Extracellular matrix of the synovial intimal cell layer

A new serum biochemical marker of synovium turnover predicts radiographic progression in patients with early arthritis

OBJECTIVE

To investigate whether serum Col 3-4, a new biochemical marker of synovial tissue turnover, was associated with progression of joint damage in patients with early arthritis.

METHODS

A total of 788 early arthritis patients (<6 months of symptoms, 82% diagnosis of RA, 18% undifferentiated arthritis) from the prospective ESPOIR study were investigated. Progression was defined as an increase of 1 or 5 unit(s) in radiographic van der Heijde modified Sharp score between baseline and 1 or 5 years, respectively. Associations between baseline Col 3-4 and progression were assessed by logistic regression.

RESULTS

Each standard deviation increase of baseline Col 3-4 levels was associated with an increased 5-yr total damage progression with an odds ratio (OR, 95% CI) of 1.51 (1.21, 1.88), which remained significant when DAS28, C-reactive protein and anti-citrullinated protein antibodies positivity were included in the model [OR (95% CI): 1.34 (1.01, 1.76)]. Further adjustment for bone erosion did not modify the association. Patients with both Col 3-4 in the highest quintile and bone erosion had a >2-fold higher risk of progression [OR (95% CI): 7.16 (2.31, 22)] than patients with either high Col 3-4 [2.91 (1.79, 4.73)] or bone erosion [2.36 (2.38, 3.70)] alone. Similar associations were observed for prediction of 12 months progression.

CONCLUSIONS

Increased serum Col 3-4 is associated with a higher risk of structural progression, independently of major risk factors. Col 3-4 may be useful in association with bone erosion to identify patients with early arthritis at higher risk.

Evaluation of expanded peripheral blood derived CD34+ cells for the treatment of moderate knee osteoarthritis

Knee osteoarthritis (OA) is a degenerative joint disease of the knee that results from the progressive loss of articular cartilage. It is most common in the elderly and affects millions of people worldwide, leading to a continuous increase in the number of total knee replacement surgeries. These surgeries improve the patient's physical mobility, but can lead to late infection, loosening of the prosthesis, and persistent pain. We would like to investigate if cell-based therapies can avoid or delay such surgeries in patients with moderate OA by injecting expanded autologous peripheral blood derived CD34+ cells (ProtheraCytes^®) into the articular joint. In this study we evaluated the survival of ProtheraCytes^® when exposed to synovial fluid and their performance in vitro with a model consisting of their co-culture with human OA chondrocytes in separate layers of Transwells and in vivo with a murine model of OA. Here we show that ProtheraCytes^® maintain high viability (>95%) when exposed for up to 96 hours to synovial fluid from OA patients. Additionally, when co-cultured with OA chondrocytes, ProtheraCytes^® can modulate the expression of some chondrogenic (collagen II and Sox9) and inflammatory/degrading (IL1β, TNF, and MMP-13) markers at gene or protein levels. Finally, ProtheraCytes^® survive after injection into the knee of a collagenase-induced osteoarthritis mouse model, engrafting mainly in the synovial membrane, probably due to the fact that ProtheraCytes^® express CD44, a receptor of hyaluronic acid, which is abundantly present in the synovial membrane. This report provides preliminary evidence of the therapeutic potential of CD34+ cells on OA chondrocytes in vitro and their survival after in vivo implantation in the knee of mice and merits further investigation in future preclinical studies in OA models.

Serum Col3-4: A new type III and IV collagen biochemical marker of synovial tissue turnover in patients with rheumatoid arthritis

The objective of this study was to develop a serum biochemical marker of the degradation of type III and IV collagens, as an index of synovium turnover, and evaluate its performance in patients with rheumatoid arthritis (RA). An enzyme-linked immunosorbent assay for serum synovial collagen fragments (Col3-4) was developed using an antibody recognizing a specific sequence from human type III collagen, which shares 70% homology with type IV collagen. Immunohistochemistry was performed to localize Col3-4 and the matrix metalloprotease MMP-9 which is upregulated in RA synovial fibroblasts in the synovial tissue from a RA patient. Serum Col3-4 was measured in patients with RA (n = 66, 73% women, mean age 62 years, median disease activity score 28 with erythrocyte sedimentation rate (DAS28-ESR) 2.6) and in sex and age matched healthy controls (n = 70, 76% women, mean age 59 years). Col3-4 immunoassay demonstrated adequate analytical performances and recognized a circulating neoepitope resulting from the cleavage of type III and IV collagens. In RA synovium tissue, Col3-4 fragments were localized in the lining layer where destructive fibroblasts are present and around blood vessels rich in type IV collagen. MMP-9 colocalized with Col3-4 staining and efficiently released Col3-4 fragments from type III and type IV collagen digestion. Serum Col3-4 was markedly increased in patients with RA (+240% vs controls, p < 0.0001) and correlated with DAS28-ESR (r = 0.53, p < 0.0001). Patients with RA and active disease (DAS28-ESR > 3.2, n = 20) had 896% (p < 0.0001) higher levels than subjects with low activity (n = 46). Serum Col3-4 is a specific and sensitive biochemical marker reflecting MMP- mediated type III and IV collagen degradation from synovial tissue. Serum Col3-4 levels are markedly increased in patients with RA, particularly in those with active disease, suggesting that it may be useful for the clinical investigation of RA.

Musculoskeletal tissues-on-a-chip: role of natural polymers in reproducing tissue-specific microenvironments

Over the past years, 3D in vitro models have been widely employed in the regenerative medicine field. Among them, organ-on-a-chip technology has the potential to elucidate cellular mechanism exploiting multichannel microfluidic devices to establish 3D co-culture systems that offer control over the cellular, physico-chemical and biochemical microenvironments. To deliver the most relevant cues to cells, it is of paramount importance to select the most appropriate matrix for mimicking the extracellular matrix of the native tissue. Natural polymers-based hydrogels are the elected candidates for reproducing tissue-specific microenvironments in musculoskeletal tissue-on-a-chip models owning to their interesting and peculiar physico-chemical, mechanical and biological properties. Despite these advantages, there is still a gap between the biomaterials complexity in conventional tissue engineering and the application of these biomaterials in 3D in vitro microfluidic models. In this review, the aim is to suggest the adoption of more suitable biomaterials, alternative crosslinking strategies and tissue engineered-inspired approaches in organ-on-a-chip to better mimic the complexity of physiological musculoskeletal tissues. Accordingly, after giving an overview of the musculoskeletal tissue compositions, the properties of the main natural polymers employed in microfluidic systems are investigated, together with the main musculoskeletal tissues-on-a-chip devices.

