Osteoarthritis

Three of the five recommendations in the first-ever list developed by the American Academy of Orthopaedic Surgeons for the American Board of Internal Medicine Foundation’s "Choosing Wisely" campaign focus primarily on treatments for symptomatic osteoarthritis.

The campaign is meant to educate patients and physicians about unnecessary and potentially harmful testing and treatment.

According to the Choosing Wisely website, the AAOS’s list was formed based on a review of the most recent approved clinical practice guidelines previously developed by AAOS physician volunteer work groups and a selection of a variety of topics frequently used in orthopaedic surgical practice with input from specialty society leaders and the Academy’s presidential leadership and board of directors. The list was created with the intent to "serve as an educational tool based on an assessment of the current scientific and clinical information and accepted approaches to treatment."

However, some specialists find fault with the recommendations. For example, Dr. Roy Altman, a professor of medicine in the division of rheumatology and immunology at the University of California, Los Angeles, said the methodology used to create the guidelines overlooks a number of treatments, including multimodal therapy, and could have the unintended consequence of allowing specialists to deny effective care to patients.

"These guidelines are not consistent with my clinical experience," Dr. Altman said. In particular, he noted that many of his patients react positively to injection treatments for osteoarthritis (OA), which the Choosing Wisely recommendations specifically discourage.

AAOS’s recommendations are as follows:

• Avoid using postoperative ultrasonography screening for deep vein thrombosis on patients receiving hip or knee arthroplasty because it is not effective at diagnosing unsuspected cases.

• Don’t use needle lavage for long-term relief in symptomatic OA treatment, as the procedure "does not lead to measurable improvements in pain, function, 50-foot walking time, stiffness, tenderness, or swelling."

• Do not use glucosamine and chondroitin sulfate to treat patients with symptomatic knee OA.

• Lateral wedge or neutral insoles do not improve pain or functional outcomes in patients; on the contrary, patients with OA of the knee may experience fewer symptoms without insoles.

• Routine postoperative splinting of the wrist after the carpal tunnel release procedure does not improve subjective outcomes, and may lead to detrimental effects, including adhesion formation, stiffness, and prevention of nerve and tendon movement.

mbock@frontlinemedcom.com

Three of the five recommendations in the first-ever list developed by the American Academy of Orthopaedic Surgeons for the American Board of Internal Medicine Foundation’s "Choosing Wisely" campaign focus primarily on treatments for symptomatic osteoarthritis.

The campaign is meant to educate patients and physicians about unnecessary and potentially harmful testing and treatment.

According to the Choosing Wisely website, the AAOS’s list was formed based on a review of the most recent approved clinical practice guidelines previously developed by AAOS physician volunteer work groups and a selection of a variety of topics frequently used in orthopaedic surgical practice with input from specialty society leaders and the Academy’s presidential leadership and board of directors. The list was created with the intent to "serve as an educational tool based on an assessment of the current scientific and clinical information and accepted approaches to treatment."

However, some specialists find fault with the recommendations. For example, Dr. Roy Altman, a professor of medicine in the division of rheumatology and immunology at the University of California, Los Angeles, said the methodology used to create the guidelines overlooks a number of treatments, including multimodal therapy, and could have the unintended consequence of allowing specialists to deny effective care to patients.

"These guidelines are not consistent with my clinical experience," Dr. Altman said. In particular, he noted that many of his patients react positively to injection treatments for osteoarthritis (OA), which the Choosing Wisely recommendations specifically discourage.

AAOS’s recommendations are as follows:

• Avoid using postoperative ultrasonography screening for deep vein thrombosis on patients receiving hip or knee arthroplasty because it is not effective at diagnosing unsuspected cases.

• Don’t use needle lavage for long-term relief in symptomatic OA treatment, as the procedure "does not lead to measurable improvements in pain, function, 50-foot walking time, stiffness, tenderness, or swelling."

• Do not use glucosamine and chondroitin sulfate to treat patients with symptomatic knee OA.

• Lateral wedge or neutral insoles do not improve pain or functional outcomes in patients; on the contrary, patients with OA of the knee may experience fewer symptoms without insoles.

• Routine postoperative splinting of the wrist after the carpal tunnel release procedure does not improve subjective outcomes, and may lead to detrimental effects, including adhesion formation, stiffness, and prevention of nerve and tendon movement.

mbock@frontlinemedcom.com

Three of the five recommendations in the first-ever list developed by the American Academy of Orthopaedic Surgeons for the American Board of Internal Medicine Foundation’s "Choosing Wisely" campaign focus primarily on treatments for symptomatic osteoarthritis.

The campaign is meant to educate patients and physicians about unnecessary and potentially harmful testing and treatment.

According to the Choosing Wisely website, the AAOS’s list was formed based on a review of the most recent approved clinical practice guidelines previously developed by AAOS physician volunteer work groups and a selection of a variety of topics frequently used in orthopaedic surgical practice with input from specialty society leaders and the Academy’s presidential leadership and board of directors. The list was created with the intent to "serve as an educational tool based on an assessment of the current scientific and clinical information and accepted approaches to treatment."

However, some specialists find fault with the recommendations. For example, Dr. Roy Altman, a professor of medicine in the division of rheumatology and immunology at the University of California, Los Angeles, said the methodology used to create the guidelines overlooks a number of treatments, including multimodal therapy, and could have the unintended consequence of allowing specialists to deny effective care to patients.

"These guidelines are not consistent with my clinical experience," Dr. Altman said. In particular, he noted that many of his patients react positively to injection treatments for osteoarthritis (OA), which the Choosing Wisely recommendations specifically discourage.

AAOS’s recommendations are as follows:

• Avoid using postoperative ultrasonography screening for deep vein thrombosis on patients receiving hip or knee arthroplasty because it is not effective at diagnosing unsuspected cases.

• Don’t use needle lavage for long-term relief in symptomatic OA treatment, as the procedure "does not lead to measurable improvements in pain, function, 50-foot walking time, stiffness, tenderness, or swelling."

• Do not use glucosamine and chondroitin sulfate to treat patients with symptomatic knee OA.

• Lateral wedge or neutral insoles do not improve pain or functional outcomes in patients; on the contrary, patients with OA of the knee may experience fewer symptoms without insoles.

• Routine postoperative splinting of the wrist after the carpal tunnel release procedure does not improve subjective outcomes, and may lead to detrimental effects, including adhesion formation, stiffness, and prevention of nerve and tendon movement.

mbock@frontlinemedcom.com

Lateral wedge insoles are ineffective, compared with control interventions, for reducing pain in patients with medial knee osteoarthritis, according to a meta-analysis of data from 12 randomized, controlled trials.

The findings of this meta-analysis suggest that although lateral wedge insoles have been considered a possible means for reducing medial loading by easing "the physical stress applied to that compartment of the joint" and thereby reducing painful knee symptoms, the available evidence does not support their use for this indication, first author Matthew J. Parkes of the University of Manchester (England) Institute of Inflammation and Repair and his colleagues reported. The study was published in the Aug. 21 issue of JAMA.

"...We found that compared with neutral inserts, lateral wedges had no association with knee pain (SMD, -0.03) and heterogeneity was much lower across trial findings."

When data from all 12 trials were considered, the overall effect estimate for lateral wedge insoles was a standardized mean difference (SMD) in pain between interventions of –0.47. This represents moderately significant pain reduction for lateral wedges, and translates into an effect size of –2.12 on the 0-20 Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain scale.

However, the effects were highly heterogenous across the studies, and a significant difference in treatment effect was noted based on the type of control condition used, with a lesser effect seen in the seven trials that used a neutral wedge as the control, the investigators said.

"When trials were grouped according to the control group treatment, we found that compared with neutral inserts, lateral wedges had no association with knee pain (SMD, -0.03) and heterogeneity was much lower across trial findings," they wrote.

The SMD of –0.03 based on these studies represented an effect size of only –0.12 between lateral wedges and neutral wedges on the WOMAC pain subscale (JAMA 2013;310:722-30).

The investigators identified the studies included in the meta-analysis through an extensive search of the literature, including searches of multiple databases for studies published from the earliest available date to May 2013. The 12 trials that met inclusion criteria involved a total of 885 patients, including 502 who received lateral wedge treatment. The primary outcome in the trials was self-reported pain.

The findings are of note because the results of studies examining knee pain following treatment have been inconsistent, and have led to conflicting recommendations.

"For example, in recent osteoarthritis treatment guidelines, the American College of Rheumatology did not recommend lateral wedge insoles as a treatment for medial knee osteoarthritis. On the other hand, the Osteoarthritis Research Society International treatment guidelines state, ‘Lateral wedged insoles can be of symptomatic benefit for some patients with medial tibiofemoral compartment [osteoarthritis] OA,’ " the investigators wrote, adding that in the United Kingdom, the National Institute for Health and Care Excellence considers "footwear with shock-absorbing properties" to be worth consideration in the absence of well-designed trial data.

The identification of effective nonsurgical treatment for knee OA is a high priority, given the increasing prevalence of the disease, the limited efficacious treatment options, and the increase in the rates of knee replacement, they said, noting that medial osteoarthritis is one of the most common subtypes of knee osteoarthritis.

This study was funded by a grant from Arthritis Research UK and by a grant from the National Institute for Health and Care Excellence to two individual authors. Multiple authors disclosed potential conflicts of interest, including a National Institute for Health Research clinical doctoral fellowship; institutional salary or grant support from Arthritis Research UK, serving as a consultant for Sunovion Pharmaceuticals and Knee Creations Ltd., and as associate editor for Arthritis Care & Research; serving as a continuing medical education activity editor and receiving payment for CME case presentations from Vindico Medical Education; and receiving grants from the Arthritis Foundation, the National Institute on Aging, and the Foundation for Physical Medicine & Rehabilitation.

Lateral wedge insoles are ineffective, compared with control interventions, for reducing pain in patients with medial knee osteoarthritis, according to a meta-analysis of data from 12 randomized, controlled trials.

The findings of this meta-analysis suggest that although lateral wedge insoles have been considered a possible means for reducing medial loading by easing "the physical stress applied to that compartment of the joint" and thereby reducing painful knee symptoms, the available evidence does not support their use for this indication, first author Matthew J. Parkes of the University of Manchester (England) Institute of Inflammation and Repair and his colleagues reported. The study was published in the Aug. 21 issue of JAMA.

"...We found that compared with neutral inserts, lateral wedges had no association with knee pain (SMD, -0.03) and heterogeneity was much lower across trial findings."

When data from all 12 trials were considered, the overall effect estimate for lateral wedge insoles was a standardized mean difference (SMD) in pain between interventions of –0.47. This represents moderately significant pain reduction for lateral wedges, and translates into an effect size of –2.12 on the 0-20 Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain scale.

However, the effects were highly heterogenous across the studies, and a significant difference in treatment effect was noted based on the type of control condition used, with a lesser effect seen in the seven trials that used a neutral wedge as the control, the investigators said.

"When trials were grouped according to the control group treatment, we found that compared with neutral inserts, lateral wedges had no association with knee pain (SMD, -0.03) and heterogeneity was much lower across trial findings," they wrote.

The SMD of –0.03 based on these studies represented an effect size of only –0.12 between lateral wedges and neutral wedges on the WOMAC pain subscale (JAMA 2013;310:722-30).

