Health-related quality of life and costs in patients with osteoarthritis on waiting list for total knee replacement

Poly beta amino ester coated emulsions of NSAIDs for cartilage treatment

Delivering drugs directly into cartilage is still the major challenge in the management and treatment of osteoarthritis (OA) resulting from the aneural, avascular and alymphatic nature of an articular cartilage structure. Progress has been made in the design of drug delivery systems that enhance corticosteroid uptake and retention in cartilage; however also non-steroidal anti-inflammatory drugs (NSAIDs) are prescribed for patients affected by OA and a drug delivery system specifically designed for this drug category is currently unavailable. We developed an approach based on the preparation of NSAID oil-in-water emulsions coated with poly-beta-amino-esters (PBAEs) to exploit the cartilage penetrating ability of such polymers and the high solubility of drugs in oil. These emulsions containing different NSAIDs (indomethacin, ketorolac, diclofenac and naproxen) exhibited enhanced and prolonged drug localisation not only in healthy cartilage tissues but also in early-stage OA samples. The critical role of the PBAE layer on oil droplets was established along with the retained biological activity of the drug as glycosaminoglycan (GAG) and collagen degradation induced by interleukin-1 (IL-1) was prevented by the novel technology. Oil-in-water coated emulsions are very flexible and cost-effective drug delivery systems and such an approach presented here could provide a substantial improvement in the therapeutic treatments of OA and thus patients' outcomes.

Optimisation and feature selection of poly-beta-amino-ester as a drug delivery system for cartilage

Drug localisation is one of the main challenges in treating cartilage; poly-beta-amino-esters (PBAEs) drug conjugates are a possible solution; their efficacy depends on the polymer structure hence the full potential of this system is still unknown.

Drug localisation is still one of the main challenges in treating pathologies affecting cartilage; poly-beta-amino-esters (PBAEs) drug conjugates are a possible solution; however, their efficacy highly depends on the polymer structure hence the full potential of this delivery system is still unknown. For the purpose of optimising the delivery system design, a large library of PBAEs was synthesised and dexamethasone (DEX) uptake in cartilage was determined. All three components of PBAE (amine, acrylate and end-capping) impacted the outcome. The most effective PBAE identified enhanced DEX uptake by 8 folds compared to an equivalent dose of the commercial formulation and also prevented, through delivery of DEX, the cartilage degradation caused by IL-1α (interleukine1α). A chemometrics based predictive model was constructed and PBAEs properties most affecting the performance of the drug delivery systems were identified. This model will allow further computer based PBAEs optimisation and fast track the bench to market process for this delivery system.

Effectiveness of a Program Combining Strengthening, Stretching, and Aerobic Training Exercises in a Standing versus a Sitting Position in Overweight Subjects with Knee Osteoarthritis: A Randomized Controlled Trial

There is an increasing incidence, prevalence, and burden of knee osteoarthritis due to a global increase in obesity and an aging population. The aim of the present study was to compare the effectiveness of the addition of aerobic exercises performed in an unloaded or loaded position to a conventional exercise program in overweight subjects with knee osteoarthritis. Twenty-four subjects were randomly allocated to receive 36 sessions of 30-min duration of either sitting aerobic exercises (experimental group) or standing aerobic exercises (control group). Pain intensity, knee disability, and quality-of-life data were collected at baseline and at 12, 24, and 36 sessions. Generalized linear mixed models (GLMMs) were constructed for the analysis of the differences. Significant differences were found in the experimental group for self-reported pain and knee pain and disability at 24 and 36 sessions (p < 0.05). Significant between-group differences were observed in change in self-reported knee pain and disability and quality of life from baseline to 24th- and 36th-session measurements in favor of the experimental group. Adherence to treatment was higher in the experimental group. Adding aerobic exercises in an unloaded position to a conventional exercise program produced superior effects over time for self-reported knee pain, knee pain and disability and quality of life compared to loaded aerobic exercises in overweight subjects with knee osteoarthritis.

Rheometer enabled study of cartilage frequency-dependent properties

Despite the well-established dependence of cartilage mechanical properties on the frequency of the applied load, most research in the field is carried out in either load-free or constant load conditions because of the complexity of the equipment required for the determination of time-dependent properties. These simpler analyses provide a limited representation of cartilage properties thus greatly reducing the impact of the information gathered hindering the understanding of the mechanisms involved in this tissue replacement, development and pathology. More complex techniques could represent better investigative methods, but their uptake in cartilage research is limited by the highly specialised training required and cost of the equipment. There is, therefore, a clear need for alternative experimental approaches to cartilage testing to be deployed in research and clinical settings using more user-friendly and financial accessible devices. Frequency dependent material properties can be determined through rheometry that is an easy to use requiring a relatively inexpensive device; we present how a commercial rheometer can be adapted to determine the viscoelastic properties of articular cartilage. Frequency-sweep tests were run at various applied normal loads on immature, mature and trypsinased (as model of osteoarthritis) cartilage samples to determine the dynamic shear moduli (G*, G′ G″) of the tissues. Moduli increased with increasing frequency and applied load; mature cartilage had generally the highest moduli and GAG depleted samples the lowest. Hydraulic permeability (K_H) was estimated from the rheological data and decreased with applied load; GAG depleted cartilage exhibited higher hydraulic permeability than either immature or mature tissues. The rheometer-based methodology developed was validated by the close comparison of the rheometer-obtained cartilage characteristics (G*, G′, G″, K_H) with results obtained with more complex testing techniques available in literature. Rheometry is relatively simpler and does not require highly capital intensive machinery and staff training is more accessible; thus the use of a rheometer would represent a cost-effective approach for the determination of frequency-dependent properties of cartilage for more comprehensive and impactful results for both healthcare professional and R&D.

A comparative prospective study between stemmed versus an unstemmed tibial component in total knee arthroplasty in obese patients

BACKGROUND

There is no consensus in the literature regarding the patients with obesity who do well with TKA, or this group is at risk of a variety of complications. Implant choices between the two types of implants which either long or standard stem can improve the likelihood that a patient with obesity will achieve high scores for function and quality of life after TKA.

METHODS

This prospective clinical study included 200 patients who were categorized into two groups: group (1) traditional (standard) unstemmed cemented tibial tray (n = 100 patients) and group (2) stemmed cemented tibial tray with the cementless press-fit stem (n = 100 patients).

RESULTS

The average follow-up was (7.6 ± 1 years) (range from 6.5 up to 10 years). The average age of the stemmed group was 55.69 ± 8.45 and for the unstemmed group was 57.3 ± 7.8. The average BMI for the stemmed patients was 38.84 ± 3.89, while for the standard (unstemmed) group was 40.0 ± 3.95. Functional results showed significant improvement in both groups but more in the stemmed group (LS) as the difference and change between pre and post were more significant at long stem (P > 0.001).

CONCLUSION

Based on our results, there were significant improvements in both groups either stemmed or unstemmed TKA but more in the stemmed group which had higher functional outcomes compared to the unstemmed group.

LEVEL OF EVIDENCE

IV.

