Kinesiophobia and Outcomes of Lower Extremity Exercise Regime in Subjects with Knee Osteoarthritis: A Case Series

Aim: To estimate the effectiveness of lower limb exercise regime in subjects with knee osteoarthritis in terms of Kinesiophobia. Methodology: This was a case series, conducted in the Physiotherapy Department Health Centre University of the Punjab Lahore after ethical approval from June 2018 to February 2019 on 44 patients with knee Osteoarthritis. Non-probability purposive sampling technique was used to enroll the participants according to predefined inclusion and exclusion criteria. Lower limb exercise regime was applied for eight weeks, thrice a week. TAMPA scale for Kinesiophobia (TSK), KOOS and 6 min walk test (6MWT) were used to measure the outcomes. Paired sample T test was applied to find the difference before and after LLEP. Statistical significance was set at P= 0.05 Results: Mean age of the participants was 52±6.54 years ranging from 41-65 years. The mean difference in pre and post treatment KOOS Score was 15.13±12.38 (P=.000), 14.34±7.97 (P=.000) for TAMPA Score and 196.00±94.01 (P=.000) for 6 Mint walk distance. Conclusion: Lower limb exercise program is found effective in the management of knee osteoarthritis. Subjects undergoing in 8 weeks lower limb exercise program showed improvement in KOOS Score, reduction in TAMPA Score, and improvement in 6 mint walk distance. Keywords: Knee Osteoarthritis, Kinesiophobia, TAMPA, knee osteoarthritis outcome score (KOOS), Lower limb exercise regime,

Correlation of Exercise Capacity with Functional Disability in Patients with Osteoarthritis of Knee

Introduction: Osteoarthritis of knee is a progressive joint disease which produces pain, inflammation and destruction of joint which in turn leads to range of motion limitation and walking disabilities. Affection in physical functioning is determined not only by just activities involving lower limb capacity but also by the activities which require use of upper extremities. Hence in this study, 6MWD and no. of rings moved in 6 minutes were taken as an outcome measures for determining the exercise capacity. KOOS is a self-administered questionnaire which was used in its cross culturally adapted format for determining the functional disability in patients. Objectives: 1. To study correlation of exercise capacity with functional disability in patients with osteoarthritis of knee. 2. To study correlation of upper limb exercise capacity with lower limb exercise capacity in patients with osteoarthritis of knee. Methods: Cross sectional, observational study including 30 patients of either gender having unilateral osteoarthritis of knee conducted in a tertiary care hospital. Results: No. of rings moved in 6 minutes and global KOOS score showed no statistically significant correlation. 6MWD and global KOOS score showed no statistically significant correlation. 6 minute walk distance and 6 minute peg board ring test showed no statistically significant correlation. Conclusion: The study suggests that there is no correlation of exercise capacity with functional disability in patients with osteoarthritis of knee. Also, there is no correlation found between upper limb exercise capacity and lower limb exercise capacity in patients with osteoarthritis of knee. KEY WORDS: Knee osteoarthritis, Knee pain, squat depth, functional disability, cardiorespiratory endurance, Knee Injury and Osteoarthritis Outcome Score, Quality of life.

Pre-TKR isokinetic quadriceps strengthening has a positive effect which may diminish following the intervention despite pain and functional improvements: A case study

We report a longitudinal survey of a 53-year-old man suffering from right knee osteoarthritis who has undergone total knee replacement (TKR). We aimed at evaluating the effect of a short preoperative isokinetic strengthening program on the functional status, pain, and quadriceps and hamstrings strength before and after TKR. The patient performed a 4-week (6 sessions) preoperative isokinetic strengthening program of the quadriceps and hamstrings. The findings for the concentric strength at 60∘/s, 6-minute walk test (6MWT), and Knee injury and Osteoarthritis Outcome Score (KOOS) were recorded. At baseline the patient presented with an overall KOOS score of 44%, a 6MWT of 444 m, a 63% and 21% strength deficits of the quadriceps and hamstrings, respectively. Following the strengthening program, the quadriceps strength of the operated limb improved (+121 Nm; +83%), but the function as reflected by the KOOS score remained unchanged. Following the TKR, the concentric isokinetic strength of the quadriceps reappeared altered (63% of deficit) despite pain and functional improvements. This case report underlines the importance of functional evaluation rather than the maximal strength to assess the effectiveness of TKR. However, further studies are necessary to conceptualize the meaning of maximal strength measurement and the impact of associated deficits, if any.

