Chondrocyte-mediated collagenolysis correlates with cartilage destruction grades in osteoarthritis.

OBJECTIVE: Osteoarthritis (OA) is associated with destruction of type II collagen-rich hyaline articular cartilage. We hypothesized that classical interstitial collagenases cleave collagen type II, leading to the increased expression of the 3/4 native type II collagen fragment (COL2-3/4C) and the corresponding denatured type II collagen fragment (COL2-3/4M), which could correlate with different cartilage destruction grades. In addition, we assessed whether these fragments could be measured in joint fluid and serve as diagnostic markers. METHODS: Cartilage specimens were obtained from the femoral heads of hip joints from total hip replacement operations. Articular gliding surfaces of the cartilage were categorized into normal (G0), fibrillated (G1), superficiallyfissured (G2) and deeplyfissured (fissures that reach to the subchondral bone) (G3). A histological scoring of the cartilage was also used. COL2-3/4C and COL2-3/4M were detected by immunohistochemical staining. Dot blotting was used to detect these fragments in joint fluid. RESULTS: COL2-3/4C and COL2-3/4M were found in the perichondrocyte matrix around lacunae. Such COL2-3/4C (p < 0.05) and COL2-3/4M (p < 0.05) immunoreactivity was significantly increased in G3 and G2 compared to GO and G1. A positive correlation (n = 35, Spearman rank correlation) was observed between the histological score and the percentage of COL2-3/4C positive lacunae (r = 0.43, p = 0.01) and COL2- 3/4M positive lacunae (r = 0.53, p = 0.001). All 7/7 joint fluid samples contained COL2-3/4C in dot blots whereas only 4/7 contained COL2-3/4M. CONCLUSION: Collagenase-cleaved collagen--both native and denatured--increases as the severity of OA increases, assessed using a macroscopic clinical and microscopic histological grading system. Collagen degradation was always most apparent around chondrocytes. Furthermore, the native COL2-3/4C fragment has potential as a joint fluid marker for OA.

Factors associated with nonunion in conservatively-treated type-II fractures of the odontoid process.

In type-II fractures of the odontoid process, the treatment is either conservative in a halo vest or primary surgical stabilisation. Since nonunion, requiring prolonged immobilisation or late surgery, is common in patients treated in a halo vest, the identification of those in whom this treatment is likely to fail is important. We reviewed the data of 69 patients with acute type-II fractures of the odontoid process treated in a halo vest. The mean follow-up was 12 months. Conservative treatment was successful, resulting in bony union in 32 (46%) patients. Anterior dislocation, gender and age were unrelated to nonunion. However, nonunion did correlate with a fracture gap (> 1 mm), posterior displacement (> 5 mm), delayed start of treatment (> 4 days) and posterior redisplacement (> 2 mm). We conclude that patients presenting with these risk factors are unlikely to achieve bony union by treatment in a halo vest. They deserve careful attention during the follow-up period and should also be considered as candidates for primary surgical stabilisation.

Assessing quality of life in individuals with hereditary blood coagulation disorders.

The aim of this study was to test the reliability and validity of the SF-36 questionnaire among the patients with hereditary blood coagulation disorders, to compare their quality of life (QoL) to that of healthy controls, and to identify the dimensions of life the patients consider most important. Results showed that the SF-36 questionnaire had good internal consistency reliability and construct and known group validity in individuals with hereditary blood coagulation disorders. Leisure activities/hobbies, availability of work/ study, followed by relationships with other people, own health and relationships with family/relatives appeared most frequently across the patients' and controls' priority ranks. The areas affected most by the disease were financial security, own health and relationships with family/relatives. A comparison of standardized scale scores suggests that blood coagulation disorders are diseases with a predominantly physical impact. Patients with blood coagulation disorders had health-related quality of life that was lower in most domains compared to healthy controls. However, when a wider concept of QoL was applied no differences between the patients' and controls' perceived QoL could be noted.

Insulin-like growth factors I and II in the aseptic loosening of total hip implants.

Periprosthetic interface tissue and pseudocapsule samples surrounding aseptically loosened hip implants and control knee synovium were studied by reverse transcriptase polymerase chain reaction (RT-PCR) and immunohistochemistry. Endothelial cells, fibroblasts, and monocyte/macrophages contained bone formation-enhancing insulin-like growth factors (IGFs). In interface tissue we found fewer IGF-I and IGF-II positive cells than in control tissue. In pseudocapsular tissue we found fewer IGF-I positive cells and an equal amount of IGF-II positive cells compared to control tissues. Decreased bone formation may contribute to net loss of bone around aseptically loosened hip implants.

