Higher risk of knee arthroplasty during ten-year follow-up if baseline radiographic osteoarthritis involves the patellofemoral joint: a CHECK Cohort Study.

BACKGROUND: Patellofemoral OA is a strong risk factor for progression to generalized whole knee OA, but it is unknown whether involvement of the patellofemoral joint in early radiographic OA (ROA) is associated with risk of undergoing future knee arthroplasty. This is clinically relevant because patellofemoral OA likely requires a different treatment approach than tibiofemoral OA, and identifying prognostic factors for future arthroplasty might assist clinicians with prioritizing and guiding early interventions that could improve long-term outcomes. Therefore, we evaluated association of baseline patellofemoral or tibiofemoral ROA with undergoing knee arthroplasty over 10 years. METHODS: Using the multicenter Cohort Hip and Cohort Knee (CHECK) study, we acquired three views of radiographs in both knees of individuals aged 45-65 years with complaints of knee symptoms in at least one knee. From baseline radiographs, we categorized each knee as having one of four patterns of ROA: no ROA, isolated patellofemoral ROA, isolated tibiofemoral ROA, or combined ROA. We evaluated the 10-year relative hazard for undergoing going arthroplasty, based on baseline ROA pattern, using Cox proportional hazard models, adjusting for age, sex body mass index, and pain severity. RESULT: Our sample (n = 842) included 671 (80%) women and had mean (SD) age 56 (5) years, and BMI 26.3 (4.0) kg/m2. Arthroplasties were undertaken in 44/1678 knees. In comparison to having no ROA at baseline, adjusted hazard ratios (aHR) for arthroplasty were highest for combined ROA (aHR 14.2 [95% CI 5.8, 34.6]) and isolated patellofemoral ROA (aHR 12.7 [5.6, 29.0]). Isolated tibiofemoral ROA was not significantly associated with arthroplasty (aHR 2.9 [0.6, 13.6]). CONCLUSIONS: In a sample of middle-aged individuals with complaints in one or both knees, the 10-year relative hazard for undergoing arthroplasty, compared to no ROA, was increased when OA involved the patellofemoral joint, regardless of whether it was isolated to the patellofemoral joint or occurred in combination with tibiofemoral OA. Further research is needed to confirm this association and to clarify the causal mechanism of this relationship. However, our results provide preliminary evidence that identifying patellofemoral ROA may be a clinically useful prognostic indicator in early knee OA.

Disk degeneration of the upper lumbar disks is associated with hip pain.

PURPOSE: A possible cause of hip pain is the presence of radiating pain from the higher lumbar spine. Identification of factors associated with hip pain arising from the lumbar spine would aid the physician. The first step in identifying possible factors is to look at the association between hip pain and osteoarthritis of the lumbar spine. METHODS: In an open population based study of people 55 years and older (Rotterdam study), 2,819 lumbar radiographs were scored for the presence and severity of individual radiographic features of disk degeneration. Hip osteoarthritis was scored on anteroposterior pelvic radiographs, and questionnaires including self-reported hip pain were taken. Logistic regression adjusted for possible confounders was used to determine the association between self-reported hip pain and the individual radiographic features of lumbar disk degeneration. RESULTS: The presence of dis space narrowing grade ≥1 at level L1/L2 was significantly associated with hip pain in the last month (men OR = 2.0; 95 % CI 1.1-3.8 and women OR = 1.7; 95 % CI 1.1-2.5). The presence of disk space narrowing grade ≥1 at level L2/L3 was only significantly associated with hip pain in women. The strength of the associations increased for self-reported chronic hip pain, especially in men (L1/L2 OR = 2.5; 95 % CI 1.3-5.0). The presence of disk space narrowing at the lower levels (L3/L4/L5/S1) was not significantly associated with hip pain. CONCLUSION: Our data provide evidence for an association between hip pain and disk space narrowing at disk level L1/L2 and L2/L3. In case of uncertainty of the cause of hip pain, evaluation of lumbar radiographs may help to identify those hip pain patients who might have pain arising from the lumbar spine.

Kellgren/Lawrence Grading in Cohort Studies: Methodological Update and Implications Illustrated Using Data From a Dutch Hip and Knee Cohort.

