Fibrocartilage in the transverse ligament of the human acetabulum

Viability and Tissue Quality of Cartilage Flaps From Patients With Femoroacetabular Hip Impingement: A Matched-Control Comparison

Background:

Chondrolabral damage is commonly observed in patients with cam-type femoroacetabular impingement (FAI). Chondral flap reattachment has recently been proposed as a possible preservation technique.

Purpose/Hypothesis:

The purpose of this study was to determine the viability and tissue quality of chondral flaps from patients with FAI at the time of arthroscopy. It was hypothesized that chondral flaps from patients with cam lesions of the hip would exhibit less viability and greater tissue degeneration than would those of a matched control group.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

Patients with cam-type FAI who were treated with hip arthroscopy between 2014 and 2016 were asked to participate in this study. The cartilage lesions were localized and classified intraoperatively according to Beck classification. A chondral flap (study group) and a cartilage sample (control group) were obtained from each patient for histologic evaluation. Cellular viability and tissue quality were examined and compared in both groups. Cellular viability was determined with live/dead staining, and tissue quality was evaluated using safranin O/fast green, hematoxylin and eosin (H&E) staining, and immunohistochemistry for collagen II. Osteoarthritis Research Society International (OARSI) grading was used for quality assessment, and Image J software was used to calculate the percentage of tissue viability and Col II stain.

Results:

A total of 10 male patients with a mean age of 38.4 years (range, 30-55 years) were enrolled. All chondral flaps were classified as Beck grade 4. The mean cellular viability of the chondral flaps was reduced (54.6% ± 25.6%), and they were found to be degenerated (OARSI grade, 4 ± 1.27). Control samples also had reduced viability (38.8% ± 30.3%) and were degenerative (OARSI grade, 3.5 ± 1.38). There was no statistically significant intergroup difference for viability (P = .203) or OARSI grade (P = .645), nor was there an intragroup correlation between viability and OARSI grade (P > .05). A significant negative correlation (r = −0.9, P = .035) was found between OARSI grade and collagen II percentage scale in 5 selected samples.

Conclusion:

Despite appearing normal macroscopically, the chondral flaps from patients with cam-type FAI displayed loss of viability and tissue degeneration. In addition, control samples obtained away from the injury area also displayed cartilage damage and degeneration. Careful consideration should be taken when attempting to reattach the chondral flap.

Differences in elements between intact and disrupted human ligamenta capitum femorum

To compare the element compositions between intact (i.e., intact throughout its length) and disrupted (i.e., ligament no longer attached to the attachment) ligaments, the contents of elements in the human ligamenta capitum femorum (LCF) were analyzed by inductively coupled plasma-atomic emission spectrometry. Histological and immunohistological assessments were also performed in both groups. The subjects were 8 men and 32 women. Trace element analyses showed that the sulfur and iron contents were significantly greater in the intact group than in the disrupted group, while the phosphorus and magnesium contents were significantly smaller in the intact group than in the disrupted group. The calcium and zinc contents were smaller in the intact group than in the disrupted group, with no significant differences. Histologically, there were fibrocartilage cells and extracellular matrix metachromasia in ligaments of the intact group. In contrast, fibrocartilage cells disappeared, and fat cells appeared instead of collagen fibrils in ligaments of the disrupted group. The LCFs of the intact group were immunohistologically positive for all components examined including collagens, glycosaminoglycans, and proteoglycans. The increase in sulfur suggested the presence of high glycosaminoglycan levels associated with fibrocartilaginous metaplasia in the ligament by compressive force. The reduction in iron may show a decreased number of blood vessels in the synovium after ligament disruption. The increases in phosphorus, magnesium, and calcium are indicative of degenerative changes including calcification and ossification. We conclude that differences in the contents of elements between intact and disrupted LCFs indicate degenerative alterations to the ligament structure after disruption.

