Viscosupplementation with High Molecular Weight Hyaluronic Acid for Hip Osteoarthritis: a Systematic Review and Meta-Analysis of Randomised Control Trials of the Efficacy on Pain, Functional Disability, and the Occurrence of Adverse Events.

PURPOSE OF THE STUDY: Hip osteoarthritis (OA) has a prevalence of around 6.4% and is the second most commonly affected joint. This review aims to assess the clinical outcomes of intra-articular high molecular weight hyaluronic acid (HMWHA) in the management of hip osteoarthritis. MATERIAL AND METHODS: We conducted a comprehensive search across PubMed, Google Scholar, and the Cochrane Library for randomised trials investigating the effectiveness of high molecular weight hyaluronic acid (HMWHA) in the treatment of hip osteoarthritis. Quality and risk of bias assessments were performed using the Cochrane RoB2 tool. To synthesise the data, we utilised the Standardised Mean Difference (SMD) for assessing pain relief through the Visual Analogue Scale (VAS) and the Lequesne index (LI) for evaluating functional outcomes. Risk Ratio (RR) was calculated to assess the occurrence of complications. RESULTS: A total of four studies involving HMWHA and control groups were included. The standardised mean difference (SMD) for the Visual Analogue Scale (VAS) (SMD -0.056; 95% CI; -0.351, 0.239; p = 0.709) and the Lequesne index (SMD -0.114; 95% CI; -0.524, 0.296; p = 0.585) were not statistically significant. Analysis for complications demonstrated an overall relative risk ratio (RR) of 0.879 (95% CI; 0.527, 1.466; p = 0.622), and was not statistically significant. DISCUSSION AND CONCLUSIONS: Intra-articular HMWHA in hip OA can significantly reduce pain and improve functional recovery when compared with the condition before treatment. However, there is no significant difference between HMWHA, or saline, or other therapeutic treatments. Currently, available evidence indicates that intra-articular HMWHA in hip OA would not increase the risk of adverse events. KEY WORDS: hip osteoarthritis, hyaluronic acid, intra-articular, molecular weight, viscosupplementation.

Impact of diabetes mellitus on osteoarthritis: a scoping review on biomarkers.

Osteoarthritis (OA) commonly affects the knee and hip joints and accounts for 19.3% of disability-adjusted life years and years lived with disability worldwide (Refs , ). Early management is important in order to avoid disability uphold quality of life (Ref. ). However, a lack of awareness of subclinical and early symptomatic stages of OA often hampers early management (Ref. ). Moreover, late diagnosis of OA among those with severe disease, at a stage when OA management becomes more complicated is common (Refs , , , ). Established risk factors for the development and progression of OA include increasing age, female, history of trauma and obesity (Ref. ). Recent studies have also drawn a link between OA and metabolic syndrome, which is characterized by insulin resistance, dyslipidaemia and hypertension (Refs , ).

Association of Pharmacologic Treatment of Depression/Anxiety With Initial Patient-Reported Outcome Measures in Patients With Hip and Knee Osteoarthritis.

