An In Vitro System to Study the Effect of Subchondral Bone Health on Articular Cartilage Repair in Humans.

Chondrocyte-based cartilage repair strategies, such as articular chondrocyte implantation, are widely used, but few studies addressed the communication between native subchondral bone cells and the transplanted chondrocytes. An indirect co-culture model was developed, representing a chondrocyte/scaffold-construct repair of a cartilage defect adjoining bone, where the bone could have varying degrees of degeneration. Human BM-MSCs were isolated from two areas of subchondral bone in each of five osteochondral tissue specimens from five patients undergoing knee arthroplasty. These two areas underlaid the macroscopically and histologically best and worst cartilage, representing early and late-stage OA, respectively. BM-MSCs were co-cultured with normal chondrocytes suspended in agarose, with the two cell types separated by a porous membrane. After 0, 7, 14 and 21 days, chondrocyte-agarose scaffolds were assessed by gene expression and biochemical analyses, and the abundance of selected proteins in conditioned media was assessed by ELISA. Co-culture with late-OA BM-MSCs resulted in a reduction in GAG deposition and a decreased expression of genes encoding matrix-specific proteins (COL2A1 and ACAN), compared to culturing with early OA BM-MSCs. The concentration of TGF-ß1 was significantly higher in the early OA conditioned media. The results of this study have clinical implications for cartilage repair, suggesting that the health of the subchondral bone may influence the outcomes of chondrocyte-based repair strategies.

Design and psychometric testing of a new patient-reported outcome measure for ankle treatment.

BACKGROUND: Several outcome scores are used to assess the outcome of ankle surgery, but many are not validated and there is currently no 'gold-standard'. Consequently, there is demand to develop a new 'gold-standard' score to assess ankle surgery. The study aim was to review existing scores to develop and validate a new patient-reported outcome measure (PROM) to assess the outcome of operative ankle surgery. METHODS: The questionnaire items covered three areas: pain, symptoms and activity. The scale was reviewed by a patient group, resulting in the Oswestry Ankle score (Os-Ankle). The Os-Ankle was validated using a cohort of 206 patients at both pre-operative and post-operative stages of ankle surgery. Patients provided two other outcome scores, the scores currently used at our centre: the Manchester-Oxford Foot Questionnaire (MOxFQ) and the Veterans Rand-12 (VR-12). Factor analysis and Rasch were determined to assess the psychometric testing and design of the Os-Ankle score. A follow up paper assesses the validity of the Os-Ankle against two existing scores. RESULTS: Results of the factor and Rasch analysis suggested that 12-items should be removed. The remaining 18-items fitted the Rasch model well, suggesting good internal consistency. CONCLUSION: A new ankle PROM, the Os-Ankle, was successfully developed and demonstrated good psychometric testing. The Os-Ankle evaluates pain, symptoms and activities and results in a single score. The Os-Ankle has been validated in our follow up paper, and is ready to be implemented by ankle clinicians to monitor clinical outcomes. With the publication of two back to back papers, it will allow for further engage with other clinicians and other centres. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Regenerative Medicine: A Review of the Evolution of Autologous Chondrocyte Implantation (ACI) Therapy.

Articular cartilage is composed of chondrons within a territorial matrix surrounded by a highly organized extracellular matrix comprising collagen II fibrils, proteoglycans, glycosaminoglycans, and non-collagenous proteins. Damaged articular cartilage has a limited potential for healing and untreated defects often progress to osteoarthritis. High hopes have been pinned on regenerative medicine strategies to meet the challenge of preventing progress to late osteoarthritis. One such strategy, autologous chondrocyte implantation (ACI), was first reported in 1994 as a treatment for deep focal articular cartilage defects. ACI has since evolved to become a worldwide well-established surgical technique. For ACI, chondrocytes are harvested from the lesser weight bearing edge of the joint by arthroscopy, their numbers expanded in monolayer culture for at least four weeks, and then re-implanted in the damaged region under a natural or synthetic membrane via an open joint procedure. We consider the evolution of ACI to become an established cell therapy, its current limitations, and on-going strategies to improve its efficacy. The most promising developments involving cells and natural or synthetic biomaterials will be highlighted.

A case study: Glycosaminoglycan profiles of autologous chondrocyte implantation (ACI) tissue improve as the tissue matures.

