Potential Mechanism of Action of Intra

Transcription

Potential Mechanism of Action of Intra-articular Hyaluronan
Therapy in Osteoarthritis: Are the Effects Molecular
Weight Dependent?
P e t e rG h o s h a n d D i e g o G u i d o l i n
Background:Hyaluronan,or hyaluronicacid (HA),is the maior hydrodynamic
nonprotein component of joint synovial fluid (SF). lts unique viscoelastic
propertiesconfer remarkableshock absorbingand lubricatingabilitiesto SF,
sizeand hydrophilicityserveto retainfluid
while its enormousmacromolecular
in the joint cavity during articulation.HA restrictsthe entry of large plasma
proteinsand cellsinto SF but facilitatessolute exchangebetweenthe synovial
capillariesand cartilageand other joint tissues. In addition, HA can form a
pericellularcoat around cells,interact with proinflammatorymediators,and
bind to cell receptors,such as cluster determinant (CD)44and receptor for
hyaluronate-mediated
motility (RHAMM),where it modulates cell proliferation, migration,and gene expression.All these physicochemicaland biologic
propertiesof HA have been shown to be molecularweight (MW) dependent.
Objective:Intra-articular(lA) HA therapy has been used for the treatment of
knee osteoarthritis(OA) for more than 30 years. However,the mechanisms
responsiblefor the reported beneficialclinical effects of this form of treatment
remain contentious. Furthermore,there are a variety of pharmaceuticHA
preparationsof different MW available for the treatment of OA, but the
significanceof their MWs with respectto their pharmacologicactivitieshave
not been reviewed previously.The objective of the present review is to redress
this deficiency.
Methods: We reviewed in vitro and in vivo reports to identify those pharmacologicactivitiesof HA that were consideredrelevantto the ability of this
agent to relievesymptoms and protect joint tissues in OA. Where possible,
reports were selectedfor inclusionwhen the pharmacologiceffects of HA had
been studied in relationto its MW. In many studies,only a single HA preparation had been investigated.In these instances,the experimentaloutcomes
reportedwere comparedwith similarstudiesundertakenwith HAs of different
MWs.
Results:Although in vitro studieshave generallyindicatedthat high MW-HA
preparationswere more biologicallyactivethan HAs of lower MW, this finding
was not confirmedusing animal models of OA. The discrepancymay be partly
explained by the enhanced penetration of the lower MW HA preparation
through the extracellularmatrix of the synovium, thereby maximizing its
concentrationand facilitatingits interactionwith target synovial cells. However,there is accumulatingexperimentalevidenceto show that the binding of
HAs to their cellularreceptorsis dependenton their molecularsize;the smaller
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Fitliu S.p.A. Abtuu
Petel Ghosh. I)Sc. PhD. FRACI. FRSC: A:sot'iutt, Proles:or.
{,rrlit,rsitl
Reseuxlt, Dtpurtntettt of Sll.qen.
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Seminars in Arthritis and Rheumatism,Yol 32, No 1 iAugust), 2002: pp 10-37
INTRA-ARTICULA
HR
YALURONAN
T H E R A P YI N O S T E O A R T H R I T I S
HA molecularspeciesoften elicits an opposite cellularresponseto that produced by the higher MW preparations.Studies using large animal models of
OA have shown that HAs with MWs within the range of 0.5 x 106-1.0x 106Da
were generallymore effectivein reducingindicesof synovialinflammationand
restoring the rheologicalproperties of SF (visco-induction)than HAs with
MW > 2.3 x 106Da. Theseexperimentalfindings were consistentwith light
and electron microscopicstudies of synovial membrane and cartilagebiopsy
specimensobtainedfrom OA patientsadministered5 weekly lA injectionsof
HA of MW = 0.5 x 106-0.73
x 106Da in which evidenceof partialrestorationof
normal joint tissue metabolismwas obtained.
Conclusions;By mitigating the activities of proinflammatory mediators and
pain producing neuropeptidesreleasedby activated synovial cells, HA may
improve the symptoms of OA. In addition,HAs within the MW range of 0.5 x
106-1.0x 106 Da partially restore SF rheological properties and synovial
fibroblastmetabolismin animal models.Thesepharmacologicactivitiesof HA
could accountfor the reportedlong-termclinicalbenefitsof this OA therapy.
However, clinical evidence has yet to be describedto support the animal
studiesthat indicatedthat HAs with MW > 2.3 x 106Da may be lesseffective
in restoringSF rheologythan HAs of half this size.
Semin Arthritis Rheum 32:10-37.Copyright 2002, Elsevier Science (USA). All
rights reserved.
INDEXWORDS:Hyaluronan;molecularweight; osteoarthritis;pharmacology.
o l h v a l u r o n i ca c i c l ( H A ) .
fI-YALURONAN.
lI
is the rnost abundant-ulycosantinoglycan
( G A G ) i n m a m m a l i a nt i s s L r eI t. i s p r e s e nitn h i g h
c o n c e n t r a t i o ni ns c o n n e c t i v e
t i s s u e .s u c ha s s k i n .
vitreoushumor. cartilage.and umbilicalcord. but
the largest single reservoiris the synovial lluid
(SF) of tl.recliarthrodialjoints. where concentra( 1.2t.The high
tions of 0.5-,1rng/ntl-nre achievecl
concentration
of HA in SF is essentialfirl normal
joint function. becauscHA conlèr'serceptional
visco-elasticityand lubricatingpropcrtiesto SF.
particularll,during hi.ehshearcgncliti6ns.Uncler
dynarnicloadingof diarthrodialjoints. shearthinning and a reductionin r,iscosityoccurbecauseof
decreasep
d h y s i c a le n t a n s l e m e n tosf H A n t o l e cules ancl their realignlltentto clirectionsntole
parallelwith the axis of articulation.TheseLrniclue
non-Newtonianrheologicalproperticsof HA not
only reducewear anciattritionof articularcaltilage
r tl s os t a b i l i z ej o i n t sa t
d u r i n gj o i n t m o t i o n( 3 - 5 1 b L a
low shearlates (6).
In addition.the high exclusionproperries
of HA
moleculesrestrictthe entry of plasrnaproteinsintct
the aqueousphaseof SF. This excltLsion
eftèct is
dependenton the molecularwei-eht(MW) rlf the
ploteins;ie. lar-lemolecules(suchasplasrnaalpha-
2-macroglobuIin)
essentially
ale exclnclecl
thtrr the
S F w a t e r s p a c e( 7 . 8 ) .B y c o n t r a s tH
. A facilitates
the transportof u'ilterand small solutesthroughSF
to articLrlar
cartila-ce
fiom capillariesin the syno(lA)
viunr and reclucesfluiclloss as intra-articr-rlar'
pressureis raisec'l
during.jointflcxion (8- | 0). Thcse
propertiesof HA are importantfbr the nLrtlitionof
iu'ticularcartila-ce
as well as tbr the climinationof
metabolitesanclnoxioussubstances
from the .jornt
cavity.
HA MOLECULAR
STRUCTURE
T h e d i r c r s c p h v s i c o c h c r n i cparl o p e r t i e o
sf HA
alise flont its unicluernercromolecular
strLlcture.
Thc HA is an cxceptionallylon-u(3-30 g.nt) and
unbranchecl
nonsulfitted
GAC conrposecl
of' repeating disaccharicle
r-rnits
N-acetyl-elucosarnine.
of
and
- u l u c u l o n iacc i dg l y c o s i d i c a l llyi n k e ctlh r o u g ht h e r r
r c s p e c t i v el - . 1r i n - gp o s i t i o n s( F i - gI ) .
groupoxygensat the -ulucuronvlHy'clroxyl
l ancl
slucosamine3-positiilnsare usedfbr furtherpol1,merizationof the HA disaccharideunits to tbrrn
chains that. when releasedfiom the ccll plasntii
mernblane.
areof variablelen-eth
and thr-rs
polydispersity.Despitethe sirnplicityof the HA primary
structure.this linear polvelectrolyteadoptscorn-
G H O S HA N D G U I D O L I N
A
N2
l- rLl
G1
B
N1
CHr
O=C'
CH.OH
"Ho\\--o
LoÇ_è:_-o
N H- ^ , ,
y-F1..
o- - r ,
"ta", H
G2
N2
Gr
N1
F i g 1 . S t r u c t u r eo f H A i n ( A ) d i m e t h y ls u l f o x i d ea n d ( B ) i n a q u e o u sd i m e t h y ls u l f o x i d ea s d e t e r m i n e d
b y p r o t o n N M R s p e c t r o s c o p ys h o w i n g t h e s u g g e s t e dh y d r o g e nb o n d i n g b e t w e e n t h e c a r b o x y la n d
a c e t a m i d og r o u p s a n d r i n g o x y g e n a n d h y d r o x y l g r o u p s i n t h e r e s p e c t i v eg l u c u r o n y l( G . , ,G r ) a n d
N - a c e t y l g l u c o s a m i n(eN l , N 2 ) r i n g s . I n t h e a q u e o u s e n v i r o n m e n t ,( B ) s t r u c t u r e sw i t h h y d r o g e n
b o n d e d w a t e r b r i d g e s b e t w e e n t h e f u n c t i o n a lg r o u p s a r e p r o p o s e d .P a n e l ( C ) s h o w s a m o l e c u l a r
m o d e l o f a s e g m e n to f t h e H A m o l e c u l ew i t h t h e h y d r o g e nb o n d s l o c k e di n p o s i t i o n sa s i n d i c a t e di n
( A ) .U n d e rt h e s e c o n d i t i o n s ,8 C H g r o u p s( s h o w n w i t h a c r o s s )b e c o m ea l i g n e dc o n f e r r i n gr e g i o n so f
h y d r o p h o b i cc h a r a c t e rT. h e s eh y d r o p h o b i cr e g i o n sa r e r e p e a t e da l o n g t h e H A c h a i n a n d a r e c o n s i d e r e d t o p a r t i c i p a t ei n i n t r a - c h a i ni n t e r a c t i o n sa n d b i n d i n gt o p h o s p h o l i p i d sA. d a p t e df r o m S c o t t ( 1 2 ) .
plex confbrmationsin solution.which engenclelit
with diversebiolo-eicproperties.
Within the joint cavity. HA moleculesare predorninatelysynthesizedby the type B synovial
cells. These cells elaboratea polydispersecl
HA
populationwith MWs within the ran-reof 2 x
1 0 " - 1 0x 1 0 " D a . t h e s i z ed e p e n d i n -orn t h ei o i n t
l o c a t i o na n d s p e c i e s( 1 , 2 . 1 1 )F. u r t h e n n c l r H
e .A r s
producedin largequantities.which encoura-res
the
fbrmationof extensir,'e
macromolecular
entanglc-
HYALURONAN
THERAPY
IN OSTEOARTHRITIS
INTRA-ARTICULAR
13
mentsand networksthat confèr unusualstifïness
tied high or Iou' MW HA preparationswith the
phospholipid. clipahnitoyl-D.L-phosphaticlvlchoto SF as mentionedpreviouslv.
and viscoelasticitl,
line. the proporticlnof flexible chain segmentsrn
Although the ring orientationsadoptedby' the HA
HA relativeto stifl' segmentscould be increased
chains in solution are lar-uely'-eovernedby' the
( 2 2 t . A d d i t i o n a ls t u d i e ss h o w e dt h a t h i g h l y p u l i stericrestrictions
to their rotationaboutthe various
gly'cosidic
f i e d H A c o u l db i n c lt o a v a r i e t yo 1 ' p h o s p h o l i p i d s .
linkages.the hydrogenbondingbetrn,een
functional -groupson the rings is an impoltanl
including the pnrinllarlrnatorvplateletactivating
liictor (2 I -23).
determinantof HA conlirrmation.This uas shor"'n
of HA. palticuThesernolecularcharacteristics
bv rneansof proton nuclearnragneticresonilnce
(NMR) spectroscop)'.
r'u'ith
MW
r.r'hichshou,ecl
clecreasing
lalll the lossof chainrigiclit-vthe prescncc
o1'hydrogen-boncling
betnieenthe glr"rculonr
I caro r i n t e r a c t i o nu i t h p h o s p h o l i p i d sh. a v e i r n p o r s ith respecto its
boxyl group anclthe adjacentacetanrickr
h1'drogen
t a n t p h l , s i o k r g i ci n r p l i c a t i o n w
o 1 ' t h e N - a c c t r ' l h e x o s u r t . r i nrt' 'i n g ( r i r r \ \ i r t c r '
inlrusn
r o v i n lm e c h a n i s notl a c t i o ni n o s t e o a r t h r i t i s
(o,\)
b l i d - s e so
) f H A i n a q u e o u sc l i n r e t hI r s u l t i r r i c l c
s o l u t i o n s( l 2 - 1 . + () F i g I i . l ' h e a d d i t i o n r l . u r r i c rt r r
RATIONALE
F O RT H E U S E O F I A H A I N O A
r i n g r o t a t i o ni m p o s e cbl r t h c s cb i l a t e r l lh r c l l o s c n
blidges favors a confixniation lirr H,\ riherehr
. l o i n ts p a c en u r r ( ) \i \n g ( c i r u s c bt ly l i b r i l l a t i o na n c l
I o s so 1 ' c a r t i l a s es) .c l e r o s i sa.n c ls u b c h o n d l ablo n e
e a c h d i s a c c h a r i duc n i t a l o n g t h e c h a i n i s n r a i n br osteophytosis
at the
tained at 180' to the next. conl'erlin-sa l-lirld
rernodelingaccornpaniccl
joint margins are consiclered
the cardinal racliohelical synlnretr)'.Significantlr'.this conlirlmation
also exposeson alternatesideso1'thehelix repcatl o g i c s i g n so f O A . H o v u e v e ri .t - r e n e r a l l yi s a c in-9clustelsof 8 contiguousring C anclH atonrs
also coexists
cepted that sl,novial inUanttnatiot't
r.'u'ith
and is probably'cl'ivingthe
that were consiclered
to representlociitionso1'hr'thesepatholo-sies
d l o p h o b i c i n( F i g l ) . M o l e c r - r l an r o c l c l i nagn r lc n c l i n i c a l l ra c t i v ec l i s e l s.eT h e S F l r o n rO A p a t i e n t s
t v e l so f i n l l u n t n r a t o rtvr e c l t a e r g l ' c a l c L r l a t i o ni nsd i c a t e ct hl a t I H A c l r a r n :r ' u n c o n t a i n ss i g n i t i c l r nl e
t rl'l l r c t i rl r t i o t t
n i n u a n t i p a r a l l etl o c u c l r o t h e r c o u l c l u n t l e l l r r
t o r . u n t i t r t h c lr l a l k c l s o l i l r . t r . t t t tcr e
i n t e r a c t i o nuss i n St h c s cI r rr l r . r r t l - 1 l f i r . l i n r l r ù r ' u n rC ' - r a
e ï - t e c t i vien t e r c h a i n
' ec t i rc l t r o t ei n l c ' re l s a r e
p h o b i cr e g i t t n s( 1 . 11. . 5
e l e ru t e crl l r ) r .
