Degenerative arthritis of the knee secondary to ochronosis

Alkaptonuria is a rare disease in which a deficiency in the homogentisate 1, 2-dioxygenase enzyme results in a buildup of homogentisic acid. Ochronosis, the deposition of excess homogentisic acid in connective tissue, causes brownish-black pigmentation and weakening of the tissue ultimately resulting in chronic inflammation, degeneration, and osteoarthritis. There is currently no definitive cure for alkaptonuric ochronosis, and management is usually symptomatic. However, total joint replacements in severe cases of ochronotic osteoarthritis have comparable outcomes to osteoarthritic patients without ochronosis. We report a case of a patient with ochronotic arthritis of the knee treated with total knee arthroplasty.     

Cementless total knee arthroplasty in ochronotic arthropathy: a case report with a 4-year follow-up

Alkaptonuria is an inherited metabolic disorder characterized by the absence of the enzyme homogentisic acid oxidase, which leads to the accumulation of homogentisic acid, produced during normal metabolism of phenylalanine and tyrosine. Ochronosis, which is the dark pigmentation of connective tissues in patients with long-lasting alkaptonuria, can cause severe cartilage destruction in large joints and the vertebral column. Knee joint involvement, which occurs at relatively early ages, can be quite restrictive. Arthroplasty may be the treatment of choice in these patients because of limited mobility and diffuse involvement of the joint. We report a 48-year-old man who had been treated with cementless total knee arthroplasty. Theoretically, there are no bone ingrowth deficits that might be detrimental for the stabilization of cementless prostheses in ochronotic arthropathy because the bone tissue is not primarily affected by the disease. The 4-year follow-up of cementless total knee arthroplasty was satisfactory without any evidence of loosening.     

Comparative outcomes of total joint arthroplasty

A prospective pre- and postoperative general health/quality-of-life factor comparison, using the Rand SF-36 Health Status Questionnaire (TyPE Specification, Quality Quest [Health Outcomes Institute, Minneapolis, MN]), was carried out on a consecutive series of patients with diagnosed osteoarthritis undergoing total hip and knee arthroplasty between March 1991 and March 1994. Study groups consisted of 85 total hip arthroplasty patients, 93 total knee arthroplasty patients, and 65 single-stage bilateral total knee arthroplasty patients, all treated at the same specialty hospital, under the care of three senior orthopaedic surgeons. The average patient age was 69 years. Significant improvements in quality-of-life measures including physical functioning, social functioning, role functioning/physical problem, role functioning/emotional problem, mental health, energy/fatigue, pain, and change in health were noted in all hip and knee arthroplasty patients 6 months, 1 year, and 2 years after surgery (P < .05). There appeared to be no significant differences in quality-of-life measures between hip and knee arthroplasty patients. Results therefore indicate that total hip and knee arthroplasty significantly improve the functional status and quality of life among patients suffering from osteoarthritis.     

A rare cause of arthropathy: An ochronotic patient with black joints

INTRODUCTION

Alkaptonuria is an autosomal recessive disorder of metabolism. The pathogenesis of alkaptonuria includes chronic inflammation, degeneration, and eventually osteoarthritis. Ochronotic arthropathy is a rare condition found in patients with alkaptonuria.

PRESENTATION OF CASE

A 60-year-old female presented for evaluation after a 10-year history of low back pain, right hip pain, and bilateral knee pain. A cementless right total hip and a cemented left knee replacement were performed. Intraoperatively, the joint surfaces, neighboring ligaments, and tendons were black with pieces of black cartilage tissue. Histological sections of bone and soft tissue demonstrated classic findings of ochronosis, including multiple pigmented areas, reactive giant cells, and a thickened, inflamed synovium.

DISCUSSION

The management of ochronotic arthropathy in alkaptonuria patients is usually conservative, but replacement surgery is offered for severely affected hip and knee joints. A few reports of the surgical treatment of ochronotic arthropathy have been published. This report describes a case of ochronotic hip and knee arthritis treated with total hip and knee arthroplasties.

CONCLUSION

Joint replacement has excellent outcomes in a patient with significant degenerative arthropathy due to ochronosis.     

