Knee

SAN DIEGO – Rheumatoid arthritis patients undergoing surgery who stayed on their antirheumatic medication perioperatively didn’t have a higher risk of early postoperative infection compared with those who temporarily stopped treatment before surgery, according to findings from a large national Veterans Affairs study.

Rheumatologists are frequently consulted about this issue. Evidence to guide practice has been scarce, however, and until now many rheumatologists and surgeons have taken a conservative approach, reasoning that the immunosuppressive drugs employed in controlling inflammation in rheumatoid arthritis might also increase the risk of surgical wound infection.

A common practice has been to have RA patients stop their medication a month ahead of elective surgery, or at least two drug half-lives beforehand, then start treatment again roughly a month after the operation, or when the wound has healed. The new Veterans Affairs (VA) study findings suggest this practice may be unnecessary, Dr. Zaki Abou Zahr said at the annual meeting of the American College of Rheumatology.

Dr. Bernard Ng, his senior coinvestigator in the study, added that temporarily stopping antirheumatic agents before surgery may actually be harmful in that it increases the risk of a flare of the RA, which in turn would impede postoperative rehabilitation.

But there is a major caveat regarding the VA study: Participation was restricted to RA patients on only a single conventional disease-modifying antirheumatic drug (DMARD) or biologic agent leading up to surgery. This restriction, imposed to make for a more clear-cut analysis, means that the study results can’t be extrapolated to patients on multidrug therapy. And multidrug therapy is quite common. Indeed, slightly more than half of RA patients in the VA health care system are on combination therapy, most often methotrexate plus a biologic agent, noted Dr. Ng, chief of rheumatology at the VA Puget Sound Health Care System, Seattle.

Dr. Abou Zahr presented the retrospective cohort study involving 6,548 RA patients in VA administrative databases, all of whom were on antirheumatic drug monotherapy prior to surgery. The surgery was of all types, including cardiothoracic, gastrointestinal, vascular, and orthopedic, as well as emergent and elective.

The primary endpoints were the rate of wound infections, both superficial and deep, within 30 days post surgery, and the general infection rate – including pneumonia, sepsis, and urinary tract infections – during the same time frame.

Sixty-two percent of the 1,480 RA patients on a single biologic agent did not stop taking it preoperatively. One key study finding was that neither their postoperative wound infection rate nor their general infection rate differed significantly from rates in patients who temporarily halted their biologic agent. The same held true among the 70% of patients on a single conventional DMARD who did not stop taking their medication preoperatively, according to Dr. Abou Zahr of Baylor College of Medicine, Houston.

Dr. Ng said the investigators plan to extend their work to include RA patients on multiple antirheumatic drugs that they do or don’t temporarily stop when undergoing surgery within the VA system. The researchers also plan to take a close look at patients undergoing specific types of surgery to see if the postoperative infection risk in patients who remain on treatment varies according to their operation.

Dr. Fehmida Zahabi, a rheumatologist from Plano, Tex., who chaired a press conference highlighting the VA study findings, said that while she’d like to see a confirmatory study, "I think we’re getting to the point where we’re saying we should cautiously keep these patients on their medications. That’s what the data suggest."

She noted that before the VA study, the very limited evidence available to guide practice in this area centered on a 12-year-old British randomized trial involving RA patients on methotrexate undergoing elective orthopedic surgery. Those assigned to stop the drug from 2 weeks before surgery to 2 weeks post surgery had significantly more infections, surgical complications, and RA flares within 6 weeks after surgery (Ann. Rheum. Dis. 2001;60:214-7).

As for patients on multidrug therapy who are scheduled for surgery, her inclination until evidence becomes available for guidance is to pare down the regimen preoperatively, while keeping the patient on one or two drugs.

The VA study was funded by the Department of Veterans Affairs. Dr. Abou Zahr and Dr. Ng reported having no conflicts of interest.

[email protected]

SAN DIEGO – Rheumatoid arthritis patients undergoing surgery who stayed on their antirheumatic medication perioperatively didn’t have a higher risk of early postoperative infection compared with those who temporarily stopped treatment before surgery, according to findings from a large national Veterans Affairs study.

Rheumatologists are frequently consulted about this issue. Evidence to guide practice has been scarce, however, and until now many rheumatologists and surgeons have taken a conservative approach, reasoning that the immunosuppressive drugs employed in controlling inflammation in rheumatoid arthritis might also increase the risk of surgical wound infection.

A common practice has been to have RA patients stop their medication a month ahead of elective surgery, or at least two drug half-lives beforehand, then start treatment again roughly a month after the operation, or when the wound has healed. The new Veterans Affairs (VA) study findings suggest this practice may be unnecessary, Dr. Zaki Abou Zahr said at the annual meeting of the American College of Rheumatology.

Dr. Bernard Ng, his senior coinvestigator in the study, added that temporarily stopping antirheumatic agents before surgery may actually be harmful in that it increases the risk of a flare of the RA, which in turn would impede postoperative rehabilitation.

But there is a major caveat regarding the VA study: Participation was restricted to RA patients on only a single conventional disease-modifying antirheumatic drug (DMARD) or biologic agent leading up to surgery. This restriction, imposed to make for a more clear-cut analysis, means that the study results can’t be extrapolated to patients on multidrug therapy. And multidrug therapy is quite common. Indeed, slightly more than half of RA patients in the VA health care system are on combination therapy, most often methotrexate plus a biologic agent, noted Dr. Ng, chief of rheumatology at the VA Puget Sound Health Care System, Seattle.

Dr. Abou Zahr presented the retrospective cohort study involving 6,548 RA patients in VA administrative databases, all of whom were on antirheumatic drug monotherapy prior to surgery. The surgery was of all types, including cardiothoracic, gastrointestinal, vascular, and orthopedic, as well as emergent and elective.

The primary endpoints were the rate of wound infections, both superficial and deep, within 30 days post surgery, and the general infection rate – including pneumonia, sepsis, and urinary tract infections – during the same time frame.

Sixty-two percent of the 1,480 RA patients on a single biologic agent did not stop taking it preoperatively. One key study finding was that neither their postoperative wound infection rate nor their general infection rate differed significantly from rates in patients who temporarily halted their biologic agent. The same held true among the 70% of patients on a single conventional DMARD who did not stop taking their medication preoperatively, according to Dr. Abou Zahr of Baylor College of Medicine, Houston.

Dr. Ng said the investigators plan to extend their work to include RA patients on multiple antirheumatic drugs that they do or don’t temporarily stop when undergoing surgery within the VA system. The researchers also plan to take a close look at patients undergoing specific types of surgery to see if the postoperative infection risk in patients who remain on treatment varies according to their operation.

Dr. Fehmida Zahabi, a rheumatologist from Plano, Tex., who chaired a press conference highlighting the VA study findings, said that while she’d like to see a confirmatory study, "I think we’re getting to the point where we’re saying we should cautiously keep these patients on their medications. That’s what the data suggest."

She noted that before the VA study, the very limited evidence available to guide practice in this area centered on a 12-year-old British randomized trial involving RA patients on methotrexate undergoing elective orthopedic surgery. Those assigned to stop the drug from 2 weeks before surgery to 2 weeks post surgery had significantly more infections, surgical complications, and RA flares within 6 weeks after surgery (Ann. Rheum. Dis. 2001;60:214-7).

As for patients on multidrug therapy who are scheduled for surgery, her inclination until evidence becomes available for guidance is to pare down the regimen preoperatively, while keeping the patient on one or two drugs.

The VA study was funded by the Department of Veterans Affairs. Dr. Abou Zahr and Dr. Ng reported having no conflicts of interest.

[email protected]

SAN DIEGO – Rheumatoid arthritis patients undergoing surgery who stayed on their antirheumatic medication perioperatively didn’t have a higher risk of early postoperative infection compared with those who temporarily stopped treatment before surgery, according to findings from a large national Veterans Affairs study.

Rheumatologists are frequently consulted about this issue. Evidence to guide practice has been scarce, however, and until now many rheumatologists and surgeons have taken a conservative approach, reasoning that the immunosuppressive drugs employed in controlling inflammation in rheumatoid arthritis might also increase the risk of surgical wound infection.

A common practice has been to have RA patients stop their medication a month ahead of elective surgery, or at least two drug half-lives beforehand, then start treatment again roughly a month after the operation, or when the wound has healed. The new Veterans Affairs (VA) study findings suggest this practice may be unnecessary, Dr. Zaki Abou Zahr said at the annual meeting of the American College of Rheumatology.

Dr. Bernard Ng, his senior coinvestigator in the study, added that temporarily stopping antirheumatic agents before surgery may actually be harmful in that it increases the risk of a flare of the RA, which in turn would impede postoperative rehabilitation.

But there is a major caveat regarding the VA study: Participation was restricted to RA patients on only a single conventional disease-modifying antirheumatic drug (DMARD) or biologic agent leading up to surgery. This restriction, imposed to make for a more clear-cut analysis, means that the study results can’t be extrapolated to patients on multidrug therapy. And multidrug therapy is quite common. Indeed, slightly more than half of RA patients in the VA health care system are on combination therapy, most often methotrexate plus a biologic agent, noted Dr. Ng, chief of rheumatology at the VA Puget Sound Health Care System, Seattle.

Dr. Abou Zahr presented the retrospective cohort study involving 6,548 RA patients in VA administrative databases, all of whom were on antirheumatic drug monotherapy prior to surgery. The surgery was of all types, including cardiothoracic, gastrointestinal, vascular, and orthopedic, as well as emergent and elective.

The primary endpoints were the rate of wound infections, both superficial and deep, within 30 days post surgery, and the general infection rate – including pneumonia, sepsis, and urinary tract infections – during the same time frame.

Sixty-two percent of the 1,480 RA patients on a single biologic agent did not stop taking it preoperatively. One key study finding was that neither their postoperative wound infection rate nor their general infection rate differed significantly from rates in patients who temporarily halted their biologic agent. The same held true among the 70% of patients on a single conventional DMARD who did not stop taking their medication preoperatively, according to Dr. Abou Zahr of Baylor College of Medicine, Houston.

Dr. Ng said the investigators plan to extend their work to include RA patients on multiple antirheumatic drugs that they do or don’t temporarily stop when undergoing surgery within the VA system. The researchers also plan to take a close look at patients undergoing specific types of surgery to see if the postoperative infection risk in patients who remain on treatment varies according to their operation.

Dr. Fehmida Zahabi, a rheumatologist from Plano, Tex., who chaired a press conference highlighting the VA study findings, said that while she’d like to see a confirmatory study, "I think we’re getting to the point where we’re saying we should cautiously keep these patients on their medications. That’s what the data suggest."

She noted that before the VA study, the very limited evidence available to guide practice in this area centered on a 12-year-old British randomized trial involving RA patients on methotrexate undergoing elective orthopedic surgery. Those assigned to stop the drug from 2 weeks before surgery to 2 weeks post surgery had significantly more infections, surgical complications, and RA flares within 6 weeks after surgery (Ann. Rheum. Dis. 2001;60:214-7).

As for patients on multidrug therapy who are scheduled for surgery, her inclination until evidence becomes available for guidance is to pare down the regimen preoperatively, while keeping the patient on one or two drugs.

The VA study was funded by the Department of Veterans Affairs. Dr. Abou Zahr and Dr. Ng reported having no conflicts of interest.

[email protected]

Three of the five recommendations in the first-ever list developed by the American Academy of Orthopaedic Surgeons for the American Board of Internal Medicine Foundation’s "Choosing Wisely" campaign focus primarily on treatments for symptomatic osteoarthritis.

The campaign is meant to educate patients and physicians about unnecessary and potentially harmful testing and treatment.

According to the Choosing Wisely website, the AAOS’s list was formed based on a review of the most recent approved clinical practice guidelines previously developed by AAOS physician volunteer work groups and a selection of a variety of topics frequently used in orthopaedic surgical practice with input from specialty society leaders and the Academy’s presidential leadership and board of directors. The list was created with the intent to "serve as an educational tool based on an assessment of the current scientific and clinical information and accepted approaches to treatment."

However, some specialists find fault with the recommendations. For example, Dr. Roy Altman, a professor of medicine in the division of rheumatology and immunology at the University of California, Los Angeles, said the methodology used to create the guidelines overlooks a number of treatments, including multimodal therapy, and could have the unintended consequence of allowing specialists to deny effective care to patients.

"These guidelines are not consistent with my clinical experience," Dr. Altman said. In particular, he noted that many of his patients react positively to injection treatments for osteoarthritis (OA), which the Choosing Wisely recommendations specifically discourage.

AAOS’s recommendations are as follows:

• Avoid using postoperative ultrasonography screening for deep vein thrombosis on patients receiving hip or knee arthroplasty because it is not effective at diagnosing unsuspected cases.

• Don’t use needle lavage for long-term relief in symptomatic OA treatment, as the procedure "does not lead to measurable improvements in pain, function, 50-foot walking time, stiffness, tenderness, or swelling."