t . T h i s s t r g g:et i ( ) l t\ \ i t \ c ( ) r t \ tiueral ilc \ o 1 's r n o v i a l t t t e r t . t s i s t e n t w i t h e a l l i e r v i s c o e l a s t i cn r c i r s r . u ' c n r c n t \ . I r . t t r t . t u n o l . t i : t o l o g
N M R t ' e l a x a t i o nt e c h n i q u c s .r o t a l r ' - s h u r k r r i i n g blanc biopsr s1'rccinrcns
ll'onrO,\ piltientsshouecl
prcse
lvnielectron microscopy. and computcr nroclclin!r.
thc
nce ol' T helperanclT rul"rprc-ssion
which had inclicatedthat HA could undergointll.rphocvtes. B l-vnrphocvtes.
nracrophage-exan(l
p r e s s i n lH L A - D B i n l y r n p h o i cl li r l l i c l c s .w h e l e a s
c h a i n a n c li n t e l c h a i na s s o c i a t i o n(s1 6 - 1 9 ) .H o u ,
eVel'.the chenricalnatureof theseinteractions
and
clifTusecellular infiltratecontaininggranulocvtes.
the relativeorientationo1'theacljacent
T and B lyrnphocylcsand HLA-DR positivernacchainshatl
nol beenresolved.
lophagesu'ere identitieclin many of the biol.rsy'
It was proposedthat the interchainduplcx cous p e c i n t e nesx a r t r i n e1d- 1 0 . 3) .1U s i n - ei n s i t uh v b r i c l plin-ls betweenthesL'h1-'drophobic
pttches cor-rld
ization and biotin labeleclriboprobes.Sn.ritlrct iil
( 3 2) c o n f i r m e dt h e p l e s c n c co f c y t o k i n e s( i n t e r l c u accountfor many'o1'lheknown phvsicalpfoperttes
(
2
(
)
.
l
l
)
.
o f H A . s n c ha s i t s L r n u s u a lhl yi g h s t i f f n e s s
k i n [ L l - l r r a n c lB . t u n r o rn e c r o s i sl a c t o r-' a ) a n c l
Furthermore.
thesecontiguousCH regionsofl'clccl
I L - I r e c e p t o ru n t a g o n i s (t l L - I r a ) . i n s y n o v i a l
possiblesitestbr aclditionirlIryclrophobic
intemcmembranebiopsl specinrensfl'ori'rOA patients.
tions. such as with cell membranes.anclbiologi.tMoreover.the leiels of thescproinflarnmatol'1,
call1,in.rportant
lipicls(21,).Experirnentalsuppolt
lt'rkinescorlclatcdwith the radiologicgraclingof
fbr such complex tbrmationsu'as pluvided b1' a
thatthe cytokinrdiseaseseveritl,.It wasconclr-rdecl
s t u d yu s i n g' H - N M R s p e c t r o s c o p( 2) ,2 ) .T h e c h a i n
pnrfilesanclthe cleclinein o1'lL-I ra actir.'ity
"vere
f l e x i b i l i t y( s t i f f n e s so; 1 ' av a r i e t yo 1 ' H A sw a s l r e a n o t d i s s i n r i l atlo t h a t s e e ni n r h e u m a t o i da r t h r i t i s
suredfiom the spin-spinrelaxationtirneso1'thcir'
synoviur.n
but was cl1'alesserintensitv.Thesedata
acetamiclo
were consistentwith the report of Wagner et al
-qfoupprotons.The stitfnesso1'highly
(33) who useclPCR to quantitatecytokineslevels
purified HA preparationsincreasedas the MW
increased;however. bl sonicatirr-u
highlv pulii n s y n o v i a lb i o p s y s p e c i m e n sf r o r n O A j o i n t s .
14
They are also consistent with the stucly by
Roir,'ainen
et al (34) and Marok et al (3-5).who
leportedthe increasedexpressionof oncoprotcins
and proinflarnmatory
mediatornuclearfactortranscriptionfàctorsin OA synovialcells.
The presence
of prointlamrnatory
cytokines.free
radicalsand proteinasesin OA synoviu can ildl'erselyaftect the rnetabolisr.n
of the lining type B
fibloblasts,leiidingto the biosynthesis
ol HA w,itlr
abnonnalMW. as has becn shown b1'analysisclf
S F f r o m p a t h o l o g ijco i n t s( - 5 , I1. 3 6 . 3 7) . I n a d c l i r i o n .
HA alsornaybe depolyrrrelized
bv oxlgen-clerilecl
fl'eeradicals(38-.10)and intlacellularlrbr hValut'ctniclases.
iind other -tlycosiclascs
tÏrnt svrtoritrcytesand ler-rkocytes
in the sr nor iLrr.r.r
t-1l .-11r.
T h e c l e c l i n ei n H A r n o l c c u l asr i z t 'c o u p l e dn i t h
i t s d i l u t i o n b y i n t i l t r a t i o no l p l u s n l r l l u i d a n d
p r o t e i n s( c a u s e db r i n c r e a s e sdr n o ri a l n t e r l b l a n c
p e l n r e a b i l i )t lr e d u c ct h e r h e o l o g i c al lt r o p c l t i e so f
S F -l i o n r O A . j o i n t st - 5 . 1 1 . 3 6 . 3 7 . -A1s0 )a. c o n s c qLlcnce.
it n asconiendedthatcaltila-rcattlitionand
subchonclral
bone rentoclclingwas enhancedcontributingto progressionof OA and clinical syrrrptonts.
On the basisof thc leciucecl
rheologicalpropert i e s o f t h e H A i n O A . j o i n t f i u i c l .B u l a z sa n c l
Denlinger(;13)anclothers(-1-1.-15)
inrrorlrrccrl
rhe
c o n c e pot f v i s c o s u p p l e n t L ' n t l r ti inonn .h i eh t h c u t r n o l m a l S F l l u i d w a s a s p i r a t e cf rl o t n t h c i r l f c e t ù r l
. j o i n t .t h e n r e p l a c e cul i t h p u r i t r e dh i g h \ l \ \ H . \ .
T h c r a t i o n a l ef b r t h e u s e o f t h i s p n r c c d u r ei n t h e
treatnrentcll'OA was to l'estoreol supltlentent
SF
viscoelasticitw
y .h i c l t i v o u l d i n t p n r v e. j o i n rl i r n c tiOnalitl and consecluenllv
decreases)'lilpt()nt\.
Although clinical str.rdies
undertakent() tcst thc
Balazs h1'pothesisr,,,eresupportivcin telnt' o1'
l e l i e f o f O A s v r n p t o t l s( . 1 3 - 4 8 )i .t w a s o b s e r r c c l
that the clinical oLltcorresubtainedb1' this approach also coLrldbe achievedlvith HAs u ith
MWs less than the HA in SF aspiratedfiorn rhc
o i n t . F u l t h e l n r o r et h. e c l i n i c a cl l f l c t i r e c l e t è c t i vj e
nessof the therapl'rvasol'tenin excessof serclal
w e e k s o r e v e n t r - r o n t h su.' h i c h w a s i n c o l t s i \ t e n t
lvith the kno'"vnrate of clealanceof HA liorrr
s y n o v i ajlo i n t s .
I nj e c t i o no f r a d i o l a b e l eHd A i n t o k n e ej o i n t s o f
norrtral rabbits afforded tvera-qehalf-lives lbr
c l e a r a n coef l c s st h a n2 - 1h o u l s( - 1 9 - . t l tI.n a s h e e p
rnodelof arthritisinclucedby IA injectiono1'rvpcIl
collagen,pharrnokineticstudiesshoweclthat the
metabolichalÈlitè of lA injectcclradiolabeled
HA
cleclincdfhrrr 2l hoursbetbreinductionof arthlitis
to a lrean valueof I 1.5hoursafier lA in jectionof
the antigen(-52).Fulthen.norc.
analysisof the clata
indicatedthat the meantl'actionalturno\rerfate of
racliolabeled
HA injectedinto the inflamedjornts
uas alrrost clor-rble
that in the noninflamedjoints
(3.-5%/hr 6.3c,4
llt). This increiisedturno.n'erof
racliolabcled
HA in the inflar.necl
.jointswas accolnpaniedbv accurnr.rlation
of its rnetabolite.
tl'itiatecl
'uruter'.
in lvmph and trlood.
It is clcur lhrnr theserellortsthat the obsened
I u n g - t e l ncr l i n i c l l b c n c l i t sa l ' f b r d e db 1 'I A a d n t i n istlutronof HA cannotbe fully accontrrrcldatecl
bv
t h e e o n c e pot f v i s c o s u p p l e m c n t a t i H
o no.w e i . ' c ri 'f.
tht-HA Lrsccl
firr IA therapyin OA u'asnot nterell'
l c t i n s a s a v i s c o e l a s t iS
c F sLrpplemen
b tu t , " r , a s
crhibiting usefulphamracolociceftèctson thc uncler'lying
pathologicsresponsible
for the svntptonrs.
then its lon-g-term
clinical efficacr nricht be fationalized.
A r c v i e v uo' f t h e e \ t c n s i \c l i t e r a t u r eo n H A
shovnecl
that it dicl crhibit ir spectrLulof phalnrac o l o s i ca c t i ri t i c s .n r a n ro l r rh i c hc o L r l c. rlc c o u nf tb r
its abilitr to leducc-pain ancl inflarnntationancl
c c t i ii t v i n O A . M o r e c l l , e r .
l . r o r s i b lnr r o c l i l rc l i s c u . a
t h c s el u b o r a t o r sr t r r c l i ei n: d i c a t e ct hi a tt h e b i o l o g i c
a c t i \ i t i e so l ' H A p r e p a l a t i o nns' a s d e p e n d e nnt o t
o n l v o n t l ' r cc o n c e n t r a t i o nuss e db L r ta l s o o n t h e i r '
\IW,
P H A R M A C O L O G IBCA S I SF O R T H E
USEOF HA IN OA
It is nou' wiclel-racccl)tcclthat HA bincls to
l e t e r n t i n u nl C
s p c c i l i cr e c e p t o r(sc l u s t c d
t D l - 1 - 1i n. t f a c e l h l l aar d h c s i o nn t o l e c u l eJ I C A \ , l1- I . r e c e p t o r
l i r r h v a l r - r l o n u t e - n t c c ln
ilto
e t il l i n l R H A M M I I t h a t
are e\pressecl
bv a u rrlelan-rreol cclls. incluclin,g
t h o s ei m p l i c a t e ci nl t h c p a t h o k r g yo f O A ( c g . r n llanrnratolycells.sr n()\iocytcs.ancichonclrocvtes)
l - 5 3 - 6 6 )I .t a l s os t f o n - l l livn t c l a c t sr v i t ha v a l i e t yo f
p l o t e i n s( h y ' a l a t l l r c r i nssu) c. ha sl i n k p l o t e i n w
. hich
is part tl1' a.g.grecan
lncl r crsican cornplexe
s in
cartila.ue(67) ancl firnns pericellular ntatliccs
ntouncllnany tvpùs of cells. including chonclroc 1 ' t e s( 6 3) .
l-hc finclin-uof speciliccell rcceptofsfor HA.
ncltiiblyCD4;1.sLrpporta pharntacolo-ric
nrechanisrn of action filr this GAG in OA. and because
thescleceptorsare wiclelyclistributed
on the surf acesof manytypesof cells.it alsoaccoLlnts
fbl the
cliversityol' its efIècts.
15
INTRA-ARTICULA
HR
YALURONAN
The binding of HA to CD:l:l anclRHAMM and
their variousisofbrmshas beenreportedto trig-uer'
a varietyof intlacellulnrsignalcvents.suchls the
protein phosphorylaticlncascades.cl"tokine rel e a s e .a n d s t i m u l a t i o no f c e l l c v c l e p n r t e i n s( 6 8 7 0 ) . M a n y o f t h e s ec e l l u l a rp r o c e s s ehsa v e b e e n
l ill not be clisr e r . ' i e w eedl s e w h e l e( 6 3 . 7 1 ) a n c w
cussedin detail hcre.Nevertheless,
it is impoilant
to note that. in -leneral.tlre consecluencc
of'these
receptorinteractionsby HA is to stinrulatetnllrsduction anclothcr si-cnalin-g
pathwavsthat nrocluprinralill
late cell fnnctionalactivitiesmanitèstecl
b y c e l l n r i g r a t i o np. l o l i f è r ' a t i o na.n d e n d o c r t o s r r .
Fi-eure2 sho'"vs
r.rscherriatic
reprcscntation
o1'sonrc
o f t h c H A - C D . ! l s i g n a l i n gp l t h \ \ ' i r ) st h u t h a r e
b c c ni d e n t i l l c da s r c p o l t e cbl r l - e t 'a n dS l r i c c rt l I t .
S t u d i e so n t h e e f ï è c t so l ' H . \ s o n C D - 1 -c1c l l u l r r r '
signalin-lhave shovn'n
that thc lesultscun l-rcconon the sizc-of thc HA moletladictorvclependin-u
c u l e sr . r s c cFl .o r i n s t l n c c .l o r i M W - H A s ( 0 . 2 8 x
1 0 6D a a n c l0 . - 1 7x l 0 ( ' D a ) r v e r es h o w nt o p r o motechenrokinegenccxprcssionby macropha-ues.
