Hyaluronic acid (HA) is a linear polysaccharide which occurs naturally as a constituent of synovial fluid. The HA concentration in the joint decreases inexorably during the progression of knee osteoarthritis (OA) and so, for nearly five decades, HA has been trialled and used in the treatment of knee OA. There are strong data from clinical trials, meta-analyses and umbrella reviews to support the use of intra-articular hyaluronic acid (IAHA) in the treatment of patients with knee OA, though not in patients with acute, active OA experiencing a flare. The majority of the literature suggests that IAHA has a positive safety profile despite a few meta-analyses suggesting an increased risk of serious adverse effects. Further qualitative analysis integrating patient preferences for multi-modal and/or non-surgical management is required in order to further explore these findings. IAHA has been combined with a number of additional agents, including mannitol, sorbitol, chondroitin sulphate, tranexamic acid, polynucleotides and hybrid IAHA formulations. These show variable performance beyond the baseline effect of their constituents. It is crucial to consider the patient’s preference when considering treatments for knee OA. Specific to IAHA, patients seek minimally invasive, lower-risk, and non-steroidal options with at least moderate efficacy and advantageous safety profiles. Hyaluronic acid is a naturally occurring constituent of synovial fluid and there are strong studies supporting its use in the treatment of osteoarthritis (outside the context of disease flares). The majority of literature supports a highly advantageous safety profile for hyaluronic acid in terms of adverse effect profile. Intra-articular hyaluronic acid (IAHA) can be injected in combination with other agents; including mannitol, sorbitol, chondroitin sulphate, tranexamic acid, polynucleotides and hybrid IAHA formulations, which show potential efficacy beyond their constituents alone.

To optimize osteoporosis therapy with the parathyroid hormone fragment teriparatide (PTH1-34), we sought to determine whether strontium (Sr) could potentiate the bone anabolic action of intermittent PTH1-34 in ovariectomized rats. Female rats were either Sham-operated or ovariectomized (Ovx) at 6 months of age. Eight weeks after surgery, Ovx rats received either vehicle solutions, 625 mg/kg/day Sr (5 days per week), 8 µg/kg/day PTH1-34 (5 days per week), or the combined treatments for 8 weeks. PTH1-34 reversed Ovx-induced deterioration of trabecular microarchitecture, apparent volumetric bone mineral density (vBMD), and strength, whereas Sr alone increased tissue-level vBMD without significantly affecting trabecular bone mass. Co-treatment with Sr and PTH1-34 further increased trabecular thickness (+ 8.9

Viscosupplementation by intra-articular injections of hyaluronic acid (HA) is used to treat symptomatic osteoarthritis. Exogenous HA remains in the joint cavity for a short period of time (days) while claimed pain relief period lasts over months. There is a clear lack of understanding of viscosupplementation mechanism of action. Here, we hypothesize that HA penetrates the cartilage and contributes to the restoration of its mechanical quality. Confocal microscopy and bio-indentation were used to confirm HA penetration into cartilage and modulation of cartilage quality. Bio-indentation was performed on rat distal femurs incubated overnight in HA solutions, using phosphate buffered saline (PBS) as control. For this proof-of-concept evaluation, measurements of elastic modulus (MPa) and of maximal force (mu N) were recorded before and immediately after exposure with HA, as well as after an additional washout with PBS. Cartilage thickness at the site of indentation was evaluated by contrast enhanced computed tomography with an ionic contrast agent. Indentation depths were located in the upper part of hyaline cartilage. Ostenil (R), commercial product containing 1 % HA, induced a decrease in indentation depth in the range of forces influencing the whole cartilage thickness, together with an increase of the elastic modulus. Then, bio-indentation and size distribution of HA chains via SEC-SLS were assessed for a range of commercially available products. The results showed higher modulation of cartilage quality in the presence of 0.25-1 MDa HA chains. The present in vitro study suggests that HA modulates cartilage quality and might thus explain the long-term beneficial effect of viscosupplementation.

