Search

Aim Develop a prediction model for incident radiographic IPJ osteoarthritis when multiple clinical risk factors are present. Methods This study used secondary analysis from the Chingford 1000 Women Study, a prospective cohort of women aged 45 to 64 years. At baseline, anthropometric, clinical, and lifestyle measured had been collected. Hand radiographs had been taken at baseline and 10 years, read using the Kellgren-Lawrence atlas. For the current study, participants with osteoarthritis (Kellgren-Lawrence ≥2) in any IPJ at baseline were excluded. Risk factors were selected from baseline based on biological plausibility, a published systematic review, and a Delphi study of Hand Surgeons. Incident osteoarthritis was diagnosed at 10 years if ≥ 1 IPJ was Kellgren-Lawrence ≥2. The model was built with logistic regression and elastic net penalisation, and performance assessed through discrimination (c-statistic) and calibration (c-slope). Complete case analysis was used. Results Of 1,003 participants, 459 participants were included in this study (median age: 51 years, 202 (44%) with IPJ osteoarthritis at follow-up). Manual occupation (P Conclusions Osteoarthritis at the base of thumb and IPJs might be a continuum of the same disease. Knowledge of these modifiable and non-modifiable risk factors can inform prevention strategies.

Background: Over the past decade, there has been a growth in the use of ankle replacements. Data from national joint registries have shown between-country differences in the utilization of ankle replacement. The reasons for these differences are, however, not well understood. Our aims were to describe and compare the annual incidence of primary ankle replacement between countries and, to examine potential reasons for variation over time. Methods: We used aggregate data and summary statistics on ankle replacements for the period 1993 to 2019 from national joint replacement registries in Australia, Finland, New Zealand, Norway, Sweden and the United Kingdom. From the annual recorded counts of procedures, demographic data were extracted on age, sex distribution, and indication(s) for primary ankle replacement. Registry-level summary results were also obtained on data completeness, counts of hospitals/units, and health care providers performing ankle replacements annually and data collection processes (mandatory vs voluntary). Annual ankle replacement incidence for all diagnoses and, by indication categories (osteoarthritis [OA] and rheumatoid arthritis [RA]), were calculated per 100 000 residential population aged ≥18 years. Results: For the period with data from all 6 countries (2010-2015), New Zealand had the largest annual incidence (mean ± SD) of 3.3 ± 0.2 ankle replacement procedures per 100 000 population whereas Finland had the lowest incidence (0.92 replacements). There were no common temporal trends in the utilization of ankle replacements. Over the years studied, OA was the predominant diagnosis in the United Kingdom, Australia, and New Zealand, whereas RA was the most common indication in Scandinavia. Conclusion: In these 6 countries, we found marked differences in the utilization of ankle replacements. Registry-related factors including data completeness and the number of hospitals/surgeons performing ankle replacements are likely to contribute to the observed between-country differences and need to be carefully considered when interpreting comparisons for this less common site for joint replacement surgery. Level of Evidence: Level III, retrospective study.

Context How different pitching roles affect the risk of arm injury in professional pitchers is currently unclear. Objectives To investigate differences between professional baseball starting and relief pitchers in the hazard of (1) arm injury and (2) elbow and shoulder injury. Design Prospective cohort study. Setting Minor League Baseball (MiLB) from 2013 to 2019. Patients or Other Participants Pitchers in MiLB. Main Outcome Measure(s) Pitchers were followed for the entire MiLB season, and athlete-exposures and injuries were recorded. Risk ratios and risk difference were calculated between starting and relieving MiLB pitchers. A Cox survival analysis was then performed in relation to time to arm injury between starting and relieving MiLB pitchers. Subgroup analyses were conducted for elbow and shoulder injuries. Results A total of 297 pitchers were included, with 85 270 player-days recorded. The incidence of arm injuries was 11.4 per 10 000 athlete-exposures. Starting pitchers demonstrated a greater risk ratio (1.2 [95% CI = 1.1, 1.3]), risk difference (13.6 [95% CI = 5.6, 21.6]), and hazard of arm injury (2.4 [95% CI = 1.5, 4.0]) than relief pitchers. No differences were observed for the hazard of elbow injury between starting and relief pitchers (1.9; 95% CI = 0.8, 4.2). Starting pitchers had a greater hazard of shoulder injury than relief pitchers (3.8 [95% CI = 2.0, 7.1]). Conclusions Starting pitchers displayed a 2.4 times greater hazard of arm injury than relief pitchers. Subgroup analyses indicated that starters exhibited a greater hazard of shoulder injury than relievers, but no differences occurred for the hazard of elbow injury. However, due to the wide CIs, these subgroup analyses should be interpreted with caution. Clinicians may need to consider cumulative exposure and fatigue and how these factors relate to different pitching roles when assessing the risk of pitching arm injury.

Background Sport participation has many physical and psychosocial benefits, but there is also an inherent risk of injury, subsequent osteoarthritis and psychological challenges that can negatively impact quality of life (QOL). Considering the multifaceted impacts of sport participation on QOL across the lifespan, there is a need to consolidate and present the evidence on QOL in former sport participants. Objective To evaluate QOL and life satisfaction in former sport participants, and determine what factors are associated with QOL and life satisfaction in this population. Methods Eight electronic databases were systematically searched in July 2018 to retrieve all articles that evaluated QOL or life satisfaction in former sport participants. Two authors independently screened titles/abstracts and full texts, extracted data, and appraised methodological quality using a modified Downs and Black Checklist. Random-effects meta-analysis estimated pooled mean and 95% confidence intervals (Cis) for Mental Component Scores (MCS) and Physical Component Scores (PCS) derived from the SF-12, SF-36, VR-12 and VR-36 measures. MCS and PCS were pooled for all former sport participants, as well as professional- and collegiate-athlete subgroups. Data that were inappropriate for meta-analysis (i.e. EQ-5D, PROMIS and life-satisfaction outcomes) were collated and reported descriptively. Results Seventeen articles evaluated QOL or life satisfaction in a total of 6692 former athletes [eight studies (n = 4255) former professional athletes; six studies (n = 1946) former collegiate athletes; two studies (n = 491) included both] with a mean age ranging from 21 to 66 years. Most studies were cross-sectional (15 of 17 articles) and 12 studies had a moderate risk of bias (n = 1 high-risk, n = 4 low-risk). Unpublished data were provided for five studies. Meta-analysis of seven studies resulted in a pooled PCS mean (95% CI) of 50.0 (46.6–53.3) [former professional athletes from two studies: 46.7 (42.1–51.2), former collegiate athletes from five studies: 51.2 (48.4–53.9)] and a pooled MCS of 51.4 (50.5–52.2) [former professional athletes: 52.7 (51.3–54.2), former collegiate athletes: 50.9 (50.0–51.8)]. Factors associated with worse QOL or life satisfaction in former athletes included involuntary retirement from sport (three studies), collision/high-contact sport compared with low/no-contact sport (three studies), three or more concussions compared with no/fewer concussions (two studies), increased body mass index (BMI) (worse PCS, three studies), and osteoarthritis or musculoskeletal issues (worse PCS and MCS, three studies; worse PCS but not MCS, two studies). Conclusions Former athletes had similar PCS and better MCS, compared to general-population norms. Former athletes with impaired PCS reported better MCS than population norms, highlighting the need to use an instrument that differentiates between physical and mental components of QOL in former sport participants. Factors associated with worse QOL that may explain between-study variation include involuntary retirement, collision/high contact sports, concussion, BMI and osteoarthritis. PROSPERO CRD42018104319. Electronic supplementary material The online version of this article (10.1007/s40279-019-01163-0) contains supplementary material, which is available to authorized users.

Osteoarthritis (OA) is a major cause of pain and physical disability in adults, and an increasingly common disease given its associations with aging and a growing obese/overweight population. Paracetamol is widely recommended for analgesia at an early stage in the management of OA, and, although frequently prescribed, evidence suggests the efficacy of paracetamol for OA pain is low. Furthermore, there have been recent concerns over the safety profile of paracetamol, with reports of gastrointestinal, cardiovascular, hepatic and renal adverse events. This narrative review summarizes recent literature on the benefits and harms of paracetamol for OA pain. Data on long-term paracetamol safety are derived largely from observational evidence, and are difficult to interpret given the potential biases of such data. Nonetheless, a considerable degree of toxicity is associated with paracetamol use among the general population, especially at the upper end of standard analgesic doses. Paracetamol is linked to liver function abnormalities and there is evidence for liver failure associated with non-intentional paracetamol overdose. Safety data for paracetamol use in the older population (aged >65 years) are sparse; however, there is some evidence that frail elderly people may have impaired paracetamol clearance. Given that the analgesic benefit of paracetamol in OA joint pain is uncertain and potential safety issues have been raised, more careful consideration of its use is required.

Background: Some controversy exists regarding the safety of intra-articular hyaluronic acid (IAHA) in the management of osteoarthritis (OA). Objective: The objective of this study was to re-assess the safety profile of IAHA in patients with OA, through a comprehensive meta-analysis of randomized, placebo-controlled trials. Methods: A comprehensive literature search was undertaken in the databases MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus. Randomized, double-blind, placebo-controlled, parallel-group trials that assessed adverse events (AEs) with IAHA in patients with OA were eligible for inclusion. Authors and/or study sponsors were contacted to obtain the full report of AEs. The primary outcomes were overall severe and serious AEs, as well as the following MedDRA System Organ Class (SOC)-related AEs: gastrointestinal, cardiac, vascular, respiratory, nervous system, skin and subcutaneous tissue disorders, musculoskeletal, renal and urinary disorders, infections and infestations, and hypersensitivity reaction. Results: Database searches initially identified 1481 records. After exclusions according to the selection criteria, 22 studies were included in the qualitative synthesis, and nine studies having adequate data were ultimately included in the meta-analysis. From the studies excluded according to the pre-specified selection criteria, 21 with other pharmacological OA treatments permitted during the trials were a posteriori included in a parallel qualitative synthesis, from which eight studies with adequate data were finally included in a parallel meta-analysis. Since this meta-analysis was designed to assess safety, the exclusion criterion on concomitant anti-OA medication was crucial. However, due to the high number of studies that allowed mainly concomitant oral non-steroidal anti-inflammatory drugs (NSAIDs), we decided to include them in a post hoc parallel analysis in order to compare the results from the two analyses. No statistically significant difference in odds was found between IAHA and placebo for all types of SOC-related disorders, except for infections and infestations, for which significantly lower odds were found with IAHA compared with placebo, both overall (odds ratio [OR] = 0.61, 95% confidence interval [CI] 0.40–0.93; I 2 = 0%) and in studies without concomitant anti-OA medication (OR = 0.49, 95% CI 0.27–0.89). There were significant increased odds of reporting serious AEs with IAHA compared with placebo, both overall (OR = 1.78, 95% CI 1.21–2.63; I 2 = 0%) and in studies with concomitant anti-OA medication (OR = 1.78, 95% CI 1.10–2.89), but not in studies without concomitant anti-OA medication (OR = 1.78, 95% CI 0.92–3.47). Conclusions: Using the available data on studies without any concomitant anti-OA medication permitted during clinical trials, IAHA seems not to be associated with any safety issue in the management of OA. However, this evidence was associated with only a “low” to “moderate” certainty. A possible association with increased risk of serious AEs, particularly when used with concomitant OA medications, requires further investigation.

