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Background Limiting treatment to those recommended by the American Academy of Orthopaedic Surgeon Clinical Practice Guidelines has been suggested to decrease costs by 45% in the year prior to total knee arthroplasty, but this only focuses on expenditures leading up to, but not including, the surgery and not the entire episode of care. We evaluated the treatment costs following knee osteoarthritis (OA) diagnosis and determined whether these are different for patients who use intra-articular hyaluronic acid (HA) and/or knee arthroplasty. Methods Claims data from a large commercial database containing de-identified data of more than 100 million patients with continuous coverage from 2012 to 2016 was used to evaluate the cumulative cost of care for over 2 million de-identified members with knee OA over a 4.5-year period between 2011 and 2015. Median cumulative costs were then stratified for patients with or without HA and/or knee arthroplasty. Results Knee OA treatment costs for 1,567,024 patients over the 4.5-year period was $6.60 billion (mean $4210/patient) as calculated by the authors. HA and knee arthroplasty accounted for 3.0 and 61.5% of the overall costs, respectively. For patients who underwent knee arthroplasty, a spike in median costs occurred sooner for patients without HA use (around the 5- to 6-month time point) compared to patients treated with HA (around the 16- to 17-month time point). Conclusions Non-arthroplasty therapies, as calculated by the authors, accounted for about one third of the costs in treating knee OA in our cohort. Although some have theorized that limiting the use of HA may reduce the costs of OA treatment, HA only comprised a small fraction (3%) of the overall costs. Among patients who underwent knee arthroplasty, those treated with HA experienced elevated costs from the surgery later than those without HA, which reflects their longer time to undergoing knee arthroplasty. The ability to delay or avoid knee arthroplasty altogether can have a substantial impact on the cost to the healthcare system.

BACKGROUND: Several nonoperative options have been recommended for the treatment of knee osteoarthritis (OA), with varying degrees of evidence. Adhering to the American Academy of Orthopaedic Surgeons clinical practice guidelines has been suggested to decrease direct treatment costs by 45% in the year before knee arthroplasty, but this does not consider the cost of the entire episode of care, including the cost of surgery and postsurgery care. OBJECTIVES: To analyze the total treatment costs after a diagnosis of knee OA, as well as the proportion of arthroplasty interventions as part of the total knee OA–related costs, and whether the total costs differed for patients who received intra-articular hyaluronic acid and/or had knee arthroplasty. METHODS: We identified patients newly diagnosed with knee OA using the 5% Medicare data sample from January 2010 to December 2015. Patients were excluded if they were aged

Background: Total knee arthroplasty (TKA) is a surgical treatment for patients with knee osteoarthritis (KOA) that no longer experience symptom relief from non-operative or pharmacologic treatments. Non-operative KOA management aims to address patient symptoms and improve function, as well as forestall or mitigate the large costs associated with TKA. The primary objective of this study was to examine the relationship between intra-articular hyaluronic acid (IA-HA) treatment and delaying TKA in patients with KOA compared to patients not receiving IA-HA, as well as to identify differences in KOA-related costs incurred among patients who received or did not receive IA-HA. Methods: This was a retrospective analysis of an administrative claims database from October 1st, 2010 through September 30th, 2015. Kaplan–Meier survival analysis was conducted to determine the TKA-free survival of patients who received IA-HA, stratified by the number of injection courses received versus those who did not receive any IA-HA. Median KOA-related costs per year were calculated for 2 comparisons: (1) patients who received IA-HA versus patients who did not receive IA-HA, among patients who eventually had TKA, and (2) patients who received IA-HA versus patients who did not receive IA-HA, among patients who did not have TKA. Results: A total of 744 734 patients were included in the analysis. A delay to TKA was observed after IA-HA treatment for patients treated with IA-HA compared to those who did not receive IA-HA. At 1 year, the TKA-free survival was 85.8% (95% CI: 85.6%-86.0%) for patients who received IA-HA and 74.1% (95% CI: 74.0%-74.3%) for those who did not receive IA-HA. At 2 years, the TKA free survival was 70.8% (70.5%-71.1%) and 63.7% (63.5%-63.9%) in the 2 groups, respectively. Patients treated with multiple courses of IA-HA demonstrated an incremental increase in delay to TKA with more courses of IA-HA, suggesting that the risk of TKA over the study time period is reduced with additional IA-HA courses. The hazard ratio for the need of TKA was 0.85 (95% CI 0.84-0.86) for a single course and 0.27 (95% CI 0.25-0.28) for ⩾5 courses, both compared to the no IA-HA group. In patients that eventually had TKA, the median KOA-related costs were lower among those who received IA-HA before their TKA ($860.24, 95% CI: 446.65-1722.20), compared to those who did not receive IA-HA ($2659.49, 95% CI: 891.04-7480.38). For patients who did not have TKA, the median and interquartile range (IQR) KOA-related costs per year were similar for patients who received IA-HA compared with those who did not. Conclusion: These results demonstrate that within a large cohort of KOA patients, individuals who received multiple courses of IA-HA had a progressively greater delay to TKA compared to patients who did not receive IA-HA treatment. Also, for patients who progressed to TKA, IA-HA treatment was associated with a large reduction in KOA-related healthcare costs. Based on these results, multiple, repeat courses of IA-HA may be beneficial in substantially delaying TKA in KOA patients, as well as minimizing KOA-related healthcare costs.

