Why It’s Important
Meniscal tears are prevalent in over 80% of people with established knee osteoarthritis (OA). Some patients elect to participate in physical therapy and activity modification for meniscal tear management. If these measures are not effective patients are offered arthroscopic partial meniscectomy (APM). APM is conducted over 300,000 times in the US annually. However, it is unclear how APM impacts the progression of underlying cartilage damage and osteophyte formation in comparison to patients who use more conservative management such as physical therapy (PT).
What We Did
We compared differences for Kellgren-Lawrence (KL) grade and OARSI radiographic scores at baseline and 60 months between patients who had undergone an APM and those who only utilized PT. Differences in osteoarthritis changes and knee pain where ultimately evaluated between the two groups.
What We Found
Data was collected from a sample of 142 subjects with 100 having undergone APM and 42 in the PT group. We found that subjects treated with APM had greater progression in OARSI Score due to osteophyte progression, but not in KL grade, compared to the PT group.
Why It’s Important
Physical Activity (PA) positively impacts health by preventing disease, improving quality of life (QoL), and lowers healthcare expenditure. However, Americans with osteoarthritis (OA) often do not meet PA guidelines despite benefits of improved knee pain and function that result from exercise. This causes significant losses of quality-adjusted life years (QALYs) for the OA population. Determination of cost-effective interventions promoting PA is necessary among individuals with knee OA to increase activity levels and mitigate losses of QALYs. Physical activity programs have been found to increase participant activity levels and functional impairments but have not been implemented for the OA population. The potential value of such interventions can be determined through cost-effectiveness analyses to provide individuals with OA the best outcomes.
What We Did
The Arthritis Foundation developed the Walk With Ease (WWE) program to educate people with arthritis on safe exercise practices and improve arthritis symptoms. We used the Osteoarthritis Policy (OAPol) Model, a computer simulation model of knee OA, to assess the cost-effectiveness of WWE relative to OA. Subjects with knee OA were categorized into three groups based on their PA level at baseline visit: inactive (0–30 min of PA/week), insufficiently active (31–179 min of PA/week), and active (≥180 min of PA/week). Base-case analysis was restricted to participants who were inactive or insufficiently active. Another group of subjects were offered the program without preselection by baseline activity level. We used QALYs and costs over a 2-year period to determine the incremental cost-effectiveness ratio (ICER). Scenario and probabilistic sensitivity analyses were utilized to determine the impact of uncertainty in model parameters on our results.
What We Found
We found that implementing WWE to usual care led to an ICER of $47,900/QALY in the base case analysis. Subjects who received the program without preselection by baseline activity, the ICER for WWE + usual care was estimated at $83,400/QALY. WWE offered to inactive or insufficiently active individuals were indicated to have a 52% chance of having an ICER < %50,000/QALY due to the results of the probabilistic sensitivity analysis. Our findings indicate that the WWE program is a cost-effective program for inactive and insufficiently active individuals. Similar programs should be considered for treatment plan implementation for individuals with OA.
Why It’s Important
The majority of knee OA patients have stable pain trajectories long term which includes those with flare and remission patterns. Now knee OA may be classified as acute-on-chronic, but understanding within-patient variability is important to shed light on patients’ pain experiences. We aimed to describe frequency and duration of pain worsening episodes.
What We Did
We selected patients with radiographic, symptomatic knee OA from the Osteoarthritis Initiative to analyze. We looked at clinically relevant increases in WOMAC pain scores and sustained worsening of pain.
What We Found
Most patients reported at least one episode of a clinically important increase in WOMAC pain, but less than have experience sustained pain worsening.
Why It’s Important
Low back pain is a large cause of physician visits, disability, and medical costs. Facet joint arthropathy has been found in 40-85% of patients with this pain but it is also present in asymptomatic individuals. Facet joint degeneration may be underestimated by current imaging modalities such as MRI. We aim to summarize and evaluate the existing literature of MRI grading systems that describe the severity of degeneration.
What We Did
We performed a literature search of relevant papers published between 1985 and 2022. From these, we collected data on inter-reader reliability, and we compared the features of inflammation described by each grading system.
What We Found
We found 6 studies that matched our inclusion criteria. While reliable, the systems varied regarding what precise tissues and phenomena were included in their grading.
Why It’s Important
The FDA recommends that coordinating centers of multicenter clinical trails perform in-person site visits to the child sites to ensure the study process is standardized and held to the highest standard. The MeTeOR trial scheduled site visits for winter 2021 and spring 2022, but due to the COVID-19 pandemic, travel was precluded and videoconference visits were employed instead.
What We Did
We devised a virtual site visit structure with 3 stages: preparation for the visit, the virtual meeting, and follow up. A virtual study visit was performed for each of the 5 MeTeOR child sites.
What We Found
We found that the virtual visits ran smoothly and were appreciated by site staff for its efficiency and effectiveness. We found assessing physical workspaces over videoconferencing was difficult. These visits offer many advantages including time, money and efficiency.
Why It’s Important
Meniscal damage is common in people with both asymptomatic and symptomatic knee OA (KOA) aged 45-65. This damage increases the risk for OA development and progression. No systematic summary of the various studies documenting meniscal damage and its contribution to the development of KOA has been performed yet.
What We Did
We identified 15 studies that assessed the relationship between meniscal pathology and OA incidence. We then reviewed each article and summarized their findings based on what meniscal pathology they analyzed including: meniscal tear, tear characteristics, meniscal extrusion, as well as other meniscal pathologies.
What We Found
Preventative and therapeutic strategies can be prompted by early detection of a meniscal pathology and can help avoid or delay knee OA for this population.
Why It’s Important
Nociplastic pain in knee OA is pain arising from abnormal loading of the damaged joint without evidence of tissue damage. Patients with this type of pain may have less relief following NSAIDs, corticosteroid injections and TKRs, but gabapentanoids may present a better opportunity to alleviate this pain. Prescriptions of gabapentanoids have grown in recent years despite the lack of analyses that weigh the risks of adverse events with the pain benefits.
What We Did
We used the OAPol model to examine the value of gabapentin in treating knee OA by comparing usual care, usual care + gabapentin to only those with nociplastic pain, and usual care + gabapentin to everyone. Key outcomes included QALYs, lifetime direct medical costs, and ICERs.
What We Found
Gabapentin seems to lead to greater costs without any benefits in pain, thus it is not of good value. This is driven largely by the risk of adverse events.
Why It’s Important
Studies have shown that PT provides substantial and comparable symptom relief when compared to arthroscopic partial meniscectomy (APM) for patients with meniscal tear and osteoarthritic damage. While some studies have shown those who undergo APM have greater degenerative changes on imaging compared to PT, the clinical importance of these findings is not yet known. The goal of the study was to use MeTeOR data to assess whether worsening in MRI after 18 months leads to subsequent worsening in knee pain over the following 3.5 years.
What We Did
We used MeTeOR patient data to assess the change in cartilage surface damage between baseline and 18 months. We then evaluated if this change was associated with a change in KOOS pain score from 18 to 60 months.
What We Found
We found that there was no association between early change in cartilage surface area and change in pain score. We also found no relation between changes in bone marrow lesions, osteophytes, or synovitis and subsequent pain.
Why It’s Important
There are a number of subgroups of OA, such as inflammatory OA, that may benefit from tailored treatments. Identification of effusion-synovitis (E-S) via MRI is the gold standard for detection and quantification of inflammation, but it is very costly. Intra-articular aspiration with analysis of the synovial fluid white blood cell count (SF WBC) has been used to determine inflammatory vs non-inflammatory arthritis, but it is unclear if it is valid to assess intra-articular inflammation. We sought to determine the sensitivity and specificity of SF WBC by comparing it to MRI E-S.
What We Did
We identified patient records of those who had knee OA, SF WBC and an MRI within 12 months of the aspiration. MRIs were read for E-S using the MOAKS. We used Youden’s Index to identify the best cut-point for SF WBC.
What We Found
SF WBC did not act as a strong proxy for inflammation on MRI as the sensitivity and specificity were limited. Further research into the association between MRI and SF measured E-S is needed.
Why It’s Important
Patients who have a BMI over 40 and advanced knee OA have a higher risk for complications following TKR as well as higher surgical costs. Weight loss, such as that caused by bariatric surgery, may be beneficial for these patients prior to undergoing a TKR. Study of the value of weight loss interventions prior to TKR has not been extensive and as such, we sought to evaluate the clinical and economic implications of surgical and non-surgical weight loss for patients with Class III obesity prior to TKR.
What We Did
We used the OAPol model to evaluate the value of Roux-En-Y Gastric Bypass (RYGB), Laparoscopic Sleeve Gastrectomy (LSG), and Lifestyle Non-surgical Weight Loss (LNSWL) interventions. Our primary outcomes were cost, QALE and ICERs and we conducted deterministic and probabilistic sensitivity analyses to examine the robustness of our conclusions.
What We Found
We found that RYGB is the most cost-effective option and provides good value. Immediate TKR without weight loss is not economically efficient.
Why It’s Important
Studies have suggested that racial disparities exist in access to care and patient outcomes for various orthopaedic surgical procedures. These studies, however, have not reported patient-reported outcome measurements (PROMs) at baseline and there are currently no studies evaluating racial disparities in sports medicine.
What We Did
We evaluated a cohort of white, Black and patients of other races who underwent an APM. Their PROMs included KOOS-pain and -function scales as well as the VR-12 Mental Component Summary. The associations of race with these scores were determined by multivariate modeling.
What We Found
Black patients had worse knee pain and function as well as worse articular cartilage damage at the time of surgery. The three most important risk factors for KOOS-pain and -function scales are baseline mental health, BMI and patient age.
Why It’s Important
Osteoarthritis is the most common joint disorder in the US and is a focus of many research studies. These studies use pain and physical function as key outcomes which can be measured by self-report questionnaires or with objective physical performance measures. While objective physical performance measures have been associated with clinically important outcomes in persons with OA, limited studies have examined associations between self-report measures and objective tests in those who are treated nonoperatively.
What We Did
We analyzed the baseline data from the Osteoarthritis Registry of Biomarker and Imaging Trajectories. Self-reported tests included the KOOS pain and ADL scales as well as other measures, and the objective tests included single leg balance test, 30 second sit to stand, timed up and go, and 40 meter fast paced walk. Pearson correlation coefficients were used to examine the association between performance and KOOS.
What We Found
We found that self-reported function had weak to modest correlations with the objective function tests. This suggests the potential value of including objective measures of functional status in OA trials.
Why It’s Important
Treatment plans for meniscal tears include arthroscopic partial meniscectomy (APM) and physical therapy (PT), and while APM was heavily favored amongst clinicians up until 2007, research in the past 15 years has produced evidence that may better inform treatment decisions.
What We Did
We performed a narrative review to identify key gaps in knowledge and to provide guidance for clinicians treating people with knee pain and meniscal tears. Studies that were included in our review addressed treatment outcomes for meniscal tear in middle-aged and older persons.
What We Found
APM and PT provide comparable pain relief, and thus PT should be recommended as the first line of treatment in patients with symptomatic meniscal tears. The presence of radiographic OA, meniscal tear type, pain at baseline, and the history of prior meniscal surgeries all have influence on how much benefit patients may receive after undergoing APM. We note that knees that undergo APM may have greater osteoarthritic changes on x-rays compared to patients undergoing nonoperative therapy. We encourage further research in this research area and suggest that APM be offered only if PT does not alleviate symptoms.
Why It’s Important
Degenerative meniscal tears are very common and are often addressed with physical therapy (PT) and/or surgically with arthroscopic partial meniscectomy (APM). While research indicates that APM may result in similar or only slightly improved outcomes to PT, high trial crossover rates complicate analysis.
What We Did
We used the Osteoarthritis Policy (OAPol) Model to conduct a cost-effectiveness analysis comparing three treatment strategies: 1) PT alone, 2) immediate surgery, and 3) PT + optional surgery for those whose pain was not controlled by PT. We estimated total healthcare costs and quality-adjusted life-years (QALYs) over 5 years, to calculate incremental cost-effectiveness ratios (ICERs).
What We Found
Optional APM following initial PT is cost-effective, with an ICER of $30,900/QALY when compared to PT alone. Immediate surgery, compared with PT + optional surgery, has an ICER of $473,800/QALY. We concluded that APM is generally not cost-effective as a first-line treatment; however, APM following initial PT has high value, significantly improving quality of life at a reasonable cost.
Why It’s Important
Bronchiectasis is a disease associated with rheumatoid arthritis (RA) and includes bronchial dilation, inflammation, and recurrent infection. People with RA-associated bronchiectasis (RA-BR) are at a higher risk for morbidity and mortality compared to the general population and those with RA but no bronchiectasis. Despite its important clinical presentation, there are a limited number of studies focused on the risk factors associated with RA-BR development.
What We Did
We used a large institutional biobank to perform a case-control study in order to identify risk factors for RA-BR. Medical record reviews and chest CT evaluations were done to identify patients who fit the criteria. The patients were divided into those who had RA-BR without interstitial lung disease and those with RA but no RA-associated lung diseases.
What We Found
We found that RA-BR was associated with seropositivity (RA markers present in patients’ blood), lower BMI at diagnosis of RA, and older age at RA diagnosis. These findings stress the important and complex interactions between airway inflammation and RA.
Why It’s Important
Arthroscopic partial meniscectomy (APM) is one of the most common orthopedic surgeries, often performed for patients with tears of their meniscus. However, recent studies have suggested that while APM may help reduce pain and improve function in the short term, the surgery could accelerate the progression of osteoarthritis (OA) in the long term.
What We Did
We compared the progression of osteoarthritis in people who had APMs for a meniscal tear, people who had a meniscal tear but didn’t have an APM, and people who did not have a meniscal tear, to determine whether APMs did in fact accelerate the progression of osteoarthritis. Using data from the Osteoarthritis Initiative (OAI), we identified an equal number of patients who had an APM (but no previous knee surgeries), meniscal tears but did not undergo an APM, and no meniscal tear. We looked at x-rays for these patients taken over six years of follow-up and used changes in joint space width as an estimate of osteoarthritis progression over time.
What We Found
In the first year after surgery, patients who underwent APM experienced faster progression of OA (measured by increased joint space narrowing) compared to patients with and without meniscal tears who did not have APMs. After the first year, however, all three groups experienced similar rates of OA progression/joint space narrowing.
Why It’s Important
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is linked to disease relapses, increased risk of end-stage renal disease (ESRD) and excess mortality. While ANCA testing has long been a central component of AAV diagnosis, ANCA measurements after treatment has been a controversial practice. There is conflicting data regarding the impact of achieving serological remission of ANCA on later risk of AAV relapse, ESRD, and death.
What We Did
We used data from a number of sources to collect information on AAV relapse, ESRD and death rates. We then emulated a hypothetical clinical trial comparing the risk of relapse, ESRD and death 5 years after initial diagnosis between those who did and did not achieve serological remission within 180 days of induction treatment.