Does Preoperative Balance Training Reduce Pain and Improve Joint Function in Patients After Total Knee Arthroplasty? A Randomized Controlled Trial

Background Part of patients undergoing TKA did not achieve the expected physiological function results. The purpose of this study was to investigate whether preoperative balance training can reduce pain and improve joint function after TKA.Methods 100 patients with knee osteoarthritis (OA) prepared for TKA, according to the inclusion and exclusion criteria, were randomly divided into balance training group (50 patients) and control group (50 patients). The main evaluation outcomes of the study included early functional milestones, ROM, WOMAC score, keen society score (KSS), KOOS score, and complications at 1 month (baseline) and 1 day before surgery, 6 weeks (main endpoint) and 52 weeks (1 year) after surgery.Results 4 patients lost to follow-up at 1 month before surgery, 96 received planned surgery and 86 underwent a complete postoperative evaluation. After TKA, many indicators of the two groups, including WOMAC score, KSS, KOOS score, were significantly improved compared with before surgery. At 52 weeks after TKA, no statistically significant difference between the balance training group and control group in attain early functional milestones, ROM, WOMAC score, KSS, KOOS score, and complications; however, at 6 weeks after surgery, balance training group had better early benefits in stopping all narcotics (P = 0.045), relieving pain (P = 0.037), improving function (P = 0.017) and quality of life (QOL) (P = 0.028).Conclusions Although there were no difference between preoperative balance training group and control group at the 52 weeks after surgery, however, preoperative balance training can relieve pain and improve function in the early stage (6 weeks), but adequately statistically powered trials are needed to confrm the accuracy of the study resultsTrial Registration ChiCTR2000032789.

Early Clinical and Radiological outcomes of the New Anatomic Knee System : Minimum 3-year Follow-up.

Background: For total knee arthroplasty (TKA), implant design and proper coverage are important for achieving patient satisfaction. An asymmetrical anatomic implant (Persona® knee system, Zimmer Biomet, Warsaw, Indiana) enables accurate coverage and minimal bone cutting. This study aimed to analyze the clinical and radiological outcomes of TKA using an asymmetrical anatomic implant over a minimum 3-year follow-up.Methods: The medical records of 94 patients who underwent 132 TKAs using the Persona® knee system, between April 2015 and January 2016 were reviewed. Pre- and post-operative clinical outcomes (assessed using the International Knee Documentation Committee (IKDC), Western Ontario and McMaster Universities Arthritis Index (WOMAC), and Knee Injury and Osteoarthritis Outcome Score (KOOS) scores, and range of motion (ROM) were reviewed. The mechanical hip-knee-ankle (HKA) axis, component overhang and underhang and presence of a radiolucent line (RLL) were evaluated. Liner thickness were also reviewed.Results: At 3-year follow-up, the mean ROM improved from 108.4° to 130.3°. The mean IKDC subjective, WOMAC and global KOOS score significantly improved from 29.2 to 70.3, from 64.2 to 11.5, and from 66.6 to 21.7, respectively (p<0.0001). The mean mechanical HKA axis indicated the correction of the malalignment (from 9.2° varus to 0.3° varus, p<0.001). The incidence rates of >3-mm bone-to-implant size mismatch were 6.8% and 8.3% for the femoral and tibial components, respectively. RLL was found in seven cases, but they were small (>2 mm) and did not progress. In 36.3% of the knees, the additional liner thickness (11 or 13mm) was used. No case of implant loosening or early failure related to the implant design occurred. Conclusion: TKA using the Persona® knee system improved all the clinical knee scores and ROM without signs of early failure. This knee system also provides more implant size options than the conventional TKA systems and facilitates ligament balancing.