Objectives To compare outcomes of total knee replacement (TKR) and total hip replacement (THR) for individuals with RA and OA. Methods We performed a cohort study using routinely collected data. Oxford Knee Score, Oxford Hip Score, and EuroQol 5-dimension 3-level (EQ-5D-3L) questionnaires were collected before and 6 months after surgery. Multivariable regressions were used to estimate the association between diagnosis and post-operative scores after controlling for pre-operative scores and patient characteristics. Results Study cohorts included 2070 OA and 142 RA patients for TKR and 2030 OA and 98 RA patients for THR. Following TKR, the median Oxford Knee Score was 37 [interquartile range (IQR) 29–43] for OA and 36 (27–42) for RA while the median EQ-5D-3L was 0.76 (0.69–1.00) and 0.69 (0.52–0.85), respectively. After THR, the Oxford Hip Score was 42 (IQR 36–46) for OA and 39 (30–44) for RA while the EQ-5D-3L was 0.85 (0.69–1.00) and 0.69 (0.52–1.00), respectively. The estimated effect of RA, relative to OA, on post-operative scores was −0.05 (95% CI −1.57, 1.48) for the Oxford Knee Score, −0.09 (−0.13, −0.06) for the EQ-5D-3L following TKR, −1.35 (−2.93, −0.22) for the Oxford Hip Score, and −0.08 (−0.12, −0.03) for the EQ-5D-3L following THR. Conclusion TKR and THR led to substantial improvements in joint-specific scores and overall quality of life. While diagnosis had no clinically meaningful effect on joint-specific outcomes, improvements in general quality of life were somewhat less for those with RA, which is likely due to the systemic and multijoint nature of rheumatoid disease.

Background and purpose — 1 in 5 patients are dissatisfied following unicompartmental or total knee arthroplasty (UKA or TKA). This may be partly explained by failing to return to desired activity post-arthroplasty. To facilitate return to desired activity, a greater understanding of predictors of return to desired activity in UKA and TKA patients is needed. We compared rates of return to desired activity 12 months following UKA vs. TKA, and identified and compared predictors of return to desired activity 12 months following UKA vs. TKA. Patients and methods — Patients were prospectively recruited from 2 hospitals prior to undergoing UKA or primary TKA. Patients reported preoperatively the activity/activities that were limited due to their knee that they wished to return to after arthroplasty. At 12-months postoperatively, patients reported whether they had returned to these activities (‘return to desired activity’). Preoperative predictors evaluated were age, sex, BMI, education, comorbidities, pain expectations, Oxford Knee Score (OKS), UCLA Activity Score, and EQ-5D. Generalized linear models assessed the relationship between potential predictors and return-to-desired-activity. Results — The response rate of all patients eligible for 12-month follow-up was 74%. TKA patients (n = 575) were older (mean (SD) 70 (9) vs. 67 (10)) with a greater BMI (31 (6) vs. 30 (5)) than patients undergoing UKA (n = 420). 75% of UKA and 59% of TKA patients returned to desired activity. TKA patients had a greater risk of non-return to desired activity than patients undergoing UKA (risk ratio (95% CI) 1.5 (1.2–1.8)). Predictors of non-return to desired activity following UKA were worse OKS (0.96 (0.93–0.99)), higher BMI (1.04 (1.01–1.08)), and worse expectations (1.9 (1.2–2.8)). Predictors of non-return to desired activity following TKA were worse EQ-5D (0.53 (0.33–0.85)) and worse OKS (0.98 (0.96–1.0)). Interpretation — UKA patients were more likely to return to desired activity than TKA patients. Predictors of return to desired activity differed following UKA and TKA. Optimizing selection of arthroplasty procedure based on patient characteristics and targeting predictors of poor outcome may facilitate return to desired activity with potential to enhance postoperative satisfaction.

Background/Aims Population-based studies suggest an association between pain in elderly adults and cognitive impairment. However, the temporal relationship between chronic pain and cognitive decline is uncertain: most studies are cross-sectional or have short follow-up periods. Our aim was to examine the association between two pain phenotypes - bodily pain and multi-joint pain - in middle-life and cognitive impairment in later-life in a prospective cohort study with 23 years’ follow-up. We also set out to examine the association with mortality. In contrast to much previous work, this study has available a comprehensive depth of information on health and pain characteristics over a long follow-up period. Methods Bodily pain and multi-joint pain at 3 timepoints between baseline and year 10 was measured in participants from the Chingford Women’s Study. Secondary analyses were performed on the two dimensions of bodily pain, pain intensity and interference. Multivariable logistic regression analysis was used to assess the association with cognition at year 23: the primary cognitive outcome was Mini-Mental State Examination (MMSE) score ≤28, with a secondary outcome of ≤ 26. Multivariable Cox regression analysis was used to evaluate the association between each pain exposure and all-cause mortality between years 10 and 23. Analyses were adjusted for education, socio-demographic factors, and modifiable risk factors for cognitive impairment including depression and analgesia use. Results 282 (28.1%) and 276 (27.5%) women were included in analyses for cognition and bodily pain and multi-joint pain respectively. Women with severe bodily pain showed a non-significant greater odds of MMSE ≤28 compared to those with no/mild bodily pain (OR 2.56, 95%CI 0.94-6.95, P = 0.07). Those with severe bodily pain had significantly greater odds of MMSE ≤26 (OR 7.31, 95%CI 2.11-25.36, P = 0.002). However, there was no association with multi-joint pain. Secondary analysis of the two dimensions of bodily pain demonstrated that pain interference displayed a stronger relationship with both MMSE thresholds compared to pain intensity. Women with severe bodily pain and repeated multi-joint pain each had higher crude all-cause mortality, but this was not statistically significant (log-rank test for trend, P = 0.11 & 0.068, respectively). Further adjustment left the association with both pain exposures and all-cause mortality entirely attenuated. Conclusion After 13 years’ follow-up, severe bodily pain but not multi-joint pain in mid-life was associated with subsequent cognitive impairment, determined by MMSE ≤26. Women with severe bodily pain and multi-joint pain had higher crude all-cause mortality rate, but this was not statistically significant after adjustment. Pain interference displayed a stronger association with cognitive impairment; this may reflect the impact of pain on functional status. This study represents the first time the consequences of mid-life pain on later life cognition were examined. Chronic pain, which is largely untreated, may thus represent a modifiable cause of cognitive impairment. Disclosure E. Kelleher: None. S. Hawley: None. A. Delmestri: None. N. Arden: None. I. Tracey: None. A. Soni: None.

Background/Aims Total hip arthroplasty is increasingly offered at younger ages whilst simultaneously people are being encouraged to work to older ages. Ultimately, more people will expect to need to return to work post-THA. We explored the rates of return to work and the trajectories of remaining in work post-THA, with particular attention to the physical demands of the post-operative job. Methods Patients from the Geneva Hip Arthroplasty Registry and the Clinical Outcomes of Arthroplasty (COASt) study who underwent unilateral THA at least 5 years previously were identified. Participants were eligible if they were Results Of the 1,453 eligible people, 817 (56%) returned the questionnaire. Post-operation 508 people returned to work (RTW) of whom: 446 were working at the time of the THA; 46 had stopped working pre-operatively; and 16 did not provide pre-operative work status. The median follow-up post-THA was 7.5 years (IQR 6.2 -12.1). Detailed occupational exposure information was available for 405 of the 508 who returned to work (203 men and 202 women). After adjusting for age at operation, sex, body mass index, time to reach best post-operative function, cohort and age at follow-up, reporting leaving a job because of problems with the replaced hip was strongly associated with: occupational standing > 4 hours/day (HR: 3.37, 95%CI 1.44-7.86), kneeling/squatting (HR: 95%CI 3.67, 1.61-8.40) and carrying/lifting> 10 kg (HR: 5.68, 95%CI 2.37-13.62) . Mutually adjusted models showed that the effect of lifting/carrying weights in excess of 10 kg remained statistically significant (p < 0.01). Conclusion These findings suggest that some jobs may be more difficult to manage post-THA, in particular if they involve prolonged standing, kneeling/squatting or lifting heavy weights. Subject to replication in other cohorts, these findings may be important to discuss with patients at the time of surgery and could imply a particular role for post-THA rehabilitation amongst people needing to RTW in physically-demanding jobs. Disclosure E. Zaballa: None. E. Harris: None. A. Lübbeke-Wolff: None. C. Cooper: None. N. Arden: None. G. Ntani: None. K. Walker-Bone: None.

Objectives Synovitis in symptomatic knee OA (KOA) is common and is associated with joint symptoms. Optimal synovial measurement on MRI is, however, unclear. Our aims were to examine the relationship between MRI measures of synovitis and knee symptoms in symptomatic KOA. Methods Data from a randomized, multicentre, placebo-controlled trial (UK-VIDEO) of vitamin-D therapy in symptomatic KOA were utilized. Participants reported knee symptoms using WOMAC at baseline and annually. On contrast-enhanced (CE) MRI, synovial thickness was measured using established, semi-quantitative methods whilst synovial tissue volume (STV) was assessed as absolute STV (aSTV) and relative to the width of femoral condyle (rSTV). STV of the infrapatellar region was also assessed. Associations between synovial measures and symptoms were analysed using multiple linear regression modelling. Results No linear association was observed between knee symptoms and synovitis thickness scores. Whole-joint aSTV (0.88, 95% CI: 0.17, 1.59) and infrapatellar aSTV (5.96, 95% CI: 1.22, 10.7) were positively associated with knee pain. Whole-joint rSTV had a stronger association with pain (7.96, 95% CI: 2.60, 13.33) and total scores (5.63, 95% CI: 0.32, 10.94). Even stronger associations were found for infrapatellar rSTV with pain (55.47, 95% CI: 19.99, 90.96), function (38.59, 95% CI: 2.1, 75.07) and total scores (41.64, 95% CI: 6.56, 76.72). Conclusions Whole-joint and site-specific infrapatellar STV measures on CE-MRI were associated with knee pain, respectively. Volumes relative to the size of the femoral condyle may be promising outcome measures in KOA trials.

