Validade dos critérios de classificação da osteoartrite de joelho: ELSA-Brasil Musculoesquelético (ELSA-Brasil ME) / Validity of the knee osteoarthritis classification criteria: ELSA-Brasil Musculoskeletal (ELSA-Brasil ME)

Introdução: Vários critérios de classificação de osteoartrite (OA) de joelhos estão disponíveis na literatura, geralmente divididos em clínicos, clínico-radiográficos e radiográficos. A existência de diferentes critérios de classificação de OA de joelhos dificulta uniformizar e comparar resultados em estudos epidemiológicos, assim como a investigação de fatores de risco e manifestações clínicas associados à OA de joelhos. O conhecimento sobre a capacidade desses diferentes critérios em discriminar indivíduos com e sem OA, assim como conhecer a força de associação de fatores de risco, da presença de dor e de limitação funcional com os diferentes critérios, é essencial para se compreender as vantagens e limitações do uso de cada um deles. Objetivo: avaliar a validade de diferentes critérios de classificação de OA de joelhos em uma amostra de servidores públicos acompanhados pelo Estudo Longitudinal de Saúde do Adulto, ELSA-Brasil Musculoesquelético (ELSA-Brasil ME). Método: trata-se de um estudo transversal de validação de diferentes critérios de classificação de OA de joelho, a saber: OA sintomática, OA radiográfica, OA pelo American College of Rheumatology (ACR clínico e clínico-radiográfico) e OA pela definição do National Institute for Health and Care Excellence (NICE). Os participantes do estudo foram provenientes da coorte ELSA-Brasil ME, um estudo ancilar ao Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). O ELSA-Brasil ME acompanha 2901 servidores públicos, ativos e aposentados, em um dos seis centros de investigação do ELSA-Brasil, localizado no estado de Minas Gerais, Brasil. O presente estudo foi realizado em uma subamostra de conveniência com 250 participantes do ELSA-Brasil ME, de ambos os sexos, com idade entre 39 e 78 anos. A avaliação foi feita por uma reumatologista (RCCM) no período de fevereiro de 2014 a junho de 2015. Apenas um joelho por indivíduo foi incluído, aquele com OA pela reumatologista. Quando ambos ou nenhum dos joelhos apresentava OA, foi feita a seleção por sorteio aleatório simples. Avaliou-se o desempenho dos critérios de classificação de OA descritos anteriormente, tendo como padrão-referência a avaliação clínico-radiográfica da reumatologista. Foram apresentados dados de prevalência, sensibilidade, especificidade, valores preditivos positivo e negativo e acurácia (IC 95%;α=5%). Posteriormente, a validade de construto convergente desses critérios foi avaliada a partir da associação entre a presença de OA de joelho identificada pelos critérios e as seguintes variáveis explicativas: índice de massa corporal (IMC), dor atual e limitação funcional (subjetiva e objetiva). A presença da dor atual em joelhos e a limitação funcional subjetiva foram avaliadas pelo Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) e a limitação funcional objetiva pelo teste sentar e levantar repetido. Associações foram testadas por modelos de regressão logística binária e multinomial (IC 95%;α=5%). Resultados: a idade média foi de 56,1 anos (DP=8,7), 51,2% eram homens. A maior prevalência de OA ocorreu na avaliação da reumatologista (39,2%), seguido de OA pelo NICE (36,8%) e pelo critério OA radiográfica (22,0%). OA radiográfica demonstrou sensibilidade e especificidade de 51,0% e 96,7%, respectivamente. A definição pelo NICE apresentou sensibilidade de 57,0% e especificidade de 76,3%. Os demais critérios mostraram boa especificidade, mas sensibilidade menor que 30,0%. Na avaliação de validade de construto convergente, IMC, dor atual e limitação funcional subjetiva se associaram à OA de joelho identificada por todos os critérios, sendo a magnitude da associação particularmente forte entre dor atual e OA segundo o critério ACR clínico (OR 21,7; IC95% 7,12-66,12) e entre limitação funcional subjetiva e OA segundo o NICE (OR 32,5; IC95% 13,4-79,0). Limitação funcional objetiva apresentou associação com os critérios OA sintomática e ACR clínico e clínico-radiográfico. Conclusões: o presente estudo demonstrou que dentre os critérios avaliados a OA radiográfica demonstrou melhor desempenho quanto à sensibilidade e especificidade, seguido pela definição de OA pelo NICE. Os critérios OA sintomática e OA pelo ACR clínico e clínico-radiográfico não se mostraram adequados para estudos que objetivam avaliar prevalência, devido à baixa sensibilidade dos mesmos. Entretanto, podem ser uma alternativa em estudos longitudinais nos quais é favorável o uso de critérios com boa especificidade. Quanto à validade de construto convergente, de forma geral, os resultados encontrados oferecem suporte para todos os critérios investigados, já que houve associação de IMC, dor atual e limitação funcional subjetiva com todos os critérios e a limitação funcional objetiva apenas não se associou à OA radiográfica e ao NICE. É importante ressaltar que a escolha de qual critério utilizar em um estudo requer levar em conta qual combinação melhor atende aos objetivos preconizados pelo estudo.

