Anterior knee symptoms after S-ROM hinge implantation

Purpose: To evaluate the performance of a canal filling hinge device for complex knee arthroplasty. Methods: Thirty-seven (4 primary hinge implantation and 33 revision cases) patients who had undergone arthroplasty with the S-ROM third generation hinge device for a combination of massive bone loss or ligamentous insufficiency were prospectively examined with a minimum of 5-year follow-up. Median age at surgery was 72 years (range: 43 to 87 years). Principal indications included aseptic loosening or massive osteolysis (24 cases), infection (8 cases) and periprosthetic fracture (4 cases). All patients exhibited either grade 2 (N = 12) or grade 3 (N = 25) AORI bone loss or a grade 3 medial ligament deficiency. Results: One patient experienced implant failure (71 months), and one patient suffered late deep infection (36 months). Mean WOMAC score improved from 27 to 62. Four patients required patellar resurfacing for persistent pain. The 5-year survivorship was 86%. Conclusions: While the S-ROM device may offer satisfactory medium term outcome for complex end stage knee disease, we report a high rate of debilitating anterior knee symptoms.

Optimal stimulation duration of tens in the management of osteoarthritic knee pain

Objective: This study examined the optimal stimulation duration of transcutaneous electrical nerve stimulation (TENS) for relieving osteoarthritic knee pain and the duration (as measured by half-life) of post-stimulation analgesia. Subjects: Thirty-eight patients received either: (i) 20 minutes (TENS20); (ii) 40 minutes (TENS40); (iii) 60 minutes (TENS60) of TENS; or (iv) 60 minutes of placebo TENS (TENSPL) 5 days a week for 2 weeks. Methods: A visual analogue scale recorded the magnitude and pain relief period for up to 10 hours after stimulation. Results: By Day10, a significantly greater cumulative reduction in the visual analogue scale scores was found in the TENS40 (83.40%) and TENS60 (68.37%) groups than in the TENS20 (54.59%) and TENSPL (6.14%) groups (p 3 0.000), such a group difference was maintained in the 2-week followup session (p 3 0.000). In terms of the duration of post-stimulation analgesia period, the duration for the TENS40 (256 minutes) and TENS60 (258 minutes) groups was more prolonged than in the other 2 groups (TENS20 = 168 minutes, TENSPL = 35 minutes) by Day10 (p 3 0.000). However, the TENS40 group produced the longest pain relief period by the follow-up session. Conclusion: 40 minutes is the optimal treatment duration of TENS, in terms of both the magnitude (VAS scores) of pain reduction and the duration of post-stimulation analgesia for knee osetoarthritis.

Clinical features of patellar tendinopathy and their implications for rehabilitation

This study investigated the clinical features of patellar tendinopathy (PT), with focus on individuals with unilateral and bilateral PT. A cross-sectional study design was employed to compare individuals with unilateral (n = 14) or bilateral (n = 13) PT and those without PT (control, n = 31). Features assessed included thigh strength (normalized peak knee extensor torque) and flexibility (sit-and-reach and active knee extension), calf endurance (heel-rise test), ankle flexibility (dorsiflexion), alignment measures (arch height and leg length difference), and functional measures (hop for distance and 6 m hop test). Groups were matched for age and height; however, unilateral and bilateral PT had greater mass with a higher body mass index (BMI) than control. Also, bilateral PT performed more sport hours per week than both unilateral PT and control. Unilateral PT had less thigh strength than control and bilateral PT, whereas bilateral PT had more thigh flexibility than control and unilateral PT. Both unilateral and bilateral PT had altered alignment measures compared to control. Features that predicted symptoms in PT were lower thigh flexibility and strength, whereas those that predicted function were higher thigh strength and lower ankle flexibility.  These findings indicate that unilateral and bilateral PT represent distinct entities, and that thigh strength appears particularly important in PT as it predicted both symptoms and function in PT.

Comparative accuracy of magnetic resonance imaging and ultrasonography in confirming clinically diagnosed patellar tendinopathy

Background: Diagnosis of patellar tendinopathy is based primarily on clinical examination; however, it is commonplace to image the patellar tendon for diagnosis confirmation, with the imaging modalities of choice being magnetic resonance imaging (MRI) and ultrasonography (US). The comparative accuracy of these modalities has not been established.

