Clinical and MRI results in 67 patients operated for gluteus medius and minimus tendon tears with a median follow-up of 4.6 years.

INTRODUCTION: Although various techniques can be used to repair gluteal tendon tears, the long-term outcome is unclear and published studies typically involve only a small number of patients. The goals of this study were to determine (1) if functional improvement can be obtained, (2) if the repairs are continuous based on MRI, and (3) which factors determine success. HYPOTHESIS: Gluteus medius and minimus tears can be repaired effectively with an open double-row technique. MATERIAL AND METHODS: Seventy-three patients were operated on between 2003 and 2010. Of these patients, 67 (62 women, 5 men) were available for review consisting of functional clinical tests and MRI of the hip and pelvis. A double-row repair was performed on all tendon tears, no matter the type of injury. Age, body mass index (BMI), fatty degeneration and muscle atrophy were also evaluated to determine if these variables affected the outcome. RESULTS: The average follow-up was 4.6 years (range 1-8). The pre-operative scores had improved at the last follow-up: (1) pain (VAS): 8.7 ± 1.1 versus 1.7 ± 2.7 at the follow-up, (P<0.001), (2) Lequesne index: 12.3 ± 2.6 versus 4.0 ± 4.0 at the follow-up, (P<0.001), (3) Harris Hip Score: 50.5 ± 8 versus 87.9 ± 15.5 at the follow-up, (P<0.001). There were 11 failures (16%) including two repeat tears that were reoperated successfully. In the other 56 patients, the MRI showed no signs of the initial tear or bursitis. Of the four factors (age, BMI, fatty degeneration, muscle atrophy) that were potential predictors of the outcome, only muscle atrophy had a negative impact on functional outcome (P<0.05). CONCLUSION: Using an open double-row technique to repair gluteal tendon tears led to 85% of patients having good clinical results with significant improvement in symptoms and disappearance of abnormal findings on MRI. This technique can be used with all types of tendon tears, but should be performed before muscle atrophy sets in. LEVEL OF PROOF: Level IV-retrospective study.

Descriptive epidemiology of mechanical hip pathology in adults under 50 years of age. Prospective series of 292 cases: Clinical and radiological aspects and physiopathological review.

Two hundred and ninety-two patients, aged between 16 and 50 years and presenting with mechanical hip pathology, were included in a prospective multicenter study. The descriptive study concerned the clinical examination and analysis of three X-ray views (AP pelvic, Lequesne false profile and lateral axial view). The series comprised 62% males, mean age 35 years, with 53% right side and 22% bilateral involvement. Initial trauma was reported in 19% of cases, and direct familial history of hip pathology in 20%. Seventy percent of the patients played sports, 30% were high-level athletes, and 17% played combat sports. The physical impingement sign was present in 18% to 65% of cases depending on the variant studied. On imaging (n=241), 62% of hips showed osteoarthritis, with 25% at the evolved stage. In the series, as a whole, there was a 35% rate of dysplasia, 63% of impingement and 5% of normal X-ray results. The radiologic impingement aspects were 58% cam-type, 19% pincer-type and 23% mixed. Twenty-two percent of dysplasia cases showed signs of associated impingement. Pain experienced exclusively in flexion/internal rotation/adduction on examination showed little sensitivity (20%) but considerable specificity (86%) for the main diagnosis of impingement. The links between impingement and dysplasia are discussed, and an integrative schema of all risk factors is put forward.

Imaging data in a prospective series of adult hip pain in under-50 year-olds.

