Chondrogenic potential of IL-10 in mechanically injured cartilage and cellularized collagen ACI grafts.

OBJECTIVE: The application of adjunctive mediators in Autologous chondrocyte implantation (ACI) techniques might be useful for improving the dedifferentiated chondrocyte phenotype, to support neocartilage formation and inhibit post-traumatic cartilage destruction. In this study we examined if (a) interleukin 10 treatment can cause chondrogenic phenotype stabilization and matrix preservation in mechanically injured cartilage and if (b) IL-10 can promote chondrogenesis in a clinically applied collagen scaffold for ACI treatment. MATERIALS AND METHODS: For (a) bovine articular cartilage was harvested, subjected to an axial unconfined injury and treated with bovine IL-10 (1-10,000 pg/ng/ml). For (b) a post-operatively remaining ACI graft was treated with human IL-10. Expression levels of type I/II/X collagen, SOX9 and aggrecan were measured by qPCR (a,b). After 3 weeks cell death was analyzed (nuclear blebbing and TUNEL assay) and matrix composition was determined by GAG measurements and immunohistochemistry (aggrecan, type I/II collagen, hyaluronic acid). STATISTICS: One way ANOVA analysis with Bonferroni's correction. RESULTS: (a) IL-10 stabilized the chondrogenic phenotype after injurious compression and preserved matrix integrity. This was indicated by elevated expression of chondrogenic markers COL2A1, ACAN, SOX9, while COL1A1 and COL10A1 were reduced. An increased GAG content paralleled this and histological staining of type 2 collagen, aggrecan and toluidine blue were enhanced after 3 weeks. (b) IL-10 [100 pg/ml] improved the chondrogenic differentiation of human chondrocytes, which was accompanied by cartilaginous matrix formation after 3 weeks of incubation. CONCLUSION: Interleukin-10 is a versatile adjuvant candidate to control the post-injurious environment in cartilage defects and promote chondrogenesis in ACI grafts.

IL-10 reduces apoptosis and extracellular matrix degradation after injurious compression of mature articular cartilage.

OBJECTIVE: The aim of this study was to examine whether anti-inflammatory interleukin-10 (IL-10) exerts chondroprotective effects in an in vitro model of a single mechanical injury of mature articular cartilage. METHOD: Articular cartilage was harvested from the femoro-patellar groove of adult cows (Bos taurus) and cultured w/o bovine IL-10. After 24 h of equilibration explants were subjected to an axial unconfined compression (50% strain, velocity 2 mm/s, held for 10 s). After 96 h cell death was measured histomorphometrically (nuclear blebbing, NB) and the release of glycosaminoglycans (GAG, DMMB assay) and nitric oxide (NO, Griess-reagent) were analyzed. mRNA levels of matrix degrading enzymes and nitric oxide synthetase were measured by quantitative real time PCR. Differences between groups were calculated using a one-way ANOVA with a Bonferroni post hoc test. RESULTS: Injurious compression significantly increased the number of cells with NB, release of GAG and nitric oxide and expression of MMP-3, -13, ADAMTS-4 and NOS2. Administration of IL-10 significantly reduced the injury related cell death and release of GAG and NO, respectively. Expression of MMP-3, -13, ADAMTS-4 and NOS2 were significantly reduced. CONCLUSION: Joint injury is a complex process involving specific mechanical effects on cartilage as well as induction of an inflammatory environment. IL-10 prevented crucial mechanisms of chondrodegeneration induced by an injurious single compression. IL-10 might be a multipurpose drug candidate for the treatment of cartilage-related sports injuries or osteoarthritis (OA).

The glucocorticoid receptor and STAT6 physically and functionally interact in T-lymphocytes.

