Michel Lequesne

EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT)

BACKGROUND Osteoarthritis (OA) is the most common joint disease encountered throughout Europe. A task force for the EULAR Standing Committee for Clinical Trials met in 1998 to determine the methodological and logistical approach required for the development of evidence based guidelines for treatment of knee OA. The guidelines were restricted to cover all currently available treatments for knee OA diagnosed either clinically and/or radiographically affecting any compartment of the knee. METHODS The first stage was the selection of treatment modalities to be considered. The second stage comprised a search of the electronic databases Medline and Embase using a combination of subject headings and keywords. All European language publications in the form of systematic reviews, meta-analyses, randomised controlled trials, controlled trials, and observational studies were included. During stage three all the relevant studies were quality scored. The summary statistics for validated outcome measures, when available, were recorded and, where practical, the numbers needed to treat and the effect size for each treatment were calculated. In the fourth stage key clinical propositions were determined by expert consensus employing a Delphi approach. The final stage ranked these propositions according to the available evidence. A second set of propositions relating to a future research agenda was determined by expert consensus using a Delphi approach. RESULTS Over 2400 English language publications and 400 non-English language publications were identified. Seven hundred and forty four studies presented outcome data of the effects of specific treatments on knee OA. Quantitative analysis of treatment effect was possible in only 61 studies. Recommendations for the management of knee OA based on currently available data and expert opinion are presented. Proposals for a future research agenda are highlighted. CONCLUSIONS These are the first clinical guidelines on knee OA to combine an evidence based approach and a consensus approach across a wide range of treatment modalities. It is apparent that certain clinical propositions are supported by substantial research based evidence, while others are not. There is thus an urgent need for future well designed trials to consider key clinical questions.

Evaluation of the structure‐modifying effects of diacerein in hip osteoarthritis: ECHODIAH, a three‐year, placebo‐controlled trial

OBJECTIVE To evaluate the ability of diacerein, an interleukin-1beta inhibitor, to slow the progressive decrease in joint space width observed in patients with hip osteoarthritis (OA). METHODS In this randomized, double-blind, placebo-controlled 3-year study, 507 patients with primary OA of the hip (by the American College of Rheumatology criteria) received diacerein (50 mg twice a day) or placebo. The minimal hip joint space width was measured by a central reader on yearly pelvic radiographs, using a 0.1-mm-graduated magnifying glass. RESULTS Baseline characteristics were comparable in the 2 treatment groups (255 patients receiving diacerein, 252 receiving placebo); 238 patients (47%) discontinued the study, mainly because of adverse events in the diacerein group (25% versus 12% with placebo) and because of inefficacy in the placebo group (14% versus 7% with diacerein). The percentage of patients with radiographic progression, defined by a joint space loss of at least 0.5 mm, was significantly lower in patients receiving diacerein than in patients receiving placebo, both in the intent-to-treat analysis and in the completer analysis (50.7% versus 60.4% [P = 0.036] and 47.3% versus 62.3% [P = 0.007], respectively). In those patients who completed 3 years of treatment, the rate of joint space narrowing was significantly lower with diacerein (mean +/- SD 0.18 +/- 0.25 mm/year versus 0.23 +/- 0.23 mm/year with placebo; P = 0.042). Diacerein had no evident effect on the symptoms of OA in this study. However, a post hoc covariate analysis that took into account the use of analgesics and antiinflammatory drugs showed an effect of diacerein on the Lequesne functional index. Diacerein was well tolerated during the 3-year study. The most frequent adverse events were transient changes in bowel habits. CONCLUSION This study confirms previous clinical findings indicating that the demonstration of a structure-modifying effect in hip OA is feasible, and shows, for the first time, that treatment with diacerein for 3 years has a significant structure-modifying effect as compared with placebo, coupled with a good safety profile. The clinical relevance of these findings requires further investigation.

Radiological progression of hip osteoarthritis: definition, risk factors and correlations with clinical status.

