Long-term effects of hyaluronan on experimental osteoarthritis in the rabbit knee

OBJECTIVE

Long-term assessment of the effect of hyaluronan (HA) on the articular cartilage and synovium in an animal knee joint during the development of osteoarthritis (OA).

DESIGN

Sixty mature New Zealand white rabbits underwent unilateral anterior cruciate ligament transection (ACLT) and were divided into two groups. Group 1 (SA) received intra-articular injections of 0.3 ml hyaluronan (HA) (i.e., ARTZ, MW: 8 x 10(5)) beginning 4 weeks after ACLT, once a week for 5 weeks. Group 2 (SV) received injections of the vehicle (phosphate buffered saline) in the same fashion as with the SA group. The contralateral nonoperated knee served as control. All animals were killed 21 weeks after surgery and their knee joints evaluated by gross morphologic, histologic, histomorphometric and biochemical analyses.

RESULTS

Gross morphological inspection indicated that the femoral condyles from the knees injected with vehicle suffered more severe cartilage damage than cartilage from the knees injected with HA. Furthermore, two out of three histomorphometric parameters measured in the HA-treated cartilage (i.e., cartilage thickness and cartilage area which were not statistically different than control) provided evidence showing a protective effect of HA on the femoral condyles following ACLT. Biochemical analysis showed articular cartilage remaining on the femoral condyles following ACLT to have similar characteristics to contralateral controls. However, DNA concentration in the synovium from the ACLT knees of the vehicle-treated animals was greater than contralateral control, while this parameter was not statistically different than contralateral control in the HA treated animals.

CONCLUSIONS

These results demonstrate a protective effect of HA on preservation of the articulating surface of the femoral condyle following ACLT up to 21 weeks post-surgery.

Effects of diacerhein on granuloma induced cartilage breakdown in the mouse

OBJECTIVE

Diacerhein, an anti-osteoarthritic agent, was tested for its ability to suppress synthesis of proinflammatory cytokines in a model of granuloma-induced cartilage breakdown.

DESIGN

50 TO mice received a subcutaneous implant of cotton-wrapped rat femoral head cartilage for a period of 2 weeks. Animals (N = 10/group) were dosed daily with either 6 mg/kg p.o. diclofenac or diacetylrhein at 5, 15 or 50 mg/kg p.o. in 0.1.ml 1% gum tragacanth which served as a control. Implanted cartilages were assayed for glycosaminoglycan (GAG) and hydroxyproline content. The surrounding granulomas were assayed for interleukin-1 alpha (IL-1 alpha), tumour necrosis factor-alpha (TNF-alpha) and IL-6. Statistical analysis was by Mann-Whitney U test.

RESULTS

Diclofenac had no significant effect on GAG or hydroxyproline content of implanted cartilage or on granuloma cytokine concentrations. Diacerhein protected implanted cartilages against hydroxyproline loss, implanted control cartilages contained 220 micrograms hydroxyproline compared with diacerhein at 5, 15 and 50 mg/kg which produced a 21, 16 and 59% decrease in hydroxyproline loss compared with non-implanted controls (P < 0.05, 0.05 and 0.001) respectively. Diacerhein also protected against GAG loss at 5 mg/kg and 50 mg/kg, control cartilages contained 134 micrograms GAG compared with diacerhein at 5 mg/kg and 50 mg/kg which produced a 24 and 38% decrease in GAG loss respectively (P < 0.05 for both). Diacerhein significantly reduced granuloma interleukin-1 alpha content at 5 mg/kg (control level of 2.4 micrograms/ml reduced by 58%; P < 0.05), reduced TNF-alpha at 5 mg/kg and 15 mg/kg (reduced by 61%: P < 0.01 and 49%: P < 0.05 respectively; control level of 469 pg/ml) and reduced IL-6 at 15 mg/kg and 50 mg/kg (control level of 537 pg/ml reduced by 60 and 51%, respectively; P < 0.01 for both).

CONCLUSIONS

The mechanism of the chondroprotective effects of diacerhein is not understood but may be explained by a reduction in the concentrations of proinflammatory cytokines.

Benefits of hormone replacement therapy--overview and update

Postmenopausal estrogen deficiency may result in a wide variety of physiologic disorders, including vasomotor symptoms, urogenital atrophy, an increase in the risk of coronary heart disease, osteoporotic fractures, and Alzheimer's disease. The growing body of evidence, including much that is newly published, demonstrating that hormone replacement therapy (HRT) can largely prevent or mitigate these sequelae, will be reviewed in this paper. The efficacy of HRT in alleviating vasomotor and urogenital discomfort, the most common symptoms of postmenopausal estrogen deficiency, is well established. Evidence from over 30 epidemiologic studies indicates that estrogen reduces the risk of coronary heart disease (CHD) by 50%. The risk of major CHD has been found to be markedly reduced in women who receive combined estrogen/progestogen therapy compared to nonusers (or estrogen-alone users). Estrogen is recommended as the modality of choice to prevent bone loss: data supporting a positive effect of estrogen on the risk of wrist and vertebral fracture are quite favorable. Similarly, outcomes of recent investigations have demonstrated a positive impact of HRT on both psychological function and the risk of osteoarthritis. In addition, HRT substantially reduces the risk of colon cancer. Moreover, the potential for HRT to delay the progression or reduce the risk for developing Alzheimer's disease is a new area of research that shows promise. Improvements in quality-of-life assessments have also been reported in conjunction with the relief of menopausal symptoms by HRT. Clinicians should be aware of the large amount of new evidence that strengthens the case for wider use of HRT. Based on these new data, physicians may conclude that HRT would benefit the majority of their postmenopausal patients and thus encourage HRT use in the absence of known risk factors.

Effects of diacerhein in an accelerated canine model of osteoarthritis

OBJECT

To determine whether diacerhein has a disease-modifying effect in an accelerated canine model of osteoarthritis.

DESIGN

Fourteen adult mongrel dogs underwent unilateral L4-S1 dorsal root ganglionectomy (DRG), followed 3 weeks later by ipsilateral anterior cruciate ligament transection. Seven dogs received diacerhein (15-20 mg/kg) daily throughout the interval between DRG and sacrifice, eight weeks after ligament transection. The other seven dogs served as OA controls.