Humeral torsion (HT) has been linked to pitching arm injury risk after controlling for shoulder range of motion. Currently measuring HT uses expensive equipment, which inhibits clinical assessment. Developing an HT predictive model can aid clinical baseball arm injury risk examination. Therefore, the purpose of this study was to develop and internally validate an HT prediction model using standard clinical tests and measures in professional baseball pitchers.An 11-year (2009-2019) prospective professional baseball cohort was used for this study. Participants were included if they were able to participate in all practices and competitions and were under a Minor League Baseball contract. Preseason shoulder range of motion (external rotation [ER], internal rotation [IR], horizontal adduction [HA]) and HT were collected each season. Player age, arm dominance, arm injury history, and continent of origin were also collected. Examiners were blinded to arm dominance. An a priori power analysis determined that 244 players were needed for accurate prediction models. Missing data was low (3%); thus, a complete case analysis was performed. Model development followed the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) recommendations. Regression models with restricted cubic splines were performed. Following primary model development, bootstrapping with 2000 iterations were performed to reduce overfitting and assess optimism shrinkage. Prediction model performance was assessed through root mean square error (RMSE), RA total of 407 professional pitchers (age: 23.2 [standard deviation 2.4] years, left-handed: 17%; arm history prevalence: 21%) participated. Predictors with the highest influence within the model include IR (0.4, 95% CI 0.3, 0.5; P.001), ER (-0.3, 95% CI -0.4, -0.2; P.001), HA (0.3, 95% CI 0.2, 0.4; P.001), and arm dominance (right-handed: -1.9, 95% CI -3.6, -0.1; P = .034). Final model RMSE was 12, REvery 3° of IR explained 1° of HT. Every 3° of ER explained 1° less of HT, and every 7° of HA explained 1° of HT. Right-handers had 2° less HT. Models demonstrated good predictive performance. This predictive model can be used by clinicians to infer HT using standard clinical test and measures. These data can be used to enhance professional baseball arm injury examination.

Objective: To identify post-operative risk factors for the development of chronic pain after knee replacement. Design: Primary knee replacements in persons aged ≥18 years between April 2008 and December 2016 from the National Joint Registry, linked with English Hospital Episode Statistics data, and Patient Reported Outcome Measures. The outcome was chronic pain 6-months after surgery (Oxford Knee pain score). Logistic regression modelling identified risk factors for chronic pain outcome. Results: 258,386 patients; 56.7% women; average age 70.1 years (SD ±8.8 years). 43,702 (16.9%) were identified as having chronic pain 6-months post-surgery. Within 3 months of surgery complications were uncommon: intra-operative complications 1,224 (0.5%); ≥1 medical complication 6,073 (2.4%)); 32,930 (12.7%) hospital readmissions; 3,848 (1.5%) re-operation; 835 (0.3%) revision. Post-surgical risk factors of chronic pain were: mechanical complication of prosthesis odds ratio (OR) 1.56 (95% Confidence Interval 1.35, 1.80); surgical site infection OR 1.13 (0.99, 1.29); readmission OR 1.47 (1.42, 1.52); re-operation OR 1.39 (1.27, 1.51); revision OR 1.92 (1.64, 2.25); length of stay e.g. 6+ vs. Conclusions: We identified a number of post-operative factors relating to the operation and early recovery that are associated with chronic pain following primary knee replacement. The model had weak discriminatory ability indicating that there remains considerable unexplained variability in chronic pain outcome.

Bisphosphonates are contraindicated in patients with stage 4+ chronic kidney disease. However, they are widely used to prevent fragility fractures in stage 3 chronic kidney disease, despite a lack of good-quality data on their effects.The aims of each work package were as follows. Work package 1: to study the relationship between bisphosphonate use and chronic kidney disease progression. Work package 2: to study the association between using bisphosphonates and fracture risk. Work package 3: to determine the risks of hypocalcaemia, hypophosphataemia, acute kidney injury and upper gastrointestinal events associated with using bisphosphonates. Work package 4: to investigate the association between using bisphosphonates and changes in bone mineral density over time.This was a new-user cohort study design with propensity score matching.Data were obtained from UK NHS primary care (Clinical Practice Research Datalink GOLD database) and linked hospital inpatient records (Hospital Episode Statistics) for work packages 1-3 and from the Danish Odense University Hospital Databases for work package 4.Patients registered in the data sources who had at least one measurement of estimated glomerular filtration rate of 45 ml/minute/1.73 mBisphosphonate use, identified from primary care prescriptions (for work packages 1-3) or pharmacy dispensations (for work package 4), was the main exposure.Work package 1: chronic kidney disease progression, defined as stage worsening or starting renal replacement. Work package 2: hip fracture. Work package 3: acute kidney injury, hypocalcaemia and hypophosphataemia identified from Hospital Episode Statistics, and gastrointestinal events identified from Clinical Practice Research Datalink or Hospital Episode Statistics. Work package 4: annualised femoral neck bone mineral density percentage change.Bisphosphonate use was associated with an excess risk of chronic kidney disease progression (subdistribution hazard ratio 1.12, 95% confidence interval 1.02 to 1.24) in work package 1, but did not increase the probability of other safety outcomes in work package 3. The results from work package 2 suggested that bisphosphonate use increased fracture risk (hazard ratio 1.25, 95% confidence interval 1.13 to 1.39) for hip fractures, but sensitivity analyses suggested that this was related to unresolved confounding. Conversely, work package 4 suggested that bisphosphonates improved bone mineral density, with an average 2.65% (95% confidence interval 1.32% to 3.99%) greater gain in femoral neck bone mineral density per year in bisphosphonate users than in matched non-users.Confounding by indication was a concern for the clinical effectiveness (i.e. work package 2) data. Bias analyses suggested that these findings were due to inappropriate adjustment for pre-treatment risk. work packages 3 and 4 were based on small numbers of events and participants, respectively.Bisphosphonates were associated with a 12% excess risk of chronic kidney disease progression in participants with stage 3B+ chronic kidney disease. No other safety concerns were identified. Bisphosphonate therapy increased bone mineral density, but the research team failed to demonstrate antifracture effectiveness.Randomised controlled trial data are needed to demonstrate antifracture efficacy in patients with stage 3B+ chronic kidney disease. More safety analyses are needed to characterise the renal toxicity of bisphosphonates in stage 3A chronic kidney disease, possibly using observational data.This study is registered as EUPAS10029.This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inBisphosphonates are used to prevent fractures in people with fragile bones. People with chronic kidney disease have a high risk of fracturing, but the safety and effectiveness of bisphosphonates in severe chronic kidney disease is unclear. The aim of this study was to assess the benefits (e.g. bone strength improvement and fracture prevention) and the risks of unwanted effects associated with bisphosphonates for people with moderate to severe chronic kidney disease.Anonymised primary and secondary care electronic medical records data from the UK NHS were used, as well as a Danish equivalent that included bone density scans. Anyone in these databases with a measure of reduced kidney function that suggested moderate to severe chronic kidney disease was eligible, which was 220,000 people from the UK. Over 20,000 of them used bisphosphonates. Bisphosphonate users were matched to non-users with similar age, sex and other characteristics.Bisphosphonate users had a 12% higher risk of their chronic kidney disease getting worse than non-users. Their risks of other side effects, such as acute kidney injuries and gastrointestinal problems, did not change. Bisphosphonate users had a 25% higher risk of fractures than non-users in the UK database, probably because the matching methods did not create similar-enough groups of users and non-users. However, it was found that bisphosphonate improved bone density in the Danish database. Bone density is a proxy for bone strength, so better bone density should mean fewer fractures.These results suggest that bisphosphonate therapy may make moderate to severe chronic kidney disease worse. More studies are needed on how bisphosphonates affect milder chronic kidney disease. Bisphosphonates were associated with better bone strength, but it could not be demonstrated that they reduced fracture risk. More data are required, probably from a placebo-controlled trial, to determine whether or not bisphosphonates prevent fractures in people with moderate to severe chronic kidney disease and whether or not this is worth the risk of their chronic kidney disease worsening.

Background Osteoarthritis (OA) is a chronic joint disease, with increasing global burden of disability and healthcare utilisation. Recent meta-analyses have shown a range of effects of OA on mortality, reflecting different OA definitions and study methods. We seek to overcome limitations introduced when using aggregate results by gathering individual participant-level data (IPD) from international observational studies and standardising methods to determine the association of knee OA with mortality in the general population. Methods Seven community-based cohorts were identified containing knee OA-related pain, radiographs, and time-to-mortality, six of which were available for analysis. A two-stage IPD meta-analysis framework was applied: (1) Cox proportional hazard models assessed time-to-mortality of participants with radiographic OA (ROA), OA-related pain (POA), and a combination of pain and ROA (PROA) against pain and ROA-free participants; (2) hazard ratios (HR) were then pooled using the Hartung–Knapp modification for random-effects meta-analysis. Findings 10,723 participants in six cohorts from four countries were included in the analyses. Multivariable models (adjusting for age, sex, race, BMI, smoking, alcohol consumption, cardiovascular disease, and diabetes) showed a pooled HR, compared to pain and ROA-free participants, of 1.03 (0.83, 1.28) for ROA, 1.35 (1.12, 1.63) for POA, and 1.37 (1.22, 1.54) for PROA. Discussion Participants with POA or PROA had a 35–37% increased association with reduced time-to-mortality, independent of confounders. ROA showed no association with mortality, suggesting that OA-related knee pain may be driving the association with time-to-mortality. Funding Versus Arthritis Centre for Sport, Exercise and Osteoarthritis and Osteoarthritis Research Society International.