• Do not use glucosamine and chondroitin sulfate to treat patients with symptomatic knee OA.

• Lateral wedge or neutral insoles do not improve pain or functional outcomes in patients; on the contrary, patients with OA of the knee may experience fewer symptoms without insoles.

• Routine postoperative splinting of the wrist after the carpal tunnel release procedure does not improve subjective outcomes, and may lead to detrimental effects, including adhesion formation, stiffness, and prevention of nerve and tendon movement.

[email protected]

Three of the five recommendations in the first-ever list developed by the American Academy of Orthopaedic Surgeons for the American Board of Internal Medicine Foundation’s "Choosing Wisely" campaign focus primarily on treatments for symptomatic osteoarthritis.

The campaign is meant to educate patients and physicians about unnecessary and potentially harmful testing and treatment.

According to the Choosing Wisely website, the AAOS’s list was formed based on a review of the most recent approved clinical practice guidelines previously developed by AAOS physician volunteer work groups and a selection of a variety of topics frequently used in orthopaedic surgical practice with input from specialty society leaders and the Academy’s presidential leadership and board of directors. The list was created with the intent to "serve as an educational tool based on an assessment of the current scientific and clinical information and accepted approaches to treatment."

However, some specialists find fault with the recommendations. For example, Dr. Roy Altman, a professor of medicine in the division of rheumatology and immunology at the University of California, Los Angeles, said the methodology used to create the guidelines overlooks a number of treatments, including multimodal therapy, and could have the unintended consequence of allowing specialists to deny effective care to patients.

"These guidelines are not consistent with my clinical experience," Dr. Altman said. In particular, he noted that many of his patients react positively to injection treatments for osteoarthritis (OA), which the Choosing Wisely recommendations specifically discourage.

AAOS’s recommendations are as follows:

• Avoid using postoperative ultrasonography screening for deep vein thrombosis on patients receiving hip or knee arthroplasty because it is not effective at diagnosing unsuspected cases.

• Don’t use needle lavage for long-term relief in symptomatic OA treatment, as the procedure "does not lead to measurable improvements in pain, function, 50-foot walking time, stiffness, tenderness, or swelling."

• Do not use glucosamine and chondroitin sulfate to treat patients with symptomatic knee OA.

• Lateral wedge or neutral insoles do not improve pain or functional outcomes in patients; on the contrary, patients with OA of the knee may experience fewer symptoms without insoles.

• Routine postoperative splinting of the wrist after the carpal tunnel release procedure does not improve subjective outcomes, and may lead to detrimental effects, including adhesion formation, stiffness, and prevention of nerve and tendon movement.

[email protected]

Three of the five recommendations in the first-ever list developed by the American Academy of Orthopaedic Surgeons for the American Board of Internal Medicine Foundation’s "Choosing Wisely" campaign focus primarily on treatments for symptomatic osteoarthritis.

The campaign is meant to educate patients and physicians about unnecessary and potentially harmful testing and treatment.

According to the Choosing Wisely website, the AAOS’s list was formed based on a review of the most recent approved clinical practice guidelines previously developed by AAOS physician volunteer work groups and a selection of a variety of topics frequently used in orthopaedic surgical practice with input from specialty society leaders and the Academy’s presidential leadership and board of directors. The list was created with the intent to "serve as an educational tool based on an assessment of the current scientific and clinical information and accepted approaches to treatment."

However, some specialists find fault with the recommendations. For example, Dr. Roy Altman, a professor of medicine in the division of rheumatology and immunology at the University of California, Los Angeles, said the methodology used to create the guidelines overlooks a number of treatments, including multimodal therapy, and could have the unintended consequence of allowing specialists to deny effective care to patients.

"These guidelines are not consistent with my clinical experience," Dr. Altman said. In particular, he noted that many of his patients react positively to injection treatments for osteoarthritis (OA), which the Choosing Wisely recommendations specifically discourage.

AAOS’s recommendations are as follows:

• Avoid using postoperative ultrasonography screening for deep vein thrombosis on patients receiving hip or knee arthroplasty because it is not effective at diagnosing unsuspected cases.

• Don’t use needle lavage for long-term relief in symptomatic OA treatment, as the procedure "does not lead to measurable improvements in pain, function, 50-foot walking time, stiffness, tenderness, or swelling."

• Do not use glucosamine and chondroitin sulfate to treat patients with symptomatic knee OA.

• Lateral wedge or neutral insoles do not improve pain or functional outcomes in patients; on the contrary, patients with OA of the knee may experience fewer symptoms without insoles.

• Routine postoperative splinting of the wrist after the carpal tunnel release procedure does not improve subjective outcomes, and may lead to detrimental effects, including adhesion formation, stiffness, and prevention of nerve and tendon movement.

[email protected]

Denosumab is approved for the treatment of giant cell tumors of the bone, the Food and Drug Administration announced June 13.

Rare and usually noncancerous, giant cell tumors of the bone generally affect 20- to 40-year-olds. Most of these tumors destroy growing bone, causing pain, limited range of motion, and bone fractures. Rarely, the tumors become cancerous and spread to the lungs.

Denosumab (Xgeva) is indicated for use in patients who are not candidates for surgical resection of their tumors or when surgery is likely to result in severe morbidity, such as loss of limbs or joint removal. It should be used only in adolescents whose bones have matured, the FDA said in a statement.

"Today’s approval of Xgeva provides a needed treatment option for patients with GCTB who are not surgical candidates or who would otherwise have to undergo extensive, life-altering surgery," said Dr. Richard Pazdur, director of the Office of Hematology and Oncology Products in the FDA’s Center for Drug Evaluation and Research.

The FDA reviewed denosumab under its priority review program as the drug was granted orphan product designation because GCTB is a rare disease.

The safety and effectiveness of denosumab for GCTB were established in two clinical trials that enrolled 305 adult or adolescent patients with confirmed GCTB that was recurrent, unresectable, or would be associated with severe morbidity if surgically managed.

After an average of 3 months, tumors reduced in size among 47 of 187 patients whose tumors could be measured. Over an average follow-up of 20 months, GCTBs regrew in three patients whose tumors originally became smaller during treatment.

Common side effects of denosumab included joint pain, headache, nausea, fatigue, back pain, and extremity pain. The most common serious side effects were osteonecrosis of the jaw and osteomyelitis. Women of reproductive potential should use highly effective contraception while taking denosumab because of potential fetal harm, according to the FDA.

Denosumab was approved in 2010 to prevent fractures when cancer has spread to the bones. It is marketed by Amgen.

[email protected]

On Twitter @maryjodales

Denosumab is approved for the treatment of giant cell tumors of the bone, the Food and Drug Administration announced June 13.

Rare and usually noncancerous, giant cell tumors of the bone generally affect 20- to 40-year-olds. Most of these tumors destroy growing bone, causing pain, limited range of motion, and bone fractures. Rarely, the tumors become cancerous and spread to the lungs.

Denosumab (Xgeva) is indicated for use in patients who are not candidates for surgical resection of their tumors or when surgery is likely to result in severe morbidity, such as loss of limbs or joint removal. It should be used only in adolescents whose bones have matured, the FDA said in a statement.

"Today’s approval of Xgeva provides a needed treatment option for patients with GCTB who are not surgical candidates or who would otherwise have to undergo extensive, life-altering surgery," said Dr. Richard Pazdur, director of the Office of Hematology and Oncology Products in the FDA’s Center for Drug Evaluation and Research.

The FDA reviewed denosumab under its priority review program as the drug was granted orphan product designation because GCTB is a rare disease.

The safety and effectiveness of denosumab for GCTB were established in two clinical trials that enrolled 305 adult or adolescent patients with confirmed GCTB that was recurrent, unresectable, or would be associated with severe morbidity if surgically managed.

After an average of 3 months, tumors reduced in size among 47 of 187 patients whose tumors could be measured. Over an average follow-up of 20 months, GCTBs regrew in three patients whose tumors originally became smaller during treatment.

Common side effects of denosumab included joint pain, headache, nausea, fatigue, back pain, and extremity pain. The most common serious side effects were osteonecrosis of the jaw and osteomyelitis. Women of reproductive potential should use highly effective contraception while taking denosumab because of potential fetal harm, according to the FDA.

Denosumab was approved in 2010 to prevent fractures when cancer has spread to the bones. It is marketed by Amgen.

[email protected]

On Twitter @maryjodales

Denosumab is approved for the treatment of giant cell tumors of the bone, the Food and Drug Administration announced June 13.

Rare and usually noncancerous, giant cell tumors of the bone generally affect 20- to 40-year-olds. Most of these tumors destroy growing bone, causing pain, limited range of motion, and bone fractures. Rarely, the tumors become cancerous and spread to the lungs.

Denosumab (Xgeva) is indicated for use in patients who are not candidates for surgical resection of their tumors or when surgery is likely to result in severe morbidity, such as loss of limbs or joint removal. It should be used only in adolescents whose bones have matured, the FDA said in a statement.

"Today’s approval of Xgeva provides a needed treatment option for patients with GCTB who are not surgical candidates or who would otherwise have to undergo extensive, life-altering surgery," said Dr. Richard Pazdur, director of the Office of Hematology and Oncology Products in the FDA’s Center for Drug Evaluation and Research.

The FDA reviewed denosumab under its priority review program as the drug was granted orphan product designation because GCTB is a rare disease.

The safety and effectiveness of denosumab for GCTB were established in two clinical trials that enrolled 305 adult or adolescent patients with confirmed GCTB that was recurrent, unresectable, or would be associated with severe morbidity if surgically managed.

After an average of 3 months, tumors reduced in size among 47 of 187 patients whose tumors could be measured. Over an average follow-up of 20 months, GCTBs regrew in three patients whose tumors originally became smaller during treatment.

Common side effects of denosumab included joint pain, headache, nausea, fatigue, back pain, and extremity pain. The most common serious side effects were osteonecrosis of the jaw and osteomyelitis. Women of reproductive potential should use highly effective contraception while taking denosumab because of potential fetal harm, according to the FDA.

Denosumab was approved in 2010 to prevent fractures when cancer has spread to the bones. It is marketed by Amgen.

[email protected]

On Twitter @maryjodales

PHILADELPHIA – Knowledge of a patient’s age, gender, quality of life score, and radiographic knee osteoarthritis severity helps predict the odds of a patient undergoing total knee arthroplasty in the next 5 years.

Few studies have looked at the predictors of total knee arthroplasty (TKA) in community-based cohorts, despite the heavy burden of TKA in the United States, said Dr. Marc C. Hochberg, head of rheumatology and clinical immunology, University of Maryland, Baltimore. An estimated 4 million Americans already live with TKA, and more than half of adults diagnosed with knee osteoarthritis (OA) will undergo TKA (J. Bone Joint Surg. Am. 2013;95:385-92).

For the current analysis, Dr. Hochberg and his associates obtained 48 months of annual clinical follow-up data on 6,406 patients in the Osteoarthritis Initiative who had symptomatic, radiographic knee OA or who were at risk for the condition. Follow-up at 60 months involved only questionnaires. Consensus readings of knee radiographs were used for the analysis, along with knee-specific multiple variable regression models. The best models were selected based on Chi-square values and area under the receiver operating characteristic curve (AUC). Radiographic knee OA Kellgren-Lawrence (KL) severity grade 0, 1, 2, 3, and 4 was present in the right knee of 36%, 18%, 28%, 14%, and 3.5% of patients and in the left knee of 38%, 18%, 26%, 14.4%, and 3.3% of patients.

A little more than half of participants were women (58.4%), mean body mass index was 28.7 kg/m², mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score was 2.47 (0-20 scale), mean WOMAC function score was 8.33 (0-68 scale), and mean Knee injury and Osteoarthritis Outcome Score (KOOS) (quality of life) was 66.10 (0-100 scale). Their average age was 62.7, he said at the World Congress on Osteoarthritis, sponsored by the Osteoarthritis Research Society International.

During the 60 months of follow-up, there were 91 right and 102 left TKAs. The AUC for age, sex, and BMI was 0.64 for the right knee and 0.67 for the left knee.

The best TKA prediction models included age, sex, BMI, and KOOS quality-of-life score, improving the AUC to 0.78 for the right knee and 0.80 for the left knee, Dr. Hochberg said. Addition of the WOMAC pain score was associated with a marginal, but significant improvement in the AUC (0.79 and 0.80, respectively). When KL grade was added to these models, the AUC reached 0.89 and 0.91 for the right and left knees, respectively, he said. Sensitivity analyses failed to demonstrate additional effects of other baseline variables when added.

Limitations of the study included the relatively few TKAs, that most patients had KL grade 2 at baseline, proportional hazards analyses were not used, and the study did not consider a correlation between knees or the change in independent variables over time, he said.

