Total hip replacement (THR) is most often performed to treat end-stage symptomatic osteoarthritis. Patients typically present with increasing pain, restricted mobility and stiffness. In this procedure, the femoral head and part of the femoral neck are excised. The acetabulum is enlarged and an acetabular cup is inserted. The femoral head is replaced by a femoral component, the stem of which is inserted into the medullary canal of the femur. The components can be either cemented in place or press-fit (cementless). The THR concept was popularised by Sir John Charnley in the 1960s and although, over half a century of development has resulted in incremental improvements, the procedure is not dramatically different from the one he described. However, over the last two decades there have been significant changes in the types of bearing surfaces used. Metal on polyethylene continues to be the workhorse for the majority of cases. In the young and active, bearing surfaces with low wear rate are increasingly used. Since the early 1960s, THR has played an important role in alleviating pain and restoring mobility to millions of people. The cost-effectiveness of THR in treating advanced osteoarthritis makes it one of the most successful of all surgical interventions.

PURPOSE Knee osteoarthritis is a common, debilitating chronic disease. Prolotherapy is an injection therapy for chronic musculoskeletal pain. We conducted a 3-arm, blinded (injector, assessor, injection group participants), randomized controlled trial to assess the efficacy of prolotherapy for knee osteoarthritis.

METHODS

Ninety adults with at least 3 months of painful knee osteoarthritis were randomized to blinded injection (dextrose prolotherapy or saline) or at-home exercise. Extra- and intra-articular injections were done at 1, 5, and 9 weeks with as-needed additional treatments at weeks 13 and 17. Exercise participants received an exercise manual and in-person instruction. Outcome measures included a composite score on the Western Ontario McMaster University Osteoarthritis Index (WOMAC; 100 points); knee pain scale (KPS; individual knee), post-procedure opioid medication use, and participant satisfaction. Intention-to-treat analysis using analysis of variance was used.

RESULTS

No baseline differences existed between groups. All groups reported improved composite WOMAC scores compared with baseline status (P <.01) at 52 weeks. Adjusted for sex, age, and body mass index, WOMAC scores for patients receiving dextrose prolotherapy improved more (P <.05) at 52 weeks than did scores for patients receiving saline and exercise (score change: 15.3 ± 3.5 vs 7.6 ± 3.4, and 8.2 ± 3.3 points, respectively) and exceeded the WOMAC-based minimal clinically important difference. Individual knee pain scores also improved more in the prolotherapy group (P = .05). Use of prescribed postprocedure opioid medication resulted in rapid diminution of injection-related pain. Satisfaction with prolotherapy was high. There were no adverse events.

CONCLUSIONS

Prolotherapy resulted in clinically meaningful sustained improvement of pain, function, and stiffness scores for knee osteoarthritis compared with blinded saline injections and at-home exercises.

BACKGROUND:

Even though osteoarthritis (OA) is the most common musculoskeletal dysfunction, there are no effective pharmacological treatments to treat OA due to lack of understanding in OA pathology. To better understand the mechanism in OA pathogenesis and investigate its effective target, we analyzed miRNA profiles during OA pathogenesis and verify the role and its functional targets of miR-488.

RESULTS:

Human articular chondrocytes were obtained from cartilage of OA patients undergoing knee replacement surgery and biopsy samples of normal cartilage and the expression profile of miRNA was analyzed. From expression profile, most potent miR was selected and its target and functional role in OA pathogenesis were investigated using target validation system and OA animal model system. Among miRNAs tested, miR-488 was significantly decreased in OA chondrocytes Furthermore, we found that exposure of IL-1beta was also suppressed whereas exposure of TGF-beta3 induced the induction of miR-488 in human articular chondrocytes isolated from biopsy samples of normal cartilages. Target validation study showed that miR-488 targets ZIP8 and suppression of ZIP8 in OA animal model showed the reduced cartilage degradation. Target validation study showed that miR-488 targets ZIP8 and suppression of ZIP8 in OA animal model showed the reduced cartilage degradation.

