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Refereed/Peer-reviewed Objectives: To (i) evaluate psychological distress and general health in Australian golfers and compare with a general population-based sample, and (ii) explore the relationship between playing golf, psychological distress and general health in individuals with osteoarthritis. Design: Cross sectional. Methods: A cross-sectional survey collected outcomes in 459 Australian Golfers (Kessler-10 Psychological Distress Scale, Short-Form 12 (Health Status), International Physical Activity Questionnaire, osteoarthritis status). Outcomes were compared between Australian golfers and a general population-based sample (Australian Health Survey, n = 16,370). Modified Poisson regression estimated the relationship between playing golf and general health in all participants and a subgroup with osteoarthritis (n = 128 golfers, n = 2216 general population). All analyses were adjusted for age, sex, education and smoking status. Results: Playing golf was associated with lower psychological distress (adjusted mean difference (95 % confidence interval) − 2.5 (− 4.1 to − 0.9)) and a greater likelihood of reporting good to excellent general health (adjusted relative risk (95 % confidence interval) 1.09 (1.05 to 1.13)) compared to the general population. Amongst people with osteoarthritis, playing golf was associated with lower psychological distress (adjusted mean difference − 4.0 (95 % confidence interval − 6.5 to − 1.5)) and a greater likelihood of reporting good to excellent general health (adjusted relative risk (95 % confidence interval) 1.3 (1.2 to 1.4)). Conclusions: Golfers had lower levels of psychological distress and better general health than the general population, and this relationship was strongest in individuals with osteoarthritis.

Background Baseball injuries are a significant problem and have increased in incidence over the last decade. Reporting injury incidence only gives context to rate but not in relation to severity or injury time loss. Hypothesis/Purpose The purpose of this study was to 1) incorporate both modifiable and non-modifiable factors to develop an arm injury burden prediction model in Minor League Baseball (MiLB) pitchers; and 2) understand how the model performs separately on elbow and shoulder injury burden. Study Design Prospective longitudinal study Methods The study was conducted from 2013 to 2019 on MiLB pitchers. Pitchers were evaluated in spring training arm for shoulder range of motion and injuries were followed throughout the season. A model to predict arm injury burden was produced using zero inflated negative binomial regression. Internal validation was performed using ten-fold cross validation. Subgroup analyses were performed for elbow and shoulder separately. Model performance was assessed with root mean square error (RMSE), model fit (R2), and calibration with 95% confidence intervals (95% CI). Results Two-hundred, ninety-seven pitchers (94 injuries) were included with an injury incidence of 1.15 arm injuries per 1000 athletic exposures. Median days lost to an arm injury was 58 (11, 106). The final model demonstrated good prediction ability (RMSE: 11.9 days, R2: 0.80) and a calibration slope of 0.98 (95% CI: 0.92, 1.04). A separate elbow model demonstrated weaker predictive performance (RMSE: 21.3; R2: 0.42; calibration: 1.25 [1.16, 1.34]), as did a separate shoulder model (RMSE: 17.9; R2: 0.57; calibration: 1.01 [0.92, 1.10]). Conclusions The injury burden prediction model demonstrated excellent performance. Caution should be advised with predictions between one to 14 days lost to arm injury. Separate elbow and shoulder prediction models demonstrated decreased performance. The inclusion of both modifiable and non-modifiable factors into a comprehensive injury burden model provides the most accurate prediction of days lost in professional pitchers. Level of Evidence 2

Background: In an ageing population with high levels of multi-morbidity, the preventative effects of exercise rehabilitation(ER) are significant. The NHS currently delivers ER mainly in disease-specific areas. There is a lack of published data to support the long term effectiveness of this model. In the light of emerging evidence supporting the effectiveness of physical activity for multi-morbidity, it is timely to consider different models of ER service delivery. Engagement with and adherence to ER is an important factor in its long term effectiveness. Active involvement and engagement with users is therefore essential at the service design level. The objective of this project, therefore, is to involve users in the preliminary stages of service re-design by seeking to identify and prioritise service needs from a users perspective. These priorities will be used to form the aims of a co-design project with ongoing involvement of service users, aims which can be investigated as individual research questions.Methods: Forty people with multi-morbidity participated in discussion forums. Themes from the forums were summarised and presented in a format to inform the aims of future service co-design. Results: People with multi-morbidity were interested in involvement in the re-design of NHS rehabilitation services. People felt the NHS could and should do much more to support people to exercise because the barriers and motivators for exercise are inextricably linked to the symptoms of illness. Traditional NHS models of rehabilitation were challenged and participants suggested novel and exciting ideas about potential service design. Conclusions and discussion: Participants understand the potential value of exercise and are motivated to exercise. Motivation is thwarted by perceived barriers to competence, autonomy and cultural and social relatedness. Service users have novel and exciting ideas about how the NHS could improve exercise rehabilitation services in order to improve acceptability and accessibility to all. Together with ongoing service user involvement, these ideas can form the aims of a co-design project and ultimately will be developed into research questions in an evaluation of a new complex exercise rehabilitation intervention.

