Aims

To explore key stakeholder views around feasibility and acceptability of trials seeking to prevent post-traumatic osteoarthritis (PTOA) following knee injury, and provide guidance for next steps in PTOA trial design.

Focal cartilage defects (FCDs) found in medial and lateral compartments of the knee are accompanied with patient-reported pain and loss of joint function. There is a deficit of evidence to explain why they occur. We hypothesise that aberrant knee joint loading may be partially responsible for FCD pathology, therefore this study aims to use 3-dimensional motion capture (MoCap) analysis methods to investigate differences in gait biomechanics of subjects with symptomatic FCDs.

11 subjects with Outerbridge grade II FCDs of the tibiofemoral joint (5 medial compartment, 6 lateral compartment) and 10 non-pathological controls underwent level-gait MoCap analysis using an infra-red camera (Qualisys) and force-plate (Bertec) passive marker system. 6-degree of freedom models were generated and used to calculate spatio-temporal measures, and frontal and sagittal plane knee, hip and ankle rotation and moment waveforms (Visual 3D). Principle component analysis (PCA) was used to score subjects based on common waveform features, and PC scores were tested for differences using Mann-Whitney tests (SPSS).

No group differences were found in BMI, age or spatio-temporal measures. Medial-knee FCD subjects experienced higher (p=0.05) overall knee adduction moments (KAMs) compared to controls. Conversely, lateral-knee FCD subjects found lower (p=0.031) overall KAMs. Knee flexion and extension moments (KFMs/KEMs) were relatively reduced (p=0.013), but only in medial FCD subjects. This was accompanied by a significantly (p=0.019) higher knee flexion angle (KFA) during late-stance.

KAMs have been shown to be predictive of frontal plane joint contact forces, and therefore our results may be reflective of FCD subjects overloading their respective diseased knee condyles. The differences in knee sagittal plane knee moments (KFMs/KEMs) and angles (KFA) seen in medial FCD subjects are suggestive of gait adaptations to pain. Overall these results suggest treatments of FCDs should consider offloading the respective affected condyle for better surgical outcomes.

Glutamate is a neurotransmitter that transmits mechanical signals in bone (1) and activates glutamate receptors and transporters, in bone, cartilage, meniscus and synovium (2). Glutamate receptor activation influences inflammatory, degenerative and nociceptive pathways in arthritic joints (2). Thus glutamate signalling is a mechanism whereby mechanical load can directly influence joint pathology and pain. We have investigated components of glutamate signalling in the subchondral bone of patients with osteoarthritis to determine which are expressed and whether this varies in anatomical regions subject to different loads. Subchondral bone was sampled from tibial cuts derived from total knee arthroplasty (n=2, TKR, Kellgren Lawrence grade 3) and from tibial drill hole sites from high tibial osteotomy (n=5, HTO, KL grades 2 and 3) for osteoarthritis. RNA was extracted, reverse transcribed and RT-PCR performed for a housekeeping gene GAPDH, a glutamate transporters (EAAT-1, EAAT1ex9skip), glutamate receptors (NR2A and KA1), a bone matrix protein, osteocalcin, and signaling molecules (osteoprotegerin [OPG], RANKL). We found differential mRNA expression in different regions of subchondral bone. In one TKR patient, EAAT-1 expression was significantly reduced in the anterior zone versus the middle or posterior zones of the tibial plateau (ANOVA, p<0.001). HTO bone cores were subdivided medial/lateral and anterior/posterior. Good quality RNA was obtained from bone cores removed from drill holes during HTO surgery, with GAPDH, osteocalcin, EAAT-1, EAAT1ex9skip, NR2A, KA1, OPG and RANKL mRNA expression detected. In one patient, comparison of gene expression in bone cores obtained pre and post HTO revealed that EAAT1ex9skip was rarely detected in post-op bone whereas KA1 was rare in pre-op bone. This differential mRNA expression may be due to the altered loading through the joint caused by the osteotomy, although these on/off differences need to be quantified to confirm this.

We have shown that glutamate transporters and receptors are expressed in human subchondral bone. Activation of these receptors and transporters by the increased synovial fluid concentrations of glutamate released in arthritis will influence pathological changes and nociception. In some patients, glutamate transporter mRNA expression appears to vary with anatomical location in bone, or after HTO surgery, consistent with our original discovery of this transporter as mechanically-regulated in bone (1). If glutamatergic signaling is mechanically regulated in the human knee, this will vary during arthritic disease progression and after joint realignment, providing a direct mechanism linking mechanical loading through the joint to pathology and pain in arthritis.

Purpose: Since the neurotransmitter glutamate mediates nociceptive and pathological processes in arthritis, we have investigated how glutamate receptor and transporter expression varies with anatomical site or disease severity in subchondral bone of patients with osteoarthritis.

Methods and Results: Subchondral bone was sampled from tibial cuts derived from total knee arthroplasty (n=2, TKR, Kellgren Lawrence[KL] grade 3) and from tibial drill hole sites from high tibial osteotomy (n=2, HTO, KL grades 2 and 3) for osteoarthritis. RNA was extracted, reverse transcribed and RT-PCR performed for the housekeeping gene GAPDH, the glutamate transporter EAAT-1, and glutamate receptors (NR2A and KA1). Quantitative RT-PCR assessed differences in the expression of EAAT-1, a dominant negative splice variant called EAAT-1ex9skip and osteocalcin after normalisation to GAPDH.

