It’s a good thing orthopaedists don’t rely solely on X-rays to diagnose hip osteoarthritis (OA), because an analysis of data from two large cohort studies casts doubt about the utility of radiographs in diagnosing hip OA in older patients.
Using pain localized to the groin or anterior hip or provoked by internal rotation as the clinical standard for diagnosing hip OA, the researchers compared participants’ reports of such pain with radiographic evidence. In the first cohort study (n=946), only 15.6% of hips in patients reporting frequent hip pain showed radiographic evidence of osteoarthritis. In the second study (n=4366), only 9.1% of hips in patients with frequent pain showed radiographic evidence of hip OA. Conversely, pain was not present in many hips with radiographic evidence of osteoarthritis.
These findings strongly indicate that many cases of hip arthritis would be missed if clinicians relied solely, or even largely, on radiographs. The findings also suggest that overdiagnosis of osteoarthritis would be likely if doctors relied on radiographs rather than examining patients and obtaining an appropriate history. The authors conclude that “health professionals should continue to evaluate and treat patients with hip pain suggestive of osteoarthritis despite negative radiographic findings.” This study is also a good reminder for physicians to treat patients, not imaging studies.
It’s a generally accepted “fact” that total knee arthroplasty (TKA) ranks among the most significant modern medical advancements. But the October 22, 2015 NEJM published the first rigorously controlled randomized study that “proves” that “fact” by comparing TKA to nonsurgical management.
One hundred patients with moderate-to-severe knee osteoarthritis were randomly assigned to undergo TKA followed by 12 weeks of rigorous nonsurgical treatment, or the nonsurgical treatment alone. Over a 12-month follow-up period, TKA was superior to nonsurgical treatment in terms of pain relief and functional improvement, but it was also associated with a higher number of serious adverse events, including deep-vein thrombosis and infection.
The study authors concluded that “the benefits and harms of the respective treatments underscore the importance of considering patients’ preferences and values during shared decision making about treatment for moderate-to-severe knee osteoarthritis.” JBJS Deputy Editor Jeffrey Katz, MD concurred with that conclusion in an accompanying editorial: “Treatment decisions should be shared between patients and their clinicians and anchored by the probabilities of pain relief and complications and the importance patients attach to these outcomes,” he wrote. “Each patient must weigh these considerations and make the decision that best suits his or her values.”
Surgeons in the US perform more than 700,000 knee arthroscopies annually, but a recent BMJ systematic review/meta-analysis suggests that the pain-relief efficacy of those procedures in middle aged and older adults with degenerative knee disease are inconsequential and short-lived.
In analyzing nine randomized trials that assessed the benefits of knee arthroscopy versus control treatments including exercise and sham surgery among almost 1300 patients, the Scandinavian authors found marginal improvements in pain at three and six months after surgery, but not thereafter (overall effect size of 0.14). The results were similar in subgroups with radiographically confirmed osteoarthritis.
In analyzing nine other studies (two randomized and seven observational) assessing possible harm from knee arthroscopy, authors found non-negligible rates of adverse effects, including deep vein thrombosis (4 events per 1000 surgeries), infection (2 events per 1000 surgeries), and pulmonary embolism and death (1 event each per 1000 surgeries).
The authors conclude that these findings “do not support the practise of arthroscopic surgery for middle aged or older patients with knee pain with or without signs of osteoarthritis.”
In an accompanying editorial, Andrew Carr, FRCS, from the UK’s Botnar Research Centre, notes that only two of the nine randomized trials analyzed to determine benefit were adequately blinded, but he basically agrees that “in robust and bias-free trials that use placebo controls, active treatment works no better than control treatment.” Considering the harm analysis the authors present, Dr. Carr concludes that “we may be close to a tipping point where the weight of evidence against arthroscopic knee surgery for pain is enough to overcome concerns about the quality of the studies, confirmation bias, and vested interests.”
OrthoBuzz readers, are we near that tipping point—or beyond it?
Many orthopaedists and primary care clinicians recommend acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) as a first-line approach for patients with osteoarthritis (OA) or back pain. However, two recent studies call into question how well these pharmacological approaches actually work.
A study employing a new-user design and data from the Osteoarthritis Initiative concluded that short-term use of prescription NSAIDs (such as naproxen, celecoxib, and meloxicam) had no clinical effect in more than 1,800 patients with radiographically confirmed knee osteoarthritis. Long-term use (defined as NSAID use reported at three consecutive annual assessments) was associated with clinically important but not statistically significant improvements in stiffness and function (per WOMAC scales), but not pain. Notably, the rate of NSAID use at all three annual assessments was very low, and the authors concluded that the common discontinuation of NSAID use suggested in this study “call[s] for further understanding of the extent to which potential side effects [of NSAIDs] can be mitigated with gastroprotective agents.”
A meta-analysis of acetaminophen’s effectiveness (13 randomized trials with a total of 5,366 patients) found that the medication did not improve pain, disability, or quality of life for back-pain sufferers, and that its pain-relieving effects in people with knee or hip OA were statistically but not clinically significant. These findings led an editorialist commenting on the meta-analysis to conclude that “the time has come to shift our attention away from tablets as the default option for managing chronic musculoskeletal pain.” As alternatives, he recommended topical NSAIDs, physical therapy, and better coaching on patient self-management. The editorialist also emphasized that these findings should not prompt clinicians to increase prescriptions for opioids.
A randomized study of 80 postmenopausal women with mild knee osteoarthritis found that those assigned to a supervised progressive-impact exercise program (including jumping and change-of-movement exercises) thrice weekly for a year experienced more biochemical improvements in their patellar cartilage, as determined by MRI T2 relaxation time, than those in a non-intervention control group. The exercise group also saw greater improvement in muscle strength and aerobic capacity, while patient-reported KOOS-score changes were similar in both groups.
