A novel large animal model of posttraumatic osteoarthritis induced by inflammation with mechanical stability.

OBJECTIVES: Animal models are needed to reliably separate the effects of mechanical joint instability and inflammation on posttraumatic osteoarthritis (PTOA) pathogenesis. We hypothesized that our modified intra-articular drilling (mIAD) procedure induces cartilage damage and synovial changes through increased inflammation without causing changes in gait. METHODS: Twenty-four Yucatan minipigs were randomized into the mIAD (n=12) or sham control group (n=12). mIAD animals had two osseous tunnels drilled into each of the tibia and femur adjacent to the anterior cruciate ligament (ACL) attachment sites on the left hind knee. Surgical and contralateral limbs were harvested 15 weeks post-surgery. Cartilage degeneration was evaluated macroscopically and histologically. Synovial changes were evaluated histologically. Interleukin-1 beta (IL-1ß), nuclear factor kappa B (NF-κB), and tumor necrosis factor alpha (TNF-α) mRNA expression levels in the synovial membrane were measured using quantitative real-time polymerase chain reaction. IL-1ß and NF-κB levels in chondrocytes were assessed using immunohistochemistry. Load asymmetry during gait was recorded by a pressure-sensing walkway system before and after surgery. RESULTS: The mIAD surgical knees demonstrated greater gross and histological cartilage damage than contralateral (P<.01) and sham knees (P<.05). Synovitis was present only in the mIAD surgical knee. Synovial inflammatory marker (IL-1ß, NF-κB, and TNF-α) expression was three times higher in the mIAD surgical knee than the contralateral (P<.05). Chondrocyte IL-1ß and NF-κB levels were highest in the mIAD surgical knee. In general, there were no significant changes in gait. CONCLUSIONS: The mIAD model induced PTOA through inflammation without affecting gait mechanics. This large animal model has significant applications for evaluating the role of inflammation in PTOA and for developing therapies aimed at reducing inflammation following joint injury.

Long-Term Bilateral Neuromuscular Function and Knee Osteoarthritis after Anterior Cruciate Ligament Reconstruction.

Neuromuscular function is thought to contribute to posttraumatic osteoarthritis (PTOA) risk in anterior cruciate ligament (ACL)-reconstructed (ACLR) patients, but sensitive and easy-to-use tools are needed to discern whether complex muscle activation strategies are beneficial or maladaptive. Using an electromyography (EMG) signal analysis technique coupled with a machine learning approach, we sought to: (1) identify whether ACLR muscle activity patterns differed from those of healthy controls, and (2) explore which combination of patient outcome measures (thigh muscle girth, knee laxity, hop distance, and activity level) predicted the extent of osteoarthritic changes via magnetic resonance imaging (MRI) in ACLR patients. Eleven ACLR patients 10-15 years post-surgery and 12 healthy controls performed a hop activity while lower limb muscle EMG was recorded bilaterally. Osteoarthritis was evaluated based on MRI. ACLR muscle activity patterns were bilaterally symmetrical and differed from those of healthy controls, suggesting the presence of a global adaptation strategy. Smaller ipsilateral thigh muscle girth was the strongest predictor of inferior MRI scores. The ability of our EMG analysis approach to detect meaningful neuromuscular differences that could ultimately be related to thigh muscle girth provides the foundation to further investigate a direct link between muscle activation patterns and PTOA risk.

Quantitative MRI Biomarkers to Predict Risk of Reinjury Within 2 Years After Bridge-Enhanced ACL Restoration.