Measurement of Value in Anterior Cruciate Ligament Reconstruction: Patient-Level Value Analysis for the two-year Episode of Care

Objectives: Value-based payment models attempt to incentivize healthcare practices that reduce costs while improving patient outcomes. In order to optimize value, orthopaedic practices need a mechanism to quantify the value of the care that is provided to each individual patient. While this concept has been applied to total joint arthroplasty, sports has been largely excluded. Patient-level value-analysis (PLVA) defines value as a patient’s outcome achieved divided by the total cost of their episode of care. Measuring value on the patient-level allows a single number to describe value of the care received. The purpose of this study is to report PLVA and measure factors that influences the value of care delivered. Methods: All patients that underwent an ACL reconstruction for an acute ACL tear between the years of 2009 and 2016 at a single outpatient orthopaedic surgery center were identified via retrospective review of a prospectively collected patient-reported outcomes (PROs) registry. Patient demographics were collected via the electronic medical record (EMR) (Figure 2). The episode of care was defined as 2 years after surgery. The knee osteoarthritis outcomes score (KOOS) system was collected at initial preoperative baseline and two-years following surgery. The total cost-of-care was determined using time-driven activity-based-costing (TDABC). This formula derives the cost of care as a function of the time spent for each activity and personnel cost contributions for all involved. This process was performed at all phases: surgical intervention, all clinical follow-ups, and physical therapy (PT) sessions. Results: A total of 611 patients were included for this investigation. The patient sample was primarily female (n=355, 58.1%), average age of 28.9 + 12.9 [27.9, 30.0], and average BMI of 25.5 + 4.5 [25.2, 25.9]. A total of 151 (24.7%) patients were treated with an allograft with 128 (84.8%) utilizing a bone-patellar-bone (BTB) graft source. A total of 460 (75.3%) patients were treated with autograft with 272 (59.1%) utilizing a BTB graft source. The KOOS score was 65.3 + 15.9 [63.6, 66.9] at baseline and 83.2 + 13.5 [81.8, 84.6] at two-years, representing an improvement of 17.9 + 16.8 [16.2, 19.7]. There was a poor correlation between the change in two-year KOOS score and the TDABC cost-of-care (r=0.11). Autograft BTB demonstrated the highest overall value at two-years, 0.74 (ANOVA F: p<0.01), with an estimated 64.3% of patients falling in the “Above Average + Low Cost,” quadrant (Figure 1). Conclusion: This is the first study to apply PLVA methodology over the entire episode of care for ACL reconstructions. In our study, there was no correlation between an increased cost-of-care and an improvement in patient-reported outcomes. The autograft BTB demonstrated the greatest patient-level value within this cohort. With the growing focus of healthcare transitioning towards value-based delivery, PLVA offers orthopaedic practices and healthcare institutions a quantitative framework to evaluate the value of individual patient care delivery over the entire episode of care. This data can be utilized to drive physician behavior change, develop better care pathways, and optimize care delivery. [Figure: see text][Figure: see text]

FRI0653-HPR AN OLEUROPEIN-BASED DIETARY SUPPLEMENT IMPROVES JOINT FUNCTIONALITY IN OLDER PEOPLE WITH HIGH KNEE JOINT PAIN

