Yet more evidence that osteoarthritis is not a cartilage disease.
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Cartilage Diseases↗
Biomedical subjects
P A Dieppe
Publications and source records attributed to P A Dieppe.
Analysis of regional variation in hip and knee joint replacement rates in England using Hospital Episodes Statistics.
OBJECTIVES: Total hip and knee joint replacements are effective interventions for people with severe arthritis, and demand for these operations appears to be increasing as our population ages. This study explores regional variations in health care and inequalities in the provision of these expensive interventions, which are high on the UK Government's health agenda. STUDY DESIGN: The Hospital Episode Statistics (HES) for England were analysed. The HES database holds information on patients who are admitted to National Health Service (NHS) hospitals in England. METHODS: Age-standardized procedure rates were calculated using 5-year age groups with the English mid-year population of 2000 as the reference. Univariate associations between age-standardized operation rates and regional characteristics were assessed using Pearson's correlation coefficient. RESULTS: Age and sex-standardized surgery rates vary by 25-30%. For both hip and knee replacement, rates are highest in the South West and Midlands and lowest in the North West, South East and London regions. In the case of knee replacement, there are also marked differences in the sex ratios between regions. The variable that explained most variation in hip replacement rates was the proportion of older people in the region. In the case of knee replacement, the number of NHS centres offering surgery in the region was the main explanatory variable, with regions with fewer centres having the highest provision rates. CONCLUSION: These data can help to inform planning of services. They suggest that there may be inequities as well as inequalities in the provision of primary joint replacement surgery in England.
Aged↗
Is progressive osteoarthritis an atheromatous vascular disease?
Growing evidence from epidemiological studies suggests that osteoarthritis (OA) is linked to atheromatous vascular disease. This hypothesis article proposes that OA, or at least OA structural progression, may be an atheromatous vascular disease of subchondral bone. Further epidemiological studies, imaging investigations of relevant blood vessels, and trials of the effects of statins on the prevention and treatment of OA are needed to examine this hypothesis.
Atherosclerosis↗
Outcomes of total knee replacement: a qualitative study.
OBJECTIVE: To investigate patients' experiences of outcome from a total knee replacement (TKR). METHODS: In-depth interviews were conducted with 25 patients 3 months before TKR, with 10 interviewed again 6 months after surgery. Patients were purposively sampled to include a range of demographic characteristics. Interviews were audiotaped and transcribed. Methods of constant comparison were used to analyse the data. RESULTS: Individuals struggled to make sense of their outcome and often described it in contradictory terms. When asked directly, most reported a good outcome, but further discussion revealed concern and discomfort with continuing pain and mobility difficulties. These apparently contradictory accounts were consistent with the presentation of public and private views, were dependent on the context of patients' lives, and represented an adaptation to their changed health state. CONCLUSION: Individuals reported their outcome from TKR as good despite the continued experience of pain and immobility. Although TKR has been shown to be a highly effective procedure using quantitative methods, they may need to be qualified by these qualitative findings.
Adult↗
Measurement of cartilage volumes in rheumatoid arthritis using MRI.
MRI is a valuable imaging modality for assessment of the articular cartilage in rheumatoid arthritis (RA) and is potentially of use in monitoring disease progression and response to therapy. In this study, we investigated the sources of error in volume measurements obtained by segmentation of MR images of knee cartilage in patients with RA and followed cartilage volume in a group of RA patients for 12 months. 23 RA patient volunteers were recruited for knee imaging. Six subjects were imaged at baseline only, six were imaged at baseline and again within an hour in the same imaging session, six subjects were imaged at baseline and 7 days, and 17 subjects were imaged at baseline, 4+/-2 months and 12 months. Imaging was performed at 1.0 T using a three-dimensional spoiled gradient-echo sequence with fat-suppression. Manual image segmentation was performed once or twice on the lateral tibial, medial tibial, patellar and femoral compartment by either one or two segmenters. Coefficients of variation (CoV) for repeated volume measurement of total cartilage were 2.2% (same segmenter, same scan), 5.2% (different segmenter, same scan), 4.9% (same segmenter, different scan, same session), and 4.4% (same segmenter, different scan, different session). Over the 12 month duration of the study there was no significant change in total cartilage volume, nor were there significant changes in volume in any individual compartment. This measurement technique is reproducible, but any net change in cartilage volume over 1 year is very small.
