A study in vivo of the effects of a static compressive load on the proximal tibial physis in rabbits

Axial mechanical loading to ex vivo mouse long bone regulates endochondral ossification and endosteal mineralization through activation of the BMP-Smad pathway during postnatal growth

Mechanical loading contributes to bone development, growth, and metabolism. However, the mechanisms underlying long bone mineralization via changes in loading during the growth period are unclear. The aim of the present study was to investigate the regulatory mechanisms underlying endochondral ossification and endosteal mineralization by developing an ex vivo organ culture model with cyclic axial mechanical loads. The metacarpal bones of 3-week-old C57BL/6 mice were exposed to mechanical loading (0, 7.8, and 78 mN) for 1 h/day for 4 days. Histomorphometry revealed that axial mechanical loading regulated the thickness of the calcified zone in the growth plate and endosteal mineralization in the diaphysis in a load-dependent manner. Mechanical loading also resulted in load-dependent upregulation of endochondral ossification and bone mineralization-related genes, including bone morphogenetic protein 2 (Bmp2). Recombinant human BMP-2 administration caused similar changes in tissue structures. Conversely, inhibition of the BMP-Smad pathway diminished the stimulatory effects of mechanical loading and BMP-2 administration, suggesting that the effects of mechanical loading may be exerted through activation of the BMP-Smad pathway with the results of gene ontology and pathway analyses. Mechanical loading increased alkaline phosphatase activity and decreased carbonic anhydrase IX (Car9) mRNA expression, resulting in a significant pH increase in the culture supernatant. We hypothesize that, through activation of the BMP-Smad pathway, mechanical loading downregulates Car9, which may alkalize the local milieu, thereby inducing bone formation and long bone mineralization. Our results showed that cyclic axial mechanical loading increased endochondral ossification and endosteal mineralization in developing mouse long bones, which may have resulted from changes in the pH, ALP activity, and Pi/PPi of the extracellular environment. These findings advance our understanding of the regulation of mineralization mechanisms by mechanical loading mediated through activation of the BMP-Smad pathway.

Part 2. Review and meta-analysis of studies on modulation of longitudinal bone growth and growth plate activity: A micro-scale perspective

Macro-scale changes in longitudinal bone growth resulting from mechanical loading were shown in Part 1 of this review to depend on load magnitude, anatomical location, and species. While no significant effect on longitudinal growth was observed by varying frequency and amplitude of cyclic loading, such variations, in addition to loading duration and species, were shown to affect the morphology, viability, and gene and protein expression within the growth plate. Intermittent compression regimens were shown to preserve or increase growth plate height while stimulating increased chondrocyte presence in the hypertrophic zone relative to persistent and static loading regimens. Gene and protein expressions related to matrix synthesis and degradation, as well as regulation of chondrocyte apoptosis were shown to exhibit magnitude-, frequency-, and duration-dependent responses to loading regimen. Chondrocyte viability was shown to be largely preserved within physiological bounds of magnitude, frequency, amplitude, and duration. Persistent static loading was shown to be associated with overall growth plate height in tension only, reducing it in compression, while affecting growth plate zone heights differently across species and encouraging mineralization relative to intermittent cyclic loading. Lateral loading of the growth plate, as well as microfluidic approaches are relatively understudied, and age, anatomical location, and species effects within these approaches are undefined. Understanding the micro-scale effects of varied loading regimes can assist in the development of growth modulation methods and device designs optimized for growth plate viability preservation or mineralization stimulation based on patient age and anatomical location.

Depth and strain rate-dependent mechanical response of chondrocytes in reserve zone cartilage subjected to compressive loading

