Knee Osteoarthritis: Will Tissue Engineering Replace Orthotics

McCormick School of Engineering

Masters in Biomedical Engineering Candidate

Janeen Williams (100%)

Abstract
We plan to compare the non-operative technique of a knee brace and the operative
technique of stem cell implantation on the treatment of knee osteoarthritis. We plan to
investigate the physical and kinematic changes in the knee joint environment as a
function of treatment option. Potential subjects will be imaged for changes in cartilage
and meniscus volume every 3 months for 1 year. At these intervals, a kinematic
evaluation will be performed by using Vicon analysis software to determine changes in
locomotion. Other functional motor changes will be evaluated through the use of
goniometers during sit to stand, stand to sit, and stair climbing tasks. Changes in pain
will be used to determine the efficacy of the treatment. VAS scores will be analyzed as a
function of time for each treatment group. At the conclusion of the described
experiments we will have obtained quantitative data that allows clinicians, scientists,
and patients to evaluate biological and mechanical differences in the knee environment,
functional differences in knee mobility and psychological differences in pain that are due
to differences in treatment choice.

Specific Aims
The occurrence of arthritis in the United States is expected to rise to a population of 67
million Americans by the year 2030 (Van Manen [1]). In addition, the United States has
a growing population of the elderly and obese populations; two categories that are
particularly at risk to knee osteoarthritis (KOA.). Orthotic devices are regularly used by
KOA patients to relieve pain on the affected knee. However, this is not a cure to the
progressive loss of cartilage that accompanies KOA nor is it an available option for
those in the obese populations. Other options are available that target these issues.
Tissue engineering solutions can be used to regenerate cartilage in the affected area.
Previous studies have shown implantation of mesenchymal stem cells reduced the
negative impact of KOA on patients daily lives but also limited the affect of KOA on the
knee joint by restoring cartilage in that area (Hollander [2], Centeno [3], Davatchi [4]).
It is unknown if long term restoration of daily function and mobility granted from tissue
engineering techniques has the ability to supersede the temporary relief attributed to
orthotics. Although these two techniques seem incomparable, they both alter the
mechanical environment of the osteoarthritic knee. The progressive nature of KOA
results in gradual and painful loss of joint space. The performance of tissue engineering
therapies and orthotics on joint space has not been. A global comparison of the impact
of both tissue engineering and orthotic techniques on relief of KOA symptoms will allow
the scientific community to alter the way we approach treatment.
We seek to establish quantitative measures of the long-term effects of regenerative
implantation at the knee compared to external mechanical support of the surrounding
joint. Previous studies have used MRI to show the positive effect of regenerative
implantation on KOA in humans (Centeno [5]). In addition, long-term studies on
mesenchymal stem cell implantation in humans have provided evidence to efficacy and
safety (Wakitani [6]). We hypothesize that due to the environmental change within the
arthritic knee, the long-term effects of tissue engineering techniques will supersede
those of an orthotic device. We aim to:
Identify long-term changes in cartilage and meniscus
We hypothesize an increase in cartilage and meniscus volume for those who received
the implantation. In contrast, we expect degeneration of remainder cartilage for orthotic
users.
Quantitate differences in pain alleviation and joint function
We expect regenerative implantation to have better pain alleviation than the use of an
orthotic device. Joint function improvements will have a proportional relationship with
pain alleviation.
Identification of the long-term benefits of mesenchymal stem cell implantation versus
daily use of an orthotic knee brace will allow patients with KOA along with their
orthopedists to select the treatment most suitable to the patients lifestyle.

