Development of a Cartilage Shear-Damage Model to Investigate the Impact of Surface Injury on Chondrocytes and Extracellular Matrix Wear

Clinical relevance of joint line obliquity after high tibial osteotomy for medial knee osteoarthritis remains controversial: a systematic review

PURPOSE

To systematically review the literature on the association between knee joint line obliquity (KJLO) and clinical outcome after high tibial osteotomy (HTO) for medial knee osteoarthritis and summarize the KJLO cut-off value used when studying this association.

METHODS

A systematic search was conducted in three databases (PubMed, Embase, and Web of Science) on September 2022, updated on February 2023. Eligible studies describing postoperative KJLO in relation to clinical outcome after HTO for medial knee osteoarthritis were included. Nonpatient studies and conference abstracts without full-text were excluded. Two independent reviewers assessed title, abstract and full-text based on the inclusion and exclusion criteria. The modified Downs and Black checklist was used to assess the methodological quality of each included study.

RESULTS

Of the seventeen studies included, three had good methodological quality, thirteen fair quality, and one had poor quality. Conflicting findings were shown on the associations between postoperative KJLO and patient-reported outcome, medial knee cartilage regeneration, and 10-year surgical survival in sixteen studies. Three good-quality studies found no significant differences in lateral knee cartilage degeneration between postoperative medial proximal tibial angle > 95° and < 95°. Joint line orientation angles by the tibial plateau of 4° and 6°, joint line orientation angle by the middle knee joint space of 5°, medial proximal tibial angles of 95° and 98°, and Mikulicz joint line angle of 94° were KJLO cut-off values used in the included studies.

CONCLUSION

Based on current evidence, the actual association between postoperative KJLO and clinical consequences after HTO for medial knee osteoarthritis cannot be ascertained. The clinical relevance of KJLO after HTO remains controversial.

LEVEL OF EVIDENCE

IV.

Structural clues to articular calcified cartilage function: A descriptive review of this crucial interface tissue

Articular calcified cartilage (ACC) has been dismissed, by some, as a remnant of endochondral ossification without functional relevance to joint articulation or weight-bearing. Recent research indicates that morphologic and metabolic ACC features may be important, reflecting knee joint osteoarthritis (OA) predisposition. ACC is less investigated than neighbouring joint tissues, with its component chondrocytes and mineralised matrix often being either ignored or integrated into analyses of hyaline articular cartilage and subchondral bone tissue respectively. Anatomical variation in ACC is recognised between species, individuals and age groups, but the selective pressures underlying this variation are unknown. Consequently, optimal ACC biomechanical features are also unknown as are any potential locomotory roles. This review collates descriptions of ACC anatomy and biology in health and disease, with a view to revealing its structure/function relationship and highlighting potential future research avenues. Mouse models of healthy and OA joint ageing have shown disparities in ACC load-induced deformations at the knee joint. This raises the hypothesis that ACC response to locomotor forces over time may influence, or even underlie, the bony and hyaline cartilage symptoms characteristic of OA. To effectively investigate the ACC, greater resolution of joint imaging and merging of hierarchical scale data will be required. An appreciation of OA as a 'whole joint disease' is expanding, as is the possibility that the ACC may be a key player in healthy ageing and in the transition to OA joint pathology.

Advances in organ-on-a-chip systems for modelling joint tissue and osteoarthritic diseases

Joint-on-a-chip (JOC) models are powerful tools that aid in osteoarthritis (OA) research. These microfluidic devices apply emerging organ-on-a-chip technology to recapitulate a multifaceted joint tissue microenvironment. JOCs address the need for advanced, dynamic in vitro models that can mimic the in vivo tissue environment through joint-relevant biomechanical or fluidic integration, an aspect that existing in vitro OA models lack. There are existing review articles on OA models that focus on animal, tissue explant, and two-dimensional and three-dimensional (3D) culture systems, including microbioreactors and 3D printing technology, but there has been limited discussion of JOC models. The aim of this article is to review recent developments in human JOC technology and identify gaps for future advancements. Specifically, mechanical stimulation systems that mimic articular movement, multi-joint tissue cultures that enable crosstalk, and systems that aim to capture aspects of OA inflammation by incorporating immune cells are covered. The development of an advanced JOC model that captures the dynamic joint microenvironment will improve testing and translation of potential OA therapeutics.

