Educational attainment and osteoarthritis: differential associations with radiographic changes and symptom reporting.

Educational attainment has been negatively associated with the prevalence, morbidity and mortality of many diseases. With knee osteoarthritis as an example, we used NHANES I data to examine whether the cross-sectional association between formal education and disease is due to known risk factors, and also whether educational attainment is more strongly associated with self-reported symptoms or with radiographic change. We found univariate associations between osteoarthritis and low levels of education. For radiographic knee osteoarthritis in women, and in both sexes combined, this relationship was explained by controlling for known risk factors, which included age, knee injury, race, obesity, and occupation. However, even after adjusting for these major risk factors and the presence of radiographic changes, reporting of knee pain and arthritis at any site remained significantly associated with low educational attainment, especially for those with less than or equal to 8 years of education.     

Accurate intra-articular knee joint injection in the obese? 'Fat Chance!'--A clinical lesson and recommendations for secondary referral

Corticosteroid joint injections are perceived as being an effective treatment for symptomatic knee osteoarthritis, with a very low risk of complications. While the procedure is often performed in secondary care by orthopaedic surgeons and rheumatologists (and trainees in either specialty), the role of general practitioners (GPs) in chronic disease management has long existed with joint injections also frequently performed in primary care. The perception that serious complications from corticosteroid knee joint injections are rare and that their benefits in treating symptomatic knee osteoarthritis significantly outweigh the risks has not been well addressed. We present a case of a 71-year-old obese female who presented to her general practitioner (GP) with worsening left knee pain and radiographic changes consistent with osteoarthritis. She was administered a corticosteroid joint injection, which gave minimal relief, and over the next few days resulted in worsening severe pain, erythema and swelling. She returned to the GP who commenced oral antibiotics and referred her to casualty. A large knee abscess was diagnosed and intravenous antibiotics were commenced. The patient was admitted under the orthopaedic surgeons with her treatment consisting of multiple surgical procedures over a prolonged duration. Although lengthy, her postoperative recovery was unremarkable. Based on this case report and our review of the literature, we highlight the potential complications associated with corticosteroid knee joint injections and suggest certain patients for whom we would recommend secondary referral before any intervention in primary care.     

Knee disorders in carpet and floor layers and painters.

In an evaluation of the effect of kneeling work on the knees, 168 actively working carpet and floor layers and 146 house painters were examined with the aid of a questionnaire, a clinical examination, and radiography. Reported knee pain, knee accidents, and treatment regimens for the knees were more common among the carpet and floor layers than among the painters. Radiographic changes of the tibiofemoral joint were noted equally in the two occupational groups, but osteophytes of the patella were more common among the carpet and floor layers than among the painters. In a multivariate analysis, the determinants of osteophytosis of the knee were age, occupation, knee accidents, and smoking, and osteophytosis may be due to more frequent workbreaks from kneeling postures among smoking workers. This study indicates that kneeling work increases the risk of knee disorders and such radiographic changes that might be an initial sign of knee degeneration.     

EURACT: EUROPEAN ACADEMY OF TEACHERS IN GENERAL PRACTICE AND FAMILY MEDICINE

Abstract

Corticosteroid joint injections are perceived as being an effective treatment for symptomatic knee osteoarthritis, with a very low risk of complications. While the procedure is often performed in secondary care by orthopaedic surgeons and rheumatologists (and trainees in either specialty), the role of general practitioners (GPs) in chronic disease management has long existed with joint injections also frequently performed in primary care. The perception that serious complications from corticosteroid knee joint injections are rare and that their benefits in treating symptomatic knee osteoarthritis significantly outweigh the risks has not been well addressed. We present a case of a 71-year-old obese female who presented to her general practitioner (GP) with worsening left knee pain and radiographic changes consistent with osteoarthritis. She was administered a corticosteroid joint injection, which gave minimal relief, and over the next few days resulted in worsening severe pain, erythema and swelling. She returned to the GP who commenced oral antibiotics and referred her to casualty. A large knee abscess was diagnosed and intravenous antibiotics were commenced. The patient was admitted under the orthopaedic surgeons with her treatment consisting of multiple surgical procedures over a prolonged duration. Although lengthy, her postoperative recovery was unremarkable. Based on this case report and our review of the literature, we highlight the potential complications associated with corticosteroid knee joint injections and suggest certain patients for whom we would recommend secondary referral before any intervention in primary care.     