Introduction: the classification criteria for knee osteoarthritis (OA) available in the literature are usually divided into three main groups; clinical, clinical-radiographic and radiographic. The existence of different knee OA classification criteria makes it difficult to standardize and compare results in epidemiological studies, and also to investigate risk factors and clinical manifestations associated with knee OA. It is essential to understand the extent to which these different criteria are able to discriminate between subjects with and without OA. It is also important to know the strength of association of the following items with the different criteria: risk factors, the presence of pain and the functionality Objective: To evaluate the validity of different knee osteoarthritis (OA) classification criteria: radiographic OA, symptomatic OA, clinical and clinical-radiographic criteria of the American College of Rheumatology (ACR) and the OA definition proposed by the National Institute for Health and Care Excellence (NICE). Method: A cross-sectional study of the validity of different knee OA classification criteria, radiographic OA, symptomatic OA, clinical and clinical-radiographic criteria of the American College of Rheumatology (ACR) and the OA definition proposed by the National Institute for Health and Care Excellence (NICE). The subjects were from the ELSA-Brasil Musculoskeletal cohort (ELSA-Brasil MSK), an ancillary investigation on musculoskeletal disorders of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). The ELSA- Brasil MSK follows 2901 active and retired civil servants at one of the six ELSA-Brasil investigations centers, located in the State of Minas Gerais, Brazil. The present study was carried out using a convenience subsample with 250 male and female subjects aged between 39 and 78 selected from ELSA-Brasil MSK. The assessment was made by a rheumatologist (RCCM) between February 2014 and June 2015. Only one knee per subject was included i.e., the one that had OA according to the rheumatologist and, when both or none of the knees were affected, one knee was randomly selected for analysis. The performance of the classification criteria of knee OA described before was evaluated, using as reference-standard the clinicalradiographic evaluation of the rheumatologist. OA prevalence, sensitivity, specificity, positive and negative predictive values and accuracy were presented (CI 95%; α = 5%). After that the construct validity of the criteria was evaluated by the relationship between the presence of knee OA identified by the criteria and the following explanatory variables: body mass index (BMI), pain and the functional limitation. The presence of current pain in knees and the subjective functional limitation were evaluated using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the objective functional limitation was evaluated by the five-times sitto-stand test (FTSTS). Associations were tested by bivariate and multinomial logistic regression models (CI 95% ;α=5%). Mean age was 56.1 years (SD=8.7); 51.2% were male. The highest knee OA prevalence was observed in OA according to the rheumatologist, followed by the NICE definition (36,8%) and radiographic OA (22.0%).The sensitivity and the specificity of radiographic OA were 51% and 96.7%, respectively, while the NICE definition showed 57.0% and 76.3%, respectively. The other OA criteria showed good levels of specificity, but the levels of sensitivity were below 30%. In the convergent construct validity evaluation, BMI, current pain and subjective functional limitation were associated with knee OA identified by all criteria. The magnitude of the estimates were particularly strong between current pain and OA according to the ACR clinical criteria (OR 21.7; 95%CI 7.12-66.12) and between subjective functional limitation and OA according to NICE (OR 32.5; 95%CI 13.4- 79.0). The objective functional limitation was associated with symptomatic OA and with clinical and clinical-radiographic ACR criteria. Conclusions: the present study demonstrated that among the evaluated criteria, radiographic OA showed the best performance, followed by the NICE OA definition. The other criteria, namely symptomatic OA, clinical ACR and clinical-radiographic ACR were not adequate for studies that aim to evaluate prevalence, due to the low sensitivity of these criteria. However, they may be an alternative in longitudinal studies in which it is appropriate to use criteria with good specificity. Regarding the convergent construct validity, overall, our results offer support for all of the investigated criteria, since there was an association of BMI, pain and subjective functional limitation with all the criteria and the objective functional limitation was not radiographic OA and NICE. It is important to emphasize that the choice of criteria for a study requires deciding which the combination best meets the study objectives.

