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British Journal of Rheumatology 1998;37:532538

JOINT STIFFNESS AND ARTICULAR GELLING: INHIBITION OF THE FUSION OF


ARTICULAR SURFACES BY SURFACTANT
B. A. HILLS and K. THOMAS
Paediatric Respiratory Research Centre, Mater Childrens Hospital, Brisbane, Australia
SUMMARY
It was proposed some years ago that, in osteoarthritis, one source of joint stiness arises from articular gelling, but, if so,
why does this not occur in the normal joint? In a preliminary experiment using agar gels, it is shown how such fusion of gel
surfaces can be inhibited by surface-active phospholipid (SAPL)both synthetic and humanas quantied by the shear stress
needed to cause cleavage between samples after prolonged contact. On the other hand, normal bovine articular cartilage (BAC)
does not fuse to itself, but can be made to do so if rinsed with a powerful lipid solvent known to remove the outermost layer
of adsorbed SAPL along with the hydrophobicity so characteristic of the normal waxy surface it imparts. It is then shown
how the inhibition of gel fusion can be restored by treating both bovine and human articular surfaces with exogenous SAPL
derived from human AC and with synthetic SAPL. Samples of human articular cartilage excised from osteoarthritic hips and
knees during total joint replacement showed a 55% greater tendency to fuse together than normal BAC. This was exacerbated
by solvent rinsing and can be attributed to a deciency in the outermost lining of SAPL previously studied as a load-bearing
boundary lubricant capable of reducing friction and wear to the remarkably low levels observed physiologically. Hence, joint
stiness can be attributed, in part, to a deciency in the lubricating layer of SAPL lining the normal articular surface where it
can inhibit articular gelling/gel fusion, possibly imparting other desirable physiological functions. The possibility of clinical
replenishment of SAPL in the osteoarthritic joint is discussed.
Krx vons: Articular gelling, Joint stiness, Osteoarthritis, Synovial surfactant.
JoiN1 stiness can arise from several sources, and is Problems of unwanted adhesion are usually resolved
often associated as much with structures around the in the physical sciences by applying a very thin coating
joint as within the joint itself. In rheumatoid arthritis, of a release (anti-stick) agent to the surface. These
a neurogenic component has also been identied [1], release agents are usually surfactants in which molec-
while in osteoarthritis, which is more a disease of the ules bind to the surface by their polar ends, thus
cartilage itself [2], the stiness tends to be more orientating their non-polar moieties outwards to
localized [3] and is essentially mechanical in nature impart a hydrophobic surface much less conducive to
[4]. Focusing on cartilage, Wright [3, 4] made a most adhesion [6]. The layer may be no more than a
interesting observation when attributing stiness to monolayer, while, often, the same surfactant lining is
articular gelling, but, apparently, never pursued this also a good boundary lubricant, as witnessed in every-
phenomenon in detail. day life in many paper coatings [7].
Although the contribution of this component may It could, therefore, be particularly signicant that a
not be as great as Wright originally envisaged, it lining of surface-active phospholipid (SAPL) has been
emphasizes how the diarthrodial joint violates one of identied on the normal articular surface and shown
the basic principles of lubrication engineering. It is the to possess the capability to reduce friction to the very
golden rule, when designing moving systems, never to
low levels recorded in the normal joint, and to do so
have two surfaces of the same material sliding against
under high load [8]. Moreover, this lining has been
each other for fear of their welding or binding to
shown to be decient in osteoarthritis [9]. As the
each other when they come into contact at start-up or
outermost layer of boundary lubricant deposited from
shut-down as the uid lm is squeezed out. This
synovial uid (SF), this coating of SAPL could also
aspect is very pertinent in the joint where the articular
explain the extreme hydrophobicity of the normal
surface has been described in the light of more recent
articular surface [10, 11] and many other features
studies as a proteoglycan-rich hydrated gel supported
reviewed elsewhere [ 12].
on a collagen matrix [5]. Gels such as these, whose
The question which this line of deduction poses is
rheology is determined largely by hydrogen bonding
whether the lining of SAPL demonstrated on the
[5], are highly likely to fuse together, reviving the
normal articular surface can act as a release agent and,
concept of articular gelling. At least, it poses the vital
in particular, whether it can prevent gel fusion, includ-
question of why this does not occur in the normal
ing articular gels. SAPL has been shown to be a good
joint and what agent could be present to prevent gel
release agent, maintaining patency in the Eustachian
fusion from occurring.