INTRODUCTION: Depression and anxiety are common comorbidities that may exacerbate osteoarthritis (OA)-related pain. We aim to evaluate the effect of pharmacologic treatment of depression/anxiety on hip and knee patient-reported outcome measures (PROMs). METHODS: A multi-institutional PROMs database was queried for patients with depression or anxiety and hip or knee OA who completed a PROMs questionnaire at an initial orthopaedic visit between January 2015 and March 2023. Data on demographics, comorbidities, and duration of pharmacologic treatment of depression/anxiety were obtained. Patients were stratified into three cohorts based on treatment duration. PROMs were compared across cohorts. RESULTS: Two thousand nine hundred sixty patients who completed PROMs at their initial orthopaedic visit had both OA and depression/anxiety. One hundred thirty-four (4.5%) received pharmacologic treatment of depression/anxiety for < 1 year, versus 196 (6.6%) for more than 1 year. In unadjusted analyses, patients with pharmacologic treatment had significantly lower Patient-Reported Outcomes Measurement Information System (PROMIS)-Physical (39.8 [IQR 34.9, 44.9] vs 42.3 [37.4, 47.7], P < 0.001) and PROMIS-Mental (43.5 [36.3, 50.8] vs 48.3 [41.1, 53.3], P < 0.001) scores than those without treatment. After adjusting for demographics and comorbidities, only differences in PROMIS-Mental scores remained statistically significant, with pharmacologic treatment associated with lower scores (ß = -2.26, 95% CI, [-3.29, -1.24], P < 0.001). On secondary analysis including duration of pharmacologic treatment, < 1 year of treatment was associated with significantly lower PROMIS-Mental scores than those not treated (ß = -4.20, 95% CI [-5.77, -2.62], P < 0.001) while scores of patients with more than 1 year of treatment did not differ significantly from those without treatment. CONCLUSION: :Our results indicate that pharmacologic treatment of depression/anxiety is associated with improved psychological health but not with improved physical symptoms related to OA. We observed a nonsignificant trend that patients with depression/anxiety who warrant pharmacologic treatment tend to have worse physical symptoms than those who do not; however, unadjusted analyses suggest this is a complex relationship beyond the isolated effect of pharmacologic treatment.

Neuropathic pain in patients with osteoarthritis of the hip before and after total hip arthroplasty.

OBJECTIVES: The pain associated with osteoarthritis (OA) was thought to be nociceptive; however, neuropathic pain is also observed. We investigated the relationship between hip OA and neuropathic pain using the PainDETECT questionnaire (PDQ). METHODS: A total of 159 hips of 146 consecutive patients who underwent total hip arthroplasty (THA) with a diagnosis of OA were enrolled in this study. The prevalence of each pain phenotype was evaluated preoperatively and at 6 months postoperatively using the PDQ. Patient characteristics and numerical rating scale (NRS) scores were compared between a group with possible neuropathic pain (NP group) and a group with nociceptive pain (non-NP group). RESULTS: Before THA, neuropathic, unclear, and nociceptive pain was observed in 18, 36, and 105 hips, respectively. The prevalence in the NP group was 54 hips, accounting for approximately one-third of all hips, which decreased significantly to seven hips after THA. A significantly higher NRS score was observed in the NP group, both before and after THA. CONCLUSION: Approximately one-third of the patients with hip OA had neuropathic pain. Therefore, neuropathic pain should be considered when treating patients with hip OA.

Advanced osteoarthritis of the hip as reason for extensive asymmetric leg edema: a rare case report and review of the literature.

An enlarged iliopectineal bursa (IB) can cause pressure on iliofemoral veins. Clinical presentation can manifest as asymmetrical lower extremity edema. This case report demonstrates extensive asymmetrical leg edema caused by femoral vein compression based on iliopectineal bursitis (IB-itis) associated with advanced osteoarthritis (OA) of the left hip joint with an outline of relevant current literature. A female patient presented with left hip pain and edema in the leg. X-ray showed severe OA of the left hip. Computed Tomography (CT) concluded a cystic abnormality at the left iliopsoas muscle associated with the joint consistent with IB-itis, associated with a degenerative left hip joint. Hybrid total hip replacement was performed. At three-month follow-up her left leg showed no longer signs of extensive edema and she walked without the use of walking aids. IB-itis is mostly associated with rheumatoid arthritis (RA). There are no reports which only describe OA as cause of IB-itis. Extensive asymmetrical leg edema can be caused by venous compression of the femoral vein by an IB-itis. If the latter is the consequence of advanced hip OA, a total hip replacement can yield excellent clinical outcomes both functionally and with regard to the edema.

Effectiveness of a telehealth-delivered clinician-supported exercise and weight loss program for hip osteoarthritis - protocol for the Better Hip randomised controlled trial.

