Faculty Bibliography

Background/Purpose: High body mass index (BMI, kg/m2) is a modifiable risk factor that has been associated with the development and progression of osteoarthritis (OA) and knee pain. While total knee arthroplasty (TKA) is the gold standard for the treatment of end stage OA, morbidly obese patients (BMI>=40kg/m2) are often required to lose weight prior to TKA due to increased surgical risk and a higher rate of complications. While conservative weight-loss often fails to help these patients, bariatric surgery can be an alternative option. Here we present interim data from the trial entitled "Surgical Weight-loss to Improve Functional Status Trajectories following arthroplasty for painful knee osteoarthritis". This current multi-center, prospective study compares pain and functional outcomes in patients receiving bariatric surgery prior to TKA versus obese patients who go straight to TKA.
Method(s): Patients with BMI >=40 kg/m2 and painful knee osteoarthritis who met the indications for TKA were recruited at four hospital centers. Patients with a BMI >35 kg/m2 were also recruited if they had a qualifying comorbid condition including obstructive sleep apnea, diabetes, hypertension or hyperlipidemia. Patients were assigned to either the bariatric (BAR) or TKA arm based on surgical choice (goal n=150 for each arm), with all bariatric patients having anatomy-altering sleeve gastrectomy or gastric bypass. At baseline and several time points after surgery (Figure 1), we documented height, weight, the Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog pain (VAS) scales, and the Western Ontario and McMaster Universities Arthritis Index (WOMAC), and had patients perform functional assessments (Timed-Up and Go, 30-second Chair Stand and 40-meter fast paced walk test). We targeted minimum detectable change (MDC) in outcomes for the VAS for knee pain (33% reduction), Timed Up and Go (decrease by 2 seconds), 30-second Chair Stand (increase by 2 reps), 40-meter fast paced walk (increase by 0.16 m/s), WOMAC score (16% reduction), and the KOOS pain score (10-point improvement). Using a logistic regression to adjust for age and baseline BMI, we compared the percentage of patients in the two arms who achieved an MDC for the various outcomes.
Result(s): To date, 25 BAR and 28 TKA patients have completed their follow-up visits through at least 6 months. Although there was a similar sex distribution, the bariatric group was younger (52 vs 60 years old, p=0.0023) with a higher baseline BMI (47.0 vs 41.6 p=0.0006). Most bariatric patients achieved comparable improvement to the TKA cohort with regards to the benchmarks of the 30-second Chair Stand (TKA 54% vs BAR 33%, p=0.156), KOOS pain score (TKA 91% vs BAR 67%, p=0.130), the Visual Analog Pain Scale (TKA 50% vs BAR 39%, p=0.466), Timed Up and Go test (TKA 43% vs BAR 22%, p=0.141) and the 40-meter fast paced walk (TKA 61% vs BAR 35%, p=0.073). The TKA cohort had a greater percent with a MDC for the WOMAC (TKA 88% vs BAR 54%, p=0.030).
Conclusion(s): In morbidly obese patients who are eligible for TKA, bariatric surgery may result in modest improvements in knee outcomes and may eventually delay the need for a TKA

