Effect of low loading and joint immobilization for spontaneous repair of osteochondral defect in the knees of weightless (tail suspension) rats

Joint Cartilage in Long-Duration Spaceflight

This review summarizes the current literature available on joint cartilage alterations in long-duration spaceflight. Evidence from spaceflight participants is currently limited to serum biomarker data in only a few astronauts. Findings from analogue model research, such as bed rest studies, as well as data from animal and cell research in real microgravity indicate that unloading and radiation exposure are associated with joint degeneration in terms of cartilage thinning and changes in cartilage composition. It is currently unknown how much the individual cartilage regions in the different joints of the human body will be affected on long-term missions beyond the Low Earth Orbit. Given the fact that, apart from total joint replacement or joint resurfacing, currently no treatment exists for late-stage osteoarthritis, countermeasures might be needed to avoid cartilage damage during long-duration missions. To plan countermeasures, it is important to know if and how joint cartilage and the adjacent structures, such as the subchondral bone, are affected by long-term unloading, reloading, and radiation. The use of countermeasures that put either load and shear, or other stimuli on the joints, shields them from radiation or helps by supporting cartilage physiology, or by removing oxidative stress possibly help to avoid OA in later life following long-duration space missions. There is a high demand for research on the efficacy of such countermeasures to judge their suitability for their implementation in long-duration missions.

Clinical Validation of Pain Management Manipulative Therapy for Knee Osteoarthritis With the Squeeze-Hold Technique: A Case Series

OBJECTIVE

The purpose of this case series was to describe the short-term and long-term clinical effects of a manual technique for treating osteoarthritis (OA) knee pain.

METHODS

This study measured of the immediate effect and long-term effect by using a case series of different groups of subjects. Knee OA and activity restriction in patients were evaluated by using the Kellgren-Lawrence (K/L) Grading Scale and the Japanese Knee Osteoarthritis Measure (JKOM) index. In the intervention, lower limb muscles were squeezed by hand for 20 seconds. Each squeeze was performed for both lower limbs. Passive range-of-motion (ROM) exercise was performed on the knee joint. In one set of cases, immediate effects were measured after a one-time treatment with pretreatment and posttreatment outcome measures. Eleven people with knee OA participated in the study. On a visual analogue scale (VAS) for pain, muscle stiffness, and muscular hemodynamics for estimation of muscle blood flow were recorded before and after the squeeze-hold treatment. In another set of cases, the treatment was given to all patients once a week for 6 months, and long-term effects were measured. Data on 5 subjects with knee OA were collected for 6 months after initial treatment. The VAS for pain and JKOM were recorded every month for 6 months.

RESULTS

For immediate effects, the VAS was 69 ± 21 mm before treatment and 26 ± 22 mm after treatment. Muscle stiffness was 8.8 ± 3.6 (absolute number) before treatment and 3.5 ± 2.1 after treatment. Tissue (muscle) oxygen saturation was 60.1 ± 5.7% before treatment and 65.3 ± 4.8% after treatment. Total hemoglobin was 24.3 ± 3.3 (absolute number) before treatment and 25 ± 2.3 after treatment. A tendency for reduction in OA knee pain and muscle stiffness was observed, and a tendency for increase was observed in the blood flow in the muscle. For long-term effects in all 5 participants (any K/L grade, any JKOM score), OA knee pain and JKOM score improved gradually through 6 months.

CONCLUSIONS

The participants in this case series showed improvement in pain and function. These findings indicate the feasibility of a larger study on the squeeze-hold intervention for OA knee pain.