Defining arthritis and measuring functional status in elders: methodological issues in the study of disease and physical disability.

This study explores the degree to which the association of knee osteoarthritis with physical disability changes with different definitions of osteoarthritis in 1,416 Framingham Study elders. When all categories of radiographic osteoarthritis were aggregated into a single "arthritis" variable and dependence upon human assistance in one or more functional activities combined into a single variable, elders with osteoarthritis had only moderately increased odds for dependence after controlling for age or sex (OR = 1.25). A definition of osteoarthritis based only upon symptoms produced larger odds for dependency (OR = 1.85). Elders with mild osteoarthritis and infrequent knee pain had no significantly elevated risk for dependence in any of the seven functional activities. Elders with infrequently symptomatic, moderate to marked radiographic osteoarthritis were at increased risk for dependence in stair climbing, walking a mile, housekeeping, and carrying bundles. Elder with radiographic osteoarthritis accompanied by frequent pain had an increased odds of dependence in stair climbing, walking a mile, and housekeeping. Using a generic definition of "arthritis" and aggregating functional activities may underestimate the impact of osteoarthritis on physical disability in the elderly and obscure the task-specific nature of that relationship.     

关节镜下有限清理术及辅助药物治疗膝关节骨性关节炎临床研究

目的探讨关节镜下有限清理术及辅助药物治疗膝关节骨性关节炎的临床疗效,并总结相关的治疗经验。方法 56例膝骨性关节炎患者(68膝)在关节镜诊断性检查后,行选择性的刨削增生肥厚的滑膜、修整成形磨损破裂的半月板、摘除游离体及剥脱的关节软骨、磨削症状性骨赘、修整磨损的软骨缺损区,并用大量生理盐水灌洗膝关节腔等方法结合辅助药物进行治疗。结果所有患者术后随访6～28个月,平均16个月。膝关节功能评分由术前43分增加到术后78分,优良率为82.4%。结论关节镜下有限清理术及辅助药物治疗膝关节骨性关节炎具有创伤小、恢复快、并发症低、疗效好等优点,能够缓解症状、改善关节功能、提高患者生活质量。     

关节镜下有限清理术及辅助药物治疗

目的探讨关节镜下有限清理术及辅助药物治疗膝关节骨性关节炎的临床疗效,并总结相关的治疗经验。方法56例膝骨性关节炎患者（68膝）在关节镜诊断性检查后,行选择性的刨削增生肥厚的滑膜、修整成形磨损破裂的半月板、摘除游离体及剥脱的关节软骨、磨削症状性骨赘、修整磨损的软骨缺损区,并用大量生理盐水灌洗膝关节腔等方法结合辅助药物进行治疗。结果所有患者术后随访6～28个月,平均16个月。膝关节功能评分由术前43分增加到术后78分,优良率为82．4％。结论关节镜下有限清理术及辅助药物治疗膝关节骨性关节炎具有创伤小、恢复快、并发症低、疗效好等优点,能够缓解症状、改善关节功能、提高患者生活质量。     

Validation of Chinese Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) in patients scheduled for total knee replacement

Objective Our aim was to cross-culturally validate Chinese Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) in patients with knee osteoarthritis (OA) scheduled for total knee replacement in Singapore. Methods Chinese WOMAC was translated from the original English version following standard guidelines. Patients were asked to complete a questionnaire containing the WOMAC (twice within 6 days), the Short Form 36 (SF-36), and the EuroQoL EQ-5D. Reliability was assessed using Cronbach’s alpha and intraclass correlation coefficients (ICC), dimensionality using item-to-domain correlations and factor analyses. Convergent and discriminant construct validity was assessed using six each a priori hypotheses. Results Chinese WOMAC was well accepted by the patients in the pilot test. The Chinese and English versions were therefore administered to a consecutive sample of 131 Chinese- and 127 English-speaking subjects, respectively, with knee OA. Cronbach’s alpha exceeded 0.7 for all domains except for Chinese pain domain, whereas the ICC exceeded 0.7 for all domains. Hypothesized item-to-domain correlations were observed for all items except for four items in Chinese physical function domain. The factor analyses yielded seven and five factors with eigenvalues of more than 1.0 in the Chinese and English versions, respectively. A total of 10/12 a priori construct validity hypotheses were satisfied for the Chinese version. Weak correlations between WOMAC pain and SF-36 bodily pain and moderate correlation between WOMAC pain and EQ-5D anxiety/depression were observed. Conclusions Chinese WOMAC was well accepted and demonstrated acceptable psychometric properties in Singaporean patients with severe knee OA.     

