Kellgren-Lawrence Score Research Articles

The Relationship between Psychological Profiles and Longitudinal Pain Trajectories in People with Chronic Knee Pain

Considerable evidence demonstrates that radiographic findings (e.g., osteophytes) are only modestly associated with the severity of knee pain, suggesting that other biopsychosocial factors likely influence symptom severity. Multiple psychological factors have been linked to worse health outcomes in people with chronic knee pain; however, it remains unclear whether psychological profiles might help explain variability in knee pain severity. The primary goal of this study was to identify unique psychological differences among people with and without chronic knee pain, and then examine whether psychological profiles longitudinally predicted knee pain trajectories over two years. Individuals with (n = 180) and without (n = 64) knee pain were enrolled via community and clinic-based recruitment at two study sites in the Southeastern US. All participants provided sociodemographic information and self-reported psychological measures. Baseline psychological measures included assessments of perceived stress, passive/active coping, somatic symptoms, positive/negative affect, optimism, depression, and anxiety. Individuals with knee pain completed X-rays to determine radiographic disease severity via the Kellgren-Lawrence (KL) scale prior to provision of self-reported pain severity and pain interference every 3 months for two years. Individuals with knee pain had higher ratings of depression, anxiety, positive/negative affect, passive/active coping, perceived stress, and somatic symptoms when compared to individuals without knee pain (all p's < .05). Individuals with knee pain were clustered into four separate psychological profiles (Low-risk, low-moderate risk, high-moderate risk, and high risk). Controlling for baseline KL scores, age, education, and income, linear mixed models revealed the group with the high-risk psychological profile demonstrated the greatest severity of pain and interference over two years when compared to the other groups. Results indicate that psychological profiles, in addition to other pieces of evidence such as radiographic disease severity, may be useful for longitudinally predicting severity of knee pain and related interference over time. Grant support from 5R37AG033906-12.

Do Physicians Overestimate Radiographic Findings in Patients Undergoing Knee Arthroplasty?

BackgroundTotal knee arthroplasty (TKA) is 1 of the top 2 most common and expensive surgical procedures among Medicare beneficiaries. Due to the procedure’s high annual cost, overdiagnosis and subsequent overutilization of TKA has substantial health-policy implications. Concerns regarding the overexaggeration of radiographic findings and overutilization of TKA have been expressed by medical insurers. Currently, the standard of care for assessing potential knee arthroplasty candidates includes assigning a Kellgren-Lawrence (KL) radiographic score. Our study investigated the accuracy of reported preoperative KL scores in patients undergoing TKA.Material and methodsRecords of 277 patients who had underwent TKA at our institution for knee osteoarthritis were randomly selected from a large patient data registry and retrospectively reviewed. Two blinded raters assigned KL scores to the radiographs obtained during the preoperative assessment, which were compared to the scores reported by the operative surgeon. An intraclass correlation coefficient (ICC) was calculated to determine inter-rater reliability.ResultsBetween blinded raters, ICC3k = 0.88 (95% confidence interval: 0.86-0.90, P < .001), demonstrating good reliability. Between all raters, ICC2k = 0.89 (95% confidence interval: 0.86-0.90, P < .001), also demonstrating good agreement. Raters fully agreed on the KL classification for 196 patients (70.76%). Compared with blinded raters, the operative surgeon assigned lower KL scores.ConclusionReporting of KL score is consistent between operative surgeons and independent reviewers. In cases of disagreement between reviewers, the operative surgeon was generally more conservative in their estimation of the extent of osteoarthritis present radiographically. Concerns regarding inflation of radiographic findings to support surgical preauthorization are unwarranted.

Effects of Intra-articular Coinjections of Hyaluronic Acid and Hypertonic Dextrose on Knee Osteoarthritis: A Prospective, Randomized, Double-Blind Trial