Role of oxygen as a regulator of stem cell fate during the spontaneous repair of osteochondral defects

The complexity of the in vivo environment makes it is difficult to isolate the effects of specific cues on regulating cell fate during regenerative events such as osteochondral defect repair. The objective of this study was to develop a computational model to explore how joint specific environmental factors regulate mesenchymal stem cell (MSC) fate during osteochondral defect repair. To this end, the spontaneous repair process within an osteochondral defect was simulated using a tissue differentiation algorithm which assumed that MSC fate was regulated by local oxygen levels and substrate stiffness. The developed model was able to predict the main stages of tissue formation observed by a number of in vivo studies. Following this, a parametric study was conducted to better understand why interventions that modulate angiogenesis dramatically impact the outcome of osteochondral defect healing. In the simulations where angiogenesis was reduced, by week 12, the subchondral plate was predicted to remain below the native tidemark, although the chondral region was composed entirely of cartilage and fibrous tissue. In the simulations where angiogenesis was increased, more robust cell proliferation and cartilage formation were observed during the first 4 weeks, however, by week 12 the subchondral plate had advanced above the native tidemark although any remaining tissue was either hypertrophic cartilage or fibrous tissue. These results suggest that osteochondral defect repair could be enhanced by interventions where angiogenesis is promoted but confined to within the subchondral region of the defect. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1026-1036, 2016.

Current clinical evidence for the use of mesenchymal stem cells in articular cartilage repair

INTRODUCTION

Articular cartilage is renowned for its poor intrinsic capacity for repair. Current treatments for osteoarthritis are limited in their ability to reliably restore the native articular cartilage structure and function. Mesenchymal stem cells (MSCs) present an attractive treatment option for articular cartilage repair, with a recent expansion of clinical trials investigating their use in patients.

AREAS COVERED

This paper provides a current overview of the clinical evidence on the use of MSCs in articular cartilage repair.

EXPERT OPINION

The article demonstrates robust clinical evidence that MSCs have significant potential for the regeneration of hyaline articular cartilage in patients. The majority of clinical trials to date have yielded significantly positive results with minimal adverse effects. However the clinical research is still in its infancy. The optimum MSC source, cell concentrations, implantation technique, scaffold, growth factors and rehabilitation protocol for clinical use are yet to be identified. A larger number of randomised control trials are required to objectively compare the clinical efficacy and long-term safety of the various techniques. As the clinical research continues to evolve and address these challenges, it is likely that MSCs may become integrated into routine clinical practice in the near future.

Advancement of the Subchondral Bone Plate in Translational Models of Osteochondral Repair: Implications for Tissue Engineering Approaches

Subchondral bone plate advancement is of increasing relevance for translational models of osteochondral repair in tissue engineering (TE). Especially for therapeutic TE approaches, a basic scientific knowledge of its chronological sequence, possible etiopathogenesis, and clinical implications are indispensable. This review summarizes the knowledge on this topic gained from a total of 31 translational investigations, including 1009 small and large animals. Experimental data indicate that the advancement of the subchondral bone plate frequently occurs during the spontaneous repair of osteochondral defects and following established articular cartilage repair approaches for chondral lesions such as marrow stimulation and TE-based strategies such as autologous chondrocyte implantation. Importantly, this subchondral bone reaction proceeds in a defined chronological and spatial pattern, reflecting both endochondral ossification and intramembranous bone formation. Subchondral bone plate advancement arises earlier in small animals and defects, but is more pronounced at the long term in large animals. Possible etiopathologies comprise a disturbed subchondral bone/articular cartilage crosstalk and altered biomechanical conditions or neovascularization. Of note, no significant correlation was found so far between subchondral bone plate advancement and articular cartilage repair. This evidence from translational animal models adverts to an increasing awareness of this previously underestimated pathology. Future research will shed more light on the advancement of the subchondral bone plate in TE models of cartilage repair.