Background/Purpose: Symptomatic knee osteoarthritis (SKOA) patients with obesity who undergo bariatric surgery experience knee pain relief, though the reduced mechanical load explains only part of the improvement. A reduction in inflammatory biomarkers from adipose tissue may also impact pain. We previously identified an IL1RN haplotype (TTG; rs419598, rs315952, and rs9005) that associates with OA severity and inflammatory markers. We aimed to determine whether TTG distinguishes patients who lose more weight and have more significant decreases in inflammation with greater knee OA pain relief.
Method(s): From 2013-2019 we enrolled patients >=30 years old with BMI >=30 kg/m 2 and painful knee OA who planned surgical (sleeve gastrectomy, gastric bypass, or laparoscopic band) or medical weight loss (MWL) at Bellevue Hospital or NYU Langone Health. Patients with lupus, rheumatoid arthritis, or psoriatic arthritis were excluded. Weight-bearing knee x-rays assessed OA severity to confirm a Kellgren-Lawrence grade of at least 1 (scale 0-4). Participants completed the Knee Injury and Osteoarthritis Outcomes (KOOS) questionnaire and provided blood at baseline and 1, 3, 6, and 12 months. Patients were genotyped to determine whether they carried 1 or 2 copies of the TTG haplotype (TTG-1/2) or none (TTG-0). Sleeve was the most common weight loss intervention, therefore our analysis is focused on this surgical subset to minimize variable effects on weight and biomarkers.
Result(s): We enrolled 113 patients (95 F, 18 M) with painful knee OA prior to their weight loss intervention. The mean age, BMI, and KOOS pain at baseline were 50.3 +/- 12.0 years, 44.8 +/- 8.9 kg/m 2, and 48.4 +/- 18.2 (0-100, with 100 = no pain). Of 113 patients, 48 underwent sleeve, 20 bypass, 9 laparoscopic banding, 12 did not have the surgery, and 24 pursued medical weight loss. The 77 who completed surgery had a mean % excess weight loss (%EWL) of 51.7 after 6 months, with significant decreases in hsCRP (4.4 mg/L) and leptin (32.8 ng/dL), and mean KOOS pain improvement of 22.4 (MCID= 16.7). The corresponding changes for patients who tried various MWL regimens were modest at best. We obtained the IL1RN haplotype for 45 of the 48 sleeve patients, and found 34 (70.8%) carried the TTG-1 or TTG 2 haplotype while 11 were TTG-0 (with similar baseline age, BMI, and KOOS for the two groups). At each follow-up time point through 6 months (Figure 1), TTG-1/2 patients had more difficulty losing weight than the TTG-0 group (p< 0.005 by ANOVA), with corresponding smaller reductions in hs CRP (p=0.36) and leptin (p=0.006). TTG-1/2 carriers also reported less KOOS pain relief relative to the TTG-0 group (p=0.021), markedly at 1 and 3 months with some improvement later (Table 1). All of these findings held true when only plotting data only from the 23 patients (18 TTG-1/2, 5 TTG-0) who completed each of the followup visits.
Conclusion(s): SKOA patients with obesity achieve marked excess weight loss, reductions in inflammatory mediators, and knee pain relief with bariatric surgery. The subset of patients with the TTG-0 IL1RN haplotype demonstrated more significant and/or rapid improvement in each of these outcomes, suggesting a potential predictor of which OA patients will have a more successful response to bariatric surgery

Background/Purpose: Hand osteoarthritis (HOA) data is often obtained from large knee OA cohorts. Targeted HOA cohorts in Europe have shed light on this disease, but the etiologies and pathophysiology remain less defined than other sites of OA. Some studies suggest a metabolic role of adiposity in OA (beyond mechanical load), as evidenced by prevalent HOA in obese patients, while other reports link hormonal status to HOA pain. Our dedicated cohort of HOA patients aims to study factors that contribute to its prevalence and severity.
Method(s): From 2016 to 2020, we enrolled patients with interphalangeal (IP) OA, regardless of 1 st carpometacarpal (CMC) involvement. Patients with rheumatoid arthritis, psoriatic arthritis or lupus were excluded. Demographic and relevant history data were collected. Participants completed adapted versions of the Michigan Hand Outcomes (MHQ) and QuickDASH Outcome questionnaires to assess pain, stiffness, and function. The semi-quantitative scores were aggregated and normalized to a 0-100 scale. Hand x-rays, if available, were scored in binary fashion for joint narrowing, osteophytes, and central erosions in all 20 joints (18 IPs, 2 1st CMCs). Blood and urine were banked for future assays.
Result(s): We screened 337 patients and found 170 to be eligible and willing to enroll. The present cohort is 80.0% Caucasian and 78.8% female with an average age of 66.3+/-9.5 years (range 42-90) and BMI of 26.2+/-5.0 kg/m 2 (range 16.4-42.1). Bilateral hand x-rays, available for 149 patients, involved 10.5+/-5.1 joints with OA on average, with 102 (68.4%) having concurrent IP and CMC OA. Radiographs revealed central erosive changes in >=1 joint in 36.5% of patients, with this subset also reporting a higher number of affected joints (12.5 vs. 9.1, p=< 0.001). Patients with BMI > 30 kg/m 2 had significantly more hand pain (p=0.022) and stiffness (p=0.047) by the adapted MHQ, and more disability (p=0.025) by the QuickDASH, compared to those with BMI < 25 despite similar ages and joint burden by x-ray (Table 1). Patients reporting OA in additional sites also reported more hand pain (p=0.018) and more disability (p=0.003), though this signal could be confounded by this subgroup's advanced age (67.7 vs. 62.3 years, p=0.01). Women reported significantly more pain (p=0.035), disability (p=0.004), and a higher average number of joints affected (p=0.02) than men with similar ages and BMI. A small subgroup of likely perimenopausal women (ages 48-54) reported more pain and disability than their older counterparts, despite a lower mean BMI and fewer hand joints affected by OA. (Figure. 1). Our analyses did not reveal any association between hand symptoms and tobacco use, comorbidities, or prior hand trauma.
Conclusion(s): We have established the only registry and biorepository in North America focused on hand OA, which could enhance progress made by existing cohorts. HOA pain and disability independently associated with adiposity, and was more severe in women. We postulate that hormonal influences during the perimenopausal state may increase HOA symptoms during those years. As we run assays on stored biospecimens, we anticipate the HONEY cohort will further our understanding of HOA etiologies and pathophysiology while facilitating future clinical trials

