The factors associated with pain severity in patients with knee osteoarthritis vary according to the radiographic disease severity: a cross-sectional study

Diagnostic accuracy of a novel ultrasound imaging index for knee osteoarthritis: Evaluation of sensitivity, specificity, and predictive values

PURPOSE

We aimed to develop and validate a new ultrasonography (US) index for the diagnosis of primary medial-type knee osteoarthritis (OA).

METHODS

In total, 156 patients (203 limbs) underwent standing knee radiography and the US for suspected knee OA. Total osteophyte height (TOH) and distance between bones (DBB) aided diagnosis. Logistic regression identified optimal cutoff values. Thresholds from logistic regression informed recipient operating characteristic curve (ROC) analysis, balancing sensitivity and specificity. These thresholds were then applied in the differential thermal analysis (DTA) to construct a 2 × 2 table.

RESULTS

The TOH-DBB index showed that a DBB of 5.6 mm or less was required to diagnose primary medial-type knee arthropathy. The results in the 2 × 2 table were 41 true-positive (TP), 10 false negative (FN), 22 true-negative (TN), and 7 false positive (FP). A DBB of 5.6 mm or less and TOH of 4.7 mm or more were necessary to diagnose severe deformity. The results in the 2 × 2 table were 10 TP, 4 FN, 23 TN, and 4 FP.

CONCLUSION

The TOH-DBB index was confirmed to capture changes in primary medial-type knee OA across various stages.

Association of adipokines with severity of knee osteoarthritis assessed clinically and on magnetic resonance imaging

Objectives

We aimed to evaluate the association between the adipokines: Leptin, Adiponectin, Resistin, and high sensitive-C-reactive protein (hs-CRP) with clinical, radiographical and magnetic resonance imaging (MRI) assessment of knee osteoarthritis (OA) severity.

Design

We performed a cross-sectional study in participants with earlier knee OA. Demographics, clinical (WOMAC), radiographical and MRI (BLOKS scoring) severity of knee OA were assessed. Serum leptin, adiponectin, resistin and hs-CRP were measured. Association of adipokines and hs-CRP with clinical, radiographic and MRI severity outcomes were evaluated using regression models with adjustment with age, sex, and body mass index (BMI).

Results

137 participants with earlier knee OA (82% women, mean ​± ​SD age: 55.5 ​± ​7.8 years) were included. Participants had moderate knee OA symptoms, mean WOMAC pain and function were 30.6 ​± ​18.0, and 31.7 ​± ​19.8 respectively. Mean BMI was 27.0 ​± ​5.9 ​kg/m2. After adjustment with age, sex and BMI, serum leptin was positively associated with osteophyte size, cartilage integrity, infrapatellar synovitis and effusion. While hs-CRP was associated with meniscus extrusion and adiponectin was associated with WOMAC pain and function.

Conclusion

Serum adipokines, particularly leptin was associated with severity of various structural defects of the knee joint on MRI beyond age, sex and BMI in earlier knee OA.

Prevalence and Characteristics of Knee Osteoarthritis Among the General Public in Saudi Arabia

Background Knee osteoarthritis (OA) is a chronic and progressive knee joint condition that is influenced by multiple factors. This research aims to examine the prevalence and characteristics of knee OA among the general public in Saudi Arabia. Methodology This cross-sectional online survey was conducted in September 2023 in Saudi Arabia. This research used a previously developed questionnaire to validate the diagnosis of OA, which was performed in accordance with the diagnostic criteria established by the American College of Rheumatology (ACR). The Western Ontario and McMaster Universities Arthritis Index questionnaire (WOMAC) was used to examine the severity and characteristics of knee OA patients. A binary logistic regression analysis was conducted to determine the variables that influence the severity of knee OA and the likelihood of developing OA. Results A total of 1,019 individuals participated in this study. Around one-third of the participants (34.5%) fulfilled the ACR criteria for knee OA diagnosis. Overall, the mean WOMAC score was 34.1 (18.8) out of 96, which represents 35.5% of the maximum obtainable score and demonstrates a low degree of knee OA severity. The mean pain sub-scale score was 7.4 (3.8) out of 20, which represents 37.0% of the maximum obtainable score and demonstrates a low level of pain intensity. The mean stiffness sub-scale score was 2.7 (1.8) out of 8, which represents 33.8% of the maximum obtainable score and demonstrates a low degree of stiffness in joints. The mean physical function sub-scale score was 24.0 (14.0) out of 68, which represents 35.3% of the maximum obtainable score and demonstrates a low level of physical function difficulty. Females, older participants (above 40 years), those with high body mass index (28.8 kg/cm2 and higher), non-smokers, those with comorbidities, those who did not practice daily physical activity, those who had a family history of knee OA, and those who suffered from flat feet, rheumatoid arthritis, gout, lupus, or back or hip pain were more likely to develop knee OA and have severe OA (p < 0.05). Conclusions The findings of this study demonstrated a significant prevalence rate of knee OA and highlighted a discrepancy between the rates obtained by diagnostic criteria and those determined through clinical diagnosis. Several significant factors that contribute to the development of OA encompass lifestyle choices such as food and exercise, familial predisposition, genetic influences, and the presence of comorbidities. To effectively tackle this intricate matter, it is imperative to adopt a patient-centered strategy and prioritize early intervention.

A higher intramuscular fat in vastus medialis is associated with functional disabilities and symptoms in early stage of knee osteoarthritis: a case-control study

BACKGROUND

The characteristics of muscle degeneration in individual quadriceps in early knee osteoarthritis (OA) and the association of muscle quantity and quality on knee dysfunction remain unclear. This study aimed to clarify the characteristics of muscle degeneration in individual quadriceps muscles in early knee OA and elucidate the association of muscle volume and intramuscular adipose tissue (intraMAT) with knee dysfunction, including functional disabilities, symptoms, and joint morphology.

METHODS

Fifty participants were categorized into early knee OA and healthy control groups. 3.0 T magnetic resonance imaging (MRI) using T1-weighted and Dixon methods and 3D SPACE in the thigh muscle and knee joint regions was performed. Quadriceps muscle volume, intraMAT, and whole-organ MRI score (WORMS) were assessed. The Knee Society Score (KSS) was used to evaluate functional disabilities and knee symptoms. Univariate analysis of variance was conducted with covariates to clarify the differences in muscle volume and intraMAT between the two groups. Multiple linear regression analyses were performed using the KSS function and symptom subcategories and WORMS as dependent variables and muscle volume, intraMAT, and the presence of early knee OA as independent variables, such as potential confounders.

RESULTS

The quadriceps intraMAT, especially in the vastus medialis (VM), was significantly higher in patients with early knee OA than in healthy controls. The VM intraMAT, not muscle volume, was significantly associated with KSS function [B =  - 3.47; 95% confidence interval [CI], - 5.24 to - 1.71; p < 0.001] and symptom scores [B =  - 0.63; 95% CI, - 1.09 to - 0.17; p = 0.008], but not with WORMS.

CONCLUSION

These findings suggest that higher VM intraMAT is characteristic of quadriceps muscle degeneration in early knee OA and its increase is associated with functional disabilities and symptoms.

Role of central obesity on pain onset and its association with cardiovascular disease: a retrospective study of a hospital cohort of patients with osteoarthritis

OBJECTIVES

To determine the role of central obesity (CO) in the onset and severity of joint pain and in predicting cardiovascular disease (CVD) in subjects affected with osteoarthritis (OA).

DESIGN

Retrospective analysis on the onset of OA joint pain and CO. Waist circumference (WC), Waist-to-height ratio andwaist-to-hip ratio (WHR) were measured at the interview and defined according to the WHO criteria. Cross-sectional analyses on the association of comorbidities, including CVD, pain severity (number of joints and pain score) and CO.

SETTINGS AND PARTICIPANTS

Medical records and interviews of a hospital cohort study of 609 patients with OA. Analyses included analysis of variance, mean differences (MDs), SE and logistic regression. Areas under the receiver operating characteristic curve (AUROC) compared the predictive value of the sex-specific CVD models.

OUTCOME MEASURES

Onset of OA joint pain (years) and severity according to body mass index (BMI) and WC categories. Predictive value of WC for CVD by sex. Education level, disability, smoking and alcohol use were used to adjust the analysis.

RESULTS

Subjects with OA and CO by WHR started 2 years earlier with pain symptoms and had more joints affected than those without CO (MD=1.96 years, SE=0.95, p=0.04 and MD=0.32, SE=0.15 and p=0.04, respectively). Age and hypertension were associated with CVD in both genders, and NSAIDs use only in males. In addition, respiratory disease, hypercholesterolaemia, stairs difficulty, a wider WC and obesity were significant risk factors in females, improving 12.7% in the prediction of CVD cases, compared with only age and BMI (AUROCC=0.793 and 0.666, respectively, p=0.03 for the difference between AUROCs).

CONCLUSION

CO is associated with the onset of joint pain, and all pain analysed variables. CO has a role in CVD in women affected with OA and might help predict CVD cases.