Background Intra-articular hyaluronic acid (IA-HA) is a common therapy used to treat knee pain and suppress knee inflammation in knee osteoarthritis (OA), typically prescribed in regimens ranging from a single injection to 5 weekly injections given once weekly. We conducted a systematic review to determine the efficacy of IA-HA, with subgroup analyses to explore the differences in knee pain and adverse events (AEs) across different dosing regimens. Methods We conducted a systematic search of the literature to identify studies evaluating IA-HA for the management of knee OA compared to IA-saline. Primary outcome measure was the mean knee pain score at 13 Weeks (3 months) or 26 weeks (6 months). Secondary outcome was the number of treatment-related AEs and treatment-related serious adverse events (SAEs). We evaluated differences in levels of pain and AEs/SAEs between dosing regimens compared to IA-Saline. Results Thirty articles were included. Overall, IA-HA injections were associated with less knee pain compared to IA-Saline injections for all dosing regimens. 2–4 injections of IA-HA vs. IA-Saline produced the largest effect size at both 3-months and 6-months (Standard mean difference [SMD] = −0.76; −0.98 to −0.53, 95% CI, P

The use of diagnostic and interventional ultrasound has significantly increased over the past decade. A majority of the increased utilization is by nonradiologists. In sports medicine, ultrasound is often used to guide interventions such as aspirations, diagnostic or therapeutic injections, tenotomies, releases, and hydrodissections. This American Medical Society for Sports Medicine (AMSSM) position statement critically reviews the literature and evaluates the accuracy, efficacy, and cost-effectiveness of ultrasound-guided injections in major, intermediate, and small joints, and soft tissues, all of which are commonly performed in sports medicine. New ultrasound-guided procedures and future trends are also briefly discussed. Based on the evidence, the official AMSSM position relevant to each subject is made.