Imbalance of RANKL/RANK/OPG system in interface tissue in loosening of total hip replacement.

In the differentiation of osteoclasts the differentiation factor (RANKL) interacts with the receptor activator of NF-kappaB (RANK) in a direct cell-to-cell contact between osteoblast and (pre)osteoclast. This is inhibited by soluble osteoprotegerin (OPG). The mRNA levels of both RANKL (p < 0.01) and RANK (p < 0.05) were high in peri-implant tissue and RANKL+ and RANK+ cells were found in such tissue. Double labelling also disclosed soluble RANKL bound to RANK+ cells. We were unable to stimulate fibroblasts to express RANKL in vitro, but monocyte activation with LPS gave a fivefold increase in RANK mRNA levels. In contrast to RANKL and RANK expression in peri-implant tissue, expression of OPG was restricted to vascular endothelium. Endothelial cell OPG mRNA levels were regulated by TNF-alpha and VEGF, but not by hypoxia. It is concluded that activated cells in the interface tissue overproduce both RANKL and RANK and they can interact without interference by OPG.

Osteoporosis and the orthopaedic surgeon.

During the recent years, data regarding osteoporosis has accumulated and indicates that osteoporotic fractures in Scandinavia still increase. At the same time diagnostics and treatments have been improved. However, only a minority of patients with fractures and osteoporosis become identified. Surgeons and hospitals treating fractures should find means to detect patients who suffer from fractures due to osteoporosis, and establish programs for further evaluation and adequate treatment.

Apparatus to test insertion and removal torque of bone screws.

This paper describes affordable equipment for testing bone screw torque, corresponding to ASTM standard F543-00 for testing metallic medical bone screws. Correct testing of thin and long bone screws is essential due to screw failures during insertion and removal of the screws. Furthermore, insertion torque is an important factor in predicting fixation strength, screw pull-out force and effects of surface treatment of screws. The capability of the custom-built tester was determined using polytetrafluoroethylene and wood disc samples and bone screws. Bovine cortical bones allowed testing to the failure limit, i.e. the torque increased in long screws to the fracture limit. For 2.7 and 3.5 mm thick self-tapping cortical bone screws, the failure torques were 30-50 per cent higher than the minimum values required by the standard (1.0 and 2.3 N m respectively). The equipment provided reproducible results and fulfilled the ASTM standard very well. Preliminary testing with amorphous diamond coated bone screws showed good durability of the coating and on average 10-15 per cent lower torque values compared with uncoated screws. The equipment can be used to measure insertion and removal torques as described in the standard. Furthermore, it also allows testing of normal screws and bolts.

Interleukin-6 in aseptic loosening of total hip replacement prostheses.

OBJECTIVE: To investigate the level of interleukin-6 (IL-6) expression in the synovial-like interface membrane (SLIM) and in the pseudosynovial tissue surrounding the artificial hip joints, as well as in the pseudosynovial fluid from aseptically loosened total hip replacement (THR) prostheses. METHODS: A series of methods were used in this study including immunohistochemical staining, double immunofluorescence labeling, enzyme-linked immunosorbent assay (ELISA), and reverse transcriptase polymerase chain reaction (RT-PCR). RESULTS: IL-6 was found in all SLIM and the pseudosynovial tissue samples from aseptic loosening of THR. Semi-quantitative morphometry showed that IL-6 containing cells were more numerous in the SLIM (911 +/- 197; p < 0.01) and the pseudosynovial tissue samples (883 +/- 310; p < 0.01) than in the control synovial tissue (291 +/- 184). Double labeling confirmed that macrophages and fibroblasts were the predominant cell types expressing IL-6. These findings were confirmed by RT-PCR. ELISA revealed no difference in the IL-6 concentration between the pseudosynovial fluid and the control synovial fluid obtained from the patients undergoing hip arthroscopy. CONCLUSIONS: IL-6 locally produced in SLIM may in a paracrine manner contribute to periprosthetic osteolysis of the nearby bone. In contrast, fluid phase IL-6 does not seem to contribute to this end.

