J Cushnaghan

Prediction of the progression of joint space narrowing in osteoarthritis of the knee by bone scintigraphy.

OBJECTIVES--To test the hypothesis that bone scintigraphy will predict the outcome of osteoarthritis (OA) of the knee joint. METHODS--Ninety four patients (65 women, 29 men; mean age 64.2 years) with established OA of one or both knee joints were examined in 1986, when radiographs and bone scan images (early and late phase) were also obtained. The patients were recalled, re-examined, and had further radiographs taken in 1991. Paired entry and outcome radiographs were read by a single observer, blinded to date order and other data. Scan findings and other entry variables were related to outcome. Progression of OA of the knee was defined as an operation on the knee or a decrease in the tibiofemoral joint space of 2 mm or more. RESULTS--Over the five year study period 10 patients died and nine were lost to follow up. Fifteen had an operation on one or both knees (22 knees). Of the remaining 120 knees (60 patients) analysed radiographically, 14 (12%) had progressed in the manner defined. Of 32 knees with severe scan abnormalities, 28 (88%) showed progression, whereas none of the 55 knees with no scan abnormality at entry progressed. The strong negative predictive power of scintigraphy could not be accounted for by disease severity or any combination of entry variables. Pain severity predicted a subsequent operation, but age, sex, symptom duration, and obesity had no predictive value. CONCLUSIONS--Scintigraphy predicts subsequent loss of joint space in patients with established OA of the knee joint. This is the first description of a powerful predictor of change in this disease. The finding suggests that the activity of the subchondral bone may determine loss of cartilage.

The Bristol 'OA500' study: progression of osteoarthritis (OA) over 3 years and the relationship between clinical and radiographic changes at the knee joint.

Five hundred patients with established, symptomatic limb joint OA have been recruited into an on-going prospective study of the natural history of the condition. Four hundred and fifteen patients (mean age 65.6 years, female to male ratio 2.05:1) were available for a full clinical and radiographic review 3 years after entry (mean entry to follow-up interval 37.6 months, range 31-41). The majority reported an overall worsening of their condition, although pain severity did not change. There was an overall increase in disability (Steinbrocker) and the use of walking aids in the group but 57 patients (13.7%) improved, 38 of whom had undergone joint surgery. There was a strong correlation between changes in different clinical outcome measures, but none of the baseline variables predicted change over 3 years with the exception of an association between pain severity and subsequent surgery. One hundred and ninety-three of the 415 patients had knee joint disease at entry. One hundred and forty-five of these patients had knee radiographs and full clinical data available from both time points. Some change was seen in 85 of 276 evaluable tibiofemoral joints (30.1%), but only 10 patellofemoral joints. There was a strong correlation between changes in joint space, osteophyte and subchondral bone scelerosis. However, there was no correlation between radiographic and clinical changes. It is concluded that radiographic change may not be a good surrogate for clinical outcome in established OA. This has implications for the design of long-term studies of possible structure modifying agents in OA.

Long-term outcome following total knee arthroplasty: a controlled longitudinal study

Objectives: To assess long-term outcome and predictors of prognosis following total knee arthroplasty (TKA) for osteoarthritis. Methods: We followed-up 325 patients from 3 English health districts approximately 6 years after TKA, along with 363 controls selected from the general population. Baseline data, collected by interview and examination, included age, sex, comorbidity, body mass index (BMI), functional status and preoperative radiographic severity of osteoarthritis. Functional status at follow-up was assessed by postal questionnaire. Predictors of change in physical function were analysed by linear regression. Results: Between baseline and follow-up, patients reported an improvement of 6 points in median Short Form 36 Health Survey (SF-36) physical function score, whereas in controls there was a deterioration of 14 points (p<0.001). Median SF-36 vitality score declined by 10 points in patients and 5 points in controls (p = 0.005), while their median SF-36 mental health scores improved by 12 and 13 points, respectively (p = 0.2). The improvement in physical function was smaller in patients who were obese than in patients who were non-obese, but compared favourably with a substantial decline in the physical function of obese controls. Better baseline physical function and older age predicted worse changes in physical function in patients and controls. Improvement in physical function tended to be greater in patients with more severe radiological disease of the knee, and was less in those who reported pain at other joint sites at baseline. Conclusions: Improvements in physical function following TKA for osteoarthritis are sustained beyond 5 years. The benefits are apparent in patients who are obese as well as non-obese, and there seems no justification for withholding TKA from obese patients solely on the grounds of their body mass index.

Osteoarthritis of the knee joint: an eight year prospective study.

Thirty one patients (25 women, six men, mean age 71.7 years) with established osteoarthritis (OA) of the knee were examined clinically and radiologically on two occasions, eight years apart. Four patients thought they had got better, two of whom had striking functional improvement. Seven remained the same and 20 patients got worse, two needing knee surgery and many developing severe disabilities. Most of the patients had a history of slow acquisition of OA at new joint sites, hand disease emerging as the commonest other site of involvement. Changes in symptoms, disability, and radiographs did not correlate. Three of the four patients who improved symptomatically lost range of motion at the knee and developed more severe changes on their radiographs. Chondrocalcinosis of the knee was seen in five patients, including two of those who improved.

Radiographic assessment of the knee joint in osteoarthritis.

