Novel strategies for the treatment of osteoarthritis

Intraarticular STP Radiofrequency for Painful Osteoarthritis in the Knee: A Retrospective Single Center Analysis

OBJECTIVE

Osteoarthritis (OA) is the most common cause of chronic knee pain, often a debilitating condition that can cause a significant reduction in functional capacity. Radiofrequency is a form of neuromodulation that modulates pain signal transmission and has become progressively more common as a treatment for knee pain. This retrospective study aims to evaluate the efficacy of intraarticular radiofrequency in patients with chronic knee OA pain.

MATERIALS AND METHODS

In this retrospective study, we included 129 patients undergoing intraarticular pulsed radiofrequency using the Poisson curve for energy distribution (Sluijter-Teixeira Poisson radiofrequency) (STP) from March 2018 to November 2019. Knee osteoarthritis severity was assessed prior to the procedure using the Lequesne Index, classifying patients into six groups based on level of severity. Pain intensity was assessed through a 10-cm visual analog scale (VAS), and level of patient satisfaction was assessed through a questionnaire.

RESULTS

In the sample, pain reduction as measured by VAS compared to baseline prior to the procedure was statistically significant immediately following the procedure, at 30 days and at 90 days (p<0.001); this difference was less significant at 180 days (p<0.005). Efficacy in patients with moderate to severe disability was considerably greater than in patients with very severe to extremely severe disability. 57.36% reported that they were very satisfied, 29.46% satisfied, 9.3% neither satisfied nor dissatisfied, 2.33% dissatisfied, and 1.55% very dissatisfied.

CONCLUSION

Our results suggest that STP radiofrequency may be a safe and effective procedure for knee OA, able to significantly reduce VAS scores at 1 month and 3 months compared to baseline. Based on our results, a key factor to consider when treating knee OA with STP radiofrequency is that it is more effective among patients with a lower level of disability. Due to the retrospective observational study design, prospective longitudinal investigation is required to further support the recommendation of STP radiofrequency for knee OA.

Arrabidaea chica Verlot fractions reduce MIA-induced osteoarthritis progression in rat knees

This study aims to investigate the activity of n-hexane, ethyl acetate and butanol fractions obtained from Arrabidaea chica Verlot against MIA-induced osteoarthritis (OA). The antinociceptive potentials of each fraction were evaluated through a cyclooxygenase (COX) 1 and 2 inhibition test and an in vivo OA-model. In addition, toxicity assessments in the liver, spleen and kidney, as well as radiographic and histopathological knee analyses, were performed. The chemical composition of the n-hexane fraction was elucidated, and a molecular docking protocol was carried out to identify which compounds are associated with the detected bioactivity. The n-hexane A. chica fraction preferentially inhibits COX-2, with 90% inhibition observed at 10 µg/mL. The fractions also produced significant improvements in OA incapacity, motor activity and hyperalgesia parameters and in radiological knee conditions. However, concerning the histopathological evaluations, these improvements were only significant in the hexane and ethyl acetate fraction treatments, which resulted in better average scores, suggesting that these fractions slow OA-promoted joint injury progression. Histopathological organ analyses indicate that the fractions are not toxic to animals. Twenty compounds were identified in the n-hexane fraction, comprising fatty acids, terpenes and phytosterols. In silico analyses indicate the presence of favourable interactions between some of the identified compounds and the COX-2 enzyme, mainly concerning alpha-tocopherol (Vitamin E), squalene and beta-sitosterol. The findings indicate that A. chica fractions display analgesic, anti-inflammatory properties, are non-toxic and are able to slow OA progression, and may, therefore, be prioritized as natural products in OA human clinical trials.

Impact-induced cartilage damage assessed using polarisation-sensitive optical coherence tomography

Non-invasive determination of structural changes in articular cartilage immediately after impact and rehydration provides insight into the response and recovery of the soft tissue, as well as provides a potential methodology for clinicians to quantify early degenerative changes. In this study, we use polarisation-sensitive optical coherence tomography (PS-OCT) to examine subtle alterations of the optical properties in healthy and early-stage degenerate articular cartilage immediately after impact loading to identify structurally relevant metrics required for understanding the mechanical factors of osteoarthritic initiation and progression. A custom-designed impact testing rig was used to deliver 0.9 J and 1.4 J impact energies to bovine articular cartilage. A total of 52 (n=26 healthy, n=26 mildly degenerate) cartilage-on-bone samples were imaged before, immediately after, and 3 h after impact. PS-OCT images were analyzed to assess changes relating to surface irregularity, optical attenuation, and birefringence. Mildly degenerate cartilage exhibits a significant change in birefringence following 1.4 J impact energies compared to healthy samples which is believed to be attributable to degenerate cartilage being unable to fully utilise the fluid phase to distribute and dampen the energy. After rehydration, the polarisation-sensitive images appear to 'optically-recover' reducing the reliability of birefringence as an absolute metric. Surface irregularity and optical attenuation encode diagnostically relevant information and may serve as markers to predict the mechanical response of articular cartilage. PS-OCT with its ability to non-invasively image the sub-surface microstructural abnormalities of cartilage presents as an ideal modality for cartilage degeneration assessment and identification of mechanically vulnerable tissue.