*€,t{*f{*
whereasa comrnercialpreparationof HA with an
M W o f 6 . 1 x l 0 ô D a d i d n o t ( 7 2 ) .T h e s ec l a t al e d
O h k a w a r ae t a l ( 7 2 ) t o s u g g e stth a t l o w M W H A
tl'agrrrcntsgenefateddr.rring.joint inllammation
ma)' perpetLlate
this processby enhancingexpression of -ueneproductsby residentmacrophages.
also ma1,ploThe srrallcr MW HA prepat'ittions
nrotc r.rsciirlcellLrlareffects.Ohkawaraet al (72)
slrorieclthat an HA preparationof MW : 0.2 x
1 0 " D a \ \ ' a s r n o l ' ec l ' l c c t iei i n n r a i r t t u i n i ntgh e
s u r ri v l l o f b l o o cel o s i n o p h i ltsh a nH A w i t h a n M W
o l . l X 1 0 ( ' - 6x 1 0 6 D a . o h k a w a r ae t a l ( 7 1 )
proltosgllthat thc protccti\c-cl'tèctaffordedbv the
l o r rc r '\ l \ \ ' H A o n t h e s ec c l l sr i a s n r e c l i l t evcila t h e
i n c r c l s c r lc r p r c s s i o no l ' g r a r t u l o ct er t n a c t ' o p h a t c
r I' ) - l - la c t vi a t i o l r .
c o l i r r r-rr t in r ul l t i n g f u c t o rl-r l ' t c C
T h c n r c - e h u n i s nr er ss l - r o n s i bl ilrcr t h e s ec o n t r a s t cell
inu \l\\ -rlcpcn(lL'nt
ef fect\ of HAs on clil'tèrent
but may. in part.
tvpes are still poorlr unclclstoocl
be relateclto thc clLlstcrin-e
and crcss-linkingof
It ts
CD:l;l receptorsolr their plasmamet.nbrane.
knoi.vnthat bindin-sof HA to the CD.l.l link nrocl-
"-**"*.*rfe
-'- |
**g.+**.#
El*
;4:tm'fp *fT1
^
qEÈF=-:1--:'Èsç-
@el
?:æ
v
ô9
,-.'^^@
\@v_,
c
T@,
@9;;;
'ttll
-
Fig 2. Diagrammatic representation of the CD44 cell surface receptors showing their possible
i n t r a c e l l u l a sr i g n a l i n gp a t h w a y s ,w h i c h c a n b e a c t i v a t e db y H A . T h e 4 s i g n a l i n gc a s c a d e si n v o l v i n g
CD44 have been identified. Pathway (A) requires activation of the src-relatedtyrosine kinases,(B)
heterodimerizationof CD44- erb 82 may activate a MAP kinase (MAPK) cascade,(C) the nuclear
transcription factor xB (NF-rÊ) may be activated through HA interaction with CD44 and a protein
kinaseC (PKC()dependentcascade,and (D) activationof GTPasesby HA-CD44interactioncan lead to
reorganizationof the actin cytoskeleton.Modified from Lee and Spicer (71).
'16
ule rrses discrete hexasaccharicleelements along
t h e G A G c h a i n ( 7 3 ) . T h e H A o l i - e o m e r so i 2 0 - 3 0
sugar units can therefbre interiict with rrure than I
CD4-l receptor. Nkrreo'uer'.these HA chain t'r'agInents can displace macrornolecular HA frutm its
m L r l t i p l eb i n d i n g s i t e s( 7 3 ) . F o r a c e l l u l a r f' e s p o n s e
to ensue atter HA binding. the fitrrlation of a stable
receptor complex involving c(x)perati\e interact i o n s o f ' s e v c r a lC D J - 1 r e c e p t o r s( c l u s t c r i n g )w i t h a
single HA molccular strancl lnr\
( 6 3 . 7 3 - 7 .)5.
bc requirecl
I t i s p o s s i b l e . b u t a s Y c t L l l i p f o Y c l r t. h a t H A
p r e p a r a t i o n sw i t h i n a s p e c i l i c r i z e r a n g e c o u l c l
provoke a pattern of CD-t-l clusteling and cross-
clinical practice: an example is Hylan G-F 10.
which is a rnixture of a hi-uhMW HA with a
cross-linked HA prepalation. the curnbinatron
hal'ing an MW range of 6 x 10"-23 X 10" Da.
Hou'er,'er.rnany of the HA preparations currentlv
u s e d t o t r e a t C ) A h a r . eM W s i n t h e o r d e r o f 1 . 0 X
l0(' Da or less ancl nlost ol'these are lcportecl to be
cfficacior,rs.Ale r.'n'e
to assunle that these riLrious
H A p l e p a r a t i o n sa r e c l i r . r i c l l l ve c l u i v a l e not r i s M W
reallv an irnpoltlLntlctenrinant ol'clinical efteetive ness'.t
l i n k i n g o n b i n d i n g . u ' h i c h t h e n r r i g g e r sa 1 1i l t t r a c e l lLrlal si-enal.whercas the lar:Jcl'H,\ rnolecr-rlcs
nrav
Notwithstancling the irnportance of these cprcstirrns.satisfactorvanswershave not been generatecl
b y c l i n i c a l i n r . e s t i g a t i o n sI .t m i g h t b e a r g r - r e tdh a t .
e v e n i f w ' e l l - c o n t r o l l e db l i n c l e ccl o m p a r a t i v cc l i n i rvere undertaken u'ith HAs of difterent
cul stLrclies
o c c L r p vt h e s e r r L r l t i p l eC D - 1 - 1l i n k i n s s r t c sh u t p r e V e n t r e c e p t o | c r o s s l i n k r n sa n r l u c c l l u l l r r r e u c t l o l t
( 7 6 ) . B e c a L r steh e H . \ l l r e \ e l t ti n n o r n t u le( ) n l t ù L t iù\
t i s s u e si s g e n e t t l l r o l h i g h \ l \ \ . r t u o u l t l . c c n t t r r
\ 1 W s . i t i s d o u b t f u l t h a t t h e n r e t h o c l sc u r r e n t l r r r r u i i u b l c[ ( ) r \ s c s s i ] a t i e n tr e \ p ( ) r ) \ et o t h e s e p a l ' a t c
H . \ t f ù i r t r ) r c n t\s 0 t r l t l l - r es c n s r t nc e n r l r - r gtho d e t e c t
\ n l i t l I r l l l t c r c r ) r ' ci\n e l n t i e l rcl l l i c r r e r 'T. h e p r o b l e n t
ntake biolo!Iic:ertse tirl it not lr) uuntilluuLl\l\
s t i m u l a t ea n a c t i r e r e \ l ) ( ) n \ c t h l l t l t c e e l l : i t . u r '
r o u n c l sS
. tuclieb
s y S n r i t ha n d ( i h o : h t 7 7 r i n 1 9 8 7
t o r r l t l l r c l L r r t l t c re. o n t | o r r n t l c t lh , r t h e s t r o n g p l a e c b o c l f c e t l ù [ r ( ) r ' t cl (i rl f L \ t | c i i t l l l c n t (s7 9 ) . a s w e l l
l u st h e p r e s c n t l i n r i t u t i o n r o t n o l r i n ra s i v e m e t h o c l s
o f a s s e s s r r .\ttgn l c t u l a l ( o r r l i : c l l ' c ) n t o t l i f i c a t i o ni n
O r \ a n c l t h e p a t i c n t ' s I c \ p ( ) n \ a t o t l I L r gt f e a t n l e n t s
o \ e r a p c l ' i o d o f t i r r r e s u t l i r ' r c l r tt ( ) ( l c t c c t \ r . l c h
o n t h e i n v i t r o e f t e c t so f H A s u r t h a u i d e l a n - l e o f
M W s u n h u n r a n s y n o i , i a l t i b r o b l a s t sb i o s v n t h c s r s
of HA provided erperimental er,iclenccto support
such an interpretation.
Hon'ever. thc situation is further cornplicated b1,
the |cccnt obser.n,ation
that HA can feaclil.n'enter
cells bv an unusual endocl'tic route un(l interact
w i t h s p e c i f i ci n t r a c e l l u l a rp f o t e i n s( 7 8 ) . F o u l i n t r u c e l l u l a rH A b i n c l i n gp r c t t e i n (sr e c e p t o r s ) h l r eb e e r r
d e s c r i b e d( 6 3 . 7I ) . O n e o f t h e s e .R H A \ l \ l s i s n o r m a l l v a s s o c i a t e cwl i t h t h e a c t i n c \ t ( ) s k c l r ' l o nu n c l
n r i c r o t u b L l l e sr ., ,h c r e i t c o l o c a l i z e su i t h e r k I p r o t e i n i i n c l M E K I u n c i n r o d u l a t e st h e i r s i g n a l i n g .
Significantll'.the bincling domain fitr elk I on
RHAMM is the sarneas tor HA. sug-sesring
rhe
possibilitv that the HA ntay cornpete lirr the erk I
b i n c l i n - sc i t e w i t h i n t h e c e l l ( 7 1 ) .
stnlcturûl chan-!es.
Bv contrlst. in r,itromodels unrl uninlrl nrotlels
o f O A a l l o r , i.' j o i n t t i s s L r e tso b c u r r u l rz c r l r l i r c c t l r ' .
tusins r alidatetl rrtethoclsrrt ils:ùssllent untl oftèr'
o t h e r a d v a n t a g e sf i r r c o n r p l r i n L t l t c r r c t i ri t r e s o f
r l i f f è r e n t c l r u g su n c l e rt l r c : u n t c c r p c r i n r c n t u l c o r r r l i t i o n s . T h e s e r n o c l c l r l u r rc h e c r t r l r r l c l v u s e c lt o
r - \ ' a l u a t et h e l e l a t i r c P i r u r n r u c o l o u i cet f è c t s o f H A
o l ' d i f t è r ' e n tM W a n c l h l \ ù , ' c l r c r l t c r lu s e f u l i n f i r r ' t t t t t t i o (t rt l l l h i \ i r t t | r ' t l l r tlt,t' l r i t .
F o l t h e a b o v c r e i i s o n : . r i e h u r c c o n f i n e c lt l i i s
l c r i e l v t o i n r i t r o a n t l i l n i l l r i r l i n r e s t i g a t i o n st h a t
h a v c e v a l u a t e c lt h c P l l u ' r n a c o l o u i c a c t r v i t i e s o f
H A s o f c l i t f e r c n t \ l \ \ . W h e r e p o s s i b l e .u e a l s c r
D e s p i t ee r i s t i n - se \ t e n s i v e l i t e f a t u f et h u t c l e a r l v
h a s s h o w n m o l e c u l a rs i z e c h a r a c t e l i s t i c o
sf HA ale
have includecl the lr-u fcports clescribin.ulabolat o r y s t u d i c so n . j o i n t t i s s u e b i o p s y , s p r ' c i n r e nosr
i n r p o r t a n t d e t e r r n i n a n t so f i t s b i o l o g i c a c t i r i t v .
there has been linritecl recognition of this fact in
clinical practice. It generalll, has been acceptecl
fluicls taken fnrrl OA patients before ancl afier a
c o u r s c u t l A t r e a t n r e n tw i t h t h i s a g e n t .
that the higher MW prc-paratior.rs
wor-rldbe superior
to HAs of lowcr MW because the firrnter wor-rlcl
better fulfill the requirernents fbr ef'Tectiver.iscosLlpplementationas clescribeclby Balazs and Denlinger (.13)anclother investigators(.1,+-;18
). Indeecl.
E F F E C T SO F H A O N I N F L A M M A T O R Y C E L L S
AND IMMUNOMODULATION IN VITRO
An earlf in vitro stuclybv Forresterand Wilkins o n ( 8 0 ) s h o r , i e dt h a t H A o f 0 . 7 x 1 0 6 D a M W
inhibited leLrkocvtcntigration. chemotaxis. unclad-
H A s w i t h h i g h M W a r e i n c f e a s i n g l yb e i n g u s e c li n
hesion in a concentlution de-penclent
manner. For-
I N T R A - A R T I C U L AH
RY A L U R O N A NT H E R A P YI N O S T E O A R T H R I T I S
40
rester.ind Wilkinson (tlO)showeda leductionon
bindingof chemotiicticfhctorsto thecell surf-ace
in
i30
*..l
the plesenceof HA. Neitl'reldextransullatc nur
f
i-Tll
chondroitinsulfirtchad any' el1ècton neutrophil
miglirtion.Theseobservalionswere confirrrrccl
bl
Partsce
h t a l ( 8 1) w h o s u g g e s r erchla rh i g hM W - H A
i n s v n o v i a jl o i n t s p r o v i c l e da p h v s i c a lb a r r i e rt o
e n t l ' vo 1 ' p o l y m o r p h o n u c l e( aPrM N ) c e l l si n t o t h e
c a v i t l. U s i n _H
r A o f u n c l i s c l o s eMdW . P i s k oe t a l
Hyaluronan concentration (mg/ml)
(82) nrade the observationthat. at norntal.joint
Fig 3. Inhibitory effectsof HA of different MWs
concentrations
of :1 rn-e/rnL.HA inhibitedneutloa
n d c o n c e n t r a t i o n so n a c t i v a t e d n e u t r o p h i l phil phagocytosis.
Hclwcver.at a concentration
of
m
e d i a t e dc a r t i l a g ed e g r a d a t i o n .N C = n e g a t i v e
I rng/nrL. as occurs in inllantecl.joints.no sLrch
c
o
n t r o l ,p Q = p o s i t i v ec o n t r o l ( w i t h o u t H A ) . ( : )
ef-fectwas observed.Stuclicshv Tantot()ct ll
H A - M W 0 . 2 8 x 1 0 6D a , ( - ) H A - M W 0 . 9 5 x 1 0 6
( 8 3 . 8 . 1e
) x a n r i n e dt h e i n v i t r o c f ï c c t : o l . l H . \
D
a . ( w ) H A - M W 2 . 0 x 1 0 6D a . T h e d a t a s h o w s
p r e p a r a t i o nwsi t h M W s o f 0 . 3 x l 0 " l ) r . 0 f l i 1 0 "
t
h
a t t h e H A p r e p a r a t i o nw i t h a n M W o l 2 . 0 x
D a . a n d 1 . 9 X 1 0 " D a o n p h l g o c r t o : r sc.l t ù n r o 1
0
6D a w a s s i g n i f i c a n t l ym o r e e f f e c t i v ea t r e d u c gc.n-ilclir
taris. and procluctionol' orr
ctl Îl't-.clutli,
i
n
g
t h e l o s so f g l y c o s a m i n o g l y c a n( sG A G s lf r o m
cals bv stil'nulrtL-(l
P\l\ lcLrkocrtc-s
lncl ntilctl)c
a
r
t i l a g et h a n H A s o f l o w e r M W . * * P < . 0 1 ;
p h a g e sT. h e h i g h \ l \ \ ' H , \ p f e p a r a t r o(n1 . 9 X l 0 ( '
* * * P < . 0 0 1 .M o d i f i e df r o m T o b e t t o e t a l { 8 6 } .