The role of the growth plate reserve zone is not well understood. It has been proposed to serve as a source of stem cells and to produce morphogens that control the alignment of clones in preparation for the transition into the proliferative zone. We hypothesized that if such a role exists, there are likely to be mechanoregulatory stimuli in cellular response through the depth of the reserve zone. A poroelastic multiscale finite element model of bone/growth-plate/bone was developed for examining the reserve zone cell transient response when compressed to 5% of the cartilage thickness at strain rates of 0.18%/s, 5%/s, 50%/s, and 200%/s. Chondrocyte maximum principal strains, height-, width-, and membrane-strains were found to be highly dependent on reserve zone tissue depth and strain rate. Cell-level strains and fluid transmembrane outflow from the cell were influenced by the permeability of the calcified cartilage between subchondral bone plate and reserve zone and by the applied strain rate. Cell strain levels in the lower reserve zone were less sensitive to epiphyseal permeability than in the upper reserve zone. In contrast, the intracellular fluid pressures were relatively uniform with reserve zone tissue depth and less sensitive to epiphyseal permeability. Fluid shear stress, induced by fluid flow over the cell surface, provided mechanoregulatory signals potentially sufficient to stimulate reserve zone chondrocytes near the subchondral bone plate interface. These results suggest that the strain rate and tissue depth dependence of cell-level strains and cell surface fluid shear stress may provide mechanoregulatory cues in the reserve zone.

An investigation to validate the equivalence of physes obtained from different anatomic regions in a single animal species: Implications for choosing experimental controls in clinical studies

Control tissue in studies of various orthopedic pathologies is difficult to obtain and presumably equivalent biopsies from other anatomic sites have been utilized in its place. However, for growth plates, different anatomic regions are subject to dissimilar mechanical forces and produce disproportionate longitudinal growth. The purpose of this study was to compare gene expression and structure in normal physes from different anatomic regions within a single animal species to determine whether such physes were equivalent. Thirteen female New Zealand white rabbits (five 15-week-old and eight 19-week-old animals) were euthanized and physes harvested from their proximal and distal femurs and proximal tibiae. Harvested physes were divided into groups for histological, immunohistochemical (IHC), and reverse transcription-quantitative polymerase chain reaction analyses. All physes analyzed demonstrated no apparent differences in morphology or proteoglycan staining intensity on histological examination or in type II collagen presence determined by IHC study. Histomorphometric measures of physeal height as well as gene expression of type II collagen and aggrecan were found to be statistically significantly equivalent (p < 0.05) among the three different bones from the total number of rabbits. Summary data suggest that the structural similarities and statistical equivalence determined among the various physes investigated in the rabbit validate these tissues in this species for use as surrogate controls by which physeal abnormalities may be compared and characterized in the absence of otherwise normal control tissues. Other species may exhibit the same similarities and equivalence among different physes so that such tissues may serve in like manner as controls for assessing a variety of orthopedic conditions, including those occurring in humans.

Unravelling the hip pistol grip/cam deformity: Origins to joint degeneration

This article reviews a body of work performed by the investigators over 9 years that has addressed the significance of cam morphology in the development of hip osteoarthritis (OA). Early hip joint degeneration is a common clinical presentation and preexisting abnormal joint morphology is a risk factor for its development. Interrogating Hill's criteria, we tested whether cam-type femoroacetabular impingement leads to hip OA. Strength of association was identified between cam morphology, reduced range-of-movement, hip pain, and cartilage degeneration. By studying a pediatric population, we were able to characterize the temporality between cam morphology (occurring 1st) and joint degeneration. Using in silico (finite element) and in vivo (imaging biomarkers) studies, we demonstrated the biological plausibility of how a cam deformity can lead to joint degeneration. Furthermore, we were able to show a biological gradient between degree of cam deformity and extent of articular damage. However, not all patients develop joint degeneration and we were able to characterize which factors contribute to this (specificity). Lastly, we were able to show that by removing the cam morphology, one could positively influence the degenerative process (experiment). The findings of this body of work show consistency and coherence with the literature. Furthermore, they illustrate how cam morphology can lead to early joint degeneration analogous to SCFE, dysplasia, and joint mal-reduction post-injury. The findings of this study open new avenues on the association between cam morphology and OA including recommendations for the study, screening, follow-up, and assessment (patient-specific) of individuals with cam morphology in order to prevent early joint degeneration. Statement of significance: By satisfying Hill's criteria, one can deduct that in some individuals, cam morphology is a cause of OA. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:3125-3135, 2018.