Expression of caspase-1 in synovial membrane-like interface tissue around loosened hip prostheses.

Caspase-1 expression in synovial membrane-like interface tissue (SMLIT) around loosened hip prostheses and osteoarthritic synovial samples was studied. Caspase-1 mRNA was found in SMLIT and synovial tissue. There is no difference in the copy numbers of caspase-1 mRNA between these samples. Both precursor and active forms of caspase-1 proteins appeared in these samples, but the number of positive cells was higher in SMLIT than in synovial tissue. Double labeling revealed that most caspase-1-positive cells were macrophages and fibroblasts. In the lining-like layers and deep stroma of SMLIT, many cells were double positive for active caspase-1 and interleukin-1 beta (IL-1beta). In contrast, the number of active caspase-1/IL-18 double-positive cells was very low. We conclude that caspase-1 synthesis is increased in SMLIT. Caspase-1 can be involved in implant loosening by processing IL-1beta precursor into its mature form, which is a potent osteoclast-activating factor and a major proinflammatory mediator.

Dendritic cells in rheumatoid synovial membrane after total removal of the hyaline articular cartilage.

OBJECTIVE: To investigate the effect of total removal of the hyaline articular cartilage on dendritic cells in synovial membrane in rheumatoid arthritis (RA) or ankylosing spondylitis (AS). PATIENTS AND METHODS: Immunohistochemical staining for two dendritic cell markers, CD35 and RFD1, was carried out on synovial membrane specimens from arthritis patients undergoing primary (n=10) or revision (n=8) total hip replacement (THR). The results are expressed as the number (mean+/-standard deviation) of positive cells per 1000 total cells. RESULTS: CD35-(112+/-9) and RFD1-(27+/-5) positive cells were found in all primary RA synovial membrane, while only two out of eight synovial membrane samples from revision THR contained CD35-positive follicular dendritic cells (nine and 12 cells), and no revision samples contained any RFD1-positive interdigitating dendritic cells. CONCLUSION: Removal of the hyaline articular cartilage reduces the infiltration and functional differentiation of dendritic cells in synovial membrane. Our findings suggest that the antigen driving chronic arthritis/synovitis is contained in the hyaline articular cartilage.

Quantitative analysis of mRNA expression of TIMPs in the periprosthetic interface tissue of loose hips by real-time PCR system.

Matrix metalloproteinases (MMPs) and their endogenous inhibitors, tissue inhibitors of metalloproteinases (TIMPs), have been reported to play a critical role in extracellular degradation around artificial hip joints. Although messenger ribonucleic acid (mRNA) expression patterns of several MMPs and TIMPs were reported, there is no report of quantitative mRNA analysis of TIMPs in periprosthetic tissues. In this study, mRNA expression of four different types of TIMPs in periprosthetic interface tissue of loose hips was analyzed by a quantitative polymerase chain reaction system. The mRNA expression level of TIMP-1, -2, and -3 in periprosthetic interface tissue was significantly higher than that in control. In contrast, the mRNA expression level of TIMP-4 in the periprosthetic interface tissue was lower. This study suggested that increased levels of TIMP-1, -2, and -3, and decreased levels of TIMP-4 may contribute to pathologic extracellular matrix degradation in combination with MMPs, thus leading to prosthetic loosening and osteolysis around artificial total hip joints.

Anatomical reconstruction of ruptured lateral ligaments of upper ankle joint.

BACKGROUND AND AIMS: It seems that a certain patient population after conservatively treated ankle distorsions later develops chronic symptoms such as instability, pain and swelling. MATERIAL AND METHODS: The present study comprised 20 such patients, who underwent an anatomical reconstruction of ruptured ankle ligament(s) (FC, FTA and/or FTP). Patients were followed in average for 22 months postoperatively. RESULTS: Sixteen of them had excellent or good results. Clinically 5 and radiologically 4 patients had instability of the operatively treated ankle joint at the follow-up. Instability and subjective patient satisfaction did not correlate at all. CONCLUSION: Anatomical reconstruction of ruptured ankle ligaments in chronic posttraumatic instability syndrome is technically possible to perform in almost all cases. The present method of anatomical ligament reconstruction usually results in good stability, diminishes symptoms and in most cases leads into a normal functional capacity.

Removal of hyaline articular cartilage reduces lymphocyte infiltration and activation in rheumatoid synovial membrane.