Hypothesis: Magnetic resonance imaging and US have good (>80%) accuracy and show substantial agreement in confirming clinically diagnosed patellar tendinopathy.

Study Design: Cohort study (diagnosis); Level of evidence, 2.

Methods: Magnetic resonance imaging and US (gray scale [GS-US] and color Doppler [CD-US]) features of 30 participants with clinically diagnosed patellar tendinopathy and 33 activity-matched, asymptomatic participants were prospectively compared. Accuracy, sensitivity, specificity, positive and negative predictive values, and the likelihood of positive and negative test results were determined for each technique.

Results: The accuracy of MRI, GS-US, and CD-US was 70%, 83%, and 83%, respectively (P = .04; MRI vs GS-US). The likelihood of positive MRI, GS-US, and CD-US was 3.1, 4.8, and 11.6, respectively. The MRI and GS-US had equivalent specificity (82% vs 82%; P = 1.00); however, the sensitivity of GS-US was greater than MRI (87% vs 57%; P = .01). Sensitivity (70% vs 87%; P = .06) and specificity (94% vs 82%; P = .10) did not differ between CD-US and GS-US.

Conclusions: Ultrasonography was more accurate than MRI in confirming clinically diagnosed patellar tendinopathy. GS-US and CD-US may represent the best combination for confirming clinically diagnosed patellar tendinopathy because GS-US had the greatest sensitivity, while a positive CD-US test result indicated a strong likelihood an individual was symptomatic.

Low-intensity pulsed ultrasound for chronic patellar tendinopathy : a randomized, double-blind, placebo-controlled trial

Objective. Patellar tendinopathy (PT) is a common and significant clinical condition for which there are few established interventions. One intervention that is currently being used clinically to manage PT symptoms is the introduction of low-intensity pulsed ultrasound (LIPUS). The aim of this study was to investigate the clinical efficacy of LIPUS in the management of PT symptoms.

Methods. A randomized, double-blind, placebo-controlled study was conducted. Volunteers with clinically and radiologically confirmed PT were randomly allocated to either an active-LIPUS (treatment) or inactive-LIPUS (placebo) group. LIPUS was self-administered by participants for 20 min/day, 7 days/week for 12 weeks. All participants also completed a daily, standardized eccentric exercise programme based on best practice. Primary outcomes were change in pain during the participant's most aggravating activity in the preceding week, measured on 10 cm visual analogue scales for both usual (VAS-U) and worst (VAS-W) tendon pain.

Results. Out of 156 individuals who volunteered, 37 met the eligibility criteria and were randomized to either active-LIPUS (n = 17) or inactive-LIPUS (n = 20). Using an intention-to-treat analysis, VAS-U and VAS-W for the entire cohort decreased by 1.6 ± 1.9 cm (P < 0.01) and 2.5 ± 2.4 cm (P < 0.01), respectively. There were no differences between the active- and inactive-LIPUS groups for change in VAS-U (–0.2 cm; 95% CI, –1.5, 1.1 cm) (P = 0.74) or VAS-W (–0.5 cm; 95% CI, –2.1, 1.1 cm) (P = 0.57). A per-protocol analysis provided similar results.

Conclusions. These findings suggest that LIPUS does not provide any additional benefit over and above placebo in the management of symptoms associated with PT.

Effects of laterally wedged insoles on symptoms and disease progression in medial knee osteoarthritis: a protocol for a randomised, double-blind, placebo controlled trial

Background: Whilst laterally wedged insoles, worn inside the shoes, are advocated as a simple, inexpensive, non-toxic self-administered intervention for knee osteoarthritis (OA), there is currently limited evidence to support their use. The aim of this randomised, double-blind controlled trial is to determine whether laterally wedges insoles lead to greater improvements in knee pain, physical function and health-related quality of life, and slower structural disease progression as well as being more cost-effective, than control flat insoles in people with medial knee OA.