Background & Significance

Osteoarthritis of the knee is a degenerative disease characterized by abnormal articular
cartilage in the patellofemoral joint or the medial or lateral portion of the tibiofemoral
joint (Iorio [7]). Pain and discomfort from this disease is a product of mechanical
changes in the knee joint environment. Treatment options tend to focus on alleviating
excess stress on the knee through non-operative and operative techniques.
Due to the physical risk and financial burden of surgery, non-operative techniques are
often exhausted before considering operative techniques. The American Academy of
Orthopaedic Surgeons suggest the following in their clinical practice evidence-based
guidelines for non-operative treatment of KOA: weight loss, aerobic exercise,
acetaminophen, nonsteroidal anti-inflammatory drugs, and corticosteroid injections
(American Academy of Orthopaedic Surgeons [8]). Interestingly, orthotic devices are not
included in the guideline although knee braces are prevalent among KOA patients
(Brouwer [9]). Operative techniques are traditionally conserved for older patients when
pain cannot be alleviated through non-operative techniques. Operative techniques
include arthroscopic debridement, total knee arthoplasty, microfraction or abrasion
arthoplasty, and implantation of articular cartilage (Van Manen [1]). The use of
arthoscopic treatment is controversial since unsuccessful surgeries have been
associated with increased arthritic deterioration (Edelson [10]). In addition, a criterion for
total knee arthoplasty involves weight loss for the highly invasive surgery which limits a
large subpopulation of KOA patients. A particularly low cost solution to resulting joint
pain is a knee brace orthotic.
Although quantitative measures have shown the relief of a knee brace is slight
compared to more conservative techniques such as weight loss and exercise, it remains
a popular recommendation within the osteoarthritis community (Brouwer [11]). Knee
braces can off-load the affected joint compartment (Van Manen [1]). Most commonly,
this functions by providing an opposing valgus force to correct varus misalignment
(Ramsey [12]). In addition to pain relief, studies have shown that bracing of the affected
knee joint improved stability and subsequently daily life function (Matsuno [13]).
Although treatment guidelines suggest exhausting non-operative techniques, knee
braces have limitations. A 2006 study on knee brace use for treatment of KOA showed
that 41.6% of brace wearers terminated use after the first 3 months (Brouwer [11]). A
survey of these subjects demonstrated challenges such as skin irritation, poor fit, or lack
of efficacy. Despite these limitations knee orthotics should be evaluated not only against
conservative treatment, but operative techniques. Present studies have not compared
knee braces to more conservative operative strategies such as articular cartilage
replacement.
In recent years, tissue engineering has been incorporated into operative strategies for
KOA treatment. Loss of cartilage is often a challenge in alleviating characteristics of
KOA. This is due to the absence of blood vessels in cartilage. Regenerative tissue
engineering techniques have been shown to promote the presence of cartilage in the
affected joint. In a 2006 study by Hollander et al, the affected joint enhanced the

maturation of implanted hyaline cartilage (Hollander [2]). Two years later, Centeno et al
cultivated analogous mesenchymal stem cells from a subjects bone marrow and
treated KOA with an injection into the affected knee (Centeno [5]). The subject regained
an increased range of motion and experienced a decrease in painful sensations. As of
2015, there are 8 clinical trials that are actively recruiting for stem cell therapy in the
treatment of KOA (clinicaltrials.gov [14]). The presence of clinical trials show that there
is still more to understand about the use of mesenchymal stem cells in KOA.
Particularly, it is unknown how long-term stem cell implantation compares to nonoperative KOA relief techniques.
At the conclusion of the proposed study, we will be able to identify and quantitate the
long-term changes in the knee environment and perceived pain for patients who wear a
knee brace and patients who have received cartilage replacement therapy. The longterm objectives of this study are to provide KOA patients with therapeutic options best
suited for their lifestyles. At the conclusion of the proposed study, we will be better able
to assess if cartilage replacement surgery should be considered before long-term use of
an orthotic device. This clinical application can save time, money, and reduced potential
stress from months of interacting with a low efficacy non-operative technique.
.
Proposed Work
Aim 1: Identify long-term changes in cartilage and meniscus
There does not appear to be a critical evaluation of how the cartilage and meniscus of
the arthritic knee changes over time with different non-operative and operative
strategies. The objective of the proposed research is to target this problem and identify
a quantitative method for analyzing changes in cartilage and meniscus volume over a
period of 1 year. Our working hypothesis is that we anticipate an increase in cartilage
and meniscus volume for those who received the implantation. In contrast, we expect
degeneration of remainder cartilage for orthotic users.
Our approach is to assign a knee brace or cartilage replacement therapy to a
randomized subject population. Their knee joint will be evaluated using magnetic
resonance imaging (MRI). An analysis of these images will allow us to determine
changes in volume. The rationale for this aim is that a nonbiased, quantifiable metric for
change is required to provide a true comparison of long-term efficacy between the two
treatment modalities. The outcome of the proposed experiment is a quantifiable
measure on a large cohort of KOA patients that will be applied to the KOA population at
large. This will have a positive impact on the field for its wide and direct application,
furthered understanding of cartilage replacement therapy, and use in clinical
assessments of potential treatment options for the growing population of KOA patients.
There have been a multitude of studies that evaluate the use of knee orthotics in KOA
patients (Squyer [15], Brouwer [9], Callaghan [16]). These studies have focused on the
extended use of orthotics by the patient, the use of knee bracing on off-loading of the
arthritic joint, or the use of knee bracing on decreasing the presence of bone marrow

