S Kluzek

Is osteoarthritis a metabolic disorder

BACKGROUND Obesity is associated with an increased risk of developing osteoarthritis (OA), even in non-weight bearing joints. High levels of adipose tissue-associated inflammation may explain this association. SOURCES OF DATA AND AREAS OF DEBATE Published evidence looking at the associations between components of Metabolic Syndrome (MetS) and knee, hip or hand OA and the higher mortality described with knee OA. EMERGING POINTS Development of MetS and OA shares a relationship with adipose tissue-associated inflammation. This review supports this inflammatory pathway being part of the shared mechanism behind obesity as a risk factor for OA and the recently described OA-associated increased mortality. TIMELY AREAS FOR DEVELOPMENT In an era of an obesity epidemic, this review identifies a need for well-designed cohort studies assessing early metabolic changes in populations at high risk of OA and MetS, and to identify risk factors for increased mortality in patients with OA.

Painful knee but not hand osteoarthritis is an independent predictor of mortality over 23 years follow-up of a population-based cohort of middle-aged women.

To assess whether joint pain or radiographic osteoarthritis (ROA) of the knee and hand is associated with all-cause and disease-specific mortality in middle-aged women. Methods Four subgroups from the prospective community-based Chingford Cohort Study were identified based on presence/absence of pain and ROA at baseline: (Pain−/ROA−; Pain+/ROA−; Pain−/ROA+; Pain+/ROA+). Pain was defined as side-specific pain in the preceding month, while side-specific ROA was defined as Kellgren–Lawrence grade ≥2. All-cause, cardiovascular disease (CVD) and cancer-related mortality over the 23-year follow-up was based on information collected by the Office for National Statistics. Associations between subgroups and all-cause/cause-specific mortality were assessed using Cox regression, adjusting for age, body mass index, typical cardiovascular risk factors, occupation, past physical activity, existing CVD disease, glucose levels and medication use. Results 821 and 808 women were included for knee and hand analyses, respectively. Compared with the knee Pain−/ROA− group, the Pain+/ROA− group had an increased risk of CVD-specific mortality (HR 2.93 (95% CI 1.47 to 5.85)), while the knee Pain+/ROA+ group had an increased HR of 1.97 (95% CI 1.23 to 3.17) for all-cause and 3.57 (95% CI 1.53 to 8.34) for CVD-specific mortality. We found no association between hand OA and mortality. Conclusion We found a significantly increased risk of all-cause and CVD-specific mortality in women experiencing knee pain with or without ROA but not ROA alone. No relationship was found between hand OA and mortality risk. This suggests that knee pain, more than structural changes of OA is the main driver of excess mortality in patients with OA.

Behavioural physical activity interventions in participants with lower-limb osteoarthritis: a systematic review with meta-analysis

Objective To assess effectiveness of osteoarthritis interventions to promote long-term physical activity behaviour change. Design A systematic review and meta-analysis. Protocol registration PROSPERO CRD4201300444 5 (http://www.crd.york.ac.uk/prospero/). Study selection Randomised controlled trials (RCTs) comparing physical activity interventions with placebo, no/or minimal intervention in community-dwelling adults with symptomatic knee or hip osteoarthritis. Primary outcomes were change in physical activity or cardiopulmonary fitness after a minimum follow-up of 6 months. Data extraction Outcomes were measures of physical activity (self-reported and objectively measured) and cardiovascular fitness. Standard mean differences between postintervention values were used to describe the effect sizes. Results 27 984 titles were screened and 180 papers reviewed in full. Eleven RCTs satisfied inclusion criteria, total study population of 2741 participants, mean age 62.2. The commonest reasons for study exclusion were follow-up less than 6 months and no physical activity measures. The majority of included interventions implement an arthritis self-management programme targeting coping skills and self-efficacy. Seven studies used self-report measures, the pooled effect of these studies was small with significant heterogeneity between studies (SMD 0.22 with 95% CI −0.11 to 0.56, z=1.30 (p=0.19) I2 statistic of 85%). Subgroup analysis of 6–12 month outcome reduced heterogeneity and increased intervention effect compared to control (SMD 0.53, 95% CI 0.41 to 0.65, z=8.84 (p<0.00001) I2 of 66%). Conclusions Arthritis self-management programmes achieve a small but significant improvement in physical activity in the short term. Effectiveness of intervention declines with extended follow-up beyond 12 months with no significant benefit compared to control. The small number of studies (11 RCTs) limited ability to define effective delivery methods. Investigation of behavioural lifestyle interventions for lower limb osteoarthritis populations would benefit from consensus on methodology and outcome reporting. This includes use of validated physical activity reporting tools and planning for long-term follow-up.