Effusion detected by ultrasonography and overweight may predict the risk of knee osteoarthritis in females with early knee osteoarthritis: a retrospective analysis of Iwaki cohort data

BACKGROUND

Knee osteoarthritis (OA) has enormous medical and socioeconomic burdens, which early diagnosis and intervention can reduce. We investigated the influence of knee effusion on the progression of knee OA in patients with early knee OA.

METHODS

A total of 404 participants without radiographic knee OA were assessed from a 3-year longitudinal analysis. Participants were classified into non-OA and early knee OA groups. The effusion area (mm²) was quantified using ultrasonography. Receiver operating characteristic and logistic regression analyses were performed.

RESULTS

At the 3-year follow-up, 114 of 349 knees (32%) had progressed from non-OA and 32 of 55 knees (58%) had progressed from early knee OA to radiographic knee OA. Logistic regression analysis showed that female sex (odds ratio [OR] 3.36, 95% confidence interval [CIs] 2.98-5.42), early knee OA (OR 2.02, 95% CI 1.08-3.75), body mass index (OR 1.11, 95% CI 1.02-1.19), and effusion area (OR 1.01, 95% CI 1.01-1.02) were significantly correlated with knee OA progression. Women who were overweight (body mass index ≥ 25 kg/m²) with more severe effusion had a higher risk of OA progression (area under the curve = 0.691, OR = 6.00) compared to those not overweight (area under the curve = 0.568, OR = 1.91).

CONCLUSION

Knee effusion may be an indicator of the progression of early-stage knee OA.

Effect of disease-modifying anti-rheumatic drugs in osteoarthritis: A meta-analysis

OBJECTIVE

Osteoarthritis (OA) displays features of systemic and local inflammation, suggesting that DMARDs used in rheumatoid arthritis could potentially also be effective in OA. However, studies of the effects of DMARDs in OA have yielded conflicting data, and have been insufficiently large to draw conclusions. In this meta-analysis, we aimed to estimate the effect of DMARDs - such as methotrexate, hydroxychloroquine, TNF, and IL-1 inhibitors - on OA.

METHODS

We searched for relevant articles of randomized controlled trials published up to March 2022, using Pubmed, EMBASE, and the Cochrane Library. Studies were reviewed in accordance with PRISMA 2020 guidelines. The effects of DMARDs on OA outcomes (symptoms, quality of life, ESR) were expressed as the standardized mean difference.

RESULTS

We retrieved 29 references. Among these, 23 randomized controlled trials compared the effects of DMARDs versus placebo or other treatments on disease activity, including 1143 DMARD-treated OA patients and 1155 OA patients in the control group. We found statistically significant improvement of pain and stiffness with methotrexate, especially in knee OA. TNF inhibitors improved the swollen joint count in hand OA, and inflammation parameters, without change in pain, stiffness, or function. Hydroxychloroquine and IL-1 inhibitors were not effective.

CONCLUSION

Overall, the presently available data regarding the effects of DMARDs on OA symptoms intensity are disappointing. Only methotrexate might have an analgesic effect, especially in knee OA, which warrants further investigation.

Association between knee inflammation and knee pain in patients with knee osteoarthritis: a systematic review

OBJECTIVE

To systematically review the literature on the relationship between markers of inflammation and pain in patients with knee osteoarthritis (OA).

METHODS

We searched MEDLINE, Web of Science and EMBASE databases from inception until June 2021. Eligible articles had to report on the association between inflammation (as measured by effusion, synovitis, baker's cysts, cytokines and C-reactive protein) and pain in patients with radiographic knee OA. Two reviewers independently performed a screening on title and abstracts, data extraction and risk of bias assessment using the Newcastle-Ottawa Scale (NOS). A best evidence synthesis was conducted for each inflammatory sign included in this review.

RESULTS

37 studies were included. Articles reported on the following measures: effusion or synovitis assessed via ultrasound (n = 9) or magnetic resonance imaging (MRI) (n = 17); baker's cyst (n = 3); cytokine concentrations (n = 11); and C-reactive protein levels (n = 4). The strength of the association between inflammation and pain does not exceed the moderate level (i.e., correlation coefficient values ranging from 0.19 to 0.61). Moderate levels of evidence were found for the association between synovitis (measured with ultrasound or contrast enhanced MRI) and pain. The levels of evidence between effusion (assessed via ultrasound), effusion/synovitis (assessed via non-contrast enhanced MRI), Baker's cyst, cytokines, C-reactive protein and pain were conflicting.

CONCLUSIONS

Different inflammatory markers are associated with pain but the correlation ranges from weak to moderate, and the quality of evidence from conflicting to moderate. Further research is needed to strengthen the level of evidence and to establish mechanisms.

Metabolic obesity and the risk of knee osteoarthritis progression in elderly community residents: A 3-year longitudinal cohort study

OBJECTIVE

Metabolic syndrome is a major health problem worldwide associated with obesity, thus drawing attention to its relation to osteoarthritis (OA). However, it is still uncertain whether metabolic syndrome or body fat distribution is associated with knee OA. The aim of this longitudinal study was to elucidate the association between metabolic obesity and adverse structural changes of knee OA assessed by magnetic resonance imaging (MRI).

METHODS

Participants were recruited from the Hallym Aging Study cohort in Korea. Knee MRI scans, along with dual-energy X-ray absorptiometry, were assessed in 226 participants at baseline and after 3 years. The structural progression in the tibiofemoral joint was evaluated using the semi-quantitative Whole-Organ MRI Score (WORMS) for cartilage morphology and bone marrow lesions (BML). Logistic regression with generalized estimating equation was performed for associations of metabolic risk factors with worsening of WORMS scores at the subregional level.

RESULTS

In the medial compartment, fat mass in women was associated with cartilage loss, but the statistical significance disappeared after adjusting for body mass index. Metabolic syndrome and each of its components were not associated with cartilage loss or increase of BML. On the other hand, the interaction effects of metabolic syndrome on the association between obesity and knee OA progression were not significant.

CONCLUSION

In this cohort, metabolic effects of obesity on knee cartilage damage and BML were not demonstrated. Further large-scale studies are required to prove the causal relationship between metabolic obesity and knee OA.

Clinically Relevant Molecular Biomarkers for Use in Human Knee Osteoarthritis: A Systematic Review

OBJECTIVE

Biomarkers in osteoarthritis (OA) could serve as objective clinical indicators for various disease parameters, and act as surrogate endpoints in clinical trials for disease-modifying drugs. The aim of this systematic review was to produce a comprehensive list of candidate molecular biomarkers for knee OA after the 2013 ESCEO review and discern whether any have been studied in sufficient detail for use in clinical settings.

DESIGN

MEDLINE and Embase databases were searched between August 2013 and May 2018 using the keywords "knee osteoarthritis," "osteoarthritis," and "biomarker." Studies were screened by title, abstract, and full text. Human studies on knee OA that were published in the English language were included. Excluded were studies on genetic/imaging/cellular markers, studies on participants with secondary OA, and publications that were review/abstract-only. Study quality and bias were assessed. Statistically significant data regarding the relationship between a biomarker and a disease parameter were extracted.

RESULTS

A total of 80 studies were included in the final review and 89 statistically significant individual molecular biomarkers were identified. C-telopeptide of type II collagen (CTXII) was shown to predict progression of knee OA in urine and serum in multiple studies. Synovial fluid vascular endothelial growth factor concentration was reported by 2 studies to be predictive of knee OA progression.

CONCLUSION

Despite the clear need for biomarkers of OA, the lack of coordination in current research has led to incompatible results. As such, there is yet to be a suitable biomarker to be used in a clinical setting.

A Retrospective Analysis of Clinical Outcome and Predictive Factors for Responders with Knee Osteoarthritis to a Single Injection of Leukocyte-Poor Platelet-Rich Plasma

Although various platelet-rich plasma (PRP) kits are commercially available, the efficacy of these kits for knee osteoarthritis (KOA) has not been fully investigated. This study aimed to investigate the short-term results of leukocyte-poor PRP (LP-PRP) and the factors that contribute to its efficacy. We retrospectively reviewed 124 patients with KOA who were treated with LP-PRP. White blood cell (WBC) and platelet counts in the whole blood and the LP-PRP were measured. KOA severity was assessed using radiography. Clinical evaluation was performed both prior to injection and after an average of 3.3 weeks after the injection using the Japanese Knee Osteoarthritis Measure (JKOM). Responders were defined based on the JKOM. The contributing factors for responders were examined using a multivariate logistic analysis. The responder rate was 58.1% and the contributing factors for responders were a higher visual analog scale score before injection, WBC count in whole blood, and platelet concentration ratio of LP-PRP. The LP-PRP improved the clinical scores in the short term. Certain patient characteristics before injection and the concentration ratio of LP-PRP may be predictors of its efficacy; these may provide clues for elucidating which components of LP-PRP act on KOA pathologies.