BACKGROUND: Quantitative magnetic resonance imaging (qMRI) methods were developed to establish the integrity of healing anterior cruciate ligaments (ACLs) and grafts. Whether qMRI variables predict risk of reinjury is unknown. PURPOSE: To determine if qMRI measures at 6 to 9 months after bridge-enhanced ACL restoration (BEAR) can predict the risk of revision surgery within 2 years of the index procedure. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Originally, 124 patients underwent ACL restoration as part of the BEAR I, BEAR II, and BEAR III prospective trials and had consented to undergo an MRI of the surgical knee 6 to 9 months after surgery. Only 1 participant was lost to follow-up, and 4 did not undergo MRI, leaving a total of 119 patients for this study. qMRI techniques were used to determine the mean cross-sectional area; normalized signal intensity; and a qMRI-based predicted failure load, which was calculated using a prespecified equation based on cross-sectional area and normalized signal intensity. Patient-reported outcomes (International Knee Documentation Committee subjective score), clinical measures (hamstring strength, quadriceps strength, and side-to-side knee laxity), and functional outcomes (single-leg hop) were also measured at 6 to 9 months after surgery. Univariate and multivariable analyses were performed to determine the odds ratios (ORs) for revision surgery based on the qMRI and non-imaging variables. Patient age and medial posterior tibial slope values were included as covariates. RESULTS: In total, 119 patients (97%), with a median age of 17.6 years, underwent MRI between 6 and 9 months postoperatively. Sixteen of 119 patients (13%) required revision ACL surgery. In univariate analyses, higher International Knee Documentation Committee subjective score at 6 to 9 months postoperatively (OR = 1.66 per 10-point increase; P = .035) and lower qMRI-based predicted failure load (OR = 0.66 per 100-N increase; P = .014) were associated with increased risk of revision surgery. In the multivariable model, when adjusted for age and posterior tibial slope, the qMRI-based predicted failure load was the only significant predictor of revision surgery (OR = 0.71 per 100 N; P = .044). CONCLUSION: Quantitative MRI-based predicted failure load of the healing ACL was a significant predictor of the risk of revision within 2 years after BEAR surgery. The current findings highlight the potential utility of early qMRI in the postoperative management of patients undergoing the BEAR procedure.

Preoperative Risk Factors for Subsequent Ipsilateral ACL Revision Surgery After an ACL Restoration Procedure.

BACKGROUND: Anterior cruciate ligament (ACL) revision surgery is challenging for both patients and surgeons. Understanding the risk factors for failure after bridge-enhanced ACL restoration (BEAR) may help with patient selection for ACL restoration versus ACL reconstruction. PURPOSE: To identify the preoperative risk factors for ACL revision surgery within the first 2 years after BEAR. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Data from the prospective BEAR I, II, and III trials were used to determine the preoperative risk factors for ACL revision surgery. All patients with a complete ACL tear (aged 13-47 years, depending on the trial), who met all other inclusion/exclusion criteria and underwent a primary BEAR procedure within 30 to 50 days from the injury (dependent on the trial), were included. Demographic data (age, sex, body mass index), baseline patient-reported outcomes (International Knee Documentation Committee [IKDC] subjective score, Marx activity score), preoperative imaging results (ACL stump length, notch size, tibial slope), and intraoperative findings (knee hyperextension, meniscal status) were evaluated to determine their contribution to the risk of ipsilateral ACL revision surgery. RESULTS: A total of 123 patients, with a median age of 17.6 years (interquartile range, 16-23 years), including 67 (54%) female patients, met study criteria. Overall, 18 (15%) patients required ACL revision surgery in the first 2 years after the BEAR procedure. On bivariate analyses, younger age (P = .011), having a contact injury at the time of the initial tear (P = .048), and increased medial tibial slope (MTS; P = .029) were associated with a higher risk of ipsilateral revision surgery. Multivariable logistic regression analyses identified 2 independent predictors of revision: patient age and MTS. The odds of ipsilateral revision surgery were decreased by 32% for each 1-year increase in age (odds ratio, 0.684 [95% CI, 0.517-0.905]; P = .008) and increased by 28% for each 1° increase in MTS (odds ratio, 1.280 [95% CI, 1.024-1.601]; P = .030). Sex, baseline IKDC or Marx score, knee hyperextension, and meniscal status were not significant predictors of revision. CONCLUSION: Younger age and higher MTS were predictors of ipsilateral ACL revision surgery after the BEAR procedure. Younger patients with higher tibial slopes should be aware of the increased risk for revision surgery when deciding to undergo ACL restoration.

Automated segmentation of the healed anterior cruciate ligament from T2 * relaxometry MRI scans.

