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India-Based Knee Osteoarthritis Evaluation (iKare): A Multi-Centre Cross-Sectional Study on the Management of Knee Pain and Early Osteoarthritis in India

Authors:
  • Sancheti Institute for Orthopaedics & Rehabilitation
  • Dr LH Hiranandani Hospital

Abstract and Figures

Background Access to early knee osteoarthritis treatment in low and middle income nations is often believed to be limited. We conducted a cross-sectional study in India to assess prior access to treatment among patients presenting with knee pain to specialist orthopaedic clinics. Methods The multi-centre, cross-sectional study included patients presenting with knee pain at 3 hospitals in India. Patients who met the inclusion criteria and provided informed consent completed a questionnaire designed to assess patient demographics, socioeconomic status, knee pain, treatment method, and patient's knowledge on osteoarthritis (OA). Their orthopaedic surgeons also completed a questionnaire on the severity of patient's OA and their recommended treatments. The impact of demographic characteristics on the prescription of treatment options was analyzed using logistic regression. Results A total of 714 patients met the eligibility criteria and participated in this study. The majority of patients had been experiencing pain for less than 1 year (64.8%) and had previously been prescribed medications (91.6%), supplements (68.6%), and nonpharmacological (81.9%) treatments to manage their knee OA. Current treatment recommendations included oral medications (83.3%), intra-articular injections (29.8%), and surgical intervention (12.7%). Prescription of oral medications was related to younger age, lack of deformities, and lower Kellgren-Lawrence grades (p < 0.01). Patients treated in private hospital settings were more likely to have been previously treated with medications (range, 84.3% to 92.6%; p < 0.01) and physical treatments (range, 61.8% to 84.8%; p < 0.01) than patients treated at government hospitals. Conclusions Contrary to the perception, our findings suggest a similar proportion of early knee OA treatment between India and North America.
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Osteoarthritis (OA) is one of the most common forms of
musculoskeletal diseases worldwide.1) It is estimated that
3.8% of the world’s population suffer from symptomatic
knee OA,2) which equates to approximately 277 million
people living with knee OA worldwide.3) The prevalence
of OA is similar across the globe2) and it is expected to
increase dramatically as the population ages, especially in
India-Based Knee Osteoarthritis Evaluation (iKare):
A Multi-Centre Cross-Sectional Study
on the Management of Knee Pain and
Early Osteoarthritis in India
Parag Sancheti, MD, Vijay D. Shetty, MD*, Mandeep S. Dhillon, MD,
Sheila A. Sprague, PhD, Mohit Bhandari, MD
Sancheti Institute for Orthopedics and Rehabilitation, Pune,
*Department of Orthopaedics, Dr L H Hiranandani Hospital, Mumbai,
Department of Orthopedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India,
Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Canada
Background: Access to early knee osteoarthritis treatment in low and middle income nations is often believed to be limited. We
conducted a cross-sectional study in India to assess prior access to treatment among patients presenting with knee pain to spe-
cialist orthopaedic clinics.
Methods: The multi-centre, cross-sectional study included patients presenting with knee pain at 3 hospitals in India. Patients who
met the inclusion criteria and provided informed consent completed a questionnaire designed to assess patient demographics, so-
cioeconomic status, knee pain, treatment method, and patient’s knowledge on osteoarthritis (OA). Their orthopaedic surgeons also
completed a questionnaire on the severity of patient’s OA and their recommended treatments. The impact of demographic charac-
teristics on the prescription of treatment options was analyzed using logistic regression.
Results: A total of 714 patients met the eligibility criteria and participated in this study. The majority of patients had been ex-
periencing pain for less than 1 year (64.8%) and had previously been prescribed medications (91.6%), supplements (68.6%), and
nonpharmacological (81.9%) treatments to manage their knee OA. Current treatment recommendations included oral medications
(83.3%), intra-articular injections (29.8%), and surgical intervention (12.7%). Prescription of oral medications was related to young-
er age, lack of deformities, and lower Kellgren-Lawrence grades (
p
< 0.01). Patients treated in private hospital settings were more
likely to have been previously treated with medications (range, 84.3% to 92.6%;
p
< 0.01) and physical treatments (range, 61.8% to
84.8%;
p
< 0.01) than patients treated at government hospitals.