Objective Identify risk factors for poor pain outcomes six months after primary knee replacement surgery. Methods Observational cohort study on patients receiving primary knee replacement from the UK Clinical Practice Research Datalink, Hospital Episode Statistics and Patient Reported Outcomes. A wide range of variables routinely collected in primary and secondary care were identified as potential predictors of worsening or only minor improvement in pain, based on the Oxford Knee Score pain subscale. Results are presented as relative risk ratios and adjusted risk differences (ARD) by fitting a generalized linear model with a binomial error structure and log link function. Results Information was available for 4,750 patients from 2009 to 2016, with a mean age of 69, of whom 56.1% were female. 10.4% of patients had poor pain outcomes. The strongest effects were seen for pre-operative factors: mild knee pain symptoms at the time of surgery (ARD 18.2% (95% Confidence Interval 13.6, 22.8), smoking 12.0% (95% CI:7.3, 16.6), living in the most deprived areas 5.6% (95% CI:2.3, 9.0) and obesity class II 6.3% (95% CI:3.0, 9.7). Important risk factors with more moderate effects included a history of previous knee arthroscopy surgery 4.6% (95% CI:2.5, 6.6), and use of opioids 3.4% (95% CI:1.4, 5.3) within three months after surgery. Those patients with worsening pain state change had more complications by 3 months (11.8% among those in a worse pain state vs. 2.7% with the same pain state). Conclusions We quantified the relative importance of individual risk factors including mild pre-operative pain, smoking, deprivation, obesity and opioid use in terms of the absolute proportions of patients achieving poor pain outcomes. These findings will support development of interventions to reduce the numbers of patients who have poor pain outcomes.

Summary Osteoarthritis affects over 300 million people worldwide. Here, we conduct a genome-wide association study meta-analysis across 826,690 individuals (177,517 with osteoarthritis) and identify 100 independently associated risk variants across 11 osteoarthritis phenotypes, 52 of which have not been associated with the disease before. We report thumb and spine osteoarthritis risk variants and identify differences in genetic effects between weight-bearing and non-weight-bearing joints. We identify sex-specific and early age-at-onset osteoarthritis risk loci. We integrate functional genomics data from primary patient tissues (including articular cartilage, subchondral bone, and osteophytic cartilage) and identify high-confidence effector genes. We provide evidence for genetic correlation with phenotypes related to pain, the main disease symptom, and identify likely causal genes linked to neuronal processes. Our results provide insights into key molecular players in disease processes and highlight attractive drug targets to accelerate translation., Graphical abstract, Highlights • A multicohort study identifies 52 previously unknown osteoarthritis genetic risk variants • Similarities and differences in osteoarthritis genetic risk depend on joint sites • Osteoarthritis genetic components are associated with pain-related phenotypes • High-confidence effector genes highlight potential targets for drug intervention, A multicohort genome-wide association meta-analysis of osteoarthritis highlights the impact of joint site types on the features of genetic risk variants and the link between osteoarthritis genetics and pain-related phenotypes, pointing toward potential targets for therapeutic intervention.