The investigators identified the studies included in the meta-analysis through an extensive search of the literature, including searches of multiple databases for studies published from the earliest available date to May 2013. The 12 trials that met inclusion criteria involved a total of 885 patients, including 502 who received lateral wedge treatment. The primary outcome in the trials was self-reported pain.

The findings are of note because the results of studies examining knee pain following treatment have been inconsistent, and have led to conflicting recommendations.

"For example, in recent osteoarthritis treatment guidelines, the American College of Rheumatology did not recommend lateral wedge insoles as a treatment for medial knee osteoarthritis. On the other hand, the Osteoarthritis Research Society International treatment guidelines state, ‘Lateral wedged insoles can be of symptomatic benefit for some patients with medial tibiofemoral compartment [osteoarthritis] OA,’ " the investigators wrote, adding that in the United Kingdom, the National Institute for Health and Care Excellence considers "footwear with shock-absorbing properties" to be worth consideration in the absence of well-designed trial data.

The identification of effective nonsurgical treatment for knee OA is a high priority, given the increasing prevalence of the disease, the limited efficacious treatment options, and the increase in the rates of knee replacement, they said, noting that medial osteoarthritis is one of the most common subtypes of knee osteoarthritis.

This study was funded by a grant from Arthritis Research UK and by a grant from the National Institute for Health and Care Excellence to two individual authors. Multiple authors disclosed potential conflicts of interest, including a National Institute for Health Research clinical doctoral fellowship; institutional salary or grant support from Arthritis Research UK, serving as a consultant for Sunovion Pharmaceuticals and Knee Creations Ltd., and as associate editor for Arthritis Care & Research; serving as a continuing medical education activity editor and receiving payment for CME case presentations from Vindico Medical Education; and receiving grants from the Arthritis Foundation, the National Institute on Aging, and the Foundation for Physical Medicine & Rehabilitation.

Lateral wedge insoles are ineffective, compared with control interventions, for reducing pain in patients with medial knee osteoarthritis, according to a meta-analysis of data from 12 randomized, controlled trials.

The findings of this meta-analysis suggest that although lateral wedge insoles have been considered a possible means for reducing medial loading by easing "the physical stress applied to that compartment of the joint" and thereby reducing painful knee symptoms, the available evidence does not support their use for this indication, first author Matthew J. Parkes of the University of Manchester (England) Institute of Inflammation and Repair and his colleagues reported. The study was published in the Aug. 21 issue of JAMA.

"...We found that compared with neutral inserts, lateral wedges had no association with knee pain (SMD, -0.03) and heterogeneity was much lower across trial findings."

When data from all 12 trials were considered, the overall effect estimate for lateral wedge insoles was a standardized mean difference (SMD) in pain between interventions of –0.47. This represents moderately significant pain reduction for lateral wedges, and translates into an effect size of –2.12 on the 0-20 Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain scale.

However, the effects were highly heterogenous across the studies, and a significant difference in treatment effect was noted based on the type of control condition used, with a lesser effect seen in the seven trials that used a neutral wedge as the control, the investigators said.

"When trials were grouped according to the control group treatment, we found that compared with neutral inserts, lateral wedges had no association with knee pain (SMD, -0.03) and heterogeneity was much lower across trial findings," they wrote.

The SMD of –0.03 based on these studies represented an effect size of only –0.12 between lateral wedges and neutral wedges on the WOMAC pain subscale (JAMA 2013;310:722-30).

The investigators identified the studies included in the meta-analysis through an extensive search of the literature, including searches of multiple databases for studies published from the earliest available date to May 2013. The 12 trials that met inclusion criteria involved a total of 885 patients, including 502 who received lateral wedge treatment. The primary outcome in the trials was self-reported pain.

The findings are of note because the results of studies examining knee pain following treatment have been inconsistent, and have led to conflicting recommendations.

"For example, in recent osteoarthritis treatment guidelines, the American College of Rheumatology did not recommend lateral wedge insoles as a treatment for medial knee osteoarthritis. On the other hand, the Osteoarthritis Research Society International treatment guidelines state, ‘Lateral wedged insoles can be of symptomatic benefit for some patients with medial tibiofemoral compartment [osteoarthritis] OA,’ " the investigators wrote, adding that in the United Kingdom, the National Institute for Health and Care Excellence considers "footwear with shock-absorbing properties" to be worth consideration in the absence of well-designed trial data.

The identification of effective nonsurgical treatment for knee OA is a high priority, given the increasing prevalence of the disease, the limited efficacious treatment options, and the increase in the rates of knee replacement, they said, noting that medial osteoarthritis is one of the most common subtypes of knee osteoarthritis.

This study was funded by a grant from Arthritis Research UK and by a grant from the National Institute for Health and Care Excellence to two individual authors. Multiple authors disclosed potential conflicts of interest, including a National Institute for Health Research clinical doctoral fellowship; institutional salary or grant support from Arthritis Research UK, serving as a consultant for Sunovion Pharmaceuticals and Knee Creations Ltd., and as associate editor for Arthritis Care & Research; serving as a continuing medical education activity editor and receiving payment for CME case presentations from Vindico Medical Education; and receiving grants from the Arthritis Foundation, the National Institute on Aging, and the Foundation for Physical Medicine & Rehabilitation.

MADRID – Patients with knee osteoarthritis who "retreated" into a passive coping strategy and engaged in an unhealthy lifestyle were likely to develop more long-term pain than were patients who stayed physically healthy and emotionally strong, in a large Dutch cohort study.

"To diminish pain in patients with early symptomatic OA [osteoarthritis], attention should be given not only to pain complaints, but also to effective use of coping strategies and unhealthy lifestyle factors," said the lead author of the study, Janet Wesseling, Ph.D., of University Medical Center, Utrecht, the Netherlands. "This is a further argument to take coping and lifestyle factors into account in the management of early OA."

Her findings were extracted from data in the CHECK (Cohort Hip and Cohort Knee) study, a 10-year prospective cohort study with a mirror cohort in the United States. It’s following 1,002 patients with early OA-related complaints of hip and/or knee pain (Ann. Rheum. Dis 2013;72[Suppl. 3]:152)

The study’s pain trajectory subanalysis included 5-year data on 705 patients with symptomatic knee OA. Dr. Wesseling identified three trajectories in these patients: good, moderate, and poor pain outcomes.

Patients with a good outcome trajectory (n = 222) had over time a slight decrease in pain severity and ended up with a low pain severity. Those with a moderate outcome trajectory (n = 294) had a stable course of moderate pain over time. The poor outcome trajectory group (n = 189) had an increase in pain severity over time and ended up with severe pain.

Compared with the good-outcome group, participants in the other groups were significantly more likely to have a higher body mass index (odds ratio = 1.1). Patients in the moderate- and poor-outcome groups were significantly more likely to smoke than were those in the good-outcome group (moderate outcome, OR = 1.8; poor outcome, OR = 2.3), Dr. Wesseling reported at the annual European Congress of Rheumatology.

There were significant differences in coping strategies as well. The poorer-outcome groups were more likely to have a passive coping style. They were significantly more likely to worry about their condition than was the good-outcome group (moderate outcome, OR = 2.3; poor outcome, OR = 3.5), and more likely to rest often (moderate outcome, OR = 1.6; poor outcome, OR = 2.4).

Over the long run, there were also disease-related physical differences, Dr. Wesseling noted.

After 5 years, patients in the poor-outcome group experienced more joint destruction and changes in osteophyte size, she said. By that time, 13% of patients in the poor-outcome group had at least two grade changes on the Kellgren-Lawrence Grading Scale, indicating more joint space narrowing, osteophyte formation, sclerosis, and bony contour deformity.

Over time, these patients also experienced significantly more osteophyte enlargement than did patients in the moderate- and good-outcome groups, with a mean growth of 5.2 mm, compared with 3.4 mm and 2.9 mm, respectively.

Surgical outcomes were significantly different in the poor-outcome group, Dr. Wesseling said. There were 12 total knee replacements in the poor-outcome group, compared with 4 in the moderate-outcome group and just 1 in the good-outcome group.

Distinguishing different trajectories could have implications for treatment, Dr. Wesseling noted in an interview. Clinicians can suggest improvements in the way patients choose to deal with their condition – beginning with an up-front conversation.

"At the very least, the topic should be discussed during counseling on OA. Physicians should be alert to increasing stress levels in their patients. Sometimes, physicians can help counsel patients about managing stress, but a psychological consult might also be useful. And self-management programs can help patients manage and tolerate their pain."

The CHECK study is supported by the Dutch Arthritis Association. Dr. Wesseling and her colleagues had no disclosures to report.

msullivan@frontlinemedcom.com

MADRID – Patients with knee osteoarthritis who "retreated" into a passive coping strategy and engaged in an unhealthy lifestyle were likely to develop more long-term pain than were patients who stayed physically healthy and emotionally strong, in a large Dutch cohort study.

"To diminish pain in patients with early symptomatic OA [osteoarthritis], attention should be given not only to pain complaints, but also to effective use of coping strategies and unhealthy lifestyle factors," said the lead author of the study, Janet Wesseling, Ph.D., of University Medical Center, Utrecht, the Netherlands. "This is a further argument to take coping and lifestyle factors into account in the management of early OA."

Her findings were extracted from data in the CHECK (Cohort Hip and Cohort Knee) study, a 10-year prospective cohort study with a mirror cohort in the United States. It’s following 1,002 patients with early OA-related complaints of hip and/or knee pain (Ann. Rheum. Dis 2013;72[Suppl. 3]:152)

The study’s pain trajectory subanalysis included 5-year data on 705 patients with symptomatic knee OA. Dr. Wesseling identified three trajectories in these patients: good, moderate, and poor pain outcomes.

Patients with a good outcome trajectory (n = 222) had over time a slight decrease in pain severity and ended up with a low pain severity. Those with a moderate outcome trajectory (n = 294) had a stable course of moderate pain over time. The poor outcome trajectory group (n = 189) had an increase in pain severity over time and ended up with severe pain.

Compared with the good-outcome group, participants in the other groups were significantly more likely to have a higher body mass index (odds ratio = 1.1). Patients in the moderate- and poor-outcome groups were significantly more likely to smoke than were those in the good-outcome group (moderate outcome, OR = 1.8; poor outcome, OR = 2.3), Dr. Wesseling reported at the annual European Congress of Rheumatology.

There were significant differences in coping strategies as well. The poorer-outcome groups were more likely to have a passive coping style. They were significantly more likely to worry about their condition than was the good-outcome group (moderate outcome, OR = 2.3; poor outcome, OR = 3.5), and more likely to rest often (moderate outcome, OR = 1.6; poor outcome, OR = 2.4).

Over the long run, there were also disease-related physical differences, Dr. Wesseling noted.

After 5 years, patients in the poor-outcome group experienced more joint destruction and changes in osteophyte size, she said. By that time, 13% of patients in the poor-outcome group had at least two grade changes on the Kellgren-Lawrence Grading Scale, indicating more joint space narrowing, osteophyte formation, sclerosis, and bony contour deformity.

Over time, these patients also experienced significantly more osteophyte enlargement than did patients in the moderate- and good-outcome groups, with a mean growth of 5.2 mm, compared with 3.4 mm and 2.9 mm, respectively.

Surgical outcomes were significantly different in the poor-outcome group, Dr. Wesseling said. There were 12 total knee replacements in the poor-outcome group, compared with 4 in the moderate-outcome group and just 1 in the good-outcome group.