lesions. Although feasible, there does not appear to be a study that compares the use of
knee braces to tissue engineering approaches.
A study by Hollander et al provided evidence to support tissue engineering approaches
for treatment of KOA (Hollander [2]). Implants in this study differentiated to articular
cartilage tissue after 11 months. In addition, a previous study by Centeno et al, show
increased cartilage and meniscus volume as early as 1 month post-injection (Centeno
[5]). The safety and efficacy of this procedure has been shown in an 11year study of
bone marrow derived MSC implantation for cartilage repair (Wakitani [6]). This prior
research not only provides support that this is feasible but is further justification that this
research is necessary to continue enhancing our knowledge of MSC implantation within
the knee joint.
Cartilage and meniscus volume is an important metric because it is the loss of cartilage
that leads to pain in the joint and the degenerative nature of the disease. At the point of
disease onset, cartilage breaks down. The break down of cartilage releases
macrophages in the knee compartment (Centeno [3]). The role of the macrophage is to
consume cartilage cells. Previous work has shown that the injection of stem cells not
only differentiates into cartilage but also terminates macrophage activity. Differentiation
into cartilage tissue is advantageous as it replaces the damaged tissue, relieves joint
pressure, and alleviates pain. However, deactivation of macrophages also prevents the
further degeneration of cartilage tissue. Thus, examining changes in cartilage and
meniscus volume will act as a metric of the current state of the disease.
The research design will require a large population of KOA patients since treatment will
require a significant population that meets specific criteria. We will randomly assign
groups to three groups, placebo injection, brace wearers, and stem cell injection. An
image will be taken of the arthritic knee after 1 year of treatment use and in three month
intervals after the onset of treatment. The number of subjects to obtain statistically
significant results is currently unknown. However longitudinal studies for unloading knee
brace compliance acquired subject populations between n=29 to n=89 (Squyer [15]).
Therefore, for each category, we would ideally have 59 subjects, for a total of n=177
subjects. Male and female subjects with Stage I or Stage II KOA, persistent
osteoarthritic pain, MRI confirmed KOA, age 18-65 will be recruited for the study.
Exclusion criteria include active inflammatory, endocrine, neurological, cardiac or
pulmonary disease. Subjects in the brace wearer category will wear similar low cost, off
the shelf knee braces designed for osteoarthritis relief. Subjects who will receive the
placebo injection will be the control group. A suitable brace control could not be crafted
since there does not exist a brace that will not have any known impact on the knee
compartment. In light of possible ethical concerns, the placebo group will be
encouraged to partake in more conservative non-operative techniques such as exercise
and weight loss. Subjects who will receive the MSC injection are required to participate
in an additional harvesting procedure. All injected stem cells will be autologous, bone
marrow stem cells from each patients iliac crest.