Objectives To investigate the clinical effectiveness, efficacy and cost effectiveness of splints (orthoses) in people with symptomatic basal thumb joint OA (BTOA). Methods A pragmatic, multicentre parallel group randomized controlled trial at 17 National Health Service (NHS) hospital departments recruited adults with symptomatic BTOA and at least moderate hand pain and dysfunction. We randomized participants (1:1:1) using a computer-based minimization system to one of three treatment groups: a therapist supported self-management programme (SSM), a therapist supported self-management programme plus a verum thumb splint (SSM+S), or a therapist supported self-management programme plus a placebo thumb splint (SSM+PS). Participants were blinded to group allocation, received 90 min therapy over 8 weeks and were followed up for 12 weeks from baseline. Australian/Canadian (AUSCAN) hand pain at 8 weeks was the primary outcome, using intention to treat analysis. We calculated costs of treatment. Results We randomized 349 participants to SSM (n = 116), SSM+S (n = 116) or SSM+PS (n = 117) and 292 (84%) provided AUSCAN Osteoarthritis Hand Index hand pain scores at the primary end point (8 weeks). All groups improved, with no mean treatment difference between groups: SSM+S vs SSM −0.5 (95% CI: −1.4, 0.4), P = 0.255; SSM+PS vs SSM −0.1 (95% CI: −1.0, 0.8), P = 0.829; and SSM+S vs SSM+PS −0.4 (95% CI: −1.4, 0.5), P = 0.378. The average 12-week costs were: SSM £586; SSM+S £738; and SSM+PS £685. Conclusion There was no additional benefit of adding a thumb splint to a high-quality evidence-based, supported self-management programme for thumb OA delivered by therapists. Trial registration ISRCTN 54744256 (http://www.isrctn.com/ISRCTN54744256).

Aims To calculate how the likelihood of obtaining measurable benefit from hip or knee arthroplasty varies with preoperative patient-reported scores. Methods Existing UK data from 222,933 knee and 209,760 hip arthroplasty patients were used to model an individual’s probability of gaining meaningful improvement after surgery based on their preoperative Oxford Knee or Hip Score (OKS/OHS). A clinically meaningful improvement after arthroplasty was defined as ≥ 8 point improvement in OHS, and ≥ 7 in OKS. Results The upper preoperative score threshold, above which patients are unlikely to achieve any meaningful improvement from surgery, is 41 for knees and 40 for hips. At lower scores, the probability of improvement increased towards a maximum of 88% (knee) and 95% for (hips). Conclusion By our definition of meaningful improvement, patients with preoperative scores above 41 (OKS) and 40 (OHS) should not be routinely referred to secondary care for possible arthroplasty. Using lower thresholds would incrementally increase the probability of meaningful benefit for those referred but will exclude some patients with potential to benefit. The findings are useful to support the complex shared decision-making process in primary care for referral to secondary care; and in secondary care for experienced clinicians counselling patients considering knee or hip arthroplasty, but should not be used in isolation. Cite this article: Bone Joint J 2020;102-B(7):941–949.

ObjectivesTo estimate the relationship between patient characteristics and referral decisions made by musculoskeletal hubs, and to assess the possible impact of an evidence-based referral tool.DesignRetrospective analysis of medical records and decision tree model evaluating policy changes using local and national data.SettingOne musculoskeletal interface clinic (hub) in England.Participants922 adults aged ≥50 years referred by general practitioners with symptoms of knee or hip osteoarthritis.InterventionsWe assessed the current frequency and determinants of referrals from one hub and the change in referrals that would occur at this centre and nationally if evidence-based thresholds for referral (Oxford Knee and Hip Scores, OKS/OHS) were introduced.Main outcome measureOKS/OHS, referrals for surgical assessment, referrals for arthroplasty, costs and quality-adjusted life years.ResultsOf 110 patients with knee symptoms attending face-to-face hub consultations, 49 (45%) were referred for surgical assessment; the mean OKS for these 49 patients was 18 (range: 1–41). Of 101 hip patients, 36 (36%) were referred for surgical assessment (mean OHS: 21, range: 5–44). No patients referred for surgical assessment were above previously reported economic thresholds for OKS (43) or OHS (45). Setting thresholds of OKS ≤31 and OHS ≤35 might have resulted in an additional 22 knee referrals and 26 hip referrals in our cohort. Extrapolating hub results across England suggests a possible increase in referrals nationally, of around 13 000 additional knee replacements and 4500 additional hip replacements each year.ConclusionsMusculoskeletal hubs currently consider OKS/OHS and other factors when making decisions about referral to secondary care for joint replacement. Those referred typically have low OHS/OKS, and introducing evidence-based OKS/OHS thresholds would prevent few inappropriate (high-functioning, low-pain) referrals. However, our findings suggest that some patients not currently referred could benefit from arthroplasty based on OKS/OHS. More research is required to explore other important patient characteristics currently influencing hub decisions.

