ong characterized as a wear-and-tear disorder, osteoarthritis (OA) is now understood to have a complex pathophysiology affecting multiple joints and joint structures, as captured by the Osteoarthritis Research Society International definition of OA: "The disease manifests first as a molecular derangement (abnormal joint tissue metabolism) followed by anatomic, and/or physiologic derangements (characterized by cartilage degradation, bone remodeling, osteophyte formation, joint inflammation and loss of normal joint function), that can culminate in illness." 1 Worldwide, an estimated more than 240 million persons have symptomatic, activity-limiting OA, including an estimated more than 32 million in the US. 2,3 The knee and hip are 2 commonly affected joints and are the focus of this Review. Nearly 30% of individuals older than 45 years have radiographic evidence of knee OA, about half of whom have knee symptoms. 4,5 The prevalence of symptomatic, radiographic hip OA is around 10%. 6,7 The lifetime risk of symptomatic knee OA is greater in obese persons (body mass index Ն30) than in nonobese persons (19.7% vs 10.9%). 8 Prior joint trauma, such as anterior cruciate ligament rupture and ankle fracture, increases risk, accounting for 12% of knee OA cases. 9 The prevalence of symptomatic, radiographic knee OA was 11.4% in women and 6.8% in men in one large cohort study 4 and 18.7% in women and 13.5% in men in another large cohort study. 5 Compared with men with OA, women have more severe radiographic findings and symptoms. 10 Older age and female sex are risk factors for hip OA as well as knee OA. In addition, congenital and acquired anatomic abnormalities (eg, hip dysplasia) are risk factors for hip OA. Regarding race, African American and White persons have similar prevalence of hip OA (accounting for race, sex, and body mass index), while African American individuals, especially women, have higher prevalence of knee OA. 5,7 Osteoarthritis leads to substantial cost and mortality. Fortythree percent of the 54 million individuals in the US living with IMPORTANCE Osteoarthritis (OA) is the most common joint disease, affecting an estimated more than 240 million people worldwide, including an estimated more than 32 million in the US. Osteoarthritis is the most frequent reason for activity limitation in adults. This Review focuses on hip and knee OA.OBSERVATIONS Osteoarthritis can involve almost any joint but typically affects the hands, knees, hips, and feet. It is characterized by pathologic changes in cartilage, bone, synovium, ligament, muscle, and periarticular fat, leading to joint dysfunction, pain, stiffness, functional limitation, and loss of valued activities, such as walking for exercise and dancing. Risk factors include age (33% of individuals older than 75 years have symptomatic and radiographic knee OA), female sex, obesity, genetics, and major joint injury. Persons with OA have more comorbidities and are more sedentary than those without OA. The reduced physical activity leads to a 20% higher age-adj...

Background Early research suggests the COVID-19 pandemic worsened intimate partner violence (IPV) in the US. In particular, stay-at-home orders and social distancing kept survivors in close proximity to their abusers and restricted access to resources and care. We aimed to understand and characterize the impact of the pandemic on delivery of IPV care in Boston. Methods We conducted individual interviews with providers of IPV care and support in the Greater Boston area, including healthcare workers, social workers, lawyers, advocates, and housing specialists, who continued to work during the COVID-19 pandemic. Using thematic analysis, we identified themes describing the challenges and opportunites providers faced in caring for survivors during the pandemic. Results Analysis of 18 interviews yielded four thematic domains, encompassing 18 themes and nine sub-themes. Thematic analysis revealed that the pandemic posed an increased threat to survivors of IPV by exacerbating external stressors and leading to heightened violence. On a system level, the pandemic led to widespread uncertainty, strained resources, amplified inequities, and loss of community. On an individual level, COVID-19 restrictions limited survivors’ abilities to access resources and to be safe, and amplified pre-existing inequities, such as limited technology access. Those who did not speak English or were immigrants experienced even more difficulty accessing resources due to language and/or cultural barriers. To address these challenges, providers utilized video and telephone interactions, and stressed the importance of creativity and cooperation across different sectors of care. Conclusions While virtual care was essential in allowing providers to care for survivors, and also allowed for increased flexibility, it was not a panacea. Many survivors faced additional obstacles to care, such as language barriers, unequal access to technology, lack of childcare, and economic insecurity. Providers addressed these barriers by tailoring services and care modalities to an individual’s needs and circumstances. Going forward, some innovations of the pandemic period, such as virtual interactions and cooperation across care sectors, may be utilized in ways that attend to shifting survivor needs and access, thereby improving safe, equitable, and trauma-informed IPV care.