Multiple disease-modifying osteoarthritis drug (DMOAD) trials were done in the last two decades, but no pharmacological agent has yet been approved by regulatory agencies as an effective therapy to date. Given the fact that we have seen the recent discontinuation of several late-stage drug development trials, a careful strategy is needed in formulating a plan for a successful DMOAD trial - including the various roles of imaging. This narrative review article will summarize how imaging is utilized in osteoarthritis from the perspective of disease modification to clinical utility. We will describe how semi-quantitative and quantitative magnetic resonance imaging approaches have been deployed in DMOAD trials. We will then review the utility of musculoskeletal ultrasound in research and clinical settings. Finally, novel hybrid positron emission tomography/MRI techniques and current research using artificial intelligence will be discussed, focusing on original research. Older publications are included for the discussion of the previous DMOAD trials and other relevant topics where deemed appropriate.

OBJECTIVE:Predictive biomarkers of progression in knee osteoarthritis are sought to enable clinical trials of structure-modifying drugs. A peripheral blood leukocyte (PBL) inflammatory gene signature, MRI-based bone marrow lesions (BML) and meniscus extrusion scores, meniscal lesions, and osteophytes on X-ray each have been shown separately to predict radiographic joint space narrowing (JSN) in subjects with symptomatic knee osteoarthritis (SKOA). In these studies, we determined whether the combination of the PBL inflammatory gene expression and these imaging findings at baseline enhanced the prognostic value of either alone. METHODS:PBL inflammatory gene expression (increased mRNA for IL-1β, TNFα, and COX-2), routine radiographs, and 3T knee MRI were assessed in two independent populations with SKOA: an NYU cohort and the Osteoarthritis Initiative (OAI). At baseline and 24 months, subjects underwent standardized fixed-flexion knee radiographs and knee MRI. Medial JSN (mJSN) was determined as the change in medial JSW. Progressors were defined by an mJSN cut-point (≥ 0.5 mm/24 months). Models were evaluated by odds ratios (OR) and area under the receiver operating characteristic curve (AUC). RESULTS:We validated our prior finding in these two independent (NYU and OAI) cohorts, individually and combined, that an inflammatory PBL inflammatory gene expression predicted radiographic progression of SKOA after adjustment for age, sex, and BMI. Similarly, the presence of baseline BML and meniscal lesions by MRI or semiquantitative osteophyte score on X-ray each predicted radiographic medial JSN at 24 months. The combination of the PBL inflammatory gene expression and medial BML increased the AUC from 0.66 (p = 0.004) to 0.75 (p < 0.0001) and the odds ratio from 6.31 to 19.10 (p < 0.0001) in the combined cohort of 473 subjects. The addition of osteophyte score to BML and PBL inflammatory gene expression further increased the predictive value of any single biomarker. A causal analysis demonstrated that the PBL inflammatory gene expression and BML independently influenced mJSN. CONCLUSION/CONCLUSIONS:The use of the PBL inflammatory gene expression together with imaging biomarkers as combinatorial predictive biomarkers, markedly enhances the identification of radiographic progressors. The identification of the SKOA population at risk for progression will help in the future design of disease-modifying OA drug trials and personalized medicine strategies.

