Publications by authors named "Joshua J Stefanik"

29 Publications

  • Page 1 of 1

Relationship of Patellofemoral Osteoarthritis to Changes in Performance-based Physical Function Over 7 Years: The Multicenter Osteoarthritis Study.

J Rheumatol 2021 Sep 1. Epub 2021 Sep 1.

The Multicenter Osteoarthritis Study was funded by the National Institutes of Health (NIH)/ National Institute on Aging UO1 AG18820, UO1 AG18832, UO1 AG18947, and UO1 AG19069. HFH is funded by a Canadian Institutes of Health Research Fellowship. JJS is supported by NIH/ NIAMS K23 AR070913. TN was supported by NIH/ National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) K24AR070892. This work was also supported by NIH/NIAMS P30AR072571. Funding sources had no role in the study design, collection, analysis, and interpretation of the data or the decision to submit the manuscript for publication. H.F. Hart, PhD, Faculty of Health Sciences and Bone and Joint Institute, Western University, London, Ontario, Canada; T. Neogi, MD, PhD, Division of Rheumatology, Boston University School of Medicine, Boston, Massachusetts, USA; M. LaValley, PhD, Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA; D. White, PT, PhD, Department of Physical Therapy, University of Delaware, Newark, Delaware, USA; Y. Zhang, DSc, Department of Rheumatology, Massachusetts General Hospital, Boston, Massachusetts, USA; M.C. Nevitt, PhD, MPH, Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA; J. Torner, PhD, Department of Epidemiology, The University of Iowa, Iowa City, Iowa, USA; C.E. Lewis, MD, MSPH, Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA; J.J. Stefanik, PT, PhD, Division of Rheumatology, Boston University School of Medicine, and Department of Physical Therapy, Movement, and Rehabilitation Sciences, Northeastern University, Boston, Massachusetts, USA. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. J.J. Stefanik, Department of Physical Therapy, Movement, and Rehabilitation Sciences, Northeastern University, Boston, MA 02115, USA. Email: Accepted for publication August 18, 2021.

Objective: To determine the relationship of patellofemoral osteoarthritis (PFOA) to changes in performance- based function over 7 years.

Methods: There were 2666 participants (62.2 ± 8.0 yrs, BMI 30.6 ± 5.9 kg/m, 60% female) from the Multicenter Osteoarthritis Study with knee radiographs at baseline who completed repeated chair stands and a 20-meter walk test (20MWT) at baseline, 2.5, 5, and 7 years. Generalized linear models assessed the relation of radiographic PFOA and radiographic PFOA with frequent knee pain to longitudinal changes in performance-based function. Analyses were adjusted for age, sex, BMI, tibiofemoral OA, and injury/surgery.

Results: Linear models demonstrated a significant group-by-time interaction for the repeated chair stands ( = 0.04) and the 20MWT ( < 0.0001). Those with radiographic PFOA took 1.01 seconds longer on the repeated chair stands ( = 0.02) and 1.69 seconds longer on the 20MWT ( < 0.0001) at 7 years compared with baseline. When examining the relation of radiographic PFOA with frequent knee pain to performance-based function, there was a significant group-by-time interaction for repeated chair stands ( = 0.05) and the 20MWT ( < 0.0001). Those with radiographic PFOA with frequent knee pain increased their time on the repeated chair stands by 1.12 seconds ( = 0.04) and on the 20MWT by 1.91 seconds ( < 0.0001) over 7 years.

Conclusion: Individuals with radiographic PFOA and those with radiographic PFOA with frequent knee pain have worsening of performance-based function over time. This knowledge may present opportunities to plan for early treatment strategies for PFOA to limit functional decline over time.
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http://dx.doi.org/10.3899/jrheum.210270DOI Listing
September 2021

Can MRI-defined osteoarthritis features explain anterior knee pain in individuals with, or at risk for, knee osteoarthritis? The MOST Study.

Arthritis Care Res (Hoboken) 2021 Mar 25. Epub 2021 Mar 25.

University of Delaware, (Department of Physical Therapy), Newark, USA.

Objective: The lack of strong association between knee osteoarthritis (OA) structural features and pain continues to perplex researchers and clinicians. Evaluating the patellofemoral joint in addition to the tibiofemoral joint alone has contributed to explaining this structure-pain discordance, hence justifying a more comprehensive evaluation of whole-knee OA and pain. We therefore evaluated the association between patellofemoral and tibiofemoral OA features with localized anterior knee pain (AKP) using two study designs.

Methods: Using cross-sectional data from the Multicenter Osteoarthritis Study, our first approach was a within-person, knee-matched design in which we identified participants with unilateral AKP. We then assessed MRI-derived OA features (cartilage damage, bone marrow lesions [BMLs], osteophytes, and inflammation) in both knees, and evaluated the association of patellofemoral and tibiofemoral OA features to unilateral AKP. In our second approach, MRIs from one knee per person were scored, and we evaluated the association of OA-features to AKP in participants with AKP and participants with no frequent knee pain.

Results: Using the first approach (n=71, 66% women, mean age 69 [SD 8] years), lateral patellofemoral osteophytes (odds ratio 5.0 [95% CI 1.7, 14.6]), whole-knee joint effusion-synovitis (4.7 [1.3, 16.2]), and infrapatellar synovitis (2.8 [1.0, 7.8]) were associated with AKP. Using the second approach (n=882, 59% women, mean age 69 [SD 7] years), lateral and medial patellofemoral cartilage damage (prevalence ratio 2.3 [1.3, 4.0] and 1.9 [1.1, 3.3]), and lateral patellofemoral BMLs (2.6 [1.5, 4.7]) were associated with AKP.

Conclusion: Patellofemoral but not tibiofemoral joint OA features, and inflammation were associated with AKP.
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http://dx.doi.org/10.1002/acr.24604DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8463633PMC
March 2021

The Branching and Innervation Pattern of the Radial Nerve in the Forearm: Clarifying the Literature and Understanding Variations and Their Clinical Implications.

Diagnostics (Basel) 2020 Jun 2;10(6). Epub 2020 Jun 2.

Department of Medical Education, Tufts University School of Medicine, Boston, MA 02111, USA.

Background: This study attempted to clarify the innervation pattern of the muscles of the distal arm and posterior forearm through cadaveric dissection.

Methods: Thirty-five cadavers were dissected to expose the radial nerve in the forearm. Each muscular branch of the nerve was identified and their length and distance along the nerve were recorded. These values were used to determine the typical branching and motor entry orders.

Results: The typical branching order was brachialis, brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis, supinator, extensor digitorum, extensor carpi ulnaris, abductor pollicis longus, extensor digiti minimi, extensor pollicis brevis, extensor pollicis longus and extensor indicis. Notably, the radial nerve often innervated brachialis (60%), and its superficial branch often innervated extensor carpi radialis brevis (25.7%).