Distinguishing different trajectories could have implications for treatment, Dr. Wesseling noted in an interview. Clinicians can suggest improvements in the way patients choose to deal with their condition – beginning with an up-front conversation.

"At the very least, the topic should be discussed during counseling on OA. Physicians should be alert to increasing stress levels in their patients. Sometimes, physicians can help counsel patients about managing stress, but a psychological consult might also be useful. And self-management programs can help patients manage and tolerate their pain."

The CHECK study is supported by the Dutch Arthritis Association. Dr. Wesseling and her colleagues had no disclosures to report.

msullivan@frontlinemedcom.com

MADRID – Patients with knee osteoarthritis who "retreated" into a passive coping strategy and engaged in an unhealthy lifestyle were likely to develop more long-term pain than were patients who stayed physically healthy and emotionally strong, in a large Dutch cohort study.

"To diminish pain in patients with early symptomatic OA [osteoarthritis], attention should be given not only to pain complaints, but also to effective use of coping strategies and unhealthy lifestyle factors," said the lead author of the study, Janet Wesseling, Ph.D., of University Medical Center, Utrecht, the Netherlands. "This is a further argument to take coping and lifestyle factors into account in the management of early OA."

Her findings were extracted from data in the CHECK (Cohort Hip and Cohort Knee) study, a 10-year prospective cohort study with a mirror cohort in the United States. It’s following 1,002 patients with early OA-related complaints of hip and/or knee pain (Ann. Rheum. Dis 2013;72[Suppl. 3]:152)

The study’s pain trajectory subanalysis included 5-year data on 705 patients with symptomatic knee OA. Dr. Wesseling identified three trajectories in these patients: good, moderate, and poor pain outcomes.

Patients with a good outcome trajectory (n = 222) had over time a slight decrease in pain severity and ended up with a low pain severity. Those with a moderate outcome trajectory (n = 294) had a stable course of moderate pain over time. The poor outcome trajectory group (n = 189) had an increase in pain severity over time and ended up with severe pain.

Compared with the good-outcome group, participants in the other groups were significantly more likely to have a higher body mass index (odds ratio = 1.1). Patients in the moderate- and poor-outcome groups were significantly more likely to smoke than were those in the good-outcome group (moderate outcome, OR = 1.8; poor outcome, OR = 2.3), Dr. Wesseling reported at the annual European Congress of Rheumatology.

There were significant differences in coping strategies as well. The poorer-outcome groups were more likely to have a passive coping style. They were significantly more likely to worry about their condition than was the good-outcome group (moderate outcome, OR = 2.3; poor outcome, OR = 3.5), and more likely to rest often (moderate outcome, OR = 1.6; poor outcome, OR = 2.4).

Over the long run, there were also disease-related physical differences, Dr. Wesseling noted.

After 5 years, patients in the poor-outcome group experienced more joint destruction and changes in osteophyte size, she said. By that time, 13% of patients in the poor-outcome group had at least two grade changes on the Kellgren-Lawrence Grading Scale, indicating more joint space narrowing, osteophyte formation, sclerosis, and bony contour deformity.

Over time, these patients also experienced significantly more osteophyte enlargement than did patients in the moderate- and good-outcome groups, with a mean growth of 5.2 mm, compared with 3.4 mm and 2.9 mm, respectively.

Surgical outcomes were significantly different in the poor-outcome group, Dr. Wesseling said. There were 12 total knee replacements in the poor-outcome group, compared with 4 in the moderate-outcome group and just 1 in the good-outcome group.

Distinguishing different trajectories could have implications for treatment, Dr. Wesseling noted in an interview. Clinicians can suggest improvements in the way patients choose to deal with their condition – beginning with an up-front conversation.

"At the very least, the topic should be discussed during counseling on OA. Physicians should be alert to increasing stress levels in their patients. Sometimes, physicians can help counsel patients about managing stress, but a psychological consult might also be useful. And self-management programs can help patients manage and tolerate their pain."

The CHECK study is supported by the Dutch Arthritis Association. Dr. Wesseling and her colleagues had no disclosures to report.

msullivan@frontlinemedcom.com

ESTES PARK, COLO. – Thinking outside the evidence-based guidelines is the only way to manage erosive, inflammatory osteoarthritis of the hand, which is an aggressive subtype of primary osteoarthritis frequently misdiagnosed as rheumatoid arthritis or psoriatic arthritis.

This inflammatory destructive joint disease accounts for 5%-10% of all cases of primary OA. The inflammation waxes and wanes over the course of years, resulting in knobbly, painful, inflamed knuckles and finger deformities of the distal and proximal interphalangeal joints.

Bruce Jancin/IMNG Medical Media

This form of OA most often affects white women in their 40s and 50s. A strong genetic component is involved: Two-thirds of patients with the erosive, inflammatory subtype of OA have a positive family history, Dr. Sterling West noted at a conference on internal medicine sponsored by the University of Colorado.

Misdiagnosis as rheumatoid arthritis or psoriatic arthritis can be avoided by bearing in mind that despite its aggressive nature, inflammatory OA is still a form of OA. As such, the serology is normal: There is no elevation in erythrocyte sedimentation rate (ESR) or C-reactive protein, and antinuclear antibody and rheumatoid factor testing will be negative. Unlike in rheumatoid arthritis or secondary OA due to hemochromatosis, calcium pyrophosphate disease, or trauma, there is no metacarpophalangeal joint or wrist involvement, stressed Dr. West, professor of medicine and fellowship program director at the university.

X-rays are extremely useful in making the diagnosis. A hallmark of the erosive, inflammatory subtype of OA is the gull-wing sign, a distinctive pattern of central subchondral erosions of the interphalangeal joints evocative of a seagull’s wing.

Unfortunately, OA therapy "really hasn’t changed in 100 years," according to Dr. West. But the aggressive inflammatory nature of the erosive subtype often necessitates moving beyond evidence-based, guideline-recommended treatment.

While acetaminophen at up to 4 g/day is guideline-endorsed as first-line treatment for OA because it can safely achieve up to about a 30% reduction in pain, it doesn’t work as monotherapy in the erosive, inflammatory subtype. It’s best paired with other evidence-based therapies: topical 1% diclofenac gel at 2-4 g four times daily and/or an oral nonsteroidal anti-inflammatory drug (NSAID).

"Salsalate is something that tends to get shunted off to the side. It’s certainly not our strongest NSAID, but it is one of our safest ones," the rheumatologist said.

Celecoxib (Celebrex) and other prescription NSAIDs are more potent but pose safety concerns in patients with cardiovascular disease or renal impairment. Under those circumstances, Dr. West tends not to use them, opting instead for tramadol (Ultram) or duloxetine (Cymbalta). There is good evidence for their efficacy in OA, where their pain-modulating effect is achieved via serotonin/norepinephrine reuptake inhibition.

"They’re expensive. Insurance companies often will not pay for them. Keep in mind that venlafaxine (Effexor) is another [serotonin/norepinephrine reuptake inhibitor]. And while it’s not approved for use in osteoarthritis, it certainly is less expensive and works very similarly to duloxetine and tramadol," according to Dr. West.

His go-to, non–evidence-based therapies for erosive, inflammatory OA include isotoner gloves at night. "The warmth and compression help with morning stiffness," Dr. West explained.

He also recommends application of heated paraffin wax in the morning for the same reason.

Hydroxychloroquine (Plaquenil) often effectively addresses the inflammatory component of the erosive subtype of OA. And intra-articular corticosteroid injections are "a very important treatment" that’s safe so long as a joint isn’t injected more than three or four times per year, the rheumatologist continued.

Case reports describe treatment success with anakinra (Kineret) and adalimumab (Humira). "This is a very expensive way to go. We don’t use that," he said.

Dr. West reported having no conflicts of interest.

bjancin@frontlinemedcom.com

ESTES PARK, COLO. – Thinking outside the evidence-based guidelines is the only way to manage erosive, inflammatory osteoarthritis of the hand, which is an aggressive subtype of primary osteoarthritis frequently misdiagnosed as rheumatoid arthritis or psoriatic arthritis.

This inflammatory destructive joint disease accounts for 5%-10% of all cases of primary OA. The inflammation waxes and wanes over the course of years, resulting in knobbly, painful, inflamed knuckles and finger deformities of the distal and proximal interphalangeal joints.

Bruce Jancin/IMNG Medical Media

This form of OA most often affects white women in their 40s and 50s. A strong genetic component is involved: Two-thirds of patients with the erosive, inflammatory subtype of OA have a positive family history, Dr. Sterling West noted at a conference on internal medicine sponsored by the University of Colorado.

Misdiagnosis as rheumatoid arthritis or psoriatic arthritis can be avoided by bearing in mind that despite its aggressive nature, inflammatory OA is still a form of OA. As such, the serology is normal: There is no elevation in erythrocyte sedimentation rate (ESR) or C-reactive protein, and antinuclear antibody and rheumatoid factor testing will be negative. Unlike in rheumatoid arthritis or secondary OA due to hemochromatosis, calcium pyrophosphate disease, or trauma, there is no metacarpophalangeal joint or wrist involvement, stressed Dr. West, professor of medicine and fellowship program director at the university.

X-rays are extremely useful in making the diagnosis. A hallmark of the erosive, inflammatory subtype of OA is the gull-wing sign, a distinctive pattern of central subchondral erosions of the interphalangeal joints evocative of a seagull’s wing.

Unfortunately, OA therapy "really hasn’t changed in 100 years," according to Dr. West. But the aggressive inflammatory nature of the erosive subtype often necessitates moving beyond evidence-based, guideline-recommended treatment.

While acetaminophen at up to 4 g/day is guideline-endorsed as first-line treatment for OA because it can safely achieve up to about a 30% reduction in pain, it doesn’t work as monotherapy in the erosive, inflammatory subtype. It’s best paired with other evidence-based therapies: topical 1% diclofenac gel at 2-4 g four times daily and/or an oral nonsteroidal anti-inflammatory drug (NSAID).

"Salsalate is something that tends to get shunted off to the side. It’s certainly not our strongest NSAID, but it is one of our safest ones," the rheumatologist said.

Celecoxib (Celebrex) and other prescription NSAIDs are more potent but pose safety concerns in patients with cardiovascular disease or renal impairment. Under those circumstances, Dr. West tends not to use them, opting instead for tramadol (Ultram) or duloxetine (Cymbalta). There is good evidence for their efficacy in OA, where their pain-modulating effect is achieved via serotonin/norepinephrine reuptake inhibition.

"They’re expensive. Insurance companies often will not pay for them. Keep in mind that venlafaxine (Effexor) is another [serotonin/norepinephrine reuptake inhibitor]. And while it’s not approved for use in osteoarthritis, it certainly is less expensive and works very similarly to duloxetine and tramadol," according to Dr. West.

His go-to, non–evidence-based therapies for erosive, inflammatory OA include isotoner gloves at night. "The warmth and compression help with morning stiffness," Dr. West explained.

He also recommends application of heated paraffin wax in the morning for the same reason.

Hydroxychloroquine (Plaquenil) often effectively addresses the inflammatory component of the erosive subtype of OA. And intra-articular corticosteroid injections are "a very important treatment" that’s safe so long as a joint isn’t injected more than three or four times per year, the rheumatologist continued.