What We Found
We found that achieving serological remission was associated with decreased risk of relapse, but not associated with changes in risk for ESRD or death within 5 years. This suggests that achieving serological remission (i.e. a negative ANCA assay) may result in fewer disease relapses.
Why It’s Important
Bariatric surgery is increasingly used to help individuals with severe obesity characterized by body mass indexes (BMIs) greater than 35 kg/m2. High BMI is a key risk factor for knee osteoarthritis (OA), and individuals with elevated BMIs are more susceptible to complications following total knee replacements.
What We Did
In this analysis, we assessed the value of two common bariatric surgery procedures in treating knee OA patients with BMIs greater than 35 kg/m2. We used the Osteoarthritis Policy model to estimate the value of either Roux-en-Y gastric bypass (RYGB) surgery, laparoscopic sleeve gastrectomy (LSG) in conjunction with usual care for knee osteoarthritis.
What We Found
RYGB surgery offers good value among knee OA patients with BMIs greater than 40 kg/m2 whereas LSG may provide good value among those with BMIs between 35 and 40 kg/m2.
Why It’s Important
Exercise and physical therapy are most frequently recommended as treatment options for patients with knee OA, but these treatments often have expensive provider and transportation related costs. Virtual PT visits and exercise programs have gained popularity recently and while research exists, no consensus has been reached on this practice’s effectiveness.
What We Did
We conducted a search of RCTs that had a telehealth component and evaluated knee pain that were published between January 2013 and March 2021. Pain data was extracted and differences between baseline and between groups were analyzed for minimum clinically important difference thresholds.
What We Found
Of the 11 studies identified, 1 study that compared an active group with an inactive control (waitlist or education) showed a clinically meaningful difference between the groups. 4 studies that included personalization of the exercise program demonstrated clinically meaningful improvements from baseline.
Why It’s Important
Over 800,000 patients in the United States with symptomatic knee osteoarthritis (SKOA) use opioids chronically. Opioid use can lead to opioid use disorder, which can lead to significant impairment or accidental death.
What We Did
Using the OAPol model, we estimated the opioid-related lifetime and annual costs associated with symptomatic knee OA patients in the US. We included medical, lost productivity, criminal justice, and diversion costs.
What We Found
The total lifetime opioid-related cost for the SKOA population in the US is approximately $14 billion, of which only 53% were direct medical costs. This finding emphasizes that much of the societal cost associated with opioid use is due to lost productivity, criminal justice, and diversion costs.
Why It’s Important
Symptomatic knee osteoarthritis (OA) affects an estimated 14 million individuals in the US, with up to 91% of patients with knee OA demonstrating a meniscal tear. Patients with meniscal tears often report meniscal symptoms such as catching, popping, or locking of the knees that often require an arthroscopic partial meniscectomy (APM). This study was undertaken to investigate whether patients with meniscal tears who report these meniscal symptoms have greater pain improvement with APM than physical therapy (PT).
What We Did
Using data from the Meniscal Tear in Osteoarthritis Research (MeTeOR) Trial of APM versus PT, we collected information on frequency of patient-reported meniscal symptoms at baseline and 6-month follow-up.
What We Found
Meniscal symptoms were not associated with improved pain relief. Although meniscal symptoms such as clicking and intermittent locking had greater reduction in the APM group, our findings do not support the hypothesis that patients with meniscal tear show greater pain improvement with APM compared to PT. Thus, the presence of meniscal symptoms should not inform clinical decisions surrounding APM vs. PT in patients with meniscal tear and knee OA.
Why It’s Important
An estimated 103 million persons worldwide are affected by lumbar spinal stenosis, a disabling cause of low back and leg pain. Lumbar spinal stenosis is common in older persons and is typically a degenerative disease (caused by wear and tear). Narrowing of the spinal canal compresses the nerves, causing pain, numbness and tingling of the lower legs and feet, and balance to worsen.
What We Did
We conducted a literature review of articles pertaining to the diagnosis and treatment of lumbar spinal stenosis. We discuss the pathophysiology, clinical presentation, diagnosis, and treatment of lumbar spinal stenosis.
What We Found
Approximately 11% of older adults in the US are affected by lumbar spinal stenosis. First-line therapy is activity modification, pain medication, and physical therapy. Studies have not established any long-term benefits for epidural steroid injections. Patients who continue to experience pain and functional limitations may be candidates for decompressive surgery.
Why It’s Important
Patients that are undergoing anterior cruciate ligament reconstruction (ACLR) are at a higher risk for developing post-traumatic osteoarthritis (PTOA). Patients that undergo ACLR with coincident meniscal tear are also at an increased risk for PTOA ten years after surgery. While this group of investigators previously reported that meniscal treatment predicts more radiographic PTOA 2 to 3 years after ACLR, there are a limited number of studies that have assessed changes in cartilage after ACLR with magnetic resonance imaging (MRI).
What We Did
Participants younger than 36 years of age were recruited from the nested Multicenter Orthopaedic Outcomes Network (MOON) cohort and underwent ACLR between 2005 and 2012. Patients had bilateral knee MRIs at two years after their ACLR. The cartilage on the MRI scans were assessed for cartilage damage. A proportional odds logistic regression model was built to predict cartilage damage relative to the contralateral control knee when pooled by meniscal treatment during ACLR and controlling for age, sex, body mass index, baseline MARX activity score, and baseline cartilage grade.
What We Found
In patients that required surgical treatment for their meniscal injury, cartilage damage scores were worse at two years after ACLR on MRI. Other predictors for worse cartilage damage scores shown on MRI included age, body mass index, and surgically observed cartilage damage in the patellofemoral compartment of the knee.
Why It’s Important
The MUC5B promoter variant is an established risk factor for RA associated interstitial lung disease (RA-ILD), which is a disease manifestation of RA that results in increased mortality. However, the impact of this genetic marker on the timing of RA-ILD relative to RA diagnosis and disease features remains unknown.
What We Did
We performed a retrospective cohort study and identified patients from the MGB Biobank with RA and available genotyping of the MUC5B promoter variant. Information was collected via medical record reviews, and we performed logistic regression to calculate odds ratios and 95% CIs to examine the association between the MUC5B promoter variant genotype and RA-ILD, timing of RA-ILD and age of RA diagnosis.
What We Found
We found the MUC5B promoter variant to be associated with RA-ILD, RA-ILD before or within 2 years of RA diagnosis, and RA onset after age 55. These findings expand our understanding of the MUC5B gene in RA-ILD and suggest that the MUC5B promoter variant may impact RA-ILD risk early in the RA disease course, particularly in patients with older-onset RA.
Why It’s Important
Knee osteoarthritis is a debilitating condition that affects over 14 million adults in the United States, with meniscal tears being prevalent amongst these patients. Patients diagnosed with meniscal tear may choose to pursue physical therapy or arthroscopic partial meniscectomy (APM) as first-line treatment options, though data has shown that patients who undergo APM have an increased risk of requiring total knee replacement (TKR) than patients who pursue physical therapy. Researchers do not understand why APM patients are more likely to require TKR and have looked to MRIs to identify any structural differences in the knee joint between patients who had APM vs. patients who opted for physical therapy. MRIs may serve as a useful marker for predicting how knee OA will progress in this patient population.
What We Did
Using data from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial of surgery vs physical therapy, we assessed MRIs from MeTeOR participants that were taken at baseline, 18 months after their treatment, and five years after their treatment for structural changes in the knee. The markers assessed included degenerative changes in bone marrow lesions, cartilage thickness damage, bone spurs (osteophytes), and synovitis. We were interested in finding associations between surgical vs. non-surgical treatment of meniscal tear and worsening MRI markers over five years.
What We Found
For both surgical and non-surgical treatment groups, more structural changes were seen on MRI between baseline and 18 months than 18 months and five years. APM was associated with an increased risk of worsening cartilage thickness damage, osteophytes, and synovitis in the first 18 months. APM was also associated with a significantly worsened change in osteophytes between 18 months and five years compared to physical therapy. These results suggest that the association between APM and changes in structural damage on MRI are most apparent in the first eighteen months after surgery.
Why It’s Important
Despite guidelines against the use of opioids to treat knee osteoarthritis pain, they are still used regularly. Efforts to find non-opioid regimens for treating knee OA pain should be tailored to patients at high risk for chronic opioid use.
What We Did
Utilizing Medicare usage data, we created a cohort of subjects with knee OA and grouped them based on their opioid usage (non-user, occasional user, and chronic user). We then built multivariable logistic regression models to determine correlates of chronic opioid use.
What We Found
Among 3,549 Medicare beneficiaries with knee OA and a mean age of 78 (SD 7) years,
68% were females, 9% were chronic users and 21% used opioids occasionally. Multivariable
analysis showed that non-Hispanic ethnicity, divorced status (vs. married), Medicaid eligibility,
depression, COPD, and inability to walk without assistive devices (vs. no difficulty walking) were
independently associated with chronic opioid use.
Why It’s Important
Over 7 million individuals in the US are currently living with a total joint replacement (TJR) of the knee or hip and are at risk for prosthetic joint infection (PJI). To limit the risk of PJI resulting from dental procedures, some clinicians prescribe antibiotics before these appointments, a practice that has limited supportive evidence. The use of antibiotics has its own associated risks, including cost, adverse events, and antibiotic resistance.
What We Did
We surveyed the personal, pre-dental antibiotic use of TJR recipients. Using this data, we identified factors associated with the degree of antibiotic use and determined whether those patients with even greater risk of PJI due to diabetes and rheumatoid arthritis were more likely to take antibiotics prior to dental visits.
What We Found
Of those we surveyed, about 2/3 of TJR recipients indicated they always use prophylactic antibiotics prior to dental procedures. Individuals more likely to always use antibiotics included those who received multiple TJR’s, underwent invasive dental procedures, and those more worried about getting a PJI. Those who were less likely to always use antibiotics included subjects who did not regularly receive routine dental cleanings, those who had TJRs in the earlier study period (2011-2013 vs. 2014-2016), and those who were obese (BMI >30). We did not find an association between antibiotic use and rheumatoid arthritis or diabetes status.
Why It’s Important
Dislocations after total hip replacement surgery can lead to abnormal pelvic orientation. Surgeons can determine this orientation by measuring the pelvic tilt (PT) using radiographs showing the pelvis from a lateral (side) perspective. When a lateral pelvic radiograph isn’t available before surgery, an anterior (front view) radiograph may be used to measure the sacro-femoro-pubic (SFP) angle. The PT may be estimated using the SFP. However, the SFP is not commonly measured by orthopedic surgeons. We investigated intra-reader and inter-reader reliability of SFP angle measurements using anterior pelvis radiographs performed by orthopedic surgeons of different experience levels.
What We Did
We asked an attending orthopedic surgeon and two orthopedic residents to measure the SFP angles of 29 subjects with anterior pelvis radiographs. Each reader measured the SFP of these subjects on two occasions, with each reading occurring 1-3 days apart. We then analyzed the consistency of each reader’s measurements as well as the consistency of these measurements between readers by determining their intraclass correlation coefficients (ICC) on a scale from 0 to 1, with 1 indicating highly similar SFP measurements for individual surgeons and between surgeons.
What We Found
We found intra-reader and inter-reader ICC values for SFP angle measurements ranging from 0.91 – 0.99, signifying high intra-reader and inter-reader reliability for these measurements amongst orthopedic surgeons of different experience levels. Studies like ours may serve as a helpful model for documenting reliability of image assessments.
Why It’s Important
Long-term care facilities such as nursing homes can place heavy physical and mental demands on employees who, according to the National Institute for Occupational Health and Safety (NIOSH), tend to be from groups that are disproportionately at risk for occupational health disparities. We investigated whether there is an association between the ownership structure of nursing homes (for-profit vs not-for-profit, corporate-owned vs non-corporate) and occupational safety scores according to the Workplace Integrated Safety and Health Assessment (WISH), a five-domain tool that measures the degree to which worker safety, health, and wellbeing is implemented in an organization.
What We Did
We surveyed the directors of nursing (DONs) at 543 nursing homes in California, Ohio, and Massachusetts on their occupational health practices. We then computed each organization’s Workplace Integrated Safety and Health (WISH) assessment score according to their responses. Using logistic regression, we assessed what types of nursing homes obtained WISH scores in the bottom 25th percentile and the top 75th percentile in each of the five WISH domains.
What We Found
We did not find an association between the organizational structure of a nursing home (for-profit vs. not-for-profit, corporate-owned vs non-corporate) and the WISH domain scores corresponding with survey responses from directors of nursing at these organizations. This suggests that for-profit and corporate nursing home status may not be helpful identifiers in seeking organizations that would benefit from additional workplace safety and policy development.
Why It’s Important
Over 400,000 people with meniscal tears and osteoarthritic damage receive arthroscopic partial meniscectomies (APM) each year. Research has shown that those who receive APM experience greater degenerative changes in imaging features of their joint compared to those with similar conditions who are treated non-operatively. But it is currently unknown if these changes bear clinical significance.
What We Did
Using data from the Meniscal Tear in Osteoarthritis Research (MeTeOR) Trial of APM versus physical therapy (PT), we assessed whether degenerative changes in cartilage damage, synovitis, bone marrow lesions and osteophytes, observed with Magnetic Resonance Imaging from baseline to 18 months follow-up, were associated with changes in reported pain from 18 to 60 months follow-up.
What We Found
Structural worsening on imaging was not associated with worsening pain over 3.5 years of follow-up, suggesting that these structural changes may not be clinically meaningful over this observation period.
Why It’s Important
As there are no osteoarthritis (OA) treatments that halt or slow joint damage, treatments focus on pain management and functional restoration. Pain levels of patients with OA often do not correspond with severity of joint damage, suggesting that other processes may affect OA pain. Pain sensitization, an increased responsiveness of pain-sensing neurons, may be responsible for some of this pain. Greater understanding of the role of sensitization in OA pain and how to identify it in individuals could lead to targeted therapies that better manage patients’ pain.
What We Did
We conducted a systematic review to measure associations between measures of pain sensitization and patient manifestations of OA. We begin by outlining the most common quantitative sensory testing (QST) techniques, which assess pain sensitization. Then, we focus on cross-sectional associations between these measures and both OA symptoms and joint damage severity. Finally, we review evidence of longitudinal associations between pain sensitization measures and responses to OA therapy.
What We Found
Pain pressure threshold, conditioned pain modulation, and temporal summation are the three most common measures of pain sensitization. People with OA exhibit greater sensitization as measured by these techniques compared to controls without OA. Pre-treatment testing for pain sensitization has shown some success in identifying people who experience less benefit from knee OA treatments and post-treatment testing has shown that sometimes measurements of pain sensitization can normalize in patients after successful joint replacement. These findings indicate that QST may help identify patients more susceptible to chronic pain and may lead to opportunities for personalized treatment of OA.