Oxytocin Controls Chondrogenesis and Correlates with Osteoarthritis

This study investigated the relationship of oxytocin (OT) to chondrogenesis and osteoarthritis (OA). Human bone marrow and multipotent adipose-derived stem cells were cultured in vitro in the absence or presence of OT and assayed for mRNA transcript expression along with histological and immunohistochemical analyses. To study the effects of OT in OA in vivo, a rat model and a human cohort of 63 men and 19 women with hand OA and healthy controls, respectively, were used. The baseline circulating OT, interleukin-6, leptin, and oestradiol levels were measured, and hand X-ray examinations were performed for each subject. OT induced increased aggrecan, collagen (Col) X, and cartilage oligomeric matrix protein mRNA transcript levels in vitro, and the immunolabelling experiments revealed a normalization of Sox9 and Col II protein expression levels. No histological differences in lesion severity were observed between rat OA groups. In the clinical study, a multivariate analysis adjusted for age, body mass index, and leptin levels revealed a significant association between OA and lower levels of OT (odds ratio = 0.77; p = 0.012). Serum OT levels are reduced in patients with hand OA, and OT showed a stimulatory effect on chondrogenesis. Thus, OT may contribute to the pathophysiology of OA.

A synthetic polymeric biolubricant imparts chondroprotection in a rat meniscal tear model

Intra-articular injection of hyaluronic acid (HA) is used to treat osteoarthritis (OA) as a viscosupplement, yet it only provides short-term benefit because HA is cleaved by hyaluronidase and cleared out of the joint after several days. Therefore, we developed a new polymer biolubricant based on poly-oxanorbornane carboxylate to enhance joint lubrication for a prolonged time. Rheological and biotribological studies of the biolubricant reveal viscoelastic properties and coefficient of friction equivalent and superior to that of healthy synovial fluid, respectively. Furthermore, in an ex vivo bovine cartilage plug model, the biolubricant exhibits superior long-term reduction of friction and wear prevention compared to saline and healthy synovial fluid. ISO 10993 biocompatibility tests demonstrate that the biolubricant polymer is non-toxic. In an in vivo rat medial meniscal tear OA model, where the performance of the leading HA viscosupplement (Synvisc-one®) is comparable to the saline control, treatment with the biolubricant affords significant chondroprotection compared to the saline control.

Effects of baicalein on IL-1β-induced inflammation and apoptosis in rat articular chondrocytes

In osteoarthritis (OA), activated synoviocytes and articular chondrocytes produce pro-inflammatory cytokines, such as IL-1β, that promote chondrocyte apoptosis and activate the NF-κB signaling pathway to induce catabolic factors. In this study, we examined the anti-inflammatory and anti-apoptotic effect of baicalein on IL-1β signaling and NF-κB-regulated gene products in rat chondrocytes. Rat chondrocytes were pretreated with 10 ng/ml IL-1β for 24 h and then co-treated with 10 ng/ml IL-1β and 50 μM baicalein for 0, 12, 24, 36 and 48h. The expression levels of poly(ADP-ribose) polymerase (PARP), Bcl-2, caspase-3, matrix metalloproteinase (MMP)-9, MMP-3, cyclooxygenase (COX)-2 and SOX-9 were detected by Western blot and quantitative reverse transcription-PCR (qPCR). The effects of baicalein on the translocation and phosphorylation of the NF-κB system were studied by Western blotting and immunofluorescence. Baicalein stimulated the expression of anti-apoptotic genes and reduced the pro-apoptotic and pro-inflammatory gene products in chondrocytes. Baicalein promoted SOX-9 expression in a time-dependent manner in chondrocytes. Baicalein inhibited the NF-κB activation that was induced by IL-1β in a time-dependent manner in chondrocytes. Our results suggest that the anti-inflammatory and anti-apoptotic effects of baicalein are mediated through the inhibition of the translocation of phosphorylated p65 to the nucleus.

Chitosan-Coated Collagen Membranes Promote Chondrocyte Adhesion, Growth, and Interleukin-6 Secretion

Designing scaffolds made from natural polymers may be highly attractive for tissue engineering strategies. We sought to produce and characterize chitosan-coated collagen membranes and to assess their efficacy in promoting chondrocyte adhesion, growth, and cytokine secretion. Porous collagen membranes were placed in chitosan solutions then crosslinked with glutaraldehyde vapor. Fourier transform infrared (FTIR) analyses showed elevated absorption at 1655 cm-1 of the carbon-nitrogen (N=C) bonds formed by the reaction between the (NH₂) of the chitosan and the (C=O) of the glutaraldehyde. A significant peak in the amide II region revealed a significant deacetylation of the chitosan. Scanning electron microscopy (SEM) images of the chitosan-coated membranes exhibited surface variations, with pore size ranging from 20 to 50 µm. X-ray photoelectron spectroscopy (XPS) revealed a decreased C-C groups and an increased C-N/C-O groups due to the reaction between the carbon from the collagen and the NH2 from the chitosan. Increased rigidity of these membranes was also observed when comparing the chitosan-coated and uncoated membranes at dried conditions. However, under wet conditions, the chitosan coated collagen membranes showed lower rigidity as compared to dried conditions. Of great interest, the glutaraldehyde-crosslinked chitosan-coated collagen membranes promoted chondrocyte adhesion, growth, and interleukin (IL)-6 secretion. Overall results confirm the feasibility of using designed chitosan-coated collagen membranes in future applications, such as cartilage repair.

Genetically modified chondrocytes expressing TGF-β1: a revolutionary treatment for articular cartilage damage?

INTRODUCTION

Currently, joint arthroplasty remains the only definitive management of osteoarthritis, while other treatment modalities only provide temporary and symptomatic relief. The use of genetically engineered chondrocytes is currently undergoing clinical trials. Specifically, it has been designed to induce cartilage growth and differentiation in patients with degenerative arthritis, with the aim to play a curative role in the disease process.

