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Summary Objective To develop a measure of knee joint effusion-synovitis volume and to examine the effect of vitamin D supplementation on effusion-synovitis in people with knee osteoarthritis (OA) and low vitamin D levels over 24 months. Method Symptomatic knee OA patients with low 25-(OH)D levels (12.5–60 nmol/l) were recruited for a multi-centre, randomised, placebo-controlled and double-blind trial. Participants (age 63 ± 7 years, 208 females) were allocated to either 50,000 IU monthly vitamin D 3 ( n = 209) or placebo ( n = 204) for 24 months. Knee effusion-synovitis volume in suprapatellar and other regions was measured on magnetic resonance imaging (MRI) using OsiriX software. The intra-class correlation coefficients (ICCs) were used to test inter- and intra-rater reliabilities. The least significant change criterion was used to define the increase/decrease in effusion-synovitis volume. Result The reproducibilities of effusion-synovitis volume measurement were high with ICCs ranging from 0.93 to 0.99. Over 24 months, effusion-synovitis volume remained stable in the vitamin D group but increased in placebos with a significant between-group difference (−1.94 ml, 95% confidence interval (CI): −3.54, −0.33). This effect was evident in those with baseline effusion-synovitis and with suprapatellar effusion-synovitis. The proportion with an increase in effusion-synovitis volume was lower in the vitamin D group than placebo (risk ratio (RR): 0.87, 95% CI: 0.77, 0.97). Conclusion This highly reproducible effusion-synovitis volume measurement could be a promising outcome measure in OA trials. Vitamin D supplementation could retard the progression of effusion-synovitis which can potentially benefit people with an inflammatory OA phenotype.

Summary Objective To assess the diagnostic performance of ultrasound (US) for calcium pyrophosphate deposition (CPPD) at the level of menisci, hyaline cartilage (HC), tendons, and synovial fluid (SF) of the knee, and to examine inter- and intra-observer reliability. Design We consecutively included patients with knee effusion over a 2-year period (43 patients with CPPD and 131 controls). All patients underwent SF analysis, conventional radiography (CR), and US examination using the Outcome Measures in Rheumatology (OMERACT) definition of the US characteristics of CPPD. Two independent operators performed the US, and inter-observer agreement was calculated. Intra-observer agreement was examined with static images obtained for all enrolled patients. Results US revealed calcium pyrophosphate (CPP) deposits in menisci, HC, and tendon more frequently in patients with CPPD than in control patients. The presence of US CPP deposits in SF was not significantly different between the two groups. Combined US evaluation of the three components (menisci, HC, and tendon) showed the best diagnostic performance. The sensitivity and specificity for US evaluation of the three components were 74.4% and 77.1%, respectively, while for CR evaluation, the sensitivity and specificity were 44.2% and 96.9%, respectively. Inter- and intra-observer agreement were excellent for medial (κ = 0.930, 0.972) and lateral menisci (κ = 0.905, 0.942), HC (κ = 0.844, 0.957), and SF (κ = 0.817, 0.925). Tendon showed fair inter-observer (κ = 0.532) and good intra-observer reliability (κ = 0.788). Conclusions Based on the OMERACT definition, US demonstrated better diagnostic capacity than CR to diagnose CPPD, with excellent reliability. Combined evaluation of menisci, HC, and tendon showed the best diagnostic accuracy.