Why It’s Important
Clinicians are taught that mechanical symptoms such as knee clicking, catching, and locking are indicators for meniscal tear and may be improved by arthroscopic partial meniscectomy (APM). In 2020, there were over 400,000 APM’s performed in the United States, and although APM efficacy has been thoroughly researched, there has been less investigation into the definition of “mechanical symptoms,” whether these symptoms are associated with a meniscal tear, and whether patients with mechanical symptoms are more likely to improve after APM.
What We Did
We performed a literature review using PubMed and selected 38 publications for narrative analysis focused on clinical presentation or treatment of meniscal tear.
What We Found
Mechanical symptoms only have modest sensitivity, specificity, and positive predictive value for meniscal tear. There is also very little evidence to suggest that those with mechanical symptoms experience better outcomes after arthroscopic surgery. Our findings do not support the hypothesis that mechanical symptoms are connected to the presence of meniscal tears or improved APM outcomes.
Why It’s Important
The COVID-19 pandemic exacerbated intimate partner violence (IPV) by restricting access to healthcare and support networks, forcing some survivors to remain in spaces with their abusers due to stay-at-home orders, and amplifying inequities and strains on resources. Understanding provider perspectives on these impacts of COVID-19 can inform innovative policy decisions on the provision of safe, equitable IPV care through the pandemic and beyond.
What We Did
We conducted semi-structured phone interviews with 18 IPV care providers working in healthcare, social work, legal aid, advocacy, and housing. These interviews compiled providers’ professional experience, accounts of challenges and barriers to IPV care during the pandemic, adaptations and innovations, broader implications for policy and organizations, and lessons learned. We then developed a list of codes (keywords and phrases), coded the interview transcripts, and identified common themes and sub-themes.
What We Found
We identified four overarching domains related to the impact of COVID-19 on IPV care: pandemic threat, community and system impacts, individual impacts, and adaptations and innovations. Respondents reported that the pandemic exacerbated external stressors and fear of COVID-19 infection; amplified inequities and language barriers; caused a loss of community and deterioration of mental health; and placed strain on providers. Providers also stressed the importance of hybrid care, creativity and cooperation, and willingness to modify practices — concepts that can inform decision-making in IPV care going forward.
Why It’s Important
Despite improvements in knee pain and function after total knee replacement, most patients remain sedentary post-procedure. Activity trackers such as Fitbits have shown potential in improving physical activity levels, but data is complicated due to varying participant compliance in wearing the devices. In this qualitative study, we sought to understand factors influencing engagement in physical activity post-knee replacement as well as beliefs about activity monitors – information that could aid clinicians in encouraging physical activity among their patients.
What We Did
We conducted phone interviews with 27 participants who had recently undergone or were about to undergo total knee replacement. These interviews encompassed participants’ perceptions of and participation in physical activity; perceptions of and experience with activity monitors; and strategies to encourage use of activity monitors. We then conducted a thematic analysis of the interview transcripts, identifying codes related to our primary question: “What role does physical activity play in your life? Do you plan to increase your physical activity after TKR and how, if at all, might activity monitors help you to do so?”
What We Found
We identified nine themes and one subtheme related to patient perceptions and goals related to physical activity from our thematic analysis. Overall, we found that TKR recipients often hope to overcome functional and pain limitations and become more active after surgery, acknowledging the physical and mental health benefits of exercise. In addition, participants’ perception of activity monitors was generally favorable, though individualized preferences must also be recognized in clinical implementation of these tools.
Why It’s Important
Total knee replacement (TKR) is a costly procedure with a lengthy rehabilitation process that is generally successful at relieving knee pain. However, 20-40% of TKR recipients experience persistent knee pain. Though some research indicates that preoperative pain in other joints may be linked to postoperative pain in the index knee, there is still little known about the relationship between musculoskeletal (MSK) joint complaints and TKR outcomes. We sought to investigate this question.
What We Did
We used data from our Adding Value in Knee Arthroplasty (AViKA) randomized controlled trial of TKR patients to assess problematic MSK areas in six body regions before patients underwent surgery. We continued to assess these regions 12, 24, 36, and 48 months after TKR. We then performed several statistical tests to link these measures with the subjects’ baseline and 60-month postoperative Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain and function scores.
What We Found
In this 230-person cohort, the presence of problematic MSK areas before TKR and the development of new problematic MSK areas after TKR were significantly associated with worse WOMAC pain and function outcomes at the 60-month postoperative mark. We observed the same association after adjusting for age, sex, baseline WOMAC scores, and preoperative levels of anxiety and depression. These results underscore the complexity of TKR outcomes, as both preoperative and postoperative MSK complaints appear to be associated with chronic knee pain after TKR. We hope these findings can aid clinicians in providing risk stratification and counseling to patients preoperatively and postoperatively.
Why It’s Important
Spinal metastases can place a heavy clinical and financial burden on patients. While non-operative treatment is the most common form of disease management, operative treatment is gaining wider acceptance. It is unknown which form of management is preferable for people experiencing various manifestations and neurologic impacts of the disease.
What We Did
We used a Markov state transition decision-making model to compare operative versus non-operative treatment of spinal metastases. Encounter data from 713 independently ambulating adult patients was used in addition to previously published data on non-ambulatory patients. We then calculated incremental-cost effectiveness ratios (ICER) for surgical intervention in ambulatory and non-ambulatory patients with spinal metastasis.
What We Found
Operative intervention is cost-effective for patients who present as non-ambulatory at baseline, with an ICER of $48,600 per QALY. Our analysis revealed an ICER of $899,700 per QALY for independently ambulatory patients, which indicates that for these patients, operative treatment is of low value.
Why It’s Important
Telemedicine use accelerated amid the COVID-19 pandemic, enabling patients and their physicians to safely meet for virtual visits. While convenient for patients well-equipped to transition to this mode of healthcare communication, telemedicine poses a challenge to those with limited English-language proficiency, little access to internet and technological resources, and readily available transportation in cases where in-person visits become necessary. We set out to understand the disparities in telemedicine use for the orthopaedic surgery department at Brigham and Women’s Hospital.
What We Did
Using electronic medical record data, we compared the changes in patient access to orthopaedic care through telemedicine between March 24, 2020 and May 18, 2020 to previous in-patient visits between March 24, 2019 to May 18, 2019. We obtained 11,056 encounters for this study, using race/ethnicity and primary language as our main predictors for telemedicine use and analyzed insurance status secondarily.
What We Found
The disparate use of telemedicine is associated with one’s racial and ethnic group, primary language, and insurance status. Compared to white patients, Asian patients are 27% less likely to have a telemedicine encounter. Similarly, Hispanic patients are 41% less likely to have a telemedicine encounter. Patients whose primary language is one other than English or Spanish are 66% less likely to have a telemedicine visit. Lastly, compared to privately insured patients, Medicaid-insured patients are 15% less likely to have a telemedicine visit.
Why It’s Important
Osteoarthritis is the 15th highest cause of years lived with disability (YLD) globally. Consequently, individuals with OA, especially those from disadvantaged minority backgrounds and low-income countries, experience physical, mental, and financial burdens associated with their diagnosis. This review aims to identify the social, clinical, and economic cost of osteoarthritis to individuals worldwide.
What We Did
We performed a systematic review of 85 sources of literature to determine the direct and indirect costs related to receiving care for OA worldwide. Additionally, we reviewed how the cost-effectiveness of OA treatment is quantified and what treatment cost is agreed to be of good value.
What We Found
The average global direct medical cost of OA per patient is $13,600 annually. In the U.S., loss of productivity at work accounts for more of the indirect cost of OA than the amount of days individuals missed from work. Total knee replacements globally are agreed to be cost-effective, falling below an incremental-cost effectiveness threshold of $50,000/quality-adjusted life year.
Why It’s Important
Obesity is a major risk factor for knee osteoarthritis (OA), and those with advanced knee OA often consider a total knee replacement (TKR). However, since those with morbid obesity (BMI ≥ 40 kg/m^2) are at a greater risk of surgical complications, many surgeons are worried that this risk outweighs the potential benefits of TKR.
What We Did
Using the OAPol model, we evaluated the cost-effectiveness of TKR in individuals with BMI ≥ 40 kg/m^2.
What We Found
TKR is cost-effective for patients with BMI ≥ 40 kg/m^2 under most circumstances. Withholding TKR from patients with higher BMIs may not be justified.
Why It’s Important
Upper-extremity vascularized composite allotransplantation (VCA), or hand transplant, has become a treatment of choice for some upper-limb amputees. Clinicians have noted that psychosocial factors are an important contributor to success; however, there is limited research on patient selection and personal characteristics of transplant recipients.
What We Did
We conducted interviews with transplant recipients and their primary caregivers to determine factors that recipients perceive as contributing to the success or failure of the transplant experience.
What We Found
Transplant recipients and their caregivers believe that patients with a positive attitude, strong social support, and an understanding of the challenges they will face post-transplantation will have greater surgical success. This research may help strengthen the recommendation for psychosocial evaluation and services in VCA.
Why It’s Important
Traditionally, patients who report “meniscal symptoms” (i.e. catching, clicking, or locking of the knee) have been recommended to have arthroscopic surgery as it is believed these patients will have a favorable response to surgery.
What We Did
We used MeTeOR trial data to investigate whether patients with “meniscal symptoms” have greater improvement from surgery than physical therapy. 351 subjects from 7 US medical centers were enrolled, and randomized to receive either arthroscopic partial meniscectomy (APM) or physical therapy.
What We Found
Through our statistical analysis of MeTeOR trial data, we found that the presence of “meniscal symptoms” did not influence the improvements in pain seen in either the APM or physical therapy groups. These findings emphasize that “meniscal symptoms” should not be used alone to inform whether a patient should undergo surgery or not.
Why It’s Important
An estimated more than 240 million people worldwide have symptomatic osteoarthritis (OA) that limits their activities. Nearly 30% of individuals older than 45 years have radiographic evidence of knee OA, and about half of those individuals have knee symptoms, whereas 10% have radiographic, symptomatic hip OA. Osteoarthritis leads to substantial cost in the form of wage losses and direct medical costs; it also leads to increased risk of mortality, in part because of lower levels of physical activity.
What We Did
We conducted a literature review and summarized what we know about the diagnosis and treatment of hip and knee OA.
What We Found
Hip and knee OA are common and disabling conditions. Education, exercise, and weight loss are commonly recommended treatments that have beneficial effects on pain and function. These treatments can be complemented by non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, and other medications. Total joint replacement effectively relieves pain for those with severe disease.
Why It’s Important
Symptoms like knee catching or locking, labeled “mechanical symptoms”, have traditionally been thought to arise from meniscal tear. Mechanical symptoms are also sometimes considered an indication for arthroscopic partial meniscectomy (APM), one of the most commonly performed procedures in the United States.
What We Did
We collected data on 565 patients who had knee arthroscopy from 2012-2019 and examined their symptoms, knee function, and surgical findings.
What We Found
Meniscal tears were not associated with mechanical symptoms in this analysis, which challenges the current notion that mechanical symptoms arise as a consequence of meniscal tear. Mechanical symptoms were strongly associated with cartilage damage, indicating these symptoms may arise due to degeneration of the knee.
Why It’s Important
There are currently no drugs on the market that prevent or halt the progression of knee osteoarthritis (OA). Scientists are working to develop such a drug, as an estimated half of knee OA patients eventually progress to end-stage disease and require a total knee replacement. We set out to identify predictors of disease progression; these predictors can allow us to identify those most likely to benefit from disease-modifying drugs and help us better understand drug mechanisms and actions.
What We Did
600 participants were selected for the FNIH Biomarkers Consortium, and we analyzed data from these individuals for our study. We compared knees that experienced both radiographic and pain progression over 24-48 months to those that didn’t. Radiographic progression is a narrowing in the joint space width between the tibia and femur, and it is a measure of the cartilage loss that occurs in those with knee OA. Data on imaging and biochemical biomarkers that could potentially help predict the progression of knee OA were obtained at baseline, 24 months, and 48 months. We sought out to determine the combination of biomarkers that would best predict the risk of OA progression. We used statistical models to analyze our data.
What We Found
The number of locations affected by osteophytes (bone spurs), cartilage thickness, kneecap shape, and inflammation of the joint lining/swelling predicted disease progression in most of our models. The change over time from baseline to 24 months in inflammation of the joint lining/swelling, meniscal morphology, cartilage damage, and one urine biochemical marker predicted disease progression by 48 months. These biomarkers could be used in future clinical trials to identify participants who are likely to progress and therefore provide more useful information on the efficacy of potential drugs.
Why It’s Important
Prosthetic joint infection (PJI) after total knee replacement (TKR) is costly and dangerous, and late-onset infections are often attributed to hematogenous seeding. Dental procedures can lead to this seeding, and subsequently PJI in patients who have undergone TKR. Type II diabetes (T2DM) is common in knee osteoarthritis patients undergoing knee replacement (TKR), and increases likelihood of PJI. It is recommended, yet still controversial as a practice, for all TKR patients to use antibiotic prophylaxis (AP) prior to dental procedures for two years post-TKR.
What We Did
Using the OAPol model, we compared two strategies among TKR patients with T2DM: receiving AP before dental procedures throughout lifetime following TKR, versus not receiving AP. We varied the probability of PJI, T2DM-associated infection risk, and attribution of infection to dental procedures.
What We Found
AP prior to dental procedures is cost-effective for TKR patients with T2DM. This cost-effectiveness is dependent on the risk of dental-related PJI and the efficacy of AP to prevent PJI. Our results support current guidelines for pre-dental AP, indicating use as appropriate in populations with increased infection risk.
Why It’s Important
College campus were hard hit by the COVID-19 pandemic, as close-contact living increased likelihood of transmitting the virus. Colleges had to think about and implement strategies for decreasing transmission, to protect their students, staff, and faculty. These strategies included non-pharmacological interventions such as online education, social distancing, mask wearing, isolation of COVID positive students, and frequent testing.
What We Did
We used the Clinical and Economic Analysis of COVID-19 interventions (CEACOV) model to estimate infection rate, costs and quality of life (QoL) losses. We considered contacts between and infections to students, faculty, and the community if colleges implemented combinations of the mitigation strategies listed above, and how they would affect cost of incident infections, isolation units, testing, and hospitalization, as well as QoL losses due to sickness, isolation, and mortality.
What We Found
We estimate that with no intervention on behalf of a college, among a group of 5000 students and 1000 faculty, within a community of 100,000 people, 75% of students and 16% of faculty would be infected within one semester. Closing campus would reduce student infections by 63% and faculty infections by 84%. Different mitigation strategies led to different costs per infection prevented and costs per quality adjusted life year. Minimal social distancing was never economically efficient compared to extensive social distancing. Even with campuses closed, there would likely be many infections, but a mandatory mask policy would reduce infections the most. Adding regular student testing would result in considerable additional cost per infection prevented.