Although many clinicians deem high-impact activity to be contraindicated in this population, this study suggests that postmenopausal women with mild knee OA can, under the supervision of a physical therapist, be encouraged to include high-impact exercises in their fitness regimen.
Our OrthoBuzz report of the “near-death” of glucosamine/chondroitin may have been premature, according to a recent study published online in the Annals of the Rheumatic Diseases. The randomized, double-blind study assigned 606 patients with knee osteoarthritis and moderate-to-severe pain to receive either glucosamine (500 mg) and chondroitin (400 mg) three times a day, or one daily dose of the COX-2 inhibitor celecoxib (200 mg).
The study was designed to discern noninferiority between the supplements and celecoxib, and the results over six months showed equivalent benefits in both groups. WOMAC measures of pain decreased by 50.1% in the supplement group and 50.2% in the celecoxib group. Both groups also showed a >50% reduction in the presence of joint swelling, and adverse events were low in both groups.
One thing readers may want to consider when mulling over these results: The study was sponsored by the manufacturer of the glucosamine/chondroitin product used in the trial, and all authors disclosed financial relationships with that manufacturer.
An additional perspective on these and other glucosamine/chondroitin findings comes from JBJS Deputy Editor for Research Tom Bauer, MD, an ultra-marathon runner who’s free of arthritis symptoms and does take glucosamine/chondroitin supplements. Dr. Bauer emphasizes the distinction between preventing osteoarthritis and treating it. “Most published studies in humans, like this recent one, have tested glucosamine/chondroitin in patients with pre-existing osteoarthritis,” he said. “It’s a tall order to expect any oral medication to induce actual restoration of the articular surface, so I’m eager to see a decent chondroprotective study of these supplements in athletes who do not have osteoarthritis.”
In a recent Annals of Rheumatic Diseases study, Australian researchers reported that levels of circulating leptin—a hormone that influences body weight and regulates some inflammatory processes—are negatively associated with changes in knee-cartilage thickness.
This prospective cohort study of 163 randomly selected patients (mean age of 63) used MRI to assess knee-cartilage thickness and radioimmunoassay to measure serum leptin levels at baseline and again after an average of 2.7 years. Cross-sectionally, leptin levels were negatively associated with cartilage thickness at femoral, medial tibial, lateral tibial, and patellar sites, after researchers adjusted for age, sex, BMI, and disease status. Longitudinally, baseline levels and changes in leptin over time were associated with greater differences in tibial-cartilage thickness.
The authors speculate that leptin may have a catabolic effect on cartilage that contributes to the development of osteoarthritis (OA), and that decreases in leptin levels associated with weight loss may help explain the clinical improvement in patients with knee OA who lose weight.
Researchers at the recent annual meeting of the Radiological Society of North America presented data showing that knees undergoing surgery for meniscal tears are at higher risk of developing radiographically evident osteoarthritis one year postsurgery than knees with meniscal damage that do not undergo surgery. Presenter Frank Roemer, MD said the retrospective study found that, relative to non-arthritic knees, the risk of cartilage loss was significantly increased for knees exhibiting any prevalent meniscal damage without surgery (odds ratio = 1.5), and markedly further increased for meniscally damaged knees that had surgery (odds ratio = 13.1).
Nevertheless, many people undergoing meniscal surgery benefit clinically, especially if they experienced locking of the knee before surgery. Also, people found to have “radiographic” osteoarthritis may not experience the pain or mobility limitations seen with clinically evident arthritis. Still, Roemer concluded that patients and their doctors should include the possibility of accelerated onset of arthritis when discussing the pros and cons of meniscal surgery.
Add findings from a recent study in Arthritis & Rheumatology to the growing body of evidence indicating that glucosamine and chondroitin supplements have no measurable impact on relieving knee osteoarthritis (OA). These findings add support to existing guidelines that recommend against the use of these supplements for OA treatment (see related OrthoBuzz article).
Utilizing a so-called “new user” design, researchers analyzed four-year follow-up data on more than 1,600 people who were not using glucosamine/chondroitin at baseline. In addition to measuring joint space width, researchers captured knee symptoms with WOMAC pain, stiffness, and function scales. They also employed marginal structural models to control for time-varying confounders. In the end, there were “no clinically significant differences” between supplement users and non-users, and the study authors claimed that, in addition to being consistent with meta-analyses of glucosamine/chondroitin, these findings extend the data set to include “a more general population with knee OA.
Two recent studies revealed that valgus bracing may be more effective than acupuncture for treating knee osteoarthritis.
A JAMA study of nearly 300 people 50 and older with chronic knee pain and morning stiffness found that 12 weeks of acupuncture, delivered via both needles and laser, provided no substantial pain or function benefits at 12 weeks or one year, relative to no acupuncture or a sham laser procedure. One interesting aspect of this study was its so-called Zelen design; participants were consented after randomization, and those randomized to receive no acupuncture were unaware that they were in an acupuncture trial. According to the authors, “Zelen designs can reduce the risk of bias in a treatment trial in which knowledge of the intervention may influence recruitment…and outcomes.”
Conversely, a meta-analysis of six randomized studies totaling more than 400 patients in Arthritis Care and Research found that a valgus knee brace can improve pain and function in people with medial knee osteoarthritis. The analysis examined trials that compared valgus bracing with no orthosis and with other types of orthoses, such as neoprene sleeves. In the former comparison, the valgus brace yielded improvements in both pain and function; in the latter comparison, valgus bracing improved pain but not function. An editorialist commenting on the findings opined that the clinical goal going forward should be to identify those patients who are most likely to benefit from this type of bracing and who will comply with instructions for use.