Summary Background Late-stage isolated medial knee osteoarthritis can be treated with total knee replacement (TKR) or partial knee replacement (PKR). There is high variation in treatment choice and little robust evidence to guide selection. The Total or Partial Knee Arthroplasty Trial (TOPKAT) therefore aims to assess the clinical effectiveness and cost-effectiveness of TKR versus PKR in patients with medial compartment osteoarthritis of the knee, and this represents an analysis of the main endpoints at 5 years. Methods Our multicentre, pragmatic randomised controlled trial was done at 27 UK sites. We used a combined expertise-based and equipoise-based approach, in which patients with isolated osteoarthritis of the medial compartment of the knee and who satisfied general requirements for a medial PKR were randomly assigned (1:1) to receive PKR or TKR by surgeons who were either expert in and willing to perform both surgeries or by a surgeon with particular expertise in the allocated procedure. The primary endpoint was the Oxford Knee Score (OKS) 5 years after randomisation in all patients assigned to groups. Health-care costs (in UK 2017 prices) and cost-effectiveness were also assessed. This trial is registered with ISRCTN (ISRCTN03013488) and ClinicalTrials.gov ( NCT01352247 ). Findings Between Jan 18, 2010, and Sept 30, 2013, we assessed 962 patients for their eligibility, of whom 431 (45%) patients were excluded (121 [13%] patients did not meet the inclusion criteria and 310 [32%] patients declined to participate) and 528 (55%) patients were randomly assigned to groups. 94% of participants responded to the follow-up survey 5 years after their operation. At the 5-year follow-up, we found no difference in OKS between groups (mean difference 1·04, 95% CI −0·42 to 2·50; p=0·159). In our within-trial cost-effectiveness analysis, we found that PKR was more effective (0·240 additional quality-adjusted life-years, 95% CI 0·046 to 0·434) and less expensive (−£910, 95% CI −1503 to −317) than TKR during the 5 years of follow-up. This finding was a result of slightly better outcomes, lower costs of surgery, and lower follow-up health-care costs with PKR than TKR. Interpretation Both TKR and PKR are effective, offer similar clinical outcomes, and result in a similar incidence of re-operations and complications. Based on our clinical findings, and results regarding the lower costs and better cost-effectiveness with PKR during the 5-year study period, we suggest that PKR should be considered the first choice for patients with late-stage isolated medial compartment osteoarthritis. Funding National Institute for Health Research Health Technology Assessment Programme.

Despite the impact of osteoarthritis (OA) on patients and the health service, OA remains an elusive condition to define and treat. Traditionally, OA has been diagnosed using radiographs and more recently magnetic resonance imaging; however, the last 20 years of research have changed our thinking about the disease and its treatment. We know today that OA takes up to 10–15 years to develop, has a range of risk factors, and that there is a considerable discordance between symptoms and structural signs, such that new classifications and definitions are moving away from structural criteria to combined structure and pain definitions. This chapter reviews the definition and classification of OA and its prevalence, incidence, and natural history.

This introductory chapter to the section on management of osteoarthritis (OA) emphasizes the need for a full assessment of the patient, not just in terms of joint symptoms and examination findings but a full holistic assessment of the person, including the impact of OA on their life, their illness perceptions of OA, and the presence of comorbidities. An individualized package of care can then be developed. Patients should be fully informed about OA and fully involved in all management decisions. Apart from education, which is an ongoing not one-off process, other core treatments to be considered in every person with OA are exercise (both strengthening and aerobic) and strategies to reduce adverse mechanical factors, including weight loss if overweight or obese. Topical non-steroidal anti-inflammatory drugs are the safest analgesic drug to try first for peripheral joint OA. Other treatments can be selected as required from a wide range of drug and non-pharmacological options, to address the needs of the individual. The patient requires regular follow-up for reassessment and re-adjustment of management as required. Currently there are sparse data on predictors of response to treatment, limiting a stratified medicine approach. Caveats to the research evidence for OA and its transition to clinical practice are discussed, and one way of improving this (reporting overall treatment effect and the proportion attributable to placebo in clinical trials) is presented. Optimizing contextual effects, which are an integral part of any treatment and which may explain the majority of improvement that a patient experiences for their OA, is emphasized as a key aspect of care.

