Bone Marrow Lesions and Magnetic Resonance Imaging-Detected Structural Abnormalities in Patients With Midfoot Pain and Osteoarthritis: A Cross-Sectional Study.

OBJECTIVE: To compare magnetic resonance imaging (MRI)-detected structural abnormalities in patients with symptomatic midfoot osteoarthritis (OA), patients with persistent midfoot pain, and asymptomatic controls, and to explore the association between MRI features, pain, and foot-related disability. METHODS: One hundred seven adults consisting of 50 patients with symptomatic and radiographically confirmed midfoot OA, 22 adults with persistent midfoot pain but absence of radiographic OA, and 35 asymptomatic adults underwent 3T MRI of the midfoot and clinical assessment. MRIs were read for the presence and severity of abnormalities (bone marrow lesions [BMLs], subchondral cysts, osteophytes, joint space narrowing [JSN], effusion-synovitis, tenosynovitis, and enthesopathy) using the Foot Osteoarthritis MRI Score. Pain and foot-related disability were assessed with the Manchester Foot Pain and Disability Index. RESULTS: The severity sum score of BMLs in the midfoot was greater in patients with midfoot pain and no signs of OA on radiography compared to controls (P = 0.007), with a pattern of involvement in the cuneiform-metatarsal joints similar to that in patients with midfoot OA. In univariable models, BMLs (ρ = 0.307), JSN (ρ = 0.423), and subchondral cysts (ρ = 0.302) were positively associated with pain (P < 0.01). In multivariable models, MRI abnormalities were not associated with pain and disability when adjusted for covariates. CONCLUSION: In individuals with persistent midfoot pain but no signs of OA on radiography, MRI findings suggested an underrecognized prevalence of OA, particularly in the second and third cuneiform-metatarsal joints, where BML patterns were consistent with previously recognized sites of elevated mechanical loading. Joint abnormalities were not strongly associated with pain or foot-related disability.

"I could have a proper ankle" - a qualitative study of patients' perceptions of total ankle replacement and ankle fusion surgery.

BACKGROUND: End-stage ankle osteoarthritis typically causes severe pain and impaired function. Surgical treatment involves total ankle replacement (TAR) or ankle fusion. Definitive evidence about which procedure is optimal is lacking. No previous studies have thoroughly explored patients' experiences across the entire TAR/ankle fusion pathway. This study aimed to address this gap by exploring perceptions of surgery, education, rehabilitation and outcomes among patients who had undergone TAR or ankle fusion. METHODS: Seven participants were purposively selected from an orthopaedic centre in northern England (3 females, 4 males). Participants had undergone primary TAR without revision (n = 2), TAR requiring revision (n = 3) or ankle fusion (n = 2). Each participant completed a single semi-structured interview. Interviews were digitally recorded, transcribed verbatim and analysed thematically. RESULTS: Three themes, each with two subthemes, were identified: decision-making (seeking help; surgical options), perceptions of support (information/education; clinical support) and impact on the individual (personal circumstances and beliefs; post-operative outcomes). Pain affecting participants' valued activities was key to their decision to seek help. Participants' decision between TAR and ankle fusion was influenced by multiple factors. Concerns regarding the lack of joint flexibility following fusion were highlighted, with some participants perceiving TAR as a "proper ankle" that would enable them to avoid limping. Participants obtained information from various sources, with most feeling that the education from their care team was inadequate. Participants' individual circumstances and beliefs influenced their decision-making and perceptions of their post-operative outcomes. Finally, whilst most participants were pleased with their outcomes, some experienced substantial ongoing problems such as difficulty walking and chronic pain. CONCLUSIONS: This study demonstrates the importance of providing adequate education about TAR and ankle fusion to enable patients to make informed decisions. Most participants felt that the education and clinical support they received did not fully meet their needs. Participants' personal circumstances and beliefs had a strong influence on their decision-making and perceptions of their post-operative outcomes, highlighting the need to personally tailor education and clinical support. Future work with a larger sample of patients and other key stakeholders is required to develop consensus-based guidelines on pre- and post-operative support for patients undergoing TAR/ankle fusion.

Testing a newly developed activity pacing framework for chronic pain/fatigue: a feasibility study.