Single cell transcriptomics in human osteoarthritis synovium and in silico deconvoluted bulk RNA sequencing

OBJECTIVES

To reveal the heterogeneity of different cell types of osteoarthritis (OA) synovial tissues at a single-cell resolution, and determine by novel methodology whether bulk-RNA-seq data could be deconvoluted to create in silico scRNA-seq data for synovial tissue analyses.

METHODS

OA scRNA-seq data (102,077 synoviocytes) were provided by 17 patients undergoing total knee arthroplasty; 9 tissues with matched scRNA-seq and bulk RNA-seq data were used to evaluate six in silico gene deconvolution tools. Predicted and observed cell types and proportions were compared to identify the best deconvolution tool for synovium.

RESULTS

We identified seven distinct cell types in OA synovial tissues. Gene deconvolution identified three (of six) platforms as suitable for extrapolating cellular gene expression from bulk RNA-seq data. Using paired scRNA-seq and bulk RNA-seq data, an "arthritis" specific signature matrix was created and validated to have a significantly better predictive performance for synoviocytes than a default signature matrix. Use of the machine learning tool, Cell-type Identification By Estimating Relative Subsets of RNA Transcripts x (CIBERSORTx), to analyze rheumatoid arthritis (RA) and OA bulk RNA-seq data yielded proportions of T cells and fibroblasts that were similar to the gold standard observations from RA and OA scRNA-seq data, respectively.

CONCLUSION

This novel study revealed heterogeneity of synovial cell types in OA and the feasibility of gene deconvolution for synovial tissue.

Synovium Derived Mesenchymal Stromal Cells (Sy-MSCs): A Promising Therapeutic Paradigm in the Management of Knee Osteoarthritis

Synovium-derived mesenchymal stromal cell (Sy-MSC) is a newer member of the mesenchymal stromal cell families. The first successful demonstration of the mesenchymal stromal cell from the human synovial membrane was done in 2001 and since then its potential role for musculoskeletal regeneration has been keenly documented. The regenerative effects of Sy-MSCs are through paracrine signaling, direct cell-cell interactions, and extracellular vehicles. Sy-MSCs possess superior chondrogenicity than other sources of mesenchymal stromal cells. This article aims to outline the advancement of synovium-derived mesenchymal stromal cells along with a specific insight into the application for managing osteoarthritis knee.

The peridural membrane of the spine has characteristics of synovium

The peridural membrane (PDM) is a well-defined structure between dura mater and the wall of the spinal canal. The spine may be viewed as a multi-segmented joint, with the epidural cavity and neural foramina as joint spaces and PDM as synovial lining. The objective of this investigation was to determine if PDM has histological characteristics of synovium. Samples of the PDM of the thoraco-lumbar spine were taken from 23 human cadavers and analyzed with conventional light microscopy and confocal microscopy. Results were compared to reports on similar analyses of synovium in the literature. Histological distribution of areolar, fibrous, and adipose connective tissue in PDM was similar to synovium. The PDM has an intima and sub-intima. No basement membrane was identified. CD68, a marker for macrophage-like-synoviocytes, and CD55, a marker for fibroblast-like synoviocytes, were seen in the lining and sub-lining of the PDM. Multifunctional hyaluronan receptor CD44 and hyaluronic acid synthetase 2 marker HAS2 were abundantly present throughout the membrane. Marked presence of CD44, CD55, and HAS2 in the well-developed tunica muscularis of blood vessels and in the body of the PDM suggests a role in the maintenance and lubrication of the epidural cavity and neural foramina. Presence of CD68, CD55, and CD44 suggests a scavenging function and a role in the inflammatory response to noxious stimuli. Thus, the human PDM has histological and immunohistochemical characteristics of synovium. This suggests that the PDM may be important for the homeostasis of the flexible spine and the neural structures it contains.

Synovial cell cross-talk with cartilage plays a major role in the pathogenesis of osteoarthritis

We elucidated the molecular cross-talk between cartilage and synovium in osteoarthritis, the most widespread arthritis in the world, using the powerful tool of single-cell RNA-sequencing. Multiple cell types were identified based on profiling of 10,640 synoviocytes and 26,192 chondrocytes: 12 distinct synovial cell types and 7 distinct articular chondrocyte phenotypes from matched tissues. Intact cartilage was enriched for homeostatic and hypertrophic chondrocytes, while damaged cartilage was enriched for prefibro- and fibro-, regulatory, reparative and prehypertrophic chondrocytes. A total of 61 cytokines and growth factors were predicted to regulate the 7 chondrocyte cell phenotypes. Based on production by > 1% of cells, 55% of the cytokines were produced by synovial cells (39% exclusive to synoviocytes and not expressed by chondrocytes) and their presence in osteoarthritic synovial fluid confirmed. The synoviocytes producing IL-1beta (a classic pathogenic cytokine in osteoarthritis), mainly inflammatory macrophages and dendritic cells, were characterized by co-expression of surface proteins corresponding to HLA-DQA1, HLA-DQA2, OLR1 or TLR2. Strategies to deplete these pathogenic intra-articular cell subpopulations could be a therapeutic option for human osteoarthritis.

Monitoring tissue-level remodelling during inflammatory arthritis using a three-dimensional synovium-on-a-chip with non-invasive light scattering biosensing

Rheumatoid arthritis is a chronic, systemic joint disease in which an autoimmune response translates into an inflammatory attack resulting in joint damage, disability and decreased quality of life. Despite recent introduction of therapeutic agents such as anti-TNFα, even the best current therapies fail to achieve disease remission in most arthritis patients. Therefore, research into the mechanisms governing the destructive inflammatory process in rheumatoid arthritis is of great importance and may reveal novel strategies for the therapeutic interventions. To gain deeper insight into its pathogensis, we have developed for the first time a three-dimensional synovium-on-a-chip system in order to monitor the onset and progression of inflammatory synovial tissue responses. In our study, patient-derived primary synovial organoids are cultivated on a single chip platform containing embedded organic-photodetector arrays for over a week in the absence and presence of tumor-necrosis-factor. Using a label-free and non-invasive optical light-scatter biosensing strategy inflammation-induced 3D tissue-level architectural changes were already detected after two days. We demonstrate that the integration of complex human synovial organ cultures in a lab-on-a-chip provides reproducible and reliable information on how systemic stress factors affect synovial tissue architectures.