Metabolic syndrome and development of diabetes mellitus: application and validation of recently suggested definitions of the metabolic syndrome in a prospective cohort study

The World Health Organization (WHO) and the National Cholesterol Education Program (NCEP) recently proposed definitions for the metabolic syndrome. Little is known of their validity, however. The authors assessed the sensitivity and specificity of the definitions of the metabolic syndrome for prevalent and incident diabetes mellitus in a Finnish population-based cohort of middle-aged men (n = 1,005) followed for 4 years since the late 1980s. Four definitions based on the WHO and NCEP recommendations were compared. All definitions identified persons at high risk for developing diabetes during the 4-year follow-up (odds ratios = 5.0-8.8). The WHO definition including waist-hip ratio > 0.90 or body mass index >or= 30 kg/m(2) was the most sensitive (0.83 and 0.67) and least specific (0.78 and 0.80) in detecting the 47 prevalent and 51 incident cases of diabetes. The NCEP definition in which adiposity was defined as waist girth > 102 cm detected only 61% of prevalent and 41% of incident diabetes, although it was the most specific (0.89 and 0.90). The WHO definition seems valid as judged by its relatively high sensitivity and specificity in predicting diabetes. The NCEP definition including waist > 102 cm also identifies persons at high risk for diabetes, but it is relatively insensitive in predicting diabetes.     

Individual and occupational determinants of low back pain according to various definitions of low back pain

OBJECTIVES: To test associations between non-specific low back pain and several risk factors when definitions of low back pain vary. DESIGN/SETTING/PARTICIPANTS: A cross sectional study was set up in 1991, 725 workers from four occupational sectors answered a self administrated questionnaire including the Nordic questionnaire and questions about intensity of pain and individual and occupational factors. MAIN RESULTS: Prevalence of low back pain varied from 8% to 45% according to the definition used. Psychosomatic problems, bending or carrying loads were often associated to low back pain, whereas other risk factors were related to some specific dimensions of the disorder. CONCLUSIONS: Risk factors of low back pain vary with the definition. This could explain inconsistencies found in literature reviews. To be able to compare data, it seems important to be precise what definition is used and to use comparable questionnaires.     

关节镜清理术联合透明质酸钠治疗膝骨性关节炎的效果

目的 探讨关节镜清理术联合透明质酸钠治疗膝骨性关节炎患者的效果.方法 100例膝骨性关节炎患者随机分为两组各50例,对照组采用关节镜清理术治疗,实验组采用关节镜清理术联合透明质酸钠治疗,比较两组的关节液炎性因子水平、膝关节功能以及疼痛情况.结果 治疗后,实验组的TNF-α、IL-6、IL-8水平均显著低于对照组(P＜0...     

Clínica. Localizaciones: rodilla,cadera, manos,columna, otras localizaciones

The symptoms of osteoarthritis vary widely from patient to patient, depending especially on the localization on the disease. There is a poor correlation between radiological involvement and pain. In general, symptom onset is gradual and symptoms increase slowly but progressively. The most commonly affected joints are the knees, hips, hands, and spine. The main signs and symptoms are pain, stiffness, joint deformity, and crepitus. Pain is mechanical and its causes are multifactorial; in the initial phases, pain usually manifests in self-limiting episodes but may subsequently be almost constant. The criteria of the American college of Rheumatology for the classification of osteoarthritis of the knee, hip and hands are an aid to classification and standardization but are not useful for diagnosis. Hip osteoarthritis usually produces inguinal pain in the internal and anterior sections of the muscle extending to the knee and, with progression, tends to limit mobility. Knee osteoarthritis is more frequent in women and is usually associated with hand osteoarthritis and obesity. In hand osteoarthritis, the most commonly affected joints are the distal interphalangeal joints, followed by the proximal interphalangeal joints and the trapeziometacarpal joints; the development of Heberden and Bouchard nodes is common; involvement of the trapeziometacarpal joint is called rhizarthrosis and is one of the forms of osteoarthritis that produces the greatest limitation on hand function. Osteoarthritis of the spine affects the facet joints and the vertebral bodies. Other, less frequent, localizations are the foot, elbow and shoulder, which are generally secondary forms of osteoarthritis.     