AREAS COVERED

This treatment involves the incorporation of TGF-β1, which has been determined to play an influential role in chondrogenesis and extracellular matrix synthesis. Using genetic manipulation and viral transduction, TGF-β1 is incorporated into human chondrocytes and administered in a minimally invasive fashion directly to the affected joint. Following a database literature search, we evaluated the current evidence on this product and its outcomes. Furthermore, we also briefly reviewed other treatments developed for chondrogenesis and cartilage regeneration for comparison.

EXPERT OPINION

This treatment method has sustained positive effects on functional outcomes and cartilage growth in initial trials. It allows administration in a minimally invasive manner that does not require extended recovery time. Although several treatment modalities are currently under investigation and appear promising, we hope that these effects can be sustained in further studies. Ultimately, we anticipate that the results may be reproducible in many clinical settings and allow us to effectively treat cartilage damage in patients with degenerative arthritis.

Increased levels of apoptosis and p53 in partial-thickness supraspinatus tendon tears

PURPOSE

The role of apoptosis in the progression of rotator cuff tendinopathy remains poorly understood. In particular, the extent of apoptosis in the partially torn supraspinatus tendon has not been well examined.

METHODS

Biopsies were obtained from nine partially torn supraspinatus tendons, from the matched intact subscapularis tendons, and from 10 reference subscapularis tendons. Immunohistochemistry was used to assess the density of apoptotic cells (activated caspase-3; Asp175), proliferation (Ki67), and p53 (M7001), a key protein involved in regulating cell death. The Bonar scale was used to evaluate tendon degeneration.

RESULTS

The density of apoptotic tendon cells and the density of cells expressing p53 were significantly increased in both the partially torn supraspinatus tendons and in the matched subscapularis tendons, compared with uninjured reference tendons. The Bonar score revealed significant tendon degeneration in the partially torn supraspinatus tendons compared with both matched and reference subscapularis tendons. Tendon cell proliferation was significantly increased in the partially torn supraspinatus tendons compared with reference subscapularis tendons.

CONCLUSIONS

Partial-thickness tears of the supraspinatus tendon demonstrated an increased density of apoptotic, p53+ tendon cells. The fact that apoptosis was accompanied by increased tendon cell proliferation suggests that apoptosis may be related to an ongoing injury-repair process. Increased tenocyte apoptosis may be a relatively early feature in rotator cuff tendinopathy and could represent a possible target for therapeutic intervention.

Effectiveness of thermal and athermal short-wave diathermy for the management of knee osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

To assess the effectiveness of short-wave diathermy (SWD) treatment in the management of knee osteoarthritis (KOA) and to assess whether the effects are related to the induction of a thermal effect.

METHODS

A systematic literature search was conducted in PubMed, CINAHL, PEDro, EMBASE, SPORTdiscus and Scholar Google. Included were trials that compared the use of SWD treatment in patients diagnosed with KOA with a control group (placebo SWD treatment or no intervention) and studies that used high-frequency electromagnetic energy (i.e., 27.12 MHz) with sufficient information regarding treatment dosage. Methodological quality of the included studies was assessed in accordance with the PEDro classification scale. A minimum of a 6/10 score was required for inclusion.

RESULTS

Seven studies were included in the final analysis. Treatment protocols (dosage, duration, number of treatments) varied extensively between studies. The meta-analysis of the studies with low mean power did not favour SWD treatment for pain reduction, while the results of studies employing some thermal effect were significant. No treatment effect on functional performance measures was determined.

CONCLUSION

This meta-analysis found small, significant effects on pain and muscle performance only when SWD evoked a local thermal sensation. However, the variability in the treatment protocols makes it difficult to draw definitive conclusions about the factors determining the effectiveness of SWD treatment. More research (using comparable protocols and outcome measurements) is needed to evaluate possible long-term effects of thermal SWD treatment and its cost effectiveness in patients with KOA.

Impact of inflammation on the osteoarthritic niche: implications for regenerative medicine

Osteoarthritis (OA) is the most common form of arthritis worldwide and is the sixth leading cause of disability. It costs the UK economy approximately 1% of gross national product per annum. With an aging population, the cost of chronic conditions such as OA continues to rise. Historically, treatments for OA have been limited to painkillers, physiotherapy and joint injections. When these fail, patients are referred for joint replacement surgery. With the advent of tissue engineering strategies aimed at generating new bone and cartilage for repair of osteochondral defects, there has been considerable interest in exploiting these techniques to devise new treatments for OA. To date, little consideration has been given to the OA niche and attendant inflammatory milieu for any regenerative skeletal strategy. This review highlights the importance of understanding the osteoarthritic niche in order to modify existing tissue engineering and regenerative medicine strategies for the future treatment of OA.

The osteoarthritic niche and modulation of skeletal stem cell function for regenerative medicine

Osteoarthritis (OA) is the most common cause of arthritis worldwide and represents a significant healthcare burden, particularly in the context of an ageing population. Traditionally, painkillers, injections and physiotherapy have been the mainstay of treatment, with patients being referred for joint replacement surgery (arthroplasty) when these options fail. Whilst effective in reducing pain and improving joint function, these approaches are not without potential complications. With the development of tissue-engineering techniques over recent years there has been considerable interest in applying these strategies to provide new, innovative, alternative effective means of treating OA. This review explores the unique microenvironment present within an osteoarthritic joint, highlighting the features that comprise the osteoarthritic niche and could be modulated in the development of novel treatments for OA. Existing tissue-engineering strategies for repairing bone and cartilage defects are discussed, with particular reference to how these might be modified, both to improve existing treatments, such as impaction bone grafting, as well as in the development of future treatments for OA.