OBJECTIVES: To test the feasibility of using a new activity pacing framework to standardise healthcare professionals' instructions of pacing, and explore whether measures of activity pacing/symptoms detected changes following treatment. DESIGN: Single-arm, repeated measures study. SETTING: One National Health Service (NHS) Pain Service in Northern England, UK. PARTICIPANTS: Adult patients with chronic pain/fatigue, including chronic low back pain, chronic widespread pain, fibromyalgia and chronic fatigue syndrome/myalgic encephalomyelitis. INTERVENTIONS: Six-week rehabilitation programme, standardised using the activity pacing framework. OUTCOME MEASURES: Feasibility was explored via patients' recruitment/attrition rates, adherence and satisfaction, and healthcare professionals' fidelity. Questionnaire data were collected from patients at the start and end of the programme (T1 and T2, respectively) and 3 months' follow-up (T3). Questionnaires included measures of activity pacing, current/usual pain, physical/mental fatigue, depression, anxiety, self-efficacy, avoidance, physical/mental function and quality of life. Mean changes in activity pacing and symptoms between T1-T2, T2-T3 and T1-T3 were estimated. RESULTS: Of the 139 eligible patients, 107 patients consented (recruitment rate=77%); 65 patients completed T2 (T1-T2 attrition rate=39%), and 52 patients completed T3 (T1-T3 attrition rate=51%). At T2, patients' satisfaction ratings averaged 9/10, and 89% attended ≥5 rehabilitation programme sessions. Activity pacing and all symptoms improved between T1 and T2, with smaller improvements maintained at T3. CONCLUSION: The activity pacing framework was feasible to implement and patients' ability to pace and manage their symptoms improved. Future work will employ a suitable comparison group and test the framework across wider settings to explore the effects of activity pacing in a randomised controlled trial. TRIAL REGISTRATION NUMBER: NCT03497585.

Activity pacing: moving beyond taking breaks and slowing down.

This brief communication responds to the paper by Jeong and Cho (Qual Life Res 26(4):903-911, 2017) that has described activity pacing in limited terms of adjusting activities through going at a slower rate and taking breaks. Activity pacing was reported as not involving goal setting, in comparison to other strategies for long-term conditions such as Acceptance and Commitment Therapy. This brief communication aims to challenge this limited perception of activity pacing in light of numerous studies that recognise pacing to be a more complex strategy. Pacing is considered to be a multifaceted coping strategy, including broad themes of not only adjusting activities, but also planning activities, having consistent activity levels, acceptance of current abilities and gradually increasing activities, and one that includes goal setting as a key facet. It is essential that pacing is both defined and measured as a multifaceted strategy in order to assess the outcomes of pacing, and for meaningful comparisons with other strategies regarding efficacy for the management of long-term conditions.

Development and Reliability of a Preliminary Foot Osteoarthritis Magnetic Resonance Imaging Score.

OBJECTIVE: Foot osteoarthritis (OA) is very common but underinvestigated musculoskeletal condition and there is little consensus as to common magnetic resonance imaging (MRI) features. The aim of this study was to develop a preliminary foot OA MRI score (FOAMRIS) and evaluate its reliability. METHODS: This preliminary semiquantitative score included the hindfoot, midfoot, and metatarsophalangeal joints. Joints were scored for joint space narrowing (JSN; 0-3), osteophytes (0-3), joint effusion/synovitis, and bone cysts (present/absent). Erosions and bone marrow lesions (BML) were scored (0-3) and BML were evaluated adjacent to entheses and at sub-tendon sites (present/absent). Additionally, tenosynovitis (0-3) and midfoot ligament pathology (present/absent) were scored. Reliability was evaluated in 15 people with foot pain and MRI-detected OA using 3.0T MRI multi-sequence protocols, and assessed using ICC as an overall score and per anatomical site. RESULTS: Intrareader agreement (ICC) was generally good to excellent across the foot in joint features (JSN 0.90, osteophytes 0.90, effusion/synovitis 0.46, cysts 0.87), bone features (BML 0.83, erosion 0.66, BML entheses 0.66, BML sub-tendon 0.60) and soft tissue features (tenosynovitis 0.83, ligaments 0.77). Interreader agreement was lower for joint features (JSN 0.43, osteophytes 0.27, effusion/synovitis 0.02, cysts 0.48), bone features (BML 0.68, erosion 0.00, BML entheses 0.34, BML sub-tendon 0.13), and soft tissue features (tenosynovitis 0.35, ligaments 0.33). CONCLUSION: This preliminary FOAMRIS demonstrated good intrareader reliability and fair interreader reliability when assessing the total feature scores. Further development is required in cohorts with a range of pathologies and to assess the psychometric measurement properties.

Interpreting outcome following foot surgery in people with rheumatoid arthritis.

