Clinical Manifestations, Histopathological Changes And Quality Of Life In Patients With Advanced Knee Osteoarthritis Caused By Age, Trauma, Obesity And Their Combination

Objective — to reveal and analyze clinical characteristics, knee joint histopathology, and quality of life in patients at late stages of knee osteoarthritis (OA) triggered by age, trauma, metabolic syndrome, or their combination. Material and methods — We studied 120 subjects with knee OA (sensu Altman R.D., 1991) of Kellgren-Lawrence Grades 3-4. They were distributed among 4 groups (30 participants in each) based on the presence of age-related, post-traumatic, metabolic, or combined phenotypes. Clinical examination of patients with pain and their functional status evaluation (via Visual Analogue Scale, WOMAC, Lequesne index), quality of life assessment (MOS SF-36 questionnaire), along with histopathological study of medial tibial plateau cartilage and synovial membrane, were caried out, followed by statistical data processing. Results — Age-related OA phenotype was characterized by the latest clinical onset [59.5 (54-68) years of age] with the largest average patient age [72.5 (63-77) years], moderate to severe pain and knee dysfunction [total WOMAC score of 160 (127-190) points and Lequesne index of 20 (8-21) points], severe degenerative cartilage lesions [8.5 (6-10) points sensu Mankin] with high-grade synovitis [5 (3-8) points sensu Krenn]. Post-traumatic OA phenotype was distinguished by the lowest pain, stiffness and knee functional limitations [total WOMAC score of 129 (100-166), Lequesne index of 15 (14-19)], the highest quality of life in patients [physical component summary of 34.1 (30.5-36.1) points, mental component summary of 40.4 (32.9-43.8) points] against the background of local severe cartilage lesions [8 (6-8) sensu Mankin] with reparative pattern and synovial fibrosis. For metabolic OA phenotype, the typical traits included female-biased sex ratio (87%), high prevalence of clinical synovitis (77%), severe pain and functional knee disorders [total WOMAC score of 188 (162-207) points, Lequesne index of 20 (19-23) points], the worst quality of life [physical component summary of 28.0 (24.3-31.9) points, mental component summary of 30.9 (26.9-35.9) points], vascular invasion of cartilage, and high-grade synovitis [4 (3-5) points sensu Krenn]. Combined OA phenotype was characterized by variable clinical and histopathological features. Conclusion — Comprehensive comparative clinical and morphological analysis of late-stage knee OA of various origin was completed, and age-related, post-traumatic, metabolic and combined OA phenotypes were studied. The methodological basis for differential approach to treating different categories of OA patients was developed.

Heel pain in female patients with early knee osteoarthritis

Background Multiple lower limb joint involvement is one of the most common and debilitating musculoskeletal conditions, while the complaints from both heel and knee pain are considered the most frequent. For that reason, in this cross-sectional study, the association between heel pain (HP) and early knee osteoarthritis (EKOA) was investigated; the most painful site and side of HP, the prevalence, and risk factors for disabling HP in patients with EKOA were identified. Results Bilateral HP (56%) and posterior HP (54%) were found to be the most prevalent complaints, and 66% of patients reported the HP to be non-disabling. There was a very high positive statistically significant correlation between the Manchester Foot Pain Disability Index (MFPDI) and both the Health Assessment Questionnaire (HAQ) and the total Western Ontario and McMaster University Osteoarthritis (WOMAC) score (p ≤ 0.001), while there was a high negative statistically significant correlation between MFPDI and quadriceps angle of the most affected knee (p = 0.002). A higher total WOMAC score (OR 1.077, 95% CI 1.014 to 1.145) significantly increases the risk of developing disabling HP, while wearing 2–3-cm heels during the past month was found to be protective against the development of disabling HP (odds ratio < 1). Conclusion Disabling HP was present in a third of patients with EKOA and HP, and it was associated with flat shoe wear as well as a high total WOMAC score. Also, it had a statistically significant correlation with varus knee mal-alignment. Furthermore, decreased functional ability in the presence of HP was found to lead to significant disability. Moreover, a striking finding in this study was the longer mean duration of HP compared to the duration of knee symptoms.