RESULTS

The mean volume of synovial fluid obtained from the OA knee of the diacerhein-treated dogs was approximately 40% less than that from the OA knee of the controls. In addition, diacerhein appeared to reduce the severity of fibrillation (femoral condyle) and full-thickness ulceration (trochlear ridge) of the articular cartilage and the level of collagenase activity in extracts of the OA cartilage, and to increase net PG synthesis in the OA cartilage, although none of the above changes were statistically significant.

CONCLUSION

The differences between the diacerhein group and untreated OA controls, even though not statistically significant, suggest that diacerhein was active in this rapidly progressive model of OA. Because changes associated with initiation of OA may be different than those associated with progression, whether diacerhein has a disease-modifying effect should be examined in a less rapidly progressive model.

Athletics and osteoarthritis

Athletes, and an increasing number of middle aged and older people who want to participate in athletics, may question whether regular vigorous physical activity increases their risk of developing osteoarthritis. To answer this, the clinical syndrome of osteoarthritis must be distinguished from periarticular soft tissue pain associated with activity and from the development of osteophytes. Sports that subject joints to repetitive high levels of impact and torsional loading increase the risk of articular cartilage degeneration and the resulting clinical syndrome of osteoarthritis. However, moderate habitual exercise does not increase the risk of osteoarthritis; selected sports improve strength and mobility in older people and people with mild and moderate osteoarthritis. People with abnormal joint anatomy or alignment, previous significant joint injury or surgery, joint instability, above-average body weight, disturbances of joint or muscle innervation or inadequate muscle strength probably have increased risk of osteoarthritis. These people and those with early osteoarthritis can benefit from regular physical activity, but they should have a careful evaluation of their joint structure and function before participation. They should consider measures that decrease the intensity and frequency of impact and torsional loading of joints, including use of sports equipment that decreases joint impact loading, maintaining or improving muscle strength, tone, and general conditioning so that muscle contractions help protect joints from injury and high impact, and decreasing body weight.

Is hormone replacement therapy protective for hand and knee osteoarthritis in women?: The Chingford Study

OBJECTIVES

To explore whether hormone replacement therapy (HRT) has a protective role for osteoarthritis (OA) of the hand and knee in a cross sectional study of women in the general population.

METHODS

1003 women aged 45-64 (mean age 54.2) from the Chingford Study were asked details of HRT use. Standard anteroposterior radiographs of hands, knees were taken and scored according to the methods of Kellgren and Lawrence (grade 2+ positive for OA), and using individual features of osteophytes and joint space narrowing. Analysis compared ever use (> 12 months) versus never use, and current use (> 12 months) versus never use. Only 606 definitely postmenopausal women were included in the analysis. Odds ratios and 95% confidence intervals were calculated using logistic regression for risk of user versus non-user at each site, adjusted for age, height and weight, menopausal age and for bone mineral density of the femoral neck.

RESULTS

For current users (n = 72) there was a significant protective effect of HRT for knee OA (defined by Kellgren and Lawrence grade or osteophytes 0.31 (95% CI 0.11, 0.93), and a similar but not significant effect for moderate joint space narrowing of the knee, 0.41 (95% CI 0.05, 3.15) and for distal interphalangeal OA 0.48 (95% CI 0.17, 1.42). No clear effect was seen for the carpometacarpal joint, CMC OA 0.94 (95% CI 0.44, 2.03). When analysing ever users (n = 129) the protective effect was reduced. For ex-users of > 12 months (mean duration 40.7 months), there was no overall protective effect of HRT for OA. Additional adjustment for hysterectomy, physical activity, social class, and smoking made little difference to the results.

CONCLUSIONS

These data show an inverse association of current HRT use and radiological OA of the knee suggestive of a protective effect. The effect was weaker in the hand joints. The mechanism of the protection is unclear but has important implications for aetiopathogenesis.

The short-term effect of autogenous auricular cartilage graft following discectomy on the osteoarthrotic temporomandibular joint in sheep

The aim of this experimental study was to determine the effect of auricular cartilage graft replacement on the progression of experimentally induced osteoarthrosis in sheep. Bilateral osteoarthrosis was induced in the sheep temporomandibular joint (TMJ). Three months later, discectomy and autogenous auricular cartilage grafting were performed unilaterally. At sacrifice, three months postrepair and six months postinduction of osteoarthrosis, it was found that the untreated side had extensive condylar osteoarthrosis and the grafted side showed evidence of fibrous repair. The graft prevented intra-articular adhesions and reduced degenerative changes, but there was a tendency towards graft perforation. Auricular cartilage grafting was effective in minimizing osteoarthrotic effects on the TMJ in the early stages after grafting.

Five-year longitudinal study on limited food consumption and development of osteoarthritis in coxofemoral joints of dogs

OBJECTIVE

To examine the effects of limited food intake on frequency and severity of osteoarthritis in coxofemoral joints of labrador Retrievers.

DESIGN

Dogs were paired according to gender and body weight, within each litter at 8 weeks of age. One dog of each pair was fed ad libitum. The limit-fed pairmate was fed 75% of the amount eaten the previous day by the ad libitum-fed counterpart.

ANIMALS

48 Labrador Retrievers.

PROCEDURE

All dogs received the same diet. Radiographic evaluation of coxofemoral joints for frequency and severity of osteoarthritis were made when dogs were 4 and 6 months and 1, 2, 3, and 5 years old.

RESULTS

Radiographic evaluation for osteoarthritis indicated greater frequency and more severity of osteoarthritis in the ad libitum-fed group of dogs.

CLINICAL IMPLICATIONS

Analysis of data suggested that limit feeding of dogs over a 5-year period minimizes development of osteoarthritis in the coxofemoral joints.

A review of long-term studies evaluating the efficacy of weight loss in ameliorating disorders associated with obesity

Obesity leads to and exacerbates many serious disorders, including hypertension, dyslipidemia, cardiovascular disease, non-insulin-dependent diabetes mellitus, gallbladder disease, respiratory dysfunction, gout, and osteoarthritis. Many short-term studies have shown that weight loss can ameliorate or, in some cases, reverse such disorders. Fewer long-term studies-defined as those whose combined acute intervention and follow-up phases extend for at least 1 year-of the therapeutic benefits of weight loss on specific disorders have been undertaken. Those long-term studies that have been performed tend to confirm the results of briefer studies. Even when weight loss has been comparatively modest or some degree of weight regain has occurred, weight loss is generally associated with a decrease in risk factors and the alleviation of clinical symptoms.

