Osteoarthritis Research Society International Guidelines Research Articles

Effects of Male and Female Sex on the Development of Posttraumatic Osteoarthritis in the Porcine Knee After Anterior Cruciate Ligament Surgery

Background: Posttraumatic osteoarthritis (PTOA) is a common sequela of anterior cruciate ligament (ACL) injury, even when surgical treatment is selected. The effect of patient sex on cartilage health after ACL injury and surgical treatment has been less studied. Purpose/Hypothesis: The study objective was to compare the macroscopic cartilage damage that develops after ACL surgery in male and female Yucatan minipigs. It was hypothesized that after ACL surgery, the macroscopic cartilage damage of the tibiofemoral joints from female animals would be greater than that from male animals. Additionally, it was hypothesized that the effect of sex on the macroscopic cartilage damage would depend on surgical treatment. Study Design: Controlled laboratory study Methods: Twelve-month follow-up data were obtained for 55 adolescent Yucatan minipigs (22 female/33 male) that were randomized to 1 of 3 experimental groups: no treatment (ACL transection [ACLT]), ACL reconstruction, and bridge-enhanced ACL restoration. The Osteoarthritis Research Society International guidelines were used to determine a standardized macroscopic cartilage damage score on 5 surfaces of the knee joint. Results: Females had significantly worse mean total macroscopic cartilage damage scores on the surgical side (adjusted P value [P adj] = .04) and significantly better scores on the contralateral side (P adj = .01) when compared with males. The trochlear damage scores were also significantly worse in females for surgical limbs (P adj = .009) and significantly better for the contralateral limbs (P adj < .001) when compared with males. Although there were no significant differences in total macroscopic cartilage damage scores between sexes within treatment groups on the surgical limbs (ACLT, P adj = 0.45; ACL reconstruction, P adj = .56; bridge-enhanced ACL restoration, P adj = .23), the mean trochlear scores on the surgical limb of females were significantly worse than those of the males in the ACLT group (P adj = .003). Conclusion: Mean total macroscopic cartilage damage scores of Yucatan minipigs were significantly worse in females than males, regardless of treatment. These differences were predominantly found in the trochlear scores across all treatment groups. Clinical Relevance: These data suggest that patient sex could be more influential in the progression of PTOA than surgical treatment after ACL injury. Identifying factors responsible for this discrepancy may prove valuable to identify targets to slow PTOA progression in male and female ACL-injured populations.

Consequences on Private Insurance Coverage: The AAOS Clinical Practice Guidelines and Hyaluronic Acid Injections.

Consequences on Private Insurance Coverage: The AAOS Clinical Practice Guidelines and Hyaluronic Acid Injections.

Review of Nonsurgical Treatment Guidelines for Lower Extremity Osteoarthritis

Osteoarthritis (OA) is a chronic debilitating disease affecting over 30 million Americans. Many health providers fall prey to believing it is a normal part of aging, leading to inadequate management. Recommendations from the American Academy of Orthopaedic Surgeons (AAOS), American College of Rheumatology (ACR) and Osteoarthritis Research Society International (OARSI) guidelines provide the nurse practitioner options for treating those with OA who are not undergoing surgical management. These interventions include weight loss, exercise, and the use of nonsteroidal anti-inflammatory drugs. Although supported by evidence, these interventions are oftentimes not practiced in primary care. This article presents evidence-based interventions for the nonsurgical treatment of hip and knee OA from the AAOS, ACR, and OARSI guidelines.

OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis

To update and expand upon prior Osteoarthritis Research Society International (OARSI) guidelines by developing patient-focused treatment recommendations for individuals with Knee, Hip, and Polyarticular osteoarthritis (OA) that are derived from expert consensus and based on objective review of high-quality meta-analytic data. We sought evidence for 60 unique interventions. A systematic search of all relevant databases was conducted from inception through July 2018. After abstract and full-text screening by two independent reviewers, eligible studies were matched to PICO questions. Data were extracted and meta-analyses were conducted using RevMan software. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence Profiles were compiled using the GRADEpro web application. Voting for Core Treatments took place first. Four subsequent voting sessions took place via anonymous online survey, during which Panel members were tasked with voting to produce recommendations for all joint locations and comorbidity classes. We designated non-Core treatments to Level 1A, 1B, 2, 3, 4A, 4B, or 5, based on the percentage of votes in favor, in addition to the strength of the recommendation. Core Treatments for Knee OA included arthritis education and structured land-based exercise programs with or without dietary weight management. Core Treatments for Hip and Polyarticular OA included arthritis education and structured land-based exercise programs. Topical non-steroidal anti-inflammatory drugs (NSAIDs) were strongly recommended for individuals with Knee OA (Level 1A). For individuals with gastrointestinal comorbidities, COX-2 inhibitors were Level 1B and NSAIDs with proton pump inhibitors Level 2. For individuals with cardiovascular comorbidities or frailty, use of any oral NSAID was not recommended. Intra-articular (IA) corticosteroids, IA hyaluronic acid, and aquatic exercise were Level 1B/Level 2 treatments for Knee OA, dependent upon comorbidity status, but were not recommended for individuals with Hip or Polyarticular OA. The use of Acetaminophen/Paracetamol (APAP) was conditionally not recommended (Level 4A and 4B), and the use of oral and transdermal opioids was strongly not recommended (Level 5). A treatment algorithm was constructed in order to guide clinical decision-making for a variety of patient profiles, using recommended treatments as input for each decision node. These guidelines offer comprehensive and patient-centered treatment profiles for individuals with Knee, Hip, and Polyarticular OA. The treatment algorithm will facilitate individualized treatment decisions regarding the management of OA.

Inhibition of cartilage degradation and suppression of PGE2 and MMPs expression by pomegranate fruit extract in a model of posttraumatic osteoarthritis

ObjectiveOsteoarthritis (OA) is characterized by cartilage degradation in the affected joints. Pomegranate fruit extract (PFE) inhibits cartilage degradation in vitro. The aim of this study was to determine whether oral consumption of PFE inhibits disease progression in rabbits with surgically induced OA. MethodsOA was surgically induced in the tibiofemoral joints of adult New Zealand White rabbits. In one group, animals were fed PFE in water for 8 wk postsurgery. In the second group, animals were fed PFE for 2 wk before surgery and for 8 wk postsurgery. Histologic assessment and scoring of the cartilage was per Osteoarthritis Research Society International guidelines. Gene expression and matrix metalloproteinases (MMP) activity were determined using quantitative reverse transcriptase polymerase chain reaction and fluorometric assay, respectively. Interleukin (IL)-1 β, MMP-13, IL-6, prostaglandin (PG)E2, and type II collagen (COL2A1) levels in synovial fluid/plasma/culture media were quantified using enzyme-linked immunosorbent assay. Expression of active caspase-3 and poly (ADP-ribose) polymerase p85 was determined by immunohistochemistry. Effect of PFE and inhibitors of MMP-13, mitogen-activated protein kinase (MAPK) and nuclear factor (NF)-κB was studied in IL-1 β-stimulated rabbit articular chondrocytes. ResultsSafranin-O-staining and chondrocyte cluster formation was significantly reduced in the anterior cruciate ligament transaction plus PFE fed groups. Expression of MMP-3, MMP-9, and MMP-13 mRNA was higher in the cartilage of rabbits given water alone but was significantly lower in the animals fed PFE. PFE-fed rabbits had lower IL-6, MMP-13, and PGE2 levels in the synovial fluid and plasma, respectively, and showed higher expression of aggrecan and COL2A1 mRNA. Significantly higher numbers of chondrocytes were positive for markers of apoptosis in the joints of rabbits with OA given water only compared with those in the PFE-fed groups. PFE pretreatment significantly reduced IL-1 β induced IL-6 and MMPs expression in rabbit articular chondrocytes. These effects were also mimicked using MMP-13, MAPK, and NF-κB inhibitors in IL-1 β-stimulated rabbit chondrocytes. In an in vitro activity assay, PFE blocked the activity of MMP-13. Like MAPK and NF-κB inhibitors, PFE was also effective in inhibiting IL-1 β-induced PGE2 production in rabbit chondrocytes. PFE also reversed the inhibitory effect of IL-1β on COL2A1 mRNA and protein expression in IL-1 β-stimulated rabbit chondrocytes. ConclusionThe present data highlight the chondroprotective effects of PFE oral consumption in a model of posttraumatic OA and suggest that PFE-derived compounds may have potential value in the management of OA.