CONCLUSIONS:

miR-488 acts as a positive role for chondrocyte differentiation/cartilage development by inhibiting MMP-13 activity through targeting ZIP-8.

Degenerative musculoskeletal conditions such as osteoarthritis and rotator cuff tendinopathy show increased incidence with age. The aim of this study was to evaluate a number of tissue characteristics associated with rotator cuff tendinopathy and ageing in samples of human supraspinatus tendon from individuals over a wide age range.Patients attending our shoulder clinic for treatment of traumatic shoulder instability or rotator cuff pathology were recruited to the study and tissue samples were obtained at the time of outpatient or surgical treatment. Participants were categorised by age into six groups: under 35, 35-44, 45-54, 55-64, 65-74 and 75 years and over. Samples were taken under ultrasound guidance from the supraspinatus tendon. The biopsies were obtained in clinic under local anaesthetic for the injection group and in the operating theatre for the surgical and control groups. The tissue samples were wax embedded, sectioned and stained using the following markers: H&E to assess cellularity; CD34 to identify vascular endothelial tissue; MIB-1 to identify proliferating cells; Active Caspase-3 to identify cells undergoing apoptosis; SIRT-1 as a marker of ageing.Table 1 details the composition of the age groups. The immuno histochemical results (figure 1) show a comparison of tissue characteristics evaluated across the spectrum of age. No significant change in cellularity was seen between the groups. Vascularity (CD34) of the supraspinatus tissue showed a significant reduction with age, showing a rapid decline in vascularity from 55 years of age onwards. A similar pattern of expression was seen for proliferation (MIB-1) with the major decline in proliferative activity occurring between 55 and 65 years. Cellular apoptosis (Active Caspase-3) showed a decline in the older age groups although this only reached significance in the 65-74 year old age group. SIRT-1 as a potential marker of tissue ageing showed a declining trend across the age groups with significant reduction in expression seen in the two oldest age groups. Figure 1.Histological analyses (*p<0.05 t-test vs<35 years age group)). Table 1.Group Sizes Age Group (years)No.under 351635 to 441145 to 541555 to 642565 to 741775 and over11The results demonstrate significant changes in several major features of tissue activity and viability within the supraspinatus tendon as age increases. Once age reached 55 years and over, the tissue demonstrated significant reductions in cellular activity and potential viability matching with the peak age of onset of rotator cuff pathology. SIRT-1 showed a constant gradual decline in expression as age increased, in keeping with the existing theories that reduction of SIRT-1 activity may be associated with cell senescence and ageing. The study was limited by the recruitment of tissue samples from a population attending for hospital treatment. The results may include some bias associated with pathological tissue changes unrelated to the patients' age. Despite this limitation, however, this work has shown a clear and significant pattern of tissue change associated with increasing age in the population studied and will lead to future work employing similar methods to investigate the tissue changes seen in a healthy ageing population.

PURPOSE:

In principle, double echo steady state (DESS) offers morphological and quantitative T2 imaging of cartilage within one single scan. However, accurate T2 estimation is hampered by its prominent T1 dependency in the limit of low flip angles, generally used to image cartilage morphology, as for the osteoarthritis initiative. A new postprocessing approach is introduced to overcome this T1 -related bias for rapid DESS-based T2 quantification in the low flip angle regime.

METHODS:

Based on a rough global T1 estimator and a golden section search, T2 is extracted from the ratio of the two echoes acquired with DESS. The new relaxometry method is evaluated from simulations and in vivo 3D measurements of the knee joint at 3T.

RESULTS:

A pronounced reduction in the T1 -related bias of DESS-T2 estimation and increased zonal variation in T2 between deep and superficial cartilage layers are observed. The improvement becomes particularly evident in the range of low flip angles (α < 45°), commonly used for morphological DESS imaging.

