Incidence Of Total Knee Replacement Research Articles

THE BURDEN OF END-STAGE OSTEOARTHRITIS IN AUSTRALIA: A POPULATION-BASED STUDY ON THE INCIDENCE OF TOTAL KNEE ARTHROPLASTY ATTRIBUTABLE TO OVERWEIGHT/OBESITY

To determine the risk of total knee replacement (TKR) for primary osteoarthritis (OA) associated with overweight/obesity in the Australian population.This population-based study analyzed 191,723 cases of TKR collected by the Australian Orthopaedic Association National Joint Registry and population data from the Australian Bureau of Statistics. The time-trend change in incidence of TKR relating to BMI was assessed between 2015-2018. The influence of obesity on the incidence of TKR in different age and gender groups was determined. The population attributable fraction (PAF) was then calculated to estimate the effect of obesity reduction on TKR incidence.The greatest increase in incidence of TKR was seen in patients from obese class III. The incidence rate ratio for having a TKR for obesity class III was 28.683 at those aged 18-54 years but was 2.029 at those aged >75 years. Females in obesity class III were 1.7 times more likely to undergo TKR compared to similarly classified males. The PAFs of TKR associated with overweight or obesity was 35%, estimating 12,156 cases of TKR attributable to obesity in 2018. The proportion of TKRs could be reduced by 20% if overweight and obese population move down one category.Obesity has resulted in a significant increase in the incidence of TKR in the youngest population in Australia. The impact of obesity is greatest in the young and the female population. Effective strategies to reduce the national obese population could potentially reduce 35% of the TKR, with over 10,000 cases being avoided.

Long-term outcomes on the rates of total knee replacement amongst patients with end-stage knee osteoarthritis who meet surgical criteria and received a non-invasive biomechanical intervention.

Long-term outcomes on the rates of total knee replacement amongst patients with end-stage knee osteoarthritis who meet surgical criteria and received a non-invasive biomechanical intervention.

Total Knee Replacement After Arthroscopic Meniscectomy in Knee Osteoarthritis: A Nationwide Population-Based Cohort Study.

Recent studies raise concerns that arthroscopic meniscectomy (AM) for degenerative tear may be detrimental to the maintenance of the joint structure. This study was performed to examine the rate of total knee replacement (TKR) among patients with knee osteoarthritis (OA) who underwent AM for meniscal tears and compare this rate with those who did not. A retrospective cohort study was conducted using the National Health Insurance Database of South Korea. Among knee OA patients aged 50-79, those who were treated with AM due to meniscal damage from 2007 to 2009 were selected as the AM group while those not treated with AM despite the presence of meniscal damage were selected as control group. Both were matched based on a propensity score and followed-up until the earliest occurrence of: TKR, death, or 10 years. Cox proportional hazards models were used to compare the outcome. A total of 36,974 patients were included in AM groups and non-AM group after 1:1 matching. TKR occurred in 9.62% and 7.64% in AM and non-AM groups with the average duration after meniscectomy of 5.88 ± 2.77 and 5.50 ± 2.94 years, respectively. After adjustment for baseline confounders, the TKR rate in the AM group was calculated to be 25% higher than that in the non-AM group (subdistribution hazard ratio, 1.25; 95% confidence interval, 1.16-1.34). The mortality rate was 5.20%, which did not significantly differ between groups. OA patients who underwent AM for the meniscal injury had higher incidence of TKR up to 10 years of follow-up than the non-operated group. The greater TKR utilization observed in patients undergoing AM merits caution when treating OA patients with meniscal injury.

Metformin use and the risk of total knee replacement among diabetic patients: a propensity-score-matched retrospective cohort study

Metformin has been shown to modulate meta-inflammation, an important pathogenesis in knee osteoarthritis (OA). The study aimed to test the association between regular metformin use with total knee replacement (TKR) in patients with diabetes. This is a retrospective study with electronic records retrieved in Hong Kong public primary care. Patients with diabetes aged ≥ 45 who visited during 2007 to 2010, were followed up for a four-year period from 2011 to 2014 to determine the incidence of TKR. Propensity score matching based on age, sex, co-medications and chronic conditions was conducted to adjust for confounding. Cox regression was implemented to examine the association between metformin use and TKR. In total, 196,930 patients were eligible and 93,330 regular metformin users (defined as ≥ 4 prescriptions over the previous year) and non-users were matched. Among 46,665 regular users, 184 TKRs were conducted, 17.1% fewer than that among non-users. Cox regression showed that regular metformin users had a 19%-lower hazard of TKR [hazard ratio (HR) = 0.81, 95% confidence interval: 0.67 to 0.98, P = 0.033], with a dose–response relationship. Findings suggest a potential protective effect of metformin on knee OA progression and later TKR incidence among diabetic patients.