In lymphocytes, glucocorticoids (GC)- and interleukin-4-signaling pathways are known to interact, as evidenced by inhibition of IL-4-mediated proliferation by dexamethasone or suppression of GC-induced apoptosis by IL-4. In this study, we characterized the molecular basis for this reciprocal interference. We report that, in murine CTLL-2 cells, IL-4 inhibits GC-induced MMTV (mouse mammary tumor virus) promoter transactivation, and that GC suppress IL-4-induced transactivation of a STAT6 (signal transducers and activators of transcription 6)-responsive promoter without affecting IL-4-stimulated STAT6 DNA-binding. Moreover, we evidenced a physical association between GC receptor and STAT6, which proved to be functionally relevant, since STAT6 overexpression increased the IL-4 inhibitory effect on GC-induced MMTV transactivation.

Gas flow MRI using circulating laser-polarized 129Xe.

We describe an experimental approach that combines multidimensional NMR experiments with a steadily renewed source of laser-polarized 129Xe. Using a continuous flow system to circulate the gas mixture, gas phase NMR signals of laser-polarized 129Xe can be observed with an enhancement of three to four orders of magnitude compared to the equilibrium 129Xe NMR signal. Due to the fact that the gas flow recovers the nonequilibrium 129Xe nuclear spin polarization in 0.2 to 4 s, signal accumulation on the time scale of seconds is feasible, allowing previously inaccessible phase cycling and signal manipulation. Several possible applications of MRI of laser-polarized 129Xe under continuous flow conditions are presented here. The spin density images of capillary tubes demonstrate the feasibility of imaging under continuous flow. Dynamic displacement profiles, measured by a pulsed gradient spin echo experiment, show entry flow properties of the gas passing through a constriction under laminar flow conditions. Further, dynamic displacement profiles of 129Xe, flowing through polyurethane foams with different densities and pore sizes, are presented.

Xenon-131 surface sensitive imaging of aerogels in liquid xenon near the critical point.

In recent years, optically pumped xenon-129 has received a great deal of attention as a contrast agent in gas-phase imaging. This report is about the other NMR active xenon isotope (i.e., xenon-131, S = 32) which exhibits distinctive features for imaging applications in material sciences that are not obtainable from xenon-129 (S = (1/2)). The spin dynamics of xenon-131 in gas and liquid phases is largely determined by quadrupolar interactions which depend strongly on the surface of the surrounding materials. This leads to a surface dependent dispersion of relaxation rates, which can be substantial for this isotope. The dephasing of the coherence due to quadrupolar interactions may be used to yield surface specific contrast for imaging. Although optical pumping is not practical for this isotope because of its fast quadrupolar relaxation, a high spin density of liquid xenon close to the critical point (289 K) overcomes the sensitivity problems of xenon-131. We report the first xenon-131 magnetic resonance images and have tested this technique on various meso-porous aerogels as host structures. Aerogels of different densities and changing levels of hydration can clearly be distinguished from the images obtained.

Extracorporeal shock wave therapy in the treatment of lateral epicondylitis : a randomized multicenter trial.

BACKGROUND: On the basis of observational trials, numerous investigators have recommended extracorporeal shock wave therapy as an alternative treatment for chronic lateral epicondylitis of the elbow. However, there has been no evidence of its efficacy from well-designed randomized clinical trials. The objective of this study was to find out whether extracorporeal shock wave therapy in combination with local anesthesia was superior to placebo therapy in combination with local anesthesia. METHODS: A randomized multicenter trial with a parallel-group design was conducted. Following administration of local anesthesia, either extracorporeal shock wave therapy with three treatments of 2000 pulses each and a positive energy flux density (ED+) of 0.07 to 0.09 mJ/mm (2) or placebo therapy was applied on an outpatient basis. Treatment allocation was blinded for patients and for observers. The primary end point was based on the rate of success, as determined with the Roles and Maudsley score and whether additional treatment was required, twelve weeks after the intervention. Crossover was possible after assessment of the primary end point. Secondary end points were the Roles and Maudsley score, subjective pain rating, and grip strength after six and twelve weeks and after twelve months. The planned number of 272 patients was included in the study. RESULTS: The primary end point could be assessed for 90.8% of the patients. The success rate was 25.8% in the group treated with extracorporeal shock wave therapy and 25.4% in the placebo group, a difference of 0.4% with a 95% confidence interval of -10.5% to 11.3%. Similarly, there was no relevant difference between groups with regard to the secondary end points. Improvement was observed in two-thirds of the patients from both groups twelve months after the intervention. Few side effects were reported. CONCLUSIONS: Extracorporeal shock wave therapy as applied in the present study was ineffective in the treatment of lateral epicondylitis. The previously reported success of this therapy appears to be attributable to inappropriate study designs. Different application protocols might improve clinical outcome. We recommend that extracorporeal shock wave therapy be applied only in high-quality clinical trials until it is proved to be effective.

