N-acetylcysteine inhibits post-impact chondrocyte death in osteochondral explants

Global trends and current research in post-traumatic osteoarthritis: A bibliometric and visualization analysis from 2010 to 2024

BACKGROUND

To investigate global trends and current research on post-traumatic osteoarthritis (PTOA) from 2010 to 2024 using bibliometric and visualization techniques.

METHODS

A bibliometric analysis was conducted using data from the Web of Science Core Collection. The study examined publication trends, author contributions, institutional collaborations, keyword co-occurrence, and citation patterns, employing CiteSpace software to analyze key metrics such as publication frequency, centrality, and clustering.

RESULTS

A total of 3100 articles were published between 2010 and 2024, with a steady increase over the years, peaking at 320 articles in 2023. Most publications were from the USA (1141 articles), China (502), and Germany (268), with key fields being Orthopedics, Surgery, and Rheumatology. Early research focused on different types of osteoarthritis, while recent studies highlight therapeutic advances such as cartilage repair and oxidative stress. Co-citation analysis identified influential authors like Lohmander LS, and key research clusters include total hip arthroplasty and regenerative medicine.

CONCLUSION

Over the past decade, PTOA research has expanded substantially, driven by contributions from Orthopedics and Surgery, and supported by growing international collaboration, particularly between the United States, China, and European countries. Future research directions should prioritize elucidating the molecular mechanisms underlying PTOA, advancing diagnostic methodologies, and developing innovative therapeutic approaches to improve patient outcomes. The interdisciplinary nature and international cooperation observed are essential to addressing the complex challenges posed by PTOA.

A reciprocal relationship between mitochondria and lipid peroxidation determines the chondrocyte intracellular redox environment

In orthopedic research, many studies have applied vitamin E as a protective antioxidant or used tert-butyl hydroperoxide to induce oxidative injury to chondrocytes. These studies often support the hypothesis that joint pathology causes oxidative stress and increased lipid peroxidation that might be prevented with lipid antioxidants to improve cell survival or function and joint health; however, lipid antioxidant supplementation was ineffective against osteoarthritis in clinical trials and animal data have been equivocal. Moreover, increased circulating vitamin E is associated with increased rates of osteoarthritis. This disconnect between benchtop and clinical results led us to hypothesize that oxidative stress-driven paradigms of chondrocyte redox function do not capture the metabolic and physiologic effects of lipid antioxidants and prooxidants on articular chondrocytes. We used ex vivo and in vivo cartilage models to investigate the effect of lipid antioxidants on healthy, primary, articular chondrocytes and applied immuno-spin trapping techniques to provide a broad indicator of high levels of oxidative stress independent of specific reactive oxygen species. Key findings demonstrate lipid antioxidants were pro-mitochondrial while lipid prooxidants decreased mitochondrial measures. In the absence of injury, radical formation was increased by lipid antioxidants; however, in the presence of injury, radical formation was decreased. In unstressed conditions, this relationship between chondrocyte mitochondria and redox regulation was reproduced in vivo with overexpression of glutathione peroxidase 4. In mice aged 18 months or more, overexpression of glutathione peroxidase 4 significantly decreased the presence of pro-mitochondrial peroxisome proliferation activated receptor gamma and deranged the relationship between mitochondria and the redox environment. This complex interaction suggests strategies targeting articular cartilage may benefit from adopting more nuanced paradigms of articular chondrocyte redox metabolism.

A New Method for Creating Impact-Induced Intra-Articular Fractures in a Rabbit Model Induces Severe Post-Traumatic Osteoarthritis

OBJECTIVES

The objective of this work was to develop a model of intra-articular fracture (IAF) in a rabbit and document the speed and severity of degenerative joint changes after fracture fixation.

METHODS

With Institutional Animal Care & Use Committee approval, impact-induced IAFs were created in the distal tibia of 16 New Zealand White rabbits. Fractures were fixed with a plate and screws. Pain and function were monitored at regular postoperative intervals with limb loading analysis. Twelve or 26 weeks after fracture, animals were euthanized for histological assessment of cartilage degeneration and micro-computed tomography analysis of bone histomorphometry.

RESULTS

Eleven animals successfully completed the study. Maximum foot force in the fractured limb was 41% ± 21% lower than preoperative values ( P = 0.006) 12 weeks after fracture and remained 25% ± 13% lower ( P = 0.081) after 26 weeks. Cortical bone mineral density in micro-computed tomography images was 34% ± 13% lower 12 weeks after fracture ( P < 0.001) and remained (42% ± 8%) lower 26 weeks after fracture ( P < 0.001). Twelve weeks after fracture, Mankin scores of cartilage degeneration were significantly higher in the medial talus ( P = 0.007), lateral talus ( P < 0.001), medial tibia ( P = 0.017), and lateral tibia ( P = 0.002) of the fractured limb compared with the uninjured contralateral limb. Average Mankin scores in the talus increased from 12 to 26 weeks (5.9 ± 0.9 to 9.4 ± 0.4; P < 0.001 lateral; 5.4 ± 1.8 to 7.8 ± 2.0; P = 0.043 medial), indicating substantial and progressive joint degeneration.

CONCLUSIONS

The ankle joint of the New Zealand White rabbit provides the smallest available model of impact-induced IAF that can be treated with clinically relevant techniques and replicates key features of healing and degeneration found in human patients.

The role of mitochondrial reactive oxygen species in chondrocyte mechanotransduction

Chondrocytes are mechanosensitive cells able to sense and respond to external mechanical stimuli through the process of mechanotransduction. Previous studies have demonstrated that mechanical stimulation causes mitochondrial deformation leading to mitochondrial reactive oxygen species (ROS) release in a dose-dependent manner. For this reason, we focused on elucidating the role of mitochondrial ROS as anabolic signaling molecules in chondrocyte mechanotransduction. Chondrocyte-seeded agarose gels were subjected to mechanical stimuli and the effect on matrix synthesis, ROS production, and mitogen-activated protein kinases (MAPK) signaling was evaluated. Through the use of ROS-specific staining, superoxide anion was the primary ROS released in response to mechanical stimuli. The anabolic effect of mechanical stimulation was abolished in the presence of electron transport chain inhibitors (complexes I, III, and V) and superoxide anion scavengers. Subsequent studies were centered on the involvement of MAPK pathways (ERK1/2, p38, and JNK) in the mechanotransduction cascade. While disruption of the ERK1/2 pathway had no apparent effect, the anabolic effect of mechanical stimulation was abolished in the presence of p38 and JNK pathway inhibitors. This suggest the involvement of apoptosis stimulating kinase 1 (ASK1), an upstream redox-sensitive MAP3K shared by both the JNK and p38 pathways. Future experiments will focus on the involvement of the thioredoxin-ASK1 complex which disassociates in the presence of oxidative stress, allowing ASK1 to phosphorylate several MAP2Ks. Overall, these findings indicate superoxide anion as the primary ROS released in response to mechanical stimuli and that the resulting anabolic effect on chondrogenic matrix biosynthesis arises from the ROS-dependent activation of the p38 and JNK MAPKs.

Endogenus chondrocytes immobilized by G-CSF in nanoporous gels enable repair of critical-size osteochondral defects

Injured articular cartilage is a leading cause for osteoarthritis. We recently discovered that endogenous stem/progenitor cells not only reside in the superficial zone of mouse articular cartilage, but also regenerated heterotopic bone and cartilage in vivo. However, whether critical-size osteochondral defects can be repaired by pure induced chemotatic cell homing of these endogenous stem/progenitor cells remains elusive. Here, we first found that cells in the superficial zone of articular cartilage surrounding surgically created 3 × 1 mm defects in explant culture of adult goat and rabbit knee joints migrated into defect-filled fibrin/hylaro1nate gel, and this migration was significantly more robust upon delivery of exogenous granulocyte-colony stimulating factor (G-CSF). Remarkably, G-CSF-recruited chondrogenic progenitor cells (CPCs) showed significantly stronger migration ability than donor-matched chondrocytes and osteoblasts. G-CSF-recruited CPCs robustly differentiated into chondrocytes, modestly into osteoblasts, and barely into adipocytes. In vivo, critical-size osteochondral defects were repaired by G-CSF-recruited endogenous cells postoperatively at 6 and 12 weeks in comparison to poor healing by gel-only group or defect-only group. ICRS and O'Driscoll scores of articular cartilage were significantly higher for both 6- and 12-week G-CSF samples than corresponding gel-only and defect-only groups. Thus, endogenous stem/progenitor cells may be activated by G-CSF, a Food and Drug Administration (FDA)-cleared bone-marrow stimulating factor, to repair osteochondral defects.

