA with conflicting results about stem cell injection. These findings collectively contribute to show the growing burden of OA, but also to help the understanding of OA pathophysiology and inform ongoing efforts to enhance management for people with OA.

Sex differences in osteoarthritis prevalence, pain perception, physical function and therapeutics

OBJECTIVE

Women have a higher prevalence of osteoarthritis (OA) and worse clinical courses than men. However, the underlying factors and therapeutic outcomes of these sex-specific differences are incompletely researched. This review examines the current state of knowledge regarding sex differences in OA prevalence, risk factors, pain severity, functional outcomes, and use and response to therapeutics.

METHODS

PubMed database was used with the title keyword combinations "{gender OR sex} AND osteoarthritis" plus additional manual search of the included papers for pertinent references, yielding 212 references. Additional references were added and 343 were reviewed for appropriateness.

RESULTS

Globally, women account for 60% of people with osteoarthritis, with a greater difference after age 40. The higher risk for women may be due to differences in joint anatomy, alignment, muscle strength, hormonal influences, obesity, and/or genetics. At the same radiographic severity, women have greater pain severity than men, which may be explained by biologically distinct pain pathways, differential activation of central pain pathways, differences in pain sensitivity, perception, reporting, and coping strategies. Women have greater limitations of physical function and performance than men independent of BMI, OA severity, injury history, and amount of weekly exercise. Women also have greater use of analgesic medications than men but less use of arthroplasty and poorer prognosis after surgical interventions.

CONCLUSIONS

The recognition of sex differences in OA manifestations and management could guide tailoring of sex-specific treatment protocols, and analysis of sex as a biological variable in future research would enhance development of precision medicine.

Sexual dimorphism in articular tissue anatomy - Key to understanding sex differences in osteoarthritis?

OBJECTIVE

Osteoarthritis (OA) prevalence and incidence varies between women and men, but it is unknown whether this follows sex-specific differences in systemic factors (e.g. hormones) and/or differences in pre-morbid joint anatomy. We recognize that classifications of sex within humans cannot be reduced to female/male, but given the lack of literature on non-binary individuals, this review is limited to the sexual dimorphism of articular morphotypes.

METHODS

Based on a Pubmed search using relevant terms, and input from experts, we selected articles based on the authors' judgment of their relevance, interest, originality, and scientific quality; no "hard" bibliometric measures were used to evaluate their quality or importance. Focus was on clinical rather than pre-clinical studies, with most (imaging) data being available for the knee joint.

RESULTS

After introducing "sexual dimorphism", the specific literature on articular morphotypes is reviewed, structured by: radiographic joint space width (JSW), meniscus, ligaments, articular cartilage morphology, articular cartilage composition and deformation, and articular tissue response to treatment.

CONCLUSIONS

Sex-specific differences were clearly observed for JSW, meniscus damage, ligament size, and cartilage morphometry (volume, thickness, and surface areas) but not for cartilage composition. Ligament and cartilage measures were smaller in women even after matching for confounders. Taken together, the findings indicate that female (knee) joints may be structurally more vulnerable and at greater risk of OA. The "one size/sex fits all" approach must be abandoned in OA research, and all observational and interventional studies should report their results for sex-specific strata, at least in pre-specified secondary or post-hoc analyses.

Influence of Sex and Gender on Musculoskeletal Conditions and How They Are Reported

ABSTRACT

There is increasing evidence that musculoskeletal tissues are differentially regulated by sex hormones in males and females. The influence of sex hormones, in addition to other sex-based differences such as in anatomical alignment and immune-system function, impact the prevalence and severity of disease as well as the types of injuries that affect the musculoskeletal system and the outcomes of prevention measures and treatment. Literature specifically addressing sex differences related to the musculoskeletal system is limited, underscoring the imperative for both basic and clinical research on this topic. This review highlights areas of research that have implications for bone and cartilage health, including growth and development, sports injuries, osteoarthritis, osteoporosis, and bone frailty. It is clear that important aspects of the musculoskeletal system have been understudied. Consideration of how sex hormone therapy will affect musculoskeletal tissues in prepuberty, during puberty, and in adults is vital, yet little is known. The purpose of this article is to foster awareness and interest in advancing our understanding of how sex differences influence orthopaedic practice.

The impact of Yoga on patients with knee osteoarthritis: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

The objective of this review is to conduct a comprehensive and systematic assessment of the efficacy of Yoga as an intervention for knee osteoarthritis (KOA).

METHODS

We searched PubMed, Cochrane Library, Embase, Web of Science, and PEDro as of January 3, 2024. Retrieved a total of 200 articles. Standardised mean differences (SMDs) and 95% confidence intervals (CI) were calculated.

RESULTS

The study included a total of 8 trials and involved 756 KOA patients. The results indicated that compared to the control group, Yoga exercise showed significant improvements in alleviating pain (SMD = -0.92; 95% CI = -1.64 ~ - 0.20; P = 0.01, I2 = 94%), stiffness (SMD = -0.51; 95% CI = -0.91 ~ -0.12; P = 0.01; I2 = 66%) and physical function (SMD = -0.53; 95% CI = -0.89 ~ -0.17; P = 0.004; I2 = 59%) among KOA patients. However, there was no significant improvement observed in terms of activities of activity of daily living (ADL) (SMD = 1.03; 95% CI = -0.01 ~ 2.07; P = 0.05; I2 = 84%), and quality of life (QOL) (SMD = 0.21; 95% CI = -0.33 ~ 0.74; P = 0.44; I2 = 83%) with the practice of Yoga.