SummaryObjectiveLittle is known of how to routinely elicit hyaline cartilage repair tissue in middle-aged patients. We tested the hypothesis that in skeletally aged rabbit knees, microdrill holes can be stimulated to remodel the bone plate and induce a more integrated, voluminous and hyaline cartilage repair tissue when treated by subchondral chitosan/blood implants.DesignNew Zealand White rabbits (13 or 32 months old, N = 7) received two 1.5 mm diameter, 2 mm depth drill holes in each knee, either left to bleed as surgical controls or press-fit with a 10 kDa (distal hole: 10K) or 40 kDa (proximal hole: 40K) chitosan/blood implant with fluorescent chitosan tracer. Post-operative knee effusion was documented. Repair tissues at day 0 (N = 1) and day 70 post-surgery (N = 6) were analyzed by micro-computed tomography, and by histological scoring and histomorphometry (SafO, Col-2, and Col-1) at day 70.ResultsAll chitosan implants were completely cleared after 70 days, without increasing transient post-operative knee effusion compared to controls. Proximal control holes had worse osteochondral repair than distal holes. Both implant formulations induced bone remodeling and improved lateral integration of the bone plate at the hole edge. The 40K implant inhibited further bone repair inside 50% of the proximal holes, while the 10K implant specifically induced a “wound bloom” reaction, characterized by decreased bone plate density in a limited zone beyond the initial hole edge, and increased woven bone (WB) plate repair inside the initial hole (P = 0.016), which was accompanied by a more voluminous and hyaline cartilage repair (P

SummaryObjectiveTo compare ultrasonographic (US) findings with clinical and radiographic assessment in knee osteoarthritis (OA).MethodsFifty patients with primary knee OA were studied. Clinical assessment of both knees was performed by the same rheumatologist who recorded a visual analogue scale (VAS) for pain (VASP). All patients underwent a US examination of their knees by a second blinded rheumatologist. Weight-bearing anteroposterior and lateral knee radiographs were read by a third blinded rheumatologist who assessed the Kellgren and Lawrence (K–L) grade, the femorotibial (FT) space width and the presence of patello-femoral degenerative signs.ResultsForty patients had bilateral symptomatic knee OA and 10 unilateral symptomatic OA. All knees showed radiographic FT degenerative signs. US findings in symptomatic knees were effusion (47%), protrusion of the medial meniscus (MMP) with displacement of the medial collateral ligament (MCLD) (61%) and Baker's cyst (22%). US effusion, MMP and MCLD were associated with a significantly higher VAS score for pain (P

s / Osteoarthritis and Cartilage 22 (2014) S57–S489 S407 729 PAIN RELIEF, FUNCTIONAL RECOVERY AND ASSOCIATED MEDICAL TREATMENTS REDUCTION IN LARGE-SCALE POPULATION WITH OSTEOARTHRITIS RECEIVING INJECTIONS OF VISCOSUPPLEMENT INCORPORATING HIGH CONCENTRATION OF SORBITOL F. Radenne. Aptissen SA, Meyrin, Switzerland Purpose: Synolis V-A is a visco-antalgic composed of highly concentrated non-crosslinked hyaluronic acid (2%) from biofermentation origin combined with a high concentration of Sorbitol (4%). Sorbitol is an endogenous molecule which functions as an oxygen free radical (OFR) scavenger. We hypothesize that anti-oxidant effect of sorbitol may play an active role in rapid and strong pain reduction in patients with osteoarthritis, and therefore influence function recovery and medication intake reduction. Methods: 1147 patients with a majority suffering from knee Osteoarthritis (92.9%), were enrolled in a Non-Interventional Study conducted in 398 centres in Germany. Studied population had an average age of 63.3 years, including 499 males and 614 females, and was distributed into the following grades according to Kellgren–Lawrence scale: Grade I – 6.7%, Grade II – 31.4%, Grade III – 48.0% and Grade IV – 13.9%. Patients were assessed for pain level and functional impairment using 5 points Likert scale (scoring from 0 1⁄4 None to 4 1⁄4 Very Severe). Patients received between 1 and 3 intraarticular (IA) injections of 2 ml of Synolis V-A. Selected primary criteria were variations of pain and function impairment scores, between baseline and following the time points: week1, week 12 and week 24. Selected secondary criterion was the evaluation of concomitant medical treatments (topical, NSAID, corticosteroids and analgesics) prior to treatment initiation and at week 24. Results: Selected Histological Measures from Best Subset Regression Modeling: Average pain level (pooled data) scored at 2.61 (n 1⁄4 1125) at baseline, 1.68 (n1⁄4 832) at week 1, 1.14 (n1⁄4 1085) at week 12 and 1.07 (n 1⁄4 1030) at week 24. Average functional impairment level (pooled data) scored at 1.99 (n 1⁄4 1103) at baseline, 1.47 (n 1⁄4 819) at week 1, 1.07 (n 1⁄4 1074) at week 12 and 1.02 (n 1⁄4 1031) at week 24. Patients with no reported medical treatment increased by 120%, from 354 patients