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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 3  |  Page : 795-799

The effect of metabolic syndrome on patients with knee osteoarthritis


1 Department of Rheumatology, Physical Medicine and Rehabilitation, Faculty of Medicine, Zagazig University, Zagazig, Egypt
2 Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission16-Apr-2017
Date of Acceptance02-Jul-2017
Date of Web Publication31-Dec-2018

Correspondence Address:
Wafaa A Fadel
Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_250_17

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  Abstract 


Objective
The aim was to study the effect of metabolic syndrome (MS) on the severity of knee osteoarthritis (OA), as well as its association with generalized OA.
Background
Knee OA is a major cause of disability. Studies suggested that metabolic factors may have a negative effect on cartilage and may play a role in the pathogenesis of OA.
Patients and methods
A total of 60 patients with primary knee OA were divided into two groups: group I included patients with knee OA and MS and group II included patients with knee OA and without MS. Both groups were matched regarding age, disease duration, and MS (BMI). All were subjected to demographic data, blood pressure measurement, waist circumference, BMI, laboratory investigations, knees and hands radiograph, disease severity assessment by Lequesne functional index, and radiological Kellgren and Lawrence score.
Results
Group I patients were significantly more affected with varus deformity, flexion deformity, and tenderness over knee joint line and hand OA than group II patients. Radiologic findings revealed higher grades of Kellgren and Lawrence score grading system in group I patients than group II. The patellofemoral OA showed significantly higher mean in group I than in group II. The total functional score of Lequesne for knee OA showed significantly higher mean in group I (P < 0.001).
Conclusion
MS in patients with knee OA is associated with more severe clinical signs, progressive radiological damage, severe grades of functional disability, and more frequent affection with generalized OA in comparison with patients with OA without MS.

Keywords: generalized osteoarthritis, knee osteoarthritis, Lequesne functional index, metabolic syndrome, radiological Kellgren and Lawrence score


How to cite this article:
Al Hewala AE, Soliman SG, El Sharaqi DR, Fadel WA. The effect of metabolic syndrome on patients with knee osteoarthritis. Menoufia Med J 2018;31:795-9

How to cite this URL:
Al Hewala AE, Soliman SG, El Sharaqi DR, Fadel WA. The effect of metabolic syndrome on patients with knee osteoarthritis. Menoufia Med J [serial online] 2018 [cited 2019 Jan 24];31:795-9. Available from: http://www.mmj.eg.net/text.asp?2018/31/3/795/248734




  Introduction Top


Osteoarthritis (OA) is the most common chronic degenerative joint disease that causes disability and handicap, which leads to a decline in physical function[1].

OA is defined as a common complex disorder with multiple risk factors. These risk factors can broadly be divided into genetic factors and constitutional factors[2].

OA has different causes but with similar pathological and clinical outcomes. OA affects the articular cartilage and also the entire joint, including the subchondral bone, ligaments, capsule, synovial membrane, and periarticular muscles[3].

Cardiovascular risk factors (e.g., dyslipidemia, hypertension, diabetes, and abdominal obesity) commonly cluster together. This clustering is called metabolic syndrome (MS)[4].

OA development has been associated with parameters of MS: dyslipidemia, type 2 diabetes and central obesity, and hypertension; this may explain the increased overall and cardiovascular mortality seen in those with both MS and symptomatic knee OA[5].

Not only is MS associated with a high risk of developing severe symptomatic knee OA[6] but it is also associated with hand OA, particularly erosive hand OA[7].

C-reactive protein (CRP), a marker of low-grade systemic inflammation and an important cardiovascular risk factor, is commonly elevated with MS, and increased CRP levels have been found in patient with incident knee OA, progressive knee OA, and erosive hand OA[8].

Our present study was designed to assess the metabolic factors (associated with higher cardiovascular risk) in patients with knee OA and to compare knee OA severity in patients with and without MS as well as its association with generalized OA.


  Patients and Methods Top


The study was done by Physical Medicine, Rheumatology and Rehabilitation Department in collaboration with Clinical Pathology Department.

This study got approval from the ethics committee, and all patients gave an informed and written consent.

Patients

A total of 60 patients diagnosed as having primary knee OA according to the American College of Rheumatology clinical criteria for knee OA[9] with age more than 35–55 years old and disease duration more than 2 years were included. Patients were divided into two groups: group I included 30 patients experiencing knee OA and MS (according to the MS definition of National Cholesterol Education Program Adult Treatment Panel III, 2002)[4] and group II included 30 patients having knee OA without MS.