OBJECTIVE: The Cohort Hip and Cohort Knee (CHECK) is a cohort of middle-aged individuals with hip or knee pain. Radiographs were assigned Kellgren/Lawrence (K/L) scores under different conditions at each follow-up visit for 10 years. We aimed to describe and consolidate each scoring approach, then illustrate implications of their use by comparing baseline K/L scores assigned using 2 of these approaches, and evaluating their respective associations with joint replacement and incident radiographic osteoarthritis (ROA). METHODS: We compared baseline K/L scores assigned to hips and knees using 2 scoring approaches: 1) assigned by senior researchers to baseline images alone and 2) assigned by trained readers, with images read paired and in known sequence with up to 10 years of follow-up radiographs (Poisson regression). We evaluated the associations of baseline ROA (any: K/L grade ≥1; established: K/L ≥2) with joint replacement, and of K/L 1 joints with incident established ROA (survival analysis). RESULTS: Of 1,002 participants (79% women, mean ± SD age 55.9 ± 5.2 years, body mass index 26.2 ± 4.0 kg/m2 ), the second scoring approach had 2.4 times (95% confidence interval [95% CI] 1.8-3.1 for knees) and 2.9 times (95% CI 2.3-3.7 for hips) higher prevalence of established ROA than the first approach. Established hip ROA had a higher risk of joint replacement using the first approach (hazard ratio [HR] 24.2 [95% CI 15.0-39.8] versus second approach HR 7.7 [95% CI 4.9-12.1]), as did knees (HR 19.3 [95% CI 10.3-36.1] versus second approach HR 4.8 [95% CI 2.4-9.6]). The risk of incident ROA did not differ by approach. CONCLUSION: This study demonstrates that evaluating ROA prevalence and predicting outcomes depends on the scoring approach.

Incidence and Prevalence of Knee Osteoarthritis Using Codified and Narrative Data From Electronic Health Records: A Population-Based Study.

OBJECTIVE: To determine the incidence and prevalence of knee osteoarthritis (OA) using codified and narrative data from general practices throughout The Netherlands. METHODS: This retrospective cohort study was conducted using the Integrated Primary Care Information database. Patients with codified knee OA were selected, and an algorithm was developed to identify patients with narratively diagnosed knee OA only. Point prevalence proportions and incidence rates among people age ≥30 years were assessed from 2008 to 2019. The association of comorbidities with codified knee OA was analyzed using multivariable logistic regression. RESULTS: The positive predicted value of narratively diagnosed knee OA only was 94.0% (95% confidence interval [95% CI] 87.4-100%) and for codified knee OA 96.0% (95% CI 90.6-100%). Including narrative data in addition to codified data resulted in a prevalence 1.83-2.01 times higher (over the study years); prevalence increased from 5.8% to 11.8% between 2008 and 2019. The incidence rate was 1.93-2.28 times higher and increased from 9.98 per 1,000 person-years to 13.8 per 1,000 person-years between 2008 and 2019. Among patients with codified knee OA, 39.4% were previously diagnosed narratively with knee OA, on average ~3 years earlier. Comorbidities influenced the likelihood of being recorded with codified knee OA. CONCLUSION: Our study of a Dutch primary care database showed that current incidence and prevalence estimates based on codified data alone from electronic health records are underestimated. Narrative data can be incorporated in addition to codified data to identify knee OA patients more accurately.

Prevalence and development of hip and knee osteoarthritis according to American College of Rheumatology criteria in the CHECK cohort.