Case reports describe treatment success with anakinra (Kineret) and adalimumab (Humira). "This is a very expensive way to go. We don’t use that," he said.

Dr. West reported having no conflicts of interest.

bjancin@frontlinemedcom.com

ESTES PARK, COLO. – Thinking outside the evidence-based guidelines is the only way to manage erosive, inflammatory osteoarthritis of the hand, which is an aggressive subtype of primary osteoarthritis frequently misdiagnosed as rheumatoid arthritis or psoriatic arthritis.

This inflammatory destructive joint disease accounts for 5%-10% of all cases of primary OA. The inflammation waxes and wanes over the course of years, resulting in knobbly, painful, inflamed knuckles and finger deformities of the distal and proximal interphalangeal joints.

Bruce Jancin/IMNG Medical Media

This form of OA most often affects white women in their 40s and 50s. A strong genetic component is involved: Two-thirds of patients with the erosive, inflammatory subtype of OA have a positive family history, Dr. Sterling West noted at a conference on internal medicine sponsored by the University of Colorado.

Misdiagnosis as rheumatoid arthritis or psoriatic arthritis can be avoided by bearing in mind that despite its aggressive nature, inflammatory OA is still a form of OA. As such, the serology is normal: There is no elevation in erythrocyte sedimentation rate (ESR) or C-reactive protein, and antinuclear antibody and rheumatoid factor testing will be negative. Unlike in rheumatoid arthritis or secondary OA due to hemochromatosis, calcium pyrophosphate disease, or trauma, there is no metacarpophalangeal joint or wrist involvement, stressed Dr. West, professor of medicine and fellowship program director at the university.

X-rays are extremely useful in making the diagnosis. A hallmark of the erosive, inflammatory subtype of OA is the gull-wing sign, a distinctive pattern of central subchondral erosions of the interphalangeal joints evocative of a seagull’s wing.

Unfortunately, OA therapy "really hasn’t changed in 100 years," according to Dr. West. But the aggressive inflammatory nature of the erosive subtype often necessitates moving beyond evidence-based, guideline-recommended treatment.

While acetaminophen at up to 4 g/day is guideline-endorsed as first-line treatment for OA because it can safely achieve up to about a 30% reduction in pain, it doesn’t work as monotherapy in the erosive, inflammatory subtype. It’s best paired with other evidence-based therapies: topical 1% diclofenac gel at 2-4 g four times daily and/or an oral nonsteroidal anti-inflammatory drug (NSAID).

"Salsalate is something that tends to get shunted off to the side. It’s certainly not our strongest NSAID, but it is one of our safest ones," the rheumatologist said.

Celecoxib (Celebrex) and other prescription NSAIDs are more potent but pose safety concerns in patients with cardiovascular disease or renal impairment. Under those circumstances, Dr. West tends not to use them, opting instead for tramadol (Ultram) or duloxetine (Cymbalta). There is good evidence for their efficacy in OA, where their pain-modulating effect is achieved via serotonin/norepinephrine reuptake inhibition.

"They’re expensive. Insurance companies often will not pay for them. Keep in mind that venlafaxine (Effexor) is another [serotonin/norepinephrine reuptake inhibitor]. And while it’s not approved for use in osteoarthritis, it certainly is less expensive and works very similarly to duloxetine and tramadol," according to Dr. West.

His go-to, non–evidence-based therapies for erosive, inflammatory OA include isotoner gloves at night. "The warmth and compression help with morning stiffness," Dr. West explained.

He also recommends application of heated paraffin wax in the morning for the same reason.

Hydroxychloroquine (Plaquenil) often effectively addresses the inflammatory component of the erosive subtype of OA. And intra-articular corticosteroid injections are "a very important treatment" that’s safe so long as a joint isn’t injected more than three or four times per year, the rheumatologist continued.

Case reports describe treatment success with anakinra (Kineret) and adalimumab (Humira). "This is a very expensive way to go. We don’t use that," he said.

Dr. West reported having no conflicts of interest.

bjancin@frontlinemedcom.com

Symptomatic hand osteoarthritis is associated with a significant increase in the risk of coronary heart disease events, although the association was not significant for asymptomatic hand osteoarthritis, according to results from a study presented at the annual European Congress of Rheumatology.

A population-based cohort study of 1,348 participants from the Framingham Heart Study found more than double the incidence of coronary heart disease among individuals with symptomatic hand OA, compared with those without hand OA (hazard ratio, 2.26; 95% confidence interval, 1.22-4.18), Dr. Ida K. Haugen reported.

The study defined symptomatic hand OA as one or more hand joints with Kellgren-Lawrence grade of 2 or above and pain in the same joint. The definition excluded individuals with rheumatoid arthritis (RA).

The association persisted even after adjustment for lower limb pain (HR, 2.00; 95% CI, 0.96-4.15), to account for the physical inactivity potentially associated with OA in lower limb joints, according to Dr. Haugen from Diakonhjemmet Hospital in Oslo, and her associates.

However, individuals with radiographic but not symptomatic hand OA showed a nonsignificant increase in the risk of coronary heart disease (HR, 1.60; 95% CI, 0.96-2.66).

The study set out to examine a possible association between hand OA and cardiovascular disease, based on the premise that hand OA is especially likely to be related to metabolic rather than mechanical causes.

"We hypothesized that the association between hand OA and coronary heart disease could be mediated through metabolic factors, such as hyperlipidemia and diabetes, or a more sedate lifestyle due to generalized OA," Dr. Haugen said in an interview.

"Radiographic hand OA is very prevalent in the general population, and only a proportion of those with radiographic hand OA may experience symptoms," she said. "We believe that symptomatic hand OA represents more severe hand OA and, further, the association between hand OA and coronary heart disease may be mediated through factors associated with pain, such as synovitis."

Synovitis has been shown in other diseases such as RA to increase the risk of cardiovascular disease due to the development of atherosclerosis, Dr. Haugen said.

The study failed to find any significant associations between hand OA – either symptomatic or radiographic only – and cardiovascular events, overall mortality, heart failure, and atherothrombotic stroke.

"[W]e hypothesize that the varying associations may be due to different risk factors for coronary heart disease versus cerebrovascular disease and congestive heart failure; for example, hypertension seems to be more important for cerebrovascular disease than for coronary heart disease," Dr. Haugen said.

While further research is needed to explore the mechanisms of the association, Dr. Haugen suggested that clinicians note that patients with hand OA may be at greater risk of coronary heart disease, and preventive strategies may therefore be of greater importance in this group.

Dr. Haugen reported having no relevant financial disclosures.

Symptomatic hand osteoarthritis is associated with a significant increase in the risk of coronary heart disease events, although the association was not significant for asymptomatic hand osteoarthritis, according to results from a study presented at the annual European Congress of Rheumatology.

A population-based cohort study of 1,348 participants from the Framingham Heart Study found more than double the incidence of coronary heart disease among individuals with symptomatic hand OA, compared with those without hand OA (hazard ratio, 2.26; 95% confidence interval, 1.22-4.18), Dr. Ida K. Haugen reported.

The study defined symptomatic hand OA as one or more hand joints with Kellgren-Lawrence grade of 2 or above and pain in the same joint. The definition excluded individuals with rheumatoid arthritis (RA).

The association persisted even after adjustment for lower limb pain (HR, 2.00; 95% CI, 0.96-4.15), to account for the physical inactivity potentially associated with OA in lower limb joints, according to Dr. Haugen from Diakonhjemmet Hospital in Oslo, and her associates.

However, individuals with radiographic but not symptomatic hand OA showed a nonsignificant increase in the risk of coronary heart disease (HR, 1.60; 95% CI, 0.96-2.66).

The study set out to examine a possible association between hand OA and cardiovascular disease, based on the premise that hand OA is especially likely to be related to metabolic rather than mechanical causes.

"We hypothesized that the association between hand OA and coronary heart disease could be mediated through metabolic factors, such as hyperlipidemia and diabetes, or a more sedate lifestyle due to generalized OA," Dr. Haugen said in an interview.

"Radiographic hand OA is very prevalent in the general population, and only a proportion of those with radiographic hand OA may experience symptoms," she said. "We believe that symptomatic hand OA represents more severe hand OA and, further, the association between hand OA and coronary heart disease may be mediated through factors associated with pain, such as synovitis."

Synovitis has been shown in other diseases such as RA to increase the risk of cardiovascular disease due to the development of atherosclerosis, Dr. Haugen said.

The study failed to find any significant associations between hand OA – either symptomatic or radiographic only – and cardiovascular events, overall mortality, heart failure, and atherothrombotic stroke.

"[W]e hypothesize that the varying associations may be due to different risk factors for coronary heart disease versus cerebrovascular disease and congestive heart failure; for example, hypertension seems to be more important for cerebrovascular disease than for coronary heart disease," Dr. Haugen said.

While further research is needed to explore the mechanisms of the association, Dr. Haugen suggested that clinicians note that patients with hand OA may be at greater risk of coronary heart disease, and preventive strategies may therefore be of greater importance in this group.

Dr. Haugen reported having no relevant financial disclosures.

Symptomatic hand osteoarthritis is associated with a significant increase in the risk of coronary heart disease events, although the association was not significant for asymptomatic hand osteoarthritis, according to results from a study presented at the annual European Congress of Rheumatology.

A population-based cohort study of 1,348 participants from the Framingham Heart Study found more than double the incidence of coronary heart disease among individuals with symptomatic hand OA, compared with those without hand OA (hazard ratio, 2.26; 95% confidence interval, 1.22-4.18), Dr. Ida K. Haugen reported.

The study defined symptomatic hand OA as one or more hand joints with Kellgren-Lawrence grade of 2 or above and pain in the same joint. The definition excluded individuals with rheumatoid arthritis (RA).

The association persisted even after adjustment for lower limb pain (HR, 2.00; 95% CI, 0.96-4.15), to account for the physical inactivity potentially associated with OA in lower limb joints, according to Dr. Haugen from Diakonhjemmet Hospital in Oslo, and her associates.

However, individuals with radiographic but not symptomatic hand OA showed a nonsignificant increase in the risk of coronary heart disease (HR, 1.60; 95% CI, 0.96-2.66).

The study set out to examine a possible association between hand OA and cardiovascular disease, based on the premise that hand OA is especially likely to be related to metabolic rather than mechanical causes.

"We hypothesized that the association between hand OA and coronary heart disease could be mediated through metabolic factors, such as hyperlipidemia and diabetes, or a more sedate lifestyle due to generalized OA," Dr. Haugen said in an interview.

"Radiographic hand OA is very prevalent in the general population, and only a proportion of those with radiographic hand OA may experience symptoms," she said. "We believe that symptomatic hand OA represents more severe hand OA and, further, the association between hand OA and coronary heart disease may be mediated through factors associated with pain, such as synovitis."

Synovitis has been shown in other diseases such as RA to increase the risk of cardiovascular disease due to the development of atherosclerosis, Dr. Haugen said.

The study failed to find any significant associations between hand OA – either symptomatic or radiographic only – and cardiovascular events, overall mortality, heart failure, and atherothrombotic stroke.

"[W]e hypothesize that the varying associations may be due to different risk factors for coronary heart disease versus cerebrovascular disease and congestive heart failure; for example, hypertension seems to be more important for cerebrovascular disease than for coronary heart disease," Dr. Haugen said.