ObjectiveTo determine whether intra-articular coinjection with hypertonic dextrose improves the outcome of hyaluronic acid (HA) prolotherapy for knee osteoarthritis (OA). DesignProspective, randomized, double-blind trial. SettingMedical center in Taiwan. ParticipantsIn total, 104 participants who fulfilled the American College of Rheumatology clinical and radiographic criteria for knee OA with a Kellgren-Lawrence score of 2 or 3 were recruited (N=104). InterventionsThe participants were blocked randomized to the treatment (HA and hypertonic dextrose) or control (HA and normal saline) group. Ultrasound-guided knee intra-articular injections were administered once a week for 3 weeks. Main Outcome MeasuresThe primary outcomes were performance-based physical function measures (regular and fastest walking speed, stair climbing time, and chair rising time), and the secondary outcomes were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Knee Injury and Osteoarthritis Outcome Score (KOOS). The outcome measures were assessed before the injections and at 1 week and 1, 3, and 6 months after the injections. The data were analyzed through repeated-measures analysis of covariance. ResultsSignificant intergroup difference-in-differences favoring the treatment group were observed for improvements in stair climbing time (−1.6; 95% confidence interval, −8.56 to 4.16; P=.38) and WOMAC physical function (−21.2; 95% confidence interval, −126.05 to 103.83; P = .045) at 6 months. The group×time interaction effects favored the treatment group for regular (P=.001) and fastest walking speed (P=.001) and chair rising time (P=.038); WOMAC stiffness (P < .001) and physical function (P = .003); and KOOS for pain (P = .035), other symptoms (P=.022), and quality of life (P=.012). ConclusionsCompared with HA plus normal saline coinjections, HA plus dextrose coinjections resulted in more significant improvements in stair climbing time and physical function at 6 months, effectively decreased pain, and improved physical function and physical functional performance from 1 week to 6 months. HA plus dextrose coinjections could be a suitable adjuvant therapy for patients with knee OA.

Preoperative Factors and Patient-Reported Outcomes After Total Hip Arthroplasty: Multivariable Prediction Modeling

Although total hip arthroplasty (THA) has been established as a cost-effective intervention, some patients experience ongoing pain and dissatisfaction. There is interest in predicting postoperative outcomes based on preoperative data, but the relative contribution of different preoperative factors is unclear. The study's aim was to develop multivariable prediction models for the assessment of patient-reported outcomes. Registry data on 1412 patients undergoing THA for osteoarthritis at two hospitals between 2013 and 2018 was used. Potential predictors included age, sex, body mass index, spoken language, education level, previous THA, American Society of Anaesthesiologists (ASA) score, lower back pain, depression/anxiety, other lower limb arthritis, number of other comorbidities, the preoperative expectation of pain and function, EuroQol Visual Analogue Scale (EQ-VAS) and preoperative OHS. Radiographic scores were also used: joint space narrowing (JSN), osteophytes, sclerosis, and an overall grade based on the Kellgren-Lawrence (KL) classification. Outcomes assessed were the patient-rated improvement, satisfaction, and OHS at six months. JSN or overall KL scores were the most important predictors (P < .001) for all outcomes, with better radiographic scores associated with worse outcomes. Other predictors associated with poorer outcomes were lower back pain and lower expectation (predicting poor improvement), lower education and higher ASA (predicting lower satisfaction) and younger age, female sex, non-English speakers, lower preoperative EQ-VAS, lower education, back pain, and anxiety/depression (predicting lower OHS). Preoperative radiological scores are an important predictor of patient-reported outcomes at six months postoperatively. Understanding the relative strengths and significance of different factors in predicting outcomes will help the clinician and patient decision-making for THA.

Concentration of Selected Metalloproteinases and Osteocalcin in the Serum and Synovial Fluid of Obese Women with Advanced Knee Osteoarthritis.

The aim of the study was to evaluate the levels of selected MMPs (matrix metalloproteinases) and osteocalcin in the serum and synovial fluid of obese women with osteoarthritis and their correlations with clinical status. The studied group consisted of 39 overweight females undergoing primary total knee arthroplasty due to osteoarthritis (OA). The staging of knee OA was evaluated according to the Ahlbӓck and Kellgren–Lawrence scores. Synovial fluid and peripheral blood samples were obtained. The levels of selected MMPs and osteocalcin were assessed using commercial ELISA kits. The mean value of MMP3 was significantly higher in patients with more advanced disease in both serum (p = 0.0067) and synovial fluid (p = 0.0328). The pro-MMP13 level tended to be higher in synovial fluid in the case of more advanced stages (p = 0.0882), with no tendency regarding the serum level (p = 0.9595). The synovial level of pro-MMP1 was significantly correlated with the synovial concentration of MMP9 and MMP3. The synovial level of MMP9 also showed a significant correlation with the synovial level of MMP3 and pro-MMP13. Furthermore, it was found that the serum level of MMP3 was significantly correlated with the synovial pro-MMP13 level. A correlation between the osteocalcin level in serum and its synovial level was determined. The serum MMP9 level showed a significant correlation with BMI, whereas the synovial MMP9 level was notably correlated with age. Our results showed that the levels of MMP3, MMP9, and pro-MMP13 increased in more advanced radiological stages of OA, indicating the underlying inflammatory process of OA.

Relationship Between the Choice of Clinical Treatment, Gait Functionality and Kinetics in Patients With Comparable Knee Osteoarthritis.