The differences in bone nanomechanical properties between cortical (Ct) and trabecular (Tb) bone remain uncertain, whereas knowing the respective contribution of each compartment is critical to understand the origin of bone strength. Our purpose was to compare bone mechanical and intrinsic properties of Ct and Tb compartments, at the bone structural unit (BSU) level, in iliac bone taken from a homogeneous untreated human population.Among 60 PMMA-embedded transiliac bone biopsies from untreated postmenopausal osteoporotic women (64 ± 7 year-old), >2000 BSUs were analysed by nanoindentation in physiological wet conditions [indentation modulus (elasticity), hardness, dissipated energy], by Fourier transform infrared (FTIRM) and Raman microspectroscopy (mineral and organic characteristics), and by X-ray microradiography (degree of mineralization of bone, DMB). BSUs were categorized based on tissue age, osteonal (Ost) and interstitial (Int) tissues location and bone compartments (Ct and Tb).Indentation modulus was higher in Ct than in Tb BSUs, both in Ost and Int. dissipated energy was higher in Ct than Tb, in Int BSUs. Hardness was not different between Ct and Tb BSUs. In Ost or Int BSUs, mineral maturity (conversion of non-apatitic into apatitic phosphates) was higher in Ct than in Tb, as well as for collagen maturity (Ost). Mineral content assessed as mineral/matrix (FTIRM and Raman) or as DMB, was lower in Ct than in Tb. Crystallinity (FTIRM) was similar in BSUs from Ct and Tb, and slightly lower in Ct than in Tb when measured by Raman, indicating that the crystal size/perfection was quite similar between Ct and Tb BSUs. The differences found between Ost and Int tissues were much higher than the difference found between Ct and Tb for all those bone material properties. Multiple regression analysis showed that Indentation modulus and dissipated energy were mainly explained by mineral maturity in Ct and by collagen maturity in Tb, and hardness by mineral content in both Ct and Tb.In conclusion, in untreated human iliac bone, Ct and Tb BSUs exhibit different characteristics. Ct BSUs have higher indentation modulus, dissipated energy (Int), mineral and organic maturities than Tb BSUs, without difference in hardness. Although those differences are relatively small compared to those found between Ost and Int BSUs, they may influence bone strength at macroscale.

The need to consume adequate dietary protein to preserve physical function during ageing is well recognized. However, the effect of protein intakes on glucose metabolism is still intensively debated. During age-related estrogen withdrawal at the time of the menopause, it is known that glucose homeostasis may be impaired but the influence of dietary protein levels in this context is unknown. The aim of the present study is to elucidate the individual and interactive effects of estrogen deficiency and suboptimal protein intake on glucose homeostasis in a preclinical model involving ovariectomy (OVX) and a 13 week period of a moderately reduced protein intake in 7 month-old ageing rats. To investigate mechanisms of action acting via the pancreas-liver-muscle axis, fasting circulating levels of insulin, glucagon, IGF-1, FGF21 and glycemia were measured. The hepatic lipid infiltration and the protein expression of GLUT4 in the gastrocnemius were analyzed. The gene expression of some hepatokines, myokines and lipid storage/oxidation related transcription factors were quantified in the liver and the gastrocnemius. We show that, regardless of the estrogen status, moderate dietary protein restriction increases fasting glycemia without modifying insulinemia, body weight gain and composition. This fasting hyperglycemia is associated with estrogen status-specific metabolic alterations in the muscle and liver. In estrogen-replete (SHAM) rats, GLUT4 was down-regulated in skeletal muscle while in estrogen-deficient (OVX) rats, hepatic stress-associated hyperglucagonemia and high serum FGF21 were observed. These findings highlight the importance of meeting dietary protein needs to avoid disturbances in glucose homeostasis in ageing female rats with or without estrogen withdrawal.