Adult↗
Unmet need for joint replacement: a qualitative investigation of barriers to treatment among individuals with severe pain and disability of the hip and knee.
OBJECTIVE: To explore barriers to health-care utilization in respondents with moderate to severe hip/knee symptoms of pain and disability. METHODS: In-depth interviews were carried out with 27 participants who had high levels of hip/knee pain and disability (according to New Zealand scores). There were 10 men and 17 women; median age 76 yr (range 51-91). The data were analysed thematically using the constant comparison technique. RESULTS: Three types of barrier were identified: (i) people's own perceptions of need and reluctance to seek treatment, (ii) perceptions and experiences of primary care and (iii) experiences of treatment in secondary care. Pessimism about availability of treatments, and concerns about effectiveness and risks of surgery, made older people reluctant to seek medical help. Such views were often confirmed by GPs. Some of those referred to a hospital specialist were told that they were too young or too mobile for surgery. CONCLUSION: Barriers to treatment and unmet need for joint replacement exist in the UK, particularly amongst older people.
Age Factors↗
No loss of cartilage volume over three years in patients with knee osteoarthritis as assessed by magnetic resonance imaging.
OBJECTIVE: Magnetic resonance imaging (MRI) has the potential to provide accurate quantification of structural changes in joint disease, with sensitivity to change, as it can provide direct visualization of the cartilage and bone. In this study, we investigated whether knee cartilage volume, as assessed by MRI, is sensitive to change over time in patients with osteoarthritis (OA). DESIGN: Sixteen patient volunteers (10 male, six female) with established OA of the knee were entered into the study and demographic data recorded. At baseline, 12 months and 37+/-2 months, patients underwent simple measures of disease severity, as well as extended weight-bearing AP knee X-rays. In addition the patient's index knee was imaged using MR at 1.0 T using a 3-D spoiled gradient-echo sequence with fat-suppression, repetition time 50 ms, echo time 11 ms, flip-angle 40 degrees, sagittal slice thickness 1.56 mm and in-plane pixel resolution 0.55 mm. Manual image segmentation was performed on all knee cartilage compartments and the respective cartilage volumes determined. RESULTS: Eleven of the original patients recruited completed the 3-year study. Radiographic features indicated that the majority had a spectrum of well-established OA at entry. The average decrease in medial tibiofemoral joint space width was 0.21+/-0.37 mm (mean+/-S.D.). Comparison of MR images at baseline and 37+/-2 months indicated little evidence of cartilage lesion shape or size change in any of the compartments. There was no significant MRI volume change in any of the knee cartilage compartments over the course of 1 year. The change in total knee cartilage volume, as measured by MRI, was a loss of only 1.6%, or 0.36+/-1.3 ml (mean+/-S.D.), over the 3 years. CONCLUSIONS: The failure to identify loss of cartilage volume over 3 years in this cohort of patients with established knee OA using MRI challenges the face validity of this endpoint to assess structural changes in OA.
Aged↗
Who should have priority for a knee joint replacement?
OBJECTIVES: To explore patients' views on who should have priority for total knee replacement (TKR). METHODS: In-depth, semistructured interviews were conducted with 25 patients on the waiting list for a TKR. RESULTS: All participants were willing to comment on waiting lists and prioritization for TKR. Two major themes emerged: what they thought should happen, and what they thought did happen. They thought that priority should be based on length and degree of suffering, pain severity, immobility, paid employment, payment of National Insurance contributions, and caring for dependants. In contrast, they thought that what actually happened depended on age and weight, excessive complaining and access to private practice. CONCLUSIONS: The participants agreed with health professionals that pain and disability should be key criteria on which to prioritize people for a TKR. However, they also argued for a fair decision-making process that also included additional factors specific to the patient's circumstances. Criteria to aid prioritization for joint surgery need to accommodate the views of patients as well as professionals.
Adult↗
Variations in cartilage catabolism in different equine joints in response to interleukin-1 in vitro.
An explant system was used to investigate the hypothesis that cartilage from different equine joints might respond differently to challenge with interleukin-1alpha (IL-1alpha). Pairs of normal cartilage samples were taken from the metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints of six horses. One of each pair was stimulated with 10 ng/ml human recombinant IL-1alpha for three days, and the supernatants and remaining cartilage explants were analysed for their total content of glycosaminoglycans. A significantly higher percentage of glycosaminoglycans was released from the cartilage of the proximal and distal interphalangeal joints than from the metacarpophalangeal joint.
