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Reinhard J, Oláh T, Laschke MW, Goebel LKH, Schmitt G, Speicher-Mentges S, Menger MD, Cucchiarini M, Pape D, Madry H. Modulation of early osteoarthritis by tibiofemoral re-alignment in sheep. Osteoarthritis Cartilage 2024; 32:690-701. [PMID: 38442768 DOI: 10.1016/j.joca.2024.02.892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 01/30/2024] [Accepted: 02/18/2024] [Indexed: 03/07/2024]
Abstract
OBJECTIVE To investigate whether tibiofemoral alignment influences early knee osteoarthritis (OA). We hypothesized that varus overload exacerbates early degenerative osteochondral changes, and that valgus underload diminishes early OA. METHOD Normal, over- and underload were induced by altering alignment via high tibial osteotomy in adult sheep (n = 8 each). Simultaneously, OA was induced by partial medial anterior meniscectomy. At 6 weeks postoperatively, OA was examined in five individual subregions of the medial tibial plateau using Kellgren-Lawrence grading, quantification of macroscopic OA, semiquantitative histopathological OA and immunohistochemical type-II collagen, ADAMTS-5, and MMP-13 scoring, biochemical determination of DNA and proteoglycan contents, and micro-computed tomographic evaluation of the subchondral bone. RESULTS Multivariate analyses revealed that OA cartilaginous changes had a temporal priority over subchondral bone changes. Underload inhibited early cartilage degeneration in a characteristic topographic pattern (P ≥ 0.0983 vs. normal), in particular below the meniscal damage, avoided alterations of the subarticular spongiosa (P ≥ 0.162 vs. normal), and prevented the disturbance of otherwise normal osteochondral correlations. Overload induced early alterations of the subchondral bone plate microstructure towards osteopenia, including significantly decreased percent bone volume and increased bone surface-to-volume ratio (all P ≤ 0.0359 vs. normal). CONCLUSION The data provide high-resolution evidence that tibiofemoral alignment modulates early OA induced by a medial meniscus injury in adult sheep. Since underload inhibits early OA, these data also support the clinical value of strategies to reduce the load in an affected knee compartment to possibly decelerate structural OA progression.
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Affiliation(s)
- Jan Reinhard
- Center of Experimental Orthopaedics, Saarland University, 66421 Homburg, Germany.
| | - Tamás Oláh
- Center of Experimental Orthopaedics, Saarland University, 66421 Homburg, Germany; Cartilage Net of the Greater Region, 66421 Homburg, Germany.
| | - Matthias W Laschke
- Institute for Clinical and Experimental Surgery, Saarland University Medical Center and Saarland University, 66421 Homburg, Germany.
| | - Lars K H Goebel
- Center of Experimental Orthopaedics, Saarland University, 66421 Homburg, Germany; Cartilage Net of the Greater Region, 66421 Homburg, Germany.
| | - Gertrud Schmitt
- Center of Experimental Orthopaedics, Saarland University, 66421 Homburg, Germany.
| | | | - Michael D Menger
- Institute for Clinical and Experimental Surgery, Saarland University Medical Center and Saarland University, 66421 Homburg, Germany.
| | - Magali Cucchiarini
- Center of Experimental Orthopaedics, Saarland University, 66421 Homburg, Germany; Cartilage Net of the Greater Region, 66421 Homburg, Germany.
| | - Dietrich Pape
- Cartilage Net of the Greater Region, 66421 Homburg, Germany; Clinique d'Eich, Centre Hospitalier de Luxembourg, Eich, 1460 Luxembourg, Germany.
| | - Henning Madry
- Center of Experimental Orthopaedics, Saarland University, 66421 Homburg, Germany; Cartilage Net of the Greater Region, 66421 Homburg, Germany.
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Deng H, Chen Z, Kang J, Liu J, Chen S, Li M, Tao J. The mediating role of synovitis in meniscus pathology and knee osteoarthritis radiographic progression. Sci Rep 2024; 14:12335. [PMID: 38811752 PMCID: PMC11137050 DOI: 10.1038/s41598-024-63291-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 05/27/2024] [Indexed: 05/31/2024] Open
Abstract
Meniscus pathologies (damage, extrusion) and synovitis are associated with knee osteoarthritis (KOA); however, whether synovitis mediates the relationship between meniscus pathologies and KOA radiographic progression remains unclear. We conducted an observational study in the Osteoarthritis Initiative (OAI) cohort, with a 48-month follow-up. Meniscus pathology and synovitis were measured by MRI osteoarthritis knee score (MOAKS) at baseline and 24 months, and a comprehensive synovitis score was calculated using effusion and Hoffa synovitis scores. The knee osteoarthritis radiographic progression was considered that Kellgren-Lawrence (KL) grade and joint space narrowing (JSN) grade at 48 months were increased compared to those at baseline. This study included a total of 589 participants, with KL grades mainly being KL1 (26.5%), KL2 (34.1%), and KL3 (30.2%) at baseline, while JSN grades were mostly 0 at baseline. A logistic regression model was used to analyze the relationship between meniscus pathology, synovitis, and KOA progression. Mediation analysis was used to evaluate the mediation effect of synovitis. The average age of the participants was 61 years old, 62% of which were female. The medial meniscus extrusion was longitudinally correlated with the progression of KL (odds ratio [OR]: 2.271, 95% confidence interval [CI]: 1.412-3.694) and medial JSN (OR: 3.211, 95% CI: 2.040-5.054). Additionally, the longitudinal correlation between medial meniscus damage and progression of KOA (OR: 1.853, 95% CI: 1.177-2.941) and medial JSN (OR: 1.655, 95% CI: 1.053-2.602) was significant. Synovitis was found to mediate the relationship between medial meniscus extrusion and KL and medial JSN progression at baseline (β: 0.029, 95% CI: 0.010-0.053; β: 0.022, 95% CI: 0.005-0.046) and beyond 24 months (β: 0.039, 95% CI: 0.016-0.068; β: 0.047, 95% CI: 0.020-0.078). However, we did not find evidence of synovitis mediating the relationship between meniscal damage and KOA progression. Synovitis mediates the relationship between medial meniscus extrusion (rather than meniscus damage) and KOA progression.