Combined Experimental Approach and Finite Element Modeling of Small Molecule Transport Through Joint Synovium to Measure Effective Diffusivity

Trans-synovial solute transport plays a critical role in the clearance of intra-articularly (IA) delivered drugs. In this study, we present a computational finite element model (FEM) of solute transport through the synovium validated by experiments on synovial explants. Unsteady diffusion of urea, a small uncharged molecule, was measured through devitalized porcine and human synovium using custom-built diffusion chambers. A multiphasic computational model was constructed and optimized with the experimental data to extract effective diffusivity for urea within the synovium. A monotonic decrease in urea concentration was observed in the donor bath over time, with an effective diffusivity found to be an order of magnitude lower in synovium versus that measured in free solution. Parametric studies incorporating an intimal cell layer with varying thickness and varying effective diffusivities were performed, revealing a dependence of drug clearance kinetics on both parameters. The findings of this study indicate that the synovial matrix impedes urea solute transport out of the joint with little retention of the solute in the matrix.

Spatially resolved proteomics in osteoarthritis: State of the art and new perspectives

Osteoarthritis (OA) is one of the most common diseases worldwide caused by chronic degeneration of the joints. Its high prevalence and the involvement of several tissues define OA as a highly heterogeneous disease. New biological markers to evaluate the progression of the pathology and improve its prognosis are needed. Among all the different -omic strategies applied to OA, solution phase bottom-up proteomics has made an extensive contribution to the field of biomarker research. However, new technologies for protein analysis should be considered for a better understanding of the disease. This review focuses on complementary proteomic methodologies and new technologies for translational research of OA and other rheumatic pathologies, especially mass spectrometry imaging and protein imaging methods not applied by the OA community yet.

Characterization of the binding site for d-deprenyl in human inflamed synovial membrane

AIMS

d-Deprenyl when used as a positron emission tomography tracer visualizes peripheral inflammation. The major aim of the current study was to identify and investigate the properties of the binding target for d-deprenyl in synovial membrane explants from arthritic patients.

MAIN METHODS

Thirty patients diagnosed with arthritis or osteoarthritis were enrolled into the study. Homologous and competitive radioligand binding assays utilizing [³H]d-deprenyl were performed to investigate the biochemical characteristics of the binding site and assess differences in the binding profile in synovial membranes exhibiting varying levels of inflammation.

KEY FINDINGS

The [³H]d-deprenyl binding assay confirmed the existence of a single, saturable population of membrane-bound protein binding sites in synovial membrane homogenates. The macroscopically determined level of inflammation correlated with an increase in [³H]d-deprenyl binding affinity, without significant alterations in binding site density. Selective monoamine oxidase B inhibitor, selegiline competed for the same site as [³H]d-deprenyl, but failed to differentiate the samples with regard to their inflammation grade. A monoamine oxidase A inhibitor, pirlindole mesylate showed only weak displacement of [³H]d-deprenyl binding. No significant alterations in monoamine oxidase B expression was detected, thus it was not confirmed whether it could serve as a marker for ongoing inflammation.

SIGNIFICANCE

Our study was the first to show the biochemical characteristics of the [³H]d-deprenyl binding site in inflamed human synovium. We confirmed that d-deprenyl could differentiate between patients with varying severity of synovitis in the knee joint by binding to a protein target distinct from monoamine oxidase B.

Delineating the synovial fluid proteome: recent advancements and ongoing challenges in biomarker research

There is an urgent need for identifying novel serum biomarkers that can be used to improve diagnosis, predict disease progression or response to therapy, or serve as therapeutic targets for rheumatic diseases. Synovial fluid (SF) is secreted by and remains in direct contact with the synovial membrane, and can reflect the biochemical state of the joint under different physiological and pathological conditions. Therefore, SF is regarded as an excellent source for identifying biomarkers of rheumatologic diseases. The use of high-throughput and/or quantitative proteomics and sophisticated computational software applied to analyze the protein content of SF has been well-adopted as an approach to finding novel arthritis biomarkers. This review will focus on some of the potential pitfalls of biomarker studies using SF, summarize the status of the field of SF proteomics in general, as well as discuss some of the most promising biomarker study approaches using proteomics. A brief status of the biomarker discovery efforts in rheumatoid arthritis, osteoarthritis and juvenile idiopathic arthritis is also provided.

The synovium as a privileged site in rheumatoid arthritis: cadherin-11 as a dominant player in synovial pathology

Rheumatoid arthritis is a systemic disease in which an autoimmune response translates primarily into joint inflammation with attendant joint destruction. While evidence implicates both the adaptive and innate immune system in rheumatoid synovitis, several lines of evidence now support the concept that the synovial tissue itself actively participates in the destructive inflammatory processes of arthritis. Specifically, the resident mesenchymal cells, the fibroblast-like synoviocytes (FLSs), frame a synovial microenvironment that responds to, augments and perpetuates the inflammatory process. Moreover, the FLSs have been recognised as the dominant cells mediating joint destruction. The identification of cadherin-11 expression on FLS provided an opportunity to unravel molecular mechanisms by which these resident mesenchymal cells govern processes that result in destructive synovitis in the context of systemic autoimmune disease. Herein, we discuss the unfolding biology of the synovial cadherin with its implications for the synovial pathology in arthritis, especially rheumatoid arthritis.

The normal synovium

This paper describes the structure and function of the normal synovium including the cellular content, nerve and vascular supply and how normal synovium maintains homeostasis within the joint. It is important to understand normal synovium before appreciating the changes that occur in the synovial membrane which leads to the pathology seen in inflammatory arthritides such as Rheumatoid Arthritis.

