Interventional Radiology for Rheumatic Diseases

Imaging plays a key role in the management of rheumatological pathologies, also as guidance for diagnostic and therapeutic interventional procedures, as it can provide better accuracy and safety compared to palpation-guided interventions. Inflammatory and degenerative conditions nonresponsive to systemic treatment may benefit from intra-articular and periarticular administration of drugs, with therapeutic and symptomatic actions or providing a bridge for surgery. Desired effects include reduction of inflammation and pain and improvement of physical function of patients. Training and knowledge of indications, appropriate procedures, contraindications, and side effects are necessary to obtain maximum accuracy and safety in performing interventional procedures.

Rapid Recovery after Reparation of Full-Thickness Chondral Defects of the Knee with the Use of Hyaluronan (HA)-Based 3-D Scaffold

Articular cartilage injuries are found in up to 60% of patients who undergo an arthroscopic knee procedure, and those that totally affect articular cartilage (grade IV) have limited regenerative capacity and extended time for recovery. 3-D scaffolds represent a novel solution to address this type of injury. Our purpose was to analyze the MRI findings and functional status of patients that underwent repair of chondral defects either by microfractures or Hyaluronan (HA) 3-D scaffolding. We conducted a retrospective study of patients with chondral defects. The outcomes analyzed in this study included anatomical changes evaluated by the Henderson score (based on MRI findings) at baseline, 6, and 12 months after surgery, and improvement in functionality evaluated by the Modified Cincinnati Knee Rating System (MCKRS) at baseline and 6 months after surgery. Clinical and demographic characteristics were similar for both groups. There was a statistically significant improvement in Henderson score for the 3-D scaffold-treated group at 6 months versus the microfracture group (p < 0.0001). Improvement in functionality, measured by the MCKRS, was more frequently found in the 3-D scaffold-treated group. In conclusion, the use of HA 3-D scaffolding was superior, with faster recovery evident 6 months after the surgery that progressed to full recovery in all patients a year after surgery. Future studies with a randomized design might help to support our findings. This study provides level III evidence.

The Combination of Glucocorticoids and Hyaluronic Acid Enhances Efficacy in IL-1β/IL-17-Treated Bovine Osteochondral Grafts Compared with Individual Application

Patients with knee osteoarthritis often receive glucocorticoid (GC) or hyaluronic acid (HA) injections to alleviate symptoms. This study evaluated the impact of Triamcinolone Hexacetonide (a GC), HA, and a combination of both on bovine osteochondral grafts exposed to IL-1β and IL-17 in an ex vivo culture. Metabolic activity increased with GC treatment. GCs and GCs/HA counteracted cytokine effects, with gene expressions similar to untreated controls, while HA alone did not. However, HA improved the coefficient of friction after two weeks. The highest friction values were observed in GC-containing and cytokine-treated groups. Cytokine treatment reduced tissue proteoglycan content, which HA could mitigate, especially in the GC/HA combination. This combo also effectively controlled proteoglycan release, supported by reduced sGAG release. Cytokine treatment led to surface cell death, while GCs, HA, or their combination showed protective effects against inflammation. The GC/HA combination had the best overall results, suggesting its potential as a superior treatment option for osteoarthritis.

Biomimetic Hyaluronic Acid-Based Brush Polymers Modulate Chondrocyte Homeostasis via ROS/Ca2+/TRPV4

Bionic mimics using natural cartilage matrix molecules can modulate the corresponding metabolic activity by improving the microenvironment of chondrocytes. A bionic brush polymer, HA/PX, has been found to reverse the loss of cartilage extracellular matrix (ECM) and has promising applications in the clinical treatment of osteoarthritis (OA). However, the unknown bioremediation mechanism of HA/PX severely hinders its clinical translation. In OA, the massive loss of the ECM may be attributed to a decrease in transient receptor potential vanilloid 4 (TRPV4) activity, which affects reactive oxygen species (ROS) clearance and [Ca2+]i signaling, initiating downstream catabolic pathways. In this study, we investigated the bioremediation mechanism of HA/PX in a model of interleukin 1β (IL-1β)-induced inflammation. Through TRPV4, HA/PX reduced ROS accumulation in chondrocytes and enhanced [Ca2+]i signaling, reflecting a short-term protection capacity for chondrocytes. In addition, HA/PX balanced the metabolic homeostasis of chondrocytes via TRPV4, including promoting the secretion of type II collagen (Col-II) and aggrecan, the major components of the ECM, and reducing the expression of matrix metal-degrading enzyme (MMP-13), exerting long-term protective effects on chondrocytes. Molecular dynamics (MD) simulations showed that HA/PX could act as a TRPV4 activator. Our results suggest that HA/PX can regulate chondrocyte homeostasis via ROS/Ca2+/TRPV4, thereby improving cartilage regeneration. Because the ECM is a prevalent feature of various cell types, HA/PX holds promising potential for improving regeneration and disease modification for not only cartilage-related healthcare but many other tissues and diseases.

