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Background: Numerous cross-sectional studies have shown that persons with radiographic features of osteoarthritis (OA) of the hips and knees have higher adjusted levels of bone mineral density (BMD). Objective: Data from the Baltimore Longitudinal Study of Aging were examined to determine (1) whether persons with radiographic features of OA of the hands and knees had different rates of bone loss than subjects with normal knee radiographs, and (2) whether persons with normal knee radiographs who had higher adjusted levels of BMD were at greater risk of developing radiographic features of knee OA. Design: Longitudinal cohort study. Subjects: 298 Caucasian men and 139 Caucasian women aged 20 and above who had radiographs of the hands and knees read for features of OA and two or more measurements of BMD at the forearm at least 4 years apart. 179 Caucasian men and 110 Caucasian women aged 20 and above who had longitudinal knee radiographs on average 10 years apart, a subgroup of whom had baseline measurement of lumbar spine and/or femoral neck BMD. Results: Women with radiographic OA of the hand had a significantly greater adjusted rate of bone loss at the radius than women with normal hand radiographs; no such differences were noted in men for hand OA. There were no significant differences in adjusted rate of bone loss at the radius in men or women by presence of radiographic knee OA. Higher BMD at the lumbar spine but not at the femoral neck was associated with an increased risk of developing incident radiographic knee OA after adjustment for age, gender, and body mass index. Conclusions: These data demonstrate that persons with radiographic OA lose bone at different rates than those with normal radiographs and that this relationship varies between the site of OA and the site of measurement of BMD. In addition, they further support a role for higher bone mass in the development of radiographic knee OA. Further studies are needed to examine the relationship between changes in bone mass and radiographic progression of OA.

To describe the impact of arthritis and other rheumatic conditions on hospitals by describing the magnitude and characteristics of these hospitalizations.Data from the 1997 National Hospital Discharge Survey were used to examine this impact. Arthritis was defined using International Classification of Diseases, 9th Revision, Clinical Modification, codes specified by the National Arthritis Data Workgroup. Arthritis-related hospitalizations were analyzed by principal diagnosis of arthritis and by any-listed arthritis diagnosis.In 1997, there were an estimated 744,000 hospitalizations with a principal arthritis diagnosis (3% of hospitalizations). Compared with nonarthritis hospitalizations, persons hospitalized with a principal arthritis diagnosis were older, had fewer comorbidities, had shorter hospital stays, were more likely to undergo a procedure, and were more likely to be discharged to short- and long-term care facilities. The most common diagnoses and procedures related to osteoarthritis. This profile was consistent with a healthier-than-average hospital population electively admitted for specific procedures and subsequent rehabilitation. There were an estimated 2.5 million hospitalizations with an any-listed arthritis diagnosis (9% of hospitalizations). Persons hospitalized with an any-listed arthritis diagnosis were older, had more comorbidities, and had longer hospital stays than those with principal arthritis or nonarthritis hospitalizations. This profile was consistent with a sicker-than-average hospital population nonelectively admitted for reasons other than their arthritis, especially cardiovascular disease.Arthritis has a sizable impact on the hospital care system. As our population ages, this impact, in both human and economic terms, is likely to increase.

Objective To investigate the relationship between anxiety and depression and reporting of knee pain in the community. Methods Subjects (n = 374) were community volunteers aged 40 years and above who are participants in the Baltimore Longitudinal Study of Aging, a prospective multidisciplinary research study of normative aging. Knee pain was defined by the First National Health and Nutrition Examination Survey question “have you ever had pain in or around your knee on most days for at least one month?”; anxiety and depression were measured by the relevant subscales of the Arthritis Impact Measurement Scales questionnaire. All subjects had standing anteroposterior radiographs, read for Kellgren and Lawrence (K + L) grade. Results After adjustment for age, women reporting “ever” knee pain had significantly higher anxiety scores than those reporting “never” pain (3.06 ± 0.26 versus 2.35 ± 0.17; P = 0.025). Pain reporting was related neither to anxiety scores in men, nor to depression in either sex. Analysis stratified by radiographic severity, adjusted for age and gender, showed that differences in anxiety were confined to those reporting knee pain in the absence of radiographic change (i.e., K + L grade 0). Conclusions In the community, women reporting knee pain in the absence of radiographic osteoarthritis have higher anxiety scores than those without pain. Depression was not significantly related to knee pain in this population. Psychosocial factors may explain some of the discrepancy between reported knee pain and structural change as seen on x-ray.