OBJECTIVE: To analyze the effect of removal of hyaline articular cartilage on synovial membrane pathology in chronic arthritis. METHODS: Synovial membrane samples were obtained from patients with rheumatoid arthritis or ankylosing spondylitis in association with total hip arthroplasty, either primary or revision surgery. Synovial membrane histopathology was assessed by immunochemical staining and morphometry. RESULTS: CD68 positive macrophages were common in revision synovial membranes. In contrast, T lymphocytes were much more common in primary rheumatoid synovial membranes (p < 0.001). Many T lymphocytes in primary synovial membrane were HLA-D/DR positive (p < 0.001) and interleukin 2 receptor (IL-2R) positive (p < 0.001) and contained interferon-gamma(IFN-gamma; p < 0.001) and tumor necrosis factor-beta (TNF-beta; p < 0.001). In contrast, revision synovial membranes from patients with chronic arthritis contained only a few HLA-D/DR positive T cells and practically no IL-2R, IFN-gamma, or TNF-beta positive activated T lymphocytes. CONCLUSION: The components of hyaline articular cartilage may be the source of autoantigen responsible for perpetuation of chronic arthritides.

Acid attack and cathepsin K in bone resorption around total hip replacement prosthesis.

Normal bone remodeling and pathological bone destruction have been considered to be osteoclast-driven. Osteoclasts are able to attach to bare bone surface and produce an acidic subcellular space. This leads to acid dissolution of hydroxyapatite, allowing cathepsin K to degrade the organic type I collagen-rich osteoid matrix under the acidic condition prevailing in Howship lacunae. Using a sting pH electrode, the interface membrane around a loosened total hip replacement prosthesis was found to be acidic. Confocal laser scanning disclosed irregular demineralization of the bone surface in contact with the acidic interface. Cathepsin K, an acidic collagenolytic enzyme, was found in interface tissue macrophages/giant cells and pseudosynovial fluid. Tissue extracts contained high levels of cathepsin K messenger RNA (mRNA) and protein. These observations suggest the presence of an acid- and cathepsin K-driven pathological mechanism of bone resorption, mediated not by osteoclasts in subosteoclastic space, but rather by the uncontrolled activity of macrophages in extracellular space.

Musculoskeletal pain and functional ability in haemophilia A and B. Physiotherapy and rehabilitation in haemophilia patients.

The present study was carried out to evaluate the progress of physical musculoskeletal ability and pain in Finnish haemophilia A and B patients during a given period of time and to find out the role of rehabilitation and physiotherapy in this process. In the physiotherapy/rehabilitation group, pain index by visual analogue scale (VAS) improved through time by 26%/4.6%. The nontreatment group showed slight aggravation. Regression analysis revealed that age, pain intensity, and functional disability in 1994 were the only significant explanatory factors influencing musculoskeletal functional ability at the end of the study. The current study was not planned as an intervention study and yet the results show some evidence, although not strongly, of the positive effect of physiotherapy and inpatient rehabilitation courses in reducing pain and functional disability for haemophilia patients. One of the important contributions of physiotherapy and rehabilitation is their educational role.

No lymphokines in T-cells around loosened hip prostheses.

Research results have been contradictory about the role of lymphocytes and immune response in aseptic loosening of total hip replacement (THR). Conclusive evidence is still lacking in spite of extensive in vivo and in vitro studies. Our study was designed to check whether T-cells were activated and if they produced lymphokines in synovial membrane-like interface tissue around loosened THRs. Tissue sections were stabilized and permeabilized to allow the cytokine-specific antibodies to penetrate through the cell membrane and the membranes of intracellular organelles. This technique, combined with computer-assisted image analysis, permits the detection and quantitation of lymphokine-producing cells. We found that the number of T-cells was low, and none of the T-cells was activated, as shown by the absence of interleukin-2 receptor (IL-2R) immunoreactivity. There was no cell producing lymphokines, such as interleukin-2 (IL-2), interferon-gamma (IFN-gamma), and tumor necrosis factor-beta (TNF-beta). Our results suggest that T-cell-mediated immune response is not actively involved in aseptic loosening of THR.

Hyaluronan synthases, hyaluronan, and its CD44 receptor in tissue around loosened total hip prostheses.