Background:OLE provides oleuropein the most prevalent phenolic component in olive leaves and has been shown to have potent anti-inflammatory and anti-oxidant effects potentially interesting for joint health (1).Objectives:The aim of this study was to investigate the effects of a 6-month intervention with an Olive Leaf Extract (OLE) standardized for oleuropein content on knee functionality and biomarkers of bone/cartilage metabolism and inflammation.Methods:The study was a randomized, double-blind, placebo-controlled, multi-centric trial of 124 subjects with mild knee pain or mobility issues. Subjects were randomized equally to receive twice a day one capsule of either maltodextrin (control treatment, CT) or 125-mg OLE (BonoliveTM, an Olive Leaf Extract containing 50 mg of Oleuropein) for 6 months. The co-primary endpoints were Knee injury and Osteoarthritis Outcome Score (KOOS) using a self-administered questionnaire and serum Coll2-1NO2 specific biomarker of cartilage degradation. The secondary endpoints were each of the five sub-scales of the KOOS questionnaire, Knee pain VAS score at rest and at walking, OARSI core set of performance-based tests and serum biomarkers (Coll2-1, MPO, CTX1, osteocalcin, PGE2 and Vplex cytokines assay in serum) and concentration of Oleuropein’s metabolites in urine.Results:Primary (global KOOS score, biomarker Coll2-1 NO2) and secondary endpoints (the five subscales of the KOOS score) improved time dependently in both groups. OLE treatment showed significantly elevated urinary oleuropein metabolites (oleuropein aglycone, hydroxytyrosol, homovanillyl alcohol and isomer of homovanillyl alcohol), and was well tolerated without significant differences in number of subjects with adverse events. At 6 months, OLE group showed a higher global KOOS score compared to placebo (treatment difference = 3.73; 95% CI = [-4.08;11.54]; p = 0.34), without significant changes of inflammatory and cartilage remodeling biomarkers. Subgroup analyses demonstrated a large and significant treatment effect of OLE in subjects with high walking pain at baseline (14.4; 95% CI = [1.19;27.63], p=0.03). This was observed at 6 months for the global KOOS score and each different subscale and for pain at walking (-23.07;95% CI = [-41.8;-4.2];p=0.02). These treatment effects at 6 months were significant for KOOS score as well as for the subscales Pain and QoL and the pain at walking.Conclusion:OLE was not effective on joint discomfort in people with low to moderate pain at baseline but significantly benefited subjects with high pain at treatment initiation. As oleuropein is well-tolerated, OLE can be used to relieve knee joint pain and enhance mobility in subjects with articular pain the most painful subjects.References:[1] Horcajada MN, Sanchez C, Membrez Scalfo F, Drion P, Comblain F, Taralla S, Donneau AF, Offord EA, Henrotin Y. Oleuropein or rutin consumption decreases the spontaneous development of osteoarthritis in the Hartley guinea pig. Osteoarthritis Cartilage. 2015 Jan;23(1):94-102Disclosure of Interests:Marie-Noelle Horcajada Employee of: nestlé, Maurice Beaumont Employee of: nestle, Nicolas Sauvageot Employee of: Nestlé, Laure Poquet Employee of: Nestlé, Madleen Saboudjian Employee of: Nestlé, Anne-Christine Hick Employee of: Artialis SA, Berenice Costes Employee of: Artialis SA, Laetitia Garcia Employee of: Artialis, Yves Henrotin Grant/research support from: HEEL, TILMAN

Comparison of a video versus paper questionnaire on functional limitation in lower limb osteoarthritis

Introduction The video Animated Activity Questionnaire (AAQ) was developed to assess the impact of lower limb osteoarthritis (OA) on daily functional activities. The objective of the study was to compare the video and the HOOS/KOOS paper questionnaires and to assess the effect of order of administration. Material and methods Patients recruited in the KHOALA cohort were randomized in two groups: AAQ questionnaire first (AAQ-first group) and HOOS (hip)/KOOS (knee) questionnaire first (H/KOOS-first group). Within group differences between AAQ and HOOS/KOOS scores were compared using a Student t-test. The Spearman correlation coefficient between AAQ score and HOOS/KOOS score was calculated in each group then compared, using Fisher z-transformation. Results Among 200 randomized patients, 188 (65.8 years, 66.0% women) completed the questionnaires: 99 in the AAQ-first group and 89 in the H/KOOS-first group. The AAQ score was 85.9 (SD: 13.7) in the AAQ-first versus 87.8 (SD: 13.1) in the H/KOOS-first group (p = 0.34). The H/KOOS score was 72.5 (SD: 21.2) in the AAQ-first versus 73.5 (SD: 18.4) in the H/KOOS-first group (p = 0.71). The Spearman correlation coefficient between AAQ and H/KOOS in the AAQ-first was 0.84[0.77–0.89] and 0.73[0.61–0.81] in H/KOOS-first group. These correlations differed between groups significantly (p = 0.02). Conclusion This study found video AAQ and paper HOOS/KOOS questionnaire highly correlated, with a moderate but significant effect of order administration of video and paper questionnaires evidencing a stronger correlation when the videos were viewed first.

