Osteoarthritis in the UK Armed Forces: a review of its impact, treatment and future research

Abstract

Within the UK Armed Forces, musculoskeletal injuries account for over half of all medical downgrades and discharges. Data from other Armed Forces show that osteoarthritis (OA), more common in military personnel, is likely to contribute to this, both in its primary form and following injury (post-traumatic OA, PTOA), which typically presents in the third or fourth decade. OA is not a progressive ‘wear and tear’ disease, as previously thought, but a heterogenous condition with multiple aetiologies and modulators, including joint damage, abnormal morphology, altered biomechanics, genetics, low-grade inflammation and dysregulated metabolism. Currently, clinical diagnosis, based on symptomatic or radiological criteria, is followed by supportive measures, including education, exercise, analgesia, potentially surgical intervention, with a particular focus on exercise rehabilitation within the UK military. Developments in OA have led to a new paradigm of organ failure, with an emphasis on early diagnosis and risk stratification, prevention strategies (primary, secondary and tertiary) and improved aetiological classification using genotypes and phenotypes to guide management, with the introduction of biological markers (biomarkers) potentially having a role in all these areas. In the UK Armed Forces, there are multiple research studies focused on OA risk factors, epidemiology, biomarkers and effectiveness of different interventions. This review aims to highlight OA, especially PTOA, as an important diagnosis to consider in serving personnel, outline current and future management options, and detail current research trends within the Defence Medical Services.

Current status of catabolic, anabolic and inflammatory biomarkers associated with structural and symptomatic changes in the chronic phase of post-traumatic knee osteoarthritis– a systematic review

“…2 ), and this remains an important unanswered question requiring further attention, as do the relative change in biomarker concentration over time. Longitudinal studies, such as those cited in this review [ 37 , 39 , 40 ] and elsewhere [ 8 ], offer an opportunity for this.…”

“…The single study with different pathology, combat-related traumatic amputation [ 40 ], had the most significant changes in serum biomarkers. It is possible that this could be related to the systemic response following trauma, and the influence of this on PTOA and biomarker concentrations should be explored [ 8 ].…”

“…Biomarkers have a wide range of potential applications, including for disease-modifying OA drug (DMOAD) trials, for the targeted identification and recruitment of those with high-risk progressive OA and as outcome measures alongside existing measures including joint space narrowing and pain scores [ 6 , 7 ]. In addition, clinical use of biomarkers will allow early, pre-symptomatic identification of disease activity, allow commencement of preventative measures, and demonstrate the effect of interventions on the post-traumatic development of OA [ 8 ].…”

“…However, these biomarkers have not yet been fully approved, with further work required to understand the relationships of biomarkers to underlying pathophysiology and individual patient phenotypes. This would allow biomarkers to guide phenotype-specific interventions and judge the impact of specific pharmacological treatments on pre-identified pathophysiological processes in a very heterogeneous condition [ 8 , 24 , 25 ]. Examples of this include the use of intra-articular steroid to suppress inflammation as an anti-catabolic agent [ 24 ], or Sprifermin, recombinant human fibroblast growth factor-18, as an anabolic agent [ 26 ].…”