[Knee joint ligament reconstruction--indications, results]

Cruciate ligament injuries have increased in number in the last 10 to 20 years. Nonoperative treatment of ligament injuries about the knee joint has lost some of its popularity; however, there are only very few randomized prospective studies demonstrating that operative reconstructions of knee ligament injuries do have a positive effect on preventing late osteoarthritic changes. In contrast, one of the best studies recently published shows that there may even be some increased rate of osteoarthritis in reconstructed patients. Why this? The concept of the 'Envelope of Load Acceptance' may explain, why some of the patients who opt for a nonoperative treatment of cruciate ligament injuries do very well. They lower the load and frequency to the knee joint and diminish their activity level. Patients with successfully treated ligament lesions about the knee joint may wish to go back to their preinjury level and may want to reach their preinjury 'shell' of load acceptance [Scott Dye, 1995]; however, this may already be too much for their knees [physiological overload] and may eventually lead to the osteoarthritic changes about the knee joint. Careful consultation of each individual patient's case of knee ligament injuries is essential for the successful treatment, a treatment which may reduce the rate of osteoarthritis and reduce costs for the injured and the community.

Chondral delamination of the knee in soccer players

This study reports on the diagnosis and treatment of chondral delamination in the knees of soccer players. The authors attempted to provide a clinical standard for comparison with emerging cartilage repair techniques. Twenty-three consecutive chondral fractures in a homogeneous population of athletes were evaluated using physical examination, magnetic resonance imaging, and arthroscopic examination. All knees were treated with debridement to a stable border and removal of the calcified cartilage base. Results were graded using the scoring system advocated by proponents of chondral transplant. All patients reported pain that limited soccer activities. Effusions occurred in 48%, joint line tenderness in 33%, and crepitus in 19% of the knees. Results from magnetic resonance imaging correlated with arthroscopic examination in 21% of the knees. Arthroscopic examinations revealed lesions on the medial femoral condyle in eight patients, the patella in six, the lateral femoral condyle in six, and the trochlea in three. Athletes returned to play at an average of 10.8 weeks. Repeat arthroscopic procedures in eight cases revealed fibrocartilage at the initial site. There were 6 excellent, 9 good, 0 fair, and 0 poor results at their 1-year followup examinations (15 knees). The definitive diagnosis of chondral delamination relies on a thorough arthroscopic probing of the articular surface. The early functional results of this treatment compare favorably with the autologous transplantation technique. Caution, however, is recommended when treating articular cartilage injuries because no long-term data exists on whether any treatment modality can prevent the development of degenerative joint disease.

Chondroprotective effect of intraarticular injections of interleukin-1 receptor antagonist in experimental osteoarthritis. Suppression of collagenase-1 expression

OBJECTIVE

To investigate the in vivo effect of recombinant human interleukin-1 receptor antagonist (rHuIL-1Ra) on the development of lesions and the expression of metalloproteases in the canine experimental osteoarthritis (OA) model.

METHODS

The right anterior cruciate ligament was sectioned percutaneously in 3 groups of dogs. The control group (n = 5) received an intraarticular injection of sterile physiologic saline (1 ml) twice weekly for 4 weeks starting on the day of surgery. The remaining 2 groups received intraarticular injections of either 2 mg (n = 6) or 4 mg (n = 5) rHuIL-1Ra in 1 ml of physiologic saline according to the same schedule as the first group. All dogs were killed 4 weeks after surgery. The macroscopic appearance of femoral condyle osteophytes and the size and severity of cartilage lesions on femoral condyles and tibial plateaus were evaluated, as were the histologic features of cartilage and synovial membrane. Levels of collagenase-1 and stromelysin-1 messenger RNA expression in cartilage and synovium were determined by Northern blotting.

RESULTS

Recombinant human IL-1Ra exerted a dose-dependent protective effect on the development of osteophytes and cartilage lesions in vivo. Treatment with rHuIL-1Ra reduced the incidence (saline-treated group 70%, 2 mg rHuIL-1Ra-treated group 42%, 4 mg rHuIL-1Ra-treated group 20%) and size (saline-treated group 2.3 +/- 0.7 mm [mean +/- SEM], 2 mg rHuIL-1Ra-treated group 0.7 +/- 0.3 mm, 4 mg rHuIL-1Ra-treated group 0.5 +/- 0.3 mm) of femoral condyle osteophytes. In addition, a dose-dependent decrease in the size (saline-treated group 24.40 +/- 8.17 mm2, 2 mg rHuIL-1Ra-treated group 20.90 +/- 8.01 mm2, 4 mg rHuIL-1Ra-treated group 7.70 +/- 5.16 mm2) and the grade (0-4 scale; saline-treated group 1.20 +/- 0.29, 2 mg rHuIL-1Ra-treated group 1.00 +/- 0.26, 4 mg rHuIL-1Ra-treated group 0.30 +/- 0.21) of the tibial plateau cartilage lesions was found, with a significant difference (P < 0.04) reached only with 4 mg rHuIL-1Ra. Similarly, the histologic lesions in dogs treated with 4 mg rHuIL-1Ra (Mankin scale; mean +/- SEM 2.95 +/- 0.53) were significantly less severe (P < 0.002) compared with those in the saline-treated group (4.95 +/- 0.54). Importantly, rHuIL-1Ra treatment led to a significant reduction (P < 0.005) of collagenase-1 expression in OA cartilage.

CONCLUSION

This study demonstrated that intraarticular injections of rHuIL-1Ra can protect against the development of experimentally induced OA lesions. This effect could result, at least in part, from a reduction of collagenase-1 expression. However, other catabolic processes involved in the degradation of OA cartilage may also be affected.

Patient education interventions in osteoarthritis and rheumatoid arthritis: a meta-analytic comparison with nonsteroidal antiinflammatory drug treatment

OBJECTIVE

To compare the effects of education interventions and nonsteroidal antiinflammatory drug (NSAID) treatment on pain and functional disability in patients with osteoarthritis (OA), and on pain, functional disability, and tender joint counts in patients with rheumatoid arthritis (RA).

METHODS

Two meta-analyses were performed: one of controlled trials of patient education interventions and one of placebo-controlled trials of NSAID treatments.