Absence of spinal response to extracorporeal shock waves on the endogenous opioid systems in the rat.

Extracorporeal shock wave therapy (ESWT) seems to be a new therapeutic strategy for chronic pain due to tendopathies. Neurophysiological mechanisms of action for pain relief following ESWT are still unknown. The aim of this study was to investigate if the analgesic effect of ESWT is caused by modulation of the endogenous spinal opioid system. Rats were treated with two different energy flux densities (0.04 and 0.11mJ/mm(2)) and immunohistochemical analysis of met-enkephalin (MRGL) and dynorphin (Dyn) was performed at 4 or 72 h after ESWT. ESWT had no modulatory influence on the expression of the spinal opioid systems. Different energy doses or repetitive treatment did not alter MRGL or Dyn immunoreactivity in the spinal cord. Furthermore, a delayed effect of ESWT at 72 h after treatment was not detectable. We conclude from these findings that the analgesic effects of ESWT treatment are not supported by endogenous opioids.

Low-energy extracorporeal shock-wave treatment (ESWT) for tendinitis of the supraspinatus. A prospective, randomised study.

We have performed a controlled, randomised study to analyse the effects of low-energy shock-wave therapy (ESWT) on function and pain in tendinitis of the supraspinatus without calcification. There were 20 patients in the treatment group and 20 in the control group. The former group received 6,000 impulses (energy flux density, 0.11 mJ/mm2) in three sessions after local anaesthesia. The control group had 6000 impulses of sham ESWT after local anaesthesia. The patients were examined at six and 12 weeks after treatment by an independent observer who evaluated the Constant score and level of pain. We found an increase in function and a reduction of pain in both groups (p < or = 0.001). Statistical analysis showed no difference between the groups for the Constant score and for pain. We therefore do not recommend ESWT for the treatment of tendinitis of supraspinatus.

Extracorporeal shockwave therapy (ESWT) in the treatment of plantar fasciitis--a biometrical review.

The application of extracorporeal shockwave therapy (ESWT) as a treatment for conservatively unsuccessfully treated plantar fasciitis has experienced a rapid increase over the last years. However, the efficacy of ESWT has not yet been established unequivocally, as published studies have led to inconsistent results. Furthermore, reviews on clinical trials on ESWT are either not up to date, incomplete, or methodologically inadequate. As a consequence, a systematic literature search was conducted which yielded 21 relevant articles on ESWT in the treatment of plantar fasciitis. These were rated according to biometrical criteria for the conduct of therapeutic trials based on international guidelines. None of the rated trials fulfilled all of the criteria, and it is concluded that at this point the efficacy of ESWT can be neither confirmed nor excluded. Randomised and controlled clinical trials are required to adequately estimate the value of ESWT as a treatment for plantar fasciitis.

[Effects of extracorporeal shock waves (ESW) on human bone marrow cell cultures]. / Einwirkung extrakorporaler Stosswellen (ESW) auf humane Knochenmarkszellkulturen.