Fluid movement and joint capsule strains due to flexion in rabbit knees

Diarthrodial joints are freely moveable joints containing synovial fluid (SF) within a connective tissue joint capsule that allows for low-friction and low-wear articulation of the cartilaginous ends of long bones. Biomechanical cues from joint articulation regulate synoviocyte and cartilage biology via joint capsule strain, in turn altering the composition of SF. Joint flexion is clinically associated with pain in knees with arthritis and effusion, with the nociception possibly originating from joint capsule strain. The hypothesis of this study was that knee fluid volume distribution and joint capsule strain are altered with passive flexion in the rabbit model. The aims were to (a) determine the volume distribution of fluid in the joint at different total volumes and with flexion of rabbit knees ex vivo, (b) correlate the volume distribution for the ex vivo model to in vivo data, and (c) determine the strains at different locations in the joint capsule with flexion. During knee flexion, ∼20% of anteriorly located joint fluid moved posteriorly, correlating well with the fluid motion observed in in vivo joints. Planar joint capsule principal strains were ∼100% (tension) in the proximal-distal direction and ∼-40% (shortening) in the circumferential direction, relative to the femur axis and 30° strain state. The joint capsule strains with flexion are consistent with the mechanics of the tendons and ligaments from which the capsule tissue is derived. The movement and mixing of SF volume with flexion determine the mechanical and biological fluid environment within the knee joint. Joint fluid movement and capsular strains affect synovial cell biology and likely modulate trans-synovial transport.

Immigration check for neutrophils in RA lining: laminin alpha5 low expression regions act as exit points

OBJECTIVE

A correlation exists between the absence of alpha5-laminin and transit checkpoint fenestrations in vascular basement membranes. We hypothesized that similar laminin alpha5 low expression regions might exist in synovial lining, which, although lacking basement membrane, contains all basement membrane components in its interstitial matrix.

METHODS

Laminin alpha4 and alpha5 chains and lactoferrin were stained using immunofluorescence and cathepsin G and neutrophil elastase using immunoperoxidase. Quantitative real-time polymerase chain reaction (qRT-PCR) was used to measure laminin alpha4 and alpha5 mRNA copy numbers in cultured synovial fibroblasts, without/with tumour necrosis factor-alpha (TNFalpha) and interleukin-1beta (IL-1beta).

RESULTS

Laminin alpha4 and alpha5 chains were found in the intercellular matrix in synovial lining samples of trauma and revision total hip replacements. Laminin alpha5 was weaker in osteoarthritis (OA) and rheumatoid arthritis (RA), and RA synovial lining also contained local low expression areas. Double staining disclosed convergence of lactoferrin-degranulating neutrophils towards these laminin alpha5 low expression regions. In cultured OA synovial fibroblasts, laminin alpha5 mRNA decreased (p < 0.05) at 1 ng/mL TNFalpha and was not found at all in cultured resting or cytokine-stimulated RA fibroblasts. Degranulation of cathepsin G and neutrophil elastase was seen in neutrophils passing through blood vessels or synovial lining.

CONCLUSIONS

Migrating neutrophils in RA seem to use laminin alpha5 chain low expression regions to exit synovial tissue to enter synovial fluid. Transmigrating neutrophils remodel the intercellular matrix by releasing their proteolytic granular contents to enhance these low expression checkpoints and/or to produce chemotactic stimuli. In RA fibroblasts this is facilitated by cytokine-mediated down-regulation or lack of laminin alpha5 synthesis.

Synovial fibroblasts self-direct multicellular lining architecture and synthetic function in three-dimensional organ culture

OBJECTIVE

To define the intrinsic capacity of fibroblast-like synoviocytes (FLS) to establish a 3-dimensional (3-D) complex synovial lining architecture characterized by the multicellular organization of the compacted synovial lining and the elaboration of synovial fluid constituents.

METHODS

FLS were cultured in spherical extracellular matrix (ECM) micromasses for 3 weeks. The FLS micromass architecture was assessed histologically and compared with that of dermal fibroblast controls. Lubricin synthesis was measured via immunodetection. Basement membrane matrix and reticular fiber stains were performed to examine ECM organization. Primary human and mouse monocytes were prepared and cocultured with FLS in micromass to investigate cocompaction in the lining architecture. Cytokine stimuli were applied to determine the capacity for inflammatory architecture rearrangement.

RESULTS

FLS, but not dermal fibroblasts, spontaneously formed a compacted lining architecture over 3 weeks in the 3-D ECM micromass organ cultures. These lining cells produced lubricin. FLS rearranged their surrounding ECM into a complex architecture resembling the synovial lining and supported the survival and cocompaction of monocyte/macrophages in the neo-lining structure. Furthermore, when stimulated by cytokines, FLS lining structures displayed features of the hyperplastic rheumatoid arthritis synovial lining.

CONCLUSION

This 3-D micromass organ culture method demonstrates that many of the phenotypic characteristics of the normal and the hyperplastic synovial lining in vivo are intrinsic functions of FLS. Moreover, FLS promote survival and cocompaction of primary monocytes in a manner remarkably similar to that of synovial lining macrophages. These findings provide new insight into inherent functions of the FLS lineage and establish a powerful in vitro method for further investigation of this lineage.

A Role for Hyaluronan in the Preservation of Interstitial Structure

Hydraulic resistance of interstitium is of major importance in body fluid distribution. In the synovial lining it is vital for the retention of intra-articular fluid, and is attributed chiefly to the network of interstitial biopolymers occupying intercellular gaps in the tissue. Selective removal of synovial hyaluronan (HA) by protease-free hyaluronate lyase results in an almost 10x increase in synovial hydraulic permeability from 0.48 +/- 0.24 microL min(-1) cm H2O (control) to 4.56 +/- 0.40 microL min(-1) cm H2O (mean +/- SD, n = 6 rabbits, p < .001, t test) leading to the hypothesis that hyaluronan plays a major role in the organization of interstitial matrix structure. To test whether removal of hyaluronan causes significant changes in synovial ultrastructure, morphometry of hyaluronidase-treated synovium was carried out. Following hyaluronidase, the thickness of the synovial lining was reduced from 13.0 +/- 1.6 microm (control) to 10.6 +/- 1.6 microm (mean +/- SD throughout, n = 50 measurements per rabbit, 6 rabbits. p < .001, t test). This was accompanied by a significant reduction of synovial interstitial volume fraction from 76.2 +/- 20.6% (control) to 67.04 +/- 24.94% (p < .001, t test), and an increase in collagen bundle volume as a fraction of interstitial volume from 40.75 +/- 4.97% (control) tissue to 48.77 +/- 11.72% (p < .0001, t test). The findings indicate that the removal of hyaluronan chains leads to morphological disruption. Thus, hyaluronan chains play a major role in the organization of synovial structure. The observed morphological changes are insufficiently large to explain fully the great rise in hydraulic permeability observed on HA removal. The latter is likely to be due to disruption of tertiary architecture at the molecular organization level.