While further research is needed to explore the mechanisms of the association, Dr. Haugen suggested that clinicians note that patients with hand OA may be at greater risk of coronary heart disease, and preventive strategies may therefore be of greater importance in this group.

Dr. Haugen reported having no relevant financial disclosures.

PHILADELPHIA – Home exercise DVDs do not enhance long-term adherence to prescribed exercise in patients with knee osteoarthritis, despite producing substantial improvements in pain and physical function at 2 years in a randomized controlled trial.

As with most home exercise DVDs, things started off great.

Patrice Wendling/IMNG Medical Media

Patients who took home a 30-minute DVD after watching it alongside a physiotherapist reported exercising 5.5 and 5.1 times per week at 3 months and 6 months, compared with just 4.3 and 3.9 times per week among controls given detailed verbal and hands-on instruction in a quadriceps exercise protocol, but no video (P = .0358; P =.0369).

At 12 months and 24 months, however, there was no significant difference in exercise adherence between the two groups (P = .169; P = .324), Dr. Harukazu Tohyama said at the World Congress on Osteoarthritis.

The investigators also hypothesized that use of a home exercise DVD could prevent radiographic progression of knee osteoarthritis (OA), but this was not the case among the study’s 107 patients.

The DVD group showed a significant increase in femorotibial angle at 12 and 24 months over baseline values (both P less than .05), but the difference between groups was not significant at either time point (P = .334; P = .293), said Dr. Tohyama, who is on the faculty of the department of sports medicine at Hokkaido University in Sapporo, Japan.

Joint space area, minimum joint space width, and osteophyte area were also similar between groups, as assessed using a fully automated knee OA computer-aided diagnosis (KOA-CAD) measuring system (Osteoarthritis Cartilage. 2008;16:1300-6).

The DVD-based program encompassed muscle stretching, active range-of-motion exercises, and five forms of muscle strengthening. Both the DVD and control group had their intervention reinforced at a clinic visit 4 weeks after randomization.

Members of the audience suggested that a single visit at 4 weeks without additional boosters is not enough to promote adherence. They also questioned whether a 24-month follow-up is long enough to detect whether OA progression is occurring, and cautioned that the study numbers may be too small to draw such a conclusion.

Dr. Tohyama responded that a 24-month follow-up is sufficient for joint OA, but that "for joint [space] narrowing, 24 months is not enough. We need longer follow-up."

Of the 107 patients randomized, 48 were available for analysis in the DVD group and 23 in the control group. The remainder was lost to follow-up or refused the allocation.

The patients were more than 50 years old and had Kellgren-Lawrence grade 2, 3, or 4 knee OA and knee pain. Patients requiring regular or intermittent use of steroids or nonsteroidal anti-inflammatory drugs were excluded.

Scores on the WOMAC (Western Ontario and McMaster Universities Arthritis Index) for all categories were significantly greater in the DVD group than in the control group at 3, 6, 12, and 24 months, Dr. Tohyama said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

WOMAC scores at 6 months in the DVD and control groups were 2.7 vs. 0.2 for pain (P = .0001), 0.60 vs. –0.20 for stiffness (P = .0020), and 8.3 vs. 0.7 for function (P = .0001).

At 24 months, the corresponding scores were 2.2 vs. 0.6 (P = .023), 0.60 vs. –0.07 (P = .011), and 7.3 vs. 2.3 (P = .014).

Improvement in the physical component of the Short Form-8 Health Survey was also significantly greater in the DVD group than in the control group at 3, 6, and 12 months (12 months: 8.3 vs. 2.3; P = .002), but not at 24 months (7.1 vs. 4.1; P = .07).

No significant between-group differences were observed on the SF-8 mental component at any of the time points, he said.

Body mass decreased significantly early on in the DVD group, at 3 and 6 months, compared with controls, but the decline waned along with adherence, and was no longer significant at 12 or 24 months.

Although exercise DVDs may be popular and engaging, "I think what is most important for adherence improvement is to form an exercise habit," Dr. Tohyama said in an interview.

The Japanese Orthopaedic Association sponsored the study. Dr. Tohyama reported having no financial disclosures.

pwendling@frontlinemedcom.com

PHILADELPHIA – Home exercise DVDs do not enhance long-term adherence to prescribed exercise in patients with knee osteoarthritis, despite producing substantial improvements in pain and physical function at 2 years in a randomized controlled trial.

As with most home exercise DVDs, things started off great.

Patrice Wendling/IMNG Medical Media

Patients who took home a 30-minute DVD after watching it alongside a physiotherapist reported exercising 5.5 and 5.1 times per week at 3 months and 6 months, compared with just 4.3 and 3.9 times per week among controls given detailed verbal and hands-on instruction in a quadriceps exercise protocol, but no video (P = .0358; P =.0369).

At 12 months and 24 months, however, there was no significant difference in exercise adherence between the two groups (P = .169; P = .324), Dr. Harukazu Tohyama said at the World Congress on Osteoarthritis.

The investigators also hypothesized that use of a home exercise DVD could prevent radiographic progression of knee osteoarthritis (OA), but this was not the case among the study’s 107 patients.

The DVD group showed a significant increase in femorotibial angle at 12 and 24 months over baseline values (both P less than .05), but the difference between groups was not significant at either time point (P = .334; P = .293), said Dr. Tohyama, who is on the faculty of the department of sports medicine at Hokkaido University in Sapporo, Japan.

Joint space area, minimum joint space width, and osteophyte area were also similar between groups, as assessed using a fully automated knee OA computer-aided diagnosis (KOA-CAD) measuring system (Osteoarthritis Cartilage. 2008;16:1300-6).

The DVD-based program encompassed muscle stretching, active range-of-motion exercises, and five forms of muscle strengthening. Both the DVD and control group had their intervention reinforced at a clinic visit 4 weeks after randomization.

Members of the audience suggested that a single visit at 4 weeks without additional boosters is not enough to promote adherence. They also questioned whether a 24-month follow-up is long enough to detect whether OA progression is occurring, and cautioned that the study numbers may be too small to draw such a conclusion.

Dr. Tohyama responded that a 24-month follow-up is sufficient for joint OA, but that "for joint [space] narrowing, 24 months is not enough. We need longer follow-up."

Of the 107 patients randomized, 48 were available for analysis in the DVD group and 23 in the control group. The remainder was lost to follow-up or refused the allocation.

The patients were more than 50 years old and had Kellgren-Lawrence grade 2, 3, or 4 knee OA and knee pain. Patients requiring regular or intermittent use of steroids or nonsteroidal anti-inflammatory drugs were excluded.

Scores on the WOMAC (Western Ontario and McMaster Universities Arthritis Index) for all categories were significantly greater in the DVD group than in the control group at 3, 6, 12, and 24 months, Dr. Tohyama said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

WOMAC scores at 6 months in the DVD and control groups were 2.7 vs. 0.2 for pain (P = .0001), 0.60 vs. –0.20 for stiffness (P = .0020), and 8.3 vs. 0.7 for function (P = .0001).

At 24 months, the corresponding scores were 2.2 vs. 0.6 (P = .023), 0.60 vs. –0.07 (P = .011), and 7.3 vs. 2.3 (P = .014).

Improvement in the physical component of the Short Form-8 Health Survey was also significantly greater in the DVD group than in the control group at 3, 6, and 12 months (12 months: 8.3 vs. 2.3; P = .002), but not at 24 months (7.1 vs. 4.1; P = .07).

No significant between-group differences were observed on the SF-8 mental component at any of the time points, he said.

Body mass decreased significantly early on in the DVD group, at 3 and 6 months, compared with controls, but the decline waned along with adherence, and was no longer significant at 12 or 24 months.

Although exercise DVDs may be popular and engaging, "I think what is most important for adherence improvement is to form an exercise habit," Dr. Tohyama said in an interview.

The Japanese Orthopaedic Association sponsored the study. Dr. Tohyama reported having no financial disclosures.

pwendling@frontlinemedcom.com

PHILADELPHIA – Home exercise DVDs do not enhance long-term adherence to prescribed exercise in patients with knee osteoarthritis, despite producing substantial improvements in pain and physical function at 2 years in a randomized controlled trial.

As with most home exercise DVDs, things started off great.

Patrice Wendling/IMNG Medical Media

Patients who took home a 30-minute DVD after watching it alongside a physiotherapist reported exercising 5.5 and 5.1 times per week at 3 months and 6 months, compared with just 4.3 and 3.9 times per week among controls given detailed verbal and hands-on instruction in a quadriceps exercise protocol, but no video (P = .0358; P =.0369).

At 12 months and 24 months, however, there was no significant difference in exercise adherence between the two groups (P = .169; P = .324), Dr. Harukazu Tohyama said at the World Congress on Osteoarthritis.

The investigators also hypothesized that use of a home exercise DVD could prevent radiographic progression of knee osteoarthritis (OA), but this was not the case among the study’s 107 patients.

The DVD group showed a significant increase in femorotibial angle at 12 and 24 months over baseline values (both P less than .05), but the difference between groups was not significant at either time point (P = .334; P = .293), said Dr. Tohyama, who is on the faculty of the department of sports medicine at Hokkaido University in Sapporo, Japan.

Joint space area, minimum joint space width, and osteophyte area were also similar between groups, as assessed using a fully automated knee OA computer-aided diagnosis (KOA-CAD) measuring system (Osteoarthritis Cartilage. 2008;16:1300-6).

The DVD-based program encompassed muscle stretching, active range-of-motion exercises, and five forms of muscle strengthening. Both the DVD and control group had their intervention reinforced at a clinic visit 4 weeks after randomization.

Members of the audience suggested that a single visit at 4 weeks without additional boosters is not enough to promote adherence. They also questioned whether a 24-month follow-up is long enough to detect whether OA progression is occurring, and cautioned that the study numbers may be too small to draw such a conclusion.

Dr. Tohyama responded that a 24-month follow-up is sufficient for joint OA, but that "for joint [space] narrowing, 24 months is not enough. We need longer follow-up."

Of the 107 patients randomized, 48 were available for analysis in the DVD group and 23 in the control group. The remainder was lost to follow-up or refused the allocation.

The patients were more than 50 years old and had Kellgren-Lawrence grade 2, 3, or 4 knee OA and knee pain. Patients requiring regular or intermittent use of steroids or nonsteroidal anti-inflammatory drugs were excluded.

Scores on the WOMAC (Western Ontario and McMaster Universities Arthritis Index) for all categories were significantly greater in the DVD group than in the control group at 3, 6, 12, and 24 months, Dr. Tohyama said at the meeting, which was sponsored by the Osteoarthritis Research Society International.

WOMAC scores at 6 months in the DVD and control groups were 2.7 vs. 0.2 for pain (P = .0001), 0.60 vs. –0.20 for stiffness (P = .0020), and 8.3 vs. 0.7 for function (P = .0001).

At 24 months, the corresponding scores were 2.2 vs. 0.6 (P = .023), 0.60 vs. –0.07 (P = .011), and 7.3 vs. 2.3 (P = .014).

Improvement in the physical component of the Short Form-8 Health Survey was also significantly greater in the DVD group than in the control group at 3, 6, and 12 months (12 months: 8.3 vs. 2.3; P = .002), but not at 24 months (7.1 vs. 4.1; P = .07).

No significant between-group differences were observed on the SF-8 mental component at any of the time points, he said.