In a prospective Canadian study, willingness to undergo surgery was the strongest predictor of the time to first hip or knee total joint replacement (TJR) (Arthritis Rheum. 2006;54:3212-20), while an international OARSI Task Force reported that pain and disability was higher in patients recommended for hip or knee TJR (Osteoarthritis Cartilage 2011;19:147-54). The Task Force, which included Dr. Hochberg, could not, however, identify cut points for pain and disability that would discriminate between those who did or did not get the nod for surgery.

The Osteoarthritis Initiative is sponsored by the National Institutes of Health. Dr. Hochberg reported serving as a consultant for Allergan, Bioiberica, Iroko, Merck, and Pfizer, and as a scientific/medical advisory board member for Eli Lilly and Merck.

[email protected]

PHILADELPHIA – Knowledge of a patient’s age, gender, quality of life score, and radiographic knee osteoarthritis severity helps predict the odds of a patient undergoing total knee arthroplasty in the next 5 years.

Few studies have looked at the predictors of total knee arthroplasty (TKA) in community-based cohorts, despite the heavy burden of TKA in the United States, said Dr. Marc C. Hochberg, head of rheumatology and clinical immunology, University of Maryland, Baltimore. An estimated 4 million Americans already live with TKA, and more than half of adults diagnosed with knee osteoarthritis (OA) will undergo TKA (J. Bone Joint Surg. Am. 2013;95:385-92).

For the current analysis, Dr. Hochberg and his associates obtained 48 months of annual clinical follow-up data on 6,406 patients in the Osteoarthritis Initiative who had symptomatic, radiographic knee OA or who were at risk for the condition. Follow-up at 60 months involved only questionnaires. Consensus readings of knee radiographs were used for the analysis, along with knee-specific multiple variable regression models. The best models were selected based on Chi-square values and area under the receiver operating characteristic curve (AUC). Radiographic knee OA Kellgren-Lawrence (KL) severity grade 0, 1, 2, 3, and 4 was present in the right knee of 36%, 18%, 28%, 14%, and 3.5% of patients and in the left knee of 38%, 18%, 26%, 14.4%, and 3.3% of patients.

A little more than half of participants were women (58.4%), mean body mass index was 28.7 kg/m², mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score was 2.47 (0-20 scale), mean WOMAC function score was 8.33 (0-68 scale), and mean Knee injury and Osteoarthritis Outcome Score (KOOS) (quality of life) was 66.10 (0-100 scale). Their average age was 62.7, he said at the World Congress on Osteoarthritis, sponsored by the Osteoarthritis Research Society International.

During the 60 months of follow-up, there were 91 right and 102 left TKAs. The AUC for age, sex, and BMI was 0.64 for the right knee and 0.67 for the left knee.

The best TKA prediction models included age, sex, BMI, and KOOS quality-of-life score, improving the AUC to 0.78 for the right knee and 0.80 for the left knee, Dr. Hochberg said. Addition of the WOMAC pain score was associated with a marginal, but significant improvement in the AUC (0.79 and 0.80, respectively). When KL grade was added to these models, the AUC reached 0.89 and 0.91 for the right and left knees, respectively, he said. Sensitivity analyses failed to demonstrate additional effects of other baseline variables when added.

Limitations of the study included the relatively few TKAs, that most patients had KL grade 2 at baseline, proportional hazards analyses were not used, and the study did not consider a correlation between knees or the change in independent variables over time, he said.

In a prospective Canadian study, willingness to undergo surgery was the strongest predictor of the time to first hip or knee total joint replacement (TJR) (Arthritis Rheum. 2006;54:3212-20), while an international OARSI Task Force reported that pain and disability was higher in patients recommended for hip or knee TJR (Osteoarthritis Cartilage 2011;19:147-54). The Task Force, which included Dr. Hochberg, could not, however, identify cut points for pain and disability that would discriminate between those who did or did not get the nod for surgery.

The Osteoarthritis Initiative is sponsored by the National Institutes of Health. Dr. Hochberg reported serving as a consultant for Allergan, Bioiberica, Iroko, Merck, and Pfizer, and as a scientific/medical advisory board member for Eli Lilly and Merck.

[email protected]

PHILADELPHIA – Knowledge of a patient’s age, gender, quality of life score, and radiographic knee osteoarthritis severity helps predict the odds of a patient undergoing total knee arthroplasty in the next 5 years.

Few studies have looked at the predictors of total knee arthroplasty (TKA) in community-based cohorts, despite the heavy burden of TKA in the United States, said Dr. Marc C. Hochberg, head of rheumatology and clinical immunology, University of Maryland, Baltimore. An estimated 4 million Americans already live with TKA, and more than half of adults diagnosed with knee osteoarthritis (OA) will undergo TKA (J. Bone Joint Surg. Am. 2013;95:385-92).

For the current analysis, Dr. Hochberg and his associates obtained 48 months of annual clinical follow-up data on 6,406 patients in the Osteoarthritis Initiative who had symptomatic, radiographic knee OA or who were at risk for the condition. Follow-up at 60 months involved only questionnaires. Consensus readings of knee radiographs were used for the analysis, along with knee-specific multiple variable regression models. The best models were selected based on Chi-square values and area under the receiver operating characteristic curve (AUC). Radiographic knee OA Kellgren-Lawrence (KL) severity grade 0, 1, 2, 3, and 4 was present in the right knee of 36%, 18%, 28%, 14%, and 3.5% of patients and in the left knee of 38%, 18%, 26%, 14.4%, and 3.3% of patients.

A little more than half of participants were women (58.4%), mean body mass index was 28.7 kg/m², mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score was 2.47 (0-20 scale), mean WOMAC function score was 8.33 (0-68 scale), and mean Knee injury and Osteoarthritis Outcome Score (KOOS) (quality of life) was 66.10 (0-100 scale). Their average age was 62.7, he said at the World Congress on Osteoarthritis, sponsored by the Osteoarthritis Research Society International.

During the 60 months of follow-up, there were 91 right and 102 left TKAs. The AUC for age, sex, and BMI was 0.64 for the right knee and 0.67 for the left knee.

The best TKA prediction models included age, sex, BMI, and KOOS quality-of-life score, improving the AUC to 0.78 for the right knee and 0.80 for the left knee, Dr. Hochberg said. Addition of the WOMAC pain score was associated with a marginal, but significant improvement in the AUC (0.79 and 0.80, respectively). When KL grade was added to these models, the AUC reached 0.89 and 0.91 for the right and left knees, respectively, he said. Sensitivity analyses failed to demonstrate additional effects of other baseline variables when added.

Limitations of the study included the relatively few TKAs, that most patients had KL grade 2 at baseline, proportional hazards analyses were not used, and the study did not consider a correlation between knees or the change in independent variables over time, he said.

In a prospective Canadian study, willingness to undergo surgery was the strongest predictor of the time to first hip or knee total joint replacement (TJR) (Arthritis Rheum. 2006;54:3212-20), while an international OARSI Task Force reported that pain and disability was higher in patients recommended for hip or knee TJR (Osteoarthritis Cartilage 2011;19:147-54). The Task Force, which included Dr. Hochberg, could not, however, identify cut points for pain and disability that would discriminate between those who did or did not get the nod for surgery.

The Osteoarthritis Initiative is sponsored by the National Institutes of Health. Dr. Hochberg reported serving as a consultant for Allergan, Bioiberica, Iroko, Merck, and Pfizer, and as a scientific/medical advisory board member for Eli Lilly and Merck.

[email protected]

PHILADELPHIA – Preoperative neuromuscular exercise does not significantly improve function or pain 3 months after total hip or knee replacement, according to a randomized, controlled trial in 165 patients.

The study’s primary endpoint of self-reported activities of daily living (ADLs) at 3 months was similar in patients who exercised prior to surgery and those who did not (mean between-group difference 4.4 points; P = .096). The change from baseline in the group who exercised prior to surgery was 29 points vs. 25 points in the surgery-only group, on a 100-point, worst-to-best scale.

Patrice Wendling/IMNG Medical Media

Joint-related quality of life (mean 4.5 points; P = .22) and pain (mean 3.6 points; P = .09) were also not significantly different between the two groups, Dr. Allan Villadsen said at the World Congress on Osteoarthritis Research Society.

The 8 weeks of twice-weekly exercise, however, was not for naught.

Patients improved immediately following exercise and this improvement carried over to 6 weeks after surgery, "indicating an earlier onset of recovery," he said. "Therefore, we believe exercise constitutes a viable treatment option for the individual patient who’s willing to engage in exercise prior to total hip or knee replacement and possibly obtain an earlier onset of recovery."

While preoperative exercise has been shown to improve function in other settings, little is known about its role in knee- and hip-replacement surgery for patients with severe osteoarthritis (OA). A meta-analysis of 23 randomized controlled trials involving 1,461 patients reported a small improvement in physical function and pain 3 weeks after total hip arthroscopy, but no effects in total knee replacement 3 months after surgery (Osteoarthritis Cartilage 2011;19:1381-95).A subsequent systematic review and meta-analysis, however, suggests that the therapeutic validity of the exercise programs used in the studies may have hampered the beneficial effects (PLos One 2012;7:e38031). In addition, the sample sizes were small, and the calculated effect sizes for pain and physical function were based on only two to four studies, observed Dr. Villadsen of the Institute of Sport Science and Clinical Biomechanics, University of Southern Denmark, Odense.

The current trial randomly assigned 165 patients with severe symptomatic hip or knee OA scheduled for unilateral primary total joint replacement to receive a brochure recommending exercise prior to surgery and a 3-hour information session with health professionals or the same intervention plus individualized group-based neuromuscular exercise guided by a physiotherapist. The sessions were designed to improve sensorimotor control and range of motion, and included warm up on a stationary bike, a circuit program, and a walking cool-down period, Dr. Villadsen said at the meeting, sponsored by Osteoarthritis Research Society International (OARSI).

Hip OA was present in 43 of the 84 patients in the exercise arm and 41 of the 81 controls. Their mean age was 67 years and mean ADL score on the 100-point Hip Disability and Osteoarthritis Outcome Score (HOOS) or Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaires was 50.6 and 45.6, respectively.

At 6 weeks, the between-group difference in activities of daily living on both the HOOS and KOOS questionnaires was 5.2, favoring the exercise group (P = .05), Dr. Villadsen said.

During a discussion of the results, an audience member asked whether the patients had tried exercise prior to joint replacement, which is the current recommendation. Dr. Villadsen said they did not track this, but that anecdotally, "Many of these patients are not offered what is recommended in the international guidelines, which is very disturbing ... if you asked them, many of them never even exercised before."

Session moderator and orthopedic surgeon Dr. Victor Goldberg, with Case Western Reserve University in Cleveland said it’s difficult to tease out the effects of surgery in analyses like these, but agreed that many patients are being sent to surgery without having been counseled to exercise. Part of the problem is that patients with mild to moderate OA are typically cared for by primary care physicians, who aren’t as well versed as rheumatologists and orthopedic surgeons are on the impairment, he said in an interview.

"That’s one of the charges of OARSI and our guidelines, is to really put it out in the community," he added.

"These kinds of studies, which point to the need for intervention in arthroplasty, particularly with well-done neuromuscular exercise programs, are very important to the overall management of these patients," Dr. Goldberg said. It’s needed because 15%-23% of patients after surgery say " ‘I’m not much better; I still hurt.’ "

Self-reported data at 1 year are currently being processed and will be included in a manuscript on the cost-effectiveness of the intervention, Dr. Villadsen said in an interview.

Dr. Villadsen reported having no financial disclosures.

[email protected]

PHILADELPHIA – Preoperative neuromuscular exercise does not significantly improve function or pain 3 months after total hip or knee replacement, according to a randomized, controlled trial in 165 patients.

The study’s primary endpoint of self-reported activities of daily living (ADLs) at 3 months was similar in patients who exercised prior to surgery and those who did not (mean between-group difference 4.4 points; P = .096). The change from baseline in the group who exercised prior to surgery was 29 points vs. 25 points in the surgery-only group, on a 100-point, worst-to-best scale.

Patrice Wendling/IMNG Medical Media

Joint-related quality of life (mean 4.5 points; P = .22) and pain (mean 3.6 points; P = .09) were also not significantly different between the two groups, Dr. Allan Villadsen said at the World Congress on Osteoarthritis Research Society.

The 8 weeks of twice-weekly exercise, however, was not for naught.

Patients improved immediately following exercise and this improvement carried over to 6 weeks after surgery, "indicating an earlier onset of recovery," he said. "Therefore, we believe exercise constitutes a viable treatment option for the individual patient who’s willing to engage in exercise prior to total hip or knee replacement and possibly obtain an earlier onset of recovery."