Conclusions: Contrary to the perception, our findings suggest a similar proportion of early knee OA treatment between India and
North America.
Keywords: Osteoarthritis, Knee, India, Cross-sectional studies
Original Article Clinics in Orthopedic Surgery 2017;9:286-294 • https://doi.org/10.4055/cios.2017.9.3.286
Copyright © 2017 by The Korean Orthopaedic Association
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0)
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Clinics in Orthopedic Surgery pISSN 2005-291X eISSN 2005-4408
Received November 1, 2016; Accepted April 24, 2017
Correspondence to: Mohit Bhandari, MD
Department of Surgery, Division of Orthopaedic Surgery, McMaster
University, 239 Wellington Street North, Suite 110, Hamilton, ON, L8L
8E7, Canada
Tel: +1-905-527-4322, Fax: +1-905-523-8781
E-mail: bhandam@mcmaster.ca
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Clinics in Orthopedic Surgery Vol. 9, No. 3, 2017 www.ecios.org
low and-middle income nations.4,5) The prevalence of knee
OA in rural and urban India is estimated to be 3.9% and
5.5%, respectively.2,6)
OA is a progressive, irreversible disease for which
there is no cure. Treatment of OA in North America gen-
erally focuses on symptom management, with a hope of
improving knee function, which eventually requires knee
replacement surgery as the disease progresses.5) Treatment
typically includes a combination of pharmaceutical inter-
ventions (i.e., analgesics and anti-inflammatories), natural
supplements, and intra-articular injections of corticoste-
roids or hyaluronic acid (HA) in addition to active treat-
ment (i.e., physical therapy, exercises, orthotics, or manual
therapy aimed at improving strength and mobility).5) As
knee OA advances and conservative treatments are no lon-
ger effective for alleviating symptoms, surgical procedures
become necessary.
In low and middle income nations, such as India,
access to appropriate treatment is often limited and de-
pends upon accessibility of healthcare services, insurance,
availability of different treatment options, and the ability
of the patient to pay for health care.7) Little is known about
access to treatment of OA in India and the factors associ-
ated with presenting to specialist care for consideration of
surgical management. We, therefore, conducted a national
cross-sectional study across three clinical sites in India to
assess prior access to treatments among patients present-
ing with knee pain at specialist orthopaedic clinics. We ex-
amined the characteristics of patients, severity of OA, and
treatment recommendations and explored predictors of
accessing various treatments and the impact of private and
public hospital system on access to care. We hypothesized
that patients presenting with knee pain would have had
limited access to care, have a higher severity of disease, be
recommended nonsurgical care, and there would be nu-
merous factors that predict access to treatment, including
being treated in a private hospital.
METHODS
Study Design
We conducted a multi-centre, cross-sectional study that
included patients presenting with knee pain at three hos-
pitals in India. Patients who met the inclusion criteria and
provided informed consent completed a questionnaire
designed to assess patient demographics, socioeconomic
status, knee pain and treatment method, and their knowl-
edge about OA. Their orthopaedic surgeons completed
a questionnaire on the severity of patient’s OA and their
recommended treatments. Prior to initiation of the study,
approval was obtained for the overall study from the In-
stitutional Review Board Services and the Research Ethics
Board at each participating hospital. Informed consent
was received from all participants prior to participation in
the study. This study was performed in accordance with
the Declaration of Helsinki.
Questionnaire Development
The questionnaire was developed by the authors for the
purpose of this study by using the current literature and
input from content experts. The questionnaire was re-
viewed by 10 orthopaedic surgeons and research meth-
odologists for face and content validity. In addition, 10
Indian orthopedic surgeons reviewed the questionnaire
for cultural sensitivities and identified any questions that
they believed would cause a problem for the patient, the
attending physician, and/or the research coordinator. This
approach helped to ensure that all questions were worded
adequately and were culturally relevant and appropriate.
