Aims

This study was performed to investigate the association between the acetabular morphology and the joint space narrowing rate (JSNR) in the non-arthritic hip.

Aims

To assess the incidence of radiological lateral osteoarthritis (OA) at 15 years after medial unicompartmental knee arthroplasty (UKA) and assess the relationship of lateral OA with symptoms and patient characteristics.

Varus malalignment increases the susceptibility of cartilage to mechanical overloading, which stimulates catabolic metabolism to break down the extracellular matrix and lead to osteoarthritis (OA). The altered mechanical axis from the hip, knee to ankle leads to knee joint pain and ensuing cartilage wear and deterioration, which impact millions of the aged population. Stabilization of the remaining damaged cartilage, and prevention of further deterioration, could provide immense clinical utility and prolong joint function. Our previous work showed that high tibial osteotomy (HTO) could shift the mechanical stress from an imbalanced status to a neutral alignment. However, the underlying mechanisms of endogenous cartilage stabilization after HTO remain unclear. We hypothesize that cartilage-resident mesenchymal stem cells (MSCs) dampen damaged cartilage injury and promote endogenous repair in a varus malaligned knee. The goal of this study is to further examine whether HTO-mediated off-loading would affect human cartilage-resident MSCs' anabolic and catabolic metabolism. This study was approved by IACUC at Xi'an Jiaotong University. Patients with medial compartment OA (52.75±6.85 yrs, left knee 18, right knee 20) underwent open-wedge HTO by the same surgeons at one single academic sports medicine center. Clinical data was documented by the Epic HIS between the dates of April 2019 and April 2022 and radiographic images were collected with a minimum of 12 months of follow-up. Medial compartment OA with/without medial meniscus injury patients with unilateral Kellgren /Lawrence grade 3–4 was confirmed by X-ray. All incisions of the lower extremity healed well after the HTO operation without incision infection. Joint space width (JSW) was measured by uploading to ImageJ software. The Knee injury and Osteoarthritis Outcome Score (KOOS) toolkit was applied to assess the pain level. Outerbridge scores were obtained from a second-look arthroscopic examination. RNA was extracted to quantify catabolic targets and pro-inflammatory genes (QiaGen). Student's t test for two group comparisons and ANOVA analysis for differences between more than 2 groups were utilized. To understand the role of mechanical loading-induced cartilage repair, we measured the serial changes of joint space width (JSW) after HTO for assessing the state of the cartilage stabilization. Our data showed that HTO increased the JSW, decreased the VAS score and improved the KOOS score significantly. We further scored cartilage lesion severity using the Outerbridge classification under a second-look arthroscopic examination while removing the HTO plate. It showed the cartilage lesion area decreased significantly, the full thickness of cartilage increased and mechanical strength was better compared to the pre-HTO baseline. HTO dampened medial tibiofemoral cartilage degeneration and accelerate cartilage repair from Outerbridge grade 2 to 3 to Outerbridge 0 to 1 compared to untreated varus OA. It suggested that physical loading was involved in HTO-induced cartilage regeneration. Given that HTO surgery increases joint space width and creates a physical loading environment, we hypothesize that HTO could increase cartilage composition and collagen accumulation. Consistent with our observation, a group of cartilage-resident MSCs was identified. Our data further showed decreased expression of RUNX2, COL10 and increased SOX9 in MSCs at the RNA level, indicating that catabolic activities were halted during mechanical off-loading. To understand the role of cartilage-resident MSCs in cartilage repair in a biophysical environment, we investigated the differentiation potential of MSCs under 3-dimensional mechanical loading conditions. The physical loading inhibited catabolic markers (IL-1 and IL-6) and increased anabolic markers (SOX9, COL2). Knee-preserved HTO intervention alleviates varus malalignment-related knee joint pain, improves daily and recreation function, and repairs degenerated cartilage of medial compartment OA. The off-loading effect of HTO may allow the mechanoregulation of cartilage repair through the differentiation of endogenous cartilage-derived MSCs