Inflammatory mechanisms in post-traumatic osteoarthritis: a role for CaMKK2

Post-traumatic osteoarthritis (PTOA) is a multifactorial disease of the cartilage, synovium, and subchondral bone resulting from direct joint trauma and altered joint mechanics after traumatic injury. There are no current disease-modifying therapies for PTOA, and early surgical interventions focused on stabilizing the joint do not halt disease progression. Chronic pain and functional disability negatively affect the quality of life and take an economic toll on affected patients. While multiple mechanisms are at play in disease progression, joint inflammation is a key contributor. Impact-induced mitochondrial dysfunction and cell death or altered joint mechanics after trauma culminate in inflammatory cytokine release from synoviocytes and chondrocytes, cartilage catabolism, suppression of cartilage anabolism, synovitis, and subchondral bone disease, highlighting the complexity of the disease. Current understanding of the cellular and molecular mechanisms underlying the disease pathology has allowed for the investigation of a variety of therapeutic strategies that target unique apoptotic and/or inflammatory processes in the joint. This review provides a concise overview of the inflammatory and apoptotic mechanisms underlying PTOA pathogenesis and identifies potential therapeutic targets to mitigate disease progression. We highlight Ca2+/calmodulin-dependent protein kinase kinase 2 (CaMKK2), a serine/threonine protein kinase that was recently identified to play a role in murine and human osteoarthritis pathogenesis by coordinating chondrocyte inflammatory responses and apoptosis. Given its additional effects in regulating macrophage inflammatory signaling and bone remodeling, CaMKK2 emerges as a promising disease-modifying therapeutic target against PTOA.

Posttraumatic osteoarthritis: from basic science to clinical implications

Posttraumatic osteoarthritis (PTOA) is a subset of osteoarthritis that occurs after joint injury and is associated with degradation of articular cartilage and subchondral bone. As compared with primary osteoarthritis, PTOA occurs in a time window initiated by a traumatic event resulting in damage to layers of joint structure and alterations in joint shape. As techniques in open reduction and internal fixation continue to mature, our success in preventing posttraumatic osteoarthritis has not kept pace. Advances in research in the subchondral bone, inflammatory response, and joint mechanics continue to open our understanding of this posttraumatic process. In addition, there are possibilities emerging as biological agents to therapeutically alter the progression of PTOA.

Injury-related cell death and proteoglycan loss in articular cartilage: Numerical model combining necrosis, reactive oxygen species, and inflammatory cytokines

Osteoarthritis (OA) is a common musculoskeletal disease that leads to deterioration of articular cartilage, joint pain, and decreased quality of life. When OA develops after a joint injury, it is designated as post-traumatic OA (PTOA). The etiology of PTOA remains poorly understood, but it is known that proteoglycan (PG) loss, cell dysfunction, and cell death in cartilage are among the first signs of the disease. These processes, influenced by biomechanical and inflammatory stimuli, disturb the normal cell-regulated balance between tissue synthesis and degeneration. Previous computational mechanobiological models have not explicitly incorporated the cell-mediated degradation mechanisms triggered by an injury that eventually can lead to tissue-level compositional changes. Here, we developed a 2-D mechanobiological finite element model to predict necrosis, apoptosis following excessive production of reactive oxygen species (ROS), and inflammatory cytokine (interleukin-1)-driven apoptosis in cartilage explant. The resulting PG loss over 30 days was simulated. Biomechanically triggered PG degeneration, associated with cell necrosis, excessive ROS production, and cell apoptosis, was predicted to be localized near a lesion, while interleukin-1 diffusion-driven PG degeneration was manifested more globally. Interestingly, the model also showed proteolytic activity and PG biosynthesis closer to the levels of healthy tissue when pro-inflammatory cytokines were rapidly inhibited or cleared from the culture medium, leading to partial recovery of PG content. The numerical predictions of cell death and PG loss were supported by previous experimental findings. Furthermore, the simulated ROS and inflammation mechanisms had longer-lasting effects (over 3 days) on the PG content than localized necrosis. The mechanobiological model presented here may serve as a numerical tool for assessing early cartilage degeneration mechanisms and the efficacy of interventions to mitigate PTOA progression.

In Vitro Models and Proteomics in Osteoarthritis Research

This review summarizes and exemplifies the current understanding of osteoarthritis in vitro models and describes their relevance for new insights in the future of osteoarthritis research. Our friend and highly appreciated colleague, Prof. Alan Grodzinsky has contributed greatly to the understanding of joint tissue biology and cartilage biomechanics. He frequently utilizes in vitro models and cartilage explant cultures, and recent work also includes proteomics studies. This review is dedicated to honor his 75-year birthday and will focus on recent proteomic in vitro studies related to osteoarthritis, and within this topic highlight some of his contributions to the field.

Multiscale In Silico Modeling of Cartilage Injuries

Injurious loading of the joint can be accompanied by articular cartilage damage and trigger inflammation. However, it is not well-known which mechanism controls further cartilage degradation, ultimately leading to post-traumatic osteoarthritis. For personalized prognostics, there should also be a method that can predict tissue alterations following joint and cartilage injury. This chapter gives an overview of experimental and computational methods to characterize and predict cartilage degradation following joint injury. Two mechanisms for cartilage degradation are proposed. In (1) biomechanically driven cartilage degradation, it is assumed that excessive levels of strain or stress of the fibrillar or non-fibrillar matrix lead to proteoglycan loss or collagen damage and degradation. In (2) biochemically driven cartilage degradation, it is assumed that diffusion of inflammatory cytokines leads to degradation of the extracellular matrix. When implementing these two mechanisms in a computational in silico modeling workflow, supplemented by in vitro and in vivo experiments, it is shown that biomechanically driven cartilage degradation is concentrated on the damage environment, while inflammation via synovial fluid affects all free cartilage surfaces. It is also proposed how the presented in silico modeling methodology may be used in the future for personalized prognostics and treatment planning of patients with a joint injury.

Identifying small molecules for protecting chondrocyte function and matrix integrity after controlled compressive injury

Objective

Articular cartilage injury is central for the development of post-traumatic osteoarthritis (PTOA). With few disease-modifying therapies successful at offsetting progressive osteoarthritis (OA), our goal is to use a high throughput screening platform of cartilage injury to identify novel chondroprotective compounds. Targeting articular cartilage damage immediately after injury remains a promising therapeutic strategy to overcome irreversible tissue damage.

Method

We constructed a single impact-cartilage screening method using a multi-platen system that simultaneously impacts 48 samples and makes use of engineered cartilage tissue analogs (known as CTAs). Drug libraries were screened and assessed for their ability to alter two crucial biological responses to impact injuries, namely matrix degradation and cell stress.

Results

Over 500 small molecules were screened for their ability to alter proteoglycan loss, matrix metalloproteinase activity, and cell stress or death. Fifty-five compounds passed through secondary screening and were from commercial libraries of natural and redox, stem cell related compounds, as well as protease, kinase and phosphatase inhibitors. Through secondary screening, 16 promising candidates exhibited activity on one or more critical function of chondrocytes. While many are mechanistically known compounds, their function in joint diseases is not known.

Conclusion

This platform was validated for screening drug activity against a tissue engineered model of PTOA. Multiple compounds identified in this manner have potential application as early protective therapy for treating PTOA, and require further study. We propose this screening platform can identify novel molecules that act on early chondrocyte responses to injury and provide an invaluable tool for therapeutic development.

Extracellular biomolecular free radical formation during injury

Determine if oxidative damage increases in articular cartilage as a result of injury and matrix failure and whether modulation of the local redox environment influences this damage. Osteoarthritis is an age associated disease with no current disease modifying approaches available. Mechanisms of cartilage damage in vitro suggest tissue free radical production could be critical to early degeneration, but these mechanisms have not been described in intact tissue. To assess free radical production as a result of traumatic injury, we measured biomolecular free radical generation via immuno-spin trapping (IST) of protein/proteoglycan/lipid free radicals after a 2 J/cm² impact to swine articular cartilage explants. This technique allows visualization of free radical formation upon a wide variety of molecules using formalin-fixed, paraffin-embedded approaches. Scoring of extracellular staining by trained, blinded scorers demonstrated significant increases with impact injury, particularly at sites of cartilage cracking. Increases remain in the absence of live chondrocytes but are diminished; thus, they appear to be a cell-dependent and -independent feature of injury. We then modulated the extracellular environment with a pulse of heparin to demonstrate the responsiveness of the IST signal to changes in cartilage biology. Addition of heparin caused a distinct change in the distribution of protein/lipid free radicals at sites of failure alongside a variety of pertinent redox changes related to osteoarthritis. This study directly confirms the production of biomolecular free radicals from articular trauma, providing a rigorous characterization of their formation by injury.