The minimum clinically important difference (MCID) was developed to ascertain the smallest change in an outcome that patients perceive as beneficial. The objectives of the present review were (1) to compare the MCIDs for pain assessments used among guidelines and meta-analyses investigating different nonsurgical therapies for knee osteoarthritis and (2) to compare the effect estimates of different nonsurgical interventions against a single commonly-utilized MCID threshold. METHODS: Systematic and manual searches were conducted to identify guidelines and meta-analyses evaluating pain outcomes for nonsurgical knee osteoarthritis interventions. Individual treatment effects for pain were presented on a common scale (the standardized mean difference [SMD]). To evaluate the perception of the relative benefit of each nonsurgical treatment, the variation in MCIDs selected from the published MCID literature was assessed. RESULTS: Thirty-seven guidelines and meta-analyses were included. MCIDs were often presented as an SMD or a mean difference (MD) on a validated scale and varied in magnitude across sources. This analysis demonstrated that intra-articular hyaluronic acid, intra-articular corticosteroids, and acetaminophen all had relatively larger effect sizes than topical nonsteroidal anti-inflammatory drugs (NSAIDs). Higher-molecular-weight intra-articular hyaluronic acid had a greater relative effect compared with both non-selective and cyclooxygenase-2-selective oral NSAIDs. Evaluating the treatment effect estimates against a commonly utilized MCID revealed similarities in which observations attained clinical significance among treatments; however, this observation varied across the range of reported MCIDs. CONCLUSIONS: The present review confirmed the variability in the MCIDs for pain assessments that are used across guidelines and meta-analyses evaluating nonsurgical interventions for knee osteoarthritis. This variability may yield conflicting treatment recommendations, ranging from rejecting treatments that are indeed efficacious to accepting treatments that may not be beneficial. Additional research is required to determine why some nonsurgical therapies are more consistently recommended in knee osteoarthritis guidelines than others as these findings suggest similarities in their effect estimates for pain. Relevant stakeholders need to reach a consensus on a standard approach to determining the MCIDs for these therapies to ensure that appropriate and effective treatment options are available to patients prior to invasive surgical intervention. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objective Osteoarthritis (OA) is a disabling disease that produces severe morbidity reducing physical activity. Our position statement on treatment of knee OA with viscosupplementation injection [hyaluronic acid (HA)] versus steroid [intra-articular corticosteroid (IAS)] and placebo [intra-articular placebo (IAP)] is based on the evaluation of treatment effect by examining the number of subjects within a treatment arm that met the Outcome Measures in Rheumatoid Arthritis Clinical Trials-Osteoarthritis Research Society International (OMERACT-OARSI) criteria, which is different and more relevant than methods used in other reviews which examined if the average change across the treatment groups was clinically different. Data sources We performed a systematic literature search for all relevant articles from 1960 to August 2014 in the MEDLINE, EMBASE, and Cochrane CENTRAL. We performed a network meta-analysis (NMA) of the relevant literature to determine if there is a benefit from HA as compared with IAS and IAP. Main results Eleven articles met the inclusion criteria from the search strategy. On NMA, those subjects receiving HA were 15% and 11% more likely to respond to treatment by the OMERACT-OARSI criteria than those receiving IAS or IAP, respectively (P Conclusions In light of the aforementioned results of our NMA, the American Medical Society for Sport Medicine recommends the use of HA for the appropriate patients with knee OA.

Objective To validate the ability of the American College of Rheumatology (ACR) clinical classification criteria and the ACR clinical plus radiographic classification criteria for osteoarthritis of the knee to predict articular cartilage damage. Methods Ninety subjects with knee osteoarthritis (OA) who were enrolled in a prospective study determining the therapeutic efficacy of arthroscopic irrigation were characterized as to whether they fulfilled the ACR clinical classification criteria or the ACR clinical plus radiographic classification criteria. Ten rheumatoid arthritis (RA) patients were included as controls. Cartilage damage was defined using the ACR/Knee Arthroscopy Osteoarthritis Scale (ACR/KAOS) system, which is a validated outcome instrument for knee OA based on arthroscopic visualization. Mean values of the damage scores in each group were calculated and compared by t -test to determine statistical significance between the 3 groups. Results The mean ACR/KAOS score for the 10 RA patients was 1.8 [SD 1.22; range 0 to 4]. Of the 90 OA patients who underwent arthroscopy, only 73 patients had sufficient videotape to make an accurate assessment by the blinded assessor. The mean ACR/KAOS score for the 6 OA patients who fulfilled only the ACR clinical classification was 17.4 [SD 11.3; range 5 to 34.3] and the mean ACR/KAOS score for the 67 patients who fulfilled the ACR clinical plus radiographic classification criteria was 42.0 [SD 29.1; range 5.1 to 118.4]. These differences were statistically significant (RA versus OA clinical P = 0.02; RA versus OA clinical + radiographic P ≤ 0.01). Nonparametric multivariate analysis did not reveal significant correlations between ACR/KAOS scores and WOMAC global scores ( r = 0.11, P = 0.39), patient VAS ( r = 0.29, P = 0.022), and age ( r = 0.29, P = 0.08). Conclusions The ACR clinical and clinical plus radiographic criteria for OA of the knee accurately predict cartilage damage as assessed by arthroscopy. Furthermore, the ACR clinical classification criteria identify OA patients with cartilage damage before any radiographic change, while the ACR clinical plus radiographic classification criteria identify OA patients with more severe cartilage damage. Relevance The ACR classification criteria correlates well with articular cartilage damage in patients with OA.