Conclusions: The radial nerve exhibits significant variability in the posterior forearm. However, there is enough consistency to identify an archetypal pattern and order of innervation. These findings may also need to be considered when planning surgical approaches to the distal arm, elbow and proximal forearm to prevent an undue loss of motor function. The review of the literature yielded multiple studies employing inconsistent metrics and terminology to define order or innervation.
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http://dx.doi.org/10.3390/diagnostics10060366DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7345276PMC
June 2020

Psychological and Pain Sensitization Characteristics Are Associated With Patellofemoral Osteoarthritis Symptoms: The Multicenter Osteoarthritis Study.

J Rheumatol 2020 11 1;47(11):1696-1703. Epub 2020 Mar 1.

J.J. Stefanik, PT, PhD, Department of Physical Therapy, Movement and Rehabilitation Sciences, Northeastern University, Boston, Massachusetts, USA.

Objective: Determine the relation of symptomatic and structural features of patellofemoral osteoarthritis (PFOA) to psychological characteristics and measures of pain sensitization, in older adults with or at risk of knee osteoarthritis (OA).

Methods: This study included 1112 participants from the Multicenter Osteoarthritis Study (713 females, mean age 66.8 ± SD 7.6 yrs, body mass index 29.5 ± 4.8 kg/m). Participants were grouped based on the presence of PFOA symptoms (anterior knee pain and pain on stairs) and magnetic resonance imaging (MRI) PFOA (full-thickness cartilage lesion with bone marrow lesion): (1) patellofemoral (PF) symptoms with MRI PFOA; (2) PF symptoms without MRI PFOA; (3) MRI PFOA without PF symptoms; and (4) no PF symptoms or MRI PFOA (no PFOA). Relation of PFOA classification to depressive symptoms, catastrophizing, temporal summation (TS) and pressure pain thresholds (PPT) was evaluated using logistic (categorical variables) and linear regression (continuous variables).

Results: Compared with no PFOA, those with PF symptoms with or without MRI PFOA had significantly greater odds of depressive symptoms, catastrophizing, and patellar TS (OR range 1.5-2.01), and those with PF symptoms without MRI PFOA had significantly greater odds of wrist TS (OR 1.66). Males with PF symptoms without MRI PFOA had significantly lower pressure PPT at the patella compared with no PFOA and those with MRI PFOA only (no symptoms). There were no significant differences at the wrist for males, or the patella or wrist for females.

Conclusion: Persons with PFOA symptoms, regardless of MRI PFOA status, are more likely to demonstrate depressive symptoms, catastrophizing, and TS. Males with PFOA symptoms without MRI PFOA demonstrate local hyperalgesia.
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http://dx.doi.org/10.3899/jrheum.190981DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8005266PMC
November 2020

Using Cumulative Load to Explain How Body Mass Index and Daily Walking Relate to Worsening Knee Cartilage Damage Over Two Years: The MOST Study.

Arthritis Rheumatol 2020 06 2;72(6):957-965. Epub 2020 May 2.

University of Delaware, Newark.

Objective: Knee cartilage damage is often linked to mechanical overloading. However, cartilage requires mechanical load to remain healthy, suggesting that underloading may be detrimental. This study was undertaken to examine knee overloading and underloading by defining cumulative load as the joint effects of body mass index (BMI) and daily walking, and examine the relationship between cumulative load and worsening cartilage damage over 2 years.

Methods: We used data from the Multicenter Osteoarthritis Study. Steps/day, measured by accelerometry, and BMI were calculated at the 60-month visit. Cartilage damage on magnetic resonance imaging was semiquantitatively scored using the Whole-Organ Magnetic Resonance Imaging Score (WORMS) at the 60-month and 84-month visits; worsening damage was defined as increased WORMS between visits. Risk ratios (RRs) and 95% confidence intervals (95% CIs) were calculated using binomial regression, with adjustment for potential confounders.

Results: Our study included 964 participants, 62% of whom were female, with a mean ± SD age of 66.9 ± 7.5 years. Participants had a mean ± SD BMI of 29.7 ± 4.8 kg/m and walked a mean ± SD of 7,153 ± 2,591 steps/day. Participants who walked a moderate number of steps/day (6,000-7,900) or a high number of steps/day (>7,900) and had a high BMI (>31 kg/m ) had a greater risk of worsening medial tibiofemoral (TF) damage (RR 2.83 [95% CI 1.46-5.48] and RR 2.61 [95% CI 1.50-4.54], respectively) compared with those who walked similar steps/day and had a low BMI (18-27 kg/m ). Participants with a low number of steps/day (<6,000) and a low BMI had a greater risk of worsening medial TF and lateral patellofemoral (PF) damage (RR 2.03 [95% CI 1.06-3.92] and RR 2.28 [95% CI 1.06-4.85], respectively) compared with those who walked a high number of steps/day and had a low BMI. Effect estimates for other compartments of the knee did not reach statistical significance.

Conclusion: This study provides preliminary evidence that both overloading and underloading may be detrimental to medial TF cartilage, and underloading may be detrimental to lateral PF cartilage.
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http://dx.doi.org/10.1002/art.41181DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8020569PMC
June 2020

Slower Walking Speed Is Related to Early Femoral Trochlear Cartilage Degradation After ACL Reconstruction.

J Orthop Res 2020 03 18;38(3):645-652. Epub 2019 Nov 18.

Department of Mechanical Engineering, University of Delaware, Newark, Delaware.

Post-traumatic patellofemoral osteoarthritis (OA) is prevalent after anterior cruciate ligament reconstruction (ACLR) and early cartilage degradation may be especially common in the femoral trochlear cartilage. Determining the presence of and factors associated with early femoral trochlear cartilage degradation, a precursor to OA, is a critical preliminary step in identifying those at risk for patellofemoral OA development and designing interventions to combat the disease. Early cartilage degradation can be detected using quantitative magnetic resonance imaging measures, such as tissue T relaxation time. The purposes of this study were to (i) compare involved (ACLR) versus uninvolved (contralateral) femoral trochlear cartilage T relaxation times 6 months after ACLR, and (ii) determine the relationship between walking speed and walking mechanics 3 months after ACLR and femoral trochlear cartilage T relaxation times 6 months after ACLR. Twenty-six individuals (age 23 ± 7 years) after primary, unilateral ACLR participated in detailed motion analyses 3.3 ± 0.6 months after ACLR and quantitative magnetic resonance imaging 6.3 ± 0.5 months after ACLR. There were no limb differences in femoral trochlear cartilage T relaxation times. Slower walking speed was related to higher (worse) femoral trochlear cartilage T relaxation times in the involved limb (Pearson's r: -0.583, p = 0.002) and greater interlimb differences in trochlear T relaxation times (Pearson's r: -0.349, p = 0.080). Walking mechanics were weakly related to trochlear T relaxation times. Statement of clinical significance: Slower walking speed was by far the strongest predictor of worse femoral trochlear cartilage health, suggesting slow walking speed may be an early clinical indicator of future patellofemoral OA after ACLR. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:645-652, 2020.
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http://dx.doi.org/10.1002/jor.24503DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7028512PMC
March 2020

Obesity is related to incidence of patellofemoral osteoarthritis: the Cohort Hip and Cohort Knee (CHECK) study.

Rheumatol Int 2020 Feb 8;40(2):227-232. Epub 2019 Nov 8.