BACKGROUND: Foot surgery is common in RA but the current lack of understanding of how patients interpret outcomes inhibits evaluation of procedures in clinical and research settings. This study aimed to explore which factors are important to people with RA when they evaluate the outcome of foot and ankle surgery. METHODS AND RESULTS: Semi structured interviews with 11 RA participants who had mixed experiences of foot surgery were conducted and analysed using thematic analysis. Responses showed that while participants interpreted surgical outcome in respect to a multitude of factors, five major themes emerged: functional ability, participation, appearance of feet and footwear, surgeons' opinion, and pain. Participants interpreted levels of physical function in light of other aspects of their disease, reflecting on relative change from their preoperative state more than absolute levels of ability. Appearance was important to almost all participants: physical appearance, foot shape, and footwear were closely interlinked, yet participants saw these as distinct concepts and frequently entered into a defensive repertoire, feeling the need to justify that their perception of outcome was not about cosmesis. Surgeons' post-operative evaluation of the procedure was highly influential and made a lasting impression, irrespective of how the outcome compared to the participants' initial goals. Whilst pain was important to almost all participants, it had the greatest impact upon them when it interfered with their ability to undertake valued activities. CONCLUSIONS: People with RA interpret the outcome of foot surgery using multiple interrelated factors, particularly functional ability, appearance and surgeons' appraisal of the procedure. While pain was often noted, this appeared less important than anticipated. These factors can help clinicians in discussing surgical options in patients.

The 'Switch' study protocol: a randomised-controlled trial of switching to an alternative tumour-necrosis factor (TNF)-inhibitor drug or abatacept or rituximab in patients with rheumatoid arthritis who have failed an initial TNF-inhibitor drug.

BACKGROUND: Rheumatoid Arthritis (RA) is one of the most common autoimmune diseases, affecting approximately 1% of the UK adult population. Patients suffer considerable pain, stiffness and swelling and can sustain various degrees of joint destruction, deformity, and significant functional decline. In addition, the economic burden due to hospitalisation and loss of employment is considerable, with over 50% of patients being work-disabled within 10 years of diagnosis. Despite several biologic disease modifying anti-rheumatic drugs (bDMARD) now available, there is a lack of data to guide biologic sequencing. In the UK, second-line biologic treatment is restricted to a single option, rituximab. The aim of the SWITCH trial is to establish whether an alternative-mechanism-TNF-inhibitor (TNFi) or abatacept are as effective as rituximab in patients with RA who have failed an initial TNFi drug. METHODS/DESIGN: SWITCH is a pragmatic, phase IV, multi-centre, parallel-group design, open-label, randomised, controlled trial (RCT) comparing alternative-mechanism-TNFi and abatacept with rituximab in patients with RA who have failed an initial TNFi drug. Participants are randomised in a 1:1:1 ratio to receive alternative mechanism TNFi, (monoclonal antibodies: infliximab, adalimumab, certolizumab or golimumab or the receptor fusion protein, etanercept), abatacept or rituximab during the interventional phase (from randomisation up to week 48). Participants are subsequently followed up to a maximum of 96 weeks, which constitutes the observational phase. The primary objective is to establish whether an alternative-mechanism-TNFi or abatacept are non-inferior to rituximab in terms of disease response at 24 weeks post randomisation. The secondary objectives include the comparison of alternative-mechanism-TNFi and abatacept to rituximab in terms of disease response, quality of life, toxicity, safety and structural and bone density outcomes over a 12-month period (48 weeks) and to evaluate the cost-effectiveness of switching patients to alternative active therapies compared to current practice. DISCUSSION: SWITCH is a well-designed trial in this therapeutic area that aims to develop a rational treatment algorithm to potentially inform personalised treatment regimens (as opposed to switching all patients to only one available (and possibly unsuccessful) therapy), which may lead to long-term improved patient outcomes and gains in population health. TRIAL REGISTRATION: UKCRN Portfolio ID: 12343; ISRCTN89222125 ; NCT01295151.

Use of conservative and surgical foot care in an inception cohort of patients with rheumatoid arthritis.

OBJECTIVES: To describe conservative and surgical foot care in patients with RA in England and explore factors that predict the type of foot care received. METHODS: Use of podiatry and type of foot surgery were outcomes recorded in an inception cohort involving nine rheumatology centres that recruited patients with RA between 1986 and 1998 across England. Associations between patient-specific factors and service use were identified using univariate logistic regression analyses. The independence of these associations was then verified through multiple binary logistic regression modelling. RESULTS: Data were collected on 1237 patients with RA [66.9% females, mean (s.d.) age at disease onset = 54.36 (14.18) years, median DAS = 4.09 (1st quartile = 3.04, 3rd quartile = 5.26), median HAQ = 1 (0.50, 1.63)]. Interventions involving the feet in the cohort were low with only 364 (30%) out of 1218 receiving podiatry and 47 (4%) out of 1237 patients having surgery. At baseline, female gender, increasing age at onset, being RF positive and higher DAS scores were each independently associated with increased odds of seeing a podiatrist. Gender, age of onset and baseline DAS were independently associated with the odds of having foot surgery. CONCLUSIONS: Despite the known high prevalence of foot pathologies in RA, only one-third of this cohort accessed podiatry. While older females were more likely to access podiatry care and younger patients surgery, the majority of the RA population did not access any foot care.