D a ) u a s t h e l l o s t c . f t è c t i vien h i b i t o ro f c h e n t o t a x r s
a n d . t o a l c s s e re x t e n t .p h a g c l c v t ifcu n c t i o n s A
. t
concentration\up to 2 rng/ml. none of the HAs
str-rdied
inlluencedthe ploduction of oxygen-clelvmphocyteprolilèration(87). Tu,o mechanisnts
rivccltl'eeradicalswhen cellsu,crestintulateduith
fbr HA effèctswere proposecl
by' tlieseinvestiglieither serum opsonizeclzlntosan or litrmvl-rnettors:one bl, reducingcell intefactions
andthc other
leu-phepeptide.It rn,as
ploposeclthatthe effècrsol'
by' the binding o1'rnilogenenhancingfnctors lcH A o n t h e i i c t i v a t e cnle L r t r r r p l tui lcsl c r i a i n t e r a c lcaseclby the stintulatedlymphocvtes(87).
tion vuiththeir CI)-1-1
ecll recr.1'rrot's.
The rnodulatingeffèctsof HA on inflantmaturv
D u r i n - gt h e i n l l u n r n r i r t o tp' \r o e c \ \ .P \ l \ l r . L t k o
e c l l a c t i v i t i e sa l s o u ' a s s u p p o f l c db v a n i n v i t r o
c y t c s n r e c l i a tbeo t h en z v n t r l i cu n ( l o r i r l r r t icr 1 r 're.
' t u r l r ' o r " lru h b i t n e u t r o p h ial c l h c : i o na n c la g g l e g u r a d i c a lr e l l c t t o n sl.e a d i n gt o t i s \ t - t cr l u n l r g c . ' l - h r '
t i o n . I n h i b i t i o n\ \ a s c k r s c - r l c p c n d eanbt o re 1 0 0
H A e x h i b i t e dM \ \ ' - d e p c n c i e fnet a c r i v e
o \ \ g c n\ l ) ù pr/nrl-rrnrH
l , \ s n i t h N I \ \ ' s. . I x 1 0 " D a r i e l e
c i e s s c a v e n g i n -agc t i v i t v t h e l e b vp r o t e c t i n u. j o i n t
ilLletr\c (liN).
t i s s u e st i o m o x i d a t i v ed a n t a s e( 8 . 5 )I.n t h i s r e : . : l r r t l .
EFFECTS
OF HA ON SYNOVIAL
PrestitrnclScott(8-5)r'eportecl
lhut an HA plePuluF
I
B
R
O
B L A S TIS
N VITRO
tion with an MW ol' 1.2 X 10" l)a \\'a\ ntorc
ctfectivethtrnHAs of 0. 176 X l0(' Da anclO.(r(rfi
x
Hunran slnor ial fibroblastsderiveclfronr OA
I0(' Da MWs in protecting tenclontibroblasts
culturedwith HAs respondccl
bi, up.jointsvu'hen
againstoxidativeclantage.
Theseinvesti-gators
susregulatin-uor down-regulatin-u
cnclogenousHA
svnthesis.clependingon the media concentratictn
-gestedthat HA forrned a meshworkaroutrclthe
cells u'hich was anchoredto their HA receptors
(77).
a n d t h e M W o f t h e e x o s e n o u sH A a c l c l e d
therebvreducin-s
the et'fectiveinteractionbetu'een
S t i r n u l a t i oon1 ' H As y n t h e s irs' , , apsl o d u c e db y H A s
the radicalgeneratin-s
speciesand the cell mcnr$ i t h M W s > 0 . - 5 X 1 0 ( 'D a a t c o n c e n t r a t i o nbse brane.Sirnilar conclusiorrsvu'ereleachedb1' Totueen l0 pgllnl and -100pg/ntl-. Hou'ever.lower
betto et al (tl6). who desclibecla colrclationbeMW-HA preparations
had n'rinirrialeltèct. ercept
tween inl.ribitionof ueutrophilrnediatecl
cartilage
at highconcentration
wsh e n i n h i b i t i o no f H A s v n damageand HA MW and conccntrationin vitro
t h e s i sw a s o b s e n ' e dA. n i n t r i g L r i ntgi n d i n gi n t h i s
(Fig 3). An HA plepalntionr,"ithan avera-se
MW
stucll'lvaq that the cell responseappealeclto deof 0.92 X 106Da was rnoreetI-ectilethan a lower
creaser.l'henHAs clf MW >3 X l0"-rl X l0'- Da
M W - H A ( 0 . 1 1x 1 0 6D a ) a g a i n srtn i t o g e n - i n c | - r c e c i were used.The authorshy'pothesized
that llA svnG
i[ïffi
18
thesiswas mediateclby interacticlnof this GAG
with surfacereceptors
on thesetibroblasts
thatonly
promoteda si-rnalfol incleasecl
synthesisby bindin-cto HA within a ccrtain molecularsize range
(see the sectionon HA receptorsfbr further disc u s s i o no f t h i s p o i n t ) .
Theseclatasuggestthat synoviiillype B cclls.the
major sourceof svnovialHA. ntay be capablcof
sensingtheir extlaccllularHA environnrentancl
translatingsuchinfbrmationinto the expressionof
gencs.rvhichleirdto the de novctsynthcsisof HA.
This processrequiresactivationof the enzvrncHA
svnthase.which is locatedat the inncr sulfaceof
thc plasmamernbrane(89).
O t h e r s t u d i se u ' i t h s v n o v i a l fi b r ' o b l a s t h
sur..
shown that the releascof arachiclrniclcitl lnrl
production
i n. t P G E . )f n r n t p l . r o s
c l fp r o s t a r l u n c l E
p h o l i p i d sb 1 ' e c l L r i (n9c0 ) a n csl t i n r u l a t ehcLl r n l r nO . \
c e l l s u ' a s i n h i b i t e cbl l t h c p r e s e n c o
el ' e r o s e n o u s
HA. the eflbct again bein-rclepenclent
on its conc e n t r a t i o na n c lM W ( 9 1 . 9 2 ) .H i g h M W - H A ( 2 ^
10" Da) was the most potentpl'eparation
but HAs
w i t h M W b e r w e e n0 . 2 8 x 1 0 " - 0 . 9 8X l 0 . D a a l s o
were active.particulallyat concentraticlns
between
1 . 0t r n d2 . 0 m g / m l .
Pelicellulartibrinoll'tic acti\ it\ ^ as tleterntinecl
b y a s s e s s r . n eo nl ' t h e l e r e l so f u P A { u r i n i r l rp J u s r n i n o - u canc t i v a t o r )p. l a s n t i n o r : ci n
t c t i v u t ( )i rn I t i t r i t o r - 1 . a n c lL t - P A R( u r i n a r r l t l a s n t i n o u cinr e l l \ l r t o t '
receptof)secretecl
in cultule br hr.rrlanO.\ srnov i a l f i b l o b l a s t sw. a s i n h i b i t e cbl r t h e p r e r e n c eo f
H A w i t h a n r e a nM W o f 0 . 9 x l 0 " D a ( t ) - l t .T h i s
efTèctrlay have been ruecliated
h1' thc inltibitoly
cf-fects
of HA on PGE. prociuction(93). Hor',cvcr.
becauseHA also sLrppl'esses
the prodLrctionof
lL-lB by svnor.'iirlcells by acting on thc CD:l-l
r e c e p t o r( 9 2 ) . a r e d u c t i o ni n t h e a c t i r i t v o f t h i s
c y t o k i n ec a n n o tb e e x c l u d e d .[ L - l B L r p r c g L r l a t c s
fibrinolyticactivitl'nsindicatedby increasecl
u-PA
and t-PA expression
by chondrocytes
anclslnovial
fibroblasts(9,1).Fibrin depositionis a conin.rorr
fèatureof SF derivedfrom rheurnatoid
arthritisand
O A j o i n t s( 9 - 5 ) .
When synovial fibroblastsfiom human OA
joints wereculturedin the presence
of HA of MW
of 0.9 x 10ôDa. secretionof uPA anclits inhibiror
plasminogenactivatorinhibitor-1were decreased
over a 48-hourperiod (93). This findin-cwils consistentwith a plevit'rusOA study fiom the sarre
group using HA of the sameMW. which showecl
that the declineirr theseSF tàctorscorrelatedwith
a decreasein patientsymptoms2 weeks after lA
administlation(96). Theseresultscontrastedwith
sirnilarin vitro studiesthatevaluatedHAs of MWs
o f I x l 0 ô D a . 0 . 5 x 1 0 6 a. n d0 . 0 6 - x5 l 0 ( ' D a o n
thc cxprcssionof proinflarnmatorycytokine ancl
chenrokinernessa-ge
b1' chonclrocyte
anclsynol'ial
librclblastsll'onr OA .joinls.wl.rereno ef1èctwas
s h o w n( 9 7 ) .
EFFECTS
O F H A O N C H O N D R O C Y T EASN D
ARTICULAR
CARTILAGE
IN VITRO
A d u l t r a b b i tu f t i c u l a fc h o n c l r o c v t ecsu l t u r e di n
the plescrtcco1'a rcconrbirtant
hurran intelleukin
l l h l l t - l p a n c lH A o f N l \ \ ' b e t w e e n0 . 5 X l 0 ô
D a - 1 . 0x l 0 ( ' D a r l e r c c a p a b l co l ' i n h i b i t i n gP G E ,
protlr.rction
ir.t it concentrationnrilnncr'.however.
tlrc hi-gherMW preparations
uere the rnoreactive
(9E). The rhlL- I B induceclproductionof superoxide anionfiee radicalby bovinechondrocvtes
also
was miti-uated
by HA of MW 0.8 x 106Da (99).
confirmingthat HA fiactions with MW < 1.0 x
106Da are capableof rr.roclulating
the responseof
articularchondrclcytes
to inflammiitolymediators
i n v i t r o .T h i s a n t i c y t o k i naec t i v i t yo f H A a l s ow a s
s h o u ' nu ' i t h f c s p c c t o t h c l h l L - l B o r t u n t o rn e c l o sis luctor-rr nrecliatecl
releaseo1' protco-ult,cans
t i o n r t h e ù \ t l i l c c l l u l i u ' r l l t r i r o f i r n n i a t L r rrea b b i t
c l t o t t t l t r r e r t et :l ( ) ( ) ) u n t l b o r i r t c c r p l a n t c u l t u r e s
t l 0 l t . . \ l t l r o u g ht h e l en a sa n r a r k e cdle p e n d e n coyf
t h i si n h i b i t i o n( ) nt h L r- ' c s p e - c t iHv A
c concentrations
Lrsccl.
HAs ri ith \l\\ s rr ithin the ran-ccof 0.3 X 106
D a - 1 . 9 r l 0 ( ' I ) a a l l c x h i b i t e ds i m i l a r a c t i v i t y
( l 0 l ) . T h i s f i n d i n - sc o n t r a s t e w
d ith the studyof
K i k u c h i a n d S h i r n m e i( 1 0 2 ) w h o r e p o r t e dt h a t
culturin-eyoun-rrabbitarticularchondrocytes
with
HA of 0.3 X 106Da clecreasecl
proteoglycansvnthesis'nvhilepreparations
with MWs > 0.8 X 106
Da stirnulatecl
it. Moreover'.the releaseo1'pnlteoglycansfnrrn the nratlixin the presence
or absence
o f I L - l B a l s r )u ' a sc l i n t i n i s h ebcvl c o c u l t u r i n -wui t h
the high MW prepalationsbut not with the low
MW species.In a str-rd1'
on proteoglycansynthesis
in bclr.'ine
articLrlarcartilageexplantsin the presenceand absenceof IL- 1B.it wasreportedthat HA
penetrirtecl
the cartilageand iiccumulatedin the
pericellularmatrix of chondrocytes
therebyrnaint a i n i n gs y n t h e s i sw. h i c h w a s s u p p r e s s ebdy f L - l B
in the absenceof HA (103). Evidenceto support
this finding was providedby a study that showed
that a HA fiaction with an MW of 0.8 x l0ô Da
enhanceclprolifèrationand matrix synthesisby
I N T R A . A R T I C U L AH
immaturerabbitchondrocytes
culturedin collagen
gels ( 10.1).Similar lindings were reported fbr
equine chondrocytesand cartila-eeexplantscultured in the presenceof HA ( 105).
The turnoverof componentsof the cxtracellLrliir
matrixof cartilageis largelydeterminedby thc fine
balancebetweenthe activit,vof rnatrixrnetalloproteinases(MMPs anclthe a-ggrecanilses)
anclthcir'
r e s p e c t i v ei n h i b i t o r s( T I M P - 1 . - 2 . - 3 . - - 1 )( 1 0 6 1 0 9 ) .E x p o s u r eo f I L - l a s t i m u l a t e b
d c l v i n ec h o n x
HAs
rvith
MWs
of
drocytesto
0.-5 l0('. 1.0 x
x
lOn and 2.0
l0' Da haclminirnaletfect on tl.rtproductionof str'omehsin(N'lN'lP-3)
bLrtproclucecl
a markeclconcentrationancl N,IW-dcpcnrlcnt
cnh a n c e m e notf T I M P - I r e l e a s e
o n c e l l sc u l t u r e df i r r '
2 - t ld a y s( l l 0 ) ( F i - g- 1 ) I. n a s u b s e c l r . rset nu td rt I | | t .
ex vivo culture evicience\\ u\ pro\ idctl thlrt I..\
t l . r e r a p yu'i t h H A ( o 1 'N 1 \ \ ' o t ' 0 . 8 r 1 0 " D l t
attenuatecl
nitlic oricle raclicalnreclirtc'rl
cl.rontlrt,cvte apoptosisin a rahbit nroclelof OA.