Two hundred and ninety-two patients under the age of 50 years, presenting with mechanical hip pain, were included in a prospective multicenter study. In 241 cases, imaging assessment included AP standing pelvic X-ray and Lequesne's false profile (LFP) and/or lateral neck (Ducroquet, Dunn or variant) hip X-ray. Cross-sectional arthroscan and/or arthro-MRI images were available in 81 cases. Exploration looked for acetabular and femoral head/neck dysplasia liable to induce cam or pincer anterior femoroacetabular impingement (AFAI), respectively. Labral and chondral lesions arise secondarily to hip osteoarthritis (HOA) and/or AFAI. Two-thirds of patients showed HOA. Only 6% showed a strictly normal aspect on imaging. More than half (52%) of cases had cam AFAI, half of these involving an osteophytic neck, associated in more than 90% of cases with large multifocal bone spurs of the head, neck and acetabula. These cases were considered ambiguous, due to the uncertainty as to the congenital nature of the cervico-cephalic dysmorphy; if they are excluded, only 23% of the series involved cam AFAI. Crossover sign on AP standing pelvic X-ray is the best assessment criterion for acetabular retroversion, the most frequent form of acetabular dysplasia underlying pincer AFAI, and should be explored for. Secondary neck lesions were visible only on lateral neck view in 42% of cases: this view should be included in standard radiologic work-up in under-50 year-olds. The alpha angle can be measured on this type of lateral view and on axial arthroscan and arthro-MR images; more than half of the cases in which it was pathological involved an osteophytic neck and thus a pseudo-cam effect.

Gluteal tendinopathy in refractory greater trochanter pain syndrome: diagnostic value of two clinical tests.

OBJECTIVE: To evaluate the value (sensitivity and specificity) of 2 modified physical tests for the diagnosis of gluteal tendinopathy in patients with refractory greater trochanter pain syndrome (GTPS). METHODS: The 2 tests were prospectively evaluated by a single physician in all consecutive patients with persistent (> or =4 months) GTPS and no hip joint arthropathy seen on radiography between 2002 and 2006. The 2 tests evaluated the occurrence of pain similar to spontaneous pain during a single-leg stance held for 30 seconds and resisted external derotation in a supine position (hip flexed 90 degrees ) then prone position (hip extended). A matched control population without hip pain was examined similarly. Tendinitis, tendon tear, and associated bursitis in the target group were documented by magnetic resonance imaging (MRI) in transverse, coronal, and sagittal planes, with MRI serving as the gold standard. RESULTS: Seventeen patients completed the study (mean +/- SD age 68.1 +/- 10.8 years, mean duration of symptoms 13 months). MRI revealed tendinopathy and/or bursitis of the gluteus medius and/or minimus tendons in all patients, with evidence of tearing in 15. Sensitivity and specificity were 100% and 97.3%, respectively, for the single-leg stance test and 88% and 97.3%, respectively, for the resisted external derotation test in the supine position. CONCLUSION: The 30-second single-leg stance and resisted external derotation tests had very good sensitivity and specificity for the diagnosis of tendinous lesion and bursitis in patients with MRI-documented refractory GTPS.

Molecular markers of cartilage breakdown and synovitis at baseline as predictors of structural progression of hip osteoarthritis. The ECHODIAH Cohort.

OBJECTIVE: To determine whether systemic markers of bone, cartilage, and synovium can predict structural progression of osteoarthritis (OA). METHODS: Patients with painful hip OA were treated with diacerein or placebo in a multicentre, prospective, double blind, 3 year follow up trial. The following information was collected at entry: demographics, characteristics of hip OA, and 10 markers: N-propeptides of collagen types I and III, cartilage oligomeric matrix protein, YKL-40, hyaluronan (sHA), matrix metalloproteinases-1 and -3, C reactive protein, C-terminal crosslinking telopeptides of collagen types I and II (uCTX-II). Radiographs were obtained at entry and every year. Structural progression was defined as a joint space decrease > or =0.5 mm or requirement for total hip replacement. Grouped survival analysis was performed with time to structural progression as dependent variable, and clinical data, radiographic findings, treatment groups (diacerein versus placebo), and markers as explanatory measures. RESULTS: In the 333 patients in whom all markers were measured, high functional impairment, a joint space width <2 mm, and lateral migration of the femoral head at baseline increased the risk of progression, but diacerein had a protective effect (relative risk = 0.75; 95% confidence interval (CI) 0.54 to 0.96). In addition, patients in whom uCTX-II and sHA were in the upper tertile had a relative risk of progression of 3.73 (95% CI 2.48 to 5.61) compared with patients with markers in the two lower tertiles. CONCLUSION: In this large cohort, combined measurements of uCTX-II and sHA were a new predictor of the structural progression of hip OA.

EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).

OBJECTIVE: To develop evidence based recommendations for the management of hip osteoarthritis (OA). METHODS: The multidisciplinary guideline development group comprised 18 rheumatologists, 4 orthopaedic surgeons, and 1 epidemiologist, representing 14 European countries. Each participant contributed up to 10 propositions describing key clinical aspects of hip OA management. Ten final recommendations were agreed using a Delphi consensus approach. Medline, Embase, CINAHL, Cochrane Library, and HTA reports were searched systematically to obtain research evidence for each proposition. Where possible, outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. Effect size, rate ratio, number needed to treat, and incremental cost effectiveness ratio were calculated. The quality of evidence was categorised according to the evidence hierarchy. The strength of recommendation was assessed using the traditional A-D grading scale and a visual analogue scale. RESULTS: Ten key treatment propositions were generated through three Delphi rounds. They included 21 interventions, such as paracetamol, NSAIDs, symptomatic slow acting disease modifying drugs, opioids, intra-articular steroids, non-pharmacological treatment, total hip replacement, osteotomy, and two general propositions. 461 studies were identified from the literature search for the proposed interventions of efficacy, side effects, and cost effectiveness. Research evidence supported 15 interventions in the treatment of hip OA. Evidence specific for the hip was strikingly lacking. Strength of recommendation varied according to category of research evidence and expert opinion. CONCLUSION: Ten key recommendations for the treatment of hip OA were developed based on research evidence and expert consensus. The effectiveness and cost effectiveness of these recommendations were evaluated and the strength of recommendation was scored.

The normal hip joint space: variations in width, shape, and architecture on 223 pelvic radiographs.

OBJECTIVES: To determine the range of normal radiographic joint space width (JSW) values and the shape of the normal hip, and the influence of age, sex, dysplasia, coxa profunda, and acetabular roof curve abnormalities on these values. METHODS: On routine conventional pelvic radiographs taken in the supine position in patients with no history of hip or lumbar pain, JSW was measured at three points (superolateral, apical, superomedial), together with the VCE, HTE, and neck shaft angles; acetabular depth; and femoral head diameter. RESULTS: 223 radiographs (446 hips) from 127 women and 96 men (mean age 51.3 years) were examined. Interindividual variations in JSW were large (apical site: 4.19 (0.92) mm; range 2-7). Mean JSW values were higher at the superolateral site than at the apical and superomedial sites in nearly 80% of cases. Women had lower JSW values than men. JSW values did not fall with age. Marked right/left JSW asymmetry was seen in 13/221 (5.9%) subjects. Eight cases of acetabular dysplasia (7 unilateral) and 16 cases of coxa profunda were found, but no cases of acetabular protrusion. The JSW was thicker in dysplastic hips, and thinner in hips with coxa profunda. A roof curve abnormality was found in 96/446 (21.5%) hips. CONCLUSIONS: Normal JSW values vary widely; the JSW is commonly narrower at the superomedial site than at the apical site, and is sometimes asymmetric. The roof curve is dysmorphic in about 20% of patients. These findings may have important implications for epidemiological studies and early diagnosis of osteoarthritis of the hip.

EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).