In order to harvest the stem cells an incubator, 25G needles, analgesics, pre-operative
disinfectant preparation solutions, and standard tissue seeding solutions such as
tryptophan, and cell media will be needed. Other equipment necessary to perform this
research includes a GE 3.0 T MRI machine for imaging.
A type of statistical analysis needed to validate this study includes an ANOVA analysis
to determine differences amongst the population groups. Analysis of the MRI images
will be performed using standard imaging software. Statistical significance will be
checked with cross-correlation techniques.
We expect to see the largest decrease in cartilage and meniscus volume for the
placebo group. We anticipate loss of cartilage and meniscus volume in the brace wearer
group. This loss will be less than the volume lost in the placebo group. However,
cartilage and meniscus loss in the brace wearer group will be substantial compared to
the implanted group. We expect the MSC implanted group to have an increased volume
of cartilage and meniscus tissue. If this is not the case, we can at least expect
consistent volumes of the cartilage and meniscus as compared to pre-implantation
MRIs.
If our experiments produce the expected results they will be interpreted as follows. A
decrease in cartilage and meniscus volume will be seen in the placebo group due to the
conservative treatment. Subjects in the brace wearer group will have less loss of
volume than the placebo group due to the affect of offloading on the affected joint.
Superior performance to the placebo group is also expected based on a previous
studys assessment that knee braces perform better than conservative treatments
(Brouwer [11]). The MSCs implantation group will have an increase in volume due to the
differentiation of stem cells into cartilage and meniscus tissue. This group could also
potentially have a constant amount of volume in the affected joint which would suggest
macrophage deactivation in that area.
We expect to see a positive increase in cartilage and meniscus volume for the
implantation group and a negative impact on cartilage and meniscus volume for the
knee brace group through MRI. These expected outcomes will achieve our first aim by
providing a quantitative and qualitative measure of changes in the cartilage and
meniscus of the affected joint. These outcomes are important because they facilitate a
direct juxtaposition between a traditional therapeutic technique and a more novel
approach.
An anticipated problem for this study is an inability to replicate the results shown in a
previous study (Centeno [5]). Inexperience with a novel technique can lead to errors.
This problem is unlikely to happen because the proper technique will be perfected
through practice in cadavers and shadowing of specialists in this area. If the perceived
problem were to happen, our lab will evaluate our implantation protocol and identify
areas that can be improved.

The proposed time to achieve our first aim is a year. Checkpoints every three months
will allow quantitative measures to be obtained throughout the year. At the conclusion of
this study, our lab will have secured quantifiable data that will allow us to determine the
changes in the environment of the arthritic knee as a function of choice in treatment.
Attainment of this data is imperative for the successful alleviation of KOA pain and
discomfort through careful evaluation of potential treatment options.
Aim 2: Quantitate differences in pain alleviation and joint function

Persistent pain in the arthritic joint is often a determining factor when going from a nonoperative technique to an operative technique. The objective of the proposed research
is to evaluate quantitative differences in pain alleviation between knee brace users and
KOA patients who have received stem cell therapy. Our working hypothesis is that we
expect regenerative implantation to have better pain alleviation than the use of an
orthotic device. In addition, joint function will be negatively correlated with pain
alleviation for each subject group.
Our approach is to use the same cohort of subjects obtained from Aim 1. When subjects
return for imaging, they will be asked to perform locomotive tasks. Kinematic data will
be evaluated. The subjects will report pain on a WOMAC scale. The rationale for this
aim is that changes in lower limb functionality and pain are more tangible measures of
treatment superiority for the average patient. The outcome of the proposed experiment
is a relatable measure of efficacy that can be used in diagnosis. The impact of this
research is that patients can analyze their options from the perspective of what will
make my day to day interactions, such as walking up stairs or going from sitting to
standing, more pain free.
Experiments that are focused on pain alleviation are particularly justified in KOA patients
because of the prevalence of using pain as a measure to determine if surgery should be
considered (Van Manen [1]). The Journal of the American Osteopathic Association
published an article that refers to minimizing pain a total of 36 times. Pain is often a
recorded measure in efficacy experiments (Van Manen [1]).
The subject groups, described previously, will perform functions to that will allow us to
evaluate mobility in a home setting. A kinematic analysis will provide a quantitative
measure of changes in range of motion. Subjects will be asked to rank their pain on the
WOMAC visual analog scale. From a comprehensive review of braces and orthoses on
KOA management, we were exposed to a number of pain scales currently being used in
the clinic and in research (Brouwer [9]). We selected the WOMAC scale due to its
simplicity and encompassment of day to day activities.
Subjects will be asked to walk on a treadmill, move from a sitting position to a standing
position, move from a standing position to a sitting position, and walk on stairs.
Subjects respiratory rate will be measured for safety. During locomotion, the subjects
primary lower limb joints (hip joint, knee, and ankle) will be monitored using retroflective
markers. This will be recorded and later analyzed with a Vicon analysis system. In
addition, the subject will wear goniometer sensors that will provide the measure of knee