The burden of end-stage osteoarthritis in Australia: a population-based study on the incidence of total knee replacement attributable to overweight/obesity

To determine the risk of total knee replacement (TKR) for primary osteoarthritis (OA) associated with overweight/obesity in the Australian population. This population-based study analyzed 191,723 cases of TKR collected by the Australian Orthopaedic Association National Joint Registry and population data from the Australian Bureau of Statistics. The time-trend change in incidence of TKR relating to BMI was assessed between 2015 and 2018. The influence of obesity on the incidence of TKR in different age and gender groups was determined. The population attributable fraction (PAF) was then calculated to estimate the effect of obesity reduction on TKR incidence. The greatest increase in incidence of TKR was seen in patients from obese class III. The incidence rate ratio for having a TKR for obesity class III was 28.683at those aged 18-54 years but was 2.029at those aged >75 years. Females in obesity class III were 1.7 times more likely to undergo TKR compared to similarly classified males. The PAFs of TKR associated with overweight or obesity was 35%, estimating 14,287 cases of TKR attributable to obesity in 2018. The proportion of TKRs could be reduced by 20% if overweight and obese population move down one category. Obesity has resulted in a significant increase in the incidence of TKR in the youngest population in Australia. The impact of obesity is greatest in the young and the female population. Effective strategies to reduce the national obese population could potentially reduce 35% of the TKR, with over 10,000 cases being avoided.

Total knee replacement after high tibial osteotomy: time-to-event analysis and predictors.

BACKGROUND:An important aim of high tibial osteotomy (HTO) is to prevent or delay the need for total knee replacement (TKR). We sought to estimate the frequency and timing of conversion from HTO to TKR and the factors associated with it.METHODS:We prospectively evaluated patients with osteoarthritis (OA) of the knee who underwent medial opening wedge HTO from 2002 to 2014 and analyzed the cumulative incidence of TKR in July 2019. The presence or absence of TKR on the HTO limb was identified from the orthopedic surgery reports and knee radiographs contained in the electronic medical records for each patient at London Health Sciences Centre. We used cumulative incidence curves to evaluate the primary outcome of time to TKR. We used multivariable Cox proportional hazards analysis to assess potential preoperative predictors including radiographic disease severity, malalignment, correction size, pain, sex, age, body mass index (BMI) and year of surgery.RESULTS:Among 556 patients who underwent 643 HTO procedures, the cumulative incidence of TKR was 5% (95% confidence interval [CI] 3%–7%) at 5 years and 21% (95% CI 17%–26%) at 10 years. With the Cox proportional hazards multivariable model, the following preoperative factors were significantly associated with an increased rate of conversion: radiographic OA severity (adjusted hazard ratio [HR] 1.96, 95% CI 1.12–3.45), pain (adjusted HR 0.85, 95% CI 0.75–0.96)], female sex (adjusted HR 1.67, 95% CI 1.08–2.58), age (adjusted HR 1.50 per 10 yr, 95% CI 1.17–1.93) and BMI (adjusted HR 1.31 per 5 kng/m2, 95% CI 1.12–1.53).INTERPRETATION:We found that 79% of knees did not undergo TKR within 10 years after undergoing medial opening wedge HTO. The strongest predictor of conversion to TKR is greater radiographic disease at the time of HTO.

Incidence of Total Knee Replacement in Patients With Previous Anterior Cruciate Ligament Reconstruction.