Erasmus MC, University Medical Center, Rotterdam, The Netherlands.

To determine the longitudinal association of baseline body mass index and change in body mass index over 8 years to incident of patellofemoral osteoarthritis at the 8-year follow-up. A sample of 528 women and men, aged 45-65 years, with knee complaints and without radiographic evidence of patellofemoral and tibiofemoral osteoarthritis at baseline, were selected from the Cohort Hip and Cohort Knee cohort. Incidence of patellofemoral osteoarthritis was defined as presence of radiographic patellofemoral osteoarthritis (with or without tibiofemoral osteoarthritis) at the 8-year follow-up. Baseline body mass index data were categorized into normal, overweight, and obese weight-categories. Logistic regression analyses, adjusted for age and sex, were conducted to determine the association of baseline body mass index and change in body mass index to patellofemoral osteoarthritis incidence 8 years later. Obesity was associated with greater odds of radiographic patellofemoral osteoarthritis incident (odds ratio: 1.8 [95% CI 1.1, 3.1]) 8 years later. There were no significant associations observed between body mass index change over 8 years and incidence of radiographic patellofemoral osteoarthritis in overweight and obese individuals. Obesity is associated with increased odds of developing radiographic patellofemoral osteoarthritis 8 years later.
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http://dx.doi.org/10.1007/s00296-019-04472-9DOI Listing
February 2020

Mediating Role of Bone Marrow Lesions, Synovitis, Pain Sensitization, and Depressive Symptoms on Knee Pain Improvement Following Substantial Weight Loss.

Arthritis Rheumatol 2020 03 22;72(3):420-427. Epub 2020 Jan 22.

Boston University School of Medicine, Boston, Massachusetts, and University of Manchester, NIHR Manchester Biomedical Research Centre, and Manchester University NHS Foundation Trust, Manchester, UK.

Objective: Massive weight loss leads to marked knee pain reduction in individuals with knee pain, but the reason for the reduction in pain is unknown. This study was undertaken to quantify the contribution of magnetic resonance imaging (MRI)-evidenced changes in pain-sensitive structures, bone marrow lesions (BMLs), and synovitis, and changes in pain sensitization or depressive symptoms, to knee pain improvement after substantial weight loss.

Methods: Morbidly obese patients with knee pain on most days were evaluated before bariatric surgery or medical weight management and at 1-year follow-up for BMLs and synovitis seen on MRI, the pressure pain threshold (PPT) at the patella and the right wrist, depressive symptoms (using the Center for Epidemiologic Studies Depression scale [CES-D]), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain survey. Natural-effects models were used to quantify the extent that achieving a minimum clinically important difference (MCID) of ≥18% on the WOMAC pain scale could be mediated by weight loss-induced changes in BMLs, synovitis, PPT, and depressive symptoms.

Results: Of 75 participants, 53.3% lost ≥20% of weight by 1 year. Of these, 75% attained the MCID for pain improvement, compared with 34.3% in those who had <20% weight loss. Mediation analyses suggested that, in those with at least 20% weight loss, the odds of pain improvement increased by 62%, 15%, and 22% through changes in patella PPT, wrist PPT, and CES-D, respectively, but pain improvement was not mediated by MRI changes in BMLs or synovitis.

Conclusion: Weight loss-induced knee pain improvement is partially mediated by changes in pain sensitization and depressive symptoms but is independent of MRI changes in BMLs and synovitis.
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http://dx.doi.org/10.1002/art.41125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7050338PMC
March 2020

Relation of Patellofemoral Joint Alignment, Morphology, and Radiographic Osteoarthritis to Frequent Anterior Knee Pain: Data from the Multicenter Osteoarthritis Study.

Arthritis Care Res (Hoboken) 2020 08 3;72(8):1066-1073. Epub 2020 Jul 3.

University of Delaware, Newark, and School of Medicine, Boston University and Northeastern University, Boston, Massachusetts.

Objective: Patellofemoral (PF) alignment and trochlear morphology are associated with PF osteoarthritis (OA) and knee pain, but whether they are associated with localized anterior knee pain is unknown, which is believed to be a symptom specific to PF joint pathology. We therefore aimed to evaluate the relation of PF alignment and morphology, as well as PFOA and tibiofemoral OA, to anterior knee pain.

Methods: The Multicenter Osteoarthritis Study is a cohort study of individuals with, or at risk for, knee OA. We evaluated cross-sectional associations of PF alignment, trochlear morphology, and PF and tibiofemoral radiographic OA, with localized anterior knee pain (defined with a pain map). We used 2 approaches: a within-person knee-matched evaluation of participants with unilateral anterior knee pain (conditional logistic regression), and a cohort approach comparing those with anterior knee pain to those without (binomial regression).

Results: With the within-person knee-matched approach (n = 110; 64% women, mean age 70 years, body mass index [BMI] 30.9), PF alignment, morphology, and tibiofemoral OA were not associated with unilateral anterior knee pain. Radiographic PFOA was associated with pain, odds ratio 5.3 (95% confidence interval [95% CI] 1.6-18.3). Using the cohort approach (n = 1,818; 7% of knees with anterior knee pain, 59% women, mean age 68 years, BMI 30.4), results were similar: only PFOA was associated with pain, with a prevalence ratio of 2.2 (95% CI 1.4-3.4).

Conclusion: PF alignment and trochlear morphology were not associated with anterior knee pain in individuals with, or at risk for, knee OA. Radiographic PFOA, however, was associated with pain, suggesting that features of OA, more so than mechanical features, may contribute to localized symptoms.
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http://dx.doi.org/10.1002/acr.24004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6911012PMC
August 2020

Step Rate and Worsening of Patellofemoral and Tibiofemoral Joint Osteoarthritis in Women and Men: The Multicenter Osteoarthritis Study.

Arthritis Care Res (Hoboken) 2020 01;72(1):107-113

Boston University and Northeastern University, Boston, Massachusetts.

Objective: To determine the association of self-selected walking step rate with worsening of cartilage damage in the patellofemoral (PF) joint and tibiofemoral (TF) joint compartments at a 2-year follow-up visit.

Methods: The Multicenter Osteoarthritis Study (MOST) is a prospective cohort of men and women with or at risk of knee osteoarthritis. Self-selected step rate was measured using an instrumented GAITRite walkway (CIR Systems) at the 60-month visit. Cartilage damage was semiquantitatively graded on magnetic resonance images at the 60- and 84-month visits in the medial and lateral PF and TF compartments. Step rate was divided into quartiles, and logistic regression was used to determine the association of step rate with the risk of worsening cartilage damage in men and women separately. Analyses were adjusted for age, body mass index, and knee injury/surgery.

Results: A total of 1,089 participants were included. Mean ± SD age was 66.9 ± 7.5 years, mean ± SD body mass index was 29.6 ± 4.7 kg/m , and 62.3% of the participants were women. Women with the lowest step rate had increased risk of lateral PF (risk ratio [RR] 2.1 [95% confidence interval (95% CI) 1.1-3.8]) and TF (RR 1.8 [95% CI 1.1-2.9]) cartilage damage worsening 2 years later compared to those with the highest step rate. Men with the lowest step rate had increased risk of medial TF cartilage damage worsening 2 years later (RR 2.1 [95% CI 1.1-3.9]).