Shoulder pain cost-of-illness in patients referred for public orthopaedic care in Australia

Objective The aim of this study was to calculate the societal economic burden of shoulder pain in patients on the orthopaedic waiting list at an Australian public hospital and calculate the cost (from the government's perspective) of care delivered by the hospital for those patients. Methods A cost-of-illness analysis was undertaken in a cohort of 277 orthopaedic patients on the Gold Coast in Australia. Outcomes included a health care costs and impacts questionnaire, work absenteeism, presenteeism questionnaires (Work Limitations Questionnaire (WLQ) and Work Productivity and Activity Impairment Questionnaire (WPAI)) and hospital care provision over a 2-year period. Results The mean societal cost of healthcare and domestic support was AU$20.72 per day (AU$7563 annually) per patient on the orthopaedic waiting list. When absenteeism and presenteeism were included, the cost per patient who was employed was AU$38.04 per day (AU$13885 annually) calculated with the WLQ and AU$61.31 per day (AU$22378 annually) calculated with the WPAI. The mean per-patient cost to government of public hospital care was AU$2622 in Year 1 and AU$3835.78 (s.d. 4961.28) over 2 years. The surgical conversion rate was 22%, and 51% of hospital care cost was attributable to outpatient services. Conclusions Public orthopaedic shoulder waiting lists create a large economic burden for society; few referrals require surgery and just over half the hospital care costs are for out-patient services. New models of care that better manage shoulder pain and identify surgical candidates before orthopaedic referral could reduce this burden. What is known about the topic? Little is known about the cost of shoulder pain in Australia, or the cost of patients referred for public orthopaedic care. What does this paper add? This article quantifies the costs of shoulder pain and the value of lost production from shoulder pain. The time spent waiting for public hospital orthopaedic appointments and the costs associated with waiting demonstrate that the time spent on a waiting list is a key driver of the economic burden. What are the implications for practitioners? Greater resourcing to reduce public orthopaedic shoulder waiting lists may be helpful, but system change is also required. Earlier and more accurate identification of surgical cases could reduce inefficient referrals and improve hospital productivity. Collaboration between clinicians and policy makers is needed to design more economically efficient shoulder care.

Self-reported physical activity is related to knee muscle strength on the unaffected side and walking ability in patients with knee osteoarthritis awaiting total knee arthroplasty: a cross-sectional study

Background: Additional evidence regarding the effectiveness of self-management programs for patients awaiting total knee arthroplasty is required.Objective: The study aimed to determine if self-reported physical activity was related to muscle strength and walking ability in patients with knee osteoarthritis awaiting total knee arthroplasty.Methods: The study included subjects with knee osteoarthritis awaiting total knee arthroplasty (n = 767). Walking ability and bilateral knee muscle strength were measured as dependent variables. Self-report physical activity was assessed based on the guidelines from the Japanese Ministry of Health, Labor and Welfare. Multiple regression models determined if self-reported physical activity was significantly related to dependent variables, after accounting for other related factors.Results: Physical activity was associated with both higher knee flexion (β = -0.09, p = .013) and higher extension (β = -0.09, p = .007) muscle strength on the unaffected side only. In addition, physical inactivity was associated with a lower walking ability level (TUG: β = 0.08, p = .015; 5mWT: β = 0.10, p = .005).Conclusions: These results can help health-services providers develop educational and/or self-management programs to maintain muscle strength on the unaffected side and walking ability in patients awaiting total knee arthroplasty.

Global management of patients with knee osteoarthritis begins with quality of life assessment: a systematic review

Background

Knee osteoarthritis (KOA) is a prevalent form of chronic joint disease associated with functional restrictions and pain. Activity limitations negatively impact social connectedness and psychological well-being, reducing the quality of life (QoL) of patients. The purpose of this review is to summarize the existing information on QoL in KOA patients and share the reported individual factors, which may influence it.

Methods

We conducted a systematic review examining the literature up to JAN/2017 available at MEDLINE, EMBASE, Cochrane, and PsycINFO using KOA and QOL related keywords. Inclusion criteria were QOL compared to at least one demographic factor (e.g., age, gender), lifestyle factor (e.g., functional independence), or comorbidity factor (e.g., diabetes, obesity) and a control group. Analytical methods were not considered as part of the original design.

Results

A total of 610 articles were reviewed, of which 62 met inclusion criteria. Instruments used to measure QoL included: SF-36, EQ-5D, KOOS, WHOQOL, HAS, AIMS, NHP and JKOM. All studies reported worse QoL in KOA patients when compared to a control group. When females were compared to males, females reported worse QOL. Obesity as well as lower level of physical activity were reported with lower QoL scores. Knee self-management programs delivered by healthcare professionals improved QoL in patients with KOA. Educational level and higher total mindfulness were reported to improve QoL whereas poverty, psychological distress, depression and lacking familial relationships reduce it. Surgical KOA interventions resulted in good to excellent outcomes generally; although, results varied by age, weight, and depression.

Conclusion

KOA has a substantial impact on QoL. In KOA patients, QoL is also influenced by specific individual factors including gender, body weight, physical activity, mental health, and education. Importantly, education and management programs designed to support KOA patients report improved QoL. QoL data is a valuable tool providing health care professionals with a better comprehension of KOA disease to aid implementation of the most effective management plan.

Comparison of effectiveness of the home exercise program and the home exercise program taught by physiotherapist in knee osteoarthritis

BACKGROUND

Home-based exercise therapy is effective in reducing pain and improving function in adults with osteoarthritis of the knee.

OBJECTIVE

To investigate and compare the effectiveness of the home exercise program and the home exercise program taught by a physiotherapist in knee osteoarthritis.

METHODS

The study was conducted with 80 patients with knee osteoarthritis. The patients were randomized into two groups. The first group was given the home exercise brochure by the orthopedist, while the second group did home exercises under the guidance of the physiotherapist. The goniometer for the range of motion (ROM) of the knee, Myometer for evaluation of the quadriceps and hamstring muscles strength, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Form Health Survey (SF-36) were used for evaluation.

RESULTS

Statistically significant improvements were found in the post-treatment ROM, VAS, quadriceps and hamstring muscles strength, WOMAC and SF-36 values in both groups (p< 0.05). When the change values were compared, the evaluation results of group II were better than group I statistically (p< 0.05).

CONCLUSIONS

This study proved that home exercises taught by a physiotherapist were more useful for patients with knee osteoarthritis. When the home exercise program is implemented, a new role is created for a physiotherapist.

Does ethnicity and education influence preoperative disability and expectations in patients undergoing total knee arthroplasty?

AIM

To investigate whether minority ethnicity and the duration of education influence preoperative disability and expectations in patients undergoing total knee arthroplasty.

METHODS

We prospectively included 829 patients undergoing primary unilateral total knee arthroplasty (TKA) from April 2013 to December 2014 at a single centre. Patients filled in pre-operative questionnaires with information regarding place of birth, duration of education, expectations for outcome of surgery and baseline characteristics. Patients were stratified based on ethnicity. Majority ethnicity was defined as born in the study country and minority ethnicity was defined as born in any other country. Similarly, patients were stratified based on duration of education in groups defined as < 9 years, 9-12 years and > 12 years, respectively.

RESULTS

We found that 92.2% of patients were of majority ethnicity. We found that 24.5%, 44.8% and 30.8% of patients had an education of < 9 years, 9-12 years and > 12 years, respectively. The mean preoperative (pre-OP) oxford knee score (OKS) in the total population was 23.6. Patients of minority ethnicity had lower mean pre-OP OKS (18.6 vs 23.9, P < 0.001), higher pain levels (VAS 73.0 vs 58.7, P < 0.001), expected higher levels of post-OP pain (VAS 14.1 vs 6.1, P = 0.02) and of overall symptoms (VAS 16.6 vs 6.4, P = 0.006). Patients with > 12 years education had lower mean pre-OP OKS (21.5 vs 23.8 and 24.6, P < 0.001) and higher pre-OP VAS pain (65.4 vs 59.2 and 56.4, P < 0.001) compared to groups with shorter education. One year post-operative (post-OP) patients of minority ethnicity had lower mean OKS, higher pain and lower QoL. One year post-OP patients with > 12 years education reported higher pain compared to patients with shorter educations. However, the response-rate was low (44.6%), and therefore post-OP results were not considered to be significant.