Botanical Extracts from Rosehip (Rosa canina), Willow Bark (Salix alba), and Nettle Leaf (Urtica dioica) Suppress IL-1β-Induced NF-κB Activation in Canine Articular Chondrocytes

The aim of this study was to characterize the anti-inflammatory mode of action of botanical extracts from rosehip (Rosa canina), willow bark (Salix alba), and nettle leaf (Urtica dioica) in an in vitro model of primary canine articular chondrocytes. Methods. The biological effects of the botanical extracts were studied in chondrocytes treated with IL-1β for up to 72 h. Expression of collagen type II, cartilage-specific proteoglycan (CSPG), β1-integrin, SOX-9, COX-2, and MMP-9 and MMP-13 was examined by western blotting. Results. The botanical extracts suppressed IL-1β-induced NF-κB activation by inhibition of IκBα phosphorylation, IκBα degradation, p65 phosphorylation, and p65 nuclear translocation. These events correlated with downregulation of NF-κB targets including COX-2 and MMPs. The extracts also reversed the IL-1β-induced downregulation of collagen type II, CSPG, β1-integrin, and cartilage-specific transcription factor SOX-9 protein expression. In high-density cultures botanical extracts stimulated new cartilage formation even in the presence of IL-1β. Conclusions. Botanical extracts exerted anti-inflammatory and anabolic effects on chondrocytes. The observed reduction of IL-1β-induced NF-κB activation suggests that further studies are warranted to demonstrate the effectiveness of plant extracts in the treatment of OA and other conditions in which NF-κB plays pathophysiological roles.

Tenocyte apoptosis in the torn rotator cuff: a primary or secondary pathological event?

Little information exists on the contribution of apoptosis to pathological tendon changes in rotator cuff tendinopathy. The purpose of this study was to quantitate the rate of tenocyte apoptosis in torn supraspinatus tendons and in the matched intact subscapularis and to examine the potential relation between apoptotic index (AI) and tendon pathology. In addition, the authors examined tenocyte density, proliferation rate and p53 gene expression patterns to gain further insight into relevant pathological mechanisms in the torn suprapinatus. 15 torn supraspinatus tendons with matched intact subscapularis tendon samples and 10 reference subscapularis samples were collected. Immunohistochemistry was used to define the AI (F7-26), proliferation rate (Ki67) and presence of p53 (M7001). Tendon degeneration was evaluated according to the Bonar scale. Expression of p53 and relevant genes (n=84) was examined on a subset of samples using microfluidic arrays. The AI was significantly increased in torn supraspinatus tendon and matched subscapularis tendon (R² =0.5742; p=0.0005). Cell density and proliferation rate were also elevated in torn supraspinatus compared with reference subscapularis tendons (p<0.05). A significant increase in p53 occurred specifically in torn supraspinatus tendon (p<0.05), and several genes encoding p53-inhibiting proteins were downregulated in association, including HDAC1 (p<0.05), MDM4 (p<0.001) and PPM1D (p<0.05). Our results suggest that tenocyte apoptosis results from more than one mechanism in the injured rotator cuff, including both intrinsic factors related specifically to the torn supraspinatus tendon, as well as a more generalised effect on the adjacent subscapularis tendon.

Inflammatory response in patients with active and inactive osteoarthritis

In the present study, we have investigated comparatively the inflammatory response of patients with active and inactive osteoarthritis. The sera from 31 healthy individuals, 37 patients with active OA, and 19 patients with inactive OA were assayed for TNF-alpha, IL-6, sRANKL, RANTES, and MRP8 using ELISA in order to evaluate their potential as markers of disease activity. Also, the spontaneous and LSP-induced release of TNF-alpha and IL-6 by peripheral blood neutrophils was determined. The activation of OA is associated with elevated TNF-alpha, IL-6, and RANTES serum levels while sRANKL and MRP8 appeared to be increased in both active and inactive OA. The neutrophil spontaneous and up-regulated by LPS cytokine release can contribute to the exacerbation of OA.

Suppression of early experimental osteoarthritis by in vivo delivery of the adenoviral vector-mediated NF-kappaBp65-specific siRNA

OBJECTIVE

This study was to use adenoviral vector-mediated nuclear factor-kappaBp65 (NF-kappaBp65)-specific siRNA (Ad-siRNA(NF-kappaBp65)) to suppress the progression of early osteoarthritis (OA) in rat model, and therefore to explore a new gene therapy for OA.

METHODS

Reverse transcription polymerase chain reaction was performed to confirm the silencing effect of Ad-siRNA(NF-kappaBp65) in cultured rat chondrocytes. Transection of the medial collateral ligament plus partial medial meniscectomy was operated in the knee of rats to establish OA model. Histological analysis was made to assess the morphological change of cartilage and synovium, and enzyme-linked immunosorbent assay was made to measure the expression of cytokines, such as interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha (TNF-alpha), in synovial fluid. The silencing effect of Ad-siRNA(NF-kappaBp65) on NF-kappaBp65 in cartilage and synovium of knee was measured with Western blot and the activation of NF-kappaB was measured with electrophoretic mobility shift assays.

RESULTS

Ad-siRNA(NF-kappaBp65) can inhibit the activation of NF-kappaB and the expression of NF-kappaBp65 in cartilage and synovium of the knee, restrain the induction of IL-1beta and TNF-alpha in synovial fluid, alleviate the inflammation of synovium and reduce the degradation of cartilage in early phase of experimental OA.

CONCLUSIONS

Ad-siRNA(NF-kappaBp65) can suppress the progression of the early experimental OA which suggests that Ad-siRNA(NF-kappaBp65) has potential to be a useful preventive and therapeutic agent for OA.