Description of the Questionnaire
The questionnaire included 5 sections and 31 items. The
first section included 10 demographic questions. The sec-
ond section asked the patient about their affected knee and
included questions on their diagnosis, level of pain, and
functional limitations. The questionnaire also included a
section that asks the patient how their knee OA was man-
aged in the past (i.e., medications, supplements, braces,
physiotherapy, etc.). Their surgeon completed the remain-
ing 2 sections which included questions on the severity of
OA (6 questions) as well as their recommended treatments
(3 questions). Prior to initiating the study, the question-
naire was reviewed by 10 orthopaedic surgeons and re-
search methodologists for face and content validity, and
then was reviewed by 10 Indian orthopedic surgeons for
cultural sensitivities. This approach helped to ensure that
all questions were worded adequately and were culturally
relevant and appropriate.
Clinical Sites
Three hospitals in India were selected to participate in the
study based upon patient volume, research infrastructure,
and interest in the study. The clinical sites included 1 gov-
ernment and 2 private hospitals.
Eligibility Criteria
The study had minimal exclusion criteria. The inclusion
criteria were: (1) at least 18 years of age; (2) presence of
knee pain; (3) patient’s ability to understand and com-
plete the questionnaire; and (4) patients agreement to
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participate in the study. The exclusion criteria included:
(1) a history of total knee arthroplasty (TKA); (2) an open
wound or evidence of recent surgery in the affected knee;
(3) a current or history of tumour in the affected knee or
proximal skeletal structure; and (4) a current or history of
fracture in the tibial plateau, femoral condyle, or patella.
Data Collection
After providing informed consent, study participants
completed the questionnaire under research coordina-
tor’s supervision. The questionnaire took approximately
10 minutes to complete. The participants surgeon then
completed their section of the questionnaire. The research
coordinator at the clinical site then checked each question-
naire for completeness and entered the questionnaire into
the study’s electronic data capture system.
Data Analysis
Descriptive statistics for continuous variables are present-
ed as means with standard deviations, and categorical vari-
ables are presented as proportions. The primary outcome
was the recommended treatment reported as a categorical
variable. The impact of demographic characteristics on
the prescription of treatment options was analyzed using
logistic regression.
RESULTS
Participant Screening
A total of 807 patients were screened for participation in
this study across the hospitals, of which 93 were deemed
ineligible to participate in the study. The reasons for ineli-
gibility included previous history of TKA in the affected
knee (91 patients) and a fracture of the tibial plateau,
femoral condyle, or patella (2 patients). Ultimately, 714
patients met the eligibility criteria and participated in this
study.
Demographics
The mean age of the included patients was 55.6 years (Table 1).
The majority of patients were female (63.9%) and lived in
urban locations (89.2%). The mean body mass index (BMI)
was 25.6 kg/m2. Most patients made less than Rs300,000
(approximately $4,660) annually (62.2%) and did not have
health insurance (69.3%). Approximately half of the pa-
tients had a comorbid disease at the time of the assessment
(54.2%). Common comorbidities included hypertension
(40.8%), diabetes (24.4%), and osteoporosis (11.8%) Table 1.
Demographics were similar between the government and
private hospitals; however, government hospitals had more
rural patients and patients with lower incomes (p < 0.01).
Medical History of the Affected Knee
The majority of patients presenting with knee pain had
been experiencing pain for less than 1 year (64.8%) (Table
2). Two-thirds of the study participants had bilateral knee
pain (66.0%). Over half of the patients (62.3%) had been
previously diagnosed with knee OA by a clinician, and
most had received this diagnosis within the past year
(62.2%). Kellgren-Lawrence (K-L) grades 1 and 2 were
most common with 35.0% and 31.1% of patients falling in
these categories, respectively. Approximately one third of
the patients had deformities of the knee (33%), with 32.2%
of all patients having a varus deformity. Patients present-
ing to government hospitals were 2.3 times more likely to
have suffered from knee pain for more than 6 years than
patients presenting to a private hospital (p < 0.01).