The combined role of wear particles, macrophages and lymphocytes in the loosening of total joint prostheses

This review considers the causes of loosening of prosthetic joint replacement paying attention to the biological mechanisms rather than other effects that are physical, such as component fracture and other failure related to mechanical problems. Infection accounts for approximately 1.5 per cent of joint loosening and when it occurs it is a cause of serious concern to the surgeon. The loosening of prosthetic joints in the absence of infection is by far the most common reason for revision surgery and is known as aseptic loosening. While this may be multifactorial in terms of causation, and non-biological factors may contribute significantly in a particular individual, a significant part is undoubtedly played by the generation of wear debris, mainly from the bearing surfaces of the joint, and the cellular reaction to this in the implant bed. Phagocytic cells (macrophages and multinucleated giant cells) are the ones that remove foreign material from the tissues, and the ways in which these cells function in the interface between implant and bone are described. Mediators produced locally include numerous cytokines, enzymes and integrins. There is evidence for interactions between macrophages and locally recruited lymphocytes, which may or may not give rise to an immunologically mediated process.Sensitization of individuals having metal implants in place has been shown by positive skin tests or blood lymphocyte transformation tests and in these cases has been accompanied by loosening and failure of the replacement joint. The question remains as to whether this process is also present in a proportion of individuals with aseptic loosening in the absence of clearly defined clinical evidence of sensitization.Numerous studies performed by the author's group and, latterly, by others suggest that the cellular reactions detected in the tissues in cases of aseptic loosening are indeed those of contact sensitization. There is good evidence to show that a type IV cell-mediated immune reaction is taking place, with TH1 cell involvement and active antigen presentation. The extent to which sensitization is present in individual cases of aseptic loosening remains a subject for further work and this needs all the sophisticated molecular methods now available to modern biology to be applied in appropriate prospective clinical studies coupled with experimental models in vitro and in vivo. Immunological processes may play a more important part in joint loosening than previously considered.

Type IV collagen alpha-chain composition in synovial lining from trauma patients and patients with rheumatoid arthritis

OBJECTIVE

Normal synovial lining is composed of macrophage-like type A and fibroblast-like type B lining cells. This sheet-like structure lacks a basement membrane, but its intercellular substance contains some basement membrane components, including type IV collagen. We undertook this study to determine the alpha-chain composition of type IV collagen in normal and arthritic synovial lining, using monoclonal alpha-chain antibodies.

METHODS

Samples were analyzed using avidin-biotin-peroxidase complex staining for the presence of collagen alpha1/2(IV), alpha3(IV), alpha4(IV), alpha5(IV), alpha6(IV), matrix metalloproteinase 2 (MMP-2), and MMP-9, and the enzyme activity was detected using gelatin zymography. Double immunofluorescence was performed for type IV collagen/MMP-9 and type IV collagen/CD68. Synovial fibroblasts were studied using quantitative reverse transcriptase-polymerase chain reaction.

RESULTS

In mildly inflamed synovium from 5 trauma patients, alpha1/2(IV) chains were strongly stained, but alpha5(IV) and alpha6(IV) chains were weakly stained. Coding messenger RNA was shown in cultured synovial fibroblasts. Basement membranes of blood vessels contained all alpha(IV) chains and served as useful positive sample controls. In the synovial lining from 5 patients with rheumatoid arthritis (RA), all alpha-chains were absent/very weakly stained. This was coupled with numerous type A lining cells containing MMP-9 (type IV collagenase), also found in synovial fluid.

CONCLUSION

Synovial lining has a unique and very limited alpha-chain composition, different from that of the vascular basement membrane, which contains all alpha-chains. This special composition and lack of nidogen are probably of relevance for the bidirectional translining diffusion. Such tentative alpha-chain-dependent adhesive and transport-regulating properties seem to be deranged in RA, probably in part due to type IV collagenases produced in the lining and/or released by transmigrating or synovial fluid neutrophils.

Interstitial matrix proteins determine hyaluronan reflection and fluid retention in rabbit joints: effect of protease

Hyaluronan (HA) retention inside the synovial cavity of joints serves diverse protective roles. We tested the hypothesis that HA retention is mediated by the network of extracellular matrix proteins in the synovial lining. Cannulated rabbit knee joints were infused with HA solution with or without pretreatment by chymopapain, a collagen-sparing protease. Trans-synovial fluid escape rate was measured and, after a period of trans-synovial filtration, samples of intra-articular fluid and subsynovial fluid were analysed for HA to assess its trans-synovial ultrafiltration. In control joints, HA ultrafiltration was confirmed by postfiltration increases in intra-articular HA concentration (259 +/- 17% of infused concentration) and reduced subsynovial concentration (30 +/- 8%; n = 11). The proportion of HA molecules reflected by the synovium was 57-75%. Chymopapain treatment increased the hydraulic permeability of the synovial lining approximately 13-fold, almost abolished the trans-synovial difference in HA concentration and reduced the HA reflected fraction to 3-7% (n = 6; P < 0.001, ANOVA). Structural studies confirmed that chymopapain treatment depleted the matrix of proteoglycans but preserved its collagen. The findings thus demonstrate that HA ultrafiltration and synovial hydraulic permeability are determined by the network of non-collagen, extracellular matrix proteins. This may be important clinically, since protease activity is raised in rheumatoid arthritis, as are HA and fluid escape.

The expression of CD44 in archival paraffin embedded interface tissues of failed orthopaedic implants

CD44 hyaluronan receptor is present on large number of different cell type. It acts as one of the adhesion proteins, binding to hyaluronan and is known to play a part in cell migration from vessels in inflammation. The aim of this study was to examine the presence and distribution of CD44 in interface membrane in aseptic loosening. Immunohistochemistry (IHC) using human anti-mouse CD44 antibody studied 20 aseptically loosened interface samples. Extracted protein from all cases was examined by Western blot and RT-PCR. CD44 was detected in 85% of interfaces by IHC and the presence of protein confirmed by blotting and RT-PCR, which showed the mRNA level for CD44. CD44 was expressed by macrophage, multinucleated giant cells, mast cells and lymphocytes. Further studies are needed to characterise the role of this molecule in the inflammatory response to wear debris in aseptic loosening.