Methods/Design: Two hundred participants with painful radiographic medial knee OA and varus malalignment will be recruited from the community and randomly allocated to lateral wedge or control insole groups using concealed allocation. Participants will be blinded as to which insole is considered therapeutic. Blinded follow up assessment will be conducted at 12 months after randomisation. The outcome measures are valid and reliable measures recommended for OA clinical trials. Questionnaires will assess changes in pain, physical function and health-related quality-of-life. Magnetic resonance imaging will measure changes in tibial cartilage volume. To evaluate cost-effectiveness, participants will record the use of all health-related treatments in a log-book returned to the assessor on a monthly basis. To test the effect of the intervention using an intention-to-treat analysis, linear regression modelling will be applied adjusting for baseline outcome values and other demographic characteristics.

Discussion: Results from this trial will contribute to the evidence regarding the effectiveness of laterally wedged insoles for the management of medial knee OA.

Trial registration: ACTR12605000503628; NCT00415259.

Efficacy of progressive aquatic resistance training for tibiofemoral cartilage in postmenopausal women with mild knee osteoarthritis: a randomised controlled trial

OBJECTIVE: To study the efficacy of aquatic resistance training on biochemical composition of tibiofemoral cartilage in postmenopausal women with mild knee osteoarthritis (OA).

DESIGN: Eighty seven volunteer postmenopausal women, aged 60-68 years, with mild knee OA (Kellgren-Lawrence grades I/II and knee pain) were recruited and randomly assigned to an intervention (n = 43) and control (n = 44) group. The intervention group participated in 48 supervised aquatic resistance training sessions over 16 weeks while the control group maintained usual level of physical activity. The biochemical composition of the medial and lateral tibiofemoral cartilage was estimated using single-slice transverse relaxation time (T2) mapping and delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC index). Secondary outcomes were cardiorespiratory fitness, isometric knee extension and flexion force and knee injury and OA outcome (KOOS) questionnaire.

RESULTS: After 4-months aquatic training, there was a significant decrease in both T2 -1.2 ms (95% confidence interval (CI): -2.3 to -0.1, P = 0.021) and dGEMRIC index -23 ms (-43 to -3, P = 0.016) in the training group compared to controls in the full thickness posterior region of interest (ROI) of the medial femoral cartilage. Cardiorespiratory fitness significantly improved in the intervention group by 9.8% (P = 0.010).

CONCLUSIONS: Our results suggest that, in postmenopausal women with mild knee OA, the integrity of the collagen-interstitial water environment (T2) of the tibiofemoral cartilage may be responsive to low shear and compressive forces during aquatic resistance training. More research is required to understand the exact nature of acute responses in dGEMRIC index to this type of loading. Further, aquatic resistance training improves cardiorespiratory fitness.

The maximum tolerated dose of walking for people with severe osteoarthritis of the knee: a phase I trial

OBJECTIVE: To determine how much physical activity, in the form of walking, can be safely and feasibly tolerated for people with severe knee osteoarthritis (OA). DESIGN: Phase I dose response trial with escalating walking doses of 10, 20, 35, 50, 70, and 95 min over 1 week, were prescribed non-randomly to people with severe knee OA. The primary stopping rule was a substantial increase in knee pain. The primary outcomes were an estimation of the maximum tolerated dose of walking; and the proportion of people who did not complete the dose for feasibility reasons. The secondary outcomes were pain, stiffness and activity limitation Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). RESULTS: Twenty-four participants (13 women) aged 53-83 years, and average body mass index (BMI) of 34 kg/m(2) (SD 9) were recruited. Three participants were assigned to each dose between 10 and 70 min, and nine participants assigned to the 95-min dose. The trial was stopped at 95 min due to the maximum number of adverse events occurring at this dose. Therefore, the maximum tolerated dose was 70 min. No participant stopped due to reasons related to feasibility. There was a moderate association between dose and increased activity (linear R(2) = 0.31, cubic R(2) = 0.69) and reduced stiffness (linear R(2) = 0.20, cubic R(2) = 0.52), with increased benefits at moderate to higher doses. CONCLUSIONS: There is preliminary evidence that 70 min per week of moderate intensity supervised walking was safe and feasible for people with severe OA of the knee; for higher doses there was a risk of exacerbating knee pain levels.