RESULTS

Nineteen patient education trials comprised of 32 treatment arms and 28 NSAID trials comprised of 46 treatment arms were included. The weighted average effect size for pain was 0.17 in the education trials and 0.66 in the NSAID trials. The average effect size for functional disability was 0.03 in the education trials and 0.34 in the NSAID trials; effects of education were much larger in RA studies than in OA studies. In RA studies, the average effect size for the tender joint count was 0.34 in the education trials and 0.43 in the NSAID trials. Because most patients in the education trials were being treated with medications, the effect sizes of these trials represent the additional, or marginal, effects of patient education interventions beyond those achieved by medication.

CONCLUSIONS

Based on this meta-analysis, patient education interventions provide additional benefits that are 20-30% as great as the effects of NSAID treatment for pain relief in OA and RA, 40% as great as NSAID treatment for improvement in functional ability in RA, and 60-80% as great as NSAID treatment in reduction in tender joint counts in RA.

Preferences in the management of osteoarthritis of the hip and knee: results of a survey of community-based rheumatologists in the United States

OBJECTIVE

To determine rheumatologists' preferences in the medical management of osteoarthritis (OA) of the hip and knee, and examine possible variations in these preferences.

METHODS

A stratified random sample of 1,001 rheumatologists in community-based practice in the United States was surveyed by mail.

RESULTS

Responses were obtained form 594 subjects (529 white, 499 male, mean +/- SD age 47.4 +/- 8.1 years). Over 80% used acetaminophen or nonaspirin, nonsteroidal antiinflammatory drugs (NSAIDs) either always or frequently for the management of OA of the hip and knee. A majority used the following nonpharmacologic methods either always or frequently: weight loss, cane or crutch, physical and/or occupational therapy referral, and exercise. Variation in practice preferences was noted by age (< 47 versus > or = 47 years), sex, board certification in rheumatology, and number of patients seen per month. Respondents felt that severe pain and limitation of function were the most important factors in recommending total join arthroplasty for patients.

CONCLUSION

These data demonstrate that practicing rheumatologists most often use either acetaminophen and/or NSAIDs in combination with nonpharmacologic methods in the medical management of OA of the hip and knee. The existence of variation in practice preferences has policy implications.

2,5-Diarylisothiazolone: novel inhibitors of cytokine-induced cartilage destruction

A series of 2,5-diarylisothiazolones is reported that inhibit the IL-1 beta-induced breakdown of bovine nasal septum cartilage in an organ culture assay. The synthesis and preliminary SAR of these compounds are described. These compounds represent a novel, nonpeptide lead series approach to the mediation of the chronic cartilage breakdown associated with arthritic disease. These compounds are relatively resistant to reductive metabolism by liver microsomal preparations and appear to inhibit cartilage breakdown by interfering with the proteolytic activation of matrix metalloproteinases.

[Rupture of the posterior cruciate ligament: status of current treatment]

The posterior cruciate ligament acts as a complex system and is formed by the anterolateral an posteromedial bundle an the meniscofemoral ligaments. The main function of the ligament is stabilization of the tibia against posterior subluxation in flexion of the knee. Isolated PCL deficiency is compensated by increased quadriceps action in many patients for years, although natural history studies demonstrate retropatellar and medial osteoarthritis after 5-15 years in a not yet defined percentage. Osseous avulsion of the PCL from the tibia have a good prognosis when treated by open reduction and stable fixation. Ruptures of the ligament should not be treated by suture repair, since this technique has failed to restore posterior knee stability in most studies. Augmented repair and reconstruction of the ligament tend to improve the objective results, although the clinical data are not yet conclusive. Complex posterior instability should be treated by acute ligament reconstruction, since the results of conservative treatment are inferior and operative treatment in chronic complex posterior instability is extremely difficult. Potential osseous abnormalities (varus morphotype) and posterolateral rotatory instability must be addressed in these cases. PCL reconstruction with a patellar tendon graft can be performed with a two tunnel technique or with a Femur tunnel and a direct tibial graft fixation via a posterior approach. The results reported in the literature do not support the use of augmentation devices in PCL surgery.

Long-term follow-up of modified condylotomy for internal derangement of the temporomandibular joint

OBJECTIVES

The purpose of this study was to evaluate disk position and patient response 10 years after modified condylotomy for symptomatic reducing disk displacement.

STUDY DESIGNS

Questionnaires and invitations to return for examination and temporomandibular joint magnetic resonance imaging were mailed to 39 consecutive patients 10 years after modified condylotomy.

RESULTS

On a 10-point scale the mean pain experienced by the 17 respondents (27 joints) to the questionnaire was 2.0. Ninety percent of 20 joints (12 patients) examined were free of tenderness to palpation. Magnetic resonance imaging in 10 patients (17 joints) showed disk reduction in 59%, displacement with reduction in 29%, and displacement without reduction in 12%. Eighty-five percent of the joints met American Association of Oral and Maxillofacial surgeons criteria for a successful therapeutic outcome.

CONCLUSIONS

The study suggests a role for modified condylotomy in the long-term management of symptoms associated with reducing disk displacement. Further, modified condylotomy can frequently reverse an internal derangement and seems to protect against the natural progression of osteoarthrosis.

Coping with osteoarthritis by older adults

OBJECTIVE

To extend to patients with osteoarthritis (OA) the coping model developed for patients with rheumatoid arthritis.

METHODS

Relationship among appraisal, coping, and impact of OA were examined in a prospective study. Older men and women with OA (n = 82) were recruited from the community and were assessed at baseline, 1 month, and 4 months. Appraisal at baseline was measured by an interview addressing patients' beliefs about the intensity of their OA. Active, passive, and behavioral coping were assessed at 1 month, and the impact on OA pain, affective status, and mood was assessed at 4 months.

RESULTS

Appraisal of OA as more intense was related to the use of more passive coping at 1 month, and was also related to more negative mood at 4 months. Active coping was predictive of less depressed affective status, whereas passive coping was predictive of subsequent worsening of negative mood. These relationships remained significant after controlling for demographic and medical history variables and functional status measures associated with dependent variables. No relation of either appraisal or coping to pain or positive mood was observed.