Preoperative patellofemoral anatomy affects failure rate after isolated patellofemoral inlay arthroplasty

Purpose To analyze whether preoperative patellofemoral anatomy is associated with clinical improvement and failure rate after isolated patellofemoral arthroplasty (PFA) using a modern inlay-type trochlear implant. Methods Prospectively collected 24 months data of patients treated with isolated inlay PFA (HemiCAP® Wave, Arthrosurface, Franklin, MA, USA) between 2009 and 2016, and available digitalized preoperative imaging (plain radiographs in three planes and MRI) were retrospectively analyzed. All patients were evaluated using the WOMAC score, Lysholm score, and VAS pain. Patients revised to TKA or not achieving the minimal clinically important difference (MCID) for the total WOMAC score or VAS pain were considered failures. Preoperative imaging was analyzed regarding the following aspects: Tibiofemoral OA, patellofemoral OA, trochlear dysplasia (Dejour classification), patellar height (Insall–Salvati index [ISI]; Patellotrochlear index [PTI]), and position of the tibial tuberosity (TT–TG and TT–PCL distance). Results A total of 41 patients (61% female) with a mean age of 48 ± 13 years could be included. Fifteen patients (37%) were considered failures, with 5 patients (12%) revised to TKA and 10 patients (24%) not achieving MCID for WOMAC total or VAS pain. Failures had a significantly higher ISI, and a significantly lower PTI. Furthermore, the proportion of patients with a pathologic ISI (> 1.2), a pathologic PTI (< 0.28), and without trochlear dysplasia were significantly higher in failures. Significantly greater improvements in clinical outcome scores were observed in patients with a higher preoperative grade of patellofemoral OA, ISI ≤ 1.2, PTI ≥ 0.28, TT–PCL distance ≤ 21 mm, and a dysplastic trochlea. Conclusion Preoperative patellofemoral anatomy is significantly associated with clinical improvement and failure rate after isolated inlay PFA. Less improvement and a higher failure rate must be expected in patients with patella alta (ISI > 1.2 and PTI < 0.28), absence of trochlear dysplasia, and a lateralized position of the tibial tuberosity (TT–PCL distance > 21 mm). Concomitant procedures such as tibial tuberosity transfer may, therefore, be considered in such patients. Level of evidence Level III, retrospective analysis of prospectively collected data.

Lower serum levels of alpha tocopherol and lycopene is associated with higher pain and physical disability in subjects with primary knee osteoarthritis: A case-control study

Background: We aimed to determine dietary intake and serum concentration of α-tocopherol and lycopene in subjects with knee osteoarthritis (KOA) in relation to pain intensity and functional status and comparing them with healthy controls. Methods: This case-control study was conducted among 35 patients with primary KOA and 35 matched healthy subjects selected using convenience sampling method. Dietary intakes of alpha-tocopherol and lycopene were estimated from 24-hour dietary records. Visual Analogue Scale (VAS) and Western Ontario and McMaster (WOMAC) index were used to assess the pain and functional status, respectively. Results: Serum concentrations of alpha-tocopherol ( 0.024 ± 0.005 vs. 0.028 ± 0.007 μmol/ml, p-value = 0.021) and lycopene ( 0.616 ± 0.191 vs. 0.727 ± 0.159 μmol/l, p-value = 0.011) were significantly lower in OA patients in comparison with healthy controls. Dietary intake of alpha-tocopherol was negatively associated with total WOMAC score ( r = –0.401, p–value = 0.021) and pain ( r = –0.356, p-value = 0.042) and physical function ( r = –0.355, p-value = 0.043) subscales. Dietary intake of lycopene was negatively associated with total WOMAC score ( r = –0.616, p-value < 0.001) and pain ( r = –0.348, p-value = 0.047) and physical function ( r = –0.606, p-value < 0.001) subscales. Additionally, serum concentration of alpha-tocopherol was negatively associated with total WOMAC score ( r = –0.574, p-value < 0.001) and physical function subscale ( r = –0.571, p-value < 0.001). Serum concentration of lycopene was negatively associated with total WOMAC score ( r = –0.360, p-value = 0.040) and physical function subscale ( r = –0.350, p-value = 0.046) Conclusion: Serum concentrations of α-tocopherol and lycopene were significantly lower in patients with KOA than in healthy controls. Significant negative association was detected between serum concentration and dietary intake of α-tocopherol and lycopene with functional disability in patients with KOA.