Recentlvit vuasreported( I l 2) thatthe anti Fasinducedapoptosisof culturedhumanchondrocytes
was reclucedu'l.renthey were culturedin the prescnceof HA with ar.rMW of 0.5 x 106-0.73x 106
Da. In this stutly,the anti-apoptotic
effèct of HA
was signilicantlyclecreased
by the adclitiono1'both
a n t i - C D : 1 a4 n d a n t i - I C A M - l t o t h e c L r l t u r e sT.h c
c o m b i n a t i o no f t h e 2 a n t i b o c l i chsa t l a n u r l d i t i r e
inhibitolv effect. Thesc clata suggesteilthut thc
a n t i - a p o p t o ta
i cc t i \ i t ) ' o f H . \ r i u s n r c r l i l r t etr' lr r i t '
b i n d i n gt o s p e c i l i cc e l l u l a rr e c c p t o r sT. u o t r t h e r
HAs n'ith difterent\'IWs also ucrc cxarrincclbr
( I l2). Significantly'.
theseinvestigatofs
HA of Nl\\'
-0.06 x 10(' Da did not reduce the anti-Fasinduced apoptosisof chondrocytesuhilc H,\ ol
h i g h e rM W ( 1 . 0 X 1 0 6D a ) w i r sl e s se t Ï e c t i r et h a n
H A w i t h a n M W o f 0 . 5 X 1 0 . - 0 . 7 3X l 0 " D a .
The known stirnulatoryaction of tlbroncctin
frargments
on the enhancedreleaseol' proteoglyc a n s f i o m b o v i n e c a l t i l a g ei n c u l t u r e( l 1 3 ) w a s
abrogatedin the presenceof HA of MW of 0.8 x
1 0 6D a ( 1 1 ; l ) .E x p l a n t so f h u n t a na n k l e o r k n e e
joint cartikigeswere used in these latter expenrnentswith HA cultureconcentration
of 1.0mg/rnL
maintainedover 20 days. Proteo-elycan
levels rn
the tissueswerepreservedby enhancement
of therr
synthesisalthclughaggrecrnaseactirity \\'ils not
completelysuppressed.
It was proposeclthat the
prcltectiverole of HA undertheseconditionswas
achievedby its blockadeof fibronectinentry into
cartilageandthuscontactwith chondrocytes.
How-
50
f
40
30
20
o
E
o
o
E
10
o
,_-,..,K_
1250 r.'--
TIMP-1
1000
o
750
500
=
F
250
0
Exposure time (days)
Fig 4. Effects of HAs of different MW on the
p r o d u c t i o no f s t r o m e l y s i n( M M P - 3 )a n d t i s s u e
TIMP-1)
i n h i b i t o ro f m a t r i x m e t a l l o p r o t e i n a s e -( 1
b
o
v
i
n
ea r t i c i n c u l t u r e so f l L - l a l p h a s t i m u l a t e d
(
n
(
ular chondrocytes. ) Control+ lL-1a, ) HAM W = 0 . 5 x 1 0 6D a ,( r . ) H A - M W= 1 . 0 x 1 0 6D a ,
( f ) H A - M W 2 . 0 x 1 0 6D a , ( m ) C o n t r o l - l l - 1 o .
T h e s e s t u d i e ss h o w e d t h a t w h i l e n o n e o f t h e
HA preparationsreducedstromelysinactivity in
lL-1 stimulated cultures of chondrocytes and
m a y h a v es l i g h t l yi n c r e a s e dM M P - 3l e v e l s ,T I M P
p r o d u c t i o n w a s m a r k e d l y e n h a n c e d ,p a r t i c u larly by the HAs with the higher MWs. lt was
suggested that the net result of these effects
w o u l d b e a r e d u c t i o ni n c a r t i l a g ec a t a b o l i s mi n
t h e p r e s e n c eo f t h e h i g h M W H A s . * P < . 0 5 ,
* * P < . 0 1 ,* x * P < . 0 0 1 M
. o d i f i e df r o m Y a s u ie t a l
( 11 0 ) .
ever. the stimulatoryeffèctsof HA on proteo-ulyto be via an inclependent
can synthesisappearecl
mechanism.
IN VIVOEFFECTS
OF HA IN
ANIMALMODELS
EffeÛ.so.fHA irr
Artttlgesic
urtd Artti-itt.fluntntutort
AttitrtulMrrlcl.s
The HA rnodulates
acuteand chronicinflammamodelsand
tion in a doselelatedmannerin anin.ral
to be relatedto its
this ef-fecthasbeenhypothesized
rrodulation of the early stagesof the immune
p r o c e s s( l l 5 , l 1 6 ) . l n t h e s t u d yb y I a i e n t ia n d D i
Rosa (l l5), adjuvantarthritisin the rat was suppressecl
by usingHA of MW of 0.5 x 106-0.73^
20
l 0 ( ' D a w h e n i t w a s - e i v e ns u b c u t a n e o u s l rB, .e c a u s e
thc ntt AA rnodel is cl'iven bv T-lvnrphocyte acti
vatit'rr.r.tl'rc investigators sLlggesteclthat HA nas
r n o d u l a t i n gt h e c a r l v s t a g e so l i n r n t u n ep t ' o c c s s i n - u
( c e l l u l a r a n t i g e n p r e s e n t a t i o lat n d / o l r e c o g n i t i o n ) .
T h c a n a l - u e s i ce l l ' c c t s o f H A l r a s b e e n i n r e s r i g a t e c li n I a n i m a l n r o d e l s o 1 'p a i n . t h c a c c t i c a c i c l
r , v r i t h i n gt e s t m o d e l ( I l 7 ) a n d t h e b l l c l v k i n r n ( B K )
l e t r o s l a d e I A a d r n i n i s t r a t i o nn t o c l eI t I 1 7 .I l 8 t . A
H A p r c p a r a t i o nu ' i t h a n M W o f 0 . 1 J 6X l 0 ( ' l ) a n ' a s
e t f e c t i v e i n l e d u c i n g t h c h v p e r a l g c s i ai n d u c e c lb \ ,
both these nrcthods tbr up to 7l lrouls ultcrr it r,i,as
l u s c d o r , e r t h e c o n c c n t r a t i o n r a n s e o 1 ' 1 . 5 -1 0 . 0
r n g / n r l -l A ( l l 7 ) . I t u a s n o t c d t h a t o t h c l p o l v s a c charicles( rrethr'Ice-lI Lrloseanclchonclr'oiti
n polvs ull a t e ) u ' i t h s i n i r l a r v i s c o s i t l o r p o l v a n i o n i cc h a r a c t e r i s t i c s t o H A e x h i b i t e c ln o a n a l c e s i ca c t i \ , i t l i n
t h e s c p a i n n r o d e l su ' h e n u s e d a t t h e s a r n ed o : c s .
I n t h c e a r l v s t u d y ( l 1 7 . t .t h e i n v e\ t i g u t o l ' \ s r . l g
g c s t e d t h a t t h e a n a l g e s i ce l ï e c t o l ' H . \ u a s r n c t l i
a t e d b y i t s a b i l i t v t o b i n c l p a i l t p r . o d uier ) r p e[ r r i t i c s
o r p r e V e n tt h c i r i n t e | a c t i 0 n $ i t l t t h c i I P l r i t rr . ' . t ' l r
t o r s . H o u c Y e r ' .t h i s e r l t i i - l n a t i o n\ \ i t \ l i i t ù l | c r i : c t l
( | l 8 ) * ' h c n t h c a n a l g e s iùct 1 e c to\ 1 ' H . \ :u i t h \ l \ \ .
o l ' 0 . 0 - 1x l 0 ( ' . 0 . 3 1 x 1 0 " . 0 . i { ( r ^ . 1 0 " . l n t l l . . l r
l 0 " D a \ \ ' e r ec o n t p a r e ctl t r c r a l u a t r n - ltrl t c r i a l k i t r g
behavior of rats aclntinistefeclIA IlK. This stucll
shou'edtlrat HAs u,ith MWs o1'0.u6 x l0'' and
2.3 x l0t' Da had alnrost iclentical potcncr ancl
duration o1' ac1ic'rnin tlris rnodel. n hclr.us H.\
t t l i - u o s a c c h a r i c lc o
s n t a i n i n g 6 - f i n r o n o s u s l r lr r r r i l :
a n t a g o n i z e dt h e a n a l g e s i ap r o c l L r c c lrrl r t h e h i , ' l r c t '
M W H A s . N I o r c - o v e rt' h. c a n u l s c s i er . l ' l c e to 1 H . . \
\ \ ' a sn o t p r e v e n t e ( b
l t p r i o r u ( l n l l ) i \ t l i - r t i ( )on1 u l l K
a n t a - u o r t i s1to t h c a n i r , t r l s i n r - l ruet r n c t h a l H . \ u u s
n o t s i n r p l v b l o c k i n g t h e B K r c c e p t o r .T h c s c l i n c l
i n g s s u g - u e s t etdh a t H A w a s s o r l r c h o n i n l l L r e
ncinS
p a i n t l a n s r r i s s i o ni n t h i s a n i n t a l n t o d e l b r i n t c t a c t ing nith CD.i.l receptors irncl possiblt otltel' parn
GHOSH
A N DG U I D O L I N
[:/|ccts rll HA in Artitrtul Mtilel.s o/'OA
l n t h e a n t e r i o r c n r c i a t e l i . u a r n e n tt r a n s ec t r t r n
( A C L T ) O A n r o d e l i n t h c c l o - u(.r r v e e k l r l A i n j c c lions of HA of M\\' 0.5 X 10"-0.73 r l0'- Da.
u'hcn gircn cithcr I vn'eeo
k r l 0 u ' e e k sa l ' t e li n c l u c i n g t h c c x p e l i n r e n t a lO A . u e r e f e p o r t e dt o l e d u c c
o s t e o p h Y t e \a n c lo t h e r p a t h o l o g i cc h a n g e si n c a | t i l a s c . s l n o r i a l r n c n r b r a n ea
. n c l n r e n i s c i( l l 0 . I l I ) .
RcrlLrcccl
oteoglvciln
cie-uraclat
ion anclertractibi | l)f
i t r t o s e t h e r u i t h i n r p l o v e c lb i o c h e r l i c r L al n r l h i s t o nrorphonretric scores o1 caflilage clanragc also
\ \ ' e r e n o t e d i n t h e H A - t r e a t e d a n i n r a l s .A d c l i t i o n alll'. it \\'as su.g-gested
1l'onr the rrorphologic data
t h a t . a t i e r I A H A t r e a t n r e n t .c c l l s o 1 'c l e s t a h i l i z e d
j o i n t s u ' e r e r r ( ) r e \ i a b l e a n c l n r c t u b o l i c u l l t a c t i re
a n d t h a t t h i s e f 1 è c tu ' a s n r a i n t a i n c r l i l ' n t o t ' ct h l L nJ
l r l o n t h sp o s t t | c u t n r e n(t l 2 l r .
\ \ ' c n z c t a l t l l l t a l s o u s c ' ttlh e . \ C ' [ - l ' c a n i n eO A
t t t o r l c l l r t t t : t L r t l i c t lt l t c c h a n s e : i n r l L r c c di n p a t e l l a
! i t l ' t i ] i l g ù \. 1 .( r . t t r t t l l l I l l g l t t l l : l l l t c t s u r ' - 9 C r A
t.tlt1 1 1 ; 1\ 1\ c: | c u t l n r i r r i : t c rt l- e5 \ ec k l r I A p l a c e b ( )o r
o 5
Il \ r\l\\
10"0.'.1
10"Da) injcctions.
e( ) n ) n r ù nl!l r - ! l ( ) r r c c k : i r t t i r | t s a c r i t i c e . H i s t o p l t h o l o u i e i L n r lc l ù a t f ( ) l lt r . l n . l n l s r i o l t t t t i e t ' o s e t t p r ,
\ t u d i c \ : h o s e t l t h u t - i u c c k l r i i t . j r . c t i o nosf t h i s s i z u
H A d e l u re r l t h c l ) 1 1 ) ! l t ' c \ \ r ( ) o
r 'ft d e g e n e r a l i cr
c h a r r . e eisn t h e p a t e l l a l c a r t i l a s c .
I n a n o t l r e rs. t u d r , u s i n - ut h e a r l u l t c a n i n e A C [ - T
n r o d e l .S n r i t hc t a l ( 1 2 3 . 1 2 - 1i n) i e c t e dt h e u n s r a b l c
j o i n t n ' i t l t c i t h e r s a l i n eo r H A r , i t h a n M W o 1 '1. 5 u
1 0 " 1 ; , , I d u r a l t e r \ L l r g e r va n d a t u ' e e k l t ' i n t c - r r u l :
t h c l c l r l t c r - l o l r t o t u l t r l - r r n . i e c t i o n sT.h e a n i t l a l s
-['he
n el e k i l l c t l I I r r c c k ' a l i er , \ C l - t r a n s c c t i o n .
r L ' \ u l l \ o l t h c s c c r p r ' r ' i r r r e r r t rl c - t l S n t i t h e t a l
t Ili.Illt
t o c o n c l u t l ct h l i t u r l r n i n i s t l u t i oor rl t h i s
s i z c H . \ p l c p a r . u t i r r ni r r t o t l t t O , \ . j o i n t s h a c l n o
c t l e c t o n t l . t c r o l u r r r c . e o n c e n t t ' a t i o no. r M W o 1 '
e n r l o s c n o u s H A p t ' c s e n ti n S F . F o c a l u l c e r a t r t r n
a n d u t l . j u c c nht r p c r l r r r p h l o 1 ' a r t i c u l acl a r t i l a g eu ' i t h
producin-upathu'a),sthat are presently unknou n.
T h r o u g h a n e l e c t l o p h r s i o l o g i ct c c h n r q u eo f l s -
o s t e o p h r ' t o s i sr t t h e . i o i n t t . r . l i r ' - u i \n\sc t ' e er ) n t n t o l t
p a t h o l o s i c o b s c r r a t i o n s i n t h e A C I - T ' . j o i n t s .A l -
s e s s i n -er rx p e f i m en t a l p a i n i n a n i n t r l s . S h i m a z a k ic t
a l ( l l 9 t s h o u . ' e ct h
l a t I 0 . t 1 6 X 1 0 " D a l l ' a c r i o no 1 '
t h o L r g ht h e -e x t e n l o f ' o s l e o p h y t o s i sa n d s v n o v i t i s
\\'ùrc not leduced bv thc HA treatltlellt. cartilagr.
HA afkrrded an anal-lesic etÈct. Although no receptor studies lvele undertaken bv these inr.estiqa-
hvpertlophv as incliciitedbv prote-oglrcanler,'clsirr
t h c t i s s u e s u a s d e c r e a s e d .O n t h e b a s i s < t f t h e i r '
l i n d i n g s . S m i t h e t a l ( 1 2 3 . 1 2 . 1s) u - u g e s t etchl a t t h e
tors. thev suggestedthat HA inhibited thc interaction betu'een BK and its receptor locatccl at the
nerve endin-ssand concluciedthat HA possiblv acts
as a rnoclulatorof thc neurophl,siolngic condition
o 1 't h c j o i n t .
analgesic cllèct contèl'r'eclb1, HA administration
a l l o u ' e d a n i r n a l st o b c a r r n o r e u ' e i g h t o n t h e u n s t a ble.joint.