Persistently moderate DAS-28 is not benign: loss of function occurs in early RA despite step-up DMARD therapy.

OBJECTIVES: Current UK management of RA initially employs conventional DMARDs, with biological therapy reserved for DMARD-resistant RA patients with persistently high 28-joint disease activity score (DAS-28). The aim of this study was to examine the effect on patient-reported function of persistently moderate DAS-28 despite modern step-up DMARD therapy in an early arthritis cohort. METHODS: Data were obtained from the Yorkshire Early Arthritis Register, a cohort of early (<12 months) RA patients treated with dose-escalated DMARDs. Change in HAQ exceeding the minimum clinically important difference (MCID) was determined for three values of MCID (0.22, 0.31 and 0.49). Changes in HAQ over Months 6-12 were compared between patients whose DAS-28(ESR) was persistently high (> 5.1 at 6- and/or 9-month visits and at the 12-month visit), persistently moderate (>3.2 and ≤ 5.1) or persistently low (≤ 3.2). RESULTS: We selected 194 patients for this analysis. Deteriorating HAQ scores were observed in 10.9% of patients with persistently low DAS-28 compared with 21.4% (persistently moderate DAS-28) and 46.7% (persistently high DAS-28), respectively, for MCID = 0.22; 7.3, 14.3 and 20.0% for MCID = 0.31; 5.5, 10.7 and 11.1% for MCID = 0.49. CONCLUSIONS: A high DAS-28 was generally associated with a greater degree of functional decline, but persistent moderate elevation of DAS-28 was associated with important functional deterioration in 10-21% of early RA patients (depending on choice of MCID) following a modern DMARD protocol. A proportion of patients with persistently moderate DAS-28 may therefore benefit from more aggressive therapy than that allowed by current UK recommendations.

Ligament and bone pathologic abnormalities more frequent in neuropathic joint disease in comparison with degenerative arthritis of the foot and ankle: implications for understanding rapidly progressive joint degeneration.

OBJECTIVE: The variable disease progression of osteoarthritis (OA) and the basis for rapid joint deterioration in some subgroups of patients are poorly understood. To explore an anatomic basis for rapidly progressive OA, this observational study compared the magnetic resonance imaging (MRI) patterns of disease between patients with neuropathic joint disease (NJD) and patients with degenerative arthritis of the ankle and foot. METHODS: MR images of the foot and ankle of patients with early NJD (n = 7) and patients with OA (n = 15) were assessed. The anonomized MR images were dichotomously scored by a musculoskeletal radiologist for the presence of the following abnormalities per bone (of a total of 14 bones): cartilage defects, bone cysts, bone marrow edema, fractures, joint debris, joint effusions, tendinopathy, tendinitis, and ligament tears. RESULTS: Although the degree of cartilage damage and joint cyst formation was comparable between the groups, the degree of ligament tears, or change in MRI signal intensity in the ligaments, was significantly greater in patients with NJD compared with patients with OA (median of 3 tears versus 0, of 14 total bones; P < 0.01). Moreover, in patients with early NJD compared with patients with OA, there was a significantly greater degree of diffuse bone marrow edema (median of 6.5 tarsal bones versus 2 adjacent bones, of 14 total bones; P < 0.01), a greater number of bone fractures (median 4 versus 0; P < 0.01), and more frequent bone debris (median 4.5 versus 0; P = 0.013). CONCLUSION: This analysis of NJD in the foot and ankle shows the predominance of bone and ligament abnormalities in NJD compared with the pattern of involvement in OA. These findings highlight the importance of structures other than articular cartilage in OA of the ankle and foot, and suggest that rapid joint degeneration in NJD may be more ligamentogenic or osteogenic in nature.

Effect of the early use of the anti-tumor necrosis factor adalimumab on the prevention of job loss in patients with early rheumatoid arthritis.