Correlation between serum pro inflammatory cytokines and clinical scores of knee osteoarthritic patients using resveratrol as a supplementary therapy with meloxicam

OBJECTIVE:

The objective of this study was to analyze the associations between the pro-inflammatory markers with the clinical outcomes of knee osteoarthritis (OA) in patients using resveratrol as an add-on treatment with meloxicam.

MATERIALS AND METHODS:

This was a double-blind controlled clinical investigation, with 110 eligible patients with OA assigned randomly to receive 15 mg a day meloxicam with either resveratrol 500 mg a day or placebo for 90 days. The standard tools for assessment of pain severity and physical functions were utilized. The tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and IL-6 in the blood were evaluated. Spearman's correlation coefficient test was used to determine the significance of correlations.

RESULTS:

The regression analysis to determine the correlation between reductions of the inflammatory biomarkers with the amelioration of the clinical scores showed a nonsignificant weak correlation between these variables. Total clinical scores of each assessment tool that was used “Knee Injury and OA Outcome Score (KOOS) and WOMAC” displayed a weak and nonsignificant correlation with TNF-α, IL-1β blood level. The Spearman's correlation shows a relatively nonsignificant association between IL-6 levels and KOOS, WOMAC, and Visual Analog Scale scores after incorporating resveratrol as an adjuvant with meloxicam for 90 days.

CONCLUSION:

A weak and nonsignificant correlation between serum biomarkers and the clinical outcomes has been suggested in patients with painful knee OA treated with meloxicam and resveratrol.

Extensive cytokine analysis in synovial fluid of osteoarthritis patients

OBJECTIVE

Osteoarthritis (OA) is a joint disease characterized by articular cartilage loss and afflicts many people worldwide. However, diagnostic methods and treatment options remain limited and are often characterized by low sensitivity and low efficacy. The focus of the present study was to identify proteomic biomarkers in synovial fluid to improve diagnosis and therapy of OA patients.

METHODS

Antibody array technology was utilized for protein expression profiling of synovial fluid from 24 OA patients and 24 healthy persons.

RESULTS

Compared with healthy persons, twenty proteins showed lower expression levels in OA patients, while thirty proteins had higher levels. Among these differential proteins, GITRL, CEACAM-1, FSH, EG-VEGF, FGF-4, PIGF, Cystatin EM and NT-4 were found for the first time to be differentially expressed in OA. Bioinformatics analysis showed that most of these differential proteins were involved leukocytes events, and some differentially expressed proteins including IL-18, CXCL1, CTLA4, MIP-3b, CD40, MMP-1, THBS1, CCL11, PAI-1, BAFF, aggrecan, angiogenin and follistatin were located in central positions of the protein-protein interaction (PPI) network.

CONCLUSION

We speculate that leukocyte proliferation and migration to the joint may be an important pathogenesis of OA, which needs a further validation. The central proteins of the PPI network may play a more pivotal role in OA. The newly identified differentially expressed proteins may be novel biomarkers for OA diagnosis and targets for OA therapy.

Interrelationship of MMP-9, Proteoglycan-4, and Inflammation in Osteoarthritis Patients Undergoing Total Hip Arthroplasty

Osteoarthritis (OA) is a chronic condition marked by joint pain, inflammation and loss of articular cartilage, that can be treated with total joint arthroplasty (TJA) at end stages. TJA is marked by post-operative inflammation, which directly effects levels of cartilage degradation biomarkers, proteoglycan-4 (PRG4) and matrix metalloproteinase-9 (MMP-9). PRG4 is a protective glycoprotein that is decreased in individuals with OA. MMP-9 is a matrix metalloproteinase that contributes to articular cartilage loss and is elevated in OA patients. It is upregulated by pro-inflammatory markers, such as IL-1, IL-6 and CRP. This study aims to elucidate the immediate post-operative changes in levels of PRG4, MMP-9, IL-6, CRP, and WBC in patients undergoing TJA to clarify the role of inflammation in recovery after surgery and in the overall pathogenesis of OA. Blood was collected at 3 time points (day 0, day 1 post-operatively, and days 5-7 post-operatively), from 63 patients undergoing TJA due to OA, and levels of these biomarkers were quantified. IL-6, CRP, WBC and MMP-9 were lowest at day 0, highest at day 1, and stabilized at an intermediate level at days 5-7. Meanwhile, PRG4 followed the opposite trend. These studies suggest that IL-6, CRP and WBC showed predictable fluctuations, with pro-inflammatory biomarkers upregulating MMP-9 and downregulating PRG4. Measuring these biomarkers may help expose the role of inflammation in the post-surgical recovery of TJA patients and in long-term pathogenesis of OA. These levels may help risk stratify patients pre-operatively and help develop individualized post-surgical plans.

Criterion validity of ultrasound in the identification of calcium pyrophosphate crystal deposits at the knee: an OMERACT ultrasound study

OBJECTIVE

To evaluate the discriminatory ability of ultrasound in calcium pyrophosphate deposition disease (CPPD), using microscopic analysis of menisci and knee hyaline cartilage (HC) as reference standard.

METHODS

Consecutive patients scheduled for knee replacement surgery, due to osteoarthritis (OA), were enrolled. Each patient underwent ultrasound examination of the menisci and HC of the knee, scoring each site for presence/absence of CPPD. Ultrasound signs of inflammation (effusion, synovial proliferation and power Doppler) were assessed semiquantitatively (0-3). The menisci and condyles, retrieved during surgery, were examined microscopically by optical light microscopy and by compensated polarised microscopy. CPPs were scored as present/absent in six different samples from the surface and from the internal part of menisci and cartilage. Ultrasound and microscopic analysis were performed by different operators, blinded to each other's findings.

RESULTS

11 researchers from seven countries participated in the study. Of 101 enrolled patients, 68 were included in the analysis. In 38 patients, the surgical specimens were insufficient. The overall diagnostic accuracy of ultrasound for CPPD was of 75%-sensitivity of 91% (range 71%-87% in single sites) and specificity of 59% (range 68%-92%). The best sensitivity and specificity were obtained by assessing in combination by ultrasound the medial meniscus and the medial condyle HC (88% and 76%, respectively). No differences were found between patients with and without CPPD regarding ultrasound signs of inflammation.

CONCLUSION

Ultrasound demonstrated to be an accurate tool for discriminating CPPD. No differences were found between patents with OA alone and CPPD plus OA regarding inflammation.

Detection of synovitis in early knee osteoarthritis by MRI and serum biomarkers in Japanese general population

To investigate synovitis' influence on early knee osteoarthritis (EKOA) by serum biomarkers and magnetic resonance imaging (MRI) findings in Japanese women. We enrolled 255 women aged 30-70 without radiographic abnormalities (Kellgren-Lawrence grade ≥ 2). Knee injury, OA outcome scores (KOOS), clinical examinations, and standing radiograph were used for classification criteria of EKOA. Participants were classified into normal knee group and EKOA group. All participants underwent MRIs of their right knee. The amount of effusion-synovitis volume was quantified. We compared serum matrix metalloproteinases-3 levels (MMP-3), high-sensitivity C-reactive protein, interleukin-6, and adiponectin between the groups. The relationship between synovitis and EOKA was investigated using multiple linear regression. Fifty-four participants (21%) were classified as EKOA. Serum MMP-3 concentration and effusion-synovitis volume were higher in patients with EKOA (p = 0.025 and p = 0.001, respectively). Effusion-synovitis volume negatively correlated with all KOOS subscales and positively correlated with serum MMP-3 concentration. Serum MMP-3 concentration was associated with effusion-synovitis volume β = 0.60, p < 0.001). There was mildly active but definitive synovitis in EKOA. This was an observational study so that no conclusions can be drawn regarding cause-effect for synovitis and symptoms. Future studies should conduct follow-up of participants with synovitis to assess the progression of knee OA.

Molecular and imaging biomarkers of local inflammation at 2 years after anterior cruciate ligament injury do not associate with patient reported outcomes at 5 years

OBJECTIVE

To estimate the association between molecular or imaging inflammatory biomarkers at 2 years after anterior cruciate ligament (ACL) injury and patient-reported outcomes at 5 years.

METHODS

For 116 ACL-injured patients, molecular biomarkers of inflammation (synovial fluid and serum cytokines) and Hoffa- and effusion-synovitis as visualized on magnetic resonance imaging (MRI) were assessed 2 years post-injury. Knee injury and Osteoarthritis Outcome Score (KOOS) and SF-36 were assessed at 2 and 5 years. We used multiple imputation to handle biomarker values that were below the level of detection or missing, and linear regression for statistical analyses.

RESULTS

None of the synovial fluid cytokines or imaging biomarkers of inflammation at 2 years were associated with any of the patient-reported outcomes at 5 years. With each log10 unit higher of serum tumor necrosis factor concentration the knee-related quality of life of KOOS was increased (i.e., better outcome) by 35 (95% confidence interval 7 to 63) points. No other serum biomarker measured at 2 years was associated with patient-reported outcome at 5 years.