CONCLUSION

Minority ethnicity and the duration of education influence preoperative disability and expectation in patients undergoing TKA. This should be taken into account when patients are advised pre-operatively.

Preoperative Pain Neuroscience Education Combined With Knee Joint Mobilization for Knee Osteoarthritis: A Randomized Controlled Trial

OBJECTIVES

This study aimed to first compare the effects of a preoperative treatment combining pain neuroscience education (PNE) with knee joint mobilization versus biomedical education with knee joint mobilization on central sensitization (CS) in patients with knee osteoarthritis, both before and after surgery. Second, we wanted to compare the effects of both interventions on knee pain, disability, and psychosocial variables.

MATERIALS AND METHODS

Forty-four patients with knee osteoarthritis were allocated to receive 4 sessions of either PNE combined with knee joint mobilization or biomedical education with knee joint mobilization before surgery. All participants completed self-administered questionnaires and quantitative sensory testing was performed at baseline, after treatment and at a 1 month follow-up (all before surgery), and at 3 months after surgery.

RESULTS

Significant and clinically relevant differences before and after surgery were found after treatments for both knee pain and disability, and some measures of CS (ie, widespread hyperalgesia, CS inventory), with no significant between-group differences. Other indicators of CS (ie, conditioned pain modulation, temporal summation) did not change over time following either treatment, and in some occasions the observed changes were not in the expected direction. Patients receiving PNE with knee joint mobilization achieved greater improvements in psychosocial variables (pain catastrophizing, kinesiophobia) both before and after surgery.

DISCUSSION

Preoperative PNE combined with knee joint mobilization did not produce any additional benefits over time for knee pain and disability, and CS measures compared with biomedical education with knee joint mobilization. Superior effects in the PNE with knee joint mobilization group were only observed for psychosocial variables related to pain catastrophizing and kinesiophobia.

Opportunities and challenges for the discovery and validation of proteomic biomarkers for common arthritic diseases

Osteoarthritis (OA) and rheumatoid arthritis (RA) are most prevalent among all the rheumatic diseases, and currently, there are no reliable biochemical measures for early diagnosis or for predicting who is likely to progress. Early diagnosis is important for making decisions on treatment options and for better management of patients. This narrative review highlights the first-generation biomarkers identified over the last two decades and focuses on the discovery and validation of candidate OA biomarkers from recent mass-spectrometry-based proteomic studies for diagnosis and monitoring disease outcomes in human. It discusses the challenges and opportunities for discovery of novel biomarkers and progress in the development of techniques for measuring biomarkers, and provides directions for future discovery and validation of biomarkers for OA and rheumatoid arthritis.

Distribution and Drivers of Average Direct Cost of Osteoarthritis in Canada From 2003 to 2010

OBJECTIVE

To estimate the distribution and drivers of the average direct cost of osteoarthritis (OA) in Canada using a population-based health microsimulation model of OA from 2003 to 2010.

METHODS

We used a previously published microsimulation model to estimate the distribution of average cost of OA across different cost components and OA stages. OA stages were defined according to the patient flow within the health care system. Cost components associated with pharmacologic and nonpharmacologic treatments, physician visits, and hospitalization were included. Scenario analysis was performed to evaluate average cost drivers from 2003 to 2010.

RESULTS

During the study period, the OA population size grew from 2.9 to 3.6 million, while the average cost increased from $577 to $811 (Canadian) per patient per year. The highest increase in share of cost components was for total joint replacement (TJR) surgery (24% to 32%). The highest average cost was incurred by patients in stage 4 (during and after revision surgery), while around 80% of OA patients were in stage 1 (OA diagnosed but has not visited an orthopedic surgeon). Increase in the proportion of OA patients receiving TJR surgeries (34%) and price inflation (29%) were the most significant drivers of average cost.

CONCLUSION

The average cost of OA has been increasing during the study period mostly due to an increase in the proportion of patients receiving TJR surgeries and price inflation. The distribution of average cost of OA across disease stages needs to be considered when designing policies targeting specific aspects of OA care.

Long-Term Safety and Efficacy of Fulranumab in Patients With Moderate-to-Severe Osteoarthritis Pain: A Phase II Randomized, Double-Blind, Placebo-Controlled Extension Study

OBJECTIVE

To evaluate the long-term safety and efficacy of fulranumab in patients with knee or hip pain caused by moderate-to-severe chronic osteoarthritis (OA).

METHODS

In this phase II double-blind, placebo-controlled extension study, patients who were randomized in equal proportions to receive subcutaneous doses of either placebo or fulranumab (1 mg every 4 weeks, 3 mg every 8 weeks, 3 mg every 4 weeks, 6 mg every 8 weeks, or 10 mg every 8 weeks) in the 12-week double-blind efficacy phase and who completed this double-blind efficacy phase were eligible to continue the dosage throughout a 92-week double-blind extension phase, followed by a 24-week posttreatment follow-up period. Safety assessments included evaluation of treatment-emergent adverse events (TEAEs), pre-identified AEs of interest, and joint replacements. Efficacy assessments included changes from baseline to the end of the double-blind extension phase in scores on the patient's global assessment and the pain and physical function subscales of the Western Ontario and McMaster Universities Osteoarthritis Index.

RESULTS

Overall, 401 of the 423 patients who completed the 12-week double-blind efficacy phase entered the extension study. Long-term sustained improvements were observed in all efficacy parameters following fulranumab treatment (1 mg every 4 weeks, 3 mg every 4 weeks, and 10 mg every 8 weeks) as compared with placebo. Similar percentages of patients in both groups experienced TEAEs (88% taking placebo and 91% taking fulranumab; all phases). Across all fulranumab groups, arthralgia (21%) and OA (18%) (e.g., exacerbation of OA pain) were the most common TEAEs. The most common serious TEAEs were the requirement for knee (10%) and hip (7%) arthroplasty, with 80% occurring during the posttreatment follow-up period. Neurologic-related TEAEs (28%; all phases) were generally mild-to-moderate. Overall, 81 joint replacements were performed in 71 patients (8 [11%] receiving placebo and 63 [89%] receiving fulranumab); 15 patients (21%) had rapid progression of OA (RPOA). All cases of RPOA occurred in fulranumab-treated patients who were concurrently receiving nonsteroidal antiinflammatory drugs and occurred in joints with preexisting OA.

CONCLUSION

Long-term treatment with fulranumab was generally well-tolerated and efficacious. RPOA was observed as a safety signal. Future studies are warranted to demonstrate whether the risk of RPOA can be reduced in patients taking fulranumab.

Do Stemmed Tibial Components in Total Knee Arthroplasty Improve Outcomes in Patients With Obesity?

BACKGROUND

Recent clinical studies have reported that patients with higher body mass index (BMI) are more likely to experience premature failure of total knee arthroplasty (TKA), lower knee scores, and perhaps more pain in the prosthetic joint. However, it is not known whether certain implant design features such as tibial stems might be associated with differences in the frequency of tibial pain in patients with higher BMIs.

QUESTIONS/PURPOSES

Therefore, it was our aim to compare (1) function and pain (as measured by the New Knee Society Score, Knee Injury and Osteoarthritis Outcome Score [KOOS], and visual analog pain scores); (2) quality of life (as measured by SF-12); and (3) mechanical complications and premature revision (defined as revision before 2 years) between patients with obesity undergoing TKA (BMI > 30 kg/m²) who received either a stemmed or an unstemmed tibial component.

