Introduction
Knee osteoarthritis is a common type of arthritis characterized by cartilage loss, joint space narrowing, osteophyte formation, synovitis, and subchondral osteosclerosis, and it can cause knee joint stiffness, pain, and limited mobility. As KOA is one of the most disabling diseases, it is estimated that more than 10% of people older than 60 years are affected by this disease. Pain, disability pensions and arthroplasty have caused significant burdens on individuals and society [
1‐
3]. Despite the increasing sophistication in the treatment and management of KOA, there are still patients suffering from pain and a low quality of life. This is why it is important to determine what factors influence the occurrence and development of KOA.
Many factors can influence the progression of KOA to varying degrees. These include age-related cartilage degeneration, sex-related metabolism and regulatory differences, genetic and racial differences in cartilage formation, body mass index (BMI)-related cartilage wear, and other factors, such as medical interventions, comorbidities, and differences in income, diet, and lifestyle [
4‐
10]. As mentioned above, the progression of KOA is closely associated with cartilage loss and is characterized by clinical signs and symptoms such as decreased mJSW score on imaging, pain, and limited daily living [
3].
To better treat and manage KOA, much research has been conducted. Moreover, Campbell showed that ipsilateral knee flexion contracture is associated with worsening of contralateral knee function and contracture [
11], and Metcalfe indicated that 80% of unilateral KOA cases develop into bilateral KOA within 12 years [
12]. These studies indicate that one knee may be affected by osteoarthritis in the contralateral knee and progress to osteoarthritis. However, when one knee already has osteoarthritis, it is not yet clear whether its progression is affected by contralateral KOA. Because bilateral KOA (5%) is more common than unilateral KOA (2%) in the clinic [
13], it is essential to determine whether the progression of KOA is influenced by contralateral knees with osteoarthritis. In our study, we evaluated the progression of knee osteoarthritis by mJSW and the future arthroplasty rate because they reflect the amount of cartilage and the severity of osteoarthritis, respectively.
Discussion
The articular cartilage of the knee is a thin layer of special connective tissue with good viscosity and elasticity that can significantly decrease the friction coefficient of the articular surface of the knee [
23]. In addition, special material properties enable the cartilage to withstand high contact forces. Moreover, it also forms a dynamic bearing structure with the subchondral bone and disperses the force it receives to the subchondral bone to protect the knee well [
24]. Therefore, it is difficult to ignore the role of articular cartilage in studies on KOA. Giuseppe Musumeci et al. indicated that, whether the damage is caused by inflammatory and metabolic factors or mechanical wear, the target of damage in KOA patients is articular cartilage [
25], and an important index for evaluating cartilage loss is the joint space on imaging [
3]. In our study, through a strict research design, we found that knees with osteoarthritis have a greater mJSW decrease and greater incidence of future KA when the contralateral knee also has osteoarthritis. Similarly, Wirth et al. included one hundred twenty participants and followed up for four years and reported a greater quantity of articular cartilage loss in a knee with osteoarthritis when the contralateral knee suffered from osteoarthritis by evaluating cartilage thickness changes on MRI images of the knee [
26]. Eckstein F et al. also reported that the speed of articular cartilage loss is quicker when the contralateral knee has severe osteoarthritis than when the contralateral knee has earlier osteoarthritis through one year and four years of follow-up of one hundred fifty participants [
27]. A greater degree of articular cartilage loss indicates more severe and frequent pain and activity difficulty, and the failure of two knees causes a vicious cycle, leading to a worse outcome [
28].
Differ from previous studies which don’t differentiate the side of the knee or just select a more severe or less severe side to study, and conclude a normal knee is easier affected and becomes worse when the contralateral knee has osteoarthritis [
12,
29,
30]. Our study divided right and left knees into two cohorts, and each cohort was divided into two groups, making this research more rigorous than them. There are also some papers that have evaluated the severity of KOA through cartilage change, but they did not balance the variables in baseline demographics that have an effect on the target knee, making the conclusion less convincing [
31‐
34]. In our study, PSM was used to balance all covariates according to the baseline demographics of the two groups. Factors that can influence the development of KOA were not significantly different between the two groups. The only difference between the two groups was whether the patient had osteoarthritis in the contralateral knee. This could greatly reduce the interference of confounding factors. In the data selection, we strictly followed the inclusion and exclusion criteria and deleted data that did not meet the criteria. The covariates we selected have already been confirmed to be the main risk factors affecting the development of KOA through published studies.
There are also several limitations in our study. First, although the use of PSM to balance covariates among baseline demographic variables has made our conclusions more convincing, it also brings limitations. Here may still be some variables that have an impact on the development of KOA that we have not included, such as a history of lower limb trauma and the use of sodium hyaluronate treatment through intra-articular injection [
35,
36]. This means that we did not balance these variables, and they may influence the accuracy of the conclusions we obtained [
37]. Second, due to limitations in terms of the data and participants involved in the OAI, we considered only the variables mentioned above and variables such as the CCI and medicine, including many additional subdivided items such as heart disease and diabetes in the CCI, nonsteroidal anti-inflammatory drugs (NSAIDs), and salicylic acid in medicine. The follow-up date was also limited to two or four years because of the fixed follow-up date. In addition to variable selection, uncontrollable factors, such as changes in gait pattern, load force of the knee joint, and decreases in physical activity, cannot be ignored. These changes can lead to adaptive changes in the hip and ankle and further impact the ipsilateral and contralateral knee through joint interaction with the lower limbs [
38‐
40], these changes may also influence the accuracy of our results and conclusions. Finally, a retrospective study has several limitations itself, the most important point is that our conclusions cannot be applied to the clinical diagnosis and treatment of KOA directly in patients aged less than forty-five years and more than seventy-nine years. However, additional support from similar studies is needed, especially for prospective randomized controlled trials. Nevertheless, our study clarified the relationship between the progression of KOA on one side and contralateral KOA.
Conclusions
Knee with osteoarthritis had lower minimum joint space width and higher future arthroplasty rate when the contralateral knee was also had osteoarthritis compared with not. These findings will be of great help in the management and treatment of patients with bilateral KOA, which is more common in clinical practice. Therefore, we recommend paying more attention to patients who have osteoarthritis in both knees. This includes close monitoring and regular follow-up to observe any changes in the disease. Early intervention on one knee with osteoarthritis, such as rehabilitation, functional exercise, drugs, or surgical treatment, if indicated, can delay the development of osteoarthritis in the other knee. These methods have significant clinical value in terms of pain relief and improvement in quality of life.
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