Osteoartritis (artrosis) de rodilla / Knee osteoarthritis (osteoarthrosis)

La artrosis de rodilla (OA) es uno de los principales problemas de salud a nivel mundial debido a su alta prevalencia y costos asociados. Los conocimientos disponibles demuestran que el componente inflamatorio es fundamental en el desarrollo de esta condición, abandonándose el concepto de que la OA es una enfermedad puramente degenerativa. En el presente escrito revisaremos, basándonos en la literatura disponible, la epidemiología y los factores de riesgo involucrados, los nuevos conocimientos fisiopatológicos, el enfrentamiento clínico y los tratamientos disponibles tanto médicos como quirúrgicos de esta condición...

Knee osteoarthritis (OA) is one of the major public health problems worldwide, due to its high prevalence and associated costs. The available knowledge shows that the inflammatory component is critical in the development of this condition, abandoning the concept that OA is only a degenerative disease. A review is presented in this article, based on the available literature, on the epidemiology and risk factors involved, recent knowledge about the pathophysiological and clinical management, and the medical and surgical treatments available for this condition...

Prótesis total de rodilla por gonartrosis grado IV / Total knee replacement due to grade IV gonarthrosis

Objetivo: Describir la evolución clínica de pacientes operados de prótesis total de rodilla por gonartrosis grado IV secundaria a enfermedad angular en varo. Material y métodos: Estudio descriptivo, incluimos pacientes operados de artroplastía total de rodilla por gonartrosis secundaria a enfermedad angular en varo. Utilizamos las siguientes variables: género, edad, lado afectado, tipo de abordaje, tipo de prótesis, tipo de marcha postquirúrgica, infección, estado vascular, dolor postquirúrgico, rechazo de material protésico, deformidad angular en varoflexión pre- y postquirúrgicas. Resultados: Revisamos 13 expedientes, 69.2% hombres y 30.8% mujeres, la edad media 72.38, mínima 56-máxima 82, DE 7.11 años. Seis (46.2%) rodillas izquierdas y 7 (53.8%) derechas. A todos los pacientes se les realizó abordaje para-rotuliano medial y balance óseo, al 23.1% se le realizó balance capsuloligamentario; a 7.6% se les colocó prótesis total de rodilla posteroestabilizada y al 93.3% no posteroestabilizada; 1 (7.6%) paciente presentó infección, ninguno presentó compromiso vascular, 76.9% presentaron marcha asistida con bastón, 15.4% marcha independiente y 7.6% no presentó marcha. El grado promedio de deformidad angular prequirúrgico fue 15.77 y el postquirúrgico promedio menor o igual a 5º, la diferencia de promedios grados pre- y postquirúrgicos fue 36.719 y en flexión 0.439, p = 0.00 y p = 0.669 respectivamente (t pareada). Conclusión: Podemos concluir que la evolución clínica de los pacientes con gonartrosis secundaria a enfermedad angular en varo postoperados de ATR es buena, las complicaciones son similares a la literatura.

