Objectives: To assess results of knee cartilage restoration on MRI of autologous adipose stem cell therapy in treatment of knee osteoarthritis (OA) after 12 months. Subjects and methods: 84 patients with primary knee.
Journal of military parmaco-medicine n07-2017 ASSESSMENT OF RESULTS OF KNEE CARTILAGE RESTORATION IN MRI OF AUTOLOGOUS ADIPOSE STEM CELL THERAPY ON TREATMENT OF KNEE OSTEOARTHRITIS Ta Viet Hung*; Nguyen Minh Nui*; Tran Ngoc Dung* Nguyen Thi Phi Nga*; Le Van Dong** Do Minh Trung**; Tran Viet Tien* SUMMARY Objectives: To assess results of knee cartilage restoration on MRI of autologous adipose stem cell therapy in treatment of knee osteoarthritis (OA) after 12 months Subjects and methods: 84 patients with primary knee OA were divided into groups: 42 patients were treated by autologous adipose stem cell (AASC), 42 patients were treated with sodium hyaluronate A descriptive cross-sectional, randomized controlled study was created to evaluate the cartilage restoration on MRI of AASC group compared with control group Results: Cartilage thickness and circularity index increased in study group, especially circularity index increased markedly after months (T24) and this index was higher than that in the control group at all time of study (p < 0.05) Conclusion: Knee cartilage had a good recovery after treatment with AASC * Keywords: Knee osteoarthritis; Autologous adipose stem cells; Cartilage restoration; MRI INTRODUCTION Osteoarthritis is a common bone and joint disease It is considered as a leading cause of pain and disability in older people in Vietnam and many countries around the world There was over 27 million OA patients in the US in 2010 and this number in the UK was over million people [2] Knee is the most common joint suffering from OA Pain and dysfunction related to OA badly affected the quality of life, limited ability of working and routine activities of patients In recent years, AASC therapy has opened a new trend in treatment of OA Adipose stem cells have important characteristics such as immune regulation and differentiation into cartilage cells Furthermore, with its endocrine mechanism, adipose stem cell can protect joint cartilage from destruction and re-initiation of precursor cells According to the findings of clinical studies, AASC therapy in OA treatment significantly improved the degree of joint pain, significant rehabilitation of joint mobility, especially injured cartilage recovery [5] In Vietnam, application of AASC in treatment of OA has marked the initial pilot phase with short follow-up and inconsistent evaluation of treatment effect Therefore, we carried out this study with a view to: Evaluating the cartilage restoration on MRI of the method using AASC in treatment of OA after 12 months * 103 Hospital ** Vietnam Military Medical University Corresponding author: Ta Viet Hung (hungtv103@gmail.com) Date received: 18/07/2017 Date accepted: 16/08/2017 144 Journal of military phrmaco-medicine nO7-2017 SUBJECTS AND METHODS Subjects 84 patients were diagnosed with primary knee OA following to ACR 1991 standard; stage I-II following to Kellgren-Lawrence classification [1] All patients were treated at the Department of Joints and Endocrinology, Military Hospital 103 from June 2014 to December 2015 Patients were randomly divided into groups: study group: 42 patients (84 joints) were treated with AASC with injections each 2-month apart Control group: 42 patients (84 joints) were injected with doses of sodium hyaluronate into knee, each 2-monthapart, too Excluded from the study those patients who did not agree to continue the study; not enough study data; patients with coagulopathy; anesthetic allergic; heart and lung diseases, kidney failure, severe liver failure Methods A prospective, cross-sectional descriptive, comparative randomized controlled study * Techniques: - AASC was collected from abdominal fat tissue aspiration, isolation and activation by autologous platelet-rich plasma and monochromatic laser light - Injection of activated adipose stem cell into knee joints in study group and sodium hyaluronate in control group: In the treatment process, each patient was given injections, each 2-month apart The number of injected cells per patient was approximately equal, about 20 x 106 cells/joint - Evaluation of MRI results: T0 (before injection), after 24 weeks (T24) and after 48 weeks (T48) Morphometric analysis of knee cartilage including femur cartilage and tibia cartilage were run by US Department of Health Image-J software The steps were as follows: * Study design: Figure 1: Cartilage injury analysis on MRI using Image-J software + From the patient's MRI image (figure 1A), the analyzed cartilage was cut out (figure 1B) 145 Journal of military parmaco-medicine n07-2017 Set the light signal threshold so that the entire solid bone, spongy bone and soft tissue of joints become the background signal Then deleted the background to retain the analyzed cartilage (figure 1C), each of which measures as follows: - Center cartilage thickness (mm) - Area of cartilage in the central section (cm2) - Circularity: * Statistical analysis: The study was approved by the Ethics Council before the research activities were conducted The data were processed using SPSS 16.0 RESULTS Table 1: Changing the central cartilage thickness at medial condyle of femur on MRI at monitoring time (mm) Monitoring time T0 (1) Study group (n = 84 joints) Control group (n = 84 joints) p 3.83 ± 0.44 3.80 ± 0.51 > 0.05 T24 (2) 4.00 ± 0.44 3.87 ± 0.52 > 0.05 T48 (3) 3.88 ± 0.43 3.83 ± 0.43 > 0.05 p2,1 < 0.05, p3,2 > 0.05 p2,1 > 0.05, p3,2 > 0.05 p3,1 > 0.05 p3,1 > 0.05 p At the medial condyle of femur, the study group had a thicker cartilage than the control group; however, the difference was not statistically significant The study group reached the highest cartilage thickness at T24 (after months), it was significantly higher than pretreatment (p < 0.05) Table 2: Changing the central cartilage thickness at lateral condyle of femur on MRI at monitoring time (mm) Monitoring time T0 (1) Study group (n = 84 joints) Control group (n = 84 joints) p 3.87 ± 0.38 3.88 ± 0.53 > 0.05 T24 (2) 4.0 ± 0,39 3.85 ± 0.53 > 0.05 T48 (3) 3.94 ± 0.38 3.82 ± 0.52 > 0.05 p2,1 < 0.05, p3,2 > 0.05 p2,1 > 0.05, p3,2 > 0.05 p3,1 > 0.05 p3,1 > 0.05 p At the lateral condyle of femur, the study group had a thicker cartilage than the control group At the same time, the study group reached the highest cartilage thickness at T24, it was significantly different with pre-treatment (p < 0.05) 146 Journal of military phrmaco-medicine nO7-2017 Table 3: Changing the central cartilage thickness at medial condyle of tibia on MRI at monitoring time (mm) Monitoring time T0 (1) Study group (n = 84 joints) Control group (n = 84 joints) p 3.91 ± 0.43 3.83 ± 0.41 > 0.05 T24 (2) 4.00 ± 0.44 3.80 ± 0.39 < 0.05 T48 (3) 3.96 ± 0.44 3.79 ± 0.40 < 0.05 p2,1 > 0.05, p3,2 > 0.05 p2,1 > 0.05, p3,2 > 0.05 p3,1 > 0.05 p3,1 > 0.05 p At the medial condyle of tibia, the study group had a thicker cartilage than the control group; however, the difference was not statistically significant Table 4: Changing the central cartilage thickness at lateral condyle of tibia on MRI at monitoring time (mm) Monitoring time T0 (1) Study group (n = 84 joints) Control group(n = 84 joints) p 3.88 ± 0.45 3.85 ± 0.42 > 0.05 T24 (2) 3.91 ± 0.46 3.81 ± 0.41 > 0.05 T48 (3) 3.88 ± 0.46 3.81 ± 0.40 > 0.05 p2,1 > 0.05, p3,2 > 0.05 p2,1 > 0.05, p3,2 > 0.05 p3,1 > 0.05 p3,1 > 0.05 p At the lateral condyle of femur, the study group had a thicker cartilage than the control group; however, the difference was not statistically significant Table 5: Changing circularity index at medial condyle of femur on MRI at monitoring time Monitoring times T0 (1) Study group (n = 84 joints) Control group (n = 84 joints) p 0.0696 ± 0.007 0.068 ± 0.006 > 0.05 T24 (2) 0.079 ± 0.007 0.07 ± 0.0075 < 0.001 T48 (3) 0.077 ± 0.007 0.068 ± 0.007 < 0.001 p2,1 < 0.001, p3,2 > 0.05 p2,1 > 0.05, p3,2 > 0.05 p3,1 < 0.001 p3,1 > 0.05 p At the medial condyle of femur, the study group had an increasing circularity index during the study, while the circularity index was significantly higher than that in the control group at both post-treatment points (p < 0.001) 147 Journal of military parmaco-medicine n07-2017 Table 6: Changing circularity index at lateral condyle of femur on MRI at monitoring time Monitoring time T0 (1) Study group (n = 84 joints) Control group (n = 84 joints) p 0.06 ± 0.0077 0.061 ± 0.009 > 0.05 T24 (2) 0.069 ± 0.006 0.062 ± 0.007 < 0.001 T48 (3) 0.068 ± 0.008 0.060 ± 0.01 < 0.001 p2,1 < 0.01, p3,2 > 0.05 p3,1 < 0.01 p2,1 > 0.05, p3,2 > 0.05 p3,1 > 0.05 p At the lateral condyle of femur, the study group had an increasing circularity index during the study, while the circularity index was significantly higher than the control group at both post-treatment points (p < 0.001) Table 7: Changing circularity index at medial condyle of tibia on MRI at monitoring time Monitoring time T0 (1) Study group (n = 84 joints) Control group (n = 84 joints) p 0.12 ± 0.008 0.12 ± 0.013 > 0.05 T24 (2) 0.124 ± 0.006 0.12 ± 0.01 < 0.001 T48 (3) 0.121 ± 0.0078 0.114 ± 0.015 < 0.001 p2,1 < 0.01, p3,2 > 0.05 p3,1 < 0.01 p2,1 > 0.05, p3,2 < 0.01 p3,1 < 0.01 p At the medial condyle of tibia, the study group had a significantly higher circularity index than the control group at both post-treatment points (p < 0.001) In the study group, the thickness of cartilage increased compared with before treatment, while the control group progressively decreased Table 8: Changing circularity index at lateral condyle of tibia on MRI at monitoring time Monitoring time T0 Study group (n = 84 joints) Control group (n = 84 joints) p 0.112 ± 0.0097 0.110 ± 0.011 > 0.05 (2) 0.119 ± 0.01 0.110 ± 0.01 < 0.01 (3) 0.117 ± 0.009 0.10 ± 0.009 < 0.01 p2,1 < 0.01, p3,2 > 0.05 p2,1 > 0.05, p3,2 < 0.01 p3,1 < 0.01 p3,1 < 0.01 (1) T24 T48 p At the lateral condyle of tibia, the study group had a significantly higher circularity index than the control group at both post-treatment points (p < 0.001) In the study group, the thickness of cartilage increased compared with pre-treatment while the control group progressively decreased 148 Journal of military phrmaco-medicine nO7-2017 DISCUSSION To assess cartilage damage, some methods can be taken respectively such as: ultrasound, MRI, endoscopic and cartilage histopathology Each evaluation method has its own vulnerability classification, however all of them are relative In order to follow and evaluate changes in cartilage in this new treatment, we selected patients with early degenerative lesions and used the US Department of Health Image-J software to analyze the morphology of knee cartilage The examined sites included femur cartilage and tibia cartilage through several indexes such as cartilage thickness and circularity index Cartilage thickness were measured at the center, front and back of the femur cartilage and at the center of tibia cartilage In patients with knee OA, the cartilage usually damages the body's most affected areas, including the central cartilage Considering the central cartilage thickness of the cartilage help to evaluate the effect of knee OA treatment by autologous adipose stem cell injection The circularity Index is a reliable measure of cartilage wear In knee cartilage of OA patients, the cartilage surface is damaged leading to reduce smoothness and increase the cartilage's circumference more than normal cartilage, so the circularity index decreases Thus, in our study, we used this indicator to monitor the extent of articular cartilage, thereby evaluating the effectiveness of the therapy After examining in detail, the results showed that in the group treated with stem cell, changes in cartilage thickness such as femur cartilage, central tibia cartilage after treatment was higher than before treatment, however, the difference was not statistically significant (tables to 4) Meanwhile, the circularity index increased in group