BACKGROUND: Autologous chondrocyte implantation (ACI) has been used to treat cartilage defects in thousands of patients worldwide with good clinical effectiveness 10-20years after implantation. Information concerning the quality of the repair cartilage is still limited because biopsies are small and rare. Glycosaminoglycan structure influences physiological function and is likely to be important in the long term stability of the repair tissue. The aim of this study was to assess glycosaminoglycans in ACI tissue over a two year period. METHODS: Biopsies were taken from one patient (25years old) at 12months and 20months post-ACI-treatment and from three normal cadavers (21, 22 and 25years old). Fluorophore-assisted carbohydrate electrophoresis (FACE) was used to quantitatively assess the individual glycosaminoglycans. RESULTS: At 12months the ACI biopsy had 40% less hyaluronan than the age-matched cadaveric biopsies but by 20months the ACI biopsy had the same amount of hyaluronan as the controls. Both the 12 and 20month ACI biopsies had less chondroitin sulphate disaccharides and shorter chondroitin sulphate chains than the age-matched cadaveric biopsies. However, chondroitin sulphate chain length doubled as the ACI repair tissue matured at 12months (3913Da±464) and 20months (6923Da±711) and there was less keratan sulphate as compared to the controls. CONCLUSIONS: Although the glycosaminoglycan composition of the repair tissue is not identical to mature articular cartilage its quality continues to improve with time.

Immortalisation with hTERT Impacts on Sulphated Glycosaminoglycan Secretion and Immunophenotype in a Variable and Cell Specific Manner.

BACKGROUND: Limited options for the treatment of cartilage damage have driven the development of tissue engineered or cell therapy alternatives reliant on ex vivo cell expansion. The study of chondrogenesis in primary cells is difficult due to progressive cellular aging and senescence. Immortalisation via the reintroduction of the catalytic component of telomerase, hTERT, could allow repeated, longitudinal studies to be performed while bypassing senescent phenotypes. METHODS: Three human cell types: bone marrow-derived stromal cells (BMA13), embryonic stem cell-derived (1C6) and chondrocytes (OK3) were transduced with hTERT (BMA13H, 1C6H and OK3H) and proliferation, surface marker expression and tri-lineage differentiation capacity determined. The sulphated glycosaminoglycan (sGAG) content of the monolayer and spent media was quantified in maintenance media (MM) and pro-chondrogenic media (PChM) and normalised to DNA. RESULTS: hTERT expression was confirmed in transduced cells with proliferation enhancement in 1C6H and OK3H cells but not BMA13H. All cells were negative for leukocyte markers (CD19, CD34, CD45) and CD73 positive. CD14 was expressed at low levels on OK3 and OK3H and HLA-DR on BMA13 (84.8%). CD90 was high for BMA13 (84.9%) and OK3 (97.3%) and moderate for 1C6 (56.7%), expression was reduced in BMA13H (33.7%) and 1C6H (1.6%). CD105 levels varied (BMA13 87.7%, 1C6 8.2%, OK3 43.3%) and underwent reduction in OK3H (25.1%). 1C6 and BMA13 demonstrated osteogenic and adipogenic differentiation but mineralised matrix and lipid accumulation appeared reduced post hTERT transduction. Chondrogenic differentiation resulted in increased monolayer-associated sGAG in all primary cells and 1C6H (p<0.001), and BMA13H (p<0.05). In contrast OK3H demonstrated reduced monolayer-associated sGAG in PChM (p<0.001). Media-associated sGAG accounted for ≥55% (PChM-1C6) and ≥74% (MM-1C6H). CONCLUSION: In conclusion, hTERT transduction could, but did not always, prevent senescence and cell phenotype, including differentiation potential, was affected in a variable manner. As such, these cells are not a direct substitute for primary cells in cartilage regeneration research.

Biomechanical properties of single chondrocytes and chondrons determined by micromanipulation and finite-element modelling.

