The Use of NSAIDs and Nutritional Supplements in Athletes with Osteoarthritis: Prevalence, Benefits, and Consequences

The use of nonsteroidal antiinflammatory medications (NSAIDs) and nutraceuticals, such as glucosamine and chondroitin, is common among athletes at all ages and levels of participation. The use of these drugs has significant effects on pain and swelling associated with injury; however, this use does have significant risks to the gastrointestinal, hepatic, and renal organ systems. In the athlete with degenerative changes in the joints, the use of these medications can become chronic and lead to an increased risk of adverse effects. The purpose of this article is to examine the incidence of injury in sports, the prevalence of osteoarthritis in athletes, and the use of common over-the-counter medications and supplements. In addition, the mechanism of action, adverse side effects, and behavioral patterns for use of these medications will be analyzed.

Oral treatment with PD-0200347, an ?2? ligand, reduces the development of experimental osteoarthritis by inhibiting metalloproteinases and inducible nitric oxide synthase gene expression and synthesis in cartilage chondrocytes

OBJECTIVE

To examine the in vivo effects of PD-0200347, an alpha(2)delta ligand of voltage-activated Ca(2+) channels and a compound chemically related to pregabalin and gabapentin, on the development of cartilage structural changes in an experimental dog model of osteoarthritis (OA). The effects of PD-0200347 on the major pathways involved in OA cartilage degradation, including matrix metalloproteinases (MMPs) and the inducible form of nitric oxide synthase (iNOS), were also studied.

METHODS

OA was surgically induced in dogs by sectioning the anterior cruciate ligament. OA dogs were randomly distributed into 3 groups and treated orally with either 1) placebo, 2) 15 mg/kg/day of PD-0200347, or 3) 90 mg/kg/day of PD-0200347. Dogs were killed 12 weeks after surgery. The severity of the lesions was scored macroscopically and histologically. Cartilage specimens from the femoral condyles and tibial plateaus were processed for RNA extraction and quantitative reverse transcription-polymerase chain reaction (RT-PCR) or immunohistochemistry. Specific probes and antibodies were used to study the messenger RNA and protein levels of iNOS, MMP-1, MMP-3, and MMP-13.

RESULTS

No clinical signs of drug toxicity were noted in the treated animals. Treatment with PD-0200347 at both dosages tested (15 and 90 mg/kg/day) reduced the development of cartilage lesions. There was a reduction in the score of lesions, with a statistically significant (P = 0.01) difference when the highest dosage of the drug was administered. The reduction in the score was mainly related to a decrease in the surface size of the lesions. Quantitative RT-PCR showed that PD-0200347 significantly reduced the expression of MMP-13, a key mediator in OA. Immunohistochemical analyses showed that treatment with PD-0200347 significantly reduced the synthesis of all key OA mediators studied.

CONCLUSION

This study demonstrated the efficacy of PD-0200347 in reducing the progression of cartilage structural changes in a dog model of OA. It also showed that this effect is linked to the inhibition of the major pathophysiologic mediators responsible for cartilage degradation.

Exercise self-efficacy, exercise benefits and barriers, and commitment to a plan for exercise among Korean women with osteoporosis and osteoarthritis

This study compared perceived exercise self-efficacy, exercise benefits, exercise barriers, and commitment to a plan for exercise between Korean women with a diagnosis of either osteoporosis or osteoarthritis. The influence of exercise self-efficacy, exercise benefits and barriers on commitment to a plan for exercise was also assessed in each group. Participants in the study were 154 Korean women over 40 years of age who were recruited from hospitals, health centers or a nursing home. The two groups differed on commitment to a plan for exercise with commitment greater among women with osteoporosis. Exercise self-efficacy was the most influential variable on commitment to a plan for exercise accounting for 27% of the variance in commitment among osteoporosis patients and 53% of the variance among osteoarthritis patients. This study generated information relevant to tailoring exercise interventions to the differing needs and perceptions of Korean women with osteoporosis and osteoarthritis.

Osteoarthritis and osteoporosis in postmenopausal women: clinical similarities and differences

Osteoarthritis and osteoporosis are two major health problems affecting more than 60% of post-menopausal women in the United States. The promotion of healthy aging and the prevention and reduction of morbidity and mortality is a main concern for healthcare providers. The similarities and differences in pathophysiology, diagnosis, and treatment for osteoarthritis and osteoporosis are often not clear for clinicians. Some osteoporosis treatments, including bisphosphonates and vitamin D, seem to have a beneficial effect on osteoarthritis as well. A review of these two conditions in terms of bone mineral density, bone turnover, hormonal effects, and treatment options will be discussed.

Osteochondral autologous transplantation for the treatment of full-thickness articular cartilage defects of the shoulder

We performed eight osteochondral autologous transplantations from the knee joint to the shoulder. All patients (six men, two women; mean age 43.1 years) were documented prospectively. In each patient the stage of the osteochondral lesion was Outerbridge grade IV with a mean size of the affected area of 150 mm2. All patients were assessed by using the Constant score for the shoulder and the Lysholm score for the knee. Standard radiographs, magnetic resonance imaging and second-look arthroscopy were used to assess the presence of glenohumeral osteoarthritis and the integrity of the grafts. After a mean of 32.6 months (8 to 47), the mean Constant score increased significantly. Magnetic resonance imaging revealed good osseointegration of the osteochondral plugs and congruent articular cartilage at the transplantation site in all but one patient. Second-look arthroscopy performed in two cases revealed a macroscopically good integration of the autograft with an intact articular surface. Osteochondral autologous transplantation in the shoulder appears to offer good clinical results for treating full-thickness osteochondral lesions of the glenohumeral joint. However, our study suggests that the development of osteoarthritis and the progression of pre-existing osteoarthritic changes cannot be altered by this technique.