淫羊藿苷治疗骨性关节炎的研究进展

骨性关节炎是一种好发于负重较大的膝关节、髋关节及脊柱等部位的慢性关节疾病,其病因复杂,至今尚未阐明。随着我国人口老龄化的加剧,骨关节炎的发病率不断增高,2015年统计数据发现我国大陆地区骨性关节炎的发病率约为13%。目前临床上针对骨性关节炎有保守及手术等疗法,如膝关节骨性关节炎可保守治疗也可行单髁置换、胫骨高位截骨及双间室置换等手术疗法,手术治疗创伤大,费用高,远期效果并非一劳永逸。而现有的保守疗法远期效果并不显著,所以寻找新的有效的治疗药物显得更为迫切。近年来研究发现淫羊藿苷在治疗骨关节炎方面有着显著的作用,它可促进骨髓间充质干细胞成软骨分化及促进软骨细胞增殖,有效修复骨性关节炎所致的软骨病损;可抑制软骨细胞外基质的降解,延缓骨关节炎所致的软骨组织破坏;可促进成骨细胞增殖,在骨性关节炎早期促进成骨及解除矿化障碍,阻止软骨下骨的进一步病变;可抑制破骨细胞的破骨作用,达到保护软骨下骨的目的;还可抑制炎症因子所致的滑膜炎症反应,缓解关节炎所致疼痛等症状。总之,淫羊藿苷可有效治疗骨性关节炎,尤以早期为著。目前的研究仅局限于组织细胞及动物实验,为明确淫羊藿苷治疗骨性关节炎的有效性及安全性,尚需更多的临床型研究予以证实,这也是今后的研究方向。     

The role of ADAMTS genes in the end stage of hip osteoarthritis

PurposeThe aim of this study is to investigate which ADAMTS genes play a major role in the development of primary hip osteoarthritis, by comparing the tissue and blood samples in patients with hip osteoarthritis and a control group.Material and methodsHuman articular cartilage was obtained from femoral heads of 15 patients with end stage osteoarthritis undergoing total hip replacement. As the control group, the cartilages was obtained from femoral heads of 15 patients, who did not have osteoarthritis or degenerative changes in hip joint, undergoing hip replacement following the fracture of the femoral neck. After the cartilage samples were taken from the resection materials, the DNA polymorphisms in the patients' cartilage samples were tested by Polymerase Chain Reaction (PCR), the serum levels of aggrecanase genes were analyzed with Enzyme-Linked ImmunoSorbent Assay (ELISA).ResultsThe level of ADAMTS5 and ADAMTS9 genes were found significantly lower as a result of ELISA analysis degenerative arthritis group than the control group (p < 0,05). ADAMTS 1, 4, 8, 15 were similar between the two groups in ELISA analysis (p > 0,05). As a result of quantitative real time RT-PCR analysis, the level of ADAMTS8 mRNA increased 3.5 fold in hip degenerative arthritis group when compared with femoral neck fractures group. ADAMTS1, ADAMTS4 and ADAMTS5 expression levels in hip degenerative arthritis group were decreased 2.5, 2 and 2.5 fold, respectively. ADAMTS9, 15 were found to be similar between two groups.ConclusonAs a result of this study on hip osteoarthritis, the ADAMTS8 levels was found to be significantly higher in the end stage of hip osteoarthritis. Unlike similar studies on knee osteoarthritis, ADAMTS1,4,5 levels were found to be lower.     

Proteoglycan alterations during developing experimental osteoarthritis in a novel hip joint model

Degenerative hip joint disease was induced in dogs by extra-articular surgery that created a condition that mimics hip dysplasia. Decreased acetabular coverage of the femoral head gave altered mechanical load, with ensuing cartilage degeneration. For comparison, degenerative knee joint disease was induced in other dogs by transection of the anterior cruciate ligament of the knee. The femoral head articular cartilage showed macroscopic signs of degeneration within a month. No macroscopical changes of synovitis were present. Chemical analysis of cartilage samples showed loss of proteoglycans. Guanidine hydrochloride extracts of the cartilage contained proteoglycan fragments that could be separated by equilibrium density gradient centrifugation in cesium chloride. The data indicate that proteoglycans are fragmented by proteolytic cleavage and lost from the cartilage. The proteoglycans remaining in the tissue are smaller and have lost the ability to aggregate with hyaluronic acid. Similarly, in experimental knee joint osteoarthritis, the proteoglycan content of the cartilage decreased. The structural changes of those proteoglycans remaining were of a different nature, with no changes in proteoglycan size or aggregation properties, possibly indicating that both degradation and repair took place in the knee articular cartilage and/or that fragments were rapidly lost from the tissue. This may follow from different surgical procedures, only the one used for the hip joint being extra-articular, or from the different anatomy and physiology of the hip joint and the knee joint.     