The development of radiographic systems for the grading of osteoarthritis requires knowledge of the reproducibility of their individual component features. This paper reports the reproducibility, both within and between observers, for five commonly used radiographic features of osteoarthritis in the tibiofemoral and patellofemoral compartments of the knee joint. The results suggest that assessments of joint space narrowing, osteophyte, and bony contour in the tibiofemoral compartments are more reproducible than those of sclerosis and cyst. Patellofemoral assessments, with the exception of osteophyte, are considerably less reproducible between observers than tibiofemoral assessments.

Erosive osteoarthritis: Is it a separate disease entity?

Erosive osteoarthritis (EOA) characteristically involves the hands of middle-aged women. The diagnosis is essentially radiological and depends upon the presence of articular surface erosions. This study investigates whether this radiological feature is a marker of a specific clinical entity. From a series of 500 consecutive patients attending a rheumatology clinic with symptomatic limb joint osteoarthritis, 24 were identified by radiological criteria to have EOA. These were age-sex matched with 24 patients from the same series who presented with osteoarthritis of the hand. Those with EOA had nearly twice as many radiographically abnormal joints in the hands as the controls (274: 144). This was almost entirely due to an increase in distal (134: 68) and proximal (79: 24) interphalangeal joint involvement, 71% of which were erosive. Erosions were found apart from the hands in both elbows of one patient with EOA. Otherwise only minor differences were present between the two groups in terms of distribution and incidence of osteoarthritic changes. There were no distinguishing serological or other clinical differences. This study has demonstrated that erosions in EOA are associated with more severe hand disease but are not apparently a marker of a separate disease entity. EOA appears to be an aggressive acute form of hand osteoarthritis and may represent the hand equivalent of similar forms of osteoarthritis in the shoulder, hip and knee.

Clinical assessment of osteoarthritis of the knee.

The repeatability of physical signs used to assess osteoarthritis of the knee has not been systematically examined. The within and between observer variation of 10 commonly used physical signs to determine osteoarthritis of the knee has been assessed here. The results obtained show variation in the repeatability of these signs. For those examining the tibiofemoral joints the repeatability was greater than for those examining the patellofemoral joint. It would therefore seem vital to take note of the repeatability of physical signs in determining the number of subjects to be studied in epidemiological studies and therapeutic studies in osteoarthritis.

Clinical tool to identify patients who are most likely to achieve long-term improvement in physical function after total hip arthroplasty†

To develop a clinical risk prediction tool to identify patients most likely to experience long‐term clinically meaningful functional improvement following total hip arthroplasty (THA).

The predictive role of scintigraphy in radiographic osteoarthritis of the hand

Sixty-seven patients with symptomatic knee osteoarthritis (OA) (26 male, 42 female, mean age 62.7 years) have been followed prospectively for a mean of 67.3 months (range 60-72 months). Hand radiographs were obtained at entry and at follow-up. Scintigraphic images of the hands were obtained at entry, and the predictive value of scan abnormalities for subsequent radiographic change was examined. Forty-six of 203 scan-positive joints at entry showed radiographic change, compared with 41 of 2075 scan-negative joints (P < 0.0001). The thumb base was more often involved than other joints and scintigraphy was a better predictor of change at this site than at other joints in the hand. This study confirms the predictive value of scintigraphy in hand OA and suggests that thumb base and interphalangeal joint OA behave differently.

Screening in the community to reduce fractures in older women (SCOOP): a randomised controlled trial

BACKGROUND Despite effective assessment methods and medications targeting osteoporosis and related fractures, screening for fracture risk is not currently advocated in the UK. We tested whether a community-based screening intervention could reduce fractures in older women. METHODS We did a two-arm randomised controlled trial in women aged 70-85 years to compare a screening programme using the Fracture Risk Assessment Tool (FRAX) with usual management. Women were recruited from 100 general practitioner (GP) practices in seven regions of the UK: Birmingham, Bristol, Manchester, Norwich, Sheffield, Southampton, and York. We excluded women who were currently on prescription anti-osteoporotic drugs and any individuals deemed to be unsuitable to enter a research study (eg, known dementia, terminally ill, or recently bereaved). The primary outcome was the proportion of individuals who had one or more osteoporosis-related fractures over a 5-year period. In the screening group, treatment was recommended in women identified to be at high risk of hip fracture, according to the FRAX 10-year hip fracture probability. Prespecified secondary outcomes were the proportions of participants who had at least one hip fracture, any clinical fracture, or mortality; and the effect of screening on anxiety and health-related quality of life. This trial is registered with the International Standard Randomised Controlled Trial registry, number ISRCTN 55814835. FINDINGS 12 483 eligible women were identified and participated in the trial, and 6233 women randomly assigned to the screening group between April 15, 2008, and July 2, 2009. Treatment was recommended in 898 (14%) of 6233 women. Use of osteoporosis medication was higher at the end of year 1 in the screening group compared with controls (15% vs 4%), with uptake particularly high (78% at 6 months) in the screening high-risk subgroup. Screening did not reduce the primary outcome of incidence of all osteoporosis-related fractures (hazard ratio [HR] 0·94, 95% CI 0·85-1·03, p=0·178), nor the overall incidence of all clinical fractures (0·94, 0·86-1·03, p=0·183), but screening reduced the incidence of hip fractures (0·72, 0·59-0·89, p=0·002). There was no evidence of differences in mortality, anxiety levels, or quality of life. INTERPRETATION Systematic, community-based screening programme of fracture risk in older women in the UK is feasible, and could be effective in reducing hip fractures. FUNDING Arthritis Research UK and Medical Research Council.