The majority of patients had previously been pre-
scribed medications (91.6%), supplements (68.6%), and
nonpharmacological (81.9%) treatments to manage their
knee OA (Table 2). The most commonly used medical
treatments were nonsteroidal anti-inflammatory drugs
(69.0%) and topical agents (59.2%). Commonly used sup-
plements included vitamins (35.6%), glucosamine (26.2%),
and chondroitin (14.8%). Over half of the patients had
previously received treatment from physiotherapists
(55.2%). There were multiple differences in the previous
management of knee OA between the patients treated
at a private hospital and those at a government hospital
(Table 2). For example, patients at private hospitals were
more likely than patients at government hospitals to have
been previously treated with medications (range, 84.3% to
92.6%; p < 0.01) and physical treatments (range, 61.8% to
84.8%; p < 0.01). Table 3 summarizes the reported levels
of knee pain and functional limitations between patients
presenting to government and public hospitals.
Recommended Management of Knee OA
At the current clinic visit, almost all patients received a
treatment recommendation for their knee OA (97.8%)
(Table 4). Physicians frequently prescribed oral medica-
tions (83.3%) whereas intra-articular injections of either
HA or corticosteroids were recommended less frequently
(29.8%). Surgical management was recommended to
13.2% of patients, which included TKA (98.9% of recom-
mended surgeries) and unicompartmental knee arthro-
plasty (1.1% of recommended surgeries). The most com-
mon reasons for not recommending surgery were that the
patient’s OA was too mild (44.4%) and that the clinician
prescribed medications or physiotherapy instead (32.1%).
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Table 1. Patient Characteristics
All patients (n = 714) Private hospital (n = 625) Government hospital (n = 89)
Age (yr) 55.6 ± 11.1 55.3 ± 11.3 57.9 ± 9.4
Sex
Male 258 (36.1) 223 (35.7) 35 (39.3)
Female 456 (63.9) 402 (64.3) 54 (60.7)
Body mass index (kg/m2)25.6 ± 3.5 25.2 ± 3.2 27.9 ± 3.9
Residence
Rural 77 (10.8) 52 (8.3) 25 (28.1)
Urban 637 (89.2) 573 (91.7) 64 (71.9)
Language
Hindi 269 (37.7) 233 (37.3) 36 (40.5)
Marathi 260 (36.4) 260 (41.6) 0
Punjabi 64 (9.0) 18 (2.9) 46 (51.7)
Tulu 39 (5.5) 39 (6.2) 0
English 35 (4.9) 35 (5.6) 0
Gujrati 15 (2.1) 15 (2.4) 0
Tamil 14 (2.0) 14 (2.2) 0
Bengali 9 (1.3) 8 (2.3) 1 (1.1)
Other 9 (1.3) 3 (0.5) 6 (6.7)
Income (Rs)
< 50,000 8 (1.1) 08 (9.5)
50,001–100,000 30 (4.2) 13 (2.1) 17 (20.2)
100,001–300,000 291 (40.8) 262 (41.9) 29 (34.5)
300,001–500,000 178 (24.9) 156 (25.0) 22 (26.2)
> 500,000 22 (3.1) 14 (2.2) 8 (9.5)
Unknown 17 (2.4) 15 (2.4) 2 (2.2)
Refused to answer 168 (23.5) 165 (26.4) 3 (3.7)
Health insurance
None 495 (69.3) 435 (69.6) 60 (67.4)
Private 149 (20.9) 136 (21.8) 13 (15.6)
Government 70 (9.8) 54 (8.6) 16 (18.0)
Comorbidity
None 327 (45.8) 284 (45.4) 43 (48.3)
Hypertension 291 (40.8) 253 (40.5) 38 (42.7)
Diabetes 174 (24.4) 166 (26.6) 8 (9.0)
Osteoporosis 84 (11.8) 84 (13.4) 0
Thyroid disorder 28 (4.9) 23 (7.1) 5 (5.6)
Heart 25 (3.5) 25 (4.0) 0
Lung 11 (1.5) 10 (1.6) 1 (1.1)
Neurological 3 (0.4) 3 (0.5) 0
Kidney 2 (0.3) 2 (0.3) 0
Gastrological 2 (0.3) 02 (2.2)
Infection 1 (0.1) 01 (1.1)
Cancer 1 (0.1) 1 (0.2) 0
Coagulopathy 000
Liver 000
Other 5 (0.7) 3 (0.5) 2 (2.2)
Smoking status
Never smoked 614 (86.0) 534 (85.4) 80 (90.0)
Current smoker 59 (8.3) 57 (9.1) 2 (2.2)
Ex-smoker 37 (5.2) 31 (5.0) 6 (6.7)
Unknown 4 (0.5) 3 (0.5) 1 (1.1)
Other joints with OA
No other OA 661 (92.6) 576 (92.2) 85 (95.5)
Lower back 47 (6.6) 47 (7.5) 0
Hand 7 (1.0) 4 (0.6) 3 (3.4)
Hip 4 (0.6) 4 (0.6) 0
Values are presented as mean ± standard deviation or number (%).