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Affiliation(s)
- Hui Deng
- Department of Orthopedics, Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Zhijun Chen
- Department of Orthopedics, Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Jiawei Kang
- Department of Orthopedics, Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Jun Liu
- Department of Orthopedics, Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Shenliang Chen
- Department of Orthopedics, Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Mingzhang Li
- Department of Orthopedics, Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Jun Tao
- Department of Orthopedics, Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China.
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O'Sullivan O, Ladlow P, Steiner K, Hillman C, Stocks J, Bennett AN, Valdes AM, Kluzek S. Current status of catabolic, anabolic and inflammatory biomarkers associated with structural and symptomatic changes in the chronic phase of post-traumatic knee osteoarthritis- a systematic review. OSTEOARTHRITIS AND CARTILAGE OPEN 2023; 5:100412. [PMID: 37877037 PMCID: PMC10590857 DOI: 10.1016/j.ocarto.2023.100412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/26/2023] Open
Abstract
Post-traumatic OA (PTOA) can occur within 5 years after a significant injury and is a valuable paradigm for identifying biomarkers. This systematic review aims to summarise published literature in human studies on the associations of known serum and synovial fluid biomarkers at least a year from injury to structural, symptomatic changes and underlying PTOA processes. A systematic review was performed using PRISMA guidelines, prospectively registered on PROSPERO (CRD42022371838), for all 'wet' biomarkers a year or more post-injury in 18-45-year-old participants. Three independent reviewers screened search results, extracted data, and performed risk of bias assessments (Newcastle-Ottawa Scale). Study heterogeneity meant a narrative synthesis was undertaken, utilising SWiM guidelines. 952 studies were identified, 664 remaining after deduplication. Following first-round screening, 53 studies underwent second-round screening against pre-determined criteria. Eight studies, with 879 participants (49 % male), were included, measuring serum (n = 7), synovial fluid (SF, n = 6), or both (n = 5). The pooled participant mean age was 29.1 (±4). 51 biomarkers were studied (serum = 38, SF = 13), with no correlation between paired serum and SF samples. One serum biomarker, cartilage oligomeric matrix protein (COMP), and four SF biomarkers, interleukin (IL)-1β, IL-6, tumour necrosis factor (TNF), and COMP, were measured in multiple studies. Associations were described between 11 biomarkers related to catabolism (n = 4), anabolism (n = 2), inflammation (n = 4) and non-coding RNA (n = 1), with OA imaging changes (X-ray and MRI), pain, quality of life and function. Widespread differences in study design and methodology prevented meta-analysis, and evidence was generally weak. A unified approach is required before widespread research and clinical biomarker use.