Aims. To explore the clinical relevance of joint space width (JSW) narrowing on standardized-flexion (SF) radiographs in the assessment of cartilage degeneration in specific subregions seen on MRI sequences in knee osteoarthritis (OA) with neutral, valgus, and varus alignments, and potential planning of partial knee arthroplasty. Methods. We retrospectively reviewed 639 subjects, aged 45 to 79 years, in the Osteoarthritis Initiative (OAI) study, who had symptomatic knees with Kellgren and Lawrence grade 2 to 4. Knees were categorized as neutral, valgus, and varus knees by measuring hip-knee-angles on hip-knee-ankle radiographs. Femorotibial JSW was measured on posteroanterior SF radiographs using a special software. The femorotibial compartment was divided into 16 subregions, and MR-tomographic measurements of cartilage volume, thickness, and subchondral bone area were documented. Linear regression with adjustment for age, sex, body mass index, and Kellgren and Lawrence grade was used. Results. We studied 345 neutral, 87 valgus, and 207 varus knees. Radiological JSW narrowing was significantly (p < 0.01) associated with cartilage volume and thickness in medial femorotibial compartment in neutral (r = 0.78, odds ratio (OR) 2.33) and varus knees (r = 0.86, OR 1.92), and in lateral tibial subregions in valgus knees (r = 0.87, OR 3.71). A significant negative correlation was found between JSW narrowing and area of subchondral bone in external lateral tibial subregion in valgus knees (r = −0.65, p < 0.01) and in external medial tibial subregion in varus knees (r = −0.77, p < 0.01). No statistically significant correlation was found in anterior and posterior subregions. Conclusion. SF radiographs can be potentially used for initial detection of cartilage degeneration as assessed by MRI in medial and lateral but not in anterior or posterior subregions. Cite this article: Bone Joint Res 2021;10(3):173–187

Introduction. Chronic uneven distribution of forces over the articular cartilage, which are present in OA, has been shown to be a risk factor for the development of OA. Certain regions of the articular cartilage will be exposed to increased chronic peak loads, whereas other regions encounter a corresponding relative reduction of transmitted forces. This has a well known influence on cartilage viability and is a precursor of degenerative progression. Congruence of joints has an important impact on force distribution across articular surfaces. Therefore, tibiofemoral incongruence could lead to alterations of load distribution and ultimately to progressive degenerative changes. In clinical practice the routine method for evaluation of progressive OA is analysis of joint space width (JSW) using weight bearing radiographs. Recent studies have suggested that JSW has a strong positive correlation with cartilage compression, volume and meniscal extrusion. Lateral unicondylar knee arthroplasty (UKA) has gained increasing popularity over the last decade in the treatment of isolated unicompartmental osteoarthritis (OA). However, progressive degenerative alterations of the medial compartment following lateral unicompartmental knee arthroplasty remains a leading cause of revision surgery. Therefore, the purpose of this study is to evaluate the medial compartment congruence (MCC) and joint space width (JSW) alterations following lateral UKA. Methods. The MCC of 53 knees following lateral UKA was evaluated on pre- and postoperative radiographs and compared to 41 healthy knees, using an Interative Closest Point (ICP) algorithm. The ICP algorithm calculated the Congruence Index (CI) by performing a rigid transformation that best aligns the digitized tibial and femoral surfaces (figure 1A). Inner, middle and outer JSW was measured by subdividing the medial compartment into four quarters on weight bearing tunnel view radiographs pre- and postoperatively (figure 1B). Results. The measured CI of the healthy control group was 0.99. The pre-operative CI of knees undergoing lateral UKA was 0.92, which significantly improved to 0.96 (p<0.0001) post-operatively (figure 2). Post-operatively the inner JSW increased (p=0.006) and the outer decreased (p=0.002). JSW was restored post-operatively since no significant differences were noted in all three measured post-operative JSW locations compared to the control group (figure 3). Conclusion. Our data suggests that lateral UKA improves MCC and normalizes JSW of the medial compartment, potentially preventing osteoarthritic progression in the uninvolved medial compartment