The use of a non-ionic surfactant (P188) to save chondrocytes from necrosis following impact loading of chondral explants

While current injury criteria for the automotive industry are based on bone fracture, the majority of knee injuries suffered in collisions each year do not involve fracture of bone. Instead, clinical studies of traumatic joint injury often document early pain and development of chronic diseases, such as osteoarthritis. Previous studies suggest chronic disease can be initiated by cell death that occurs in articular cartilage during mechanical trauma to the joint. In the current investigation early necrosis of chondrocytes was investigated after blunt trauma to chondral explants. A non-ionic surfactant (P188) was explored as a potential tool for early intervention into the disease process, as this surfactant has been shown to repair damaged membranes in other cell lines. Three groups of adult bovine chondral explants were equilibrated for 48 h in culture media. Two groups were then loaded to 25 MPa in unconfined compression. Half the specimens in each group were incubated in media supplemented with 8 mg/ml P188 immediately after loading, while the other half was returned to standard media. At 1 and 24 h the percentages of live and dead cells in compressed and control groups were determined with a cell viability stain. At 1 h post-trauma, P188 incubated specimens had a significantly increased percentage of live cells in the superficial zone versus the no-P188 group. At 24 h the percentages of live cells in all three zones of the P188-treated explants were significantly greater than in the no treatment group. This study showed that P188 surfactant could help restore the integrity of cell membranes in cartilage damaged by blunt mechanical trauma. With the ability of P188 to "save" chondrocytes from early necrotic death using in vitro chondral explants, its role in prevention of a post-traumatic osteoarthritis in a diarthrodial joint should be further explored using in vivo animal models.

[Current views on the prevention of ailments of the musculoskeletal system through muscle strengthening programs]

Because of an increasingly older population structure and the enhanced relevance of body composition, the prevention of problems arising from the musculoskeletal system has become of central importance. Strengthening and muscle-building training have been proven to be useful even for older people. The training is focused on the types of movement and exertion that frequently occur in the "activities of daily living." In addition, a purely hypertrophic training for building muscle mass must be differentiated from a more sensorimotor oriented training with situational employment of the muscles for optimizing motor control and coordination. There are no contraindications for strength training when the program is adapted to the individual. The rate of injury is small, even for people at low performance levels.

[Joint destruction and matrix metalloproteinases--regulation by pharmacologic inhibitors and growth factors]

Matrix metalloproteinase (MMP) plays an important role in degradation of cartilage matrix. The expression of MMPs in cartilage or syovial membrane was increased in osteoarthritis or rheumatoid arthritis. We summarized the regulation mechanism of MMP production, and described pharmacologic inhibitors such as non steroidal anti-inflammatory drugs, steroid and growth factors, which might be useful to prevention of joint destruction.

[Balneology, an ancient preventive and therapeutic option in arthrosis]

Arthrosis is defined as a group of distinct diseases with different etiology, having the same biological, morphological, and clinical modifications. The pathological process affects not only the cartilage but also includes the whole joint, the subchondral bone, the capsula, the synovial membrane and the musculature around the joint. Finally, the degenerated cartilage suffers a fibrization, a fissure and an ulceration, disappearing from the surface of the joint. The arthrotic degenerative process is complex and includes numerous factors which initiate the destructive process, progressively altering the joint structure. In fact, the cartilage suffers a chondrolysis process and consequently it disappears from the joint surface. In its turn, the bone reacts by producing a subtendonal osteocondensation type and synovial osteophytosis, responding by an inflammatory reaction, determined by the particles and elements produced by the chondrolysis. The therapy is individualized preferably immediately after the beginning, through non-pharmacological, pharmacological and surgical methods, so that it may influence its evolution and maintain functional the joint touched by the degenerative process. The purpose of the paper is to emphasize the importance of balneotherapy as a non-pharmacological method in the therapy of arthrosis, especially in maintaining the arthrotic joint at a normal level of functionality and of the tissues around the joint, which has a mobilizing and stabilizing function.

[Role of cleavage of type II collagen by collagenase in osteoarthritis and its progression]

Now, the biomarker for bone metabolism have important role on treatment of osteoporosis. It is important to develop the reliable biomarker to detect the early stage of osteoarthritis. The biomarker could be useful tool not only to study what exercise is good for the treatment and prevention of progression of osteoarthritis but also to develop new drug therapy. We focused on role of cleavage of type II collagen by collagenase in osteoarthritis with immunoassay for the specific cleavage site.

New methods for assessing cartilage contact stress after articular fracture

Progress in reducing the incidence and severity of posttraumatic arthritis depends in part on avoiding deleterious stress levels at residual local incongruities. Systematic efforts to elucidate factors adversely influencing cartilage's mechanical environment in turn depend on the availability of suitable modalities to assess intraarticular contact stresses. This has been and remains a challenging biomechanical problem. Technologic approaches used in the past have included mathematical analyses and indwelling physical sensors, each with advantages and limitations. Two emerging, mutually complementary capabilities show promise of dramatically altering the state of the art in this important field. The first of these methodologies, voxel-based contact finite element analysis, provides accurate computational estimates of cartilage stress on a patient-specific basis, and does so while accommodating arbitrarily idiosyncratic patterns of local articular incongruity. The second methodology, instrumentational, involves transient pressure distribution recordings using specially designed piezoresistive array sensors. Operational considerations for both of these new assessment technologies are described, and promising directions for future development are outlined.