Suppression of NF-kappaB activation by curcumin leads to inhibition of expression of cyclo-oxygenase-2 and matrix metalloproteinase-9 in human articular chondrocytes: Implications for the treatment of osteoarthritis

Pro-inflammatory cytokines such as interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha (TNF-alpha) play a key role in the pathogenesis of osteoarthritis (OA). Anti-inflammatory agents capable of suppressing the production and catabolic actions of these cytokines may have therapeutic potential in the treatment of OA and a range of other osteoarticular disorders. The purpose of this study was to examine the effects of curcumin (diferuloylmethane), a pharmacologically safe phytochemical agent with potent anti-inflammatory properties on IL-1beta and TNF-alpha signalling pathways in human articular chondrocytes maintained in vitro. The effects of curcumin were studied in cultures of human articular chondrocytes treated with IL-1beta and TNF-alpha for up to 72h. Expression of collagen type II, integrin beta1, cyclo-oxygenase-2 (COX-2) and matrix metalloproteinase-9 (MMP-9) was monitored by western blotting. The effects of curcumin on the expression, phosphorylation and nuclear translocation of protein components of the NF-kappaB system were studied by western blotting and immunofluorescence, respectively. Treatment of chondrocytes with curcumin suppressed IL-1beta-induced NF-kappaB activation via inhibition of IkappaBalpha phosphorylation, IkappaBalpha degradation, p65 phosphorylation and p65 nuclear translocation. Curcumin inhibited the IL-1beta-induced stimulation of up-stream protein kinase B Akt. These events correlated with down-regulation of NF-kappaB targets including COX-2 and MMP-9. Similar results were obtained in chondrocytes stimulated with TNF-alpha. Curcumin also reversed the IL-1beta-induced down-regulation of collagen type II and beta1-integrin receptor expression. These results indicate that curcumin has nutritional potential as a naturally occurring anti-inflammatory agent for treating OA through suppression of NF-kappaB mediated IL-1beta/TNF-alpha catabolic signalling pathways in chondrocytes.

Intra-articular distribution and residence time of Hylan A and B: a study in the goat knee

OBJECTIVE

This study evaluates the viscosupplementation material Hylan A and B in relation to its: (1) joint distribution, residence time and mechanism of removal and/or degradation, and (2) associated synovial fluid leukocyte response, in a goat model.

METHOD

One green fluorophore was covalently bound to the Hylan A low molecular weight (MW) molecule (viscous fluid fraction) and a second red fluorophore was covalently bound to Hylan B high MW molecule (globule gel-like fraction). Goats were anesthetized and the right knee received 0.5 ml of test material or unbound fluorophore dyes. Gross and histological serial evaluations were performed over an 8-week period.

RESULTS

By 24 h, the non-covalently linked control labels were not present in the tissues. For the covalently linked labels, the green fluorophore Hylan A diminished rapidly in intensity grossly but persisted to 28 days within the superficial synovial and articular cartilage layers in histologic sections. The red fluorophore linked Hylan B was seen only as globules in the synovial fluid. Mononuclear cells remained attached to these globules for 28 days and showed phagocytosis of the globules as well as the green fluorophore Hylan A. The globules were absent at 56 days after injection. The synovial fluid leukocyte count peaked at 24h (mean 9767 cells/mm(3) +/- 8574 S.D.) and declined by 7 days.

CONCLUSIONS

The smaller MW Hylan was removed more rapidly than the higher MW Hylan. The globules were degraded by a different mechanism involving monocytes/macrophages on the surface of the higher MW globules.

Evidence-based recommendations for monitoring bone disease and the response to enzyme replacement therapy in Gaucher patients

BACKGROUND

Bone disease is a serious complication of Gaucher disease. Untreated, it can result in pain, permanent bone damage and disability. Enzyme replacement therapy reverses many of the clinical signs of Gaucher bone disease but early assessment and treatment, and regular monitoring, are essential in optimising outcomes.

SCOPE

In September 2005, a group of European experts met to review current knowledge and identify best practice and unmet needs in the monitoring of Gaucher bone disease and the response to enzyme replacement therapy.

METHODS

Medline searches of peer-reviewed literature (no date restrictions) were conducted and supplemented by additional information considered relevant by panellists to furthering discussions.

FINDINGS AND CONCLUSIONS

The group's recommendations included: currently used biochemical bone markers are not clinically practical or reliable; plain X-rays should not be the sole method of assessing bone disease; MRI is the most sensitive method for monitoring bone marrow infiltration by Gaucher cells; semi-quantitative methods for assessing bone marrow infiltration in routine clinical practice should use readily available technology, include an assessment of Gaucher cell infiltration in the lumbar spine and femur, and be validated for inter-rater reliability and in comparison to other methods; a multidisciplinary approach is required for the treatment of Gaucher patients; all Gaucher patients should receive a comprehensive initial radiologic evaluation for bone disease and ongoing radiological monitoring at least once every 2 years.

NF-kappaBp65-specific siRNA inhibits expression of genes of COX-2, NOS-2 and MMP-9 in rat IL-1beta-induced and TNF-alpha-induced chondrocytes

OBJECTIVE

Small interfering RNA (siRNA) triggers RNA interference in mammalian somatic cells. Nuclear factor kappaB (NF-kappaB) is a transcription factor that is implicated in inflammation and immune activation. This study was to use NF-kappaBp65-specific siRNA to inhibit the expression of genes of cyclooxygenase-2 (COX-2), nitric oxide synthase-2 (NOS-2) and matrix metalloproteinase-9 (MMP-9), which is paralleled with the initiation and progression of cartilage lesions in osteoarthritis (OA) model, in induced chondrocytes, and therefore to explore a new gene therapy for OA.