Serum cartilage oligomeric matrix protein and development of radiographic and painful knee osteoarthritis. A community-based cohort of middle-aged women.

Abstract Context and objective: We evaluated the predictive value of serum cartilage oligomeric matrix protein (sCOMP) levels over 20 years on the development of radiographic (RKOA) and painful knee osteoarthritis (KOA) in a longitudinal cohort of middle-aged women. Materials and methods: Five hundred and ninety-three women with no baseline KOA underwent 5-year knee radiographs over 20-years and were asked about knee pain a month before each assessment. A repeated measures logistic regression model was used where the outcomes were recorded at 5, 10, 15 and 20-years follow-up. Results: The highest quartile of sCOMP was associated with increased risk of RKOA with overall OR of 1.97 (95% CI: 1.33–2.91) over 20 years when compared with the lowest sCOMP quartile. The association with painful KOA was similar and also independent, but only when the fourth and third sCOMP quartiles were compared. Discussion and conclusion: This study demonstrates that sCOMP levels are predictive of subsequent structural changes and incidence of painful KOA, independently of age and BMI.

Adipokines as potential prognostic biomarkers in patients with acute knee injury

Abstract This review considers adipokines as predictive biomarkers for early onset post-traumatic knee osteoarthritis (KOA). Serum concentrations of leptin and resistin can predict radiographic changes and are elevated in early KOA, with higher leptin concentrations independently associated with more severe knee changes. Plasma concentrations of resistin are chronically elevated after injury. Leptin, resistin, chemerin and vistfatin induce catabolic enzymes associated with cartilage degeneration. Available literature on adipokines in post-traumatic KOA pathogenesis suggests that they could contribute to risk prediction of early onset post-traumatic KOA. Further research is needed to further understand the association between adipokines, synovitis and long-term outcomes in this population.

Associations Between Clinical Evidence of Inflammation and Synovitis in Symptomatic Knee Osteoarthritis: A Cross-Sectional Substudy.

Painful knee osteoarthritis (KOA) has been associated with joint inflammation. There is, however, little literature correlating signs of localized inflammation with contrast‐enhanced (CE) magnetic resonance imaging (MRI) of synovium. This study examined the relationship between clinical and functional markers of localized knee inflammation and CE MRI–based synovial scores.

Association of metabolic syndrome with knee and hand osteoarthritis: A community-based study of women.