Bone quality is altered mainly by osteoporosis, which is treated with modulators of bone quality. Knowledge of their mechanisms of action is crucial to understand their effects on bone quality. The goal of our study was to compare the action of alendronate (ALN) and strontium ranelate (SrRan) on the determinants of bone quality. The investigation was performed on over 60 paired human iliac biopsies. Paired samples correspond to biopsies obtained from the same patient, one before treatment (baseline) and one after 12 months of treatment, in postmenopausal women with osteoporosis. Vibrational spectroscopy (Raman and FTIRM) and nanoindentation were used to evaluate the effect of both drugs on bone quality at the ultrastructural level. Outcomes measured by vibrational spectroscopy and nanoindentation are sensitive to bone age. New bone packets are distinguished from old bone packets. Thus, the effect of bone age is distinguished from the treatment effect. Both drugs modify the mineral and organic composition in new and old bone in different fashions after 12 months of administration. The new bone formed during ALN administration is characterized by an increased mineral content, carbonation and apatite crystal size/perfection compared to baseline. Post-translational modifications of collagen are observed through an increase in the hydroxyproline/proline ratio in new bone. The proteoglycan content is also increased in new bone. SrRan directly modulates bone quality through its physicochemical actions, independent of an effect on bone remodeling. Strontium cations are captured by the hydrated layer of the mineral matrix. The mineral matrix formed during SrRan administration has a lower carbonate content and crystallinity after 12 months than at baseline. Strontium might create bonds (crosslinks) with collagen and noncollagenous proteins in new and old bone. The nanomechanical properties of bone were not modified with either ALN or SrRan, probably due to the short duration of administration. Our results show that ALN and SrRan have differential effects on bone quality in relation to their mechanism of action.

OBJECTIVES:This in vitro study aimed to compare changes in retentive force due to cyclic dislodging of three novel un-splinted attachments.MATERIALS AND METHODS:Experimental models simulating a mandibular two-implant overdenture situation, with implants positioned with various interimplant discrepancies (0°, 20°, 40°, and 60°) were fabricated. Three attachment systems were tested, "N": a straight or 15°-angulated stud; "L": a sole straight stud; and "C": a straight or individually angulated stud. All models underwent wet testing and were subjected to 10,000 insertion-removal cycles in a universal testing machine. The mean retentive forces were calculated for cycles 10, 100, 1,000, 5,000, and 10,000. Multiple mixed-effects linear regression models were applied for statistical analyses (⍺ < 0.05).RESULTS:"N" demonstrated an increasing retention until 1,000 cycles, which subsequently diminished back to its initial retention at 10,000 cycles, showing no significant loss during the entire experiment. Statistical models demonstrated no effect of implant angulation on retention, except for 60° after 10,000 cycles (p < .05). "L" showed an early peak at 100 cycles and did not significantly lose retentive force before 5,000 cycles. Angulations of 40° or higher were shown to lead to lower retentive forces (0° vs. 40° cycle 5,000: p < .05; 0° vs. 60° cycle 100: p < .05, ≥cycle 1,000: p < .001). "C" showed stable retentive forces with no significant loss only at 10,000 cycles (all angles: p < .001) or 5,000 cycles (0° vs. 60°: p < .05).CONCLUSIONS:All systems showed retentive forces promising successful clinical use in implant overdentures, even in situations with extremely angulated implants. Specific abutments compensating interimplant angulation maintain retention longer in situations with high axe divergencies.

ABSTRACT Sclerostin (Scl) antibodies (Scl-Ab) potently stimulate bone formation, but these effects are transient. Whether the rapid inhibition of Scl-Ab anabolic effects is due to a loss of bone cells’ capacity to form new bone or to a mechanostatic downregulation of Wnt signaling once bone strength exceeds stress remains unclear. We hypothesized that bone formation under Scl-Ab could be reactivated by increasing the dose of Scl-Ab and/or by adding mechanical stimuli, and investigated the molecular mechanisms involved in this response, in particular the role of periostin (Postn), a co-activator of the Wnt pathway in bone. For this purpose, C57Bl/6, Postn−/− and Postn+/+ mice were treated with vehicle or Scl-Ab (50 to 100 mg/kg/wk) for various durations and subsequently subjected to tibia axial compressive loading. In wild-type (WT) mice, Scl-Ab anabolic effects peaked between 2 and 4 weeks and declined thereafter, with no further increase in bone volume and strength between 7 and 10 weeks. Doubling the dose of Scl-Ab did not rescue the decline in bone formation. In contrast, mechanical stimulation was able to restore cortical bone formation concomitantly to Scl-Ab treatment at both doses. Several Wnt inhibitors, including Dkk1, Sost, and Twist1, were upregulated, whereas Postn was markedly downregulated by 2 to 4 weeks of Scl-Ab. Mechanical loading specifically upregulated Postn gene expression. In turn, Scl-Ab effects on cortical bone were more rapidly downregulated in Postn−/− mice. These results indicate that bone formation is not exhausted by Scl-Ab but inhibited by a mechanically driven downregulation of Wnt signaling. Hence, increasing mechanical loads restores bone formation on cortical surfaces, in parallel with Postn upregulation. © 2020 American Society for Bone and Mineral Research (ASBMR).