CONCLUSIONS

The findings suggests that as patients' appraisals of the intensity of their OA decrease, less use of passive coping strategies, which are associated with poorer outcomes, should result. It is recommended that interventions to reduce OA impact should include both modification of appraisals of OA and modification of patients' coping strategies.

Do antioxidant micronutrients protect against the development and progression of knee osteoarthritis?

OBJECTIVE

Cumulative damage to tissues, mediated by reactive oxygen species, has been implicated as a pathway that leads to many of the degenerative changes associated with aging. We hypothesized that increased intake of antioxidant micronutrients might be associated with decreased rates of osteoarthritis (OA) in the knees, a common age-related disorder.

METHODS

Participants in the Framingham Osteoarthritis Cohort Study underwent knee evaluations by radiography at examinations 18 (1983-1985) and 22 (1992-1993). Usual dietary intake was assessed using the Food Frequency Questionnaire, administered at examination 20 (1988-1989). Knees without OA at baseline (Kellgren and Lawrence [K&L] grade < or = 1) were classified as having incident OA if they had a K&L grade > or = 2 at followup. Knees with OA at baseline were classified as having progressive OA if their score increased by > or = 1 at followup. Knees were also classified as having cartilage loss or osteophyte growth if their maximal joint space narrowing or osteophyte growth score increased by > or = 1 (range 0-3). The association of vitamin C, beta carotene, and vitamin E intake, ranked in sex-specific tertiles, with incidence and progression of OA was compared with that of a panel of nonantioxidant vitamins, Bl, B6, niacin, and folate, using logistic regression and generalized estimation equations to adjust for correlation between fellow knees. The lowest tertile for each dietary exposure was used as the referent category. Odds ratios (OR) were adjusted for age, sex, body mass index, weight change, knee injury, physical activity, energy intake, and health status.

RESULTS

Six hundred forty participants received complete assessments. Incident and progressive OA occurred in 81 and 68 knees, respectively. We found no significant association of incident OA with any nutrient. A 3-fold reduction in risk of OA progression was found for both the middle tertile (adjusted OR = 0.3, 95% confidence interval [95% CI] 0.1-0.8) and highest tertile (adjusted OR = 0.3, 95% CI 0.1-0.6) of vitamin C intake. This related predominantly to a reduced risk of cartilage loss (adjusted OR = 0.3, 95% CI 0.1-0.8). Those with high vitamin C intake also had a reduced risk of developing knee pain (adjusted OR = 0.3, 95% CI 0.1-0.8). A reduction in risk of OA progression was seen for beta carotene (adjusted OR = 0.4, 95% CI 0.2-0.9) and vitamin E intake (adjusted OR = 0.7, 95% CI 0.3-1.6), but was less consistent. No significant associations were observed for the nonantioxidant nutrients.

CONCLUSION

High intake of antioxidant micronutrients, especially vitamin C, may reduce the risk of cartilage loss and disease progression in people with OA. We found no effect of antioxidant nutrients on incident OA. These preliminary findings warrant confirmation.

Weight and osteoarthritis

Osteoarthritis is the most common form of arthritis. It increases in prevalence with age. About 5% of the US population is affected with hip or knee osteoarthritis; 9.5% of adults aged > 62 y have knee osteoarthritis. Because of its frequency and associated pain and disability, osteoarthritis accounts for much of the disability in lower extremities in the elderly. More than 70% of total hip and knee replacements are for osteoarthritis. Because osteoarthritis is so common, the modification of factors that increase osteoarthritis risk could prevent substantial pain and disability in the elderly and the use of costly health care services. Overweight persons are at high risk of osteoarthritis in the knee and probably also in the hips and hands. The mechanism by which overweight causes osteoarthritis is poorly understood; a contribution from both local increased force across the joint and systemic factors is likely. Better evidence is needed on the effects of weight loss, but preliminary studies suggest that weight loss can both prevent the onset of symptomatic disease and alleviate symptoms when present.

Long-term follow-up results of rotational acetabular osteotomy in painful dysplastic hips: efficacy in delaying the onset of osteoarthritis

We evaluated the results of rotational acetabular osteotomies in 13 severely dysplastic hips (11 patients) with subluxation. All of the patients were women, aged 20 to 35 years at the time of surgery, and 40 years or more at the time of follow-up. At a minimum follow-up period of 10 years, the patients had minimal or no pain. Of the 13 hips, 12 showed no significant findings of osteoarthritis. Comparing the outcome of these patients with the natural evolution of severely dysplastic hips, we concluded that rotational acetabular osteotomy may prevent the onset of osteoarthritis.

Arthroscopic osteochondral autograft transplantation in anterior cruciate ligament reconstruction: a preliminary clinical study

The high incidence of chondral defects of the femoral condyles associated with chronic ACL tears is widely recognised. However, treatment is difficult and controversial. This preliminary report presents our experience with arthroscopic osteochondral autograft transplantation in ACL-deficient knees. The series consists of 12 cases of arthroscopic osteochondral autograft transplantation in conjunction with ACL reconstruction using bone-patellar tendon-bone autograft; eight procedures were primary, and four were revisions of failed synthetic grafts. The patients' ages ranged from 22 to 42 years. There were ten male and two female patients. Chondral lesions in this series ranged from 10 to 22 mm in diameter. Donor site was selected prior to notchplasty, and three to five osteochondral cylinders, 5-10 mm in diameter, 10-15 mm long, were harvested. Improved surgical technique, tubular cutting instruments enabling minimal damage to harvested articular cartilage, and press-fit insertion yielded promising uniform results in ten of 12 cases with 2 years' follow-up. This study addresses the important issue of articular cartilage defects in ACL-deficient knees and possible prevention of premature joint degeneration. The aim of arthroscopic osteochondral autograft transplantation is to slow down the development of osteoarthrosis.

Knee joint moments in work-related situations

Circumstantial evidence in the literature points towards a relationship between heavy labour and arthrosis of the knee. The aim of this study was to demonstrate which occupational activities yield the greatest knee moments and thus indicate possible gonarthrosis-inducing occupational hazards. Twelve healthy and uninjured medical students were studied in set occupational situations in a laboratory for gait analysis, using a force plate with video display of force vectors and knee joints (VIFOR). With normal walking as a baseline for moment it was found that activities involving knee flexion, such as lifting objects from one level to the other, climbing stairs and ladders, and jumping down, revealed a significant increase in moment. On the other hand, carrying objects in one or both hands did not yield significant increase in knee moment compared with normal walking. Flexed knee lifting had significantly lower moment than jumping down from a height of 0.5 m on to one or both feet. Three levels of knee moment could thus be identified, i.e., normal walking, flexed knee lifting and jumping down.