METHODS

Western blot and reverse transcriptase polymerase chain reaction (RT-PCR) were performed to optimize the silencing effects of NF-kappaBp65-specific siRNA in cultured rat chondrocytes, and then to determine the expression of COX-2, NOS-2 and MMP-9 in induced chondrocytes. The activation of NF-kappaB was determined by electrophoretic mobility shift assay (EMSA). Western blot and RT-PCR were subjected to densitometric analysis and then band intensities were also determined.

RESULTS

The NF-kappaBp65-specific siRNA inhibited the expression of NF-kappaBp65 and activation of NF-kappaB, reducing significantly the expression of COX-2, NOS-2 and MMP-9 induced by interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha (TNF-alpha) in cultured chondrocytes.

CONCLUSIONS

NF-kappaBp65-specific siRNA can inhibit the expression of COX-2, NOS-2 and MMP-9 in IL-1beta-induced and TNF-alpha-induced chondrocytes. This suggests that NF-kappaBp65-specific siRNA has potential to be a useful, preventive and therapeutic agent for OA at early stages.

Future Directions in Treatment of Joint Disease in Horses

Osteoarthritis is one of the most economically important diseases facing equine practitioners. The loss of use associated with joint disease is a leading problem in the equine industry. Although osteoarthritis in all species is believed to be a multifactorial disease that is not well understood, significant advances are being made. This article presents areas of research that are relatively well developed but have not made it to commercialization or routine clinical practice and looks at new applications being investigated for peo-ple that may have an equine application.

Fluoroquinolones cause changes in extracellular matrix, signalling proteins, metalloproteinases and caspase-3 in cultured human tendon cells

Antimicrobial therapy with fluoroquinolones can be associated with tendinitis and other tendon disorders as an adverse reaction associated with this class of antimicrobials. Here we investigated aspects of the mechanism of quinolone-induced tendotoxicity in human tenocytes focussing mainly on the question whether fluoroquinolones may induce apoptosis. Monolayers of human tenocytes were incubated with ciprofloxacin or levofloxacin at different concentrations (0, 3, 10, 30 and 100mg/L medium) for up to 4 days. Ultrastructural changes were studied by electron microscopy, and alterations in synthesis of specific proteins were determined using immunoblotting. At concentrations, which are achievable during quinolone therapy, 3mg ciprofloxacin/L medium significantly decreased type I collagen; similar changes were observed with 3mg ciprofloxacin or 10mg levofloxacin/L medium for the beta(1)- integrin receptors. Effects were intensified at higher concentrations and longer incubation periods. Cytoskeletal and signalling proteins, such as activated shc or erk 1/2, were significantly reduced by both fluoroquinolones already at 3mg/L. Furthermore, time- and concentration-dependent increases of matrix metalloproteinases as well as of the apoptosis marker activated caspase-3 were found. Apoptotic changes were confirmed by electron microscopy: both fluoroquinolones caused typical alterations like condensed material in the nucleus, swollen cell organelles, apoptotic bodies and bleb formation at the cell membrane. Our results provide evidence that besides changes in receptor and signalling proteins apoptosis has to be considered as a final event in the pathogenesis of fluoroquinolone-induced tendopathies.

Role of the Growth Hormone/Insulin-like Growth Factor-1 Paracrine Axis in Rheumatic Diseases

OBJECTIVES

Hypothalamic-pituitary axis abnormalities have been associated with systemic disturbances in several rheumatic diseases. Longitudinal analysis of erythrocyte, serum, urinary and synovial fluid growth hormone (GH), insulin-like growth factor-1 (IGF-1), and somatostatin levels could provide important surrogate measures of disease activity in rheumatic diseases.

METHODS

The authors reviewed the population and longitudinal studies literature on GH, IGF-1, and somatostatin levels in rheumatic disorders using the PubMed and Medlines databases from the National Library of Medicine. In addition to the literature search, primary data were analyzed for basal somatostatin levels in patients with hand, knee, and spine osteoarthritis (OA) as well as primary and secondary hip OA.

RESULTS

A review of the literature supports the view that hypothalamic-pituitary axis dysfunction accompanies clinical symptoms in many rheumatic diseases. In studies from our laboratory, serum GH levels were elevated in patients with OA, rheumatoid arthritis (RA), fibromyalgia, and diffuse idiopathic skeletal hyperostosis but not in patients with gout, pseudogout, or systemic lupus erythematosus. In OA and RA, synovial fluid GH levels exceeded serum GH levels. However, the literature remains controversial regarding the significance of changes in IGF-1 levels in rheumatic disorders. Many studies support an inverse relationship between age and IGF-1. Elevated serum GH levels in various rheumatic diseases were not coupled to changes in serum IGF-1 in diffuse idiopathic skeletal hyperostosis, RA, and fibromyalgia. In particular, serum IGF-1 levels in OA were shown to be lower or no different compared with age-matched normal subjects. Further, in OA, impaired articular chondrocyte response to IGF-1 was attributed, in part, to low synovial fluid IGF-1 that further compromised IGF-1 chondrocyte responses as a result of increased levels of synovial fluid IGF-1 binding proteins. Of note, serum somatostatin levels and "specific" somatostatin receptor levels were often lower in RA and systemic lupus erythematosus, but basal serum somatostatin levels were generally not altered in OA.

CONCLUSIONS

The results of these analyses support the view that some rheumatic diseases such as OA and diffuse idiopathic skeletal hyperostosis, heretofore considered to be purely focal and degenerative, could be reclassified as systemic metabolic disturbances. We propose that serum GH, IGF-1, and somatostatin levels be monitored on a longitudinal basis during the course of medical therapy of rheumatic diseases to determine the extent to which changes in clinical symptoms (exemplified by reduced pain and inflammation and improved range of joint motion) are accompanied by changes in the basal concentration of these hypothalamic/pituitary-related hormones.