Conclusion: Lower step rate was associated with increased risk of cartilage damage worsening in the lateral PF and TF compartments in women and worsening medial TF joint damage in men. Future research is necessary to understand the influence of step rate manipulation on joint biomechanics in women and men.
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http://dx.doi.org/10.1002/acr.23864DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6717684PMC
January 2020

The Spectrum of Learning and Teaching: The Impact of a Fourth-Year Anatomy Course on Medical Student Knowledge and Confidence.

Anat Sci Educ 2020 Jan 11;13(1):19-29. Epub 2019 Mar 11.

Department of Physical Therapy, Northeastern University, Boston, Massachusetts.

There is growing demand from accrediting agencies for improved basic science integration into fourth-year medical curricula and inculcation of medical students with teaching skills. The objective of this study was to determine the effectiveness of a fourth-year medical school elective course focused on teaching gross anatomy on anatomical knowledge and teaching confidence. Fourth-year medical student "teacher" participants' gross anatomy knowledge was assessed before and after the course. Students rated their overall perceived anatomy knowledge and teaching skills on a scale from 0 (worst) to 10 (best), and responded to specific knowledge and teaching confidence items using a similar scale. First-year students were surveyed to evaluate the effectiveness of the fourth-year student teaching on their learning. Thirty-two students completed the course. The mean anatomy knowledge pretest score and posttest scores were 43.2 (±22.1) and 74.1 (±18.4), respectively (P < 0.001). The mean perceived anatomy knowledge ratings before and after the course were 6.19 (±1.84) and 7.84 (±1.30), respectively (P < 0.0001) and mean perceived teaching skills ratings before and after the course were 7.94 (±1.24) and 8.53 (±0.95), respectively (P = 0.002). Student feedback highlighted five themes which impacted fourth-year teaching assistant effectiveness, including social/cognitive congruence and improved access to learning opportunities. Together these results suggest that integrating fourth-year medical students in anatomy teaching increases their anatomical knowledge and improves measures of perceived confidence in both teaching and anatomy knowledge. The thematic analysis revealed that this initiative has positive benefits for first-year students.
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http://dx.doi.org/10.1002/ase.1872DOI Listing
January 2020

Patient-Reported Outcomes One to Five Years After Anterior Cruciate Ligament Reconstruction: The Effect of Combined Injury and Associations With Osteoarthritis Features Defined on Magnetic Resonance Imaging.

Arthritis Care Res (Hoboken) 2020 03;72(3):412-422

La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia.

Objective: Persistent symptoms and poor quality of life (QoL) are common following anterior cruciate ligament reconstruction (ACLR). We aimed to determine the influence of a combined ACL injury (i.e., concomitant meniscectomy and/or arthroscopic chondral defect at the time of ACLR and/or secondary injury/surgery to ACLR knee) and cartilage defects defined on magnetic resonance imaging (MRI), bone marrow lesions (BMLs), and meniscal lesions on patient-reported outcomes 1 to 5 years after ACLR.

Methods: A total of 80 participants (50 men; mean ± SD age 32 ± 14 years) completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee (IKDC) questionnaires as well as a 3T MRI assessment at 1 and 5 years after ACLR. Median patient-reported outcome scores were compared between isolated and combined ACL injuries and with published normative values. Using multivariate regression, we evaluated the association between compartment-specific MRI cartilage, BMLs, and meniscal lesions and patient-reported outcomes at 1 and 5 years.

Results: Individuals with a combined injury had significantly worse scores in the KOOS subscale of function in sport and recreation (KOOS sport/rec) and in the IKDC questionnaire at 1 year, and worse scores in the KOOS subscales of pain (KOOS pain), symptoms (KOOS symptoms), and QoL (KOOS QoL) and in the IKDC questionnaire at 5 years compared to those with an isolated injury. Although no feature on MRI was associated with patient-reported outcomes cross-sectionally at 1 year, patellofemoral cartilage defects at 1 year were significantly associated with worse 5-year KOOS symptoms (β = -9.79, 95% confidence interval [95% CI] -16.67, -2.91), KOOS sport/rec (β = -7.94, 95% CI -15.27, -0.61), KOOS QoL (β = -8.29, 95% CI -15.28, -1.29), and IKDC (β = -4.79, 95% CI -9.34, -0.24) scores. Patellofemoral cartilage defects at 5 years were also significantly associated with worse 5-year KOOS symptoms (β = -6.86, 95% CI -13.49, -0.24) and KOOS QoL (β = -11.71, 95% CI -19.08, -4.33) scores.

Conclusion: Combined injury and patellofemoral cartilage defects shown on MRI are associated with poorer long-term outcomes. Clinicians should be vigilant and aware of individuals with these injuries, as such individuals may benefit from targeted interventions to improve QoL and optimize symptoms.
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http://dx.doi.org/10.1002/acr.23854DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6693993PMC
March 2020

Sex-Specific Influence of Quadriceps Weakness on Worsening Patellofemoral and Tibiofemoral Cartilage Damage: A Prospective Cohort Study.

Arthritis Care Res (Hoboken) 2019 10 5;71(10):1360-1365. Epub 2019 Sep 5.

Boston University School of Medicine, Boston, Massachusetts, and University of Delaware, Newark.

Objective: Reports on quadriceps weakness as a risk factor for incident and progressive knee osteoarthritis are conflicting, potentially due to differing effects of muscle strength on patellofemoral and tibiofemoral compartments. This study aimed to examine the sex-specific relation of quadriceps strength to worsening patellofemoral and tibiofemoral cartilage damage over 84 months.

Methods: The Multicenter Osteoarthritis Study is a cohort study of individuals with or at risk for knee osteoarthritis. Maximal quadriceps strength was assessed at baseline. Cartilage damage was semiquantitatively assessed by magnetic resonance imaging at baseline and 84-month follow-up using the Whole-Organ Magnetic Resonance Imaging Score (WORMS). Worsening patellofemoral and tibiofemoral cartilage damage was defined as any WORMS score increase in each subregion within medial and lateral compartments separately. Logistic regression with generalized estimating equations was used to assess the sex-specific relation of quadriceps strength to worsening cartilage damage.

Results: A total of 1,018 participants (mean ± SD age 61 ± 8 years, and mean ± SD body mass index 29.3 ± 4.5 kg/m ; 64% female) were included. Quadriceps weakness increased the risk of worsening lateral patellofemoral cartilage damage in women (risk ratio for lowest versus highest quartile of strength 1.50 [95% confidence interval 1.03-2.20]; P = 0.007 for linear trend) but not in men. There was generally no association between quadriceps weakness and worsening cartilage damage in the medial or lateral tibiofemoral compartment for either women or men.