Objective: The objective of this study was to investigate the relationship between the choice of clinical treatment, gait functionality, and kinetics in patients with comparable knee osteoarthritis. Design: This was an observational case-control study. Setting: The study was conducted in a university biomechanics laboratory. Participants: Knee osteoarthritis patients were stratified into the following groups: clinical treatment (conservative/total knee replacement (TKR) planned), sex (male/female), age (60–67/68–75), and body mass index (BMI) (<30/≥30). All patients had a Kellgren–Lawrence score of 2 or 3 (N = 87). Main Outcome Measures: All patients underwent gait analysis, and two groups of dependent variables were extracted:• Spatiotemporal gait variables: gait velocity, stride time, and double-support time, which are associated with patient functionality.• Kinetic gait variables: vertical, anterior–posterior, and mediolateral ground reaction forces, vertical free moment, joint forces, and moments at the ankle, knee, and hip. Multifactorial and multivariate analyses of variance were performed. Results: Functionality relates to treatment decisions, with patients in the conservative group walking 25% faster and spending 24% less time in the double-support phase. However, these differences vary with age and are reduced in older subjects. Patients who planned to undergo TKR did not present higher knee forces, and different joint moments between clinical treatments depended on the age and BMI of the subjects. Conclusions: Knee osteoarthritis is a multifactorial disease, with age and BMI being confounding factors. The differences in gait between the two groups were mitigated by confounding factors and risk factors, such as being a woman, elderly, and obese, reducing the variability of the gait compression loads. These factors should always be considered in gait studies of patients with knee osteoarthritis to control for confounding effects.

Automatic detection and classification of knee osteoarthritis using deep learning approach.

We developed a tool for locating and grading knee osteoarthritis (OA) from digital X-ray images and illustrate the possibility of deep learning techniques to predict knee OA as per the Kellgren-Lawrence (KL) grading system. The purpose of the project is to see how effectively an artificial intelligence (AI)-based deep learning approach can locate and diagnose the severity of knee OA in digital X-ray images. Selection criteria: Patients above 50years old withOAsymptoms (knee joint pain, stiffness, crepitus, and functional limitations) were included in the study. Medical experts excluded patients with post-surgical evaluation, trauma, and infection from the study. We used 3172Anterior-posterior view knee joint digital X-ray images. We have trained the FasterRCNNarchitecture to locate the knee joint space width (JSW) region in digital X-ray images and we incorporate ResNet-50 with transfer learning to extract the features. We have used another pre-trained network (AlexNet with transfer learning) for the classification of knee OA severity. We trained the region proposal network (RPN) using manual extract knee area as the ground truth image and the medical experts graded the knee joint digital X-ray images based on the Kellgren-Lawrence score. An X-ray image is an input for the final model, and the output is a Kellgren-Lawrence grading value. The proposed model identified the minimal kneeJSWarea with a maximum accuracy of 98.516%, and the overall kneeOAseverity classification accuracy was 98.90%. Today numerous diagnostic methods are available, but tools are not transparent and automated analysis ofOAremains a problem. The performance of the proposed model increases while fine-tuning the network and it is higher than the existing works. We will extend this work to grade OA in MRI data in the future.

Erosive Hand OsteoArthritis (EHOA): analysis of consecutive patients presenting with EHOA in a hospital-based rheumatology practice and its implications for an upcoming interventional study.

Erosive Hand OsteoArthritis (EHOA) is a common rheumatological problem. We aim to determine characteristics of EHOA patients: comorbidities, radiographic erosivity and pain experienced after being diagnosed, in order to find which of these are potentially relevant in upcoming interventional trials. Retrospective analysis of EHOA patients within the electronic database in one centre, with a telephone interview on pain as experienced even exceeding 12months after being diagnosed. Eighty-four non-academic EHOA patients were found: 89% females (median age 69years), 11% males (similar age distribution). Kellgren-Lawrence (KL) erosivity scores in both sexes were comparable; DIPs scored higher than PIP's. Comorbid conditions were crystal-induced arthritis, rheumatoid arthritis (RA) and psoriatic arthritis (PsA) in 8%, 5% and 1%, respectively; seropositivity for rheumatoid factor and anti-citrullinated protein antibodies in 8% and 1% respectively. Pain worst experienced often exceeded a visual analogue score of 5.0, but was unrelated to the total KL score. Some pain reduction was reached with non-steroidals (perorally/transcutaneously) as deduced from continued use in 1 in 3. In many EHOA patients, there is an unmet need regarding the treatment of pain, which per se was not directly correlated with erosivity score. Future studies may be designed considering the aforementioned characteristics, acting on the inflammatory process resulting in PIP/DIP erosions, with the exclusion of RA and PsA in order to get a clean study on EHOA. Several studies with monoclonal antibodies have been performed but demonstrated ineffectivity on the outcome of pain. Hope glooms with the arrival of innovative small molecules that may reach EHOA target cells. Key Points • Erosive handOA is a common problem in non-academic rheumatology; it is often associated with significant pain in both sexes exceeding a VASpain of 5.0 even years after being diagnosed; 1 in 3 found some relief in non-steroidals perorally/transcutaneously. • Future studies will have to focus on (episodic) inflammatory hand OA resulting in proven erosivity (EHOA) located in PIP plus DIP joints and may have to exclude comorbid active crystal-induced arthritis as well as rheumatoid/psoriatic arthritis and possibly even RF/ACPA seropositivity in order to get a clean study on EHOA. • As several big monoclonals have failed in EHOA, we may have to search for promising new drugs within the group of small molecules. These will have to show a significant pain-reducing effect and preferably also a disease-modifying osteoarthritis drug (DMOAD) effect.