OBJECTIVES The BRAIN-Q is a tool aimed at maximising the accuracy and minimising measurement error for retrospectively assessing concussions. This paper reports the agreement of the BRAIN-Q tool when compared to extant questionnaire questions, and its reproducibility when compared with its telephonic version (tBRAIN-Q). METHODS The BRAIN-Q entails a 3-stage process: defining a concussion, creating a visual timeline with life events, and establishing detailed characteristics for each reported concussion. It was designed to be administered in-person by trained personnel, and was used in the BRAIN study. Its performance was compared with the MSK study, which previously collected a few questions in a broader self-administered questionnaire, and with the tBRAIN-Q Recall, its telephonic version. RESULTS In total, 101 participants were included, of whom 9 were re-assessed with the tBRAIN-Q. The agreement of the BRAIN-Q with the muscle skeletal-questionnaire for rugby-related concussion was 86.7% (κ=0.6). Rugby-related concussion with loss of consciousness showed lower agreement (82.0%; κ=0.6). The comparison between the BRAIN-Q and the tBRAIN-Q showed good reproducibility. CONCLUSIONS The BRAIN-Q is a relatively easy tool to administer in face-to-face assessments, and it showed optimal reproducibility. It includes a well-established definition of concussion, and is used to collect detailed information on each concussion, allowing for a number of subgroup analyses (e.g., by severity, age, or context). The BRAIN-Q is easily adaptable to other sporting settings.

IntroductionRugby football (Union and League) provides physical activity (PA) with related physical and mental health benefits. However, as a collision sport, rugby research and media coverage predominantly focus on injuries in elite players while the overall impact on health and well-being remains unclear. This study aims to provide a greater understanding of the risks and benefits of rugby participation in a diverse sample of men and women, current and former rugby Union and League players from recreational to the elite level of play. We will explore: (1) joint-specific injuries and concussion; (2) joint pain and osteoarthritis (OA); (3) medical and mental health conditions; (4) PA and sedentary behaviour and (5) well-being (quality of life, flourishing and resilience).Methods and analysisThe Rugby Health and Well-being Study is designed in two phases: (1) a UK-wide cross-sectional survey and (2) cross-validation using health register data from Scotland. Participants will be at least 16 years old, current or former rugby players who have played rugby for at least one season. We will report standardised, level of play-, sex- and age-stratified prevalence of joint injury, concussion, medical conditions and PA. We will describe injury/concussion prevention expectations and protective equipment use. Rugby-related factors associated with injury, pain, OA, PA, health and well-being will be explored in regression models. We will compare joint pain intensity and duration, elements of pain perception and well-being between recreational and elite players and further investigate these associations in regression models while controlling for confounding variables. In the second phase, we will validate self-reported with health register data, and provide further information on healthcare use.Ethics and disseminationThe Yorkshire and the Humber—Leeds East Research Ethics Committee (REC reference: 19/HY/0377) has approved this study (IRAS project ID 269424). The results will be disseminated through scientific publications, conferences and social media.

Bisphosphonates are the first-line treatment for preventing fractures in osteoporosis patients. However, their use is contraindicated or to be used with caution in chronic kidney disease (CKD) patients, primarily because of a lack of information about their safety and effectiveness. We aimed to investigate the safety of oral bisphosphonates in patients with moderate to severe CKD, using primary-care electronic records from two cohorts, CPRD GOLD (1997-2016) and SIDIAP (2007-2015) in the UK and Catalonia, respectively. Both databases were linked to hospital records. SIDIAP was also linked to end-stage renal disease registry data. Patients with CKD stages 3b to 5, based on two or more estimated glomerular filtration rate measurements less than 45 mL/min/1.73 m2 , aged 40 years or older were identified. New bisphosphonate users were propensity score-matched with up to five non-users to minimize confounding within this population. Our primary outcome was CKD stage worsening (estimated glomerular filtration rate [eGFR] decline or renal replacement therapy). Secondary outcomes were acute kidney injury, gastrointestinal bleeding/ulcers, and severe hypocalcemia. Hazard ratios (HRs) were estimated using Cox regression and Fine and Gray sub-HRs were calculated for competing risks. We matched 2447 bisphosphonate users with 8931 non-users from CPRD and 1399 users with 6547 non-users from SIDIAP. Bisphosphonate use was associated with greater risk of CKD progression in CPRD (sub-HR [95% CI]: 1.14 [1.04, 1.26]) and SIDIAP (sub-HR: 1.15 [1.04, 1.27]). No risk differences were found for acute kidney injury, gastrointestinal bleeding/ulcers, or hypocalcemia. Hence, we can conclude a modest (15%) increased risk of CKD progression was identified in association with bisphosphonate use. No other safety concerns were identified. Our findings should be considered before prescribing bisphosphonates to patients with moderate to severe CKD. © 2020 American Society for Bone and Mineral Research (ASBMR).

BackgroundHealth related quality of life (HRQoL) and flourishing are constructs that encompasses a holistic representation of physical, psychological, and social health. The underlying psychological factors that can affect HRQoL and flourishing in sports participants is poorly understood. The purpose of this study was to i) evaluate HRQoL (physical and mental-components) and flourishing in recreational and elite and current and former cricketers; ii) determine the effect of resilience, playing-standard, and playing status on HRQoL and flourishing in cricketers.MethodsThe Cricket Health and Wellbeing Study (n = 2598 current and former cricketers, aged ≥18 years) collected cross-sectional questionnaire data including the Flourishing Scale, Short Form-8 (physical (PCS) and mental (MCS) component scores), resilience (European Social Survey), highest standard-of-play, and playing status. Multivariable linear regressions with fractional polynomials were utilised, adjusted for age, gender, total cricket-seasons, comorbidity, ≥ 4-week time-loss injury, and orthopaedic surgery.ResultsTwo thousand two hundred eighty individuals (aged (mean (SD)) 51.7(14.7) years, 61% played recreationally, 37% former cricketers) were included in analyses. The median (IQR) PCS was 51.4(46.9–55.9), MCS was 54.3(50.0–58.6), and Flourishing Scale score was 48 [ (1–7)] .Greater resilience was associated with better PCS (effect (95% CI) 1.41(0.70–2.11)), MCS (4.78(4.09–5.48)), and flourishing (2.07(2.55–3.59)) compared to less resilience. Playing standard was not associated with HRQoL. Playing at an elite standard was associated with greater flourishing (1.21(0.68, 1.73)), compared with playing recreationally. Current cricket participation was associated with better PCS (3.61(2.92–4.30)) and flourishing scores (0.53(0.02–1.04)), compared to former cricket participation.ConclusionCricketers reported high levels of mental-components of HRQoL and flourishing, and this was similar in recreational, elite, current and former cricketers. Current cricket participation and a higher standard-of-play was associated with greater flourishing. Current cricket participation was also associated with better PCS, however playing-status was not related to MCS. Further research is needed to understand if cricket participation may have psychological benefits that persist beyond cricket retirement.

ObjectiveTo identify patients at risk of mid-late term revision of hip replacement to inform targeted follow-up.DesignAnalysis of linked national data sets from primary and secondary care (Clinical Practice Research Datalink (CPRD-GOLD); National Joint Registry (NJR); English Hospital Episode Statistics (HES); Patient-Reported Outcome Measures (PROMs)).ParticipantsPrimary elective total hip replacement (THR) aged≥18.Event of interestRevision surgery≥5 years (mid-late term) after primary THR.Statistical methodsCox regression modelling to ascertain risk factors of mid-late term revision. HR and 95% CI assessed association of sociodemographic factors, comorbidities, medication, surgical variables and PROMs with mid-late term revision.ResultsNJR-HES-PROMs data were available from 2008 to 2011 on 142 275 THR; mean age 70.0 years and 61.9% female. CPRD GOLD-HES data covered 1995–2011 on 17 047 THR; mean age 68.4 years, 61.8% female. Patients had minimum 5 years postprimary surgery to end 2016. In NJR-HES-PROMS data, there were 3582 (2.5%) revisions, median time-to-revision after primary surgery 1.9 years (range 0.01–8.7), with 598 (0.4%) mid-late term revisions; in CPRD GOLD, 982 (5.8%) revisions, median time-to-revision 5.3 years (range 0–20), with 520 (3.1%) mid-late term revisions.Reduced risk of mid-late term revision was associated with older age at primary surgery (HR: 0.96; 95% CI: 0.95 to 0.96); better 6-month postoperative pain/function scores (HR: 0.35; 95% CI: 0.27 to 0.46); use of ceramic-on-ceramic (HR: 0.73; 95% CI: 0.56 to 0.95) or ceramic-on-polyethylene (HR: 0.76; 95% CI: 0.58 to 1.00) bearing surfaces.Increased risk of mid-late term revision was associated with the use of antidepressants (HR: 1.32; 95% CI: 1.09 to 1.59), glucocorticoid injections (HR: 1.33; 95% CI: 1.06 to 1.67) and femoral head size≥44 mm (HR: 2.56; 95% CI: 1.09 to 6.02)No association of gender, obesity or Index of Multiple Deprivation was observed.ConclusionThe risk of mid-late term THR is associated with age at primary surgery, 6-month postoperative pain and function and implant factors. Further work is needed to explore the associations with prescription medications observed in our data.