Shear strain and inflammation-induced fixed charge density loss in the knee joint cartilage following ACL injury and reconstruction: A computational study

Excessive tissue deformation near cartilage lesions and acute inflammation within the knee joint after anterior cruciate ligament (ACL) rupture and reconstruction surgery accelerate the loss of fixed charge density (FCD) and subsequent cartilage tissue degeneration. Here, we show how biomechanical and biochemical degradation pathways can predict FCD loss using a patient-specific finite element model of an ACL reconstructed knee joint exhibiting a chondral lesion. Biomechanical degradation was based on the excessive maximum shear strains that may result in cell apoptosis, while biochemical degradation was driven by the diffusion of pro-inflammatory cytokines. We found that the biomechanical model was able to predict substantial localized FCD loss near the lesion and on the medial areas of the lateral tibial cartilage. In turn, the biochemical model predicted FCD loss all around the lesion and at intact areas; the highest FCD loss was at the cartilage-synovial fluid-interface and decreased toward the deeper zones. Interestingly, simulating a downturn of an acute inflammatory response by reducing the cytokine concentration exponentially over time in synovial fluid led to a partial recovery of FCD content in the cartilage. Our novel numerical approach suggests that in vivo FCD loss can be estimated in injured cartilage following ACL injury and reconstruction. Our novel modeling platform can benefit the prediction of PTOA progression and the development of treatment interventions such as disease-modifying drug testing and rehabilitation strategies.

Prediction of local fixed charge density loss in cartilage following ACL injury and reconstruction: A computational proof-of-concept study with MRI follow-up

The purpose of this proof-of-concept study was to develop three-dimensional patient-specific mechanobiological knee joint models to simulate alterations in the fixed charged density (FCD) around cartilage lesions during the stance phase of the walking gait. Two patients with anterior cruciate ligament (ACL) reconstructed knees were imaged at 1 and 3 years after surgery. The magnetic resonance imaging (MRI) data were used for segmenting the knee geometries, including the cartilage lesions. Based on these geometries, finite element (FE) models were developed. The gait of the patients was obtained using a motion capture system. Musculoskeletal modeling was utilized to calculate knee joint contact and lower extremity muscle forces for the FE models. Finally, a cartilage adaptation algorithm was implemented in both FE models. In the algorithm, it was assumed that excessive maximum shear and deviatoric strains (calculated as the combination of principal strains), and fluid velocity, are responsible for the FCD loss. Changes in the longitudinal T_1ρ and T₂ relaxation times were postulated to be related to changes in the cartilage composition and were compared with the numerical predictions. In patient 1 model, both the excessive fluid velocity and strain caused the FCD loss primarily near the cartilage lesion. T_1ρ and T₂ relaxation times increased during the follow-up in the same location. In contrast, in patient 2 model, only the excessive fluid velocity led to a slight FCD loss near the lesion, where MRI parameters did not show evidence of alterations. Significance: This novel proof-of-concept study suggests mechanisms through which a local FCD loss might occur near cartilage lesions. In order to obtain statistical evidence for these findings, the method should be investigated with a larger cohort of subjects.

Articular Cartilage Friction, Strain, and Viability Under Physiological to Pathological Benchtop Sliding Conditions