OA: osteoarthritis.
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Table 2. Disease Characteristics
All patients (n = 714) Private hospital (n = 625) Government hospital (n = 89)
Duration of knee pain (yr)
< 1 463 (64.8) 425 (68.0) 38 (42.7)
1–5 202 (28.3) 170 (27.2) 32 (35.9)
6–10 37 (5.2) 26 (4.2) 11 (12.4)
> 11 12 (1.7) 4 (0.6) 8 (9.0)
Affected knee
Left 130 (18.2) 112 (17.9) 18 (20.2)
Right 113 (15.8) 104 (16.6) 9 (10.1)
Bilateral 471 (66.0) 409 (65.5) 62 (69.7)
Diagnosed with knee OA
Yes 445 (62.3) 389 (62.2) 56 (62.9)
No 269 (37.7) 236 (37.8) 33 (37.1)
Time since OA diagnosis (yr)
< 1 277 (62.2) 252 (64.8) 25 (44.6)
1–5 146 (32.8) 127 (32.6) 19 (33.9)
6–10 19 (4.3) 8 (2.1) 11 (19.6)
> 11 3 (0.7) 2 (0.5) 1 (1.8)
Kellgren-Lawrence grade
0 5 (0.7) 4 (0.8) 1 (1.1)
1 250 (35.0) 222 (42.1) 28 (31.5)
2 222 (31.1) 204 (38.7) 18 (20.2)
3 106 (14.8) 74 (14.0) 32 (36.0)
4 33 (4.6) 23 (4.4) 10 (11.2)
Deformity
No visible deformity 478 (67.0) 403 (64.5) 75 (84.3)
Varus 230 (32.2) 216 (34.6) 14 (15.7)
Knee effusion 6 (0.8) 6 (0.9) 0
Recurvatum 000
Previous medication
Other NSAID 493 (69.0) 433 (69.3) 60 (67.4)
Topical agent 424 (59.2) 424 (67.8) 0
Acetaminophen 181 (25.3) 147 (23.5) 34 (38.2)
None 60 (8.4) 46 (7.4) 14 (15.7)
Corticosteroid 41 (5.7) 34 (5.4) 7 (7.9)
Ibuprofen 30 (4.2) 21 (3.4) 9 (10.1)
Aspirin 8 (1.1) 1 (0.2) 7 (7.9)
Cox-2 5 (0.7) 3 (0.5) 2 (2.2)
Other 5 (0.7) 4 (0.6) 1 (1.1)
Previous supplement use
Vitamins 254 (35.6) 246 (42.2) 8 (9.0)
None 224 (31.4) 191 (30.6) 33 (37.1)
Glucosamine 187 (26.2) 133 (21.3) 54 (60.7)
Chondroitin 106 (14.8) 99 (15.8) 7 (7.9)
Calcium carbonate 40 (5.6) 39 (6.2) 1 (1.1)
Methylsulfonylmethane 6 (0.8) 6 (1.0) 0
Other 46 (6.4) 45 (7.2) 1 (1.1)
Previous physical treatment
Physiotherapy 394 (55.2) 376 (60.2) 18 (20.2)
Ice or heat 166 (23.2) 141 (22.6) 25 (28.1)
Exercise 130 (18.2) 88 (14.1) 42 (47.2)
None 129 (18.1) 95 (15.2) 34 (38.2)
Relaxation technique 73 (10.2) 63 (10.1) 10 (11.2)
Splint 69 (9.7) 63 (10.1) 4 (4.5)
Diet 28 (3.9) 12 (1.9) 16 (18.0)
Yoga 7 (1.0) 07 (7.9)
Arthroscopy 6 (0.8) 6 (1.0) 0
Massage 5 (0.7) 05 (5.6)
Other 2 (0.3) 02 (2.2)
Values are presented as number (%).