Non-linear dependence of interstitial fluid pressure on joint cavity pressure and implications for interstitial resistance in rabbit knee

AIMS

Synovium retains lubricating fluid in the joint cavity. Synovial outflow resistance estimated as dPj/dQs (Pj, joint fluid pressure and Qs trans-synovial flow) is greater, however, than expected from interstitial glycosaminoglycan concentration. This study investigates whether subsynovial fluid pressure increases with intra-articular pressure, as this would reduce the estimated resistance estimate.

METHODS

Interstitial fluid pressure (Pif) was measured as a function of distance from the joint cavity in knees of anaesthetized rabbits, using servo-null pressure-measuring micropipettes and using an external 'window'. Joint fluid pressure Pj was either endogenous (-2.4 +/- 0.4 cmH2O, mean +/- SEM) or held at approximately 4, 8 or 15.0 cmH2O by a continuous intra-articular saline infusion that matched the trans-synovial interstitial drainage rate.

RESULTS

At endogenous Pj the peri-articular Pif was subatmospheric (-1.9 +/- 0.3 cmH2O, n = 19). At raised Pj the Pif values became positive. Gradient dPif /dx was approximately 20 times steeper across synovium than subsynovium. Pif close to the synovium-subsynovium border (Pif*) increased as a non-linear function of Pj to 1.4 +/- 0.2 cmH2O (n = 23) at Pj = 4.3 +/- 0.1 cmH2O : 2.3 +/- 0.2 cmH2O (n = 17) at Pj = 7.6 +/- 0.2 cmH2O: and 3.0 +/- 0.4 cmH2O (n = 26) at Pj = 15 +/- 0.2 cmH2O (P = 0.03, anova).

CONCLUSIONS

Synovial resistivity is approximately 20x subsynovial resistivity. The increase in Pif*with Pj means that true synovial resistance d(Pj-Pif*)/dQs is overestimated 1.5x by dPj/dQs. This narrows but does not eliminate the gap between analysed glycosaminoglycan concentration, 4 mg ml(-1), and the net interstitial biopolymer concentration of 11.5 mg ml(-1) needed to generate the resistance.

Evidence for a role of hyaluronan in the spacing of fibrils within collagen bundles in rabbit synovium

Synovial hydraulic resistance is vital for the retention of intra-articular fluid, and originates within the matrix of biopolymers in the intercellular gaps. Specific digestion of hyaluronan resulted in a increase in synovial hydraulic permeability from 0.478+/-0.24 microl min(-1) cm H(2)O(-1) in control tissue to 4.561+/-0.40 microl min(-1) cm H(2)O(-1) (mean+/-S.D., n=6 rabbits, P<0.001 t test). To investigate whether hyaluronidase also altered the interstitial ultrastructure, morphometry of hyaluronidase treated synovium was carried out. The most striking novel finding was that hyaluronidase treatment reduced extrafibrillar volume fraction within the synovial collagen bundles from 50.5+/-11.1% to 36.8+/-15.5% (mean+/-S.D., n=6 rabbits, P<0.001, two-way anova). This was accompanied by a reduction in interfibrillar centre to centre spacing from 101+/-11 (control) to 84+/-6 nm (mean+/-S.D.; n=6 rabbits, P<0.001) in enzyme-treated bundles. Individual fibrils showed a small but highly significant reduction in cross-sectional diameter from 76.9+/-6.3 to 72.5+/-6.3 nm (mean+/-S.E.; P<0.001) after hyaluronidase treatment. The findings indicate that hyaluronan chains have a major organisational role within the collagen bundle itself. The trans-synovial pathway comprises bundles and substantial areas of intervening, bundle-free matrix, and it is possible that bundle collapse contributes to a rise in overall permeability by increasing the inter-bundle space.

Borrelia burgdorferi and its tropisms for adhesion molecules in the joint

Borrelia burgdorferi, the spirochete that causes Lyme disease, has evolved elegant strategies for interacting with its mammalian hosts. Among them are several distinct mechanisms of adhesion to cells and extracellular matrix components. The mammalian receptors for B. burgdorferi that have been most thoroughly studied, and for which candidate bacterial ligands have been identified, are decorin, fibronectin, glycosaminoglycans, and beta3-chain integrins. This diversity of adhesion mechanisms allows B. burgdorferi to infect multiple tissues, including the synovial tissues of the joints.

Integrin expression at the bone/biomaterial interface

The aim of this study was to visualize integrin expression by cells in interface tissue in relation to their ligands. Tissue samples were obtained from 25 patients undergoing revision of aseptically loose total joint replacements. Serial sections were immunolabeled for the integrins alpha(2)beta(1), alpha(v)beta(3), alpha(4)beta(1), alpha(L)beta(2) (CD11a), alpha(M)beta(2) (CD11b), and alpha(X)beta(2) (CD11c), and the ligands fibronectin, laminin, vitronectin, intercellular adhesion molecule-1, and vascular adhesion molecule-1. Most cells were found to express alpha(2)beta(1), most macrophages and giant cells expressed CD11b, and the majority of CD11a was found on perivascular T lymphocytes. From the small amount of alpha(4)beta(1) and vascular adhesion molecule-1 expression in the interface tissue and the combination of CD11a, CD11b, and intercellular adhesion molecule-1 expression, it would seem that macrophages use beta(2) integrins to transmigrate.

Histochemical analyses of glycosaminoglycans in the synovial membrane of the canine knee joint

The accurate localization and nature of glycosaminoglycans in the synovial membrane of the canine knee joint were examined histochemically by means of the selective sensitized diamine procedures based upon high and low iron diamine stainings in combination with enzyme digestions. Using these methods, it was possible to clearly and easily detect exceedingly small amounts of glycosaminoglycans in synovial tissues, which cannot be visualized by methods employed to date. The sensitized high iron diamine (S-HID) procedure resulted in positive reactions of varying intensities in the intercellular matrix of synovial intima, and in the extracellular matrix and small capillary walls of the superficial layer in the synovial subintima, and also reacted vividly in the extracellular matrix and blood vessel walls of the deeper layer in the synovial subintima. In particular, the sensitized low iron diamine (S-LID) procedure resulted in positive reactions of the extracellular matrix in the synovial subintimal layers. The S-HID and S-LID procedures combined with the enzyme digestions proved that glycosaminoglycan molecular species such as chondroitin sulfate A/C, dermatan sulfate, heparan sulfate and hyaluronic acid are present in various concentrations in the synovial membrane of the canine knee joint. The present results were discussed with reference to the histophysiological and pathophysiological functions of glycosaminoglycans in the synovium of domestic mammals.