Animals↗
Effect of alignment of the medial tibial plateau and x-ray beam on apparent progression of osteoarthritis in the standing anteroposterior knee radiograph.
OBJECTIVE: Previous studies of knee osteoarthritis (OA) have yielded variable estimates of the rate of joint space narrowing (JSN) in the standing anteroposterior (AP) radiograph, due largely to longitudinal changes in the alignment of the medial tibial plateau (MTP) and x-ray beam. To characterize this bias, we examined serial radiographs of subjects with knee OA in population-based and clinical OA cohorts from 3 locations in the United States and the United Kingdom. METHODS: Radiographic features of knee OA (e.g., osteophytosis, JSN) and MTP alignment in 428 OA knees were evaluated by consensus of 2 readers. Alignment was considered satisfactory if the anterior and posterior margins of the MTP were superimposed within 1 mm. Readers were blinded to subject identity, and films were read in random order. The minimum medial joint space width was also measured manually (standard error of repeated measurements 0.20 mm) in serial knee images. RESULTS: Only 14% of serial radiographs exhibited alignment of the MTP in both images. In OA knees with satisfactory alignment in both images, the mean rate of JSN over 2-3 years (0.26 mm/year) was significantly larger (P = 0.004) than that in OA knees with misalignment in 1 or both radiographs and was 86% more rapid than the mean JSN in all OA knees. Moreover, the within-group standard deviation of JSN was significantly smaller among knees with reproduced alignment of the MTP than in knees in which misalignment occurred in 1 or both images (P = 0.006). CONCLUSION: Poor standardization of knee positioning in serial standing AP radiographs in previous studies of OA progression has obscured the rate and variability of articular cartilage loss in subjects with knee OA. True JSN (i.e., JSN that is not attributable to longitudinal changes in the alignment of the MTP with the x-ray beam in serial radiographic examinations) may occur more rapidly, and with less between-subject variability, than that previously thought to be characteristic of knee OA.
Aged↗
Concerns about the methodology used in developing the 2000 update of the American College of Rheumatology recommendations for management of hip and knee osteoarthritis.
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Humans↗
Cross-sectional comparison of synovial fluid biochemical markers in equine osteoarthritis and the correlation of these markers with articular cartilage damage.
OBJECTIVE: To investigate the relationship between biochemical markers in the synovial fluid of osteoarthritic and contralateral equine joints and gross articular cartilage pathology. DESIGN: Twenty-two horses underwent bilateral arthroscopy of their carpal or metacarpophalangeal joints following recent onset lameness. The degree of cartilage damage in each joint was scored and synovial fluid, from both the clinically affected and the contralateral joint, was collected. Bone specific alkaline phosphatase (BAP), 5D4 epitope of keratan sulphate (KS), total glycosaminoglycans (GAG) and hyaluronan (HA) were measured. RESULTS: The mean age of the horses was 4.1 years and the maximum duration of lameness was three months. Joints examined were midcarpal, antebrachiocarpal and metacarpophalangeal. The median concentration (semi-interquartile range) of BAP was significantly higher in the clinically active joint than in the contralateral joint, 21.75 (6.22) vs. 12.35 (4.07) units, while the other biomarkers measured were significantly lower in the clinically active joint than in the contralateral joint, i.e. KS 8.79 (1.96) microg/ml vs. 16.39 (5.65) microg/ml, KS:GAG ratio 0.19 (0.04) vs. 0.31 (0.10) and HA 741.6 (222) microg/ml vs. 1061.75 (325) microg/ml. BAP was positively (R=0.57), and KS (R=-0.57) and KS:GAG ratio (R=-0.49) were negatively correlated to the degree of cartilage damage within the joint. CONCLUSION: The correlation between articular cartilage damage and synovial fluid BAP and KS imparts validity to their potential use as non-invasive diagnostic aids in equine osteoarthritis (OA). The positive correlation between BAP and cartilage damage suggests that there is a link between bone turnover and cartilage damage in OA.
Alkaline Phosphatase↗
Osteoarthritis: new insights. Part 2: treatment approaches.