OBJECTIVE: To compare work disability and job loss in early rheumatoid arthritis (RA) patients receiving adalimumab plus methotrexate (adalimumab + MTX) versus MTX alone. METHODS: In this multicenter, randomized, controlled trial, patients with RA for <2 years who had never taken MTX and who self-reported work impairment were randomized to adalimumab + MTX or placebo + MTX for 56 weeks. Primary outcome was job loss of any cause and/or imminent job loss at or after week 16. Secondary outcomes included disease activity, function (Health Assessment Questionnaire [HAQ] score), and RA quality of life (RAQoL) questionnaire score. Work was evaluated with work diaries and the RA Work Instability Scale. RESULTS: Although job loss during the 56-week study was significantly lower with adalimumab + MTX (14 of 75 patients) compared with MTX alone (29 of 73 patients; P=0.005), the primary end point was not met (12 of 75 versus 20 of 73 patients; P=0.092), likely owing to early drop out in the MTX group. There were significant improvements in American College of Rheumatology 20% response criteria, 28-joint Disease Activity Score, DeltaHAQ, DeltaRAQoL, and working time lost in the adalimumab + MTX group. Twenty-four serious adverse events were reported in 17 participants, with no differences between groups. CONCLUSION: Adalimumab + MTX reduced job loss and improved productivity in early RA when compared with MTX alone, which supports the early use of anti-tumor necrosis factor therapy and suggests its cost efficacy.

The Foot Posture Index: Rasch analysis of a novel, foot-specific outcome measure.

OBJECTIVE: To investigate the internal construct validity of a clinician-assessed measure of foot position, the Foot Posture Index (FPI), versions FPI-8 and FPI-6. DESIGN: Rasch analysis of baseline FPI scores from studies conducted during the development of the instrument. SETTING: A community-based and a hospital-based study, conducted at 2 institutions. PARTICIPANTS: Measures were obtained from 143 participants (98 men, 45 women; age range, 8-65y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Rasch analysis was undertaken using RUMM2020 software in order to evaluate the following properties of the FPI: unidimensionality of each item included in the FPI, the differential item functioning (DIF) of each item, and item and person separation indices. RESULTS: In the developmental draft of the instrument, the 8-item FPI-8 showed some misfit to the Rasch model (chi(16)(2) test=27.63, P=.03), indicating lack of unidimensionality. Two items were identified as problematic in the Rasch modeling: Achilles' tendon insertion (Helbing's sign), which showed illogical response ordering and "congruence of the lateral border of the foot," which showed misfit, indicating that this item may be measuring a different construct (chi(2)(2) test=15.35, P<.01). All FPI-8 items showed an absence of DIF, and the person separation index (PSI) was good (PSI=.88). The revised FPI-6, which does not include the 2 problematic items, showed unidimensionality (chi(12)(2) test=11.49, P=.49), indicating a good overall fit to the model, and improvement over the preliminary version. With the removal of the 2 problematic items, there were no disordered thresholds; all items remained DIF free and all individual items displayed a good fit to the model. The person-separation index for the FPI was similar for both the 8-item (FPI-8=.880) and 6-item (FPI-6=.884) versions. CONCLUSIONS: The original FPI-8 showed significant mismatching to the model. The 2 items in the FPI-8 that were identified as problematic in clinical validation studies were also found to be contributing to the lack of fit to the Rasch model. The finalized 6-item instrument showed good metric properties, including good individual item fit and good overall fit to the model, along with a lack of differential item functioning. This analysis provides further evidence for the validity of the FPI-6 as a clinical instrument for use in screening studies and shows that it has the potential to be analyzed using parametric strategies.

Quantifying peri-meniscal synovitis and its relationship to meniscal pathology in osteoarthritis of the knee.

The objectives of this study were to validate a semiquantitative scoring system for estimating perimeniscal synovitis in osteoarthritic (OA) knees and to examine the relationship between the extent of synovitis and the degree of meniscal pathology using gadolinium-enhanced magnetic resonance imaging (MRI). Forty-three subjects with clinically diagnosed OA knee were assessed for peri-meniscal synovitis using gadolinium-enhanced MRI. Quantitative measurements of synovitis were made by summing areas in consecutive slices within generated regions of interest, and the synovitis was also scored semi-quantitatively using a 0-3 scale. Meniscal pathology (extrusion, degeneration and tearing) was also scored semiquantitatively. Establishment of a correlative relationship was undertaken using Spearman's rho (rho). A total of 86 sites were assessed. The semi-quantitative synovitis score correlated well with the quantitative synovitis score (rho>0.9). A moderate association between medial meniscal extrusion and synovitis was demonstrated (rho=0.762, P<0.000), although this association was not as strong in the lateral compartment (rho=0.524, P<0..000). The results suggest the semiquantitative scoring system is valid for assessing perimeniscal synovitis. The relationship between meniscal pathology and adjacent synovitis requires further study.