METHODS

In this randomized controlled trial, 120 patients with a BMI > 30 kg/m² scheduled for primary arthritis TKAs and end-stage knee osteoarthritis were included. Patients were stratified into groups defined as moderately obese (BMI 30-35 kg/m², N = 60) and severely obese (BMI > 35 kg/m², N = 60) groups. Patients in each stratified subgroup then were randomized to receive either a stemmed (10 mm/100 mm) proximally cemented tibial component or the other, a standard cemented component. Patients were evaluated preoperatively and 2 years after surgery using the new Knee Society Score (KSS), KOOS, SF-12 score, and a visual analog pain score after 100 meters of walking. Although no minimum clinically important differences (MCIDs) have yet been defined for the new KSS, we considered differences smaller than 10 points to be unlikely to be clinically important; the MCID for the KOOS is estimated at 8 to 10 points, the SF-12 to be 4 points, and the visual analog scale to be 2 cm on a 10-cm scale. Patients were followed until death, revision, or for a minimum of 2 years (mean, 3 ± 0.8 years; range, 2-4 years). No patient was lost to followup before 2 years.

RESULTS

Although we found that patients treated with stemmed TKAs had higher functional outcomes, the differences were small and unlikely to be clinically important (subjective KSS mean 69 ± 7 points versus 75 ± 7, mean difference 6 points, 95% confidence interval [CI] 2-11, p = 0.03; objective KSS mean 80 ± 6 points versus 85 ± 6 points, mean difference 5 points, 95% CI 0-9, p = 0.01). Compared with patients with a stemmed TKA, patients with a standard implant reported lower KOOS pain subscores (81 ± 9 versus 76 ± 8; p = 0.04) and lower KOOS symptom subscores (74 ± 7 versus 68 ± 7; p = 0.03). The proportions of patients experiencing complications were not different with the numbers available for all groups and subgroups.

CONCLUSIONS

Although we detected differences in some patient-reported outcomes scores for pain and function favoring implants with stems, the differences were small and unlikely to be clinically important. Because these stems may have disadvantages, perhaps including difficulty of revision, we cannot draw a strong conclusion in support of their use.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Greater pre-operative anxiety, pain and poorer function predict a worse outcome of a total knee arthroplasty

PURPOSE

Around 10-30 % of patients are dissatisfied with the results of their total knee arthroplasty (TKA). This review aimed to identify and evaluate the predictors of outcome measured by the three domains of health-related quality of life (pain, stiffness and function). The focus was on pre-operative psychological factors as related to other patient-related variables.

METHODS

A systematic search was performed using the following databases: MEDLINE, PubMed, AMED, CINAHL, PsychINFO, SciFinder, Scopus, EMBASE, Cochrane, Lilacs, Web of Science and ScienceDirect. The quality of identified studies was assessed using the Critical Appraisal Skills Programme Cohort checklist.

RESULTS

Ten studies met the eligibility criteria. From these, nine patient-related predictors of outcome were identified (depression, anxiety, age at surgery, gender (being female), medical co-morbidities, BMI, level of education, pre-operative pain severity and pre-operative knee function). Greater anxiety, pre-operative pain and function were the most significant factors to predict a poorer outcome of a TKA. The results of depression, gender (female), medical co-morbidities, BMI and level of education were variable among the included studies. There was very little evidence to support older age at operation as a predictor of poorer outcome.

CONCLUSION

Patients experiencing high levels of pain before surgery should be informed of the chances of improvement by having a TKA. A validated psychological screening tool that separates depression and anxiety is recommended as part of the pre-operative assessment stage. Patients presenting with symptoms of depression and anxiety should be identified and consulted before a TKA.

LEVEL OF EVIDENCE

II.

Increasing comorbidity is associated with worsening physical function and pain after primary total knee arthroplasty

Background

Previous studies suggested that pre-operative comorbidity was a risk factor for worse outcomes after TKA. To our knowledge, studies have not examined whether postoperative changes in comorbidity impact pain and function outcomes longitudinally. Our objective was to examine if increasing comorbidity postoperatively is associated with worsening physical function and pain after primary total knee arthroplasty (TKA).

Methods

We performed a retrospective chart review of veterans who had completed Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Short Form-36 (SF36) surveys at regular intervals after primary TKA. Comorbidity was assessed using a variety of scales: validated Charlson comorbidity index score, and a novel Arthroplasty Comorbidity Severity Index score (Including medical index, local musculoskeletal index [including lower extremity and spine] and TKA-related index subscales; higher scores are worse ), at multiple time-points post-TKA. We used mixed model linear regression to examine the association of worsening comorbidity post-TKA with change in WOMAC and SF-36 scores in the subsequent follow-up periods, controlling for age, length of follow-up, and repeated observations.

Results

The study cohort consisted of 124 patients with a mean age of 71.7 years (range 58.6–89.2, standard deviation (SD) 6.9) followed for a mean of 4.9 years post-operatively (range 1.3–11.4; SD 2.8). We found that post-operative worsening of the Charlson Index score was significantly associated with worsening SF-36 Physical Function (PF) (beta coefficient (ß) = -0.07; p < 0.0001), SF-36 Bodily Pain (BP) (ß = -0.06; p = 0.002), and WOMAC PF subscale (ß = 0.08; p < 0.001; higher scores are worse) scores, in the subsequent periods. Worsening novel medical index subscale scores were significantly associated with worsening SF-36 PF scores (ß = -0.03; p = 0.002), SF-36 BP (ß = -0.04; p < 0.001) and showed a non-significant trend for worse WOMAC PF scores (ß = 0.02; p = 0.11) subsequently. Local musculoskeletal index subscale scores were significantly associated with worsening SF-36 PF (ß = -0.05; p = 0.001), SF-36 BP (ß = -0.04; p = 0.03) and WOMAC PF (ß = 0.06; p = 0.01) subsequently. None of the novel index subscale scores were significantly associated with WOMAC pain scores. TKA complications, as assessed by TKA-related index subscale,  were not significantly associated with SF-36 or WOMAC domain scores.

Conclusions

Increasing Charlson index as well as novel medical and local musculoskeletal index subscale scores (from novel Arthroplasty  Comorbidity Severity Index) post-TKA correlated with subsequent worsening of physical function and pain outcomes post-TKA. Further studies should examine which comorbidity management could have the greatest impact on these outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-1261-y) contains supplementary material, which is available to authorized users.

Economic impact of lower-limb osteoarthritis worldwide: a systematic review of cost-of-illness studies

OBJECTIVE

An overview of the economic consequences - overall costs as well as cost breakdown (direct and indirect) - of hip and knee osteoarthritis (OA) worldwide.

METHODS

A systematic literature search of EMBASE, MEDLINE, Scopus and Cochrane databases for articles was performed independently by two rheumatologists who used the same predefined eligible criteria. Papers without abstracts and in languages other than English or French were excluded. Extracted costs were converted to an annual cost and to 2013 euros (€) by using the Consumer Price Index of the relevant countries and the 2013 Purchasing Power Parities between these countries and the European Union average.

RESULTS

A total of 45 abstracts were selected, and 32 articles were considered for the review. The studied populations were heterogeneous: administrative, hospital and national health survey data. Annual total costs per patient ranged from 0.7 to 12 k€, direct costs per patient from 0.5 to 10.9 k€ and indirect costs per patient from 0.2 to 12.3 k€. The weighted average annual costs per patient living with knee and hip OA were 11.1, 9.5 and 4.4 k€ for total, direct and indirect costs, respectively.

CONCLUSIONS

This review highlights the heterogeneity of studies and lack of methodologic consensus to obtain reliable cost-of-illness estimates for lower-limb OA. However, costs induced by the disease seem substantial and deserve to be more extensively explored.

Kinesio Taping does not improve the symptoms or function of older people with knee osteoarthritis: a randomised trial

QUESTION

Does Kinesio Taping reduce pain and swelling, and increase muscle strength, function and knee-related health status in older people with knee osteoarthritis?