CONCLUSION

Local joint inflammation assessed by biomarkers in synovial fluid and Hoffa- and effusion-synovitis on MRI at 2 years after an ACL injury did not associate with patient-reported outcomes at 5 years. Thus, chronic inflammation in the ACL-injured knee, as reflected by the biomarkers studied here, seems not to be a key determinant for the long-term patient-reported outcomes.

Early knee osteoarthritis prevalence is highest among middle-aged adult females with obesity based on new set of diagnostic criteria from a large sample cohort study in the Japanese general population

PURPOSE

A few new criteria for early detection and prevention of early knee osteoarthritis (EKOA) have been proposed. However, its prevalence, risk factors, relationship with function and prognosis have not been clarified. The purpose of this study was to investigate the prevalence of EKOA and its risk factors in the Japanese general population.

METHODS

A total of 1104 volunteers (443 males, 661 females) who participated in the Iwaki cohort study in Japan were enrolled in this cross-sectional study. Their bilateral weight-bearing anterior-posterior knee radiographs were classified by Kellgren-Lawrence (KL) grade. EKOA (KL grade 0/1) was defined according to the following criteria: knee injury and osteoarthritis outcome score < 85%, joint line tenderness, and crepitus and its prevalence among age-sex groups was calculated. Logistic regression analyses were performed to determine the risk factors for EKOA.

RESULTS

Eight hundred and twenty-two participants had KL grade 0/1, and the EKOA prevalence was 9.5% in males and 15.0% in females (p = 0.011). The prevalence of EKOA increased with age. The highest prevalence was noted in females aged 50-59 years. Logistic regression analysis showed that the risk factors for EKOA were age (p < 0.001, odds ratio (OR) 1.1), female sex (p = 0.002, OR 2.5), high body mass index (p < 0.001, OR 1.2), and history of knee injury (p < 0.001, OR 21.7).

CONCLUSIONS

The highest EKOA prevalence was observed in middle adult females (50-59 years old). The risk factors for EKOA were female sex, ageing, obesity and knee injury history, which were extremely similar to those of definitive knee osteoarthritis.

LEVEL OF EVIDENCE

Level I in diagnostic studies-investigating a diagnostic test.

Implication of HYBID (Hyaluronan-Binding Protein Involved in Hyaluronan Depolymerization) in Hyaluronan Degradation by Synovial Fibroblasts in Patients with Knee Osteoarthritis

Cell migration-inducing hyaluronidase 1 (CEMIP), also known as hyaluronan (HA)-binding protein involved in HA depolymerization (HYBID), plays a role in HA degradation. CEMIP2, also known as transmembrane protein 2 (TMEM2), possessing a sequence similarity with HYBID, is reported as a hyaluronidase in mice. However, the expression of these molecules in osteoarthritic synovium and their involvement in HA degradation in synovial fluid (SF) from patients with knee osteoarthritis remain elusive. This study examined their expression in synovial tissue and the relationship with molecular weight of HA in SF in knee osteoarthritis patients. Quantification of mRNA demonstrated that HYBID expression is significantly (5.5-fold) higher in osteoarthritic synovium than in normal control synovium, whereas TMEM2 expression level is similar between the two groups. By immunohistochemistry, HYBID was localized mainly to CD68-negative and fibroblast-specific protein 1-positive synovial lining cells and sublining fibroblasts in osteoarthritic synovium. The mRNA expression levels of HYBID, but not TMEM2, in osteoarthritic synovium positively correlated with distribution of lower-molecular-weight HA with below 1000 kDa in SF. HA-degrading activity in osteoarthritic synovial fibroblasts was abrogated by siRNA-mediated knockdown of HYBID. Among the 12 factors examined, IL-6 significantly up-regulated the HYBID expression and HA-degrading activity in osteoarthritic synovial fibroblasts. These data suggest that HYBID overexpressed by IL-6-stimulated synovial fibroblasts is implicated in HA degradation in osteoarthritic synovium.

Musculoskeletal Pain, Physical Function, and Quality of Life After Bariatric Surgery

OBJECTIVES

To evaluate the longitudinal effects of metabolic and bariatric surgery (MBS) on the prevalence of musculoskeletal and lower extremity (LE) pain, physical function, and health-related quality of life.

METHODS

The Teen Longitudinal Assessment of Bariatric Surgery study (NCT00474318) prospectively collected data on 242 adolescents undergoing MBS at 5 centers over a 3-year follow-up. Joint pain and physical function outcomes were assessed by using the Health Assessment Questionnaire Disability Index, Impact of Weight on Quality of Life - Kids, and the Short Form 36 Health Survey. Adolescents with Blount disease (n = 9) were excluded.

RESULTS

Prevalent musculoskeletal and LE pain were reduced by 40% within 12 months and persisted over 3 years. Adjusted models revealed a 6% lower odds of having musculoskeletal pain (odds ratio = 0.94, 95% confidence interval: 0.92-0.99) and a 10% lower odds of having LE pain (odds ratio = 0.90, 95% confidence interval: 0.86-0.95) per 10% reduction of BMI. The prevalence of poor physical function (Health Assessment Questionnaire Disability Index score >0) declined from 49% to <20% at 6 months (P < .05), Physical comfort and the physical component scores, measured by the Impact of Weight on Quality of Life - Kids and the Short Form 36 Health Survey, improved at 6 months postsurgery and beyond (P < .01). Poor physical function predicted persistent joint pain after MBS.

CONCLUSIONS

Joint pain, impaired physical function, and impaired health-related quality of life significantly improve after MBS. These benefits in patient-reported outcomes support the use of MBS in adolescents with severe obesity and musculoskeletal pain and suggest that MBS in adolescence may reverse and reduce multiple risk factors for future joint disease.

Changes of serum inflammatory factors and miR-145 expression in patients with osteoarthritis before and after treatment and their clinical value

BACKGROUND

Osteoarthritis is a chronic degenerative disease with an incidence of 50% in people over 65 years old and 80% in people over 80 years old worldwide. It is the second leading reason of loss of working capacity after cardiovascular diseases and severely affects the society and families. Therefore, finding biological markers related to the diagnosis and treatment of osteoarthritis is of great significance in clinical practice.

AIM

To observe the changes and clinical value of serum inflammatory factors and miR-145 expression in patients with osteoarthritis before and after treatment.

METHODS

Eighty-three patients with knee osteoarthritis (observation group) who were admitted to our hospital from April 2013 to June 2015, and 60 healthy people (control group) during the same period were selected. After 4 wk of treatment, the levels of miR-145, tumor necrosis factor (TNF)-α, interleukin (IL)-6, and IL-10 were compared between the control group and the observation group before treatment. The correlation of miR-145, TNF-α, IL-6, and IL-10 levels with visual analogue scale (VAS), Lysholm, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores was assessed by Pearson correlation analysis. The correlation of the expression of miR-145, TNF-α, IL-6, and IL-10 with Kellgren-Lawrence (K-L) grades was assessed by Spearman correlation analysis. The critical levels of miR-145, TNF-α, IL-6, and IL-10 in distinguishing different K-L grades were determined by receiver operating characteristic (ROC) curve analysis.

RESULTS

The expression level of miR-145 in the observation group was significantly higher than that in the control group before treatment (P < 0.05). After treatment, the expression level of miR-145 in the observation group was significantly lower than that before treatment (P < 0.05). The levels of TNF-α and IL-6 in the observation group were significantly higher than those in the control group (P < 0.05), and the level of IL-10 was significantly lower than that in the control group (P < 0.05). After treatment, the levels of TNF-α and IL-6 in the observation group were significantly lower than those before treatment (P < 0.05), and IL-I0 level was significantly higher than that before treatment (P < 0.05). VAS and WOMAC scores were both positively correlated with miR-145, TNF-α, and IL-6 (P < 0.05), and negatively correlated with IL-10 (P < 0.05), while Lysholm scores were negatively correlated with miR-145, TNF-α, and IL-6 (P < 0.05), and positively correlated with IL-10 (P < 0.05). K-L grades were positively correlated with miR-145, TNF-α, and IL-6 (P < 0.05), and negatively correlated with IL-10 (P < 0.05). The area under the ROC curve (AUC) and specificity of TNF-α in differentiating K-L grades I-II were the highest, which were 0.785 and 97.45%, respectively, and miR145 had the highest sensitivity of 94.59%; the AUC and sensitivity of IL-6 in differentiating K-L grades II-III were the highest, which were 0.766 and 97.30%, respectively, and TNF-α had the highest specificity of 86.68%.

CONCLUSION

MiR-145 and inflammatory factors have certain diagnostic value in osteoarthritis, and they are expected to become potential indicators for the diagnosis and evaluation of osteoarthritis in the future.