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Background: Health care disparities are prevalent within pediatric orthopaedics in the United States. Social determinants of health, such as income, race, social deprivation, place of residence, and parental involvement, all play a role in unequal access to care and disparate outcomes. Although there has been some effort to promote health equity both within pediatric orthopaedics and the US health care system altogether, disparities persist. In this review, we aim to identify major sources of inequality and propose solutions to achieve equitable care in the future. Methods: We searched the PubMed database for papers addressing disparities in pediatric orthopaedics published between 2016 and 2021, yielding 283 papers. Results: A total of 36 papers were selected for review based upon new findings. Insurance status, race, and social deprivation are directly linked to poorer access to care, often resulting in a delay in presentation, time to diagnostic imaging, and surgery. Although these disparities pervade various conditions within pediatric orthopaedics, they have most frequently been described in anterior cruciate ligament/meniscal repairs, tibial spine fractures, adolescent idiopathic scoliosis, and upper extremity conditions. Treatment outcomes also differ based on insurance status and socioeconomic status. Several studies demonstrated longer hospital stays and higher complication rates in Black patients versus White patients. Patients with public insurance were also found to have worse pain and function scores, longer recoveries, and lower post-treatment follow-up rates. These disparate outcomes are, in part, a response to delayed access to care. Conclusions: Greater attention paid to health care disparities over the past several years has enabled progress toward achieving equitable pediatric orthopaedic care. However, delays in access to pediatric orthopaedic care among uninsured/publicly insured, and/or socially deprived individuals remain and consequently, so do differences in post-treatment outcomes. Reducing barriers to care, such as insurance status, transportation and health literacy, and promoting education among patients and parents, could help health care access become more equitable.

Background: Traditionally defined “meniscal” and “mechanical” symptoms are thought to arise from meniscal tears. Yet meniscal tears and cartilage damage commonly coexist in symptomatic knees. To better characterize the primary driver of these symptoms, we investigated whether the presence of preoperative patient-reported knee symptoms (PRKS), including knee catching/locking, grinding/clicking/popping, and pain with pivoting, are associated with various intra-articular pathological conditions diagnosed at knee arthroscopy. Methods: We collected prospective data from 565 consecutive patients who underwent knee arthroscopy from 2012 to 2019 and had PRKS collected via the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire. The diagnosis of meniscal pathology and concomitant cartilage damage was confirmed and classified intraoperatively. We used multivariable regression models, adjusting for possible confounders, to examine the association of specific pathological conditions of the knee with the presence of preoperative PRKS. Results: Tricompartmental cartilage damage was strongly associated with significantly worse PRKS, with an increase of 0.33 point (95% confidence interval [CI] = 0.08 to 0.58; p = 0.01) on a 0 to 4-point scale. We did not observe an association between meniscal pathology and preoperative PRKS. Conclusions: Contrary to current dogma, this study demonstrates that traditionally defined “meniscal” and “mechanical” knee symptoms are strongly associated with the burden and severity of underlying cartilage damage rather than with specific meniscal pathology. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objective Although most total knee replacement (TKR) recipients report less pain and improved function after TKR, many remain sedentary. We aimed to understand TKR recipients’ motivations for undergoing TKR, perceptions of and goals related to physical activity, and the role, if any, that activity monitors might play in their recovery. Methods We conducted a qualitative study, individually interviewing 27 participants who had recently undergone or were about to undergo TKR. We conducted a thematic analysis to better understand participants’ views of the benefits and barriers to physical activity after TKR. Results We identified nine themes and one subtheme that identify patients’ initial motivations for undergoing TKR and may help TKR recipients achieve increased activity levels and a perceived successful recovery. Some key messages that emerged from our work include the following: exercise is necessary for physical and mental health, pain and functional limitation interfere with daily life, tracking steps motivates individuals to increase activity levels, and different incentives (for engaging in physical exercise and using an activity monitor) are effective for different individuals. Conclusion Participants recognized the health benefits of physical activity, and many believed activity monitor use would help them become more active after surgery. Both external and internal factors played a role in motivating individuals to become more active and wear activity monitors.

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Objective Inflammation is a potential pain generator and treatment target in knee osteoarthritis (OA). Inflammation can be detected on magnetic resonance imaging (MRI) and by synovial fluid white blood cell count (WBC). However, the performance characteristics of synovial fluid WBC for the detection of synovitis have not been established. This study was undertaken to determine the sensitivity and specificity of synovial fluid WBC in identifying inflammation in knee OA using MRI effusion‐synovitis as the gold standard. Methods We identified records of patients seen at an academic center with a diagnosis code for knee OA, a procedural code for knee aspiration, and a laboratory order for synovial fluid WBC in the same encounter, as well as an MRI within 12 months of the aspiration. MRIs were read for effusion‐synovitis using the MRI OA Knee Score (MOAKS). We dichotomized effusion‐synovitis as 1) none or small, or 2) medium or large. We calculated the sensitivity and specificity of synovial fluid WBC using MRI effusion‐synovitis (medium/large) as the gold standard. We used the Youden index to identify the best cut point. Results We included 75 patients. Mean ± SD age was 63 ± 12 years, and 69% were female. The synovial fluid WBC was higher in the medium/large effusion‐synovitis group (median 335 [interquartile range (IQR) 312]) than in the none/small group (median 194 [IQR 272]). The optimal cut point was 242, yielding a sensitivity of 71% (95% confidence interval [95% CI] 56–83%) and specificity of 63% (95% CI 41–81%). Conclusion The sensitivity and specificity of synovial fluid WBC in identifying effusion‐synovitis on MRI were limited. Further research is needed to better understand the association between MRI and effusion‐synovitis measured by synovial fluid and to determine which measure more strongly relates to synovial histopathology and patient outcomes.