Why It’s Important
While the most common source of knee pain in adults over 50 is knee osteoarthritis (OA), subchondral insufficiency fracture of the knee (SIFK) are also prevalent and require different treatment. Knee OA is commonly diagnosed using X-rays, however SIFK is difficult to detect this way. Physicians often treat patients with SIFK differently than patients with knee OA. Specifically, weight-bearing exercises are recommended for knee OA while treatment recommendations for SIFK often involve a period of reduced weight-bearing to allow the fracture to heal.
What We Did
We examined MRIs from participants in our TeMPO study, and scans that were suspected to show a subchondral insufficiency fracture of the knee were reviewed by radiologists. We reported the prevalence of SIFK and the clinical and image characteristics of participants of these subjects.
What We Found
10 out of 340 MRIs examined were found to have SIFK, which is a prevalence of 2.94% in this participant. Half of these participants did not have meniscal tears. This indicates that approximately 3% of patients managed with weight-bearing exercise for suspected meniscal tear may have SIFK, a diagnosis usually managed by reducing weight-bearing exercise.
Why It’s Important
Depression is poorly managed in knee osteoarthritis (OA) patients and is associated with more severe pain and lower quality of life. Duloxetine is a medication that has been shown to be effective at reducing both OA pain and depressive symptoms. There have been no studies to date that evaluate the cost-effectiveness of adding duloxetine into knee OA care that also account for duloxetine’s effect on depression symptoms.
What We Did
Using the OAPol model we evaluated the cost-effectiveness of adding duloxetine to usual knee OA care under two strategies: adding duloxetine only for subjects who screen positive for depressive symptoms, or for all subjects, regardless of depressive symptoms.
What We Found
Adding duloxetine to usual care for knee OA without screening for depressive symptoms is cost-effective at cost thresholds that are frequently used in the American healthcare system. The cost-effectiveness of duloxetine was driven more by its pain relieving properties than its effect on depressive symptoms, as it was cost-effective even in a population without depressive symptoms. These findings underscore the benefits of not restricting the use of duloxetine to individuals with depressive symptoms in the treatment of knee OA.
Why It’s Important
Intra-articular (IA) injections are often recommended for the treatment of osteoarthritis (OA), but not much is known about physicians’ perceptions about this course of treatment. More therapies for OA are emerging, and many are delivered through IA injection. Therefore, understanding physicians’ beliefs about IA injection therapies is essential to understanding their treatment decisions.
What We Did
We performed interviews with 18 physicians who care for patients with knee OA to ascertain what factors they consider when recommending for or against IA therapy and what they perceive to be the benefits and drawbacks of IA injections.
What We Found
When making decisions about IA injection therapies, physicians factor in the uncertain efficacy of these treatments and the need to manage patient expectations. Some providers relied on evidence and guidelines while others were swayed more by their prior clinical experience. High out-of-pocket costs were seen as a barrier to use. These findings may help in the delivery of IA injections for OA and in development of injectable treatments.
Why It’s Important
Many patients with knee osteoarthritis (OA) have inadequately managed pain. A number of previous studies have shown duloxetine, an antidepressant, to be an effective treatment for patients with knee OA pain regardless of whether they have depressive symptoms. We sought to evaluate the cost-effectiveness of adding duloxetine to the usual care strategy for patients with knee OA pain, no longer controlled by NSAIDs.
What We Did
We used the OAPol model to compare the usual care strategy to the usual care strategy preceded by duloxetine for a cohort in which NSAIDs failed to provide adequate pain relief. We varied the age and pain severity of the cohort, as well as the pain efficacy, cost, and toxicity of duloxetine to determine its cost-effectiveness in various circumstances.
What We Found
Duloxetine was cost-effective for younger individuals with knee OA who had severe pain. Duloxetine may also be a valuable additional treatment for patients of all ages who have less pain or are not interested in surgery. Lastly, duloxetine could be used as a method of reducing the utilization of total knee replacement (TKR). These results suggest that clinicians should consider a patient’s disease severity, age at diagnosis, and interest in considering TKR when prescribing duloxetine.
Why It’s Important
Spinal metastases are tumors that have spread to the spinal column from cancer in another part of the body. These tumors can greatly impair function and cause emotional distress. While both operative and nonoperative treatments have the potential to improve a patient’s quality of life, they can also carry substantial risk. Patients and clinicians must balance risks with potential rewards when deciding on a treatment plan. Patients with spinal metastases often prefer to rely on clinician recommendations for care, so we sought to understand the process of decision-making from the clinician’s perspective.
What We Did
We conducted focus groups and interviews with spine-care clinicians who had a dedicated interest in the treatment of spinal metastases. We asked a set of questions to determine what factors influence spine surgeons and other clinicians when deciding on an operative or nonoperative treatment strategy for a patient with spinal metastases.
What We Found
Clinicians emphasized the importance of multidisciplinary care. They describe that input from a diverse range of disciplines is necessary for developing a comprehensive and successful treatment plan. The care team should work cohesively and may include surgeons, oncologists, palliative care physicians (physicians who work with patients who are seriously ill), and physiatrists (physical medicine and rehabilitation physicians). The team generates a set of treatment choices to present to patients based on predicted benefits and risks, but the final decision rests with the patient and their family. Our findings can inform future research on treatment plans for patients with spinal metastases.
Why It’s Important
Intra-articular injections are a common knee osteoarthritis (OA) treatment, but not much is known about the factors patients consider when deciding whether to receive an injection. We aimed to better understand patient attitudes towards injections, including facilitators of and barriers to injections for knee OA.
What We Did
We held focus groups and individual interviews with 15 patients with knee OA, including people who had and had not received prior injection. We analyzed the interviews to identify themes that shaped participants’ decisions to receive a specific injection.
What We Found
A variety of factors shaped the decisions made around injections, the most influential of which were: impact of OA on their lives, attitudes towards side effects, uncertain efficacy, specific features of injectables, the ways they gathered and processed information about injection options, and the availability of certain injections. Participant attitudes were influenced by both physician and peer explanations, and they noted a lack of consensus among physicians regarding injection efficacy. Our findings suggest it may be helpful for clinicians to navigate these concerns in joint decision-making discussions with their patients.
Why It’s Important
Despite evidence that physical activity is associated with reduced pain and improved health, half of the US knee osteoarthritis population are not physically active. Our aim was to examine the losses due to physical inactivity and the benefits associated with greater physical activity in this population.
What We Did
We used our OAPol model to estimate quality of life years lost due to inactivity as well as potential benefits of increased physical activity in a population with knee osteoarthritis ages 45 and older. We measure the benefit by quality adjusted life-year (QALY), a metric that accounts for risk aversion and preferences for quantity and quality of life. We conducted analyses to see how many QALYs would be saved and cases of disease averted if 5%, 10%, and 20% of the inactive and insufficiently active populations were at higher activity levels.
What We Found
On average, for each person, 0.66 of a QALY was lost due to inactivity and 0.57 of a QALY due to insufficient activity. Overall, over 4.4 million total QALYs were lost due to inactivity relative to activity. If 20% of the inactive knee osteoarthritis population were active instead, cancer, CVD, and DM incidence would reduce by 2.5%, 5.1%, and 5.8% respectively. Quality of life in this population can be improved with physical activity.
Why It’s Important
The number of total knee replacements performed in the United States continues to rise, and although the surgery has high success rates, up to 20% of patients experience suboptimal outcomes. The great majority of total knee replacements is performed due to osteoarthritis, which is diagnosed mainly through knee radiographs. The goal of this study was to investigate associations between preoperative radiographic findings and post-operative outcomes, to help inform preoperative planning and setting of expectations for patients.
What We Did
We used data from the AViKA trial, which consists of 308 patients undergoing primary unilateral total knee replacement. We measured preoperative radiographic osteoarthritis severity using the Osteoarthritis Research Society International (OARSI) score, which results in a more standardized and specific assessment of severity than the Kellgren-Lawrence (KL) system. We obtained pain relief and functional improvement outcomes using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores and Knee injury and Osteoarthritis Outcome Score (KOOS) from questionnaires at 6 weeks pre-surgery and 2 years post-surgery. We investigated the relationship of these outcomes to OARSI scores, KL grade, and joint-space narrowing scores.
What We Found
We did not observe a clinically important association between preoperative radiographic severity of osteoarthritis and patient-reported outcomes 2 years post total knee replacement, consistent with prior literature. Regardless of preoperative severity, subjects experienced meaningful postoperative pain relief and functional improvement. Our findings only reflect outcomes of individuals already indicated for total knee replacement, and radiographic osteoarthritis assessment should not be used alone to indicate a patient for this surgery.
Why It’s Important
Some patients with knee osteoarthritis (OA) experience slow disease progression, while others experience rapid deterioration. Identifying patients who experience rapid disease worsening could allow better recruitment strategies for clinical trials and identifying risk factors for rapid progression could shed light on targets for the prevention of structural deterioration.
What We Did
We used data from the Osteoarthritis Initiative (OAI) for our analysis, and our study cohort included subjects with radiographic and symptomatic knee OA. The outcome we assessed was joint space width (JSW, the measurement of separation between the femur and tibia) assessed at baseline and at least one follow-up time over a period of 8 years. We used a method called latent class growth analysis to identify subgroups of JSW progression. Since we might expect that subjects who progress more rapidly are more likely to undergo total knee replacement (TKR), we modeled time to knee replacement to correct for biases due to these subjects dropping out.
What We Found
Rapid disease progression is relatively rare. The majority of subjects fell into a stable trajectory group with an average loss of 0.5 mm of JSW over 8 years. Around 4% of subjects fell into a late progressing trajectory with stable JSW over the first 3-4 years and an average loss of 2 mm JSW over years 4-8. Lastly, around 8% of subjects were in an early progressing trajectory, with a loss of 2 mm JSW over the first 4 years then stabilizing. Patients who undergo total knee replacement are usually in worse condition prior to surgery, but since TKR is relatively uncommon when you consider the size of the population with knee OA, incorporating TKR information doesn’t make a big difference in estimates of disease progression. Lastly, obesity, varus alignment (bowlegged), and previous knee surgery increased the odds of subjects falling into one of the progressing trajectories.
Why It’s Important
The growth of cause-based running has created a race within the race for the Boston Marathon. Charity runners are younger, female, and generally from the Boston area, while qualifiers are largely middle-aged, male, and reside throughout the United States and internationally. Therefore, the Boston Marathon is uniquely positioned to examine race-day medical risks for different groups of runners. By understanding the unique patterns of illness and injury among these groups, we can help optimize the health and safety of runners as well as assist with planning for races like the Boston Marathon.
What We Did
In addition to compiling data about the Boston Marathon and reviewing prior research regarding the health and safety of race runners, we interviewed three experienced coaches who work directly with cause-based runners preparing for the Boston Marathon. The three collectively coach more than 1000 charity runners each year, and each is affiliated with multiple teams.
What We Found
Each coach emphasizes strength training and cross-training to prepare for the race and provides access to educational resources regarding training, nutrition, and injury prevention. Medical providers should understand that cause-based runners are often inexperienced and require focused screening, prevention, and treatment. Lastly, education may be the key to reducing injury risk at endurance events; prior research has shown that providing an educational program to high-risk runners can reduce serious medical encounters during the race.
Why It’s Important
Knee osteoarthritis (OA) can have varying pain and imaging presentations in different patients, which can make predicting the progression of the disease difficult. As research into disease modifying osteoarthritis drugs (DMOADs) is ongoing, it is important to investigate different potential targets for these therapeutics. Further understanding of patterns in groups of patients who display similar levels of pain and knee deterioration on imaging can play a key role in future DMOAD clinical trials. If the rate of disease progression differs among patients in different groups (based on their pain and joint structure), this could prove especially relevant when looking for future DMOAD targets.
What We Did
We analyzed data from over 400 patients in the Foundation for National Institutes of Health (FNIH) Osteoarthritis Biomarkers Consortium cohort, which was comparable in size to a clinical trial population. These patients were split into 4 groups based on their radiographic and symptomatic progression: patients with both types of progression (composite), patients with neither, patients with only radiographic progression (JSL), and patients with only pain progression. Patients were further categorized by the presence of knee inflammation, cartilage loss/meniscal tear, and/or bone marrow lesions (BML). The relationship between each phenotype to the odds of being either in the JSL or composite group compared with those who do not exhibit that phenotype was evaluated using logistic regression.
What We Found
Those exhibiting BML had a higher odds of being in the JSL and composite categories (increased odds of having both radiographic and pain progression). Inflammation and cartilage loss/meniscal tear were not strongly associated with any particular outcome. This method of categorizing patients by their structural and pain progression may prove useful in future clinical trials.
Why It’s Important
Knee osteoarthritis (OA) affects about 14 million adults in the United States, and there are no non-surgical treatments proven to reverse or stop structural damage to the knee joint. The only non-surgical ways of effectively treating knee OA involve reducing pain and improving knee function. These non-pharmacological, non-surgical (NPNS) treatments are low cost and low risk, which makes them the ideal first-line approaches for treating patients with knee OA. These NPNS treatments can include acupuncture, exercise, ultrasound, laser, and transcutaneous electrical nerve stimulation (TENS). Previous studies have shown that these NPNS treatments are underused by physicians, so further research to understand their effectiveness can help to inform future treatment strategies.
What We Did
We reviewed previously published literature to identify randomized controlled trials testing the effectiveness of NPNS strategies. We analyzed 25 studies and split them into two groups, one for acupuncture and one for topical energy modalities (TEM). The proportion of the treatment effect, or reduction in pain, that can be attributed to contextual effects (which can include the placebo effect, effects of simultaneously occurring therapies, other factors not related to the treatment itself) is an important metric in understanding the effects of a treatment alone. We calculated these contextual effects (PCE) by dividing the change in pain in the placebo group by the change in pain for the treatment group for each trial. The PCE was then log transformed and combined across studies using a random effects model.
What We Found
Contextual effects may explain about 61% and 69% of the treatment effect experienced by patients using acupuncture and TEM treatments, respectively. This shows that factors outside the direct effect of an active treatment may play a large role in the reduction of pain. If contextual effects play such a role in the analgesic effects of NPNS treatments, this may indicate that ethically increasing contextual effects could help to further reduce pain in the future.
Why It’s Important
Full thickness cartilage loss (FTCL) is a major determinant of future knee arthroplasty in older adults with minimal to moderate knee osteoarthritis. Therefore, identifying patients who will progress to FTCL may help in developing strategies to prevent OA progression. It is not known if there is a threshold for baseline cartilage thickness or decrease in cartilage thickness over time that could be used to predict relevant future cartilage damage. The goal of this study was to investigate if quantitative baseline cartilage thickness and its change over a year, measured using quantitative MRI, are associated with FTCL in KOA.