OA: osteoarthritis, NSAID: nonsteroidal anti-inflammatory drug, Cox-2: cyclooxygenase inhibitors.
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Overall, approximately 10% of patients lacked resources to
pay for arthroplasty: 8.8% of patients at private hospitals
lacked the resources to pay for surgery compared to 18.8%
of patients at government hospitals (p < 0.01). Surgeons
were also asked if they would consider an implantable
joint-unloading prosthesis as an alternative treatment, and
approximately half (49.2%) of surgeons felt it would be an
acceptable alternative. At the time of their clinic visit, over
half of the surgeons (56.2%) indicated that they would also
consider other surgical options such as knee realignment
surgery.
Factors Associated with Prescribing Different
Treatments
Prescription of oral medications was related to younger
age, lack of deformities, and lower K-L grades (p < 0.01)
(Table 5). Intra-articular injection prescription was associ-
ated with the patient having health insurance (p < 0.01).
The recommendation of surgical interventions (realign-
ment surgery) and TKA was related to higher K-L grades
(p < 0.01). Increased prescription of oral medications in
government hospitals approached statistical significance (p
= 0.0232), whereas the increased likelihood of a surgeon to
prescribe surgery in private hospitals approached statisti-
cal significance (p = 0.0171).
DISCUSSION
Our findings suggest early knee OA care in India is simi-
lar to that in North America. Interesting similarities and
differences are evident when we compare the treatment
recommendation data in India collected for the current
study with that published in a recent study of 537 patients
who presented with knee OA to an orthopaedic service in
the United States.8) In the present study, 83.3% of patients
in India were prescribed oral medications, which is highly
comparable to 82.1% using any form of pain medication
for the treatment of knee OA in the US.8) When compar-
ing intra-articular injections, 55.4% of US patients had
received injections while in the present study only 29.8%
Table 3. Level of Pain and Functional Limitation
Characteristic All patients (n = 714) Private hospital (n = 625) Government hospital (n = 89)
Knee pain when
Walking long distance 670 (93.8) 589 (94.2) 81 (91.0)
Transitioning from seated to standing 653 (91.5) 579 (92.6) 74 (83.1)
Standing 548 (76.7) 502 (80.3) 46 (51.7)
Sitting 426 (59.7) 391 (62.6) 35 (39.3)
Walking short distance 359 (50.3) 323 (51.7) 36 (40.4)
Sleeping 167 (23.4) 134 (21.4) 33 (37.1)
Lying down 112 (15.7) 77 (12.3) 35 (39.3)
Avoid using stairs because of knee pain 584 (81.8) 510 (81.6) 74 (83.1)
Knee stiffness when waking in the morning 462 (64.7) 392 (62.7) 70 (78.6)
Knee pain limits daily activity 335 (46.9) 271 (43.4) 64 (71.9)
Ambulatory aid
None 650 (91.0) 574 (91.8) 76 (85.4)
Cane 56 (7.7) 48 (7.7) 8 (9.0)
Walker 4 (0.6) 2 (0.3) 2 (2.2)
Crutch 2 (0.3) 2 (0.3) 0
Knee cap 2 (0.3) 02 (2.2)
Wheelchair 1 (0.1) 01 (1.1)
Values are presented as number (%).