A Pilot trial evaluating meta050, a proprietary combination of reduced iso-alpha acids, rosemary extract and oleanolic acid in patients with arthritis and fibromyalgia

The aim of this open-label, 8-week observational trial was to investigate the efficacy of Meta050 (a proprietary, standardized combination of reduced iso-alpha-acids from hops, rosemary extract and oleanolic acid) on pain in patients with rheumatic disease. Osteoarthritis, rheumatoid arthritis and fibromyalgia patients were given 440 mg Meta050 three times a day for 4 weeks, which was changed to 880 mg twice a day for the subsequent 4 weeks in the majority of patients. Pain and condition-specific symptoms were assessed using a standard visual analog scale (VAS), an abridged arthritis impact measurement scale (AIMS2) and the fibromyalgia impact questionnaire. Fifty-four subjects with rheumatic disease completed the trial. Following treatment, a statistically significant decrease in pain of 50% and 40% was observed in arthritis subjects using the VAS (p < 0.0001; Wilcoxon-ranked sums) and AIMS2 (p < 0.0001), respectively. Fibromyalgia subject scores did not significantly improve. A decreasing trend of C-reactive protein, a marker for inflammation, was also observed in those subjects who presented with elevated C-reactive protein. No serious side effects were observed. These observations suggest that Meta050 at a dosage of 440 mg three times a day has a beneficial effect on pain in arthritis subjects.

Cytokines as therapeutic targets for osteoarthritis

Osteoarthritis (OA) is a debilitating, progressive disease of diarthrodial joints associated with the aging process. With the exception of anti-inflammatory corticosteroids and nonsteroidal anti-inflammatory drugs which inhibit cyclo-oxygenase-2, the enzyme responsible for prostaglandin biosynthesis in inflammation, no specific therapy based on fundamental intracellular pathways of chondrocytes and synoviocytes exists for the medical management of OA. At the molecular level, OA is characterized by an imbalance between chondrocyte anabolism and catabolism. Disruption of chondrocyte homeostasis primarily affects the cartilage extracellular matrix (ECM), which is responsible for the biomechanical properties of the tissue. Recent evidence has implicated cytokines, among which interleukin (IL)-1, tumor necrosis factor-alpha, IL-6, and IL-17 seem most involved in the OA process of cartilage destruction. The primary role of these cytokines is to modulate the expression of matrix metalloproteinases and cartilage ECM proteins. Cartilage repair that could restore the functional integrity of the joint is also impaired because chondrocytes in OA cartilage appear unable to respond to insulin-like growth factor-1 or respond abnormally to transforming growth factor-beta. As these growth factors also modulate cytokine expression, they may prove useful in designing strategies for suppressing 'chondrocyte activation'. Although cytokines and growth factors provide a potential therapeutic target for OA, it will be necessary to elucidate the fundamental mechanisms that cytokines employ to cause chondrocyte and synoviocyte dysfunction before 'anti-cytokine' therapy can be employed in the medical management of the disease.

Suppression of early experimental osteoarthritis by gene transfer of interleukin-1 receptor antagonist and interleukin-10

Gene therapy offers a radically different approach to the treatment of arthritis. We demonstrated that cDNA coding for human interleukin-1 receptor-antagonist protein (IL-1Ra) and cDNA coding for human interleukin-10 (IL-10) can be delivered, by ex vivo techniques, to the synovial lining of joints, intra-articular expression of gene significantly reduced cartilage matrix degradation and cartilage breakdown. To achieve this, lapine synoviocytes were first transduced in culture by retroviral infection. The genetically modified synoviocytes were then transplanted by intra-articular injection into the knee joints of OA rabbits, assay of joint lavages confirmed that the gene expression was not lost 14 days after transfer. Knees receiving the IL-1Ra gene had significantly reduced cartilage breakdown. Delivery of the IL-10 gene was less effective, having only a moderate effect on cartilage breakdown. When both genes were injected together, there was a greater inhibition of cartilage breakdown, suggesting that simultaneous gene delivery may be necessary to treat OA by targeting the activities of multiple inflammatory effectors.

Cell death and tendinopathy

Apoptosis and necrosis are presently recognized as the two major types of physiological and pathological cell death. Apoptosis is a tightly regulated cell deletion process that differs morphologically and biochemically from necrotic cell death. Tendinopathy is defined as a tendon injury that originates from intrinsic and extrinsic etiological factors. Excessive apoptosis has recently been described in degenerative tendon. The increased number of apoptotic tendon cells in degenerative tendon tissue could affect the rate of collagen synthesis and repair. Impaired or dysfunctional protein synthesis may lead to weaker tendon tissue and eventually increase the risk for tendon rupture. Clearly, there are many details to insert into this pathway, but there is hope that if the fine details of the pathway can be fleshed out, then strategies may be able to be developed to break the cycle at one or more points and prevent or treat tendinopathy more effectively.

Articular cartilage biology

Articular cartilage is a complex tissue maintained by chondrocytes, which undergo metabolic changes as a result of aging, disease, and injury. These changes may hinder tissue maintenance and repair, resulting in accelerated loss of articular surface and leading to end-stage arthritis. Researchers are investigating both normal and pathologic cellular and molecular processes as well as the development of chondroprotective agents to improve the metabolic function of articular cartilage. Current research is helping to clarify the mechanisms by which a variety of agents, such as glucosamine, chondroitin sulfate, hyaluronic acid, green tea, glucocorticoids, and nonsteroidal anti-inflammatory drugs, can modify the symptoms and course of osteoarthritis. Also under investigation are methods of stimulating repair or replacing damaged cartilage, such as matrix metalloproteinase inhibitors, gene therapy, growth factors, cytokine inhibitors, and artificial cartilage substitutes. Tissue engineering, the combining of artificial matrices with cells and growth factors or genes, offers great potential for improving patient care.