What We Did
This study used a retrospective cohort of participants from the Foundation for the NIH OA Biomarkers consortium, consisting of 600 participants with baseline KL (Kellgren and Lawrence) radiographic severity grade of 1, 2, or 3. We quantitatively assessed each knee’s tibial and femoral cartilage thickness, and examined the odds of developing widespread FTCL (wsFTCL) in these knee regions at 24 months according to baseline and 12 month cartilage thickness in the same region. We also investigated whether there were optimal cut-off values for baseline thickness or 12-month change in thickness that were associated with incidence of wsFTCL at 24 months.
What We Found
KL grade provides an incomplete picture of knee osteoarthritis severity, as adults with FTCL have a greater likelihood of progressing to knee replacement than adults with the same KL grade without FTCL. This investigation showed that tibial and femoral baseline cartilage thickness are associated with wsFTCL over 24 months, on a continuous scale. This may help to stratify patients with low cartilage thickness in weight-bearing knee regions into a progressor group that should receive a more intensive treatment despite radiographic disease status. Cut-off values for baseline thickness and 12 month change in thickness could not accurately predict wsFTCL incidence, limiting their utility as a classification tool for risk of wsFTCL development.
Why It’s Important
Knee arthroscopy is one of the most commonly performed outpatient orthopaedic procedures, and opioid prescriptions are standard of care afterwards. Recent evidence suggests that patients do not take all the pills prescribed to them, as well as that NSAIDS can offer adequate pain relief post arthroscopy.
Previous work has shown that patient resilience can affect post-surgical outcomes. The goal of this study was to evaluate the Brief Resilience Score (BRS) as a predictor for patient satisfaction with nonopioid pain management and patient-reported outcome measures (PROMs) after arthroscopic partial meniscectomy or chondroplasty.
What We Did
We followed 132 patients receiving arthroscopic partial meniscectomy or chondroplasty from the same surgeon. Each patient underwent an outpatient procedure and was prescribed ibuprofen or acetaminophen. We determined their BRS before surgery and documented patient recorded outcome measures (PROMs) with 3- and 6-month post-op questionnaires.
What We Found
Our findings suggest that preoperative resilience score, as measured by the BRS, does not correlate with patient-reported functional outcome or satisfaction with a nonopioid pain regimen after knee arthroscopy. Although many knee arthroscopy patients report high satisfaction with nonopioid postoperative pain regimens, some still report dissatisfaction. It is important to identify a reliable predictor for satisfaction with nonopioid regimens, as a step toward decreasing the orthopaedic community’s significant contribution to opioid overprescribing.
Why It’s Important
Although physical activity (PA) has health and pain benefits for individuals with knee OA, levels of PA in the US knee OA population remain low. Long-term sustainability of programs is a common concern surrounding funding for PA programs in the OA population. We aimed to evaluate how even a program with short-lived direct efficacy could be beneficial and cost-effective over a lifetime horizon.
What We Did
We used the OAPol Model to analyze the cost-effectiveness of adding a 3-year PA-promoting program (health coaching, wearable activity monitor, & financial incentives) to usual care, compared to usual care alone. We examined long-term impacts on disease incidence and quality of life in a population of adults with knee OA who were inactive at the start of the program.
What We Found
The PA program we modeled was cost-effective and reduced long-term incidence of cardiovascular disease and diabetes, even if only 10% of the inactive OA population participated. These results offer justification for policymakers and payers considering a PA program incorporated into standard knee OA care.
Why It’s Important
Previous work has shown that diet and exercise is an effective and cost-effective intervention for knee osteoarthritis. The affordability of diet and exercise is less clear but just as important, as the intervention is unlikely to be utilized if it is unaffordable for insurers. The aim of this study was to better understand the impact of a knee osteoarthritis diet and exercise program on insurer budgets.
What We Did
Using our Osteoarthritis Policy Model (OAPol), we estimated changes in medical expenditures with and without a diet and exercise program for two types of insurance: a commercial plan covering 200,000 people between the age of 25 and 64 and a Medicare Advantage plan covering 200,000 people over the age of 64. We modeled the efficacy of the diet and exercise intervention (measured by pain and weight fluctuations), in addition to intervention costs and adherence. Sensitivity analyses were also done, in which time horizon, intervention efficacy, and intervention cost were varied.
What We Found
There is no established threshold defining what is affordable and what is not. Our results, however, show that a diet and exercise program for knee osteoarthritis is comparable in cost to other health-promotion interventions. Over three years, the modeled diet and exercise intervention increased spending by $752,200 and $6 million in the commercial and Medicare plans, respectively. During those three years, opioid use was reduced by 6% and total knee replacements by 5% in the commercial plan. In the Medicare plan, opioid use was reduced by 5% and knee replacements by 4%.
Why It’s Important
The treatment of spinal metastases poses a challenging decision regarding surgical vs. non-surgical management. Surgery poses additional risks, but may improve function, pain, and cognition. Little is known, however, about how patients weigh these considerations. A better understanding of patient preferences about treatment for metastatic spinal disease can inform discussions with patients and their families, as well as improve shared-decision making.
What We Did
We interviewed 23 patients with spinal metastases. We asked patients about how they make the decision to pursue surgical or non-surgical treatment and what they expected the outcome of each treatment to be. We analyzed the interviews to identify themes related to this decision-making process.
What We Found
The gravity of being diagnosed with spinal metastatic disease and the implications of the treatment choice shaped patients’ views of who should make the decision and how much risk they were willing to accept. Feeling a sense of urgency and anxiety regarding their diagnosis, patients tended to defer to physicians’ treatment recommendations, frequently without a thorough understanding of the different treatment options. Our findings can help clinicians better understand patients’ decision-making process when considering treatments for spinal metastases and may inform their approach to discussing treatment options and addressing patients’ sense of urgency to make a treatment decision.
Why It’s Important
The burden of trauma disproportionately affects people in low- and middle-income countries. In Malawi, a low-income country, the resources to manage musculoskeletal trauma remain inadequate. The majority of healthcare services are provided by public hospitals, which includes both district and more specialized central hospitals. Femoral shaft fracture is a common injury treated either non-operatively and operatively in Malawian hospitals. We were motivated to better understand the current capacity of public hospitals in Malawi to manage musculoskeletal trauma.
What We Did
We developed a survey tool to measure the capacity to manage femoral shaft fractures at the public hospitals in Malawi. The survey assessed the infrastructure, manpower, and essential material resources (such as pain management, inpatient ward nurses, and x-ray diagnosis) that were available to manage these fractures in both operative and non-operative settings. The survey also captured the most common reasons for the unavailability of resources, and we were able to identify the most commonly missing essential items. Survey data was collected from all 25 Malawian district hospitals and 4 central hospitals.
What We Found
None of the district or central hospitals had every essential resource to manage femoral fractures. District hospitals had an average of 71% of essential resources, and central hospitals had 76% of essential resources. Operative treatment of femoral shaft fractures was available at three out of four of the central hospitals. Our findings provide areas within the musculoskeletal trauma system in Malawi to target for future improvement.
Why It’s Important
Spinal metastatic disease, a type of cancer with a poor prognosis and high mortality, is becoming increasingly common. Treatment for spinal metastatic disease can be complex, and the best course of treatment for each individual patient can be ambiguous. While several prognostic scores have been developed to guide treatment decisions, they can be difficult to assess and do not accurately predict the prognosis of all patients with spinal metastatic disease. Thus, there is a need for a prognostic score that is both easy to calculate and accurately predicts the prognosis of patients with spinal metastatic disease.
The New England Spinal Metastatic Score (NESMS) is a recently developed prognostic score that is easy to compute, and therefore could fill this need. However, the ability of this score to predict a range of patient’s prognosis has yet to be determined.
What We Did
To address this question, we developed the prospective observational study of spinal metastasis treatment (POST). During POST, we followed 200 patients with spinal metastatic disease for one year. At the beginning of the study, we determined patients’ NESMS score and recorded information about patients’ disease and planned course of treatment. One, three, six, and twelve months after the beginning of the study we recorded information about the progression of patient’s disease and treatment.
What We Found
We are currently analyzing the data collected during the POST project in order to determine the utility of NESMS as a prognostic score for patients with spinal metastatic disease.
Why It’s Important
There are more than 20,000 new diagnoses of metastatic epidural compression made each year, which can increase risk of physiologic decline, neurological deterioration, and mortality within the year of diagnosis. Treatment of patients with spinal metastases is complex, and both operative and non-surgical management have shown benefit in various situations. This study aims to describe specific characteristics that may be associated with non-operative failure leading to surgery.
What We Did
Conducted a retrospective review of patients treated for spinal metastases from 2005 – 2017. Using multivariable Poisson regression, we identified factors associated with non-operative failure, which was defined as any individual who underwent a surgical intervention within 1 year of starting a non-operative treatment regimen.
What We Found
Based on the retrospective evaluation of patients who failed non-operative treatment measures, we found that 9% of patients with spinal metastases initially treated non-operatively received surgical intervention within 1 year. Additionally, we identified several factors that are independently associated with a greater risk of non-operative treatment failure, including vertebral body collapse, pathologic fracture, and neurologic signs or symptoms at presentation.
Why It’s Important
Vitamin D and marine ꙍ-3 fatty acids (n-3 FA) are two supplements widely consumed due to advertised benefits of disease prevention and systemic inflammation reduction. The potential health benefits associated with these supplements has drawn considerable attention from both the medical field and popular press. There has been substantial observational evidence in favor of the supplements; however, measurable effects on systemic inflammation in the general adult population has yet to be well established as many past trials have been inconsistent. Because both supplements have little to no negative side effects, if found to be efficacious, they would provide a valuable treatment option for systemic inflammation.
What We Did
The VITamin D and OmegA-3 Trial (VITAL) is a recently completed clinical study (enrolling men over 50 and women over 55 for a total of 25,871 subjects) that looked for a potential link between Vitamin D and ꙍ-3 fatty acids to cancer and cardiovascular disease prevention. Participants were randomized into four treatment arms: Vitamin D and n-3 FA, Vitamin D only, n-3 FA only, or placebo only. As part of the study, consenting participants filled out questionnaires (relating to demographics), provided blood samples, and followed eating/fasting protocols at baseline and 1-year follow-up.
Interleukin-6 (IL-6), tumor necrosis factor receptor 2 (TNFR2), and high sensitivity C-reactive protein (hsCRP) are common biomarkers used to assess levels of systemic inflammation. We identified 1561 participants within the VITAL trial who had sufficient blood samples drawn at baseline and 1-year follow-up in order to perform assays of these biomarkers. Furthermore, we ensured this population was balanced by the various demographic variables collected and that there was equal representation from each treatment arm. Using the assays, we compared each biomarker’s concentration from the baseline blood sample to the 1-year follow-up sample, hypothesizing that one or both supplements would significantly reduce IL-6, TNFR2, and/or hsCRP.
What We Found
We found no evidence that either vitamin D or n-3 FA – two widely used over-the-counter nutritional supplements – reduced any of the three systemic inflammation biomarkers tested over 1 year. These results contradict our original hypothesis and prove challenging to explain from a biological perspective. Furthermore, they conflict with past studies that found inverse relationships between vitamin D and n-3 FA levels and biomarkers of systemic inflammation. Ultimately, our findings address important questions about the impact that these supplements have on inflammatory pathways and suggest that it is unlikely to experience anti-inflammatory benefits from taking them. It is important to note that although often small and involving varied doses and durations, other studies have shown n-3 FA supplements have a greater positive effect on patients with chronic inflammation, are overweight, or who take them for longer. Recently, scientists have become interested in determining if the biomarkers measured here do not show the full picture, and that perhaps n-3 FA’s impact a different pathway.
Why It’s Important
Musculoskeletal trauma poses a disproportionately large burden of disease to low- and middle-income countries, in part because they cannot afford the imaging and medical equipment necessary to perform surgical fixation of fractures. While the Surgical Implant Generation Network (SIGN) has greatly increased access to treatment in these countries with the creation of intramedullary nails, which do not require intraoperative fluoroscopy equipment, these countries still lack radiographic imaging equipment and a uniform assessment for determining whether a musculoskeletal fracture has fully healed. In fact, no such assessment exists in the global medical community, even in well-resourced countries with access to post-operative radiographic imaging equipment. In this paper, we assess the reliability of the Squat and Smile (S&S) test as a measure of fracture healing and as a predictor of future healing. The S&S involves photographing the patient at a distance while he or she squats as deeply as possible, with as little support as possible.
What We Did
Using the SIGN database, which contains S&S test results from patients treated in facilities that receive aid from SIGN, we selected 150 patients who underwent intramedullary nail treatment for a femur or tibia fracture between January 2010 and January 2015. We visually analyzed each patient’s S&S photographs from the one-year follow-up and assigned grades to patients on a 0 to 2 scale, based on the extent of flexion when squatting. We also analyzed these patients’ radiographic data to calculate Radiographic Union Scale for Tibia fractures (RUST) scores, which is one of the primary methods used by clinicians today to assess fracture healing after intramedullary nailing and which we used as a gold standard comparator.
What We Found
In this retrospective review of patients who have undergone fracture fixation with SIGN intramedullary implants, we found that the S&S test demonstrates reliable scoring with the RUST method but has low sensitivity and specificity (11% and 85%, respectively, at one-year follow-up). Overall, these findings suggest that the S&S test does not describe radiographic healing and that it should not be used in isolation when making decisions about clinical management. Indeed, further data, including clinical findings such as infection, pain, and ability to bear weight and/or radiographic findings, should be used to make clinical decisions regarding the status of fracture healing.
Why It’s Important
Total joint replacements are common in the U.S., with more than 100,000 being performed each year. Diabetic patients who receive total joint replacement are at increased risk for a poor surgical outcome if they have hyperglycemia (high blood sugar) prior to surgery. However, we don’t know how often patients are screened for hyperglycemia before total joint replacement. The goal of this study was to determine how often hemoglobin A1c (which indicates excess sugar in the blood) was measured within three months prior to total joint replacement among Medicare enrollees.
What We Did
We used Medicare claims data filed between January 2010 and December 2014 to determine the proportion of total joint replacement patients who had their hemoglobin A1c level tested within 90 days before their surgery. Serum blood glucose level testing was also tracked. A total of 465,566 patients were included in the analysis.
What We Found
Among diabetic patients getting total joint replacement, hemoglobin A1c was tested within 90 days of surgery in 26% of those not receiving diabetes medication, 39% of those receiving noninsulin medication, and 43% of those receiving insulin medication. Hemoglobin A1c was tested in just 5% of non-diabetic patients. Serum blood glucose level testing was done for 45% – 50% of diabetic patients (depending on their medication status) and just 37% of non-diabetic patients.
Despite the importance of screening for hyperglycemia prior to total joint replacement, especially among diabetic patients, the appropriate tests were not done in nearly half of all diabetic patients included in the analysis.