This pilot study was developed to compare the relative diagnostic accuracies of physical findings, magnetic resonance imaging (MRI) and arthroscopy for internal derangements in knee osteoarthritis (OA) patients. Nine patients with locking and/or giving way in 10 knees underwent MRI and arthroscopy; the relative diagnostic accuracies for meniscal tears were studied and compared with physical findings. Eleven meniscal and no cruciate ligament tears were noted by MRI and/ or arthroscopy. Using arthroscopy as the comparison standard, the sensitivity of MRI for meniscal tears was 33.3%, specificity was 96.6%, and diagnostic accuracy was 75.0%. No significant correlations between physical findings and MRI or arthroscopy findings were found. It seemed that participants with normal radiographs had false positive MRIs more frequently. These preliminary data suggest that physical findings may not be adequate for the diagnosis of meniscal tears in patients with associated knee OA. A larger study may be warranted to further test this hypothesis. Because the presence of a meniscal tear may change therapy toward specific physical therapy modalities and/or meniscal repair, knee OA patients with mechanical symptoms may require an MRI or arthroscopy to establish the presence of a meniscal tear. Further testing is required to confirm the suggestion from these cases that patients with normal or minimally abnormal radiographs may require a diagnostic arthroscopy rather than an MRI to demonstrate a meniscal tear.

Background The use of diagnostic and interventional ultrasound has significantly increased over the past decade. A majority of the increased utilisation is by non-radiologists. In sports medicine, ultrasound is often used to guide interventions such as aspirations, diagnostic or therapeutic injections, tenotomies, releases and hydrodissections. Objective Critically review the literature related to the accuracy, efficacy and cost-effectiveness of ultrasound-guided injections (USGIs) in major, intermediate and small joints; and soft tissues. Design Systematic review of the literature. Results USGIs are more accurate than landmark-guided injections (LMGIs; strength of recommendation taxonomy (SORT) Evidence Rating=A). USGIs are more efficacious than LMGIs (SORT Evidence Rating=B). USGIs are more cost-effective than LMGIs (SORT Evidence Rating=B). Ultrasound guidance is required to perform many new procedures (SORT Evidence Rating=C). Conclusions The findings of this position statement indicate there is strong evidence that USGIs are more accurate than LMGI, moderate evidence that they are more efficacious and preliminary evidence that they are more cost-effective. Furthermore, ultrasound-guided (USG) is required to perform many new, advanced procedures and will likely enable the development of innovative USG surgical techniques in the future.

Objective: To determine if visually-guided arthroscopic irrigation is an effective therapeutic intervention in patients with early knee osteoarthritis. Design: Ninety patients with knee osteoarthritis were randomized in a double-blind fashion to receive either arthroscopic irrigation with 3000 ml of saline (treatment group) or the minimal amount of irrigation (250 ml) required to perform arthroscopy (placebo group). The primary outcome variable was aggregate WOMAC score. Results: The study did not demonstrate an effect of irrigation on arthritis severity as measured by aggregate WOMAC scores, the primary outcome variable; the mean change in aggregate WOMAC score at 12 months was 15.5 (95% Cl 7.7, 23.4) for the full irrigation group compared to 8.9 (95% Cl 4.9, 13.0) for the minimal irrigation group (P=0.10). Full irrigation did have a statistically significant effect on patients' self-reported pain as measured by the WOMAC pain subscale and by a visual analog scale (VAS) (the secondary outcome variables). Mean change in WOMAC pain scores decreased by 4.2 (95% Cl -0.9, 9.4) for the full irrigation group compared with a mean decrease of 2.3 (95% Cl -0.1, 4.7) in the minimal irrigation group (P=0.04). Mean VAS pain scores decreased by 1.47 (95% Cl -1.2, 4.1) in the full irrigation group compared to a mean decrease of 0.12 (95% Cl 0.0, 0.3) in the minimal irrigation group (P=0.02). A hypothesis-generating post-hoc analysis of the effect of positively birefrigent intraarticular crystals showed that patients with and without intraarticular crystals had statistically significant improvements in pain assessments and aggregate WOMAC scores at 12 months; patients with crystals had statistically greater improvements in pain. Conclusions: Visually-guided arthroscopic irrigation may be a useful therapeutic option for relief of pain in a subset of patients with knee OA, particularly in those who have occult intraarticular crystals. (C) 2000 OsteoArthritis Research Society International.