DESIGN

Randomised, controlled trial with concealed allocation, intention-to-treat analysis and blinded assessment.

PARTICIPANTS

Seventy-six older people with knee osteoarthritis.

INTERVENTION

The experimental group received three simultaneous Kinesio Taping techniques to treat pain, strength and swelling. The control group received sham taping. All participants kept the taping on for 4 days.

OUTCOME MEASURES

The outcomes were: concentric muscle strength of knee extensors and flexors, measured by isokinetic dynamometry with an angular velocity of 60 deg/second normalised for body mass [(Nm/kg) x 100 (%)]; pressure pain threshold via digital pressure algometry (kgf/cm(2)); lower-limb swelling via volumetry (l) and perimetry (cm); physical function via the Lysholm Knee Scoring Scale (0 = worst to 100=best); and knee-related health status via the Western Ontario and McMaster (WOMAC) osteoarthritis index (0=best to 96=worst). Outcomes were measured at Day 4 (end of the taping period) and Day 19 (follow-up) after the start of the treatment.

RESULTS

At Day 4, there were no significant between-group differences for knee extensor muscle strength (MD -1%, 95% CI -7 to 5), knee flexor muscle strength (MD 2%, 95% CI -3 to 7), the pressure pain threshold at any measured point, volumetry (MD 0.05 L, 95% CI -0.01 to 0.11), perimetry at any measured point, Lysholm score (MD -4 points, 95% CI -9 to 2), or WOMAC score (MD -2 points, 95% CI -8 to 4). The lack of significant between-group difference was also seen at the follow-up assessment on Day 19.

CONCLUSION

The Kinesio Taping techniques investigated in this study provided no beneficial effects for older people with knee osteoarthritis on any of the assessed outcomes.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials, RBR-36r3t5. [Wageck B, Nunes GS, Bohlen NB, Santos GM, de Noronha M (2016) Kinesio Taping does not improve the symptoms or function of older people with knee osteoarthritis: a randomised trial.Journal of Physiotherapy62: 153-158].

The Association of Health-Related Quality of Life with Severity of Visual Impairment among People Aged 40-64 Years: Findings from the 2006-2010 Behavioral Risk Factor Surveillance System

PURPOSE

To examine the association of health-related quality of life (HRQoL) with severity of visual impairment among people aged 40-64 years.

METHODS

We used cross-sectional data from the 2006-2010 Behavioral Risk Factor Surveillance System to examine six measures of HRQoL: self-reported health, physically unhealthy days, mentally unhealthy days, activity limitation days, life satisfaction, and disability. Visual impairment was categorized as no, a little, or moderate/severe. We examined the association between visual impairment and HRQoL using logistic regression accounting for the survey's complex design.

RESULTS

Overall, 23.0% of the participants reported a little difficult seeing, while 16.8% reported moderate/severe difficulty seeing. People aged 40-64 years with moderate/severe visual impairment had more frequent (≥14) physically unhealthy days, mentally unhealthy days, and activity limitation days in the last 30 days, as well as greater life dissatisfaction, greater disability, and poorer health compared to people reporting no or a little visual impairment. After controlling for covariates (age, sex, marital status, race/ethnicity, education, income, state, year, health insurance, heart disease, stroke, heart attack, body mass index, leisure-time activity, smoking, and medical care costs), and compared to people with no visual impairment, those with moderate/severe visual impairment were more likely to have fair/poor health (odds ratio, OR, 2.01, 95% confidence interval, CI, 1.82-2.23), life dissatisfaction (OR 2.06, 95% CI 1.80-2.35), disability (OR 1.95, 95% CI 1.80-2.13), and frequent physically unhealthy days (OR 1.69, 95% CI 1.52-1.88), mentally unhealthy days (OR 1.84, 95% CI 1.66-2.05), and activity limitation days (OR 1.94, 95% CI 1.71-2.20; all p < 0.0001).

CONCLUSION

Poor HRQoL was strongly associated with moderate/severe visual impairment among people aged 40-64 years.

Estimating the health care burden of prescription opioid abuse in five European countries

Background

Opioid abuse, including abuse of prescription opioids (“RxOs”) and illicit substances like heroin, is a serious public health issue in Europe. Currently, there is limited data on the magnitude of RxO abuse in Europe, despite increasing public and scientific interest in the issue. The purpose of this study was to use the best-available data to derive comparable estimates of the health care burden of RxO abuse in France, Germany, Italy, Spain, and the United Kingdom (EU5).

Methods

Published data on the prevalence of problem opioid use and the share of opioid abuse patients reporting misuse of non-heroin opioids were used to estimate the prevalence of RxO abuse in the EU5 countries. The costs of RxO abuse were calculated by applying published estimates of the incremental health care costs of opioid abuse to country-specific estimates of the costs of chronic pain conditions. These estimates were input into an economic model that quantified the health care burden of RxO abuse in each of the EU5 countries. Sensitivity analyses examined key assumptions.

Results

Based on best-available current data, prevalence estimates of RxO abuse ranged from 0.7 to 13.7 per 10,000 individuals across the EU5 countries. Estimates of the incremental health care costs of RxO abuse ranged from €900 to €2,551 per patient per year. The annual health care cost burden of RxO abuse ranged from €6,264 to €279,927 per 100,000 individuals across the EU5 countries.

Conclusion

This study suggests that RxO abuse imposes a cost burden on health systems in the five largest European countries. The extent of RxO abuse in Europe should be monitored given the potential for change over time. Continued efforts should be made to collect reliable data on the prevalence and costs of RxO abuse in Europe to facilitate an accurate characterization of the extent of this potentially growing problem.

Socio-economic costs of osteoarthritis: a systematic review of cost-of-illness studies

OBJECTIVE

The burden of illness that can be attributed to osteoarthritis is considerable and ever increasing. The aim of this systematic review is to analyze currently available data derived from cost-of-illness studies on the healthcare and non-healthcare costs of osteoarthritis.

METHODS

PubMed, Index Medicus Español (IME), and the Spanish Database of Health Sciences [Índice Bibliográfico Español en Ciencias de la Salud (IBECS)] were searched up to the end of April 2013. This study adhered to the PRISMA guidelines. Articles were reviewed and the study quality assessed by two independent investigators with consensus resolution of discrepancies.

RESULTS

We identified 39 studies that investigated the socio-economic cost of osteoarthritis. Only nine studies took a social perspective. Rather than estimating the incremental cost of osteoarthritis, nine studies estimated the total cost of treating patients with osteoarthritis without a control for comorbidity. The other 30 studies determined the incremental cost with or without a control group. Only nine studies assessed a comprehensive list of healthcare resources. The annual incremental healthcare costs of generalized osteoarthritis ranged from €705 to €19,715. The annual incremental non-healthcare-related costs of generalized osteoarthritis ranged from €432 to €11,956.

CONCLUSIONS

The study concludes that the social cost of osteoarthritis could be between 0.25% and 0.50% of a country׳s GDP. This should be considered in order to foster studies that take into account both healthcare and non-healthcare costs.

Patient factors predict functional outcomes after cruciate retaining TKA: a 2-year follow-up analysis

We analyzed preoperative patient characteristics and postoperative functional outcomes to identify the most predictive preoperative characteristics of postoperative functional outcome for Cruciate Retaining (CR) TKA. In a prospective, multicenter study, 307 knees with minimum 2-year follow-up were first divided into groups based on 2-year functional performance. Logistic regression then determined SF-36 General Health Score (GHS) to be the most predictive preoperative patient characteristic. Subsequently, a second analysis was performed using preoperative SF-36 GHS to stratify patients into groups. Statistical significance was achieved in both analyses by gender, BMI and hypertension. Statistical significance was achieved in a single analysis by age, preoperative narcotic use, preoperative metabolic medication usage, preoperative pulmonary disease and preoperative use of medication for anxiety or depression.