CONCLUSION:

Using a simple global T1 estimate, the reliability of DESS-T2 quantification can be considerably increased. The results emphasize the potential of DESS to fuse accurate quantitative T2 and morphological imaging of the musculoskeletal system within one single scan. Magn Reson Med, 2013. © 2013 Wiley Periodicals, Inc.

OBJECTIVE:

To investigate the postoperative efficacy of a supervised programme of neuromuscular exercise prior to hip or knee arthroplasty.

METHODS:

In this assessor-blinded randomised controlled trial, we included 165 patients scheduled for hip or knee arthroplasty due to severe osteoarthritis (OA). An 8-week preoperative neuromuscular supervised exercise programme was delivered twice a week for 1 h as adjunct treatment to the standard arthroplasty procedure and compared with the standard arthroplasty procedure alone. The primary outcome was self-reported physical function measured on the activities of daily living (ADL) subscale in the Hip disability and Osteoarthritis Outcome Score (HOOS) and the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaires for patients with hip and knee OA, respectively. Primary endpoint was 3 months after surgery.

RESULTS:

165 patients randomised to the two groups were on average 67±8 years, 84 (51%) had hip OA and 92 (56%) were women. 153 patients (93%) underwent planned surgery and were evaluated postoperatively. There was no statistically significant difference in effects between hip or knee patients (p=0.7370). Three months postoperatively, no difference was found between groups for ADL (4.4, 95% CI -0.8 to 9.5) or pain (4.5, 95% CI -0.8 to 9.9). However, there was a statistically significant difference indicating an effect of exercise over the entire period (baseline to 3-months postoperatively) (p=0.0029).

CONCLUSIONS:

Eight weeks of supervised neuromuscular exercise prior to total joint arthroplasty (TJA) of the hip or knee did not confer additional benefits 3 months postoperatively compared with TJA alone. However, the intervention group experienced a statistically significant short-term benefit in ADL and pain, suggesting an earlier onset of postoperative recovery.

TRIAL REGISTRATION:

ClinicalTrials NCT01003756.

Objective.

To determine whether tactile acuity is disrupted in people with knee OA and to determine whether tactile acuity, a clinical signature of primary sensory cortex representation, is related to motor imagery performance (MIP; evaluates working body schema) and pain.Methods. Experiment 1: two-point discrimination (TPD) threshold at the knee was compared between 20 participants with painful knee OA, 20 participants with arm pain and 20 healthy controls. Experiment 2: TPD threshold, MIP (left/right judgements of body parts) and usual pain were assessed in 20 people with painful knee OA, 17 people with back pain and 38 healthy controls (20 knee TPD; 18 back TPD).

Results.

People with painful knee OA had larger TPD thresholds than those with arm pain and healthy controls (P < 0.05). TPD and MIP were not related in people with knee OA (P = 0.88) but were related in people with back pain and in healthy controls (P < 0.001). Pain did not relate to TPD threshold or to MIP (P > 0.15 for all).

Conclusion.

In painful knee OA, tactile acuity at the knee is decreased, implying disrupted representation of the knee in primary sensory cortex. That TPD and MIP were unrelated in knee OA, but related in back pain, suggests that the relationship between them may vary between chronic pain conditions. That pain was not related to TPD threshold nor MIP suggests against the idea that disrupted cortical representations contribute to the pain of either condition.

PURPOSE:

Individuals after arthroscopic partial medial meniscectomy (APM) are at increased risk of developing knee osteoarthritis. Knee muscle weakness and a higher external knee adduction moment (KAM) are potential risk factors for knee osteoarthritis. This exploratory longitudinal study assessed these risk factors at baseline in an APM group (3 months after surgery) and control group, and again 2 years later (follow-up).

METHODS:

Eighty-two participants with medial APM and 38 healthy controls were assessed at baseline, with 66 (79%) and 23 (61%) respectively retested at follow-up. Outcome measures included isokinetic knee muscle strength and medial knee joint load inferred through indices of the KAM during normal and fast pace walking.