Background:Hand osteoarthritis (OA) is a chronic, progressive disease, commonly affecting middle aged women. OA at the interphalangeal joints (IPJs) or the thumb base are considered different disease subsets (1). Few studies have investigated individual risk factors for IPJ OA progression (2). Prediction models can be used to calculate overall disease risk from multiple risk factors. This can guide prevention and treatment options.Objectives:Develop and internally validate a prediction model for IPJ OA progression.Methods:Data from the Chingford 1000 Women Study (Chingford Study), the largest population-based cohort worldwide assessing hand OA, was used. It is representative of the middle-aged female population in the United Kingdom (3). At baseline, 1,003 women aged 45 to 64 years’ old were recruited, and 693 measurements taken. Hand radiographs were taken at baseline and after ten years, read using the Kellgren-Lawrence (KL) atlas (inter-observer correlation: ≥0.7 (4)).For the current study, participants must have had OA (KL ≥2 in ≥1 IPJ) on baseline hand radiographs. Participants with KL 4 in all 16 IPJs at baseline were excluded. Risk factors from the Chingford Study at baseline were selected by biological plausibility, literature evidence (2), and hand surgeons‘ consensus (5): age (years), occupation (manual versus non manual), OA in ≥1 thumb base (KL ≥2 versus KL2), family history of hand OA (yes versus no). The outcome was defined on an ordinal scale for the number of IPJs (up to >5 IPJs) with OA progression (increase by KL ≥1), at ten years’.The prediction model was developed using a penalized proportional odds logistic regression. Odds ratios (95% confidence intervals) were reported for each risk factor. The model was internally validated using 2,000 bootstrap iterations. Model performance was assessed for discrimination (C-statistic), and calibration (C-slope). 3.5% of data was missing, and complete case analysis was used.Results:699 women had baseline hand radiographs: 38 were unreadable, 459 had no IPJ OA. Seven participants had missing data (occupation: 5, BMI: 1, family history: 1) and were excluded. 195 participants were included this study. Median age at baseline was 59 (interquartile range: 8) years.181 (92.8%) participants had OA progression at 10 years (Figure 1). Thumb base OA (odds ratio: 1.32 (0.93 to 1.88)) was most strongly associated with IPJ OA progression (Table 1). C-statistic was 0.57, and calibration slope was 1.38 for the optimism-corrected model.Table 1.Odds ratios for risk factorsRisk factorOdds ratio (95% confidence interval)Age (years)1.02 (0.99 to 1.06)Occupation (manual versus non manual)0.88 (0.60 to 1.29)Thumb base OA (Kellgren-Lawrence grade ≥2 versus 1.32 (0.93 to 1.88)Family history of hand OA (yes versus no)1.03 (0.72 to 1.45)Body mass index (kg/m2)1.04 (0.99 to 1.09)OA: OsteoarthritisConclusion:More stringent cut-offs for OA progression would be clinically useful. It was only weakly possible to predict which participants with IPJ OA would progress. This suggests that other risk factors, such as gender, ethnicity and genetics, may be predominant.Figure 1.Hand interphalangeal joints with osteoarthritis progression (Kellgren-Lawrence grade ≥1) at 10 years’ follow upReferences:[1]Kloppenburg M, et al. Research in hand osteoarthritis: time for reappraisal and demand for new strategies. Ann Rheum Dis. 2007;66(9):1157-61.[2]Shah K, et al. Risk factors for the progression of finger interphalangeal joint osteoarthritis: a systematic review. Rheumatol Int. 2020;40(11):1781-1792.[3]Hart DJ, Spector TD. The relationship of obesity, fat distribution and osteoarthritis in women in the general population: the Chingford Study. J Rheumatol. 1993;20:331-335.[4]Hart DJ, et al. Reliability and reproducibility of grading radiographs for osteoarthritis of the hand. Br J Rheum. 1993;32:S1.[5]Shah K, et al. Delphi consensus of risk factors for development and progression of finger interphalangeal joint osteoarthritis. J Hand Surg Eur Vol. 2019;44(10):1089-1090.Acknowledgements:We would like to thank all of the participants of The Chingford 1000 Women Study, Professor Tim Spector, Dr Deborah Hart, Dr Alan Hakim, Maxine Daniels, Alison Turner, James van Santen and Julie Damnjanovic for their time and dedication.Disclosure of Interests:Karishma Shah: None declared, Garrett Bullock: None declared, Alan Silman: None declared, Dominic Furniss: None declared, Nigel Arden Consultant of: Receives personal fees from Pfizer/Lily for consultancy outside the scope of this work, Grant/research support from: Receives grant from Merck outside the scope of this work, Gary Collins: None declared

Knee osteoarthritis (OA) is a heterogeneous disease associated with substantial effects on quality of life, and its clinical management is difficult. Among the several available guidelines for the management of knee OA, those from OARSI and ESCEO were updated in 2019. Here, we examine the similarities and differences between these two guidelines and provide a narrative to help guide health-care providers through the complexities of non-surgical management of knee OA. OARSI and ESCEO both recommend education, structured exercise and weight loss as core treatments, topical NSAIDs as first-line treatments and oral NSAIDs and intra-articular injections for persistent pain. Low-dose, short-term acetaminophen, pharmaceutical grade glucosamine and chondroitin sulfate are recommended by ESCEO whereas OARSI strongly recommends against their use (including all glucosamine and chondroitin formulations). Despite this difference, the two guidelines are consistent in the majority of their recommendations and provide useful treatment recommendations for individuals with OA and health-care providers.

Radiographic osteoarthritis (OA) is most prevalent in the hand. The association of hand injury with pain or OA is unclear. The objective was to describe the relationship between hand injury and ipsilateral pain and OA in cricketers. Data from former and current cricketers aged ≥ 30 years was used. Data included history of cricket-related hand/finger injury leading to > 4 weeks of reduced exercise, hand/finger joint pain on most days of the last month, self-reported history of physician-diagnosed hand/finger OA. Logistic regression assessed the relationship between injury with hand pain (in former cricketers) and with OA (in all cricketers), adjusted for age, seasons played, playing standard. Of 1893 participants (844 former cricketers), 16.9% reported hand pain, 4.3% reported OA. A history of hand injury increased the odds of hand pain (OR (95% CI) 2.2, 1.4 to 3.6). A history of hand injury also had increased odds of hand OA (3.1, 2.1 to 4.7). Cricket-related hand injury was related to an increased odds of hand pain and OA. This highlights the importance of hand injury prevention strategies within cricket. The high prevalence of hand pain is concerning, and further research is needed to determine the impacts of hand pain.

Objective The study aim was to determine whether lifetime occupation was associated with the presence of radiographic osteoarthritis (ROA) of the first metatarsophalangeal joint (MTPJ) in women. Method Data were collected from the prospective, population-based Chingford 1000 Women study. This cohort of women, aged 45–64 years at inception, was established in 1989 from a single general practice in Chingford, UK. Data has subsequently been collected repeatedly. Data from baseline, year six and year ten was used for the purposes of this cross-sectional study. The primary outcome was the presence of dorsal view ROA of the first MTPJ. The main exposure was lifetime occupation, categorised according to levels of occupation previously defined via international consensus: 1. Sedentary, 2. Light, 3. Light manual, 4. Heavy manual. Logistic regression analyses were conducted to quantify the relationship between lifetime occupation type and the presence of ROA of the first MTPJ, adjusting for age, body mass index and lifetime high-heeled footwear use as potential interactive variables for each decade. Results Data for 209 women were included within this study. The mean (SD) age was 57 (±5.2) years. Predominant lifetime occupation was reported as sedentary by 51.7%, as light by 0%, as light manual by 33.5% and as heavy manual by 14.8% of participants. There were no statistical associations between lifetime occupation type and the presence of ROA of the first MTPJ in either the unadjusted (OR = 0.99, CI = 0.78–1.26,P = 0.96) partially adjusted (for age and BMI; OR = 1.00, CI = 0.78–1.29, P = 0.99) or fully adjusted models (for age, BMI and lifetime high heel footwear use for each decade of working life (OR = 1.02, CI = 0.79–1.31, P = 0.91); high-heel footwear use up to 20s (OR = 0.83, CI = 0.71–1.31, P = 0.83); high-heel footwear use in 20–30s (OR = 1.00, CI = 0.75–1.3, P = 0.98); high-heel footwear use in 30–40s (OR = 1.00, CI = 0.70–1.42, P = 0.99); high-heel footwear use in 40–50s (OR = 0.90, CI = 0.58–1.40, P = 0.65); high-heel footwear use in 50s (OR = 0.63,CI = 0.36–1.09, P = 0.10). Conclusions The findings suggest that lifetime occupation is not associated with the presence of ROA of the fist metatarsophalangeal joint. There does not appear to be any interactive effect between lifetime occupation, lifetime high-heel footwear use, age or BMI and ROA of the first MTPJ. In later life a positive trend towards increased ROA in those who reported lifetime high-heel footwear use was noted and this may be worthy of further research.

Knee osteoarthritis (OA) is a heterogeneous disease associated with substantial effects on quality of life, and its clinical management is difficult. Among the several available guidelines for the management of knee OA, those from OARSI and ESCEO were updated in 2019. Here, we examine the similarities and differences between these two guidelines and provide a narrative to help guide health-care providers through the complexities of non-surgical management of knee OA. OARSI and ESCEO both recommend education, structured exercise and weight loss as core treatments, topical NSAIDs as first-line treatments and oral NSAIDs and intra-articular injections for persistent pain. Low-dose, short-term acetaminophen, pharmaceutical grade glucosamine and chondroitin sulfate are recommended by ESCEO whereas OARSI strongly recommends against their use (including all glucosamine and chondroitin formulations). Despite this difference, the two guidelines are consistent in the majority of their recommendations and provide useful treatment recommendations for individuals with OA and health-care providers.

Osteoarthritis subgroups/phenotypes, based on pain experience over time, inform on symptom development and delivery of treatment options and open a new avenue toward personalized medicine., Knee osteoarthritis (OA) is a heterogeneous disease, and identification of its subgroups/phenotypes can improve patient treatment and drug development. We aimed to identify homogeneous OA subgroups/phenotypes using pain development over time; to understand the interplay between pain and functional limitation in time course; and to investigate subgroups' responses to available pharmacological and surgical treatments. We used group-based trajectory modelling to identify pain trajectories in the phase-3 VIDEO trial (n = 474, 3-year follow-up) and also in the Osteoarthritis Initiative cohort study (n = 4796, 9-year follow-up). We extended trajectory models by (1) fitting dual trajectories to investigate the interplay between pain and functional limitation over time, and (2) including analgesic use as a time-varying covariate. Also, we investigated the relationship between trajectory groups and knee replacement in regression models. We identified 4 pain trajectory groups in the trial and 6 in the cohort. These overlapped and led us to define 4 OA phenotypes: low-fluctuating, mild-increasing, moderate-treatment-sensitive, and severe-treatment-insensitive pain. Over time, functional knee limitation followed the same trajectory as pain with almost complete concordance (94.3%) between pain and functional limitation trajectory groups. Notably, we identified a phenotype with severe pain that did not benefit from available treatments, and another one most likely to benefit from knee replacement. Thus, knee OA subgroups/phenotypes can be identified based on patients' pain experiences in studies with long and regular follow-up. We provided a robust approach, reproducible between different study designs, which informs clinicians about symptom development and delivery of treatment options and opens a new avenue toward personalized medicine in OA.