Health-related quality of life after total joint arthroplasty: a scoping review

A scoping review was completed to summarize the change in health status after THA and TKA. Although a recent study has performed a systematic review of functional recovery after THA,(61) we reviewed a broad topic of HRQL changes after total joint arthroplasty. This scoping review was not restricted by study design; however, the majority of studies were prospective single group, observational studies so that change over time could be reported. A variety of HRQL measures were used, including disease-specific, generic, and utility measures. We reported on 33 studies that met our inclusion criteria. Most studies’ primary outcomes were disease-specific measures. Not surprisingly, MCIDs were reported with recovery both short term and long term. These clinically relevant changes were accompanied with large effect sizes for pain and function using disease-specific measures such as the WOMAC. In general, smaller changes were reported with joint stiffness; however, this may also be related to inherent measurement properties of the WOMAC in that it uses two questions to evaluate stiffness. Overall, large effect sizes, in excess of 1.0, were seen not only short term but also long term, that is, more than a year after surgery. The changes may also be reflected in the low rate of complications reported with total joint arthroplasty.(62) The generic health measures showed a smaller magnitude of change, which is to be expected given the construct of these measures evaluate overall health and includes the effect of other health conditions. That being said, the largest changes were seen in those domains that were primary to total joint arthroplasty, pain and physical function. A challenge of evaluating change of health status after total joint arthroplasty is that each measure has individual strengths and limitations. This review introduced the measures and the MCIDs when available to evaluate clinical change. The derived MCIDs should be considered carefully because these values are dependent on a number of features such as the study setting, methodology used to derive the values, baseline scores, and severity of the disease.(63) Change over time was also presented by the effect sizes. The effect size provided another perspective to measuring recovery after total joint arthroplasty in which comparison across measures can be made. Regardless of the type of outcome measure, large effect sizes are seen with total joint arthroplasty both over short-term and long-term outcomes. Because a number of HRQL measures are used to evaluate the outcomes after total joint arthroplasties, comparisons can be challenging. This review summarized published findings to help place the magnitude of change seen with total joint arthroplasty in perspective. Changes seen with HRQL are one aspect of evaluating outcomes from a patient perspective; however, recovery is a complex concept(64) that needs many clinical and research-oriented measures to evaluate the full spectrum of recovery.

Cost-effectiveness of nonpharmacologic, nonsurgical interventions for hip and/or knee osteoarthritis: systematic review

OBJECTIVE

To investigate the cost-effectiveness of nonpharmacological, nonsurgical interventions for the treatment of hip and/or knee osteoarthritis.

METHODS

We identified economic evaluations or cost studies associated with randomized or quasi-randomized controlled trials that assessed nonpharmacologic, nonsurgical interventions for the treatment of hip and/or knee osteoarthritis. Medline, Embase, PubMed, National Health Service Economic Evaluation Database, CENTRAL, EconLit, and OpenSIGLE were searched up to October 1, 2010. Study characteristics extracted include study population, health outcomes, and economic analysis elements. Economic analyses were assessed by using the Quality of Health Economic Studies instrument, and the methodological quality of the randomized controlled trials was graded by using an internal validity checklist. All costs were converted to 2008 US dollars.

RESULTS

Ten economic evaluations and one randomized controlled trial reporting health-care costs met our inclusion criteria. Interventions included exercise programs, acupuncture, rehabilitation programs, and lifestyle interventions. Six of the 11 studies exhibited high risks of bias for the cost and/or effect components of their cost-effectiveness estimate. Six studies used comparators of unknown cost-effectiveness. Four studies reported cost-effectiveness estimates lower than $50,000 per quality-adjusted life-year. All studies evaluating exercise interventions found the programs to be cost saving.

CONCLUSIONS

There is only limited evidence for the cost-effectiveness of conservative treatments for the management of hip and/or knee osteoarthritis. More high-quality economic evaluations of conservative interventions are needed to further inform practice.

Higher body mass index is not associated with worse pain outcomes after primary or revision total knee arthroplasty

We assessed whether higher body mass index (BMI) is associated with higher risk of moderate-severe knee pain 2 and 5 years after primary or revision total knee arthroplasty (TKA).We adjusted for sex, age, comorbidity, operative diagnosis, and implant fixation in multivariable logistic regression. Body mass index (reference, b 25 kg/m2) was not associated with moderate severe knee pain at 2 years post primary TKA (odds ratio [95% confidence interval], 25-29.9, 1.02[0.75-1.39], P = .90; 30-34.9, 0.93 [0.65-1.34], P = .71; 35-39.9, 1.16 [0.77-1.74], P = .47; ≥ 40,1.09 [0.69-1.73], [all P values ≥ .47]). Similarly, BMI was not associated with moderate-severe pain at 5-year primary TKA and at 2-year and 5-year revision TKA follow-up. Lack of association of higher BMI with poor pain outcomes post-TKA implies that TKA should not be denied to obese patients for fear of suboptimal outcomes.

Is longer waiting time for total knee replacement associated with health outcomes and medication costs? Randomized clinical trial

BACKGROUND

The aim of this prospective randomized study was to evaluate the effect of waiting time (WT) on health-related quality of life (HRQoL), knee pain and physical function, and the use and costs of medication of patients awaiting total knee replacement.

METHODS

When placed on the waiting list, 438 patients were randomized into a short waiting time (SWT ≤ 3 months) or a nonfixed waiting time (NFWT > 3 months) group. HRQoL was measured by the 15D, and pain and physical function by modified Knee Society Clinical Rating System at baseline, admission, and 3 and 12 months postoperatively. The costs of medication due to osteoarthritis were calculated at the same measurement points. All analyses were performed using the intention-to-treat principle.

RESULTS

The mean WT was 94 and 239 days in the SWT and NFWT groups, respectively. Apart from higher weekly cost of medication in the SWT group at admission and better HRQoL in the NFWT group 1 year postoperatively, there were no statistically significant differences between the groups in other outcomes during the follow-up.

CONCLUSION

Those in the SWT group had higher weekly costs of medication at admission, and reached better HRQoL 3 months earlier than those in the NFWT group, but the latter had better HRQoL after operation. Otherwise, the length of WT was not associated with different health and HRQoL outcomes in the groups.

Predictors of moderate-severe functional limitation after primary Total Knee Arthroplasty (TKA): 4701 TKAs at 2-years and 2935 TKAs at 5-years

OBJECTIVE

Investigate whether body mass index (BMI), comorbidity, gender and age predict patient-reported functional limitation 2- and 5-years after primary Total Knee Arthroplasty (TKA).

METHODS

Overall moderate-severe activity limitation was defined as > or = 2 activities (walking, stairs, rising from chair) with moderate-severe limitation. Complete dependence on walking aids or inability to walk was assessed (reference, no dependence). Multivariable logistic regression models were adjusted additionally for income, diagnosis, distance from medical center, American Society of Anesthesiologists (ASA) score and implant type.