Knee joint distraction (KJD) has been associated with clinical and structural improvement and synovial fluid (SF) marker changes. However, structural changes have not yet been shown satisfactorily in regular care, since radiographic acquisition was not fully standardized. AI-based modules have shown great potential to reduce reading time, increase inter-reader agreement and therefore function as a tool for treatment outcome assessment. The objective was to analyse structural changes after KJD in patients using this AI-based measurement method, and relate these changes to clinical outcome and SF markers. 20 knee OA patients (<65 years old) were included in this study. KJD treatment was performed using an external fixation device, providing 5 mm distraction for 6 weeks. SF was aspirated before, during and immediately after treatment. Weight-bearing antero-posterior knee radiographs and WOMAC questionnaires were collected before and ~one year after treatment. Radiographs were analysed with the Knee Osteoarthritis Labelling Assistant (KOALA, IB Lab GmbH, Vienna, Austria), and 10 pre-defined biomarker levels in SF were measured by immunoassay. Radiographic one-year changes were analysed and linear regression was used to calculate associations between changes in standardized joint space width (JSW) and WOMAC, and changes in JSW and SF markers. After treatment, radiographs showed an improvement in Kellgren-Lawrence grade in 7 of 16 patients that could be evaluated; 3 showed a worsening. Joint space narrowing scores and continuous JSW measures improved especially medially. A greater improvement in JSW was significantly associated with a greater improvement in WOMAC pain (β=0.64;p=0.020). A greater increase in MCP1 (β=0.67;p=0.033) and lower increase in TGFβ1 (β=-0.787;p=0.007) were associated with JSW improvement. Despite the small number of patients, also in regular care KJD treatment shows joint repair as measured automatically on radiographs, significantly associated with certain SF marker change and even with clinical outcome

It is unclear whether patients with early radiographic osteoarthritis (OA) but severe hip symptoms benefit from total hip replacement (THR). We aimed to assess which factors were associated with successful THR in this patient group. From a consecutive series of 1,935 patients undergoing THR we identified 70 (3.6%) patients with early OA (Kellgren and Lawrence (KL) grades 0-2). These were compared with 200 patients with advanced OA (KL grades 3–4). Outcomes were Oxford Hip Scores (OHS), EQ5D and EQ-VAS scores; compared pre-operatively with one year post-operatively. We investigated which clinical and radiographic (plain x-ray, CT, MRI) features predicted successful THR in the early OA group. Success was defined as reaching a postoperative OHS≥42. The early OA group were significantly younger (61 vs 66 years; P=0.0035). There were no significant differences in body mass index, ASA grade or gender. After adjusting for confounders, the advanced OA group had a significantly greater percentage of possible change (PoPC) in OHS (75.8% versus 50.4%; P<0.0001) and improvement in EQ5D (0.151 versus 0.002; P<0.0001). There were no significant differences in complication, revision or readmission rates. In the early OA group, we identified 16/70 (22.9%) patients who had a ‘successful’ THR. Of those with early OA, 38 patients had pre-operative CT or MRI scans. Patients who had a ‘successful’ THR were significantly more likely to have subchondral cysts on CT/MRI (91.7% versus 57.7%; P=0.0362). The presence of cysts on CT/MRI was associated with a significantly greater PoPC in OHS (61.6% versus 38.2%; P=0.0353). The combination of cysts and joint space width (JSW) <1mm was associated with a PoPC of 68%. Plain radiographs were found to significantly underestimate the narrowest JSW compared to CT/MRI (2.4mm versus 1.0mm; P<0.0001). We advise caution in performing THRs in patients with early OA (KL grades 0-2) on plain radiographs. We advocate pre-operative cross-sectional imaging (CT or MRI) in these patients. In the absence of cysts on cross-sectional imaging, a THR seems unlikely to provide a satisfactory outcome