While preoperative exercise has been shown to improve function in other settings, little is known about its role in knee- and hip-replacement surgery for patients with severe osteoarthritis (OA). A meta-analysis of 23 randomized controlled trials involving 1,461 patients reported a small improvement in physical function and pain 3 weeks after total hip arthroscopy, but no effects in total knee replacement 3 months after surgery (Osteoarthritis Cartilage 2011;19:1381-95).A subsequent systematic review and meta-analysis, however, suggests that the therapeutic validity of the exercise programs used in the studies may have hampered the beneficial effects (PLos One 2012;7:e38031). In addition, the sample sizes were small, and the calculated effect sizes for pain and physical function were based on only two to four studies, observed Dr. Villadsen of the Institute of Sport Science and Clinical Biomechanics, University of Southern Denmark, Odense.

The current trial randomly assigned 165 patients with severe symptomatic hip or knee OA scheduled for unilateral primary total joint replacement to receive a brochure recommending exercise prior to surgery and a 3-hour information session with health professionals or the same intervention plus individualized group-based neuromuscular exercise guided by a physiotherapist. The sessions were designed to improve sensorimotor control and range of motion, and included warm up on a stationary bike, a circuit program, and a walking cool-down period, Dr. Villadsen said at the meeting, sponsored by Osteoarthritis Research Society International (OARSI).

Hip OA was present in 43 of the 84 patients in the exercise arm and 41 of the 81 controls. Their mean age was 67 years and mean ADL score on the 100-point Hip Disability and Osteoarthritis Outcome Score (HOOS) or Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaires was 50.6 and 45.6, respectively.

At 6 weeks, the between-group difference in activities of daily living on both the HOOS and KOOS questionnaires was 5.2, favoring the exercise group (P = .05), Dr. Villadsen said.

During a discussion of the results, an audience member asked whether the patients had tried exercise prior to joint replacement, which is the current recommendation. Dr. Villadsen said they did not track this, but that anecdotally, "Many of these patients are not offered what is recommended in the international guidelines, which is very disturbing ... if you asked them, many of them never even exercised before."

Session moderator and orthopedic surgeon Dr. Victor Goldberg, with Case Western Reserve University in Cleveland said it’s difficult to tease out the effects of surgery in analyses like these, but agreed that many patients are being sent to surgery without having been counseled to exercise. Part of the problem is that patients with mild to moderate OA are typically cared for by primary care physicians, who aren’t as well versed as rheumatologists and orthopedic surgeons are on the impairment, he said in an interview.

"That’s one of the charges of OARSI and our guidelines, is to really put it out in the community," he added.

"These kinds of studies, which point to the need for intervention in arthroplasty, particularly with well-done neuromuscular exercise programs, are very important to the overall management of these patients," Dr. Goldberg said. It’s needed because 15%-23% of patients after surgery say " ‘I’m not much better; I still hurt.’ "

Self-reported data at 1 year are currently being processed and will be included in a manuscript on the cost-effectiveness of the intervention, Dr. Villadsen said in an interview.

Dr. Villadsen reported having no financial disclosures.

[email protected]

PHILADELPHIA – Preoperative neuromuscular exercise does not significantly improve function or pain 3 months after total hip or knee replacement, according to a randomized, controlled trial in 165 patients.

The study’s primary endpoint of self-reported activities of daily living (ADLs) at 3 months was similar in patients who exercised prior to surgery and those who did not (mean between-group difference 4.4 points; P = .096). The change from baseline in the group who exercised prior to surgery was 29 points vs. 25 points in the surgery-only group, on a 100-point, worst-to-best scale.

Patrice Wendling/IMNG Medical Media

Joint-related quality of life (mean 4.5 points; P = .22) and pain (mean 3.6 points; P = .09) were also not significantly different between the two groups, Dr. Allan Villadsen said at the World Congress on Osteoarthritis Research Society.

The 8 weeks of twice-weekly exercise, however, was not for naught.

Patients improved immediately following exercise and this improvement carried over to 6 weeks after surgery, "indicating an earlier onset of recovery," he said. "Therefore, we believe exercise constitutes a viable treatment option for the individual patient who’s willing to engage in exercise prior to total hip or knee replacement and possibly obtain an earlier onset of recovery."

While preoperative exercise has been shown to improve function in other settings, little is known about its role in knee- and hip-replacement surgery for patients with severe osteoarthritis (OA). A meta-analysis of 23 randomized controlled trials involving 1,461 patients reported a small improvement in physical function and pain 3 weeks after total hip arthroscopy, but no effects in total knee replacement 3 months after surgery (Osteoarthritis Cartilage 2011;19:1381-95).A subsequent systematic review and meta-analysis, however, suggests that the therapeutic validity of the exercise programs used in the studies may have hampered the beneficial effects (PLos One 2012;7:e38031). In addition, the sample sizes were small, and the calculated effect sizes for pain and physical function were based on only two to four studies, observed Dr. Villadsen of the Institute of Sport Science and Clinical Biomechanics, University of Southern Denmark, Odense.

The current trial randomly assigned 165 patients with severe symptomatic hip or knee OA scheduled for unilateral primary total joint replacement to receive a brochure recommending exercise prior to surgery and a 3-hour information session with health professionals or the same intervention plus individualized group-based neuromuscular exercise guided by a physiotherapist. The sessions were designed to improve sensorimotor control and range of motion, and included warm up on a stationary bike, a circuit program, and a walking cool-down period, Dr. Villadsen said at the meeting, sponsored by Osteoarthritis Research Society International (OARSI).

Hip OA was present in 43 of the 84 patients in the exercise arm and 41 of the 81 controls. Their mean age was 67 years and mean ADL score on the 100-point Hip Disability and Osteoarthritis Outcome Score (HOOS) or Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaires was 50.6 and 45.6, respectively.

At 6 weeks, the between-group difference in activities of daily living on both the HOOS and KOOS questionnaires was 5.2, favoring the exercise group (P = .05), Dr. Villadsen said.

During a discussion of the results, an audience member asked whether the patients had tried exercise prior to joint replacement, which is the current recommendation. Dr. Villadsen said they did not track this, but that anecdotally, "Many of these patients are not offered what is recommended in the international guidelines, which is very disturbing ... if you asked them, many of them never even exercised before."

Session moderator and orthopedic surgeon Dr. Victor Goldberg, with Case Western Reserve University in Cleveland said it’s difficult to tease out the effects of surgery in analyses like these, but agreed that many patients are being sent to surgery without having been counseled to exercise. Part of the problem is that patients with mild to moderate OA are typically cared for by primary care physicians, who aren’t as well versed as rheumatologists and orthopedic surgeons are on the impairment, he said in an interview.

"That’s one of the charges of OARSI and our guidelines, is to really put it out in the community," he added.

"These kinds of studies, which point to the need for intervention in arthroplasty, particularly with well-done neuromuscular exercise programs, are very important to the overall management of these patients," Dr. Goldberg said. It’s needed because 15%-23% of patients after surgery say " ‘I’m not much better; I still hurt.’ "

Self-reported data at 1 year are currently being processed and will be included in a manuscript on the cost-effectiveness of the intervention, Dr. Villadsen said in an interview.

Dr. Villadsen reported having no financial disclosures.

[email protected]

BIRMINGHAM, ENGLAND – Long-term bisphosphonate use reduced the risk for joint implant failure and subsequent hip or knee revision survey in 40% of patients in a large, retrospective, observational study.

The rate for revision surgery at a median of 2.6 years’ follow-up was 1.88% in the 1,911 participants who had taken bisphosphonates for at least 6 months, compared with 4.36% in the 10,755 nonbisphosphonate users (hazard ratio, 0.62).

"The observed effect size is stronger in patients with higher therapy duration and adherence," Dr. Daniel Prieto-Alhambra reported at the annual meeting of the British Society for Rheumatology.

"This association does not differ by age, gender, joint replaced, or fracture history," added Dr. Prieto-Alhambra, senior clinical research fellow from the Nuffield department of orthopaedics, rheumatology, and musculoskeletal sciences at the University of Oxford, England.

Osteolysis and aseptic loosening are the most common causes of revision surgery, the researcher noted, adding that bisphosphonates have antiosteoclast activity that may have potential benefits on implant survival.

"Patients need to be on treatment for at least 6 months for the drug to be effective," Dr. Prieto-Alhambra emphasized. He later said after his presentation that data from a sub-analysis suggest that patients benefit further if they started therapy in the weeks following surgery.*

Data used in the study were obtained from Danish nationwide health registries on more than 80,000 patients aged 40 years or older who had total hip arthroplasty (THA) or total knee arthroplasty (TKA) in Denmark between 1998 and 2007. Patients were excluded if they had experienced a prior hip fracture; had inflammatory arthritis or used disease-modifying antirheumatic drugs; or had Paget’s disease, bone cancer, or metastasis. Baseline characteristics of those who did and those who did not use bisphosphonates were comparable except for calcium and vitamin D supplementation, which was higher in the bisphosphonate-treated group (9.9% vs. 4.8%).

The longer the duration of treatment, the less chance there was for implant failure: 5 implants failed in 352 (1.4%) patients treated with bisphosphonates for more than 2 years (HR, 0.53); 16 (1.6%) in 1,006 patients treated for 1-2 years (HR, 0.52); and 15 (2.7%) in 553 patients treated for 6-12 months (HR, 1.31).

Adherence was assessed using a medication possession ratio (MPR), with lower MPR values indicating poorer adherence. Failure rates were 3%, 2.9%, and 1.5% for MPRs of less than 0.5 (HR, 0.93), 0.5-0.79 (HR, 0.48), and 0.8 or greater (HR, 0.56), respectively.

The study’s findings support those of a recent U.K. population-based, retrospective cohort study (BMJ 2011 [doi:10.1136/bmj.d7222]) that involved more than 41,000 primary THA/TKA patients.

The U.K. data showed that fewer surgical revisions occurred at 5 years in bisphosphonate users (0.93% vs. 1.96% in nonusers), and that there was a 46% decrease in the risk of revision surgery (HR for implant survival of 0.54; P = .047). It was also estimated, however, that at least 107 patients would need to be treated with bisphosphonates to avoid one revision surgery.

Osteoarthritis accounts for more than 90% of THAs and TKAs performed in the United Kingdom, with 1 in 75 patients experiencing implant failure and revision surgery within 3 years of the index surgery. Such surgery is associated with a worse clinical outcome than the primary procedure, and it is also associated with greater health care costs (PLoS Med. 2008;5:e179). Bisphosphonates could potentially offer a simple and hopefully cost-effective solution to reducing the likelihood of such surgery.

"Confirmation in a randomized controlled trial is needed to test the efficacy of bisphosphonates to improve implant survival, Dr. Prieto-Alhambra said.

A 40% reduction in the risk of aseptic loosening of the prosthesis is potentially very good news for patients, observed Dr. Ken Poole, a clinical lecturer at the University of Cambridge, England. Randomized trial data would be welcomed and warranted, he added.

Dr. Poole, who was chairing the session at which these data were presented, highlighted that this was another "good news" story for bisphosphonates, adding to recent evidence that they increased survival after hip fracture and have also been associated with reductions in the incidence of certain cancers.

"Many of my patients are well versed in the potential harms of bisphosphonate treatments for osteoporosis, often because of enthusiastic media coverage of the ‘bad news’ aspect," he said in an interview.

"The upshot is that ‘at-risk’ patients are increasingly reluctant to commence therapy; indeed, it is easy to find out about rare and frightening side effects like osteonecrosis of the jaw and atraumatic fractures of the femur from a few clicks on the Internet," Dr. Poole commented.

Although serious adverse events should be borne in mind when considering treatment choice, Dr. Poole noted that bisphosphonates were effective for osteoporosis in the right patients, and that Dr. Prieto-Alhambra’s study was one of several identifying additional health benefits in patients undergoing total hip or knee replacement.

A poor public perception of bisphosphonates could influence adherence, and there is recent evidence that only 30% of women actually take their prescriptions to the pharmacist (Osteoporos. Int. 2013 [doi:10.1007/s00198-013-2326-5]). Concern over calcium supplementation causing heart attacks and stroke might also be a factor, as this, together with vitamin D, goes along with bisphosphonate use. Indeed, a study of 233 women taking bisphosphonates for osteoporosis also presented at the British Society for Rheumatology meeting found that a lack of concomitant calcium and vitamin D supplementation was predictive of poor adherence (Rheumatology 2013;52[Suppl. 1]:i116-7; abstract 163). Other predictive factors were older age and the use of sleeping tablets.

Dr. Prieto-Alhambra and Dr. Poole had no conflicts of interests.

* Revised, 5/1/13

BIRMINGHAM, ENGLAND – Long-term bisphosphonate use reduced the risk for joint implant failure and subsequent hip or knee revision survey in 40% of patients in a large, retrospective, observational study.

The rate for revision surgery at a median of 2.6 years’ follow-up was 1.88% in the 1,911 participants who had taken bisphosphonates for at least 6 months, compared with 4.36% in the 10,755 nonbisphosphonate users (hazard ratio, 0.62).

"The observed effect size is stronger in patients with higher therapy duration and adherence," Dr. Daniel Prieto-Alhambra reported at the annual meeting of the British Society for Rheumatology.