Maturation- and degeneration-dependent articular cartilage metabolism via optical redox ratio imaging

From the two metabolic processes in healthy cartilage, glycolysis has been associated with proliferation and oxidative phosphorylation (oxphos) with matrix synthesis. Recently, metabolic dysregulation was significantly correlated with cartilage degradation and osteoarthritis progression. While these findings suggest maturation predisposes cartilage to metabolic instability with consequences for tissue maintenance, these links have not been shown. Therefore, this study sought to address three hypotheses (a) chondrocytes exhibit differential metabolic activity between immaturity (0-4 months), adolescence (5-18 months), and maturity (>18 months); (b) perturbation of metabolic activity has consequences on expression of genes pertinent to cartilage tissue maintenance; and (c) severity of cartilage damage is positively correlated with glycolysis and oxphos activity as well as optical redox ratio in postadolescent cartilage. Porcine femoral cartilage samples from pigs (3 days to 6 years) underwent optical redox ratio imaging, which measures autofluorescence of NAD(P)H and FAD. Gene expression analysis and histological scoring was conducted for comparison against imaging metrics. NAD(P)H and FAD autofluorescence both demonstrated increasing intensity with age, while optical redox ratio was lowest in adolescent samples compared to immature or mature samples. Inhibition of glycolysis suppressed expression of Col2, Col1, ADAMTS4, and ADAMTS5, while oxphos inhibition had no effect. FAD fluorescence and optical redox ratio were positively correlated with histological degeneration. This study demonstrates maturation- and degeneration-dependent metabolic activity in cartilage and explores the consequences of this differential activity on gene expression. This study aids our basic understanding of cartilage biology and highlights opportunity for potential diagnostic applications.

Effectiveness of Clinical-Grade Chondroitin Sulfate and Ascorbic Acid in Mitigating Cryoprotectant Toxicity in Porcine Articular Cartilage

High concentrations of cryoprotective agents (CPAs) are required to achieve successful vitrification of articular cartilage; however, CPA cytotoxicity causes chondrocyte death. To reduce CPA toxicity, supplementation with research-grade additives, in particular chondroitin sulfate (CS) and ascorbic acid (AA), have previously been shown to improve chondrocyte recovery and metabolic function after exposure to CPAs at hypothermic conditions. However, it is necessary to evaluate the pharmaceutical equivalent clinical grade of these additives to facilitate the supplementation of additives into future vitrification protocols, which will be designed for vitrifying human articular cartilage in tissue banks. We sought to investigate the effectiveness of clinical-grade CS, AA, and N-acetylcysteine (NAC) in mitigating toxicity to chondrocytes during CPA exposure and removal, and determine whether a combination of two additives would further improve chondrocyte viability. We hypothesized that clinical-grade additives would exert chondroprotective effects comparable to those of research-grade additives, and that this protective effect would be enhanced if two additives were combined when compared with a single additive. The results indicated that both clinical-grade and research-grade additives significantly improved cell viability (p < 0.10) compared with the negative control (CPA with no additives). CS, AA, and NAC+AA increased cell viability significantly (p < 0.10) compared with the negative control. However, NAC, NAC+CS, and CS+AA did not improve cell viability when compared with the negative control (p > 0.10). We demonstrated that supplementation with clinical-grade CS or AA significantly improved chondrocyte viability in porcine cartilage subjected to high CPA concentrations, whereas supplementation with clinical-grade NAC did not benefit chondrocyte viability. Supplementation with clinical-grade additives in CPA solutions can mitigate CPA toxicity, which will be important in translating previously developed effective protocols for the vitrification of articular cartilage to human tissue banks.

Is interleukin-17 implicated in early knee osteoarthritis pathogenesis as in rheumatoid arthritis?

Background

Interleukin-17 (IL-17) is a cytokine that promotes activation of multiple catabolic pathways resulting in cartilage and tissue damage. It has features making it increasingly attractive as a biological marker, especially in rheumatoid arthritis (RA) and osteoarthritis (OA). However, its expression is heterogeneous; not all patients’ exhibit high IL-17 levels, and its level along the disease course is still challenging to predict.

Aim of the work

The objectives of this study were to compare serum IL-17 levels in patients with early knee OA and in RA patients, to determine its correlation with disease activity in RA and to determine if it is correlated with functional scores in both RA and OA.

Subjects and methods

Twenty early knee OA patients (32.7 ± 3.7) years were included. Diagnosis of early OA was based on Luyten et al. 2012 early knee OA classification (early OA 2012). This study also included 25 RA patients aged 32.8 ± 5.1 years, and the diagnosis was according to 2010 ACR-EULAR classification criteria for RA. The current work also included a control group of 20 healthy volunteers aged 31.9 ± 3.2 years. The serum IL-17 level was assessed by using the ELISA technique.

Results

Serum IL-17 level was significantly high in early knee OA patients (5.2 pg/ml) and was significantly higher in RA patients (5.9 pg/ml) compared to the control group (4.9 pg/ml) (P < 0.001).

Conclusions

The increased serum IL-17 level in patients with early knee OA suggests its pathogenic role in the disease. Serum IL-17 positive correlation with the severity of knee OA-related pain proposes that it may be a potential marker to target for early treatment of knee OA-related pain.

Automated quantification of live articular chondrocyte fluorescent staining using a custom image analysis framework

The goal of this study was to develop, validate, and implement an image analysis framework to automatically analyze chondrocytes in 3D image stacks of cartilage acquired using a fluorescent confocal microscope. Source specimens consist of viable osteochondral tissue co-stained with multiple live-cell dyes. Our framework utilizes a seeded watershed-based algorithm to automatically segment individual chondrocytes in each 2D slice of the confocal image stack. The resulting cell segmentations are colocalized in 3D to eliminate duplicate segmentation of the same cell resulting from the visibility of fluorescence signal in multiple imaging planes, and the 3D cell distribution is used to automatically define the cartilage tissue volume. The algorithm then provides chondrocyte density data, and the associated segmentation can be used as a mask to extract and quantify per cell intensity of a secondary, functional dye co-staining the chondrocytes. The accuracy of the automated chondrocyte segmentation was validated against manual segmentations (average IOU = 0.79). When applied to a cartilage surrogate, this analysis framework estimated chondrocyte density within 10% of the true density and demonstrated a good agreement between framework's counts and manual counts (R²  = 0.99). In a real application, the framework was able to detect the increased dye signal of monochlorobimane (MCB) in chondrocytes treated with N-acetylcysteine (NAC) after mechanical injury, quantifying intracellular biochemical changes in living cells. This new framework allows for fast and accurate quantification of intracellular activities of chondrocytes, and it can be adapted for broader application in many imaging and treatment modalities, including therapeutic OA research.

Migrating Progenitor Cells Derived From Injured Cartilage Surface Respond to Damage-Associated Molecular Patterns

OBJECTIVE

To delineate the response of migrating chondrogenic progenitor cells (CPCs) that arose from the surface of mechanically injured articular cartilage to proinflammatory damage-associated-molecular-patterns (DAMPs).

DESIGN

Bovine CPCs and non-CPC chondrocytes isolated from either impacted or scratched articular cartilage were studied. Those 2 types of cells were treated with mitochondrial DAMPs (MTDs; 10 nM fMLF and 10 µg/mL CpG DNA), or 10 nM HMGB1, or 10 ng/mL IL-1b for 24 hours. At the end of experiments, conditioned media and cell lysates were collected for analysis of expression levels of matrix metalloproteinases (MMPs), chemokines, and cytokines that are associated with cartilage degeneration with Western blotting and quantitative polymerase chain reaction. The difference of expression levels was compared by Welch's t-test.

RESULTS

Our data indicated that HMGB1 and MTDs remarkably upregulated pro-MMP-13 expression in CPCs. Compared with non-CPCs, CPCs expressed significantly more baseline mRNAs of MMP-13, CXCL12, and IL-6. MTDs greatly increased the expression of MMP-13 and IL-6 in CPCs by over 100-fold (P < 0.001). MTDs also significantly increased IL-8 expression in CPCs to a similar extent (P < 0.001). However, when IL-1b was present, CPCs expressed less MMP-3 and active MMP-13 proteins as well as less CCL2 and IL-6 than did non-CPCs.

CONCLUSIONS

We concluded that CPCs were more sensitive than non-CPCs in response to DAMPs, especially MTDs. The proinflammatory nature of CPCs implied their critical role in the early phase of posttraumatic osteoarthritis development.