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Affiliation(s)
- Oliver O'Sullivan
- Academic Department of Military Rehabilitation (ADMR), Defence Medical Rehabilitation Centre (DMRC), Stanford Hall, Loughborough, UK
- Academic Unit of Injury, Recovery and Inflammation Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Peter Ladlow
- Academic Department of Military Rehabilitation (ADMR), Defence Medical Rehabilitation Centre (DMRC), Stanford Hall, Loughborough, UK
- Department of Health, University of Bath, Bath, UK
| | - Kat Steiner
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Charles Hillman
- Academic Unit of Injury, Recovery and Inflammation Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Joanne Stocks
- Academic Unit of Injury, Recovery and Inflammation Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Alexander N. Bennett
- Academic Department of Military Rehabilitation (ADMR), Defence Medical Rehabilitation Centre (DMRC), Stanford Hall, Loughborough, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Ana M. Valdes
- Nottingham NIHR Biomedical Research Centre, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
- Department of Twin Research & Genetic Epidemiology, King's College London, London, UK
| | - Stefan Kluzek
- Academic Unit of Injury, Recovery and Inflammation Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Nottingham, Nottingham, UK
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Huang P, Lin J, Shen H, Zhao X. PSD95 as a New Potential Therapeutic Target of Osteoarthritis: A Study of the Identification of Hub Genes through Self-Contrast Model. Int J Mol Sci 2023; 24:14682. [PMID: 37834131 PMCID: PMC10572132 DOI: 10.3390/ijms241914682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/18/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
Osteoarthritis (OA) is a worldwide joint disease. However, the precise mechanism causing OA remains unclear. Our primary aim was to identify vital biomarkers associated with the mechano-inflammatory aspect of OA, providing potential diagnostic and therapeutic targets for OA. Thirty OA patients who underwent total knee arthroplasty were recruited, and cartilage samples were obtained from both the lateral tibial plateau (LTP) and medial tibial plateau (MTP). GO and KEGG enrichment analyses were performed, and the protein-protein interaction (PPI) assessment was conducted for hub genes. The effect of PSD95 inhibition on cartilage degeneration was also conducted and analyzed. A total of 1247 upregulated and 244 downregulated DEGs were identified. Significant differences were observed between MTP and LTP in mechanical stress-related genes and activated sensory neurons based on a self-contrast model of human knee OA. Cluster analysis identified DLG4 as the hub gene. Cyclic loading stress increased PSD95 (encoded by DLG4) expression in LTP cartilage, and PSD95 inhibitors could alleviate OA progression. This study suggests that inhibiting PSD95 could be a potential therapeutic strategy for preventing articular cartilage degradation.
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Affiliation(s)
- Ping Huang
- Department of Orthopaedics, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China; (P.H.); (J.L.)
| | - Jieming Lin
- Department of Orthopaedics, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China; (P.H.); (J.L.)
| | - Hongxing Shen
- Department of Spine Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Xiang Zhao
- Department of Orthopaedics, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China; (P.H.); (J.L.)
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Zhang J, Yang K, Wang C, Gu W, Li X, Fu S, Song G, Wang J, Wu C, Zhu H, Shi Z. Risk factors for chronic ankle instability after first episode of lateral ankle sprain: A retrospective analysis of 362 cases. JOURNAL OF SPORT AND HEALTH SCIENCE 2023; 12:606-612. [PMID: 36931594 PMCID: PMC10466191 DOI: 10.1016/j.jshs.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 12/12/2022] [Accepted: 02/18/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Chronic ankle instability (CAI) is a common sequela following an acute lateral ankle sprain (LAS). To treat an acute LAS more effectively and efficiently, it is important to identify patients at substantial risk for developing CAI. This study identifies magnetic resonance imaging (MRI) manifestations for predicting CAI development after a first episode of LAS and explores appropriate clinical indications for ordering MRI scans for these patients. METHODS All patients with a first-episode LAS who received plain radiograph and MRI scanning within the first 2 weeks after LAS from December 1, 2017 to December 1, 2019 were identified. Data were collected using the Cumberland Ankle Instability Tool at final follow-up. Demographic and other related clinical variables, including age, sex, body mass index, and treatment were also recorded. Univariable and multivariable analyses were performed successively to identify risk factors for CAI after first-episode LAS. RESULTS A total 131 out of 362 patients with a mean follow-up of 3.0 ± 0.6 years (mean ± SD; 2.0-4.1 years) developed CAI after first-episode LAS. According to multivariable regression, development of CAI after first-episode LAS was associated with 5 prognostic factors: age (odds ratio (OR) = 0.96, 95% confidence interval (95%CI): 0.93-1.00, p = 0.032); body mass index (OR = 1.09, 95%CI: 1.02-1.17, p = 0.009); posterior talofibular ligament injury (OR = 2.17, 95%CI: 1.05-4.48, p = 0.035); large bone marrow lesion of the talus (OR = 2.69, 95%CI: 1.30-5.58, p = 0.008), and Grade 2 effusion of the tibiotalar joint (OR = 2.61, 95%CI: 1.39-4.89, p = 0.003). When patients had at least 1 positive clinical finding in the 10-m walk test, anterior drawer test, or inversion tilt test, they had a 90.2% sensitivity and 77.4% specificity in terms of detecting at least 1 prognostic factor by MRI. CONCLUSION MRI scanning is valuable in predicting CAI after first-episode LAS for those patients with at least 1 positive clinical finding in the 10-m walk test, anterior drawer test, and inversion tilt test. Further prospective and large-scale studies are necessary for validation.
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Affiliation(s)
- Jieyuan Zhang
- National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China; Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai 200233, China
| | - Kai Yang
- Department of Radiology, Shanghai Sixth People's Hospital, Shanghai 200233, China
| | - Cheng Wang
- National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China; Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai 200233, China
| | - Wenqi Gu
- National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China; Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai 200233, China
| | - Xueqian Li
- National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China; Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai 200233, China
| | - Shaoling Fu
- National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China; Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai 200233, China
| | - Guoxun Song
- National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China; Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai 200233, China
| | - Jiazheng Wang
- National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China; Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai 200233, China
| | - Chenglin Wu
- National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China; Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai 200233, China
| | - Hongyi Zhu
- National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China; Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai 200233, China; Institute of Clinical Research, National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China.
| | - Zhongmin Shi
- National Center for Orthopaedics, Shanghai Sixth People's Hospital, Shanghai 200233, China; Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai 200233, China.