Rheumatology and musculoskeletal medicine

Musculoskeletal disease accounts for a large proportion of a general practitioner's (GP's) workload. Proper management can not only improve quality of care, but also increase job satisfaction and reap rewards under the new contract. Osteoporosis creates a huge socioeconomic burden of disease and disability. Identifying high-risk groups in primary care and using preventative treatment can result in a substantial reduction in morbidity and mortality. GPs can help by presenting a unified lifestyle message, advising on fall prevention, and providing effective treatment; in particular, calcium and vitamin D for female nursing home residents. Osteoarthritis is eminently treatable in primary care with a number of management options for GPs, in addition to drug therapy. Glucosamine and chondroitin have few side effects and are worth recommending to patients with mild knee osteoarthritis. Rheumatoid arthritis can cause significant disability, which can be limited by early diagnosis, referral, and treatment. Severe refractory rheumatoid arthritis may warrant referral for consideration of biologic therapy. Assessment of the cardiovascular risk and possible use of statins in rheumatoid patients may reduce their cardiovascular mortality. GPs should aim to help patients to achieve optimum quality of life by using a holistic approach and by allowing maximum choice and control over their disease.

Assessment of articular displacement of distal radius fractures

Intraarticular step and gap displacements represent the most common indication for surgical treatment of distal radius fractures. Most often, treatment decision making relies only on good-quality plain radiographs taken before and after reduction with measurement accuracy maximized by using the longitudinal axis method. When plain radiographs alone prove insufficient, CT scans or tomograms will significantly improve interobserver and intraobserver reliability of measurements, especially when evaluated using the arc method. Tomography is an effective method for postoperative evaluation of fractures immobilized in splints or casts. The role of MRI in assessing intraarticular distal radius fractures is limited to confirming injuries to carpal ligaments or the triangular fibrocartilage complex. Intraoperatively, we use fluoroscopy to obtain 30 degrees cephalad posteroanterior views and as 22 degrees lateral views to best observe articular surface reduction. Our current operative indications include fractures with radiocarpal or distal radioulnar joint step or gap deformities greater than 1-2 mm, gross distal radioulnar joint instability, or those with extensive metaphyseal comminution rendering them particularly unstable after closed reduction. In general, we tend to lean toward operative fixation in younger, more active patients.

Rhein inhibits interleukin-1 beta-induced activation of MEK/ERK pathway and DNA binding of NF-kappa B and AP-1 in chondrocytes cultured in hypoxia: a potential mechanism for its disease-modifying effect in osteoarthritis

In the present report, we show that bovine articular chondrocytes cultured in low oxygen tension, i.e. in conditions mimicking their hypoxic in vivo environment, respond to IL-1beta (10 ng/mL) by an increased DNA binding activity of NF-kappaB and AP-1 transcription factors. Incubation of the cells with 10(-5) M rhein for 24 h was found to reduce this activity, particularly in the case of AP-1. Mitogen activated kinases (ERK-1 and ERK-2) were activated by exposure of the chondrocytes to 1-h treatment with IL-1beta. This effect was greater in hypoxia (3% O2) than in normoxia (21% O2). Rhein was capable of reducing the IL-1beta-stimulated ERK1/ERK2 pathway whatever the tension of oxygen present in the environment. The level of c-jun protein, an element of AP-1 complex, was increased by exposure of the chondrocytes to IL-1beta after 2, 6, and 24 h. Addition of rhein at 10(-5) M for 24 h did not reduce the c-jun protein amount. The mRNA steady-state levels of collagen type II (COL2A1) and aggrecan core protein were found to be significantly increased by a 24-h treatment with 10(-5) M rhein. This stimulating effect was also observed in the presence of IL-1beta, suggesting that the drug could prevent or reduce the IL-1beta-induced inhibition of extracellular matrix synthesis. IL-1-induced collagenase (MMPI) expression was significantly decreased by rhein in the same conditions. In conclusion, rhein can effectively inhibit the IL-1-activated MAPK pathway and the binding of NF-kappaB and AP-1 transcription factors, two key factors involved in the expression of several proinflammatory genes by chondrocytes. In addition, the drug can reduce the procatabolic effect of the cytokine, by reducing the MMPI synthesis, and enhance the synthesis of matrix components, such as type II collagen and aggrecan. These results may explain the antiosteoarthritic properties of rhein and its disease-modifying effects on OA cartilage, in spite of absence of inhibition at prostaglandin level.