Clinical pathogenesis and diagnosis of osteoarthritis

New insights into the metabolism of cartilage have increased respect for efforts designed to prevent osteoarthritis. The aging of the population adds to the desire to diagnose and manage the disease before patients become seriously disabled.

Remodeling of articular step-offs. Is osteoarthrosis dependent on defect size?

One of the major unresolved questions in trauma repair concerns the degree of step-off that can be accepted in a joint surface. In answer to this question, a new rabbit model of femoral step-off was developed. Osteoarthrotic changes in cartilage and bone and the failure of repair responses were seen at 20 weeks in the presence of a 3-mm wide sagittal defect displaced 5 mm from the joint surface and spanning the anteroposterior extent of the medial femoral condyle. This study examined the effects of a similar defect, displaced 2 mm from the joint surface, to determine whether the development of osteoarthrosis is dependent on the size of the step-off. Defects were created in 18 New Zealand white rabbits. In a second group, the medial joint surface was osteotomized, but was not displaced. In contrast to th first study, cartilaginous and bony repair resulted in closure of the surgical defect and restoration of femoral congruity. Histologic and biochemical parameters did not differ significantly between groups. The results indicate that cartilage and bone possess the ability to remodel small articular step-offs and to restore joint congruity. Furthermore, the combined data suggest that the development of osteoarthrosis requires significant articular incongruity.

Weight and osteoarthritis

Overweight persons are at high risk of osteoarthritis (OA) in the knee, and probably in the hips and hands. The mechanism by which overweight causes OA is poorly understood, with a likely contribution from both local increased force across the joint and systemic factors. Better evidence is needed on the effects of weight loss, but preliminary studies suggest that weight loss can both prevent the onset of symptomatic disease and alleviate symptoms, when present.

Growth factor actions on articular cartilage

Polypeptide growth factors play a major role in the regulation of cell behavior, including that of articular chondrocytes. Among the most influential of these factors identified for articular cartilage are insulin like growth factor I (IGF-I), basic fibroblast growth factor (bFGF), and transforming growth factor beta (TGF beta). IGF-I stimulates articular chondrocyte matrix synthetic and mitotic activity and inhibits chondrocyte mediated matrix catabolism. The role of bFGF as a potent mitogen for articular chondrocytes is well established. In contrast, this factor appears to play a complex role in matrix synthesis and degradation, promoting both anabolic and catabolic functions. Both IGF-I and bFGF have been shown to augment articular cartilage repair in vivo. TGF beta is particularly dependent upon the context in which it acts, eliciting seemingly opposite effects under different experimental conditions. These and other factors interact to modulate their respective actions, creating effector cascades and feedback loops of intercellular and intracellular events that control articular chondrocyte functions. Elucidation of the actions and interactions of these factors may be expected to clarify the etiopathogenesis of osteoarthritis and possibly offer novel methods for its treatment.

Therapeutic targets in osteoarthritis

Osteoarthritis (OA) can be considered as a disease process, amenable to therapy, or as a consequence of evolution, resulting in special disadvantages to long lived humans. Possible therapeutic targets are considered for both models of the condition. Targets for a disease process might include inhibition of tissue destruction, or the stimulation of natural repair processes. Therapeutic targets for the disadvantages of OA include novel approaches to the treatment of pain and physical disability. The 2 approaches are not mutually exclusive, and both should be pursued.

Anterior cruciate ligament reconstruction combined with valgus tibial osteotomy (combined procedure)

We assessed the patients who were operated on in a combined procedure from 1980 to 1992 with anterior cruciate ligament (ACL) insufficiency, cartilaginous lesions of the medial compartment, lesion of medial meniscus and varus malalignment. The combined operative procedure was autologous intra-articular ACL reconstruction with the middle third of the patellar ligament--partially augmented with Kennedy-ligament augmentation device (LAD) in hot dog technique--and high tibial osteotomy. The patients were examined according to the criteria of IKDC including testing of anterior stability with the KT-1000 arthrometer. Radiographically we checked axis and arthritis according to a modified score of Kannus. Twenty-seven of 34 patients who fulfilled the inclusion criteria could be followed up in three categories (2-5 years post-operatively, 5-10 years postoperatively, over 10 years post-operatively). Total qualification was good in 37%; there were no perioperative complications. Rehabilitation was not prolonged. Eighty-nine percent practised their preoperative job, over 50% had a higher level of sports activities than preoperatively, and more than 25% regained their pretraumatic sports capacity. Two-thirds had no giving way and less than 3 mm translation difference in comparison to the contralateral knee. Seventy-five percent of patients would accept the operation again. Radiological findings had no correlation to overall qualification. The encouraging results with respect to many of the criteria suggest using the combined procedure in a young patient with ACL insufficiency, varus malalignment and medial compartment damage including medial meniscus lesion.

Low-selenium diet, bone, and articular cartilage in rats

The pathophysiology of secondary osteoarthritis remains largely obscure. Our attention has been drawn to Kashin-Beck disease (KBD), which has been attributed to Se deficiency. To obtain information regarding the prevention, prediction of progression, and treatment of this condition, we performed histological and biochemical studies on bone and articular cartilage specimens obtained from rats fed a low-Se diet. A low-Se diet was prepared and fed to Wistar rats for 3-11 mo, after which the rats were killed under general anesthesia, and their articular cartilages were studied microscopically and electron microscopically. The bone mineral density (BMD) of the femur was determined by the microdensitometry method and ash weight. In addition, serum Se, Ca, P, Alk Phos, T3, T4, and urinary Se were measured. In the low-Se group, impaired weight gain was observed from the 5th mo, and head alopecia was found in 60% of the animals. Microscopically, no clear changes in the articular chondrocytes were apparent, whereas with the electron microscope, chondrocytes in the deep layer showed degeneration of nuclei and endoplasmic reticular ballooning. From the 5th mo, a decrease in BMD (ash weight) was noted. Serum Se concentrations, alkaline phosphatase activity, and urine Se concentrations were decreased in the Se-deficient rats, whereas serum Ca, P, T3, and T4 values did not differ from those of a control group. Also, a decrease in sulfotransferase activity, which is involved in transfer in the process of synthesis of glycosaminoglycan, which is a proteoglycan carbohydrate chain, was found.(ABSTRACT TRUNCATED AT 250 WORDS)

Intermittent cyclic therapy with etidronate in the prevention of corticosteroid induced bone loss

OBJECTIVE

To assess the potential efficacy of intermittent cyclic therapy (ICT) with etidronate in the treatment of patients with corticosteroid induced osteoporosis.