M a r s h a l l e t a l ( 1 2 5 ) u s c c 'al r t h r o s c o p vt o t r a n s e c t
INTRA-ARTICULA
HR
YALURONAN
1.0
the ACL bilaterally ancl unclertakepartial neLlrectomv in adult nron-rreldo-gs.Anirnals were aclntrni s t e r e d3 w ' e e k l v I A H v l a n G - F 2 0 ( a m i x t u l e o f
chernicalll' cross-linketl HA and HA isolateclfrorn
cock's cornbs) with MWs in the orclcr of 6 ..
l 0 ' - 2 3 . 0 X l 0 o D a o r s a l i n c i n . j e c t i o n sf w e e k s o r
I months afier surgerv. All -rroups were killecl 6
rnonths latel and joint tissuc clarlase u,us assessecl
b . , ' u s i n g a s t a n d a r dl n e t h o d o t h i s t o l o g i c s c o l i n g .
T h e a n i m a l s t h a t r e c e i v c dt h e l a t c t l e a t n t e n tL - l r l a n
protocol hacl si-enificanllv less se',cre f)A cont
parecl with the plucebo or earlv HA treutrlent
groLrps.
An importlLnt stu(lv on the ct'tects ot rlil'fcrcnt
M W - H A s o r 1 s v n o \ i t l c h a n - s e sr n t h c , \ ( ' l - r l e t i 'fhc
c i e n t c l o g w a s u n c l e r t a k c nb v A s u r i c t l l l l l ( r r
5 w e c k l v I A i n . j e c t i o no
s f H A r . ' , i t h\ ' 1 \ \ s o t l ) . N + ^
1 0 " D a o r 1 . 3 x 1 0 " D u r r e r e u c l r l i n i s t c l c t iI n t o n t l t
a t i e r s t t r g e r - r 'c. x c c l t t d u l i n g t h e l u s t r r e c k n h c n
s i z e e c l u i ra l e n t l l u o r e s ec ' i n - l u h e lrel H . \ p r c p r i r l
t i o n s t e l c u s c r l t o t l et r - r r l i n e t h c c \ t e n t ( ) l l ) ù n c 'fhc
t r a t i o n ( ) f t h e c l i f t è r c n tH . . \ s i n r o t h e s r r t o ri u n t .
S F s v u ' e r ea n u l rz e c l f i r l r o l u n t c l L n c P
l (iE- colttent
r . r h i l et h e s v n o r i a * e r e c r a n t i n e d f b r c c l l p r o l i t e r ' r u t r o nr. a c u o l a r r l e g e n e r a t i o nH. A c l i s t r i b u t i o ni.L n c l
l r e a t s h o c k p l o t e i n ( H s p 7 2 ) e r p l e s s i o n .C l e a t 'd i l lercnces \\,ere noted betrveen the eftects of the l
H A p r e p a r a t i o n su s e c l T
. h e s m a l l e r0 . 8 + x 1 0 " D l
H A p r e p a r a t i o l t\ \ i r s l l t o r e p o t c r ) t i r t l c r l u c i n q r r r f l a r n m i i t o r yc h a n g e si n t h c . r n o r r L r r n p. l r t i e u l i r l l \
l v i t h l e g a r c l t o r l a i n t u i n i n s t h ù l i h u n ( i l r r e el r l r t l
r n t e n s i t l "o i H s 1 t 7 l . r r h i c h r s l r p r ( ) t c i r )r ) t ; r r k c r, ' l
c e l l r i a b i l i n . S i g n i l i c a r r t l \ ,t .h e \ t f o n s c r l n r i i i r '
t h r i t i c a c t i v i t y n o t e c lt b r t h e l o w e r N I W - H A r c . l a tive to the hi-ch N'lW analo-9uecorrelateclu ith the
e x t e n t o f i t s p e n e t r a t i o ni n t o t h e s y n o r , i u n t .
'fhe
e n h a n c e cp
l e n e t r a t i o no f t h e s n t a l l e r : i z c t l
HA through the syncx,ialtissues.observedbr ,\s;.rli
c t a l ( 1 2 6 ) . w a s c o n s i s t e n tr v i t h t h e s t u c l i e su h i c h
e n r a n a t e df i o r r t h e L e v i c k - s r o u p ( 8 . 1 0 .I 2 7 . I l S )
which showed that trans-synor,'ialflor', und llou
buffèring by svnovial HA in rabbit .joinrs * as
d e p e n d e n to n i t s c h a i n l e n g t h ( F i g . 5 1 .f h e n r o r e r n e n t o f H A a c r c s st h e s v n o r , ' i ailn t i n t a o f t h e . j o i n t
rvould appear. in rabbits at leâst. to be lintitcd bv
the presencein this tissue of a graclicntof sulf'atccl
G A G s a n c lc o l l a g e n s( 1 2 9 ,I 3 0 ) . T h e s em a t r i x c o m ponents r.vouldbe expected to restrict the clitïusion
o f n r a c r o m o l e c u l e ss.u c h a s H A t h r o u g h t h e t i s s u e .
a s a f u n c t i o n o f t h e i r c h a l g e a n d s i z e .a l t h o L r g ht h i s
may be an oversirnplitjcation of a cornplex rela-
21
Iil
0.8
.9
()
(!
at)
'-o
o
o
(J
0.2
0.1
o5
'-l
90
) 80"/"
ll:li:iilalir:i
l
r,,:.1
l.::l:,]:.1'
l..rl:litl:t,:rl
K
l..l,,,l:l...1
ti
530
2O"/o
2200
H A m o l e c u l a rw e i g h t( k D a )
F i g 5 . R e l a t i o n s h i pb e t w e e nH A m o l e c u l a rs i z e
and trans-synovialflow as describedby Coleman
etal (127l..Note that the crossingfraction for HA
with averageMWs of 530 kDa was approximatefy 75%, whereas with HA of MW 2200 kDa
i t w a s a p p r o x i m a t e l y2 0 % . T h eg r e a t e rp e n e t r a t i o n o f t h e l o w e r M W - H A s p e c i e st h r o u g h s y n o v i a l t i s s u e c o u l d e x p l a i nt h e h i g h e r a c t i v i t y o f
t h e s e p r e p a r a t i o n si n a n i m a l m o d e l s o f O A .
t i o n s h i p .N e r e r t h e l c s s c. l c p l e t i o no f C . A G s a n c lH A
frorn the svnovilrm by digestion riith hvaluronid a s e i n c r e a s e ctl h e h y ' d r a L r l i cp c l n r r ' l i b i l i n o t ' t h c
t i s s u e st l 3 | t . s u p p o r t i n . u
t h e i i u s s r g n c rrl o l e a s p a r t
-fhc
r r t l r l i f f L r s i o nh u r l i c r ' .
Scott et ltl t l.l I ) studr
r ' r r r r l tbl e o l r c l c r l r n ee i n . j o i n l u t - t l t r - o p u t h r se us c. h a s
( ) . \ . u h c r - ci n e t c l r s c t ln t t i t r r e a t a b o l i s n tc o u p l e c l
u i t h t i r n t i n i : h c t l H . - \ r l r r i c er r l u r s i z e r v o u l c l- g r e a t l )
c n h l i n e er t s e \ r t l r o n t t l t e . j o r n tc a v i t v w h i l e c o n ù ( ) n ) l t a n t l \i n el c L r s i n st h e e n t r y o f l a r g e M W p r o tcrn: ll'onr llla\ilra. The structural inter'-relation: h i p s b e t u e e n t h c s c j o i n t c o r n p a r t n t c n t s .t h e i r
r c s p e c t l V em a t n x c o m p o n e n t s a n d t h e r o u t e s o f
e x c h a n g c o f H A a n d o t h c f s o l u t e n t o l c c L r l c sb e t w e e n t h e n r i s s h o w n c l i a g r a n t n t a t i c a i li yn, F i g L r r e6 .
R a h b i t r n o c l e l so f O A h a v e b e e n i n r l L r c c cblv I A
i n . i e c t i o no f e n z v n r e s ( l . l l t . o r f i b r o n e c t i n f r a - u r n e n t s ( 1 3 3 ) . p a r t i a l n r e n i s c e c t o n i )(' 1 3 - 11. 3 5 ) . o r
A C L t l a n s e c t i o n( I - 1 6 -1 3 9 ) .A l l t h e s en t o d e l sh a v e
b e e n u s e dt o e v l l u a t e t h e a b i l i t y o f H A t < ti n l l u e n c e
ioint tissr-repatholo.lies aticr arthropathic induct i o n . M o s t o f t h e s e s t u c l i e sh a v c b e e n c o n c l u c t e d
rvith HA of MW =0.1J.1x l0" Da.
Fur the most part. these rabbit str-rdieshave
supported a beneficial ettect of this MW-HA with
respect trl rapidly pro-uressin,rdisease ancl have
proviclecleviclencethat one of the mechanislns of
F i g 6 . D i a g r a m m a t i cr e p r e s e n t a t i o no f t h e s y n o v i a lc o m p a r t m e n t ss h o w i n g t h e m a j o r m a t r i x c o m p o n e n t si n t h e i n t i m a a n d s u b i n t i m aw h i c h c o u l d i n f l u e n c ep a s s a g eo f H A m o l e c u l e sf r o m t h e s y n o v i a l
c a v i t y i n t o t h e c i r c u l a t i o nv i a t h e l y m p h a t i c s .N u t r i e n t a n d m e t a b o l i t ee x c h a n g eb e t w e e n c a r t i l a g e
a n d t h e s y n o v i u mi s f a c i l i t a t e db y H A . b u t l a r g eM W p l a s m ap r o t e i n sa r e n o r m a l l ye x c l u d e df r o m S F .
T h e e x t r a c e l l u l asr p a c es u r r o u n d i n gt h e s y n o v i a l i n i n g c e l l si s r i c h i n H A a n d p r o t e o g l y c a n sT. h e t y p e
B s y n o v i a lf i b r o b l a s t sa r e t h e m a j o r s o u r c eo f H A w h i l e t h e t y p e A c e l l sa r e s p e c i a l i z e d
macrophages.
See references18,10,127-130)
for further details.
actionof HA in protectin-u
cartilageis via the clown
regulation of pro-inflantntatorycytokines and
M M P a c t i ri,t i e si n t h e s v n o v i atli s s u e (sl l 9 ) . I n t h e
s t u c l i eos f K i k u c h i e t a l ( 1 3 : 1 )I. I A H A p r e p a r i i tionswitl.rMWs of 0.8 x 10" Da anclI .c.)x l0(' Da
\\"erecompal'eclin erpartial rneniscectontrntoclel
w h e na d r l i n i s t e r eactl c o n c e n t r a t i o o
n fs I . i o r l e: s .
A n i r n a l sw e r e s i v e n 2 H A o r s a l i n el A i nj e c t i o n s
pet'week imntediatell'after surgeryuntil sact'iliec
2 or zl weekslater.This short-termhistopatholouic
s t u d y 'i n d i c i i t e dt h a t t h e h i - s h e rM W - H A a t l 1 r
concentlationwas more el'fèctivein minirnizing
early cartilagede-gradation
than the lower MW
preparatlon.
In a seriesof pLrblications
fiorn the Antiel -troup
( 1 3 7 - 1 3 9 )u s i n g a r a b b i t O A m o d e l i n d u c e db y
unilateralACL transection.it was shou'nthat IA
adnrinistrationof HA u'ith an avera-seMW of
0.8.1 X 106 Da affbrdecllon-q-tel'ntprotective et-fects to .jointcartilage.possiblyby thc down re-ru l a t i o no f M M P - 3 a n d l l - l B a c t i v i t yi n s y n o v i u m
but not cartilage.A more recentstudy fiom thrs
group also reportedthat lA administered
HA suppressednitric oxide radical productionin syno-
v i u n r a n c lt h e m e n i s c o
i f . j o i n t si n t h c i r r a b b i tO A
rnodel:however.the influenceof HA molecular
s i z e o n t h e s et i s s u ec h a n g e s\ \ r l \ n o t i n v e s t i g e t e d
( l.+0).
Hou'er,er'.
in an earliershort-termstLrdy( 1.1I ). .1
diftelent HA preparationswcrc exantineclin the
. \ C l - T r u b b i tO A n r o t l c rl i h c r et h e l ' u e r e . l i . , e nl b r
. 5r i e c k s .c o n t n r e n c i r .I rnot o n t ha l i c r O A i n c l u c t i o n .
. \ t s a c l i l i c r -I u c c k l f t c r t h c ' l a s t H A i n j e c t i o n .
h i s t o n r o r p h o r n e t rai cn c l b i o c h e n t i c aal s s e s s m e n t
u u s n r a d eo f . j o i n t c u r t i l a g ca n c l s v n o v i u m rA. l thou.ehall HA prelrarations
affbrclecl
someprotection to cartilage.the'N,lWlbnnulationsn'ith MW >
0.8 X 106Da were nroreaffectivethan the lower
MW preparations.
Openiinclalthroscopicmeniscectttmies
arecommon orthopedicprocedures
that are f}equentlyaccompaniedby prernaturecartilage degeneration
and the onsetof OA irrespectiveof the amountof
rneniscnsexcised(142-116).Tissuedegeneration
and the onsetof OA is thou-shtto arisefiom the
hi-chfbcal and shearingstresses
imposedon artlcular cartilage and subchondralbone causedby
excisionof the weight-bearing
rleniscus(1.17-150).