OARSI guidelines for the non-surgical management of knee osteoarthritis

To develop concise, up-to-date, patient-focused, evidence-based, expert consensus guidelines for the management of knee osteoarthritis (OA), intended to inform patients, physicians, and allied healthcare professionals worldwide. Thirteen experts from relevant medical disciplines (primary care, rheumatology, orthopedics, physical therapy, physical medicine and rehabilitation, and evidence-based medicine), three continents and ten countries (USA, UK, France, Netherlands, Belgium, Sweden, Denmark, Australia, Japan, and Canada) and a patient representative comprised the Osteoarthritis Guidelines Development Group (OAGDG). Based on previous OA guidelines and a systematic review of the OA literature, 29 treatment modalities were considered for recommendation. Evidence published subsequent to the 2010 OARSI guidelines was based on a systematic review conducted by the OA Research Society International (OARSI) evidence team at Tufts Medical Center, Boston, USA. Medline, EMBASE, Google Scholar, Web of Science, and the Cochrane Central Register of Controlled Trials were initially searched in first quarter 2012 and last searched in March 2013. Included evidence was assessed for quality using Assessment of Multiple Systematic Reviews (AMSTAR) criteria, and published criticism of included evidence was also considered. To provide recommendations for individuals with a range of health profiles and OA burden, treatment recommendations were stratified into four clinical sub-phenotypes. Consensus recommendations were produced using the RAND/UCLA Appropriateness Method and Delphi voting process. Treatments were recommended as Appropriate, Uncertain, or Not Appropriate, for each of four clinical sub-phenotypes and accompanied by 1-10 risk and benefit scores. Appropriate treatment modalities for all individuals with knee OA included biomechanical interventions, intra-articular corticosteroids, exercise (land-based and water-based), self-management and education, strength training, and weight management. Treatments appropriate for specific clinical sub-phenotypes included acetaminophen (paracetamol), balneotherapy, capsaicin, cane (walking stick), duloxetine, oral non-steroidal anti-inflammatory drugs (NSAIDs; COX-2 selective and non-selective), and topical NSAIDs. Treatments of uncertain appropriateness for specific clinical sub-phenotypes included acupuncture, avocado soybean unsaponfiables, chondroitin, crutches, diacerein, glucosamine, intra-articular hyaluronic acid, opioids (oral and transdermal), rosehip, transcutaneous electrical nerve stimulation, and ultrasound. Treatments voted not appropriate included risedronate and electrotherapy (neuromuscular electrical stimulation). These evidence-based consensus recommendations provide guidance to patients and practitioners on treatments applicable to all individuals with knee OA, as well as therapies that can be considered according to individualized patient needs and preferences.

Can natural products serve as potential treatments for osteoarthritis?

Can natural products serve as potential treatments for osteoarthritis?

Management of Mild-to-Moderate Osteoarthritis: A Study of the Primary Care Perspective

Objectives: Examine the knowledge, attitudes, and practice patterns of primary care clinicians regarding the management of mild-to-moderate osteoarthritis (OA). Design: Case vignette-based survey. Methods: A survey was distributed to 251 physicians, physician assistants (PAs), and nurse practitioners (NPs) in the primary care setting. The survey assessed practice patterns in the management of patients with mild-to-moderate OA, as well as attitudes toward guidelines and future educational topics that may be of benefit to the clinician. Results: We found that primary care clinicians are most likely to treat mild-to-moderate OA with an oral nonsteroidal anti-inflammatory drug regimen. Patients with initial or recurrent OA were “very likely” to be recommended to a physical therapy maintenance program. Two-thirds of respondents claimed to be unfamiliar with Osteoarthritis Research Society International guidelines for OA management. Conclusion: This study reflects the need for further education for primary care physicians, NPs, and PAs on the management of OA.