The Clinical Efficacy and Safety of Gumiganghwal-Tang in Knee Osteoarthritis: A Phase II Randomized Double Blind Placebo Controlled Study

Background. Gumiganghwal-tang (GMGHT) is a traditional herbal medicine consisting of nine different herbs. GMGHT inhibits the mRNA expression and production of inflammatory cytokines tumor necrosis factor-α (TNF- α), interleukin-6 (IL-6), and TNF- β on lipopolysaccharide- (LPS-) stimulated peritoneal macrophages in a dose-dependent manner. It is empirically used for the treatment of inflammatory disease, but there are few reports of clinical trials that investigate its efficacy and safety. The current study aimed to investigate the clinical efficacy and safety of GMGHT in patients with knee osteoarthritis (OA). Methods. This was a multicenter, two-armed, double-blinded, randomized, placebo controlled study of GMGHT over 6 weeks. Eligible patients who fulfilled the American College of Rheumatology criteria for OA were randomized to receive either GMGHT or the placebo. Clinical assessments included measurement of knee pain and function using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), patient global assessment (PGA), and knee pain scores every 2 weeks. Results. A total of 128 patients were enrolled (91.4% female; mean age, 58.7 ± 8.1 years). At baseline, pain visual analogue score (VAS) was 67.2 ± 1.4, resp. 71.3 ± 1.6 (treatment, resp. placebo group, p=0.84), and total WOMAC score was 55.2 ± 1.6, resp. 55.6 ± 1.5 (p = 0.84). After 6 weeks, the pain VAS was 43.0 ± 2.5, resp. 61.6 ± 2.5 (p < 0.01) and the total WOMAC score was 34.1 ± 2.4, resp. 46.9 ± 1.8 (p < 0.01). No patients withdrew because of treatment emergent adverse events. Expected adverse events including dyspepsia, liver function abnormality, and lower extremity edema were comparable between both groups. Conclusions. Treatment with GMGHT resulted in significant improvement in pain, function, and global assessment, and it was generally safe and well tolerated in patients with OA.

GRADE 1-2 OSTEOARTHRITIS OF KNEE JOINT;

Objectives: To determine the outcome of isometric exercises (Quadriceps) aloneand in combination with grade 1-2 Knee joint mobilizations to manage pain and to improvephysical functioning in patients of knee Osteoarthritis. Study Design: A Quasi experimentalstudy on 80 freshly diagnosed Osteoarthritis patients. Setting: Physiotherapy Department ofFatima Memorial Hospital Shadman. Methods: Those patients were divided in two groups(Mobilization group and Combination group). There was no significant difference between age,education, co-morbidities and initial WOMAC score in different domains (pain, stiffness, physicalfunction) and total WOMAC score of the two treatment groups before treatment. WOMAC scalewas used as an assessment tool to measure the outcome of treatment in different groupsbefore and after treatment (follow up 2weeks). Results: There was significant improvementseen in all 3 domains of WOMAC scale (pain, stiffness and physical activity) in Combinationgroup in Grade 1-2 knee Osteoarthritis. According to Paired t test mean difference betweenpost-Pre values of both groups was highly significant (p=0.000) in all domains. Conclusion:Combination of (Grade1- 2 Maitland and Isometric of Quadriceps) was seen more effective interms of improvement in pain, stiffness and physical activity in Grade 1- 2 Osteoarthritis thanthe quadriceps isometrics alone.