To determine the rate of total knee replacement (TKR) after anterior cruciate ligament reconstruction (ACL-R) compared to the general population. Retrospective review. All hospitals that performed TKR and ACL-R in Manitoba between 1980 and 2015. All patients that underwent TKR and ACL-R in Manitoba between 1980 and 2015. Patient factors gathered at time of surgery included: age, sex, urban or rural residence, neighborhood income quintile, and resource utilization band (RUB). Each person was matched with up to 5 people from the general population who had never had ACL-R and had not had a TKR at the time of the case ACL-R. The rate of TKR after ACL-R. Overall from 1980 to 2015, 8500 ACL-R were identified within the 16 to 60 years age group with a resultant 42 497 population matches. Sex was predominantly male. The mean age of the ACL-R group at the time of TKR was 53.7 years, whereas the mean age for the matched cohort was 58.2 years, P < 0.001. Those with ACL-R were 4.85 times more likely to go on to have TKR. Apart from age, no other risk factors examined (location, year of surgery, place of residence, income quintile, and RUB) seemed to increase risk of TKR after ACL-R. Patients who underwent ACL-R were 5 times more likely to undergo TKR.

Association of the Intensive Lifestyle Intervention With Total Knee Replacement in the Look AHEAD (Action for Health in Diabetes) Clinical Trial

BackgroundEvidence has established obesity as a risk factor for total knee replacement (TKR) due to osteoarthritis. Obesity is a risk factor for TKR. Randomized trials such as Look AHEAD (Action for Health in Diabetes) have shown long-term successful weight loss with an intensive lifestyle intervention (ILI). It is unknown, however, if intentional weight loss can reduce the risk of TKR. MethodsLook AHEAD randomized persons aged 45-76 with type 2 diabetes who had overweight or obesity to either an ILI to achieve/maintain 7% weight loss or to standard diabetes support and education (DSE). Reported knee pain was assessed using the Visual Analog Scale and Western Ontario McMaster University Osteoarthritis Index questionnaire in 5125 participants without previous TKR. Cox proportional hazard regression was used to model differences in risk of TKR in relation to randomization group assignment (ILI vs DSE) along with baseline body mass index category and baseline knee pain as potential confounders from baseline through Look AHEAD-Extension. ResultsBaseline mean ± SD Western Ontario McMaster University Osteoarthritis Index knee pain scores did not differ by treatment assignment (ILI: 3.6 ± 2.9, DSE: 3.9 ± 3.0, P = .08); as expected due to randomization. During follow up, the 631 (12%) participants who reported having a TKR were more likely to have been heavier (P < .001) and older (P < .001) at enrollment, but risk of TKR did not differ by treatment group assignment (hazard ratio [HR] 1.07, 95% confidence interval [CI] 0.91-1.25, P = .43). Heterogeneity of treatment effect was observed according to baseline knee pain (interaction P = .02). In persons without knee pain at baseline, there was a 29% reduced risk of TKR in ILI compared to DSE (HR 0.71, 95% CI 0.52-0.96). However, in persons with knee pain at baseline, there was no statistically significant association of treatment assignment with respect to subsequent TKR incidence (HR 1.11, 95% CI 0.92-1.33). ConclusionFindings suggest that intensive lifestyle change including physical activity, dietary restriction and behavioral changes to achieve weight loss for prevention of TKR may be most effective in preventing TKR prior to the development of knee pain.

Five-Year Outcome of Operative and Nonoperative Management of Meniscal Tear in Persons Older Than Forty-Five Years.

To determine the 5-year outcome of treatment for meniscal tear in osteoarthritis. We examined 5-year follow-up data from the Meniscal Tear in Osteoarthritis Research trial (METEOR) of physical therapy versus arthroscopic partial meniscectomy. We performed primary intent-to-treat (ITT) and secondary as-treated analyses. The primary outcome measure was the Knee Injury and Osteoarthritis Outcome Score (KOOS) pain scale; total knee replacement (TKR) was a secondary outcome measure. We used piecewise linear mixed models to describe change in KOOS pain. We calculated 5-year cumulative TKR incidence and used a Cox model to estimate hazard ratios (HRs) for TKR, with 95% confidence intervals (95% CIs). Three hundred fifty-one participants were randomized. In the ITT analysis, the KOOS pain scores were ~46 (scale of 0 [no pain] to 100 [most pain]) at baseline in both groups. Pain scores improved substantially in both groups over the first 3 months, continued to improve through the next 24 months (to ~18 in each group), and were stable at 24-60 months. Results of the as-treated analyses of the KOOS pain score were similar. Twenty-five participants (7.1% [95% CI 4.4-9.8%]) underwent TKR over 5 years. In the ITT model, the HR for TKR was 2.0 (95% CI 0.8-4.9) for subjects randomized to the arthroscopic partial meniscectomy group, compared to those randomized to the physical therapy group. In the as-treated analysis, the HR for TKR was 4.9 (95% CI 1.1-20.9) for subjects ultimately treated with arthroscopic partial meniscectomy, compared to those treated nonoperatively. Pain improved considerably in both groups over 60 months. While ITT analysis revealed no statistically significant differences following TKR, greater frequency of TKR in those undergoing arthroscopic partial meniscectomy merits further study.