INTRODUCTION: Extracorporeal shockwave therapy (ESWT) is a new method of treating insertion tendopathy and pseudo-arthrosis, the clinical importance of which cannot yet be definitively assessed, and the underlying mechanisms of which are still unclear. AIM: To develop an experimental set-up enabling the standardised application of ESWT to human bone marrow cell culture and the determination of the effect of ESWT. MATERIAL AND METHODS: After 14 days incubation, human bone marrow cell cultures were subjected to ESWT using 200/500 pulses at an energy flux densities ED + of 0.03, 0.04, 0.07, 0.11 and 0.25 millijoule/mm2. Samples were obtained for LDH measurement 15 minutes, 4 h and 18 h after ESWT. Transmission light microscopy was carried out before and after ESWT to determine cell numbers and for morphological analysis. RESULTS: Gaps in the cellular tissue first appear at an energy of 0.01 millijoule/mm2. At energies of 0.25 millijoule/mm2, morphologically altered cells, thinned out cellular tissue with a cell-free focal zone are found. At low energy levels, defects have been repaired ca. 1 week after ESWT. No significant increase in LDH was detected at any of the energy levels applied. CONCLUSION: Increasing energy and higher pulse frequency is associated with an increase in the size and number of holes in cellular tissue and in cell separation. Regeneration capability (regrowth, sprouting, normal cell form) decreases as the energy level increases. Changes can be detected even at the lowest energy flux densities, which up until now had been assumed to have no effect on cell morphology or number. The standardised application of ESWT to human bone marrow cell cultures provides reproducible results that can be controlled by a placebo ESWT application.

[Value of exact focusing of extracorporeal shock waves (ESWT) in therapy of tendinitis calcarea. A prospective randomized study]. / Bedeutung der exakten Fokussierung extrakorporaler Stosswellen (ESWT) bei der Therapie der Tendinitis calcarea. Eine prospektive randomisierte Studie.

A controlled randomized study was designed to analyse the effect of extracorporeal shockwave therapy (ESWT) focussed on either the calcified region or the insertion of the supraspinatus tendon. The study included 50 patients who were treated with a Storz Minilith SI-1 prototype shockwave generator. In the treated group, 4000 impulses (ED+ 0.78 ml/mm2) were applied, under local anaesthesia to the insertion of the supraspinatus in 2 treatment sessions. Control patients received ESWT focussed on the calcified region. Follow-up examinations were carried out 12 weeks after treatment by an independent observer. We found functional improvement and pain reduction in both groups. Statistical analyses showed significant superiority of ESWT focussed on the calcified region for the parameters constant-score (primary endpoint, p < 0.001) and pain intensity (p = 0.001). For the treatment of calcific tendinitis affecting the supraspinatus, we recommend accurate fluoroscopy-controlled focussing of ESWT on the calcification. Focussing on the calcification rather than on the insertion of the supraspinatus tendon is significantly more effective. On the basis of our results, ESWT requires the use of suitable shockwave generators that permit accurate focussing.

[Impact of the quality of clinical trials in orthopedics and traumatology on the status of evidence]. / Auswirkungen der Qualität klinischer Studien in der Orthopädie und Unfallchirurgie auf den Erkenntnisstand.

Medical decisions have to be founded on the current scientific state of the art. To evaluate the efficacy of any therapeutical measure, controlled clinical trials are necessary. Firstly, we describe important principles for the design and conduct of controlled clinical trials. Secondly, we list examples from the topical literature and discuss these regarding adherence to the described principles. The accepted quality criteria for clinical trials have insufficiently been transferred to the area of clinical orthopedic and traumatologic research. As a consequence, the evidence for many therapeutical measures is low. We point out frequently occurring flaws in the design and conduct of controlled clinical trials. A brief introduction to the interpretation of clinical trials and meta analyses is given. In orthopedics and traumatology, well designed controlled clinical trials have to be enforced. This is a prerequisite for evaluating therapeutical measures on a scientific basis.

[Update on rheuma-orthopedics - role and therapeutic options]. / Update Rheumaorthopädie - Aufgabe und therapeutische Optionen.

Orthopaedic treatment options for rheumatological patients have been further developed over recent years. For orthopaedic treatment, a range of different interventions are offered: orthoses and special technical aids as well as injections for joints and tendons, or surgery. Surgical interventions cover joint preservation, restitution and arthrodeses. Improvements in equipment and surgical procedures also make minimally invasive interactions possible for rheumatoid diseases. Thus, postoperative morbidity has been reduced significantly. Improvement in function, reduction of pain and prevention of recurrent local inflammation are primary. Considering these aims, arthrodeses are restricted to special indications. Joint preservation and restitution are the predominant measures used. The various procedures are discussed.