Anti-inflammatory effects of tibial axial loading on knee articular cartilage post traumatic injury

Early therapeutic intervention to mitigate inflammatory responses following joint injury may offer a potential strategy to prevent post-traumatic osteoarthritis (PTOA). In-vitro studies have demonstrated uniaxial dynamic compression mitigates the catabolic and apoptotic responses of articular cartilage (AC) in response to mechanical injury. The objectives of this study were (1) to develop a custom device that can apply dynamic tibial axial loading (TAL) to knee AC by mimicking therapeutic, in-vitro loading conditions and (2) to investigate the potential of TAL to reduce the inflammatory response of AC post traumatic acute joint injury using an ex-vivo porcine model. A TAL device was fabricated to apply dynamic compressive loading to knee AC by combining tibial axial compressive loading with continuous passive motion. Computational analyses demonstrated that the loading condition applied to the knee by the TAL device closely simulate uniaxial dynamic compression reported in previous in-vitro studies. Following single impact injury, injured porcine knees were subjected to TAL with a magnitude of 1/4 body weight at a frequency of 1 Hz for 30 min. AC samples were harvested 8 h post injury for analysis of pro-inflammatory cytokine expression (IL-1β and TNF-α). Expression of both cytokines was upregulated following injury; however, the change was notably mitigated in the specimens subjected to TAL. Thus, TAL may be an effective and potentially, practical-to-administer early intervention strategy to mitigate rapidly occurring detrimental events following acute AC injury, potentially slowing down progression to PTOA.

Intra-Articular Adeno-Associated Virus-Mediated Proteoglycan 4 Gene Therapy for Preventing Post-Traumatic Osteoarthritis

OBJECTIVE

Lubricin, a glycoprotein encoded by the proteoglycan 4 (PRG4) gene, is an essential boundary lubricant that reduces friction between articular cartilage surfaces. The loss of lubricin subsequent to joint injury plays a role in the pathogenesis of post-traumatic osteoarthritis (PTOA). Here we describe the development and evaluation of an adeno-associated virus (AAV)-based PRG4 gene therapy intended to restore lubricin in injured joints. The green fluorescent protein (GFP) gene was inserted the PRG4 gene to facilitate tracing the distribution of the transgene product (AAV-PRG4-GFP) in vivo.

METHODS

Transduction efficiency of AAV-PRG4-GFP was evaluated in joint cells, and the conditioned medium containing secreted PRG4-GFP was used for shear loading/friction and viability tests. In vivo transduction of joint tissues following intra-articular injection of AAV-PRG4-GFP was confirmed in the mouse stifle joint in a surgical model of destabilization of the medial meniscus (DMM), and chondroprotective activity was tested in a rabbit anterior cruciate ligament transection (ACLT) model.

RESULTS

In vitro studies showed that PRG4-GFP has lubricin-like cartilage binding and anti-friction properties. Significant cytoprotective effects were seen when cartilage was soaked in PRG4-GFP prior to cyclic shear loading (n = 3). Polymerase chain reaction and confocal microscopy confirmed the presence of PRG4-GFP DNA and protein, respectively, in a mouse DMM (n = 3 per group). In the rabbit ACLT model, AAV-PRG4-GFP gene therapy enhanced lubricin expression (p = 0.001 versus AAV-GFP: n = 7-14) and protected the cartilage from degeneration (p = 0.014 versus AAV-GFP: n = 9-10) when treatments were administered immediately post-operation, but efficacy was lost when treatment was delayed for 2 weeks.

CONCLUSION

AAV-PRG4-GFP gene therapy protected cartilage from degeneration in a rabbit ACLT model; however, data from the ACLT model suggest that early intervention is essential for efficacy.

Mechanisms linking mitochondrial mechanotransduction and chondrocyte biology in the pathogenesis of osteoarthritis

Mechanical loading is essential for chondrocyte health. Chondrocytes can sense and respond to various extracellular mechanical signals through an integrated set of mechanisms. Recently, it has been found that mitochondria, acting as critical mechanotransducers, are at the intersection between extracellular mechanical signals and chondrocyte biology. Much attention has been focused on identifying how mechanical loading-induced mitochondrial dysfunction contributes to the pathogenesis of osteoarthritis. In contrast, little is known regarding the mechanisms underlying functional alterations in mitochondria induced by mechanical stimulation. In this review, we describe how chondrocytes perceive environmental mechanical signals. We discuss how mechanical load induces mitochondrial functional alterations and highlight the major unanswered questions in this field. We speculate that AMP-activated protein kinase (AMPK), a master regulator of energy homeostasis, may play an important role in coupling force transmission to mitochondrial health and intracellular biological responses.

Chondrocytes respond both anabolically and catabolically to impact loading generally considered non-injurious

We aimed to determine the longitudinal effects of low-energy (generally considered non-injurious) impact loading on (1) chondrocyte proliferation, (2) chondroprogenitor cell activity, and (3) EGFR signaling. In an in vitro study, we assessed 127 full-thickness, cylindrical osteochondral plugs of bovine cartilage undergoing either single, uniaxial unconfined impact loads with energy densities in the range of 1.5-3.2mJ/mm³ or no impact (controls). We quantified cell responses at two, 24, 48, and 72 h via immunohistochemical labeling of Ki67, Sox9, and pEGFR antibodies. We compared strain, stress, and impact energy density as predictors for mechanotransductive responses from cells, and fit significant correlations using linear regressions. Our study demonstrates that low-energy mechanical impacts (1.5-3.2mJ/mm³) generally stimulate time-dependent anabolic responses in the superficial zone of articular cartilage and catabolic responses in the middle and deep zones. We also found that impact energy density is the most consistent predictor of cell responses to low-energy impact loading. These spatial and temporal changes in chondrocyte behavior result directly from low-energy mechanical impacts, revealing a new level of mechanotransductive sensitivity in chondrocytes not previously appreciated.

Mitochondrial dysfunction triggers a catabolic response in chondrocytes via ROS-mediated activation of the JNK/AP1 pathway

Mitochondrial function is impaired in osteoarthritis (OA) but its impact on cartilage catabolism is not fully understood. Here, we investigated the molecular mechanism of mitochondrial dysfunction-induced activation of the catabolic response in chondrocytes. Using cartilage slices from normal and OA cartilage, we showed that mitochondrial membrane potential was lower in OA cartilage, and that this was associated with increased production of mitochondrial superoxide and catabolic genes [interleukin 6 (IL-6), COX-2 (also known as PTGS2), MMP-3, -9, -13 and ADAMTS5]. Pharmacological induction of mitochondrial dysfunction in chondrocytes and cartilage explants using carbonyl cyanide 3-chlorophenylhydrazone increased mitochondrial superoxide production and the expression of IL-6, COX-2, MMP-3, -9, -13 and ADAMTS5, and cartilage matrix degradation. Mitochondrial dysfunction-induced expression of catabolic genes was dependent on the JNK (herein referring to the JNK family)/activator protein 1 (AP1) pathway but not the NFκB pathway. Scavenging of mitochondrial superoxide with MitoTEMPO, or pharmacological inhibition of JNK or cFos and cJun, blocked the mitochondrial dysfunction-induced expression of the catabolic genes in chondrocytes. We demonstrate here that mitochondrial dysfunction contributes to OA pathogenesis via JNK/AP1-mediated expression of catabolic genes. Our data shows that AP1 could be used as a therapeutic target for OA management.This article has an associated First Person interview with the first author of the paper.

Iatrogenic Articular Cartilage Injury in Arthroscopic Hip and Knee Videos and the Potential for Cartilage Cell Death When Simulated in a Bovine Model

PURPOSE

To determine the incidence and characterize the severity of iatrogenic cartilage injuries.

METHODS

Technique videos of arthroscopic femoral acetabular impingement procedures and meniscus repairs on VuMedi (n = 85) and Arthroscopy Techniques (n = 45) were reviewed and iatrogenic cartilage injuries were identified and graded (minor, intermediate, and major injury) by 2 independent reviewers. To demonstrate that even minor injuries on a cellular scale result in damage, a bovine osteochondral explant was used to create comparable minor iatrogenic injuries at varied forces that do not disrupt the articular surface (1.5 N, 2.5 N, and 9.8 N). Dead chondrocytes at the site of injury were stained with ethidium homodimer-2 and imaged with an Olympus FV1000 confocal microscope. χ² tests were used for analysis; all results with P < .05 were considered significant.

RESULTS

In total, 130 videos of arthroscopic meniscus and femoral acetabular impingement procedures were analyzed and the incidence of iatrogenic cartilage injury was 73.8%. There were 110 (70.0%) minor, 35 (22.3%) intermediate, and 11 (7.0%) major iatrogenic injuries. All forces tested in the minor injury bovine model resulted in chondrocyte death at the site of contact.

CONCLUSIONS

Iatrogenic articular cartilage injuries are common in arthroscopy, occurring in more than 70% of the surgeon-published instructional videos analyzed. At least some chondrocyte death occurs with minor simulated iatrogenic injuries (1.5 N).

CLINICAL RELEVANCE

The high rate of cartilage damage during arthroscopic technique videos likely under-represents the true incidence in clinical practice. Cell death occurs in the bovine minor injury model with minimal contact forces. This suggests iatrogenic cartilage damage during arthroscopy could contribute to clinical outcomes.