Osteoarthritis is the most common form of arthritis, affecting millions of people in the United States. It is a complex disease whose etiology bridges biomechanics and biochemistry. Evidence is growing for the role of systemic factors, such as genetics, diet, estrogen use, and bone density, and local biomechanical factors, such as muscle weakness, obesity, and joint laxity. These risk factors are particularly important in the weight-bearing joints, and modifying them may help prevent osteoarthritis-related pain and disability. Major advances in management to reduce pain and disability are yielding a panoply of available treatments ranging from nutriceuticals to chondrocyte transplantation, new oral anti-inflammatory medications, and health education. This article is part 2 of a two-part summary of a National Institutes of Health conference that brought together experts in osteoarthritis from diverse backgrounds and provided a multidisciplinary and comprehensive summary of recent advances in the prevention of osteoarthritis onset, progression, and disability. Part 2 focuses on treatment approaches; evidence for the efficacy of commonly used oral therapies is reviewed and information on alternative therapies, including nutriceuticals and acupuncture, is presented. Biomechanical interventions, such as exercise and bracing, and behavioral interventions directed toward enhancing self-management are reviewed. Current surgical approaches are described and probable future biotechnology-oriented approaches to treatment are suggested.
Acupuncture Therapy↗
Osteoarthritis: new insights. Part 1: the disease and its risk factors.
Osteoarthritis is the most common form of arthritis, affecting millions of people in the United States. It is a complex disease whose etiology bridges biomechanics and biochemistry. Evidence is growing for the role of systemic factors (such as genetics, dietary intake, estrogen use, and bone density) and of local biomechanical factors (such as muscle weakness, obesity, and joint laxity). These risk factors are particularly important in weight-bearing joints, and modifying them may present opportunities for prevention of osteoarthritis-related pain and disability. Major advances in management to reduce pain and disability are yielding a panoply of available treatments ranging from nutriceuticals to chondrocyte transplantation, new oral anti-inflammatory medications, and health education. This article is part 1 of a two-part summary of a National Institutes of Health conference. The conference brought together experts on osteoarthritis from diverse backgrounds and provided a multidisciplinary and comprehensive summary of recent advances in the prevention of osteoarthritis onset, progression, and disability. Part 1 focuses on a new understanding of what osteoarthritis is and on risk factors that predispose to disease occurrence. It concludes with a discussion of the impact of osteoarthritis on disability.
Age Distribution↗
Diurnal variation in the femoral articular cartilage of the knee in young adult humans.
Our objective was to test the hypothesis that diurnal changes occur in thickness or volume of the femoral articular cartilage of the knee in asymptomatic young adults. Fat-suppressed three-dimensional (3D) spoiled gradient-echo magnetic resonance imaging (MRI) was employed. Six volunteers each were scanned early in the morning and at the end of a working day spent mainly standing. This protocol was repeated on 3 successive weeks. Femoral cartilage volumes were obtained via semiautomatic segmentation that employed a seeding algorithm. These segmentations then were regridded onto a 500-pixel template, and differences in the resulting thickness maps were assessed. Analysis of variance showed no significant diurnal variation in overall volume or thickness. The reproducibility for volume (test-retest coefficient of variation) was 1.6%. There were, however, statistically-significant diurnal changes in the thickness maps. Cartilage thickness decreased by up to 0.6 mm during the day in each of the following three specific locations: the patellofemoral compartment, the lateral tibiofemoral compartment, and the medial tibiofemoral compartment. Elsewhere, cartilage thickness was unchanged or increased by up to 0.5 mm. We conclude that, in asymptomatic young adults, cartilage volume does not change during the day; however, the cartilage does become thinner in locations that encounter the greatest biomechanical force.
Adult↗
Risk factors for the incidence and progression of radiographic knee osteoarthritis.