Descriptive epidemiology of hip and knee replacement in rheumatoid arthritis: An analysis of UK electronic medical records

ObjectiveTo provide descriptive data on rates of total hip replacement (THR) and total knee replacement (TKR) within a large RA cohort and describe variation in risk. MethodsIncident RA patients (1995 to 2014) were identified from the Clinical Practice Research Datalink (CPRD). First subsequent occurrence of THR and TKR were identified (analysed separately) and incidence rates calculated, stratified by sex, age, BMI, geographic region, and quintiles of the index of multiple deprivation (IMD) score. ResultsThere were 27,607 RA patients included, with a total of 1,028 THRs (mean age at surgery: 68.4 years) and 1,366 TKRs (mean age at surgery: 67.6 years), at an overall incidence rate per 1,000 person-years (PYs) [95% CI] of 6.38 [6.00–6.78] and 8.57 [8.12–9.04], respectively. TKR incidence was similar by gender but THR rates were higher in females than males. Rates of TKR but not THR rose according to BMI. An increasing trend was observed in rates of both outcomes according to age (although not ≥75) but of decreasing rates according to socio-economic deprivation. There was some evidence for regional variation in TKR. The 10-year cumulative incidence was 5.2% [4.9, 5.6] and 7.0% [6.6, 7.4] for THR and TKR, respectively. ConclusionWe provide generalizable estimates of THR and TKR incidence in the UK RA patient population and note variation across several key variables. Increased BMI was associated with a large increase in TKR but not THR incidence. Increased deprivation was associated with a downward trend in rates of THR and TKR.

Patellar tendon enthesis abnormalities and their association with knee pain and structural abnormalities in older adults

To describe associations between presence of patellar tendon enthesis (PTE) abnormalities and symptoms, structural abnormalities, and total knee replacement (TKR) in older adult cohort. PTE abnormalities (presence of abnormal bone signal and/or bone erosion), were measured on T2-weighted magnetic resonance (MR) images at baseline in 961 community-dwelling older adults. Knee pain and function limitation were assessed using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Bone marrow lesions (BMLs), cartilage volume and defects score, and infrapatellar fat pad (IPFP) area were measured using validated methods. Incidence of TKR was determined by data linkage. Participants with abnormal PTE bone signal and/or erosion was 20%. Cross-sectionally, presence of PTE abnormalities was associated with greater pain intensity while going up and down stairs (β=0.22 (95% confidence interval (CI); 0.03, 0.41)), greater risk of femoral BMLs (RR=1.46 (1.12, 1.90)) and worse tibial cartilage defects score (RR=1.70 (1.16, 2.47), and smaller IPFP area (β=-0.27 (-0.47,-0.06) cm2), after adjustment of confounders. Longitudinally, presence of baseline PTE abnormalities was associated with a deleterious increase in tibial BML size (RR=1.52 (1.12, 2.05)) over 10.7 years but not symptoms, other structural changes, or TKR. PTE abnormalities are common in older adults. Presence of cross-sectional but not longitudinal associations suggests they are commonly co-exist with other knee structural abnormalities but may not play a major role in symptom development or structural change, excepting tibial BMLs.

Trajectories of femorotibial cartilage thickness among persons with or at risk of knee osteoarthritis: development of a prediction model to identify progressors