Pathomechanisms of Posttraumatic Osteoarthritis: Chondrocyte Behavior and Fate in a Precarious Environment

Traumatic injuries of the knee joint result in a wide variety of pathomechanisms, which contribute to the development of so-called posttraumatic osteoarthritis (PTOA). These pathogenetic processes include oxidative stress, excessive expression of catabolic enzymes, release of damage-associated molecular patterns (DAMPs), and synovial inflammation. The present review focuses on the underlying pathomechanisms of PTOA and in particular the behavior and fate of the surviving chondrocytes, comprising chondrocyte metabolism, regulated cell death, and phenotypical changes comprising hypertrophy and senescence. Moreover, possible therapeutic strategies, such as chondroanabolic stimulation, anti-oxidative and anti-inflammatory treatment, as well as novel therapeutic targets are discussed.

Manganese dioxide nanoparticles protect cartilage from inflammation-induced oxidative stress

Oxidative stress has been implicated in the pathogenesis of osteoarthritis and has become an important therapeutic target. Investigations of various antioxidant supplements, reactive oxidative species (ROS) pathway mediators, and free radical scavengers for treating osteoarthritis have demonstrated common disadvantages including poor bioavailability and stability, as well as rapid joint clearance or release profiles from delivery vehicles. Moreover, these therapies do not target cartilage, which irreversibly degenerates in the presence of oxidative stress. The goal of this study was to engineer a nanoparticle system capable of sustained retention in the joint space, localization to cartilage, and mitigation of oxidative stress. Towards this goal, ROS scavenging manganese dioxide nanoparticles with physicochemical properties (less than 20 nm and cationic) that facilitate their uptake into cartilage were developed and characterized. These particles penetrated through the depth of cartilage explants and were found both in the extracellular matrix as well as intracellularly within the resident chondrocytes. Furthermore, the particles demonstrated chondroprotection of cytokine-challenged cartilage explants by reducing the loss of glycosaminoglycans and release of nitric oxide. Quantitative PCR analysis revealed that the particles mitigated impacts of oxidative stress related genes in cytokine-challenged chondrocytes. When injected intra-articularly into rats, the particles persisted in the joint space over one week, with 75% of the initial signal remaining in the joint. Biodistribution and histological analysis revealed accumulation of particles at the chondral surfaces and colocalization of the particles with the lacunae of chondrocytes. The results suggest that the manganese dioxide nanoparticles could be a promising approach for the chondroprotection of osteoarthritic cartilage.

Real-time optical redox imaging of cartilage metabolic response to mechanical loading

OBJECTIVE

Metabolic dysregulation has recently been identified as a key feature of osteoarthritis. Mechanical overloading has been postulated as a primary cause of this metabolic response. Current methods of real-time metabolic activity analysis in cartilage are limited and challenging. However, optical redox imaging leverages the autofluorescence of co-enzymes NAD(P)H and FAD to provide dye-free real-time analysis of metabolic activity. This technique has not yet been applied to cartilage. This study aimed to assess the effects of a compressive load on cartilage using optical redox imaging.

METHOD

Cartilage samples were excised from porcine femoral condyles. To validate this imaging modality in cartilage, glycolysis was inhibited via 2-deoxy-D-glucose (2DG) and oxidative phosphorylation was inhibited by rotenone. Optical redox images were collected pre- and post-inhibition. To assess the effects of mechanical loading, samples were subjected to a compressive load and imaged for approximately 30 min. Load and strain parameters were determined using high-speed camera images in Matlab. A range of loading magnitudes and rates were applied across samples.

RESULTS

2DG and rotenone demonstrated the expected inhibitory effects on fluorescence intensity in the channels corresponding to NAD(P)H and FAD, respectively. Mechanical loading induced an increase in NAD(P)H channel fluorescence which subsided by 30 min post-loading. Magnitude of loading parameters had mixed effects on metabolites.

CONCLUSIONS

Optical redox imaging provides an opportunity to assess real-time metabolic activity in cartilage. This approach revealed a metabolic response to a single load and can be used to provide insight into the role of metabolism in mechanically-mediated cartilage degradation.

Targeting mitochondrial responses to intra-articular fracture to prevent posttraumatic osteoarthritis

We tested whether inhibiting mechanically responsive articular chondrocyte mitochondria after severe traumatic injury and preventing oxidative damage represent a viable paradigm for posttraumatic osteoarthritis (PTOA) prevention. We used a porcine hock intra-articular fracture (IAF) model well suited to human-like surgical techniques and with excellent anatomic similarities to human ankles. After IAF, amobarbital or N-acetylcysteine (NAC) was injected to inhibit chondrocyte electron transport or downstream oxidative stress, respectively. Effects were confirmed via spectrophotometric enzyme assays or glutathione/glutathione disulfide assays and immunohistochemical measures of oxidative stress. Amobarbital or NAC delivered after IAF provided substantial protection against PTOA at 6 months, including maintenance of proteoglycan content, decreased histological disease scores, and normalized chondrocyte metabolic function. These data support the therapeutic potential of targeting chondrocyte metabolism after injury and suggest a strong role for mitochondria in mediating PTOA.

Prevention of post-traumatic osteoarthritis after intra-articular knee fractures using hyaluronic acid: a randomized prospective pilot study

PURPOSE

Based on the irreversible destruction of hyaline cartilage, post-traumatic osteoarthritis (PTOA) is a notorious sequelae after intra-articular knee fractures. This study evaluates the clinical efficacy and applicability of immediate post-operative intra-articular injection of hyaluronic acid (IA HA) into the knee joint with an intra-articular fracture.

METHODS

Prospective randomized case-control study involving 40 patients (20 in each group) with intra-articular knee fracture with an average follow-up of 23 months (range 18-24 months). Twenty patients with intra-articular distal femoral or intra-articular proximal tibial fractures who met our inclusion criteria received three intra-articular hyaluronic acid injections weekly starting immediately after ORIF. Another 20 patients serving as a control group received no injection after ORIF. Patients were assessed functionally with Knee injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee (IKDC) score. Plain X-rays and when indicated CT scans were used to assess radiological union.

RESULTS

The results showed patients treated with intra-articular hyaluronic acid injection after fixation had significantly less pain (KOOS) (p = 0.01). No significant difference was found between both groups in other KOOS-related outcome measures, complications, functional outcome, or quality of life.

CONCLUSIONS

These preliminary results support a direct role for hyaluronic acid in the acute phase of the inflammatory process that follows articular injury and provides initial evidence for the efficacy of IA HA.

Osteoarthritis year in review 2018: biology

This Year in Review highlights a selection of articles published between the 2017 and 2018 Osteoarthritis Research Society International (OARSI) World Congress meetings within the field of osteoarthritis biology, presented at OARSI 2018. Selected articles were obtained from a PubMed search covering cartilage, subchondral bone, inflammation, ageing, pain and animal models. Studies focused on biomechanics, biomarkers, genetics and epigenetics, imaging and clinical studies were excluded due to their coverage in other articles within the OARSI Year in Review series. Significant themes including the role of progenitor cells in cartilage homeostasis and repair, novel signalling mechanisms controlling chondrocyte phenotypic stability and the influence of disrupted or senescent chondrocytes were identified and are discussed in this review. Overarching conclusions derived from these study areas indicate that promising avenues of intervention are on the horizon, however further understanding is required in order to target therapeutic treatments to suitable patient subgroups and disease stages.

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.

Altered kinematics after anterior cruciate ligament reconstruction, and their role in the prevention of osteoarthritis

Background/Aims:

Anterior cruciate ligament injury is common, and anterior cruciate ligament reconstruction has become the standard of care that aims to restore knee stability, return to activity, and prevent secondary injury.

Methods:

A literature review was carried out using PubMed and Science Direct databases from 1998 through 2017. Search terms included: anterior cruciate ligament reconstruction and knee osteoarthritis; kinematics after anterior cruciate ligament reconstruction; and prevention of knee osteoarthritis. A total of 356 studies matched the search terms. After removing duplicates and any studies that were not relevant, 73 studies remained.

Findings:

Individuals usually have impaired neuromuscular control after reconstruction, and abnormal biomechanical patterns may lead to loading of cartilage areas that are not commonly loaded and that, longitudinally, can lead to osteoarthritis. The knee adduction moment indicates loading of the knee joint and has been associated with the development of osteoarthritis and altered gait mechanics have also been implicated in the increased rate of osteoarthritis after anterior cruciate ligament reconstruction, including differences in tibial rotation during walking. Furthermore, altered ankle joint mechanics may be the result of deviations in ankle joint alignment secondary to the structural changes at the knee. It is clear that abnormal mechanical stimulation may cause dysfunction of articular chondrocytes and breakdown of cartilage extracellular matrix, leading to articular cartilage degradation and chondrocyte death. The affected joint will progress to post-traumatic osteoarthritis.