[German Acupuncture Trials (gerac) address problems of methodology associated with acupuncture studies]. / Zur Problematik von Akupunkturstudien am Beispiel der Methodik von gerac.

OBJECTIVE: Conflicting or ambivalent findings on the effectiveness of body acupuncture in pain treatment are often attributed to flaws in study methodology. The paper describes the methodology used for the German Acupuncture Trials (gerac), which demonstrates that it is possible to design acupuncture studies in accordance with the standards of good clinical practice. METHOD: Approximately 1000 chronic pain sufferers per indication (migraine, tension-type headache, low back pain (cLBP), or gonarthrosis) are randomly allocated to one of three treatment groups (verum acupuncture, sham acupuncture, or established conservative therapy). Patients are blind to the type of acupuncture. All patients receive ten sessions of treatment (two per week) with an option of adding five more treatments in cases of slight but insufficient improvement (number of headache days or von Korff pain score). Participating physicians are in private practice, representing a variety of specialties. All have completed at least a 140-hour training course in acupuncture. Mandatory and optional verum and sham points are predefined. The point selection is individualized according to the criteria of traditional Chinese medicine (TCM). Primary outcome measures are number of headache days per month, von Korff Graded Chronic Pain Scale or Hannover Functional Ability Questionnaire (cLBP), or WOMAC scores (gonarthrosis). Data are assessed by trained telephone interviewers not involved in treatment and blind to types of acupuncture. PRESENT STATUS: Over 500 participating physicians in ten urban areas of Germany. Patient recruitment for cLBP and gonarthrosis was completed in November 2003 and March 2004 respectively. Recruitment for chronic headaches will be completed in autumn 2004. CONCLUSIONS: The gerac trials prove that it is possible to design and carry out acupuncture studies in accordance to stringent standards of methodology and clinical practice. The results will form a basis for the assessment of acupuncture effectiveness in Germany and abroad.

[Extracorporeal shockwave therapy in treatment of epicondylitis humeri radialis. A current overview]. / Die extrakorporale Stosswellentherapie zur Behandlung der Epicondylitis humeri radialis. Ein aktueller Uberblick.

In the past, extracorporeal shock-wave therapy (ESWT) has been used increasingly as a treatment for conservatively unsuccessfully treated radiohumeral epicondylitis. However, published reviews of clinical trials on the efficacy of ESWT have led to inconsistent results and are outdated or methodologically inadequate. As a consequence, a systematic literature search was conducted which yielded 20 relevant papers that described trials on the efficacy of ESWT in the treatment of radiohumeral epicondylitis. These were rated according to biometrical criteria for the conduct of therapeutic trials. None of the rated trials fulfilled all of the criteria, and it is concluded that the efficacy of ESWT in the treatment of epidondylitis can presently be neither confirmed nor excluded.

False-positive sonographic hip examinations in newborns with congenital varus deformity of the proximal femur.

In cases of congenital varus deformity of the proximal femur, the screening of hip dysplasia can lead to misinterpretations. The false-positive ultrasound result is caused by the superiorly displaced greater trochanter in hips with coxa vara, which narrows the scan window. In this paper three typical patients are presented to demonstrate that the use of additional non-standard views cannot exclude hip dysplasia in all cases. Hence, such patients with femoral abnormalities and doubtful sonographic findings should be further evaluated by arthrography or magnetic resonance imaging to rule out additional hip dysplasia.

Specific inhibition of interleukin-4-dependent Stat6 activation by an intracellularly delivered peptide.

The transcription factor Stat6 (signal transducer and activator of transcription 6) is activated following stimulation with interleukin (IL)-4 or IL-13. Stat6 binds via a single SH2 domain first to tyrosine-phosphorylated motifs in the IL-4Ralpha chain, and then to another Stat6 molecule, which results in the formation of active dimers. We show here that a peptide derived from the Stat6-binding region of IL-4Ralpha (Stat6BP) is an effective inhibitor when it is delivered into cells by coupling with a membrane-permeable peptide. Stat6BP completely inhibited IL-4 dependent phosphorylation of Stat6, as well as basal and IL-4 stimulated transcription from a reporter gene construct with a Stat6-dependent promoter, while IL-3 and IL-4 dependent phosphorylation of Stat5 was not affected. The inhibitory effect of Stat6BP was transient, but could be prolonged by treating the cells with the phosphatase inhibitor pervanadate.