BACKGROUND: We aimed to evaluate the prevalence of hip and knee osteoarthritis (HOA and KOA) according to American College of Rheumatology (ACR) criteria among participants with suspected early symptomatic osteoarthritis (OA) in the CHECK cohort. We also assessed whether participants not fulfilling ACR criteria at baseline develop ACR-defined OA at 2-year and/or 5-year follow up, and which baseline factors are associated with this development. METHODS: The CHECK cohort included 1002 subjects with first presentation of knee and/or hip complaints. The primary outcome was onset of HOA and/or KOA according to the ACR criteria, including the clinical classification criteria and the combined clinical and radiographic classification criteria at 2-year and/or 5-year follow up. RESULTS: Of the participants with hip complaints, 63% (n = 370) were classified as having HOA at baseline according to the ACR criteria. Of those not classified with HOA at baseline, 40% developed HOA according to the clinical or combined clinical/radiographic ACR criteria after 2 and/or 5 years. Up to 92% of participants (n = 829) with knee complaints were classified as having KOA at baseline; of those not classified with KOA at baseline, 55% developed KOA according to the clinical ACR criteria or the clinical/radiographic ACR criteria after 2 and/or 5 years. The following factors were associated with development of HOA: morning stiffness (OR 2.39; 95% CI 1.14-4.98), painful internal rotation (OR 2.53; 95% CI 1.23-5.19), hip flexion < 115° (OR 2.33; 95% CI 1.17-4.64) and erythrocyte sedimentation rate (ESR) < 20 mm/h (OR 2.94; 95% CI 1.13-7.61). No variables were associated with development of KOA at 2-year and/or 5-year follow up. CONCLUSIONS: A large proportion of persons with hip complaints not fulfilling the ACR criteria at baseline develop HOA after 2 and/or 5 years of follow up. Almost all persons with knee complaints already fulfill the clinical and/or radiographic ACR criteria for OA, and half of the persons not fulfilling criteria at baseline will do so after 5 years of follow up. Several individual ACR criteria for HOA at baseline were associated with the development of HOA at follow up. This association was not proven for KOA, probably because of the small number of subjects developing KOA in this study.

Characteristics associated with joint replacement in early symptomatic knee or hip osteoarthritis: 6-year results from a nationwide prospective cohort study (CHECK).

BACKGROUND: Many patients with osteoarthritis (OA) of the knee and/or hip undergo total joint replacement (TJR) because of severely progressed symptoms. AIM: To determine patient and disease characteristics associated with undergoing TJR in participants with recent-onset knee and/or hip OA. DESIGN AND SETTING: Participants with hip or knee pain from the nationwide prospective Cohort Hip and Cohort Knee (CHECK) study were included. METHOD: The outcome measure was total hip arthroplasty (THA) or total knee arthroplasty (TKA) during 6 years of follow-up. Joint-dependent characteristics were compared using generalised estimating equations (GEE). Multivariable models were built for both subgroups. Differences in symptomatic and radiographic progression were determined between baseline and 2-year follow-up (T2). RESULTS: The knee subgroup included 751 participants (1502 knees), and there were 538 participants in the hip subgroup (1076 hips). Nineteen participants (22 knees) underwent TKA and 53 participants (62 hips) THA. Participants who underwent TKA had higher baseline body mass index, painful knee flexion, and higher Kellgren and Lawrence scores. Participants who underwent THA had painful internal hip rotation and showed more severe radiographic OA features. Participants who underwent TKA or THA showed more rapid symptomatic and radiographic OA progression at T2. CONCLUSION: In patients with recent-onset knee or hip pain, radiographic OA features already exist and a substantial number of patients fulfil existing criteria for knee and hip OA. A trend was observed in rapid progression of radiographic and symptomatic OA severity among patients with TKA and THA. Early detection of OA by the GP is important in managing knee and hip OA.

Additional Value of Different Radiographic Views on the Identification of Early Radiographic Hip and Knee Osteoarthritis and Its Progression: A Cohort Study.

OBJECTIVE: To investigate the prevalence and progression of early radiographic osteoarthritis (OA) of the hip and knee on different radiographic views, to determine whether different radiographic views have additional value in detecting early hip and knee radiographic OA cases or progression. METHODS: In the Cohort Hip and Cohort Knee (CHECK) study (n = 1,002), 5 different radiographs were obtained: an anteroposterior and faux profile view of the hips, and posteroanterior, mediolateral, and skyline views of the knees. The prevalence of radiographic OA was estimated based on each view separately and in combinations. We determined whether different radiographic views have additional value in detecting and determining the progression of radiographic OA cases, compared to standard projections. RESULTS: In the hip, we found 22.9% more cases when we combined both views. In the knee, we detected 79.7% more radiographic OA cases when we combined information from all 3 different radiographic views than when using only the posteroanterior view. Progression was seen in 33.1% more cases when using 2 hip radiographs, and in 65.1% more cases when using 3 knee radiographs. CONCLUSION: The use of different radiographic views increased the number of participants classified as having radiographic OA in an early OA cohort, both at baseline and at followup. The progression of early radiographic OA is demonstrated more frequently when multiple different radiographic views are used.