Conclusions:

The restoration of normal knee anatomy and mechanics, such as returning the joint to normal function, improving muscle strength, functional movement prevention programmes, restoring gait symmetry and weight management are recommended.

Biomechanics of osteochondral impact with cushioning and graft Insertion: Cartilage damage is correlated with delivered energy

Articular cartilage is susceptible to impact injury. Impact may occur during events ranging from trauma to surgical insertion of an OsteoChondral Graft (OCG) into an OsteoChondral Recipient site (OCR). To evaluate energy density as a mediator of cartilage damage, a specialized drop tower apparatus was used to impact adult bovine samples while measuring contact force, cartilage surface displacement, and OCG advancement. When a single impact was applied to an isolated (non-inserted) OCG, force and surface displacement each rose monotonically and then declined. In each of five sequential impacts of increasing magnitude, applied to insert an OCG into an OCR, force rose rapidly to an initial peak, with minimal OCG advancement, and then to a second prolonged peak, with distinctive oscillations. Energy delivered to cartilage was confirmed to be higher with larger drop height and mass, and found to be lower with an interposed cushion or OCG insertion into an OCR. For both single and multiple impacts, the total energy density delivered to the articular cartilage correlated to damage, quantified as total crack length. The corresponding fracture toughness of the articular cartilage was 12.0 mJ/mm². Thus, the biomechanics of OCG insertion exhibits distinctive features compared to OCG impact without insertion, with energy delivery to the articular cartilage being a factor highly correlated with damage.

Mitoprotective therapy preserves chondrocyte viability and prevents cartilage degeneration in an ex vivo model of posttraumatic osteoarthritis

No disease-modifying osteoarthritis (OA) drugs are available to prevent posttraumatic osteoarthritis (PTOA). Mitochondria (MT) mediate the pathogenesis of many degenerative diseases, and recent evidence indicates that MT dysfunction is a peracute (within minutes to hours) response of cartilage to mechanical injury. The goal of this study was to investigate cardiolipin-targeted mitoprotection as a new strategy to prevent chondrocyte death and cartilage degeneration after injury. Cartilage was harvested from bovine knee joints and subjected to a single, rapid impact injury (24.0 ±1.4 MPa, 53.8 ± 5.3 GPa/s). Explants were then treated with a mitoprotective peptide, SS-31 (1µM), immediately post-impact, or at 1, 6, or 12 h after injury, and then cultured for up to 7 days. Chondrocyte viability and apoptosis were quantified in situ using confocal microscopy. Cell membrane damage (lactate dehydrogenase activity) and cartilage matrix degradation (glycosaminoglycan loss) were quantified in cartilage-conditioned media. SS-31 treatment at all time points after impact resulted in chondrocyte viability similar to that of un-injured controls. This effect was sustained for up to a week in culture. Further, SS-31 prevented impact-induced chondrocyte apoptosis, cell membrane damage, and cartilage matrix degeneration.

CLINICAL SIGNIFICANCE

This study is the first investigation of cardiolipin-targeted mitoprotective therapy in cartilage. These results suggest that even when treatment is delayed by up to 12 h after injury, mitoprotection may be a useful strategy in the prevention of PTOA. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 9999:1-10, 2018.

Mitochondrial dysfunction is an acute response of articular chondrocytes to mechanical injury

Mitochondrial (MT) dysfunction is known to occur in chondrocytes isolated from end-stage osteoarthritis (OA) patients, but the role of MT dysfunction in the initiation and early pathogenesis of post-traumatic OA (PTOA) remains unclear. The objective of this study was to investigate chondrocyte MT function immediately following mechanical injury in cartilage, and to determine if the response to injury differed between a weight bearing region (medial femoral condyle; MFC) and a non-weight bearing region (distal patellofemoral groove; PFG) of the same joint. Cartilage was harvested from the MFC and PFG of 10 neonatal bovids, and subjected to injurious compression at varying magnitudes (5-17 MPa, 5-34 GPa/s) using a rapid single-impact model. Chondrocyte MT respiratory function, MT membrane polarity, chondrocyte viability, and cell membrane damage were assessed in situ. Cartilage impact resulted in MT depolarization and impaired MT respiratory function within 2 h of injury. Cartilage from a non-weight bearing region of the joint (PFG) was more sensitive to impact-induced MT dysfunction and chondrocyte death than cartilage from a weight-bearing surface (MFC). Our findings suggest that MT dysfunction is an acute response of chondrocytes to cartilage injury, and that MT may play a key mechanobiological role in the initiation and early pathogenesis of PTOA.

CLINICAL SIGNIFICANCE

Direct therapeutic targeting of MT function in the early post-injury time frame may provide a strategy to block perpetuation of tissue damage and prevent the development of PTOA. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:739-750, 2018.

Comparison of Intra-articular Injection of Hyaluronic Acid and N-Acetyl Cysteine in the Treatment of Knee Osteoarthritis: A Pilot Study

Objective To compare the relative effectiveness of intra-articular N-acetyl cysteine (NAC) and hyaluronic acid (HA) on pain, function and cartilage degradation markers in patients with mild to moderate knee osteoarthritis (OA). Design We prospectively conducted a clinical trial with 20 patients having a diagnosis of Kellgren-Lawrence grade 2-3 knee OA, and randomly allocated to the HA or NAC groups. Groups were matched on age, sex, and body mass index. Injections of 3-mL HA (Hylan G-F 20) or 3-mL NAC (Asist ampoule) were administered as a single shot. Functional status and pain were evaluated before and after injection, using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and the visual analogue scale (VAS) scores. Pre- and posttreatment concentrations of serum C-reactive protein (CRP), synovial fluid chondroitin-6-sulfate (C-6S), matrix metalloproteinase-3 (MMP-3), cross-linked C-terminal telopeptide of type 2 collagen (CTX-II), total oxidant status (TOS), and total antioxidant concentration (TAC) were obtained. Results WOMAC, VAS scores, and CRP levels were comparable between groups prior to treatment. Both HA and NAC produced comparable reductions in TOS and MMP-3. NAC was more effective in reducing C-6S and CTX-II ( P < 0.05). No effects on TAC were noted. Conclusions NAC is effective in lowering some cartilage degradation markers, with comparable outcomes to HA for pain and function. NAC could provide a cheaper alternative to HA for intra-articular injection treatment of mild to moderate knee OA. Future placebo controlled trials are warranted to evaluate effectiveness in a larger patient population with a wider range of age and OA severity.

DAMPs Synergize with Cytokines or Fibronectin Fragment on Inducing Chondrolysis but Lose Effect When Acting Alone

OBJECTIVE AND DESIGN

To investigate whether endogenous damage-associated molecular patterns (DAMPs) or alarmins originated from mitochondria or nucleus stimulates inflammatory response in articular chondrocytes to cause chondrolysis which leads to cartilage degradation featured in posttraumatic osteoarthritis (PTOA).

MATERIALS

Primary cultures of bovine or human chondrocytes isolated from cartilage of weight-bearing joints.

TREATMENT

Chondrocytes were subjected to mitochondrial DAMPs (MTDs) or HMGB1, a nuclear DAMP (NuD), with or without the presence of an N-terminal 29 kDa fibronectin fragment (Fn-f) or proinflammatory cytokines (IL-1β and TNF-α). Injured cartilage-conditioned culturing medium containing a mixture of DAMPs was employed as a control. After 24 hrs, the protein expression of cartilage degrading metalloproteinases and iNOS in culture medium or cell lysates was examined with Western blotting, respectively.

RESULTS

HMGB1 was synergized with IL-1β in upregulating expression of MMP-3, MMP-13, ADAMTS-5, ADAM-8, and iNOS. Moreover, a moderate synergistic effect was detected between HMGB1 and Fn-f or between MTDs and TNF-α on MMP-3 expression. However, when acting alone, MTDs or HMGB1 did not upregulate cartilage degrading enzymes or iNOS.

CONCLUSION

MTDs or HMGB1 could only stimulate inflammatory response in chondrocytes with the presence of cytokines or Fn-f.

Modeling the effect of blunt impact on mitochondrial function in cartilage: implications for development of osteoarthritis

OBJECTIVE

Osteoarthritis (OA) is a disease characterized by degeneration of joint cartilage. It is associated with pain and disability and is the result of either age and activity related joint wear or an injury. Non-invasive treatment options are scarce and prevention and early intervention methods are practically non-existent. The modeling effort presented in this article is constructed based on an emerging biological hypothesis-post-impact oxidative stress leads to cartilage cell apoptosis and hence the degeneration observed with the disease. The objective is to quantitatively describe the loss of cell viability and function in cartilage after an injurious impact and identify the key parameters and variables that contribute to this phenomenon.

METHODS

We constructed a system of differential equations that tracks cell viability, mitochondrial function, and concentrations of reactive oxygen species (ROS), adenosine triphosphate (ATP), and glycosaminoglycans (GAG). The system was solved using MATLAB and the equations' parameters were fit to existing data using a particle swarm algorithm.