Introduction. As orthopaedics shifts towards value-based models of care, methods of evaluating the value of procedures such as a total hip arthroplasty (THA) will become crucial. Patient reported outcome measures (PROMs) can offer a meaningful way for patient-centered input to factor into the determination of value. Despite their benefits, PROMs can be difficult to interpret as statistically significant, but not clinically relevant, differences between groups can be found. One method of correcting this issue is by using a minimal clinically important improvement (MCII), defined as the smallest improvement in a PROM determined to be important to patients. This study aims to find demographic and surgical factors that are independently predictive of failing to achieve a MCII in pain and physical function at 1-year following THA. Methods. A total of 976 patients were enrolled into a prospective international, multicenter study evaluating the long-term clinical performance of two acetabular shells and two polyethylene liners from a single manufacturer. All patients consented to be followed with plain radiographs and a set of PROMs preoperatively and at 1-year after surgery. The outcomes considered in this study were achieving literature-defined MCIIs in pain and physical function at one year after THA. The MCII in pain was defined as achieving a 2-point decrease on the Numerical Rating Scale (NRS)-Pain or reporting a 1-year NRS-Pain value of 0, indicating no pain. The MCII in physical function was defined as achieving an 8.29-point increase on the SF-36 Physical Function subscore. Univariate analyses were conducted to determine if there were statistically significant differences between patients who did achieve and did not achieve a MCII. Variables tested included: demographic and surgical factors, general and mental health state, and preoperative radiographic findings such as deformity and joint space width (JSW). Significant variables were entered into a multivariable binary logistic regression. Receiver-operating characteristic (ROC) analysis was used to generate cutoff values for significant continuous variables. Youden's index was used to identify cutoff points that maximized both specificity and sensitivity. Results. Of 976 enrolled patients, 630 (65%) patients had complete preoperative and 1-year PROMs and a valid preoperative radiograph. Of the final cohort, 59 (9%) patients did not achieve the MCII in pain and 208 (33%) patients did not achieve the MCII in physical function following THA. Multivariable analysis determined that higher preoperative JSW (odds ratio (OR)=2.04; p<0.001), and lower preoperative SF-36 Mental Composite Score (MCS) (OR=0.96; p<0.001) were independently predictive of not achieving a MCII in pain. ROC analysis determined that cutoff points for preoperative JSW and MCS were 0.65mm and 47.4 points, respectively. In a separate multivariable regression, we found higher preoperative JSW (OR=1.40; p=0.010) and higher preoperative HHS (OR=1.03; p<0.001) to be independently predictive of not achieving a MCII in physical function. Cutoff points for preoperative JSW and HHS were respectively 0.65mm and 50.5 points. Conclusion. In the upcoming era of value-based orthopaedics, each treatment must produce a meaningful clinical improvement per dollar spent. To help achieve this goal, this study has identified that patients with less severe OA, poor mental health, and good preoperative hip function are at a higher risk for not achieving MCIIs in pain or function after THA. Surgeons can use this analysis to discuss the appropriateness of a THA with their patients, frame patient expectations, and broach the possibility of delaying surgery if the patient has risk factors for poor improvement

Background/Objective: Since estrogen receptors (ERα/ERβ) were identified in human chondrocytes, animal-and experimental studies have demonstrated the importance of continued estrogen production for the integrity of articular cartilage. However, human epidemiological support of the hypothesis has been inconclusive. The present study investigated the relationship between reduced bone mineral densities (BMD), as a surrogate parameter of endogenous estrogen status – assessed by digital x-ray radiogrammetry (DXR), and reduced minimum hip joint space width (JSW). Methods: Standardised hand radiographs of the Copenhagen Osteoarthritis Study cohort of 3.913 adults (1.470M/2.443F) with a mean age of 60 years (range, 18–92), were analysed by the X-Posure. ™. digital software v. 2.0 (Sectra-Pronosco). The system is operator independent. From 1.200 individual measurements per radiograph mean BMD was calculated. Minimum hip joint JSW was assessed in standardized, pelvic radiographs. Results: DXR-BMD decreased in both men and women after the age of 45 years, progressively more so in women. While minimum hip JSW in men remained relatively unaltered throughout life, a marked decline in female minimum hip JSW after 45 years was observed. We found moderate, but highly significant relationships between reduced BMD and reduced hip JSW in women (p < 0.001), adjusted for age and dysplastic joint incongruity. Conclusion: We believe that the present study supports the hypothetical relationship between reduced estrogen levels and hip joint space width reduction in women

