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

The Meniscus: Basic Science and Therapeutic Approaches

The proper function and longevity of the knee joint are ensured by the knee menisci. Their susceptibility to damage and injury is one of the main risk factors for rapid cartilage loss and the development of osteoarthritis. The vascularization pattern and nutritional status of a torn meniscus determine its potential for healing and the success of meniscus surgery. Blood supply is a crucial factor in assessing healing potential. Knee cartilage volume loss and its modification often result from meniscal damage or excision, leading to osteoarthritis. Modern methods for preserving meniscal tissue are currently the treatment of choice. Magnetic resonance imaging (MRI) is the gold standard for assessing meniscus lesions. It provides a comprehensive evaluation of tear stability and progression risk. Additionally, it offers high sensitivity and specificity. Arthrography combined with computed tomography (CT) can be used for patients who are unable to undergo MRI. Other methods, such as X-ray and ultrasound, are not useful for the typical diagnosis of meniscal lesions. Minimally invasive surgery has become the gold standard for both treatment and diagnosis. Modern techniques, such as all-inside compression sutures and other suturing techniques, are also considered. In contrast, in the past, open total meniscectomy was routinely performed as the gold standard, based on the mistaken belief that the menisci were functionless. Currently, new treatment methods for meniscal lesions are being explored, including mesenchymal stem cells, synthetic implants, and platelet-rich plasma (PRP). The crucial role of the menisci in knee biomechanics drives the development of modern solutions focused on preserving meniscal tissue.

Intra-Articular Injection of Human Umbilical Cord-Derived Mesenchymal Stromal Cells Reduces Radiographic Osteoarthritis in an Ovine Model

OBJECTIVE

To determine if mesenchymal stromal cells (MSCs) derived from human umbilical cords (hUC) could reduce degeneration developing when injected into the knee of a large animal model of osteoarthritis (OA).

DESIGN

Ten million culture-expanded UC-MSCs (pooled from 3 human donors) were injected in 50 μL of tissue culture medium into the left stifle joints of 7 sheep whose medial meniscus was transected 4 weeks previously. Seven other sheep had only 50 μL of medium injected as the no treatment "control" group. After 8 weeks the sheep underwent euthanasia, the joints were excised and examined macroscopically, via x-ray and magnetic resonance imaging (MRI), both via histology for degenerative and inflammatory changes and immunohistochemically to identify any human cells within the joint tissues. Activity monitoring both before meniscus transection and euthanasia was also undertaken.

RESULTS

There was a significant reduction in the Kellgren-Lawrence x-ray score for joints injected with hUC-MSCs compared with the control joints. Likewise, macroscopic, MRI, synovitis and OARSI histology scores were all lower (better) in the joints injected with hUC-MSCs than in the control arm, but not significantly. Activity levels and synovitis scores were similar in both groups of animals.

CONCLUSIONS

hUC-MSCs appear to modify and reduce the development of osteoarthritic changes in the ovine stifle joint after meniscal destabilization, an injury which commonly leads to OA in humans. These results are encouraging for the potential benefit of culture expanded UC-MSCs as an allogeneic cell therapy in patients who may have early OA following a meniscal injury of the knee.

Animal Models of Osteoarthritis: Updated Models and Outcome Measures 2016-2023

Purpose

Osteoarthritis (OA) is a global musculoskeletal disorder that affects primarily the knee and hip joints without any FDA-approved disease-modifying therapies. Animal models are essential research tools in developing therapies for OA; many animal studies have provided data for the initiation of human clinical trials. Despite this, there is still a need for strategies to recapitulate the human experience using animal models to better develop treatments and understand pathogenesis. Since our last review on animal models of osteoarthritis in 2016, there have been exciting updates in OA research and models. The main purpose of this review is to update the latest animal models and key features of studies in OA research.

Method

We used our existing classification method and screened articles in PubMed and bibliographic search for animal OA models between 2016 and 2023. Relevant and high-cited articles were chosen for inclusion in this narrative review.

Results

Recent studies were analyzed and classified. We also identified ex vivo models as an area of ongoing research. Each animal model offers its own benefit in the study of OA and there are a full range of outcome measures that can be assessed. Despite the vast number of models, each has its drawbacks that have limited translating approved therapies for human use.

Conclusion

Depending on the outcome measures and objective of the study, researchers should pick the best model for their work. There have been several exciting studies since 2016 that have taken advantage of regenerative engineering techniques to develop therapies and better understand OA.