OBJECTIVES: To update the EULAR recommendations for management of knee osteoarthritis (OA) by an evidence based medicine and expert opinion approach. METHODS: The literature search and guidelines were restricted to treatments for knee OA pertaining to clinical and/or radiological OA of any compartment of the knee. Papers for combined treatment of knee and other types of OA were excluded. Medline and Embase were searched using a combination of subject headings and key words. Searches for those treatments previously investigated were conducted for January 1999 to February 2002 and for those treatments not previously investigated for 1966 to February 2002. The level of evidence found for each treatment was documented. Quality scores were determined for each paper, an effect size comparing the treatment with placebo was calculated, where possible, and a toxicity profile was determined for each treatment modality. RESULTS: 497 new publications were identified by the search. Of these, 103 were intervention trials and included in the overall analysis, and 33 treatment modalities were identified. Previously identified publications which were not exclusively knee OA in the initial analysis were rejected. In total, 545 publications were included. Based on the results of the literature search and expert opinion, 10 recommendations for the treatment of knee OA were devised using a five stage Delphi technique. Based on expert opinion, a further set of 10 items was identified by a five stage Delphi technique as important for future research. CONCLUSION: The updated recommendations support some of the previous propositions published in 2000 but also include modified statements and new propositions. Although a large number of treatment options for knee OA exist, the evidence based format of the EULAR Recommendations continues to identify key clinical questions that currently are unanswered.

Sex differences in hip osteoarthritis: results of a longitudinal study in 508 patients.

OBJECTIVE: To evaluate sex differences in the clinical and structural presentation, and natural history of hip OA. METHODS: A multicentre, prospective, longitudinal, five year follow up study of 508 patients (302 women, 206 men, mean age 63 (7) years) with painful hip OA. Data collected were baseline demographics, symptomatic, therapeutic, and structural variables; symptomatic variables and changes in joint space width (JSW) during the first year's follow up; requirement for total hip arthroplasty (THA) between the end of the first and fifth years. STATISTICAL ANALYSIS: evaluation of sex differences (a) at baseline, in the main characteristics of hip OA using multivariate logistic regression; (b) during the first year of follow up, in the radiological progression of the disease; (c) during the five years of follow up, in the requirement for THA using Kaplan-Meier curves and the log rank test, and of the parameters related to THA, using a multivariate Cox analysis. RESULTS: At entry, women presented more frequently than men with polyarticular OA (mean (SD) articular score 306 (162) v 235 (127)), and superomedial migration of the femoral head (40% v 19%), and had more severe symptomatic disease (patient's overall assessment 46 (23) v 40 (26)). The change in JSW did not differ between women and men after one year, but a greater proportion of women had rapid structural progression (OR=2.34, 95% CI 1.1 to 5.2). THA was performed more often in women. Multivariate analysis suggested that the decision to perform surgery was related more closely to the symptomatic and structural severity of the disease than to the sex of the patient. CONCLUSION: Hip OA in women is more frequently part of a polyarticular OA, and displays greater symptomatic and structural severity.

Relevant change in radiological progression in patients with hip osteoarthritis. I. Determination using predictive validity for total hip arthroplasty.

OBJECTIVE: To determine a cut-off point above which a change in joint space width (JSW) could be considered as relevant in patients with hip osteoarthritis (OA) on the basis of predicted need for subsequent total hip arthroplasty (THA). METHODS: A multicentre, prospective, longitudinal, 5-yr follow-up study was performed. A pelvic radiograph was obtained at entry and after 1 and 2 yr. For each film, the narrowest JSW was measured using a 0.1 mm graduated magnifying glass. The absolute and relative differences between baseline and 1 and 2 yr of follow-up were calculated. We determined the cut-off points above which an absolute or relative decrease in JSW between baseline and 1 and 2 yr of follow-up could be considered relevant on the basis of the predicted need for THA during the remaining years of the study. The need for THA was categorized as 'yes' or 'no'. Thereafter, for each observed change in JSW (0.1 per 0.1 mm or 1% per 1%), the sensitivity and specificity for subsequent THA were calculated. The choice of cut-off was based on maximal sensitivity and specificity, using the graphic representation of correct classification probabilities. In this way it was possible to obtain the best measured JSW threshold with maximal true positive and minimal false positive results. RESULTS: A total of 423 and 385 patients met the criteria for analysis using the decrease in JSW between baseline and 1 and 2 yr respectively. The best cut-off points were absolute decreases in JSW of 0.2 and 0.4 mm and relative decreases in JSW of 15 and 20% after 1 and 2 yr respectively, with corresponding ranges of sensitivity and specificity of 68-75 and 67-78%. CONCLUSION: This work determined the cut-off above which a change in JSW could be considered clinically relevant in patients with hip OA, on the basis of predicted subsequent need for THA. For validation, similar studies should be conducted in other countries with different health-care systems.