Prior Anterior Cruciate Ligament Reconstruction Does Not Compromise the Functional Outcomes of Medial Unicompartmental Knee Arthroplasty Although Revision for Progressive Arthritis May Occur Earlier.

Anterior cruciate ligament (ACL) deficiency is commonly considered a contraindication for unicompartmental knee arthroplasty (UKA). The purpose of this study is to compare the outcomes of UKA after prior ACL reconstruction (rACL cohort) to UKA with an intact native ACL (nACL cohort). Forty-five patients from 3 institutions who underwent medial UKA after prior rACL were matched by age, gender, preoperative function scores, and body mass index to 90 patients who underwent UKA with an intact nACL. Primary outcomes were Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, Oxford Knee Scores, Knee Society Functional Scores, and Kellgren-Lawrence scores in the unresurfaced, lateral tibiofemoral compartment. Secondary outcomes were postoperative complications and the need for revision to TKA. At a mean of 3.6 years, all PROMs improved significantly with no differences identified between groups. The incidence of revision TKA was similar between cohorts (P= 1.00); however, the mean time to revision for progressive osteoarthritis was 4.0 years in the nACL group and 2.2 years in the rACL group. Twenty percent of rACL patients had a postoperative complication compared to 8% in the nACL group. Despite presenting with a similar degree of lateral arthritis, a greater percentage of patients developed Kellgren-Lawrence scores of ≥3 in the rACL cohort (9%) than in the nACL cohort (0%). A previously reconstructed ACL does not appear to compromise the short-term functional outcomes of UKA; however, there is a higher rate of minor complications and progression of lateral compartment arthritis, which should be considered with patients in the shared decision process.

The Intercalary Fragment in Posterior Malleolus Fractures: Characterization and Significance

Methods of fixation in ankle fractures involving the posterior malleolus have become increasingly scrutinized. With the increase in computed tomography (CT), an intercalary fracture fragment (ICF) adjacent to the posterior malleolus has been oft described. Treatment of the ICF remains controversial and the purpose of this study was to evaluate radiographic and clinical outcomes in patients who had direct reduction and fixation of this fragment compared to those where the ICF was not fixed. This retrospective study included 249 trimalleolar and posterior pilon ankle fractures grouped into those who had the ICF reduced and fixed (n = 74) and those where the ICF was not directly addressed (n = 175). CT scans were evaluated for size and location of the ICF. Demographic, radiographic and intraoperative variables were collected and analyzed. The group which had the ICF reduced and fixed had decreased Kellgren-Lawrence scores (p = .001). There was also a higher rate of repeat surgery in the group who had the ICF fixed, although not meeting statistical significance. There were no differences in size or location of the ICF fragment between groups. We did identify similarities with other studies in regard to size and posterolateral location of the ICF between groups. However, based on worsening radiographic outcomes of the group where the ICF was reduced and fixed, we do not necessarily recommend universal treatment of this fragment. The surgeon's goal should always be a concentric articular reduction and treatment of the ICF should be considered on a case-by-case basis.