tube [13], but this need not apply to the aqueous
environment of the articular surface. This study has
been designed to address these questions by undertak-
Submitted 18 July 1997; revised version accepted 10 November
ing four basic experiments designed to test the concept
1997.
of articular gelling as an example of gel fusion and its
Correspondence to: B. A. Hills, Paediatric Respiratory Research
Centre, South Brisbane, Queensland, 4101, Australia. inhibition by SAPL by: (i) demonstrating that when
1998 British Society for Rheumatology
532
HILLS AND THOMAS: SURFACTANT INHIBITS ARTICULAR FUSION 533
articular surfaces (human or bovine) are rinsed with a Preliminary experiment
A very simple experiment was performed in which lipid solvent to remove all lipid in Zone I cartilage,
two agar blocks, as used in culture dishes, were placed those surfaces will fuse together if left in contact;
together face to face after removing any excess moisture (ii) demonstrating that when the lipid is left intact
by gently blotting those faces. The blocks were then on normal bovine cartilage, fusion is inhibited; (iii )
laid horizontally on a watchglass and placed in a demonstrating that when articular surfaces from
refrigerator at 4C overnight after covering them with osteoarthritic hips and knees are placed in contact,
aluminium foil. The following day, they were found to there is some degree of fusion which can be eliminated
be fused together and, if forced apart, the plane of by applying additional human SAPL; (iv) a very
cleavage did not follow the original boundary. Clearly, preliminary experiment is also included to demonstrate
this was an example of gel fusion as depicted in Fig. 1.
how SAPL can also inhibit the fusion of gels not
The experiment was then repeated with the exception
specic to the joints, such as agar, which is a classical
that 200 ml of a solution of DPPC in PG were spread
example of a structure held together by hydrogen
across the surface (without owing over the sides)
bonding [14].
before the agar gel surfaces were placed together. The
following day, the two blocks separated very easily
MATERIALS AND METHODS
along their original plane of contact.
In these studies, the degree of release is quantied
as the shearing force needed to separate the surfaces
Quantication of gel fusion
after a standardized period of contact, shearing being
In repeating the above experiment, the dierences
considered more relevant to the joint than a perpendic-
were not always as dramatic and it became clear that
ular pull as employed in standard adhesion/release
the degree of fusion needed to be quantied. The
tests. In the physical sciences, release is considered a
simplest index, and one considered most relevant clinic-
dierent mechanism to lubrication, arising from over-
ally, was measurement of the shearing force needed to
coming fusion/binding as opposed to friction [7];
break the bonding caused by gel fusion, shearing also
although the same agents may be used to reduce both.
being the relevant mode of initiating cleavage in a
sti joint.
This was achieved by attaching each agar block to
Materials
a balsa wood strip using superglue and clamping these
Nutrient agar gel was prepared from Nutrient Agar
stripsone to the moveable carriage and the other to
Powder (Sigma #N0394) as a solution of 23 g/l in
the base plate of the machine normally employed to
water and allowed to set as a slab 3 mm in thickness.
measure the coecient of friction. This device is essen-
This slab was then cut into blocks 2 2 cm.
tially a modication of the apparatus devised by Radin
Bovine articular cartilage was obtained from the
and co-workers [16] for measuring kinetic friction, as
patellae of steers killed at the local abattoir and placed
described in detail elsewhere [8]. The basic congura-
in saline at 0C within 15 min of death. Strips of
tion is shown in Fig. 2. Essentially, the carriage is
cartilage were excised from these bones, each measur-
moved at 3 mm/min, pulled by a cord attached to a
ing 2.5 cm1 cm23 mm. Similar strips of arthritic
human cartilage were excised from discarded hips and
knees replaced by the orthopaedic surgeons during
routine total joint replacement. In the knees, tissue
was excised from the lateral chondyles since those
surfaces did not display the deep brillation found on
the medial chondyles. In hips, care was taken to avoid
any worn surfaces and any marginal areas of hyaline
cartilage distinguishable as opaque white tissue [15].
Thus, for human tissue, samples were standardized as
1 1 cm.
SAPL was provided in the form of i-a dipalmitoyl
phosphatidylcholine (DPPC) from Sigma (#P9671).