In osteogenesis imperfecta (OI), vertebrae brittleness causes thorax deformations and leads to cardiopulmonary failure. As sclerostin-neutralizing antibodies increase bone mass and strength in animal models of osteoporosis, their administration in two murine models of severe OI enhanced the strength of vertebrae in growing female Crtap−/− mice but not in growing male Col1a1Jrt/+ mice. However, these two studies ignored the impact of antibodies on spine growth, fracture rates, and compressive mechanical properties. Here, we conducted a randomized controlled trial in oim/oim mice, an established model of human severe OI type III due to a mutation in Col1a2. Five-week-old female WT and oim/oim mice received either PBS or sclerostin antibody (Scl-Ab) for 9 weeks. Analyses included radiography, histomorphometry, pQCT, microcomputed tomography, and biomechanical testing. Though it did not modify vertebral axial growth, Scl-Ab treatment markedly reduced the fracture prevalence in the pelvis and caudal vertebrae, enhanced osteoblast activity (L4), increased cervico-sacral spine BMD, and improved the lumbosacral spine bone cross-sectional area. Scl-Ab did not impact vertebral height and body size but enhanced the cortical thickness and trabecular bone volume significantly in the two Scl-Ab groups. At lumbar vertebrae and tibial metaphysis, the absolute increase in cortical and trabecular bone mass was higher in Scl-Ab WT than in Scl-Ab oim/oim. The effects on trabecular bone mass were mainly due to changes in trabecular number at vertebrae and in trabecular thickness at metaphyses. Additionally, Scl-Ab did not restore a standard trabecular network, but improved bone compressive ultimate load with more robust effects at vertebrae than at metaphysis. Overall, Scl-Ab treatment may be beneficial for reducing vertebral fractures and spine deformities in patients with severe OI.

Osteogenesis imperfecta type III (OI) is a serious genetic condition with poor bone quality and a high fracture rate in children. In a previous study, it was shown that a monoclonal antibody neutralizing sclerostin (Scl-Ab) increases strength and vertebral bone mass while reducing the number of axial fractures in oim/oim, a mouse model of OI type III. Here, we analyze the impact of Scl-Ab on long bones in OI mice. After 9 weeks of treatment, Scl-Ab significantly reduced long bone fractures (3.6 ± 0.3 versus 2.1 ± 0.8 per mouse, p < 0.001). In addition, the cortical thickness of the tibial midshaft was increased (+42%, p < 0.001), as well as BMD (+28%, p < 0.001), ultimate load (+86%, p < 0.05), plastic energy (+184%; p < 0.05) and stiffness (+172%; p < 0.01) in OI Scl-Ab mice compared to OI vehicle controls. Similar effects of Scl-Ab were observed in Wild type (Wt) mice. The plastic energy, which reflects the fragility of the tissue, was lower in the OI than in the Wt and significantly improved with the Scl-Ab treatment. At the tissue level by nanoindentation, Scl-Ab slightly increased the elastic modulus in bones of both OI and Wt, while moderately increasing tissue hardness (+13% compared to the vehicle; p < 0.05) in Wt bones, but not in OI bones. Although it did not change the properties of the OI bone matrix material, Scl-Ab reduced the fracture rate of the long bones by improving its bone mass, density, geometry, and biomechanical strength. These results suggest that Scl-Ab can reduce long-bone fractures in patients with OI.

Hip fracture in the elderly is associated with an increase in disability and mortality. Early intervention programs accelerate the recovery period and reduce mortality. The intervention of geriatricians, with direct responsibility during the acute phase, has demonstrated an optimal benefit, as well as joint management by a geriatrician and an orthopedist. Recruiting motivated patients, able to walk with or without help before the fracture and regardless of their cognitive level, ensures successful intervention and reduced costs. The most effective interventions are those aimed at recovery of activities of daily living, with occupational therapy and muscle training. Correction of protein and vitamin intake also has a significant effect on the patient's progress in rehabilitation.