RESULTS

Overall moderate-severe activity limitation was reported by 20.7% at 2-years and 27.1% at 5-years. Significantly predictors of overall moderate-severe activity limitation 2-years post-TKA (odds (95% confidence interval)) were: BMI 30-34.9, 1.5 (1.0, 2.0), 35-39.9, 1.8 (1.3, 2.7) and > or = 40, 3.0 (2.0, 4.5) vs BMI < or = 25; higher Deyo-Charlson index, 1.7 (1.4, 2.2) per 5-point increase; female gender, 2.0 (1.7, 2.5); age 71-80, 2.1 (1.5, 2.8) and age > 80, 4.1 (2.7, 6.1) vs age < or = 60. At 5-years post-TKA, significant predictors of overall moderate-severe activity limitation were: BMI 35-39.9, 2.1 (1.4, 3.3) and > or = 40, 3.9 (2.3, 6.5); higher Deyo-Charlson index, 1.4 (1.0, 1.8); female gender, 2.2 (1.7, 2.7); age 71-80, 2.4 (1.7, 3.5) and age > 80, 4.7 (2.8, 7.9). Complete dependence on walking aids was significantly higher at 2- and 5-years, respectively, in patients with: higher comorbidity, 2.3 (1.5, 3.3) and 2.1 (1.4, 3.2); female gender 2.4 (1.5, 3.9) and 1.7 (1.1, 2.6); age 71-80, 1.4 (0.8, 2.6) and 1.5 (0.8, 2.8); and age > 80, 3.2 (1.6, 6.7) and 5.1 (2.3, 11.0).

CONCLUSIONS

Modifiable (BMI, comorbidity) and non-modifiable predictors (age, gender) increased the risk of functional limitation and walking-aid dependence after primary TKA. Interventions targeting comorbidity and BMI pre-operatively may positively impact function post-TKA.

The cost utility of autologous chondrocytes implantation using ChondroCelect® in symptomatic knee cartilage lesions in Belgium

BACKGROUND

Knee cartilage lesions increase the risk of developing osteoarthritis (OA), and may eventually result in a total knee replacement (TKR). There is currently no consensus on the optimal treatment of cartilage lesions. ChondroCelect® (CC) is a cell-based therapy approved for use in autologous chondrocytes implantation (ACI) to treat symptomatic cartilage defects of the femoral condyle. Its capacity to safely restore good-quality cartilage was demonstrated in a randomized controlled trial (RCT) versus the surgical procedure microfracture (MFX).

OBJECTIVE

This study investigated the cost utility of CC used in ACI compared with MFX to treat symptomatic knee cartilage lesions in Belgium.

METHODS

A decision tree model comparing CC with MFX over a 40-year horizon was developed in TreeAge Pro™. The key timepoints of the model were (i) clinical assessment 5 years after initial intervention (success or no success, with or without re-operation); (ii) development of OA at 15 years (yes/no); (iii) need for TKR at 20 years (yes/no); and (iv) need for prosthesis revision at 35 years (yes/no). Clinical data provided by the RCT of CC versus MFX were the clinical success (response) rate based on the Knee injury and Osteoarthritis Outcome Score (KOOS) at 36 months (82.9% vs 62.0%; p = 0.048) and the proportion of good structural repair/presence of hyaline cartilage based on International Cartilage Repair Society (ICRS II) visual item at 12 months (44.9% vs 23.2%; p = 0.023). Utility scores by surgery outcome were derived from the SF-36 questionnaire responses collected in the RCT. Conservative assumptions related to the incidences of OA, TKR and prosthesis revision relied on a literature search. A patient chart review (n = 82) provided follow-up costs by surgery outcome. National tariffs were applied to direct medical resources used (healthcare payer perspective, year 2008 costs). Annual discounting was applied to costs (3%) and effects (1.5%) as recommended by the Belgian pharmacoeconomic guidelines.

RESULTS

The incremental cost per QALY gained for CC compared with MFX was €16,229, with a difference in costs of €20,802 and 1.282 QALYs gained. Sensitivity analyses indicated that the key model drivers were the proportion of patients with hyaline cartilage and the correlation between hyaline cartilage formation and later avoidance of OA. Probabilistic sensitivity analyses showed robustness of the results, with 80% of the simulations below the usual UK National Institute for Health and Clinical Excellence (NICE) threshold of €22,000 per QALY.

CONCLUSIONS

Assuming a good correlation between high-quality cartilage repair and avoidance of OA at a later stage, the benefits of the cell therapy CC over MFX in terms of QALYs gained and OA-related costs avoided appear real. Further research is required to explore long-term effects of cartilage repair and reduce uncertainty on quality of life of patients with OA before and after joint replacement.

Cultural adaptation and validation of the Persian version of the Arthritis Impact Measurement Scales 2-Short Form in patients with osteoarthritis of the knee

PURPOSE

To translate and validate the Persian version of the Arthritis Measurement Scales 2-Short Form (AIMS2-SF) in patients with osteoarthritis (OA) of the knee.

METHOD

The translation and cultural adaptation of the original questionnaire was carried out in accordance with published guidelines. One hundred and fourteen consecutive Persian-speaking patients with OA of the knee were participated in this study. The Short Form Health Survey (SF-36) and visual analogue scales (VAS) for pain and joint stiffness were used to test convergent validity of the Persian AIMS2-SF. In addition, 35 randomly selected patients were asked to complete the questionnaire 3 days later for the second time.

RESULTS

The Persian AIMS2-SF showed statistically significant good convergent validity, as assessed with the relevant subscales of the Persian SF-36 and VAS for pain and joint stiffness. Cronbach's alpha coefficient for the Persian AIMS2-SF components ranged from 0.68 to 0.80. The Persian AIMS2-SF components showed good to excellent test-retest reliability with intraclass correlation coefficient ranged from 0.72 to 0.83 (p < 0.01).

CONCLUSIONS

The Persian version of the AIMS2-SF is a reliable and valid instrument to measure functional disability and health-related quality of life in patients with OA of the knee in Iran. It is simple and easy to use and now can be applied in clinical settings and future outcome studies in Iran.

Translation and validation study of the Persian version of the Arthritis Impact Measurement Scales 2 (AIMS2) in patients with osteoarthritis of the knee

BACKGROUND

The Arthritis Impact Measurement Scales 2 (AIMS2) has not been translated and validated for Persian-speaking patients with osteoarthritis of the knee. This was to provide a validated instrument to measure functional disability and health-related quality of life in patients with osteoarthritis of the knee in Iran. The aim of this study was to culturally adapt and validate the AIMS2 for Persian-speaking patients with osteoarthritis of the knee in Iran.

METHODS

A consecutive sample of patients with knee osteoarthritis were asked to complete the AIMS2, the Short Form Health Survey (SF-36) and four visual analog scales for pain, joint stiffness, patient's and physician's global assessment. Internal consistency and convergent validity were applied to examine psychometric properties of the AIMS2. In addition, 30 randomly selected patients were asked to complete the questionnaire two days later for the second time for test-retest reliability. Finally factor structure of the Persian AIMS2 was performed using the principal component factor analysis.

RESULTS

In all 230 patients were entered into the study. The mean (SD) age of the participants was 56.9 (8.7) years and the mean (SD) duration of disease was 7.2 (3.5) years. Cronbach's alpha coefficient and intraclass correlation coefficient (ICC) for the Persian AIMS2 scales ranged from 0.74 to 0.92 and 0.85 to 0.96, respectively. The correlation between most of the Persian AIMS2 scales and the physical and mental summary scores of the SF-36 and the visual analogue scales for pain, joint stiffness, patient's and physician's global assessment were statistically significant indicating a good convergent validity (p < 0.05). The results obtained from factor analysis indicated three latent factors that jointly accounted for 67.5% of the total variance.

CONCLUSION

The results showed that the Persian AIMS2 had reasonably good internal consistency, test-retest reliability, and convergent validity in patients with osteoarthritis of the knee. It is simple and easy to use and now can be applied in the future studies in Iran. However, its sensitivity to change needs still to be studied.

A population-based nested case-control study of the costs of hip and knee replacement surgery

BACKGROUND

Studies of total joint arthroplasty (TJA) have not evaluated the costs and outcomes in the context of expected arthritis worsening.

OBJECTIVES

Using a cost-consequence approach, to examine changes in direct health care costs and arthritis severity after TJA for hip/knee arthritis compared with contemporaneous changes in matched controls.