A Monosodium Iodoacetate Osteoarthritis Lameness Model in Growing Pigs

Lameness is a common problem in pigs, causing welfare issues in affected pigs and economic losses for farmers. It is often caused by osteoarthrosis (OA) in its acute or chronic form. We assessed face and construct validity of a potential model for naturally-occurring OA and its progression to chronic OA. Such a model would allow the assessment of possible interventions. Monosodium-iodoacetate (MIA) or isotonic saline was deposited in the intercarpal joint of 20 growing pigs. Functional effects were assessed using subjective (visual lameness scoring) and objective (kinetic gait analysis) techniques at several timepoints. Structural effects were assessed by histopathology at 68 days. Eight out of 10 MIA treated animals had histopathological OA lesions confirmed in the target joint, while for all saline treated animals the target joint was judged to be normal. Pressure mat analysis revealed increased asymmetric weight bearing in these animals compared to the control group on day 3, 14, 28 and 56. Visual scoring only showed a difference between groups on day 1. MIA did not cause prolonged visible lameness, thus face validity for OA under field conditions was not entirely met. Since objective gait parameters showed decreased weightbearing as a behavioral expression of pain, it may be used as a general model for movement-induced pain in pigs.

Bone marrow lesion is associated with disability for activities of daily living in patients with early stage knee osteoarthritis

Osteoarthritis of the knee (knee OA) induces pain, loss of mobility and diminished activities of daily living (ADL). Although an understanding of the pathophysiology of early stage knee OA has been developed, the structural changes associated with disability for ADL in early stage knee OA are still unclear. The aim of the present study was to examine magnetic resonance imaging (MRI)-detected changes associated with disability for ADL in patients with early stage knee OA. One hundred and thirty-two patients with early stage medial knee OA (Kellgren-Lawrence grade ≤ 2) who first visited the outpatient clinic at our university hospital were included. They were also examined by 3.0-Tesla knee MRI. The OA-associated structural changes were scored using the Whole-Organ Magnetic Resonance Imaging Score (WORMS), and clinical manifestations were evaluated by the Japanese Knee Osteoarthritis Measure (JKOM). Median quartile regression was used for the analysis. Cartilage lesion, subchondral bone attrition and osteophytes were observed in all patients. Bone marrow lesions (BMLs) and synovitis were observed in 60% and 55% of the patients, respectively. Subchondral cysts and ligament changes were observed in 6% and 17% of the patients, respectively. Pain severity of the patients was associated with medial cartilage lesions (coefficient 2.50, 95% confidence interval 0.61-4.40, p < 0.01). Disability for ADL of the patients was associated with BMLs in the medial side of the knee joint (0.82, 0.21-1.02, p = 0.04). BMLs in the medial side of the knee joint were associated with disability for ADL of patients with early stage medial knee OA.

Contribution of Infrapatellar Fat Pad and Synovial Membrane to Knee Osteoarthritis Pain

Osteoarthritis (OA) is the most common form of joint disease and a major cause of pain and disability in the adult population. Interestingly, there are patients with symptomatic OA displaying pain, while patients with asymptomatic OA that do not experience pain but show radiographic signs of joint damage. Pain is a complex experience integrating sensory, affective, and cognitive processes related to several peripheral and central nociceptive factors besides inflammation. During the last years, the role of infrapatellar fat pad (IFP), other than the synovial membrane, has been investigated as a potential source of pain in OA. Interestingly, new findings suggest that IFP and synovial membrane might act as a functional unit in OA pathogenesis and pain. The present review discuss the role of IFP and synovial membrane in the development of OA, with a particular focus on pain onset and the possible involved mediators that may play a role in OA pathology and pain mechanisms. Inflammation of IFP and synovial membrane may drive peripheral and central sensitization in KOA. Since sensitization is associated with pain severity in knee OA and may potentially contribute to the transition from acute to chronic, persistent pain in knee OA, preventing sensitization would be a potentially effective and novel means of preventing worsening of pain in knee OA.

Comparative Analysis of Peptide Composition and Bioactivity of Different Collagen Hydrolysate Batches on Human Osteoarthritic Synoviocytes

Collagen hydrolysates (CHs) are heterogeneous mixtures of collagen peptides that are often used as nutraceuticals for osteoarthritis (OA). In this study, we compared the peptide composition and pharmacological effects of three different CH preparations (CH-Alpha^®, Peptan^® B 2000 and Mobiforte^®) as well as their production batches. Our biochemical analysis using MALDI-TOF mass spectrometry and the ICPL™-isotope labelling method revealed marked differences between different CH preparations and even between some production batches of the same preparation. We also investigated the pharmacological effects of these CHs on human fibroblast-like synoviocytes (FLS). No significant effects on cultured FLS could be demonstrated for either production batch of CH-Alpha^®, Peptan^® B 2000, and Mobiforte^® analyzing a small number of pharmacological relevant targets. Thus, our study already shows for the first time that different production batches of the same CH preparation as well as different CH preparations can differ significantly in their peptide composition. In this line, further studies are also needed to verify equal pharmacological efficacy of CH batches on a much broader range of (patho)physiological relevant targets. If OA patients are to be offered a safe and effective nutraceutical a better knowledge about all potential effects as well as ensuring the same active-substance levels are a prerequisite.

Elevated High-Sensitivity C-Reactive Protein And Interleukin-6 Plasma As Risk Factors For Symptomatic Lumbar Osteoarthritis In Postmenopausal Women

AIM

To determine whether elevated high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), and erythrocyte sedimentation rate (ESR), as risk factors of symptomatic lumbar osteoarthritis (OA) in estrogen deficiency postmenopausal women.

METHODS

A case-control study was conducted between January and June 2017. The inclusion criteria include post-menopausal women with estrogen deficiency with low back pain. Exclusion criteria were: patients with a history of undergoing bilateral oophorectomy, taking hormonal replacement therapy or corticosteroid, malignancies, and lumbosacral spine trauma. The blood examinations were taken to measure IL-6 level by ELISA, hs-CRP level by spectrophotometry and ESR by modified Westergren method.

RESULTS

A group of 44 pairs of subjects were divided equally into case and control groups showed that in estrogen deficiency postmenopausal women, an increased level of hs-CRP increased the risk for symptomatic lumbar OA (OR = 2.83, CI95% = 1.065-8.776, p = 0.034). Also, a high level of IL-6 increased the risk of symptomatic lumbar OA (OR = 2.7, CI95% = 0.991-8.320, p = 0.033). No such significant findings were found for an increased ESR level.

CONCLUSION

Elevated level of plasma hs-CRP and IL-6 were concluded as risk factors for symptomatic lumbar OA in post-menopausal women.

Suitable reference gene selection for gene expression studies in knee osteoarthritis synovium using quantitative PCR analysis

Osteoarthritis (OA) is the leading cause of musculoskeletal disability in the elderly. Insights into the biological features of OA are obtained by characterization of the molecular features by gene expression profiling using reverse transcription-quantitative PCR (RT-qPCR). However, it has recently become evident that the use of suitable reference genes is required for appropriate normalization of this technique. Here total RNA was isolated from the synovium of 18 men and 20 women who underwent total knee arthroplasty for knee OA (KOA). We validated the expression stability of 7 candidate housekeeping genes (ACTB, B2M, GAPDH, HPRT1, RPL13A, SDHA, and YWHAZ) in the synovium of KOA with 3 commonly used algorithms (geNorm, NormFinder, and BestKeeper). Additionally, we evaluated expression profiles of the steroid hormone receptor (AR, ESR1, ESR2, GR, MR, and PR) and proinflammatory cytokines (IL1B and IL6) genes in the synovium and their correlations with the risk factors of KOA, using the most and least stable housekeeping genes for comparison. Results showed that HPRT1 was the most stable gene, whereas B2M was the least stable. RT-qPCR analysis revealed sexually dimorphic expression of AR, IL1B, and IL6; intercorrelations between steroid hormone receptor expression levels and female-specific correlations of IL1B expression with ESR1 and PR expression, IL6 expression with ESR1 and GR expression, and body mass index with AR and PR expression; and the choice of the least stable reference gene altered several correlations and statistical significances. In conclusion, HPRT1 was identified as the suitable reference gene for normalization in the OA synovium.

Knee pain and health-related quality of life among older patients with different knee osteoarthritis severity in Saudi Arabia

Objective

There is a lack of knowledge about health-related quality of life (HRQoL) in Saudi patients with musculoskeletal impairment, particularly among older adult populations. Thus, the current research aimed to determine the association of knee osteoarthritis (OA) severity with knee pain (KP) and HRQoL among older patients in Riyadh, Saudi Arabia.

Methods

In a multicenter cross-sectional study, we recruited 209 consecutive males and females aged ≥55 years with radiographically diagnosed knee OA from five hospitals across Riyadh, Saudi Arabia. According to the Kellgren & Lawrence classification, patients were classified into two groups: mild/moderate knee OA (n = 126) and severe knee OA (n = 83). KP and HRQoL were assessed using the pain visual analogue scale (VAS) and the 36-Item Short Form Health Survey (SF-36), respectively. A higher score on the pain VAS and the SF-36 represented worse KP and better HRQoL, respectively.

