Thesis (M. Phil.)--University of Hong Kong, 1995. / Includes bibliographical references (leaf 86-89).

Thesis (Ph.D.)--Ohio University, March, 2005. / Includes bibliographical references (p. 118-125)

Thesis (Ph.D.)--Ohio University, March, 2005. / Title from PDF t.p. Includes bibliographical references (p. 118-125)

Knee osteoarthritis (OA) is the commonest form of lower limb OA with a lifetime risk of over 40%. It is a disease characterised by symptoms such as pain and loss of function. In addition there are typical structural features on both radiographs and MRI. Knee OA represents a spectrum of disease, ranging from early preclinical cartilage change to established full thickness disease. Anteromedial knee OA is a particular phenotype of knee OA where disease is confined to the medial compartment. Whilst end stage arthritis is treated reliably with joint arthroplasty, those with early stage disease are treated with a variety of non- surgical interventions with varying success. This thesis is concerned with understanding the disease of patients that have early radiographic changes but symptoms not controlled by conservative measures. Up to 150 of these patients a year present to the Nuffield Orthopaedic Centre, Oxford. They have been described as being in the “Treatment Gap”. A series of validation studies were performed to determine the optimal method for diagnosing cartilage defects within the knee. The three commonest diagnostic methods were examined for their validity. Arthroscopic assessments of cartilage lesions demonstrated a moderate level of intra and inter observer reliability. In contrast, radiographs and MRI demonstrated high levels of reliability. When using MRI as a criterion standard, both radiographs and arthroscopic assessment were found to have poor accuracy. Based on the work in this thesis a formal definition of the cartilage changes exhibited in early knee OA was proposed. A cross sectional cohort of 100 patients with the symptoms and radiological features of early knee OA were identified. Their pain and function profile was compared to two comparison groups of patients at the end stage of knee OA (defined by the need for partial or total arthroplasty). In up to 78% of individual cases those with early OA had pain and function profiles as bad as those with end stage disease. The cross sectional symptoms of early knee OA demonstrate a marked discordance with their mild radiographic changes. The same cohort was extended to 125 patients. They were followed over one year with monthly PROM assessments to determine how symptoms change over time. 43% of patients experience a clinical improvement over 12 months, 31% experience a clinical deterioration and 26% remain unchanged. The range in OKS variation over 12 months was on average 12 points, with clinically relevant variation occurring on 45% of monthly measurements. Patients with early knee OA can expect to experience considerable variation in their symptoms over 12 months and this must be considered when planning interventions. A number of patients with early knee OA were noticed to demonstrate medial meniscal extrusion. Using data from the Osteo Arthritis Initiative (OAI) a nested case control study was designed to determine how the presence of meniscal extrusion in an otherwise normal knee affects the risk of developing knee OA over the next 48 months. This demonstrated an Odds Ratio of 3.5, suggesting that meniscal extrusion is a considerable risk factor for the development of OA. The presence of a knee injury or operative intervention to the index meniscus was shown to increase this risk. Many phenotypes of OA are known to demonstrate familial aggregation. In an attempt to determine where the earliest structural changes occur in medial compartment knee OA, a cohort of patients selected only for their family history of the disease were developed. This cohort was compared to spouse controls for the presence of knee OA, as well as meniscal extrusion and long leg alignment. In addition, a functional analysis of their cartilage was performed. This cohort was not shown to be at increased risk of disease compared to controls. Discussion of the possible reasons for this finding is presented. Early knee osteoarthritis is a considerable clinical problem. This thesis has aided the understanding of the condition by firstly defining the radiological description of these patients. Secondly, their cross sectional and longitudinal symptom profile have been described for the first time. In addition, the presence of an extruded meniscus has been demonstrated as a substantial risk factor for the disease. Finally, family history has not been demonstrated as a risk factor for the disease within the limits of the study described here. Future work has been proposed.

Towards understanding regional meniscus characteristics important for tissue engineering efforts, meniscus cells were characterized biomechanically and an effective method for isolating these cells for tissue engineering was determined. It was found that the meniscus contains cells that are biomechanically distinct, with outer meniscus cells showing higher stiffness than inner cells. It was also determined that meniscus cells as a whole were more biomechanically similar to ligament cells than to articular chondrocytes, indicating that tissue properties may correlate with cellular mechanics. In addition to showing regionally distinct biomechanical properties, enzymatic isolation of meniscus cells was found to cause varying phenotypic changes in cells from the inner, middle, and outer regions. A comparison of isolation techniques also indicated that sequential digestion of meniscus tissue with pronase and collagenase was able to yield more cells with higher viability than other techniques tested, and those isolated cells created stiffer and more glycosaminoglycan (GAG) rich constructs when used in a tissue engineering modality than cells isolated using only collagenase. The identification of an effective mode of isolating meniscus cells is of great use to tissue engineering efforts, as they often require a large cell numbers. These findings illustrate that known regional variations in meniscus cell phenotype and biochemical composition are also evident in cellular mechanics, and phenotypic responses of these cells to isolation are varied and distinct. To be successful tissue replacements, tissue engineered meniscus constructs must not elicit an immune response and must have sufficient mechanical properties to survive when implanted. To determine if allogeneic or xenogeneic implantation of scaffold-free meniscus constructs could be feasible, the immunogenicity of bovine and leporine meniscus cells and articular chondrocytes were determined in an in vitro model system. It was found that neither bovine nor leporine meniscus cells or articular chondrocytes caused activation of leporine immune cells, suggesting that they may serve as allogeneic or xenogeneic cell sources for meniscus engineering. Additional analysis of the mechanical role of meniscus GAGs indicated that they are mechanically important in all regions of the meniscus, but especially in the inner region where the relatively high GAG content affects both compressive and tensile properties. Therefore, tissue engineering efforts should try to recapitulate GAG content and distribution to enhance the functionality of meniscus replacements. As a major obstacle for meniscus engineering is the identification of an abundant cell source, this thesis also investigated the use of skin cells as an alternative to primary cells for tissue engineering. Previously identified chondroinducible dermis cells were found to have multilineage differentiation capacity, and were subsequently termed dermis isolated adult stem cells (DIAS). DIAS cells were also able to be expanded in monolayer without losing chondroinductive capacity, and were able to create constructs with cartilaginous properties which could be varied with growth factor application. Given the ease of expansion and ability of DIAS cells to form fibrocartilaginous tissue, these cells present an abundant cell source for meniscus tissue engineering.