Assessment of acetabulum anteversion aligned with the transverse acetabulum ligament: cadaveric study using image-free navigation system

The transverse acetabulum ligament (TAL) has been used as an intraoperative anatomical landmark to position the acetabulum cup in total hip arthroplasty (THA). However, the validity of the use of TAL has not been clarified. The purpose of this study was to examine the orientation of the cup component aligned with the TAL in cadaveric study. The 31 hips in 25 whole-body embalmed cadavers were examined. The donors were 12 men and 13 women. Simulated THA procedure using image-free navigation system was performed and a trial cup with a diameter of approximately 2 mm less than the size of the acetabulum were inserted and snugly fitted on the TAL through the posterior wall of acetabulum. The orientation of the cup component was measured using an image-free THA navigation system. The measured radiographic anteversion and inclination angles averaged 18.2±7.2° (range: 2.0-33.2°) and 43.5±4.2° (range: 33.1-51.0°) respectively. Based on the Lewinnek's safe zone criteria, 26 hips (80.6%) were judged to be within the. Moreover, in the analysis of the gender difference of TAL angles, the average anteversion angle was shown to be significant larger in female than male population. The TAL can be effectively used an intraoperative landmark to align the acetabulum component helping reduce the risk of dislocation after surgery. In the intraoperative judgment, a gender difference in the alignment of the TAL should be taken into consideration.

Lower limb activity in the Cis-Baikal: entheseal changes among middle Holocene Siberian foragers

Lower limb entheseal changes are evaluated in order to reconstruct activity levels and more fully understand cultural and behavioral variation among the middle Holocene (ca. 9,000-3,000 years BP) foragers of Siberia's Cis-Baikal region. The four cemetery samples examined span a period of diachronic change characterized by an 800- to 1,000-year discontinuity in the use of formal cemeteries in the region. Two of the cemetery samples represent the early Neolithic Kitoi culture, dating from 8,000 to 7,000/6800 cal. BP; the other two represent the late Neolithic-early Bronze Age Isakovo-Serovo-Glazkovo (ISG) cultural complex, dating from 6,000/5,800 to 4,000 cal. BP. Findings suggest a dynamic pattern of cultural variability in the Cis-Baikal, with spatial distribution (i.e., site location within particular microregions) appearing to be just as important a factor as cultural/temporal affiliation in explaining intersample differences in entheseal morphology. In addition, intrasample comparisons reveal increasing sexual disparity with advancing age at death, emphasizing the influence of sex-related activities on lower limb entheseal changes. Finally, results from the separate fibrous and fibrocartilaginous datasets appear to be largely congruous, implying that activity patterns in the Cis-Baikal may have similar effects on the morphology of both types of entheses.

Fibrocartilage in various regions of the human glenoid labrum. An immunohistochemical study on human cadavers

PURPOSE

The nature and the distribution of fibrocartilage at the human glenoid labrum are unclear, and a better understanding may help to restore its function in open and arthroscopic Bankart repair. Aim of this study was to describe the fibrocartilage extent within the labrum at clinically relevant sites of the glenoid in order to relate the molecular composition of the labrum to its mechanical environment.

METHODS

Twelve fresh frozen human cadaveric shoulders (mean age 38 years) were obtained, and sections perpendicular to the glenoid rim at the 12, 2, 3, 4, 6 and 9 o' clock position were labelled with antibodies against collagen I and II, aggrecan and link protein.

RESULTS

A fibrocartilaginous transition zone with a characteristic collagen fibre orientation was found in 81% of cases, evenly distributed (83-92%) around the glenoid rim. The percentage of labrum cross-sectional area comprised of fibrocartilage averaged 28% and ranged from 26% at 12 o'clock on the glenoid clock face to 30% at 3 o'clock. The highest amount of fibrocartilage (82%) was found in the region neighbouring the hyaline articular cartilage. In the region beyond the bony edge of the glenoid, fibrocartilage cross-sectional area did not exceed 12-17%.

CONCLUSION

Fibrocartilage is present at all examined positions around the glenoid rim and constitutes up to 1/3 of the cross-sectional area of the labrum. In turn, the percentage of fibrocartilage in different regions of its cross-section varies considerably. The findings suggest that the penetration of fibrocartilaginous tissue may be reduced by avoiding the highly fibrocartilage transition zone during restoration of labral detachment.