In vivo, articular cartilage is exceptionally resistant to wear, damage, and dysfunction. However, replicating cartilage's phenomenal in vivo tribomechanics (i.e., high fluid load support, low frictions and strains) and mechanobiology on the benchtop has been difficult, because classical testing approaches tend to minimize hydrodynamic contributors to tissue function. Our convergent stationary contact area (cSCA) configuration retains the ability for hydrodynamically-mediated processes to contribute to interstitial hydration recovery and tribomechanical function via 'tribological rehydration'. Using the cSCA, we investigated how in situ chondrocyte survival is impacted by the presence of tribological rehydration during the reciprocal sliding of a glass counterface against a compressively loaded equine cSCA cartilage explant. When tribological rehydration was compromised during testing, by slow-speed sliding, 'pathophysiological' tribomechanical environments and high surface cell death were observed. When tribological rehydration was preserved, by high-speed sliding, 'semi-physiological' sliding environments and suppressed cell death were realized. Inclusion of synovial fluid during testing fostered 'truly physiological' sliding outcomes consistent with the in vivo environment but had limited influence on cell death compared to high-speed sliding in PBS. Subsequently, path analysis identified friction as a primary driver of cell death, with strain an indirect driver, supporting the contention that articulation mediated rehydration can benefit both the biomechanical properties and biological homeostasis of cartilage.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12195-021-00671-2.

A MOVING CONTACT OF ARTICULATION ENHANCES THE BIOSYNTHETIC AND FUNCTIONAL RESPONSES OF ARTICULAR CARTILAGE

Biomechanical influences play a fundamental role in the structural, functional, and biosynthetic properties of articular cartilage. During physiologic joint loading, the contact area between two surfaces migrates due to the primary and secondary motions of the joint. It has been demonstrated that a migratory contact area plays a critical role in reducing the coefficient of friction at the cartilage surface. However, a detailed analysis of the influences that a migratory contact area plays on the structural, functional, and biosynthetic properties remain to be explored. In this study, bovine cartilage explants were placed in a biotribometer. Explants were subjected to compression and shear forces of migratory contact area, namely moving contact (MC) articulation, or stationary contact area, namely stationary contact (SC) articulation. Free swelling explants were used as control. In a separate study, bovine cartilage-bone grafts were used for frictional testing. On histologic analysis, the SC group had evidence of surface fibrillations, which was not evident in the MC group. Compared to the SC group, the MC group cartilage explants had increased chondrocyte viability, increased lubricin synthesis, and comparable proteoglycan synthesis and release. MC articulation had reduced coefficient of friction as compared to SC articulation. MC articulation led to reduced surface roughness as compared to SC articulation. In conclusion, a migratory contact area can play an important role in maintaining the structural, function, and biosynthetic properties of articular cartilage. This study provides further evidence of the importance of migratory contact area and in vitro assessment of natural joint movement, which can be further evaluated in the context of cartilage homeostasis and disease.

Effect of Loading on the Adhesion and Frictional Characteristics of Top Layer Articular Cartilage Nanoscale Contact: A Molecular Dynamics Study

Articular cartilage is a water-lubricated naturally occurring biological interface imparting unique mechanical and ultralow frictional properties in bone joints. Although the material of cartilage, synovial fluid composition, and their lubricating modes and properties have been extensively investigated at various scales experimentally, there is still a lack of understanding of load bearing, adhesion, and friction mechanisms of the cartilage-cartilage interface from an atomistic perspective under heavy loads. In this study, the effect of loading on adhesion and frictional behavior in articular cartilage is investigated with a proposed atomistic model for top layer cartilage-cartilage contact in unhydrated conditions using molecular dynamics (MD) simulations. Pull-off tests reveal that cohesive interactions occur at the interface due to formation of heavily interpenetrated atomistic sites leading to stretching and localized pulling of fragments during sliding. Sliding tests show that friction is load- and direction-dependent with the coefficient of friction (COF) obtained in the range of 0.20-0.75 at the interface for sliding in parallel and perpendicular directions to the collagen axis. These values are in good agreement with earlier nanoscale experimental results reported for the top layer cartilage-cartilage interface. The COF reduces with an increase in load and tends to be higher for the parallel sliding case than for the perpendicular case owing to the presence of the constant number of H-bonds. Overall, this work contributes toward understanding sliding in unhydrated biointerfaces, which is the precursor of wear, and provides insights into implant research.