The weightless environment during spaceflight induces site-specific bone loss. The 30-day Bion-M1 mission offered a unique opportunity to characterize the skeletal changes after spaceflight and an 8-day recovery period in mature male C57/BL6 mice. In the femur metaphysis, spaceflight decreased the trabecular bone volume (−64% vs. Habitat Control), dramatically increased the bone resorption (+140% vs. Habitat Control) and induced marrow adiposity invasion. At the diaphysis, cortical thinning associated with periosteal resorption was observed. In the Flight animal group, the osteocyte lacunae displayed a reduced volume and a more spherical shape (synchrotron radiation analyses), and empty lacunae were highly increased (+344% vs. Habitat Control). Tissue-level mechanical cortical properties (i.e., hardness and modulus) were locally decreased by spaceflight, whereas the mineral characteristics and collagen maturity were unaffected. In the vertebrae, spaceflight decreased the overall bone volume and altered the modulus in the periphery of the trabecular struts. Despite normalized osteoclastic activity and an increased osteoblast number, bone recovery was not observed 8 days after landing. In conclusion, spaceflight induces osteocyte death, which may trigger bone resorption and result in bone mass and microstructural deterioration. Moreover, osteocyte cell death, lacunae mineralization and fatty marrow, which are hallmarks of ageing, may impede tissue maintenance and repair.

OBJECTIVES:(i) To assess the effects of mechanical overloading on implant integration in rat tibiae, and (ii) to numerically predict peri-implant bone adaptation.MATERIALS AND METHODS:Transcutaneous titanium implants were simultaneously placed into both tibiae of rats (n = 40). After 2 weeks of integration, the implants of the right tibiae were stimulated daily for 4 weeks with loads up to 5N (corresponding to peak equivalent strains of 3300 ± 500 με). The effects of stimulation were assessed by ex vivo mechanical tests and quantification of bone mineral density (BMD) in selected regions of interests (ROIs). Specimen-specific finite element models were generated and processed through an iterative algorithm to mimic bone adaptation.RESULTS:Bilateral implantation provoked an unstable integration that worsened when mild (2-4N) external loads were applied. In contrast, a stimulation at 5N tended to "counterbalance" the harmful effects of daily activity and, if applied to well-integrated specimens, significantly augmented the implants' resistance to failure (force: +73% P < 0.01, displacement: +50% P < 0.01 and energy: +153% P < 0.01). Specimen-specific numerical predictions were in close agreement with the experimental findings. Both local and overall BMD variations, as well as the implants' lateral stability, were predicted with small errors (0.14 gHA/cm3 and 0.64%, respectively).CONCLUSIONS:The rats' daily activity detrimentally affects implant integration. Conversely, external stimulations of large magnitudes counterbalance this effect and definitively improve integration. These changes can be predicted using the proposed numerical approach.

Searchable abstracts of presentations at key conferences on calcified tissues ISSN 2052-1219 (online)

Long term durability of osseointegrated implants depends on bone adaptation to stress and strain occurring in proximity of the prosthesis. Mechanical overloading, as well as disuse, may reduce the stability of implants by provoking bone resorption. However, an appropriate mechanical environment can improve integration. Several studies have focused on the definition of numerical methods to predict bone peri-implant adaptation to the mechanical environment. Existing adaptation models differ notably in the type of mechanical variable adopted as stimulus but also in the bounds and shape of the adaptation rate equation. However, a general comparison of the different approaches on a common benchmark case is still missing and general guidelines to determine physically sound parameters still need to be developed. This current work addresses these themes in two steps. Firstly, the histograms of effective stress, strain and strain energy density are compared for rat tibiae in physiological (homeostatic) conditions. According to the Mechanostat, the ideal stimulus should present a clearly defined, position and tissue invariant lazy zone in homeostatic conditions. Our results highlight that only the octahedral shear strain presents this characteristic and can thus be considered the optimal choice for implementation of a continuum level bone adaptation model. Secondly, critical modeling parameters such as lazy zone bounds, type of rate equation and bone overloading response are classified depending on their influence on the numerical predictions of bone adaptation. Guidelines are proposed to establish the dominant model parameters based on experimental and simulated data.