METHODS

Cohort study in a tertiary care university affiliated hospital in corticosteroid treated patients, with polymyalgia rheumatica, asthma, systemic lupus erythematosus, rheumatoid arthritis, or temporal arteritis, examining the effects of ICT etidronate. Patients were included if they were taking corticosteroids for a minimum of one year. Comparison patients were those who had been taking corticosteroids for a minimum of one year and who had not been treated with etidronate or other medication which might alter bone metabolism. A total of 68 patients were included from 253 considered. The mean (SD) dose of prednisone in the ICT etidronate treated patients was 9.3 (6.2) mg and in the comparison patients 9.4 (5.9) mg. The duration of prednisone therapy was 7.8 (5.8) years and 3.4 (4.2) years, respectively (p2 < 0.001). An analysis of covariance demonstrated that this difference did not alter our primary outcome measure. The primary outcome measure was the difference in the percentage change from baseline to one year of followup in bone mineral density (BMD) of the lumbar spine between treatment and comparison groups.

RESULTS

ICT etidronate resulted in a statistically significant and clinically important increase in BMD. The BMD of the lumbar spine increased by 3.82% (0.65%), [95% confidence interval (CI), 2.51 to 5.14%] in the 35 ICT etidronate treated patients and decreased by 1.78% (0.76%), [95% CI, -3.34 to -0.23%] in the 33 comparison patients after 12 months (p2 < 0.0001).

CONCLUSIONS

ICT etidronate prevented loss of vertebral bone density in patients with corticosteroid induced osteoporosis. Controlled, double blind, prospective trials with longer followup are needed to confirm these results and to demonstrate that increases in bone mass translate into decreased fracture rates.

[Long-term surgical results of osteochondrosis dissecans of the knee joint in adolescents less than 16 years of age]

The correct therapy of osteochondritis dissecans in patients under 16 years is very important to prevent the knee joint from secondary arthritis. We analysed clinical, radiological and with MRI the long term (10 years) results of a follow-up study on 36 patients under 16 years with 42 operatively treated osteochondritis dissecans of the knee joint. There were excellent and good results in 81% of the patients. After an average of 10 years there were no signs of arthritis which would necessitate any treatment.

Magnetic resonance imaging of bone marrow and osteochondral injury

Posttraumatic occult subcortical fractures represent a heterogeneous group of lesions, with different subgroups associated with a high incidence of osteochondral sequelae. The role of MR imaging must be to determine the significance of the different subgroups of occult fractures in the pathogenesis of posttraumatic osteoarthritis. The ultimate goal is to minimize the eventual effects of impactive forces on the osteochondral complex at the time of detection. Modifications in immediate and rehabilitative management of such patients will ensure maintenance of the best possible chondral integrity.

The physiologic basis of continuous passive motion for articular cartilage healing and regeneration

This article historically reviews the limited potential of articular cartilage to heal or regenerate, past emphasis on rest as opposed to motion, and the reasoning that led the author to create the biologic concept of continuous passive motion (CPM) in 1970. The basic premises and hypotheses of CPM are stated. A brief summary is provided of 19 scientific investigations of CPM in rabbits, with particular emphasis on the beneficial short-term and long-term effects of CPM in intra-articular fractures. The conclusions from the basic research are summarized. The clinical applications of CPM to the care of patients are discussed with respect to the indications and the results.

Kashin-Beck disease. An analysis of research and public health activities based on a bibliography 1849-1992

The main feature of Kashin-Beck disease (KBD) is short stature caused by multiple focal necroses in the growth plate of the tubular bones. This leads to a secondary, sometimes severe osteoarthrosis. The disease was first described in Russia from the Bajkal area by Kashin 1848 and later, 1906, by Eugene Beck. Modern literature is mainly from China. The main theory originally proposed by Russian investigators was that KBD was caused by a toxic effect of mycotoxin. The focus on the disease gradually shifted to China where the causal theory has been based on the effects of selenium deficiency and its interaction with mycotoxins. These main hypotheses may be unified in one theory. KBD is appreciated as a public health problem estimated to affect some 1-3 million people across China. National and provincial registers on KBD exist for selected affected areas. Current incidence is probably declining. Preventive efforts have been undertaken but are usually not controlled for effectiveness nor by putative causal mechanisms. More research into the causal mechanisms is required. A combination of difficulties to obtain literature, including primary material together, and cultural and language barriers have been a main obstacle to more active participation by the international research community. This bibliography is an attempt to help improve this situation. The bibliography covers the period 1849-1992. The analysis of this bibliography shows a broad and intensive, though sometimes insufficiently coordinated research. Many authorities and research bodies are involved. The possibility to develop coordinated projects within a common framework, and thus to use research results to prevent KBD, has been a major source of inspiration in making this review. The review covers 499 publications directly related to KBD and 1415 references to these publications. KBD publications have been retrieved from conventional international journals, usually in English, publications in Russian, as well as unpublished reports in Chinese provided at site visits. The papers are classified by key words. The references in these publications have also been similarly classified and are in part analysed. Based on publications identified from several sources, direction of research and public health efforts from 1848 to 1992 are described. Finally, mainly based on questions raised by and recommendations from a WHO workgroup meeting in 1992, some major components of research activities and public health program are proposed.

Prolonged effect of iodoacetate on articular cartilage and its modification by an anti-rheumatic drug

The intra-articular injection of iodoacetate into the knee joint of rats produced changes in the articular cartilage which resembled those of osteoarthritis. It caused virtually total loss of many of the oxidative enzymes, indicating inhibition of the main oxidative pathways. Treatment with an anti-rheumatic drug had little early effect but ultimately led to partial restoration of these pathways. The reduced progression of cartilage degradation induced by this drug was accompanied by some unusual histological features.