Objective: To describe the clinical evolution of patients with total knee replacement surgery due to grade IV gonarthrosis secondary to varus angular deformity. Material and methods: A descriptive trial where we included patients who underwent total knee arthroplasty due to gonarthrosis secondary to varus angular deformity. We used the following variables, sex, age, affected side, type of approach, type of prosthesis, type of gait post-surgically, infection, vascular status, post-surgical pain, rejection of prosthetic material, varus-flection angular deformity pre and post-surgically. Results: We reviewed 13 files, 69.2% men and 30.8% women, the mean age was 72.38, minimum 56, maximum 82, DE 7.11 years. Six (46.2%) left knees and 7 (53.8%) right knees. All patients had a medial parapatellar approach and bone balancing, 23.1% had ligament balancing; 7.6% had a total knee replacement stabilized posteriorly and 93.3% not stabilized posteriorly; 1 (7.6%) patient had infection, none had vascular involvement, 76.9% had to walk with a cane, 15.4% walked on their own and 7.6% had no gait. The average grade of the angular deformity pre-surgery was 15.77 and the average post-surgery was less than or equal to 5º, the difference of average grades pre and post-surgery was 36.719 and in flection 0.439, p= 0.00 and p= 0.669 respectively (paired t). Conclusion: We can conclude that the clinical evolution of patients with gonarthrosis secondary to varus angular deformity who underwent TKA is good, complications are similar to those in the literature.

The association of anthropometric measures and osteoarthritis knee in non-obese subjects: a cross sectional study

OBJECTIVE: Body mass index (BMI) and knee osteoarthritis have a strong association, but other anthropometric measures lack such associations. To date, no study has evaluated non-obese knee osteoarthritis to negate the systemic and metabolic effects of obesity. This study examines the validity of the contention that BMI and other anthropometric measures have a significant relationship with knee osteoarthritis. METHODS: In total, 180 subjects with a diagnosis of knee osteoarthritis were recruited and classified according to Kellgren-Lawrence (KL) grades. Body mass index, mid-upper arm circumference, waist-hip ratio and triceps-skinfold thickness were recorded by standard procedures. Osteoarthritis outcome scores (WOMAC) were evaluated. RESULTS: (1) In both genders, the BMI was significantly higher for KL grade 4 than for grade 2; triceps-skinfold thickness was positively correlated with the joint space width of the tibial medial compartment. (2) In males, triceps-skinfold thickness significantly increased as the KL grades moved from 2 to 4; the significantly higher BMI found in varus aligned knees was positively correlated with WOMAC scores. (3) In females, the waist-hip ratio was significantly higher for KL grade 4 than for grade 2; a significant correlation was found between BMI and WOMAC scores. The waist-hip ratio was significantly associated with varus aligned knees and it positively correlated with WOMAC scores and with the joint space width of the tibial medial compartment. The mid-upper arm circumference demonstrated no correlation with knee osteoarthritis. CONCLUS'ON: This study validates the contention that BMI and other anthropometric measures have a significant association with knee osteoarthritis. Contrary to common belief, the triceps-skinfold thickness (peripheral fat) in males and the waist-hip ratio (central fat) in females were more strongly associated with knee osteoarthritis than BMI.

Evaluación de la artrosis mediante resonancia magnética luego de la reconstrucción del ligamento cruzado anterior a largo plazo / Long-term evaluation of osteoarthritis with magnetic resonance imaging after ACL reconstruction

El objetivo del trabajo fue el de evaluar los cambios artrósicos luego de la reconstrucción del LCA con tendón rotuliano mediante resonancia magnética nuclear (RMN) en una serie de pacientes con un seguimiento promedio de 14 años. Método: Cuarenta y cinco pacientes (48 rodillas) que habían sido operados con reconstrucción del LCA con 2 incisiones usando el tendón rotuliano como autoinjerto, 38 masculinos y 7 femeninos con un promedio de edad de 40 años (rango 27-56). Antes o durante la reconstrucción meniscetomias internas o rupturas fueron encontrados en un 65% de los pacientes y meniscectomias externas o rupturas en un 14 por ciento. Los pacientes tuvieron un seguimiento promedio de 14 años (rango 10-20 años). Fueron evaluados con el score de Lysholm e IKDC. Los cambios artrósicos fueron gradificados con la escala de Noyes y Stables modificada por Recht para RMN. Resultados: Luego de 14 años promedio el promedio de Lysholm fue de 94 (80-100) Y de acuerdo IKDC 44 por ciento de los pacientes A, 50 por ciento B y 6 por ciento C. La diferencia artrométrica promedio fue de 2,7 mm (rango l-5). El test de pivot shift fue negativo en el 86 por ciento de los casos. Sin embargo 73 por ciento de la serie presentó cambios artrósicos (44 por ciento leves, 29 por ciento moderados). Hubo correlación entre el desarrollo de la artrosis y las meniscectomias pero no hubo correlación con la estabilidad de la rodilla. Conclusión: A pesar que la reconstrucción del LCA puede dar estabilidad luego de 14 años promedio de seguimiento, la progresión de la artrosis, especialmente en pacientes con meniscectomias, impresiona ser un problema no resuelto.

