Summary Objective Epidemiological data suggest low serum 25-hydroxyvitamin D3 (25-OH-D3 ) levels are associated with radiological progression of knee osteoarthritis (OA). This study aimed to assess ...whether vitamin D supplementation can slow the rate of progression. Method A 3 year, double-blind, randomised, placebo-controlled trial of 474 patients aged over 50 with radiographically evident knee OA comparing 800 IU cholecalciferol daily with placebo. Primary outcome was difference in rate of medial joint space narrowing (JSN). Secondary outcomes included lateral JSN, Kellgren and Lawrence grade, WOMAC pain, function, stiffness and the Get up and Go test. Results Vitamin D supplementation increased 25-OH-D3 from an average of 20·7 (SD 8·9) μg/L to 30·4 (SD 7·7) μg/L, compared to 20·7 (SD 8·1) μg/L and 20·3 (SD 8·1) μg/L in the placebo group. There was no significant difference in the rate of JSN over three years in the medial compartment of the index knee between the treatment group (average -0.01 mm/year) and placebo group (-0.08 mm/year), average difference 0.08 mm/year, (95% CI -0·14 to 0·29, p=0.49). No significant interaction was found between baseline vitamin D levels and treatment effect. There were no significant differences for any of the secondary outcome measures. Conclusion Vitamin D supplementation did not slow the rate of JSN or lead to reduced pain, stiffness or functional loss over a three year period. On the basis of these findings we consider that vitamin D supplementation has no role in the management of knee OA.
Abstract Background This study aimed at identifying preoperative predictors of patient-reported outcomes after total knee arthroplasty (TKA) and at investigating their association with the outcomes ...over time. Methods We used data from 2080 patients from the Knee Arthroplasty Trial who received primary TKA in the United Kingdom between July 1999 and January 2003. The primary outcome measure was the Oxford knee score (OKS) collected annually over 10 years after TKA. Preoperative predictors included a range of patient characteristics and clinical conditions. Mixed-effects linear regression model analysis of repeated measurements was used to identify predictors of overall OKS, and pain and function subscale scores over 10 years, separately. Results Worse preoperative OKS, worse mental well-being, body mass index greater than 35 kg/m2 , living in the most deprived areas, higher American Society of Anesthesiologists grade, presence of comorbidities, and history of previous knee surgery were associated with worse overall OKS over 10 years after surgery. The same predictors were identified for pain and function subscale scores, and for both long-term (10 years) and short-to-medium-term outcomes (1 and 5 years). However, fitted models explained more variations in function and shorter-term outcomes than in pain and longer-term outcomes, respectively. Conclusion The same predictors were identified for pain and functional outcomes over both short-to-medium term and long term after TKA. Within the factors identified, functional and shorter-term outcomes were more predictable than pain and longer-term outcomes, respectively. Regardless of their preoperative characteristics, on average, patients achieved substantial improvement in pain over time, although improvement for function was less prominent.
Abstract Background General recommendations for a reference case for economic studies in rheumatic diseases were published in 2002 in an initiative to improve the comparability of cost-effectiveness ...studies in the field. Since then, economic evaluations in osteoarthritis (OA) continue to show considerable heterogeneity in methodological approach. Objectives To develop a reference case specific for economic studies in OA, including the standard optimal care, with which to judge new pharmacologic and non-pharmacologic interventions. Methods Four subgroups of an ESCEO expert working group on economic assessments (13 experts representing diverse aspects of clinical research and/or economic evaluations) were charged with producing lists of recommendations that would potentially improve the comparability of economic analyses in OA: outcome measures, comparators, costs and methodology. These proposals were discussed and refined during a face-to-face meeting in 2013. They are presented here in the format of the recommendations of the recently published Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement, so that an initiative on economic analysis methodology might be consolidated with an initiative on reporting standards. Results Overall, three distinct reference cases are proposed, one for each hand, knee and hip OA; with diagnostic variations in the first two, giving rise to different treatment options: interphalangeal or thumb-based disease for hand OA and the presence or absence of joint malalignment for knee OA. A set of management strategies is proposed, which should be further evaluated to help establish a consensus on the “standard optimal care” in each proposed reference case. The recommendations on outcome measures, cost itemisation and methodological approaches are also provided. Conclusions The ESCEO group proposes a set of disease-specific recommendations on the conduct and reporting of economic evaluations in OA that could help the standardisation and comparability of studies that evaluate therapeutic strategies of OA in terms of costs and effectiveness.
Risk profiling and education are strategies implemented to help reduce injury risk; however, currently. there is little evidence on the effect of these interventions on injury incidence. The purpose ...of this study was to evaluate the influence of risk profiling and education on upper extremity injury incidence in minor league (MiLB) pitchers and to stratify by injury severity.