This was dispensed in two forms: either as a solution
in a non-volatile solvent (propylene glycol; PG) or in
a standard volatile solvent of hexane:ethanol (9:1)
(HexEth) widely used as a vehicle for depositing SAPL
Fic. 1.Depicting how two blocks of an aqueous gel (a), if placed
onto various liquid and solid surfaces [6]. These solu-
in contact (b), will tend to fuse together (c) and, depending upon
tions ranged in concentration from 10 to 200 mg/ml
contact time, will require an appreciable shearing force (F) to
for both solvents.
separate them; although cleavage (d) may not occur in the original
Human SAPL was obtained by rinsing the articular
plane of contact (b). This could be relevant to adhesive wear [22].
surfaces of 12 hips and 32 knees replaced at surgery
On the other hand, cleavage can occur spontaneously, or at a much
with Folch reagent (chloroform:methanol 2:1) and
lower shearing force ( f ), if the surfaces are coated with a monolayer
of a release agent such as human SAPL prior to contact (e). evaporating the elutriant to dryness under N
2
.
BRITISH JOURNAL OF RHEUMATOLOGY VOL. 37 NO. 5 534
curved surfaces, the clamp was also needed to keep
them at, a task made easier by reducing the sample
size to 1 1 cm. The rinsing procedure followed that
described in detail elsewhere [11] for the recovery of
adsorbed SAPL from articular surfaces for analysis
and evaluation of lubrication capability. The weight
(W) needed to keep the surfaces at was kept constant,
gel fusion being conveniently quantied as a dimen-
sionless ratio:
Cleavage index =F/W (2)
Fic. 2.Demonstrating the principle of the machine used for meas-
where F is the shearing force needed to initiate
uring the shearing force and, hence, shear stress needed to cause
cleavage.
cleavage between the two agar blocks depicted in Fig. 1 or between
In an ancillary experiment, we attempted to restore
two articular surfaces from the same joint. In the case of articular
the release/anti-fusion property of the original articular
cartilage, the weight (W) clamping the surfaces together and
surfaces by applying SAPL in two forms: either syn- keeping them at increases the shearing force (F or f ), requiring the
force of cleavage to be quantied as a cleavage index dened by thetic DPPC or lipid harvested from rinsings of the
equation (2). This simplied diagram accentuates the thicknesses of
articular surfaces of human hips and knees, as
the layers for demonstration purposes, while the shearing force was
described in detail elsewhere [11].
applied in the plane of fusion.
Human articular cartilage
The above experiment was next performed upon force transducer in the plane of the fusing surfaces.
This system records the maximum force (F) which is human articular surfaces excised from arthritic knees
replaced at surgery as described above. Unlike normal generated just before shearing occurs between the two
gel samples. The experiment is then repeated using the bovine articular cartilage, there was some degree of
fusion and this was again quantied as the cleavage same gel, but interposing a very thin SAPL layer
between the samples, as described above, and the new index dened in equation (2). This experiment was
repeated upon the same pairs of surfaces after rinsing shearing force ( f) is recorded. The ability of the
surfactant to eect release, i.e. to inhibit gel fusion, is with Folch reagent to remove any adsorbed SAPL. It
is important to remember that these values of the calculated as:
cleavage index, involving the rupture of gel fusion, will
Release factor =100(Ff )/F% (1)
be much higher than coecients of friction (kinetic or
static) which involves sliding only. In this experiment, no weight (W) was used as depicted
in Fig. 2 since the gel surfaces were perfectly at.
RESULTS
Agar gel Surfactant runs
The procedure described above was repeated by It was found that SAPL greatly reduced the shearing
force needed to cause cleavage of agar gel blocks held depositing the 200 ml of SAPL solution over one of the
surfaces prior to contact with its counterface at concen- together overnight in the refrigerator. The results are
summarized in Table I and depicted graphically in trations of 10, 50, 100, 150 and 200 mg DPPC/ml PG.
A further control was performed with PG alone. Fig. 3. It can be seen that gel fusion was inhibited by
SAPL whether this agent was dispensed in PG or In a second series of runs, 200 ml of DPPC solution
in hexane:ethanol were touched o onto a horizontal hexane:ethanol. It can be seen that the solvent PG
promotes fusion, while hexane:ethanol alone is not gel surface over which it spread spontaneously as
though on water. The solvent then evaporated, leaving signicantly dierent from the untreated control. It
is also noted that the shearing force is independ- the DPPC as a very thin coating. This procedure was
repeated at concentrations of 10, 50, 100, 150 and ent of DPPC concentration when deposited from
hexane:ethanol, but somewhat dose dependent when 200 mg/ml, all runs being performed 10 times.
the solvent is PG. Otherwise, the release properties are
quite similar and range from 61 to 84%. Bovine articular surfaces
A preliminary experiment was performed in which On two further agar blocks, we used SAPL of human
origin in hexane:ethanol when the release factors were two samples of normal bovine articular cartilage were
clamped together with their articular surfaces in con- 70 and 74%, indicating the universal nature of the
natural material as a release agent. tact and placed in the refrigerator as described above.