Relevant change in radiological progression in patients with hip osteoarthritis. II. Determination using an expert opinion approach.

AIM: To determine the minimum clinically important difference (MCID) in joint space width (JSW) progression in patients with hip osteoarthritis (OA), based upon evaluation by a panel of clinical experts as a gold standard. METHODS: A sample of 298 patients with hip OA was selected from a multicentre, prospective, longitudinal, 3-yr follow-up study. A pelvic radiograph was obtained at entry and after 3 yr. For each film, the narrowest JSW was measured using a 0.1-mm graduated magnifying glass. The difference between baseline and 3-yr follow-up JSW was calculated. Two senior rheumatologists, who were experts in osteoarthritis, evaluated each pair of films and noted whether a clinically relevant deterioration in osteoarthritis stage occurred at 3 yr compared with baseline. Interobserver reliabilities were evaluated using the kappa coefficient and proportions of agreements. Then, for each measured difference in JSW (0.1 mm per 0.1 mm), the sensitivity and specificity for MCID, defined as the assessment of expert 1, expert 2 or a combination of both, were calculated. This allowed us to obtain, from graphic representations of the correct classification probabilities, the best measured JSW threshold, with the maximal true positive and the minimal false positive results. RESULTS: The mean measured change in JSW was -0.63 +/- 0.74 mm. Experts 1 and 2 considered the decrease in JSW to be clinically relevant in 122 (40.9%) and 100 pairs (33.6%) respectively. The proportion of agreements between the experts was 79.9%, with a kappa coefficient of 0.572. The best measured JSW threshold was -0.4 mm for expert 1, expert 2 and the combination of both; sensitivity and specificity were 0.75 and 0.8, 0.71 and 0.72, and 0.75 and 0.7 respectively. CONCLUSION: This study suggests that a change of at least 0.4 mm in the radiological JSW could be considered clinically relevant. Other studies using other sets of patients and other methods are needed for validation.

[Clinical and radiographic status of patients in the ECHODIAH study who underwent THA Pertinence of the pain-function index for operative decision making]. / Statut clinique et radiologique des patients avec prothèse totale de hanche dans l'étude ECHODIAH.

DATA COLLECTION: The ECHODIAH study conducted to evaluate the chondromodulator effect of diacerein on the osteoarthritic hip joint has provided epidemiological data on patient symptoms at three-month intervals. Patients with degenerative hip joints evaluated their pain and handicap on visual analog scales. The Lequesne functional score was also determined. A radiographic study was performed every year. IMPROVED PREDICTIVE FACTORS: Among the 507 patients included in the study, 135 underwent total hip arthroplasty. Clinical and radiological evaluations of the operated patients demonstrated that the Lequesne functional score was the best predictive factor with an optimal cutoff at 12 points. The second best predictive factor was the radiographic measurement of the joint space.

Evaluation of the structure-modifying effects of diacerein in hip osteoarthritis: ECHODIAH, a three-year, placebo-controlled trial. Evaluation of the Chondromodulating Effect of Diacerein in OA of the Hip.