Purpose of study: The aim of this project was to ascertain whether tibio-femoral joint space width (JSW) measured both on Schuss and full extension radiographic views were predictive and accurate relative to the articular cartilage findings on arthroscopy. Methods & Results: The study was a prospective trial. The criterion for recruitment was knee pain indicative of arthritis that required arthroscopic assessment with a view to possible surgical management. Joint space narrowing (JSN) was assessed in the affected knee, in both the standing full extension and Schuss views. Joint arthroscopy was performed and each compartment area of the knee was calibrated and graded corresponding to the arthritic changes identified. In the 60 patients recruited, 61.7% were found to have grade 4 arthritic changes on knee arthroscopy. JSN in those with associated grade 4 changes on arthroscopy on either full extension or Schuss views was 75.7% and 78.4% respectively. However in 24.3% of those with grade 4 changes on arthroscopy no JSN was demonstrated on either full extension or Schuss views. Arthroscopic assessment of severe arthritic changes of the knee was significantly superior compared to the radiographic method (p< 0.05). Conclusions: The findings suggest that despite narrowed JSW measured on either radiographic view being indicative of severe articular cartilage loss, neither view accurately predicts articular cartilage loss in less advanced cases. In cases of grade 4 changes and no JSN the sites of articular cartilage loss corresponded to sites that are less likely to be accurately represented on either radiographic view. Our findings suggest that knee arthroscopy may be better suited to identifying smaller patches of cartilage loss whose surface area may not be sufficient to cause JSN but may still cause symptoms. We suggest knee arthroscopy is indicated in patients with knee pain suspicious of arthritis but who lack obvious JSN on either full extension or Schuss views. This enables micro-fracture techniques to be used with the aim of attenuating disease progression, and offers a thorough lavage that may also provide symptom relief

Summary. The dGEMRIC index correlates more strongly with the pattern of radiographic joint space narrowing in hip osteoarthritis at five year follow-up than morphological measurements of the proximal femur. It therefore offers potential to refine predictive models of hip osteoarthritis progression. Introduction. Longitudinal general population studies have shown that femoroacetabular impingement increases the risk of developing hip osteoarthritis, however, morphological parameters have a low positive predictive value. Arthroscopic debridement of impingement lesions has been proposed as a potential strategy for the prevention of osteoarthritis, however, the development of such strategies requires the identification of individuals at high risk of disease progression. We investigated whether delayed Gadolinium-Enhanced MRI of Cartilage (dGEMRIC) predicts disease progression. This imaging modality is an indirect measure of cartilage glycosaminoglycan content. Patients and Methods. 34 asymptomatic individuals from a longitudinal cohort study (sibkids) were assessed at baseline with the collection of Patient Reported Outcome Measures (PROMs), anteroposterior and cross-table lateral radiographs, 3D morphological MRI, and dGEMRIC at 3T of their index hip. A dGEMRIC index was calculated as a ratio of the anterosuperior acetabular cartilage T1 relaxation time and the total femoral and acetabular cartilage T1 relaxation time. 29 individuals were followed up at 5 years for repeat assessment (average age 51 years and range 36 to 67). Radiological measurements were made by a single observer using in house Hipmorf software. Radiographic disease progression was assessed using minimum joint space width (JSW), lateral sourcil JSW, and medial sourcil JSW. These were measured on baseline and five year follow-up anteroposterior radiographs with an intra-observer ICC of 0.916. Alpha angle measurements were made by the same observer on radiographs and MRI radial slices with an intra-observer ICC of 0.926. Results. Mean minimum JSW for the cohort fell by 0.16mm over five years (p=0.024). Baseline dGEMRIC index did not correlate with change in minimum JSW (r=0.031 p=0.873). There was a moderate correlation between baseline dGEMRIC and the direction of JSW loss (change in JSW at the lateral sourcil minus change in JSW at the medial sourcil) (r=0.561 p=0.002). There was a weak correlation between the change in Non-Arthritic Hip Score and baseline dGEMRIC (r=0.256 P=0.180). Maximum alpha angle measured on baseline MRI radial slices did not correlate with change in minimum JSW and weakly correlated with the direction of JSW narrowing (r=0.273 p=0.160). Conclusion. A low dGEMRIC index indicates reduced glycosaminoglycan concentration in the anterosuperior acetabular cartilage compared with the total femoral and acetabular cartilage. This correlates with lateral JSW narrowing relative to medial JSW narrowing as osteoarthritis progresses. The dGEMRIC index correlates better with osteoarthritis progression than alpha angle measurements and offers the potential to refine a predictive model for osteoarthritis progression to aid patient selection for clinical trials