EXPLORING GENDER‐DEPENDENT DIFFERENCES IN PATTERNS OF CARTILAGE LOSS USING RESPONSIVENESS HEAT MAPS: DATA FROM THE OAI

Understanding gender-specific differences in patterns of cartilage loss can improve our knowledge of the pathogenesis of knee osteoarthritis (KOA) development and progression and may inform clinical trials of treatments for KOA. Quantitative cartilage assessment using segmentation software offers an ideal method for appreciating these patterns. The goal of our study was to examine gender differences in patterns of cartilage loss in the central weight-bearing regions of the medial femur (MF), lateral femur (LF), medial tibia (MT), and lateral tibia (LT) using cartilage segmentation software. We measured cartilage volume change in the indexed knee of 480 subjects with Kellgren-Lawrence (KL) 2 and 3 from the OAI at the baseline (BL) and 96-month (mo) time points using the local area cartilage segmentation (LACS) method. Briefly, the LACS method uses robust coordinate systems fixed to anatomical landmarks to find the cartilage volume or thickness in consistent sub-regions on each cartilage plate. (See Figure 1.) Using the coordinate systems, LACS permits assessment of change in much smaller sub-regions through the use of responsiveness heat maps. The average age, BMI, and KL score were 59.5years, 28.7kg/m 2 , 2.03 (males) and 60.5years, 28.8kg/m 2 , 1.99 (females). Figure 2 shows heat map images of the change in cartilage volume from BL to 96mo for males and females. The intensity of the colors (red for loss, blue for gain) represents the standardized response mean (SRM) value at each location. We observed more focused thinning for females in the lateral/posterior portion of the MF and the medial side of the LT. An increase in cartilage thickness in the posterior side of the LF sub-region was also observed for females, as shown with the blue area. Similar patterns were observed for other follow-up time points (i.e., BL to 24mo, BL to 48mo, and BL to 72mo) and when stratifying by age, BMI and KL score. Heat maps of smaller subregions were capable of illustrating gender-specific differences in patterns of cartilage loss, differences that may offer insight into the variation of gender differences in the natural history of KOA. Heat maps of cartilage thickness changes may be useful in evaluating the benefit of interventions for KOA. NIH AR071409 none CORRESPONDENCE ADDRESS: jduryea@bwh.harvard.edu .

A Multivariate Analysis to Predict Total Hip Arthroplasty Dislocation With Preoperative Diagnosis, Surgical Approach, Spinal Pathology, Cup Orientation, and Head Size.

There are several risk factors for dislocation after total hip arthroplasty (THA), but few studies include radiographic assessment of implants, with spine pathology and patient characteristics. This study estimates the rate of dislocation by patient gender, age, race/ethnicity, body mass index, Charlson Comorbidity Index, spine pathology, prior spine fusion, levels affected, radiographic Kellgren-Lawrence score of spine osteoarthritis, THA indication, surgical approach, and femoral head size. Seventy-six primary THA patients between January 2007 and 2020 with a dislocation were matched on age and gender to subjects without a known history of dislocation using a 2:1 allocation. Univariable and multivariable survival models that account for matched strata were used to estimate the rate of dislocation. Median follow-up of patients at risk for dislocation was 26.48 months (95% confidence interval [CI] 23.75-36.40). On multivariable analysis, patients with an indication other than primary osteoarthritis were 3.69 (95% CI 2.22-6.13, P < .001) times more likely to dislocate than those with osteoarthritis. Patients with a spine pathology were also nominally more likely to dislocate (hazard ratio 1.76, 95% CI 0.97-3.18, P= .06), and patients receiving a posterior surgical approach were 2.74 (95% CI 1.11-6.76, P= .03) times more likely than those receiving a non-posterior approach to dislocate. Patients with THA indication other than primary osteoarthritis and receiving a posterior surgical approach, and to a lesser degree spinal pathology, were identified as affecting the rate of dislocation. After correcting for other variables, femoral head size, cup orientation, and patient factors were not predictive. Level IV, case-control study.

Comparison of Robotic and Conventional Unicompartmental Knee Arthroplasty Outcomes in Patients with Osteoarthritis: A Retrospective Cohort Study.

Robotic-arm-assisted unicompartmental knee arthroplasty (RUKA) was developed to increase the accuracy of bone alignment and implant positioning. This retrospective study explored whether RUKA has more favorable overall outcomes than conventional unicompartmental knee arthroplasty (CUKA). A total of 158 patients with medial compartment osteoarthritis were recruited, of which 85 had undergone RUKA with the Mako system and 73 had undergone CUKA. The accuracy of component positioning and bone anatomical alignment was compared using preoperative and postoperative radiograph. Clinical outcomes were evaluated using questionnaires, which the patients completed preoperatively and then postoperatively at six months, one year, and two years. In total, 52 patients from the RUKA group and 61 from the CUKA group were eligible for analysis. The preoperative health scores and Kellgren–Lawrence scores were higher in the RUKA group. RUKA exhibited higher implant positioning accuracy, thus providing a superior femoral implant angle, properly aligned implant placement, and a low rate of overhang. RUKA also achieved higher accuracy in bone anatomical alignment (tibial axis angle and anatomical axis angle) than CUKA, but surgical time was longer, and blood loss was greater. No significant differences were observed in the clinical outcomes of the two procedures.