Exclusion criteria included the following: patients with traumatic or inflammatory arthritis, postmenopausal female patients with OA, patients currently receiving physiotherapy for knee, patients having serious cardiovascular and/or pulmonary disease, and patients having autoimmune or rheumatic diseases. All patients were subjected to the following: demographic data, clinical assessment, medical history, clinical examination, and general examination including chest, heart, abdomen, and locomotion system findings. Joints were examined.

Methods

Disease functional assessment was done by the Lequesne Algofunctional knee OA index (LAI)[10]. Basically, the LAI includes three sections with a total of 24 points. The first section addresses pain and discomfort (eight points), the second section addresses walking distance (eight points), and the third section addresses activities of daily living (eight points). According to the total score of Lequesne index, the degree of disability is as follows: extremely severe = 14, very severe = 11–13, severe = 8–10, moderate = 5–7, and minor = 1–4.

Laboratory investigations

Laboratory findings included fasting blood sugar[11], serum levels of triglycerides (mg/dl), high-density lipoprotein cholesterol (mg/dl)[11], and CRP[12].

Radiographic assessment

Plain radiographs of both knees [anteroposterior (A/P), lateral, and sky line views] and hands (A/P view) were taken. The knee (A/P) radiographs were graded according to Kellgren and Lawrence (K/L) grading system[13] and lateral and sky line views were analyzed for detection of patellofemoral OA.

Statistical analysis

The data collected were tabulated and analyzed by statistical package for the social sciences version 22.0 on IBM compatible computer (SPSS Inc., Chicago, Illinois, USA).

The following two types of statistics were done.

Descriptive statistics

In descriptive statistics, quantitative data were presented in the form of mean, SD, and range, and qualitative data were presented in the form of numbers and percentages.

Analytical statistics

χ2-teat: it was used to study the association between two qualitative variables.

Fischer's exact test: it was used for 2 × 2 tables when expected cell count of more than 25% of cases were less than 5.

Student's t-test: it is a test of significance used for comparison between two groups having quantitative variables.

Mann–Whitney U-test (nonparametric test): it is a test of significance used for comparison between two groups not normally distributed having quantitative variables.

Pearson's correlation (r): it is a test used to measure the association between two quantitative variables.

P value greater than 0.05 was considered nonsignificant.

P value less than 0.05 was considered significant.

P value less than 0.001 was considered statistically highly significant.


  Results Top


In this work, there was no significant difference between both groups in terms of age, disease duration, BMI, and specific occupational risk factors for knee OA, as shown in [Table 1].
Table 1: Demographic data of studied patients

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Clinically, patients with MS (group I) were significantly more frequently affected with varus deformity (P = 0.01), flexion deformity (P = 0.04), tenderness over joint line (P = 0.0001), hand pain or crepitus (P = 0.02), and Heberden's or Bouchard's nodes (P = 0.01) than patients in group II. Knee effusion and morning stiffness were more frequent in group I than group II patients, but it did not reach the significance level as shown in [Table 2].
Table 2: Comparison of clinical signs between studied groups

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Radiologically, group I patients had significantly lower mean joint space width of medial tibiofemoral compartment than group II (P = 0.0001), as shown in [Table 3]. All patients of group I had patellofemoral OA (100%) compared with 80% of group II (P = 0.02), as shown in [Table 3], and they were significantly more frequent in grades 3 and 4 and less frequent in grades 1 and 2 of K/L grading system than group II patients (P = 0.02), as shown in [Table 3].
Table 3: Comparison of radiographic signs between studied groups

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Patients of group I had significantly higher mean total score of LAI for knee OA, and more patients of group I had severe and extremely severe degrees of handicap than group II patients [Table 4].
Table 4: Comparison between studied groups regarding Lequesne index

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In our study, diabetes and waist circumference were positively correlated with radiological K/L grades of knee OA and total functional score of Lequesne; moreover, triglycerides level was significantly positively correlated with total functional score of Lequesne, whereas high-density lipoprotein cholesterol showed negative correlation with K/L grades or total functional score [Table 5].
Table 5: Correlation between radiological Kellgren and Lawrence score grades, total functional score of Lequesne, and diagnostic criteria of metabolic syndrome

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Group I patients had significantly higher percentage of symptomatic (P = 0.0001) and radiographic hand OA (P = 0.002) than group II patients, as shown in [Table 6]. Moreover, positive CRP test was more significantly found in group I than group II patients (P = 0.04), as shown in [Table 6].
Table 6: Comparison of hand osteoarthritis and C-reactive protein in studied groups

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  Discussion Top


OA, the most common joint disease, is a degenerative disorder that results from the biochemical breakdown of articular cartilage in the synovial joints. Although OA is thought to occur largely owing to excessive wear and tear, secondary nonspecific inflammatory changes may also affect the joints, as stated by Stacy[14] and Kluzek et al.[3].