Treatment with recombinant interferon-beta reduces inflammation and slows cartilage destruction in the collagen-induced arthritis model of rheumatoid arthritis

We investigated the therapeutic potential and mechanism of action of IFN-beta protein for the treatment of rheumatoid arthritis (RA). Collagen-induced arthritis was induced in DBA/1 mice. At the first clinical sign of disease, mice were given daily injections of recombinant mouse IFN-beta or saline for 7 days. Disease progression was monitored by visual clinical scoring and measurement of paw swelling. Inflammation and joint destruction were assessed histologically 8 days after the onset of arthritis. Proteoglycan depletion was determined by safranin O staining. Expression of cytokines, receptor activator of NF-kappaB ligand, and c-Fos was evaluated immunohistochemically. The IL-1-induced expression of IL-6, IL-8, and granulocyte/macrophage-colony-stimulating factor (GM-CSF) was studied by ELISA in supernatant of RA and osteoarthritis fibroblast-like synoviocytes incubated with IFN-beta. We also examined the effect of IFN-beta on NF-kappaB activity. IFN-beta, at 0.25 microg/injection and higher, significantly reduced disease severity in two experiments, each using 8-10 mice per treatment group. IFN-beta-treated animals displayed significantly less cartilage and bone destruction than controls, paralleled by a decreased number of positive cells of two gene products required for osteoclastogenesis, receptor activator of NF-kappaB ligand and c-Fos. Tumor necrosis factor alpha and IL-6 expression were significantly reduced, while IL-10 production was increased after IFN-beta treatment. IFN-beta reduced expression of IL-6, IL-8, and GM-CSF in RA and osteoarthritis fibroblast-like synoviocytes, correlating with reduced NF-kappaB activity. The data support the view that IFN-beta is a potential therapy for RA that might help to diminish both joint inflammation and destruction by cytokine modulation.

Effectiveness of Harpagophytum extracts and clinical efficacy

Various preparations from Harpagophytum procumbens are used for the treatment of pain in the joints and lower back. Studies published in peer reviewed journals were examined for their clinical evidence. The studies offering preparations with 50-60 mg harpagoside in the daily dosage are of better quality and provide more reliable evidence on efficacy than a proprietary ethanol extract with half the amount of harpagoside per day. However, confirmatory studies are required for all extracts before they can gain a place in treatment guidelines.

Self-caring of women with osteoarthritis living at different levels of independence

Successful management of chronic conditions such as osteoarthritis (OA) may improve health and quality of life and foster independence. Health professionals need to understand what women do to manage their OA by self-caring in order to support the improvement of health in older adults. A descriptive study of difficulties of living with and self-caring of OA was conducted. Sixty women over 65 years old who lived in homes in the community, in assisted living (AL) apartments, and in long-term care (LTC) facilities participated in interviews. Data were the reports of symptoms and self-caring behaviors. Descriptive, Kendall tau-b and tau-c, and chi-square analyses revealed that there were similarities and differences among the women. All of the women used a variety of self-caring techniques. Differences included that community-residing women reported more often that they had pain, moved too slowly, and had sleep disturbances. Community-residing women reported more negative emotions, while reporting significantly more often that they used a wide range of positive coping methods. By anticipating severe physical and functional problems of living with OA and difficulties in self-caring, health care providers may help women maintain an independent lifestyle.

Menopausal status, hormone replacement therapy use and risk of self-reported physician-diagnosed osteoarthritis in women attending menopause clinics in Italy

OBJECTIVE

In order to offer data on the association between menopausal status, hormone replacement therapy use and risk of self-reported physician-diagnosed osteoarthritis (OA) in women around menopause, we analyzed information collected in the framework of a large epidemiological study conducted in Italy.

METHODS

Since 1997, a large cross sectional study has been conducting on the characteristics of women around menopause attending a network of first level outpatients menopause clinics in Italy for general counseling about menopause or treatment of menopausal symptoms. Eligible for the study were women consecutively observed at the participating centers. Up to March 2000, a total of 42464 women (mean age 53 years) were observed. Women were asked, using the same questionnaire, about their general characteristics and habits, and if they suffer of OA diagnosed by a physician requiring medical or surgical treatment.

RESULTS

A total of 12521 women reported OA. The risk of OA increased with body mass index (BMI), the odds ratio, OR, being for BMI>or equal to 27 versus <24, 1.56 (95%CI 1.47-1.64). The risk increased with a history of osteoporosis/osteopenia (OR 1.65, 95%CI 1.57-1.74) and was lower in more educated women (OR high school/university degree vs. primary school degree 0.79, 95%CI 0.75-0.84). Considering menopausal status, women in spontaneous or surgical menopause were, at increased risk of OA (OR 1.13, 95%CI 1.07-1.21, and 1.18, 95%CI 1.08-1.28, respectively, in women in surgical and spontaneous menopause). No clear relationship, however, emerged with age at menopause. Ever hormonal replacement therapy users were at decreased risk of OA, the OR being for ever users in comparison with never 0.73 (95%CI 0.69-0.78).

CONCLUSION

This analysis gives some epidemiological support to the hypothesis that estrogen deficiency may increased the risk of OA.

The effect of wedged insoles on the lateral thrust of anterior cruciate ligament-insufficient knees

BACKGROUND

Patients with untreated anterior cruciate ligament insufficiency often develop osteoarthritis. In Japan, laterally or medially elevated insoles have been widely used for the relief of symptoms associated with unicompartmental osteoarthritis of the knee.

HYPOTHESIS

The use of a valgus wedge in the shoe of a patient with anterior cruciate ligament insufficiency will decrease lateral thrust.

STUDY DESIGN

Controlled laboratory study.

METHODS

An accelerometer was used to measure thrust force in 60 control knees and 35 knees with anterior cruciate ligament insufficiency. The sensor was attached to the affected and the control anterior tibial tubercles to record motion in the medial-lateral and perpendicular directions. The lateral thrust immediately after heel strike was measured continuously by a telemeter under stabilized walking conditions. Measurements were made both with and without wedged insoles.

RESULTS

When compared with the control knee, the peak value of lateral acceleration immediately after heel strike was significantly greater in the anterior cruciate ligament-insufficient knees. However, lateral thrust decreased significantly in the anterior cruciate ligament-insufficient knees when a wedged insole was used.