A chondrocyte and its surrounding pericellular matrix (PCM) are defined as a chondron. Single chondrocytes and chondrons isolated from bovine articular cartilage were compressed by micromanipulation between two parallel surfaces in order to investigate their biomechanical properties and to discover the mechanical significance of the PCM. The force imposed on the cells was measured directly during compression to various deformations and then holding. When the nominal strain at the end of compression was 50 per cent, force relaxation showed that the cells were viscoelastic, but this viscoelasticity was generally insignificant when the nominal strain was 30 per cent or lower. The viscoelastic behaviour might be due to the mechanical response of the cell cytoskeleton and/or nucleus at higher deformations. A finite-element analysis was applied to simulate the experimental force-displacement/time data and to obtain mechanical property parameters of the chondrocytes and chondrons. Because of the large strains in the cells, a nonlinear elastic model was used for simulations of compression to 30 per cent nominal strain and a nonlinear viscoelastic model for 50 per cent. The elastic model yielded a Young's modulus of 14 ± 1 kPa (mean ± s.e.) for chondrocytes and 19 ± 2 kPa for chondrons, respectively. The viscoelastic model generated an instantaneous elastic modulus of 21 ± 3 and 27 ± 4 kPa, a long-term modulus of 9.3 ± 0.8 and 12 ± 1 kPa and an apparent viscosity of 2.8 ± 0.5 and 3.4 ± 0.6 kPa s for chondrocytes and chondrons, respectively. It was concluded that chondrons were generally stiffer and showed less viscoelastic behaviour than chondrocytes, and that the PCM significantly influenced the mechanical properties of the cells.

Molecular profiling of single cells in response to mechanical force: comparison of chondrocytes, chondrons and encapsulated chondrocytes.

A chondrocyte and its surrounding pericellular matrix (PCM) are defined as a chondron. The PCM plays a critical role in enhancing matrix production, protecting the chondrocyte during loading and transducing mechanical signals. Tissue engineering involves the design of artificial matrices which aim to mimic PCM function for mechanical strength and signalling motifs. We compare the mechanical performance and mechanoresponsiveness of chondrocytes with and without PCM, and encapsulated by alternate adsorption of two oppositely charged polyelectrolytes; chitosan and hyaluronan. Zeta potential measurements confirmed the success of the encapsulation. Encapsulation did not influence chondrocyte viability or metabolic activity. Cells were compressed by micromanipulation with final deformations to 30%, 50% and 70%. Force-displacement data showed that the larger the deformation at the end of compression, the greater the force on the cell. Mechanoresponsiveness of cells was studied by combining single cell PCR with dynamic compression at 20% and 40%. Aggrecan and Type II collagen gene expression were significantly increased in encapsulated chondrocytes and chondrons compared to chondrocytes whereas dynamic compression had no effect on SOX9 or lubricin gene expression. Our results demonstrate that although encapsulation can mimic responses of chondrocytes to biomechanical compression the molecular profile did not reach the enhanced levels observed with chondrons.

Strain-dependent viscoelastic behaviour and rupture force of single chondrocytes and chondrons under compression.

The chondron in articular cartilage includes the chondrocyte and its surrounding pericellular matrix (PCM). Single chondrocytes and chondrons were compressed between two parallel surfaces by a micromanipulation technique to investigate their biomechanical properties and to discover the mechanical significance of the PCM. The force imposed on the cells was measured directly during deformation at various compression speeds and deformations up to cell rupture. When the deformation at the end of compression was 50%, relaxation showed that the cells were viscoelastic, but this viscoelasticity was generally insignificant at 30% deformation or lower. When the deformation was 70%, the cells had deformed plastically. Chondrons ruptured at a mean deformation of 85 +/- 1%, whilst chondrocytes ruptured at a mean deformation of 78 +/- 1%. Chondrons were generally stiffer than chondrocytes and showed less viscoelastic behaviour than chondrocytes. Thus, the PCM significantly influences the mechanical properties of the cells.

Gene expression profiles of dynamically compressed single chondrocytes and chondrons.

A chondrocyte produces a hydrated pericellular matrix (PCM); together they form a chondron. Previous work has shown that the presence of the PCM influences the biological response of chondrocytes to loading. The objective of this study was to determine the gene expression profiles of enzymatically isolated single chondrocytes and chondrons in response to dynamic compression. Cartilage specific extracellular matrix components and transcription factors were examined. Following dynamic compression, chondrocytes and chondrons showed variations in gene expression profiles. Aggrecan, Type II collagen and osteopontin gene expression were significantly increased in chondrons. Lubricin gene expression decreased in both chondrons and chondrocytes. Dynamic compression had no effect on SOX9 gene expression. Our results demonstrate a clear role for the PCM in interfacing the mechanical signalling in chondrocytes in response to dynamic compression. Further investigation of single chondrocytes and chondrons from different zones within articular cartilage may further our understanding of cartilage mechanobiology.