Why It’s Important
Symptomatic knee osteoarthritis (OA) affects approximately 14 million adults in the United States. Moreover, 60-90% of people with symptomatic OA have meniscal tears. While physical therapy (PT) is accepted as a first-line treatment for patients with knee OA and meniscal tear, there are many musculoskeletal treatment regimens and scarce literature on the efficacy of PT interventions for patients with meniscal tear in the setting of OA. Thus, understanding which elements of a PT or home exercise program provide the best results for this patient population, and the role of contextual factors, remains and important research gap.
What We Did
An interdisciplinary team of physical therapists, physicians, and researchers sought to develop and refine a standardized PT intervention and a standardized home exercise program for people with meniscal tear and knee OA to be implemented in the Treatment of Meniscal Tear in Osteoarthritis (TeMPO) study with and without physical therapist supervision respectively.
Phase 1: A core group of physical therapists, physicians, and research methodologists assembled an expert panel of physical therapists from four academic US centers to guide the creation of both TeMPO programs.
Phase 2: Literature on physical therapy and strengthening programs for patients with both degenerative meniscal tear and concomitant knee OA was reviewed.
Phase 3: An e-mail survey was administered to experienced physical therapists to better understand PT treatments currently used in our target population.
Phase 4: The initial expert panel was expanded to add more orthopaedic surgeons, rheumatologists, researchers and physical therapists from the four study sites to form the trial research team.
Phase 5: The research team and physical therapists created a standardized instructional video and hard copy program booklet to guide patients who would be completing the TeMPO exercises without physical therapist supervision.
Phase 6: The research team held focus groups with potential patients to solicit feedback for final edits to the TeMPO exercise program and its instructional materials.
What We Found
The investigators were able to agree on a multi-faceted, in-clinic PT intervention and standardized home exercise program, which will serve as templates for in-clinic and home-based care for patients with symptomatic degenerative meniscal tear and knee OA. These interventions will be tested as part of the TeMPO trial.
Why It’s Important
Symptomatic knee osteoarthritis (OA) affects over 14 million people in the United States, and 60-90% of those with knee OA have a meniscal tear as well. Recent studies have suggested that patients with meniscal tear who are treated with arthroscopic partial meniscectomy (APM) plus physical therapy (PT) or PT alone report similar outcomes a year after treatment, indicating that PT is a reasonable initial treatment for meniscal tear in the setting of OA. No studies, however, have examined the effectiveness of PT when compared to placebo or to a home exercise program. We have designed the TeMPO Trial to better understand what aspects of PT that are effective for treating meniscal tear in individuals with OA.
What We Did
We developed the protocol for a randomized clinical trial (RCT) that includes four treatment programs:
- A protocolized home exercise program
- A protocolized home exercise program with adherence optimization (text or email reminder messages)
- A protocolized home exercise program with adherence optimization plus therapist-directed placebo PT
- A protocolized home exercise program with adherence optimization plus therapist-directed PT (exercise and manual therapy)
Subjects aged 45 to 85 years old who are seeking treatment for knee pain and meet the inclusion criteria will be randomly assigned to one of these treatment programs. We will compare participants’ self-reported pain at the beginning and end of the three-month treatment.
What We Found
The trial is currently ongoing at four sites: Brigham and Women’s Hospital (Boston, Massachusetts), University at Buffalo Jacobs School of Medicine and Biomedical Sciences (Buffalo, New York), The Cleveland Clinic (Cleveland, Ohio), and the University of Pittsburgh Medical Center (Pittsburgh, PA). We plan to recruit 856 subjects and aim complete recruitment in 2022. Results from this trial will advance our understanding of the aspects of PT that are most efficacious for treating symptomatic meniscal tear in those with knee OA.
Why It’s Important
Meniscal tears, damage to cartilage in the knee, are painful and typically treated with either surgery to remove the meniscus or physical therapy. As surgery is costly and carries risks such as infection, it is important to understand whether it is more effective than physical therapy at relieving pain.
What We Did
In this study, we followed patients with meniscal tears for five years. These patients were randomly assigned to receive either physical therapy or surgical treatment of their meniscal tears. Five years after their treatment, we asked patients to fill out a survey describing their pain level and we determined whether patients had undergone knee replacement surgery.
What We Found
We found that treatment with surgery or physical therapy resulted in similar pain relief over the five year period. We observed that the group that received meniscal surgery also underwent more total knee replacements over five years; however, we could not determine if this difference was due to random chance.
Why It’s Important
An estimated 3 million to 5 million patients are living with spinal metastatic disease. Decisions for operative or nonoperative management remain challenging for patients with spinal metastases, especially when life expectancy and quality of life are not easily predicted. We conducted the Spinal Metastasis Treatment in Determining Ambulatory Status (STRIDES) study to evaluate the effects of operative and nonoperative management on maintenance of ambulatory function and survival in patients treated for spinal metastases.
What We Did
The study included patients treated for spinal metastases between 2005 and 2017 who were 40 to 80 years old, were independent ambulators at presentation, and had fewer than 5 medical comorbidities. We used propensity matching to yield a sample in which operatively and nonoperatively treated patients were similar with respect to key baseline demographic and clinical characteristics (Age, sex, BMI , number of comorbidities, serum albumin, and vertebral body collapse). We were looking at the influence of operative care and nonoperative care on ambulatory function 6 months after presentation as the primary outcome. Survival at 6 months and survival at 1 year were secondary outcomes.
What We Found
We identified 929 individuals eligible for inclusion, with 402 (201 operative patients and 201 nonoperative patients) retained after propensity score matching. Patients treated operatively had a lower likelihood than those treated nonoperatively of being nonambulatory 6 months after presentation as well as a reduced risk of 6-month mortality. Our results indicate that in a group of patients with similar demographic and clinical characteristics, those treated operatively were less likely to lose ambulatory function 6 months after presentation than those managed nonoperatively. For patients with spinal metastases, our data can be incorporated into discussions about the treatments that align best with patients’ preferences regarding surgical risk, mortality, and ambulatory status.
Why It’s Important
Meniscal tears are a common injury among patients with knee osteoarthritis (OA) and account for approximately half of the nearly one million arthroscopic knee surgeries performed annually in the United States. Arthroscopic partial meniscectomy (APM), though, has not yet been shown to provide a clear benefit in the management of meniscal tears as compared to physical therapy (PT) or sham surgery. This study aims to answer the question of whether the degree of joint damage in a patient’s knee is associated with better or worse outcomes for APM over PT.
What We Did
Data collected from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial were used to test the hypothesis that patients with less severe joint damage would experience greater pain reduction with APM plus PT as opposed to PT alone. MeTeOR participants all had radiographic evidence of OA and an MRI-confirmed meniscal tear and had been randomly assigned to either an APM-plus-PT or a PT-alone treatment group. For this analysis, 220 MeTeOR participants were assigned a “damage score” based on MRI features such as the number of bone marrow lesions and the extent of cartilage damage. The damage score could be 0 (least damage), 1 (moderate damage), or 2 (greatest damage). Using linear models, the association between damage score and pain relief at 6 months was tested for the APM-plus-PT and PT-alone groups.
What We Found
Participants with damage scores of 0 and 1 showed greater improvement (more pain relief) with APM-plus-PT as opposed to just PT-alone. Those with a damage score of 0 experienced a 15-point average reduction in pain as quantified by the Knee injury and Osteoarthritis Outcome Score (KOOS). Those with a damage score of 1 experienced a 7-point average reduction in pain. For those with a damage score of 2 (greatest damage), pain relief at 6 months was similar for both the APM-plus-PT and PT-alone treatments. These results suggest that patients with OA, meniscal tear, and less joint damage on MRI may achieve greater pain reduction with an APM-plus-PT approach rather than just PT.
Why It’s Important
Engaging in regular physical activity (PA) has been shown to have numerous positive health impacts, including a decreased risk of cardiovascular disease, diabetes, high blood pressure and cancer, among others. Yet less than half of Americans meet PA recommendations (150 minutes per week of moderate-intensity PA or 75 minutes per week of vigorous-intensity PA). PA has also been shown to differ based on race, with black individuals engaging in less moderate-to-vigorous physical activity (MVPA) than white individuals. The racial disparity in PA is thought to contribute to racial disparities in health conditions like diabetes and high blood pressure, which are more prevalent among black individuals. One method shown to be effective at increasing PA is workplace wellness programs, but it is not known whether the outcomes of such programs differ by race. Armed with a better understanding of how workplace wellness programs may differentially affect black and white participants, we can tailor such programs to meet employees’ needs.
What We Did
The B-Well initiative, a prospective cohort study, aimed to increase PA among Brigham and Women’s Hospital employees who were insufficiently active. The study lasted 26 weeks, 24 of which incorporated financial incentives for increasing PA or meeting PA recommendations. Data on employees’ weekly minutes of MVPA, average daily step counts, frequency of meeting personal goals or PA recommendations, and Fitbit adherence were collected. An analysis of covariance was conducted for each measured outcome. Race was used as the primary independent variable.
What We Found
Analysis showed that both black and white participants increased their PA as part of the B-Well program. Black participants benefited from the program just as much as, if not more than, white participants. Black participants walked significantly more daily steps than white participants (an average of 9128 steps per day as compared to 7826 steps per day) and exhibited a greater increase in MVPA from baseline over the course of the program. No significant differences in average weekly MVPA, Fitbit adherence, or frequency of meeting personal goals or PA recommendations were found. These findings suggest that workplace wellness programs are a viable option for increasing employees’ PA, thereby decreasing the cost and burden of various health conditions.
Why It’s Important
Musculoskeletal injuries affect a large proportion of people worldwide. Prescribing opioids for pain relief following orthopaedic trauma surgeries has been common practice for quite some time. Over the past 20 years, opioid prescriptions and related deaths in the US have greatly increased causing the CDC to declare a nationwide opioid epidemic. Prescribing opioids for post-orthopaedic surgery is considered problematic as it appears to be a major contributing factor to the epidemic. As a result, US physicians and policymakers are working to reduce the rates and amounts of opioid prescriptions used to treat pain. We know that orthopaedic injuries and surgeries happen all around the world, yet variation in drug use to treat post-operative pain for similar injuries among countries around the world is not well documented or understood. This study investigated how and when physicians in two other countries, one low-income and one high-income, prescribe opioids, compared to those in the United States. A better understanding of the variation that exists across countries and cultures around the world may help inform domestic prescription as well as future policy.
What We Did
We surveyed a total of 139 residents from 9 different academic residence programs across Haiti, the Netherlands, and the US, using vignettes of 10 different orthopaedic trauma cases. Each vignette detailed the procedure done as well as the sex and age of the patient. We surveyed residents because at each of the 9 participating centers, residents were the primary prescribers of post-operative pain managing drugs. The survey asked residents to record the type of drug, dose, number of tablets, and total number of days that they would prescribe the drug to treat post-operative pain for each of the 10 cases. Due to varying availability of drugs in different countries, we standardized opioid prescriptions by converting all values to morphine milligram equivalents (MMEs). As a result, we collected data about MMEs prescribed per case, per day, and the total number of days of the prescription.
What We Found
Regardless of the surgery site or age of the patient, residents from the United States prescribed significantly more total MMEs per case than those in Haiti and the Netherlands, with residents in the Netherlands prescribing the second most. Residents in the US and Netherlands used oxycodone as their drug of choice, while those in Haiti chose tramadol. Within the US, patients <40 years old were prescribed greater amounts of MMEs than those >70. Across all three countries, surgeries involving the femur and tibial plateau received the most MMEs, while ankle and wrist surgeries received the least. Beyond just total MMEs prescribed, we found that US resident physicians prescribe opioids more frequently, with a higher daily dosage, and for a greater number of days after surgery than Dutch and Haitian residents. These results suggest that US residents have a heavy reliance on opioids compared to other countries and indicate that further research is required to learn about how these other countries use non-pharmacologic ways to treat post-operative pain. Generally, our findings signal a need for reassessment of our current prescription habits as we seek to find new ways of treating pain that maximize effectiveness yet reduce provider contributions to the devastating opioid crisis.
Why It’s Important
Despite evidence that physical activity (PA) improves health, over half of the 14 million people in the US with knee osteoarthritis (OA) are not physically active. Among persons with knee OA, PA has been shown to reduce pain, improve mental health, and decrease the incidence of cardiovascular disease (CVD) and diabetes mellitus (DM). Quantifying individual and population losses in quality of life (QoL) that result from physical inactivity is therefore important for promoting PA among persons with knee OA, as well as demonstrating the need for funding public health exercise interventions that target populations that may benefit from increased PA.
What We Did
Using the OAPol model, we estimated the health-related QoL losses due to inactivity and insufficient levels of PA in the US population with knee OA, ages 45 and older. We estimated losses both at the individual level and across the entire population of interest, stratified by sex and race/ethnicity. To quantify these losses, we used “quality-adjusted life years” (QALYs), a metric that accounts for risk aversion and preferences for quantity and quality of life and allows for standardized comparisons across different health states and interventions.
What We Found
We found that the US knee OA population loses over 4.3 million QALYs due to inactivity. Further, if only 20% of the inactive knee OA population became active, over 870,000 QALYs could be saved and the incidence of disease could be significantly reduced: over 95,000 cases of cancer, 222,000 cases of cardiovascular disease, and 214,000 cases of diabetes could be averted. On an individual level, we found that an inactive person with knee OA can lose between 0.58-0.81 QALYs relative to an active counterpart, depending on race and gender, with Black-Hispanic and Black Non-Hispanic women experiencing the highest per-person QALYs lost. Going forward, these findings can help to target future PA interventions in the OA populations that will produce the greatest QoL gains.
Why It’s Important
The burden of injury and trauma related deaths are disproportionately high in low-income and middle-income countries, such as Malawi. Death and nonfatal musculoskeletal injuries result in health care costs and disability that perpetuate a vicious cycle of poverty and decreased productivity. The incidence of musculoskeletal injury is increasing without an adequate hospital infrastructure to manage such trauma. This is resulting in delayed clinic presentation which worsens the burden of trauma-related disability in low-resource settings.
What We Did
Using data from the Malawi Fracture Care Registry, we performed a retrospective cohort study including adult and pediatric patients with isolated musculoskeletal injuries. We examined 11 covariates from the registry that were thought to be associated with patient outcome. These included: age, sex, education level, occupation, season of injury, day of injury, injury mechanism, injury type or extremity of injury, referral status, hospital of presentation, and estimated travel time.
What We Found
In Malawi, delayed presentation to a clinic is common amongst patients with fractures independent of age, sex, education level, or occupation. However, sustaining injury over the weekend and living farther away from the hospital were both associated with an increased risk of delayed presentation. Also, tibial or fibular injury in the pediatric cohort was associated with a 36% increased risk of delayed presentation. This study warrants further investigation into the factors resulting in delayed clinic presentation as delayed treatment can worsen trauma-related disability. Future research is also needed to elucidate the perceptions of injury and when patients seek formal treatment in settings like Malawi.