Conclusion: Low quadriceps strength increased the risk of worsening cartilage damage in the lateral patellofemoral joint of women, suggesting that optimizing quadriceps strength may help prevent worsening of structural damage in the patellofemoral joint in women.
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http://dx.doi.org/10.1002/acr.23773DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6453735PMC
October 2019

Worsening Knee Osteoarthritis Features on Magnetic Resonance Imaging 1 to 5 Years After Anterior Cruciate Ligament Reconstruction.

Am J Sports Med 2018 10 4;46(12):2873-2883. Epub 2018 Sep 4.

La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, La Trobe University, Melbourne, Victoria, Australia.

Background: An anterior cruciate ligament (ACL) injury is a well-established risk factor for the long-term development of radiographic osteoarthritis (OA). However, little is known about the early degenerative changes (ie, <5 years after injury) of individual joint features (ie, cartilage, bone marrow), which may be reversible and responsive to interventions.

Purpose: To describe early degenerative changes between 1 and 5 years after ACL reconstruction (ACLR) on magnetic resonance imaging (MRI) and explore participant characteristics associated with these changes.

Study Design: Case-control study; Level of evidence, 3.

Methods: Seventy-eight participants (48 men; median age, 32 years; median body mass index [BMI], 26 kg/m) underwent 3.0-T MRI at 1 and 5 years after primary hamstring autograft ACLR. Early tibiofemoral and patellofemoral OA features were assessed with the MRI Osteoarthritis Knee Score. The primary outcome was worsening (ie, incident or progressive) cartilage defects, bone marrow lesions (BMLs), osteophytes, and meniscal lesions. Logistic regression with generalized estimating equations evaluated participant characteristics associated with worsening features.

Results: Worsening of cartilage defects in any compartment occurred in 40 (51%) participants. Specifically, worsening in the patellofemoral and medial and lateral tibiofemoral compartments was present in 34 (44%), 8 (10%), and 10 (13%) participants, respectively. Worsening patellofemoral and medial and lateral tibiofemoral BMLs (14 [18%], 5 [6%], and 10 [13%], respectively) and osteophytes (7 [9%], 8 [10%], and 6 [8%], respectively) were less prevalent, while 17 (22%) displayed deteriorating meniscal lesions. Worsening of at least 1 MRI-detected OA feature, in either the patellofemoral or tibiofemoral compartment, occurred in 53 (68%) participants. Radiographic OA in any compartment was evident in 5 (6%) and 16 (21%) participants at 1 and 5 years, respectively. A high BMI (>25 kg/m) was consistently associated with elevated odds (between 2- and 5-fold) of worsening patellofemoral and tibiofemoral OA features.

Conclusion: High rates of degenerative changes occur in the first 5 years after ACLR, particularly the development and progression of patellofemoral cartilage defects. Older patients with a higher BMI may be at particular risk and should be educated about this risk.
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http://dx.doi.org/10.1177/0363546518789685DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6379915PMC
October 2018

Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis.

Br J Sports Med 2019 Oct 9;53(20):1268-1278. Epub 2018 Jun 9.

La Trobe Sports and Exercise Medicine Research Centre, School of Allied Health, La Trobe University, Bundoora, Victoria, Australia.

Background: Knee MRI is increasingly used to inform clinical management. Features associated with osteoarthritis are often present in asymptomatic uninjured knees; however, the estimated prevalence varies substantially between studies. We performed a systematic review with meta-analysis to provide summary estimates of the prevalence of MRI features of osteoarthritis in asymptomatic uninjured knees.

Methods: We searched six electronic databases for studies reporting MRI osteoarthritis feature prevalence (ie, cartilage defects, meniscal tears, bone marrow lesions and osteophytes) in asymptomatic uninjured knees. Summary estimates were calculated using random-effects meta-analysis (and stratified by mean age: <40 vs ≥40 years). Meta-regression explored heterogeneity.

Results: We included 63 studies (5397 knees of 4751 adults). The overall pooled prevalence of cartilage defects was 24% (95% CI 15% to 34%) and meniscal tears was 10% (7% to 13%), with significantly higher prevalence with age: cartilage defect <40 years 11% (6%to 17%) and ≥40 years 43% (29% to 57%); meniscal tear <40 years 4% (2% to 7%) and ≥40 years 19% (13% to 26%). The overall pooled estimate of bone marrow lesions and osteophytes was 18% (12% to 24%) and 25% (14% to 38%), respectively, with prevalence of osteophytes (but not bone marrow lesions) increasing with age. Significant associations were found between prevalence estimates and MRI sequences used, physical activity, radiographic osteoarthritis and risk of bias.

Conclusions: Summary estimates of MRI osteoarthritis feature prevalence among asymptomatic uninjured knees were 4%-14% in adults aged <40 years to 19%-43% in adults ≥40 years. These imaging findings should be interpreted in the context of clinical presentations and considered in clinical decision-making.
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http://dx.doi.org/10.1136/bjsports-2018-099257DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6837253PMC
October 2019

Changes in Pain Sensitization After Bariatric Surgery.

Arthritis Care Res (Hoboken) 2018 10;70(10):1525-1528

Boston University School of Medicine, Boston, Massachusetts.

Objective: To evaluate changes in pain (at the knee and elsewhere) and pain sensitization in obese subjects with knee pain who were having bariatric surgery compared with similarly obese individuals who were undergoing medical management.

Methods: This study included a cohort of subjects who were having bariatric surgery and those undergoing medical management. Knee pain severity of the more painful knee (index knee) was assessed at baseline and at 12 months using the Western Ontario and McMaster Universities Osteoarthritis Index. The pressure pain threshold (PPT) was evaluated at the index patella and the right wrist. Low patella PPT may reflect peripheral and/or central sensitization, and low wrist PPT may reflect central sensitization. The mean change in measures of pain and pain sensitization was analyzed in the surgery and medical management groups separately.

Results: A total of 45 subjects in the surgery group and 22 in the medical management group completed baseline and follow-up visits. The mean weight loss was 32.7 kg (29.0%) and 4.6 kg (4.1%) in the surgery and medical management groups, respectively. Knee pain decreased only in the surgery group, in which the PPT at the patella improved by 38.5% (P = 0.0007) and at the wrist by 30.9% (P = 0.005). There was no significant change in PPT in the medical management group.

Conclusion: Persons who underwent bariatric surgery experienced an improvement in pain sensitization, reflected by improvements in PPT. This improvement was observed not only at the patella, but also at the wrist, suggesting that central sensitization improved after bariatric surgery.
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http://dx.doi.org/10.1002/acr.23513DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6033694PMC
October 2018

International patellofemoral osteoarthritis consortium: Consensus statement on the diagnosis, burden, outcome measures, prognosis, risk factors and treatment.

Semin Arthritis Rheum 2018 04 23;47(5):666-675. Epub 2017 Sep 23.

Department of General Practice, Erasmus MC University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands; Department of Orthopaedic Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands.

Objective: To present the current status of knowledge in the field of patellofemoral (PF) osteoarthritis (OA) and formulate a research agenda in order to guide future research on this topic.

Design: A 1-day meeting was organized with the aim to bring together international experts in the field to discuss the current state of knowledge on PF OA. Experts from multiple disciplines were invited based on their scientific publications in the field of PF OA and interest in the subject. Topics discussed include the diagnosis, impact, prognosis, and treatment of PF OA.