Body mass decreased significantly early on in the DVD group, at 3 and 6 months, compared with controls, but the decline waned along with adherence, and was no longer significant at 12 or 24 months.

Although exercise DVDs may be popular and engaging, "I think what is most important for adherence improvement is to form an exercise habit," Dr. Tohyama said in an interview.

The Japanese Orthopaedic Association sponsored the study. Dr. Tohyama reported having no financial disclosures.

pwendling@frontlinemedcom.com

PHILADELPHIA – There are few certainties in medicine, but most would agree that exercise is good for you.

In older, largely postmenopausal women, a recent systematic review showed that exercise does indeed prevent weight gain, preserves lean body mass when combined with weight loss, and is a key determinant for the positive effects of weight loss later in life (Maturitas. 2012;72:13-22).

What’s not clear, however, is whether exercise plays the same positive role in weight loss in older, obese patients with knee osteoarthritis, Stephen P. Messier, Ph.D., said at the World Congress on Osteoarthritis.

"Once you take that leap – make that decision to lose weight – the question is: ‘Does exercise enhance, impede, or have no effect on the process and the potential outcomes?,’ " said Dr. Messier, professor and director of the J.B. Snow Biomechanics Laboratory at Wake Forest University, Winston-Salem, N.C.

Patrice Wendling/IMNG Medical Media

The question is highly relevant, as the risk of developing knee OA is up to 12 times higher in obese men and up to 17 times higher in obese women (Arthritis Res. Ther. 2010;12:R88).

Dr. Messier reviewed data from two long-running randomized intervention trials at Wake Forest, suggesting that exercise does not impede weight loss. Compliance was 61% for diet only and 63% for diet plus exercise in ADAPT (Arthritis, Diet and Activity Promotion).

On the other hand, adding exercise to diet doesn’t dramatically enhance weight loss, acknowledged Dr. Messier, principal investigator of ADAPT and of the IDEA (Intensive Diet and Exercise for Arthritis) trial, which had a weight loss goal of at least 10% of body weight, or twice the goal of ADAPT.

Patients who adhered to a diet with or without exercise lost more weight than did those who did neither in ADAPT, but just 2 kilograms of weight loss separated the diet-plus-exercise group from the diet-only group in IDEA. Fat loss was similar.

What was concerning was that the addition of exercise to diet did not prevent the loss of lean mass, Dr. Messier said. The mean change in lean mass was –4.2 with intensive dietary restriction vs. –4.7 with the same diet plus 15 minutes of walking and 20 minutes of weight training thrice-weekly in IDEA.

The silver lining

Knee OA patients and their physicians can take heart, as virtually every clinical outcome favored diet plus exercise over diet alone, Dr. Messier observed.

When exercise was combined with diet for 18 months, patients experienced a 30% decrease in pain and 24% improvement in function in ADAPT, with even higher results of 51% and 47% in IDEA.

"The big take-home message was that the diet and exercise group had a 50% reduction in pain, and you don’t find that with any pharmacologic intervention," he said in an interview.

Dr. Messier speculated that the loss of lean body mass with diet plus exercise could be offset by adding strength training – a tactic that is currently being studied in 370 patients with knee OA in START (Strength Training for Arthritis Trial).

"A more intensive strength training regimen may build muscle and attenuate the loss of lean body mass," he said. "If it works, we could get the best of both worlds."

Diet driving mechanistic changes

Interestingly, the data suggest that diet alone may be slightly better than diet plus exercise in improving mechanistic outcomes, Dr. Messier said.

Among the 142 sedentary overweight/obese older adults with knee OA in ADAPT, every 1 pound of weight loss resulted in a fourfold reduction in compressive forces exerted on the knee per step (Arthritis Rheum. 2005;52:2026-32).

The average change in knee compressive forces from baseline in IDEA was 11% with diet alone, 9% with diet plus exercise, and 5% with exercise alone. Reductions in interleukin-6, a marker of physical disability in older adults, were also significantly better with diet than with diet plus exercise, and the decrease was independent of gender, body mass index and other baseline values.

"Once again, it is the weight loss that counts," he said.

That said, should clinicians push their knee OA patients to exercise and diet?

Diet plus exercise should be the standard of care in our older adults with osteoarthritis of the knee, Dr. Messier concluded.

"OA and other obesity-related diseases place an enormous physical and financial burden on our health care system," he said. "Intensive weight loss, when combined with exercise, can safely achieve a mean long-term weight loss of 11.4% for compliant patients and they can expect significant improvement in symptoms relative to either exercise or diet alone. Wider adoption of intensive weight loss combined with exercise can reduce the burden of disability related to OA and obesity in our aging population."

The congress was sponsored by Osteoarthritis Research Society International. Dr. Messier reported no relevant conflicts of interest.

pwendling@frontlinemedcom.com

PHILADELPHIA – There are few certainties in medicine, but most would agree that exercise is good for you.

In older, largely postmenopausal women, a recent systematic review showed that exercise does indeed prevent weight gain, preserves lean body mass when combined with weight loss, and is a key determinant for the positive effects of weight loss later in life (Maturitas. 2012;72:13-22).

What’s not clear, however, is whether exercise plays the same positive role in weight loss in older, obese patients with knee osteoarthritis, Stephen P. Messier, Ph.D., said at the World Congress on Osteoarthritis.

"Once you take that leap – make that decision to lose weight – the question is: ‘Does exercise enhance, impede, or have no effect on the process and the potential outcomes?,’ " said Dr. Messier, professor and director of the J.B. Snow Biomechanics Laboratory at Wake Forest University, Winston-Salem, N.C.

Patrice Wendling/IMNG Medical Media

The question is highly relevant, as the risk of developing knee OA is up to 12 times higher in obese men and up to 17 times higher in obese women (Arthritis Res. Ther. 2010;12:R88).

Dr. Messier reviewed data from two long-running randomized intervention trials at Wake Forest, suggesting that exercise does not impede weight loss. Compliance was 61% for diet only and 63% for diet plus exercise in ADAPT (Arthritis, Diet and Activity Promotion).

On the other hand, adding exercise to diet doesn’t dramatically enhance weight loss, acknowledged Dr. Messier, principal investigator of ADAPT and of the IDEA (Intensive Diet and Exercise for Arthritis) trial, which had a weight loss goal of at least 10% of body weight, or twice the goal of ADAPT.

Patients who adhered to a diet with or without exercise lost more weight than did those who did neither in ADAPT, but just 2 kilograms of weight loss separated the diet-plus-exercise group from the diet-only group in IDEA. Fat loss was similar.

What was concerning was that the addition of exercise to diet did not prevent the loss of lean mass, Dr. Messier said. The mean change in lean mass was –4.2 with intensive dietary restriction vs. –4.7 with the same diet plus 15 minutes of walking and 20 minutes of weight training thrice-weekly in IDEA.

The silver lining

Knee OA patients and their physicians can take heart, as virtually every clinical outcome favored diet plus exercise over diet alone, Dr. Messier observed.

When exercise was combined with diet for 18 months, patients experienced a 30% decrease in pain and 24% improvement in function in ADAPT, with even higher results of 51% and 47% in IDEA.

"The big take-home message was that the diet and exercise group had a 50% reduction in pain, and you don’t find that with any pharmacologic intervention," he said in an interview.

Dr. Messier speculated that the loss of lean body mass with diet plus exercise could be offset by adding strength training – a tactic that is currently being studied in 370 patients with knee OA in START (Strength Training for Arthritis Trial).

"A more intensive strength training regimen may build muscle and attenuate the loss of lean body mass," he said. "If it works, we could get the best of both worlds."

Diet driving mechanistic changes

Interestingly, the data suggest that diet alone may be slightly better than diet plus exercise in improving mechanistic outcomes, Dr. Messier said.

Among the 142 sedentary overweight/obese older adults with knee OA in ADAPT, every 1 pound of weight loss resulted in a fourfold reduction in compressive forces exerted on the knee per step (Arthritis Rheum. 2005;52:2026-32).

The average change in knee compressive forces from baseline in IDEA was 11% with diet alone, 9% with diet plus exercise, and 5% with exercise alone. Reductions in interleukin-6, a marker of physical disability in older adults, were also significantly better with diet than with diet plus exercise, and the decrease was independent of gender, body mass index and other baseline values.

"Once again, it is the weight loss that counts," he said.

That said, should clinicians push their knee OA patients to exercise and diet?

Diet plus exercise should be the standard of care in our older adults with osteoarthritis of the knee, Dr. Messier concluded.

"OA and other obesity-related diseases place an enormous physical and financial burden on our health care system," he said. "Intensive weight loss, when combined with exercise, can safely achieve a mean long-term weight loss of 11.4% for compliant patients and they can expect significant improvement in symptoms relative to either exercise or diet alone. Wider adoption of intensive weight loss combined with exercise can reduce the burden of disability related to OA and obesity in our aging population."

The congress was sponsored by Osteoarthritis Research Society International. Dr. Messier reported no relevant conflicts of interest.

pwendling@frontlinemedcom.com

PHILADELPHIA – There are few certainties in medicine, but most would agree that exercise is good for you.

In older, largely postmenopausal women, a recent systematic review showed that exercise does indeed prevent weight gain, preserves lean body mass when combined with weight loss, and is a key determinant for the positive effects of weight loss later in life (Maturitas. 2012;72:13-22).

What’s not clear, however, is whether exercise plays the same positive role in weight loss in older, obese patients with knee osteoarthritis, Stephen P. Messier, Ph.D., said at the World Congress on Osteoarthritis.

"Once you take that leap – make that decision to lose weight – the question is: ‘Does exercise enhance, impede, or have no effect on the process and the potential outcomes?,’ " said Dr. Messier, professor and director of the J.B. Snow Biomechanics Laboratory at Wake Forest University, Winston-Salem, N.C.

Patrice Wendling/IMNG Medical Media

The question is highly relevant, as the risk of developing knee OA is up to 12 times higher in obese men and up to 17 times higher in obese women (Arthritis Res. Ther. 2010;12:R88).

Dr. Messier reviewed data from two long-running randomized intervention trials at Wake Forest, suggesting that exercise does not impede weight loss. Compliance was 61% for diet only and 63% for diet plus exercise in ADAPT (Arthritis, Diet and Activity Promotion).

On the other hand, adding exercise to diet doesn’t dramatically enhance weight loss, acknowledged Dr. Messier, principal investigator of ADAPT and of the IDEA (Intensive Diet and Exercise for Arthritis) trial, which had a weight loss goal of at least 10% of body weight, or twice the goal of ADAPT.

Patients who adhered to a diet with or without exercise lost more weight than did those who did neither in ADAPT, but just 2 kilograms of weight loss separated the diet-plus-exercise group from the diet-only group in IDEA. Fat loss was similar.

What was concerning was that the addition of exercise to diet did not prevent the loss of lean mass, Dr. Messier said. The mean change in lean mass was –4.2 with intensive dietary restriction vs. –4.7 with the same diet plus 15 minutes of walking and 20 minutes of weight training thrice-weekly in IDEA.

The silver lining

Knee OA patients and their physicians can take heart, as virtually every clinical outcome favored diet plus exercise over diet alone, Dr. Messier observed.

When exercise was combined with diet for 18 months, patients experienced a 30% decrease in pain and 24% improvement in function in ADAPT, with even higher results of 51% and 47% in IDEA.