Hip and knee replacement after longstanding hip arthrodesis

This study determined whether patients with severe knee disease below a hip arthrodesis can be treated successfully with total knee replacement alone or whether such patients require total hip arthroplasty followed by knee replacement. Eighteen patients who had hip arthrodesis for a mean of 33 years underwent total hip replacement alone, total knee replacement alone, or a combination of both. The Harris hip score improved from a mean of 55.3 to a mean of 86.9 points at 45 months after total hip arthroplasty. The Hospital for Special Surgery knee score improved from a mean of 33 to a mean of 78 points in patients who had total knee replacement after total hip arthroplasty. The Hospital for Special Surgery knee score improved from a mean of 35 to a mean of 44 points in patients having total knee replacement alone below a hip arthrodesis. The followup after total knee replacement averaged 53 months. These data suggest that a knee replacement alone in a patient with a fused hip is unlikely to provide a satisfactory result. Patients with severe knee disease below hip arthrodesis require total hip arthroplasty followed by knee replacement. This applies even when severe osteoarthritis of the knee is the primary complaint.     

Biochemical changes in knee joint articular cartilage after cemented prosthetic hip hemiarthroplasty in dogs.

Biochemical changes in the distal femoral articular cartilage (knee joint) after cemented prosthetic replacement of the femoral head were determined. Femurs from dogs (n = 10) that had undergone cobalt-chromium prosthetic hip hemiarthroplasty (6-8 months postoperatively) were analyzed for articular cartilage lipids in the distal femur. The quantity of phosphatidylserine increased from 0.59 +/- 0.14 mg (uninvolved) to 1.52 +/- 0.23 mg (hemiarthroplasty) lipid phosphorus/100 g tissue, and the quantity of arachidonic acid in the articular cartilage increased from 0.23 +/- 0.07 mg (uninvolved) to 2.07 +/- 0.29 mg/100 g tissue (hemiarthroplasty). Likewise, hydroxyproline content was higher in the recipient femurs (77.4 +/- 1.58 micrograms/mg cartilage) versus uninvolved femurs (71.8 +/- 1.03 micrograms/mg cartilage); the activity of acid phosphatase was greater in the recipient distal femoral cartilage as compared with the uninvolved femur, 0.07 +/- 0.01 and 0.06 +/- 0.02 mol hydrolyzed per kilogram per hour, respectively, and the hexosamine content was lower in the recipient femur knee cartilage versus knee cartilage from uninvolved femurs, 54.5 +/- 1.51 and 63.1 +/- 1.37 micrograms/mg cartilage, respectively. These biochemical changes may suggest degeneration of the knee joint articular cartilage after cemented hip hemiarthroplasty.     

Bilateral total hip arthroplasty in subjects with multiple epiphyseal dysplasia

Multiple epiphyseal dysplasia (MED) is a rare autosomal dominant skeletal dysplasia caused by abnormalities in the gene(s) coding for type IX collagen and cartilage oligomeric matrix protein. Clinically, the disease is characterized by abnormalities in the epiphyseal cartilage of multiple joints. Orthopedic manifestations include pain and restricted mobility. The disorder, which has a predilection for the femoral head and acetabulum, usually presents from the third to the fourth decade with secondary hip osteoarthritis. We report on 7 subjects affected by multiple epiphyseal dysplasia, which presented hip osteoarthritis in their third decade of life and underwent staged bilateral total hip arthroplasty. All patients experienced pain relief and improved quality of life after surgical treatment.     

Markers of joint tissue turnover in joint fluids from hips with osteonecrosis of the femoral head.