INTRA-ARTICULA
HR
YALURONAN
L.rthis respect.the OA resultin-u
fnrm rneniscectorr.ry lected by aspirationfionr joints of both -sroups
is seconclary.
befbreeachinjectionand fiom all ainirnals
5 weeks
j
u
s
l
Meniscectorny
in adultsheepincluccs
patholo-uic
i r l - l el Ih e l l r s li r r j c e t i o n p I i r r r ' t (p) ( ) s t n r ( ) r ' t e n ) .
changesin their stiflejoints. which parallelthose
The MW of the HA in the SFs collectedwas
d e s c r i b efdb r h u m i i nO A j o i n t s( 1 . 5l - l - 5 9 )B
. ccause
chromato-uraphy
cletermineclby -gel-permeation
o f t h c s es i m i l a r i t i eas n d t h e r e p r o d u c i b i l i tol 'f t h i s
coupled u'ith rnulti-angle Iaser-light scatterins
procedurein this anirnalrroclclit has beenextenphotomctrl,.Thc -uel-pcrmeaticln
chromatography
sively usedto investi-gate
currentanclnovel antistepallou,ecl
sepalationof the SF proteinsfl-omthe
a r t h r i t i ct h e r a p i e s( 1 5 6 1
. . 5 7I 6
. 0 -1 6 2t . T h e o l r n c
H A . f a c i l i t a t i n st h e u s e o f m u l t i - a n g l el a s e r - l i g h t
moclelof OA also has bccn useclto evaluatethe
scattelin-rfil' thc tlctcrntinationof its MW. The
ef'fectsof IA HA pfepafations
of ciif'felent
MW on
lcsults ol' this stuch showcdthat both HA prepagait. serum biochenricalmarkers.cartilâge.bone.
l u t i o n si n c r e a s ctdh c N , l Wo 1 ' e n d o - e e n o
HuAs i n S F
( I 6 3 -I 6 7) .
i i n d s y n o li a l t i s s u en t e t a b o l i s m
c o l l e c t e dl i o n r t h e O A j o i n t s b u t s a l i n ei n j e c t i o n s
In a stuclt'usit.t-g
the ovine OA ntoclclto inrcsrlicl not. \\'hen tlic ureanposttreatment
changein
t i - c i i t et h c r e l a t i v ec l i n i c r l . n t o l p h o l o e i ca. n r l h i o group
H,\-\l\\ tirr euch
\\'aserpressecl
as a perc h c r n i c a el f ' È c t so 1 'I d i l ' l è r c n tH A p r e p u n r t i ( ) n \ . e e n t l i s c h l i r r g lcl ' o n rt h c
b l s e l i n ev l l u e s .t h e
-uroup
a n i m a l su e r e - u i v e n. 5u c e k l r I A i n . j c c t i o nos1 ' H . \ s
H . \ p l c p l l r r t i o nu i t h \ l \ \ ' o 1 0 . 8 + X l 0 ' - D a w a s
\ \ i t h M W s o f 0 . 8 - 1x l 0 " D a o r ] . . 1x l 0 " D l , I l o t l r
ol-rrcrr
HA in
r'clto irtcrùu:ethe \l\\' of cnclo-renous
p r c p a r a t i o nisn r p r o v e ctlh t - c l i n i c l l s r c n s i n O . \
. j o i n tS F b 1 7 6 ' i . T h i s i n c r c a sicn M W u ' a ss t a t i s s h c c pa
. s c l e t e r n r i n ebcr l f o r c r -p l a t ea n u l r : i : I l ( r . jt .
ticullr cliflèrentto the nreanHA valuescletermined
H o r i ' e v e ri 'n. t h i s s t L r d rt'h. c i n t p l o r e cul c i c h t - b c a r ' lbr the physiologicbufferedsalineinjectedgroup
in.r on OA joints observeclin both HA-treatetl
(P : 0.03) (Fi_s7). This resultcontrastedwith the
-groupsuas associatedwith incleasedgross llorHA MW values obtainedfbr SF obtainedfrclnr
phologicalscoresin cartilageand enhancedosteoanimalswho recei"'edthe high MW HA preparaphyte developmentat the joint rrargins. It was
tion. u hclc an incrcaseclin N'lW of l6% was
proposedthat the increasedweight-bearing
on thc
o b s e ne d { F i g 7 ) .
joints afhrded by HA treatlnent
meniscectomized
\ l o r c r e c e n t l r t. h e o r i n e [ r i l a t e r al la t e r a n
l renrsw a s r e s p o n s i b lfeb r t h e i n c r e a s e o
c ls t c o p h r t cl i l ' pl r o t o c
c
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)
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ù
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()lt ll.rl.rL-11g-(l
rnation.Thc h i ghcr N'l\\'-H,\ prcparati
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g
e
s
i
n
r
h
c
olo-cit o p r o v o k e a g r e a t e rc a r t i l t s e h r p c r t r o p l t r er e priranr.-ters
cll
of
t'rlnr
in.jectccl
SF
u:piratu'cl
.joints
s p o n s ea s a s s e s s ebc1l 't h c n L r n t b eort c h o n d m c r t c
- 5 r r e c k ' ; r r e r i o u s l rr i i t h H A s o t ' N 4 W - 0 . - 5x
c l o n e sa n c lc h o n d r o c r t ep\ c r c l o n c ' t h a nt l ' r cI o u e r
1 0 " - 0 . 7 1X 1 0 " D a o l i . 0 X 1 0 " - 6 . 9X 1 0 " D a
MW-HA prepiu'ation.
Moreover.the biosvnthesrs
r5S-PGs
t
l 6 9 t . I n . j c c t i oonf t h c k r i ' r ' cM
r W HA significantll
of
by cartila-eeexplants clerir,eclfronr
(elasticity)and visinrprovecl
SF
storage
modulus
joints of animalsinjectedwith the hi-cherMW-HA
postinjection
cosity
significantly
more than sahne
was less than fbr thc corresponding
cartilagesof
prepalation.
or
the
lalger
MW
HA
animals who receivedthe lower MW analogue
Thesefindin-es
wereconsistentwith the studvof
(r 6 4 ) .
(
1
2
6
)
A
s
a
l
i
e
t
a
l
a n d s u g - u e s t et hda t I A a d r n i n r s I n a s u b s e q u e nstt u d y ( 1 6 8 ) .t h e o v i n e n t o c l e l
prepiirations
tration
of
HA
of MW ll'ithin the range
was usedto e."'alnate
the relativeetfectsof HAs of
x
x
of 0.5
1 0 6 - 1 . 0 1 0 6D a w e r e m o r e e f f e c t i v e
differentMW on the moleculalsizeof HA remarrrt h a n t h e l i i r - s e rH A s ( M W > 2 . 3 X 1 0 6 D a ) a t
ing in SF of OA joints 5 weeksafierterminationof
restorin-e
synovial fibroblasthonieostasis
and the
treatment.Animalsunderwentbilaterallateralrrreb i o s y n t h e s iosf H A . G i v e n t h a t t h i s a n a l y s i sw a s
niscectomyto indr.rce
OA and were then divided
undertaken
sonre5 weeksafterthe last IA injection
randomly into 2 equal-sizegroups. One -uroup
of theseagentsand that IA HA has a half-life of
received lA saline into I ioint and HA (MW
(20 hours. it is extremelyunlikely that the rn0 . 8 4 X 1 0 6D a l i n t o t h e e o n t r n l a t e rjaoli n t . o n c ei r
weekfbr 5 weeks.contmencingl6 weekspost-OA
creasein MW or rheologicalcharacteristics
obinduction.The other group were administerecl
servedwas due directlyto the presenceof residual
the
high MW-HA (MW - 2.3 x 106Da) fbllowing
exo-genous
HA in the joint. Moreover.the MW of
the sameexperimentalprotocol.The SF was colsmaller HAs used in theseexperimentswas less
24
3.0
t h e e a r l i e r o b s e r v a t i o n so l ' P u n z i e t a l ( l l l . l 7 ) )
uho repolteclclecreasecl
PGH. levels. fluid volurne.
t.5
u h i t e b l o o d c e l l c o u n t . P G E . . a n c li n c r e a s e ccl v c l i c
l d e n o s r n er n o n o p h o s p h a t lee r . ' e l si n k n e c S F o f O A
p a t i e n t st r e a t e d r " i t h a s i r n i l a r s i z e d ( 0 . 5 X l 0 ô 0.71 X l0ô Du) HA preparationF
. u r t h e r n t o r c i. n a
A'u
x2
a
o
v
=
E
l l - n r o n t h p l o s p c c t i v c r a n c l o r r i z e c lp l r c e b o - c o n t r o l l c - rtl r i a l . r h e l , \ H A ( t r t \ \ ' . . ( ) . - 5x l 0 b - 0 . 7 3 x
1 0 " D a ) a t l n r i n r s t c - r etdo s L r b . j e c twsi t h k n e e . j o r n t
e f ï u s i o n s { e o n s i r l c l c t lu s u r l a r k c r o f a f l a r e - L r po f
i t t f l a n r n r a t i o)n t r - r r o t l u e eu r sl i s n i l i c a n t r c r l u c t i o no f
the SF rolunrc lLeconrpanieb
r lv i n t p r o v c r l c n t i n
r.o
s v n r p t o n r s{ 1 7 - 3 ) .
F L r r t h c cl r i t l e n c eo f t h e c a p a c i t vo f H A t N l W 0 . 5 X 1 0 " - 0 . 7 . 1x 1 0 " l ) a ) t c t c o n t r o l . j o i n t i n f l a r l nution was ;rloridctl b1' a cvtologic ancl cvtoi l u o r i m e t l i cs t r . r do
v f t h e c e l l p o p u l a t i o n sp r e s e n tl n
thc SF of pltients lvith OA particlpating ill a
3.0
2.5
o
2.0
=
1.5
E
1.0
a
0.5
0.0
Week16
(baseline)
Week26
(post mortem)
Fig 7. Effectsof 5 weekly lA injectionsof HAs
o f M W 0 . 8 x 1 0 6D a ( - ) , M W 2 . 3 x 1 0 6D a ( - - - - )
o r p h y s i o l o g i c abl u f f e r e ds a l i n e( P B S )( i . ) o n t h e
MW of HA in SF of OA sheep joints before
treatment (week 16 post-surgery)and 5 weeks
after the last treatments {week 26) as determ i n e d b y l a s e rl i g h t s c a t t e r i n gp h o t o m e t r y .T h e
c l o s e d c i r c l e sc o r r e s p o n dt o i n d i v i d u a lH A - o r
P B S - t r e a t ejdo i n t s ( n = 5 f o r e a c hg r o u p ) .( A ) N o
s i g n i f i c a n tc h a n g e w a s o b s e r v e df o r t h e h i g h
g r o u p ,w h i c h w a s e q u i v a l e n t o
MW-HA-treated
P B S . ( B ) F o r t h e H A o f M W 0 . 8 x 1 0 6D a , t h e
m e a n c h a n g ef r o m b a s e l i n ew a s s i g n i f i c a n (t P =
.03).
t | r u b l e - b l i n d p l a c e b o - c o n t r o l l e ccll i n i c a l s t l l d v b v
( ' o r r r t k r e t a l ( 1 7 - l l .T h e H A - t r e a t e cpl r t i c n t \ h a d u
r l r ' c r ' ù l s ei n t h c r o l u r n c o f . j o i n t e f f u s i o n a n d t h e
l l L t r oo l P r ' ( ) t L ' i innst h e i r S F l e l u l i re t o t h e i f p l a s r n a
'fltc
t S l i iI ) r ' r i t i o t .
Ir'olcin\ thlrtshotetl the nrost
n r r L r k e ttii c . l i r r t i n e l L r . l c tpi rc i r l b r L n t i n(.l - l f r a c t i o n
r r l ! ( ) n r I l ù n r c n l . i r r r r n r u r o g l o l . r r l i ntsr .l r n s f è r ' r ' i n .
r r I - a n t i t r rI r r n . i c r L r l o p l a s r r r irnr .r r rri r - I g l r c o p r o t c i n . F o l t h c r r t o : t p a f t . t l t c \ c p r ' ( ) t e i n \a f e r t o t
p r o c l L r c eidn t h c . j o i n tea r i l r b u t n t u s tc l t t c r S F f r o n r
t h c p e r i p h e r n l b l o o t l r i a e l p i l l r L r i e si n t h e n t e n t b r i l n e .H e n c c . t h c i r c o n c c n l r u t r o ni n S F l c l l c c t s t h e
p e r n r e a h i l i t l r r l ' t h c ' r n o r i u l n r e n t b r a n c .w h i c h
i n c r e a s c -rsl L r r i n gi r r f l l n l n r a t i o n .A n i n c r e a s ei n t h e
S F / P r l t i o n l r . r \t h c r . c l i ) r cb e c o n s i d e r e cal r e l i t b l e
i n r l r er r t o r( ) t t h e \ c \ c l i t v o l ' s v n o r i a l i n l l a n t r n a t i o n .
( ' o r n r t l o c t r L i t l 7 - l ) u l s o r e p o r t e d a c l c c r e a s ei n
ec l i L r l l r i t r o l t h e S F ( l v h i t e b l o o c lc e l l s . n t o n o c l t e s .
l r r r p h o er t e s . P \ ' l N s ) a n c la s i g n i f i c a n tl e c l u c t t o ni n
lLetir utctl lr nrphocr"tesand tlonocvte-ntlcropl-ragc
p h c r r o n p c s i n t h e H A t r e a t e c lg r o u p e ( ) n t p a r c ctlt l
S F l l o n r t h e p l a c e b o eo n t f o l s .
thanthatobtainecl
tirr thc SF aspirated
fiorr the OA
.JOlnls.
L A B O R A T O RS
Y T U D I E SO N J O I N TT I S S U E S
S A M P L E DF R O M O A P A T I E N T S
A D M I N I S T E R EIDA H A
I nj e c t i o no f H A o f M W 0 . 8 x 1 0 1I' -. 2 x l ( ) ( 'D a
into symptomatic human ternporal nranclibular
j o i n t sp r o d u c e da s i g n i f i c a nrte c l u c t i oonf t h e t o t a l
amountof arachiclonic
acid rnetabolites
and c-v-tok i n e sp r e s e nitn S F ( 1 7 0 ) .T h i s f i n c l i n -cro n f i l n t c c l
R h e o l o g i c a le v a l u a t i o no f S F o b t a i n c c fl n t r t r O A
p a t i c n t s s u b . j e c t e ct lo u r t h r o c c l l t e s i so r 5 w e e k l y '
i n j e e t i o n so f H A o l \ 1 \ \ - 0 . . 5 ) < 1 0 6 - 0 . 7 - xl l 0 ô
D a u l s o h a s b e c n t l e s c r i b e d r | 7 5) . T h e r i s c o elasticitv of SF frorn thc HA treated groLlp was
incleaserlfcllrtive to their own prctreatnlentvirlues
ancl to SFs clerir,edtnrrn.joints of the lirthrocentesis-treateclpatients. Thesc data $'ere interpreted to
inclicate that lA adnrinistration HA of Nl\À' 0..i x
106-0.73 x l0ô Da irnprol'ecl cntlosenous
H A c o n c e n t r a t i o na n d N { W : h o w e i . e r .t h e s t u d r i s
I N T R AA R T I C U L A R
HYALURONAN
$'eakenecibrt the Iack of statistical analvsis of the
results.