OBJECTIVE It is unclear whether the association between osteoarthritis (OA) and metabolic syndrome (MetS) varies with the site of the affected joint and the presence of pain. Our aim was to describe the association between MetS and radiographic OA (ROA) affecting the knee or the hand in the presence or absence of concurrent joint pain. METHODS Cross-sectional data of 952 women, aged 45-65years from the Chingford study, a population-based longitudinal cohort of middle-aged women initiated in 1988-1989 in London (UK), was analysed. MetS was defined using the National Cholesterol Education Program Treatment Panel III criteria. Data was collected on components of MetS: waist circumference, triglycerides, high-density lipoprotein (HDL), blood pressure and blood glucose. The outcome was four knee and hand OA groups: painful ROA, ROA only, pain only and neither ROA nor pain (reference category). Multinomial logistic regression models adjusted for age and body mass index (BMI) were used to evaluate the effect of presence of MetS and its individual components on OA subgroups for knee and hand separately. RESULTS 952 eligible women, aged 45-65years was analysed. A significant association was observed between the presence and the number of MetS with painful knee ROA when adjusted for age; however, this association disappeared when BMI was included in the model. In contrast, the presence and the number of MetS were associated with painful interphalangeal (IPJ) OA after adjusting for both age and BMI. Four out of the five MetS components, including triglycerides, HDL-c, hypertension and glucose, were associated with painful IPJ OA. CONCLUSIONS MetS is associated with painful IPJ OA but not with knee OA once BMI is taking into consideration. Further attention to MetS and OA at different sites is needed to understand the metabolic phenotype in OA.

Partial mid-portion Achilles tear resulting in substantial improvement in pain and function in an amateur long-distance runner.

This case presents symptom resolution for a long-distance runner with chronic Achilles tendinopathy (AT), following a partial tear of his Achilles tendon. The patient reported a sudden pain during a morning run, with preserved function. Three hours postinjury, he was reviewed in a musculoskeletal clinic. An ultrasound scan confirmed a partial Achilles tear, associated with significant Doppler activity. His index of AT severity The Victorian Institute of Sports Assessment - Achilles Questionnaire (VISA-A) 4 hours postinjury was markedly higher compared with 2 weeks preinjury, indicating reduced symptom severity. A follow-up scan 4 weeks postinjury showed minimal mid-portion swelling and no signs of the tear. His VISA-A score showed continued symptom improvement. This case represents resolution of tendinopathic symptomatology post partial Achilles tear. While the natural histories of AT and Achilles tears remain unknown, this case may indicate that alongside the known role of loading, inflammation may be a secondary mediator central to the successful resolution of AT pain.

A large chronic pericardial effusion in an ultramarathon runner with anti-CCP positive rheumatoid arthritis

Pericardial effusions arise as an extra-articular manifestation of rheumatoid arthritis (RA). Pericardial effusions are often asymptomatic, particularly in the early phase, but patients are at risk of cardiac tamponade as the effusion progresses. We discuss the case of a 40-year-old male ultramarathon runner with RA who presented with mild pleuritic chest pain and exertional dyspnoea after a recent long-haul flight. Despite a relative tachycardia, his observations were otherwise unremarkable. His blood tests revealed a C-reactive protein (CRP) of 86 mg/L and an anti-cyclic citrullinated peptide (anti-CCP) titre of 360 units/mL. He was initially diagnosed with a pulmonary embolism; however, a large pericardial effusion was found incidentally on CT pulmonary angiogram with over 1500 mL subsequently drained. The patient’s symptoms resolved and CRP normalised 2 weeks later. This unique case illustrates that physically fit patients may physiologically compensate for large pericardial effusions and that arthritic symptoms do not correlate with the severity of extra-articular features in RA.

Confusion and abdominal symptoms following a rugby tackle

A 19-year-old man was sent to the emergency department following a pitch-side assessment for suspected concussion, unexplained upper abdominal tenderness and vomiting, following a high-impact tackle during a rugby match. A Focussed Assessment with Sonography for Trauma (FAST) scan performed in the emergency department suggested intra-abdominal free fluid, and subsequent head and abdominal CT imaging showed no intracranial lesion but confirmed a significant haemoperitoneum due to large splenic tear and bleeding. An emergency splenectomy was performed, which confirmed the rupture of an enlarged spleen with blood loss of almost 2 L into the peritoneal cavity. The patient made a full recovery following surgery. A subsequent histological examination revealed granulomatous inflammation characteristic of infectious mononucleosis. This unique case illustrates that physically fit patients with early hypovolaemic shock can present with symptoms mimicking concussion.