BACKGROUND: Hip osteoarthritis (OA) is a leading cause of chronic pain and disability worldwide. Self-management is vital with education, exercise and weight loss core recommended treatments. However, evidence-practice gaps exist, and service models that increase patient accessibility to clinicians who can support lifestyle management are needed. The primary aim of this study is to determine the effectiveness of a telehealth-delivered clinician-supported exercise and weight loss program (Better Hip) on the primary outcomes of hip pain on walking and physical function at 6 months, compared with an information-only control for people with hip OA. METHODS: A two-arm, parallel-design, superiority pragmatic randomised controlled trial. 212 members from a health insurance fund aged 45 years and over, with painful hip OA will be recruited. Participants will be randomly allocated to receive: i) Better Hip; or ii) web-based information only (control). Participants randomised to the Better Hip program will have six videoconferencing physiotherapist consultations for education about OA, prescription of individualised home-based strengthening and physical activity programs, behaviour change support, and facilitation of other self-management strategies. Those with a body mass index > 27 kg/m2, aged < 80 years and no specific health conditions, will also be offered six videoconferencing dietitian consultations to undertake a weight loss program. Participants in the control group will be provided with similar educational information about managing hip OA via a custom website. All participants will be reassessed at 6 and 12 months. Primary outcomes are hip pain on walking and physical function. Secondary outcomes include measures of pain; hip function; weight; health-related quality of life; physical activity levels; global change in hip problem; willingness to undergo hip replacement surgery; rates of hip replacement; and use of oral pain medications. A health economic evaluation at 12 months will be conducted and reported separately. DISCUSSION: Findings will determine whether a telehealth-delivered clinician-supported lifestyle management program including education, exercise/physical activity and, for those with overweight or obesity, weight loss, is more effective than information only in people with hip OA. Results will inform the implementation of such programs to increase access to core recommended treatments. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry (ACTRN12622000461796).

What are the differences in the recovery of physical function and clinical score between patients with steroid-related osteonecrosis of the femoral head and hip osteoarthritis undergoing total hip arthroplasty? A propensity score-matched study.

PURPOSE: Steroid-related osteonecrosis of the femoral head (ONFH), arising from steroid administration for underlying diseases, represents a unique pathology for total hip arthroplasty (THA) and typically affects a younger demographic compared to osteoarthritis (OA). Given the significant age-related differences, this study aims to employ propensity score matching to align patient backgrounds between these two diseases and compare physical function. Additionally, our objective is to scrutinize the patterns of clinical score recovery over the course of one year following THA. METHODS: Using propensity score matching, 29 patients each with steroid-related ONFH and OA were selected. Muscle strength (hip abductor and knee extensor) were assessed before and after THA. Additionally, recovery of the Harris Hip Score (HHS) and Oxford Hip Score (OHS) up to one year postoperatively was analyzed. RESULTS: The steroid-related ONFH group exhibited gender bias and significantly younger age compared to the OA group. Propensity score matching achieved balanced patient backgrounds. Physical function showed trends of lower hip abduction and knee extensor strength on the operative side in the steroid-related ONFH group. Notably, nonoperative knee extensor strength decreased significantly after matching. HHS and OHS were poor in steroid-related ONFH up to three months postoperatively but recovered after six months. CONCLUSIONS: Patients with steroid-related ONFH experience positive outcomes in clinical score following THA. Propensity score matching effectively identified muscle weakness on both operative and nonoperative sides, highlighting its utility in comparative analyses.

Urinary incontinence in middle-aged and older women with hip and knee osteoarthritis: An outpatient study of frequency and risk factors.

AIMS: To investigate the frequency and the factors associated with urinary incontinence (UI) in a sample of middle-aged and older women with lower limb osteoarthritis (OA). METHODS: Women aged 50 years or older with clinical hip/knee OA diagnoses were recruited for this cross-sectional study. Self-reported UI and type, sociodemographic characteristics, medical conditions, physical activity level, anthropometric and body composition measurements, muscle strength, and physical function were assessed. Uni and multivariable logistic regression were used to investigate the factors associated with UI. RESULTS: Among 100 middle-aged and older women (mean 67.27 ± 8.77 SD years), 67% reported UI. In the UI group, 33% reported stress UI, 36% reported urgency UI, and 31% reported mixed UI. In the univariate analysis, age, level of physical activity, pulmonary disease, number of medications, body mass index (BMI), number of deliveries, and activity limitation were significantly associated with UI. In the multivariable analysis, older age (60-69 years OR: 4.91, 95% CI: 1.25-19.36; ≥70 years OR: 8.06, 95% CI: 1.96-33.22), compared to 50-59 years, morbid obesity (OR: 14.10, 95% CI: 1.36-146.48), compared to BMI < 30 kg/m2 , and activity limitation (OR: 5.31, 95% CI: 1.61-17.54), assessed as short physical performance battery ≤8, remained significantly associated with UI. CONCLUSIONS: UI was highly frequent among middle-aged and older women with hip/knee OA. Older age, activity limitation, and morbid obesity were independently associated with UI. Interventions targeting physical function and weight management must be considered to prevent and treat UI in this population.