OBJECTIVES: To determine a cut off value for changes in radiological joint space width that allowed definition of radiological progression of hip osteoarthritis not related to measurement method errors and, thereafter, to determine factors predictive of radiological progression of hip osteoarthritis and to evaluate the correlations between clinical and radiological parameters. METHODS: A prospective, longitudinal (one year duration), multicentre study was made of patients with osteoarthritis of the hip (American College of Rheumatology criteria). Data on clinical activity (pain, functional impairment), demographic data (age, gender, body mass index), and femoral head migration (superolateral, superomedial, concentric) were collected when the patient entered the study; radiological grade (joint space width in millimetres at the narrowest point using a 0.1 mm graduated magnifying glass, evaluated by a single observer unaware of the chronology of the films) was recorded at the patients entry to the study and after one year. RESULTS: Analysis of the means of the differences between two analyses performed by a single observer of 30 pairs of radiographs (one performed after an interval of one year) (0.06 (SD 0.23)) suggested that a change of more than 0.56 mm (2 SD) after a one year follow up could define progression of osteoarthritis of the hip. Of the 508 patients recruited, 461 (91%) completed the one year follow up and radiological progression was observed in 102 (22%). The factors predictive of radiological progression that were identified in the multivariate analysis were: radiological joint space width at entry < or = 2 mm, superolateral migration of the femoral head, female gender, Lequesnes functional index > 10, age at entry > 65 years (odds ratios 2.11, 4.25, 2.51, 2.66, 1.90, respectively). The level of clinical parameters (pain, functional impairment) and the amount of symptomatic treatment required (non-steroidal anti-inflammatory drugs and analgesic intake) accounted for 20% (p < 0.0001) of the variability of the changes in radiological joint space width over the one year study period. CONCLUSION: These data suggest that radiological progression of hip osteoarthritis could be defined by a change in joint space width of at least 0.6 mm after a one year follow up period, is correlated with the changes in clinical status of the patients, and is related not only to demographic data (age, gender), but also to some specific characteristics of osteoarthritis (localisation, radiological severity, clinical activity).

The faux profil (oblique view) of the hip in the standing position. Contribution to the evaluation of osteoarthritis of the adult hip

OBJECTIVE The technique and results of a special oblique radiograph of the hip called the “faux profil” (FP) of the hip are described. The FP was evaluated for the detection of joint space narrowing in incipient osteoarthritis of the hip (OAH) as compared with the anteroposterior (AP) radiograph. METHODS 58 hips with incipient osteoarthritis (joint space narrowing, 0–25% on the AP view) in 48 patients were identified among 200 consecutive patients fulfilling American College of Rheumatology criteria for OAH. Joint space narrowing was measured on the AP and FP radiographs of these 58 hips. RESULTS The FP view provides a true lateral projection of the femoral head and neck, and an oblique view of the acetabulum tangential to its superoanteromedial edge. On this view, the width of the anterosuperior and posteroinferior parts of the joint space can be measured and compared. Among the 58 hips with incipient OAH, 36 (62%) showed joint space narrowing on the AP view and 51 (91%) on the FP view. Among the 22 hips without joint space narrowing on the AP radiograph, 16 (72.7%) showed joint space narrowing on the FP view, involving the anterosuperior part of the joint in 11 cases and the posteroinferior part in five cases. CONCLUSION The FP view in the standing position should be used in incipient OAH as a complement to the AP view in patients with suspected OAH but no joint space narrowing on the AP radiograph. In this situation, nearly three quarters of hips in the study had joint space narrowing on the FP view, usually in the anterosuperior part and less often in the posteroinferior part of the joint.