Intra-Operative and Anatomic Verification of a TKA Computational Model for Pre-Operative Surgical Planning

A promising measure of dynamic outcomes in Total Knee Arthroplasty (TKA) is the simulation of joint dynamics. These simulations are potentially useful for pre-operative planning, but are not yet validated for patient-specific variations in anatomy, which forms the aim of this paper. 284 patients from a database of total knee arthroplasty patients were analysed using a pre-operatively defined simulation predicting post-operative knee dynamics; each patient had previously undergone pre- and post-operative CT imaging and had been assessed using the Knee Injury and Osteoarthritis Outcome (KOOS) score at 6 months following surgery. A significant correlation was found between the simulated contact force and laxity in mid-flexion (r=-0.452, p&lt;0.0001), and between the medio- lateral difference in contact force and difference in distal-vs-posterior femoral collateral ligament offset (r=-0.473, p&lt;0.0001). A significant difference of 5 KOOS pain points (p=0.02) was found for patients with unusually low or high simulated contact force compared to normal. These results indicate the preoperative simulation is capable of distinguishing patient-specific kinematics prior to surgery, thereby demonstrating the utility of this simulation for making pre-surgical predictions of patient-specific kinematics and patient-reported outcomes.

A Prospective, Randomized, Open-Label, Multicenter, Phase III Noninferiority Trial to Compare the Clinical Efficacy of Matrix-Associated Autologous Chondrocyte Implantation With Spheroid Technology Versus Arthroscopic Microfracture for Cartilage Defects of the Knee

Background:Autologous chondrocyte implantation (ACI) and microfracture are established treatments for large, full-thickness cartilage defects, but there is still a need to expand the clinical and health economic knowledge of these procedures.Purpose:To confirm the noninferiority of ACI compared with microfracture.Study Design:Randomized controlled trial; Level of evidence, 2.Methods:Patients were randomized to be treated with matrix-associated ACI using spheroid technology (n = 52) or microfracture (n = 50). Both procedures followed standard methods. Patients were assessed by the Knee injury and Osteoarthritis Outcome Score (KOOS), MOCART (magnetic resonance observation of cartilage repair tissue) scoring system, Bern score, modified Lysholm score, International Cartilage Repair Society (ICRS) rating (histological and immunochemical scoring after rebiopsy 24 months after implantation), and International Knee Documentation Committee (IKDC) examination form. The main assessments were conducted 24 months after study treatment.Results:In the primary intention-to-treat analysis, the overall KOOS score for both ACI and microfracture yielded a statistically significant improvement relative to baseline. According to the between-group analysis, ACI passed the test of noninferiority compared with microfracture; thus, the primary goal of the study was achieved. The KOOS subscores yielded the same qualitative results as the overall KOOS score (ie, for each of these, noninferiority was demonstrated), and in 1 case (Activities of Daily Living subscore), the threshold for superiority was passed. The subgroup analyses did not yield any clear evidence of an association between treatment effect and any of the categories investigated (age, diagnosis, defect localization, sex). A histological analysis of biopsies from 16 patients (ACI: n = 9; microfracture: n = 7) suggested a better quality of repair in the patients treated with ACI.Conclusion:The efficacy of both ACI and microfracture was demonstrated with respect to both functional outcomes and morphological repair. The primary analysis confirmed the statistical hypothesis of the noninferiority of ACI, even for relatively small cartilage defects (1-4 cm2) treated in this study, the indication for which microfracture is generally accepted as the standard of care. ACI showed significant superiority in the KOOS subscores of Activities of Daily Living at 24 months and Knee-related Quality of Life at 12 months.Registration:NCT01222559 ( ClinicalTrials.gov identifier).