Three-dimensional Volumetric Visceral and Subcutaneous Fat Analysis on Opportunistic Computed Tomography Imaging of Patients With Greater Trochanteric Pain Syndrome Compared With Those With Predominant Osteoarthritis: A Case-Control Study.

OBJECTIVE: This study aimed to address the gap in knowledge assessing the impact of visceral and subcutaneous body fat on 3-dimensional computed tomography imaging in patients with greater trochanteric pain syndrome (GTPS) in comparison with those primarily diagnosed with osteoarthritis (OA). MATERIALS AND METHODS: We evaluated adult patients with a confirmed diagnosis of GTPS from our institutional hip-preservation clinic spanning 2011 to 2022. Selection criteria included their initial clinic visit for hip pain and a concurrent pelvis computed tomography scan. These patients were age- and sex-matched to mild-moderate OA patients selected randomly from the database. Visceral and subcutaneous fat areas were measured volumetrically from the sacroiliac joint to the lesser trochanter using an independent software. Interreader reliability was also calculated. RESULTS: A total of 93 patients met the study criteria, of which 37 belonged to the GTPS group and 56 belonged to the OA group. Both groups were sex and race matched. Average age in GTPS and OA groups was 59.3 years and 56 years, respectively. For GTPS group, average body mass index was 28.9 kg/m 2 , and for the OA group, average body mass index was 29.9 kg/m 2 , with no significant difference ( P > 0.05). Two-sample t test showed no significant differences in the visceral fat, subcutaneous fat, or the visceral fat to total fat volume ratio between the GTPS and OA groups. There was excellent interreader reliability. CONCLUSIONS: Our results indicate that there is no significant difference in fat distribution and volumes among GTPS and OA patients. This suggests that being overweight or obese may not be directly linked or contribute to the onset of GTPS. Other factors, such as gluteal tendinopathy, bursitis, or iliotibial band syndrome, might be responsible and need further investigation.

Total hip arthroplasty improves systemic muscle atrophy in patients with hip osteoarthritis.

BACKGROUND: To investigate muscle volume changes in all body regions after total hip arthroplasty (THA) with dual-energy X-ray absorptiometry (DEXA), and determine the positive effects of THA for systemic muscle atrophy in patients with hip osteoarthritis (HOA). METHODS: In total, 116 patients with a mean age of 65.8 (45-84) years who had undergone THA for unilateral HOA were included in this study. DEXA scans were performed serially at 2 weeks, 3, 6, 12, 18, and 24 months after THA. The normalized height squared muscle volume (NMV) and the change ratio of NMV (ΔNMV) were calculated independently for operated lower extremity (LE), non-operated LE, both upper extremities (UEs), and trunk. Skeletal mass index, which is a sum of NMV of both LEs and UEs, was evaluated at 2 weeks and 24 months after THA to identify systemic muscle atrophy equivalent to the diagnostic criteria of sarcopenia. RESULTS: ΔNMVs in non-operated LE, both UEs, and trunk increased gradually up to 6, 12, and 24 months after THA, although that in operated LE did not increase during a 24-month period. The ΔNMVs in operated LE, non-operated LE, both UEs, and trunk at 24 months after THA were +0.6%, +7.1%, +4.0%, and +4.0%, respectively (P = 0.993, P < 0.001, P < 0.001, P = 0.012). The proportion of systemic muscle atrophy significantly decreased from 2 weeks (38%) to 24 months (23%) after THA (P = 0.022). CONCLUSIONS: THA can potentially have secondary positive effects for systemic muscle atrophy exception of operated LE.