Osteonecrosis of the femoral head often results in secondary osteoarthritis of the hip joint; however, the pathologic processes underlying the destruction of articular cartilage are not fully understood. Molecular markers in the hip joint fluids were measured to examine the changes in turnover of cartilage and other joint tissues. Marker data were related to clinical, radiological, and histopathological changes in the articular cartilage of the hip. Forty-five patients (median age: 43 years) were studied. The median time between the onset of symptoms and sampling of hip synovial fluid was 6 months. Aggrecan fragments, C-propeptide of type-II collagen, matrix metalloproteinase-3, and tissue inhibitor of metalloproteinases-1 levels in joint fluid were determined by immunoassay. Osteonecrosis of the femoral head was graded by radiology as minimal collapse of the femoral head (stage 2: 26 patients), severe collapse (stage 3: 15 patients), or severe collapse with osteoarthritis (stage 4: four patients). Histological changes of the articular cartilage, consistent with early-stage osteoarthritis, were evident at stage 3 and were more advanced at stage 4. The average concentrations of proteoglycan fragments and C-propeptide of type-II collagen were 207 (SD 182) microg/ml and 19.6 (SD 19.3) ng/ml, respectively. The average concentrations of matrix metalloproteinase-3 and tissue inhibitor of metalloproteinases-1 were 177 (SD 291) nM and 23.0 (SD 9.9) nM, respectively. Measurable levels for all markers assayed were noted in the earliest stage of the disease, only a few months after the onset of symptoms and well before the appearance of radiological changes. Levels of matrix metalloproteinase-3 and molar ratios of matrix metalloproteinase-3/tissue inhibitor of metalloproteinases-1 were higher in early stage disease than in later stage disease.     

Explosive and maximal strength before and 6 months after total hip arthroplasty

Patients with unilateral hip osteoarthritis experience impairments in lower limb muscle function due to pain and disuse of the affected limb. The influence of hip osteoarthritis and subsequent total hip arthroplasty (THA) has mostly been evaluated by maximal strength tests, yet the functionally important explosive strength capabilities of hip and knee muscles are largely unknown. We aimed to evaluate hip and knee explosive and maximal strength in hip osteoarthritis patients before and after THA. Twenty‐one patients with unilateral hip osteoarthritis were evaluated before and 6 months after THA. They performed rapid maximal contractions of hip (flexor, extensor, abductor, adductor) and knee (flexor, extensor) muscles, from which explosive and maximal strength asymmetries were evaluated (involved versus uninvolved limb). Before THA, the involved limb showed significantly lower hip flexor, extensor, adductor, and knee extensor explosive and maximal strength compared to the uninvolved limb. Six months after THA surgery, hip flexor, extensor and adductor maximal and explosive strength asymmetries persisted, except for knee extensors. Explosive, but not maximal strength of hip abductors and knee extensors was lower in the involved limb before surgery and the reduced explosive strength capabilities may compromise daily living activities in hip osteoarthritis patients. After hip replacement, explosive strength asymmetries of knee extensors resolved, yet lingering asymmetries in hip flexor muscles should receive focused attention during postoperative rehabilitation. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:425–431, 2018.     

Infection after total joint arthroplasty from distal extremity sepsis

At the UCLA Medical Center in three patients treated for hematogenous infection after total joint arthroplasty, the source was apparently an infection in the extremities at a site distal to the joint arthroplasty. In a 72-year-old woman with rheumatoid arthritis infection developed in the right hip after total hip arthroplasty following a Staphylococcus aureus infection at the site of a left metatarsophalangeal arthroplasty. In a 64-year-old man with osteoarthritis the staphylococcal infection that developed after right total hip arthroplasty was seeded from a pyarthrosis of the right knee. In a 61-year-old woman with rheumatoid arthritis the sites of bilateral knee arthroplasties were seeded from a soft tissue infection of the left foot. These cases illustrate the potential for infection from local wound sepsis distal to joint arthroplasty. Such infections, particularly in patients with rheumatoid arthritis, should be treated aggressively to avoid seeding of the more proximal total joint arthroplasty site.     

Is the preoperative radiograph useful in predicting the outcome of a total hip replacement?