Management strategies for osteochondritis dissecans of the knee in the skeletally immature athlete

SYNOPSIS

Osteochondritis dissecans (OCD) is a disorder resulting in focal breakdown of the subchondral bone, with potential disruption of the overlying articular cartilage. The femoral condyles of the knee are the most common locations for OCD, and the incidence of OCD appears to be increasing among active children. Juvenile OCD (JOCD) can be distinguished from adult OCD by the presence of open growth plates. Due to a lack of evidence on its early diagnosis, optimal treatment, and long-term course of healing, JOCD presents a unique challenge for the health care team. Approximately 50% to 67% of stable JOCD lesions heal successfully with nonoperative treatment. For unstable lesions and stable lesions that fail nonoperative treatment, a variety of surgical interventions can be utilized to stimulate bony healing and address articular cartilage lesions. It is recommended that rehabilitation of JOCD be tailored to the individual patient, based on the stage and radiographic status of the lesion and the mode of surgery employed when surgically addressed. Although there is a growing body of literature on this condition, the etiology and optimal methods for treatment, rehabilitation, and evaluating outcomes remain inconclusive due to a lack of quality evidence.

LEVEL OF EVIDENCE

Therapy, level 5.

Differences in Cartilage Repair between Loading and Unloading Environments in the Rat Knee

We investigated the histopathological and immunohistochemical effects of loading on cartilage repair in rat full-thickness articular cartilage defects. A total of 40 male 9-week-old Wistar rats were studied. Full-thickness articular cartilage defects were created over the capsule at the loading portion in the medial condyle of the femur. Twenty rats were randomly allocated into each of the 2 groups: a loading group and a unloading group. Twenty rats from these 2 groups were later randomly allocated to each of the 2 groups for evaluation at 1 and 2 weeks after surgery. At the end of each period, knee joints were examined histopathologically and immunohistochemically. In both groups at 1 and 2 weeks, the defects were filled with a mixture of granulation tissue and some remnants of hyaline cartilage. The repair tissue was not stained with toluidine blue in both groups. Strong staining of type I collagen was observed in the repair tissue of both groups. The area stained with type I collagen was smaller in the unloading group than in the loading groups, and the stained area was smaller at 2 weeks than at 1 week. In the staining for type II collagen, apparent staining of type II collagen was observed in the repair tissue of both groups at 1 week. At 2 weeks, there was a tendency toward a higher degree of apparent staining in the loading group than in the unloading group. Accordingly, these results indicated that loading and unloading in the early phase of cartilage repair have both merits and demerits.

The mechanical microenvironment of high concentration agarose for applying deformation to primary chondrocytes

Cartilage and chondrocytes experience loading that causes alterations in chondrocyte biological activity. In vivo chondrocytes are surrounded by a pericellular matrix with a stiffness of ~25-200kPa. Understanding the mechanical loading environment of the chondrocyte is of substantial interest for understanding chondrocyte mechanotransduction. The first objective of this study was to analyze the spatial variability of applied mechanical deformations in physiologically stiff agarose on cellular and sub-cellular length scales. Fluorescent microspheres were embedded in physiologically stiff agarose hydrogels. Microsphere positions were measured via confocal microscopy and used to calculate displacement and strain fields as a function of spatial position. The second objective was to assess the feasibility of encapsulating primary human chondrocytes in physiologically stiff agarose. The third objective was to determine if primary human chondrocytes could deform in high-stiffness agarose gels. Primary human chondrocyte viability was assessed using live-dead imaging following 24 and 72h in tissue culture. Chondrocyte shape was measured before and after application of 10% compression. These data indicate that (1) displacement and strain precision are ~1% and 6.5% respectively, (2) high-stiffness agarose gels can maintain primary human chondrocyte viability of >95%, and (3) compression of chondrocytes in 4.5% agarose can induce shape changes indicative of cellular compression. Overall, these results demonstrate the feasibility of using high-concentration agarose for applying in vitro compression to chondrocytes as a model for understanding how chondrocytes respond to in vivo loading.

Osteochondritis dissecans of the knee in children and adolescents

PURPOSE OF REVIEW

Osteochondritis dissecans (OCD) of the knee is a well-described condition that can cause significant morbidity in children and adolescents; timely diagnosis is key to preventing compromise to the articular cartilage and maximizing opportunity to perform a restorative procedure. Juvenile OCD has a better prognosis than does adult OCD, with higher rates of spontaneous healing with conservative treatment. Still, there are certain indications for surgical restoration procedures. Controversies arise over when to decide surgical procedure and what is the best surgical treatment option in this young population.