Evaluation of lumbar and hip movement characterization and muscle activities during gait in patients with knee osteoarthritis.

Patients with knee osteoarthritis (KOA) might have gait deviations, but few previous studies have discussed gait compensatory movements of the proximal and distal parts of muscle groups related to KOA. The study aimed to measure lumbar and hip movements during gait test and collect muscle activities of the lower extremities. Thirty-four participants with KOA and 28 healthy participants aged over 50 years were recruited for this study. Lumbar and hip motions during walking test were measured using inertial measurement units. Four muscle groups of the lower extremity (erector spinae, gluteus maximus, quadriceps muscle, and gastrocnemius) activities in gait were collected using surface EMGs. KOA patients used an 2.12∘anterior inclined lumbar spine (p = 0.007) and 22.94∘ flexed hip (p = 0.001) in gait compared to healthy participants. The KOA patients had a small hip movement range 30.19∘(p = 0.001) and a higher asymmetric stance time ratio 0.39 (p = 0.006). Patients with KOA showed decreased erector spinae and gluteus maximus muscle activation and increased activation of the quadriceps and gastrocnemius muscles during gait. In conclusion, patients with KOA used a hyperlordotic lumbar and hip flexed strategy, which overactivates distal extensor muscles through the whole gait and might cause overstress on the lower extremity joints.

Fall risk in patient with dysplastic hip osteoarthritis.

PURPOSE: Patients with dysplastic hip osteo arthritis (DHOA) often have a spinopelvic imbalance, and they are more likely to experience falls. This study aimed to evaluate the risk factors for falls in patients with DHOA, including spinopelvic parameters. METHODS: In this cross-sectional study, a total of 103 patients with DHOA were included from 2019 to 2021. Fall risk was evaluated using the Fall Risk Index 5 items version (FRI-5). Demographics, functional outcomes, and spinopelvic parameters were compared between the high-risk group (FRI-5 ≥ 6) and the low-risk group (FRI-5 < 6). Multivariate analysis was performed using factors with significant differences in univariate analysis. RESULTS: High-risk and low-risk groups comprised 54 and 49 patients, respectively. Females were significantly more common in the high-risk group than in the low-risk group. The Harris Hip Score was significantly lower in the high-risk group than in the low-risk group (p = 0.02). Pelvic incidence, tilt, and obliquity were significantly higher in the high-risk group than in the low-risk group (p < 0.01). In multivariate analysis, female sex (odds ratio [OR]: 3.76, 95% confidence interval [CI]: 1.11-12.64, p = 0.03), pelvic obliquity (OR: 1.36, 95% CI: 1.09-1.71, p < 0.01), and Harris hip score (OR: 0.96, 95% CI: 0.93-0.99, p = 0.02) were identified as risk factors. CONCLUSION: Female sex, pelvic obliquity, and low Harris hip score were associated with an increased risk of falls among patients with DHOA.

Effects of device-performed and manual hip traction and vibration therapy in older adults with symptomatic hip osteoarthritis: A randomized single-blind controlled trial.

BACKGROUND: Traction-and-vibration-therapy (TVT) relieves pain in participants with hip osteoarthritis. Hip TVT is usually performed manually by the physiotherapist. OBJECTIVE: A medical device was developed to perform hip-TVT in order to investigate effects on hip disability, pain intensity, recovery of balance and functional mobility in older adults with hip osteoarthritis and also to reduce physiotherapists' workload and help standardize treatment of hip TVT. METHODS: In a block-randomized 3-month controlled trial involving 28 older adult participants with symptomatic primary hip osteoarthritis (SPHOA), one group (n= 10) received device-performed TVT, one (n= 10) manual TVT, and one (n= 8) sham/placebo therapy. Hip disability (Harris Hip Score), pain intensity (visual-analog-scale), recovery of balance and gait (Functional Gait Assessment) and functional mobility (Timed-Up-and-Go-test) were assessed at baseline, after 3 weeks without intervention, and after 3-month intervention. RESULTS: The Device TVT and Manual TVT groups exhibited superior outcomes compared to the Placebo group in terms of hip disability (p= 0.005 and p< 0.001, respectively), pain intensity (p= 0.002 and p< 0.001, respectively), and functional mobility (TUG) (p= 0.012 and p= 0.011, respectively). Furthermore, the recovery of balance and gait (FGA) showed a significant improvement in the Device TVT group when compared to the Placebo group (p= 0.043). The effect sizes ranged from 0.17 to 0.51, indicating moderate to large effects. CONCLUSION: Device-performed-TVT is comparable to manual hip-TVT for reducing pain and improving mobility in older adults with SPHOA, and may be beneficial in terms of reducing physiotherapists' workload and better therapy standardization.