Escala de puntuación para evaluar la osteoartritis de la rodilla / Rating scale for osteoarthritis knee assessment

Objetivo: desarrollar un índice para la evaluación clínica de la osteoartritis de rodilla, basados en la escala de puntuación de Bristol. Material y métodos: se realizó un estudio clinimétrico, prospectivo, controlado, observacional, transversal y analítico, en el periodo de agosto a noviembre de 2004. La muestra se integró con 55 pacientes mayores de 35 años que reunieron los criterios clínico-radiográficos para osteoartritis de la rodilla, según la Academia Americana de Reumatología. De forma estandarizada, dos ortopedistas aplicaron la escala de puntuación de Bristol a 25 pacientes, realizando análisis de sensibilidad, consistencia y validez. Con base en dicha escala, se diseñó el índice modificado para el estado clínico de la rodilla con osteoartritis Magdalena de las Salinas H- 1(MSH1). De forma estandarizada, dos ortopedistas aplicaron a 30 pacientes el MSH1, comparando el análisis de sensibilidad, consistencia y validez de ambos índices. Resultados: el coeficiente de correlación intraclase interobservador para la escala de puntuación de Bristol fue: total 0.62, función 0.84, dolor 0.40, movimiento 0.89. Para MSH1: total 0.91, función 0.92, dolor 0.79, movimiento 0.86 (p < 0.0001). La kappa ponderada para las categorías clínicas interobservador de la escala de Bristol fue de 0.51 (p = 0.002), con 80 % de acuerdo. Para MSH1 los valores de kappa ponderada fueron de 0.81 (p < 0.0001), con 90 % de acuerdo. La r de Pearson entre la puntuación total de Bristol y la puntuación radiográfica de osteoartritis fue de –0.29 (p = 0.049); entre la puntuación total del MSH1 y la puntuación radiográfica de osteoartritis fue de –0.62 (p < 0.01). Conclusiones: se diseñó el índice clinimétrico MSH1, con mejor sensibilidad, consistencia y validez que el estándar, que lo hace un instrumento útil y confiable para la evaluación funcional de la osteoartritis de la rodilla.

BACKGROUND: We undertook this study to develop a grading scale to assess knee osteoarthritis using the Bristol Score. METHODS: Between August and November 2004, a clinimetrical, prospective, group-controlled, observational, cross-sectional and analytical study was done. The study sample was comprised of 55 patients, 35 years old and over, with clinical-radiographic diagnosis of knee osteoarthritis following the American Academy of Rheumatology criteria. The Bristol Score was used in 25 patients by two standardized orthopedic surgeons. Sensitivity, consistency and validity of the Bristol Score were determined. The new grading scale to assess osteoarthritis Magdalena de las Salinas H-1(MSH1) was used in 30 patients. Sensitivity, consistency and validity of the MSH1 were also determined. Both indexes were compared in these terms. An osteoarthritis radiographic score was developed to assess the validity of the MSH1. RESULTS: Inter-observer intraclass correlation coefficient (ICC) for the Bristol Score in its categories was total 0.62, function 0.84, pain 0.40 and movement 0.89. Inter-observer ICC for MSH1 in its categories was total 0.91, function 0.92, pain 0.79 and movement 0.86 (p <0.0001). Inter-observer weighed kappa of the Bristol Score was 0.51 (p = 0.002), with 80% agreement. The weighed kappa for the MSH1 was 0.81 (p <0.0001) with 90% agreement. Correlation between the Bristol Score and the osteoarthritis radiographic score was -0.29 (p = 0.049). Correlation between the MSH1 and the radiographic score of osteoarthritis was -0.62 (p <0.01). CONCLUSIONS: MSH1 achieved better validity than the Bristol Score and can be considered a reliable instrument to assess knee osteoarthritis.