Burden of major musculoskeletal conditions

Musculoskeletal conditions are a major burden on individuals, health systems, and social care systems, with indirect costs being predominant. This burden has been recognized by the United Nations and WHO, by endorsing the Bone and Joint Decade 2000-2010. This paper describes the burden of four major musculoskeletal conditions: osteoarthritis, rheumatoid arthritis, osteoporosis, and low back pain. Osteoarthritis, which is characterized by loss of joint cartilage that leads to pain and loss of function primarily in the knees and hips, affects 9.6% of men and 18% of women aged > 60 years. Increases in life expectancy and ageing populations are expected to make osteoarthritis the fourth leading cause of disability by the year 2020. Joint replacement surgery, where available, provides effective relief. Rheumatoid arthritis is an inflammatory condition that usually affects multiple joints. It affects 0.3-1.0% of the general population and is more prevalent among women and in developed countries. Persistent inflammation leads to joint destruction, but the disease can be controlled with drugs. The incidence may be on the decline, but the increase in the number of older people in some regions makes it difficult to estimate future prevalence. Osteoporosis, which is characterized by low bone mass and microarchitectural deterioration, is a major risk factor for fractures of the hip, vertebrae, and distal forearm. Hip fracture is the most detrimental fracture, being associated with 20% mortality and 50% permanent loss in function. Low back pain is the most prevalent of musculoskeletal conditions; it affects nearly everyone at some point in time and about 4-33% of the population at any given point. Cultural factors greatly influence the prevalence and prognosis of low back pain.     

Strength of association for incident diabetes risk factors according to diabetes case definitions: the Atherosclerosis Risk in Communities Study

Prospective epidemiologic studies have characterized major risk factors for incident diabetes by a variety of diabetes case definitions. Whether different definitions alter the association of diabetes with risk factors is largely unknown. Using 1987-1998 data from the ongoing Atherosclerosis Risk in Communities (ARIC) Study, the authors assessed the relation of traditional risk factors with 3 different diabetes case definitions and 4 fasting glucose categories. They compared the study protocol case definition with 2 nested case definitions, self-reported diabetes and a multiple-evidence definition. Significant differences in risk factor associations by case definition and by screening cutpoints were observed. Specifically, the magnitude of the association between the risk factors (baseline metabolic syndrome, fasting glucose, blood pressure, body mass index, and serum insulin) and incident diabetes differed by case definition. Associations with these risk factors were weaker with a case definition based on self-report compared with other definitions. These results illustrate the potential limitations of case definitions that rely solely on self-report or those that incorporate measured glucose values to ascertain undiagnosed cases. Although the ability to identify risk factors of diabetes was consistent for the case definitions studied, tests of novel risk factors may result in different estimates of effect sizes depending on the definition used.     

Performance-based physical functioning in African-American and Caucasian women at midlife: considering body composition, quadriceps strength, and knee osteoarthritis

In 2000, body composition, x-ray-defined knee osteoarthritis, and self-reported knee pain information from a cross-sectional, community-based study of 211 African-American and 669 Caucasian women in southeast Michigan (mean age, 47 years) was related to performance-based physical functioning measures to characterize development of functional limitations. Body composition was assessed with bioelectrical impedance. Functioning measures were gait assessment, timed walk, timed stair climb with and without videography, and isometric quadriceps strength. Knee osteoarthritis was determined by Kellgren-Lawrence score from radiography, whereas knee pain was self-reported. Almost 31% of mid-aged women walked at functionally inadequate speeds, and over 12% walked at speeds considered typical of frailty in older women. Ten percent of women had skeletal muscle mass levels less than a proposed cutpoint for increased physical disability risk in older adults. Gait measures correlates included increasing age, increasing fat mass (in kilograms), knee joint pain, and reduced quadriceps strength. Stair climbing correlates included skeletal muscle mass (in kilograms) and its change, painful knee osteoarthritis, and reduced quadriceps strength. Race differences in walking measures and stair climbing time diminished when the authors accounted for other factors. Compromised physical functioning began earlier than expected, with indications that approximately 12-31% of women might benefit from interventions to forestall future decline.     