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O'Sullivan O, Behan FP, Coppack RJ, Stocks J, Kluzek S, Valdes AM, Bennett AN. Osteoarthritis in the UK Armed Forces: a review of its impact, treatment and future research. BMJ Mil Health 2023:e002390. [PMID: 37491135 DOI: 10.1136/military-2023-002390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/31/2023] [Indexed: 07/27/2023]
Abstract
Within the UK Armed Forces, musculoskeletal injuries account for over half of all medical downgrades and discharges. Data from other Armed Forces show that osteoarthritis (OA), more common in military personnel, is likely to contribute to this, both in its primary form and following injury (post-traumatic OA, PTOA), which typically presents in the third or fourth decade. OA is not a progressive 'wear and tear' disease, as previously thought, but a heterogenous condition with multiple aetiologies and modulators, including joint damage, abnormal morphology, altered biomechanics, genetics, low-grade inflammation and dysregulated metabolism. Currently, clinical diagnosis, based on symptomatic or radiological criteria, is followed by supportive measures, including education, exercise, analgesia, potentially surgical intervention, with a particular focus on exercise rehabilitation within the UK military. Developments in OA have led to a new paradigm of organ failure, with an emphasis on early diagnosis and risk stratification, prevention strategies (primary, secondary and tertiary) and improved aetiological classification using genotypes and phenotypes to guide management, with the introduction of biological markers (biomarkers) potentially having a role in all these areas. In the UK Armed Forces, there are multiple research studies focused on OA risk factors, epidemiology, biomarkers and effectiveness of different interventions. This review aims to highlight OA, especially PTOA, as an important diagnosis to consider in serving personnel, outline current and future management options, and detail current research trends within the Defence Medical Services.
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Affiliation(s)
- Oliver O'Sullivan
- Academic Department of Military Rehabilitation, DMRC Stanford Hall, Loughborough, LE12 5QW, UK
- Academic Unit of Injury, Recovery and Inflammation Sciences, University of Nottingham, Nottingham, UK
| | - F P Behan
- Department of Bioengineering, Imperial College London, London, UK
| | - R J Coppack
- Academic Department of Military Rehabilitation, DMRC Stanford Hall, Loughborough, LE12 5QW, UK
- Centre for Sport, Exercise and Osteoarthritis Research, Versus Arthritis, Nottingham, UK
| | - J Stocks
- Academic Unit of Injury, Recovery and Inflammation Sciences, University of Nottingham, Nottingham, UK
| | - S Kluzek
- Academic Unit of Injury, Recovery and Inflammation Sciences, University of Nottingham, Nottingham, UK
- Centre for Sport, Exercise and Osteoarthritis Research, Versus Arthritis, Nottingham, UK
| | - A M Valdes
- Academic Unit of Injury, Recovery and Inflammation Sciences, University of Nottingham, Nottingham, UK
- Department of Twin Research and Genetic Epidemiology, King's College London, London, UK
| | - A N Bennett
- Academic Department of Military Rehabilitation, DMRC Stanford Hall, Loughborough, LE12 5QW, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
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Lisee C, Bjornsen E, Berkoff D, Blake K, Schwartz T, Horton WZ, Pietrosimone B. Changes in biomechanics, strength, physical function, and daily steps after extended-release corticosteroid injections in knee osteoarthritis: a responder analysis. Clin Rheumatol 2023:10.1007/s10067-023-06568-x. [PMID: 36929315 DOI: 10.1007/s10067-023-06568-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 02/21/2023] [Accepted: 02/28/2023] [Indexed: 03/18/2023]
Abstract
INTRODUCTION/OBJECTIVE To determine changes in gait biomechanics, quadricep strength, physical function, and daily steps after an extended-release corticosteroid knee injection at 4 and 8 weeks post-injection in individuals with knee osteoarthritis as well as between responders and non-responders based on changes in self-reported knee function. METHOD The single-arm, clinical trial included three study visits (baseline, 4 weeks, and 8 weeks post-injection), where participants received an extended-release corticosteroid injection following the baseline visit. Time-normalized vertical ground reaction force (vGRF), knee flexion angle (KFA), knee abduction moment (KAM), and knee extension moment (KEM) waveforms throughout stance were collected during gait biomechanical assessments. Participants also completed quadricep strength, physical function (chair-stand, stair-climb, 20-m fast-paced walk) testing, and free-living daily step assessment for 7 days following each visit. RESULTS All participants demonstrated increased KFA excursion (i.e., greater knee extension angle at heel strike and KFA at toe-off), increased KEM during early stance, improved physical function (all p < 0.001), and increased quadricep strength at 4 and 8 weeks. KAM increased throughout most of stance at 4 and 8 weeks post-injection (p < 0.001) but appears to be driven by gait changes in non-responders. Non-responders demonstrated lesser vGRF during late stance and lesser KEM and KFA throughout stance compared to responders at baseline. CONCLUSIONS Extended-release corticosteroid injections demonstrated short-term improvements in gait biomechanics, quadricep strength, and physical function for up to 4 weeks. However, non-responders demonstrated gait biomechanics associated with osteoarthritis progression prior to the corticosteroid injection, suggesting that non-responders demonstrate more deleterious gait biomechanics prior to corticosteroid injection. Key Points • Individuals with knee osteoarthritis who were treated with extended-release corticosteroid injections demonstrated improvements in gait biomechanics and physical function for 8 weeks. • Individuals with knee osteoarthritis, who walked with aberrant walking biomechanics before treatment, failed to respond to extended-release corticosteroid treatment. • Future research should determine the mechanisms contributing to the short-term changes in gait biomechanics and physical function such as reduced inflammation.