The following day, the two samples fell apart upon In the preliminary experiment using the agar gels,
application of Students t-test to the data in Table I removing the clamp.
When this simple experiment was repeated, but both showed a highly signicant dierence (P<0.01)
between controls and surfaces treated with DPPC. surfaces were now rinsed with a powerful lipid solvent
( Folch reagent) prior to contact, partial fusion was There was no signicant dierence between shearing
forces for dierent concentrations of adsorbed DPPC, found to have occurred upon removing the clamp the
following day. Since the cartilage was excised from a nding consistent with the basic theory of release
HILLS AND THOMAS: SURFACTANT INHIBITS ARTICULAR FUSION 535
TABLE I
Shearing force needed to cleave agar gels with and without an SAPL coating
Maximum shearing force
Surface ( f in mN) s.r.x. n Release factor*
treatment F=196 8 10
Nonecontrol
PG alone (control ) f =366 18 10 87%
10 mg DPPC/ml PG 76 9 10 61%
50 mg DPPC/ml PG 44 7 10 78%
100 mg DPPC/ml PG 57 8 10 71%
150 mg DPPC/ml PG 56 8 10 71%
200 mg DPPC/ml PG 31 3 10 84%
Hexane:ethanol control 207 9 10 1%
10 mg DPPC/ml HexEth 77 6 10 61%
50 mg DPPC/ml HexEth 86 1 10 56%
100 mg DPPC/ml HexEth 61 6 10 69%
150 mg DPPC/ml HexEth 71 4 10 64%
200 mg DPPC/ml HexEth 65 4 10 67%
*As dened by equation (1).
ponding to a cleavage index of 0.12 0.017 (n =5).
These results are depicted in Fig. 4.
The results for bovine articular cartilage, as depicted
in Fig. 4, show a highly signicant increase in shearing
force needed to eect cleavage (P<0.001) when the
surface is rinsed with either solvent for SAPL.
However, any dierence from normal becomes insigni-
cant when SAPL is reapplied either as a human
extract or as synthetic DPPC. This must add strong
support to the concept that these treatments are replen-
ishing SAPL extracted by solvent rinsing.
Human articular cartilage
Human articular cartilage from osteoarthritic hips
and knees tended to fuse more readily than bovine
articular cartilage, as witnessed by the results given in Fic. 3.Depicting the results quoted in Table I in which it can be
seen that DPPC is an eective release agent inhibiting the fusion of
agar blocks whether applied to the surfaces as a solution in propylene
glycol (PG) or using hexane:ethanol (9:1) as a vehicle which is
allowed to evaporate. Each result is the average of 10 runs s.r.x.
agents in that a monolayer should suce [6] and any
additional surfactant is superuous.
Bovine articular cartilage
When the shearing force needed to initiate motion
was measured as a cleavage index as dened in equation
(2), the result for 10 samples was a value of
0.096 0.006 (means.r.x.). When the surfaces
were rinsed with either Folch reagent (n =4) or
hexane:ethanol (n =5), the force needed to produce
Fic. 4.Depicting the relative shearing forces needed to cleave two
cleavage (F) went o scale, even when W was reduced
normal bovine articular surfaces clamped together and how they
from 120 to 70 N (12 to 7 kg). However, when the
can be made to fuse together (cleavage index o scale) if these
SAPL was replenished on the surface by depositing a
surfaces are rst rinsed with two powerful lipid solvents ( Folch
human extract (100 mg) in hexane:ethanol as described
reagent and hexane:ethanol 9:1). Results are plotted as the cleavage
above, the shearing force was greatly reduced, corres-
index dened by equation (2), the clamping load (W) being the
ponding to a cleavage index of 0.140 0.009 (n =10).
same in all runs. It is also shown how the application of human or
When this experiment was repeated using DPPC
synthetic SAPL, i.e. DPPC, almost restores the original release
(100 mg) to replenish the SAPL elutriated by solvent
properties. The shearing force is quantied as the cleavage index as
dened in equation (2). rinsing, the shearing force was reduced further, corres-
BRITISH JOURNAL OF RHEUMATOLOGY VOL. 37 NO. 5 536
TABLE II
Shear stress needed to cleave human articular surfaces before and after solvent rinsing and replenishment of surface SAPL
Surface Shear stress Cleavage index Release factor
treatment (N/cm2) [equation (2)] n* [equation (1)]
None f =4.36 0.62 0.141 0.020 11 55%
Rinsed with Folch reagent (control ) F=9.60 1.09 0.310 0.035 12
Control treated with 500 mg human SAPL f =3.36 0.37 0.108 0.012 12 65%
Control treated with 500 mg DPPC f =1.16 0.38 0.037 0.012 12 88%
*n refers to samples from dierent joints.
result, even including replenishment with human
SAPL.