Results

Severe knee OA was significantly associated with an increased score of 3.47 (p <.0001) points on the pain VAS compared with the score reported by patients with mild/moderate knee OA. Additionally, it was significantly associated with reduced scores of 6.83 and 5.82 (both: p <.0001) points on the physical and mental composite summary subscales of the SF-36, respectively, compared with the scores of patients with mild/moderate knee OA, even after adjusting for all covariates.

Conclusion

Older patients with severe knee OA had significantly worse KP and reduced HRQoL compared to patients with mild/moderate knee conditions, even after controlling for confounders.

Association between the severity of symptomatic knee osteoarthritis and cumulative metabolic factors

BACKGROUND

The association between cumulative metabolic syndrome (MS) factors and knee osteoarthritis (KOA) has been highlighted over the past two decades.

AIMS

To clarify the relationship between cumulative MS factors and symptomatic KOA.

METHODS

A cross-sectional survey involving 119 women aged 45-88 years who were scheduled to undergo knee surgery was conducted. They were stratified into tertiles of symptoms as assessed by the Japanese Orthopedic Association score for KOA. Multinomial logistic regressions were performed using the severity of symptomatic KOA as the dependent variable and each MS factor or the cumulative MS factors as the independent variables.

RESULTS

Logistic regression analyses were performed with the upper tertile of stratified symptoms of subjects used as the reference group. After adjustment for confounders, KOA patients who had two (p = 0.004) or three or more (p < 0.0001) MS factors were significantly more likely to have severe symptoms compared to those who had no MS factors. MS factors excluding obesity were similarly analyzed. Even after additional adjustment for body mass index (BMI), KOA patients who had two or more (p = 0.005) MS factors were significantly more likely to have severe symptoms.

CONCLUSION

Among KOA female patients diagnosed using radiographic definition, the severity of symptomatic KOA was significantly associated with hypertension, dyslipidemia, and the number of MS factors after adjustment for age, BMI, strength of the knee extensor, and Kellgren-Lawrence grade. The severity of radiographic KOA was not associated with any MS factor or cumulative MS factors.

Osteoarthritis and Ageing

Ageing is a complex process of accumulation of molecular, cellular, and organ damage, leading to loss of function and increased vulnerability to disease and death, the rate and extent of which varies among individuals. Osteoarthritis (OA) is not only the most common joint disease, but is also one of the major causes of disability in people aged >65 years and is accompanied by comorbid conditions, increased mortality, and decreased quality of life. One of the major risk factors for OA is ageing. However, OA itself may be involved in the biological ageing process. This is likely to be in part a direct involvement, by contributing levels of systemic inflammation and sharing molecular pathways with biological ageing, such as mitochondrial damage leading to cell senescence. Although OA is not considered an inflammatory form of arthritis, there is evidence of subclinical low-grade inflammation in the whole joint and inflammatory processes play a key role in the disease pathogenesis. For instance, there is synovial inflammation (e.g., following injury), mechanically derived inflammation present due to biomechanical overloading of a joint, and systemic inflammation resulting from obesity. Systemic inflammation is often associated with frailty, and having a high concentration of inflammatory markers is predictive of incident frailty, some of which are known to increase with age and correlate with pain. In addition, OA may also contribute indirectly to biological ageing via the disability and pain resulting from it. Further research into the exact process linking OA and biological ageing, including frailty, is needed.

ISSLS PRIZE IN CLINICAL SCIENCE 2018: longitudinal analysis of inflammatory, psychological, and sleep-related factors following an acute low back pain episode-the good, the bad, and the ugly

STUDY DESIGN

Prospective longitudinal study.

OBJECTIVE

To determine whether systemic cytokines and C-reactive protein (CRP) during an acute episode of low back pain (LBP) differ between individuals who did and did not recover by 6 months and to identify sub-groups based on patterns of inflammatory, psychological, and sleep features associated with recovery/non-recovery. Systemic inflammation is observed in chronic LBP and may contribute to the transition from acute to persistent LBP. Longitudinal studies are required to determine whether changes present early or develop over time. Psychological and/or sleep-related factors may be related.

METHODS

Individuals within 2 weeks of onset of acute LBP (N = 109) and pain-free controls (N = 55) provided blood for assessment of CRP, tumor necrosis factor (TNF), interleukin-6 (IL-6) and interleukin-1β, and completed questionnaires related to pain, disability, sleep, and psychological status. LBP participants repeated measurements at 6 months. Biomarkers were compared between LBP and control participants at baseline, and in longitudinal (baseline/6 months) analysis, between unrecovered (≥pain and disability), partially recovered (reduced pain and/or disability) and recovered (no pain and disability) participants at 6 months. We assessed baseline patterns of inflammatory, psychological, sleep, and pain data using hierarchical clustering and related the clusters to recovery (% change in pain) at 6 months.

RESULTS

CRP was higher in acute LBP than controls at baseline. In LBP, baseline CRP was higher in the recovered than non-recovered groups. Conversely, TNF was higher at both time-points in the non-recovered than recovered groups. Two sub-groups were identified that associated with more ("inflammatory/poor sleep") or less ("high TNF/depression") recovery.

CONCLUSIONS

This is the first evidence of a relationship between an "acute-phase" systemic inflammatory response and recovery at 6 months. High inflammation (CRP/IL-6) was associated with good recovery, but specific elevation of TNF, along with depressive symptoms, was associated with bad recovery. Depression and TNF may have a two-way relationship. These slides can be retrieved under Electronic Supplementary Material.

Toward classification criteria for early osteoarthritis of the knee

OBJECTIVE

To propose draft classification criteria for early stage osteoarthritis (OA) of the knee for use in a primary care setting.

METHODS

A group of basic scientists, physician-scientists, rheumatologists, orthopedic surgeons, and physiotherapists in a workshop setting discussed potential classification criteria for early osteoarthritis of the knee. The workshop was divided into sessions around relevant topics with short state of the art presentations followed by breakout sessions, consensus discussions, and consolidation into a consensus document.

RESULTS

Three classes of criteria were agreed: (1) Pain, symptoms/signs, self-reported function, and quality of life using tools such as KOOS: scoring ≤85% in at least 2 out of these 4 categories; (2) Clinical examination: at least 1 present out of joint line tenderness or crepitus; (3) Knee radiographs: Kellgren & Lawrence (KL) grade of 0 or 1. MRI is at present not recommended as an aid to identify or define early OA in routine clinical practice or primary care, in light of the absence of validated consensus criteria and the high population prevalence of structural joint changes detected by this method. Biomarkers may have future utility in early OA classification, but no individual or set of biomarkers is yet robust enough.

CONCLUSION

Based on our consensus proposal, draft classification criteria for early OA of the knee for use in clinical studies should include patient reported outcomes such as pain and function, together with clinical signs and KL grade 0-1 on radiographs.

Serum interleukin 6 levels are associated with depressive state of the patients with knee osteoarthritis irrespective of disease severity

This cross-sectional study investigated the prevalence of depressive state and association between depressive state and serum interleukin (IL)-6 levels in knee osteoarthritis (OA) patients. A total of 115 painful knee OA patients were enrolled and divided into two groups according to the radiographic OA severity. Pain was evaluated using a visual analog scale (VAS). Depressive state was assessed by the self-rating depression scale (SDS). Serum IL-6 levels were also measured. Pearson's correlation coefficient was used to assess the correlation between the variants tested, and logistic regression analysis was used to identify factors associated with the depressive state. Fifty-two percent of the patients had an SDS score of ≥ 40, which is indicative of the depressive state. The pain VAS score (r = 0.22, p = 0.02) and serum IL-6 level (r = 0.31, p < 0.01) were independently associated with the SDS score of all early-stage knee OA patients (Kellgren-Lawrence [K/L] grade 2). However, only the serum IL-6 level was independently associated with the SDS scores of advanced-stage knee OA patients (K/L grades 3 and 4, r = 0.36, p < 0.01). A logistic regression analysis revealed that serum IL-6 level was the variable for the SDS score [odds ratio 1.41 (95% confidence interval 1.03-1.94, p < 0.03)]. Approximately half of the knee OA patients were found to be in the depressive state, and their serum IL-6 levels to be associated with the depressive state, irrespective of OA severity.

Targeting the D Series Resolvin Receptor System for the Treatment of Osteoarthritis Pain

Objective

Pain is a major symptom of osteoarthritis (OA); currently available analgesics either do not provide adequate pain relief or are associated with serious side effects. The aim of this study was to investigate the therapeutic potential of targeting the resolvin receptor system to modify OA pain and pathology.

Methods

Gene expression of 2 resolvin receptors (ALX and ChemR23) was quantified in synovium and medial tibial plateau specimens obtained from patients with OA at the time of joint replacement surgery. Two models of OA joint pain were used for the mechanistic studies. Gene expression in the joint and central nervous system was quantified. The effects of exogenous administration of the D series resolvin precursor 17(R)‐hydroxy‐docosahexaenoic acid (17[R]‐HDoHE) on pain behavior, joint pathology, spinal microglia, and astroglyosis were quantified. Plasma levels of relevant lipids, resolvin D2, 17(R)‐HDoHE, and arachidonic acid, were determined in rats, using liquid chromatography tandem mass spectrometry.