CONCLUSIONS

In general, Yoga has been found to be effective in reducing pain and stiffness in KOA patients, it can also improve the physical function of patients. However, there is limited evidence to suggest significant improvements in terms of ADL and QOL.

Prevalence and Risk Factors of Osteoarthritis in Korea: A Cross-Sectional Study

Background and Objectives: The goal of this study is to determine the prevalence of knee osteoarthritis (OA) and risk factors for the disease in Korean adults over the age of 50, as well as to provide basic data for OA prevention through management. Materials and Methods: Based on 2010-2013 data from the Korean National Health and Nutrition Survey, 7962 adults over the age of 50 who participated in radiological tests and health surveys for the diagnosis of osteoarthritis were chosen as participants. Results: The risk factors for OA occurrence were investigated using complex sample multiple logistic regression analysis. According to the findings, the prevalence of knee OA in Korea was 33.3% in this study, with the risk of OA being higher in women, the elderly, people with a lower education level, and people with obesity. Conclusions: To reduce the incidence of OA, interventions and lifestyle changes are needed to prevent the onset of disease in participants with risk factors for OA, such as older women, low education levels, and obesity.

Osteoarthritis year in review 2023: Epidemiology & therapy

OBJECTIVE

To highlight some important findings from osteoarthritis (OA) epidemiology and therapy research undertaken over the past year.

METHODS

Search of MEDLINE and EMBASE databases between April 1, 2022 to March 3, 2023 using "exp *Osteoarthritis/" as the preliminary search term. The search was limited to articles published in English and including human subjects. Final inclusions were based on perceived importance and results that may inform improved identification of risk factors or OA treatments, as well as OA subgroups of potential relevance to risk factors or treatment approaches.

RESULTS

3182 studies were screened, leaving 208 eligible for inclusion. This narrative review of thirty-three selected studies was arranged into: a) OA predictors - population-based studies, b) Specific predictors of OA and OA outcome; c) Intra-articular injections, and d) OA phenotypes. There was some suggestion of sex differences in predictors of incidence or outcomes. Body mass index changes appear largely to affect knee OA outcomes. Evidence points to a lack of benefit of viscosupplementation in knee OA; findings were variable for other injectables. Studies of OA phenotypes reveal potentially relevant clinical and pathophysiological differences.

CONCLUSIONS

Identifying risk factors for the incidence/progression of OA represents an ongoing and important area of OA research. Sex may play a role in this understanding and bears consideration and further study. For knee injectables other than viscosupplementation, additional high-quality trials appear warranted. Continued investigation and application of phenotyping across the OA disease, illness and care spectrum may be key to developing disease-modifying agents and their appropriate selection for individuals.

Evidence on risk factors for knee osteoarthritis in middle-older aged: a systematic review and meta analysis

PURPOSE

This review was made to identify the risk factors for knee osteoarthritis (KOA) in middle-older aged (≥ 40 years), and to provide the newest evidence for the prevention of KOA.

METHOD

Cohort study and case-control study of the risk factors of KOA was included from Pubmed, Web of Science, Ovid Technologies, China National Knowledge Infrastructure (CNKI), Chinese Science and Technology Periodical Database (VIP), Wanfang Database, SinoMed from their inceptions to July 2023. Two authors independently screened the literature and extracted data. Assessment of quality was implemented according to Agency for Healthcare Research and Quality (AHRQ) and Newcastle-Ottawa Quality Assessment Scale. Meta-analysis was performed using RevMan 5.3 software.

RESULTS

3597 papers were identified from the seven databases and 29 papers containing 60,354 participants were included in this review. Meta-analysis was performed for 14 risk factors, and 7 of these were statistical significance (P < 0.05). The risk factors which were analyzed in this review included trauma history in knee (1.37 [95% CI 1.03-1.82], P = 0.030), body mass index (BMI) ≥ 24 kg/m2 (1.30 [95% CI 1.09-1.56], P = 0.004), gender (female) (1.04 [95% CI 1.00-1.09], P = 0.030), age ≥ 40 (1.02 [95% CI 1.01-1.03], P = 0.007), more exercise (0.75 [95% CI 0.62-0.91], P = 0.003), a high school education background (0.49 [95% CI 0.30-0.79], P = 0.003) and an university education background (0.22 [95% CI 0.06-0.86], P = 0.030).

CONCLUSION

The risk factors analyzed in this review included trauma history in knee, overweight or obesity, gender (female), age ≥ 40 and the protective factors included more exercise and a high school or an university education background.

Personalized Nutritional Strategies to Reduce Knee Osteoarthritis Severity and Ameliorate Sarcopenic Obesity Indices: A Practical Guide in an Orthopedic Setting

Knee osteoarthritis (KOA) is one of the most common joint diseases, especially in individuals with obesity. Another condition within this population, and which presents frequently, is sarcopenic obesity (SO), defined as an increase in body fat and a decrease in muscle mass and strength. The current paper aims to describe recent nutritional strategies which can generally improve KOA clinical severity and, at the same time, ameliorate SO indices. Searches were carried out in the PubMed and Science Direct databases and data were summarized using a narrative approach. Certain key findings have been revealed. Firstly, the screening and identification of SO in patients with KOA is important, and to this end, simple physical performance tests and anthropometric measures are available in the literature. Secondly, adherence to a Mediterranean diet and the achievement of significant body weight loss by means of low-calorie diets (LCDs) remain the cornerstone nutritional treatment in this population. Thirdly, supplementation with certain micronutrients such as vitamin D, essential and non-essential amino acids, as well as whey protein, also appear to be beneficial. In conclusion, in the current review, we presented a detailed flowchart of three different nutritional tracks that can be adopted to improve both KOA and SO based on joint disease clinical severity.