Defining knee pain trajectories in early symptomatic knee osteoarthritis in primary care: 5-year results from a nationwide prospective cohort study (CHECK).

BACKGROUND: GPs have high consultation rates for symptoms related to knee osteoarthritis (OA). Many risk factors for symptomatic knee OA progression remain unknown. AIM: To define distinct knee pain trajectories in individuals with early symptomatic knee OA and determine the risk factors for these pain trajectories. DESIGN AND SETTING: Data were obtained from the multicentre prospective Cohort Hip and Cohort Knee study in the Netherlands. Participants with knee OA, according to the clinical criteria of the American College of Rheumatology, and a completed 5-year follow-up were included. METHOD: Baseline demographic, anamnestic, and physical examination characteristics were assessed. Outcome was annually assessed by the Numeric Rating Scale for pain. Pain trajectories were retrieved by latent class growth analysis. Multinomial logistic regression was used to calculate relative risk ratios. RESULTS: In total, 705 participants were included. Six distinct pain trajectories were identified with favourable and unfavourable courses. Statistically significant differences were found in baseline characteristics, including body mass index (BMI), symptom severity, and pain coping strategies between the different trajectories. Higher BMI, lower level of education, greater comorbidity, higher activity limitation scores, and joint space tenderness were more often associated with trajectories characterised by more pain at first presentation and pain progression--compared with the reference group with a mild pain trajectory. No association was found for baseline radiographic features. CONCLUSION: These results can help differentiate those patients who require more specific monitoring in the management of early symptomatic knee OA from those for whom a 'wait-and-see' policy seems justifiable. Radiography provided no additional benefit over clinical diagnosis of early symptomatic knee OA in general practice.

Epidemiology of unintentional injuries in childhood: a population-based survey in general practice.

This study aimed to assess the incidence of unintentional injuries presented in general practice, and to identify children at risk from experiencing an unintentional injury. We used the data of all 0-17-year-old children from a representative survey in 96 Dutch general practices in 2001. We computed incidence rates and multilevel multivariate regression analysis in different age strata and identified patient and family characteristics associated with an elevated injury risk. Nine thousand four hundred and eighty-four new injury episodes were identified from 105 353 new health problems presented in general practice, giving an overall incidence rate of 115 per 1000 person years (95% confidence interval [CI] = 113 to 118). Sex and residence in rural areas are strong predictors of injury in all age strata. Also, in children aged 0-4 years, a higher number of siblings is associated with elevated injury risk (> or =3 siblings odds ratio [OR] = 1.57, 95% CI = 1.19 to 2.08) and in the 12-17-year-olds, ethnic background and socioeconomic class are associated with experiencing an injury (non-western children OR = 0.67, 95% CI = 0.54 to 0.81; low socioeconomic class OR = 1.39, 95% CI = 1.22 to 1.58). Unintentional injury is a significant health problem in children in general practice, accounting for 9% of all new health problems in children. In all age groups, boys in rural areas are especially at risk to experience an injury.

Factors for pain in patients with different grades of knee osteoarthritis.

OBJECTIVE: Discordance between having pain and radiologic osteoarthritis (OA) is a well-established fact. It is suggested that this particularly applies to the less severe grades of OA. However, some people with a Kellgren/Lawrence (K/L) grade of 3 or 4 for OA are without pain. This study aimed to identify factors and differences in the factors associated with pain in persons with different grades of knee OA. METHODS: We stratified the knees of more than 5,000 participants of a population-based cohort study, the Rotterdam Study, based on the grade of knee OA. Multivariate generalized estimating equation analysis was used to analyze the association with knee pain. We tested several factors not directly related to structural damage of the knee. RESULTS: As expected, an increasing percentage of participants did not report pain with decreasing severity of knee OA: 25.8% for K/L grade 3 or 4 and 84.5% for no knee OA. Being a woman, having widespread pain, reporting general health symptoms, familial OA, and morning stiffness are factors for knee pain, but not specific for a particular grade of radiographic knee OA. Depression and hip OA showed significant interactions with the grade of OA being a factor for knee pain in knees without OA (K/L grade 0), but not in knees with OA. In addition, increasing age is protective for reporting pain in general. CONCLUSION: Several factors are associated with knee pain, but are not specific for a grade of radiographic knee OA. Two factors were associated with knee pain in the knee without signs of OA.