Objective Radiographic hand OA affects one in five adults. Symptomatic hand OA can result in functional impairment, pain and reduced quality of life. A prevalent form of hand OA is IP joint OA, however prognostic factors for IP joint OA remain poorly understood. This systematic review aimed to identify prognostic factors for IP joint OA, and to summarize the diagnostic criteria for IP joint OA in prognostic studies. Methods EMBASE, MEDLINE, Scopus and The Cochrane Library were searched from inception until 19 February 2020 (PROSPERO CRD42019116782). Eligible studies described diagnostic criteria defining IP joint OA, and assessed potential prognostic factors for IP joint OA. Risk of bias was assessed using a modified Quality in Prognosis Studies (QUIPS) tool and a best evidence synthesis was used. Results Eighteen studies were included (risk of bias: eight high, three moderate, seven low). All defined OA radiographically, and three studies incorporated clinical symptoms into their definition of OA. Forty-nine potential prognostic factors were assessed. Eight were prognostic: older age in women, female gender (both moderate evidence); family history of Heberden’s nodes, Kashin–Beck disease, older age in men, dental occupation in men, finger fracture, parity (all limited evidence). Higher BMI in women (limited evidence) was prognostic for symptomatic radiographic OA. No prognostic factors for symptomatic OA were identified. Conclusion IP joint OA is most commonly defined radiographically, yet criteria were heterogeneous. Eight prognostic factors for radiographic IP joint OA and one for symptomatic radiographic IP joint OA were identified, all with limited or moderate evidence. Further studies on causality and on prognostic pathways are needed.

Purpose: prevalence of knee osteoarthritis has been associated with work-related repetitive joint movements and excess knee load, but little is known of the relationship between specific job titles and risk of knee osteoarthritis; especially light to moderate physically demanding occupations. This review aims to assess the association between occupational exposures and knee osteoarthritis (OA).Methods: we systematically searched for observational studies that compared occupational exposures in relation to primary knee OA and total knee replacement (TKR). Occupational exposures included job titles, job categories and occupational activities such as lifting, kneeling etc. MEDLINE, EMBASE, CINAHL and Web of Science were searched for relevant literature from inception to Oct 1st, 2019. Odds ratios (OR) and 95% confidence intervals (CI) were retrieved/calculated for meta-analysis using random-effects models.Results: a total of 80 eligible studies were identified including 25 case-control (N = 20,505), 36 cross-sectional (N = 139,463) and 19 cohort studies (N = 16,824,492). Synthesis of 71 studies yielded an increased risk of knee OA (OR: 1.52; 95%CI: 1.37, 1.69), which combined different physically demanding jobs and occupational activities, compared to sedentary occupations and/or low exposure groups (Figure 1). The risk of knee OA was greater in males, industry-based studies and studies assessing lifetime occupational exposures. Specific job titles that were associated with an increased risk of knee OA included agriculture workers, construction workers, metal workers, floor layers, carpenters, craftsmen, service workers, cleaners and houseworkers. Occupational lifting, kneeling, climbing, squatting and standing were all associated with a higher risk of knee OA.Conclusions: an increased risk of knee OA was found in heavy physical demanding occupations and occupational activities supported by moderate-quality evidence. Specific job titles were mainly in agriculture and construction sectors which involve heavy lifting, frequent climbing, prolonged kneeling, squatting and standing.

Summary Bisphosphonates are contraindicated in moderate-to-severe chronic kidney disease patients. However, they are used to prevent fragility fractures in patients with impaired kidney function, despite a lack of evidence on their effects on bone density in these patients. We demonstrated that Alendronate had a positive effect on bone in these patients. Purpose This study aimed to assess the association between alendronate use and bone mineral density (BMD) change in subjects with moderate-severe chronic kidney disease (CKD). Methods We created a cohort of CKD stage 3B–5 patients by linking all DXA-based measurements in the Funen area, Denmark, to biochemistry, national health registries and filled prescriptions. Exposure was dispensation of alendronate and the outcome was annualized percentage change in BMD at the femoral neck, total hip and lumbar spine. Individuals were followed from first BMD to the latest of subsequent DXA measurements. Alendronate non-users were identified using incidence density sampling and matched groups were created using propensity scores. Linear regression was used to estimate average differences in the annualized BMD. Results Use of alendronate was rare in this group of patients: propensity score matching (PSM) resulted in 71 alendronate users and 142 non-users with stage 3B–5 CKD (as in the 1 year before DXA). Whilst alendronate users gained an average 1.07% femoral neck BMD per year, non-users lost an average of 1.59% per annum. The PSM mean differences in annualized BMD were + 2.65% (1.32%, 3.99%), + 3.01% (1.74%, 4.28%) and + 2.12% (0.98%, 3.25%) at the femoral neck, total hip and spine BMD, respectively, all in favour of alendronate users. Conclusion In a real-world cohort of women with stage 3B–5 CKD, use of alendronate appears associated with a significant improvement of 2–3% per year in the femoral neck, total hip and spine BMD. More data are needed on the anti-fracture effectiveness and safety of bisphosphonate therapy in moderate-severe CKD.

Objectives: to examine the effect of occupation on knee osteoarthritis (OA) and total knee replacement (TKR) in working-aged adults. Methods: we used longitudinal data from the Chingford, Osteoarthritis Initiative (OAI) and Multicentre Osteoarthritis (MOST) studies. Participants with musculoskeletal disorders and/or a history of knee-related surgery were excluded. Participants were followed for up to 19-years (Chingford), 96-months (OAI) and 60-months (MOST) for incident outcomes including radiographic knee OA (RKOA), symptomatic RKOA and TKR. In those with baseline RKOA, progression was defined as the time from RKOA incidence to primary TKR. Occupational job categories and work-place physical activities were assigned to levels of workload. Logistic regression was used to examine the relationship between workload and incident outcomes with survival analyses used to assess progression (reference group: sedentary occupations). Results: heavy manual occupations were associated with a 2-fold increased risk (OR: 2.07, 95% CI 1.03 to 4.15) of incident RKOA in the OAI only. Men working in heavy manual occupations in MOST (2.7, 95% CI 1.17 to 6.26) and light manual occupations in OAI (2.00, 95% CI 1.09 to 3.68) had a 2-fold increased risk of incident RKOA. No association was observed among women. Increasing workload was associated with an increased risk of symptomatic RKOA in the OAI and MOST. Light work may be associated with a decreased risk of incident TKR and disease progression.Conclusion: heavy manual work carries an increased risk of incident knee OA; particularly among men. Workload may influence the occurrence of TKR and disease progression.

Background Symptomatic thumb-base osteoarthritis (OA) affects 20% of people aged >55 years. Patients with thumb-base OA may experience pain, work disability, hand dysfunction and reduced quality of life (QoL). Although hand splints are a recommended intervention, this is supported by only low level evidence. Furthermore, the impact of placebo hand splints in OA remains unclear. This is the first trial powered to determine the efficacy of active versus placebo thumb splints, when added to a programme of self-management, for patients with symptomatic thumb-base OA. Methods A pragmatic, multi-centre, superiority randomised controlled clinical effectiveness and efficacy trial was conducted. Patients with symptomatic thumb-base OA and at least moderate thumb-base pain referred to UK out-patient occupational and physiotherapists were included. Patients with recent fractures, intra-articular joint injections and medical red flags were excluded. Eligible participants were randomised equally to either: (A) 8 weeks of self-management; (B) 8 weeks of self-management plus a verum splint; or (C) 8 weeks of self-management plus a placebo splint. The self-management programme was designed and delivered by therapists, based on recommended evidence-based practice. Participants in groups B and C were blinded to the type of splint received; clinical outcome assessors were also blinded. Participants were followed-up for 12 weeks from randomisation. The primary outcome was AUSCAN hand pain at 8 weeks. Secondary outcomes included work productivity, QoL, hand stiffness, hand function, disability and satisfaction. The trial was registered (ISRCTN. No 54744256). Results 17 UK NHS therapy departments assessed 751 patients for eligibility. 349 patients were randomised: 116, 116 and 117 to groups A, B and C, respectively. Treatment groups were well balanced for baseline characteristics. At baseline, no participants in group A received a splint; 99% and 97% of participants in groups B and C received the correct allocated splint. 80% of all participants attended their 4 week follow-up appointment. 8 week primary endpoint data were available for 84% of randomised participants; missing data were balanced across the groups. There was no evidence of clinically or statistically significant differences between treatment arms (B vs. C: -0.4 (95% CI -1.4, 0.6 p = 0.41), B vs. A: -0.5 (95% CI -1.4, 0.4 p = 0.26), C vs. A: -0.1 (95% CI -1.0, 0.8 p = 0.78). The per-protocol analysis, sensitivity analysis for missing data and analyses of secondary endpoints supported these findings. Ten participants reported adverse reactions: 3, 5 and 2 in groups A, B and C, respectively. Conclusion The addition of splinting to the recommended self-management package delivered by therapists did not confer additional benefit. Patients randomised to receive verum splints did not report better outcomes than those randomised to placebo splints. Disclosures J. Adams None. P. Barratt None. N.K. Arden None. S. Barbosa Bouças None. S. Bradley None. M. Doherty None. S. Dutton None. K. Dziedzic None. R. Gooberman-Hill None. K. Hislop None. C. Hutt-Greenyer None. V. Jansen None. R. Lunego None. I. Rombach None. M. Wiliams None.

Background The concept of osteoarthritis (OA) heterogeneity is evolving and gaining renewed interest. According to this concept, distinct subtypes of OA need to be defined that will likely require recognition in research design and different approaches to clinical management. Although seemingly plausible, a wide range of views exist on how best to operationalize this concept. The current project aimed to provide consensus-based definitions and recommendations that together create a framework for conducting and reporting OA phenotype research. Methods A panel of 25 members with expertise in OA phenotype research was composed. First, panel members participated in an online Delphi exercise to provide a number of basic definitions and statements relating to OA phenotypes and OA phenotype research. Second, panel members provided input on a set of recommendations for reporting on OA phenotype studies. Results Four Delphi rounds were required to achieve sufficient agreement on 11 definitions and statements. OA phenotypes were defined as subtypes of OA that share distinct underlying pathobiological and pain mechanisms and their structural and functional consequences. Reporting recommendations pertaining to the study characteristics, study population, data collection, statistical analysis, and appraisal of OA phenotype studies were provided. Conclusions This study provides a number of consensus-based definitions and recommendations relating to OA phenotypes. The resulting framework is intended to facilitate research on OA phenotypes and increase combined efforts to develop effective OA phenotype classification. Success in this endeavor will hopefully translate into more effective, differentiated OA management that will benefit a multitude of OA patients.