Weekly pain trajectories among people with knee or hip osteoarthritis participating in a digitally delivered first-line exercise and education treatment.

OBJECTIVE: Digital self-management programs are increasingly used in the management of osteoarthritis (OA). Little is known about heterogeneous patterns in response to these programs. We describe weekly pain trajectories of people with knee or hip OA over up to 52-week participation in a digital self-management program. METHODS: Observational cohort study among participants enrolled between January 2019 and September 2021 who participated at least 4 and up to 52 weeks in the program (n = 16 274). We measured pain using Numeric Rating Scale (NRS 0-10) and applied latent class growth analysis to identify classes with similar trajectories. Associations between baseline characteristics and trajectory classes were examined using multinomial logistic regression and dominance analysis. RESULTS: We identified 4 pain trajectory classes: "mild-largely improved" (30%), "low moderate-largely improved" (34%), "upper moderate-improved" (24%), and "severe-persistent" (12%). For classes with decreasing pain, the most pain reduction occurred during first 20 weeks and was stable thereafter. Male sex, older age, lower body mass index (BMI), better physical function, lower activity impairment, less anxiety/depression, higher education, knee OA, no walking difficulties, no wish for surgery and higher physical activity, all measured at enrolment, were associated with greater probabilities of membership in "mild-largely improved" class than other classes. Dominance analysis suggested that activity impairment followed by wish for surgery and walking difficulties were the most important predictors of trajectory class membership. CONCLUSIONS: Our results highlight the importance of reaching people with OA for first-line treatment prior to developing severe pain, poor health status and a wish for surgery.

The prevalence of foot pain and association with baseline characteristics in people participating in education and supervised exercise for knee or hip osteoarthritis: a cross-sectional study of 26,003 participants from the GLA:D® registry.

BACKGROUND: Osteoarthritis (OA) affecting the knee or hip is highly prevalent in the general population and has associated high disease burden. Early identification of modifiable risk factors that prevent, limit, or resolve disease symptoms is critical. Foot pain may represent a potentially modifiable factor however little is known about the prevalence of foot pain in people with knee or hip OA nor whether foot pain is associated with clinical characteristics. The main aim of this study was therefore to determine the prevalence of foot pain in people with knee or hip OA attending an education and supervised exercise-based intervention in Denmark (GLA:D®) and determine if baseline demographic or clinical characteristics are associated with foot pain. METHODS: Analysis was conducted on baseline data of 26,003 people with symptomatic knee or hip OA completing a pain mannequin as part of the Good Life with osteoArthritis in Denmark (GLA:D®) primary care programme. Odds Ratios (OR) and 95% confidence intervals (CI) were calculated to estimate the strength of association between baseline clinical characteristics (including pain severity in worst knee/hip joint, number of painful knee/hip joints, pain medication use and physical activity level) and the presence of baseline foot pain. RESULTS: Twelve percent of participants (n = 3,049) reported foot pain. In those people with index knee OA (n = 19,391), knee pain severity (OR 1.01 CI 1.00, 1.01), number of painful knee/hip joints (OR 1.67 CI 1.58, 1.79), and use of pain medication (OR 1.23 CI 1.12, 1.36) were statistically associated with foot pain. Excluding use of pain medication, similar associations were seen in those with index hip OA. CONCLUSION: Twelve percent of people with knee or hip OA participating in GLA:D® had foot pain. Those with worse knee/hip pain, and greater number of painful joints were more likely to report foot pain. This study is the first to demonstrate a significant relationship between clinical characteristics and foot pain in people with knee or hip OA participating in education and supervised exercise. Future investigation should consider the role that foot pain may play on knee and hip related outcomes following therapeutic intervention.