Why It’s Important
Physical activity is associated with improved quality of life and lower all-cause mortality, and accelerometers—such as the FitBit and ActiGraph— are devices that allow us to measure physical activity. Accelerometers have been widely used in osteoarthritis (OA) research, but there was not a study that compared Fitbit estimates to ActiGraph physical activity measures. We aimed to understand the accuracy of Fitbits compared to ActiGraphs in hopes of implementing realistic physical activity interventions for people with knee OA.
What We Did
We enrolled 15 subjects who each used the hip-worn ActiGraph for four weeks, wrist-worn ActiGraph for two weeks, and Fitbit Charge 2 for two weeks during a four-week study period. We collected data on the numbers of steps and accelerometers counts recorded by each device and calculated the time spent in sedentary, light, and moderate-to-vigorous activity. We compared the activity levels among the different accelerometers and analyzed the amount of time that each device was worn.
What We Found
We found that Fitbit overestimates the number of steps taken and underestimates minutes of moderate-to-vigorous physical activity compared to the hip-worn ActiGraph in people with knee OA. The wrist-worn ActiGraph overestimated steps and minutes of moderate-to-vigorous physical activity while underestimating sedentary time. These results give insight for researchers who are planning to use commercial accelerometers in studies.
Why It’s Important
While pain catastrophizing and widespread pain have been shown to serve as predictors of pain chronicity and severity, we do not fully understand the extent to which each is a stable or a dynamic variable. If we are able to determine whether these chronic pain characteristics reflect an inherent trait or are instead the effect of an ongoing pain stimulus, we may be able to better inform clinical practice regarding pain management, expectations of surgical procedures, and potential targets for intervention.
What We Did
In order to address these questions, we examined a prospective cohort of osteoarthritis patients undergoing unilateral elective TKR. We assessed patient-reported pain (WOMAC scale), pain catastrophizing (PCS), and widespread pain (WP) 6 weeks prior to surgery and again at 12 months post TKR. To look at the change in patient-reported pain, we found the difference in the patient’s WOMAC pain score between preoperative and post-operative time points. For both pain catastrophizing and widespread pain measures, individuals identified their pain via body pain diagrams. These were then converted to scores for pain catastrophizing and widespread pain. PCS and WP scores were subsequently categorized into one of several groups (high versus low). Changes in pain catastrophizing and widespread pain were detected by looking at the movement of individuals between groups when comparing pre-op and post-op categories.
What We Found
Both pain catastrophizing and widespread pain are dynamic, state components rather than stable, inherent characteristics. Pain catastrophizing scores were more likely to improve following total knee replacement surgery and were associated with improvements in WOMAC pain score. Widespread pain scores, however, were not significantly associated with a change in WOMAC pain, and we observed both increased and decreased widespread pain scores post-operatively as compared to pre-operatively.
Why It’s Important
If people are aware at a young enough age that they may be at risk for knee osteoarthritis (OA), they can take action to decrease their risk. For example, they might start maintaining a healthy body weight or taking steps to prevent knee injury. But younger adults, in general, do not think about diseases such as OA that, based on their prior knowledge, affect mainly older adults. People who think their risk is low may see no need to take action, but those who think their risk is high may feel defeated; therefore, correctly understanding risk of OA is important if we want to help people prevent this disease.
What We Did
We built an interactive calculator that uses basic personal information to calculate an individual’s risk of OA. We tested whether using this tool improved how accurately people estimated their own risk of OA. We also tested whether using the calculator made them more willing to change behavior to prevent OA.
Subjects were divided into two groups (Calculator Group and Control Group). The Calculator Group subjects used the risk calculator to view their own personal risk of OA. Control Group subjects only saw general (not personalized) OA risk information.
What We Found
Before anyone used the tool, both groups overestimated their risk of OA. We found that the calculator helped individuals reassess their risk of developing OA more accurately. Those who used the calculator also moved closer to being ready to start exercising. Control subjects’ perceived risks remained unchanged. The risk calculator is an effective educational tool to improve perception of OA risk.
Why It’s Important
As many as 9 of 10 people with symptomatic knee osteoarthritis (OA) also have damage to their menisci, which help with load bearing and stability in the knee. Meniscal damage can include several types of tears and other injuries, which can be viewed using MRI (magnetic resonance imaging). However, we do not know which types of meniscal damage have the greatest effect on pain and other symptoms reported by patients. We wanted to know whether certain types of injury were associated with pain or with mechanical symptoms (clicking, catching, and popping).
What We Did
Using data from the MeTeOR trial, we examined the associations between the type of meniscal damage and symptoms. Each participant had an MRI performed at the beginning of the study. We evaluated these images and placed each participant into a group based on the worst type of meniscal damage he or she had: tears to the meniscal root, maceration, long or short tears in which part of the tear is horizontal, and simple tears such as vertical tears.
What We Found
We found that root tears were associated with the highest level of pain, after taking into account other factors that influence pain. We did not find an association between the type of damage and mechanical symptoms (clicking, catching, and popping), which are often used to diagnose meniscal damage. The findings of this study suggest that root tears may contribute to greater levels of pain, and that future studies should further investigate this type of tear.
Why It’s Important
While most people who have a total knee replacement (TKR) experience large reductions in pain, some will have less pain relief following TKR. Studies have found that individuals that report ‘widespread pain’ and/or ‘pain catastrophizing’ are less likely to receive the full benefits of TKR. ‘Widespread pain’ is when someone reports having pain at many body sites far away from their knee with osteoarthritis. ‘Pain catastrophizing’ refers to a way of responding to the experience of pain, in which someone dwells on pain, worries it will get worse, and feels helpless to make it go away.
What We Did
We measured widespread pain before surgery using the body pain diagram. For each participant, we calculated a widespread pain score based on the number of body regions with pain other than the knee that was going to be replaced. We assessed whether there was any association between this widespread pain score and pain levels 12 months after surgery.
We also measured pain catastrophizing, using a survey that asks questions about how much you think about pain and whether you feel helplessness when in pain. We assessed whether having a high pain catastrophizing score would predict having worse pain at 12 months after TKR.
What We Found
We found that participants who had more widespread pain before surgery were more likely to have more knee pain at 12 months after TKR. Pain catastrophizing was also associated with higher pain 12 months after surgery. Measuring pain catastrophizing and widespread pain (using a body diagram) may help us identify people who are at risk for worse outcomes following TKR.
Why It’s Important
When meniscal tear occurs without a traumatic injury (degenerative tears), diagnosis is complicated. Degenerative meniscal tears are very common in middle-aged and older adults, but they often cause no symptoms. In addition, many people with meniscal tears also have osteoarthritis (OA). So when these patients present with knee pain, it can be hard to tell when the symptoms are caused by OA or by a torn meniscus. Doctors use physical examinations to diagnose meniscal tears that are actually causing pain (symptomatic meniscal tears or SMTs). There is a need to understand how well the physical exam works to diagnose SMT in middle-aged and older patients.
What We Did
Orthopedic surgeons assessed patients with possible SMT. If the surgeons were at least 70% confident that the patient’s symptoms were caused by meniscal tear, we considered this a diagnosis of SMT. Then, we assessed which factors were associated with having a diagnosis of SMT.
What We Found
Patients were more likely to be diagnosed with SMT if they had any of the following 6 factors: localized pain, ability to fully bend the knee, pain lasting less than 1 year, lack of varus alignment, lack of pes planus, and lack of joint space narrowing on x-rays. Doctors often use mechanical symptoms (such as locking, clicking, and popping when the knee moves) to diagnose SMT. But this study did not find that these mechanical symptoms predict experts’ diagnosis of SMT.
Why It’s Important
We know that patients with HIV are more likely to experience fractures than those without HIV. But we do not know all the factors that put patients with HIV at higher risk. There is a concern that some medications used to treat HIV (such as tenofovir disoproxil fumarate or TDF) can make bones weaker and more likely to fracture. We aimed to increase our knowledge of the safety and risks of this drug by studying whether they increase risk of fracture.
What We Did
We reviewed the medical records of 2,663 patients with HIV. Of those, 1,981 had been treated with TDF, and 682 had never used this treatment. We analyzed whether patients with certain characteristics (including the use of TDF) were more likely to have had fractures, taking into account other factors that affect the risk of fracture.
What We Found
We did not find evidence that patients who had taken TDF were more likely to experience fractures. But some factors were connected with a higher risk of fractures: being infected with hepatitis C, as well as certain markers of having advanced HIV disease. Patients with these risk factors could benefit from monitoring their bone density to help prevent fractures.
Why It’s Important
Arthroscopic partial meniscectomy (APM) is a common treatment for those with a torn meniscus (meniscal tear or MT), but it is not clear whether this surgery is better than physical therapy (PT) alone. In the MeTeOR (Meniscal Tear in Osteoarthritis) Trial, participants were randomly assigned either to have only PT (PT group) or to have APM (APM group). About one of three participants in the PT group decided to have surgery before the trial was over. After that, both groups had similar pain relief. We wanted to understand why people were switching to the surgical treatment and how much pain relief they experienced.
What We Did
We identified factors that predicted which individuals in the PT group decided to have surgery before the trial was finished.
What We Found
Patients were more likely to switch to surgery if they had a) higher pain and b) symptoms for less than 1 year before the trial. But these patients who crossed over to surgery had similar pain relief to those who had been assigned to APM in the first place. This suggests that having PT before APM may not decrease the benefits of the surgery.
Why It’s Important
Osteoarthritis (OA) is a painful and disabling condition that gets more severe over time, but it is difficult to measure this progression. One way of measuring progression is to assess features of the disease that can be seen on an MRI (“MRI biomarkers”). These include cartilage damage, osteophytes (bone growths), and damage to the meniscus and ligaments. But measuring these MRI biomarkers is only useful if they are connected with pain and other outcomes that matter to patients. We wanted to know whether changes in these biomarkers were associated with increasing pain.
What We Did
We compared patients who developed OA (pain or damage on x-rays, another way of measuring the severity of OA) at 4 years (cases) to those who did not (controls). We assessed whether worsening in each of the MRI measures of severity predicted which patients would experience OA progression and worsening pain over 2 years.
What We Found
Most of the biomarkers did predict having pain and/or damage on x-rays at 4 years. These included cartilage damage, osteophytes, meniscal extrusion, and bone marrow lesions. For all of these features, change over 2 years was also associated with worsening OA. This was the first study to examine whether worsening in MRI biomarkers can predict changes in OA that are meaningful to doctors and patients: damage to the joints as shown on x-rays, and substantial increases in pain.
Why It’s Important
In the past, people who chose to have total knee replacement (TKR) usually had severe pain, so that they felt pain even while doing less demanding activities such as walking. In recent years, more patients with low pain are choosing to have TKR. Little is known about what drives patients with low pain to make this decision, but it is plausible that they have trouble with activities like squatting, kneeling, and twisting that place higher demands on their knees. If having trouble with these activities keeps people from doing things they value (housework, recreation, etc.) they may choose TKR to regain these functions.
What We Did
Based on how much pain they had before surgery, we placed participants in 3 groups: Low, Medium, and High Pain. We asked patients how much limitation they had in less demanding activities (like walking) and more demanding activities (twisting, squatting, kneeling, jumping, and running).
What We Found
About one in five patients was in the Low Pain group before TKR. These patients were likely to report limping and other problems with daily function, as well as trouble with twisting, squatting, and kneeling. In future studies of whether TKR is appropriate for people with low pain, it will be important to consider the limitations that patients experience when trying to perform these activities.
Why It’s Important
Although total knee replacement (TKR) is common practice as a treatment for advanced osteoarthritis, not all patients experience the same degree of pain relief and knee function after this procedure. Physical therapy (PT) is prescribed immediately after the surgery in order to build muscle strength and improve mobility in the knee. We know that motivational interviewing or MI—a behavioral intervention that uses active listening to increase someone’s internal motivation—can change behavior in other areas, like addiction. We wanted to know if using MI alongside PT could help patients recover after TKR. We also wanted to discover which people might be more likely than others to benefit from MI.
What We Did
For six months following TKR, patients either (1) regularly spoke with a health coach in addition to their PT regimen, or (2) only underwent a PT regimen. We asked patients to rate their pain and knee function before surgery and six months after surgery. In addition, we asked patients to answer questions related to “pain catastrophizing,” a way of thinking in response to the experience of pain (e.g., “I worry my pain will never go away”). Our team at BWH analyzed the responses we got from patients.
What We Found
We saw improvement in both groups in terms of pain and functional ability, as well as high patient satisfaction with surgery six months after surgery. The patients who received MI improved more than the group only receiving PT; however, the difference was small. We believe it is likely that the medical support network of physicians, physical therapists, and nurses is enough motivation for patients to continue therapy in order to optimize improvement. Patients who reported having more pain catastrophizing thoughts were less likely to benefit from MI alongside PT.
Why It’s Important
Total knee arthroplasty (TKA) is one of the best treatments to decrease pain and restore function in osteoarthritis (OA), and more than 600,000 of these surgeries are performed every year in the United States. But some subgroups of people with OA may be less likely to receive TKA. The overall rates of TKA are lower for Hispanics and African Americans than for whites, and sex may affect TKA rates as well. From a health equity standpoint, it is important to understand racial, ethnic, and sex-based differences in who receives TKA.
What We Did
Using data from the Osteoarthritis Initiative, we calculated the risk of having a TKA over time in each sex, racial, or ethnic group. We determined whether demographic factors were related to the risk of TKA.
What We Found
Nonwhites with OA had lower rates of TKA than whites, adjusting for differences in their baseline severity of OA, pain, BMI, number of comorbidities, age, sex, and education. This finding confirms the racial differences in TKA use that have been observed in the general population, and highlights the need to address these racial disparities.
Why It’s Important
In light of the epidemic of opioid abuse in the United States, it is important to understand how opioid use practices after surgery vary internationally. Opioids are offered regularly after total joint replacement in the United States. But what about in developing countries? Operation Walk Boston, an international medical mission that performs total joint replacements in the Dominican Republic, provided an opportunity for cross-cultural comparison of opioid use to control pain before and after surgery.
What We Did
We interviewed surgeons in the Dominican Republic and the United States (22 in total). We asked about how surgeons help patients manage pain after total joint replacement, and the factors that go into the decision to prescribe certain medications. Our team analyzed the themes present in the interview transcripts.
What We Found
Decisions about prescribing pain medications were made differently in the two countries. American surgeons described giving patients more control in deciding which drugs to prescribe, while Dominican surgeons felt it was the doctor’s role to make these decisions. While Dominican doctors tended to follow a strict protocol for managing pain, American doctors said that prescriptions vary a lot for different patients and different doctors. In both countries, though, doctors said they try to avoid using opioids or use them for only a short time.