What's new in cartilage?

Magnetic resonance (MR) imaging of articular cartilage is important in evaluation of new surgical and pharmacologic treatments for cartilage damage. Many techniques exist for MR imaging of articular cartilage. Standard techniques for morphologic imaging of cartilage include fast spin-echo and spoiled gradient-echo imaging. These methods provide high-resolution morphologic images of cartilage but are time-consuming in the clinical setting. New methods for faster or higher-resolution morphologic imaging include techniques based on steady-state free precession imaging. These fast techniques will allow detailed evaluation of cartilage in the routine clinical setting. There are also several MR imaging methods that may provide information about the structure and physiology of cartilage. Physiologic imaging may allow detailed evaluation of the glycosaminoglycan matrix or collagen network of articular cartilage and may be the most sensitive method for detection of early changes. With the development of new therapies for osteoarthritis and cartilage injury, MR imaging of articular cartilage is of increasing clinical importance. MR imaging will play an important role in evaluation of the effectiveness of these therapies.

A systematic review of low level laser therapy with location-specific doses for pain from chronic joint disorders

We investigated if low level laser therapy (LLLT) of the joint capsule can reduce pain in chronic joint disorders. A literature search identified 88 randomised controlled trials, of which 20 trials included patients with chronic joint disorders. Six trials were excluded for not irradiating the joint capsule. Three trials used doses lower than a dose range nominated a priori for reducing inflammation in the joint capsule. These trials found no significant difference between active and placebo treatments. The remaining 11 trials including 565 patients were of acceptable methodological quality with an average PEDro score of 6.9 (range 5-9). In these trials, LLLT within the suggested dose range was administered to the knee, temporomandibular or zygapophyseal joints. The results showed a mean weighted difference in change of pain on VAS of 29.8 mm (95% CI, 18.9 to 40.7) in favour of the active LLLT groups. Global health status improved for more patients in the active LLLT groups ( relative risk of 0.52; 95% CI 0.36 to 0.76). Low level laser therapy with the suggested dose range significantly reduces pain and improves health status in chronic joint disorders, but the heterogeneity in patient samples, treatment procedures and trial design calls for cautious interpretation of the results.

Skeletal aspects of Gaucher disease: a review

In Gaucher disease, a genetic deficiency in the activity of the lysosomal enzyme beta-glucocerebrosidase (acid beta-glucosidase) causes monocytes and macrophages to store excessive amounts of glucocerebroside in lysosomes. The resulting distended cells are called Gaucher cells, and the pathology associated with this condition stems from the accumulation of Gaucher cells in organ systems. The skeletal manifestations are probably the most disabling aspect of the disease. Patients commonly experience bone pain, some suffer bone crises, and up to 20% have impaired mobility. Radiological findings include Erlenmeyer flask deformity, osteopenia, osteosclerosis, osteonecrosis, fractures and bone marrow infiltration. Findings from the Gaucher Registry show that nearly all patients with Gaucher disease have radiological evidence of skeletal involvement, and the majority have a history of serious skeletal complications. Skeletal involvement follows three basic processes: focal disease (irreversible lesions such as osteonecrosis and osteosclerosis), local disease (reversible abnormalities adjacent to heavily involved marrow such as cortical thinning and long bone deformity) and generalized osteopenia. Infarctions are involved in some of the skeletal manifestations, but the mechanisms causing high rates of bone turnover and failure of remodelling are not known. The availability of a beta-glucocerebrosidase-deficient mouse model of Gaucher disease with long-term survival should help elucidate the skeletal pathology in Gaucher disease and may ultimately lead to improved management of skeletal complications.

Apoptosis in rotator cuff tendonopathy

The aim of this study was to investigate the involvement of apoptosis (programmed cell death) in the pathogenesis of rotator cuff disorders. The edges of torn supraspinatus rotator cuff tendons were collected from patients with rotator cuff tear (n = 25). Samples of the intra-articular portion of subscapularis tendons were collected from patients without rotator cuff tear as control (n = 6). To minimize individual variance, we also collected six pairs of supraspinatus tendon and subscapularis tendon from six patients with rotator cuff tears. Apoptosis was detected by in situ DNA end labelling assay and DNA laddering assay. Immunohistochemical staining was performed to identify cells undergoing apoptosis. Control subscapularis tendon had normal morphology. Tendon from torn supraspinatus rotator cuff showed significant mucoid degeneration. Within the areas of degeneration, there were large numbers of apoptotic cells. The percentage of apoptotic cells in the degenerative rotator cuff (34%) was significantly higher than that in controls (13%) (p < 0.001). The excessive apoptosis detected in degenerative rotator cuff tissue was confirmed by DNA laddering assays. This is the first report of excessive apoptosis in degenerating rotator cuff tendon. Cells undergoing apoptosis in rotator cuff were mainly fibroblast-like cells. These finding indicate that apoptosis may play an important role in the pathogenesis of rotator cuff degeneration.

Erosive osteoarthritis: presentation, clinical pearls, and therapy

Erosive osteoarthritis (OA) is a subcategory of OA in which destructive changes occur in the joints, probably as a result of a combination of inflammatory inciters and phenomena. The major changes occur in the distal and proximal interphalangeal joints, root joints of the thumb, and less commonly other hand and centripetal joints. A familial tendency suggests hereditary predisposition, and women more likely to be afflicted than men. Diagnosis has been enhanced by newer imaging techniques such as sonography and scintigraphy. Treatment remains chiefly palliative, although there are hints that alleviation of inflammation may be more salutary than simple analgesia.