Ultrasound-guided interventions of the upper extremity joints

Ultrasound guidance is valuable for performing precise joint interventions. Joint interventions may be requested for therapeutic and diagnostic pain injections, joint aspiration in the setting of suspected infection, or contrast injection for arthrography. In practice, interventions of the shoulder girdle, elbow, and hand/wrist joints may be performed without any imaging guidance. However, imaging guidance results in more accurate interventions and better patient outcomes than those performed by palpation alone. When compared to other modalities used for imaging guidance, ultrasound has many potential advantages. Radiologists should be prepared to perform ultrasound-guided upper extremity joint interventions utilizing recommended techniques to optimize clinical practice and patient outcomes. KEY POINTS: 1. Ultrasound-guided injections of the glenohumeral, acromioclavicular, sternoclavicular, elbow, and hand/wrist joints have higher accuracy than injections performed without imaging guidance. 2. Ultrasound-guided aspirations of upper extremity joints have advantages to fluoroscopic-guided aspirations because of the potential to identify effusions, soft tissue abscess, or bursitis. 3. Ultrasound-guided contrast injection prior to MR arthrography is as accurate as fluoroscopic-guided injection for upper extremity joints.

An update on the effect of intra-articular intervention strategies using nanomaterials in osteoarthritis: Possible clinical application

Osteoarthritis (OA) is the most common progressive condition affecting joints. It mainly affects the knees and hips as predominant weight-bearing joints. Knee osteoarthritis (KOA) accounts for a large proportion of osteoarthritis and presents numerous symptoms that impair quality of life, such as stiffness, pain, dysfunction, and even deformity. For more than two decades, intra-articular (IA) treatment options for managing knee osteoarthritis have included analgesics, hyaluronic acid (HA), corticosteroids, and some unproven alternative therapies. Before effective disease-modifying treatments for knee osteoarthritis, treatments are primarily symptomatic, mainly including intra-articular corticosteroids and hyaluronic acid, so these agents represent the most frequently used class of drugs for managing knee osteoarthritis. But research suggests other factors, such as the placebo effect, have an essential role in the effectiveness of these drugs. Several novel intra-articular therapies are currently in the clinical trial processes, such as biological therapies, gene and cell therapies. Besides, it has been shown that the development of novel drug nanocarriers and delivery systems could improve the effectiveness of therapeutic agents in osteoarthritis. This review discusses the various treatment methods and delivery systems for knee osteoarthritis and the new agents that have been introduced or are in development.

Intra-articular therapies: patient preferences and professional practices in European countries

To assess patient perspective and professional practice of intraarticular therapies (IATs) across Europe, an expert international multidisciplinary panel designed two open web-based surveys: one targeting people who had experienced at least two IATs (44 items); and one targeting health care providers (HCPs) (160 items). Surveys were disseminated via patient and professional associations and social media. A descriptive analysis was performed. The surveys were answered by 200 patients and 186 HCPs from 26 countries, showing that IAT is routinely performed by rheumatologists (97%) and orthopaedic surgeons (89%), with specific training being compulsory in a few countries. The most frequent indications for IAT are arthritis (76%), osteoarthritis (74%), crystal arthritis (71%) and bursitis (70%); the most frequently injected joints are knee (78%) and shoulder (70%); and the most used compounds are glucocorticoids. The majority of HCPs report informing patients about side-effects (73%), benefits (72%), and the nature of the procedure (72%), which coincides with 27% of patients reporting that they had not been informed about benefits or potential complications of IATs; 73% of patients had not been asked whether they wanted an anaesthetic. Few HCPs (10%) obtain written consent (56% get oral consent, being mandatory for 32%), a procedure deemed necessary by 41% of the patients. 50% of patients reported a clear benefit of IAT and 20% experienced complications including pain, impaired mobility, rashes, or swelling. In summary, the practice of IAT is variable across Europe, and although patients perceive it as relatively safe and usually effective procedure, some gaps were identified.

Current updates in image-guided musculoskeletal interventions

Image-guided musculoskeletal interventions are frequently done in clinical practice. Even then, the literature regarding their effectiveness is relatively scarce. Image guidance adds value over the conventional landmark-based approach and should be preferred. We hereby try to list the commonly performed procedures along with the current practice guidelines regarding their clinical indications and periprocedural care.