Diagnostic accuracy of range of motion measurements in early symptomatic hip and/or knee osteoarthritis.

OBJECTIVE: To examine the diagnostic accuracy of hip internal rotation, hip flexion, and knee flexion measurements for the presence of osteophytosis and joint space narrowing (JSN) in early symptomatic osteoarthritis (OA). METHODS: The baseline data for 598 participants of the Cohort Hip & Cohort Knee study were used. Participants underwent a standardized physical and radiographic examination. The active range of motion (ROM) was assessed using a goniometer. The ROM cutoff with the highest discriminative ability for radiographic features of OA was defined by maximizing the sum of the sensitivity and specificity. Several diagnostic measures were calculated to establish the diagnostic accuracy of ROM measurements for the presence of radiographic features. RESULTS: In patients with hip symptoms, hip internal rotation <24° and flexion <114° were found to be the cutoffs with the highest discriminative ability to distinguish between patients with and without radiographic features. In patients with knee symptoms, knee flexion <132° was the cutoff with the highest discriminative ability. The American College of Rheumatology (ACR) criterion of hip internal rotation <15° increased the probability of the presence of osteophytosis or JSN from 25% to 58%. The diagnostic accuracy of hip and knee flexion measurements was low. CONCLUSION: To reduce the number of patients that are not identified by the ACR criterion of hip internal rotation <15°, it is recommended to change the cutoff to internal rotation <24° in patients with early symptomatic OA. Individual hip and knee flexion measurements seem to be of little diagnostic value in early symptomatic OA.

The association between lumbar disc degeneration and low back pain: the influence of age, gender, and individual radiographic features.

STUDY DESIGN: Cross-sectional open population based study (nested in a prospective cohort study). OBJECTIVE: To explore the association of the different individual radiographic features, including osteophytes and disc space narrowing, with self-reported low back pain (LBP). Different definitions of lumbar disc degeneration with self-reported LBP and disability were considered in a large open population sample. Furthermore, in order to disentangle the discrepancies in reported strength of the associations, we characterized the frequency of the different individual radiographic features of lumbar disc degeneration and definitions of lumbar disc degeneration, as well as their association with LBP status, by age, gender, and vertebral level. SUMMARY OF BACKGROUND DATA: Currently within the literature, there have been no studies that have explored different definitions of lumbar disc degeneration and their association with LBP within one study sample. METHODS: The intervertebral disc spaces (L1/2 to L5-S1) were evaluated for the presence and severity of anterior osteophytes and disc space narrowing using a semiquantitative score (grade 0-3). Logistic regression was used to determine the association between these individual radiographic features of lumbar disc degeneration and different definitions of lumbar disc degeneration for LBP. RESULTS: Lumbar radiographs were scored for 1204 men, and 1615 women. Osteophytes were the most frequent radiographic feature observed, with men having the greatest frequency. Disc space narrowing was more frequent in women than men. Both radiographic features increased in frequency with age.Disc space narrowing appeared more strongly associated with LBP than osteophytes, especially in men (odds ratio [OR] = 1.9; 95% confidence interval [CI]: 1.4-2.8). Disc space narrowing at 2 or more levels appeared more strongly associated with LBP than disc space narrowing at only 1 level (OR = 2.4; 95% CI: 1.6-3.4). After excluding level L5-S1, the strength of almost all associations increased. CONCLUSION: We are the first to report different possible lumbar disc degeneration definitions and their associations with LBP. Disc space narrowing at 2 or more levels appeared more strongly associated with LBP than other radiographic features, especially after excluding level L5-S1.