Mathematical modelling of fibre-enhanced perfusion inside a tissue-engineering bioreactor.

We develop a simple mathematical model for forced flow of culture medium through a porous scaffold in a tissue-engineering bioreactor. Porous-walled hollow fibres penetrate the scaffold and act as additional sources of culture medium. The model, based on Darcy's law, is used to examine the nutrient and shear-stress distributions throughout the scaffold. We consider several configurations of fibres and inlet and outlet pipes. Compared with a numerical solution of the full Navier-Stokes equations within the complex scaffold geometry, the modelling approach is cheap, and does not require knowledge of the detailed microstructure of the particular scaffold being used. The potential of this approach is demonstrated through quantification of the effect the additional flow from the fibres has on the nutrient and shear-stress distribution.

Glycosaminoglycans in the pericellular matrix of chondrons and chondrocytes.

This is the first study to quantitate and profile the glycosaminoglycan (GAG) composition of the pericellular matrix (PCM) of chondrons and chondrocytes using the highly sensitive technique; fluorophore-assisted carbohydrate electrophoresis (FACE). Bovine articular chondrocytes and chondrons were isolated enzymatically. High cell yield and viability were obtained for both preparations. Chondrons had strong immunofluorescent labeling for keratan sulphate and chondroitin-6 sulphate but no labeling for hyaluronan. We compared the immunofluorescent data with FACE. The quantities of total keratan sulphate were determined to be 0.013 +/- 0.002 pg cell(-1) and 0.032 +/- 0.003 pg cell(-1) in the chondrocyte and chondron preparations, respectively. Four internal keratan sulphate sugars were detected (gal beta 1,4glcNAc6S, gal6S beta 1,4glcNAc6S, glcNAc beta 1,3gal and glcNAc6S beta 1,3gal) for both preparations but they were present at significantly higher concentrations in chondron preparations (P < 0.01). Total chondroitin sulphate (CS) was determined to be 0.054 +/- 0.004 pg cell(-1) and 0.077 +/- 0.005 pg cell(-1) for chondrocyte and chondron preparations, respectively. Unsulphated CS disaccharide levels were similar but chondrons had significantly more chondroitin-4 sulphated disaccharides and chondroitin-6 sulphated disaccharides (P < 0.05). Hyaluronan acid was present at low concentrations (0.010 +/- 0.001 pg cell(-1)) in both chondrocytes and chondrons. In this study, enzyme digestion coupled with FACE separation revealed new information about the differences in GAGs from isolated chondrocyte and chondron preparations. Further investigation of the differences in GAGs from chondrocytes and chondrons from different zones of articular cartilage may be useful for tissue engineering approaches.

Glycosaminoglycan profiles of repair tissue formed following autologous chondrocyte implantation differ from control cartilage.

Currently, autologous chondrocyte implantation (ACI) is the most commonly used cell-based therapy for the treatment of isolated femoral condyle lesions of the knee. A small number of centres performing ACI have reported encouraging long-term clinical results, but there is currently a lack of quantitative and qualitative biochemical data regarding the nature of the repair tissue. Glycosaminoglycan (GAG) structure influences physiological function and is likely to be important in the long-term stability of the repair tissue. The objective of this study was to use fluorophore-assisted carbohydrate electrophoresis (FACE) to both quantitatively and qualitatively analyse the GAG composition of repair tissue biopsies and compare them with age-matched cadaveric controls. We used immunohistochemistry to provide a baseline reference for comparison. Biopsies were taken from eight patients (22 to 52 years old) 1 year after ACI treatment and from four cadavers (20 to 50 years old). FACE quantitatively profiled the GAGs in as little as 5 microg of cartilage. The pattern and intensity of immunostaining were generally comparable with the data obtained with FACE. In the ACI repair tissue, there was a twofold reduction in chondroitin sulphate and keratan sulphate compared with age-matched control cartilage. By contrast, there was an increase in hyaluronan with significantly shorter chondroitin sulphate chains and less chondroitin 6-sulphate in repair tissue than control cartilage. The composition of the repair tissue thus is not identical to mature articular cartilage.