Fibroblast biology. Development and differentiation of synovial fibroblasts in arthritis

Synovial fibroblasts occur as two phenotypes--intimal and subintimal. The specialised intimal phenotype includes expression of uridine diphosphoglucose dehydrogenase (UDPGD), vascular cell adhesion molecule-1 (VCAM-1) and complement decay-accelerating factor (DAF). These gene products contribute to specialised functions relating to tissue movement and leucocyte traffic.

Effect of depletion of glycosaminoglycans and non-collagenous proteins on interstitial hydraulic permeability in rabbit synovium

1. The hydraulic resistance of synovial interstitium helps to retain a lubricating fluid within the joint cavity. The contributions of sulphated glycosaminoglycans to resistance were assessed by selective depletion by chondroitinase ABC, keratanase and heparinases I, II and III in vivo. Also, since glycosaminoglycans do not account fully for the resistance, the contribution of non-collagenous, structural proteins in interstitium was assessed by treatment with chymopapain, a collagen-sparing protease. 2. Ringer solution containing enzyme was injected into the synovial cavity of the knee in anaesthetized rabbits. After >= 30 min the intra-articular pressure was raised and the relation between pressure (Pj) and trans-synovial outflow (Qs) determined. The slope dQs/dPj at low pressures, i.e. below yield pressure, represents the hydraulic conductance of the lining, i.e. 1/resistance. The contralateral joint received Ringer solution without enzyme as a control. Action of enzymes on the tissue was confirmed by histochemical and immunohistochemical studies. 3. Treatment with chondroitinase ABC (5 joints) increased the hydraulic conductance of the lining by 2.3 times (control, 1.34 +/- 0.22 microliter l min-1 cmH2O-1; post-enzyme, 3.11 +/- 0.45 microliter l min-1 cmH2O-1). This was significantly less than the effects of leech, Streptomyces and testicular hyaluronidases, which caused an average 4.7 times increase (P < 0.001, ANOVA). Analogous findings were made above yield pressure. 4. Treatment with keratanase (3 joints) or heparinases I, II and III (3 joints) caused no significant increase in trans-synovial flows or conductance, even though the concentration of heparan sulphate in synovium is higher than that of chondroitin sulphates or hyaluronan. 5. Treatment with chymopapain (7 joints) caused the greatest increases in trans-synovial flow, which exceeded control flow by an order of magnitude in one case. After 0.1 U chymopapain the average conductance was 6.6 times the control conductance below yield pressure. Immunohistochemical studies confirmed that chymopapain treatment removed the synovial proteoglycans. 6. It is concluded that, despite their similar resistivities in vitro, the different glycosaminoglycans do not contribute equally, weight for weight, to interstitial resistance in vivo. Hyaluronan is the dominant glycosaminoglycan governing synovial interstitial resistance. In addition, non-collagenous structural proteins contribute significantly to interstitial resistance.

Loss of laminin and of the laminin receptor integrin subunit alpha 6 in situ correlates with cytokine induced down regulation of alpha 6 on fibroblast-like synoviocytes from rheumatoid arthritis

OBJECTIVE

To investigate in situ the expression of the integrin receptor subunits alpha 6 and beta 1 and the distribution of the ligand laminin in the synovia from osteoarthritis (OA) and rheumatoid arthritis (RA) patients and to study the effect of cytokines and antirheumatic drugs on the expression of the alpha 6 and beta 1 integrin subunits on long term cultures of fibroblast-like synoviocytes (FBS) derived from OA and RA.

METHODS

The expression of the alpha 6 and beta 1 integrin subunits and the distribution of laminin were examined immunohistochemically in normal synovia and in synovia from patients with OA and RA. The effect of proinflammatory cytokines (IL1 beta and TNF alpha), and of antirheumatic drugs (salicylic acid, dexamethasone, and methotrexate) on the alpha 6 and beta 1 expression of cultured normal FBS and FBS from patients with OA and RA was determined by flow cytometry.

RESULTS

In normal synovia and in OA synovia samples with a low grade of inflammation, synovial lining cells (SLC) showed a parallel expression and distribution of alpha 6 and laminin. In synovia samples of OA with a higher grade of inflammation and in the majority of RA synovia samples laminin was pericellularly distributed in a low number of SLC, whereas alpha 6 was expressed on the surface of a high number of SLC. In RA synovia samples with severe inflammatory changes the gradual loss of laminin generally corresponded to a decrease of the alpha 6 integrin subunit. beta 1 was always strongly expressed in all synovia samples detected. Proinflammatory cytokines up regulated the expression of alpha 6 and beta 1 on OA-FBS, whereas these effectors decreases alpha 6 and beta 1 on RA-FBS. In contrast, antirheumatic drugs, in particular methotrexate and dexamethasone, reduced the expression of alpha 6 and beta 1 on OA-FBS, whereas the same treatment on RA-FBS stimulated the expression of these integrin subunits.

CONCLUSION

The gradual loss of laminin in chronic synovitis may contribute to the altered expression of alpha 6 in SLC. IL1 beta and TNF alpha down regulated the expression of the alpha 6 and beta 1 integrin subunits on long term cultures of FBS derived from RA. Therefore, these cytokines may be among the effectors regulating the expression of the alpha 6 integrin subunit in SLC in vivo. As antirheumatic drugs increase the expression of alpha 6 on RA-FBS, the presence of the laminin receptor may confer a protective effect on the synovia in vivo.

The proteoglycans and glycosaminoglycan chains of rabbit synovium

The synovial lining of joint capsules is important because it controls the flow of fluid into and out of the joint cavity. Physiological studies have shown that the glycosaminoglycans, particularly hyaluronan, have an important role in the control of fluid flow. The distribution of the glycosaminoglycans and proteoglycans in the synovium and subsynovium of rabbits (approximately 12 weeks old) was, therefore, determined immunohistochemically. Hyaluronan, chondroitin-4- and chondroitin-6-sulphates and keratan sulphate are present in the synovium and subsynovium; chondroitin-4-sulphate is at higher concentrations than chondroitin-6-sulphate. The core proteins of the chondroitin sulphate proteoglycans, biglycan and decorin, and of the keratan sulphate proteoglycan, fibromodulin, are also present. To date, fibromodulin has not been located in other synovial linings, and its presence corroborates that of keratan sulphate.