CONCLUSIONS

Use of an insole resulted in a significant decrease in lateral thrust, even in anterior cruciate ligament-insufficient knees.

CLINICAL RELEVANCE

Use of an insole is one possible prophylaxis for osteoarthritis for an anterior cruciate ligament-insufficient knee.

[Study on the role of glucosamine hydrochloride in the pathogenesis of osteoarthritis]

The role of glucosamine hydrochloride in the pathogenesis of osteoarthritis in animal models of sponge granuloma, Kaolin arthritiaand and adjuant arthritis was studied. The results showed that glucosamine hydrochloride inhibited granulation, delayed immunoreactivity, immunological-reative arthritis in daily doses of 0.25-0.75 g/kg BW orally and vascular oozing, tissue swelling and cell isolating in daily doses of 0.5-1.5 g/kg BW orally, indicating that glucosamine hydrochloride might have a preventive and theraputic effect on osteoarthritis.

Sports, joint injury, and posttraumatic osteoarthritis

Participation in sports increases the risk of joint injuries that can lead to posttraumatic osteoarthritis, a clinical syndrome caused by trauma-initiated joint degeneration that results in permanent and often progressive joint pain and dysfunction. Minimizing the risk of joint injuries and helping people with osteoarthritis participate in regular physical activity, including some sports, requires understanding of the relationships between joint use, joint injury, and joint degeneration. Lifelong participation in sports that cause minimal joint impact and torsional loading by individuals with normal joints and neuromuscular function does not increase the risik of posttraumatic osteoarthritis. In contrast, participation in sports that subject joints to high levels of impact and torsional loading increases the risk of joint injury and subsequent joint degeneration. Immediate diagnosis and appropriate treatment and rehabilitation following joint injuries decrease the risk of subsequent injuries and posttraumatic osteoarthritis. Individuals with abnormaljoint anatomy or alignment, previous significant joint injury, osteoarthritis, joint surgery, joint instability, disturbances of joint or muscle innervation or inadequate muscle strength have increased risk of joint damage during participation in athletics. These individuals can benefit from regular exercise, including selected sports, but they should have an evaluation of their joint structure and function, muscle strength, and neuromuscular function before participating in vigorous physical activity.

Naturocetic (glucosamine and chondroitin sulfate) compounds as structure-modifying drugs in the treatment of osteoarthritis

PURPOSE OF REVIEW

Several entities have been investigated carefully for the symptomatic and structural management of osteoarthritis. This review reports recent findings suggesting that such compounds may delay the structural progression of osteoarthritis.

RECENT FINDINGS

The most compelling evidence of a potential for inhibiting the structural progression of osteoarthritis has been obtained with glucosamine sulfate, whereas preliminary results obtained in patients with osteoarthritis of the hands also suggest that chondroitin sulfate could be used in the same indication. At any rate, these two compounds have clearly demonstrated a symptomatic action, mainly in osteoarthritis of the lower limbs. Patients with the less severe radiographic osteoarthritis will experience, in the long run, the most dramatic disease progression in terms of joint space narrowing. Such patients may be particularly responsive to structure-modifying drugs.

SUMMARY

Glucosamine sulfate has demonstrated its ability to reduce the progression of osteoarthritis in the lower limbs. The preliminary results obtained in the hands suggest that chondroitin sulfate could also be of interest in this indication. An important issue is that all the conclusive studies with such chemical entities resulted from the use of prescription medicines, not over-the-counter pills or food supplements.

Femoral osteotomy and iliac graft vascularization for femoral head osteonecrosis

The objective of this study was to determine the long-term clinical and radiologic outcomes of patients with osteonecrosis treated by a combination of intertrochanteric osteotomy and pedicled iliac bone block transfer. Between 1978 and 1986, 41 patients (52 hips) with a mean age of 33 years were operated on for Ficat Stages II and III disease. Thirty-three patients (44 hips) were assessed clinically and radiologically at a mean followup of 13.5 years (range, 5-20 years). Fifteen hips (15 of 44; 34%; 13 patients) had conversion surgery to a total hip arthroplasty because of progressive arthritis or collapse, or both. Six patients died and two were lost to followup. Preoperatively, the patients with failed revascularization had significantly more pain and decreased gait function than patients without failure. In the patients without failure, postoperative pain sensation and gait function improved significantly. However, flexion became restricted mainly because of progressive degeneration of the hip. Radiographically, 31% of the hips (nine hips; six patients) had severe arthritis, 59% (17 hips; 12 patients) had moderate arthritis, and only three hips (two patients) had mild arthritis. Ninety percent of patients without hip failures (26 of 29 hips; 18 patients) considered the functional outcome, including pain relief and gait function, to be successful. Despite the subjective success, this surgery could not restore normal hip anatomy, and arthritis progressed with time. Intertrochanteric osteotomy and vascularized iliac bone block transfer should be considered only in young symptomatic patients with good preoperative clinical function and Ficat Stage II disease.

Prevention for the older woman. Mobility: a practical guide to managing osteoarthritis and falls. Part 6

By anticipating issues of mobility, physicians can help older women lead more independent and satisfying lives. Osteoarthritis is a major cause of physical disability in older women. Aerobic exercise, resistance training, and judicious analgesic use can be well-tolerated interventions that reduce pain and disability. Reducing the risk of injurious falls is paramount given the prevalence of osteoporosis. Interventions that may reduce fall risk include minimizing the use of sedative-hypnotic agents, providing training in transfer skills (balance and gait training), and adapting the home environment.