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Affiliation(s)
- Caroline Lisee
- Department of Exercise and Sports Science, University of North Carolina at Chapel Hill, CB#8700, 209 Fetzer Hall, Chapel Hill, NC, 27599, USA.
| | - Elizabeth Bjornsen
- Department of Exercise and Sports Science, University of North Carolina at Chapel Hill, CB#8700, 209 Fetzer Hall, Chapel Hill, NC, 27599, USA
| | - David Berkoff
- Department of Orthopaedics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Karen Blake
- Department of Orthopaedics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Todd Schwartz
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - W Zachary Horton
- Department of Statistics, University of California Santa Cruz, Santa Cruz, CA, USA
| | - Brian Pietrosimone
- Department of Exercise and Sports Science, University of North Carolina at Chapel Hill, CB#8700, 209 Fetzer Hall, Chapel Hill, NC, 27599, USA
- Department of Orthopaedics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Evers BJ, Van Den Bosch MHJ, Blom AB, van der Kraan PM, Koëter S, Thurlings RM. Post-traumatic knee osteoarthritis; the role of inflammation and hemarthrosis on disease progression. Front Med (Lausanne) 2022; 9:973870. [PMID: 36072956 PMCID: PMC9441748 DOI: 10.3389/fmed.2022.973870] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
Knee injuries such as anterior cruciate ligament ruptures and meniscal injury are common and are most frequently sustained by young and active individuals. Knee injuries will lead to post-traumatic osteoarthritis (PTOA) in 25–50% of patients. Mechanical processes where historically believed to cause cartilage breakdown in PTOA patients. But there is increasing evidence suggesting a key role for inflammation in PTOA development. Inflammation in PTOA might be aggravated by hemarthrosis which frequently occurs in injured knees. Whereas mechanical symptoms (joint instability and locking of the knee) can be successfully treated by surgery, there still is an unmet need for anti-inflammatory therapies that prevent PTOA progression. In order to develop anti-inflammatory therapies for PTOA, more knowledge about the exact pathophysiological mechanisms and exact course of post-traumatic inflammation is needed to determine possible targets and timing of future therapies.
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Affiliation(s)
- Bob J. Evers
- Department of Experimental Rheumatology, Radboud Institute for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
- Canisius Wilhelmina Hospital, Nijmegen, Netherlands
- *Correspondence: Bob J. Evers
| | - Martijn H. J. Van Den Bosch
- Department of Experimental Rheumatology, Radboud Institute for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Arjen B. Blom
- Department of Experimental Rheumatology, Radboud Institute for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Peter M. van der Kraan
- Department of Experimental Rheumatology, Radboud Institute for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | | | - Rogier M. Thurlings
- Department of Experimental Rheumatology, Radboud Institute for Molecular Life Sciences, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
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Gong Z, Li J, He Z, Li S, Cao P, Ruan G, Zhang Y, Zeng Q, Chen R, Zheng P, Fan T, Zhao Y, Lu P, Zhu Z, Huang G. Quadriceps strength is negatively associated with knee joint structural abnormalities-data from osteoarthritis initiative. BMC Musculoskelet Disord 2022; 23:784. [PMID: 35978313 PMCID: PMC9382744 DOI: 10.1186/s12891-022-05635-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 07/06/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE The aim of this study was to explore the longitudinal associations between baseline quadriceps strength and knee joint structural abnormalities in knee osteoarthritis (KOA). METHODS This study is a longitudinally observational study based on Osteoarthritis Initiative (OAI) cohort, including men and women aged 45-79. Quadriceps strength was measured by isometric knee extension testing at baseline. Knee joint structural abnormalities, including cartilage damage, bone marrow lesions (BMLs), effusion-synovitis and Hoffa-synovitis, were evaluated by Magnetic Resonance Imaging Osteoarthritis Knee Score (MOAKS) at baseline and 1-year follow-up. Generalized estimating equations were employed to examine the associations between quadriceps strength and knee structural abnormalities. All analyses were stratified by sex. RESULTS One thousand three hundred thirty-eight participants (523 men and 815 women) with a mean age of 61.8 years and a mean BMI of 29.4 kg/m2 were included in this study. For men, no significantly longitudinal association of quadriceps strength with structural abnormalities was detected. In contrast, quadriceps strength was significantly and negatively associated with changes in cartilage damage and BMLs in lateral patellofemoral joint (PFJ) (cartilage damage: OR: 0.91, 95% CI 0.84 to 0.99, P = 0.023; BMLs: OR: 0.85, 95% CI 0.74 to 0.96, P = 0.011) and effusion-synovitis (OR = 0.88, 95% CI 0.78 to 0.99, P = 0.045) among females longitudinally. Higher quadriceps strength was significantly associated with less progression of lateral PFJ cartilage damage, BMLs and effusion-synovitis in females. CONCLUSIONS Higher quadriceps strength was associated with changes in cartilage damage and BMLs within the lateral PFJ and effusion-synovitis among females, suggesting the potential protective role of quadriceps strength on joint structures in women.