Collagen organization of the anterior cruciate ligament (ACL) can be evaluated using T2 * relaxometry. However, T2 * mapping requires manual image segmentation, which is a time-consuming process and prone to inter- and intra- segmenter variability. Automating segmentation would address these challenges. A model previously trained using Constructive Interference in Steady State (CISS) scans was applied to T2 * segmentation via transfer learning. It was hypothesized that there would be no significant differences in the model's segmentation performance between T2 * and CISS, structural measures versus ground truth manual segmentation, and reliability versus independent and retest manual segmentation. Transfer learning was conducted using 54 T2 * scans of the ACL. Segmentation performance was assessed with Dice coefficient, precision, and sensitivity, and structurally with T2 * value, volume, subvolume proportions, and cross-sectional area. Model performance relative to independent manual segmentation and repeated segmentation by the ground truth segmenter (retest) were evaluated on a random subset. Segmentation performance was analyzed with Mann-Whitney U tests, structural measures with Wilcoxon signed-rank tests, and performance relative to manual segmentation with repeated-measures analysis of variance/Tukey tests (α = 0.05). T2 * segmentation performance was not significantly different from CISS on all measures (p > 0.35). No significant differences were detected in structural measures (p > 0.50). Automatic segmentation performed as well as the retest on all segmentation measures, whereas independent segmentations were lower than retest and/or automatic segmentation (p < 0.023). Structural measures were not significantly different between segmenters. The automatic segmentation model performed as well on the T2 * sequence as on CISS and outperformed independent manual segmentation while performing as well as retest segmentation.

Hydrogel treatment for idiopathic osteoarthritis in a Dunkin Hartley Guinea pig model.

The study objective was to determine if intraarticular injections of an extracellular matrix (ECM) powder and blood composite (ECM-B) would have a significant impact on post-operative gait parameters without eliciting adverse cartilage changes or severe lymphatic reactions in an idiopathic osteoarthritis (OA) model. Twenty-one Dunkin Hartley Guinea pigs received an intraarticular injection of ECM-B in each knee and were split into sub-groups for gait assessment and post-harvest knee evaluations at 1 week (n = 5), 2 weeks (n = 5), 4 weeks (n = 5), or 8 weeks (n = 6). The results were compared with a control group (n = 5), which underwent bilateral injections of phosphate-buffered saline (PBS), gait measurements at 1, 2, 4, and 8 weeks, and post-mortem knee evaluation at 8 weeks post-injection. Hind limbs and popliteal lymph nodes were collected at the Week 8 endpoint and underwent histological analysis by a veterinary pathologist. Significant improvement in hind limb base of support was observed in the ECM-B group compared to the control group at Week 4 but was no longer significant by Week 8. No significant differences were observed between control and ECM-B groups in hind limb cartilage, synovium, or popliteal lymph node histology at Week 8. In conclusion, administration of an ECM-B material may improve gait for a limited time without significant adverse effects on the cartilage, synovium, or local lymph nodes.

Effects of Initial Graft Tension and Patient Sex on Knee Osteoarthritis Outcomes After ACL Reconstruction: A Randomized Controlled Clinical Trial With 10- to 12-Year Follow-up.

BACKGROUND: The initial graft tension applied during anterior cruciate ligament (ACL) graft fixation may promote posttraumatic osteoarthritis (PTOA). PURPOSE/HYPOTHESIS: This study sought to assess the effect of initial graft tension and patient sex on PTOA outcomes at 10 to 12 years after ACL reconstruction (ACLR). The hypothesis was that there would be no group- or sex-based differences in outcomes. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Patients were randomized to receive ACLR with a low or high initial graft tension. Outcomes were evaluated at 10 to 12 years postoperatively and compared with a matched, uninjured control group. Outcomes included clinical assessments (anteroposterior [AP] knee laxity measurement, International Knee Documentation Committee [IKDC] examination score), a functional assessment (single-leg hop for distance), patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score [KOOS], 36-Item Short Form Health Survey, Tegner activity level, patient satisfaction), and PTOA imaging (Osteoarthritis Research Society International [OARSI] radiographic score and Whole-Organ Magnetic Resonance Imaging Score [WORMS]). Two-way mixed-model analyses of variance were used to evaluate differences in outcomes between tension groups and the control group and between female and male patients. RESULTS: Both tension groups scored worse than the control group for the IKDC examination (P≤ .021), KOOS (Pain, Activities of Daily Living, Sport/Recreation, and Quality of Life subscales) (P≤ .049), and WORMS difference score (P≤ .042). The low-tension group scored worse than the control group for KOOS Symptoms (P = .016) and the OARSI difference score (P = .015). The index limb had worse scores than the contralateral limb within the high-tension group for AP laxity (P = .030) and hop deficit (P = .011). This result was also observed within both tension groups for the WORMS (P≤ .050) and within the low-tension group for the OARSI score (P = .001). Male patients had higher Tegner scores (mean ± SE) relative to female patients (male, 5.49 ± 1.88; female, 4.45 ± 1.65) and worse OARSI difference scores (male, 1.89 ± 5.38; female, 0.244 ± 0.668) (P = .007 and .034, respectively). However, no significant differences were detected between tension groups for any of the outcomes measured. CONCLUSION: Overall, ACLR failed to prevent PTOA regardless of initial graft tension. However, male patients treated with a low initial graft tension may be at greater risk for PTOA. These results do not support the hypothesis of no sex differences in outcomes at 10 to 12 years after ACLR.