which were treated by stem cell showed statistical significance compared to pre-treatment and control group (p < 0.05) The results also showed that the circularity index was statistically significant different in the same study group who were injected with adipose tissue (TGA) during the follow-up period and after months (T24) However, at the 12th month (T48), the index decreased (table to 8) This may be related to the self-life time of new differentiated cartilage, which will be degenerated and disappeared after a period of time The research by Bui Hong Thien Khanh et al (2014) through MRI analysis showed that the cartilage layers were partially regenerated at the damaged sites and thickened after months of treatment [2] According to the study by Pak (2011) in two clinical cases: 70-year-old female and 79-year-old male OA patients found that at week 12th, the thickness of the cartilage at the front of femur significantly increased This improvement has been suggested by the authors through two main mechanisms: (i) differentiation into cartilage tissue of AASC at the injured sites of patients; (ii) addition of growth factors such as TGFβ, FGF, IGF, and PDGF [5] Jo et al (2014) treated OA patient by injection of mesenchymal stem cell from autologous fat tissue into joints for 18 patients MRI images showed that the size of the damaged cartilage decreased from 497.9 ± 29.7 mm2 down to 297.9 ± 51.2 mm2 at the center of the femur in high dose injection group, a 40% decrease was shown (p = 0.004) 149 Journal of military parmaco-medicine n07-2017 Meanwhile, at the center of the tibia cartilage, the cartilage size of the injured cartilage decreased from 333.2 ± 51.2 mm2 down to 170.6 ± 48.2 mm2, a 49% decrease (p < 0.01) In the high-dose group, the cartilage volume increased gradually after months in both center cartilage of femur and tibia: 3313.7 ± 304.1 mm3 to 3780.6 ± 284.4 mm3, 14% increase (p = 0.044) and 1157.5 ± 145.8 mm3 to 1407.7 ± 150.5 mm3, 22% increase (p = 0.047) [4] CONCLUSION Knee cartilage showed a good restoration after treatment with AASC Cartilage thickness and circularity index increased The circularity index was the best after months of treatment (T24) The medium score in medial and lateral condyle of femur after months of treatment was 0.079 and 0.069, respectively and this value in medial and lateral condyle of tibia was 0.124 and 0.119, respectively The circularity index increased markedly after treatment and higher than control group at all time (p < 0.05) 150 REFERENCES Trần Ngọc Ân, Nguyễn Thị Ngọc Lan, Nguyễn Mai Hồng Thoái hóa khớp gối Phác đồ chẩn đốn điều trị bệnh xương khớp thường gặp Nhà xuất Giáo dục Việt Nam 2013, tr.178-184 Khanh Hong Thien Bui et al Symptomatic knee OA treatment using autologous adipose derived stem cells and platelet-rich plasma: a clinical study Biomedical Research and Therapy 2014, (1), pp.2-8 Fransen M, Bridgett L, March L et al The epidemiology of osteoarthritis in Asia International Journal of Rheumatic Diseases 2011, 14 (2), pp.113-121 Jo C.H et al Intra-articular injection of mesenchymal stem cells for the treatment of OA of the knee: a proof-of-concept clinical trial Stem Cells 2014, 32 (5), pp.1254-1266 Pak J Regeneration of human bones hip osteonecrosis and human cartilage in knee OA with autologous adipose-tissuederived stem cells: a case series Journal of Medical Case Reports 2011, 5, p.296 ... Injection of activated adipose stem cell into knee joints in study group and sodium hyaluronate in control group: In the treatment process, each patient was given injections, each 2-month apart... cartilage thickness of the cartilage help to evaluate the effect of knee OA treatment by autologous adipose stem cell injection The circularity Index is a reliable measure of cartilage wear In. .. of the knee: a proof -of- concept clinical trial Stem Cells 2014, 32 (5), pp.1254-1266 Pak J Regeneration of human bones hip osteonecrosis and human cartilage in knee OA with autologous adipose- tissuederived