RECENT FINDINGS

Some authors believe nonoperative management should be the first-line treatment for stable OCD lesions in children. The only consensus in regard to this modality is that, if a patient is truly asymptomatic or experiencing low-level symptoms, then the duration of nonoperative treatment should be at least 3-6 months before opting for operative treatment. In the case of failed nonsurgical management or in the setting of an unstable fragment, surgical intervention should be implemented. Recent published data suggest no difference in clinical or radiographic outcome when comparing different surgical techniques.

SUMMARY

OCD of the knee requires a timely diagnosis to maximize opportunity to perform a reparative procedure. Indications for surgical treatment are based on lesion stability, skeletal maturity, and clinical symptoms. Reestablishing the joint surface, improving the blood supply of the fragment, rigid fixation, and early motion are primary goals for osteochondral fragment preservation. When the fragment is not suitable for preservation, careful consideration of defect location and the patient's clinical presentation will determine when cartilage restoration procedures should be utilized.

Temporal and spatial migration pattern of the subchondral bone plate in a rabbit osteochondral defect model

OBJECTIVE

Upward migration of the subchondral bone plate is associated with osteochondral repair. The aim of this study was to quantitatively monitor the sequence of subchondral bone plate advancement in a lapine model of spontaneous osteochondral repair over a 1-year period and to correlate these findings with articular cartilage repair.

DESIGN

Standardized cylindrical osteochondral defects were created in the rabbit trochlear groove. Subchondral bone reconstitution patterns were identified at five time points. Migration of the subchondral bone plate and areas occupied by osseous repair tissue were determined by histomorphometrical analysis. Tidemark formation and overall cartilage repair were correlated with the histomorphometrical parameters of the subchondral bone.

RESULTS

The subchondral bone reconstitution pattern was cylindrical at 3 weeks, infundibuliform at 6 weeks, plane at 4 and 6 months, and hypertrophic after 1 year. At this late time point, the osteochondral junction advanced 0.19 [95% confidence intervals (CI) 0.10-0.30] mm above its original level. Overall articular cartilage repair was significantly improved by 4 and 6 months but degraded after 1 year. Subchondral bone plate migration correlated with tidemark formation (r = 0.47; P < 0.0001), but not with the overall score of the repair cartilage (r = 0.11; P > 0.44).

CONCLUSIONS

The subchondral bone plate is reconstituted in a distinct chronological order. The lack of correlation suggests that articular cartilage repair and subchondral bone reconstitution proceed at a different pace and that the advancement of the subchondral bone plate is not responsible for the diminished articular cartilage repair in this model.

Chondrogenesis, bone morphogenetic protein-4 and mesenchymal stem cells

OBJECTIVE

As adult cartilage has very limited potential to regenerate, cartilage repair is challenging. Available treatments have several disadvantages, including formation of fibrocartilage instead of hyaline-like cartilage, as well as eventual ossification of the newly formed tissue. The focus of this review is the application of bone morphogenetic protein-4 (BMP-4) and mesenchymal stem cells (MSCs) in cartilage repair, a combination that could potentially lead to the formation of permanent hyaline-like cartilage in the defect.

METHODS

This review is based on recent literature in the orthopaedic and tissue engineering fields, and is focused on MCSs and bone morphogenetic proteins (BMPs).

RESULTS

BMP-4, a stimulator of chondrogenesis, both in vitro and in vivo, is a potential therapeutic agent for cartilage regeneration. BMP-4 delivery can improve the healing process of an articular cartilage defect by stimulating the synthesis of the cartilage matrix constituents: type II collagen and aggrecan. BMP-4 has also been shown to suppress chondrogenic hypertrophy and maintain regenerated cartilage. Use of an appropriate carrier for BMP-4 is crucial for successful reconstruction of cartilage defects. Due to the relatively short half-life in vivo of BMP-4, there is a need to localize and maintain the delivery of BMP-4 to the injury site. Additionally, the delivery of MSCs to the wound site could improve cartilage regeneration; therefore, the carrier should function both as a cell and a protein delivery vehicle.