Effects of Repeated Co-Injections of Corticosteroids and Hyaluronic Acid on Knee Osteoarthritis: A Prospective, Double-Blind Randomized Controlled Trial

BackgroundWe compared the effects of repeated co-injections of corticosteroids plus hyaluronic acid (HA) with the effects of HA injections alone in patients with knee osteoarthritis. MethodsA double-blind randomized controlled trial was conducted between October 2016 and July 2017 at a medical center. Patients (n = 57) who fulfilled the clinical and radiographic criteria for knee osteoarthritis established by the American College of Rheumatology with a Kellgren-Lawrence score of 2 or 3 were included. They were assigned to either the HA group (n = 29) or corticosteroids plus HA group (n = 28), and injections were administered under ultrasound guidance once a week for 3 consecutive weeks. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were the primary outcomes. Physical functional performance (10-m fast walking and chair-rising time) and the Knee Injury and Osteoarthritis Outcome Score (KOOS) were secondary outcomes. The assessment was performed prior to injections, 1 week, and 1, 3, and 6 months after injections. Data were analyzed through repeated-measures analysis of covariance. ResultsBoth groups experienced decreased pain and improved physical function and physical functional performance over time. We found significant group × time interaction effects favoring the corticosteroids plus HA group in WOMAC-pain (P = .005) and physical function (P = .005), chair-rising time (P = .032), and KOOS-pain (P = .001). ConclusionsRepeated co-injections of corticosteroids plus HA more effectively decreased pain and improved physical function and physical functional performance than injections of HA alone from 1 week through 6 months posttreatment.

Increased serum AXL is associated with radiographic knee osteoarthritis severity.

ObjectiveTo investigate the expression and clinical significance of serum soluble AXL in patients with radiographic knee osteoarthritis (KOA).MethodsThere were 183 patients with KOA who were selected and divided based on the Kellgren‐Lawrence (KL) score into KL 0 subgroups (n = 42), KL I‐II subgroups (n = 90), and KL III‐IV subgroups (n = 51). Healthy volunteers (n = 170) in our hospital were selected with matched age and gender as the control group. AXL level in serum was detected by enzyme‐linked immunosorbent assay. The correlation between serum AXL with severity and clinical indicators of osteoarthritis was analyzed.ResultsThe level of serum AXL was significantly higher in the osteoarthritis group than that in the control group (P < .05). In the osteoarthritis patients, serum AXL level was increased with the increase of KL score. Serum AXL level was positively correlated with age, body mass index, erythrocyte sedimentation rate, serum C‐reactive protein, cartilage oligomeric protein, matrix metalloproteinase‐13, and transforming growth factor‐β1 levels. The cut‐off value for serum AXL was determined as 33.375 ng/mL by receiver operating curve analysis.ConclusionThe level of serum AXL in patients with osteoarthritis is significantly higher than in healthy controls, and is closely related to the severity of radiographic osteoarthritis.

Fully automated deep learning for knee alignment assessment in lower extremity radiographs: a cross-sectional diagnostic study.

Accurate assessment of knee alignment and leg length discrepancy is currently measured manually from standing long-leg radiographs (LLR), a process that is both time consuming and poorly reproducible. The aim was to assess the performance of a commercial available AI software by comparing its outputs with manually performed measurements. The AI was trained on over 15,000 radiographs to measure various clinical angles and lengths from LLRs. We performed a retrospective single-center analysis on 295 LLRs obtained between 2015 and 2020 from male and female patients over 18years. AI and expert measurements were performed independently. Kellgren-Lawrence score and reading time were assessed. All measurements were compared and non-inferiority, mean-absolute-deviation (sMAD), and intra-class-correlation (ICC) were calculated. A total of 295 LLRs from 284 patients (mean age, 65years (18; 90); 97 (34.2%) men) were analyzed. The AI model produces outputs on 98.0% of the LLRs. Manually annotations were considered as 100% accurate. For each measurement, its divergence was calculated, resulting in an overall accuracy of 89.2% when comparing the AI outputs to the manually measured. AI vs. mean observer revealed an sMAD between 0.39 and 2.19° for angles and 1.45-5.00mm for lengths. AI showed good reliability in all lengths and angles (ICC ≥ 0.87). Non-inferiority comparing AI to the mean observer revealed an equivalence-index (γ) between 0.54 and 3.03° for angles and - 0.70-1.95mm for lengths. On average, AI was 130s faster than clinicians. Automated measurements of knee alignment and length measurements produced with an AI tool result in reproducible, accurate measures with a time savings compared to manually acquired measurements.