Enthesopathy formation in the humerus: Data from known age-at-death and known occupation skeletal collections

Enthesopathies, in the guise of musculoskeletal skeletal stress markers (MSM), have been widely used to reconstruct activity levels in human skeletal populations. In general, studies have focused on their presence in the upper limb, which is used in the majority of daily activities. The aim of this study was to use some of the attachment sites on the humerus to explore the relationship between enthesopathy formation, activity, and the ageing process. The skeletal sample used in this study comprised male adult skeletons with known age-at-death and known occupations from the late-19th and early-20th century cemeteries in Portugal. The enthesopathies were recorded as either present or absent. Statistical analysis using Fishers exact tests and logistic regression was undertaken to determine whether associations could be found between specific activities or socioeconomic status (manual or nonmanual workers), and age and enthesopathy presence. Left and right sides were analyzed separately. Fisher's exact tests were used to determine the relationship between activity and enthesopathy, and they demonstrated no association between activity and enthesopathies (P > 0.01). The results of the logistic regression established that age was the single most significant factor in enthesopathy formation (P > 0.05). This study found that, in these samples, age-at-death, and therefore age-related degeneration rather than degeneration caused by activities, was the primary cause of enthesopathy formation. Considering the difficulties of reliably ageing adult human skeletal remains, this is a major issue for studies of activity using enthesopathies.

The structure of the coracoacromial ligament: fibrocartilage differentiation does not necessarily mean pathology

The coracoacromial ligament forms part of the coracoacromial arch and is implicated in impingement syndrome and acromial spur formation. Here, we describe its structure and the composition of its extracellular matrix. Ligaments were obtained from 15 cadavers, nine from older people (average age 74.7 years) and six from younger individuals (average age 24.2 years). Cryosections of methanol-fixed tissue were cut and sections were immunolabelled with monoclonal antibodies against collagens, glycosaminoglycans, proteoglycans, matrix proteins and neurofilament proteins. Both ligament entheses were highly fibrocartilaginous and immunolabelled strongly for type II collagen, aggrecan and link protein. The area of labelling was more extensive in older people. However, fibrocartilage also characterized the ligament midsubstance, particularly with increased age. Signs of fibrocartilage degeneration were more common in older people. Ligament fat (containing blood vessels and nerve fibers) was conspicuous in both age groups, especially between fiber bundles at the entheses. We conclude that fibrocartilage is a normal feature but becomes more pronounced with age. It is not necessarily pathological, for it simply indicates that the ligament is subject to compression and/or shear. Nevertheless, the prominence of fibrocartilage at the acromial enthesis may relate to the frequency with which enthesophytes develop.

An immunohistochemical study of the tissue bridging adult spondylolytic defects--the presence and significance of fibrocartilaginous entheses

Introduction Spondylolytic spondylolisthesis is an osseous discontinuity of the vertebral arch that predominantly affects the fifth lumbar vertebra. Biomechanical factors are closely related to the condition. An immunohistochemical investigation of lysis-zone tissue obtained from patients with isthmic spondylolisthesis was performed to determine the molecular composition of the lysis-zone tissue and enable interpretation of the mechanical demands to which the tissue is subject.

METHODS

During surgery, the tissue filling the spondylytic defects was removed from 13 patients. Twelve spondylolistheses were at the L5/S1 level with slippage being less than Meyerding grade II. Samples were methanol fixed, decalcified and cryosectioned. Sections were labelled with a panel of monoclonal antibodies directed against collagens, glycosaminoglycans and proteoglycans.

RESULTS

The lysis-zone tissue had an ordered collagenous structure with distinct fibrocartilaginous entheses at both ends. Typically, these had zones of calcified and uncalcified fibrocartilage labelling strongly for type II collagen and aggrecan. Labelling was also detected around bony spurs that extended from the enthesis into the lysis-zone. The entheses also labelled for types I, III and VI collagens, chondroitin four and six sulfate, keratan and dermatan sulfate, link protein, versican and tenascin.

CONCLUSIONS

Although the gap filled by the lysis tissue is a pathological feature, the tissue itself has hallmarks of a normal ligament-i.e. fibrocartilaginous entheses at either end of an ordered collagenous fibre structure. The fibrocartilage is believed to dissipate stress concentration at the hard/soft tissue boundary. The widespread occurrence of molecules typical of cartilage in the attachment of the lysis tissue, suggests that compressive and shear forces are present to which the enthesis is adapted, in addition to the expected tensile forces across the spondylolysis. Such a combination of tensile, shear and compressive forces must operate whenever there is any opening or closing of the spondylolytic gap.