Methods: Following context-setting presentations, an interactive discussion was held in order to achieve consensus on the PF OA topics of interest: (1) diagnosis and definition; (2) burden; (3) outcome measures; (4) prognosis; (5) risk factors, and (6) treatment. Groups of meeting attendees reviewed the literature on these topics and narratively summarized the current state of knowledge, and each group formulated research agenda items relevant to the specific topics of interest. Each consortium member consequently ranked the importance of all items on a 0-10 Numerical Rating Scale (NRS) (10 = extremely important, to 0 = not at all important).

Results: After ranking all formulated items on importance, 6 of the 28 research agenda items formulated received an average of 7.5 points on the NRS. The most highly ranked items covered the fields of treatment, diagnosis, and definition of PF OA.

Conclusions: We recommend to develop clear clinical criteria for PF OA and to reach consensus on the definition of PF OA by both radiographs and MRI. Additionally, more understanding is necessary to be able to distinguish PF symptoms from those arising from the tibiofemoral joint. More insight is needed on effective treatment strategies for PF OA; specifically, tailoring nonpharmacological treatments to individuals with PF OA, and determining whether isolated PF OA requires different treatment strategies than combined PF and tibiofemoral OA.
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http://dx.doi.org/10.1016/j.semarthrit.2017.09.009DOI Listing
April 2018

The prevalence of radiographic and MRI-defined patellofemoral osteoarthritis and structural pathology: a systematic review and meta-analysis.

Br J Sports Med 2017 Aug 29;51(16):1195-1208. Epub 2017 Apr 29.

La Trobe Sports and Exercise Medicine Research Centre, School of Allied Health, La Trobe University, Bundoora, Victoria, Australia.

Background: Patellofemoral osteoarthritis (PF OA) is more prevalent than previously thought and contributes to patient's suffering from knee OA. Synthesis of prevalence data can provide estimates of the burden of PF OA.

Objective: This study aims to conduct a systematic review and meta-analysis on the prevalence of PF OA and structural damage based on radiography and MRI studies in different populations.

Methods: We searched six electronic databases and reference lists of relevant cross-sectional and observational studies reporting the prevalence of PF OA. Two independent reviewers appraised methodological quality. Where possible, data were pooled using the following categories: radiography and MRI studies.

Results: Eighty-five studies that reported the prevalence of patellofemoral OA and structural damage were included in this systematic review. Meta-analysis revealed a high prevalence of radiographic PF OA in knee pain or symptomatic knee OA (43%), radiographic knee OA or at risk of developing OA (48%) and radiographic and symptomatic knee OA (57%) cohorts. The MRI-defined structural PF damage in knee pain or symptomatic population was 32% and 52% based on bone marrow lesion and cartilage defect, respectively.

Conclusion: One half of people with knee pain or radiographic OA have patellofemoral involvement. Prevalence of MRI findings was high in symptomatic and asymptomatic population. These pooled data and the variability found can provide evidence for future research addressing risk factors and treatments for PF OA.

Trial Registration Number: PROSPERO systematic review protocol (CRD42016035649).
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http://dx.doi.org/10.1136/bjsports-2017-097515DOI Listing
August 2017

Relationship of Trochlear Morphology and Patellofemoral Joint Alignment to Superolateral Hoffa Fat Pad Edema on MR Images in Individuals with or at Risk for Osteoarthritis of the Knee: The MOST Study.

Radiology 2017 09 17;284(3):806-814. Epub 2017 Apr 17.

From the Department of Physical Therapy, Movement, and Rehabilitation Sciences, Northeastern University, 360 Huntington Ave, 301 Robinson Hall, Boston, MA 02115 (J.J.S.); the Clinical Epidemiology Research and Training Unit (R.W., T.N., D.T.F., J.J.S.) and Quantitative Imaging Center, Department of Radiology (M.R., M.J., F.W.R., A.G.), Boston University School of Medicine, Boston, Mass; Department of Radiology, University of Erlangen-Nuremberg, Erlangen, Germany (F.W.R.); Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, Calif (J.A.L.); Department of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Ala (C.E.L.); and Department of Epidemiology, University of Iowa, Iowa City, Iowa (J.C.T.).

Purpose To determine the relationship of patellofemoral joint alignment and trochlear morphology to superolateral Hoffa fat pad (SHFP) edema on magnetic resonance (MR) images in older adults with or at risk for osteoarthritis of the knee. Materials and Methods Institutional review board approval and written informed consent were obtained from all subjects. The Multicenter Osteoarthritis Study is a prospective cohort study of older adults with or at risk for osteoarthritis of the knee. Subjects were recruited from Birmingham, Alabama, and Iowa City, Iowa. In this cross-sectional study, patellofemoral joint alignment (bisect offset, patellar tilt angle, and Insall-Salvati ratio), trochlear morphology (sulcus angle, lateral and medial trochlear inclination, and trochlear angle) and SHFP edema were assessed on MR images of the knee. Measures of alignment and morphology were divided into quartiles, and SHFP was determined to be present or absent. Separate logistic regression models were used to determine the relationship of each measure of alignment and morphology to the presence of SHFP edema, with adjustments for age, sex, and body mass index. Results SHFP edema was present in 152 (13.4%) of the 1134 knees that were included. When compared with knees with measurements in the lowest quartile, knees with measurements in the highest quartile for trochlear angle, bisect offset, and Insall-Salvati ratios were 1.6 (95% confidence interval [CI]: 1.0, 2.6), 2.3 (95% CI: 1.3, 4.0), and 8.9 (95% CI: 4.7, 16.9) times more likely to show SHFP edema, respectively. No relationship was found between other measures and SHFP edema. Conclusion A more anterior trochlear facet, a more laterally displaced patella, and knees with patella alta were significantly associated with SHFP edema on MR images in subjects with or at risk for osteoarthritis of the knee. RSNA, 2017.
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http://dx.doi.org/10.1148/radiol.2017162342DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5584646PMC
September 2017

The Association of Forefoot Varus Deformity with Patellofemoral Cartilage Damage in Older Adult Cadavers.

Anat Rec (Hoboken) 2017 Jun 27;300(6):1032-1038. Epub 2017 Jan 27.

Department of Physical Therapy, Massachusetts General Hospital (MGH) Institute of Health Professions, Boston, Massachusetts, 02129.