before treatment initiation to 780 at week 24. Average daily medication per patient decreased by 72% from 1.30 before treatment initiation to 0.37 at week 24. Out of 1147 patients only 24 adverse events (AEs) were reported for 22 patients (1.9%), the most common Adverse Event being “Injection site joint pain”. Conclusions: This study suggests that a strong pain relief occurs immediately after the first injection of Synolis V-A, with a relief that amplifies until week 24.Functional improvement had been observed to follow a similar trend than pain relief. With a baseline score slightly lower, the amplitude of the observed improvement was also slightly inferior to that of pain relief. Never-the-less, both average scores ended up around 1 (Mild) at week 24. The trend similarities between pain relief and functional improvement suggest a direct link between both factors; link that can be explained by the impact of pain on loss of function. Not surprisingly, pain reduction and function recovery were associated with an important drop in medication intake. 730 THE RELATIONSHIP BETWEEN MENTAL HEALTH AND FOOT PAIN P. Butterworth y, D. Urquhart z, F. Cicuttini z, H. Menz y, B. Strauss z, J. Proietto x, J. Dixon k, G. Jones{, A. Wluka z. y La Trobe Univ., Melbourne, Australia; zMonash Univ., Melbourne, Australia; xUniv. of Melbourne, Melbourne, Australia; kBaker IDI Heart and Diabetes Inst., Melbourne, Australia; {Menzies Res. Inst. Tasmania, Hobart, Australia Purpose: Although mental health is related to the persistence of musculoskeletal pain, our understanding of the association between mental health and foot pain is limited. Subsequently, we conducted a three year longitudinal study to examine in a community based population. Methods: Eighty-three community dwelling participants (mean body mass index 35.3 kg/m2 9.0) who had foot pain at study inception in 2008, and for whom measures of mental health (Mental Component Summary of the Short Form-36) were available, were invited to take part in this follow-up study in 2011. Change in foot painwas determined by the difference between the Manchester Foot Pain and Disability Index score at baseline and follow up; therefore, a decrease in the score indicates improved foot pain and an increase indicates deterioration in foot pain. Linear regression was used to determine the factors affecting change in foot pain. Results: Of the 62 respondents (75% response rate, 49 females and 13 males), there were 27 (44%) whose foot pain deteriorated. A higher Mental Component Summary score of the Short Form-36 at baselinewas associatedwith a slower progression of foot pain (beta coefficient 0.29, 95% confidence interval 0.42 to 0.01); adjusted for age, sex, body mass index and physical health. Conclusion: Mental health is associated with changes in foot pain. Clinicians dealing with this population should consider the contribution of mental health in their management and treatment of foot pain. Pain: Clinical 731 CROSS-SECTIONAL AND LONGITUDINAL ASSOCIATIONS BETWEEN KNEE JOINT EFFUSION AND KNEE PAIN IN OLDER ADULTS X. Wang y, X. Jin y, W. Han yz, Y. Cao yx, A. Halliday k, L. Blizzard y, F. Cicuttini{, G. Jones y, C. Ding y{. yMenizes Res. Inst., Univ. of Tasmania, Hobart, Australia; zDept. of Orthopaedics,3rd Affiliated Hosp. of Southern Med. Univ., Guangzhou, China; xRes. Inst. of Orthopaedics, Shuguang Hosp. Affiliated to Shanghai Univ. of Traditional Chinese Med., Shanghai, China; kDept. of Radiology, Royal Hobart Hosp., Hobart, Australia; {Dept. of Epidemiology and Preventive Med., Monash Univ., Melbourne, Australia Purpose: Knee pain is one of the most prominent symptoms of osteoarthritis (OA). Joint synovial effusion could contribute to pain, but the relationship between effusion and knee pain remains controversial. Effects of joint effusions at different knee compartments on knee pain are unclear. Aim of this study was to determine the cross-sectional and longitudinal associations between knee joint effusions at different compartments and knee pain in older adults. Methods: Population-based cohort study of older adults randomly selected from local community (N1⁄4 976,mean age 62.3 years, range from 50 to 80; 50.1% females). Knee joint effusions were measured at baseline using T2weightedmagnetic resonance imaging (MRI) at 4 compartments (suprapatellar pouch, central portion, posterior femoral recess, and subpopliteal recess). Other structural changes including cartilage defects, bone marrow lesions and meniscal lesions were assessed by MRI. OARSI atlaswasused to assess kneeosteophytes, joint spacenarrowing (JSN) and radiographic OA. Knee pain was assessed by self-administered Western Ontario and McMasters osteoarthritis index (WOMAC) questionnaire at baseline and 2.6 years later. The 5WOMAC pain subscales were clinically constructed into weight-bearing pain (including painwhenwalking on a flat surface, going up/down stairs, and when standing) and non-weightbearing pain (including pain at nightwhile