A self-directed digital exercise program for hip osteoarthritis ("My Hip Exercise"): protocol for a randomised controlled trial.

BACKGROUND: Hip osteoarthritis (OA) is a leading global cause of chronic pain and disability. Given there is no cure for OA, patient self management is vital with education and exercise being core recommended treatments. However, there is under-utilisation of these treatments due to a range of clinician and patient factors. Innovative service models that increase patient accessibility to such treatments and provide support to engage are needed. This study primarily aims to determine the effects of a self-directed digital exercise intervention comprising online education and exercise supported by a mobile app to facilitate adherence on the primary outcomes of changes in hip pain during walking and patient-reported physical function at 24-weeks when compared to online education control for people with hip OA. METHODS: We will conduct a two-arm, superiority parallel-design, randomised controlled trial involving 182 community volunteers aged 45 years and over, with painful hip OA. After completing the baseline assessment, participants will be randomly assigned to either: i) digital exercise intervention; or ii) digital education (control). Participants randomised to the intervention group will have access to a website that provides information about hip OA and its management, advice about increasing their physical activity levels, a 24-week lower limb strength exercise program to be undertaken at home three times per week, and a mobile app to reinforce home exercise program adherence. Participants in the control group will have access to a website containing only information about hip OA and its management. All participants will be reassessed at 24 weeks after randomisation. Primary outcomes are severity of hip pain while walking using an 11-point numeric rating scale and physical function using the Western Ontario and McMaster Universities Osteoarthritis Index subscale. Secondary outcomes are the Hip dysfunction and Osteoarthritis Outcome Score subscales of pain, hip-related quality of life, and function, sports and recreational activities; global change in hip condition; health-related quality of life; measures of physical activity levels; fear of movement; self efficacy for pain and for exercise; and use of oral pain medications. DISCUSSION: Innovative and scalable approaches to OA education, physical activity, and exercise are required in order to improve exercise participation/engagement and mitigate physical inactivity in the hip OA population. This will help minimise the burden of this major public health issue on individuals and society. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry (ACTRN12622001533785).

Responsiveness and interpretability of the pain subscale of the Knee and Hip Osteoarthritis Outcome Scale (KOOS and HOOS) in osteoarthritis patients according to COSMIN guidelines.