Lay Summary

Osteoarthritis (OA) is a chronic debilitating disease without any cure that affects mostly the knee and hip joints and often results in surgical joint replacement. Cartilage protects the joint from mechanical forces and degrades with age or in response to injury. The many contributing causes of OA are still being investigated, and animals are used for preclinical research and to test potential new treatments. A single consensus OA animal model for preclinical studies is non-existent. In this article, we review the many animal models for OA and provide a much-needed update on studies and model development since 2016.

Subchondral bone remodeling patterns in larger animal models of meniscal injuries inducing knee osteoarthritis - a systematic review

PURPOSE

Elucidating subchondral bone remodeling in preclinical models of traumatic meniscus injury may address clinically relevant questions about determinants of knee osteoarthritis (OA).

METHODS

Studies on subchondral bone remodeling in larger animal models applying meniscal injuries as standardizing entity were systematically analyzed. Of the identified 5367 papers reporting total or partial meniscectomy, meniscal transection or destabilization, 0.4% (in guinea pigs, rabbits, dogs, minipigs, sheep) remained eligible.

RESULTS

Only early or mid-term time points were available. Larger joint sizes allow reporting higher topographical details. The most frequently reported parameters were BV/TV (61%), BMD (41%), osteophytes (41%) and subchondral bone plate thickness (39%). Subchondral bone plate microstructure is not comprehensively, subarticular spongiosa microstructure is well characterized. The subarticular spongiosa is altered shortly before the subchondral bone plate. These early changes involve degradation of subarticular trabecular elements, reduction of their number, loss of bone volume and reduced mineralization. Soon thereafter, the previously normal subchondral bone plate becomes thicker. Its porosity first increases, then decreases.

CONCLUSION

The specific human topographical pattern of a thinner subchondral bone plate in the region below both menisci is present solely in the larger species (partly in rabbits), but absent in rodents, an important fact to consider when designing animal studies examining subchondral consequences of meniscus damage. Large animal models are capable of providing high topographical detail, suggesting that they may represent suitable study systems reflecting the clinical complexities. For advanced OA, significant gaps of knowledge exist. Future investigations assessing the subchondral bone in a standardized fashion are warranted.

Pressure sensing mat as an objective and sensitive tool for the evaluation of lameness in rabbits

In orthopaedic research, the analysis of the gait pattern is an often-used evaluation method. It allows an assessment of changes in motion sequence and pain level during postoperative follow up periods. Visual assessments are highly subjective and dependent on the circumstances. Particular challenge in rabbits is their hopping gait pattern. The aim of the present study was to establish a more objective and sensitive lameness evaluation using a pressure sensing mat. Twelve NZW rabbits were implemented in the study. They got an artificial anterior cruciate ligament transection of the right knee in connection with an experimental study, which investigated PTOA treatment. Rabbits were examined by a visual lameness score. Additionally, load of the hindlimbs was measured by the use of a pressure sensing mat and a video was recorded. Peak pressure and time force integral, defined as cumulated integral of all sensors associated to a hind paw, were evaluated. Preoperative data were collected on three independent days. As postoperative measurement time points, week 1 and week 12 after surgery were chosen. The subjective visual scoring was compared to the objective data of the pressure sensing mat. Following the visual score, lameness in week one was mild to moderate. In week twelve, rabbits were evaluated as lame free bar one. Contrary, following the values of the sensor mat, lameness in week one appeared to be more pronounced and almost all rabbits still showed low-grade lameness in week twelve. Consequently, the pressure sensing mat is more sensitive than the visual score and captures the grade of lameness much more accurately. For specific orthopaedic issues, where subtle differences in lameness are important to detect, the used system is a good supplementary evaluation method.

In Vivo Model of Osteoarthritis to Compare Allogenic Amniotic Epithelial Stem Cells and Autologous Adipose Derived Cells

Simple Summary

An early resolution of osteoarthritis (OA), through minimally invasive orthobiological solutions, would be important to enable a return to daily and sport activities, and delay prosthesis solutions. No study has yet evaluated amniotic epithelial stem cells (AECs) in OA. They could be considered a valid alternative to adipose derived cells, expanded or concentrated, because they differentiate into three lineages and express mesenchymal and embryonic markers, without a tumorigenic phenotype. The innovative aspects of this study are the comparison of three injective orthobiological treatments, the in vivo use of AECs in OA, and the evaluation of structural and inflammatory fronts of OA for up to six months.