Reproducibility and postacquisition correction methods for quantitative magnetic resonance imaging of the anterior cruciate ligament (ACL).

Quantitative magnetic resonance imaging has been used to evaluate the structural integrity of knee joint structures. However, variations in acquisition parameters between scanners pose significant challenges. Understanding the effect of small differences in acquisition parameters for quantitative sequences is vital to the validity of cross-institutional studies, and for the harmonization of large, heterogeneous datasets to train machine learning models. The study objective was to assess the reproducibility of T2 * relaxometry and the constructive interference in steady-state sequence (CISS) across scanners, with minimal hardware-necessitated changes to acquisition parameters. It was hypothesized that there would be no significant differences between scanners in anterior cruciate ligament T2 * relaxation times and CISS signal intensities (SI). Secondarily, it was hypothesized that differences could be corrected by rescaling the SI distribution to harmonize between scanners. Seven volunteers were scanned on 3T Prisma and Tim Trio scanners (Siemens). Three correction methods were evaluated for T2 *: inverse echo time scaling, z-scoring, and Nyúl histogram matching. For CISS, scans were normalized to cortical bone, scaled by the background noise ratio, and log-transformed. Before correction, significant mean differences of 6.0 ± 3.2 ms (71.8%; p = 0.02) and 0.49 ± 0.15 units (40.7%; p = 0.02) for T2 * and CISS across scanners were observed, respectively. After rescaling, T2 * differences decreased to 2.6 ± 2.7 ms (23.9%; p = 0.03), 1.3 ± 2.5 ms (10.9%; p = 0.13), and 1.27 ± 3.0 ms (19.6%; p = 0.40) for inverse echo time, z-scoring, and Nyúl, respectively, while CISS decreased to 0.01 ± 0.11 units (4.0%; p = 0.87). These findings suggest that small acquisition parameter differences may lead to large changes in T2 * and SI values that must be reconciled to compare data across magnets.

Peripheral shift in the viable chondrocyte population of the medial femoral condyle after anterior cruciate ligament injury in the porcine knee.

Anterior cruciate ligament injuries result in posttraumatic osteoarthritis in the medial compartment of the knee, even after surgical treatment. How the chondrocyte distribution within the articular cartilage changes early in this process is currently unknown. The study objective was to investigate the chondrocyte distribution within the medial femoral condyle after an anterior cruciate ligament transection in a preclinical model. Forty-two adolescent Yucatan minipigs were allocated to receive unilateral anterior cruciate ligament surgery (n = 36) or no surgery (n = 6). Central coronal sections of the medial femoral condyle were obtained at 1- and 4 weeks after surgery, and the chondrocyte distribution was measured via whole slide imaging and a cell counting batch processing tool utilized in ImageJ. Ki-67 immunohistochemistry was performed to identify proliferating cells. Empty lacunae, karyolysis, karyorrhexis, and pyknosis were used to identify areas of irreversible cell injury. The mean area of irreversible cell injury was 0% in the intact controls, 13.4% (95% confidence interval: 6.4, 20.3) at 1-week post-injury and 19.3% (9.7, 28.9) at 4 weeks post-injury (p < .015). These areas occurred closest to the femoral intra-articular notch. The remaining areas containing viable chondrocytes had Ki-67-positive cells (p < .02) and increased cell density in the middle (p < .03) and deep zones (p = .001). For the entire section, the total chondrocyte number did not change significantly post-operatively; however, the density of cells in the peripheral regions of the medial femoral condyle increased significantly at 1- and 4 weeks post-injury relative to the intact control groups (p = .032 and .004, respectively). These data demonstrate a peripheral shift in the viable chondrocyte population of the medial femoral condyle after anterior cruciate ligament injury and further suggest that chondrocytes with the capacity to proliferate are not confined to one particular cartilage layer.