BACKGROUND: The pain subscales of the Knee and Hip Osteoarthritis Outcome Scores (KOOS and HOOS) are among the most frequently applied, patient reported outcomes to assess pain in osteoarthritis patients and evaluation of the results after Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA). For the evaluation of change over time it is essential to know the responsiveness and interpretability of these measurement instruments. Aim of this study is to investigate responsiveness and interpretability of the KOOS and HOOS pain subscales in patients with knee or hip OA and patients after TKA and THA as recommended by COSMIN guidelines. COSMIN stands for COnsensus based Standards for the selection of health Measurement Instruments. COSMIN recommends methods for assessing responsiveness similar to those assessing validity, using extensive hypothesis testing to assess criterion validity and construct validity of the change score. DESIGN: This clinimetric study was conducted using data obtained from the Duloxetine in OsteoArthritis (DOA) trial. Primary knee or hip osteoarthritis patients were included. During the study, half of the participants received pre-operative targeted treatment with duloxetine, and all participants received TKA or THA. Patients filled out a set of patient-reported outcomes at several time points. METHODS: Using the criterion validity approach the change scores of the KOOS and HOOS pain subscales directly after duloxetine treatment but before TKA and THA were correlated to the Patient Global Improvement anchor-question (PGI-I). Receiver Operating Characteristic curves (ROC curves) were obtained. Using the construct validity approach, hypothesis testing was conducted investigating the correlation between change scores in the KOOS and HOOS pain subscale with change scores in other questionnaires six months after TKA and THA. For interpretability, an anchor-based approach was used to consider the Minimally Important Change (MIC) of the KOOS and HOOS pain subscale. We compared the outcomes after duloxetine treatment and six months after TKA and THA in order to investigate any response shift. RESULTS: Ninety-three participants (53 knee patients and 41 hip patients) were included. Mean change was 4.3 and 4.6 points after conservative treatment for knee and hip OA patients respectively and 31.7 and 48.8 points after TKA and THA respectively. The KOOS and HOOS pain subscales both showed a gradual increase in change scores over the different categories of improvement on the PGI-I, with an Area Under the Curve of 0.72 (95% CI 0.527-0.921) and 0.79 (95% CI 0.588-0.983) respectively. Of the predefined hypotheses, 69% were confirmed for both subscales. The MICs were between 12.2 to 37.9 for the KOOS pain subscale, and between 11.8 to 48.6 for the HOOS pain subscale, depending on whether the PGI-I was administered after conservative treatment, or six months after TKA and THA. CONCLUSIONS: This study endorses the responsiveness of the KOOS and HOOS pain subscales in patients with knee or hip OA and patients after TKA and THA based on construct and criterion validity approaches. The KOOS pain subscale might be able to detect the MIC at an individual level after arthroplasty, but both the KOOS and HOOS pain subscales were not able to do so after conservative treatment. This study is the first to report a considerable response shift in MIC of the KOOS and HOOS pain subscales. This should be taken into consideration when evaluating MIC of the KOOS and HOOS pain subscale after conservative versus operative treatment. Future research should present more reference data regarding MIC scores after different treatments.

Predictors for post-traumatic hip osteoarthritis in patients with transverse acetabular fractures following open reduction internal fixation: a minimum of 2 years' follow-up multicenter study.

BACKGROUND: The predictors of post-traumatic osteoarthritis (PTOA) in patients with transverse acetabular fractures (TAFs) following open reduction internal fixation (ORIF) remain unclear. This study aimed to investigate the risk factors for PTOA in TAFs after ORIF. METHODS: Data of TAF patients receiving ORIF were collected from January 2012 and February 2021. Patients suffered PTOA were classified as the osteoarthritis group (OG), while those without PTOA were classified as the non- osteoarthritis group (NG) with a minimum follow-up of 2 years. PTOA was diagnosed according to Tönnis OA classification during the period of follow-up. Univariate analysis, logistic regression analysis, and receiver operating characteristic (ROC) curve analyses were used to evaluate demographics, injury-related characteristics, perioperative and post-discharge information. RESULTS: Three hundred and eleven TAF patients were analyzed in this study, including 261 males and 50 females, with a mean age of 40.4 years (range 18 to 64 years). The incidence of PTOA was 29.6% (92 of 311) during the mean follow-up of 36.8 months (range 24 to 70 months). Several factors of PTOA were found using univariate analysis, including transverse fracture associated with posterior wall acetabular fracture (TPW-AF, p = 0.002), acetabular roof fracture (ARF, p = 0.001), femoral head lesion (FHL, p = 0.016), longer time from injury to surgery (TIS, p＜0.001) and physical work after surgery (PWAS, p＜0.001). Logistic regression analysis showed that TPW-AF (p = 0.007, OR = 2.610, 95%CI: 1.302-5.232), ARF (p = 0.001, OR = 2.887, 95%CI: 1.512-5.512), FHL (p = 0.005, OR = 2.302, 95%CI: 1.283-4.131), TIS (p<0.0001, OR = 1.294, 95%CI: 1.192-1.405) and PWAS (p<0.0001, 3.198, 95%CI: 1.765-5.797) were independent risk factors of PTOA. Furthermore, ROC curve analysis indicated 11.5 days as the cut-off values to predict PTOA. CONCLUSIONS: Our findings identified that TPW-AF, ARF, FHL, TIS and PWAS were independent risk factors for PTOA in patients with TAFs following ORIF. It can help orthopedic surgeons to take early individualized interventions to reduce its incidence.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective.

OBJECTIVE: To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS: We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS: The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION: This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.