Effect of depletion of interstitial hyaluronan on hydraulic conductance in rabbit knee synovium

1. The hydraulic resistance of the synovial lining to fluid outflow from a joint cavity (Qs) is important for the retention of intra-articular lubricant. The resistance has been attributed in part to extracellular glycosaminoglycans, including hyaluronan and chondroitin sulphates. Increased permeability in joints infused with testicular hyaluronidase, which digests both chondroitin sulphates and hyaluronan, supports this view. In this study the importance of interstitial hyaluronan per se was assessed using leech and Streptomyces hyaluronidases, which degrade only hyaluronan. 2. Ringer solution was infused into the knee joint cavity of anaesthetized rabbits for 30 min, with or without hyaluronidase, after which intra-articular pressure (Pj) was raised and the relation between pressure and outflow determined. 3. Treatment with Streptomyces, leech or testicular hyaluronidases increased the fluid escape rates by similar factors, namely 4- to 6-fold. After Streptomyces hyaluronidase treatment the slope d 8d s/dPj, which at low pressures represents synovial hydraulic conductance, increased from a control of 0.90 +/- 0.20 microl min-1 cmH2O-1 (mean +/- s.e.m. , n = 6) to 4.52 +/- 0.70 microl min-1 cmH2O-1. The slope d 8d s/dPj increased to a similar level after testicular hyaluronidase, namely to 4.14 +/- 1.06 microl min-1 cmH2O-1 (control, 0.54 +/- 0.24 microl min-1 cmH2O-1). Streptomyces and leech hyaluronidases were as effective as testicular hyaluronidase (no statistically significant differences) despite differences in substrate specificity. 4. It was shown using histochemical and immunohistochemical techniques that hyaluronan was removed from the synovium by leech, Streptomyces and testicular hyaluronidases. The binding of antibodies 2-B-6 and 3-B-3 showed that the core proteins of the chondroitin sulphate proteoglycans remained intact after treatment with hyaluronidases, and the binding of 5-D-4 showed that keratan sulphate was unaffected. An azocasein digestion assay confirmed that the hyaluronidase preparations had no significant proteolytic activity. 5. The effect of the hyaluronidases was four times greater than predicted from the low concentration of interstitial hyaluronan and its resistivity. Factors that might amplify the effect of hyaluronan depletion include the matrix-organizing role of hyaluronan, and/or non-uniformity of hyaluronan distribution. It is concluded that interstitial hyaluronan makes a major contribution to synovial hydraulic resistance, but the mechanisms are as yet poorly understood.

Taxol involution of collagen-induced arthritis: ultrastructural correlation with the inhibition of synovitis and neovascularization

Collagen-induced arthritis (CIA) is an animal model of rheumatoid arthritis (RA) that can be regressed with Taxol (paclitaxel), a chemotherapeutic agent. To identify structural changes that occur with involution, the synovium from naive, untreated CIA, and Taxol-treated CIA rats were evaluated by light microscopy plus transmission and scanning electron microscopy. Analysis included detailed images of vascular networks using polymeric corrosion casts. The CIA synovium was morphologically similar to human RA synovium. In CIA, the integrity of the intimal lining is lost by Type-B synoviocytes becoming highly elongated and polarized toward the joint space, resulting in non-overlapping cellular processes and the elimination of the basal lamina. In addition, the lining expanded from a width of 6-10 microns in naives to 200-250 microns in CIA due primarily to increased numbers of both Type-A and -B synoviocytes and more interstitial matrix. Vascular corrosion casts of CIA synovium illustrated a marked increase in blood vessel volume and an extensive interconnecting vascular architecture; neovascular arrays were observed to project toward the synovial surface. In Taxol-treated CIA, the synoviocyte and neovascular components reverted to the naive synovium morphology, suggesting that this agent might be useful in the therapy of RA.

Ultrastructural characteristics of the synovial membrane in osteoarthritic temporomandibular joints

PURPOSE

This study analyzed the ultrastructural characteristics of the synovial membrane in various stages of osteoarthritis (OA) of the temporomandibular joint (TMJ), and developed a classification of this involvement based on these morphologic characteristics.

PATIENTS AND METHODS

Synovial membrane biopsies were performed during unilateral arthroscopy in 40 patients. Thirty-one TMJs constituted the OA group; nine TMJs that were not involved by OA constituted the control group. During light microscopic (LM) examination, various variables were recorded and related to the duration of clinical signs and symptoms. Ten synovial membranes from osteoarthritic joints showing histologically visible pathologic changes in various stages and one control synovial membrane were selected for electron microscopic examination.

RESULTS

The initial, early, and intermediate stages of synovial membrane involvement in TMJ OA were characterized by intima hyperplasia. In the initial and early stages, active and hypertrophic intimal cells are found. In the intermediate stage, an increased number of both intracytoplasmic and extracellular filaments was predominant. Fibrosis of the subintimal tissue was initiated by an increased number of active fibroblasts. The late stage of synovial membrane involvement in TMJ OA was characterized by a relatively normal synovial intima of normal thickness, whereas extensive fibrosis was seen in the subintimal tissues.

CONCLUSIONS

Synovial membrane involvement in TMJ OA is characterized by an early proliferative phase with probable growth factor-mediated increases in the cellular activity of the synovial intima cells (resulting in hyperplasia and hypertrophy), of fibroblasts (resulting in increased production of collagen fibrils and fibrosis), and of endothelial cells (resulting in blood vessel growth and hypervascularity). The late phase is characterized by extensive fibrosis of the subintimal tissue, whether caused by sustained production of growth factors or by chronic venous insufficiency, with normal or little cellular activity.

Expression of cartilage oligomeric matrix protein by human synovium

Human synovium was analyzed for the possible expression of cartilage oligomeric matrix protein (COMP). Immunostaining with polyclonal antiserum to COMP demonstrated positive staining within the synovial cells and immediately subjacent connective tissue, with less intense staining in the deeper connective tissue. Western blot analysis using either polyclonal or monoclonal antibodies to human COMP confirmed the presence of COMP by immunoreactive bands with the same molecular mass (approximately 110 kDa) as purified articular cartilage COMP. PCR using oligonucleotides that span human COMP exons 7-13 revealed identical amplification products from cDNA prepared from either human chondrocytes or synovium. Northern blot analysis using a biotinylated-probe to human COMP, spanning exons 12-13, also reveal an identical hybridization product to either human chondrocyte or synovium total RNA. Human synovium should be considered as a potential tissue source of COMP in any investigation of biological markers of cartilage metabolism.