This brief introductory chapter summarizes some of the key clinical and structural features of osteoarthritis (OA) and highlights some general observations and concepts concerning the nature of OA. General observations include the preservation of OA throughout human evolution; the occurrence of OA in many other animals; the dynamic, metabolically active nature of OA pathophysiology; the fact that most OA never associates with symptoms or functional impairment; and the good outcome in many cases of symptomatic OA. Such observations support the concept of OA as the inherent repair process of synovial joints, which can be triggered by a range of diverse insults and in which all the joint tissues are involved. Aetiologically, OA is a common complex disorder with recognized genetic, constitutional, and environmental risk factors, and these may combine in multiple ways to cause marked variation in phenotypic presentation and in some instances ‘joint failure’ with associated symptoms and disability. Within the spectrum of OA are some discrete subsets, the best defined being nodal generalized OA. However, in many people OA does not fit neatly into one type and its phenotypic characteristics may change as it evolves. Two striking associations of OA are with ageing and with crystal deposition, especially calcium crystals but also urate crystals, and there are a number of possible mechanisms to explain these.

Intra-articular injection therapy is widely used in the management of osteoarthritis (OA). It has advantages over oral therapy in that it can provide targeted therapy to individual joint sites and at higher dose than could be achieved through oral administration and with fewer adverse effects. Intra-articular steroid therapy, the most widely used intra-articular therapy, is safe and effective in the short term particularly at the knee; though more studies are needed to better characterize the longer-term benefit. The role of intra-articular hyaluronic acid in clinical management of OA is less clear though it may have a role in selected patients in whom other therapies are contraindicated. Currently there are no factors which have been identified as being predictors of response to therapy with intra-articular therapy. Many other intra-articular agents have been used in the management of OA, however, because of the limited evidence base relating to efficacy and safety they cannot currently be recommended for use in routine clinical practice.

Painful knee osteoarthritis (KOA) has been associated with joint inflammation. There is, however, little literature correlating signs of localized inflammation with contrast-enhanced (CE) magnetic resonance imaging (MRI) of synovium. This study examined the relationship between clinical and functional markers of localized knee inflammation and CE MRI-based synovial scores.Patients with symptomatic KOA were enrolled into the randomized, double-blind, Vitamin D Evaluation in Osteoarthritis (VIDEO) trial. In this cross-sectional substudy, associations between validated MRI-based semiquantitative synovial scores of the knee and the following markers of inflammation were investigated: self-reported pain and stiffness, effusion, warmth, joint line tenderness, erythrocyte sedimentation rate, radiographic severity, and functional ability tests.A total of 107 patients satisfied the inclusion criteria of complete data and were included in the analysis. Significant associations were found between the number of regions affected by synovitis and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, effusion, and joint line tenderness. Each additional region affected by synovitis was associated with an increase in WOMAC pain (1.82 [95% confidence interval (95% CI) 0.05, 3.58], P = 0.04), and the association with extent of medial synovitis was particularly strong (3.21 [95% CI 0.43, 5.99], P = 0.02). Extent of synovitis was positively associated with effusion (odds ratio 1.69 [95% CI 1.37, 2.08], P 0.01) and negatively associated with joint line tenderness (relative risk 0.87 [95% CI 0.84, 0.90], P 0.01).There is a strong positive association between synovitis and self-reported patient pain and clinically detectable effusion. Nonoperative treatments directed at management of inflammation and future trials targeting the synovial tissue for treating KOA should consider these 2 factors as potential inclusion criteria.

Objective To assess effectiveness of osteoarthritis interventions to promote long-term physical activity behaviour change. Design A systematic review and meta-analysis. Protocol registration PROSPERO CRD4201300444 5 (http://www.crd.york.ac.uk/prospero/). Study selection Randomised controlled trials (RCTs) comparing physical activity interventions with placebo, no/or minimal intervention in community-dwelling adults with symptomatic knee or hip osteoarthritis. Primary outcomes were change in physical activity or cardiopulmonary fitness after a minimum follow-up of 6 months. Data extraction Outcomes were measures of physical activity (self-reported and objectively measured) and cardiovascular fitness. Standard mean differences between postintervention values were used to describe the effect sizes. Results 27 984 titles were screened and 180 papers reviewed in full. Eleven RCTs satisfied inclusion criteria, total study population of 2741 participants, mean age 62.2. The commonest reasons for study exclusion were follow-up less than 6 months and no physical activity measures. The majority of included interventions implement an arthritis self-management programme targeting coping skills and self-efficacy. Seven studies used self-report measures, the pooled effect of these studies was small with significant heterogeneity between studies (SMD 0.22 with 95% CI −0.11 to 0.56, z=1.30 (p=0.19) I2 statistic of 85%). Subgroup analysis of 6–12 month outcome reduced heterogeneity and increased intervention effect compared to control (SMD 0.53, 95% CI 0.41 to 0.65, z=8.84 (p