Enrichment of inflammatory mediators in the synovial fluid is associated with slower progression of mild to moderate osteoarthritis in the porcine knee.

The roles that cytokines and matrix metalloproteinases play in the onset and progression of posttraumatic osteoarthritis (PTOA) remain a topic of debate. The study objective was to evaluate the concentrations of these inflammatory mediators during the development of mild to moderate PTOA in the porcine anterior cruciate ligament (ACL) surgical model. We hypothesized that there would be more animals with detectable mediators in the pigs that develop moderate PTOA (those receiving ACL reconstruction or untreated ACL transection) compared to those that develop mild PTOA (those receiving scaffold-enhanced ACL repair). 36 Yucatan minipigs underwent ACL transection and were randomized to: 1) no further treatment, 2) ACL reconstruction, or 3) scaffold-enhanced ACL repair. Synovial fluid samples were obtained pre-operatively, and at 1, 4, 12, 26 and 52 weeks post-operatively. The concentrations of inflammatory mediator in the synovial fluid samples were evaluated via multiplex assay. Macroscopic cartilage assessments were performed following euthanasia at 52 weeks. As found in prior studies, the repair group had significantly less cartilage damage than either the ACL transected or ACL reconstruction groups (P<.03). The presence and concentrations of the biomarkers were influenced by surgical group and time. In general, the concentrations of inflammatory mediators were higher in the repair group, which exhibited less cartilage damage than the other two treatment groups. While this finding disproved the hypotheses, these data suggest that the metabolic activity of the joints exhibiting less cartilage damage remained higher over the 52-week period than those that did not.

Bridge-Enhanced Anterior Cruciate Ligament Repair Leads to Greater Limb Asymmetry and Less Cartilage Damage Than Untreated ACL Transection or ACL Reconstruction in the Porcine Model.

BACKGROUND: The extent of posttraumatic osteoarthritis (PTOA) in the porcine anterior cruciate ligament (ACL) transection model is dependent on the surgical treatment selected. In a previous study, animals treated with bridge-enhanced ACL repair using a tissue-engineered implant developed less PTOA than those treated with ACL reconstruction (ACLR). Alterations in gait, including asymmetric weightbearing and shorter stance times, have been noted in clinical studies of subjects with osteoarthritis. HYPOTHESIS: Animals receiving a surgical treatment that results in less PTOA (ie, bridge-enhanced ACL repair) would exhibit fewer longitudinal postoperative gait asymmetries over a 1-year period when compared with treatments that result in greater PTOA (ie, ACLR and ACL transection). STUDY DESIGN: Controlled laboratory study. METHODS: Thirty-six Yucatan minipigs underwent ACL transection and were randomized to receive (1) no further treatment, (2) ACLR, or (3) bridge-enhanced ACL repair. Gait analyses were performed preoperatively, and at 4, 12, 26, and 52 weeks postoperatively. Macroscopic cartilage assessments were performed at 52 weeks. RESULTS: Knees treated with bridge-enhanced ACL repair had less macroscopic damage in the medial tibial plateau than those treated with ACLR or ACL transection (adjusted P = .03 for both comparisons). The knees treated with bridge-enhanced ACL repair had greater asymmetry in hindlimb maximum force and impulse loading at 52 weeks than the knees treated with ACL transection (adjusted P < .05 for both comparisons). Although not significant, there was a trend that knees treated with bridge-enhanced ACL repair had greater asymmetry in hindlimb maximum force and impulse loading (adjusted P < .10 for both comparisons) compared with ACLR. CONCLUSION: Contrary to our hypothesis, the surgical treatment resulting in less macroscopic cartilage damage (ie, bridge-enhanced ACL repair) exhibited greater asymmetry in load-related gait parameters than the other surgical groups. This finding suggests that increased offloading of the surgical knee may be associated with a slower rate of PTOA development. CLINICAL RELEVANCE: Less cartilage damage at 52 weeks was found in the surgical group that continued to protect the limb from full body weight during gait. This finding suggests that protection of the knee from maximum stresses may be important in minimizing the development of PTOA in the ACL-injured knee within 1 year.