Yoshimura et al.[15] confirmed the role of MS in the pathomechanism of knee OA. The intimate relationship between knee OA and metabolic effect of these comorbidities, such as hypertension and type 2 diabetes, on the severity of knee OA and the progression of disease of knee OA significantly increased according to the number of MS components present.

A recent study performed by Wang et al.[16] found that MS was significant associated with a higher prevalence of hand OA.

In our study, there was no significant difference between both groups in age, disease duration, BMI, and specific occupational risk factors for knee OA; thus, the difference between groups was in presence (group I) or absence (group II) of the metabolic factors.

Clinically, the results of the present study revealed that patients with knee OA and MS were significantly more frequently affected with varus deformity, flexion deformity, and tenderness over knee joint line than patients without MS. Patients with knee OA and MS also were more frequently affected with knee effusion but without reaching the significance level. Our study had similar results as reported by Korochina and Bagirova[8].

Radiologic findings in our study revealed higher grades of K/L grading system in group I patients compared to group II. In accordance, Shin[17] performed a study on 2363 patients with knee OA. He found a higher significant association between MS and radiographic knee OA K/L score. A study performed by El Said et al.[18] also agreed with our result. They found a highly significant association between MS and K/L score.

In our present study, the total functional score of Lequesne for knee OA showed significantly higher mean. Moreover, we found higher percentage of extremely severe and very severe degrees of disability for Lequesne functional Index in group I than group II. This was in agreement with Haj Hamad et al.[19] who performed a study on 49 patients with knee OA and MS and found a significant relation (P = 0.04) between MS patients and the total functional score and degrees of disability of Lequesne for knee OA.

The results of our study also revealed that the occurrence of generalized OA (hand pain or crepitus and Heberden's or Bouchard's nodes and radiological hand OA) is significantly more in patients of group I than group II. These results are concomitant with Korochina and Bagirova[8]who performed a study on 1350 patients with knee OA, and they found a higher prevalence of hand OA in knee patients with OA with MS than those free from MS.

This is in accordance with Dahaghin et al.[20] and Wang et al.[16], as their studies concluded that MS was significantly associated with a higher prevalence of hand OA.

In our study, we found significantly more patients in group I have positive CRP test result compared with group II. This may explain the increased disease activity in group I.

This was also in agreement with Sharif et al.[21] who performed a study on 90 patients and they found that serum CRP was predictive of knee OA progression.

Punzi et al.[5] performed a study on 98 patients (67 with erosive OA and 31 with nonerosive OA). They have demonstrated that CRP levels are higher in patients with erosive OA than in those with nonerosive OA. The increase of high-sensitivity CRP level in erosive OA confirms the presence of inflammatory activity in this form of arthropathy and the possibility that a severe local injury such as OA also has a systemic component.

Inflammation plays a pivotal role in the metabolic dysfunctions that trigger heart disease, and CRP is a specific marker that gauges the effect of this systemic inflammation on the body. Recent evidence has found increased levels of CRP in patients with early knee OA. Researchers have noted that CRP has been shown to predict both the incidence and progression of OA[22].


  Conclusion Top


The presence of the MS in patients with knee OA is associated with more severe clinical signs, more progressive radiological damage, more severe grades of functional disability, and more frequent affection with generalized OA compared with patients with osteoarthritic without MS. The control of these metabolic factors may hinder progression of knee OA.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Stacy GS. Osteoarthritis, primary. eMedicine: The Medscape Journal of Medicine. Available from: http://www.medscape.com/px/trk.svr/emedsearch?extur|=http://emedicine.2007medscape.com/article/392096-overview. [Last accessed on 2017 Jan].  Back to cited text no. 14
    
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Sharif M, Shepstone L, Elson CJ, Dieppe PA, Kirwan JJR. Increased serum C reactive protein may reflect events that precede radiographic progression in osteoarthritis of the knee. Ann Rheum Dis 2000; 59:71–74.  Back to cited text no. 21
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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