RESEARCH DESIGN

Case control study nested in a population-based prospective cohort.

SUBJECTS

In a population cohort with disabling hip/knee osteoarthritis followed from 1996 to 2003, primary TJA recipients were matched with cohort nonrecipients on age, sex, region of residence, comorbidity, and inflammatory arthritis diagnosis.

MEASURES

Pre- and postoperative total and arthritis-attributable direct health care costs, arthritis severity, and general health status were compared for cases and matched controls.

RESULTS

Of 2109 participants with no prebaseline TJA, 185 cases received a single elective TJA during the follow-up period; of these, 183 cases and controls were successfully matched. Mean age was 71 years, 77.6% were female, 35.5% had > or =2 comorbidities, and 81.5% had > or =2 joints affected. At baseline, controls had less pain and disability and lower total and arthritis-attributable health care costs than cases. After surgery, although overall health care utilization was unchanged, cases experienced significant decreases in arthritis-attributable costs (mean decrease $278 including prescription drugs) and pain and disability (P < 0.0001 for all). Over the same time period, controls experienced a significant increase in total health care costs (mean increase $1978 including prescription drugs, P = 0.04) and no change or worsening of their arthritis status.

CONCLUSION

Compared with matched controls, arthroplasty is associated with significant reductions in pain, disability, and arthritis-attributable direct costs.

Work in inflammatory and degenerative joint diseases

This article focuses on work disability and sick leave and their cost; it also discusses the value of vocational rehabilitation programmes in rheumatic conditions such as rheumatoid arthritis, ankylosing spondylitis, hip and knee osteoarthritis. It acknowledges the importance of work not only for the worker who has one of these diseases but also for the public purse. Much can be done to improve the health of the persons and reduce their disability and its impact in the workplace which will have an important effect on their and their family's quality of life. It is important that neither rehabilitation nor vocational rehabilitation are regarded as bolt-on activities after drug treatment but are seen as an integral part of effective management. Publications dealing with return to work are relatively common in rheumatoid arthritis, less common in ankylosing spondylitis and relatively rare in osteoarthritis. Vocational rehabilitation programmes should aim to facilitate job retention or, failing that, to improve the ability to return to work. The process must be started with in the health arena and it has to be recognised that slow or poor practice in the health service can jeopardise the patient's work potential.

Waiting for total knee replacement surgery: factors associated with pain, stiffness, function and quality of life

Background

Recent evidences show that education and rehabilitation while waiting for knee replacement have positive effects on the patients' health status. Identification of factors associated with worse pain, function and health-related quality of life (HRQoL) while waiting for surgery could help develop pre-surgery rehabilitation interventions that target specifically these factors and prioritize patients that may benefit the most from them. The objectives of this study were to measure pain, stiffness, function and HRQoL in patients at enrolment on waiting lists for knee replacement and to identify demographic, clinical, socioeconomic and psychosocial characteristics associated with these outcomes.

Methods

This study is part of a broader study measuring the effects of pre-surgery wait in patients scheduled for knee replacement. From 02/2006 to 09/2007, 197 patients newly scheduled for total knee replacement were recruited from the waiting lists of three university hospitals in Quebec City, Canada. Pain, stiffness and function were measured with the Western Ontario and McMaster Osteoarthritis Index (WOMAC) and HRQoL was measured with the SF-36 Health Survey. Stepwise multiple regression analysis was used to assess the strength of the associations between the independent variables and the WOMAC and SF-36 scores.

Results

The scores of all eight HRQoL physical and mental domains of the SF-36 were significantly lower than aged matched Canadian normative data (p < 0.05). Contralateral knee pain, higher psychological distress, higher body mass index (BMI) and the use of a walking aid were significantly associated with worse function (p < 0.05) and contributed to 22% of the variance of the WOMAC function score (multiple r = 0.47). A higher BMI, the use of a walking aid, contralateral knee pain and advanced age were significantly associated with worse physical function (p < 0.05) and contributed to 17% of the variance of the SF-36 HRQoL physical functioning score (multiple r = 0.41).

Conclusion

Patients waiting for knee replacement have poor function and HRQoL. Characteristics that were found to be associated with these outcomes could help develop pre-surgery rehabilitation program and prioritize patients that may benefit the most from them. Such programs could include interventions to reduce psychological distress, therapeutic exercises targeting both knees and weight loss management.

Effect of comorbidity on quality of life of male veterans with prevalent primary total knee arthroplasty

This is a study of the impact of specific and overall comorbidity on health-related quality of life (HRQoL) in men with primary total knee arthroplasty (TKA). In a population-based sample of male veterans who responded to a cross-sectional survey using the validated short-form 36 for veterans (SF-36 V) and had undergone primary TKA prior to survey, eight SF-36 V domain and two summary scores (physical and mental component (PCS and MCS) summary) were compared using multivariable-adjusted multiple linear regressions between patients with and without five comorbidities--chronic obstructive pulmonary disease (COPD)/asthma, diabetes, depression, hypertension, and heart disease. Analyses were adjusted for age, five comorbidities, and time since TKA. Two hundred ninety-three male patients constituted the analytic set with mean (SD) age of 70.3 (8.8) years; 97% were Caucasian and mean (SD) duration since TKA was 2.1 (0.7) years. COPD/asthma was associated with significantly lower adjusted MCS (mean +/- standard error of mean, 47.1 +/- 0.7 vs. 43.1 +/- 1.2; p <or= 0.001) and PCS (30.1 +/- 0.6 vs. 27.7 +/- 1.0; p < 0.05), depression with significantly lower MCS (48.9 +/- 0.7 vs. 37.6 +/- 1.2; p <or= 0.001) but not PCS, hypertension with significantly lower MCS (47.0 +/- 0.7 vs. 44.3 +/- 1.0; p < 0.05) but not PCS, and heart disease with significantly lower MCS (47.4 +/- 0.8 vs. 44.2 +/- 0.9; p <or= 0.001) and PCS (30.5 +/- 0.7 vs. 28.1 +/- 0.8; p < 0.05). Diabetes was not associated with lower MCS or PCS. The overall number of comorbidities was associated with lower MCS and PCS (p <or= 0.001 for both). Medical and psychiatric comorbidity impacts physical and mental/emotional HRQoL in patients with primary TKA. The impact differs by comorbidity. Higher comorbidity load negatively impacts both physical and mental/emotional HRQoL.

Associations between physical examination and self-reported physical function in older community-dwelling adults with knee pain

BACKGROUND AND PURPOSE

Knee pain is a common disabling condition for which older people seek primary care. Clinicians depend on the history and physical examination to direct treatment. The purpose of this study was to examine the associations between simple physical examination tests and self-reported physical functional limitations.

SUBJECTS AND METHODS

A population sample of 819 older adults underwent a standardized physical examination consisting of 24 tests. Associations between the tests and self-reported physical functional limitations (Western Ontario and McMaster Universities Osteoarthritis Index physical functioning subscale [WOMAC-PF] scores) were explored.

RESULTS

Five of the tests showed correlations with WOMAC-PF scores, corresponding to an intermediate effect (r>or=.30). These were tenderness on palpation of the infrapatellar area, timed single-leg standing balance, maximal isometric quadriceps femoris muscle strength (force-generating capacity), reproduction of symptoms on patellofemoral compression, and degree of knee flexion. Each of these tests was able to account for between 7% and 13% of the variance in WOMAC-PF scores, after controlling for age, sex, and body mass index. Three of these tests are indicative of impairments that may be modifiable by exercise interventions.

DISCUSSION AND CONCLUSION

Self-reported physical functional limitations among older people with knee pain are associated with potentially modifiable physical impairments that can be identified by simple physical examination tests.