A prospective natural experiment study was conducted from 2013 to 2019 on MiLB pitchers. Beginning in the 2015 season, pitchers were examined and risk profiled for upper extremity injury. Shoulder external, internal, total range of motion, horizontal adduction, and humeral torsion were measured. Organizational risk profiling and education was implemented starting in 2015, based on preseason assessments. Chi-squared test was performed to investigate potential differences between shoulder range of motion risk categories between 2013-2014 (pre) and 2015-2019 (post) seasons. Interrupted time series analyses were performed to assess the association between organizational risk profiling and education on arm injury in MiLB pitchers and were repeated for 7-27 and 28+ day injury severity.
297 pitchers were included (pre: 119, post: 178). Upper extremity injury incidence was 1.5 injuries per 1000 athletic exposures. Pitchers in the 2015-2019 seasons demonstrated increased preseason shoulder injury risk for internal (P = .003) and external (P = .007), while the 2013-2014 seasons demonstrated greater horizontal adduction risk (P = .04). There were no differences between seasons for total range of motion risk (P =.76). Risk profiling and education resulted in an adjusted time loss upper extremity injury reduction for the 2015-2019 seasons (0.68 (95% CI: 0.47, 0.99)), which impacted 7-27 days (0.62 (95% CI: 0.42, 0.93)) but not for 28+ days (0.71 (95% CI: 0.47, 1.06)) time loss. There was no reduction in combined trunk and lower extremity injuries for the 2015-2019 seasons (1.55 (95% CI: 0.79, 3.01)).
Organizational risk profiling and education appear to reduce professional pitching overall and 7-27-day upper extremity injury risk by 33%-38%. There was no difference in trunk and lower extremity injuries over the period, strengthening the reduction in upper extremity injury risk results. This suggests that while injury risk increased over time, organizational risk profiling mitigated the expected increase in upper extremity injury rates. Risk profiling and education can be used as a clinical screening and intervention tool to help decrease upper extremity injuries in professional baseball populations.
Abstract This study identifies optimal OKS values that discriminate post-operative (TKA) patient satisfaction and determines the variation in threshold values by patient characteristics and ...expectations. It is the first to identify patient improvement using measures (PoPC) that account for patient’s pre-operative symptom severity. Of 365 primary TKA patients from a London district general hospital 84% were satisfied at 12 and 24 months. Whilst the overall OKS thresholds (follow-up, change, PoPC) were stable at 12 months (31, 11, 39.7%) and 24 months (35, 12, 38.9%), patients who were older (≥ 75 years), were underweight/normal (BMI < 25), had pre-operative symptom severity (OKS ≤ 15) and expected no pain post-surgery, required a greater (potential) improvement to be classed as satisfied. When reporting good patient outcomes, cohorts should be stratified accordingly.
Baseball has specific sport and positional demands that may modify joint pain compared with other sports. Persistent joint pain reduces function and is an underlying reason for seeking medical care. ...The pain and functional status of players after they stop competitive play are unknown. Such knowledge can assist clinicians in creating personalized physical examinations and interventions for baseball players as they transition to retirement. The purpose of this study was to (1) evaluate persistent joint pain and arm function in former baseball players and (2) determine whether playing position is associated with increased odds of joint pain and reduced arm function in former baseball players.
A cross-sectional survey was performed. Eligibility criteria consisted of (1) played ≥1 collegiate baseball season, (2) aged ≥18 years, and (3) formerly played baseball (currently retired). Outcomes assessed included persistent joint pain and Single Assessment Numeric Evaluation (SANE). Explanatory variables included playing position (position, two-way, or pitcher). Multivariable logistic and linear regressions were performed. Models were adjusted for age, body mass index, arm dominance, playing standard, years played baseball, and injury and surgery history.
A total of 117 former baseball players participated (age: 36.8 13.7 years). The mean dominant SANE score was 70.2 (standard deviation 24.1), and the mean nondominant SANE score was 85.2 (standard deviation 19.4). There was no difference in dominant arm SANE scores when stratified by arm injury history (4.6 95% confidence interval: −14.9, 5.8) or arm surgery history (−3.8 95% confidence interval: 13.4, 5.8). The shoulders had the greatest persistent joint pain prevalence (28% of all participants) and elbows (21% of all participants). There was no relationship between dominant arm pain or function and playing position.
This is the first study to demonstrate an increase in dominant arm disability in former baseball players. The high prevalence of persistent arm pain and poor arm function among former baseball players is concerning considering participants were younger than 40 years of age. No differences were observed in arm function when stratifying by arm history, surgery, or position demonstrating the potential relationship between baseball participation and arm disability after cessation of play. Clinicians should consider working with baseball players to develop long-term strategies to maintain joint health, especially in the throwing arm, when baseball players are transitioning to retirement. Future research is needed to understand the long-term effectiveness of clinical treatments and the implications of specific arm injuries such as ulnar collateral ligament tears on persistent arm pain and function.