EULAR recommendations for intra-articular therapies

OBJECTIVES

To establish evidence-based recommendations to guide health professionals using intra-articular therapies (IAT) in adult patients with peripheral arthropathies.

METHODS

A multidisciplinary international task force established the objectives, users and scope and the need for background information, including systematic literature reviews) and two surveys addressed to healthcare providers and patients throughout Europe. The evidence was discussed in a face-to-face meeting, recommendations were formulated and subsequently voted for anonymously in a three-round Delphi process to obtain the final agreement. The level of evidence was assigned to each recommendation with the Oxford levels of evidence.

RESULTS

Recommendations focus on practical aspects to guide health professionals before, during and after IAT in adult patients with peripheral arthropathies. Five overarching principles and 11 recommendations were established, addressing issues related to patient information, procedure and setting, accuracy, routine and special aseptic care, safety issues and precautions to be addressed in special populations, efficacy and safety of repeated joint injections, use of local anaesthetics and aftercare.

CONCLUSION

We have developed the first evidence and expert opinion-based recommendations to guide health professionals using IAT. We hope that these recommendations will be included in different educational programmes, used by patient associations and put into practice via scientific societies to help improve uniformity and quality of care when performing IAT in peripheral adult joints.

Effects of Viscosupplementation on Quality of Knee Joint Arthrokinematic Motion Analyzed by Vibroarthrography

OBJECTIVE

To evaluate the influence of viscosupplementation on osteoarthritic knee arthrokinematics analyzed by VAG. It is considered that intra-articular hyaluronic acid injection may improve the function of synovial joints by recovery of friction-reducing properties of articular environment.

DESIGN

Thirty-five patients with knee osteoarthritis (grade II according to the Kellgren-Lawrence system) and 50 asymptomatic subjects were enrolled in the study. Patients were analyzed at 3 time points: 1 day before and 2 weeks and 4 weeks after single injection of 1.5% cross-linked hyaluronate. Control subjects were tested once. The vibroarthrographic signals were collected during knee flexion/extension motion using an accelerator and described by variation of mean square (VMS), mean range (R5), and power spectral density for frequency of 50 to 250 Hz (P1), and 250 to 450 Hz (P2).

RESULTS

Patients before viscosupplementation were characterized by about 2-fold higher values of vibroarthrographic parameters than controls. Two weeks after the procedure, the values of R5, P1, and P2 significantly decreased, in comparison to pre-injection. At 4 weeks post-injection, we noted a significant increase in R5, P1, and P2 values, when compared to 2 weeks post-injection. Finally, at 4 weeks post-injection, the level of VMS, R5, and P2 parameters did not differ from values obtained at pre-injection.

CONCLUSIONS

We showed that viscosupplementation may be effective in providing arthrokinematics improvement, but with a relatively short period of duration. This phenomenon is observed as decreased vibroacoustic emission, which reflects a more smooth movement in the joint.

Intra-Articular Injections in Knee Osteoarthritis: A Review of Literature

Knee osteoarthritis (OA) is a chronic, degenerative, and progressive disease of articular cartilage, producing discomfort and physical disability in older adults. Thirteen percent of elderly people complain of knee OA. Management options for knee OA could be divided into the following categories: conservative, pharmacological, procedural, and surgical. Joint replacement is the gold standard, reserved for severe grades of knee OA, due to its complications rate and increased risk of joint revision. A nonsurgical approach is the first choice in the adult population with cartilage damage and knee OA. Yearly, more than 10% of knee OA-affected patients undergo intra-articular injections of different drugs, especially within three months after OA diagnosis. Several molecules, such as corticosteroids injection, hyaluronic acid (HA), and platelet-rich plasma (PRP), are managed to reduce the symptoms of patients with knee OA. The aim of this review was to offer an overview of intra-articular injections used for the treatment of OA and report the conventional pharmacological products used.

Gaelic Sport Injuries

The Gaelic sports of hurling and football, native to Ireland, are increasing in popularity worldwide. The injury profile of these sports requires multidisciplinary management by sports physicians, orthopaedic surgeons, and musculoskeletal (MSK) radiologists, among others. Advances in imaging modalities and interventional techniques have aided the diagnosis and treatment of sport injuries. In this article, we review the literature and our own institutional experience to describe common injury patterns identified in Gaelic games athletes, their main imaging features and relevant therapeutic interventions. We discuss the increasing prevalence of imaging services at sporting events and the central role of MSK radiologists in sports injury management.

Meniscectomy-induced osteoarthritis in the sheep model for the investigation of therapeutic strategies: a systematic review

PURPOSE

One of the major risk factors for OA is meniscectomy (Mx) that causes a rapid and progressive OA. Mx has been employed in various animal models, especially in large ones, to study preclinical safety and strategy effectiveness to counteract OA. The aim of the present study is to review in vivo studies, performed in sheep and published in the last ten years.