"The big take-home message was that the diet and exercise group had a 50% reduction in pain, and you don’t find that with any pharmacologic intervention," he said in an interview.

Dr. Messier speculated that the loss of lean body mass with diet plus exercise could be offset by adding strength training – a tactic that is currently being studied in 370 patients with knee OA in START (Strength Training for Arthritis Trial).

"A more intensive strength training regimen may build muscle and attenuate the loss of lean body mass," he said. "If it works, we could get the best of both worlds."

Diet driving mechanistic changes

Interestingly, the data suggest that diet alone may be slightly better than diet plus exercise in improving mechanistic outcomes, Dr. Messier said.

Among the 142 sedentary overweight/obese older adults with knee OA in ADAPT, every 1 pound of weight loss resulted in a fourfold reduction in compressive forces exerted on the knee per step (Arthritis Rheum. 2005;52:2026-32).

The average change in knee compressive forces from baseline in IDEA was 11% with diet alone, 9% with diet plus exercise, and 5% with exercise alone. Reductions in interleukin-6, a marker of physical disability in older adults, were also significantly better with diet than with diet plus exercise, and the decrease was independent of gender, body mass index and other baseline values.

"Once again, it is the weight loss that counts," he said.

That said, should clinicians push their knee OA patients to exercise and diet?

Diet plus exercise should be the standard of care in our older adults with osteoarthritis of the knee, Dr. Messier concluded.

"OA and other obesity-related diseases place an enormous physical and financial burden on our health care system," he said. "Intensive weight loss, when combined with exercise, can safely achieve a mean long-term weight loss of 11.4% for compliant patients and they can expect significant improvement in symptoms relative to either exercise or diet alone. Wider adoption of intensive weight loss combined with exercise can reduce the burden of disability related to OA and obesity in our aging population."

The congress was sponsored by Osteoarthritis Research Society International. Dr. Messier reported no relevant conflicts of interest.

pwendling@frontlinemedcom.com

BIRMINGHAM, ENGLAND – Contrary to expectations, metal-on-metal hip resurfacing for osteoarthritis was associated with higher patient survival at 10 years than was total hip arthroplasty in a large, population-based study.

Cumulative mortality rates were 2.8% for hip resurfacing versus 7.3% for cemented total hip replacement (THR; hazard ratio, 0.51). Ten-year mortality rates comparing hip resurfacing to uncemented THR were 2.6% and 3.2%, respectively (HR, 0.64).

Furthermore, the number needed to treat with hip resurfacing to prevent 1 excess death was 29 when compared to cemented THR, and it was 88 when compared to uncemented THR.

"Patients who received a metal-on-metal resurfacing [MoMR] procedure seem to have a long-term survival advantage compared to patients receiving cemented or an uncemented THR," said Dr. Adrian Kendal of the National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit at the University of Oxford, England.

"Our findings were robust after adjustment for known confounders," Dr. Kendal said at the British Society for Rheumatology annual conference. Propensity matching was used in the trial, which took age, gender, comorbidity, rurality, and social deprivation into account.

For the study, data from the English Hospital Episode Statistics database were obtained and linked to Office for National Statistics mortality records for all adults (over age 18) undergoing elective primary hip replacement for osteoarthritis in National Health Service hospitals in England and Wales between April 1999 and March 2012.

After propensity score matching, there were 91,633 procedures performed, of which 12,580 were MoMR, 37,740 were cemented THR, and 41,312 were uncemented THR.

In response to a comment that perhaps people opting for MoMR were more likely to be younger, more active, and hence more likely to exercise, Dr. Kendal conceded that other factors might exist that could have affected survival.

Speculating about why there might be such a difference in survival, he said: "I personally don’t think it’s just the use of cement, because that doesn’t explain the group that received an uncemented total hip replacement."

He added that the way the femur is prepared during THR might be important, regardless of whether or not cement is used. The known risk of thrombotic consequences also could affect survival. In addition, health care inequality might be important, as resurfacing procedures are less common than THR, perhaps because of the lack of specialized centers or dedicated teams.

Commenting on the findings after their presentation, consultant rheumatologist Dr. Alex MacGregor, of the University of East Anglia, Norwich, England, noted that similar data were published on this topic last year (BMJ 2012;344:e3319), but the results had proved somewhat controversial as the authors had a conflict of interest in favor of hip resurfacing.

Dr. MacGregor, who is a member of the National Joint Registry Steering Committee, has been involved in a subsequent reanalysis of the paper’s findings and said that the results will be made public later in the year.

"One of my concerns [with this study] is the use of the 10-year mortality endpoint. If these resurfacing procedures are saving lives, then you would expect to see a survival benefit sooner, say at 90 days," Dr. MacGregor said.

Dr. Kendal responded that they tried to account for this, but the answer will need to come from a properly organized, randomized controlled trial.

"We don’t have a conflict of interest here. If anything, we were perhaps looking for the opposite effect; we were expecting to see an increased mortality rate in the resurfacing group," Dr. Kendal said. "That was not the case as it turned out, so I am reasonably confident that our data support the findings of that BMJ article."

Dr. Kendal and Dr. MacGregor reported no conflicts of interest.

rhnews@frontlinemedcom.com

BIRMINGHAM, ENGLAND – Contrary to expectations, metal-on-metal hip resurfacing for osteoarthritis was associated with higher patient survival at 10 years than was total hip arthroplasty in a large, population-based study.

Cumulative mortality rates were 2.8% for hip resurfacing versus 7.3% for cemented total hip replacement (THR; hazard ratio, 0.51). Ten-year mortality rates comparing hip resurfacing to uncemented THR were 2.6% and 3.2%, respectively (HR, 0.64).

Furthermore, the number needed to treat with hip resurfacing to prevent 1 excess death was 29 when compared to cemented THR, and it was 88 when compared to uncemented THR.

"Patients who received a metal-on-metal resurfacing [MoMR] procedure seem to have a long-term survival advantage compared to patients receiving cemented or an uncemented THR," said Dr. Adrian Kendal of the National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit at the University of Oxford, England.

"Our findings were robust after adjustment for known confounders," Dr. Kendal said at the British Society for Rheumatology annual conference. Propensity matching was used in the trial, which took age, gender, comorbidity, rurality, and social deprivation into account.

For the study, data from the English Hospital Episode Statistics database were obtained and linked to Office for National Statistics mortality records for all adults (over age 18) undergoing elective primary hip replacement for osteoarthritis in National Health Service hospitals in England and Wales between April 1999 and March 2012.

After propensity score matching, there were 91,633 procedures performed, of which 12,580 were MoMR, 37,740 were cemented THR, and 41,312 were uncemented THR.

In response to a comment that perhaps people opting for MoMR were more likely to be younger, more active, and hence more likely to exercise, Dr. Kendal conceded that other factors might exist that could have affected survival.

Speculating about why there might be such a difference in survival, he said: "I personally don’t think it’s just the use of cement, because that doesn’t explain the group that received an uncemented total hip replacement."

He added that the way the femur is prepared during THR might be important, regardless of whether or not cement is used. The known risk of thrombotic consequences also could affect survival. In addition, health care inequality might be important, as resurfacing procedures are less common than THR, perhaps because of the lack of specialized centers or dedicated teams.

Commenting on the findings after their presentation, consultant rheumatologist Dr. Alex MacGregor, of the University of East Anglia, Norwich, England, noted that similar data were published on this topic last year (BMJ 2012;344:e3319), but the results had proved somewhat controversial as the authors had a conflict of interest in favor of hip resurfacing.

Dr. MacGregor, who is a member of the National Joint Registry Steering Committee, has been involved in a subsequent reanalysis of the paper’s findings and said that the results will be made public later in the year.

"One of my concerns [with this study] is the use of the 10-year mortality endpoint. If these resurfacing procedures are saving lives, then you would expect to see a survival benefit sooner, say at 90 days," Dr. MacGregor said.

Dr. Kendal responded that they tried to account for this, but the answer will need to come from a properly organized, randomized controlled trial.

"We don’t have a conflict of interest here. If anything, we were perhaps looking for the opposite effect; we were expecting to see an increased mortality rate in the resurfacing group," Dr. Kendal said. "That was not the case as it turned out, so I am reasonably confident that our data support the findings of that BMJ article."

Dr. Kendal and Dr. MacGregor reported no conflicts of interest.

rhnews@frontlinemedcom.com

BIRMINGHAM, ENGLAND – Contrary to expectations, metal-on-metal hip resurfacing for osteoarthritis was associated with higher patient survival at 10 years than was total hip arthroplasty in a large, population-based study.

Cumulative mortality rates were 2.8% for hip resurfacing versus 7.3% for cemented total hip replacement (THR; hazard ratio, 0.51). Ten-year mortality rates comparing hip resurfacing to uncemented THR were 2.6% and 3.2%, respectively (HR, 0.64).

Furthermore, the number needed to treat with hip resurfacing to prevent 1 excess death was 29 when compared to cemented THR, and it was 88 when compared to uncemented THR.

"Patients who received a metal-on-metal resurfacing [MoMR] procedure seem to have a long-term survival advantage compared to patients receiving cemented or an uncemented THR," said Dr. Adrian Kendal of the National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit at the University of Oxford, England.

"Our findings were robust after adjustment for known confounders," Dr. Kendal said at the British Society for Rheumatology annual conference. Propensity matching was used in the trial, which took age, gender, comorbidity, rurality, and social deprivation into account.

For the study, data from the English Hospital Episode Statistics database were obtained and linked to Office for National Statistics mortality records for all adults (over age 18) undergoing elective primary hip replacement for osteoarthritis in National Health Service hospitals in England and Wales between April 1999 and March 2012.

After propensity score matching, there were 91,633 procedures performed, of which 12,580 were MoMR, 37,740 were cemented THR, and 41,312 were uncemented THR.

In response to a comment that perhaps people opting for MoMR were more likely to be younger, more active, and hence more likely to exercise, Dr. Kendal conceded that other factors might exist that could have affected survival.

Speculating about why there might be such a difference in survival, he said: "I personally don’t think it’s just the use of cement, because that doesn’t explain the group that received an uncemented total hip replacement."

He added that the way the femur is prepared during THR might be important, regardless of whether or not cement is used. The known risk of thrombotic consequences also could affect survival. In addition, health care inequality might be important, as resurfacing procedures are less common than THR, perhaps because of the lack of specialized centers or dedicated teams.

Commenting on the findings after their presentation, consultant rheumatologist Dr. Alex MacGregor, of the University of East Anglia, Norwich, England, noted that similar data were published on this topic last year (BMJ 2012;344:e3319), but the results had proved somewhat controversial as the authors had a conflict of interest in favor of hip resurfacing.

Dr. MacGregor, who is a member of the National Joint Registry Steering Committee, has been involved in a subsequent reanalysis of the paper’s findings and said that the results will be made public later in the year.

"One of my concerns [with this study] is the use of the 10-year mortality endpoint. If these resurfacing procedures are saving lives, then you would expect to see a survival benefit sooner, say at 90 days," Dr. MacGregor said.

Dr. Kendal responded that they tried to account for this, but the answer will need to come from a properly organized, randomized controlled trial.

"We don’t have a conflict of interest here. If anything, we were perhaps looking for the opposite effect; we were expecting to see an increased mortality rate in the resurfacing group," Dr. Kendal said. "That was not the case as it turned out, so I am reasonably confident that our data support the findings of that BMJ article."