The preoperative radiographs of 1015 patients undergoing 1163 total hip replacements for osteoarthritis were evaluated to determine if a relationship exists between the extent of osteoarthritis and the clinical results of a total hip replacement. Preoperative radiographs were graded with respect to the degree of cartilage space loss, direction of cartilage space loss (femoral head migration), and severity of osteophyte formation. Followup averaged 32.1 months (range, 6-93 months). Greater degrees of cartilage space loss correlated with lower hip scores preoperatively but were unrelated to preoperative pain. These patients had statistically less pain at 6 months and 1 year. Patients with superior cartilage space loss before surgery also had statistically less pain at 6 months. However, at 3 years and beyond, pain was independent of degree of preoperative cartilage space loss, osteophyte formation, or femoral head migration. In addition, hip scores at any followup were independent of the degree of osteoarthritis observed on the preoperative radiograph. These findings provide statistical support to the concept that greater degrees of joint space loss correlate with better relief of pain and less severe joint space loss correlates with less relief of pain within the first year after total hip replacement. At 3 years and beyond, hip and pain scores were independent of the degree of preoperative osteoarthritis.     

Case report of a patient with ochronosis and arthroplasty of the hip and both knees

Alkaptonuria is a rare hereditary metabolic disorder characterised by absence of the enzyme homogentisic acid oxidase. As a result of this defect homogentisic acid accumulates and is excreted in the urine. The term ochronosis is used to describe bluish-black pigmentation of connective tissue. Ochronotic arthropathy results from the pigmented deposits in the joints of the appendicular and axial skeleton. Findings simulate those of uncomplicated degenerative joint disease, with effusion, articular space narrowing, and bony sclerosis. Our patient is a 70-year old male with ochronotic arthropathy. He has typical ears and sclera discoloration, and had arthroplasty of knees 7 and 4 years ago, respectively. In year 2002, he had undergone total right hip arthroplasty and has been admitted for rehabilitation 14th postoperative day. Individually designed rehabilitation regimen included kinesitherapy, hydrokinesitherapy, and ambulation training with gradual increase in weight bearing exercises and electro-analgesia of associated low back pain. In course of rehabilitation our patient improved his endurance with satisfying range of motion of right hip (flexion 90 degrees, abduction 40 degrees) and strength of hip and thigh musculature. The patient was able to walk with crutches without limitation. We conclude that joint destruction followed by painful locomotion due to ochronotic arthropathy is best treated by total joint arthroplasty, as described in our patient.     

Bilateral solid parameniscal masses in the knees

Parameniscal cysts of the knee joint are usually considered to be minor asymptomatic lesions associated with meniscal injury. We report on a rare case of bilateral knee masses in the medial soft tissues that resembled parameniscal cysts in terms of location and structure. The patient was an 80-year-old woman with severe osteoarthritis. Arthroscopy detected no meniscal tears in either knee. Arthrotomy with regional excision of the masses was required. The solid masses showed a capsular outer layer that contained fibrin deposits, granulation tissue, and fibrous cartilage fragments from the meniscus. We hypothesize that these unusual masses represent senescent or “ancient” meniscal cysts, the result of long-term fibrous degeneration of previous parameniscal cysts, and may co-occur with severe osteoarthritis and meniscal degeneration.     

Evaluation of the ipsilateral knee more than 40 years after successful closed reduction of DDH

Aim of the study  We asked whether the ipsilateral knee of patients treated by closed reduction for developmental hip dislocation (DDH) is affected by osteoarthritis (OA) more than 40 years later. Materials and methods  In total, 61 patients (71 hips) with the diagnosis of DDH were included in the study. The average age at the time of closed reduction was 17.9 months. The follow-up after closed reduction averaged 44.4 years. We determined the following parameters on radiographs, taken in the standing position: minimal joint space width in the medial and lateral compartments of the knee, minimal joint space width of the hip joint, radiological signs of osteoarthritis of the knee and the hip joints (Kellgren and Lawrence), knee alignment, acetabular roof obliquity (AC angle), depth of the acetabulum (ACM angle) and center–edge angle (CE angle) according to Wiberg. All radiographs were measured twice manually with ruler and goniometer by two independent investigators. Interobserver and intraobserver reliability (test–retest) was calculated for all parameters. Results  We observed that patients with bilateral DDH had significantly more joint space narrowing in the medial compartment of the knee joints than those with unilateral DDH. The length of follow-up correlated with radiological signs of OA in the hip, but not in the knee. Conclusion  We found a significant difference in medial compartment joint space narrowing between patients with unilateral DDH and those with bilateral DDH. The Kellgren–Lawrence classification, however, showed no significant differences between uni- and bilateral DDH. The knee alignment was always at the threshold of physiological values.     