METHODS

The search strategy was performed in three websites: www.scopus.com, www.pubmed.com, and www.webofknowledge.com, using "Meniscectomy and osteoarthritis in sheep" keywords.

RESULTS

The 25 included studies performed unilateral total medial Mx (MMx), unilateral partial MMx, bilateral MMx, unilateral total lateral Mx (LMx), unilateral partial LMx, and bilateral LMx and MMx combined with anterior cruciate ligament transaction. The most frequently performed is the unilateral total MMx that increases changes in cartilage and subchondral bone more than the other techniques. Gross evaluations, histology, radiography, and biochemical tests are used to assess the degree of OA. The most widely tested treatments are related to scaffolds with or without mesenchymal stem cells.

CONCLUSION

OA therapeutic strategies require the use of large animal models due to similarities with human joint anatomy. A protocol for future in vivo studies on post-traumatic OA is clarified.

Renal clearance of polymeric nanoparticles by mimicry of glycan surface of viruses

It has been shown that viral particles such as herpes simplex virus-1 and cytomegalovirus show renal clearance despite their large size (155-240 nm). Interestingly, one of the common characteristics of these viruses is their glycoprotein rich viral envelope. Since, glycosaminoglycans (GAGs) share similarities with oligosaccharide chains in the glycoproteins, we hypothesize that modification of nanoparticles (NPs) surface with naturally found GAGs could alter NP clearance characteristics by mimicking physicochemical aspects of viral glycoprotein envelope. We demonstrate that polymeric NP bearing surfaces enriched with dermatan sulfate, chondroitin sulfate, heparin sulfate, and hyaluronic acid undergo rapid renal clearance (74% of injected dose as early as 2 h) while showing reduced liver accumulation. Ultra-structural analyses suggest that the excretion of intact NPs occurs via proximal tubule secretion, but not via glomerular filtration. Finally, we demonstrate that our bioinspired NPs are able to accumulate within the epithelial tumor microenvironment despite their efficient renal clearance. Our system provides a framework to address renal toxicity associated with repeated dosing of NP and a platform to elaborate on plausible mechanism of renal clearance of virus particle.

Immunostimulatory activity of low-molecular-weight hyaluronan on dendritic cells stimulated with Aggregatibacter actinomycetemcomitans or Porphyromonas gingivalis

OBJECTIVES

Periodontitis is a chronic inflammatory disease characterized by tooth-supporting tissue destruction, which is elicited by the host's immune response triggered against periodonto-pathogen bacteria. During periodontal tissue destruction, extracellular matrix components are metabolized and fragmented. Some extracellular matrix component-derived fragments, such as low-molecular-weight hyaluronan (LMW-HA), have potent immunogenic potential, playing a role as damage-associated molecular patterns (DAMPs) during activation of immune cells. Dendritic cells (DCs) play a central role in the host's immune response displayed during periodontitis; thus, this study aimed to analyze whether LMW-HA has an immunostimulatory activity on DCs when stimulated with periodonto-pathogen bacteria.

MATERIALS AND METHODS

LMW-HA-treated and non-treated DCs were stimulated with Aggregatibacter actinomycetemcomitans or Porphyromonas gingivalis and the mRNA expression for cytokines tumor necrosis factor-α (TNF-alpha), interleukin-1β (IL-1B), interleukin-6 (IL-6), and interleukin-23 (IL-23A) was quantified by RT-qPCR. In addition, transcription factors interferon regulatory factor 4 (IRF4), interferon regulatory factor 8 (IRF8), neurogenic locus notch homolog protein 2 (NOTCH2), and basic leucine zipper ATF-like transcription factor 3 (BATF3), involved in DC activation, were analyzed.

RESULTS

Higher expression levels of TNF-alpha, IL-1B, IL-6, and IL-23A were detected in LMW-HA-treated DCs after bacterial infection, as compared with non-treated DCs. When LMW-HA-treated DCs were infected with A. actinomycetemcomitans, higher levels of IRF4, NOTCH2, and BATF3 were detected compared with non-treated cells; whereas against P. gingivalis infection, increased levels of IRF4 and NOTCH2 were detected.

CONCLUSION

LMW-HA plays an immunostimulatory role on the immune response triggered by DCs during infection with A. actinomycetemcomitans or P. gingivalis.

CLINICAL RELEVANCE

Detection of extracellular matrix component-derived fragments produced during periodontal tissue destruction, such as LMW-HA, could explain at least partly unsuccessful periodontal treatment and the chronicity of the disease.