Dr. Kendal and Dr. MacGregor reported no conflicts of interest.

rhnews@frontlinemedcom.com

Longitudinal loss of bone mineral density from the femoral neck was associated with prevalent knee osteoarthritis in an observational cohort study, lending support to the notion that osteoporosis treatments are worth further investigation for the prevention of osteoarthritis progression.

The study, led by Dr. Ji Y. Lee of the division of rheumatology at Tufts Medical Center, Boston, builds on previous research that loss of bone mineral density (BMD) is associated with the progression of radiographic joint space narrowing. The current study is the first to examine the relationship between BMD and knee osteoarthritis (OA) progression as measured by cartilage volume and thickness on MRI, providing a more sensitive measure of changes in knee cartilage (Arthritis Rheum. 2013 March 12 [doi:10.1002/art.37926]).

The study contrasts with previous research, which has shown a positive relationship between BMD and incident or prevalent radiographically measured knee OA. Other past studies have found no relationship between BMD and radiographic progression of OA or a paradoxical opposite relationship in which low BMD predicted radiographic progression, according to Dr. Lee and associates.

Because previous studies included patients who already had OA, there may have been selection bias (collider confounding) in which the variables of interest – BMD and cartilage volume and thickness – were affected by the same factors. Dr. Lee and colleagues hoped to avoid this selection bias by studying the effect of risk factors that change after disease onset – in this case, change in BMD.

The investigators analyzed a cohort of 127 patients with prevalent knee OA, defined as a Kellgren-Lawrence grade of 2 or more. The patients had at least two MRI scans over a 2-year period, but most had three scans: at baseline and at 1 and 2 years. The patients (41% men) had a mean age of 63 years and mean body mass index (BMI) of 30 kg/m². Baseline BMD averaged across two femoral neck measurements was 0.95 g/cm².

In multivariate linear regression models – adjusted for baseline values of age, gender, BMI, alignment status, and vitamin D treatment – BMD loss of 0.1 g/cm² was associated with a 1.25% per year loss of cartilage volume. For patients who lost BMD at a rate considered to be significant (calculated by the investigators to be a loss of at least 4.7% from baseline), cartilage volume loss was 1.02% per year greater than for patients without BMD loss.

The models also showed that a BMD loss of 0.1 g/cm² was associated with a significant loss of cartilage thickness at the tibia (0.028 mm/year). Those who lost at least 4.7% of BMD lost a mean of 0.021 mm in tibial cartilage thickness per year, compared with those who did not lose BMD, the investigators reported.

Baseline BMD, however, was not significantly associated with any cartilage outcomes in the study.

The biological mechanisms conjectured to link systemic BMD to cartilage loss in knee OA include the possibility that "BMD health might provide an environment that supports optimal subchondral bone turnover and remodeling in response to OA stressors, thus favoring joint stabilization" and the beneficial effect that optimal bone health might have on cartilage health via "humoral mechanisms," Dr. Lee and colleagues wrote. "Systemic BMD could also be a marker for a range of covariates that mediate or confound the relationship, such as systemic inflammation, circulating growth factors or hormones, physical activity, or frailty."

The original trial from which the observational cohort was derived, the Randomized Controlled Trial of Vitamin D for Knee OA, was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. None of the authors had financial disclosures to report.

Longitudinal loss of bone mineral density from the femoral neck was associated with prevalent knee osteoarthritis in an observational cohort study, lending support to the notion that osteoporosis treatments are worth further investigation for the prevention of osteoarthritis progression.

The study, led by Dr. Ji Y. Lee of the division of rheumatology at Tufts Medical Center, Boston, builds on previous research that loss of bone mineral density (BMD) is associated with the progression of radiographic joint space narrowing. The current study is the first to examine the relationship between BMD and knee osteoarthritis (OA) progression as measured by cartilage volume and thickness on MRI, providing a more sensitive measure of changes in knee cartilage (Arthritis Rheum. 2013 March 12 [doi:10.1002/art.37926]).

The study contrasts with previous research, which has shown a positive relationship between BMD and incident or prevalent radiographically measured knee OA. Other past studies have found no relationship between BMD and radiographic progression of OA or a paradoxical opposite relationship in which low BMD predicted radiographic progression, according to Dr. Lee and associates.

Because previous studies included patients who already had OA, there may have been selection bias (collider confounding) in which the variables of interest – BMD and cartilage volume and thickness – were affected by the same factors. Dr. Lee and colleagues hoped to avoid this selection bias by studying the effect of risk factors that change after disease onset – in this case, change in BMD.

The investigators analyzed a cohort of 127 patients with prevalent knee OA, defined as a Kellgren-Lawrence grade of 2 or more. The patients had at least two MRI scans over a 2-year period, but most had three scans: at baseline and at 1 and 2 years. The patients (41% men) had a mean age of 63 years and mean body mass index (BMI) of 30 kg/m². Baseline BMD averaged across two femoral neck measurements was 0.95 g/cm².

In multivariate linear regression models – adjusted for baseline values of age, gender, BMI, alignment status, and vitamin D treatment – BMD loss of 0.1 g/cm² was associated with a 1.25% per year loss of cartilage volume. For patients who lost BMD at a rate considered to be significant (calculated by the investigators to be a loss of at least 4.7% from baseline), cartilage volume loss was 1.02% per year greater than for patients without BMD loss.

The models also showed that a BMD loss of 0.1 g/cm² was associated with a significant loss of cartilage thickness at the tibia (0.028 mm/year). Those who lost at least 4.7% of BMD lost a mean of 0.021 mm in tibial cartilage thickness per year, compared with those who did not lose BMD, the investigators reported.

Baseline BMD, however, was not significantly associated with any cartilage outcomes in the study.

The biological mechanisms conjectured to link systemic BMD to cartilage loss in knee OA include the possibility that "BMD health might provide an environment that supports optimal subchondral bone turnover and remodeling in response to OA stressors, thus favoring joint stabilization" and the beneficial effect that optimal bone health might have on cartilage health via "humoral mechanisms," Dr. Lee and colleagues wrote. "Systemic BMD could also be a marker for a range of covariates that mediate or confound the relationship, such as systemic inflammation, circulating growth factors or hormones, physical activity, or frailty."

The original trial from which the observational cohort was derived, the Randomized Controlled Trial of Vitamin D for Knee OA, was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. None of the authors had financial disclosures to report.

Longitudinal loss of bone mineral density from the femoral neck was associated with prevalent knee osteoarthritis in an observational cohort study, lending support to the notion that osteoporosis treatments are worth further investigation for the prevention of osteoarthritis progression.

The study, led by Dr. Ji Y. Lee of the division of rheumatology at Tufts Medical Center, Boston, builds on previous research that loss of bone mineral density (BMD) is associated with the progression of radiographic joint space narrowing. The current study is the first to examine the relationship between BMD and knee osteoarthritis (OA) progression as measured by cartilage volume and thickness on MRI, providing a more sensitive measure of changes in knee cartilage (Arthritis Rheum. 2013 March 12 [doi:10.1002/art.37926]).

The study contrasts with previous research, which has shown a positive relationship between BMD and incident or prevalent radiographically measured knee OA. Other past studies have found no relationship between BMD and radiographic progression of OA or a paradoxical opposite relationship in which low BMD predicted radiographic progression, according to Dr. Lee and associates.

Because previous studies included patients who already had OA, there may have been selection bias (collider confounding) in which the variables of interest – BMD and cartilage volume and thickness – were affected by the same factors. Dr. Lee and colleagues hoped to avoid this selection bias by studying the effect of risk factors that change after disease onset – in this case, change in BMD.

The investigators analyzed a cohort of 127 patients with prevalent knee OA, defined as a Kellgren-Lawrence grade of 2 or more. The patients had at least two MRI scans over a 2-year period, but most had three scans: at baseline and at 1 and 2 years. The patients (41% men) had a mean age of 63 years and mean body mass index (BMI) of 30 kg/m². Baseline BMD averaged across two femoral neck measurements was 0.95 g/cm².

In multivariate linear regression models – adjusted for baseline values of age, gender, BMI, alignment status, and vitamin D treatment – BMD loss of 0.1 g/cm² was associated with a 1.25% per year loss of cartilage volume. For patients who lost BMD at a rate considered to be significant (calculated by the investigators to be a loss of at least 4.7% from baseline), cartilage volume loss was 1.02% per year greater than for patients without BMD loss.

The models also showed that a BMD loss of 0.1 g/cm² was associated with a significant loss of cartilage thickness at the tibia (0.028 mm/year). Those who lost at least 4.7% of BMD lost a mean of 0.021 mm in tibial cartilage thickness per year, compared with those who did not lose BMD, the investigators reported.

Baseline BMD, however, was not significantly associated with any cartilage outcomes in the study.

The biological mechanisms conjectured to link systemic BMD to cartilage loss in knee OA include the possibility that "BMD health might provide an environment that supports optimal subchondral bone turnover and remodeling in response to OA stressors, thus favoring joint stabilization" and the beneficial effect that optimal bone health might have on cartilage health via "humoral mechanisms," Dr. Lee and colleagues wrote. "Systemic BMD could also be a marker for a range of covariates that mediate or confound the relationship, such as systemic inflammation, circulating growth factors or hormones, physical activity, or frailty."

The original trial from which the observational cohort was derived, the Randomized Controlled Trial of Vitamin D for Knee OA, was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. None of the authors had financial disclosures to report.

A computer simulation model called the Osteoarthritis Policy Model (OAPol) is being used to estimate risks of symptomatic knee OA starting at 40 years of age, stratified by gender and ethnicity.

In an interview at the annual meeting of the American College of Rheumatology in Washington, Elena Losina, Ph.D., of Brigham and Women's Hospital in Boston, describes how the model can be used to develop a risk score that doctors and patients can use to calculate an individual's risk of developing knee OA and take preventive action.

The study was funded in part by the National Institute of Arthritis, Musculoskeletal and Skin Diseases of the National Institutes of Health. Dr. Losina had no financial conflicts to disclose.

A computer simulation model called the Osteoarthritis Policy Model (OAPol) is being used to estimate risks of symptomatic knee OA starting at 40 years of age, stratified by gender and ethnicity.

In an interview at the annual meeting of the American College of Rheumatology in Washington, Elena Losina, Ph.D., of Brigham and Women's Hospital in Boston, describes how the model can be used to develop a risk score that doctors and patients can use to calculate an individual's risk of developing knee OA and take preventive action.

The study was funded in part by the National Institute of Arthritis, Musculoskeletal and Skin Diseases of the National Institutes of Health. Dr. Losina had no financial conflicts to disclose.

A computer simulation model called the Osteoarthritis Policy Model (OAPol) is being used to estimate risks of symptomatic knee OA starting at 40 years of age, stratified by gender and ethnicity.

In an interview at the annual meeting of the American College of Rheumatology in Washington, Elena Losina, Ph.D., of Brigham and Women's Hospital in Boston, describes how the model can be used to develop a risk score that doctors and patients can use to calculate an individual's risk of developing knee OA and take preventive action.

The study was funded in part by the National Institute of Arthritis, Musculoskeletal and Skin Diseases of the National Institutes of Health. Dr. Losina had no financial conflicts to disclose.