[The enthesis. Physiological morphology, molecular composition and pathoanatomical alterations]

The composition of the extracellular matrix in tendons and ligaments is directly related to the mechanical environment. Local compression triggers functional adaptation that leads to cartilage-specific transformation of the tissue. The molecular composition of the extracellular matrix at the enthesis is related to the amount of stress and to the geometry of the insertion. Comparison of physiologically and non-physiologically loaded entheses shows that only certain molecules occur under relatively high amounts of local compressive stress. The occurrence of certain cartilage specific molecules is clinically relevant, because some of these molecules have been identified as autoantigens during the autoimmune response in patients with rheumatoid arthritis. These molecules constitute potential targets for the manifestation of rheumatoid arthritis at fibrocartilaginous entheses.

Molecular composition and pathology of entheses on the medial and lateral epicondyles of the humerus: a structural basis for epicondylitis

OBJECTIVES

To improve the understanding of epicondylitis by describing the normal structure and composition of the entheses associated with the medial and lateral epicondyles and their histopathology in elderly cadavers.

METHODS

Medial and lateral epicondyles were obtained from 12 cadavers. Six middle aged cadavers (mean 47 years) were used to assess the molecular composition of "normal" entheses from people within an age range vulnerable to epicondylitis. Cryosections of epicondylar entheses were immunolabelled with monoclonal antibodies against molecules associated with fibrocartilage and related tissues. A further six elderly cadavers (mean 84 years) were used for histology to assess features of entheses related to increasing age.

RESULTS

Tendon entheses on both epicondyles fused with those of the collateral ligaments and formed a more extensive structure than hitherto appreciated. Fibrocartilage (which labelled for type II collagen and aggrecan) was a constant feature of all entheses. Entheses from elderly subjects showed extensive microscopic damage, hitherto regarded as a hallmark of epicondylitis.

CONCLUSIONS

Fibrocartilage is a normal feature and not always a sign of enthesopathy. Furthermore, pathological changes documented in patients with epicondylitis may also be seen in elderly people. The fusion of the common extensor and flexor tendon entheses with those of the collateral ligaments suggests that the latter may be implicated as well. This may explain why pain and tenderness in epicondylitis may extend locally beyond the tendon enthesis and why some patients are refractory to local treatments.

Biology of Fibrocartilage Cells

Fibrocartilage is an avascular tissue that is best documented in menisci, intervertebral discs, tendons, ligaments, and the temporomandibular joint. Several of these sites are of particular interest to those in the emerging field of tissue engineering. Fibrocartilage cells frequently resemble chondrocytes in having prominent rough endoplasmic reticulum, many glycogen granules, and lipid droplets, and intermediate filaments together with and actin stress fibers that help to determine cell organization in the intervertebral disc. Fibrocartilage cells can synthesize a variety of matrix molecules including collagens, proteoglycans, and noncollagenous proteins. All the fibrillar collagens (types I, II, III, V, and XI) have been reported, together with FACIT (types IX and XII) and network-forming collagens (types VI and X). The proteoglycans include large, aggregating types (aggrecan and versican) and small, leucine-rich types (decorin, biglycan, lumican, and fibromodulin). Less attention has been paid to noncollagenous proteins, although tenascin-C expression may be modulated by mechanical strain. As in hyaline cartilage, matrix metalloproteinases are important in matrix turnover and fibrocartilage cells are capable of apoptosis.

Immunoblotting assays for keratan sulfate

The detection of microquantities of glycosaminoglycans (GAGs) in biological samples has been hampered by the lack of sensitive methods. In this paper we describe the modification and development of three sensitive assays capable of detecting nanogram quantities of GAGs in biological samples. The first assay detects total GAGs. It is a modified Alcian blue dye precipitation assay in which the dye binds to the negatively charged GAGs in CsCl-fractionated extracts from chicken tendons. This assay compares favorably with the widely used uronic acid assay in terms of its sensitivity and ability to detect all classes of GAGs, including keratan sulfate (KS). Two other assays, dot-blotting and immunoblotting, detect KS in complex mixtures and can be easily adapted for the detection of other GAGs. Both take advantage of binding of carboxyl and sulfate groups of GAGs to trivalent neodymium. In dot-blotting, samples were directly blotted onto nitrocellulose membrane soaked in Nd(2)(SO(4))(3) buffer, and KS was detected with the monoclonal anti-KS 5-D-4 antibody and an avidin-biotin complex detection system. In immunoblotting, the samples were first separated in 28% polyacrylamide gels, transferred onto a Nd(2)(SO(4))(3)-soaked nitrocellulose membrane using a phosphate buffer system, and stained and developed using the same protocol as in dot-blotting. Whereas dot-blotting allows the use of very low quantities of samples because of its high sensitivity (lower detection limit was 5 ng), immunoblotting provides more specificity.