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Affiliation(s)
- Ze Gong
- Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,School of Rehabilitation Medicine, Southern Medical University, Haizhu District, 510280, Guangzhou, China
| | - Jia Li
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Zijun He
- Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,School of Rehabilitation Medicine, Southern Medical University, Haizhu District, 510280, Guangzhou, China
| | - Shilin Li
- Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,School of Rehabilitation Medicine, Southern Medical University, Haizhu District, 510280, Guangzhou, China
| | - Peihua Cao
- Clinical Research Centre, Zhujiang Hospital, Southern Medical University, Haizhu District 510280, Guangzhou, Guangdong, China
| | - Guangfeng Ruan
- Clinical Research Centre, School of Medicine, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, China
| | - Yan Zhang
- Clinical Research Centre, Zhujiang Hospital, Southern Medical University, Haizhu District 510280, Guangzhou, Guangdong, China
| | - Qing Zeng
- Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,School of Rehabilitation Medicine, Southern Medical University, Haizhu District, 510280, Guangzhou, China
| | - Rong Chen
- Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,School of Rehabilitation Medicine, Southern Medical University, Haizhu District, 510280, Guangzhou, China
| | - Peng Zheng
- Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,School of Rehabilitation Medicine, Southern Medical University, Haizhu District, 510280, Guangzhou, China
| | - Tao Fan
- Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,School of Rehabilitation Medicine, Southern Medical University, Haizhu District, 510280, Guangzhou, China
| | - Yijin Zhao
- Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,School of Rehabilitation Medicine, Southern Medical University, Haizhu District, 510280, Guangzhou, China
| | - Pengcheng Lu
- Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China.,School of Rehabilitation Medicine, Southern Medical University, Haizhu District, 510280, Guangzhou, China
| | - Zhaohua Zhu
- Clinical Research Centre, Zhujiang Hospital, Southern Medical University, Haizhu District 510280, Guangzhou, Guangdong, China.
| | - Guozhi Huang
- Department of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China. .,School of Rehabilitation Medicine, Southern Medical University, Haizhu District, 510280, Guangzhou, China.
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10
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Osteoarthritis year in review 2021: mechanics. Osteoarthritis Cartilage 2022; 30:663-670. [PMID: 35081453 DOI: 10.1016/j.joca.2021.12.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/09/2021] [Accepted: 12/01/2021] [Indexed: 02/02/2023]
Abstract
Osteoarthritis (OA) has a complex, heterogeneous and only partly understood etiology. There is a definite role of joint cartilage pathomechanics in originating and progressing of the disease. Although it is still not identified precisely enough to design or select targeted treatments, the progress of this year's research demonstrates that this goal became much closer. On multiple scales - tissue, joint and whole body - an increasing number of studies were done, with impressive results. (1) Technology based instrument innovations, especially when combined with machine learning models, have broadened the applicability of biomechanics. (2) Combinations with imaging make biomechanics much more precise & personalized. (3) The combination of Musculoskeletal & Finite Element Models yield valid personalized cartilage loads. (4) Mechanical outcomes are becoming increasingly meaningful to inform and evaluate treatments, including predictive power from biomechanical models. Since most recent advancements in the field of biomechanics in OA are at the level of a proof op principle, future research should not only continue on this successful path of innovation, but also aim to develop clinical workflows that would facilitate including precision biomechanics in large scale studies. Eventually this will yield clinical tools for decision making and a rationale for new therapies in OA.
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11
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Oei EHG, Hirvasniemi J, van Zadelhoff TA, van der Heijden RA. Osteoarthritis year in review 2021: imaging. Osteoarthritis Cartilage 2022; 30:226-236. [PMID: 34838670 DOI: 10.1016/j.joca.2021.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/16/2021] [Accepted: 11/11/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To provide a narrative review of original articles on imaging of osteoarthritis (OA) published between January 1, 2020 and March 31, 2021, with a special focus on imaging of inflammation, imaging of bone, cartilage and bone-cartilage interactions, imaging of peri-articular tissues, imaging scoring methods for OA, and artificial intelligence (AI) applied to OA imaging. METHODS The Embase, Pubmed, Medline, Cochrane databases were searched for original research articles in the English language on human, in vivo, imaging of OA published between January 1, 2020 and March 31, 2021. Search terms related to osteoarthritis combined with all imaging modalities and artificial intelligence were applied. A selection of articles reporting on one of the focus topics was discussed further. RESULTS The search resulted in 651 articles, of which 214 were deemed relevant to human OA imaging. Among the articles included, the knee joint (69%) and magnetic resonance imaging (MRI) (52%) were the predominant anatomical area and imaging modality studied. There were also a substantial number of papers (n = 46) reporting on AI applications in the field of OA imaging. CONCLUSION Imaging continues to play an important role in the assessment of OA. Recent advances in OA imaging include quantitative, non-contrast, and hybrid imaging techniques for improved characterization of multiple tissue processes in OA. In addition, an increasing effort in AI techniques is undertaken to enhance OA imaging acquisition and analysis.