In situ deformation of growth plate chondrocytes in stress-controlled static vs dynamic compression

Longitudinal bone growth in children/adolescents occurs through endochondral ossification at growth plates and is influenced by mechanical loading, where increased compression decreases growth (i.e., Hueter-Volkmann Law). Past in vivo studies on static vs dynamic compression of growth plates indicate that factors modulating growth rate might lie at the cellular level. Here, in situ viscoelastic deformation of hypertrophic chondrocytes in growth plate explants undergoing stress-controlled static vs dynamic loading conditions was investigated. Growth plate explants from the proximal tibia of pre-pubertal rats were subjected to static vs dynamic stress-controlled mechanical tests. Stained hypertrophic chondrocytes were tracked before and after mechanical testing with a confocal microscope to derive volumetric, axial and lateral cellular strains. Axial strain in hypertrophic chondrocytes was similar for all groups, supporting the mean applied compressive stress's correlation with bone growth rate and hypertrophic chondrocyte height in past studies. However, static conditions resulted in significantly higher lateral (p<0.001) and volumetric cellular strains (p≤0.015) than dynamic conditions, presumably due to the growth plate's viscoelastic nature. Sustained compression in stress-controlled static loading results in continued time-dependent cellular deformation; conversely, dynamic groups have less volumetric strain because the cyclically varying stress limits time-dependent deformation. Furthermore, high frequency dynamic tests showed significantly lower volumetric strain (p=0.002) than low frequency conditions. Mechanical loading protocols could be translated into treatments to correct or halt progression of bone deformities in children/adolescents. Mimicking physiological stress-controlled dynamic conditions may have beneficial effects at the cellular level as dynamic tests are associated with limited lateral and volumetric cellular deformation.

Prevalence of Hypertension in Pediatric Tibia Vara and Slipped Capital Femoral Epiphysis

BACKGROUND

Slipped capital femoral epiphysis (SCFE) and tibia vara (Blount disease) are associated with childhood obesity. However, the majority of obese children do not develop SCFE or tibia vara. Therefore, it is hypothesized that other obesity-related biological changes to the physis, in addition to increased biomechanical stress, potentiate the occurrence of SCFE and tibia vara. Considering that hypertension can impose pathologic changes in the physis similar to those observed in these obesity-related diseases we set out to determine the prevalence of hypertension in patients with SCFE and tibia vara.

METHODS

Blood pressure measurements were obtained in 44 patients with tibia vara and 127 patients with SCFE. Body mass index and blood pressure were adjusted for age, sex, and height percentiles utilizing normative distribution data from the CDC. These cohorts were compared with age-matched and sex-matched cohorts derived from an obesity clinic who did not have either bone disease. A multivariable proportional odds model was used to determine association.

RESULTS

The prevalence of prehypertension/hypertension was significantly higher in the tibia vara (64%) and SCFE cohort (64%) compared with respective controls (43%). Patients diagnosed with either SCFE or tibia vara had 2.5-fold higher odds of having high blood pressure compared with age-matched and sex-matched obese patients without bone disease. Sex, age, and race did not have a significant effect on a patient's blood pressure.

CONCLUSIONS

This is the first study to establish that the obesity-related bone diseases, SCFE and tibia vara, are significantly associated with high blood pressure. These data have immediate clinical impact as they demonstrate that children with obesity-related developmental bone disease have increased prevalence of undiagnosed and untreated hypertension. Furthermore, this prevalence study supports the hypothesis that hypertension in conjunction with increased biomechanical forces together potentiate the occurrence of SCFE and tibia vara. If proven true, it is plausible that hypertension may represent a modifiable risk factor for obesity-related bone disease.

LEVEL OF EVIDENCE

Level III-case-control study.

A QUANTITATIVE AND QUALITATIVE GROWTH PLATE DESCRIPTION — A SIMPLE FRAMEWORK FOR CHONDROCYTES COLUMNAR ARRANGEMENT EVALUATION

The growth plate is a cartilaginous structure located in the metaphysis of long bones, characterized histologically by its stratification and columnar arrangement. It is responsible for assuring longitudinal growth. Evaluation of growth plate histological characteristics has been traditionally performed using qualitative observation; however, some quantitative approaches have been reported using complex techniques. Here, we propose a simple quantitative images based analysis in order to evaluate objectively columnar arrangement within growth plate. For this, we defined six descriptors that were condensated in a geometric tensor. This tensor could be used as a single parameter to evaluate the growth plate organization. Validation of the tensor was performed with growth plate microphotographs of three healthy species (rat, pig and rabbit) and an abnormal one (Csf1tl/Csf1tl rat) found in specialized literature. According to our results, the descriptors and the tensor give a complete picture of the organization of the growth plate, reflecting the expected stratification and columnar arrangement of the cells within the tissue. This methodology could be a reliable tool for evaluation of growth plate structure for research and diagnostic purposes, taking into account that it can be easily implemented.