Long-term follow-up of bucket-handle meniscal repairs: chondroprotective effect outweighs high failure risk.

Outcomes after repair of bucket-handle meniscal tears tend to be satisfying in the short-term follow-up. However, the literature is scarce regarding long-term data following repair of bucket-handle meniscal tears. The aim of this study was to assess long-term follow-up outcomes, focusing on knee osteoarthritis (OA) development and failure rate, and determine risk factors associated with failure. This is a retrospective cohort study, including all patients with bucket-handle tears within 4mm of the menisco-synovial junction, who underwent meniscal repair, either isolated or combined with anterior cruciate ligament reconstruction (ACLR) between 2004 and 2015. A combination of all-inside, outside-in, and inside-out repair technique was used in all patients. Patients over 40years old, concomitant multi-ligamentous injuries, and severe cartilage lesions documented intraoperatively were excluded. During the follow-up, a meniscus was considered healed using Barrett's criteria, while knee OA evaluation was performed according to Kellgren-Lawrence (KL) classification using standing knee radiographs. Patients were assessed preoperatively as well as postoperatively in terms of knee function using International Knee Documentation Committee (IKDC) score, Lysholm score, and Knee injury and Osteoarthritis Outcome Score (KOOS). In total, the inclusion criteria were met by 66 patients. Median age at the time of operation was 21.9years (13-39). Median follow-up was 114 (62-176) months. Total failure rate was approximately 33% at median time of 19 (6-39) months. Osteoarthritis was statistically significantly more prevalent in patients with failed repairs (mean KL score: 2.09) in comparison to patients with successful repairs (mean KL score: 0.54) p = 0.001. In addition, successful repairs were associated with higher KOOS score as compared with failed repairs (mean ± SD, 89.6 ± 4.6 vs 77.8 ± 4.9 p < 0.001), higher IKDC score (mean ± SD, 88.2 ± 5.1 vs 79.2 ± 5.2 p < 0.001), and Lysholm score (mean ± SD, 90.3 ± 5.3 vs 78.4 ± 7.8 p < 0.001). Patients with medial meniscus repair had 4.8 higher relative likelihood of failure compared to lateral meniscus [p = 0 .014, OR = 4.8 (95% Cl 1.2, 18.6)]. Patients over 16years old had 5.7 higher relative likelihood of failure [p = 0 .016, OR = 5.7 (95% Cl 0.04, 0.85)]. Concurrent ACLR did not have a significant effect on the postoperative outcomes. A high rate of clinical failure was observed after meniscal repair of bucket-handle tears. However, successful treatment led to lower rates of knee OA development and better knee function, approximately 10 years postoperatively. Meniscal repair of bucket-handle tears is recommended to improve knee function and prevent knee OA in young patients. III.

Knee biomechanics and contralateral knee osteoarthritis progression after total knee arthroplasty

BackgroundDespite the success rate of Total Knee Arthroplasty (TKA), many patients undergo contralateral TKA. It is possible that altered gait mechanics after unilateral TKA play a role in the progression of contralateral OA progression. Research questionThe purpose of this study was to identify biomechanical predictors of radiographic OA progression in the contralateral (non-surgical) knee after unilateral (primary/initial) TKA. In addition, this study quantified for patients who had contralateral OA progression. MethodsBiomechanical outcomes were collected 6–24 months after unilateral primary TKA and were used to predict changes in contralateral OA severity at follow-up. Participants were divided into “Progressor” and “Non-Progressor” groups based on changes in Kellgren-Lawrence (KL) OA grade and Joint Space Width (JSW) between baseline and follow-up testing sessions. Biomechanical factors during walking were peak knee adduction moment, knee flexion/extension excursions, knee angle at initial foot contact, and peak knee flexion/extension. Multiple independent t-tests were used to examine the magnitude of differences in biomechanical variables between the groups. Logistic regression was used to examine the association between the biomechanical predictors and change in KL scores and JSW. ResultsThe mean time between surgery and follow-up x-rays was 8.8 (2.4) years. Of 40 participants, 62.5–78% had contralateral radiographic knee OA progression by follow-up. There were no significant differences in the biomechanical variables between groups. For the regression analysis, none of the biomechanical variables were found to be predictors for contralateral OA progression. SignificanceAlthough abnormal biomechanics are known risk factors for primary knee OA, it is possible that the mechanisms that result in OA progression of the contralateral limb are different than primary knee OA progression. Future work should evaluate other objective measures of OA progression and determine if cumulative measures of joint loading are related to OA worsening.