Results

There was a positive correlation between resolvin receptor and interleukin‐6 (IL‐6) expression in human OA synovial and medial tibial plateau tissue. In rats, synovial expression of ALX was positively correlated with expression of IL‐1β, tumor necrosis factor, and cyclooxygenase 2. Treatment with 17(R)‐HDoHE reversed established pain behavior (but not joint pathology) in 2 models of OA pain. This was associated with a significant elevation in the plasma levels of resolvin D2 and a significant reduction in astrogliosis in the spinal cord in the monosodium iodoacetate–induced OA rat model.

Conclusion

Our preclinical data demonstrate the robust analgesic effects of activation of the D series resolvin pathways in 2 different animal models of OA. Our data support a predominant central mechanism of action in clinically relevant models of OA pain.

Nerve growth factor regulation and production by macrophages in osteoarthritic synovium

Nerve growth factor (NGF) functions to modulate osteoarthritis (OA)-associated pain. Although recent studies suggest that tumour necrosis factor (TNF)-α and interleukin (IL)-1β mediate NGF activity in human synovial fibroblasts, the regulation of NGF expression in human synovial macrophages remains unclear. Here, we examined the role of macrophages in the production and regulation of synovial (SYN) NGF in osteoarthritic knee joints by examining the mRNA expression of TNF-α and IL-1β in freshly isolated CD14-positive (macrophage-rich fraction) and CD14-negative cells (fibroblast-rich fraction) in synovial tissue from OA patients by quantitative polymerase chain reaction. We also examined the effects of IL-1β and TNF-α on NGF mRNA expression in cultured CD14-positive (macrophage-rich fraction) and CD14-negative cells (fibroblast-rich fraction). In addition, to examine the contribution of macrophages to NGF, TNF-α and IL-1β expression, we injected clodronate liposomes systemically into STR/Ort mice, an osteoarthritis animal model, to deplete macrophages. TNF-α and IL-1β mRNA levels in CD14-positive cells from the SYN of OA patients was significantly higher than that in CD14-negative cells, while NGF expression did not differ markedly between the two cell fractions. In addition, treatment of human cultured CD14-positive and -negative cells with IL-1β and TNF-α enhanced NGF mRNA and protein levels. Expression of NGF, IL-1β and TNF-α was also reduced significantly in STR/Ort mice upon macrophage depletion. These findings suggest that IL-1β and TNF-α regulate NGF expression and production in synovial macrophages and fibroblasts in osteoarthritic joints.

Is There a Dose-Response Relationship Between Weight Loss and Symptom Improvement in Persons With Knee Osteoarthritis?

OBJECTIVE

We examined the dose-response relationship between weight reduction and pain/functional improvement in persons with symptomatic knee osteoarthritis (KOA) participating in a community-based weight loss program.

METHODS

Consecutive participants with KOA and enrolled in the 18-week Osteoarthritis Healthy Weight for Life weight-loss program were selected. In this completer-type analysis, participants were assessed at baseline, 6 weeks, and 18 weeks for body weight and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales. The dose-response relationship between weight-change categories (>10%, 7.6-10%, 5.1-7.5%, 2.6-5.0%, and <2.5% of body weight loss) and change in KOOS scores was assessed by repeated-measures analysis of variance, controlling for sex and age, body mass index (BMI), and KOOS. The Western Ontario McMaster Universities Osteoarthritis Index function score derived from the KOOS was used to assess a meaningful clinical functional improvement.

RESULTS

A total of 1,383 persons (71% females) were enrolled. Mean ± SD age, height, and weight were 64 ± 8.7 years, 1.66 ± 0.09 meters, and 95.1 ± 17.2 kg, respectively. Mean ± SD BMI was 34.4 ± 5.2 kg/m(2) with 82% of participants obese at baseline. A total of 1,304 persons (94%) achieved a >2.5% reduction in body weight. There was a significant dose-response relationship between all KOOS subscales and percentage of weight change across all weight-change categories. Participants required ≥7.7% (95% confidence interval 5.2, 13.3) body weight loss to achieve a minimal clinically important improvement in function.

CONCLUSION

There is a significant dose-response relationship between percentage of weight loss and symptomatic improvement. This study confirms the feasibility of weight loss as a therapeutic intervention in KOA in a community-based setting.

Review of Prospects of Biological Fluid Biomarkers in Osteoarthritis

Osteoarthritis (OA) is a degenerative disease of the joints and is one of the leading causes of disability in adults. However, there are no key therapeutics for OA and medical treatment is based on managing the symptoms and slowing down progression of the disease. Diagnostics based on clinical examination and radiography have provided little information about metabolic changes in joint tissues, disease onset and progression. Due to lack of effective methods for early detection and evaluation of treatment outcome, the measurement of biochemical markers (biomarkers) shows promise as a prospective method aiding in disease monitoring. OA biomarkers that are present in biological fluids such as blood, urine and synovial fluid, sources that are easily isolated from body, are of particular interest. Moreover, there are increasingly more studies identifying and developing new biomarkers for OA. In this review, efforts have been made to summarize the biomarkers that have been reported in recent studies on patients. We also tried to classify biomarkers according to tissue metabolism (bone, cartilage and synovial metabolism markers), pathological pathways (inflammatory and genetic markers) and biological function (chemokines, growth factors, acute phase proteins, etc.).

Adrenomedullin Regulates IL-1β Gene Expression in F4/80+ Macrophages during Synovial Inflammation

Adrenomedullin (AM) plays an important role in the regulation of inflammatory processes; however, the role and expression of AM in synovial inflammation have not been determined. To investigate the expression and role of AM in inflamed synovial tissue (ST), the gene expression profiles of AM in the ST, including synovial macrophages and fibroblasts, of a murine patellar surgical dislocation model were characterized. In addition, the effects of interleukin- (IL-) 1β and AM in cultured synovial cells were also examined. CD11c⁺ macrophages were found to be elevated in ST of the surgically dislocated patella. Higher gene expression of CD11c, IL-1β, AM, receptor activity-modifying proteins 2 (RAMP2), and 3 (RAMP3) was also observed in ST obtained from the dislocated side. AM expression was also significantly increased in synovial fibroblasts and macrophages in response to IL-1β treatment. Synovial macrophages also highly expressed RAMP3 compared to fibroblasts and this expression was further stimulated by exogenously added IL-1β. Further, the treatment of the F4/80-positive cell fraction obtained from ST with AM inhibited IL-1β expression. Taken together, these findings demonstrated that AM was produced by synovial fibroblasts and macrophages in inflamed ST and that increased levels of AM may exert anti-inflammatory effects on synovial macrophages.

Metabolic Response of Human Osteoarthritic Cartilage to Biochemically Characterized Collagen Hydrolysates

The most frequent disease of the locomotor system is osteoarthritis (OA), which, as a chronic joint disease, might benefit more from nutrition than acute illnesses. Collagen hydrolysates (CHs) are peptidic mixtures that are often used as nutraceuticals for OA. Three CHs were characterized biochemically and pharmacologically. Our biophysical (MALDI-TOF-MS, NMR, AFM) and fluorescence assays revealed marked differences between CHs of fish (Peptan^® F 5000, Peptan^® F 2000) and porcine (Mobiforte^®) origin with respect to the total number of peptides and common peptides between them. Using a novel dual radiolabeling procedure, no CH modulated collagen biosynthesis in human knee cartilage explants. Peptan^® F 2000 enhanced the activities of the aggrecanase ADMATS4 and ADMATS5 in vitro without loss of proteoglycan from cartilage explants; the opposite effect was observed with Mobiforte^®. Interleukin (IL)-6, matrix metalloproteinase (MMP)-1, -3 and -13 levels were elevated in explants that were treated with Mobiforte^® and Peptan^® F 5000, but not with Peptan^® F 2000. In conclusion, the heterogeneous peptide composition and disparate pharmacological effects between CHs suggest that the effect of a CH preparation cannot be extrapolated to other formulations. Thus, the declaration of a CH as a safe and effective nutraceutical requires a thorough examination of its pleiotropic effects.

Nerve Growth Factor Regulation by TNF-α and IL-1β in Synovial Macrophages and Fibroblasts in Osteoarthritic Mice

To investigate the role of macrophages as a regulator and producer of nerve growth factor (NGF) in the synovial tissue (ST) of osteoarthritis (OA) joints, the gene expression profiles of several inflammatory cytokines in the ST, including synovial macrophages and fibroblasts, of OA mice (STR/Ort) were characterized. Specifically, real-time polymerase chain reaction analysis was used to evaluate the expression of tumor necrosis factor- (TNF-) α, interleukin- (IL-) 1β, IL-6, and NGF in CD11b+ and CD11b- cells isolated from the ST of a murine OA model. The effects of TNF-α, IL-1β, and IL-6 on the expression of NGF in cultured synovial cells were also examined. The expression of TNF-α, IL-1β, IL-6, and NGF in the ST of STR/Ort was higher than that in C57/BL6J mice. Compared to the CD11b- cell fraction, higher expression levels of TNF-α, IL-1β, and IL-6 were detected in the CD11b+ cell fraction, whereas no differences in the expression of NGF were detected between the two cell fractions. Notably, TNF-α upregulated NGF expression in synovial fibroblasts and macrophages and IL-1β upregulated NGF expression in synovial fibroblasts. IL-1β and TNF-α may regulate NGF signaling in OA joints and be suitable therapeutic targets for treating OA pain.