IntroductionCricket is a popular sport played by 2.5 billion people of all ages and abilities. However, cricket participation is decreasing in the UK, despite an increased focus of governments on increasing sport participation to enhance public health. Understanding the health benefits and mitigating the health risks of cricket participation may help cricket organisations promote cricket participation while optimising the long-term health of cricket participants. Currently, there is no literature review on the relationship between cricket participation, health and well-being; thus, this relationship remains unclear. Therefore, the aims of this scoping review were (1) to investigate the relationship between cricket participation, health and well-being and (ii) to identify the research gaps related to cricket, health and well-being.Methods and analysisDue to the broad nature of our research question and the large number of health outcomes assessed within the cricket literature and to facilitate identification of research gaps, a scoping review methodology was used. The methodology of this paper was informed by previous scoping review protocols and best practice methodological frameworks. MEDLINE, CINAHL, Embase, Scopus, PsycINFO, SPORTDiscus, Cochrane Library, EBSCO, Web of Science and PEDro and grey literature sources (Google Scholar, ClinicalTrials.gov, ISRCTN Registry and ProQuest) will be systematically searched. Studies that assess a construct related to health and/or well-being in current and/or former cricketers from all ages and standards of play will be eligible. Two reviewers will independently screen full texts of identified studies for eligibility and will perform data extraction. Results will be presented in tabular and graphical forms and will be reported descriptively.Ethics and disseminationThis research is exempt from ethics approval due to the data being available through published and public available resources. Results will be published in a peer-reviewed sports and exercise medicine journal regardless of positive or negative findings. In addition, results will be disseminated through multiple platforms, including conference presentations and social media using multimedia resources (eg, infographics, animations, videos, podcasts and blogs), to engage stakeholder groups, including cricketers, cricket coaches, sporting bodies, sports medicine professionals and policy makers. There findings will inform clinical decision making, policy changes and future research agendas.

Introduction: Musculoskeletal injuries are common during military and other occupational physical training programmes. Employers have a duty of care to reduce employees’ injury risk, where females tend to be at greater risk than males. However, quantification of principle cofactors influencing the sex-injury association, and their relative importance, remain poorly defined. Injury risk co-factors were investigated during Royal Air Force (RAF) recruit training to inform the strategic prioritisation of mitigation strategies. Material and Methods: A cohort of 1,193 (males n=990 (83%); females n=203 (17%)) recruits, undertaking Phase-1 military training, were prospectively monitored for injury occurrence. The primary independent variable was sex, and potential confounders (fitness, smoking, anthropometric measures, education attainment) were assessed pre-training. Generalised linear models were used to assess associations between sex and injury. Results: 31% of recruits (28% males; 49% females) presented with at least one injury during training. Females had a twofold greater unadjusted risk of injury during training than males (RR=1.77; 95%CI 1.49 to 2.10). After anthropometric, lifestyle and education measures were included in the model, the excess risk decreased by 34%, but the associations continued to be statistically significant. In contrast, when aerobic fitness was adjusted, an inverse association was identified; the injury risk was 40% lower in females compared with males (RR=0.59; 95%CI: 0.42 to 0.83). Conclusions: Physical fitness was the most important confounder with respect to differences in males’ and females’ injury risk, rather than sex alone. Mitigation to reduce this risk should therefore focus upon physical training, complemented by healthy lifestyle interventions.

Background: Sports participants are faced with the decision to continue or cease play when injured. The implications of playing sport while injured on joint health and health-related quality of life (HRQoL) has not been investigated. The purpose of this study was to investigate the relationship between having played sport while injured and HRQoL, osteoarthritis, and persistent joint pain; and compare findings in elite and recreational athletes. Methods: The Cricket Health and Wellbeing Study cohort was used for this study. Inclusion criteria were: age ≥18 years, played ≥1 cricket season. Questionnaire data collected included a history of playing sport injured, SF-8 (physical (PCS) and mental (MCS) component scores), physician-diagnosed osteoarthritis, and persistent joint pain (most days of the last month). Multivariable linear regressions and logistic regressions were performed. Continuous covariates were handled using fractional polynomials. Models were adjusted for age, sex, cricket-seasons played, playing status, joint injury, and orthopaedic surgery. All participants (n=2,233) were included in HRQoL analyses, only participants aged ≥30 years (n=2,071) were included in osteoarthritis/pain analyses. Results: Of the 2,233 current and former cricketers (mean age: 51.7 SD 14.7, played 30 IQR 24 cricket seasons, 60% were current cricketers, 62% played recreationally; median PCS: 51.4 IQR 9.0; MCS: 54.3 IQR 8.6) 1719 (77%) had played sport while injured. People who had played sport injured reported worse adjusted PCS (Effect(95% CI): -1.78(-2.62, -0.93) and MCS (-1.40(-2.25, -0.54), had greater odds of osteoarthritis (adjusted OR(95% CI): 1.86(1.39, 2.51) and persistent joint pain (2.34(1.85, 2.96)), compared to people who had not played sport injured. Similar relationships were observed regarding PCS, osteoarthritis and pain in elite and recreational subgroups. Playing injured was only related to worse MCS scores for elite cricketers (-2.07(-3.52, -0.63)); no relationship was observed in recreational cricketers (-0.70(-1.79, 0.39)). Conclusion: Athletes that had played sport injured had impaired HRQoL, increased odds of osteoarthritis and persistent joint pain, compared to those who had not played sport injured. Playing sport injured was only related to impaired mental-components of HRQoL in elite athletes. Recreational and elite athletes should be informed of the potential long-term health implications of playing sport while injured.

Objective: To investigate the relationship between baseball participation and health (musculoskeletal, general, and psychological health) and to identify research gaps in the existing literature. Design: Systematic scoping review. Literature Search: Medical databases and gray literature were systematically searched from inception to November 2018. Study Selection Criteria: All studies that investigated constructs related to the health of current or former baseball players were included. Data Synthesis: Data were extracted for thematic summaries. Results: Ten thousand five hundred seventy-four titles/abstracts were screened, and 678 studies were included. Ninety percent of articles included only baseball players playing in the United States, 34% of articles investigated professional baseball players, and 11% studied college baseball players. Five hundred eighty-three (86%) studies investigated musculoskeletal health, 77 (11%) general health, and 18 (3%) psychological health. Injury incidence (injuries per 1000 athlete exposures) ranged from 0.7 to 3.6 in professional, 4.7 to 5.8 in college, and 0.8 to 4.0 in high school baseball. Among baseball players, 31% to 50% reported regular tobacco use. There was limited research investigating psychological health in current or former baseball players at all competition levels. Conclusion: Almost 90% of all articles investigated musculoskeletal health, with few articles studying general or psychological health. Baseball players have high tobacco, alcohol, and drug use compared to the general population, which may have negative health outcomes. Little is understood about the long-term musculoskeletal, general, and psychological health of baseball players.

Introduction A simple tool to estimate loading on the lower limb joints outside a laboratory may be useful for people who suffer from degenerative joint disease. Here, the accelerometers on board of wearables (smartwatch, smartphone) were used to estimate the load rate on the lower limbs and were compared to data from a treadmill force plate. The aim was to assess the validity of wearables to estimate load rate transmitted through the joints. Methods Twelve healthy participants (femalen = 4, malen = 8; aged 26 ± 3 years; height: 175 ± 15 cm; body mass: 71 ± 9 kg) carried wearables, while performing locomotive activities on an anti-gravity treadmill with an integrated force plate. Acceleration data from the wearables and force plate data were used to estimate the load rate. The treadmill enabled 7680 data points to be obtained, allowing a good estimate of uncertainty to be examined. A linear regression model and cross-validation with 1000 bootstrap resamples were used to assess the validation. Results Significant correlation was found between load rate from the force plate and wearables (smartphone:R2=0.71; smartwatch:R2=0.67). Conclusion Wearables’ accelerometers can estimate load rate, and the good correlation with force plate data supports their use as a surrogate when assessing lower limb joint loading in field environments.

Background Prior research on accelerated knee osteoarthritis (AKOA) was primarily confined to the Osteoarthritis Initiative, which was enriched with people with risk factors for knee osteoarthritis (KOA). It is unclear how often AKOA develops in a community-based cohort and whether we can replicate prior findings from the Osteoarthritis Initiative in another cohort. Hence, we determined the incidence and characteristics of AKOA among women in the Chingford Study, which is a prospective community-based cohort. Methods The Chingford Study had 1003 women with quinquennial knee radiographs over 15 years. We divided the 15-year observation period into three consecutive 5-year phases. Within each 5-year phase, we selected 3 groups of participants among women who started a phase without KOA (Kellgren-Lawrence [KL] Results The person-based cumulative incidence of AKOA was 3.9% over 5 years (pooled estimate across the three 5-year phases). Among incident cases of KOA, AKOA represented ~ 15% of women with incident KOA. Women with AKOA were older than those with typical (OR = 1.56, 95%CI = 1.16–2.11) or no KOA (OR = 1.84, 95%CI = 1.40–2.43). Women with AKOA had a greater BMI than those without KOA (OR = 1.52, 95%CI = 1.17–1.97). We observed no association between group and blood pressure. Conclusions In a community-based cohort, > 1 in 7 women with incident KOA had AKOA. Like the Osteoarthritis Initiative, people with AKOA were more likely to have greater age and BMI.

Objective: This paper aims to (i) identify differences in measures of hip morphology between four racial groups using anteroposterior (AP) hip x-rays, and (ii) examine whether these differences vary by sex. Methods: 912 hip x-rays (456 individuals) from four racial groups (European Caucasians, American Caucasians, African Americans and Chinese) were obtained. Males and females (45–75 years) with no radiographic hip OA (Kellgren and Lawrence < Grade 2 or Croft < Grade 1) were included. Eleven features of hip joint morphology were analysed. Linear regression with generalised estimating equations (GEE) was used to determine race and sex differences in hip morphology. Post-hoc Bonferroni procedure was used to adjust for multiple comparisons. Results: The final analysis included 875 hips. Chinese hips showed significant differences for the majority of measures to other racial groups. Chinese were characterised by more shallow and narrow acetabular sockets, reduced femoral head coverage, smaller femoral head diameter, and a lesser angle of alignment between the femoral neck and shaft. Variation was found between other racial groups, but with few statistically significant differences. The average of lateral centre edge angle, minimum neck width and neck length differed between race and sex (p-value for interaction < 0.05). Conclusions: Significant differences were found in measures of morphology between Chinese hips compared to African Americans or Caucasian groups; these may explain variation in hip OA prevalence rates between these groups and the lower rate of hip OA in Chinese. Sex differences were also identified, which may further explain male-female prevalence differences for OA.

