HEREDITY, GENES AND OSTEOARTHRITIS

The occurrence of osteoarthritis at a minimum of ten years after reconstruction of the anterior cruciate ligament

OBJECTIVE

The objective of this study was to evaluate the incidence of radiographic osteoarthritis in the operated knee in comparison with the contralateral knee ten years after a bone-tendon bone patellar autograft ACL-reconstruction and to evaluate to which level patients regain activity ten years after reconstruction.

METHODS

Fifty-three patients with ACL instability were operated arthroscopically using the central third of the patellar tendon as a bone-tendon-bone autograft. At a minimum of 10 year follow up 28/44 patients matched the inclusion criteria and could be reached for follow-up. Evaluation included a patient satisfaction evaluation using a Visual Analog Scale, physical examination (International Knee Documentation Committee score, Tegner score, Lysholm score, KT-1000 stabilometry) and a radiological evaluation (Kellgren and Fairbanks classification).

RESULTS

The patients' satisfaction, at a mean of 10,3 year follow-up, measured with a VAS score (0-10) was high with a mean of 8.5 (range 4 to 10). The KT 1000 arthrometer laxity measurements revealed in 55% of the patients an A rating (1-2 mm), in 29% a B rating (3-5 mm) and in 16% a C rating (6-10 mm). According to the Tegner score 54% of the patients were able to perform at the same activity level as pre-operatively. The mean pre-operative Tegner score was 6.8 and the mean post-operative Tegner score was 6.0 at final follow up. The Lysholm score showed satisfactory results with a mean of 91 points (range 56 to 100). According to the Kellgren and Fairbank classifications, there is a significant difference (p < 0.05) in development of OA between the ACL injured and subsequently operated knee in comparison to the contralateral knee.

CONCLUSION

The patellar BTB ACL reconstruction does not prevent the occurrence of radiological OA after 10 years but does help the patient to regain the pre-operative level of activity.

Childhood-onset osteoarthritis, tall stature, and sensorineural hearing loss associated with Arg75-Cys mutation in procollagen type II gene (COL2A1)

OBJECTIVE

To define the clinical, radiologic, and molecular genetic characteristics of a family with early progressive osteoarthritis mimicking childhood rheumatoid arthritis, Scheuermann-like changes of the spine, tall stature, short 3 and 4 metatarsals, and moderate sensorineural hearing loss.

METHODS

We describe a 22-year-old woman and her 54-year-old mother with early progressive osteoarthritis mimicking childhood rheumatoid arthritis. The index case, her mother, and 3 other family members underwent a physical examination, anthropometric measurements, and radiologic studies. Their DNA was sequenced for the procollagen type II (COL2A1) gene.

RESULTS

Mild scoliosis was noticed in the proband at the age of 6 years, and at the age of 7 years large Schmorl's nodes were found in the vertebrae L1-2. At the age of 11 years, changes resembling Scheuermann's disease were seen, mostly in the thoracic vertebrae. At the same age, she began to have arthralgia in the weight-bearing joints and osteoarthritis progressed fast, necessitating a hip prosthesis at the age of 18 years. The proband and her mother had bilateral sensorineural hearing loss of moderate degree. Both mother and daughter had an Arg75-Cys mutation in the COL2A1 gene.

CONCLUSION

This family is the fourth example of the Arg75-Cys mutation in the COL2A1 gene, which appears to lead to a clearly recognizable phenotype. The finding suggests that sensorineural hearing loss may be a part of this syndrome.

Osteoarthritis: a review

In 1994, the Centers for Disease Control and Prevention reported that by the year 2020, arthritis will have the largest increase in numbers of new patients of any disease in the United States. The term arthritis refers to many diseases, the most common of which is osteoarthritis (OA). OA affects at least 16 million Americans, most of whom are older than 60 years. The disease is usually defined using radiologic criteria. More than 80% of people older than 75 years are symptomatic of OA. Considering cost of diagnosis, therapy (nonpharmacologic, pharmacologic, and surgical), side effects of therapy, and lost productivity, it is one of the more expensive and debilitating diseases in the United States. Given the large numbers of patients and the expense of the disease, it is not surprising that the diagnosis and care of patients with OA have come under scrutiny. The following article will provide some background on the disease and discuss management approaches that view the patient as a whole.

The anterior cruciate ligament and arthritis

In this article, the authors assess the natural history of osteoarthritis in the anterior cruciate ligament deficient knee, and examine the factors which may influence its progression: meniscal resection, osteochondral lesions, malalignment, concomitant ligamentous pathology, biological factors, and surgery. The role of anterior cruciate reconstruction, high tibial osteotomy in the coronal and sagittal plane, meniscal allografts, and combined procedures will be reviewed. Finally, the authors' approach to this increasingly common problem is presented.