There is significant variability in the trajectory of structural progression across people with knee osteoarthritis (OA). We aimed to identify distinct trajectories of femorotibial cartilage thickness over 2 years and develop a prediction model to identify individuals experiencing progressive cartilage loss. We analysed data from the Osteoarthritis Initiative (OAI) (n=1,014). Latent class growth analysis (LCGA) was used to identify trajectories of medial femorotibial cartilage thickness assessed on magnetic resonance imaging (MRI) at baseline, 1 and 2 years. Baseline characteristics were compared between trajectory-based subgroups and a prediction model was developed including those with frequent knee symptoms at baseline (n=686). To examine clinical relevance of the trajectories, we assessed their association with concurrent changes in knee pain and incidence of total knee replacement (TKR) over 4 years. The optimal model identified three distinct trajectories: (1) stable (87.7% of the population, mean change-0.08mm, SD 0.19); (2) moderate cartilage loss (10.0%,-0.75mm, SD 0.16) and (3) substantial cartilage loss (2.2%,-1.38mm, SD 0.23). Higher Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC) pain scores, family history of TKR, obesity, radiographic medial joint space narrowing (JSN) ≥1 and pain duration ≤1 year were predictive of belonging to either the moderate or substantial cartilage loss trajectory [area under the curve (AUC) 0.79, 95% confidence interval (CI) 0.74, 0.84]. The two progression trajectories combined were associated with pain progression (OR 1.99, 95% CI 1.34, 2.97) and incidence of TKR (OR 4.34, 1.62, 11.62). A minority of individuals follow a progressive cartilage loss trajectory which was strongly associated with poorer clinical outcomes. If externally validated, the prediction model may help to select individuals who may benefit from cartilage-targeted therapies.

Duration of physical activity, sitting, sleep and the risk of total knee replacement among Chinese in Singapore, the Singapore Chinese Health Study.

ObjectivesWhile the effect of physical activity on knee osteoarthritis (KOA) remains controversial, how sitting and sleep durations affect KOA is unknown. We evaluated the association between durations of physical activity, sitting and sleep, and incidence of total knee replacement (TKR) due to severe KOA.MethodsWe used data from the Singapore Chinese Health Study, a prospective cohort of 63,257 Chinese, aged 45–74 years at recruitment from 1993–1998. Height, weight, lifestyle factors, hours of sitting and sleep per day, and hours of moderate activity, strenuous sports or vigorous work per week were assessed through in-person interviews using structured questionnaires. Incident cases of TKR were identified via record linkage with nationwide hospital discharge database.ResultsCompared to those with <0.5 hour/week of moderate physical activity, participants with ≥5 hour/week had increased risk of TKR risk [hazard ratio (HR) 1.16, 95% confidence interval (CI) 1.00–1.35]. Conversely, duration of sitting activities, especially sitting at work, was associated with reduced risk in a stepwise manner. Compared to <4 hour/day of sitting, those with ≥12 hour/day had the lowest risk (HR 0.76, 95% CI 0.60–0.96, p for trend = 0.02). Sleep duration was inversely associated with reduced risk of TKR in a dose-dependent manner; compared to those with sleep ≤ 5 hour/day, participants with ≥ 9 hour/day had the lowest risk (HR 0.55, 95% CI) 0.43–0.70, p for trend <0.001).ConclusionWhile prolonged sitting or sleeping duration could be associated with reduced risk of severe KOA, extended duration of physical activity could be associated with increased risk.

The increase in total knee replacement surgery in Taiwan: A 15-year retrospective study.

Total knee replacement (TKR) is considered as one of the most success among clinical interventions for patients with who suffering from knee osteoarthritis (OA). We sought to estimate the incidence of TKR using demographics, incidence rates, lengths of hospital stay, and costs from 1996 to 2010 by analyzing Taiwan's National Health Insurance Research Database. A total of 154,553 patients obtained primary TKR surgery between 1996 and 2010. The diagnosis code for knee OA and the procedure code for TKR were selected from the records. To compare the rate of TKR between covariables, we calculated the TKR risk ratios and 95% confidence interval (CI) of these variables (gender, age, age group, and primary diagnoses). A 2-tailed P-value of .05 was considered statistically significant. The statistical package SPSS version 20.0 (SPSS, Chicago, IL) was used to conduct all the statistical analyzes. We analyzed 154,553 TKRs performed by surgeons in Taiwan from 1996 to 2010. The overall crude incidence increased from 26.4 to 74.55 TKR per 100,000 inhabitants from 1996 to 2010. TKR incidence for the 70 to 79 years age group increased from 227 to 505 per 100,000 people from 1996 to 2010. The age-standardized rate ratios for TKR of women to men ranged from 2.5 to 3.0. The mean average length of stay in hospital was 15 days in 1996 and decreased to 8 days in 2010. During the study period, the adjusted mean cost per patient decreased from US$7485 to US$4827. Health expenditures for TKR were 5% of total National Health Insurance expenditure every year. Over the 15-year period, Taiwan's TKR incidence tripled, which is consistent with population ageing. Arthritis will be a major public health issue in the ageing population in the future.