Cigarette smoking and risk of osteoarthritis in women in the general population: the Chingford study

Previous studies have suggested that smoking might be protective against the development of osteoarthritis (OA) of the knee. A group of 1003 women aged 45-64 years (mean 54.2 years) from the Chingford general population survey were studied to examine the effect of cigarette smoking on the prevalence of radiologically confirmed OA at different sites. Standard anteroposterior radiographs of the hand and knee were available in 985 women. Disease classification was made on the basis of radiological OA and symptomatic radiological OA. Odds ratios were calculated and adjusted for age and body mass index. A total of 463 (46.2%) women were ever smokers compared with 540 (53.8%) non-smokers. Ever smokers had consumed an average of 14.9 cigarettes a day for a mean of 25.7 years. For radiological OA of the distal interphalangeal joint (DIP) (140 women), proximal interphalangeal joint (40 women), carpometacarpal joint (160 women), and knee joint (118, women) there was no reduced risk of OA in ever smokers. In the small number of subjects with generalised OA (22 women) there was a non-significant 40% reduction of radiological OA in ever smokers (odds ratio 0.63; 95% confidence interval 0.24 to 1.68). Results were similar for subjects with radiographic clinical OA, except the DIP joint which showed a positive association between smoking and Heberden's nodes (odds ratio 2.02, 95% confidence interval 1.89 to 3.42). Results were similar when analysed using current smokers against never smokers. These results do not support an inverse association between cigarette smoking and OA in women. A possible inverse relation with the small subgroup of women with generalised OA and an effect of cigarettes on disease severity cannot, however, be discounted.

Strategies for the prevention of osteoarthritis

Osteoarthritis (OA) is a common age-related disorder which can result in severe pain and disability, and which is becoming one of the most important health-care challenges of the future. Previous negative attitudes to this condition are being dispelled by current research findings, which indicate that prevention and effective treatment will be possible in the future. Risk-factor analyses suggest that many cases can be prevented by reducing the amount of obesity in the community, and by changing certain high-risk occupations, as well as reducing the incidence of joint trauma. Work on the processes involved in the generation of OA have led to strategies for the secondary prevention of the condition, through drugs that either inhibit connective-tissue breakdown and/or stimulate repair. Recent developments in the management of established OA indicate that much of the pain and disability suffered in the community as a result of this disease is also preventable.

A primer of osteotomy of the weight bearing long bones in children

A. Why Perform An Osteotomy In Childhood or Adolescence? 1. Progressive deformity for which osteotomy is curative. 2. Cosmesis. 3. To prevent the development of late osteoarthritis (unproven). 4. Progressive ligamentous laxity (rare). 5. Functionally limiting deformities (rare). 6. Development of adaptive joint deformity (rare). B. When To Perform An Osteotomy 1. Immediate correction for progressive deformities or functionally limiting deformities that can not be expected to improve by the natural history of the deformity. 2. Immediate correction if the problems listed under "A" are present such as the development of adaptive joint deformity or progressive ligamentous laxity. 3. If no indication for osteotomy exists except cosmesis, consider delaying correction to avoid the need for repeated osteotomies in disorders for which recurrence is common. C. How To Do The Osteotomies 1. Perform the osteotomy at the level of the deformity when possible. 2. Choose the simplest, safest method that will accomplish specific goals. 3. Complex restoration of perfect mechanical axis and joint alignment may not be necessary. The lesser risks of simpler techniques should be considered. 4. The specific technique chosen will depend on the experience and abilities of the treating physician.

One-year evaluation of cognitive-behavioral intervention in osteoarthritis

We compared a cognitive-behavior modification and a traditional education intervention for adults with osteoarthritis (OA). Forty OA patients were randomly assigned to one of two groups: cognitive-behavior modification or didactic lectures. During ten weekly sessions, the cognitive-behavior group learned methods for coping with pain and the disabilities associated with OA. The traditional education group experienced a series of lectures from health care professionals. Prior to the interventions and following 2, 6, and 12 months, patients in both groups were evaluated with a general Quality of Well-being (QWB) scale, the Arthritis Impact Measurement Scales (AIMS), the Beck Depression Inventory (BDI), and other measures. Although there were some differences between the two groups at 2-month follow-up, by the end of 1 year, physical and psychological functioning did not differ significantly between the two groups. In comparison to baseline, both groups demonstrated initial changes on QWB, depression, and the pain component of the AIMS. Improvements in depression remained through the 1-year follow-up. Multiple regression analysis demonstrated that the mobility and physical activity aspects of the AIMS were significant long-term predictors of outcome (1 year) for general quality-of-life measures. One-year outcomes for depression were significantly predicted from scores on social support and mobility measures from the AIMS. We conclude that cognitive-behavior modification and education produce similar effects on long-term physical and psychological functioning in OA patients.

Reduction of the severity of canine osteoarthritis by prophylactic treatment with oral doxycycline

OBJECTIVE

In vitro studies have indicated that levels of neutral metalloproteinases in osteoarthritic (OA) cartilage are elevated and that doxycycline (doxy) inhibits collagenolytic and gelatinolytic activity in extracts of OA cartilage. The purpose of the present study was to test the effect of oral doxy administration on the severity of cartilage degeneration in OA.

METHODS

OA was induced in 12 adult mongrel dogs by transection of the anterior cruciate ligament (ACL) 2 weeks after dorsal root ganglionectomy. Six dogs received doxy orally from the day after ACL transection until they were killed 8 weeks later; the other 6 served as untreated OA controls.

RESULTS

The unstable knee of each untreated dog exhibited extensive full-thickness cartilage ulceration of the medial femoral condyle. In sharp contrast, cartilage on the distal aspect of the femoral condyle of the unstable knee was grossly normal in 2 doxy-treated dogs, and exhibited only thinning and/or surface irregularity in the others. Degenerative cartilage lesions on the medial trochlear ridge, superficial fibrillation of the medial tibial plateau, and osteophytosis were, however, unaffected by doxy treatment. Collagenolytic activity and gelatinolytic activity in cartilage extracts from OA knees of untreated dogs were 5-fold and 4-fold greater, respectively, than in extracts from dogs given doxy.

CONCLUSION

Prophylactic administration of doxy markedly reduced the severity of OA in weight-bearing regions of the medial femoral condyle. It remains to be determined whether administration of doxy after OA changes have developed is also effective.