Discriminative ability of functional loading tests for adolescent jumper

Objective: To investigate the reliability and validity of five squat-based loading tests that are clinically appropriate for jumper's knee. The loading tests were step up, double leg squat, double leg squat on a 25-degree decline (decline squat), single leg decline squat, and decline hop. Design: Cross-sectional controlled cohort. Subjects without knee pain comprised controls, those with extensor tendon pain comprised the jumper's knee group. Setting: Institutional athlete study group in Australia. Participants: Fifty-six elite adolescent basketball players participated in this study, thirteen comprised the jumper's knee group, fifteen athletes formed a control group. Intervention: Each subject performed each loading test for baseline and reliability data on the first testing day. Subjects then performed three days of intensive (6 h daily) basketball training, after which each loading test was reexamined. Main outcome measures: Eleven point interval scale for pain. Results: The tests that best detected a change in pain due to intensive workload were the single leg decline squat and single leg decline hop. This study found that decline tests have better discriminative ability than the standard squat to detect change in jumper's knee pain due to intensive training. The typical error for these tests ranged from 0.3 to 0.5, however, caution should be exercised in the interpretation of these reliability figures due to relatively low scores. Conclusions: The single leg decline squat is recommended in the physical assessment of adolescent jumper's knee. The decline squat was selected as the best clinical test over the decline hop because it was easier to standardise performance.

Anthropometric risk factors for patellar tendon injury among volleyball players

Objective: Abnormal imaging in the patellar tendon reveals pathology that is often associated with knee pain. Anthropometric measures of body size and mass, such as height, weight and waist-to-hip ratio (WHR), have been individually associated with abnormal imaging. The aim of this study was to investigate the anthropometric factors that have the strongest relationship with abnormal imaging in volleyball players.

Methods: Height, weight, body mass index (BMI), waist girth, hip girth and WHR were measured in a cohort of 113 competitive volleyball players (73 men, 40 women). The univariate (ANOVA) and multivariable (discriminant function analysis) association between abnormal imaging and these anthropometric factors were investigated.

Results: No significant association was found in the female volleyball players. A significant univariate association was observed between abnormal imaging and heavier weight, greater BMI, larger waist and hip girth and larger WHR in the male volleyball players. Waist girth was the only factor that retained this association in a multivariable model (p<0.05).

Conclusions: Men with a waist girth greater than 83 cm seem to be at greater risk of developing patellar tendon pathology. There may be both mechanical and biochemical reasons for this increased risk.

Development of a management algorithm for post-operative pain (MAPP) after total knee and total hip replacement: study rationale and design

Evidence from clinical practice and the extant literature suggests that post-operative pain assessment and treatment is often suboptimal. Poor pain management is likely to persist until pain management practices become consistent with guidelines developed from the best available scientific evidence. This work will address the priority in healthcare of improving the quality of pain management by standardising evidence-based care processes through the incorporation of an algorithm derived from best evidence into clinical practice. In this paper, the methodology for the creation and implementation of such an algorithm that will focus, in the first instance, on patients who have undergone total hip or knee replacement is described.

Dynamic weight-bearing assessment of pain in knee osteoarthritis: a reliability and agreement study

Purpose: To evaluate the reliability, agreement and smallest detectable change in a measurement instrument for pain and function in knee osteoarthritis; the Dynamic weight-bearing Assessment of Pain (DAP). Methods: The sample size was set to 20 persons, recruited from the outpatient osteoarthritis clinic at Frederiksberg Hospital, Copenhagen. Two physiotherapists tested all participants during two visits; at the first visit, one single DAP (including four scores) was conducted by rater one; at the second visit, DAP was conducted by both raters one and two in randomized order with concealed allocation. The time interval was approximately 1.5 h. Measurement error was estimated by standard error of measurement (SEM). The intra- and inter-rater reliability was estimated by Intra-class Correlation Coefficients for agreement based on a two-way ANOVA with random effects (single measures ICC 2.1). Smallest detectable change (SDC) and limits of agreement were calculated.Results: The pain score showed excellent reliability in terms of ICC (intra-rater 0.93, CI 0.83–0.97, inter-rater 0.91, CI 0.78–0.96), low SEM (intra-rater 0.70, inter-rater 0.86, on a scale from 0 to 10), and acceptable SDC for intra-rater test (1.95). The three knee bend scores all had ICC above 0.50, showing fair-to-good reliability. None of the knee bend scores showed acceptable SEM and SDC. Conclusions: The reproducibility of the DAP pain score meets the demands for use in clinical practice and research. The total knee bend could be useful for motivational purpose in clinical use. Testing of other psychometric properties of the DAP is pending.