Abstract The OHS/OKS are PROMs for assessing symptomatic pain and function following TJA. However, actual change in pre-operative/post-operative scores cannot distinguish patients of varying baseline ...symptom severity. The percentage of potential change (PoPC) is a simple method that accounts for this, expressing the actual change attained, as a percentage of the potential change possible. Measures are described using OHS/OKS at baseline and 6-months (1784 – TKA, 1523 – THA) from the Elective Orthopaedic Centre. Each method identified different proportions of patients as satisfied and importantly, the measures identified different patients. PoPC overcomes floor and ceiling effects and standardises measures to an easy to interpret − 100 to + 100 scale. In addition to actual change, we recommend using PoPC to assess the overall outcome of patients.
Summary Knee-replacement surgery is frequently done and highly successful. It relieves pain and improves knee function in people with advanced arthritis of the joint. The most common indication for ...the procedure is osteoarthritis. We review the epidemiology of and risk factors for knee replacement. Because replacement is increasingly considered for patients younger than 55 years, improved decision making about whether a patient should undergo the procedure is needed. We discuss assessment of surgery outcomes based on data for revision surgery from national joint-replacement registries and on patient-reported outcome measures. Widespread surveillance of existing implants is urgently needed alongside the carefully monitored introduction of new implant designs. Developments for the future are improved delivery of care and training for surgeons and clinical teams. In an increasingly ageing society, the demand for knee-replacement surgery will probably rise further, and we predict future trends. We also emphasise the need for new strategies to treat early-stage osteoarthritis, which will ultimately reduce the demand for joint-replacement surgery.
Abstract Objectives There is an important need to evaluate therapeutic approaches for osteoarthritis (OA) in terms of cost-effectiveness as well as efficacy. Methods The ESCEO expert working group ...met to discuss the epidemiological and economic evidence that justifies the increasing concern of the impact of this disease and reviewed the current state-of-the-art in health economic studies in this field. Results OA is a debilitating disease; it is increasing in frequency and is associated with a substantial and growing burden on society, in terms of both burden of illness and cost of illness. Economic evaluations in this field are relatively rare, and those that do exist, show considerable heterogeneity of methodological approach (such as indicated population, comparator, decision context and perspective, time horizon, modeling and outcome measures used). This heterogeneity makes comparisons between studies problematic. Conclusions Better adherence to guidelines for economic evaluations is needed. There was strong support for the definition of a reference case and for what might constitute “standard optimal care” in terms of best clinical practice, for the control arms of interventional studies.
Summary Background Vitamin D is crucial for maintenance of musculoskeletal health, and might also have a role in extraskeletal tissues. Determinants of circulating 25-hydroxyvitamin D concentrations ...include sun exposure and diet, but high heritability suggests that genetic factors could also play a part. We aimed to identify common genetic variants affecting vitamin D concentrations and risk of insufficiency. Methods We undertook a genome-wide association study of 25-hydroxyvitamin D concentrations in 33 996 individuals of European descent from 15 cohorts. Five epidemiological cohorts were designated as discovery cohorts (n=16 125), five as in-silico replication cohorts (n=9367), and five as de-novo replication cohorts (n=8504). 25-hydroxyvitamin D concentrations were measured by radioimmunoassay, chemiluminescent assay, ELISA, or mass spectrometry. Vitamin D insufficiency was defined as concentrations lower than 75 nmol/L or 50 nmol/L. We combined results of genome-wide analyses across cohorts using Z -score-weighted meta-analysis. Genotype scores were constructed for confirmed variants. Findings Variants at three loci reached genome-wide significance in discovery cohorts for association with 25-hydroxyvitamin D concentrations, and were confirmed in replication cohorts: 4p12 (overall p=1·9×10−109 for rs2282679, in GC ); 11q12 (p=2·1×10−27 for rs12785878, near DHCR7 ); and 11p15 (p=3·3×10−20 for rs10741657, near CYP2R1 ). Variants at an additional locus (20q13, CYP24A1 ) were genome-wide significant in the pooled sample (p=6·0×10−10 for rs6013897). Participants with a genotype score (combining the three confirmed variants) in the highest quartile were at increased risk of having 25-hydroxyvitamin D concentrations lower than 75 nmol/L (OR 2·47, 95% CI 2·20–2·78, p=2·3×10−48 ) or lower than 50 nmol/L (1·92, 1·70–2·16, p=1·0×10−26 ) compared with those in the lowest quartile. Interpretation Variants near genes involved in cholesterol synthesis, hydroxylation, and vitamin D transport affect vitamin D status. Genetic variation at these loci identifies individuals who have substantially raised risk of vitamin D insufficiency. Funding Full funding sources listed at end of paper (see Acknowledgments).
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