RESULTS:

Knee muscle strength was reduced by 14-16% in the APM leg compared to controls at baseline (p≤0.006). However, strength increased in the APM leg over the 2 years such that there were no differences compared with controls at follow-up. KAM impulse was at least 20% higher for the APM group (both legs) when compared to controls at baseline, and remained similarly higher 2 years later (p≤0.022). At baseline peak KAM was 18% higher in the APM leg as compared to controls only during fast pace walking (p=0.013). The peak KAM increased over the 2 years in the APM leg by 8-9% (p≤0.032), although there were no differences in change in KAM between the APM leg and controls.

CONCLUSION:

This study found that while knee muscle strength improved, dynamic medial joint load increased over the 2-years following APM surgery. These findings may aid in developing therapeutic interventions aimed to prevent or delay the onset of knee osteoarthritis following APM.

Pain and musculoskeletal complaints are among the most common symptoms in the general population. Despite their epidemiological, clinical and health economic importance, prevalence data on pain and musculoskeletal complaints for Germany are scarce.A cross-sectional survey of a random sample of citizens of Herne, Germany, aged ≥ 40 years was performed. A detailed self-complete postal questionnaire was used, followed by a short reminder questionnaire and telephone contacts for those not responding. The questionnaire contained 66 items, mainly addressing pain of any site, musculoskeletal complaints of any site and of knee and hip, pain intensities, the Western Ontario MacMaster Universities (WOMAC) index, medication, health care utilization, comorbidities, and quality of life.The response rate was 57.8% (4,527 of 7,828 individuals). Survey participants were on average 1.3 years older, and the proportion of women among responders tended to be greater than in the population sample. There was no age difference between the population sample and 2,221 participants filling out the detailed questionnaire. The following standardized prevalences were assessed: current pain: 59.7%, pain within the past four weeks: 74.5%, current joint complaints: 49.3%, joint complaints within the past four weeks and twelve month: 62.8% and 67.4%, respectively, knee as the site predominantly affected: 30.9%, knee bilateral: 9.7%, hip: 15.2%, hip bilateral: 3.5%, knee and hip: 5.5%. Pain and musculoskeletal complaints were significantly more often reported by women. A typical relationship of pain and joint complaints to age could be found, i.e. increasing prevalences with increasing age categories, with a drop in the highest age groups. In general, pain and joint pain were associated with comorbidity and body mass index as well as quality of life.Our data confirm findings of other recent national as well as European surveys. The high site specific prevalences of knee and hip complaints underline the necessity to further investigate characteristics and consequences of pain and symptomatic osteoarthritis of these joints in adults in Germany.

Increased external knee adduction moment during walking alters the joint biomechanics; which causes symptoms in chronic knee osteoarthritis patients.To assess additional effects of Retro-walking over conventional treatment on pain and disability in patients with acute exacerbation of chronic knee osteoarthritis.Thirty chronic knee osteoarthritis patients were randomly assigned into 2 groups. Group 'A' (7 men, 8 women) received conventional treatment. Group 'B' (8 men, 7 women) received conventional treatment and Retro-walking. Pain, assessed through visual analogue scale (VAS), and Western Ontario and McMaster Universities Arthritis Index (WOMAC) were the primary outcomes and knee range of motion (ROM), hip abductor and extensor strength were secondary outcomes; measured pre-intervention, after 1 week and after 3 weeks of intervention.Two factors analysis of variance for repeated measures was used for all outcomes. At the end of 3 weeks; WOMAC score showed highly significant difference within (P < 0.0001) and significant difference between groups (P = 0.040) also by Time × group interaction (P = 0.024), VAS showed highly significant difference within groups (P < 0.0001). Knee ROM showed significant difference within groups. Hip abductor and extensor strength showed significant difference by Time × group interaction (P < 0.05).Retrowalking is an effective adjunct to conventional treatment in decreasing disability in patients with knee osteoarthritis.