Bone growth resumption following in vivo static and dynamic compression removals on rats

Mechanical loadings influence bone growth and are used in pediatric treatments of musculoskeletal deformities. This in vivo study aimed at evaluating the effects of static and dynamic compression application and subsequent removal on bone growth, mineralization and neuropathic pain markers in growing rats. Forty-eight immature rats (28 days old) were assigned in two groups (2- and 4 weeks experiment duration) and four subgroups: control, sham, static, and dynamic. Controls had no surgery. A micro-loading device was implanted on the 6th and 8th caudal vertebrae of shams without loading, static loading at 0.2 MPa or dynamic loading at 0.2 MPa ± 30% and 0.1 Hz. In 2-week subgroups, compression was maintained for 15 days prior to euthanasia, while in 4- week subgroups, compression was removed for 10 additional days. Growth rates, histomorphometric parameters and mineralization intensity were quantified and compared. At 2 weeks, growth rates and growth plate heights of loaded groups (static/dynamic)were significantly lower than shams (p b 0.01).However, at 4 weeks, both growth rates and growth plate heights of loaded groups were similar to shams. At 4 weeks, alizarin red intensity was significantly higher in dynamics compared to shams (p b 0.05) and controls (p b 0.01). Both static and dynamic compressions enable growth resumption after loading removal, while preserving growth plate histomorphometric integrity. However, mineralization was enhanced after dynamic loading removal only. Dynamic loading showed promising results for fusionless treatment approaches for musculoskeletal deformities.

Pituitary Adenylate Cyclase Activating Polypeptide (PACAP) Pathway Is Induced by Mechanical Load and Reduces the Activity of Hedgehog Signaling in Chondrogenic Micromass Cell Cultures

Pituitary adenylate cyclase activating polypeptide (PACAP) is a neurohormone exerting protective function during various stress conditions either in mature or developing tissues. Previously we proved the presence of PACAP signaling elements in chicken limb bud-derived chondrogenic cells in micromass cell cultures. Since no data can be found if PACAP signaling is playing any role during mechanical stress in any tissues, we aimed to investigate its contribution in mechanotransduction during chondrogenesis. Expressions of the mRNAs of PACAP and its major receptor, PAC1 increased, while that of other receptors, VPAC1, VPAC2 decreased upon mechanical stimulus. Mechanical load enhanced the expression of collagen type X, a marker of hypertrophic differentiation of chondrocytes and PACAP addition attenuated this elevation. Moreover, exogenous PACAP also prevented the mechanical load evoked activation of hedgehog signaling: protein levels of Sonic and Indian Hedgehogs and Gli1 transcription factor were lowered while expressions of Gli2 and Gli3 were elevated by PACAP application during mechanical load. Our results suggest that mechanical load activates PACAP signaling and exogenous PACAP acts against the hypertrophy inducing effect of mechanical load.

The case for ceramic-on-polyethylene as the preferred bearing for a young adult hip replacement

The optimum choice of bearing surfaces in total hip arthroplasty, particularly in the younger and more active patient, remains controversial. Despite several studies demonstrating good long-term results for the metal-on-polyethylene articulation, there has been a recent vogue towards the utilisation of hard-on-hard bearings for younger patients due, in part, to concerns regarding polyethylene induced osteolysis. However, well-documented complications concerning metal-on-metal bearings and the risk of fracture in ceramic-on-ceramic bearings have raised concerns regarding the principle of the hard-on-hard bearing in the active patient. With recent technological advancements in the manufacture of both polyethylene and alumina ceramics, the in vitro properties of each material with regards to strength and toughness have been significantly improved. In addition, ceramic femoral heads have consistently been shown to produce less in vivo polyethylene wear than similar sized metal heads. This paper aims to critically review the biomechanical, in vivo and clinical studies related to the use of the ceramic on polyethylene bearing, and highlights its potential use as the preferred bearing for a young adult hip replacement.