DISCUSSION
The simple experiment with the agar gel demon-
strates the principle of gel fusion and how eectively
it can be inhibited by SAPL. At the molecular level,
gelling has always been associated with hydrogen bond-
ing [14] and so its inhibition by SAPL could be related
to the nding that even an adsorbed monolayer of
DPPC can impose a barrier to hydrogen ions, decreas-
ing permeability by an order of magnitude [17].
Hydrogen bonding has also been emphasized as a
major factor in the structure of the very hydrophilic
Fic. 5.Depicting how arthritic human cartilage derived from
proteoglycan gel [5] comprising the thick surface layer
replaced hips and knees displays a greater degree of fusion than
of articular cartilage supported on the tough collagen
normal bovine as reproduced from Fig. 4. Also demonstrated is how
matrix providing structural integrity. Hence, it is not
replenishment of SAPL can restore release and reduce articular
surprising that articular surfaces rinsed free of the fusion almost to that of normal bovine articular cartilage. This
implies a deciency of SAPL on arthritic human cartilage as outermost lipid coating are prone to gelling to them-
conrmed in other studies [20]. Note how synthetic DPPC reduces
selves, whether bovine ( Fig. 4) or human ( Fig. 5). This
articular fusion even further. Shearing forces are compared as the
outermost lipoidal layer is responsible for the very
cleavage index dened in equation (2) where the clamping load (W)
hydrophobic nature of the normal articular surface
is the same in all runs.
[10, 11], and is also an excellent boundary lubricant
capable of reducing wear [ 18] and friction to the
physiological range, which has been described as mira-
Table II and summarized in Fig. 5. It can be seen that
culously low by engineering criteria [19]. Moreover,
the average cleavage index of 0.141 0.020 compares
it imparts such remarkable lubrication under high load with 0.096 0.006 for normal bovine articular cartil-
of >130 N/cm2 (>13 kg/cm2). This same release mech-
age. When rinsed with solvent, this value was greatly
anism might still apply even if other mechanisms, e.g. increased, indicating a loss of release agent. When the
related to synovial cells, were contributing to the SAPL was replenished with the human extract of
mechanical component of joint stiness. SAPL, the shear stress needed to cause cleavage was
The observation that articular surfaces from arthritic reduced by 65%, and by 85% when replenished by
joints demonstrated a greater tendency to fuse together DPPC.
than normal bovine articular cartilage is compatible Statistical analysis of the results for arthritic human
with Wrights original concept [4] of articular gelling cartilage ( Table II ) shows a highly signicant increase
as the mechanism responsible for stiness in in shearing force upon rinsing with Folch reagent
osteoarthritis. This is demonstrated by the higher (P<104). Application of human SAPL to the solv-
shearing force, as quantied by the higher cleavage ent-rinsed arthritic cartilage shows a highly signicant
index in Fig. 5 than recorded for normal bovine artic- decrease in shearing force (P<0.001), but the mean
ular cartilage in Fig. 4. The dierence could be attrib- is lower than the original value to a moderate level of
uted to a deciency of SAPL. The origin of such a signicance (P<0.05), indicating that the arthritic
deciency is probably related to the change in the lipid human cartilage was probably decient in surfactant
prole of synovial uid recorded soon after a non- in the rst instance. This is borne out by the moderately
fracture traumatic injury of the type expected to induce signicant dierence (P<0.03) between untreated
osteoarthritis in the abused joint [20]. Our recent arthritic human and untreated normal bovine. DPPC
studies analysing solvent rinsings of the articular sur- appeared remarkably eective in restoring release,
faces of hips and knees replaced at surgery have demonstrating highly signicant (P<0.001) decreases
in the cleavage index by comparison with any other indicated deciencies of up to 60% [ 9].
HILLS AND THOMAS: SURFACTANT INHIBITS ARTICULAR FUSION 537
In the preliminary experiment with agar, it was the funding provided by the Australian Research
found that when untreated gel surfaces fused together, Council.
the plane of subsequent cleavage did not coincide
with the original plane of contactan observation
RrrrrNcrs
consistent with the concept of adhesive wear in
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We wish to thank Dr Peter McMeniman for his
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assistance in providing us with the hips and knees 23. Dobbie JW, Hind C, Meijers P, Bodart C, Tasiaux N,
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