Objective To evaluate the familial aggregation of osteoarthritis (OA) in a cohort of healthy volunteers drawn from a community setting. Methods Hand radiographs obtained between 1978 and 1991 and bilateral standing knee radiographs obtained between 1984 and 1991 were read for changes of OA, using Kellgren-Lawrence (K-L) scales. The hand sites were distal interphalangeal (DIP) joints, proximal interphalangeal (PIP) joints, and first carpometacarpal (CMC1) joints. For each joint group, the presence of OA in at least 1 joint in a joint group, the number of affected digits in each joint group, and the sum of the K-L grade across all joints were analyzed. Polyarticular OA was recorded if there were OA findings in 2 of 3 hand joint groups plus 1 or both knees. Data from 167 families with hand radiographs, 157 families with knee radiographs, and 148 families with both hand and knee radiographs were analyzed for sib-sib correlations. Results After adjustment for age, sex, and body mass index, clinically relevant sib-sib common correlations were found for OA of the DIP, PIP, and CMC1 joints, for OA at 2 or 3 hand sites, and for polyarticular OA (r = 0.33-0.81) when OA was defined according to the number of affected joints or as the sum of the K-L grade across all joints. Conclusion These results from a cohort of volunteers drawn from a community setting and ascertained without regard to OA status demonstrate familial aggregation of OA and contribute to the evidence for heritability of OA.

Objective. To examine the association between selfreported knee pain and radiographic features of osteoarthritis (OA) of the knee. Methods. A sample of participants in the Baltimore Longitudinal Study of Aging (452 Caucasian males and 223 Caucasian females) completed questionnaires and underwent a standing radiograph of both knees at the same biennial visit between 1984 and 1989. Radiographs were interpreted using both the Kellgren-Lawrence and individual features scales. Odds ratios were calculated for the association of radiographic features with knee pain after adjustment for age, sex, and body mass index. Results. Overall, 156 (23%) persons reported ever having knee pain, and 104 (15%) reported current knee pain (within the previous year). Both ever knee pain and current knee pain were significantly associated with the presence of definite knee OA (Kellgren-Lawrence grade ≥2) and with the presence of all individual features. There was a direct relationship between all measures of severity of radiographic OA and knee pain. Conclusion. These data demonstrate that radiographic features of knee OA are significantly associated with knee pain. The data also support the continued use of the Kellgren-Lawrence grading scale for defining knee OA in population studies.

Objective. To examine the relationship between serum levels of insulin-like growth factor 1 (IGF-1) and osteoarthritis (OA) of the knee. Methods. Serum IGF-1 levels were compared in 162 male and 101 female subjects age ≥20 stratified by presence of radiographic changes of OA of the knee. Results. Mean serum IGF-1 levels were significantly lower in subjects with knee OA; however, after adjustment for age-related changes in IGF-1 levels, these differences were no longer significant. Conclusion. These data fail to support the hypothesis that serum IGF-1 levels are reduced in subjects with OA of the knee independent of the known age-related changes in these levels.

OBJECTIVES Knee osteoarthritis (OA) is a major cause of disability, particularly in the elderly. The factors determining disability remain unclear. The aim of this study was to assess the impact of clinical and psychosocial variables on function in knee OA and to develop models to account for observed variance in self-reported disability. METHODS The subjects (n = 69) were hospital out-patients. Self-reported disability was measured by the Western Ontario and McMaster Universities (WOMAC) OA index. Pain was measured by the WOMAC and the McGill pain questionnaire. Depression, anxiety, helplessness, self-efficacy, fatigue and quality of life were measured by standard instruments. A detailed knee examination, including pain threshold by dolorimetry, was performed. Radiographs were scored for individual features. RESULTS Pain severity, obesity and helplessness were the most important determinants of disability: a model including these variables accounted for 59.9% variance in WOMAC disability. Anxiety remained associated with disability in some models. Disability was unrelated to radiographic change. CONCLUSIONS Function in symptomatic knee OA is determined more by pain and obesity than by structural change, at least as seen on plain X-ray. Our study provides further support for interventions targeting anxiety and helplessness in knee OA.

This chapter discusses the most common chronic diseases, arthritis and musculoskeletal in the United States. In women, the prevalence of self-reported arthritis increased with increasing age; the majority of women aged 65 and above reported the presence of an arthritis diagnosis. Age-adjusted prevalence was higher in women of non-Hispanic than of Hispanic ethnicity; there was no difference in age-adjusted prevalence between whites and blacks, but prevalence was lower in Asians. The impact of arthritis in women in the United States can be estimated by examining its relationship with disability and its associated economic costs. Musculoskeletal diseases such as arthritis are a heavy economic burden in the United States and in other developed countries. The total cost of arthritis to the US economy in 1988 (including inpatient and outpatient care, nursing home care, medications, and lost productivity) was estimated at 54.6 billion dollars; in 1992, this figure was 64.8 dollars. Less than a quarter of these costs are due to direct medical care, including inpatient and outpatient hospital and physician charges, and costs of pharmaceuticals. The vast majority of costs are attributable to indirect costs, predominantly due to lost wages.