Assessment of the treatment costs of extracorporeal shock wave therapy versus surgical treatment for shoulder diseases.

OBJECTIVE: To determine the actual costs of extracorporeal shock wave therapy (ESWT) in patients with tendinitis of the supraspinatus muscle. METHODS: A comparison of the costs of surgical treatment versus the costs for ESWT was made. The total accrued costs were determined 12 weeks after intervention, using a sample group of 60 patients with calcifying or noncalcifying tendinitis of the supraspinatus muscle. RESULTS: The costs per case ranged from EUR 2,700 to EUR 4,300 per patient for ESWT and from EUR 13,400 to EUR 23,450 for surgical treatment, dependent on the method of calculation. Approximately 65% of the per-patient cost is attributable to productivity losses in the workplace. CONCLUSIONS: In comparable short-term results, costs for operative treatment are 5-7 times higher than for ESWT. The greater trauma caused by an operative procedure leads to patients being off work for a longer period and thus a correspondingly higher social economic burden.

[Design of a multicenter study for assessing the effectiveness of extracorporeal shockwave therapy in epicondylitis humeri radialis]. / Design einer Multizenterstudie zum Wirksamkeitsnachweis der Extrakorporalen Stosswellentherapie (ESTW) bei Epicondylitis humeri radialis.

INTRODUCTION: Previously published studies concerning, extracorporeal shock-wave therapy (ESWT) in the treatment of lateral epicondylitis do not fulfil the biometric standards of modern clinical research. The objective of the trial is to show that ESWT is effective in the treatment of chronic LE. METHOD: A prospective, randomized, placebo-controlled, single-blinded, multicenter trial with an independent blinded observer was designed. The effectiveness of ESWT is evaluated by comparison with a control group in which sham-ESWT is performed, both under local anaesthesia. Outcome is determined on the basis of the Roles/Maudsley-Score. Inclusion criteria are a history of at least 6 months of LE and failure of conventional treatment. The therapy includes 3 sessions of low energy ESWT with 2000 impulses (energy flux density 0.07-0.09 mJ/mm2). Sample size is 272 patients. STATUS: Randomisation started in October 1998 and is planned over a period of two and a half years. CONCLUSION: Only a randomised clinical trial with adequate control of placebo effects and observer bias can provide the required evidence for the efficiency of ESWT in the treatment of lateral epicondylitis of the elbow.

[Magnetic resonance tomography in diagnosis and therapy follow-up of patients with congenital hip dysplasia and hip dislocation]. / Die Magnetresonanztomographie in der Diagnostik und Threrapiekontrolle von Patienten mit kongenitaler Hüftdysplasie und-luxation.

AIM: In patients with congenital dislocation of the hip the assessment of the correct position of the hip joint after closed or open reduction is very difficult to make from the radiograph with the hips in plaster. As the delayed recognition of a recurrent hip dislocation has bad effects on the outcome of the affected hip a safe and reliable imaging method must be employed. METHOD: From 1993 to 1996 6 patients with 8 congenital dislocations of the hip joint were examined by magnetic resonance imaging for evaluation of the position of the hip in plaster after reduction. Magnetic resonance imaging was performed immediately after closed or open reduction. 3 hips had to be treated by open surgery. RESULTS: The investigation confirmed that magnetic resonance imaging allows perfect differentiation between the bony and cartilaginous parts of the hip joint in plaster as well. Interpositioning of soft tissues which prevent reduction could also be visualized clearly. The best sequence in order to differentiate bony from cartilaginous structures was a gradient echo sequence in flash-technique using a flip-angle of 60 degrees. In all cases the correct position of the hip joint after reduction could be demonstrated in plaster. CONCLUSION: Therefore, magnetic resonance imaging is the imaging method of choice for confirmation and documentation of the reduced position of the hip joint in plaster. Radiographs are no longer needed.