Forefoot alignment may contribute to patellofemoral joint (PFJ) osteoarthritis (OA) via its influence on the closed chain kinematics of the lower limb. The purpose of this cadaveric study was to investigate the relationship between forefoot varus and ipsilateral cartilage damage in the medial and lateral PFJ. Forefoot alignment measurements were obtained from the feet of 25 cadavers (n = 50). Cartilage damage in the medial and lateral PFJ of each knee was scored using the Outerbridge scale. The relative odds of medial and lateral PFJ cartilage damage in limbs with forefoot varus and valgus were determined using logistic regression. The relationship between increasing varus alignment and increasing odds of medial and lateral PFJ cartilage damage was assessed. Of the 51% of limbs with forefoot varus, 91.3% had medial, and 78.3% had lateral PFJ cartilage damage, compared with 54.6% and 68.2% of those with forefoot valgus. The former also had 3.0 times (95% CI 1.2, 7.7) the odds of medial PFJ damage; no association was found with lateral damage (OR 1.4, 95% CI 0.7, 3.0). Feet in the highest tertile of varus alignment had 3.9 times (95% CI 10, 15.3, P = 0.058) the odds of medial PFJ damage as those in the lowest tertile. The results of this study suggest a relationship between forefoot varus and medial PFJ cartilage damage in older adults. As forefoot varus may be modified with foot orthoses, these findings indicate a potential role for orthoses in the treatment of medial PFJ OA. Anat Rec, 300:1032-1038, 2017. © 2016 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ar.23524DOI Listing
June 2017

Is Tibiofemoral or Patellofemoral Alignment or Trochlear Morphology Associated With Patellofemoral Osteoarthritis? A Systematic Review.

Arthritis Care Res (Hoboken) 2016 10;68(10):1453-70

La Trobe University, Bundoora, Victoria, Australia.

Objective: We conducted a systematic review to evaluate the associations of knee alignment or trochlear morphology (measured on imaging) with presence, severity, onset, and/or progression of patellofemoral osteoarthritis (PFOA).

Methods: We prospectively registered our protocol with PROSPERO (International prospective register of systematic reviews) and followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to report this review. We searched 10 electronic databases, screened citing articles, and reviewed reference lists. We extracted data and evaluated methodologic quality. Due to study design heterogeneity, we used a best-evidence synthesis to summarize the evidence.

Results: We included 16 publications (2,892 participants, 66% women) after removing 4 papers that did not meet our threshold for methodologic quality. There were 11 cross-sectional and 5 longitudinal papers. The target population was knee OA in 11 studies, PFOA in 2 studies, and other knee conditions in 3 studies. Alignment or morphology was measured using radiographs in 8 studies, magnetic resonance imaging in 7 studies, and computed tomography in 2 papers. Limitations include substantial heterogeneity in samples and methods, short followup times in longitudinal studies, and a small number of studies that specifically recruited participants with PFOA.

Conclusion: There is strong evidence that PFOA is associated with both trochlear morphology and frontal plane knee alignment, while evidence is limited but consistent in the sagittal and axial planes. These findings suggest that alignment should be evaluated clinically in individuals with PFOA. Clinical interventions targeting knee alignment warrant further investigation.
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http://dx.doi.org/10.1002/acr.22842DOI Listing
October 2016

Relation of Step Length to Magnetic Resonance Imaging-Detected Structural Damage in the Patellofemoral Joint: The Multicenter Osteoarthritis Study.

Arthritis Care Res (Hoboken) 2016 06;68(6):776-83

Boston University, Boston, Massachusetts.

Objective: To investigate the relationship of step length to the sex-specific prevalence and worsening of magnetic resonance imaging (MRI)-detected structural damage in the patellofemoral (PF) joint among a cohort of older women and men with or at risk of knee osteoarthritis (OA).

Methods: The Multicenter Osteoarthritis Study is a cohort study of persons ages 50-79 years with or at risk of knee OA. Step length was assessed using the GAITRite walkway (CIR Systems) at the 60-month visit, and cartilage damage and bone marrow lesions (BMLs) were graded on MRI at the 60- and 84-month visits. Step length was divided into sex-specific quintiles, and the relationship of step length to the prevalence and worsening of cartilage damage and BMLs in the PF joint was examined using logistic regression, adjusting for age, body mass index (BMI), leg length, and tibiofemoral joint structural damage.

Results: In 1,053 knees, 4,094 and 4,083 PF joint subregions were studied for the cartilage and BML analyses, respectively. Mean ± SD age was 65.6 ± 8.1 years and mean ± SD BMI was 29.1 ± 4.7 kg/m(2) ; 62% of participants were female. In women, compared to those with the shortest step length, those with the longest step length had 0.62 (95% confidence interval [95% CI] 0.43-0.88) and 0.59 (95% CI 0.40-0.87) times the odds of cartilage damage and BMLs, respectively. There was no cross-sectional association in men, and no longitudinal association in either sex.

Conclusion: Women with PF joint structural damage may adapt their gait by shortening their step length, but this may not be sufficient to reduce the risk of worsening damage over time.
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http://dx.doi.org/10.1002/acr.22738DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4809780PMC
June 2016

The diagnostic performance of anterior knee pain and activity-related pain in identifying knees with structural damage in the patellofemoral joint: the Multicenter Osteoarthritis Study.

J Rheumatol 2014 Aug 15;41(8):1695-702. Epub 2014 Jun 15.

From Boston University, Boston, Massachusetts; the University of California, San Francisco, California; the University of Alabama, Birmingham, Alabama; the University of Iowa, Iowa City, Iowa, USA; Klinikum Augsburg, Augsburg, Germany.J.J. Stefanik, MSPT, PhD, Research Assistant Professor of Physical Therapy and Athletic Training; T. Neogi, MD, PhD, Associate Professor of Medicine; J. Niu, DSc, Clinical Epidemiology and Research Training Unit; A. Guermazi, MD, PhD, Professor of Radiology; D.T. Felson, MD, MPH, Professor of Medicine, Boston University; F.W. Roemer, MD, Associate Professor, Klinikum Augsburg; M.C. Nevitt, PhD, Professor of Epidemiology and Biostatistics, University of California, San Francisco; C.E. Lewis, MD, Professor of Medicine, University of Alabama; N.A. Segal, MD, Associate Professor of Orthopedics and Rehabilitation, University of Iowa.

Objective: To determine the diagnostic test performance of location of pain and activity-related pain in identifying knees with patellofemoral joint (PFJ) structural damage.

Methods: The Multicenter Osteoarthritis Study is a US National Institutes of Health-funded cohort study of older adults with or at risk of knee osteoarthritis. Subjects identified painful areas around the knee on a knee pain map and the Western Ontario and McMaster Universities Osteoarthritis Index was used to assess pain with stairs and walking on level ground. Cartilage damage and bone marrow lesions were assessed from knee magnetic resonance imaging. We determined the sensitivity, specificity, positive and negative predictive values for presence of anterior knee pain (AKP), pain with stairs, absence of pain while walking on level ground, and combinations of tests in discriminating knees with isolated PFJ structural damage from those with isolated tibiofemoral joint (TFJ) or no structural damage. Knees with mixed PFJ/TFJ damage were removed from our analyses because of the inability to determine which compartment was causing pain.

Results: There were 407 knees that met our inclusion criteria. "Any" AKP had a sensitivity of 60% and specificity of 53%; and if AKP was the only area of pain, the sensitivity dropped to 27% but specificity rose to 81%. Absence of moderate pain with walking on level ground had the greatest sensitivity (93%) but poor specificity (13%). The combination of "isolated" AKP and moderate pain with stairs had poor sensitivity (9%) but the greatest specificity (97%) of strategies tested.