Tribological evaluation of a novel hybrid for repair of articular cartilage defects

The friction and wear properties of silica/poly(tetrahydrofuran)/poly(ε-caprolactone) (SiO₂/PTHF/PCL-diCOOH) hybrid materials that are proposed as cartilage tissue engineering materials were investigated against living articular cartilage. A testing rig was designed to allow testing against fresh bovine cartilage. The friction force and wear were compared for five compositions of the hybrid biomaterial articulating against freshly harvested bovine cartilage in diluted bovine calf serum. Under a non-migrating contact, the friction force increased and hence shear force applied to the opposing articular cartilage also increased, resulting in minor damage to the cartilage surface. This worse case testing scenario was used to discriminate between material formulations and revealed the increase in friction and damaged area was lowest for the hybrid containing the most silica. Further friction and wear tests on one hybrid formulation with an elastic modulus closest to that of cartilage were then conducted in a custom incubator system. This demonstrated that over a five day period the friction force, cell viability and glucosaminoglycan (GAG) release into the lubricant were similar between a cartilage-cartilage interface and the hybrid-cartilage interface, supporting the use of these materials for cartilage repair. These results demonstrate how tribology testing can play a part in the development of new materials for chondral tissue engineering. STATEMENT OF SIGNIFICANCE: Designing materials that maintain the low friction and wear of articular cartilage whilst supporting the growth of new tissue is critical if further damage is to be avoided during repair of cartilage defects. This work examines the tribological performance of a SiO₂/PTHF/PCL-diCOOH hybrid material and demonstrates a testing protocol that could be applied to any proposed material for cartilage regeneration. Tribological tests demonstrated that changing the hybrid composition decreased friction and reduced damage to the cartilage counterface. This study demonstrates how tribological testing can be integrated into the design process to produce materials with a higher chance of clinical success.

Transient stiffening of cartilage during joint articulation: A microindentation study

As a mechanoactive tissue, articular cartilage undergoes compression and shear on a daily basis. With the advent of high resolution and sensitive mechanical testing methods, such as micro- and nanoindentation, it has become possible to assess changes in small-scale mechanical properties due to compression and shear of the tissue. However, investigations on the changes of these properties before and after joint articulation have been limited. To simulate articular loading of cartilage in the context of human gait, a previously developed bioreactor system was used. Immediately after bioreactor testing, the stiffness was measured using microindentation. Specifically, we investigated whether the mechanical response of the tissue was transient or permanent, dependent on counterface material, and an effect limited to the superficial zone of cartilage. We found that cartilage surface stiffness increases immediately after articular loading and returns to baseline values within 3 hr. Cartilage-on-cartilage stiffening was found to be higher compared to both alumina- and cobalt chromium-on-cartilage stiffening, which were not significantly different from each other. This stiffening response was found to be unique to the superficial zone, as articular loading on cartilage with the superficial zone removed showed no changes in stiffness. The findings of this study suggest that the cartilage superficial zone may adapt its stiffness as a response to articular loading. As the superficial zone is often compromised during the course of osteoarthritic disease, this finding is of clinical relevance, suggesting that the load-bearing function deteriorates over time.

Shear stress induced by fluid flow produces improvements in tissue-engineered cartilage

Tissue engineering aims to create implantable biomaterials for the repair and regeneration of damaged tissues. In vitro tissue engineering is generally based on static culture, which limits access to nutrients and lacks mechanical signaling. Using shear stress is controversial because in some cases it can lead to cell death while in others it promotes tissue regeneration. To understand how shear stress works and how it may be used to improve neotissue function, a series of studies were performed. First, a tunable device was designed to determine optimal levels of shear stress for neotissue formation. Then, computational fluid dynamics modeling showed the device applies fluid-induced shear (FIS) stress spanning three orders of magnitude on tissue-engineered cartilage (neocartilage). A beneficial window of FIS stress was subsequently identified, resulting in up to 3.6-fold improvements in mechanical properties of neocartilage in vitro. In vivo, neocartilage matured as evidenced by the doubling of collagen content toward native values. Translation of FIS stress to human derived neocartilage was then demonstrated, yielding analogous improvements in mechanical properties, such as 168% increase in tensile modulus. To gain an understanding of the beneficial roles of FIS stress, a mechanistic study was performed revealing a mechanically gated complex on the primary cilia of chondrocytes that is activated by FIS stress. This series of studies places FIS stress into the arena as a meaningful mechanical stimulation strategy for creating robust and translatable neotissues, and demonstrates the ease of incorporating FIS stress in tissue culture.