Gene expression differences between ruptured anterior cruciate ligaments in young male and female subjects

BACKGROUND

The incidence of anterior cruciate ligament (ACL) injuries is two to eightfold greater in female compared with male athletes. Anatomic, hormonal, and neuromuscular factors have been associated with this disparity. This study compared gene expression and structural features in ruptured but otherwise normal ACL tissue from young female and male athletes.

METHODS

A biopsy sample of ruptured ACL tissue (which would normally have been discarded) was obtained intraoperatively from seven female and seven male athletes (12.7 to 22.6 years old). Each sample was divided into portions for histological and gene expression analyses. Specimens for gene analysis were frozen and ground, and RNA was extracted and purified. Microarray analysis was performed on RNA isolated from four female and three male study participants (13.9 to 18.5 years old) who had a noncontact injury. Genes with an expression level that differed significantly between these female and male athletes were grouped into functionally associated networks with use of IPA software (Qiagen). Three genes of interest were chosen for further validation by RT-qPCR (reverse transcription-quantitative polymerase chain reaction) analysis of the samples from all fourteen patients. Several statistical methods were used to examine sex-related differences.

RESULTS

Microarray analysis of the RNA isolated from the ruptured ACL tissue from the female and male athletes identified thirty-two genes with significant differential expression. Fourteen of these genes were not linked to the X or Y chromosome. IPA analysis grouped these genes into pathways involving development and function of skeletal muscle and growth, maintenance, and proliferation of cells. RT-qPCR confirmed significant differences in expression of three selected genes: ACAN (aggrecan) and FMOD (fibromodulin) were upregulated in female compared with male study participants, and WISP2 (WNT1 inducible signaling pathway protein 2) was downregulated. No morphological differences among the ruptured tissue from the various participants were apparent on histological examination.

CONCLUSIONS

The genes identified in this study as differing distinctly according to sex produce major molecules in the ACL extracellular matrix. Significant upregulation of ACAN and FMOD (which regulate the matrix) and downregulation of WISP2 (which is involved in collagen turnover and production) may account for the weaker ACLs in female compared with male individuals.

The character of gene expression of human periosteum used to form new tissue in allograft bone

Of more than 2 million segmental bone defects repaired annually with bone autografts and allografts, 15-40% fail. Improving healing rates may be approached with tissue engineering and use of periosteum overlying an allograft. The present study documents gene expression in human periosteum-allograft constructs compared to allografts alone. Strips of human cadaveric periosteum (26 years, f, distal femur) were sutured about sterilized human femoral cortical strut bone allograft (54 years, m) segments. After construct incubation (M199 supplemented medium) for 8 d, constructs and allografts alone were implanted in nude mice. At 10 and 20 weeks, constructs (N = 4, each group) and allografts (N = 2, each group) were retrieved and placed in RNAlater for quantitative PCR to determine expression of human- and murine-specific genes relevant to remodeling. Specimens were frozen-ground to powders and RNA was extracted, purified, reverse-transcribed, and amplified. Ribosomal protein (P0) was used to normalize sample quantities. Fold change plots were generated following statistical analyses comparing 20- to 10-week gene expression data. Allografts alone yielded no human-specific gene expression. Notable fold changes of human-specific alkaline phosphatase, bone sialoprotein, type I collagen, decorin, RANKL, RANK, cathepsin K, and osteocalcin in 20-week compared to 10-week specimens were found. Murine-specific expression of genes indicative of host mouse vascularization (RANK, type I collagen) was detected in both allograft alone and periosteum-allograft samples. Gene data confirm viable periosteum in constructs after 20 weeks. Relatively higher fold-change values of RANK, RANKL and cathepsin K indicate activities of osteoclast precursors, osteoclasts and osteoblasts involved in allograft remodeling during implantation. All additional genes of interest indicate osteoblast activity in new bone matrix formation. Gene data are directly correlated with previous and present histology work. The results of this study suggest that further investigations could help to establish whether autologous periosteum-allograft constructs could be used for the repair of bone defects.