Definición,etiopatogenia, clasificación y formas de presentación

Osteoarthritis is defined as a degenerative process affecting the joints as a result of mechanical and biological disorders that destabilize the balance between the synthesis and degradation of joint cartilage, stimulating the growth of subchondral bone; chronic synovitis is also present. Currently, the joint is considered as a functional unit that includes distinct tissues, mainly cartilage, the synovial membrane, and subchondral bone, all of which are involved in the pathogenesis of the disease.Distinct risk factors for the development of osteoarthritis have been described: general, unmodifiable risk factors (age, sex, and genetic makeup), general, modifiable risk factors (obesity and hormonal factors) and local risk factors (prior joint anomalies and joint overload). Notable among the main factors related to disease progression are joint alignment defects and generalized osteoarthritis.Several classifications of osteoarthritis have been proposed but none is particularly important for the primary care management of the disease. These classifications include etiological (primary or idiopathic forms and secondary forms) and topographical (typical and atypical localizations) classifications, the Kellgren and Lawrence classification (radiological repercussions) and that of the American College of Rheumatology for osteoarthritis of the hand, hip and knee.The prevalence of knee osteoarthritis is 10.2% in Spain and shows a marked discrepancy between clinical and radiological findings. Hand osteoarthritis, with a prevalence of symptomatic involvement of around 6.2%, has several forms of presentation (nodal osteoarthritis, generalized osteoarthritis, rhizarthrosis, and erosive osteoarthritis). Symptomatic osteoarthritis of the hip affects between 3.5% and 5.6% of persons older than 50 years and has different radiological patterns depending on femoral head migration.     

The association of knee injury and obesity with unilateral and bilateral osteoarthritis of the knee

The strength of the associations of knee injury and obesity with osteoarthritis of the knee was studied for 3,885 adults aged 45-74 years who received knee x-rays in the First National Health and Nutrition Examination Survey, 1971-1975. Bilateral osteoarthritis was more prevalent (5%) than unilateral osteoarthritis (2%). Bilateral osteoarthritis was twice as prevalent in women as in men; however, there was no sex difference in the prevalence of unilateral osteoarthritis. Odds ratios calculated by means of polychotomous logistic regression indicated that obesity, knee injury, and age were significantly associated with both unilateral and bilateral knee osteoarthritis. Obesity was a stronger predictor of bilateral osteoarthritis than was knee injury (odds ratio (OR) = 6.6 for obesity, 3.5 for right knee injury, and 3.0 for left knee injury; 95% confidence interval (CI) 4.71-9.18, 1.80-6.83, and 1.51-6.11, respectively). Knee injury was a stronger predictor of unilateral osteoarthritis than was obesity (OR = 3.4 and 2.4 for obesity in the right and left knee, respectively (95% CI 1.55-7.29 and 0.96-5.75) and OR = 16.3 and 10.9 for injury in the right and left knee, respectively (95% CI 6.50-40.89 and 3.72-31.93]. These findings suggest that different pathogenetic processes may exist for unilateral and bilateral knee osteoarthritis.     

运动疗法结合盘龙七片治疗膝骨关节炎临床观察

目的观察运用运动疗法、中成药综合疗法治疗膝骨性关节炎的临床疗效。方法将患有膝骨性关节炎78例患者,运用随机数字表法分为2组,治疗组(A组)39例采用运动疗法、盘龙七片中成药综合疗法治疗,对照组(B组)39例单纯采用非甾体消炎止痛药口服治疗,以6~12个月为观察期,观察治疗前后病人的疼痛、膝关节活动等改善情况。结果 A组疼痛、膝关节活动等症状改善情况明显优于B组。结论运用综合疗法治疗膝骨性关节炎有助于改善关节活动、减轻疼痛,提高关节稳定性,延缓病情进展,提高患者的生活质量,是较为理想的治疗方法。     

Defining osteoarthritis of the hip for epidemiologic studies

The authors compared seven radiologic indices of hip osteoarthritis to establish which provided the best definition of the disease for epidemiologic purposes. Hip joints were assessed from intravenous urograms taken in a British hospital between 1982 and 1987 in 1,315 men aged 60-75 years. The indices examined were an overall qualitative grading of osteoarthritis, four measures of joint space, the maximum thickness of subchondral sclerosis, and the size of the largest osteophyte. Minimal joint space (i.e., the shortest distance between the femoral head margin and the acetabulum) was the index most strongly associated with other radiologic features of osteoarthritis. Among a subset of 759 men who answered a questionnaire about symptoms, the overall qualitative grading, minimal joint space, and thickness of subchondral sclerosis were the radiologic indices most predictive of hip pain. Within- and between-observer repeatability were tested in a subset of 50 subjects. Measures of joint space were more reproducible than other indices. These data suggest that, at least in men, minimal joint space is the best radiologic criterion of hip osteoarthritis for use in epidemiologic studies.