The functional anatomy of the human anterior talofibular ligament in relation to ankle sprains

The anterior talofibular ligament is the most commonly injured ligament in the ankle. Despite considerable interest in the clinical outcome of treatment protocols, we do not know whether the distinctive pattern of localization of the injuries relates to regional differences in the structure and molecular composition of the ligament. To address this issue, ligaments were examined by histology and immunohistochemistry. Differences in the structure of its two attachments (i.e. entheses) were evaluated with quantitative, morphometric techniques, and regional differences in the distribution of collagens, glycosaminoglycans and proteoglycans were determined qualitatively by immunolabelling. Morphometric analyses showed that bone density was less at the fibular attachment, but that enthesis fibrocartilage was more prominent. Immunohistochemistry revealed the presence of a fibrocartilage (containing type II collagen and aggrecan) at the site where the ligament wraps around the lateral talar articular cartilage in a plantarflexed and inverted foot: the fibrocartilage is regarded as an adaptation to resisting compression. We propose that avulsion fractures are less common at the talar end of the ligament because (1) bone density is greater here than at the fibular enthesis, and (2) stress is dissipated away from the talar enthesis by the 'wrap-around' fibrocartilaginous character of the ligament near the talar articular facet.

The anatomical basis for disease localisation in seronegative spondyloarthropathy at entheses and related sites

The 2 major categories of idiopathic inflammatory arthritis are rheumatoid arthritis and the seronegative spondyloarthropathies. Whilst the synovium is the primary site of joint disease in the former, the primary site in the latter is less well defined. However, it has recently been proposed that enthesitis-associated changes in the spondyloarthropathies are primary and that all other joint manifestations are secondary. Nevertheless, some of the sites of disease localisation have not been adequately explained in terms of enthesitis. This article summarises current knowledge of the structure, function, blood supply, innervation, molecular composition and histopathology of the classic enthesis (i.e. the bony attachment of a tendon or ligament) and introduces the concept of 'functional' and articular 'fibrocartilaginous' entheses. The former are regions where tendons or ligaments wrap-around bony pulleys, but are not attached to them, and the latter are synovial joints that are lined by fibrocartilage rather than hyaline cartilage. We describe how these 3 types of entheses relate to other, and how all are prone to pathological changes in spondyloarthropathy. We propose that the inflammatory responses characteristic of spondyloarthropathies are triggered at these seemingly diverse sites, in genetically susceptible individuals, by a combination of anatomical factors which lead to higher levels of tissue microtrauma, and the deposition of microbes.

Fibrocartilage at the entheses of the suprascapular (superior transverse scapular) ligament of man--a ligament spanning two regions of a single bone

The suprascapular ligament converts the suprascapular notch into a foramen separating the vessels and nerve of the same name. It connects 2 regions of the same bone and does not cross any joint, and no mechanical function has yet been attributed to it. Nevertheless, variations in its thickness and length, and its tendency to ossify, suggest that the ligament responds to changes in mechanical load. This should be reflected in the composition of the extracellular matrix. The primary purpose of the present study is to demonstrate that the suprascapular ligament has fibrocartilaginous entheses (i.e. insertion sites), even though there is no obvious change in insertional angle that directly results from joint movement. Such a change is more typical of tendons or ligaments that cross highly mobile joints. The complete ligament (including both entheses) was removed from 7 cadavers shortly after death and fixed in 90% methanol. Cryosections were immunolabelled with a panel of monoclonal antibodies against collagens (types I, II, III, VI), glycosaminoglycans (chondroitin 4 sulphate, chondroitin 6 sulphate, dermatan sulphate and keratan sulphates), proteoglycans (aggrecan and versican) and link protein. Both entheses were strongly fibrocartilaginous, and a moderately fibrocartilaginous matrix was also detected throughout the remainder of the ligament. The extracellular matrix of both entheses labelled strongly for type II collagen, aggrecan and link protein. The fibrocartilaginous character of the entheses suggests that the insertion sites of the ligament are subject to both compressive and tensile loading and are regions of stress concentration. This in turn probably reflects the complex shape of the scapula and the presence of a conspicuous indentation (the suprascapular notch) near the ligament. The loading patterns may reflect either the attachment of muscles and/or the forces transmitted to the suprascapular ligament from the neighbouring coracoclavicular ligament.