"This association does not differ by age, gender, joint replaced, or fracture history," added Dr. Prieto-Alhambra, senior clinical research fellow from the Nuffield department of orthopaedics, rheumatology, and musculoskeletal sciences at the University of Oxford, England.

Osteolysis and aseptic loosening are the most common causes of revision surgery, the researcher noted, adding that bisphosphonates have antiosteoclast activity that may have potential benefits on implant survival.

"Patients need to be on treatment for at least 6 months for the drug to be effective," Dr. Prieto-Alhambra emphasized. He later said after his presentation that data from a sub-analysis suggest that patients benefit further if they started therapy in the weeks following surgery.*

Data used in the study were obtained from Danish nationwide health registries on more than 80,000 patients aged 40 years or older who had total hip arthroplasty (THA) or total knee arthroplasty (TKA) in Denmark between 1998 and 2007. Patients were excluded if they had experienced a prior hip fracture; had inflammatory arthritis or used disease-modifying antirheumatic drugs; or had Paget’s disease, bone cancer, or metastasis. Baseline characteristics of those who did and those who did not use bisphosphonates were comparable except for calcium and vitamin D supplementation, which was higher in the bisphosphonate-treated group (9.9% vs. 4.8%).

The longer the duration of treatment, the less chance there was for implant failure: 5 implants failed in 352 (1.4%) patients treated with bisphosphonates for more than 2 years (HR, 0.53); 16 (1.6%) in 1,006 patients treated for 1-2 years (HR, 0.52); and 15 (2.7%) in 553 patients treated for 6-12 months (HR, 1.31).

Adherence was assessed using a medication possession ratio (MPR), with lower MPR values indicating poorer adherence. Failure rates were 3%, 2.9%, and 1.5% for MPRs of less than 0.5 (HR, 0.93), 0.5-0.79 (HR, 0.48), and 0.8 or greater (HR, 0.56), respectively.

The study’s findings support those of a recent U.K. population-based, retrospective cohort study (BMJ 2011 [doi:10.1136/bmj.d7222]) that involved more than 41,000 primary THA/TKA patients.

The U.K. data showed that fewer surgical revisions occurred at 5 years in bisphosphonate users (0.93% vs. 1.96% in nonusers), and that there was a 46% decrease in the risk of revision surgery (HR for implant survival of 0.54; P = .047). It was also estimated, however, that at least 107 patients would need to be treated with bisphosphonates to avoid one revision surgery.

Osteoarthritis accounts for more than 90% of THAs and TKAs performed in the United Kingdom, with 1 in 75 patients experiencing implant failure and revision surgery within 3 years of the index surgery. Such surgery is associated with a worse clinical outcome than the primary procedure, and it is also associated with greater health care costs (PLoS Med. 2008;5:e179). Bisphosphonates could potentially offer a simple and hopefully cost-effective solution to reducing the likelihood of such surgery.

"Confirmation in a randomized controlled trial is needed to test the efficacy of bisphosphonates to improve implant survival, Dr. Prieto-Alhambra said.

A 40% reduction in the risk of aseptic loosening of the prosthesis is potentially very good news for patients, observed Dr. Ken Poole, a clinical lecturer at the University of Cambridge, England. Randomized trial data would be welcomed and warranted, he added.

Dr. Poole, who was chairing the session at which these data were presented, highlighted that this was another "good news" story for bisphosphonates, adding to recent evidence that they increased survival after hip fracture and have also been associated with reductions in the incidence of certain cancers.

"Many of my patients are well versed in the potential harms of bisphosphonate treatments for osteoporosis, often because of enthusiastic media coverage of the ‘bad news’ aspect," he said in an interview.

"The upshot is that ‘at-risk’ patients are increasingly reluctant to commence therapy; indeed, it is easy to find out about rare and frightening side effects like osteonecrosis of the jaw and atraumatic fractures of the femur from a few clicks on the Internet," Dr. Poole commented.

Although serious adverse events should be borne in mind when considering treatment choice, Dr. Poole noted that bisphosphonates were effective for osteoporosis in the right patients, and that Dr. Prieto-Alhambra’s study was one of several identifying additional health benefits in patients undergoing total hip or knee replacement.

A poor public perception of bisphosphonates could influence adherence, and there is recent evidence that only 30% of women actually take their prescriptions to the pharmacist (Osteoporos. Int. 2013 [doi:10.1007/s00198-013-2326-5]). Concern over calcium supplementation causing heart attacks and stroke might also be a factor, as this, together with vitamin D, goes along with bisphosphonate use. Indeed, a study of 233 women taking bisphosphonates for osteoporosis also presented at the British Society for Rheumatology meeting found that a lack of concomitant calcium and vitamin D supplementation was predictive of poor adherence (Rheumatology 2013;52[Suppl. 1]:i116-7; abstract 163). Other predictive factors were older age and the use of sleeping tablets.

Dr. Prieto-Alhambra and Dr. Poole had no conflicts of interests.

* Revised, 5/1/13

BIRMINGHAM, ENGLAND – Long-term bisphosphonate use reduced the risk for joint implant failure and subsequent hip or knee revision survey in 40% of patients in a large, retrospective, observational study.

The rate for revision surgery at a median of 2.6 years’ follow-up was 1.88% in the 1,911 participants who had taken bisphosphonates for at least 6 months, compared with 4.36% in the 10,755 nonbisphosphonate users (hazard ratio, 0.62).

"The observed effect size is stronger in patients with higher therapy duration and adherence," Dr. Daniel Prieto-Alhambra reported at the annual meeting of the British Society for Rheumatology.

"This association does not differ by age, gender, joint replaced, or fracture history," added Dr. Prieto-Alhambra, senior clinical research fellow from the Nuffield department of orthopaedics, rheumatology, and musculoskeletal sciences at the University of Oxford, England.

Osteolysis and aseptic loosening are the most common causes of revision surgery, the researcher noted, adding that bisphosphonates have antiosteoclast activity that may have potential benefits on implant survival.

"Patients need to be on treatment for at least 6 months for the drug to be effective," Dr. Prieto-Alhambra emphasized. He later said after his presentation that data from a sub-analysis suggest that patients benefit further if they started therapy in the weeks following surgery.*

Data used in the study were obtained from Danish nationwide health registries on more than 80,000 patients aged 40 years or older who had total hip arthroplasty (THA) or total knee arthroplasty (TKA) in Denmark between 1998 and 2007. Patients were excluded if they had experienced a prior hip fracture; had inflammatory arthritis or used disease-modifying antirheumatic drugs; or had Paget’s disease, bone cancer, or metastasis. Baseline characteristics of those who did and those who did not use bisphosphonates were comparable except for calcium and vitamin D supplementation, which was higher in the bisphosphonate-treated group (9.9% vs. 4.8%).

The longer the duration of treatment, the less chance there was for implant failure: 5 implants failed in 352 (1.4%) patients treated with bisphosphonates for more than 2 years (HR, 0.53); 16 (1.6%) in 1,006 patients treated for 1-2 years (HR, 0.52); and 15 (2.7%) in 553 patients treated for 6-12 months (HR, 1.31).

Adherence was assessed using a medication possession ratio (MPR), with lower MPR values indicating poorer adherence. Failure rates were 3%, 2.9%, and 1.5% for MPRs of less than 0.5 (HR, 0.93), 0.5-0.79 (HR, 0.48), and 0.8 or greater (HR, 0.56), respectively.

The study’s findings support those of a recent U.K. population-based, retrospective cohort study (BMJ 2011 [doi:10.1136/bmj.d7222]) that involved more than 41,000 primary THA/TKA patients.

The U.K. data showed that fewer surgical revisions occurred at 5 years in bisphosphonate users (0.93% vs. 1.96% in nonusers), and that there was a 46% decrease in the risk of revision surgery (HR for implant survival of 0.54; P = .047). It was also estimated, however, that at least 107 patients would need to be treated with bisphosphonates to avoid one revision surgery.

Osteoarthritis accounts for more than 90% of THAs and TKAs performed in the United Kingdom, with 1 in 75 patients experiencing implant failure and revision surgery within 3 years of the index surgery. Such surgery is associated with a worse clinical outcome than the primary procedure, and it is also associated with greater health care costs (PLoS Med. 2008;5:e179). Bisphosphonates could potentially offer a simple and hopefully cost-effective solution to reducing the likelihood of such surgery.

"Confirmation in a randomized controlled trial is needed to test the efficacy of bisphosphonates to improve implant survival, Dr. Prieto-Alhambra said.

A 40% reduction in the risk of aseptic loosening of the prosthesis is potentially very good news for patients, observed Dr. Ken Poole, a clinical lecturer at the University of Cambridge, England. Randomized trial data would be welcomed and warranted, he added.

Dr. Poole, who was chairing the session at which these data were presented, highlighted that this was another "good news" story for bisphosphonates, adding to recent evidence that they increased survival after hip fracture and have also been associated with reductions in the incidence of certain cancers.

"Many of my patients are well versed in the potential harms of bisphosphonate treatments for osteoporosis, often because of enthusiastic media coverage of the ‘bad news’ aspect," he said in an interview.

"The upshot is that ‘at-risk’ patients are increasingly reluctant to commence therapy; indeed, it is easy to find out about rare and frightening side effects like osteonecrosis of the jaw and atraumatic fractures of the femur from a few clicks on the Internet," Dr. Poole commented.

Although serious adverse events should be borne in mind when considering treatment choice, Dr. Poole noted that bisphosphonates were effective for osteoporosis in the right patients, and that Dr. Prieto-Alhambra’s study was one of several identifying additional health benefits in patients undergoing total hip or knee replacement.

A poor public perception of bisphosphonates could influence adherence, and there is recent evidence that only 30% of women actually take their prescriptions to the pharmacist (Osteoporos. Int. 2013 [doi:10.1007/s00198-013-2326-5]). Concern over calcium supplementation causing heart attacks and stroke might also be a factor, as this, together with vitamin D, goes along with bisphosphonate use. Indeed, a study of 233 women taking bisphosphonates for osteoporosis also presented at the British Society for Rheumatology meeting found that a lack of concomitant calcium and vitamin D supplementation was predictive of poor adherence (Rheumatology 2013;52[Suppl. 1]:i116-7; abstract 163). Other predictive factors were older age and the use of sleeping tablets.

Dr. Prieto-Alhambra and Dr. Poole had no conflicts of interests.

* Revised, 5/1/13

PALM BEACH, FLA. – Locoregional anesthesia boosts the success rate of lower-extremity amputations, while time-saving shortcuts and relying too heavily on surgical residents to perform the surgery raise the risk that an amputation patient will run into problems following surgery, according to a review of nearly 9,000 U.S. patients.

Based on these findings, "we use locoregional anesthesia when possible," and focus on "careful and meticulous handling of tissue," Dr. P. Joshua O’Brien said at the annual meeting of the Southern Surgical Association. "This is the first paper to suggest that locoregional anesthesia may have a protective effect and improve outcomes."

The study results also made Dr. O’Brien and his colleagues at Duke University in Durham, N.C., more aware that amputations "are an important procedure" even though they are often a "junior-level case frequently overseen by a senior resident." The study results prompted Duke attending surgeons to maintain "careful observation of the residents until they feel comfortable that they [the residents] adequately understand the art of performing an amputation," said Dr. O’Brien, a vascular surgeon at Duke.

The analysis he and his associates performed used data collected during 2005-2010 by the National Surgical Quality Improvement Program of the American College of Surgeons. The study included patients who underwent an above-the-knee amputation (3,415 patients – 38%), a below-the-knee amputation (4,258 patients – 48%), or a transmetatarsal amputation (1,205 patients – 14%), but excluded patients who had another surgical procedure with their amputation, prior surgery within 30 days of the amputation, a preoperative do-not-resuscitate order, or missing data; 63% of all the amputation patients had diabetes.

During 30-day postsurgical follow-up, the overall rate of amputation failure was 13%, death occurred in 7%, wound complications affected 9%, and nonwound complications affected 21%. The patients averaged a 6-day postsurgical hospital length of stay.

Early amputation failure showed a statistically significant link with the type of amputation. Patients with a transmetatarsal amputation had a 26% early failure rate, those who underwent a below-the-knee procedure had a 13% failure rate, while above-the-knee amputations failed 8% of the time.

In a multivariate analysis that controlled for patient- and procedure-related factors, several variables linked with statistically significant increases or decreases in the rate of amputation failure. Notable among the factors that increased failure rates were emergency surgery, which boosted the failure rate 2.2-fold compared with nonemergency surgery, and participation of a surgical trainee, which raised the rate 37% compared with the rate when no trainee participated. Trainee participation was common, occurring in 59% of the 8,878 amputations included in the analysis.