in bed andwhen sitting/lying). Univariable andmultivariable logistic regression analysis and generalized linear models with Poisson regression analysis were used to estimate prevalence ratios (PR) or relative risks (RR) for the association between knee effusion (0–3) and baseline or increases in knee pain. Results: Prevalence of knee joint effusion ( 2) was 42.9% at suprapatellar pouch, 48.8% at central portion, 10.3% at posterior femoral recess and 14.4% at subpopliteal recess. Cross-sectionally, knee effusion at suprapatellar pouch was significantly associated with total (PR: 1.26, 95% CI 1.08–1.48) and non-weight bearing knee pain (PR: 1.24, 95% CI 1.06–1.46), but not with weight-bearing pain, after adjustment for age, gender, BMI, rheumatoid arthritis, radiographic OA and other knee structures. Joint effusions at other compartments were not significantly associated with knee pain. Longitudinally, effusion at suprapatellar pouch was associated with increases in total (RR: 1.20, 95% CI 1.00–1.44), non-weight-bearing (RR: 1.38, 95% CI 1.09–1.75) and weight-bearing knee pain (RR: 1.26, 95% CI 1.04–1.53) after adjustment for above covariates. Effusions at posterior femoral recess and central portion were associated with increases in non-weight-bearing knee pain (RR: 1.55, 95% CI 1.25–1.91 and RR: 1.29, 95% CI 1.01–1.65; respectively) but not with weight-bearing knee pain. Effusion at subpopliteal recess was significantly associated with an increase in total knee pain (RR: 1.16, 95% CI 1.01–1.32) after adjustment for age, sex and BMI, but became non-significant after further adjustment for radiographic OA and other knee structures. Conclusions: Knee joint effusions may have compartment-specific contributions to knee pain in older adults. While suprapatellar pouch effusion is associated with both non-weight-bearing and weight-bearing knee pain, posterior femoral recess and central portion effusions are only associated with non-weight-bearing knee pain.

SummaryObjectiveTo test the hypothesis that knee effusion presence in those with knee osteoarthritis (OA) alters knee joint muscle activation patterns and sagittal plane mechanics during gait.MethodsThirty-five patients with medial compartment knee OA were assessed for the presence of effusion using a brush test. Based on the results, they were assigned to the knee effusion (n = 17) and no knee effusion (n = 18) groups. Electromyograms from seven lower extremity muscles (lateral and medial gastrocnemius, vastus lateralis and medialis, rectus femoris and the lateral and medial hamstrings), leg motion and ground reaction forces were recorded during self-selected walking. Isometric knee extensor, plantar flexor and knee flexor strength were measured. Discrete measures from angular knee motion and net external moment of force waveforms were identified. Principal component analysis extracted electromyographic waveform features. Analysis of variance models tested for main effects (group, muscle) and interactions (α = 0.05). Bonferroni post-hoc testing was employed.ResultsNo differences in age, body mass index, knee pain, Western Ontario McMaster Osteoarthritis Index scores, gait velocity and muscle strength were found between groups (P > 0.05). Individuals with effusion had a greater overall quadriceps activation and prolonged hamstring activation into mid-stance (P

Hyaluronic acid is a natural component of cartilage and is considered not only as a lubricant in joints but also as playing a physiological role in the trophic status of cartilage. Hyalectin, a selected fraction of hyaluronic acid extracted from cocks' combs, has exhibited efficacy in animal models of osteoarthritis. To assess the efficacy and tolerability of intra-articular injections of hyalectin, we conducted a prospective, randomized, placebo-controlled trial of 1 years' duration in 110 patients with painful hydarthrodial osteoarthritis of the knee. At entry and once a week for 3 weeks, aspiration of the knee effusion and intra-articular injections of either hyalectin 20 mg (H) or its vehicle (C) were performed. The vehicle acted as the control treatment. Four weeks after the last injection, the improvement was greater in the H group compared with the C group (pain: -35.5 +/- 26.4 mm vs -25.8 +/- 21.4, P = 0.03, Lequesne's functional index: -3.8 +/- 4.3 vs -2.3 +/- 3.3, P = 0.03). During the 1 year follow-up, the need to perform supplementary local therapies (joint fluid aspiration because of painful hydarthrodial episodes and/or local corticosteroid injections) was more frequent in group C (44% vs 30%, P = 0.03). Moreover, at the final visit, the physician's overall assessment of efficacy was in favor of H (77% vs 54%, P = 0.01) and the improvement in the functional index was greater in group H (-4.4 +/- 5.1 vs -2.7 +/- 4.1, P = 0.05). This study suggests that intra-articular injections of hyalectin may (1) improve clinical condition and (2) have a long-term beneficial effect in patients with osteoarthritis of the knee.