OBJECTIVE: To evaluate the ability of diacerein, an interleukin-1beta inhibitor, to slow the progressive decrease in joint space width observed in patients with hip osteoarthritis (OA). METHODS: In this randomized, double-blind, placebo-controlled 3-year study, 507 patients with primary OA of the hip (by the American College of Rheumatology criteria) received diacerein (50 mg twice a day) or placebo. The minimal hip joint space width was measured by a central reader on yearly pelvic radiographs, using a 0.1-mm-graduated magnifying glass. RESULTS: Baseline characteristics were comparable in the 2 treatment groups (255 patients receiving diacerein, 252 receiving placebo); 238 patients (47%) discontinued the study, mainly because of adverse events in the diacerein group (25% versus 12% with placebo) and because of inefficacy in the placebo group (14% versus 7% with diacerein). The percentage of patients with radiographic progression, defined by a joint space loss of at least 0.5 mm, was significantly lower in patients receiving diacerein than in patients receiving placebo, both in the intent-to-treat analysis and in the completer analysis (50.7% versus 60.4% [P = 0.036] and 47.3% versus 62.3% [P = 0.007], respectively). In those patients who completed 3 years of treatment, the rate of joint space narrowing was significantly lower with diacerein (mean +/- SD 0.18 +/- 0.25 mm/year versus 0.23 +/- 0.23 mm/year with placebo; P = 0.042). Diacerein had no evident effect on the symptoms of OA in this study. However, a post hoc covariate analysis that took into account the use of analgesics and antiinflammatory drugs showed an effect of diacerein on the Lequesne functional index. Diacerein was well tolerated during the 3-year study. The most frequent adverse events were transient changes in bowel habits. CONCLUSION: This study confirms previous clinical findings indicating that the demonstration of a structure-modifying effect in hip OA is feasible, and shows, for the first time, that treatment with diacerein for 3 years has a significant structure-modifying effect as compared with placebo, coupled with a good safety profile. The clinical relevance of these findings requires further investigation.

EULAR recommendations for the management of knee osteoarthritis. Report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials.

UNLABELLED: A task force for the EULAR standing committee for clinical trials determined the methodological and logistical approach required for the development of evidence-based guidelines for treatment of knee osteoarthirits (OA). METHODS: The first stage was the selection of treatment modalities to be considered. The second stage comprised a search of the databases of all European-language publications. All of the relevant studies were quality scored. The third stage involved determination of key clinical propositions by expert consensus employing a Delphi approach. The final stage involved ranking of these propositions according to the available evidence. A second set of propositions relating to a future research agenda was determined by expert consensus. RESULTS: Seven hundred and forty-four studies presented outcome data of the effects of specific treatments on knee OA. Quantitative analysis of treatment effect was possible in only 61 studies. Recommendations for the management of knee OA based on currently available data and expert opinion are presented. Proposals for a future research agenda are highlighted. CONCLUSIONS: These are the first clinical guidelines on knee OA to combine an evidence-based approach and a consensus approach across a wide range of treatment modalities. It is apparent that only certain clinical propositions are supported by substantial research-based evidence. There is thus an urgent need for future well-designed trials to address key clinical questions.

Measurement of the radiological hip joint space width. An evaluation of various methods of measurement.

OBJECTIVE: To determine the most relevant method of measurement of the radiographic hip joint space width (JSW). DESIGN: Seventy hips were examined from 36 patients of the ECHODIAH study having had one to four X-rays of the pelvis during the 3-year course of the study. Minimum interbone distance (MIDc), mean width of both the whole joint space (MJSWL) and a region of interest of the joint space (MJSWroi) were measured using computerized analysis of digitized radiographs. MID was also measured using a graduated eyepiece (MIDge). Reproducibility of the measurement was assessed by the intraclass coefficient of correlation. Sensitivity to change was evaluated by the standardized response mean. RESULTS: The intraobserver intraclass coefficient of correlation of MIDc and MJSWroi was 0.98 and 0.94, respectively. The mean value degrees S.D. of MJSWL, MJSWroi, MIDc and MIDge was 3.3 degrees 0.9, 2.6 degrees 0.9, 2.4 degrees 0.9 and 2.6 degrees 1.2 mm, respectively. MIDge was significantly larger than MIDc (mean difference: 0.21 degrees 0.62 mm, P<0.001), in both normal and osteoarthritic hips. However, the difference between MIDge and MIDc varied largely when considering topography of femoral head migration. Whatever the method was, a significant (P<0.001) mean decrease of nearly 0.5 mm was found in osteoarthritic hips over the 3 year follow-up. The standardized response mean for MJSWL, MJSWroi, MIDge and MIDc was 0.73, 0.75, 0.79 and 0.85, respectively. Superiority of MIDc, in term of sensitivity to change, was mainly seen in osteoarthritic hips showing a superomedial or a concentric migration of the femoral head. CONCLUSION: Minimum interbone distance measured with a computer assisted method is suggested as the most suitable method for the evaluation of hip osteoarthritis (OA) progression.

EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).

BACKGROUND: Osteoarthritis (OA) is the most common joint disease encountered throughout Europe. A task force for the EULAR Standing Committee for Clinical Trials met in 1998 to determine the methodological and logistical approach required for the development of evidence based guidelines for treatment of knee OA. The guidelines were restricted to cover all currently available treatments for knee OA diagnosed either clinically and/or radiographically affecting any compartment of the knee. METHODS: The first stage was the selection of treatment modalities to be considered. The second stage comprised a search of the electronic databases Medline and Embase using a combination of subject headings and keywords. All European language publications in the form of systematic reviews, meta-analyses, randomised controlled trials, controlled trials, and observational studies were included. During stage three all the relevant studies were quality scored. The summary statistics for validated outcome measures, when available, were recorded and, where practical, the numbers needed to treat and the effect size for each treatment were calculated. In the fourth stage key clinical propositions were determined by expert consensus employing a Delphi approach. The final stage ranked these propositions according to the available evidence. A second set of propositions relating to a future research agenda was determined by expert consensus using a Delphi approach. RESULTS: Over 2400 English language publications and 400 non-English language publications were identified. Seven hundred and forty four studies presented outcome data of the effects of specific treatments on knee OA. Quantitative analysis of treatment effect was possible in only 61 studies. Recommendations for the management of knee OA based on currently available data and expert opinion are presented. Proposals for a future research agenda are highlighted. CONCLUSIONS: These are the first clinical guidelines on knee OA to combine an evidence based approach and a consensus approach across a wide range of treatment modalities. It is apparent that certain clinical propositions are supported by substantial research based evidence, while others are not. There is thus an urgent need for future well designed trials to consider key clinical questions.

Methodology of clinical trials in hand osteoarthritis: conventional and proposed tools.

BACKGROUND: Although very common, hand osteoarthritis (OA) is rarely the focus of clinical trials aimed at determining whether a drug is effective on its symptoms and/or anatomical progression. Besides the common difficulties met in trials in OA in general, the highly unpredictable course of hand OA presents specific challenges. However, hand OA is beginning to be considered as a potential model for the study of drugs in OA, since researchers now have at their disposal new clinical tools and radiological methods to assess with better accuracy and sensitivity either its symptomatic activity or its anatomical course. METHOD: The now well-known consensual recommendations for the design and conduct of clinical trials in OA are reviewed, and the specific clinical tools and radiological methods available for the assessment of hand OA detailed. Some specific recommendations for the design of clinical trials in hand OA and the selection of patients for such trials are proposed, taking into account the particularities of this location of OA.

Femorocoxometry: angles and segments characteristic of dysplastic and dysmorphic hip conditions in adult. Measurement using a femorocoxometer for standard or reduced (digitized) films.

I have designed a new measurement instrument drawn on transparent film and suitable for any hip radiograph. It replaces the femorocoxometer first produced in France in 1963 and is intended to assist in the evaluation of hip dysplasia and subluxation, as well as of other developmental or acquired abnormalities of the hip. A new design was needed to obtain an instrument suitable not only for conventional radiographs but also for the new reduced-sized images frequently obtained today. Angles can be measured on films of the pelvis and on films of the hip taken in the standing position. Several millimeter-graduated segments have been added to the new version of the instrument to allow measurement of six distances characteristic of the development of hip dysplasia or subluxation. The instrument permits measurement of all the angles related to the architecture of the radiographic hip in the three planes, coronal (CE or VCE, HTE, and NSA angles), anteroposterior (VCA angle), and cross-sectional (femoral neck anteversion). All the parameters are described and illustrated. For each of them, the directions for use of the instrument are given step by step. A number of difficult or ambiguous measurements are discussed, and relevant recommendations are made. A table reports the classical values allowing to distinguish between the dysplastic and the normal hip.