Among the factors significantly linked with a reduced rate of amputation failures were use of locoregional anesthesia, which cut the failure rate by 25% compared with general anesthesia, and operative times of at least 40 minutes, which cut failure rates compared with surgery times of less than 40 minutes. The lowest failure rates occurred when the duration of amputation surgery lasted at least 60 minutes. Among patients included in the study, 20% received locoregional anesthesia.

The results also highlighted the important association of amputation failure with other measures of poor surgical outcomes in these amputation patients. Patients who developed amputation failure within 30 days of their surgery also had a nearly sevenfold increased rate of wound complications, and a twofold increased rate of nonwound complications; the average hospital length of stay was 10 days compared with 5 days among patients without amputation. Amputation failure had no significant impact on postoperative mortality, Dr. O’Brien said.

He said he had no relevant financial disclosures.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – Locoregional anesthesia boosts the success rate of lower-extremity amputations, while time-saving shortcuts and relying too heavily on surgical residents to perform the surgery raise the risk that an amputation patient will run into problems following surgery, according to a review of nearly 9,000 U.S. patients.

Based on these findings, "we use locoregional anesthesia when possible," and focus on "careful and meticulous handling of tissue," Dr. P. Joshua O’Brien said at the annual meeting of the Southern Surgical Association. "This is the first paper to suggest that locoregional anesthesia may have a protective effect and improve outcomes."

The study results also made Dr. O’Brien and his colleagues at Duke University in Durham, N.C., more aware that amputations "are an important procedure" even though they are often a "junior-level case frequently overseen by a senior resident." The study results prompted Duke attending surgeons to maintain "careful observation of the residents until they feel comfortable that they [the residents] adequately understand the art of performing an amputation," said Dr. O’Brien, a vascular surgeon at Duke.

The analysis he and his associates performed used data collected during 2005-2010 by the National Surgical Quality Improvement Program of the American College of Surgeons. The study included patients who underwent an above-the-knee amputation (3,415 patients – 38%), a below-the-knee amputation (4,258 patients – 48%), or a transmetatarsal amputation (1,205 patients – 14%), but excluded patients who had another surgical procedure with their amputation, prior surgery within 30 days of the amputation, a preoperative do-not-resuscitate order, or missing data; 63% of all the amputation patients had diabetes.

During 30-day postsurgical follow-up, the overall rate of amputation failure was 13%, death occurred in 7%, wound complications affected 9%, and nonwound complications affected 21%. The patients averaged a 6-day postsurgical hospital length of stay.

Early amputation failure showed a statistically significant link with the type of amputation. Patients with a transmetatarsal amputation had a 26% early failure rate, those who underwent a below-the-knee procedure had a 13% failure rate, while above-the-knee amputations failed 8% of the time.

In a multivariate analysis that controlled for patient- and procedure-related factors, several variables linked with statistically significant increases or decreases in the rate of amputation failure. Notable among the factors that increased failure rates were emergency surgery, which boosted the failure rate 2.2-fold compared with nonemergency surgery, and participation of a surgical trainee, which raised the rate 37% compared with the rate when no trainee participated. Trainee participation was common, occurring in 59% of the 8,878 amputations included in the analysis.

Among the factors significantly linked with a reduced rate of amputation failures were use of locoregional anesthesia, which cut the failure rate by 25% compared with general anesthesia, and operative times of at least 40 minutes, which cut failure rates compared with surgery times of less than 40 minutes. The lowest failure rates occurred when the duration of amputation surgery lasted at least 60 minutes. Among patients included in the study, 20% received locoregional anesthesia.

The results also highlighted the important association of amputation failure with other measures of poor surgical outcomes in these amputation patients. Patients who developed amputation failure within 30 days of their surgery also had a nearly sevenfold increased rate of wound complications, and a twofold increased rate of nonwound complications; the average hospital length of stay was 10 days compared with 5 days among patients without amputation. Amputation failure had no significant impact on postoperative mortality, Dr. O’Brien said.

He said he had no relevant financial disclosures.

[email protected]

On Twitter @mitchelzoler

PALM BEACH, FLA. – Locoregional anesthesia boosts the success rate of lower-extremity amputations, while time-saving shortcuts and relying too heavily on surgical residents to perform the surgery raise the risk that an amputation patient will run into problems following surgery, according to a review of nearly 9,000 U.S. patients.

Based on these findings, "we use locoregional anesthesia when possible," and focus on "careful and meticulous handling of tissue," Dr. P. Joshua O’Brien said at the annual meeting of the Southern Surgical Association. "This is the first paper to suggest that locoregional anesthesia may have a protective effect and improve outcomes."

The study results also made Dr. O’Brien and his colleagues at Duke University in Durham, N.C., more aware that amputations "are an important procedure" even though they are often a "junior-level case frequently overseen by a senior resident." The study results prompted Duke attending surgeons to maintain "careful observation of the residents until they feel comfortable that they [the residents] adequately understand the art of performing an amputation," said Dr. O’Brien, a vascular surgeon at Duke.

The analysis he and his associates performed used data collected during 2005-2010 by the National Surgical Quality Improvement Program of the American College of Surgeons. The study included patients who underwent an above-the-knee amputation (3,415 patients – 38%), a below-the-knee amputation (4,258 patients – 48%), or a transmetatarsal amputation (1,205 patients – 14%), but excluded patients who had another surgical procedure with their amputation, prior surgery within 30 days of the amputation, a preoperative do-not-resuscitate order, or missing data; 63% of all the amputation patients had diabetes.

During 30-day postsurgical follow-up, the overall rate of amputation failure was 13%, death occurred in 7%, wound complications affected 9%, and nonwound complications affected 21%. The patients averaged a 6-day postsurgical hospital length of stay.

Early amputation failure showed a statistically significant link with the type of amputation. Patients with a transmetatarsal amputation had a 26% early failure rate, those who underwent a below-the-knee procedure had a 13% failure rate, while above-the-knee amputations failed 8% of the time.

In a multivariate analysis that controlled for patient- and procedure-related factors, several variables linked with statistically significant increases or decreases in the rate of amputation failure. Notable among the factors that increased failure rates were emergency surgery, which boosted the failure rate 2.2-fold compared with nonemergency surgery, and participation of a surgical trainee, which raised the rate 37% compared with the rate when no trainee participated. Trainee participation was common, occurring in 59% of the 8,878 amputations included in the analysis.

Among the factors significantly linked with a reduced rate of amputation failures were use of locoregional anesthesia, which cut the failure rate by 25% compared with general anesthesia, and operative times of at least 40 minutes, which cut failure rates compared with surgery times of less than 40 minutes. The lowest failure rates occurred when the duration of amputation surgery lasted at least 60 minutes. Among patients included in the study, 20% received locoregional anesthesia.

The results also highlighted the important association of amputation failure with other measures of poor surgical outcomes in these amputation patients. Patients who developed amputation failure within 30 days of their surgery also had a nearly sevenfold increased rate of wound complications, and a twofold increased rate of nonwound complications; the average hospital length of stay was 10 days compared with 5 days among patients without amputation. Amputation failure had no significant impact on postoperative mortality, Dr. O’Brien said.

He said he had no relevant financial disclosures.

[email protected]

On Twitter @mitchelzoler

WASHINGTON – A daily dose of strontium ranelate was associated with a significant delay in joint space narrowing in adults with symptomatic primary knee osteoarthritis, based on data from the phase III Strontium Ranelate Knee Osteoarthritis Trial (SEKOIA).

Strontium renalate currently is not approved in the United States, but it is approved in more than 100 countries for treating osteoporosis, said Dr. Jean-Yves Reginster, who is head of the Center for Investigation in Bone and Articular Cartilage Metabolism at the University of Liège (Belgium).

Data from nonclinical studies have shown that strontium’s bone-building activity has a positive impact on cartilage as well, he noted at the annual meeting of the American College of Rheumatology.

To examine the effectiveness of strontium ranelate on the progression of knee osteoarthritis (OA), Dr. Reginster and his colleagues randomized 1,683 adults with symptomatic primary knee OA to 1 g of strontium ranelate per day (566 patients), 2 g/day (558 patients), or a placebo (559 patients). Complete data were available for 1,371 patients. The average age of the patients was 63 years, and 69% were women.

Overall, treatment with either dose of strontium was associated with a significant delay in the radiographic progression of knee OA, which was assessed by measuring the radiological joint space narrowing (JSN) of the medial tibiofemoral compartment of the knee joint.

After 1 year, joint space width decreased by 0.27 mm in the 2-g/day group, 0.23 mm in the 1-g/day group, and 0.37 mm in the placebo group. The differences between the 2-g/day and 1-g/day groups and the placebo group were 0.10 mm and 0.14 mm, respectively.

Significantly less radiological progression was noted in both strontium groups, compared with the placebo group. The percentage of patients with radiological progression (defined as joint space narrowing of at least 0.5 mm) was 26% in the 2-g/day group, 22% in the 1-g/day group, and 33% in the placebo group.

"The structural effect is translated clinically into a lower number of patients having a radiological progression over thresholds predictive of OA-related surgery," Dr. Reginster said. The findings suggest that strontium ranelate could reduce the need for knee surgery in OA patients, he added.

In addition, significantly more patients in the 2-g/day group exceeded the minimally perceptible clinical improvement (MCPI) threshold, compared with the placebo patients, on subscores of pain, stiffness, and physical function. The percentage of patients in the 1-g/day group above this threshold was not significantly higher than in the placebo group.

No significant differences in adverse events were observed among the three groups, and the incidence of serious adverse events was 17% in all groups.

The study findings also appeared online on Nov. 9 (Ann. Rheum. Dis. 2012 [doi:10.1136/annrheumdis-2012-202231]).

The study was sponsored by Servier. Dr. Reginster disclosed financial relationships with multiple companies, including Servier.

WASHINGTON – A daily dose of strontium ranelate was associated with a significant delay in joint space narrowing in adults with symptomatic primary knee osteoarthritis, based on data from the phase III Strontium Ranelate Knee Osteoarthritis Trial (SEKOIA).

Strontium renalate currently is not approved in the United States, but it is approved in more than 100 countries for treating osteoporosis, said Dr. Jean-Yves Reginster, who is head of the Center for Investigation in Bone and Articular Cartilage Metabolism at the University of Liège (Belgium).

Data from nonclinical studies have shown that strontium’s bone-building activity has a positive impact on cartilage as well, he noted at the annual meeting of the American College of Rheumatology.

To examine the effectiveness of strontium ranelate on the progression of knee osteoarthritis (OA), Dr. Reginster and his colleagues randomized 1,683 adults with symptomatic primary knee OA to 1 g of strontium ranelate per day (566 patients), 2 g/day (558 patients), or a placebo (559 patients). Complete data were available for 1,371 patients. The average age of the patients was 63 years, and 69% were women.

Overall, treatment with either dose of strontium was associated with a significant delay in the radiographic progression of knee OA, which was assessed by measuring the radiological joint space narrowing (JSN) of the medial tibiofemoral compartment of the knee joint.

After 1 year, joint space width decreased by 0.27 mm in the 2-g/day group, 0.23 mm in the 1-g/day group, and 0.37 mm in the placebo group. The differences between the 2-g/day and 1-g/day groups and the placebo group were 0.10 mm and 0.14 mm, respectively.

Significantly less radiological progression was noted in both strontium groups, compared with the placebo group. The percentage of patients with radiological progression (defined as joint space narrowing of at least 0.5 mm) was 26% in the 2-g/day group, 22% in the 1-g/day group, and 33% in the placebo group.

"The structural effect is translated clinically into a lower number of patients having a radiological progression over thresholds predictive of OA-related surgery," Dr. Reginster said. The findings suggest that strontium ranelate could reduce the need for knee surgery in OA patients, he added.

In addition, significantly more patients in the 2-g/day group exceeded the minimally perceptible clinical improvement (MCPI) threshold, compared with the placebo patients, on subscores of pain, stiffness, and physical function. The percentage of patients in the 1-g/day group above this threshold was not significantly higher than in the placebo group.

No significant differences in adverse events were observed among the three groups, and the incidence of serious adverse events was 17% in all groups.

The study findings also appeared online on Nov. 9 (Ann. Rheum. Dis. 2012 [doi:10.1136/annrheumdis-2012-202231]).

The study was sponsored by Servier. Dr. Reginster disclosed financial relationships with multiple companies, including Servier.

WASHINGTON – A daily dose of strontium ranelate was associated with a significant delay in joint space narrowing in adults with symptomatic primary knee osteoarthritis, based on data from the phase III Strontium Ranelate Knee Osteoarthritis Trial (SEKOIA).

Strontium renalate currently is not approved in the United States, but it is approved in more than 100 countries for treating osteoporosis, said Dr. Jean-Yves Reginster, who is head of the Center for Investigation in Bone and Articular Cartilage Metabolism at the University of Liège (Belgium).

Data from nonclinical studies have shown that strontium’s bone-building activity has a positive impact on cartilage as well, he noted at the annual meeting of the American College of Rheumatology.