Percutaneous Fat Transfer to Treat Knee Osteoarthritis Symptoms: Preliminary Results

Purpose This study aims to evaluate the safety and efficacy of autologous aspirated and purified fat tissue injected percutaneously into the knee joint for the treatment of symptomatic osteoarthritis (OA). Methods We reviewed 30 patients, who received an autologous percutaneous fat injection for the treatment of knee OA, from January 2012 to March 2015. Mean patients' age was 63.3 ± 5.3 years (range, 50–80 years). Body mass index was 25.1 ± 1.7. Clinical evaluation was based on pain visual analog scale (VAS) and WOMAC score for functional and subjective assessment. We also noted the adverse reactions and the consumption of nonsteroidal anti-inflammatory drugs in the posttreatment period. Results All patients reported improvements with respect to pain: average VAS was 7.7 ± 1.2 at baseline, 5.2 ± 0.2 at 1-month follow-up, and 4.3 ± 1 at 3-month follow-up. A slight deterioration (5.0 ± 1.1) was evidenced at 1 year. Total WOMAC score was 89.9 ± 1.7 at baseline, 66.3 ± 1 at 1 month, 68.6 ± 1.7 at 3 months, and 73.2 ± 1.8 at 12 months of follow-up. Conclusion Our preliminary findings suggest that autologous percutaneous fat injections are a valid treatment option for knee OA. Level of Evidence Level IV, therapeutic case series.

Outcome in Total Knee Arthroplasty with a Medial-Lateral Balanced versus Unbalanced Gap

Purpose To evaluate the clinical outcome in 108 total knee arthroplasty (TKA) patients with a medial-lateral balanced versus unbalanced gap after a mean follow-up of 34 months. Methods 64 women and 44 men (mean age, 69.5 years) underwent computer-assisted TKA for osteoarthritis using a cemented fixed-bearing cruciate-retaining prosthesis. The medial-lateral gap difference (measured with the prosthesis in situ and the patella reduced) was balanced (≤2 mm) in 81 patients and unbalanced (>2 mm) in 27 patients. After a mean follow-up of 34 months, patients were assessed using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire for pain, stiffness, and physical function. Scores were normalised to 0% (worst) to 100% (best). Results The balanced and unbalanced gap groups were comparable in terms of age, severity of osteoarthritis, and proportion of pre- and postoperative mechanical alignment. Compared with the balanced gap group, the unbalanced gap group had a larger medial-lateral extension gap difference (0.75±0.57 vs. 2.02±1.15 mm, p=0.001) and medial-lateral flexion gap difference (0.79±0.63 vs. 2.98±2.13 mm, p=0.001) and lower normalised total WOMAC score (84.9±18 vs. 74.8±20.8, p=0.017). Conclusion WOMAC score is better in TKAs with a medial-lateral balanced (<2 mm) gap.

SHORT-TERM RESULTS OF THE OXFORD UNICOMPARTMENTAL KNEE REPLACEMENT IN PATIENTS LESS THAN SIXTY-FIVE YEARS OF AGE

Our short-term results obtained with the Oxford unicompartmental knee prosthesis for unicompartmental knee arthrosis or AVN (avascular necrosis) in patients younger than 65 years of age are presented. Twenty patients (16 females and 4 males) with 20 prostheses were evaluated. The average age at surgery was 59 years (range 45 to 65 years). The etiology for surgery was osteoarthritis in 18 cases and AVN in two of them. Nineteen prostheses were uni-medial and one uni-lateral. After an average of 38 months, the mean Knee Society Score was excellent with 81.7 (range 29 to 100) points, the mean total WOMAC score was 26 (range 0 to 78), the mean reduced- WOMAC score 7.9 (range 0 to 24), the mean SF12 physical 36.8 (range 19.8 to 56.7), and the mean SF12 mental 47.5 (range 19 to 64). We did not find any significant correlation between the final outcome and the alignment of each component on X-ray. The only statistically significant correlation we could demonstrate was between the alignment of the knee on AP-View and the functional outcome. Three prostheses out of the twenty had to be revised, two of them due to early aseptic loosening of the tibial component and another one because of unexplained pain. Despite the relative high rate of early revisions (15%) in this group, our finding confirm the good results reported in different other studies regarding the success rate of unicompartmental knee replacement in patients under the age of 65 years.