Abstract

The challenge of osteoarthritis (OA) is to find a minimally invasive orthobiological therapy to contrast OA progression, on inflammatory and structural fronts. The aim of the present study is to compare the effects of an intra-articular injection of three orthobiological treatments, autologous culture expanded adipose-derived mesenchymal stromal cells (ADSCs), autologous stromal vascular fraction (SVF) and allogenic culture expanded amniotic epithelial stem cells (AECs), in an animal model of OA. OA was induced in 24 sheep by bilateral lateral meniscectomy and, at 3 and 6 months post-treatment, the results were analyzed with macroscopy, histology, histomorphometry, and biochemistry. All the three treatments showed better results than control (injection of NaCl), but SVF and AECs showed superiority over ADSCs, because they induced higher cartilage regeneration and lower inflammation. SVF showed better results than AECs at 3 and 6 months. To conclude, SVF seems to be more favorable than the other biological options, because it is easily obtained and rapidly used after harvesting, with good healing potential. AECs cause no discomfort and could be also considered for the treatment of OA joints.

Knee Intraosseous Injections: A Systematic Review of Clinical Evidence of Different Treatment Alternatives

OBJECTIVE

To systematically review the available clinical evidence regarding the safety and efficacy of knee intraosseous injections for the treatment of bone marrow lesions in patients affected by knee osteoarthritis.

DESIGN

A literature search was carried out on PubMed, Embase, and Google Scholar databases in January 2020. The following inclusion criteria were adopted: (1) studies of any level of evidence, dealing with subchondral injection of bone substitute materials and/or biologic agents; (2) studies with minimum 5 patients treated; and (3) studies with at least 6 months' follow-up evaluation. All relevant data concerning clinical outcomes, adverse events, and rate of conversion to arthroplasty were extracted.

RESULTS

A total of 12 studies were identified: 7 dealt with calcium phosphate administration, 3 with platelet-rich plasma, and 2 with bone marrow concentrate injection. Only 2 studies were randomized controlled trials, whereas 6 studies were prospective and the remaining 4 were retrospective. Studies included a total of 459 patients treated with intraosseous injections. Overall, only a few patients experienced adverse events and clinical improvement was documented in the majority of trial. The lack of any comparative evaluation versus subchondral drilling alone is the main limitation of the available evidence.

CONCLUSIONS

Knee intraosseous injections are a minimally invasive and safe procedure to address subchondral bone damage in osteoarthritic patients. They are able to provide beneficial effects at short-term evaluation. More high-quality evidence is needed to confirm their potential and to identify the best product to adopt in clinical practice.

A novel model of a biomechanically induced osteoarthritis-like cartilage for pharmacological in vitro studies

Excessive pressure or overload induces and aggravates osteoarthritic changes in articular cartilage, but the underlying biomechanical forces are largely ignored in existing pharmacological in vitro models that are used to investigate drugs against osteoarthritis (OA). Here, we introduce a novel in vitro model to perform pathophysiological and pharmacological investigations, in which cartilage explants are subjected to intermittent cyclic pressure, and characterize its ability to mimic OA‐like tissue reactivity. Mechanical loading time‐dependently increased the biosynthesis, content and retention of fibronectin (Fn), whereas collagen metabolism remained unchanged. This protocol upregulated the production and release of proteoglycans (PGs). The release of PGs from explants was significantly inhibited by a matrix metalloproteinase (MMP) inhibitor, suggesting the involvement of such proteinases in the destruction of the model tissue, similar to what is observed in human OA cartilage. In conclusion, the metabolic alterations in our new biomechanical in vitro model are similar to those of early human OA cartilage, and our pharmacological prevalidation with an MMP‐inhibitor supports its value for further in vitro drug studies.

Biosynthetic scaffolds for partial meniscal loss: A systematic review from animal models to clinical practice

Acute or degenerative meniscus tears are the most common knee lesions. Meniscectomy provides symptomatic relief and functional recovery only in the short- to mid-term follow-up but significantly increases the risk of osteoarthritis. For this reason, preserving the meniscus is key, although it remains a challenge. Allograft transplants present many disadvantages, so during the last 20 years preclinical and clinical research focused on developing and investigating meniscal scaffolds. The aim of this systematic review was to collect and evaluate all the available evidence on biosynthetic scaffolds for meniscus regeneration both in vivo and in clinical studies. Three databases were searched: 46 in vivo preclinical studies and 30 clinical ones were found. Sixteen natural, 15 synthetic, and 15 hybrid scaffolds were studied in vivo. Among them, only 2 were translated into clinic: the Collagen Meniscus Implant, used in 11 studies, and the polyurethane-based scaffold Actifit®, applied in 19 studies. Although positive outcomes were described in the short- to mid-term, the number of concurrent procedures and the lack of randomized trials are the major limitations of the available clinical literature. Few in vivo studies also combined the use of cells or growth factors, but these augmentation strategies have not been applied in the clinical practice yet. Current solutions offer a significant but incomplete clinical improvement, and the regeneration potential is still unsatisfactory. Building upon the overall positive results of these "old" technologies to address partial meniscal loss, further innovation is urgently needed in this field to provide patients better joint sparing treatment options.