The role of chondrocyte senescence in the pathogenesis of osteoarthritis and in limiting cartilage repair

BACKGROUND

With increasing age, the prevalence of osteoarthritis increases and the efficacy of articular cartilage repair decreases. As chondrocytes age, they synthesize smaller, less uniform aggrecan molecules and less functional link proteins, their mitotic and synthetic activity decline, and their responsiveness to anabolic mechanical stimuli and growth factors decreases. These observations led us to hypothesize that progressive cell senescence decreases the ability of chondrocytes to maintain and to restore articular cartilage.

METHODS

To test this hypothesis, we measured cell senescence markers (beta-galactosidase expression, mitotic activity, and telomere length) in human articular cartilage chondrocytes from twenty-seven donors ranging in age from one to eighty-seven years. We also assessed mitochondrial DNA, membrane potential, and numerical density. To determine if chondrocyte age changes are reversible, we transfected human articular cartilage chondrocytes with the human telomerase gene (hTERT) and human papilloma virus oncogenes (E6 and E7).

RESULTS

Beta-galactosidase expression increased with age (r = 0.84, p = 0.0001), while mitotic activity and telomere length declined (r = -0.77, p = 0.001 and r = -0.71, p = 0.0004, respectively). Decreasing telomere length was closely correlated with increasing expression of beta-galactosidase and decreasing mitotic activity. As the number of population doublings increased, mitochondrial DNA was degraded, mitochondrial membrane potential was lost, and the number of mitochondria per cell declined. Transfection of human articular cartilage chondrocytes from a forty-seven-year-old donor with hTERT and human papilloma virus proto-oncogenes E6 and E7 created a cell line that has completed more than 300 population doublings as compared with an upper limit of twenty-five population doublings for normal cells. Telomere length increased in cells transduced with hTERT.

CONCLUSIONS

These findings help to explain the previously reported age-related declines in chondrocyte synthetic activity, mitotic activity, and responsiveness to anabolic cytokines and mechanical stimuli. They also suggest that in vivo chondrocyte senescence contributes to the age-related increase in the prevalence of osteoarthritis and decrease in the efficacy of cartilage repair. The creation of immortal cells with increased telomere length suggests that the progression of human chondrocytes toward senescence is not inevitable.

Potential applications of matrix metalloproteinase inhibitors in geriatric practice

Matrix metalloproteinases are a family of enzymes that degrade different components of extracellular matrix. They play an important role in normal physiologic processes of maintaining tissue integrity and remodeling, as in wound healing, processes of development, and regeneration. However, excessive expression of MMP has been observed in many disease states, including rheumatoid arthritis and osteoarthritis, vascular remodeling in atherosclerosis and aortic aneurysm formation, neoplastic processes, macular degeneration and many others.

Glucosamine and chondroitin sulfate: biological response modifiers of chondrocytes under simulated conditions of joint stress

OBJECTIVE

To test the hypothesis that chondrocytes are more responsive to the chondroprotective agents, glucosamine (glcN) and chondroitin sulfate (CS), under in vitro conditions simulating in vivo joint stress.

DESIGN

Synthetic and anticatabolic activities of bovine articular cartilage were assayed using 35-sulfate labeling and assaying the specific activity of glycosaminoglycans (GAGs) under the conditions of enzyme-induced matrix depletion, heat stress, mechanical compression and cytokine stress.

RESULTS

The response of cartilage to simulated conditions of in vivo stress varies, depending on the type stress and age of the animal. Cartilage from aged animals was more responsive to stress and to glcN and CS. Pronase-induced matrix depletion and mechanical stress increased proteoglycan synthetic activity. Exposure to glcN and CS significantly enhanced this stress response from 85 to 191% and from 40 to 1000%, respectively. Heat stress and stromelysin digestion decreased synthetic activity, which was reversed or normalized on exposure to glcN and CS. Cartilage from young joints was somewhat refractory to the level of stress imposed and to treatment with glcN and CS.

CONCLUSION

The metabolic response of cartilage from aged animals to glcN and CS under simulated conditions of in vivo stress is significantly greater than that seen in nonstressed or young tissue. By enhancing the "protective" metabolic response of chondrocytes to stress, glcN and CS may improve its ability for repair and regeneration. These observations suggest that these compounds function as biological response modifiers (BRMs), agents which boost natural protective responses of tissues under adverse environmental conditions.

Intervention programs for arthritis and other rheumatic diseases

Disability reduction or prevention programs for people with arthritis and other rheumatic conditions reduce long-term pain and disability but reach only a fraction of their target audience. Few public health professionals are aware of these programs or their benefits. The objective of this study is to review and describe packaged (ready-to-use) arthritis self-management education and exerciselphysical activity programs that have had at least preliminary evaluation. Nine intervention programs (five self-management education programs, and four exercise/physical activity programs met study criteria). Several of the packaged arthritis interventions reviewed help people with arthritis and other rheumatic conditions maximize their abilities and reduce pain, functional limitations, and other arthritis-related problems. Other packaged interventions show promise in reducing pain, disability, and depression and in increasing self-care behaviors, but they need to be evaluated more extensively.

Experimental tibial plateau fractures augmented with calcium phosphate cement or autologous bone graft

BACKGROUND

Depression fractures of the tibial plateau are often managed with use of internal fixation and autologous bone-grafting to maintain an anatomical reduction. Bone-grafting, however, provides only limited stability. As calcium phosphate cements have appropriate mechanical properties, they may provide a more suitable alternative. The objective of this study was to compare the effect of a calcium phosphate cement with that of impacted cancellous autograft for maintaining an anatomical reduction in an experimental model of a tibial plateau fracture.