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of patients in India were prescribed knee injections.8) In
the current study, surgeons recommended that 12.7% of
patients receive surgical management of their knee OA,
which is comparable to patients presenting with consistent
knee pain in the US, where 8.8% received TKA.9)
The majority of patients included in this large cross-
sectional study had been experiencing knee pain for less
than a year and had a K-L grade of 1 or 2. Almost all
patients had previously been treated with medications
(91.6%) and/or some form of nonpharmacological treat-
ment (81.9%). Over two-thirds (69.3%) of the patients did
not have medical insurance. This suggests that patients in
India are being seen by a specialist and are receiving medi-
cal care in the early stages of OA, which goes against the
common perception that patients in India do not receive
medical treatment for early stage OA and thus eventually
present with advanced stages of OA.
Several important differences were found between
private and government hospitals. As expected, govern-
ment hospitals saw more rural patients and patients with
lower incomes (p < 0.01). Patients presenting to govern-
ment hospitals were 2.3 times more likely to have suffered
from knee pain for more than 6 years than patients pre-
senting to a private hospital (p < 0.01). At private hospitals,
8.8% of patients lacked the resources to pay for surgery
compared to 18.8% of patients at government hospitals (p
Table 4. Prescribed Treatment
Recommended treatment All patients (n = 714) Private hospital (n = 625) Government hospital (n = 89)
No treatment 16 (2.2) 15 (2.4) 1 (1.1)
Nonsurgical
Oral medication 595 (83.3) 517 (48.9) 77 (12.5)
Knee injection/viscosupplementation 213 (29.8) 189 (31.0) 24 (27.3)
Physiotherapy 2 (0.3) 2 (0.3) 0
Bracing 1 (0.1) 01 (1.1)
Surgical
Total knee arthroplasty 94 (13.2) 80 (12.8) 14 (15.9)
Unicompartmental knee arthroplasty 90 (12.6) 76 (12.2) 14 (15.9)
Arthroscopy 1 (0.1) 1 (0.2) 0
Arthroplasty 3 (0.4) 3 (0.5) 0
High tibial osteotomy 0 0 0
Reason for not recommending surgery
OA too mild 317 (44.4) 275 (44.0) 42 (47.2)
Medical management and/or physiotherapy prescribed 229 (32.1) 229 (36.6) 0
Patient lacks resources to pay 71 (9.9) 55 (8.8) 16 (18.0)
Patient too young 24 (3.4) 7 (1.1) 17 (19.1)
Patient does not have OA 19 (2.7) 19 (3.0) 0
Patient unwilling/not suited 14 (2.0) 6 (1.0) 8 (9.0)
Consideration of implantable joint-unloading
prosthesis as a potential treatment
Yes 351 (49.2) 351 (56.2) 0
No 363 (50.8) 274 (43.8) 89 (100)
Values are presented as number (%).
OA: osteoarthritis.
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< 0.01). The prescription of oral medications and surgical
intervention both approached statistical significance when
compared between 2 hospital types: patients at govern-
ment hospitals were more likely to be prescribed oral med-
ications and patients at private hospitals were more likely
to be recommended for surgical management. Patients at
private hospitals were more likely to be recommended for
surgery despite knee pain that lasted for a shorter period
of time, which may suggest a disparity in the management
of OA between private and public hospitals. When explor-
ing relationships between demographic variables and pre-
scribed treatments for patients, several associations were
identified. Firstly, the prescription of oral medications was
associated with younger age, the absence of deformities,
and lower K-L grades, which is consistent with current
treatment recommendations.10) Secondly, the prescription
of intra-articular injections was related to patients having
insurance coverage as opposed to no coverage. The higher
prescription rate of intra-articular injections to patients
with health insurance is likely be related to the high cost of
injections, and clinicians may be less willing to prescribe
the intervention to patients who are paying for the treat-
ment themselves.11) Thirdly, the prescription of surgical in-
terventions was associated with higher K-L grades, which
is also consistent with treatment guidelines and signifies
that surgical intervention is not considered as an option
unless severe OA is present.10)
This study is limited by the context of the study de-
sign. The present study is a cross-sectional evaluation of
patient demographics and treatment decisions, which is
useful for identifying relationships between variables but
not for determining outcomes or causality.12) The utiliza-
tion of a cohort study to examine outcomes of treatment
options based on demographic information may be valu-
able for examination in future research. Also, the results
of this study are limited to patients with OA in India, and
may not be generalizable to other low and middle income
nations. The results are further limited by the inclusion of
patients only presenting with knee pain, and may not be
generalizable to patients with other knee-related injuries.