Effects of mechanical injury on the tribological rehydration and lubrication of articular cartilage

Healthy articular cartilage is crucial to joint function, as it provides the low friction and load bearing surface necessary for joint articulation. Nonetheless, joint injury places patients at increased risk of experiencing both accelerated cartilage degeneration and wear, and joint dysfunction due to post-traumatic osteoarthritis (PTOA). In this study, we used our ex vivo convergent stationary contact area (cSCA) explant testing configuration to demonstrate that high-speed sliding of healthy tissues against glass could drive consistent and reproducible recovery of compression-induced cartilage deformation, through the mechanism of 'tribological rehydration'. In contrast, the presence of physical cartilage damage, mimicking those injuries known to precipitate PTOA, could compromise tribological rehydration and the sliding-driven recovery of cartilage function. Full-thickness cartilage injuries (i.e. fissures and chondral defects) markedly suppressed sliding-driven tribological rehydration. In contrast, impaction to cartilage, which caused surface associated damage, had little effect on the immediate tribomechanical response of explants to sliding (deformation/strain, tribological rehydration, and friction/lubricity). By leveraging the unique ability of the cSCA configuration to support tribological rehydration, this study permitted the first direct ex vivo investigation of injury-dependent strain and friction outcomes in cartilage under testing conditions that replicate and maintain physiologically-relevant levels of fluid load support and frictional outcomes under high sliding speeds (80 mm/s) and moderate compressive stresses (~0.3 MPa). Understanding how injury alters cartilage tribomechanics during sliding sheds light on mechanisms by which cartilage's long-term resilience and low frictional properties are maintained, and can guide studies investigating the functional consequences of physical injury and joint articulation on cartilage health, disease, and rehabilitation.

Mechanically stimulated osteochondral organ culture for evaluation of biomaterials in cartilage repair studies

Surgical procedures such as microfracture or autologous chondrocyte implantation have been used to treat articular cartilage lesions; however, repair often fails in terms of matrix organization and mechanical behaviour. Advanced biomaterials and tissue engineered constructs have been developed to improve cartilage repair; nevertheless, their clinical translation has been hampered by the lack of reliable in vitro models suitable for pre-clinical screening of new implants and compounds. In this study, an osteochondral defect model in a bioreactor that mimics the multi-axial motion of an articulating joint, was developed. Osteochondral explants were obtained from bovine stifle joints, and cartilage defects of 4 mm diameter were created. The explants were used as an interface against a ceramic ball applying dynamic compressive and shear loading. Osteochondral defects were filled with chondrocytes-seeded fibrin-polyurethane constructs and subjected to mechanical stimulation. Cartilage viability, proteoglycan accumulation and gene expression of seeded chondrocytes were compared to free swelling controls. Cells within both cartilage and bone remained viable throughout the 10-day culture period. Loading did not wear the cartilage, as indicated by histological evaluation and glycosaminoglycan release. The gene expression of seeded chondrocytes indicated a chondrogenic response to the mechanical stimulation. Proteoglycan 4 and cartilage oligomeric matrix protein were markedly increased, while mRNA ratios of collagen type II to type I and aggrecan to versican were also enhanced. This mechanically stimulated osteochondral defect culture model provides a viable microenvironment and will be a useful pre-clinical tool to screen new biomaterials and biological regenerative therapies under relevant complex mechanical stimuli. STATEMENT OF SIGNIFICANCE: Articular cartilage lesions have a poor healing capacity and reflect one of the most challenging problems in orthopedic clinical practice. The aim of current research is to develop a testing system to assess biomaterials for implants, that can permanently replace damaged cartilage with the original hyaline structure and can withstand the mechanical forces long term. Here, we present an osteochondral ex vivo culture model within a cartilage bioreactor, which mimics the complex motion of an articulating joint in vivo. The implementation of mechanical forces is essential for pre-clinical testing of novel technologies in the field of cartilage repair, biomaterial engineering and regenerative medicine. Our model provides a unique opportunity to investigate healing of articular cartilage defects in a physiological joint-like environment.