CONCLUSION

The role of BMP-4 in chondrogenesis is significant, and successful methods to deliver BMP-4, with or without MSCs, to the cartilage defect site are a promising therapy to treat cartilage defects.

Induction of chondrogenic phenotype in synovium-derived progenitor cells by intermittent hydrostatic pressure

OBJECTIVE

The aim of this study was to investigate the effect of intermittent hydrostatic pressure (IHP) on chondrogenic differentiation of synovium-derived progenitor cells (SPCs).

METHODS

SPCs, bone marrow-derived progenitor cells and skin fibroblasts from rabbits were subjected to IHP ranging from 1.0 to 5.0 MPa. The mRNA expression of proteoglycan core protein (PG), collagen type II and SOX-9 was examined using real-time reverse transcriptase-polymerase chain reaction (RT-PCR). The production of SOX-9 protein and glycosaminoglycan (GAG) by SPCs was analyzed by Western blot and the dimethylmethylene blue assay. In addition, mitogen-activated protein (MAP) kinase inhibitors for c-Jun N-terminal kinase (JNK), extracellular signal-regulated kinase (ERK), and the p38 pathway were used to identify the signal transduction pathways.

RESULTS

Real-time RT-PCR showed that mRNA expression of PG, collagen type II and SOX-9 was significantly enhanced only in SPCs receiving 5.0 MPa of IHP. The production of SOX-9 protein and GAG by SPCs was also increased by exposure to 5.0 MPa of IHP. These up-regulated expressions were suppressed by pretreatment with an inhibitor of JNK, but not with inhibitors of ERK or p38.

CONCLUSION

Our results demonstrated that the exposure of SPCs to 5.0 MPa of IHP could facilitate induction of the chondrogenic phenotype by the MAP kinase/JNK pathway. This finding suggests the potential for IHP utilization in regenerative treatments for cartilage injuries or osteoarthritis.

Dynamic biophysical strain modulates proinflammatory gene induction in meniscal fibrochondrocytes

Fibrochondrocytes of meniscus adapt to changes in their biomechanical environment by mechanisms that are yet to be elucidated. In this study, the mechanoresponsiveness of fibrochondrocytes under normal and inflammatory conditions was investigated. Fibrochondrocytes from rat meniscus were exposed to dynamic tensile forces (DTF) at various magnitudes and frequencies. The mechanoresponsiveness was assessed by examining the expression of inducible nitric oxide synthase (iNOS), tumor necrosis factor-alpha (TNF-alpha), and matrix metalloproteinase-13 mRNA expression. The mRNA and protein analyses revealed that DTF at magnitudes of 5% to 20% did not induce proinflammatory gene expression. IL-1beta induced a rapid increase in the iNOS mRNA. DTF strongly repressed IL-1beta-dependent iNOS induction in a magnitude-dependent manner. Exposure to 15% DTF resulted in >90% suppression of IL-1beta-induced mRNA within 4 h and this suppression was sustained for the ensuing 20 h. The mechanosensitivity of fibrochondrocytes was also frequency dependent and maximal suppression of iNOS mRNA expression was observed at rapid frequencies of DTF compared with lower frequencies. Like iNOS, DTF also inhibited IL-1beta-induced expression of proinflammatory mediators involved in joint inflammation. The examination of temporal effects of DTF revealed that 4- or 8-h exposure of DTF was sufficient for its sustained anti-inflammatory effects during the next 20 or 16 h, respectively. Our findings indicate that mechanical signals act as potent anti-inflammatory signals, where their magnitude and frequency are critical determinants of their actions. Furthermore, mechanical signals continue attenuating proinflammatory gene transcription for prolonged periods of time after their removal.