RESULTS

The model fits well the available data for cell viability, ATP production, and GAG content. Local sensitivity analysis shows that the initial amount of ROS is the most important parameter.

DISCUSSION

The model we constructed is a viable method for producing in silico studies and with a few modifications, and data calibration and validation, may be a powerful predictive tool in the search for a non-invasive treatment for post-traumatic osteoarthritis.

Complementary models reveal cellular responses to contact stresses that contribute to post-traumatic osteoarthritis

Two categories of joint overloading cause post-traumatic osteoarthritis (PTOA): single acute traumatic loads/impactions and repetitive overloading due to incongruity/instability. We developed and refined three classes of complementary models to define relationships between joint overloading and progressive cartilage loss across the spectrum of acute injuries and chronic joint abnormalities: explant and whole joint models that allow probing of cellular responses to mechanical injury and contact stresses, animal models that enable study of PTOA pathways in living joints and pre-clinical testing of treatments, and patient-specific computational models that define the overloading that causes OA in humans. We coordinated methodologies across models so that results from each informed the others, maximizing the benefit of this complementary approach. We are incorporating results from these investigations into biomathematical models to provide predictions of PTOA risk and guide treatment. Each approach has limitations, but each provides opportunities to elucidate PTOA pathogenesis. Taken together, they help define levels of joint overloading that cause cartilage destruction, show that both forms of overloading can act through the same biologic pathways, and create a framework for initiating clinical interventions that decrease PTOA risk. Considered collectively, studies extending from explants to humans show that thresholds of joint overloading that cause cartilage loss can be defined, that to at least some extent both forms of joint overloading act through the same biologic pathways, and interventions that interrupt these pathways prevent cartilage damage. These observations suggest that treatments that decrease the risk of all forms of OA progression can be discovered. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:515-523, 2017.

Genipin crosslinking decreases the mechanical wear and biochemical degradation of impacted cartilage in vitro

High energy trauma to cartilage causes surface fissures and microstructural damage, but the degree to which this damage renders the tissue more susceptible to wear and contributes to the progression of post-traumatic osteoarthritis (PTOA) is unknown. Additionally, no treatments are currently available to strengthen cartilage after joint trauma and to protect the tissue from subsequent degradation and wear. The purposes of this study were to investigate the role of mechanical damage in the degradation and wear of cartilage, to evaluate the effects of impact and subsequent genipin crosslinking on the changes in the viscoelastic parameters of articular cartilage, and to test the hypothesis that genipin crosslinking is an effective treatment to enhance the resistance to biochemical degradation and mechanical wear. Results demonstrate that cartilage stiffness decreases after impact loading, likely due to the formation of fissures and microarchitectural damage, and is partially or fully restored by crosslinking. The wear resistance of impacted articular cartilage was diminished compared to undamaged cartilage, suggesting that mechanical damage that is directly induced by the impact may contribute to the progression of PTOA. However, the decrease in wear resistance was completely reversed by the crosslinking treatments. Additionally, the crosslinking treatments improved the resistance to collagenase digestion at the impact-damaged articular surface. These results highlight the potential therapeutic value of collagen crosslinking via genipin in the prevention of cartilage degeneration after traumatic injury. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:558-565, 2017.

Wnt7a Inhibits IL-1β Induced Catabolic Gene Expression and Prevents Articular Cartilage Damage in Experimental Osteoarthritis

Wnt7a is a protein that plays a critical role in skeletal development. However, its effect on cartilage homeostasis under pathological conditions is not known. In this study, we found a unique inverse correlation between Wnt7a gene expression and that of MMP and IL-1β in individual human OA cartilage specimens. Upon ectopic expression in primary human articular chondrocytes, Wnt7a inhibited IL-1β-induced MMP and iNOS gene expression. Western blot analysis indicated that Wnt7a induced both canonical Wnt signaling and NFAT and Akt non-canonical signaling. Interestingly, inhibiting the canonical and Akt pathway did not affect Wnt7a activity. However, inhibiting the NFAT pathway impaired Wnt7a’s ability to inhibit MMP expression, suggesting that Wnt7a requires NFAT signaling to exert this function. In vivo, intraarticular injection of lentiviral Wnt7a strongly attenuated articular cartilage damage induced by destabilization of the medial meniscus (DMM) OA-inducing surgery in mice. Consistently, Wnt7a also inhibited the progressive increase of joint MMP activity in DMM animals. These results indicate that Wnt7a signaling inhibits inflammatory stimuli-induced catabolic gene expression in human articular chondrocytes and is sufficient to attenuate MMP activities and promote joint cartilage integrity in mouse experimental OA, demonstrating a novel effect of Wnt7a on regulating OA pathogenesis.

Peculiarities in Ankle Cartilage

Posttraumatic osteoarthritis (PTOA) is the most common form of osteoarthritis (OA) of the ankle joint. PTOA occurs as a result of several factors, including the poor regenerative capacity of hyaline articular cartilage as well as increased contact stresses following trauma. The purpose of this article is to review the epidemiology, pathogenesis, and potential targets for treatment of PTOA in the ankle joint. Previous reviews primarily addressed clinical approaches to ankle PTOA, while the focus of the current article will be specifically on the newly acquired knowledge of the cellular mechanisms that drive PTOA in the ankle joint and means for potential targeted therapeutics that might halt the progression of cartilage degeneration and/or improve the outcome of surgical interventions. Three experimental treatment strategies are discussed in this review: (1) increasing the anabolic potential of chondrocytes through treatment with growth factors such as bone morphogenetic protein-7; (2) limiting chondrocyte cell death either through the protection of cell membrane with poloxamer 188 or inhibiting activity of intracellular proteases, caspases, which are responsible for cell death by apoptosis; and (3) inhibiting catabolic/inflammatory responses of chondrocytes by treating them with anti-inflammatory agents such as tumor necrosis factor-α antagonists. Future studies should focus on identifying the appropriate timing for treatment and an appropriate combination of anti-inflammatory, chondro- and matrix-protective biologics to limit the progression of trauma-induced cartilage degeneration and prevent the development of PTOA in the ankle joint.

Antioxidative therapy in an ex vivo human cartilage trauma-model: attenuation of trauma-induced cell loss and ECM-destructive enzymes by N-acetyl cysteine

OBJECTIVE

Mechanical trauma of articular cartilage results in cell loss and cytokine-driven inflammatory response. Subsequent accumulation of reactive oxygen (ROS) and nitrogen (RNS) species enhances the enzymatic degradation of the extracellular matrix (ECM). This study aims on the therapeutic potential of N-acetyl cysteine (NAC) in a human ex vivo cartilage trauma-model, focusing on cell- and chondroprotective features.

DESIGN

Human full-thickness cartilage explants were subjected to a defined impact trauma (0.59 J) and treated with NAC. Efficiency of NAC administration was evaluated by following outcome parameters: cell viability, apoptosis rate, anabolic/catabolic gene expression, secretion and activity of matrix metalloproteinases (MMPs) and proteoglycan (PG) release.

RESULTS

Continuous NAC administration increased cell viability and reduced the apoptosis rate after trauma. It also suppressed trauma-induced gene expression of ECM-destructive enzymes, such as ADAMTS-4, MMP-1, -2, -3 and -13 in a dosage- and time-depending manner. Subsequent suppression of MMP-2 and MMP-13 secretion reflected these findings on protein level. Moreover, NAC inhibited proteolytic activity of MMPs and reduced PG release.

CONCLUSION

In the context of this ex vivo study, we showed not only remarkable cell- and chondroprotective features, but also revealed new encouraging findings concerning the therapeutically effective concentration and treatment-time regimen of NAC. Its defense against chondrocyte apoptosis and catabolic enzyme secretion recommends NAC as a multifunctional add-on reagent for pharmaceutical intervention after cartilage injury. Taken together, our data increase the knowledge on the therapeutic potential of NAC after cartilage trauma and presents a basis for future in vivo studies.

Linking Cellular and Mechanical Processes in Articular Cartilage Lesion Formation: A Mathematical Model

Post-traumatic osteoarthritis affects almost 20% of the adult US population. An injurious impact applies a significant amount of physical stress on articular cartilage and can initiate a cascade of biochemical reactions that can lead to the development of osteoarthritis. In our effort to understand the underlying biochemical mechanisms of this debilitating disease, we have constructed a multiscale mathematical model of the process with three components: cellular, chemical, and mechanical. The cellular component describes the different chondrocyte states according to the chemicals these cells release. The chemical component models the change in concentrations of those chemicals. The mechanical component contains a simulation of a blunt impact applied onto a cartilage explant and the resulting strains that initiate the biochemical processes. The scales are modeled through a system of partial-differential equations and solved numerically. The results of the model qualitatively capture the results of laboratory experiments of drop-tower impacts on cartilage explants. The model creates a framework for incorporating explicit mechanics, simulated by finite element analysis, into a theoretical biology framework. The effort is a step toward a complete virtual platform for modeling the development of post-traumatic osteoarthritis, which will be used to inform biomedical researchers on possible non-invasive strategies for mitigating the disease.