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Affiliation(s)
- E H G Oei
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
| | - J Hirvasniemi
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
| | - T A van Zadelhoff
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
| | - R A van der Heijden
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
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12
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Philpott HT, Carter MM, Birmingham TB, Pinto R, Primeau CA, Giffin JR, Lanting BA, Appleton CT. Synovial tissue perivascular edema is associated with altered gait patterns in patients with knee osteoarthritis. Osteoarthritis Cartilage 2022; 30:42-51. [PMID: 34774789 DOI: 10.1016/j.joca.2021.10.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/21/2021] [Accepted: 10/26/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To explore mechanisms of mechanoinflammation, we investigated the association between the presence of knee synovial perivascular edema and gait biomechanics that serve as surrogate measures of knee load in patients with knee osteoarthritis (OA). DESIGN Patients with symptomatic, radiographic knee OA and neutral to varus alignment undergoing total knee arthroplasty or high tibial osteotomy participated in this cross-sectional analysis. All participants underwent 3D gait analysis prior to surgery. Synovial biopsies were obtained during surgery for histopathological assessment. The association between the presence of synovial perivascular edema (predictor) and the external knee moment (outcome) in each orthogonal plane was analyzed using multivariate linear regression and polynomial mixed effects regression models, while adjusting for age, sex, BMI, and gait speed. RESULTS Ninety-two patients with complete gait and histopathological data were included. When fitted over 100% of stance, regression models indicated substantial differences between patients with and without synovial perivascular edema for knee moments in frontal, sagittal and transverse planes. The knee adduction moment was higher in patients with edema from 16 to 74% of stance, with the largest difference at 33% of stance (β = 6.87 Nm [95%CI 3.02, 10.72]); whereas the knee flexion-extension moment differed from 15 to 92% of stance, with the largest difference in extension at 60% of stance (β = -10.80 Nm [95%CI -16.20, -5.40]). CONCLUSIONS In patients with knee OA, the presence of synovial perivascular edema identified by histopathology is associated with aberrant patterns of knee loading throughout stance, supporting the link between biomechanics and synovial inflammation.
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Affiliation(s)
- H T Philpott
- Faculty of Health Sciences, University of Western Ontario, London, N6G 1H1, ON, Canada; Bone and Joint Institute, University of Western Ontario, London Health Sciences Centre-University Hospital, London, N6A 5B5, ON, Canada.
| | - M M Carter
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, N6A 5C1, ON, Canada; Bone and Joint Institute, University of Western Ontario, London Health Sciences Centre-University Hospital, London, N6A 5B5, ON, Canada.
| | - T B Birmingham
- Faculty of Health Sciences, University of Western Ontario, London, N6G 1H1, ON, Canada; Bone and Joint Institute, University of Western Ontario, London Health Sciences Centre-University Hospital, London, N6A 5B5, ON, Canada.
| | - R Pinto
- Faculty of Health Sciences, University of Western Ontario, London, N6G 1H1, ON, Canada; Bone and Joint Institute, University of Western Ontario, London Health Sciences Centre-University Hospital, London, N6A 5B5, ON, Canada.
| | - C A Primeau
- Faculty of Health Sciences, University of Western Ontario, London, N6G 1H1, ON, Canada; Bone and Joint Institute, University of Western Ontario, London Health Sciences Centre-University Hospital, London, N6A 5B5, ON, Canada.
| | - J R Giffin
- Bone and Joint Institute, University of Western Ontario, London Health Sciences Centre-University Hospital, London, N6A 5B5, ON, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, N6A 5C1, ON, Canada.
| | - B A Lanting
- Bone and Joint Institute, University of Western Ontario, London Health Sciences Centre-University Hospital, London, N6A 5B5, ON, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, N6A 5C1, ON, Canada.
| | - C T Appleton
- Bone and Joint Institute, University of Western Ontario, London Health Sciences Centre-University Hospital, London, N6A 5B5, ON, Canada; Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, N6A 5C1, ON, Canada.