angular rotation during stair climbing and sit to stand/stand to sit activities. At the
conclusion of each of these tasks, the subject will be asked to indicate the level of pain
they experienced while completing the task on a WOMAC scale. This will occur every
three months to determine change over time.
Equipment needed to achieve this aim includes a treadmill, a stairstepper, and a Vicon
system. An A-NOVA analysis will be required to determine significant differences
between the groups. Correlation analyses can be used on each three-month data set.
The placebo group is predicted to not have a significant change in kinematic data, range
of motion, or pain alleviation. The brace wear group is expected to have an increased
distance of walking on the treadmill and slight reduction of pain. It is anticipated that the
implantation group will have an increase in walking distance, greater ease and improved
timing with move from sitting and move from standing tasks. This group will have
superior pain alleviation. A lack of significant change in the placebo group will provide
further evidence to the limitations of conventional strategies. Previous studies have
shown users are able to walk further distances with the aid of a knee orthotic (Brouwer
[11]). A lack of change in the stand to sit and sit to stand tasks will be interpreted as
conditional off-loading while wearing a knee brace. Off-loading of the affected joint that
occurs as a result of wearing a knee brace will not significantly relieve the advanced
loading that occurs when moving the knee joint from 90 degrees to 180 degrees. Prior
results of knee bracing show a slight relief in pain (Matsuno, [13]). Pain alleviation and
mobility will be superior in the implantation group due to the permanent changes in the
knee environment. Statistically significant changes in range of motion and speed will be
interpreted as a result of increased cartilage around the knee joint.
Similarly to Aim 1, Aim 2 will require a year to complete. Experiments described for
determining pain alleviation and joint mobility will coincide with the images of the joint
planned to occur every three months after treatment onset.
These experiments are expected to enhance our knowledge of therapeutic therapies by
evaluating changes in range of motion, mobility, and pain for a non-operative and
operative technique for treating KOA. The expected outcomes of this research are
quantitative measures of pain, video analysis of motion over the period of a year,
kinematic analysis of joint movement, and quantitative assessment of changes in
movement that one would experience on an everyday basis. The expected outcomes
will achieve our second aim by providing the results of well used measures of joint pain
and producing a picture of functional changes in the human body. The expected
outcomes are important because it provides evidence to the growing populations of
KOA for which treatment options will have the largest impact on their quality of life.
A potential problem with these experiments is the influence of conservative factors such
as weight loss and exercise on the chosen metrics. The perceived problem is unlikely to
happen because with the exception of the placebo group, subjects in the orthotic and
tissue engineering group have already increased their exercise routine as a
conservative treatment. At the time of the study, we will have already seen the effects of

such treatment, and it should not greatly influence the year long study. However, in the
unlikely occurrence that weight loss impacts the data by showing improvements in
mobility outside of treatment use, we can normalize the data. Normalizing the data to
each individual will allow us to see if substantial changes in weight, and BMI are
correlated with changes in mobility.
At the conclusion of the described experiments we will have obtained quantitative data
that allows clinicians, scientists, and patients to evaluate biological and mechanical
differences in the knee environment, as well as functional differences in knee mobility
and psychological differences in pain. From this point, we are able to move forward in
our treatment of KOA. We can systemically evaluate if non-operative techniques should
be exhausted before looking at minimally evasive operative techniques. We can
develop technologies for further enhancing the safety and efficacy of minimally evasive
operative techniques. We can limit the prescription of treatment strategies that when
fitted and customized, might be as expensive of a operative treatment options. The
future of evaluating these therapies is providing the patient with the best possible option
for their minds, their mobility, their finances, and overall their recovery.

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