METHODS

Standardized cylindrical subchondral defects that were 8 mm in diameter and 10 mm deep were created bilaterally beneath the subchondral bone of the articular cartilage in the lateral tibial plateau of goats. An osteotome was used to fracture the overlying subchondral plate and articular cartilage. The plateau fracture fragment was completely depressed into the subchondral defect and then was anatomically reduced. The defects were randomly filled with either calcium phosphate cement or cancellous autograft. No internal fixation was used. The tibiae were harvested at varying time-periods that ranged from twenty-four hours to eighteen months. The stiffness of the healing augmented plateau fractures was determined. Histological specimens were assigned a score for degenerative changes. Loss of anatomic reduction was demonstrated in photomicrographs, and the amount of subsidence of the osteochondral fragment was measured in whole-mount histological sections.

RESULTS

The prevalence and degree of fracture subsidence was significantly reduced at all time-points in the defects treated with calcium phosphate cement compared with those filled with autograft (p < 0.05). There were no significant differences in fracture stiffness between the two treatment groups at any of the time-points examined. The calcium phosphate cement was rapidly resorbed, and the volume fraction of the calcium phosphate cement was decreased to 4% at six months. The trabecular bone volume in the defects was restored to that of the intact controls at six months in both treatment groups.

CONCLUSIONS

Cancellous autograft did not maintain an anatomical reduction of the tibial plateau fractures in this model. In contrast, augmentation with calcium phosphate cement prevented subsidence of the fracture fragment and maintained articular congruency as the fracture healed. The improved articular congruency reduced the prevalence and severity of degenerative changes in the joint.

The epidemiology of agriculture-related osteoarthritis and its impact on occupational disability

BACKGROUND

Hip and knee osteoarthritis and undiagnosed chronic joint pain are more prevalent in agricultural workers than other occupational groups, significantly impacting the ability of small farm operators and farm workers to maintain a livelihood.

METHODS

Agricultural risk factors, economic impacts, national and state AgrAbility data, gender, and farm/non-farm prevalence differences of arthritis and joint arthropathy in a Wisconsin farm cohort are reviewed.

RESULTS

Agricultural workers (primarily male) are at increased risk for developing osteoarthritis of the hip and knee. In Wisconsin, the prevalence rate of osteoarthritis is higher in a male farm vs. a male rural non-farm cohort. Arthritis comprises 10%-12% of the disability referrals to state and national AgrAbility programs. Back pain, joint injury, and orthopedic injury account for another 38%. The ability to perform agricultural job duties is significantly affected by arthritis and lack of access to health care. Obesity is an additional independent risk factor for osteoarthritis in the rural population.

CONCLUSIONS

The agricultural work force is at particular risk for arthritis-related disability. Improved access to health care for diagnosis and treatment can lessen disability. Prevention of arthritis is multi-factorial, involving ergonomic improvements, lifestyle modification to prevent obesity, and adequate medical treatment of arthritis.

The presentation of scaphoid non-union

A retrospective study of 30 patients presenting with scaphoid non-union was performed. The results showed that eight had been treated in plaster for a mean of 6 weeks and discharged from follow-up. They presented with established non-union at a mean of 60.3 months after the original fracture. Three of these cases have resulted in litigation against the surgeon. A total of 27 patients underwent bone grafting and Herbert's screw fixation achieving in union in 24. The natural history of scaphoid non-union has been examined in some detail in the literature. These studies have shown that scaphoid non-union is inevitably associated with arthritic changes that become worse with time and that freedom from symptoms is not protective from these changes. Therefore, prompt diagnosis and treatment of scaphoid non-union is vital, whether symptomatic or not, to prevent osteoarthritis developing in the future. Inadequate follow-up of treated scaphoid fractures will result in delayed diagnosis and treatment of non-union with a potentially impaired outcome and even litigation against the surgeon. It is the authors' advice that all scaphoid fractures treated in a plaster cast are reassessed clinically and radiologically 6 months post-injury.

Diagnostic and therapeutic injection of the elbow region

Joint injection of the elbow is a useful diagnostic and therapeutic tool for the family physician. In this article, the injection procedures for the elbow joint, medial and lateral epicondylitis, and olecranon bursitis are reviewed. Persistent pain related to inflammatory conditions responds well to injection in the region. Indications for elbow joint injection include osteoarthritis and rheumatoid arthritis. Corticosteroid injection is an accepted treatment option for medial and lateral epicondylitis. Olecranon bursa aspiration and injection are useful when that bursa is inflamed. The proper techniques, choice and quantity of pharmaceuticals, and appropriate follow-up essential for effective outcomes are discussed.

Psychophysiologic effects of Hatha Yoga on musculoskeletal and cardiopulmonary function: a literature review

Yoga has become increasingly popular in Western cultures as a means of exercise and fitness training; however, it is still depicted as trendy as evidenced by an April 2001 Time magazine cover story on "The Power of Yoga." There is a need to have yoga better recognized by the health care community as a complement to conventional medical care. Over the last 10 years, a growing number of research studies have shown that the practice of Hatha Yoga can improve strength and flexibility, and may help control such physiological variables as blood pressure, respiration and heart rate, and metabolic rate to improve overall exercise capacity. This review presents a summary of medically substantiated information about the health benefits of yoga for healthy people and for people compromised by musculoskeletal and cardiopulmonary disease.