Objectives To investigate the relationship between baseball pitching biomechanics and pain, injury, or surgery, in pitchers of all ages and competition levels. Design Systematic review. Methods This study was registered on Prospero (CRD42019137462). Four online databases (MEDLINE, SPORTDiscus, CINAHL, and Embase) from inception to June 13, 2019 were systematically searched. Risk of bias was assessed through the modified Downs and Black. Results 967 titles/abstracts were screened with 11 studies (1376 pitchers) included. Four studies used 3D biomechanical analyses, five studies video analysis, and two studies evaluated EMG activity. Level 1b evidence suggests that injured pitchers had greater elbow valgus torque at late arm cocking (injured: 91.6 N m, non-injured: 74.7 N m, p = 0.013) and early trunk rotation was predictive of increased upper extremity surgical risk (Hazard Ratio: 1.69 (95% CI 1.02–2.80)). Level 3b evidence observed pitchers with upper extremity surgical history had greater lateral trunk tilt at release (surgery: 29.3°, controls: 23.4°, p = 0.035), and flexor carpi ulnaris EMG activity was decreased (injured: 68% MMT, controls: 103% MMT) in pitchers with elbow injury. Conclusions Increased elbow valgus torque and early trunk rotation were injury risk factors, and elbow injured pitchers displayed diminished forearm muscle activity. Due to the low power of many of these studies, and the lack of prospective 3D biomechanical studies, other pitching biomechanical variables cannot be ascertained as injury risk factors. Future studies are needed to prospectively assess pitching injury risk through 3D biomechanical methods.

ObjectivesEffects of the UK Department of Health’s national Enhanced Recovery After Surgery (ERAS) Programme on outcomes after primary hip replacement.DesignNatural experimental study using interrupted time series to assess the changes in trends before, during and after ERAS implementation (April 2009 to March 2011).SettingSurgeries in the UK National Joint Registry were linked with Hospital Episode Statistics containing inpatient episodes from National Health Service trusts in England and patient reported outcome measures.ParticipantsPatients aged ≥18 years from 2008 to 2016.Main outcome measuresRegression coefficients of monthly means of length of hospital stay, bed day cost, change in Oxford Hip Scores (OHS) 6 months post-surgery, complications 6 months post-surgery and revision rates 5 years post-surgery.Results438 921 primary hip replacements were identified. Hospital stays shortened from 5.6 days in April 2008 to 3.6 in December 2016. There were also improvements in bed day costs (£7573 in April 2008 to £5239 in December 2016), positive change in self-reported OHS from baseline to 6 months post-surgery (17.7 points in April 2008 to 22.9 points in December 2016), complication rates (4.1% in April 2008 to 1.7% March 2016) and 5 year revision rates (5.9 per 1000 implant-years (95% CI 4.8 to 7.2) in April 2008 to 2.9 (95% CI 2.2 to 3.9) in December 2011). The positive trends in all outcomes started before ERAS was implemented and continued during and after the programme.ConclusionsPatient outcomes after hip replacement have improved over the last decade. A national ERAS programme maintained this improvement but did not alter the existing rate of change.

Background Sport participants are at increased risk of joint pain and osteoarthritis. A better understanding of factors associated with joint pain and osteoarthritis in this population could inform the development of strategies to optimise their long-term joint health. The purpose of the study was to describe the prevalence of joint pain and osteoarthritis in former cricketers, and determine whether playing position, playing standard (i.e. elite or recreational standard) and length-of-play are associated with region-specific joint pain. Methods The data were from the Cricket Health and Wellbeing Study (CHWS), a cohort of 2294 current and former cricketers (played ≥1 season) in England and Wales. For this study, eligible individuals had to be aged ≥30 years and be a former cricket participant. Joint pain was defined as region-specific (hip/knee/ankle/shoulder/hand/back) pain on most days of the last month. Osteoarthritis was defined as joint-specific doctor-diagnosed osteoarthritis. Logistic regression was used to calculate unadjusted and adjusted (for history of joint injury resulting in > 4 weeks of reduced activity +/− age) odds ratios (ORs) and 95% confidence intervals (95% CIs). Results 846 individuals from the CHWS were former cricketers aged ≥30 years (3% female, aged median 62(IQR 54–69) years, 62% played cricket recreationally, median 33(IQR 21–41) cricket seasons). One-in-two (48%) reported joint pain and 38% had been diagnosed with osteoarthritis. Joint pain and OA were most common in the knee (23% pain, 22% osteoarthritis), followed by the back (14% pain, 10% osteoarthritis) and hand (12% pain, 6% osteoarthritis). After adjusting for injury, bowlers had greater odds of shoulder pain (OR (95% CI) 3.1(1.3, 7.4)) and back pain (3.6(1.8, 7.4)), and all-rounders had greater odds of knee (1.7(1.0, 2.7)) and back pain (2.1(1.0, 4.2)), compared to batters. Former elite cricketers had greater odds of hand pain (1.6(1.0, 2.5)) than former recreational cricketers. Playing standard was not related to pain at other sites, and length-of-play was not associated with joint pain in former cricketers. Conclusions Every second former cricketer experienced joint pain on most days of the last month, and more than one in three had been diagnosed with osteoarthritis. Compared with batters, bowlers had higher odds of shoulder and back pain and all-rounders had higher odds of back and knee pain. Elite cricket participation was only related to higher odds of hand pain compared with recreational cricket participation.

To examine whether body mass index (BMI), menopausal status and hormone therapy (HT) use modify the association between physical activity (PA) patterns throughout middle age and incidence and prevalence of joint symptoms in later middle age in women.Data were from 6661 participants (born 1946-1951) in the Australian Longitudinal Study on Women's Health. Surveys were completed every three years from 1998 to 2010 with questions on joint pain and stiffness, PA, height and weight, menopausal symptoms, and HT use. PA patterns were defined as 'none-or-low', 'low-or-meeting-guidelines', 'fluctuating' or 'meeting guidelines-at-all-times' (reference pattern). Logistic regression was used to examine the association between PA patterns and prevalent (in 2010) and cumulative incident (1998-2010) joint symptoms and effect modification by patterns of BMI, menopausal status and HT.The groups representing 'fluctuating' (odds ratio [OR]=1.34, 99% confidence interval [CI]=1.04-1.72) and 'none-or-low' physical activity (OR=1.60, CI =1.08-2.35) had higher odds of incident joint symptoms than those 'meeting guidelines-at-all-times'. Stratification by BMI showed that this association was statistically significant in the obese group only. No evidence was found for effect modification by menopausal status or HT use. The findings were similar for prevalent joint symptoms.Maintaining at least low levels of physical activity throughout middle age was associated with lower prevalence and incidence of joint symptoms in later life. This apparent protective effect of physical activity on joint symptoms was stronger in obese women than in under or normal weight women, and not related to menopause and HT status. This article is protected by copyright. All rights reserved.

Objective: To estimate the impact of NICE approval of tumour necrosis factor inhibitor (TNFi) therapies on the incidence of total hip replacement (THR) and total knee replacement (TKR) among rheumatoid arthritis (RA) patients in England and Wales.Methods: Primary care data (Clinical Practice Research Datalink (CPRD)) for the study period (1995-2014) were used to identify incident adult RA patients. The age and sex-standardised 5-year incidence of THR and TKR was calculated separately for RA patients diagnosed in each six-months between 1995-2009. We took a natural experimental approach, using segmented linear regression to estimate changes in level and trend following the publication of NICE TA 36 in March 2002, incorporating a 1-year lag. Regression coefficients were used to calculate average change in rates, adjusted for prior level and trend.Results: We identified 17,505 incident RA patients of whom 465 and 650 underwent THR and TKR surgery, respectively. The modeled average incidence of THR and TKR over the biologic-era was 6.57/1,000 person years (PYs) and 8.51/1,000 PYs, respectively, with projected (had pre-NICE TA 36 level and trend continued uninterrupted) figures of 5.63/1,000 PYs and 12.92 PYs, respectively. NICE guidance was associated with a significant average decrease in TKR incidence of -4.41/1,000 PYs (95% C.I. -6.88 to -1.94), equating to a relative 34% reduction. Overall, no effect was seen on THR rates.Conclusions: Among incident RA patients in England and Wales, NICE guidance on TNFi therapies for RA management was temporally associated with reduced rates of TKR but not THR

We aimed to develop a predictive model for non-satisfaction following primary total knee replacement (TKR) and to assess its transportability to another health care system. Data for model development were obtained from two UK tertiary hospitals. Model transportation data were collected from Geneva University Hospitals in Switzerland. Participants were individuals undergoing primary TKR with non-satisfaction with surgery after one year the outcome of interest. Multiple imputation and logistic regression modelling with bootstrap backward selection were used to identify predictors of outcome. Model performance was assessed by discrimination and calibration. 64 (14.2%) patients in the UK and 157 (19.9%) in Geneva were non-satisfied with their TKR. Predictors in the UK cohort were worse pre-operative pain and function, current smoking, treatment for anxiety and not having been treated with injected corticosteroids (corrected AUC = 0.65). Transportation to the Geneva cohort showed an AUC of 0.55. Importantly, two UK predictors (treated for anxiety, injected corticosteroids) were not predictive in Geneva. A better model fit was obtained when coefficients were re-estimated in the Geneva sample (AUC = 0.64). The model did not perform well when transported to a different country, but improved when it was re-estimated. This emphasises the need to re-validate the model for each setting/country.

OBJECTIVE: Population-based osteoarthritis (OA) cohorts provide vital data on risk factors and outcomes of OA, however the methods to define OA vary between cohorts. We aimed to provide recommendations for combining knee and hip OA data in extant and future population cohort studies, in order to facilitate informative individual participant level analyses.METHOD: International OA experts met to make recommendations on: 1) defining OA by X-ray and/or pain; 2) compare The National Health and Nutrition Examination Survey (NHANES)-type OA pain questions; 3) the comparability of the Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC) scale to NHANES-type OA pain questions; 4) the best radiographic scoring method; 5) the usefulness of other OA outcome measures. Key issues were explored using new analyses in two population-based OA cohorts (Multicenter Osteoarthritis Study; MOST and Osteoarthritis Initiative OAI).RESULTS: OA should be defined by both symptoms and radiographs, with symptoms alone as a secondary definition. Kellgren and Lawrence (K/L) grade ≥2 should be used to define radiographic OA (ROA). The variable wording of pain questions can result in varying prevalence between 41.0% and 75.4%, however questions where the time anchor is similar have high sensitivity and specificity (91.2% and 89.9% respectively). A threshold of 3 on a 0-20 scale (95% CI 2.1, 3.9) in the WOMAC pain subscale demonstrated equivalence with the preferred NHANES-type question.CONCLUSION: This research provides recommendations, based on expert agreement, for harmonising and combining OA data in existing and future population-based cohorts.