Incidence of total knee replacement subsequent to intra-articular injection of the anti-inflammatory compound LMWF-5A versus saline: a long-term follow-up study to a randomized controlled trial

BackgroundThe disease modifying potential of osteoarthritis therapies are of increasing interest, including their effects on delaying total knee replacement (TKR). To date, there have been no studies to determine the effect of LMWF-5A, a novel anti-inflammatory compound derived from human serum albumin, on delaying TKR.MethodsWe evaluated time to TKR three years after patients participated in a randomized trial of three intra-articular injections of LMWF-5A or saline. Patients were contacted via last known phone number and were asked to participate in a short nine item telephone questionnaire; verbal consent was obtained. The primary endpoint was incidence of TKR (%).ResultsIn total, 39 of 45 patients responded (87% response rate). The overall incidence of TKR was 38.5% (15/39). TKR rates were higher in patients with more severe osteoarthritis defined by Kellgren-Lawrence grade 4, compared to patients with moderate osteoarthritis defined by Kellgren-Lawrence grade 3 (56% vs. 26%, p = 0.06). Overall, there were no differences in TKR rates by treatment arm (39% LMWF-5A vs. 38% saline, p = 0.92). In the severe osteoarthritis subset (n = 16), treatment with LMWF-5A resulted in a lower incidence of TKR compared to saline vehicle arm (40% vs. 83%, p = 0.15). TKR rates were significantly lower with LMWF-5A in patients who responded to treatment (14% with LMWF-5A, vs. 100% with saline, p = 0.03).ConclusionThis study demonstrates significant delays in TKR for patients with severe osteoarthritis treated with LMWF-5A, suggesting that LMWF-5A has the potential to provide structure modifying/preserving therapy in this population.

MRI-detected subchondral bone marrow lesions: does using two mri sequences improve detection and clinical relevance?

Purpose: Fluid-sensitive MRIs are preferred in scoring BMLs compared to gradient recalled echo (GRE)-type MRI sequences. However, whether one sequence correlates better with clinical osteoarthritis (OA) outcomes than the other is unknown. We aim to describe the association of bone marrow lesions (BMLs) present on two different MRI sequences with pain, physical function limitation, stiffness, cartilage defect progression, cartilage volume loss over 2.7 years, and total knee replacement (TKR) over 13.3 years in older adults. Methods: 394 community-dwelling adults aged 50–80 years were assessed at baseline and 2.7 years. BML presence at baseline was scored on T1-weighted fat-suppressed 3D gradient-recalled acquisition (T1-w GRE) and T2-weighted fat-suppressed 2D fast spin-echo (T2-w FSE) MRI sequences, at the tibial, femoral, and patellar sites. Knee pain, physical function limitation, and stiffness were assessed using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scales. Cartilage volume and defect scores were assessed using validated methods. The incidence of TKR was determined by data linkage to the Australian Orthopaedic Association National Joint Replacement Registry. Ordinal logistic, linear, log binomial, and mixed-effects regression were used for analysis. Results: BMLs were mostly present on both MRI sequences (86%) and appeared slightly larger on T2-w FSE MRI. BMLs present on T2-w FSE, T1-w GRE, and both MRI sequences were associated with increased odds of moving to a higher category of knee pain and physical function limitation (odds ratio (OR) = 1.49 to 1.70; all P < 0.05) but not stiffness. Longitudinally, BMLs present on T2-w FSE, T1-w GRE, and both MRI sequences were associated with worsening knee pain (β = 1.12 to 1.37, respectively; P < 0.05) and worsening stiffness (β = 0.45 to 0.52, respectively; all P < 0.05) but not worsening physical function limitation or total WOMAC. BMLs present on T2-w FSE, T1-w GRE, and both MRI sequences predicted site-specific cartilage defect progression (relative risk (RR) = 1.22 to 4.63; all P < 0.05) except at the medial tibial and inferior patellar sites. Lateral tibial and superior patellar BMLs present on T2-w FSE, T1-w GRE, and both MRI sequences predicted site-specific cartilage volume loss (β = −174.77 to −140.67; P < 0.05). BMLs present on T2-w FSE, T1-w GRE, and both MRI sequences were strongly associated with incident TKR. Conclusions: BMLs can be assessed on either T2-w FSE or T1-w GRE MRI sequence alone with no predictive advantage of performing both sequences, even though BMLs appear smaller on T1-w GRE MRI.