Non-clinical assessment of lubrication and free radical scavenging of an innovative non-animal carboxymethyl chitosan biomaterial for viscosupplementation: An in-vitro and ex-vivo study

OBJECTIVE

Lubrication and free radical scavenging are key features of biomaterials used for viscosupplementation (VS) of joints affected by osteoarthritis (OA). The objective of this study was to describe the non-clinical performance characterization of KiOmedine® CM-Chitosan, a non-animal carboxymethyl chitosan, in order to assess its intended action in VS and to compare it to existing viscosupplements based on crosslinked hyaluronan (HA) formulations.

METHOD

The lubrication capacity of the tested viscosupplements (VS) was evaluated in-vitro and ex-vivo. In-vitro, the coefficient of friction (COF) was measured using a novel tribological system. Meanwhile, an ex-vivo biomechanical model in ovine hindlimbs was developed to assess the recovery of join mobility after an intra-articular (IA) injection. Free radical scavenging capacity of HA and KiOmedine® CM-Chitosan formulations was evaluated using the Trolox Equivalent Antioxidant Capacity (TEAC) assay.

RESULTS

In the in-vitro tribological model, KiOmedine® CM-Chitosan showed high lubrication capacity with a significant COF reduction than crosslinked HA formulations. In the ex-vivo model, the lubrication effect of KiOmedine® CM-Chitosan following an IA injection in the injured knee was proven again by a COF reduction. The recovery of joint motion was optimal with an IA injection of 3 ml of KiOmedine® CM-Chitosan, which was significantly better than the crosslinked HA formulation at the same volume. In the in-vitro TEAC assay, KiOmedine® CM-Chitosan showed a significantly higher free radical scavenging capacity than HA formulations.

CONCLUSION

Overall, the results provide a first insight into the mechanism of action in terms of lubrication and free radical scavenging for the use of KiOmedine® CM-Chitosan as a VS treatment of OA. KiOmedine® CM-Chitosan demonstrated a higher capacity to scavenge free radicals, and it showed a higher recovery of mobility after a knee lesion than crosslinked HA formulations. This difference could be explained by the difference in chemical structure between KiOmedine® CM-Chitosan and HA and their formulations.

Finite element analysis of biomechanical effects of residual varus/valgus malunion after femoral fracture on knee joint

OBJECTIVE

Post-operative femoral shaft fractures are often accompanied by a residual varus/valgus deformity, which can result in osteoarthritis in severe cases. The purpose of this study was to investigate the biomechanical effects of residual varus/valgus deformities after middle and lower femoral fracture on the stress distribution and contact area of knee joint.

METHODS

Thin-slice CT scanning of lower extremities and MRI imaging of knee joints were obtained from a healthy adult male to establish normal lower limb model (neutral position). Then, the models of 3°, 5°, and 10° of varus/valgus were established respectively by modifying middle and lower femur of normal model. To validate the modifying, a patient-specific model, whose BMI was same to former and had 10° of varus deformity of tibia, was built and simulated under the same boundary conditions.

RESULT

The contact area and maximum stress of modified models were similar to those of patient-specific model. The contact area and maximum stress of medial tibial cartilage in normal neutral position were 244.36 mm² and 0.64 MPa, while those of lateral were 196.25 mm² and 0.76 MPa. From 10° of valgus neutral position to 10° of varus, the contact area and maximum stress of medial tibial cartilage increased, and the lateral gradually decreased. The contact area and maximum stress of medial meniscus in normal neutral position were 110.91 mm² and 3.24 MPa, while those of lateral were 135.83 mm² and 3.45 MPa. The maximum stress of medial tibia subchondral bone in normal neutral position was 1.47 MPa, while that of lateral was 0.65 MPa. The variation trend of medial/lateral meniscus and subchondral bone was consistent with that of tibial plateau cartilage in the contact area and maximum stress.

CONCLUSION

This study suggested that varus/valgus deformity of femur had an obvious effect on the contact area and stress distribution of knee joint, providing biomechanical evidence and deepening understanding when performing orthopedic trauma surgery or surgical correction of the already existing varus/valgus deformity.