Use of microscopical techniques in the study of human chondrocytes from osteoarthritic cartilage: an overview

Several microscopical techniques, such as high resolution light microscopy, Normaski microscopy, laser confocal and transmission electron microscopy, were used in a correlative morphological study of human osteoarthritic (OA) cartilage. Emphasis was made on the characterization of chondrocytes heterogeneity observed in this tissue. Novel findings were assessed in the morphological and immunocytological study of the chondrocytes organized in aggregates or "clones" typical of this degenerative disease, consisting of the modification of certain elements of the cytoskeleton that influence changes in the cell shape. Also, the presence of cilia and centrioles found in certain cell raised the question if chondrocytes are able to move and regroup as an alternative mechanism to mitosis in the formation of cell clusters or "clones." The presence of two types of secretory chondrocytes was observed and discussed. The use of a correlative approach of several microscopical techniques in a systematic morphological and immunocytological characterization of chondrocyte population within the fibrillated and nonfibrillated human osteoarthritic cartilage gave complementary information that could be important for a better understanding of the histopathogenesis of OA.

Pathogenesis and treatment of osteoarthritis

OA represents the final common pathway of a number of pathologic processes. The challenge is to define and classify the subsets of OA to understand the causes and to devise specific therapies. Effective chondroprotective therapies will be most useful when applied to high-risk individuals before the emergence of symptomatic OA. This will be feasible only with an improved understanding of the complex interaction of genes and environment in the OA disease process. Moreover, identifying the heritable bases of this disease will provide insight into the molecular mechanisms of the complex pathway that results in OA. Clinicians who encounter and treat OA patients can look forward to the development of more effective and innovative therapies based on a rapidly improving understanding of OA.

Population haplotype analysis and evolutionary relations of the COL2A1 gene

We have determined the allele frequencies and pairwise linkage disequilibria of restriction fragment length polymorphisms (RFLPs) distributed over the entire COL2A1 gene (spanning 23.6 kb) in a population of unrelated Dutch Caucasians. Pairwise linkage disequilibrium analysis of RFLP sites between exon 5B and 51 indicated a high degree of partly positive (the rare alleles of both loci are associated) and partly negative (the rare allele is associated with the common allele) linkage disequilibrium. The high degree of linkage disequilibrium enabled the assignment of 13 out of 128 possible haplotypes with 7 RFLPs. An evolutionary tree of these haplotypes was derived using a minimum spanning tree approach, indicating at least two ancestral haplotypes. Our data indicate that disease related population studies involving the COL2A1 gene should include a minimum of 4 RFLPs (D9, A9, H33, P51) to obtain 98% of possible haplotypes occurring.

Acute-phase proteins in osteoarthritis

The joint destruction of osteoarthritis (OA) comprises loss of articular cartilage resulting from an imbalance of enzyme-catalized cartilage breakdown and regeneration. OA is thought to derive from defective chondrocyte metabolism and thus to inherently lack the large-scale systemic response that is the hallmark of rheumatoid arthritis (RA). Because of the apparent absence of systemic inflammation in OA, acute-phase response proteins have not been as extensively studied in OA as they have been in RA. The diagnosis of OA almost always involves radiographic assessment of joint damage, which is useful only after the disease process has been underway for several months. Radiographic evaluation cannot give a good assessment of current disease activity and is a relatively insensitive indicator of prognosis. Cartilage breakdown products can potentially serve as direct surrogate markers of OA disease activity, but have not been extensively used because of their limited sensitivity and the technical difficulties associated with their measurement. Markers of disease activity in RA are indirect and are derived from the acute-phase response, a cycle of temporal changes in cellular and metabolic function. The early part of the acute-phase response involves the local action and production of cytokines such as interleukin-1 (IL-1), tumor necrosis factor (TNF-alpha) and IL-6. In the late acute-phase response, these cytokines can effect many systemic changes, including increased production of acute-phase proteins (APP). Three valuable surrogate markers of disease activity in RA are provided by the acute-phase response: the time-honored erythrocyte sedimentation rate (ESR) and the newer APPs C-reactive protein (CRP) and serum amyloid A (SAA). As in RA, the joint destruction of OA involves IL-1, TNF-alpha, and IL-6; however, OA can be viewed as an indolent stimulus of the later (systemic) acute-phase response. Recent studies of the acute-phase response in OA suggest that the concentrations of CRP and SAA are elevated in OA, but to a lesser extent than in RA. In the future, long-term monitoring of CRP concentrations in the blood may permit the earlier detection and more effective treatment of OA.

Knee ligament injury, surgery and osteoarthrosis. Truth or consequences?

We reviewed reports that describe development of osteoarthrosis of the knee after anterior cruciate ligament or meniscus injury. The occurrence of posttraumatic osteoarthrosis varied considerably from one report to another. The literature does not lend support to the efficacy of cruciate ligament repair or reconstruction in retarding the progression of osteoarthrosis after knee injury. We encourage prospective, controlled, randomized and masked studies that aim to evaluate the utility of ligament reconstruction, meniscus suture or meniscus transplantation for preventing posttraumatic osteoarthrosis.