Blood-nourishing and hard-softening capsule costs less in the management of osteoarthriticknee pain : A randomized controlled trial

The blood-nourishing and hard-softening (BNHS) capsule is a traditional Chinese formula used in the symptomatic treatment of inflammation and pain. We conducted this randomized controlled trial to compare the efficacy of BNHS with other commonly prescribed drugs. We recruited 120 patients from two teaching hospitals; 30 patients in each hospital were randomly assigned to receive BNHS. In one hospital, the 30 controls were given another traditional Chinese drug; whereas a Western medicine (chondroprotection drug/Viartril-s) was used as the control in the other hospital. Intervention was carried out over a period of 4 weeks. Primary outcome measures included self-reported pain level, and changes in stiffness and functional ability as measured by the Western Ontario McMaster Universities Osteoarthritis (WOMAC) index. Mixed models were used for statistical analysis. Substantial improvements in disease-specific symptoms were observed, after 4 weeks of treatment, in patients taking BNHS capsules. As assessed by the WOMAC index, pain level of the BNHS group decreased by 57% [95% confidence interval (CI) = 50, 63], stiffness by 63% (95% CI = 55, 71) and functional ability increased by 56% (95% CI = 50, 63). No significant differences were found in any of the outcome measures between the BNHS group and either of the comparison groups. No severe adverse effects were reported. However, this study lacked a placebo group; therefore, we conclude that BNHS appears to be as effective as commonly prescribed medicines for the relief of pain and dysfunction in knee osteoarthritis patients, but costs a lot less than other Western and herbal drugs in the study.

Can a disease-specific education program augment self-management skills and improve Health-Related Quality of Life in people with hip or knee osteoarthritis?

Background: Patient education and self-management programs are offered in many countries to people with chronic conditions such as osteoarthritis (OA). The most well-known is the disease-specific Stanford Arthritis Self-Management Program (ASMP). While Australian and international clinical guidelines promote the concept of self-management for OA, there is currently little evidence to support the use of the ASMP. Several meta-analyses have reported that arthritis self-management programs had minimal or no effect on reducing pain and disability. However, previous studies have had methodological shortcomings including the use of outcome measures which do not accurately reflect program goals. Additionally, limited cost-effectiveness analyses have been undertaken and the cost-utility of the program has not been explored.

Methods/design: This study is a randomised controlled trial to determine the efficacy (in terms of Health-Related Quality of Life and self-management skills) and cost-utility of a 6-week group-based Stanford ASMP for people with hip or knee OA.

Six hundred participants referred to an orthopaedic surgeon or rheumatologist for hip or knee OA will be recruited from outpatient clinics at 2 public hospitals and community-based private practices within 2 private hospital settings in Victoria, Australia. Participants must be 18 years or over, fluent in English and able to attend ASMP sessions. Exclusion criteria include cognitive dysfunction, previous participation in self-management programs and placement on a waiting list for joint replacement surgery or scheduled joint replacement.

Eligible, consenting participants will be randomised to an intervention group (who receive the ASMP and an arthritis self-management book) or a control group (who receive the book only). Follow-up will be at 6 weeks, 3 months and 12 months using standardised self-report measures. The primary outcome is Health-Related Quality of Life at 12 months, measured using the Assessment of Quality of Life instrument. Secondary outcome measures include the Health Education Impact Questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index (pain subscale and total scores), Kessler Psychological Distress Scale and the Hip and Knee Multi-Attribute Priority Tool. Cost-utility analyses will be undertaken using administrative records and self-report data. A subgroup of 100 participants will undergo qualitative interviews to explore the broader potential impacts of the ASMP.

Discussion: Using an innovative design combining both quantitative and qualitative components, this project will provide high quality data to facilitate evidence-based recommendations regarding the ASMP.