Green tea polyphenol epigallocatechin-3-gallate inhibits the IL-1 beta-induced activity and expression of cyclooxygenase-2 and nitric oxide synthase-2 in human chondrocytes

We have previously shown that green tea polyphenols inhibit the onset and severity of collagen II-induced arthritis in mice. In the present study, we report the pharmacological effects of green tea polyphenol epigallocatechin-3-gallate (EGCG), on interleukin-1 beta (IL-1 beta)-induced expression and activity of cyclooxygenase-2 (COX-2) and inducible nitric oxide synthase (iNOS) in human chondrocytes derived from osteoarthritis (OA) cartilage. Stimulation of human chondrocytes with IL-1 beta (5 ng/ml) for 24 h resulted in significantly enhanced production of nitric oxide (NO) and prostaglandin E(2) (PGE(2)) when compared to untreated controls (p <.001). Pretreament of human chondrocytes with EGCG showed a dose-dependent inhibition in the production of NO and PGE(2) by 48% and 24%, respectively, and correlated with the inhibition of iNOS and COX-2 activities (p <.005). In addition, IL-1 beta-induced expression of iNOS and COX-2 was also markedly inhibited in human chondrocytes pretreated with EGCG (p <.001). Parallel to these findings, EGCG also inhibited the IL-1 beta-induced LDH release in chondrocytes cultures. Overall, the study suggests that EGCG affords protection against IL-1 beta-induced production of catabolic mediators NO and PGE(2) in human chondrocytes by regulating the expression and catalytic activity of their respective enzymes. Furthermore, our results also indicate that ECGC may be of potential therapeutic value for inhibiting cartilage resorption in arthritic joints.

Women and arthritis: burden, impact and prevention programs

OBJECTIVES

To characterize the public health burden and impact of arthritis among women, document the growing interest in addressing arthritis as a public health problem, and review new national (Centers for Disease Control and Prevention [CDC]) and state arthritis programs.

RESULTS

Arthritis and other rheumatic diseases are a major public health problem, affecting nearly 27 million women in 1997 and accounting for 23.9 million ambulatory medical care visits and 451,000 hospitalizations among women in that year. Arthritis is also the leading cause of disability and is associated with considerable functional limitations. The 1999 National Arthritis Action Plan: A Public Health Strategy prompted first-time congressional funding to the CDC to monitor the burden of arthritis and to establish state arthritis prevention programs through cooperative agreements. The CDC's Arthritis Program also used this funding to build the public health science base, develop national health communications campaigns, foster partnerships, and initiate health systems change.

CONCLUSIONS

Arthritis in general and selected types, such as rheumatoid arthritis, systemic lupus erythmatosus (SLE), and fibromyalgia, disproportionately affect women. The CDC, state health departments, and their partners are working toward improving the quality of life for women affected by arthritis. Effective, evidence-based interventions, such as self-management education and physical activity programs, are currently available and can reduce pain, improve function, and delay disability, but they remain underused. Future research should focus on improving earlier diagnosis and increasing access to effective interventions.

Meniscal transplantation

The aims of a meniscal replacement are: 1) to reduce the pain experienced by some patients following meniscus resection; 2) to prevent the degenerative changes of cartilage and the changes in subchondral bone following meniscus resection; 3) to avoid or reduce the risk of osteoarthritis following meniscus resection; 4) to restore optimally the mechanical properties of the knee joint after meniscal resection. The results of meniscus transplantation have been studied in animals. There is no proof from these experiments that replacement of a meniscus can reduce the risk of arthritis, but there are indications that it can decrease the development of cartilage degeneration. In humans, the results of meniscus transplantation have been reported in several series of patients, operated with different techniques. There are no controlled studies of meniscus replacement in humans. In case of meniscal allograft implantation surgery should be minimally invasive, not sacrificing the original meniscal insertion points. It appears preferable to use an open technique in medial transplantation, whereas the arthroscopic approach appears to allow for easier lateral implantation.

Dome (modified Chiari) pelvic osteotomy: 10- to 18-year followup study

Ninety-six dome (modified Chiari) pelvic osteotomies in 87 patients with pain and disability because of osteoarthrosis secondary to hip dysplasia were reviewed. The mean age of the patients at the time of surgery was 29 years (range, 16-55 years). The mean followup was 13 years (range, 10-18 years). Forty-one hips were classified into a hip dysplasia stage, 32 hips into an early stage of osteoarthrosis, and 23 hips into an advanced stage of osteoarthrosis according to the radiographic grading of the Japanese Orthopaedic Association. The average preoperative Merle d'Aubigné and Postel hip score was 13.8, and the average score at final followup was 16.6. Excellent or good results with a score greater than 14 were achieved in 96% of the hips at final followup. Radiographically, signs of progression of osteoarthrosis were not seen in 87% of the hips. Osteoarthrosis progressed during the postoperative course in 13% of the hips. Four patients (four hips) eventually had a total hip arthroplasty at 13.8 years (range, 12.5-15.3 years) after surgery. The survival rate of dome pelvic osteotomy, using clinical failure as an end point, was 82% at 15 years. Using radiologic failure as an end point, 61 hips in 54 patients (survival rate, 78%) survived at 15 years. Using hip replacement as an end point, 92 hips in 83 patients (survival rate, 82%) survived at 15 years. Dome pelvic osteotomy is an excellent and effective operation for pain relief and functional maintenance of the hip.