Aseptic loosening of prosthetic components, the most common long-term complication after total hip replacement (THR), is characterized by the formation of a synovial membrane-like interface tissue (SMLIT). It was hypothesized that the hyaluronan synthase (HAS)/hyaluronan (HA)/HA receptor CD44 signalling system is responsible for the synovial-like differentiation of the interface membrane. SMLIT was therefore compared with osteoarthritis (OA) synovial membrane by using reverse transcriptase polymerase chain reaction (RT-PCR) of HAS 1, 2 and 3, histochemical HA assay, and immunohistochemistry of CD44 and its non-HA ligands. All three isoforms of HAS were found in these samples. HA and CD44 were most abundant in the lining, but the signal was actually stronger in aseptic loosening than in OA (p<0.01). The non-HA CD44 ligands, collagen type VI, fibronectin, osteopontin, and MCP-1, had a similar distribution pattern in both tissues. These results confirm the synovial-like structure of the interface tissue lining. The pressure waves and movement of the HA-rich pseudosynovial fluid seem to drive HA into the implant-to-host interface, which itself also produces HA. HA may be responsible for the induction of a synovial-like lining at the interface through HA-CD44 signalling.

High-turnover periprosthetic bone remodeling and immature bone formation around loose cemented total hip joints.

Aseptic loosening and periprosthetic osteolysis are the major problems awaiting solution in total hip surgery. The clinical investigation focused on the analysis of periprosthetic bone remodeling to clarify one important key event in the cascade of periprosthetic connective tissue weakening and osteolysis around loose artificial hip joints. Twelve acetabular bone samples adjacent to granulomatous synovial-like membrane of loose hip prosthesis were retrieved at revision surgery and processed for Villanueva bone staining for morphological observation and bone histomorphometric analysis. Eight well-fixed bony samples were used as control. Although osteoclastic surface and eroded surface by osteoclasts were evident in the periprosthetic bone from loose hip joints (p = 0.003 and p = 0.027), increased osteoid/low-mineralized bone matrix (p < 0.001) and osteoid width (p < 0.001) also were significant findings in structural analysis. In addition, not only elevated mineral apposition rate (MAR; p = 0.044) but also increased mineralizing surface (p = 0.044) and bone formation rate (BFR; p = 0.002) in loose periprosthetic bones were shown in dynamic data analysis. These results were confirmed by precise morphological observation by confocal laser scanning microscopy. Active coupling of bone formation and resorption and increased osteocytes with abundant bone canalicular projections were found in combined with the presence of immature bone matrices (osteoid and low-mineralized bone areas) in periprosthetic bones from loose hip joints. These results indicated that active osteoclastic bone resorption and/or defective bone formation are coupled with monocyte/macrophage-mediated foreign body-type granuloma in the synovial-like interface membrane of loose hip joints. Thus, this unique high-turnover periprosthetic bone remodeling with bad bone quality probably is caused by the result of cellular host response combined with inappropriate cyclic mechanical loading. The fragile periprosthetic bone may contribute to hip prosthesis loosening.

Expression of parathyroid hormone related protein in the tissue around loosened hip prostheses.

OBJECTIVE: To investigate the eventual presence and cellular source ofparathyroid hormone related protein (PTHrP) in the synovial-like interface membrane from aseptic loosening of total hip replacement (THR). METHODS: A polyclonal rabbit antiserum to the amino-terminal peptide of human PTHrP was used to stain 10 interface membrane samples from loose THR and 10 synovial tissue samples from hip osteoarthritis (OA). Quantitative microscopic assessment was done with a computer-assisted image analysis system. Western blotting was applied to verify the presence of PTHrP in both tissue samples. Double immunofluorescence labelling aimed to reveal the cellular sources of PTHrP. RESULTS: Immunoreactive PTHrP was found in all interface membrane and OA synovial tissue samples. The number of PTHrP positive cells in interface membrane was much higher than in OA synovial tissue. Positive cells were most commonly seen in the lining-like layers and sublining area of interface membrane. Double immunofluorescence labelling showed that most macrophages and fibroblasts in interface membrane were PTHrP positive. Western blotting revealed the 24-25 KD bands in both tissue samples. CONCLUSIONS: PTHrP expression is upregulated in interface membrane around loosened hip prostheses. Locally accumulated PTHrP may contribute to periprosthetic osteolysis and aseptic loosening of THR through its direct effects on bone, or indirectly via the induction of inflammatory mediators.