Differences in culture, medical practice, and the willingness to prescribe powerful opioids lead to very different strategies for pain management in the two countries.
Why It’s Important
In light of growing attention to the appropriateness of opioid use in the United States, it is important to understand how opioid use after surgery varies internationally. Opioids are offered regularly after total joint replacement (TJR) in the United States. But patients in some other countries request less opioid medication after TJR. The team of Operation Walk Boston, an international medical mission that performs TJR in the Dominican Republic, noticed that Dominican patients receive fewer opioids than patients in the United States and may manage their pain differently.
What We Did
We interviewed patients with advanced osteoarthritis (OA) who were scheduled to have a TJR. We asked open-ended questions about how they coped with pain, and how they expected to control their pain after the surgery. Then, our team analyzed the themes present in the interview transcripts.
What We Found
Most patients said they used drugs to manage pain only when necessary, and they usually used non-steroidal anti-inflammatory drugs. Many had a limited knowledge of opioid medications. Instead, patients described non-drug strategies to manage pain including relaxing, distracting oneself, exercise, faith, and prayer. Religion was used to explain pain (the idea that it was God’s will) and to cope. Personal strength and support from family members helped many patients endure pain. Patients expected to use similar strategies to manage pain after surgery.
This was the first qualitative study of how patients with advanced OA in a developing country manage their pain. It revealed a set of resources that Dominican patients use—including faith, family support, and minimal use of medications—that are different from those used by US patients.
Why It’s Important
Published studies suggest that nerve growth factor inhibitors (NGFi) relieve pain, but they may also lead to faster disease progression in osteoarthritis (OA) patients. We wanted to understand how low the cost and toxicity (negative drug effects) of NGFi would have to be in order to make them a cost-effective treatment for knee OA.
What We Did
Using the OAPol Model, we evaluated cost and toxicity thresholds under which NGFi would be a cost-effective option for knee OA treatment.
What We Found
We found that cost and the setting in which the drugs are given both play important roles in the cost-effectiveness of NGFi treatments. Our analyses also suggest that NGFi treatments could decrease the use of total knee replacement. The cost-effectiveness of this treatment will depend heavily on how the drugs are priced and on identifying patients who are suited to receive this treatment.
Why It’s Important
After total knee replacement (TKR), it is important to provide anticoagulant medications to help prevent potentially dangerous clotting events: deep vein thrombosis (DVT) and pulmonary embolism (PE). Currently, there are not clear guidelines about the best medications to use or how long they should be prescribed. Our goal was to provide guidance for physicians making these treatment decisions.
What We Did
We assessed the cost-effectiveness of different strategies for anticoagulation after TKR. We chose a variety of strategies that are realistic options in clinical practice.
What We Found
A 35-day course of rivaroxaban or of warfarin were the treatments most likely to be cost-effective after TKR. For all the medications we studied, extending the treatment from 14 days to 35 days increased the cost-effectiveness.
Why It’s Important
There is great interest in how we can help people increase their physical activity (PA) and promote weight loss. PA has many health benefits for those with chronic conditions, but few adults do the recommended amount of PA. Financial incentives (FI) can be used to give an immediate reward for healthy behavior. FI has been successful in increasing healthy behavior in a number of studies, but the data are limited for PA in those with chronic conditions.
What We Did
Using several databases, we searched for randomized controlled trials (RCTs) that met our requirements: assigning some participants to receive financial incentives (FI) for reaching their PA or weight loss goals and some to a control group not receiving FI, measuring PA objectively, and including people with chronic conditions and/or sedentary lifestyles.
What We Found
The combined results show that FI helps to increase PA and weight loss in adults with chronic conditions or sedentary lifestyles.
Why It’s Important
Postinjection paralysis (PIP) and gluteal fibrosis (GF) are two disabling conditions that may be caused by injection practices. In Uganda, they are common in children, but the exact numbers of children with these conditions was not known.
What We Did
We reviewed musculoskeletal (MSK) clinic logs and community outreach logs from the Kumi Hospital in Kumi, Uganda, to find cases of GF and PIP. We calculated the proportion of all children seen in these clinics who had a diagnosis of GF or PIP.
What We Found
Over 30% of MSK clinic visits and 40% of all outreach visits were due to GF or PIP. This highlights the need for research, treatment, and prevention of these conditions.
Why It’s Important
Celecoxib is a specific type of non-steroidal anti-inflammatory drug (NSAID) and is used to treat osteoarthritis (OA). This type of NSAID may carry a higher risk of cardiovascular side effects but has a lower risk of gastrointestinal side effects. We wanted to understand whether using generic celecoxib is cost-effective compared with traditional NSAIDs.
What We Did
Using the OAPol model, we assessed the clinical outcomes, costs, and cost-effectiveness of generic celecoxib in people with knee OA. We compared celecoxib with several other common, NSAID-based treatments.
What We Found
In knee OA patients with no comorbid conditions, we found that generic celecoxib is not cost-effective at its current cost of $880/year. Costs and/or cardiovascular side effects would have to be lower for celecoxib to be cost-effective.
Why It’s Important
Musculoskeletal conditions are common in low-resource countries and contribute to substantial disability. We have limited data on the specific conditions that are common in different countries, especially among children. Some conditions can be treated surgically, so it is important to understand how common they are and whether people are receiving appropriate care.
What We Did
We reviewed the notes for almost 5,000 children who were treated in musculoskeletal clinics at a hospital in Kumi, Uganda or in nearby communities. We noted the diagnosis and what treatment was recommended in each case.
What We Found
The most common conditions were contractures, post-injection paralysis, and infection. Some of these are caused by injections. We estimate that 50% of these cases could be prevented through earlier treatment and through policy and education to change injection practices. Detailed information on musculoskeletal conditions can help health officials make decisions about how to use healthcare resources.
Why It’s Important
Many patients with knee osteoarthritis and meniscal tear have synovitis, which refers to inflammation in the synovial membrane (a membrane located in the knee). Synovitis is important because it is associated with pain and worsening of osteoarthritis. Patients also often notice swelling in their knees. We wanted to know whether swelling can help us identify who will have synovitis as shown on MRI.
What We Did
We looked at reports of knee swelling among 276 subjects. About half had synovitis confirmed on an MRI. We assessed how well the patients’ own reports of swelling could predict who would have synovitis on MRI.
What We Found
Patient-reported swelling had only a modest ability to predict who would have synovitis on MRI. Clinically, swelling reported by patients is not an especially useful marker of synovitis on MRI.
Why It’s Important
Most people who receive a total knee replacement (TKR) do not substantially increase their physical activity after the TKR, despite having improved pain. A combination of health coaching and financial incentives can help people increase their physical activity after TKR.
What We Did
We used the OAPol Model to evaluate the cost-effectiveness of a program of health coaching and financial incentives, compared to usual care.
What We Found
Health coaching plus financial incentives is a cost-effective choice in this population if the physical activity levels that people achieve during the intervention persist.
Why It’s Important
In individuals who have knee osteoarthritis (OA) and BMI over 40, weight loss is associated with improved pain, function, and quality of life. Bariatric surgery is an effective weight loss procedure. Bariatric surgery can be considered in this group both to help with weight loss and as a treatment for OA symptoms.
What We Did
We examined trends in the bariatric surgeries performed on adults with a diagnosis of knee OA between 2005 and 2014, using data from the National Inpatient Sample. We collected data on the hospital characteristics, demographics, and surgical outcomes.
What We Found
Although the use of bariatric surgery in this population stayed constant between 2005 and 2014, the types of surgery were becoming less invasive and rates of complications decreased.
Why It’s Important
An intensive diet and exercise (D+E) program can be an effective way to reduce weight and relieve pain for patients with knee osteoarthritis (OA), as shown in the IDEA (Intensive Diet and Exercise for Arthritis) trial.
What We Did
We wanted to know whether it is cost-effective to augment typical OA treatments with a D+E intervention like the one in the IDEA trial in overweight and obese patients. We used the OAPol Model to estimate the quality-adjusted life expectancy (the time subjects live, weighted by their quality of life during that time) and lifetime costs for patients, either with or without this D+E program.
What We Found
Adding D+E to usual care in these patients was cost-effective and should be considered as part of clinical care.
Why It’s Important
Thigh muscle strength is important for helping people maintain their physical function and activities. People with knee osteoarthritis (OA) and a torn meniscus often have weaker thigh muscles than people without OA, which can contribute to worse pain, mobility, and function. We wanted to understand how thigh muscle strength relates to important clinical outcomes: pain, ability to do daily activities, and performance on functional tests.
What We Did
We tested the hamstrings and quadriceps strength of patients using a hand-held dynamometer. We assessed whether strength was associated with pain and other clinical outcomes.
What We Found
The group with the strongest quadriceps had less pain, better function, and better mobility, compared with those who had the weakest quadriceps. The same was true when comparing subjects with the strongest and weakest hamstrings.
Why It’s Important
Living with a chronic illness, such as arthritis, can require individuals to seek out healthcare, buy medication, and do other things to protect their health. Doing all this is especially challenging for individuals who live in resource-limited settings.
What We Did
We interviewed adults with arthritis in the Dominican Republic who were scheduled to receive total knee or total hip replacements. We then conducted an analysis to identify strategies that the participants use to get medical care or to make do without it.
What We Found
Dominicans with limited resources in our study used a broad variety of strategies to manage their illnesses. Their strategies fall along a spectrum from “making do with less” to finding more resources, such as loans or help with transportation to appointments. Understanding these strategies can help providers discuss treatments with their patients in resource-limited settings.
Why It’s Important
A substantial number of people with higher BMI (body mass index) undergo total knee replacement (TKR) each year. Some studies have suggested that patients with high BMI have a higher risk of medical complications after TKR compared to those with lower BMI. But we wanted to find out whether they have the same outlook in terms of improved pain and knee function following knee replacement surgery.
What We Did
We analyzed data from 633 participants who had received a TKR and filled out questionnaires at 3, 6, and 24 months after surgery. We grouped participants into the 5 BMI categories used by World Health Organization: normal weight, overweight, class-I obese, class-II obese, and class-III obese.
What We Found
Study participants in higher BMI categories started with worse pain and function, but they had larger improvements in pain and function at 3 months after surgery. By 24 months, people in all BMI categories had similar knee function and pain scores.
Why It’s Important
Adaptive sports can provide many benefits for people with disabilities. But many people who are eligible for adaptive sports do not participate. For that reason, there is interest in helping more people take part in adaptive sports. Qualitative studies can help us understand the experiences that individuals have when they do participate in adaptive sports in order to promote participation.
What We Did
We held focus groups with 17 current and former participants in the adaptive sports programs of a Boston rehabilitation hospital. Focus groups were audio-recorded and transcribed. We analyzed the transcripts to identify themes related to a) the benefits that sports participants say they experience and b) barriers to taking part in the sports program.
What We Found
Individuals who participated regularly reported that the sports programs benefited their physical health and helped them maintain positive ideas about themselves. However, they had to overcome several challenges including: transportation difficulties, the risk of being injured, and a lack of information about what each adaptive sport looks like and what skills are required. Our findings suggest ways that adaptive sports programs can promote knowledge about adaptive sports and help people overcome problems with access.
Why It’s Important
The prevalence of knee injuries is rising, and several studies have shown that knee injuries are associated with increased risk for knee osteoarthritis (OA). It is important to understand the risk of developing OA that patients face when they have already had injuries such as ACL (anterior cruciate ligament) tears.
What We Did
We used the OAPol model to forecast the risk of knee OA over the course of the lifetime in individuals who had a complete ACL tear by age 25. We also estimated their lifetime risk of undergoing total knee replacement (TKR).
What We Found
Having an ACL tear before the age of 25 puts people at higher lifetime risk for developing knee OA and for having a TKR. Those who also have a meniscal tear (MT) are at even higher risk. This study highlights the importance of preventing knee injury in young adults.
Why It’s Important
After a total knee replacement (TKR) most people do not increase the amount of physical activity (PA) they do, even if their knee pain and function improve. There is a lot of interest in finding strategies that might help people do more PA following TKR.
What We Did
We assigned participants to one of four treatments after their knee replacement surgery: attention control, health coaching conducted over the telephone, financial incentives, or a combination of health coaching and financial incentives. We asked participants to wear a Fitbit Zip before their surgery and after the intervention (at 6 months) so that we could measure their activity. We measured how many minutes of PA each participant had and how many steps each participant took daily.
What We Found
The combined intervention—health coaching and financial incentives—led to substantial increases in daily steps and daily minutes of physical activity.
Why It’s Important
Using opioids to manage pain in knee osteoarthritis (OA) involves trade-offs; pain relief is greater, but there are higher toxicities (negative effects), and patients on opioids must be monitored more frequently. In addition, many patients with OA will eventually have a total knee replacement (TKR), and those who take opioids have worse outcomes after TKR. Although the use of opioids is increasing, there are not clear guidelines for using opioids in the treatment of OA.
What We Did
We used the OAPol model to evaluate the cost-effectiveness of tramadol and oxycodone in individuals with knee OA, but with no other chronic diseases. We used published studies to find input values for the model—information about how much pain reduction and what side effects a group of patients is likely to experience due to the drugs.
What We Found
Neither tramadol nor tramadol plus oxycodone was a cost-effective treatment for knee OA. Both treatments increased cost and decreased quality adjusted life expectancy, mainly because they lead to worse pain relief after TKR. Future research should continue to investigate the impact opioids have on the outcomes of TKR.
Why It’s Important
We studied behavior in a workplace program that used financial incentives to encourage people to do more physical activity. We wanted to know if several geographic and weather-related factors that generally influence physical activity would also have an influence on participants in this program.
What We Did
We measured associations between participants’ moderate to vigorous physical activity (MVPA) and influences from the environment: weather (temperature, rain, snow, and wind) and geography (urban or rural location, distance from home to work).
What We Found
Participants who lived farther from work and in urban locations did fewer minutes of MVPA on average. Cold weather was associated with less physical activity. Future financial incentives programs may wish to consider these factors in their design.
Why It’s Important
Many patients with osteoarthritis (OA) also have multiple other chronic conditions (comorbidities) that make physicians cautious about recommending first-line OA treatments, including nonsteroidal anti-inflammatory drugs (NSAIDs). Adding stronger pain medications can bring greater pain relief, but these medications also carry a risk of serious side effects.
What We Did
Using the OAPol Model, we examined the long-term outcomes of using NSAIDs and opioids to treat pain in patients with knee OA and multiple other chronic conditions. We assessed pain relief, ill effects such as fractures, costs, and quality-adjusted life expectancy (the time subjects live, weighted by their quality of life during that time).
What We Found
We found that, for this group of older adults with multiple chronic conditions, certain NSAIDs (naproxen and ibuprofen) were more effective and cost-effective in managing OA pain than opioids or the other NSAIDs (including celecoxib).