Long-term effects of vitamin d supplementation and maintaining vitamin d sufficiency on knee osteoarthritis over 5 years

Purpose: Epidemiological studies suggest that vitamin D deficiency is associated with knee symptom and structural progression of knee osteoarthritis (OA). However, randomised controlled trials (RCTs) failed to demonstrate a significant effect of vitamin D supplementation on OA, probably due to selecting OA participants with and without vitamin D deficiency, short duration of the studies and a large proportion of participants in the placebo group reaching vitamin D sufficiency (61.3% of patients in the placebo group achieved a serum 25-hydroxyvitamin D [25(OH)D] level of > 60 nmol/l at 3 months of a clinical trial). We conducted the Vitamin D Effect on Osteoarthritis (VIDEO) clinical trial by selecting knee OA participants with vitamin D insufficiency and reported that there was no significant effect of vitamin D supplementation over 2 years on cartilage volume loss and knee pain assessed using the WOMAC scale. However, there was a significant reduction in knee pain evaluated by VAS knee pain scale, an improvement in physical function and a decrease in joint effusion-synovitis volume and bone marrow oedema compared to the placebo group. We aimed to describe the effect of vitamin D supplementation for 2 years on knee symptoms compared to placebo after 3 years of cessation of treatment, and to examine whether those maintaining sufficient serum vitamin D levels over 5 years had reduced knee symptoms compared with those who did not maintain adequate vitamin D levels over 5 years in patients with knee OA. Methods: Participants with symptomatic knee OA and low 25(OH)D (12.5-60 nmol/l) were enrolled in the VIDEO clinical trial. Participants were randomly assigned to receive monthly treatment with oral vitamin D3 (50,000 IU; n = 209) or an identical placebo (n = 204) for 2 years. 172 participants who enrolled in the study from Hobart were followed up after 3 years (5 years from baseline) of the cessation of the treatment to assess knee symptoms and vitamin D levels. Participants with serum 25(OH)D measurements at month 0, 3, 24 and 60 and were included in the post-hoc analyses. The incidence of total knee replacement was recorded and they were excluded from the symptom analyses. Participants were classified as maintaining sufficient vitamin D group if they maintained serum 25(OH)D >50 nmol/l at month 3, 24 and 60 (n = 79), and not maintaining sufficient vitamin D group (25[OH]D ≤50 nmol/l at month 3, 24 and 60, n = 62). Knee symptoms were assessed at baseline, 3, 6, 12, 24 and 60 months using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Results: The level of 25(OH)D dropped in the vitamin D group (from 87.0 nmol/l to 53.3 nmol/l) over 3 years after the cessation of the treatment. Placebo group slightly increased the vitamin D level (53.3 nmol/l to 61.7 nmol/l) over 3 years. Knee pain increased from the end of the study (2nd year) to 5 years of follow-up in the treatment (81.8 to 91.7) and placebo (75.8 to 101.1) groups. 16.7% of the participants in vitamin D and 18.5% of the participants in placebo group underwent total knee replacement surgery. There were no significant differences in WOMAC pain, stiffness or dysfunction scores and total knee replacement surgery rates or change in symptom between Vitamin D and placebo groups after 3 years of cessation of the supplementation. However, participants who maintained adequate vitamin D levels over 5 years had significantly less WOMAC knee pain (β: −38.4, 95% CI: −69.2, −7.7) and physical dysfunction (β: −98.5, 95% CI: −193.8, −3.1) than participants with vitamin D deficiency over 5 years in multivariable analyses after adjusting for age, sex and BMI.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Conclusions: Vitamin D supplementation over 2 years did not result in significant differences in change in knee symptom score over 5 years compared to placebo. However, knee OA patients maintaining sufficient serum vitamin D levels over long-term had more improvement in knee pain and physical function than those who did not maintain adequate vitamin D levels, suggesting a beneficial effect of maintaining sufficient serum vitamin D for knee OA.

Association between NICE guidance on biologic therapies with rates of hip and knee replacement among rheumatoid arthritis patients in England and Wales: An interrupted time-series analysis.