Increased radiographic progression of distal hand osteoarthritis occurring during biologic DMARD monotherapy for concomitant rheumatoid arthritis

ObjectivesA considerable proportion of patients with rheumatoid arthritis (RA) also suffer from hand osteoarthritis (OA). We here assess the association between conventional synthetic (cs) and biological (b) disease-modifying antirheumatic drugs (DMARDs) and radiographic distal interphalangeal-(DIP) OA in patients with RA.MethodsAdult RA patients from a longitudinal Swiss registry of rheumatic diseases who had ≥ 2 hand radiographs were included at the first radiograph and followed until the outcome or the last radiograph. Patients were grouped into two cohorts based on whether DIP OA was present or absent at cohort entry (cohorts 1 and 2, respectively). Modified Kellgren-Lawrence scores (KLS) were obtained by evaluating DIP joints for the severity of osteophytes, joint space narrowing, subchondral sclerosis, and erosions. KLS ≥ 2 in ≥ 1 DIP joint indicated incident or existing OA, and increase of ≥ 1 in KLS in ≥ 1 DIP joint indicated progression in existing DIP OA. Time-varying Cox regression and generalized estimating equation (GEE) analyses were performed. We estimated hazard ratios (HRs) and odds ratios (ORs) with 95% confidence intervals (CI) of DIP OA incidence (cohort 2), or progression (cohort 1), in bDMARD monotherapy, bDMARD/csDMARD combination therapy, and past or never DMARD use, when compared to csDMARD use. In post hoc analyses, we descriptively and analytically assessed the individual KLS features in cohort 1.ResultsAmong 2234 RA patients with 5928 radiographs, 1340 patients had DIP OA at baseline (cohort 1). Radiographic progression of DIP OA was characterized by new or progressive osteophyte formation (666, 52.4%), joint space narrowing (379, 27.5%), subchondral sclerosis (238, 17.8%), or erosions (62, 4.3%). bDMARD monotherapy had an increased risk of radiographic DIP OA progression compared to csDMARD monotherapy (adjusted HR 1.34 [95% CI 1.07–1.69]). The risk was not significant in csDMARD/bDMARD combination users (HR 1.12 [95% CI 0.96–1.31]), absent in past DMARD users (HR 0.96 [95% CI 0.66–1.41]), and significantly lower among never DMARD users (HR 0.54 [95% CI 0.33–0.90]). Osteophyte progression (HR 1.74 [95% CI 1.11–2.74]) was the most significantly increased OA feature with bDMARD use compared to csDMARD use. In 894 patients without initial DIP OA (cohort 2), the risk of incident OA did not differ between the treatment groups. The results from GEE analyses corroborated all findings.ConclusionsThese real-world RA cohort data indicate that monotherapy with bDMARDs is associated with increased radiographic progression of existing DIP OA, but not with incident DIP OA.

Gadolinium-free assessment of synovitis using diffusion tensor imaging.

The dynamic contrast-enhanced (DCE)-MRI parameter Ktrans can quantify the intensity of synovial inflammation (synovitis) in knees with osteoarthritis (OA), but requires the use of gadolinium-based contrast agent (GBCA). Diffusion tensor imaging (DTI) measures the diffusion of water molecules with parameters mean diffusivity (MD) and fractional anisotropy (FA), and has been proposed as a method to detect synovial inflammation without the use of GBCA. The purpose of this study is to (1) determine the ability of DTI to quantify the intensity of synovitis in OA by comparing MD and FA with our imaging gold standard Ktrans within the synovium and (2) compare DTI and DCE-MRI measures with the semi-quantitative grading of OA severity with the Kellgren-Lawrence (KL) and MRI Osteoarthritis Knee Score (MOAKS) systems, in order to assess the relationship between synovitis intensity and OA severity. Within the synovium, MD showed a significant positive correlation with Ktrans (r= 0.79, p< 0.001), while FA showed a significant negative correlation with Ktrans (r= -0.72, p= 0.0026). These results show that DTI is able to quantify the intensity of synovitis within the whole synovium without the use of exogenous contrast agent. Additionally, MD, FA, and Ktrans values did not vary significantly when knees were separated by KL grade (p= 0.15, p= 0.32, p= 0.41, respectively), while MD (r= 0.60, p= 0.018) and Ktrans (r= 0.62, p= 0.013) had a significant positive correlation and FA (r= -0.53, p= 0.043) had a negative correlation with MOAKS. These comparisons indicate that quantitative measures of the intensity of synovitis may provide information in addition to morphological assessment to evaluate OA severity. Using DTI to quantify the intensity of synovitis without GBCA may be helpful to facilitate a broader clinical assessment of the severity of OA.