OBJECTIVE:This study sought to develop and employ a comprehensive and standardized ultrasound (US) protocol and scoring atlas for the evaluation of features relevant to knee osteoarthritis (KOA) in a community-based cohort in the United States, with the goals of demonstrating feasibility, reliability, and validity. METHODS:We utilized data from the fourth follow-up (2016-2018) of the Johnston County OA Project, which includes individuals with (~50%) and without radiographic KOA. All participants underwent standardized knee radiography and completed standard questionnaires including the Knee Injury and Osteoarthritis Outcome Score (KOOS). Bilateral knee US images were obtained by a trained sonographer using a standardized protocol and scored by trained rheumatologists using an atlas developed for this study. A total of 396 knees were each scored by two readers according to the atlas. Associations between US features, radiographic findings (graded by an expert radiologist), and KOOS scores were assessed. RESULTS:Overall interreader reliability for US scoring was fair to moderate. The strongest correlations between US and radiographic features were seen for osteophytes, and similarly strong correlations were seen between US osteophytes and overall radiographic Kellgren-Lawrence Grade, demonstrating criterion validity. Features of effusion/synovitis and osteophytes were most associated with KOOS pain and impaired function. CONCLUSION/CONCLUSIONS:US is a feasible, reliable, and valid method to assess features relevant to KOA in clinical and research settings. The protocol and atlas developed in this study can be utilized to evaluate KOA in a standardized fashion in future clinical studies, enabling greater utilization of this valuable modality in osteoarthritis.

OBJECTIVE:Musculoskeletal ultrasound (MSUS) in rheumatology in the US has advanced by way of promotion of certifications and standards of use and inclusion of core fellowship curriculum. In order to inform endeavors for curricular integration, the objectives of the present study were to assess current program needs for curricular incorporation and the teaching methods that are being employed. METHODS:A needs-assessment survey (S1) was sent to 113 rheumatology fellowship program directors. For programs that taught MSUS, a curriculum survey (S2) was sent to lead faculty. Programs were stratified according to program size and use of a formal written curriculum. RESULTS:S1 (108 of 113 respondents; response rate 96%) revealed that 94% of programs taught MSUS, with 41% having a curriculum. Curricular implementation was unaffected by program size. Formal curricular adoption of MSUS was favored by 103 directors (95.3%), with 65.7% preferring such adoption to be optional. S2 (74 of 101 respondents; response rate 73%) showed that 41% of programs utilized a formal curriculum. Multiple teaching strategies were used, with content that was generally similar. Use of external courses, including the Ultrasound School of North American Rheumatologists course, was prevalent. Fewer barriers were noted compared to past surveys, but inadequate time, funding, and number of trained faculty still remained. Lack of divisional interest (P = 0.046) and interest of fellows (P = 0.012) were noted among programs without a formal curriculum. CONCLUSION:MSUS is taught by a significantly larger number of rheumatology fellowship programs today. Multiple teaching strategies are used with common content, and barriers still remain for some programs. Most program directors favor inclusion of a standardized MSUS curriculum, with many favoring inclusion to be optional.