The nature of the relation between osteoarthritis and the various forms of calcium crystals that are found within osteoarthritic joints continues to challenge and confound researchers. The most basic question is whether such crystals are directly relevant to the development of osteoarthritis, or are merely a byproduct or marker of the disease itself. The past year has produced several studies that elucidate important aspects of the molecular and cellular mechanisms of calcium pyrophosphate dihydrate and apatite crystal formation. Such studies may yield novel targets for therapeutic intervention in crystal-associated osteoarthritis. Other recent studies have provided further understanding of the mechanisms by which crystals induce inflammation. Arthroscopic assessment of patients with knee osteoarthritis refractory to traditional therapy suggests that the combined absence of chondrocalcinosis on plain films and identifiable crystals on compensated polarized light microscopy of synovial fluid from arthrocentesis may not be adequate to exclude clinically relevant crystalline deposition and inflammation. Clinical criteria are needed to identify patients with occult crystalline disease who, by virtue of crystal-induced inflammation, require more aggressive anti-inflammatory therapy than those with noninflammatory osteoarthritis.

AMSSM Research Abstracts (Clin J Sport Med 2004;14:310–311) Concussion Assessment in Football and Soccer Players Suzanne Hecht,* James C. Puffer,† Clifford Clinton,‡ Bassil Aish,§ Philip Cohen, Andrew Concoff,¶ Robert Hosey,# Alex Lai,* Joseph Luftman,** Henry Tsai* Daniel Vigil.** *UCLA Sports Medicine, Los Angeles, CA 90095, †American Board of Family Practice, Lexington, KY, ‡David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, §Huntington Beach, CA, Rutgers University Health Services, New Brunswick, NJ, ¶University of Texas—Houston, Houston, TX, #University of Kentucky, Lexington, KY, **Kaiser Permanente Sports Medicine, Los Angeles, CA. Purpose: This longitudinal study examined the reliability and clinical utility of the Standardized Assessment of Concussion (SAC) in football and soccer players over 4 years. Methods: The SAC is a brief sideline examination developed in accordance with the American Academy of Neurology and the Colorado Guidelines to evaluate neuropsychological changes following a concussion. Baseline SAC evaluations were administered to 691 athletes from 1997 to 2001 (198 NCAA Division 1 and 410 high school football players, and 83 NCAA Division 1 soccer players). The SAC was repeated on days 0, 1, 3, and 10 following concussion to the concussed player and a paired nonconcussed control player. Results: Reliability testing revealed intrarater and interrater reliability correlation coefficients equal to 0.74 and 0.60, respectively. Seventy-seven players suffered 87 concussions, with 99% of the concussions occurring in football players. The mean SAC score of concussed players was significantly decreased on day 0 compared to their mean baseline score (24.9 ± 3.9 vs. 27.0 ± 1.7; P < 0.0001) Nonconcussed control players’ mean SAC scores on day 0 significantly increased compared to their mean baseline SAC scores (26.9 ± 2.3 vs. 27.8 ± 1.8; P = 0.001). The mean difference of day 0 SAC scores in concussed players was significantly decreased as compared to their paired, nonconcussed controls. No significant difference was seen on day 1. On day 0, 29% of concussed players achieved a SAC score greater than their baseline score, and 100% of those players were symptomatic at the time of testing. Conclusions: The SAC is a reliable test. The clinical utility of the SAC is limited since 1/3 of players were able to improve their SAC score while still symptomatic from a concussion. Cumulative Effects of Concussion in High School and College Athletes Douglas B. McKeag,* Micky Collins,† Mark R. Lovell,† Corrine Ganglion.