A novel mechanobiological model can predict how physiologically relevant dynamic loading causes proteoglycan loss in mechanically injured articular cartilage

Cartilage provides low-friction properties and plays an essential role in diarthrodial joints. A hydrated ground substance composed mainly of proteoglycans (PGs) and a fibrillar collagen network are the main constituents of cartilage. Unfortunately, traumatic joint loading can destroy this complex structure and produce lesions in tissue, leading later to changes in tissue composition and, ultimately, to post-traumatic osteoarthritis (PTOA). Consequently, the fixed charge density (FCD) of PGs may decrease near the lesion. However, the underlying mechanisms leading to these tissue changes are unknown. Here, knee cartilage disks from bovine calves were injuriously compressed, followed by a physiologically relevant dynamic compression for twelve days. FCD content at different follow-up time points was assessed using digital densitometry. A novel cartilage degeneration model was developed by implementing deviatoric and maximum shear strain, as well as fluid velocity controlled algorithms to simulate the FCD loss as a function of time. Predicted loss of FCD was quite uniform around the cartilage lesions when the degeneration algorithm was driven by the fluid velocity, while the deviatoric and shear strain driven mechanisms exhibited slightly discontinuous FCD loss around cracks. Our degeneration algorithm predictions fitted well with the FCD content measured from the experiments. The developed model could subsequently be applied for prediction of FCD depletion around different cartilage lesions and for suggesting optimal rehabilitation protocols.

Stimulation of chondrocytes and chondroinduced mesenchymal stem cells by osteoinduced mesenchymal stem cells under a fluid flow stimulus on an integrated microfluidic device

The aim of the present study was to investigate the stimulation of osteoinduced mesenchymal stem cells (MSCs) into chondrogenically predifferentiated MSCs and chondrocytes in a mechanical environment. A novel two‑layer microfluidic chip was used to mimic the interstitial flow in the superficial zones of articular cartilage. The morphology, proliferation rate and the expression of collagen I, collagen II and aggrecan of chondrocytes and chondro‑MSCs were investigated. The results revealed that the cells in the bottom layer were influenced by the top layer's osteoinduced MSCs and the bottom layer's shear flow. The expression of collagen I, which may signify the effect of the shear stress on the dedifferentiation change, was weakened by the stimulation of osteoinduced MSCs on the top layer. The expression of collagen II and aggrecan was increased in the fluidic environment by osteoinduced MSCs. These results indicate that osteoinduced MSCs have a significant effect on the phenotype of chondro‑MSCs and chondrocytes in the fluidic microenvironment. The present study described a simple and promising way to rapidly evaluate cell responses to other cells in a fluidic environment, which may help to better promote the utilization of MSCs and chondrocytes in tissue engineering.

Relevance of bioreactors and whole tissue cultures for the translation of new therapies to humans

The purpose of this review is to provide a brief overview of bioreactor-based culture systems as alternatives to conventional two- and three-dimensional counterparts. The role, challenges, and future aspirations of bioreactors in the musculoskeletal field (e.g., cartilage, intervertebral disc, tendon, and bone) are discussed. Bioreactors, by recapitulating physiological processes, can be used effectively as part of the initial in vitro screening, reducing that way the number of animal required for preclinical assessment, complying with the 3R principles and, in most cases, allowing working with human tissues. The clinical significance of bioreactors is that, by providing more physiologically relevant conditions to customarily used two- and three-dimensional cultures, they hold the potential to provide a testing platform that is more predictable of a whole tissue response, thereby facilitating the screening of treatments before the initiation of clinical trials. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:10-21, 2018.