Operative treatment of calcaneal fractures: improved outcomes and low complications rates with a strict management protocol

This is a retrospective review of 80 intra-articular calcaneal fractures treated with open reduction and internal fixation by a specialist team under supervision of a single surgeon in a tertiary centre between 2005 and 2014. The fractures were evaluated with plain radiography and computed tomography, and graded using the Eastwood-Atkins classification. A lateral approach was used and all fractures were fixed with calcaneal plates. All patients had clinical and radiological follow-up. Clinical assessment included foot and ankle disability index, SF-36^® and Kerr-Atkins scores. The mean follow-up duration was 72 months (range: 12-130 months). The mean age of patients was 49 years (range: 17-73 years). There were three open fractures and eight patients had other injuries. The mean Bohler's angle improved from 6° preoperatively to 26° postoperatively. The mean foot and ankle disability index score was 78.62, the mean SF-36^® scores were 45.5 (physical component) and 52.6 (mental component), and the mean Kerr-Atkins score was 72 (range: 36-100). Early complications included one case of screw protrusion in the subtalar joint (which warranted a repeat procedure), one sural nerve injury and one wound breakdown, which healed with non-operative measures. Twelve patients had symptomatic subtalar joint osteoarthritis. Four of these had subtalar fusion. We believe that our strict protocols of patient selection, intraoperative and postoperative management produced long-term results comparable with those in the peer reviewed literature.

Injurious Loading of Articular Cartilage Compromises Chondrocyte Respiratory Function

OBJECTIVE

To determine whether repeatedly overloading healthy cartilage disrupts mitochondrial function in a manner similar to that associated with osteoarthritis (OA) pathogenesis.

METHODS

We exposed normal articular cartilage on bovine osteochondral explants to 1 day or 7 consecutive days of cyclic axial compression (0.25 MPa or 1.0 MPa at 0.5 Hz for 3 hours) and evaluated the effects on chondrocyte viability, ATP concentration, reactive oxygen species (ROS) production, indicators of oxidative stress, respiration, and mitochondrial membrane potential.

RESULTS

Neither 0.25 MPa nor 1.0 MPa of cyclic compression caused extensive chondrocyte death, macroscopic tissue damage, or overt changes in stress-strain behavior. After 1 day of loading, differences in respiratory activities between the 0.25 MPa and 1.0 MPa groups were minimal; however, after 7 days of loading, respiratory activity and ATP levels were suppressed in the 1.0 MPa group relative to the 0.25 MPa group, an effect prevented by pretreatment with 10 mM N-acetylcysteine. These changes were accompanied by increased proton leakage and decreased mitochondrial membrane potential, as well as by increased ROS formation, as indicated by dihydroethidium staining and glutathione oxidation.

CONCLUSION

Repeated overloading leads to chondrocyte oxidant-dependent mitochondrial dysfunction. This mitochondrial dysfunction may contribute to destabilization of cartilage during various stages of OA in distinct ways by disrupting chondrocyte anabolic responses to mechanical stimuli.

Sulfasalazine attenuates ACL transection and medial menisectomy-induced cartilage destruction by inhibition of cystine/glutamate antiporter

We had previously demonstrated that excitatory amino acid glutamate plays a role in the progression and severity of knee osteoarthritis (OA), and early hyaluronic acid injection attenuates the OA progression by attenuation of knee joint glutamate level, which was also related to the cystine/glutamate antiporter system X (system XC-) expression. System XC- uptakes cystine into chondrocytes for glutathione (GSH) synthesis, but the role of system XC- in OA is rarely addressed. Sulfasalazine (SSZ) is a system XC- inhibitor; SSZ was applied intra-articularly to study the function of system XC- in the development of OA in rats subjected to anterior cruciate ligament transection and medial meniscectomy (ACLT + MMx). Moerover, the system XC- activator N-acetylcysteine (NAC) was also applied to verify the role of system XC-. The intra-articular injection of SSZ significantly attenuated knee swelling and cartilage destruction in the knees of ACLT + MMx rats and this effect was blocked by NAC. The results showed that inhibition of system XC- function can attenuate ACLT + MMx-induced cartilage destruction. In the present study, system XC- inhibitor SSZ was shown to reduce glutamate content in synovial fluid and GSH in chondrocytes. It was also showed SSZ could attenuate ACLT + MMx-induced cartilage destruction, and treatment of NAC reversed the protective effect of SSZ.

Differential Interactive Effects of Cartilage Traumatization and Blood Exposure In Vitro and In Vivo

BACKGROUND

Sport injuries of the knee often lead to posttraumatic arthritis. In addition to direct damage of the cartilage, trauma-associated intra-articular bleeding may cause hemarthrosis. Both blood exposure and trauma are known to induce cell death and inflammation and to enhance proteoglycan release in cartilage.

HYPOTHESIS

Blood exposure increases chondrocyte death as well as inflammatory and degenerative processes in traumatized cartilage.

STUDY DESIGN

Controlled laboratory study.

METHODS

Human macroscopically intact osteoarthritic (OA) cartilage explants were impacted by a drop-tower system (0.59 J) and cultivated with or without 10% blood. Interactive effects were studied concerning cell survival, gene expression, and the release of mediators over 24 hours and 96 hours. To evaluate the effects of trauma and hemarthrosis in vivo, a newly established blunt cartilage trauma model in the rabbit was used. Treatment of the knee joints of mature New Zealand White rabbits consisted of the following groups: control (C), arthrotomy (A), arthrotomy with cartilage trauma (AT; 1.0 J), and arthrotomy with cartilage trauma and blood injection (ATH). After 1 and 12 weeks, inflammatory mediators in the synovial fluid and histological changes of the cartilage were determined, and immunohistological staining was performed.

RESULTS

The in vitro studies revealed a significant additional or synergistic effect of blood exposure on trauma-induced chondrocyte death, interleukin (IL)-1β and prostaglandin-E2 (PGE2) release, and matrix metalloproteinase (MMP)/pro-MMP level. Singular arthrotomy in vivo induced a temporary inflammation. Histologically, cartilage trauma caused significant OA changes that were not aggravated by an additional hemarthrosis. Trauma led to a persistent deposition of terminal complement complex (TCC), being enhanced by hemarthrosis. However, trauma-induced formation of osteophytes and arthrotomy-induced elevation of tumor necrosis factor-α release were reduced by hemarthrosis.

CONCLUSION

While blood exposure clearly aggravated trauma-induced OA processes in the in vitro model, a singular blood injection revealed heterogeneous effects in vivo, enhancing TCC deposition but reducing trauma-induced osteophyte formation while the histological score of traumatized cartilage was not further impaired.

CLINICAL RELEVANCE

The results of this study indicate that a singular, limited bleeding event might not exacerbate early trauma-induced cartilage degeneration in joint injuries. An early removal of intra-articular blood may not prevent the final resulting cartilage damage.

Joint distraction attenuates osteoarthritis by reducing secondary inflammation, cartilage degeneration and subchondral bone aberrant change

OBJECTIVE

Osteoarthritis (OA) is a progressive joint disorder. To date, there is not effective medical therapy. Joint distraction has given us hope for slowing down the OA progression. In this study, we investigated the benefits of joint distraction in OA rat model and the probable underlying mechanisms.

METHODS

OA was induced in the right knee joint of rats through anterior cruciate ligament transaction (ACLT) plus medial meniscus resection. The animals were randomized into three groups: two groups were treated with an external fixator for a subsequent 3 weeks, one with and one without joint distraction; and one group without external fixator as OA control. Serum interleukin-1β level was evaluated by ELISA; cartilage quality was assessed by histology examinations (gross appearance, Safranin-O/Fast green stain) and immunohistochemistry examinations (MMP13, Col X); subchondral bone aberrant changes was analyzed by micro-CT and immunohistochemistry (Nestin, Osterix) examinations.

RESULTS

Characters of OA were present in the OA group, contrary to in general less severe damage after distraction treatment: firstly, IL-1β level was significantly decreased; secondly, cartilage degeneration was attenuated with lower histologic damage scores and the lower percentage of MMP13 or Col X positive chondrocytes; finally, subchondral bone abnormal change was attenuated, with reduced bone mineral density (BMD) and bone volume/total tissue volume (BV/TV) and the number of Nestin or Osterix positive cells in the subchondral bone.

CONCLUSION

In the present study, we demonstrated that joint distraction reduced the level of secondary inflammation, cartilage degeneration and subchondral bone aberrant change, joint distraction may be a strategy for slowing OA progression.