Preoperative timed single leg standing time is associated with the postoperative activity of daily living in aged disabled patients with end-stage knee osteoarthritis at six-months after undergoing total knee arthroplasty

OBJECTIVES

The aim of the present study was to investigate the effect size (ES) of total knee arthroplasty (TKA) for the symptoms and lower limb function and identify preoperative factor(s) associated with the post-operative activity of daily living (ADL) in aged patients with end-stage knee OA undergoing TKA.

METHODS

Fifty-nine aged patients with end-stage knee OA (mean age: 74.6 years) were enrolled in this study. The symptoms and lower limb function of the patients were evaluated using the Japanese Knee Osteoarthritis Measure (JKOM), the timed up and go (TUG) test and timed single-legged stance test with eyes open (TSLS) before and after six months from the operation.

RESULTS

While the ES of TKA for the improvement of pain was 2.83, the ES of TKA for the improvement of ADL, TUG and TSLS were 1.30, 0.59, and 0.49, respectively. While the post-operative ADL score was not associated with the preoperative ADL or pain scores, it was associated with the preoperative TUG and TSLS scores. A multiple regression analysis revealed that the one preoperative factor associated with the postoperative ADL was the TSLS.

CONCLUSION

The preoperative TSLS is associated with the postoperative ADL in aged disabled patients with end-stage knee OA.

Plasma and synovial fluid inflammatory cytokine profiles in primary knee osteoarthritis

OBJECTIVE

The objective of this study is to compare inflammatory cytokine levels in primary knee osteoarthritis (OA) patients and healthy controls.

METHODS

A total of 32 knee OA patients and 14 healthy controls were enrolled. A multiplex immunoassay was utilized for 10 cytokines in plasma and synovial fluid.

RESULTS

Plasma IL-2, IL-4, and IL-6 concentrations were significantly greater in knee OA patients than controls. Moreover, both plasma IL-4 and IL-6 were positively correlated with the radiographic severity of knee OA.

CONCLUSIONS

Plasma IL-4 and IL-6 may serve as biomarkers reflecting the severity of OA.

Bone marrow lesions, subchondral bone cysts and subchondral bone attrition are associated with histological synovitis in patients with end-stage knee osteoarthritis: a cross-sectional study

OBJECTIVE

The aim of this study was to examine the osteoarthritis (OA)-related structural changes associated with histological synovitis in end-stage knee OA patients.

METHODS

Forty end-stage knee OA patients (female: 88%, mean age: 71.8 y) were enrolled. All participants underwent 3.0-T MRI. The structural changes, such as cartilage morphology, subchondral bone marrow lesion (BML), subchondral bone cyst (SBC), subchondral bone attrition (SBA), osteophytes, meniscal lesion and synovitis, were scored using the whole-organ MRI scoring (WORMS) method. Synovial samples were obtained from five regions of interest (ROIs) of the knee joint during total joint replacement surgery. The associations between the histological synovitis score (HSS) and WORMS or the synovial expression levels of cyclooxygenase (COX)-2, interleukin (IL)-1β, IL-6 and transforming growth factor (TGF)-β were examined using Spearman's correlation coefficient.

RESULTS

Among the seven OA-related structural changes, the BML, SBC, SBA and synovitis were significantly associated with the HSS (r = 0.33, 0.35, 0.48 and 0.36, respectively), while other morphological changes were not. Although synovial COX-2, IL-1β or IL-6 expression levels were not associated with the HSS, the synovial TGF-β expression levels were associated with the HSS.

CONCLUSION

The presence of BML, SBC and SBA was associated with histological synovitis in end-stage knee OA patients.

Synovial macrophage-derived IL-1β regulates the calcitonin receptor in osteoarthritic mice

Recent studies have reported that calcitonin gene-related peptide (CGRP) contributes to joint pain. However, regulation of the CGRP/CGRP receptor signalling in osteoarthritis (OA) is not fully understood. To investigate the regulation of CGRP/CGRP receptor signalling by macrophages in the synovial tissue (ST) of OA joints, we characterized the gene expression profiles of CGRP and CGRP receptors in the ST of OA mice (STR/Ort). In addition, we examined whether macrophage depletion by the systemic injection of clodronate-laden liposomes affected the expression of CGRP and CGRP receptors in ST. CD11c(+) macrophages in the ST of STR/Ort and C57BL/6J mice were analysed by flow cytometry. Real-time polymerase chain reaction (PCR) was used to evaluate the expression of interleukin (IL)-1β, CGRP, calcitonin receptor-like receptor (CLR) and receptor activity-modifying protein 1 (RAMP1) in F4/80(+) and F4/80(-) cells. The effects of IL-1β on the expression of CGRP and CLR by cultured synovial cells were also examined. The percentage of CD11c(+) macrophages in the ST of STR/Ort was higher than that in C57/BL6J mice. Notably, the F4/80(+) cell fraction expressed IL-1β highly, whereas the F4/80(-) cell fraction expressed CGRP, CLR, and RAMP1 highly. In addition, expression of the IL-1β and CLR genes was increased in ST, but was decreased upon macrophage depletion, and the IL-1β treatment of cultured synovial cells up-regulated CLR. Taken together, the present findings suggest that synovial macrophages are the major producers of IL-1β and regulators of CLR in OA mice. Therefore, macrophages and IL-1β may be suitable therapeutic targets for treating OA pain.

Serum hyaluronic acid concentration predicts the progression of joint space narrowing in normal knees and established knee osteoarthritis - a five-year prospective cohort study

Introduction

Serum hyaluronic acid (sHA) is a serum biomarker for knee osteoarthritis (OA). Although sHA concentration is elevated in patients with knee OA, the relationship between serum concentration and disease progression remains unclear. We examined the relationship between sHA concentration and radiographic progression of knee OA in a cohort of individuals followed for 5 years.

Methods

We prospectively enrolled 444 individuals and measured their sHA concentrations at baseline. Anterior-posterior weight bearing knee radiographs were obtained at baseline and the 5-year endpoint. Osteoarthritic knee changes were classified according to Kellgren–Lawrence (KL) grade, and joint space narrowing (JSN) was measured using a Knee Osteoarthritis Computer-Aided Diagnosis (KOACAD) system. Correlations between sHA concentration, progression in KL grade, and JSN were assessed using regression models, taking into account potentially confounding factors.

Results

OA progressed from KL grades 0 or 1 in 129 of the 323 knees, and from KL grades 2 or 3 in 61 of the 119 knees. Higher sHA concentrations were correlated with KL grade progression (p = 0.004). The mean JSN, as assessed by KOACAD over 5 years, was 0.23 ± 0.55 mm, and sHA concentration was positively correlated with progression of JSN in KL grades 0 or 1 (p = 0.021) and KL grades 2 or 3 (p = 0.008) knees.

Conclusion

Serum HA concentration was positively correlated with progression of KL grade. sHA was also positively correlated with progression of JSN in knees with and without OA, suggesting that sHA concentration may be a useful predictor of knee OA progression.

Multivariate Radiological-Based Models for the Prediction of Future Knee Pain: Data from the OAI

In this work, the potential of X-ray based multivariate prognostic models to predict the onset of chronic knee pain is presented. Using X-rays quantitative image assessments of joint-space-width (JSW) and paired semiquantitative central X-ray scores from the Osteoarthritis Initiative (OAI), a case-control study is presented. The pain assessments of the right knee at the baseline and the 60-month visits were used to screen for case/control subjects. Scores were analyzed at the time of pain incidence (T-0), the year prior incidence (T-1), and two years before pain incidence (T-2). Multivariate models were created by a cross validated elastic-net regularized generalized linear models feature selection tool. Univariate differences between cases and controls were reported by AUC, C-statistics, and ODDs ratios. Univariate analysis indicated that the medial osteophytes were significantly more prevalent in cases than controls: C-stat 0.62, 0.62, and 0.61, at T-0, T-1, and T-2, respectively. The multivariate JSW models significantly predicted pain: AUC = 0.695, 0.623, and 0.620, at T-0, T-1, and T-2, respectively. Semiquantitative multivariate models predicted paint with C-stat = 0.671, 0.648, and 0.645 at T-0, T-1, and T-2, respectively. Multivariate models derived from plain X-ray radiography assessments may be used to predict subjects that are at risk of developing knee pain.