To estimate the impact of NICE approval of tumor necrosis factor inhibitor (TNFi) therapies on the incidence of total hip replacement (THR) and total knee replacement (TKR) among rheumatoid arthritis (RA) patients in England and Wales. Primary care data [Clinical Practice Research Datalink (CPRD)] for the study period (1995-2014) were used to identify incident adult RA patients. The age and sex-standardised 5-year incidence of THR and TKR was calculated separately for RA patients diagnosed in each six-months between 1995-2009. We took a natural experimental approach, using segmented linear regression to estimate changes in level and trend following the publication of NICE TA 36 in March 2002, incorporating a 1-year lag. Regression coefficients were used to calculate average change in rates, adjusted for prior level and trend. We identified 17,505 incident RA patients of whom 465 and 650 underwent THR and TKR surgery, respectively. The modeled average incidence of THR and TKR over the biologic-era was 6.57/1000 person years (PYs) and 8.51/1000 PYs, respectively, with projected (had pre-NICE TA 36 level and trend continued uninterrupted) figures of 5.63/1000 PYs and 12.92 PYs, respectively. NICE guidance was associated with a significant average decrease in TKR incidence of -4.41/1000 PYs (95% C.I. -6.88 to -1.94), equating to a relative 34% reduction. Overall, no effect was seen on THR rates. Among incident RA patients in England and Wales, NICE guidance on TNFi therapies for RA management was temporally associated with reduced rates of TKR but not THR.

Total Knee Replacement in Young Patients: Survival and Causes of Revision in a Registry Population

BackgroundThe incidence of total knee replacements (TKRs) in young patients is increasing. Few reports described encouraging results and acceptable survival rates. However, many concerns still persist, in particular about the high rates of infection and aseptic loosening. Aim of this article was to investigate the survival of TKRs in patients aged 45 years or younger in a registry population. MethodsThe Emilia-Romagna registry RIPO was enquired about TKRs in patients ≤45 years; 238 TKRs were evaluated at a mean follow-up of 5.4 years (range 0-15.6 years), examining the features of the patients involved, the survival rate, and the reasons for revision of the knee implants. ResultsThe TKRs were generally performed in men, in private hospitals, and almost in half of the cases for other causes rather than primary osteoarthritis. The mean age was 40 years. Bicompartmental, cemented posterior-stabilized implants with fixed bearing were preferred. The survival rate was higher than 90% in the first 7 years, and then it decremented. The choice of implant did not apparently influence the survivorship. The final outcomes were acceptable, substantially in line with the previous literature about young patients. Twenty-one revisions occurred (8.8%), in particular 8 cases for aseptic loosening and 7 TKRs for infection. The rate of revision was higher than in overall population and even in some young cohorts. ConclusionTKRs in patients aged 45 years or younger seem a promising procedure, although the high rates of septic and aseptic loosening should be carefully evaluated. Prospective, well-designed studies are required to confirm and investigate these preliminary findings.

Association of anterior cruciate ligament injury with knee osteoarthritis and total knee replacement: A retrospective cohort study from the Taiwan National Health Insurance Database.

ObjectiveThis study aimed to support the potential protective role of anterior cruciate ligament (ACL) reconstruction against the development of osteoarthritis (OA).MethodsIn this retrospective cohort study, the long-term results of ACL reconstruction in Taiwan were evaluated based on data from the National Health Insurance Research Database (NHIRD). In total, 8,769 eligible cases were included from 11,921 ACL-injured patients. The cumulative incidence rates of OA and total knee replacement (TKR) were analyzed using the Kaplan-Meier estimator. Cox proportional hazards models were applied to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) of OA.ResultsThere was a lower cumulative incidence of OA among ACL-reconstructed patients (271, 33.1%) than among non-reconstructed patients (1,874, 40.3%; p < 0.001). Patients who underwent ACL reconstruction had a lower cumulative incidence of TKR during the follow-up period (0.6%) than the non-reconstructed patients (4.6%, p < 0.001). After adjusting for covariates, ACL-injured patients who underwent reconstruction within one month after ACL injury showed a significantly lower risk of OA than those who never underwent reconstruction (adjusted HR = 0.83, 95% CI = 0.69–0.99).ConclusionsThese results indicate that ACL reconstruction might not provide complete protection from OA development after traumatic knee injury but does yield a lower cumulative incidence of OA development and TKR. Moreover, based on the present study, ACL-injured patients should undergo reconstruction as early as possible (within one month) to lower the risk of OA.