Osteoarthritis: New Perspectives

Osteoarthritis (OA) is the most common and frequent disease in rheumatology. Aging and obesity are the two main risk factors linked to OA, and because of the aging population and the increasing rates of obesity, the number of OA patients stands to increase dramatically. To date, 46 million adults in the United States—more than 50 percent of adults aged 50 and over—have been diagnosed with OA: it is predicted that by the year 2030, that figure will rise to around 70 million [1]. In the last two decades, many mechanisms have been discovered about this disease. Cartilage, which previously was considered inactive tissue, is now actively studied as the main active tissue of joints; it is being studied as part of the whole joint, including other tissues as subchondral bone, synovium and tendons. OA mainly targets the major joints (knee, hip, and back) but commonly affects the hands, elbows, and ankles. Osteoarthritis is a degenerative disease caused by the loss of cartilage and inflammation: it is often—but not always— accompanied by pain and sometimes occurs subsequent to an injury as primary or secondary OA. The disease results in an imbalance between catabolic and anabolic factors in cartilage. Chondrocytes, osteoblasts, and synoviocytes seem to cross-talk and be part of the process. Current molecular and genetic approaches have led to the identification of more complex mechanisms. The practical questions this paper addresses are: how should we treat OA in the next 10 years, and how can we help aging patients manage their arthritis? Although the ultimate goal for the treatment of OA would be to halt the disease progression and restore cartilage damage and relieve pain, effective cures are not currently available and recommendations for treatment vary. The European League Against Rheumatism (EULAR), the OsteoArthritis Research Society International (OARSI) and the American College of Rheumatology (ACR) have developed various recommendations for treating OA, depending on its location [2–8]. Roddy and Doherty have written a critical review of EULAR’s and ACR’s recommendations for treating OA, which are generally similar, combining non pharmacological and pharmacological approaches [9]. Rannou et Poiraudeau recently published an exhaustive list of nonpharmacological treatments for OA, echoing the work done by Felson et al. [10] on malalignment: treatment regimens range from orthosis to exercise, patient education, and diet, depending on OA location [10–13]. The recent study by Richette et al. [14] concerning obesity and diet and OA highlighted the importance of such non pharmacological treatments [14]. Briefly, non pharmacologic treatment include orthosis (such as using insoles and specific shoes, depending on the location), moderate excercise (specific postural exercises, swimming, walking), acupuncture, thermotherapy, and walking aids such as canes crutches, frames, wheeled walkers, and walking sticks. Diet and weight loss are also recommended, although these are a challenge and a difficult process for obese patients. Defining a weight objective could lead to improvement not only with OA but also with metabolic and cardiovascular diseases. No matter the recommended treatment, education and information are vital for effecting patient compliance. Physicians and therapists play an important role in providing such education during time spent with their patients: regular phone calls may help as well. The pharmacological approach for the treatment of OA differs from Europe to the U.S., although both approaches share the common goal of managing pain while also managing disability. Pharmacological guidelines for the management of OA recommend acetaminophen up to 4g/day as first-line therapy. Alternative pharmacological therapy should be used only in the presence of an inadequate response and severe pain. If acetaminophen cannot control symptoms or if inflammation signs are detected, the use of NSAIDs at the lowest dose is recommended, with consideration of a gastro-protective agent. OARSI and EULAR guidelines recommend that if patients don’t respond to oral analgesics, they should receive intra-articular injections of either corticosteroids or hyaluronate followed by the use of opioids and narcotics only when all other pharmacological options have been considered. Surgery, including joint replacement, is recommended only as the last option [15]. Finally, the use of topical NSAIDs, capsaicin, and SYSADOA (SYmptomatic Slow-Acting Drugs for OA, which includes avocado/soybean unsaponifiables (ASU), chondroitin, diacerein, and glucosamine) is recommended by EULAR and OARSI.

The treatment and prevention of knee osteoarthritis: a tool for clinical decision-making

Background: Osteoarthritis (OA) is a major cause of disability, which will increase further with longer lifetime and higher average weight of the population. Objective: To review a hierarchy of interventions for OA in clinical practice, and compare it with the Strength of Recommendation (SOR) proposed by the Osteoarthritis Research Society International (OARSI). Methods: Search for relevant randomized controlled trials in databases, as well as published systematic reviews and meta-analyses. Results/conclusions: Preventive measures are few and uncertain; however, basic therapy includes reduction in weight in the obese and exercises to keep in shape; this is in accordance with the OARSI guidelines (OARSI, 100% consensus) emphasizing the need for obese individuals with knee OA to lose weight (OARSI, SOR = 96%). There are indications of an effect of some nutraceuticals, though further studies are needed for validation (OARSI, SOR = 63%). Pharmacological treatment has paracetamol as primary prescription, which is a safe, albeit weak analgesic. Supplementary medications are prescribed according to level of pain and possible inflammation.