Sport practice and osteoarthritis of the limbs

Participation in sports has evolved as a cause of osteoarthritis (OA), especially in hip and knee joints. OA often occurs at a relatively early age in adult life, in certain sports (soccer, rugby, racket sports and other track and field sports) and under certain conditions (high level of practice). We review preclinical considerations and published epidemiological studies. Joint overuse even without notable trauma is likely the main mechanism of OA both in these sports and in certain occupational activities (relative risk ranges from 1.5 to more than 5 depending chiefly on the category of sport and on the level and duration of practice). Irregular or sudden impacts, heavy load application on the dominant weight-bearing lower limb and the pre-existing state of the joint including dysplasia, dystrophy or previous trauma are risk factors for OA. However, recreational sport activities at a reasonable level are not likely to be harmful for most individuals, in most sport activities.

Gluteal tendinopathy in refractory greater trochanter pain syndrome: Diagnostic value of two clinical tests

OBJECTIVE To evaluate the value (sensitivity and specificity) of 2 modified physical tests for the diagnosis of gluteal tendinopathy in patients with refractory greater trochanter pain syndrome (GTPS). METHODS The 2 tests were prospectively evaluated by a single physician in all consecutive patients with persistent (> or =4 months) GTPS and no hip joint arthropathy seen on radiography between 2002 and 2006. The 2 tests evaluated the occurrence of pain similar to spontaneous pain during a single-leg stance held for 30 seconds and resisted external derotation in a supine position (hip flexed 90 degrees ) then prone position (hip extended). A matched control population without hip pain was examined similarly. Tendinitis, tendon tear, and associated bursitis in the target group were documented by magnetic resonance imaging (MRI) in transverse, coronal, and sagittal planes, with MRI serving as the gold standard. RESULTS Seventeen patients completed the study (mean +/- SD age 68.1 +/- 10.8 years, mean duration of symptoms 13 months). MRI revealed tendinopathy and/or bursitis of the gluteus medius and/or minimus tendons in all patients, with evidence of tearing in 15. Sensitivity and specificity were 100% and 97.3%, respectively, for the single-leg stance test and 88% and 97.3%, respectively, for the resisted external derotation test in the supine position. CONCLUSION The 30-second single-leg stance and resisted external derotation tests had very good sensitivity and specificity for the diagnosis of tendinous lesion and bursitis in patients with MRI-documented refractory GTPS.

Molecular markers of cartilage breakdown and synovitis at baseline as predictors of structural progression of hip osteoarthritis. The ECHODIAH* Cohort

Objective: To determine whether systemic markers of bone, cartilage, and synovium can predict structural progression of osteoarthritis (OA). Methods: Patients with painful hip OA were treated with diacerein or placebo in a multicentre, prospective, double blind, 3 year follow up trial. The following information was collected at entry: demographics, characteristics of hip OA, and 10 markers: N-propeptides of collagen types I and III, cartilage oligomeric matrix protein, YKL-40, hyaluronan (sHA), matrix metalloproteinases-1 and -3, C reactive protein, C-terminal crosslinking telopeptides of collagen types I and II (uCTX-II). Radiographs were obtained at entry and every year. Structural progression was defined as a joint space decrease ⩾0.5 mm or requirement for total hip replacement. Grouped survival analysis was performed with time to structural progression as dependent variable, and clinical data, radiographic findings, treatment groups (diacerein versus placebo), and markers as explanatory measures. Results: In the 333 patients in whom all markers were measured, high functional impairment, a joint space width <2 mm, and lateral migration of the femoral head at baseline increased the risk of progression, but diacerein had a protective effect (relative risk = 0.75; 95% confidence interval (CI) 0.54 to 0.96). In addition, patients in whom uCTX-II and sHA were in the upper tertile had a relative risk of progression of 3.73 (95% CI 2.48 to 5.61) compared with patients with markers in the two lower tertiles. Conclusion: In this large cohort, combined measurements of uCTX-II and sHA were a new predictor of the structural progression of hip OA.

Prospective study of refractory greater trochanter pain syndrome. MRI findings of gluteal tendon tears seen at surgery. Clinical and MRI results of tendon repair.