‡ *IU Sports Medicine, Indianapolis, IN, †UPMC Center for Sports Medicine, Pittsburgh, PA, ‡Sports Concussion Program, Pittsburgh, PA. Purpose: The potential cumulative effects of concussion are poorly understood. One prior study (Collins et al., JAMA. 1999;282:964–970) utilized traditional neuropsychological measures in college athletes and found deficits in speed of processing in those sustaining 2 or more prior concussions. With the recent advent of computerized neuropsychological testing, potential exists for large databases of pertinent information regarding concussion. Moreover, there is no current data examining the cumulative effects of concussion in high school athletes. The current study was designed to evaluate these issues in a very large sample of high school and college athletes. Methods: A total of 2553 high school and college athletes underwent preseason computerized neuropsychological testing utilizing ImPACT. Controlling for years of education, 3 groups were compared on their baseline ImPACT performance: those with no history of concussion (43%; n = 1098), those with 1 prior concussion (37%; n = 945), and those with 2 or more prior concussions (20%; n = 510). Results: Multivariate analysis of covariance revealed significant differences between the three groups across processing speed (PS) and reaction time (RT) composite scores (F = 4.18; P < 0.002). There was a significant decrease in processing speed and increase in reaction time (both worse performances) in the 1 (PS, mean = 35.8; RT, mean = .579) and 2 or more (PS, mean = 35.0; RT, mean = .587) concussion groups when compared to those sustaining no prior concussions (PS, mean = 36.1; RT, mean = .568). Conclusions: The cumulative effects of concussion appear to involve a decrease in mental processing speed and increase in reaction time. These data derived from ImPACT are consistent with previous data utilizing paper and pencil measures. The current analysis is the first to suggest cumulative effects of concussion in high school athletes. The Neuropsychological Consequences of Participation in an Amateur Boxing Tournament James Moriarity,* Alexander Collia,†‡ David Olson,§ John Buchanan, Patrick Leary,* Michael McStephen,† Paul McCrory.‡ *University of Notre Dame, Notre Dame, IN, †CogState Ltd., Melbourne, Victoria, Australia, ‡University of Melbourne, Parkville, Victoria, Australia, §Wauwatosa, WI, Mercy Walworth Medical Center, Lake Geneva, WI. Context: Participation in professional boxing has been demonstrated to cause chronic cognitive injury. Few studies have reported the acute cognitive function in amateur boxers postbout and none have documented the effects of repeated boxing bouts within a short time frame. Objective: To determine whether repeated concussive and subconcussive head trauma sustained by amateur boxers during a 7-day tournament causes an acute deterioration in cognitive performance. Study Design: Prospective study of 82 collegiate amateur boxers with no history of recent concussion or past history of brain injury who participated in a 7-day single-elimination boxing tournament. Neuropsychological assessment using the CogSport computerized test battery was performed at baseline and after each bout. Main Outcome Measure: Change in postbout neuropsychological performance when compared to the boxer’s own baseline performance. The cognitive tests administered in this study are simple reaction time, complex reaction time, 1-back, and continuous learning. These tasks measure psychomotor function/information processing, decision-making, working memory, and new learning, respectively. Results: The 82 study subjects fought a total of 159 times. CogSport testing was performed in 142 of the possible 159 postbout opportunities for testing. The postbout neuropsychological performance of boxers participating in 3 bouts was equivalent to that of boxers participating in 1 bout or 2 bouts. No significant changes from baseline performance were observed in any individual boxers, including those receiving standing 8 counts or for whom the referee stopped the contest. Conclusions: Amateur boxing conducted in a supervised competition does not result in acute cognitive impairment, even in boxers subjected to repeated bouts over a short time frame. CHAMPS: Characteristics of Athletic Medical Providers Study: A National Look at Sports Medicine Within Primary Care 2002 Christy Tharenos, Dan Vinson. University of Missouri–Columbia, Columbia