OBJECTIVE: Preventive strategies against knee osteoarthritis (OA) require a knowledge of risk factors that influence the initiation of the disorder and its subsequent progression. This population-based longitudinal study was performed to address this issue. METHODS: Ninety-nine men and 255 women aged > or =55 years had baseline interviews and weight-bearing knee radiographs in 1990-1991. Repeat radiographs were obtained in 1995-1996 (mean followup duration 5.1 years, median age at followup 75.8 years). Risk factors assessed at baseline were tested for their association with incident and progressive radiographic knee OA by logistic regression. RESULTS: Rates of incidence and progression were 2.5% and 3.6% per year, respectively. After adjusting for age and sex, the risk of incident radiographic knee OA was significantly increased among subjects with higher baseline body mass index (odds ratio [OR] 18.3, 95% confidence interval [95% CI] 5.1-65.1, highest versus lowest third), previous knee injury (OR 4.8, 95% CI 1.0-24.1), and a history of regular sports participation (OR 3.2, 95% CI 1.1-9.1). Knee pain at baseline (OR 2.4, 95% CI 0.7-8.0) and Heberden's nodes (OR 2.0, 95% CI 0.7-5.7) were weakly associated with progression. Analyses based on individual radiographic features (osteophyte formation and joint space narrowing) supported differences in risk factors for either feature. CONCLUSION: Most currently recognized risk factors for prevalent knee OA (obesity, knee injury, and physical activity) influence incidence more than radiographic progression. Furthermore, these factors might selectively influence osteophyte formation more than joint space narrowing. These findings are consistent with knee OA being initiated by joint injury, but with progression being a consequence of impaired intrinsic repair capacity.
Aged↗
Increased serum C reactive protein may reflect events that precede radiographic progression in osteoarthritis of the knee.
OBJECTIVE: Raised serum C reactive protein (CRP) and hyaluronate (HA) concentrations predict the progression of knee osteoarthritis (OA) in the long term but the consistency of these relations with time is unknown. The purpose of this work was therefore to determine if raised CRP and HA at entry and three years before entry (-3 years) predict radiological progression of knee OA in a group of patients between entry and five years. METHODS: Knee radiographs from 90 patients with knee OA at entry and five years follow up were assessed for progression of disease over five years. The concentrations of serum CRP and HA were measured at entry (n=90) and also in 40 serum samples available from -3 years. Odds ratios (OR) for predicting progression were calculated by logistic regression. RESULTS: Serum CRP at entry was not predictive of progression between entry and five years (OR 1.12, 95% CI 0.81, 1.55) but serum CRP at -3 years was predictive of progression (OR 1.90, 95% CI 1.01, 3.28). Serum HA concentration at entry predicted progression between entry and five years (OR 2.32, 95% CI 1.16, 4.66). CONCLUSION: These results are consistent with previous reports relating to HA, and suggest that raised serum CRP reflects events that precede a period of later radiographic progression in knee OA. However, because of the large overlap between groups, the serum CRP or HA concentration are not good predictors of individual patient progression and have a poor sensitivity and specificity.
Aged↗
EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).
BACKGROUND: Osteoarthritis (OA) is the most common joint disease encountered throughout Europe. A task force for the EULAR Standing Committee for Clinical Trials met in 1998 to determine the methodological and logistical approach required for the development of evidence based guidelines for treatment of knee OA. The guidelines were restricted to cover all currently available treatments for knee OA diagnosed either clinically and/or radiographically affecting any compartment of the knee. METHODS: The first stage was the selection of treatment modalities to be considered. The second stage comprised a search of the electronic databases Medline and Embase using a combination of subject headings and keywords. All European language publications in the form of systematic reviews, meta-analyses, randomised controlled trials, controlled trials, and observational studies were included. During stage three all the relevant studies were quality scored. The summary statistics for validated outcome measures, when available, were recorded and, where practical, the numbers needed to treat and the effect size for each treatment were calculated. In the fourth stage key clinical propositions were determined by expert consensus employing a Delphi approach. The final stage ranked these propositions according to the available evidence. A second set of propositions relating to a future research agenda was determined by expert consensus using a Delphi approach. RESULTS: Over 2400 English language publications and 400 non-English language publications were identified. Seven hundred and forty four studies presented outcome data of the effects of specific treatments on knee OA. Quantitative analysis of treatment effect was possible in only 61 studies. Recommendations for the management of knee OA based on currently available data and expert opinion are presented. Proposals for a future research agenda are highlighted. CONCLUSIONS: These are the first clinical guidelines on knee OA to combine an evidence based approach and a consensus approach across a wide range of treatment modalities. It is apparent that certain clinical propositions are supported by substantial research based evidence, while others are not. There is thus an urgent need for future well designed trials to consider key clinical questions.
Combined Modality Therapy↗