OBJECTIVES (1) To compare MRI and surgical findings in patients with refractory greater trochanter pain syndrome and (2) to assess surgical outcomes. METHODS All consecutive patients seen between 2002 and 2006 by a single clinician were selected for surgical treatment according to the following criteria: (1) tendinopathy confirmed by physical tests; (2) painful disability persisting for at least 6 months despite treatment; (3) on MRI: area of high signal intensity on T2-weighted images, in the area of gluteus medius and/or minimus tendon; and (4) absence of marked muscle atrophy or fatty degeneration. Two musculoskeletal radiologists interpreted images by consensus. A single surgeon operated on all patients. RESULTS Eight patients met the criteria for surgery. All were women, aged 71.1 (SD: 9.4). Mean symptoms duration before surgery: 14.3 months (11.8). Surgery confirmed the presence of a tear of the lateral part of the gluteus medius tendon in all eight patients, with an associated tear of its main tendon in one patient, all tears revealed on MRI. An associated tear of the gluteus minimus tendon was present at surgery in five patients, of which three were not seen on MRI (false negative). Bursitis was confirmed in all eight patients. Steady complete remission of spontaneous and provoked (physical examination) pain was observed in seven patients and partial remission in one (mean follow-up: 22.4 months (SD: 16.3)). Six MRIs performed after 20+/-12 months showed good reinsertion of the sutured tendon. CONCLUSION The eight MR images of tear of the lateral part of the gluteus medius tendon were all confirmed at surgery. Three of five associated tendon tears (gluteus minimus only) were not seen on MRI. Surgical treatment was very effective in all patients but one.

The effects of position on the radiographic joint space in osteoarthritis of the hip

The aim of the study was to assess whether radiographic hip joint space thickness was changed by weight-bearing (WB) compared with non weight-bearing (NWB) position, and to evaluate whether radiographs centered on the hip were more sensitive than pelvic X-rays to detect such a change. Anteroposterior radiographs of the pelvis were made in 30 patients with hip osteoarthritis OA (46 OA and 11 normal hips). Osteoarthritic, as well as contralateral normal hips were analyzed. Radiographs centered on OA hip were performed in 28 other patients. X-rays were made in WB and NWB positions using a standardized radiological procedure. Measurements of mean joint space width (MeanJSW) maximum joint space narrowing (MaxJSN) and joint space surface area (JSA), were made using a computerized image analysis system. The joint space width was unaffected by WB in normal joints but decreased with WB in OA joints. The decrease was significant only when considering MaxJSN in patients with a joint space thickness smaller than 2.5mm. The difference between WB and NWB was larger in radiographs centered on the hip than on pelvic X-rays. MeanJSW and JSA were found to be less sensitive than MaxJSN. The decrease of joint space width was inversely correlated with joint space size in WB. These results suggest that WB radiographs of the hip should be used in preference to NWB in studies of hip OA.

EULAR recommendations for the management of knee osteoarthritis. Report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials.

UNLABELLED A task force for the EULAR standing committee for clinical trials determined the methodological and logistical approach required for the development of evidence-based guidelines for treatment of knee osteoarthirits (OA). METHODS The first stage was the selection of treatment modalities to be considered. The second stage comprised a search of the databases of all European-language publications. All of the relevant studies were quality scored. The third stage involved determination of key clinical propositions by expert consensus employing a Delphi approach. The final stage involved ranking of these propositions according to the available evidence. A second set of propositions relating to a future research agenda was determined by expert consensus. RESULTS Seven hundred and forty-four studies presented outcome data of the effects of specific treatments on knee OA. Quantitative analysis of treatment effect was possible in only 61 studies. Recommendations for the management of knee OA based on currently available data and expert opinion are presented. Proposals for a future research agenda are highlighted. CONCLUSIONS These are the first clinical guidelines on knee OA to combine an evidence-based approach and a consensus approach across a wide range of treatment modalities. It is apparent that only certain clinical propositions are supported by substantial research-based evidence. There is thus an urgent need for future well-designed trials to address key clinical questions.