Good quality RNA was obtained from bone cores removed from drill holes during HTO surgery, with GAPDH, EAAT-1, NR2A and KA1 expression detected. Osteocalcin expression was high indicating RNA was derived from osteoblasts and osteocytes, but did not vary with anatomical site or disease status. End-stage RT-PCR indicated differential expression of EAAT-1 between medial and lateral bone samples in total knee arthroplasty, however these differences were not significant by quantitative RT-PCR. In one patient, EAAT-1 expression was significantly reduced in the anterior zone versus the middle or posterior zones (ANOVA, p< 0.001). EAAT-1ex9skip represented a significant proportion of the total EAAT-1 mRNA expression in bone from TKR patients, but appeared less abundant in HTO samples.

Conclusion: We have shown for the first time that glutamate transporters and receptors are highly expressed in subchondral bone of patients with osteoarthritis and that EAAT-1 expression may vary with anatomical location and pathology. Activation of these receptors and transporters by the increased synovial fluid concentrations of glutamate that occur in arthritis may contribute to pathological changes and nociception.

Purpose of the study: Since the neurotransmitter glutamate mediates nociceptive and pathological processes in arthritis, we have investigated how glutamate receptor and transporter expression varies with anatomical site or disease severity in subchondral bone of patients with osteoarthritis.

Methods and results: Subchondral bone was sampled from tibial cuts derived from total knee arthroplasty (n=2, TKR, Kellgren Lawrence grade 3) and from tibial drill hole sites from high tibial osteotomy (n=2, HTO, KL grades 2 and 3) for osteoarthritis. RNA was extracted, reverse transcribed and RT-PCR performed for the housekeeping gene GAPDH, the glutamate transporter EAAT-1, and glutamate receptors (NR2A and KA1). Quantitative RT-PCR assessed differences in the expression of EAAT-1, a dominant negative splice variant called EAAT-1ex9skip and osteocalcin after nor-malisation to GAPDH.

Good quality RNA was obtained from bone cores removed from drill holes during HTO surgery, with GAPDH, EAAT-1, NR2A and KA1 expression detected. Osteocalcin expression was high indicating RNA was derived from osteoblasts and osteocytes, but did not vary with anatomical site or disease status. End-stage RT-PCR indicated differential expression of EAAT-1 between medial and lateral bone samples in total knee arthroplasty, however these differences were not significant by quantitative RT-PCR. In one patient, EAAT-1 expression was significantly reduced in the anterior zone versus the middle or posterior zones (ANOVA, p< 0.001). EAAT-1ex9skip represented a significant proportion of the total EAAT-1 mRNA expression in bone from TKR patients, but appeared less abundant in HTO samples.

Conclusion: We have shown for the first time that glutamate transporters and receptors are highly expressed in subchondral bone of patients with osteoarthritis and that EAAT-1 expression may vary with anatomical location and pathology. Activation of these receptors and transporters by the increased synovial fluid concentrations of glutamate that occur in arthritis may contribute to pathological changes and nociception.

Purpose of the study: Since glutamate can activate both nociceptive and pathological processes, we have investigated glutamate signalling in patients with painful and asymptomatic meniscal tears to determine which components are expressed, whether this varies in different anatomical regions of the meniscus and whether it is influenced by pain or degeneration.

Methods and results: Meniscus samples were obtained from two patients undergoing arthroscopic partial meniscal resection for chronic degenerate painful meniscal tears, from one patient with a torn painless meniscus and from the less affected compartment of the knee joint of three patients undergoing total knee arthroplasty. Menisci were dissected into anatomical regions (anterior horn, body, posterior horn, inner vascular, outer avascular), cryosectioned and RNA extracted. RNA was reverse transcribed and PCR performed for the housekeeping gene GAPDH and glutamate receptor subunits (NR2A, AMPA GluR3, KA1). Absolute quantitative RT-PCR assessed mRNA expression of glutamate transporters (EAAT-1, EAAT-1ex9skip) and type I collagen after normalisation to GAPDH or total RNA.

Human meniscus expressed GAPDH, type 1 collagen, EAAT-1, EAAT-1ex9skip, NR2A, AMPA GluR3 and KA1 mRNAs. Levels of EAAT-1 expression, normalised to GAPDH, did not differ between the inner and outer halves, or in the anterior, middle or posterior regions of menisci from the less affected compartments of arthritic knees. EAAT-1 expression appeared greater in the 2 painful, compared with the single non-painful meniscus. Interestingly, EAAT-1ex9skip was significantly more common within the outer zones (ANOVA, P=0.040) and in the posterior horns of the menisci (ANOVA, p=0.038).

Conclusion: We have shown for the first time that glutamate receptors and transporters are expressed in human meniscus providing a potential mechanism underlying the pathophysiology of pain associated with a torn meniscus. Our preliminary data indicate that EAAT-1 and EAAT-1ex9skip expression may vary with extent of damage and anatomical location in the human meniscus.