Objective: The aggrecan proteoglycan is a major component of articular cartilage and supports the biomechanical function of this tissue. A variable number tandem repeat (VNTR) polymorphism has been discovered recently in a region of the human aggrecan gene that codes for the chondroitin sulfate attachment site. We examined whether alleles of this polymorphism displayed a non-random association with bilateral hand or knee osteoarthritis (OA) in men from the Baltimore Longitudinal Study of Aging (BLSA). Design: DNA was obtained from 93 Caucasian men, aged 60 and above, who had bilateral hand and standing knee radiographs read for changes of OA. The DNA was analyzed by polymerase chain reaction (PCR) and/or Southern blotting for the presence of the VNTR alleles. Results: Bilateral hand OA and knee OA were present in 46 and 30% of the men respectively. The following distribution of alleles was observed: allele 33 (0.5%), 29 (2.2%), 28 (31.7%), 27 (43.0%), 26 (16.7%), 25 (3.2%), 22 (2.2%) and 19 (0.5%). This distribution was similar to that detected in a random population of individuals from a separate study. In multiple logistic regression analysis, adjusting for age and body mass index, the presence of allele 27 was associated with bilateral hand OA with an odds ratio (OR)=3.23 (95% confidence intervals (CI): 1.24–8.41). No other alleles showed an association with bilateral hand OA and the association between allele 27 and bilateral knee OA was not statistically significant (OR-1.14; 95% CI: 0.45–2.88). Conclusions: These data demonstrate the first association between a human aggrecan gene polymorphic allele and hand OA. This finding supports the concept that genetic factors may play a role in the development and/or progression of some forms of age-onset OA.

OBJECTIVE--To examine the association between hand and knee osteoarthritis (OA) in a community based population. METHODS--Radiographs of 695 participants aged > or = 40 years in the Baltimore Longitudinal Study of Aging were read for changes of OA, using Kellgren-Lawrence grade > or = 2 as the case definition. RESULTS--Logistic regression analyses, adjusting for age, gender and body mass index, revealed a significant association between OA in the knee and the following joint groups: distal and proximal interphalangeal (DIP, PIP) and Hand2 (OA in two or more hand joint groups) for grade 2-4 and grade 3-4 disease, and the first carpometacarpal (CMC1) joint for grade 3-4 disease. CONCLUSION--There is an association between OA in hand sites and the knee. The strength of the associations increases with increasing disease severity. For the PIP site, there is a trend toward increasing strength of association for increasing numbers of affected joints and bilateral disease.

To examine the association of upper extremity bone mass with osteoarthritis (OA) of the knee, bilateral standing knee radiographs, taken between 1985 and 1991, in 430 Caucasian male and 266 Caucasian female subjects aged 40 years and above in the Baltimore Longitudinal Study of Aging, were read by one investigator for grade of OA using Kellgren-Lawrence scales. Several measures of upper extremity bone mass, size, and density, including combined cortical thickness (CCT), total width and percentage of cortical area of the second metacarpal, and bone mineral content (BMC), width, and density of the distal third of the left radius measured with single photon absorptiometry, were assessed at the same visit. In univariate analyses, men and women with definite knee OA were significantly older, men had significantly greater radial width, and women had significantly lower bone mass as measured by both CCT and BMC. After adjustment for age and body weight, however, men with knee OA had significantly higher BMC and radial width while neither of these measures of upper extremity bone mass and size was significantly associated with the presence of definite knee OA in women. Neither measure of upper extremity bone density was significantly associated with definite knee OA in either sex. These data suggest that, although men (but not women) with definite knee OA have significantly higher levels of adjusted radial bone mass and size, subjects with knee OA do not have significantly higher levels of adjusted bone mineral density at either upper extremity site.