Moreover, another possible limitation was the inclusion of
5 participants with a K-L grade of 0, as knee pain in these
participants may have been due to another pathology in-
cluding anterior knee pain syndrome or a meniscus tear.
However, in all 5 cases, the attending surgeon diagnosed
low grade OA despite minimal radiological changes.
Lastly, we used a nonvalidated questionnaire with our
own criteria to assess levels of pain and functional limita-
tions. Additionally, weight reduction was not included as
a nonpharmacological intervention in the questionnaire.
Table 5. Treatment Decisions and Related Variables
Treatment decision Characteristic*
t
-value
p
-value
No intervention No related characteristics
Oral medication Age (18 yr88 yr) –2.91 0.0039
Deformities (no deformitiesdeformities) –2.79 0.0056
K-L grade (04) –5.05 < 0.0001
IA injection Insurance coverage (noyes) 3.51 0.0005
Knee replacement surgery K-L grade (04) 11.43 < 0.0001
Knee realignment surgery Body mass index (14 kg/m241 kg/m2)–4.80 < 0.0001
Setting (ruralurban) 2.69 0.0074
Income (< Rs50,000> Rs500,000) 3.29 0.0011
Insurance coverage (noyes) –9.51 < 0.0001
OA length of diagnosis (< 1 yr> 11 yr) –3.58 0.0004
Deformities (noyes) –5.88 < 0.0001
Hospital type (privategovernment) –5.83 < 0.0001
IA: intra-articular, K-L: Kellgren-Lawrence.
*Only significant characteristics are shown for each treatment decision. Positive
t
-value indicates increased likelihood of prescription of treatment along the
respective characteristic. Negative
t
-value indicates decreased likelihood of prescription of treatment along the respective characteristic.
294
Sancheti et al. Management of Knee Pain and Early Osteoarthritis in India
Clinics in Orthopedic Surgery Vol. 9, No. 3, 2017 www.ecios.org
However, this study is strengthened by the large sample
size, inclusion of the three clinical sites in India, rigorous
development of the study questionnaire, and high quality
data collection.
In conclusions, this large cross-sectional study
found that most patients in India are receiving early medi-
cal management of OA despite not having insurance and
that the treatment patterns are similar to those seen in the
US. In addition, key differences were identified between
treatment in government and private hospitals, which may
lead to a discrepancy in care.
CONFLICT OF INTEREST
This study was funded by a grant from Moximed Inc.
(Hayward, CA, USA). The funder contributed to the de-
velopment of the study protocol and reviewed the results
and manuscript, but played no role in the conduct of the
st udy.
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Knee osteoarthritis is a common but often difficult problem to manage in primary care. Traditional nonsurgical management, consisting of lifestyle modification, physical therapy and pharmacologic therapy (e.g., analgesics, anti-inflammatory medications), is often ineffective or leaves residual symptoms. Viscosupplementation is a newly available option for patients with symptomatic knee osteoarthritis that involves a series of intra-articular injections of hyaluronic acid. The exact mechanism of action is unclear, although increasing the viscoelasticity of the synovial fluid appears to play a role. Clinical experience and studies of the two hyaluronic acid products available, hyaluronan and hylan G-F 20, are inconclusive but seem to indicate beneficial effects with minimal adverse reactions in a significant number of patients. The exact indications for viscosupplementation are still evolving, but it currently can be considered for use in patients who have significant residual symptoms despite traditional nonpharmacologic and pharmacologic treatments. In addition, patients who are intolerant of traditional treatments (e.g., gastrointestinal problems related to anti-inflammatory medications) can be considered for these injections. Family physicians with the ability to perform intra-articular knee injections should consider them an option in patients with symptomatic knee osteoarthritis.
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