Objective/UNASSIGNED:Osteoarthritis is highly prevalent and, on aggregate, is one of the largest contributors to US spending on hospital-based health care. This study sought to examine body mass index (BMI)-related variation in the association of osteoarthritis with healthcare utilization and expenditures. Methods/UNASSIGNED:. Study outcomes and covariates were measured during a 1-year evaluation period spanning 6 months before and after index. Multivariable regression analyses examined the association of BMI with osteoarthritis prevalence, and the combined associations of osteoarthritis and BMI with osteoarthritis-related medication utilization, all-cause hospitalization, and healthcare expenditures. Results/UNASSIGNED:< .01): utilization rates for analgesic medications (41.5-53.5%); rates of all-cause hospitalization (26.3%-32.0%); and total healthcare expenditures ($18 204-$23 372). Conclusion/UNASSIGNED:The prevalence and economic burden of osteoarthritis grow with increasing BMI; primary prevention of weight-related osteoarthritis and secondary weight management may help to alleviate this burden.

Background: Osteoarthritis (OA) is the most common form of arthritis, and knee OA is highly prevalent among older adults. Our objective was to evaluate the relationships between ultrasound (US) features and knee symptoms.
Method(s): Our sample (n=203) consisted of cross-sectional data from participants attending the fourth follow-up (2016-2018) of the Johnston County OA Project-a longitudinal population-based prospective cohort study in North Carolina. An US-trained radiology technologist scanned all participants' bilateral knees using a written protocol; the images were scored using a standardized atlas. Logistic regression modeling, using generalized estimating equations to account for correlation between knees, was used to evaluate the associations between the presence of various US features and self-reported knee symptoms and produce adjusted odds ratios and 95% confidence intervals. Each model was adjusted for sex, race, BMI, education, comorbidities, other symptomatic joints, and increasing age.
Result(s): The strongest association between knee symptoms and US features was seen for severe medial osteophytes which increased the odds of reporting knee symptoms by 11 times. Severe lateral osteophytes increased the odds of knee symptoms by over 6 times. Both medial and lateral cartilage damage more than doubled the odds of knee symptoms. Both popliteal cysts and severe effusion/synovitis tripled the odds of reporting at least mild knee symptoms; synovitis was more strongly associated with knee symptoms than effusion. The association between osteophytes and symptoms varied by age, such that participants at age 65 had four times the odds of symptoms in the presence of severe medial osteophytes, increasing to 10 times at age 75.
Conclusion(s): Older participants had significantly higher odds of knee symptoms in the presence of medial osteophytes-a key feature of OA-which clinicians may use to initiate early symptom management. Further studies are needed to evaluate the temporal relationships between US features and knee symptoms throughout the aging process

OBJECTIVE:To develop an evidence-based guideline for the comprehensive management of osteoarthritis (OA) as a collaboration between the American College of Rheumatology (ACR) and the Arthritis Foundation, updating the 2012 ACR recommendations for the management of hand, hip, and knee OA. METHODS:We identified clinically relevant population, intervention, comparator, outcomes questions and critical outcomes in OA. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available educational, behavioral, psychosocial, physical, mind-body, and pharmacologic therapies for OA. Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. A Voting Panel, including rheumatologists, an internist, physical and occupational therapists, and patients, achieved consensus on the recommendations. RESULTS:Based on the available evidence, either strong or conditional recommendations were made for or against the approaches evaluated. Strong recommendations were made for exercise, weight loss in patients with knee and/or hip OA who are overweight or obese, self-efficacy and self-management programs, tai chi, cane use, hand orthoses for first carpometacarpal (CMC) joint OA, tibiofemoral bracing for tibiofemoral knee OA, topical nonsteroidal antiinflammatory drugs (NSAIDs) for knee OA, oral NSAIDs, and intraarticular glucocorticoid injections for knee OA. Conditional recommendations were made for balance exercises, yoga, cognitive behavioral therapy, kinesiotaping for first CMC OA, orthoses for hand joints other than the first CMC joint, patellofemoral bracing for patellofemoral knee OA, acupuncture, thermal modalities, radiofrequency ablation for knee OA, topical NSAIDs, intraarticular steroid injections and chondroitin sulfate for hand OA, topical capsaicin for knee OA, acetaminophen, duloxetine, and tramadol. CONCLUSION/CONCLUSIONS:This guideline provides direction for clinicians and patients making treatment decisions for the management of OA. Clinicians and patients should engage in shared decision-making that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.