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13
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Opening Wedge High Tibial Osteotomy with Combined Use of Patient-Specific 3D-Printed Plates and Taylor Spatial Frame for the Treatment of Knee Osteoarthritis. Pain Res Manag 2021; 2021:8609921. [PMID: 34900072 PMCID: PMC8654534 DOI: 10.1155/2021/8609921] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/13/2021] [Indexed: 12/13/2022]
Abstract
Background High tibial osteotomy (HTO) is used to treat medial degeneration of the osteoarthritis (OA) knee. However, shortcomings still exist in the current procedure, like unprecise creation, inability to correct knee rotation, and internal fixed failure. Here, we reported a novel procedure: patient-specific 3D-printed plates for opening wedge high tibial osteotomy (OWHTO) combined with Taylor spatial frame (TSF). The detailed technique was described, and the clinical outcomes were evaluated. Methods We prospectively evaluate outcomes of patient-specific 3D-printed plates for OWHTO with use of TSF in 25 patients with knee OA and varus alignment. Postoperative efficacy was evaluated using the HSS knee score, pain visual simulation score (VAS), and knee joint motion (ROM), and lower limb alignment was evaluated by measuring femorotibial angle (FTA) and hip-knee-ankle (HKA). Results and Conclusion. All patients did not experience complications such as wound infection, nerve damage, or bone amputation. 25 patients were followed up for 6–18 months. The bony union at bone amputation was achieved in 3 months after surgery, and the pain symptoms were significantly alleviated or disappeared. The VAS score was significantly reduced in 6 months after surgery compared with preoperative; the HSSS score was significantly added in 6 months after surgery compared with preoperative. The ROM of knee joint increased significantly 6 months after operation compared with that before operation, and the difference was statically significant (P < 0.05). The FTA and HKA after operation were significantly superior to that before operation, and the difference was statically significant (P < 0.01). Conclusions Our study showed that patient-specific 3D-printed plates for HTO with the use of TSF have the advantages of small trauma, few complications, simple operation, and fast recovery in treating knee OA and varus alignment.
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14
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Lee J, Lee J, Lee S, Yoo SA, Kim KM, Kim WU, Cho CS, Yoon CH. Genetic deficiency of nuclear factor of activated T cells 5 attenuates the development of osteoarthritis in mice. Joint Bone Spine 2021; 89:105273. [PMID: 34537377 DOI: 10.1016/j.jbspin.2021.105273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/31/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study is aimed to investigate the role of nuclear factor of activated T cells 5 (NFAT5), originally known as the osmosensitive mammalian transcription factor, in the pathogenesis of osteoarthritis (OA) in mice. METHODS OA was induced in male C57BL/6 (wild-type) and NFAT5 haplo-insufficient (NFAT5+/-) mice via destabilization of the medial meniscus (DMM) surgery. OA severity and synovial inflammation were histologically assessed. Expression of CCL2, inflammatory cytokines, cartilage degrading enzymes was determined in the knee joints and cultured chondrocytes from wild-type and NFAT5+/- mice. RESULTS NFAT5 expression was significantly upregulated in the knee joint of a mouse after DMM surgery. NFAT5 deficiency decreased the severity of synovial inflammation and osteoarthritic changes in cartilage and subchondral bone. Moreover, NFAT5 deficiency also decreased the expression of CCL2, IL-1β, MMP-13, ADMATS-5, and macrophage infiltration in the joint. In cultured chondrocytes, hyperosmolar or IL-1β stimulation significantly enhanced the expression of NFAT5, CCL2, IL-1β, IL-6, and MMP-13, and this effect was abolished in chondrocytes from NFAT5+/- mice. Hyperosmolarity or IL-1β-induced NFAT5 and CCL2 downregulated by inhibiting p38 MAPK, JNK, and ERK pathways. CONCLUSIONS Our results indicate that NFAT5 is a crucial regulator of OA pathogenesis by upregulating CCL2 expression and macrophage recruitment. In chondrocyte, NFAT5 plays an important role in the response to hyperosmolar or IL-1β stimulation. Thus, NFAT5 could be an attractive therapeutic target for OA treatment.
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Affiliation(s)
- Jinhee Lee
- Division of Rheumatology, Department of Internal Medicine, The Catholic University of Korea, Seoul, 06591, Korea
| | - Jongmin Lee
- Division of Rheumatology, Department of Internal Medicine, The Catholic University of Korea, Seoul, 06591, Korea
| | - Saseong Lee
- Center for Integrative Rheumatoid Transcriptomics and Dynamics, The Catholic University of Korea, Seoul, 06591, Korea
| | - Seung-Ah Yoo
- Center for Integrative Rheumatoid Transcriptomics and Dynamics, The Catholic University of Korea, Seoul, 06591, Korea
| | - Ki-Myo Kim
- Center for Integrative Rheumatoid Transcriptomics and Dynamics, The Catholic University of Korea, Seoul, 06591, Korea
| | - Wan-Uk Kim
- Division of Rheumatology, Department of Internal Medicine, The Catholic University of Korea, Seoul, 06591, Korea; Center for Integrative Rheumatoid Transcriptomics and Dynamics, The Catholic University of Korea, Seoul, 06591, Korea
| | - Chul-Soo Cho
- Division of Rheumatology, Department of Internal Medicine, The Catholic University of Korea, Seoul, 06591, Korea
| | - Chong-Hyeon Yoon
- Division of Rheumatology, Department of Internal Medicine, The Catholic University of Korea, Seoul, 06591, Korea.
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