Cartilaginous deposits in subchondral bone in regions of exposed bone in osteoarthritis of the human knee: histomorphometric study of PRG4 distribution in osteoarthritic cartilage.

The objective of this study was to identify and characterize cartilaginous deposits aggregates in the subchondral bone in areas of the human osteoarthritic knee with exposed bone. A specific aim was to determine the distribution of the joint lubrication molecule, lubricin/superficial zone protein [referred to by its gene, proteoglycan4 (PRG4)], in these cartilaginous deposits and in osteoarthritic cartilage. This work was carried out in the context of assessing the potential contribution of these chondrocyte aggregates for joint resurfacing in certain cartilage repair procedures. The discarded bone cuts of femoral condyles and tibial plateaus were collected from 11 patients with advanced osteoarthritis (OA) of the knee during total knee arthroplasty; 9 women and 2 men with a mean age of 68 years. Sections of paraffin-embedded tissue were stained with Safranin-O, and with antibodies to type II collagen, alpha-smooth muscle actin (SMA), and PRG4. Chondrocyte aggregates were found in the subchondral bone of regions of exposed bone in sections from five individuals. The average diameter of cartilaginous aggregates was 152 microm, and the average depth of the aggregates below the surface was about 475 microm. Most aggregates were fibrocartilaginous and stained positive for type II collagen. Of interest was the finding that the cartilaginous deposits and osteoarthritic cartilage contained PRG4. Only a small percentage of chondrocytes stained positive for SMA. Cartilaginous deposits containing chondrocyte aggregates exist in subchondral bone in regions of exposed bone in some patients with advanced OA of the knee. These cells may be able to contribute to the resurfacing of the joint in certain cartilage repair procedures.     

Asporin and knee osteoarthritis in patients of Greek origin

Ostearthritis (OA) is characterized by focal areas of loss of the articular cartilage in synovial joints, associated with varying degrees of osteophyte formation, subchondral bone change and synovitis. The Asporin (ASPN) gene which encodes a protein of the extracellular cartilage matrix contains a triplet repeat encoding for aspartic acid (D) within exon 2 The D14 allele was found associated with knee and hip osteoarthritis in case-control study in the Japanese population. Genotyping Greek knee OA patients for the D repeats we determined that the D15 allele could be considered a risk allele for our population.     

Intra-articular Injections of the Hip and Knee With Triamcinolone vs Ketorolac: A Randomized Controlled Trial

BackgroundClinicians commonly utilize intra-articular injections to treat symptomatic primary arthritis. Steroid injections are common yet have immune-modulating effects and can alter gene expression which may delay definitive arthroplasty and further damage cartilage. Nonsteroidal anti-inflammatory injections may offer a safer profile due to their differing mechanism of action; however, there is a relative dearth of information regarding their efficacy. This noninferiority study compares the effectiveness of triamcinolone vs ketorolac in treating symptoms of moderate to advanced primary osteoarthritis of the hip and knee.MethodsIn total, 110 patients (52 hips and 58 knees) with moderate to severe radiographic primary osteoarthritis of the hip or knee were randomized in a double-blinded study to receive an ultrasound-guided intra-articular injection of ketorolac or triamcinolone. Patient-reported outcome measures were collected pre-injection and at 1 week, 1 month, and 3 months.ResultsFor hips and knees, intra-articular injections with either ketorolac or triamcinolone led to statistically significant improvements in patient-reported outcome measures. The treatment effect size was largest at 1 week and decreased over time. Primary analysis of variance comparisons revealed no significant differences between ketorolac and triamcinolone. For knee injections, post hoc secondary analysis suggests slight added durability in the triamcinolone group. Adverse effects were minimal with both interventions.ConclusionIntra-articular ketorolac injections provide comparable improvement to triamcinolone for primary hip and knee osteoarthritis. Ketorolac is an additional low-cost option for conservative management of primary osteoarthritis, and due to its differing mechanism of action, it may not propagate additional cartilage damage or preclude from early surgical intervention if unsuccessful.Trial Registration NumberNCT04441112.