To examine the effectiveness of strontium ranelate on the progression of knee osteoarthritis (OA), Dr. Reginster and his colleagues randomized 1,683 adults with symptomatic primary knee OA to 1 g of strontium ranelate per day (566 patients), 2 g/day (558 patients), or a placebo (559 patients). Complete data were available for 1,371 patients. The average age of the patients was 63 years, and 69% were women.

Overall, treatment with either dose of strontium was associated with a significant delay in the radiographic progression of knee OA, which was assessed by measuring the radiological joint space narrowing (JSN) of the medial tibiofemoral compartment of the knee joint.

After 1 year, joint space width decreased by 0.27 mm in the 2-g/day group, 0.23 mm in the 1-g/day group, and 0.37 mm in the placebo group. The differences between the 2-g/day and 1-g/day groups and the placebo group were 0.10 mm and 0.14 mm, respectively.

Significantly less radiological progression was noted in both strontium groups, compared with the placebo group. The percentage of patients with radiological progression (defined as joint space narrowing of at least 0.5 mm) was 26% in the 2-g/day group, 22% in the 1-g/day group, and 33% in the placebo group.

"The structural effect is translated clinically into a lower number of patients having a radiological progression over thresholds predictive of OA-related surgery," Dr. Reginster said. The findings suggest that strontium ranelate could reduce the need for knee surgery in OA patients, he added.

In addition, significantly more patients in the 2-g/day group exceeded the minimally perceptible clinical improvement (MCPI) threshold, compared with the placebo patients, on subscores of pain, stiffness, and physical function. The percentage of patients in the 1-g/day group above this threshold was not significantly higher than in the placebo group.

No significant differences in adverse events were observed among the three groups, and the incidence of serious adverse events was 17% in all groups.

The study findings also appeared online on Nov. 9 (Ann. Rheum. Dis. 2012 [doi:10.1136/annrheumdis-2012-202231]).

The study was sponsored by Servier. Dr. Reginster disclosed financial relationships with multiple companies, including Servier.

BARCELONA – A cartilage transplant procedure known as osteochondral allografting for femoral condyle lesions eased pain and improved function in the majority of patients, with grafts lasting as long as 20 years in more than half the recipients studied, according to Dr. Yadin Levy of Tel Aviv Medical Center, who conducted the study while a research fellow at the Scripps Clinic in La Jolla, Calif.

For this follow-up study, Dr. Levy used data from the Scripps Clinic’s osteochondral allografting (OCA) outcomes program, which has information on 614 OCA knee transplantations in 536 patients. Of these, 122 patients (129 knees) who had undergone OCA transplantation of the femoral condyle and were at least 10 years on from their initial surgery were eligible for this analysis. Most (91%) of these patients had over 10 years of follow-up. The average patient age was 31 years, and 85% were younger than 45 years.

Patients underwent surgery for pathologies including osteochondritis dissecans (45%), traumatic cartilage injury (22.5%), degenerative chondral lesion (15.5%), avascular necrosis (14.7%), and osteochondral fracture (2.3%), he said at the World Congress on Osteoarthritis.

Clinical outcome measures included the modified D’Aubigne and 18-point Postel score, the International Knee Documentation Committee (IKDC), the Knee Society (KS) function score, and subjective patient satisfaction with the outcome of their procedure. Reoperations were recorded by frequency and type, and graft survivorship was also assessed.

A mean follow-up of 14.4 years (2.4-27.5) showed that 24% of knees failed with a mean time to failure of 7.2 +/- 5.2 years.

IKDC pain scores dropped from a mean of 7.0 preoperatively to 3.8 (P less than .001) postoperatively. Function also showed improvement over the follow-up period from a mean IKDC function score of 3.4 preoperatively to 7.2 postoperatively (P less than .001). KS function improved from 65.6 to 82.5 (P less than .001). The vast majority (72%) of patients rated their operation outcome as "extremely satisfied."

With respect to graft survival, results showed that 82% survived intact for 10 years and 66% for 20 years. Patients who were older than 30 years were 3.5 times more likely to fail than patients who were younger (P less than .05). Also, patients who had experienced over two operations were 2.8 times more likely to fail than patients who had undergone one or no previous operations (P less than .05).

"The results demonstrate that this is a good treatment modality for young patients," remarked Dr. Levy.

"Firstly, [OCA] successfully treats the condition and allows the majority of patients to return to their daily activities, and secondly, it postpones the need for arthroplasty or graft removal," he added.

Many short-term follow-up studies exist providing evidence of clinical results, but very few long-term follow-up studies were available that address graft survivorship and durability, he said.

Dr. Levy explained the principle of OCA. "We basically transfer a structured articular cartilage with viable chondrocytes on the surface and underneath the bone, which acts as a scaffold," he said at the congress, sponsored by the Osteoarthritis Research Society International.

The operation is suitable for large and small chondral and osteochondral defects and can be clinically applied for cartilage repair and in complex reconstructions. "In complex reconstruction we are trying to repair the bone underneath the cartilage as well as the cartilage," he said.

"Since there is cartilage wear, the joint surfaces are not smooth and gliding, which will lead to accelerated wear and ultimately to osteoarthritis," Dr. Levy pointed out.

Cartilage problems pose a treatment challenge because the tissue is incapable of self-repair and self-regrowth. Both artificial and biological modalities exist, but according to Dr. Levy, biological treatment modalities, such as OCA, are a viable option before artificial joint replacement especially in young patients for whom there is a high risk of revision.

"ACI [autologous chondrocyte implantation] and OCA are commonly used for large lesions, of more than 4 cm. The advantage of OCA is the ability to perform a single-stage operation for large bone defect," he said.

A major advantage of the method was that, even if the first allograft failed, patients could reconvert to another allograft in the revision surgery, which would again postpone the need for arthroplasty, Dr. Levy added.

Reoperations were conducted in 47% of knees. The number of reoperations was roughly equal for graft-related and non-graft-related reasons: 23% of patients required non-graft-related reoperations including arthroscopy, such as hardware removal, while graft-related reoperations were required by 24% of patients, the majority of which (48%) were OCA revision. "The majority of failures were because of pain and radiographic fragmentation of the allografts," reported Dr. Levy.

In addition, the researchers evaluated predictors for OCA failure using logistical regression analysis. "We found that older patients who had had several pervious surgeries tended to fail more," he said. "This raises the question of whether, in the era of MRI and advanced radiographic assessments, we should treat younger patients with single operations increasing the likelihood of success."

In conclusion, Dr. Levy said that he believed OCA was a very good treatment modality, which many young patients could benefit from. "It can reduce pain, return functional ability and can postpone the need for arthroplasty."

"Ultimately, I would be happy to see [fewer] failures in the short term; however, I believe that we do not fully understand what causes graft failure and this will need further studies," he said.

Dr. Levy has not reported any relevant financial conflicts.

BARCELONA – A cartilage transplant procedure known as osteochondral allografting for femoral condyle lesions eased pain and improved function in the majority of patients, with grafts lasting as long as 20 years in more than half the recipients studied, according to Dr. Yadin Levy of Tel Aviv Medical Center, who conducted the study while a research fellow at the Scripps Clinic in La Jolla, Calif.

For this follow-up study, Dr. Levy used data from the Scripps Clinic’s osteochondral allografting (OCA) outcomes program, which has information on 614 OCA knee transplantations in 536 patients. Of these, 122 patients (129 knees) who had undergone OCA transplantation of the femoral condyle and were at least 10 years on from their initial surgery were eligible for this analysis. Most (91%) of these patients had over 10 years of follow-up. The average patient age was 31 years, and 85% were younger than 45 years.

Patients underwent surgery for pathologies including osteochondritis dissecans (45%), traumatic cartilage injury (22.5%), degenerative chondral lesion (15.5%), avascular necrosis (14.7%), and osteochondral fracture (2.3%), he said at the World Congress on Osteoarthritis.

Clinical outcome measures included the modified D’Aubigne and 18-point Postel score, the International Knee Documentation Committee (IKDC), the Knee Society (KS) function score, and subjective patient satisfaction with the outcome of their procedure. Reoperations were recorded by frequency and type, and graft survivorship was also assessed.

A mean follow-up of 14.4 years (2.4-27.5) showed that 24% of knees failed with a mean time to failure of 7.2 +/- 5.2 years.

IKDC pain scores dropped from a mean of 7.0 preoperatively to 3.8 (P less than .001) postoperatively. Function also showed improvement over the follow-up period from a mean IKDC function score of 3.4 preoperatively to 7.2 postoperatively (P less than .001). KS function improved from 65.6 to 82.5 (P less than .001). The vast majority (72%) of patients rated their operation outcome as "extremely satisfied."

With respect to graft survival, results showed that 82% survived intact for 10 years and 66% for 20 years. Patients who were older than 30 years were 3.5 times more likely to fail than patients who were younger (P less than .05). Also, patients who had experienced over two operations were 2.8 times more likely to fail than patients who had undergone one or no previous operations (P less than .05).

"The results demonstrate that this is a good treatment modality for young patients," remarked Dr. Levy.

"Firstly, [OCA] successfully treats the condition and allows the majority of patients to return to their daily activities, and secondly, it postpones the need for arthroplasty or graft removal," he added.

Many short-term follow-up studies exist providing evidence of clinical results, but very few long-term follow-up studies were available that address graft survivorship and durability, he said.

Dr. Levy explained the principle of OCA. "We basically transfer a structured articular cartilage with viable chondrocytes on the surface and underneath the bone, which acts as a scaffold," he said at the congress, sponsored by the Osteoarthritis Research Society International.

The operation is suitable for large and small chondral and osteochondral defects and can be clinically applied for cartilage repair and in complex reconstructions. "In complex reconstruction we are trying to repair the bone underneath the cartilage as well as the cartilage," he said.

"Since there is cartilage wear, the joint surfaces are not smooth and gliding, which will lead to accelerated wear and ultimately to osteoarthritis," Dr. Levy pointed out.

Cartilage problems pose a treatment challenge because the tissue is incapable of self-repair and self-regrowth. Both artificial and biological modalities exist, but according to Dr. Levy, biological treatment modalities, such as OCA, are a viable option before artificial joint replacement especially in young patients for whom there is a high risk of revision.

"ACI [autologous chondrocyte implantation] and OCA are commonly used for large lesions, of more than 4 cm. The advantage of OCA is the ability to perform a single-stage operation for large bone defect," he said.

A major advantage of the method was that, even if the first allograft failed, patients could reconvert to another allograft in the revision surgery, which would again postpone the need for arthroplasty, Dr. Levy added.

Reoperations were conducted in 47% of knees. The number of reoperations was roughly equal for graft-related and non-graft-related reasons: 23% of patients required non-graft-related reoperations including arthroscopy, such as hardware removal, while graft-related reoperations were required by 24% of patients, the majority of which (48%) were OCA revision. "The majority of failures were because of pain and radiographic fragmentation of the allografts," reported Dr. Levy.

In addition, the researchers evaluated predictors for OCA failure using logistical regression analysis. "We found that older patients who had had several pervious surgeries tended to fail more," he said. "This raises the question of whether, in the era of MRI and advanced radiographic assessments, we should treat younger patients with single operations increasing the likelihood of success."

In conclusion, Dr. Levy said that he believed OCA was a very good treatment modality, which many young patients could benefit from. "It can reduce pain, return functional ability and can postpone the need for arthroplasty."

"Ultimately, I would be happy to see [fewer] failures in the short term; however, I believe that we do not fully understand what causes graft failure and this will need further studies," he said.

Dr. Levy has not reported any relevant financial conflicts.

BARCELONA – A cartilage transplant procedure known as osteochondral allografting for femoral condyle lesions eased pain and improved function in the majority of patients, with grafts lasting as long as 20 years in more than half the recipients studied, according to Dr. Yadin Levy of Tel Aviv Medical Center, who conducted the study while a research fellow at the Scripps Clinic in La Jolla, Calif.

For this follow-up study, Dr. Levy used data from the Scripps Clinic’s osteochondral allografting (OCA) outcomes program, which has information on 614 OCA knee transplantations in 536 patients. Of these, 122 patients (129 knees) who had undergone OCA transplantation of the femoral condyle and were at least 10 years on from their initial surgery were eligible for this analysis. Most (91%) of these patients had over 10 years of follow-up. The average patient age was 31 years, and 85% were younger than 45 years.

Patients underwent surgery for pathologies including osteochondritis dissecans (45%), traumatic cartilage injury (22.5%), degenerative chondral lesion (15.5%), avascular necrosis (14.7%), and osteochondral fracture (2.3%), he said at the World Congress on Osteoarthritis.

Clinical outcome measures included the modified D’Aubigne and 18-point Postel score, the International Knee Documentation Committee (IKDC), the Knee Society (KS) function score, and subjective patient satisfaction with the outcome of their procedure. Reoperations were recorded by frequency and type, and graft survivorship was also assessed.