Conclusion: Commonly used questions purported to identify knees with PFJ structural damage do not identify this condition with great accuracy.
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http://dx.doi.org/10.3899/jrheum.131555DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4182011PMC
August 2014

Association between measures of patella height, morphologic features of the trochlea, and patellofemoral joint alignment: the MOST study.

Clin Orthop Relat Res 2013 Aug 2;471(8):2641-8. Epub 2013 Apr 2.

Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, 650 Albany Street, Suite 200, Boston, MA 02118, USA.

Background: Patellofemoral joint (PFJ) malalignment (lateral patella displacement and tilt) has been proposed as a cause of patellofemoral pain. Patella height and/or the morphologic features of the femoral trochlea may predispose one to patella malalignment.

Questions/purposes: The purposes of our study were to assess the associations among patella height, morphologic features of the trochlea, and measures of PFJ alignment and to determine which measures of patella height and morphologic features of the trochlea were the best predictors of PFJ alignment.

Methods: Measures of patella height (Insall-Salvati ratio and modified Insall-Salvati ratio), morphologic features of the trochlea (sulcus angle, trochlear angle, lateral trochlear inclination, medial trochlear inclination), and PFJ alignment (bisect offset and patella tilt angle) were assessed in 566 knees from the Multicenter Osteoarthritis Study.

Results: Bisect offset was correlated with the Insall-Salvati ratio (r = 0.25) and lateral trochlear inclination (r = -0.38). Patella tilt angle correlated with the trochlear angle (-0.27) and lateral trochlear inclination (-0.32). Linear regression models including the Insall-Salvati ratio and lateral trochlear inclination explained 20% and 11% of the variance in bisect offset and patella tilt angle, respectively.

Conclusions: Of the variables measured in the current study, the Insall-Salvati ratio and lateral trochlear inclination were the best predictors of lateral patella displacement and lateral tilt. This knowledge will aid clinicians in the identification of anatomic risk factors for PFJ malalignment and/or PFJ dysfunction.
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http://dx.doi.org/10.1007/s11999-013-2942-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3705075PMC
August 2013

Breaking the Law of Valgus: the surprising and unexplained prevalence of medial patellofemoral cartilage damage.

Ann Rheum Dis 2012 Nov 25;71(11):1827-32. Epub 2012 Apr 25.

Correspinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, Massachusetts 02118, USA.

Objectives: To compare the prevalence of medial and lateral patellofemoral (PF) cartilage damage in three large osteoarthritis (OA) studies and determine the relationship of this damage to varus, neutral and valgus knee alignment.

Methods: In the Boston OA of the Knee, Framingham OA and Multicenter OA studies, MRIs were read for cartilage morphology at the medial and lateral patella and trochlea femoris using Whole-Organ MRI Scores (WORMS). WORMS scores ≥2 (any cartilage defect), ≥3 (areas of partial thickness loss), ≥4 (diffuse partial thickness loss) and ≥5 (extensive full thickness loss) were all variously considered as thresholds to identify damage that may indicate OA. Full-limb radiographs were measured for mechanical alignment, and varus (<-2°), neutral (-2° to 2°) and valgus (>2°) knees were identified.

Results: The prevalence of medial PF cartilage damage exceeded that of lateral damage in all three studies and according to nearly every threshold. Only among severely involved knees (WORMS ≥4 or ≥5) did the prevalence of lateral PF cartilage damage approximate that of medial damage. The high prevalence of medial PF damage persisted in all strata of knee alignment. Even among knees with valgus alignment, the prevalence of lateral PF cartilage damage equalled or surpassed that of medial PF damage only when the threshold was specific to severely involved knees.

Conclusions: Medial PF cartilage damage is at least as prevalent within these older adult populations as lateral PF cartilage damage.
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http://dx.doi.org/10.1136/annrheumdis-2011-200606DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4011177PMC
November 2012

Association between measures of trochlear morphology and structural features of patellofemoral joint osteoarthritis on MRI: the MOST study.

J Orthop Res 2012 Jan 24;30(1):1-8. Epub 2011 Jun 24.

Boston University School of Medicine, Boston, MA 02118, USA.

The sulcus angle has been widely used in the literature as a measure of trochlear morphology. Recently, lateral trochlear inclination and trochlear angle have been reported as alternatives. The purpose of this study was to determine the association between measures of trochlear morphology and patellofemoral joint (PFJ) cartilage damage and bone marrow lesions (BMLs). Nine hundred seven knees were selected from the Multicenter Osteoarthritis Study, a cohort study of persons aged 50-79 years with or at risk for knee OA. Trochlear morphology was measured using lateral trochlear inclination, trochlear angle, and sulcus angle on axial MRI images; cartilage damage and BMLs were graded on MRI. We determined the association between quartiles of each trochlear morphology variable with the presence or absence of cartilage damage and BMLs in the PFJ using logistic regression. The strongest associations were seen with lateral trochlear inclination and lateral PFJ cartilage damage and BMLs, with knees in the lowest quartile (flattened lateral trochlea) having more than two times the odds of lateral cartilage damage and BMLs compared to those in the highest quartile (p < 0.0001). Lateral trochlear inclination may be the best method for assessment of trochlear morphology as it was strongly association with structural damage in the PFJ.
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http://dx.doi.org/10.1002/jor.21486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3217080PMC
January 2012

Quadriceps weakness, patella alta, and structural features of patellofemoral osteoarthritis.

Arthritis Care Res (Hoboken) 2011 Oct;63(10):1391-7

Boston University School of Medicine, Boston, Massachusetts 02118, USA.

Objective: To determine the relationship between quadriceps weakness and cartilage damage and bone marrow lesions (BMLs) in the patellofemoral joint (PFJ) and if this relationship is modified by patella alta.

Methods: The Multicenter Osteoarthritis Study is a cohort study of persons ages 50-79 years with or at risk of knee osteoarthritis. Concentric knee extensor strength was measured using an isokinetic dynamometer. Patella alta was measured using the Insall-Salvati ratio (ISR) on the lateral radiograph, and cartilage damage and BMLs were graded on magnetic resonance imaging in the PFJ. We determined the association between quadriceps weakness with cartilage damage and BMLs in the PFJ among knees with (ISR ≥1.2) and without (ISR <1.2) patella alta using multiple binomial regression.

Results: A total of 807 knees were studied (mean age 62 years, body mass index 30 kg/m(2) , ISR 1.10) and 64% were from women. Compared with the knees in the highest strength tertile, those in the lowest had 10.2% (95% confidence interval [95% CI] 3, 18), 9.1% (95% CI 2, 16), and 7.1% (95% CI 1, 13) higher prevalence of lateral PFJ cartilage damage, medial PFJ cartilage damage, and lateral PFJ BMLs, respectively. The association between quadriceps weakness with cartilage damage and BMLs was not different between knees with and without patella alta in the lateral PFJ.

Conclusion: Quadriceps weakness was associated with PFJ cartilage damage and BMLs. While both patella alta and quadriceps weakness were associated with PFJ damage, the combination of the two was not associated with more damage than either of these factors alone.
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http://dx.doi.org/10.1002/acr.20528DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3183313PMC
October 2011
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