The aim of this study was to estimate the prevalence and pattern of radiographic changes of osteoarthritis (OA) of the knee by age and gender in Caucasian participants in the Baltimore Longitudinal Study of Aging. Bilateral standing weight-bearing radiographs of the knee in 547 male and 351 female subjects (aged 20 and above) were read for changes of knee OA using Kellgren-Lawrence and individual features scales. Prevalence of definite (Kellgren-Lawrence grade > or = 2 changes) knee OA increased with advancing age in both sexes. Approximately 50 percent in both sexes showed bilateral involvement. Men aged 59 and below were more likely to have unilateral impairment than men aged 60 and above; no such differences were found in females. These data demonstrate that age and gender influence both the prevalence and pattern of radiographic changes of knee OA.

The association of obesity and body fat distribution with hand osteoarthritis was studied in 317 Caucasian female subjects aged 40 years and above in the Baltimore Longitudinal Study of Aging. Bilateral hand radiographs taken between 1978 and 1991 were read by one investigator for grade of osteoarthritis using Kellgren-Lawrence scales. Possible risk factors, assessed at same visit as the first radiograph during this interval, included age and measures of obesity, per cent body fat, and fat distribution. Results of bivariate analyses showed that increasing grade of hand osteoarthritis was associated with increasing age, greater mean levels of waist-hip ratio and per cent body fat; there was no association with body mass index. After adjustment for age, however, none of these independent variables remained significantly associated with grade of hand osteoarthritis. These data fail to support hypotheses that measures of obesity are associated with hand osteoarthritis in women independent of their known age-related changes.

The association of metabolic and physiologic factors with hand osteoarthritis was studied in 888 Caucasian male subjects aged 17-102 years in the Baltimore Longitudinal Study of Aging. Left-hand radiographs taken between 1958 and 1975 were read by one investigator for grade of osteoarthritis using Kellgren-Lawrence scales. Possible risk factors, assessed at the same visit as the last radiograph during this interval, included age and measures of bone mass, body composition, muscle mass, and muscle strength. Results of bivariate analyses of these cross-sectional data showed that increasing grade of hand osteoarthritis was associated with increasing age; greater mean levels of waist/hip ratio and percentage of body fat; and lower mean levels of percentage of cortical area, grip strength, and forearm circumference. After adjustment for age using residuals from best-fit quadratic regression models, none of these independent variables remained significantly associated with grade of hand osteoarthritis. These data fail to support hypotheses that metabolic and physiologic factors are associated with hand osteoarthritis independent of their known age-related changes.

Rationale and objectives The authors present an atlas of individual radiographic features of osteoarthritis of the knee and evaluate the inter- and intra-reader reliability of trained readers using this atlas. Methods Four trained readers graded 30 standing anterior-posterior knee radiographs for eight selected features of osteoarthritis (medial and lateral osteophytes, joint space narrowing, and sclerosis; osteophytes of the tibial spines and chondrocalcinosis) as well as the Kellgren-Lawrence global scale. Inter- and intra-reader reliability were calculated using intraclass correlation coefficients. Results For all features except sclerosis and osteophytes of the tibial spines, inter-reader reliability ranged from 0.63 to 0.83, whereas intra-reader reliability ranged from 0.82 to 0.95. Conclusion Using this atlas, trained readers are reliable in measuring the presence and severity of individual radiographic features of osteoarthritis of the knee. This atlas should be useful in clinical and epidemiologic studies of osteoarthritis of the knee.

Objective: To identify the most common sites of pain in symptomatic knee osteoarthritis (OA) and to investigate clinical, radiographic and psychosocial associations of pain occurring in different locations. Design: Sixty-eight outpatients with knee OA were interviewed in detail about their knee pain. Location of pain was recorded on a standard drawing of the knee. Validated instruments were used to measure pain severity, function, depression, anxiety, quality of life, fatigue, helplessness, self efficacy. Pain threshold was measured by dolorimetry and a knee examination performed. Radiographs (anterioposterior and lateral) were viewed if available. Results: Most (85.3%) patients reported either ‘generalized' ( N =35, 51.5%) or ‘medial' ( N =23, 33.8%) knee pain. There were no differences between groups in pain severity, demographic or psychosocial variables, pain threshold or radiographic location or severity. However, function was significantly worse in the ‘generalized' group (WOMAC function score 48.9±20.8 vs 34.2±22.3; P =0.01): this remained significant after adjustment for potential confounding factors. The difference in function was most marked for activities involving knee bending. Early morning stiffness was also greater in the generalized group. Conclusions: Knee pain is not the same in all individuals with knee OA, confirming the heterogeneity of the condition. Location of pain is usually either generalized or medial. Patients with these patterns do not differ in demographic, radiographic or psychosocial variables but important differences in functional ability can be detected, suggesting differences in the underlying causes of pain and disability between the two groups.