A mean follow-up of 14.4 years (2.4-27.5) showed that 24% of knees failed with a mean time to failure of 7.2 +/- 5.2 years.

IKDC pain scores dropped from a mean of 7.0 preoperatively to 3.8 (P less than .001) postoperatively. Function also showed improvement over the follow-up period from a mean IKDC function score of 3.4 preoperatively to 7.2 postoperatively (P less than .001). KS function improved from 65.6 to 82.5 (P less than .001). The vast majority (72%) of patients rated their operation outcome as "extremely satisfied."

With respect to graft survival, results showed that 82% survived intact for 10 years and 66% for 20 years. Patients who were older than 30 years were 3.5 times more likely to fail than patients who were younger (P less than .05). Also, patients who had experienced over two operations were 2.8 times more likely to fail than patients who had undergone one or no previous operations (P less than .05).

"The results demonstrate that this is a good treatment modality for young patients," remarked Dr. Levy.

"Firstly, [OCA] successfully treats the condition and allows the majority of patients to return to their daily activities, and secondly, it postpones the need for arthroplasty or graft removal," he added.

Many short-term follow-up studies exist providing evidence of clinical results, but very few long-term follow-up studies were available that address graft survivorship and durability, he said.

Dr. Levy explained the principle of OCA. "We basically transfer a structured articular cartilage with viable chondrocytes on the surface and underneath the bone, which acts as a scaffold," he said at the congress, sponsored by the Osteoarthritis Research Society International.

The operation is suitable for large and small chondral and osteochondral defects and can be clinically applied for cartilage repair and in complex reconstructions. "In complex reconstruction we are trying to repair the bone underneath the cartilage as well as the cartilage," he said.

"Since there is cartilage wear, the joint surfaces are not smooth and gliding, which will lead to accelerated wear and ultimately to osteoarthritis," Dr. Levy pointed out.

Cartilage problems pose a treatment challenge because the tissue is incapable of self-repair and self-regrowth. Both artificial and biological modalities exist, but according to Dr. Levy, biological treatment modalities, such as OCA, are a viable option before artificial joint replacement especially in young patients for whom there is a high risk of revision.

"ACI [autologous chondrocyte implantation] and OCA are commonly used for large lesions, of more than 4 cm. The advantage of OCA is the ability to perform a single-stage operation for large bone defect," he said.

A major advantage of the method was that, even if the first allograft failed, patients could reconvert to another allograft in the revision surgery, which would again postpone the need for arthroplasty, Dr. Levy added.

Reoperations were conducted in 47% of knees. The number of reoperations was roughly equal for graft-related and non-graft-related reasons: 23% of patients required non-graft-related reoperations including arthroscopy, such as hardware removal, while graft-related reoperations were required by 24% of patients, the majority of which (48%) were OCA revision. "The majority of failures were because of pain and radiographic fragmentation of the allografts," reported Dr. Levy.

In addition, the researchers evaluated predictors for OCA failure using logistical regression analysis. "We found that older patients who had had several pervious surgeries tended to fail more," he said. "This raises the question of whether, in the era of MRI and advanced radiographic assessments, we should treat younger patients with single operations increasing the likelihood of success."

In conclusion, Dr. Levy said that he believed OCA was a very good treatment modality, which many young patients could benefit from. "It can reduce pain, return functional ability and can postpone the need for arthroplasty."

"Ultimately, I would be happy to see [fewer] failures in the short term; however, I believe that we do not fully understand what causes graft failure and this will need further studies," he said.

Dr. Levy has not reported any relevant financial conflicts.

BARCELONA – People with knee and hip osteoarthritis tend to overstate their walking disability, but timed walking tests provide an accurate assessment of their lameness, according to a new study.

Dr. Luke Brunton, orthopedic surgeon and researcher at the musculoskeletal research unit at the University of Bristol (England), and his colleagues wanted to find out whether patient self-reports of walking could be used to accurately represent their walking ability. "We found a very poor correlation between self-reports and objective tests," said Dr. Brunton at the World Congress on Osteoarthritis.

He added that "the observers found that patients were performing much more easily than they reported. There was a much better correlation between the observers’ reports and the tests than the patient’s self-reported walking ability."

According to Dr. Brunton, walking impairment in patients with hip and knee OA was particularly important because it was part of the reason for patients’ reduced life span, is linked to social isolation, and has been associated with dementia.

"Questions on walking are very often used to assess function, quality of life, and disability in people with OA. People are commonly asked to self-report on either walking restrictions or distance limitations, however, simply asking patients may not give the whole picture," said Dr. Brunton.

The researchers looked at the correlations between self-reported walking ability and functional tests, and observers’ assessments and the same functional tests of walking ability.

Data from a large U.K. community based cohort study known as the South West and Avon Survey of Health (SASH) cohort were used including demographic and disease-related data.

Self-assessment questions were taken from the commonly used Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Lequesne assessment. WOMAC asked, ‘What degree of difficulty have you experienced walking on flat ground in the last week due to your hips or knees?’ while Lequesne asked, "What is the maximum distance you can walk with pain?"

The study involved 806 participants with a mean age of 68 years and body mass index of 28.6 kg/m². They were asked to carry out a timed 6-meter walking test and a "get up and go" test. The latter test times how long patients take to stand up from a sitting position, walk 3 meters, turn around, and sit down again.

In particular, research observers looked at whether patients had any difficulties walking and how far they said they could walk. They correlated these findings with the 6-meter walk and the "get-up and go" test results, and compared this to the correlation between patient self-reports and the same objective tests.

"We tell the observers it doesn’t matter how long the person is taking. The important thing is how easy it is for the patient to complete the test or not," explained Dr. Brunton.

A stronger association was found between observer evaluation of walking ability and the timed walk (ANOVA r2 = 0.58; P less than .001) and "get up and go" tests (ANOVA r2= 0.56; P less than .001), than patient self-reports (SF-36; ANOVA r2 = 0.23; P less than .001 and Lequesne ANOVA r2 = 0.27; P less than .001) with the objective tests. ANOVA r2 is a measure of the statistical correlation between the two variables

"It is notable that the observers were watching the patients actually carry out a test whereas patients were asked generally how well they walked," he continued, admitting it was a very different scenario being assessed. "But if you are only asking patients one question on walking you are assuming that their self-assessment and their functional test should be very similar. We have showed this isn’t the case."

The data showed most people did the test with similar times how they rated their own walking ability.

"You can’t just take a questionnaire but you may need to undertake a functional assessment too. Most clinicians would assess patients themselves rather than relying solely on questionnaires. For research, I think we also need a combination of the two methods," he said.

Dr. Brunton has reported no relevant financial disclosures. The meeting was sponsored by the Osteoarthritis Research Society International.

BARCELONA – People with knee and hip osteoarthritis tend to overstate their walking disability, but timed walking tests provide an accurate assessment of their lameness, according to a new study.

Dr. Luke Brunton, orthopedic surgeon and researcher at the musculoskeletal research unit at the University of Bristol (England), and his colleagues wanted to find out whether patient self-reports of walking could be used to accurately represent their walking ability. "We found a very poor correlation between self-reports and objective tests," said Dr. Brunton at the World Congress on Osteoarthritis.

He added that "the observers found that patients were performing much more easily than they reported. There was a much better correlation between the observers’ reports and the tests than the patient’s self-reported walking ability."

According to Dr. Brunton, walking impairment in patients with hip and knee OA was particularly important because it was part of the reason for patients’ reduced life span, is linked to social isolation, and has been associated with dementia.

"Questions on walking are very often used to assess function, quality of life, and disability in people with OA. People are commonly asked to self-report on either walking restrictions or distance limitations, however, simply asking patients may not give the whole picture," said Dr. Brunton.

The researchers looked at the correlations between self-reported walking ability and functional tests, and observers’ assessments and the same functional tests of walking ability.

Data from a large U.K. community based cohort study known as the South West and Avon Survey of Health (SASH) cohort were used including demographic and disease-related data.

Self-assessment questions were taken from the commonly used Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Lequesne assessment. WOMAC asked, ‘What degree of difficulty have you experienced walking on flat ground in the last week due to your hips or knees?’ while Lequesne asked, "What is the maximum distance you can walk with pain?"

The study involved 806 participants with a mean age of 68 years and body mass index of 28.6 kg/m². They were asked to carry out a timed 6-meter walking test and a "get up and go" test. The latter test times how long patients take to stand up from a sitting position, walk 3 meters, turn around, and sit down again.

In particular, research observers looked at whether patients had any difficulties walking and how far they said they could walk. They correlated these findings with the 6-meter walk and the "get-up and go" test results, and compared this to the correlation between patient self-reports and the same objective tests.

"We tell the observers it doesn’t matter how long the person is taking. The important thing is how easy it is for the patient to complete the test or not," explained Dr. Brunton.

A stronger association was found between observer evaluation of walking ability and the timed walk (ANOVA r2 = 0.58; P less than .001) and "get up and go" tests (ANOVA r2= 0.56; P less than .001), than patient self-reports (SF-36; ANOVA r2 = 0.23; P less than .001 and Lequesne ANOVA r2 = 0.27; P less than .001) with the objective tests. ANOVA r2 is a measure of the statistical correlation between the two variables

"It is notable that the observers were watching the patients actually carry out a test whereas patients were asked generally how well they walked," he continued, admitting it was a very different scenario being assessed. "But if you are only asking patients one question on walking you are assuming that their self-assessment and their functional test should be very similar. We have showed this isn’t the case."

The data showed most people did the test with similar times how they rated their own walking ability.

"You can’t just take a questionnaire but you may need to undertake a functional assessment too. Most clinicians would assess patients themselves rather than relying solely on questionnaires. For research, I think we also need a combination of the two methods," he said.

Dr. Brunton has reported no relevant financial disclosures. The meeting was sponsored by the Osteoarthritis Research Society International.

BARCELONA – People with knee and hip osteoarthritis tend to overstate their walking disability, but timed walking tests provide an accurate assessment of their lameness, according to a new study.

Dr. Luke Brunton, orthopedic surgeon and researcher at the musculoskeletal research unit at the University of Bristol (England), and his colleagues wanted to find out whether patient self-reports of walking could be used to accurately represent their walking ability. "We found a very poor correlation between self-reports and objective tests," said Dr. Brunton at the World Congress on Osteoarthritis.

He added that "the observers found that patients were performing much more easily than they reported. There was a much better correlation between the observers’ reports and the tests than the patient’s self-reported walking ability."

According to Dr. Brunton, walking impairment in patients with hip and knee OA was particularly important because it was part of the reason for patients’ reduced life span, is linked to social isolation, and has been associated with dementia.

"Questions on walking are very often used to assess function, quality of life, and disability in people with OA. People are commonly asked to self-report on either walking restrictions or distance limitations, however, simply asking patients may not give the whole picture," said Dr. Brunton.

The researchers looked at the correlations between self-reported walking ability and functional tests, and observers’ assessments and the same functional tests of walking ability.

Data from a large U.K. community based cohort study known as the South West and Avon Survey of Health (SASH) cohort were used including demographic and disease-related data.

Self-assessment questions were taken from the commonly used Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Lequesne assessment. WOMAC asked, ‘What degree of difficulty have you experienced walking on flat ground in the last week due to your hips or knees?’ while Lequesne asked, "What is the maximum distance you can walk with pain?"

The study involved 806 participants with a mean age of 68 years and body mass index of 28.6 kg/m². They were asked to carry out a timed 6-meter walking test and a "get up and go" test. The latter test times how long patients take to stand up from a sitting position, walk 3 meters, turn around, and sit down again.

In particular, research observers looked at whether patients had any difficulties walking and how far they said they could walk. They correlated these findings with the 6-meter walk and the "get-up and go" test results, and compared this to the correlation between patient self-reports and the same objective tests.

"We tell the observers it doesn’t matter how long the person is taking. The important thing is how easy it is for the patient to complete the test or not," explained Dr. Brunton.

A stronger association was found between observer evaluation of walking ability and the timed walk (ANOVA r2 = 0.58; P less than .001) and "get up and go" tests (ANOVA r2= 0.56; P less than .001), than patient self-reports (SF-36; ANOVA r2 = 0.23; P less than .001 and Lequesne ANOVA r2 = 0.27; P less than .001) with the objective tests. ANOVA r2 is a measure of the statistical correlation between the two variables

"It is notable that the observers were watching the patients actually carry out a test whereas patients were asked generally how well they walked," he continued, admitting it was a very different scenario being assessed. "But if you are only asking patients one question on walking you are assuming that their self-assessment and their functional test should be very similar. We have showed this isn’t the case."

The data showed most people did the test with similar times how they rated their own walking ability.

"You can’t just take a questionnaire but you may need to undertake a functional assessment too. Most clinicians would assess patients themselves rather than relying solely on questionnaires. For research, I think we also need a combination of the two methods," he said.

Dr. Brunton has reported no relevant financial disclosures. The meeting was sponsored by the Osteoarthritis Research Society International.