Aclditional support firr a cell-rnodulating el'ltcr
o f l A H A ( M W - 0 . - 5x l 0 n - 0 . 7 3X l 0 ( ' D a ) u a s
provicled b1-'ntorphologic analy'sisof cartilage biopsv specimens taken befbre ancl 6 r.nonthsaftcr'
treatnrenl ol .10 patients sLrl'f!r'ingllorr.rgonalthros i s ( 1 7 6 ) .A r t h l o s c o p i c a n c lh i s t o l o - g i ca n a l rs i s u a s
per'fblmed undel blindecl conclilions and inclicatccl
that a si-tnificant recluction of articulal cartilasc
clarna_te.
sl'novial inllarnntalion. ancl a lestolatior-r
ot'thc linin-u cells' rrorphologl,,occurrecl6 rnonths
a f t e r t l e a t n r c n t( 1 7 6 ) . A d c l i t i o n a ls t L r c l i e(sl l 7 . 1 7 8 1
on the cartilage biopsy specintensshoried that HA
t r e a t n l e n t s i - u n i l i c a n t l fi n c l e a s c d t h e n u n t h c t ' o f
viable chondrocytes presenl. rech-rced
chonclrocrte.
c a t a b o l l c a c t i v i t i e s . a n d r e s t o r e c lt h e p e r i c c l l L r l u r '
ntatfix t() normality.
M o r c r e . c c n t l y 'P. a s c l u a l iR o n c h e t t i e t a l ( 1 7 9 )
clescribecla clctailedmorphologic anal!sis of svnor ial biopsr specintens frorn ltatients palticipating
in a larrclorlizeclclinical studl clesi.unecl
to compale
t h c .e f 1 è c t s( ) 1 ' H A ( 0 . 5 x l 0 b - 0 . 7 i x l 0 ( ' t ) l t ) û n d
n r r - t h v I p l e c l n i s o l o naec e t a t ei n t h e t r c a t n t e n to l ' l r l i nran ancl sccondarr knee OA. Svnovial biopsr
s p e c i n r c n sn , e r e c o l l c c t c c la t t h e t i n t e o l ' a r t h l o s -
-
copl bcfbrc ancl 6 months after either clf the IA
treatnrentsand vu'creeraminecl by' li-tht and electr()n lDlcfoscopv.
Thc histolo-sicstucliessl.rowedditlèrences in the
c e l l p o p r - r l a l i o nasn d t h c i f d i s t r i b u t i o ni n t h e i n t i n t a
and sLlhsvnoviunrfirr the 2 ty'pes of OA. Althroscopic c'xanrinationindicated that both trcatments
r e d u c e c tl h c c \ t e n t o f s v n o v i a l i n l l a m r n a t i o n .H i s t o l o g i c a l l y ' .H A t r c a t n r c n t \ \ ' i r s n o t e d t o s i g n i t i cantlv reclr-rce
thc nurr.rbctsancl crtcnt of ag-eregat i o n o f s 1 ' n o v i a ll i n i n g c e l l s u h i l c c n c o u l a g i n l
r e p a f a t i v cp r o c e s s e si n t h e d e e p s u b s rn o v i L r n tT. h i s
later efïèct was nlol'e eviclcnt in tissues biopsiecl
from patienls with prinrarl' rather than scconclart'
oA.
Generally.both HA ancl corticosteriodtrcatI n e n t \ n r i t i s u t c csl \ n o V i a l h y p e r t r o p h ya n d i r r c r L - l \ ù ( lt h e n u n r b e r so t ' s v n o v i a l l i b r o b l a s t - l i k c
ceIIs rvhi It' clccreas
i ng nracropha-ues.
lymphocvtes.
r n u s t c e l l s . a n r l u t l i l ' r o c v t e sT.h e u l t r a s t r u c t u r l l
stucliesrcr caled l rc'cluction
in speciiilizedc1,toplasmicstrLrctufcs.
sr-rch
as thc Golgi cornplexnncl
p i n o c y t i cv e s i c l c so n t h ep l a s n r au t e l l b r a n ei n t y p e
B s y n o v i o c v t eosl ' O A b i o p s vs p e c i n t e nasn c le \ i Fig lt). Thc IA HA therapv
c l e n c eo 1 ' h y p e r p l a s(i a
partiall)'anreliorated
(Fig
this svnovialpathologl,,
d,idt:,
*{:
Fig 8. Ultrathin sections of synovial biopsy specimens taken at arthroscopy.stained with uranyl
acetate and lead citrate for transmission electron microscopy. (A) In normal subjects,the plasma
membrane of type B synoviocytesis decorated almost completely by pinocytic vesicles.(B) These
d i s a p p e a r e di n b i o p s y s p e c i m e n sd e r i v e df r o m O A j o i n t s . ( C ) T h e y b e c o m ee v i d e n t a g a i n 6 m o n t h s
a f t e r H A t h e r a p y .S c a l e :b a r s h o w n = 1 p m . M o d i f i e df r o m P a s q u a l R
i o n c h e t t ie t a l ( 1 7 9 ) .
Table 1: Summary of Studies That EvaluateDifferent HyaluronanPreparationsUsing Animal
Models of Osteoarthritis(Cont'd)
Origin and MW of HA Used
S e i k a g a k uH, A M W - 0 . 8 4 x
'1
06 Da
S e i k a g a k uH, A M W - 0 . 8 4 x
1 0 6D a
H i k a r i ,H A M W . 2 . 0 2 x 1 0 6
Da
H i k a r iH
, A M W : 0 . 9 5x 1 0 6
Da
S e i k a g a k uH, A l V l W- 0 . 8 4 x
'l
06 Da and HA IVIW= 1.9 x
'l
06 Da
S e i k a g a k uH, A l V l W- 0 . 8 4 ) <
1OG
Da
Findings
A m o u n t so f c a r t i l a g eP G s i n H A - t r e a t e jdo i n t s m o r e t h a n i n s a l i n e - t r e a t e d
groupbut 3sS-PG
s y n t h e s i sd e c r e a s e ds u g g e s t i n gt h a t c a t a b o l i s m
r e d u c e db y H A .
H A r e d u c e dF F m e d i a t e dc a r t i l a g ed e s t r u c t i o nb o t h t h e r a p e u t i c a l layn d
prophylacticalu
l ys i n g h i s t o l o g i ca n d b i o c h e m i c aal n a l y s i sT. h e
p r o t e c t i v ee f f e c tw a s s u s t a i n e df o r u p t o 4 w e e k sp o s t F F i n j e c t i o n .
B o t h H A s p r o t e c t e da g a i n s tc a r t i l a g el o s s a s d e t e r m i n e dh i s t o l o g i c a l l yH. A
M W - 2 . 0 2 x 1 0 6D a a p p e a r e ds u p e r i o rt o H A M W - 0 . 9 5 x 1 0 6D a b u t
d i f f e r e n c en o t s t a t i s t i c a l lsyi g n i f i c a n t .
H i s t o p a t h o l o g i ca s s e s s m e n t o f c a r t i l a g e s u g g e s t e d h i g h e r M W - H A m o r e
p r o t e c t i v e w h e n u s e d a t l g i Jc o n c e n t r a t i o n
l V l o r p h o l o g i ch, i s t o m o r p h o m e t r l c a, n d b i o c h e m i c a la s s e s s m e n to f c a r t i l a g e
and synovium from joints injectedwith HA indicated protectiveeffects
o n D o t nt s s u e s .
S e i k a g a k uH, A l v l W - 0 . 8 4
,1
06 DA
M o r p h o l o g i c ,h i s t o m o r p h o m e t r l c a, n d b i o c h e m i c a la s s e s s m e n to f c a r t i l a g e
and synovium from joints injectedwith HA indicated protectiveeffects
on both tissues for up to 21 weeks PO.
F i d i aH
, A M W - 0 . 5 x 1 0 6 - 0 . 7 3H i s t o m o r p h o m e t r i c a n d b i o c h e m i c a l a s s e s s m e n t o f c a r t i l a g e a n d s y n o v i u m
x 1 0 6D a
suggested higher MW-HA preparationsmore protectivethan HA lvlW S e i k a g a k uH, A M W - 0 . 8 4 x
0 . 5 - 0 . 7 3x 1 0 6 D a . H o w e v e r , s u p p r e s s i o n o f s y n o v i a l c e l l p r o l i f e r a t i o n i n
joints of rabbits treated with HA MW - 0.84 x 106Da was more
1OG
Da
P h a r m a c i aH, A M W - 3 . 6 x
1 0 6D a .
s i q n i f i c a n rl h a n w i r h H A M W
5-23
,]
06 DA
B i o m a t r i xH y l a nG 2 0 ,H A M W
-6x106Da
S e i k a g a k uH, A M W - 0 . 8 4 . ,
Effecto
s f H A o n n i t rc o x i d er e l e a s e
f r o m c a r t r l a gien c u l t u r ea n d a p o p t o s i s
1 0 6D a
S e i k a g a k uH, A M W - 0 . 8 4 x
1 0 6D a
S e i k a g a k uH, A M W - 0 . 8 4 x
1 0 6D a
a n d n i t r o t y r o s i naec c u m u l a t i obny c h o n d r o c y t e H
s .A h a d n o e f f e c o
t n
n i t r i co x i d e l e v e l si n c a r t i l a g eb u t r e d u c e dc h o n d r o c y t ea p o p t o s i s .
E f f e c t so f H A d e t e r m i n e do n M M P - 3 ,l L - 1 ,T I t M P - g1 e n e e x p r e s s i o ni n
c a r t i l a g ea n d s y n o v i u m H A h a d n o e f f e c to n g e n e e x p r e s s i o ni n
c a r t i l a g ea n d s u p p r e s s e dm i l d b u t n o t s e v e r eI V I M P -a3n d l L - 1e x p r e s s i o n
in synovium
C a r t i l a g en o t s i g n i f i c a n t l p
y r o t e c t e db y H A b u t m e n i s c a rl e g e n e r a t i o an n d
P G c o n t e n ta s d e t e r m i n e dh i s t o l o g i c a l lw
y a s e n h a n c e db y t r e a t m e n t
S e i k a g a k uH, A l V l W- 0 . 8 4 x
'1
06 Da
E f f e c t so f H A d e t e r m i n e do n n i t r i co x i d e r e l e a s ef r o m m e n i s c ia n d
s y n o v i u mi n c u l t u r ea n d n i t r o t y r o s i n a
e c c u m u l a t i o ni n t h e s et i s s u e s H
. A
h a d n o e f f e c to n n i t r o t y r o s i n a
e c c u m u l a t i o nl e v e l si n t i s s u e sb u t r e d u c e d
n i t r i co x i d e l e v e l si n c u l t u r es u p e r n a t a n t s .
F i d i a ,H A - M W 0 . 5 x 1 0 6 - 0 . 7 x3 E x t r a c t a b i l i toyf P G si n c r e a s e db y A C L Tb u t n o r m a l i z e db y H A t r e a t m e n t .
1 0 6D a
T e n i n j e c t i o n sb e t t e rt h a n 6 .
Ditro
H i s t o l o g i cA C a n d o s t e o p h y t es c o r e sr e d u c e di n H A - t r e a t e jdo i n t s i f
t r e a t m e n tc o m m e n c e d2 n d w e e k ,b u t n o t 7 t h w e e k p o s t - s u r g e r y
B i o m a t r i xH y l a nG 2 0 ,H A - M W 6 B i l a t e r aAl C L Ti n d u c e ds y m m e t r i c akl n e eO A a s d e t e r m i n e db y g r o s s
x 1 0 6D a
m o r p h o l o g ya n d h i s t o l o g y H
. A t r e a t m e n t si m p r o v e ds c o r eb u t l a t e
t r e a t m e n tb e t t e rt h a n e a r l vt r e a t m e n t .
T a b l ec o n t i n u e s .
T a b l e 1 : S u m m a r y o f S t u d i e sT h a t E v a l u a t eD i f f e r e n tH y a l u r o n a nP r e p a r a t i o n sU s i n g A n i m a l
Authors (year)
(reference)
Species
Age or Body
Weight
OA Induction.Duration
& Timing of Treatments
S m i t h e t a l \ 2 0 0 1 1\ 1 2 a )
M o n g r e ld o g
Adult (25-30
Kgt
Asari et al (1998)
B e a gIe
5 - 8m o n t h s
o l d ( 7 - 9k g )
S m i t he t a l ( 1 9 9 8 () 1 2 3 )
M o n g r e ld o g
Adult (25-30
Kg/
A C L T ,t h e n 5 w e e k l yl A H A c o m m e n c i n g
i m m e d i a t e l yP O ,s a c r i f i c e d
7 weeks
a f t e rl a s t i n j e c t i o n
W e n ze t a l ( 1 9 9 8 () 1 2 2 )
F o xh o un d s
8 . 5 - 11 m o n t h s
( 2 6 - 3 2k g )
A C L T ,t h e n 5 w e e k l yl A H A c o m m e n c i n g
3 , 6 o r 1 2 ,w e e k sP O ,s a c r i f i c e d5 w e e k s
2 yearsold
U n i l a t e r a lt o t a l m e d i a l m e n i s c e c t o m y .A t
G h o s he t a l ( 1 9 9 3 () 1 6 7 )
A C L T ,t h e n 5 w e e k l yl A H A c o m m e n s i n g
7 weeks
i m m e d i a t e l yP O ,s a c r i f i c e d
A C L T ,t h e n H A s l A w e e k l yf o r 5 w e e k s
c o m m e n c i n g4 w e e k s P O ,s a c r i f i c ea l l
g r o u p sa t 9 w e e k s P O
4 months PO 2 mL of drug or saline
g i v e n l A f o r 5 w e e k s t h e n s a c r i f i c ea l l
g r o L l p s6 m o n t h s P O
G h o s he t a l ( 1 9 9 3 () 1 6 3 )
Sheep
2 V e a r so d
. t
U n i l a t e r a lt o t a l n r e d a l m e l r i s c e c t o m yA
4 n r o n t l r sP O 2 m L o f H A o r s a l i n e
g r o u p s6
G h o s he t a l ( 1 9 9 3 () 1 6 4 )
S h e ep
2 y e a r so l d
U n i l a t e r a lt o t a l m e d i a l m e n i s c e c t o m y . A t
4 months PO 2 mL of HA or saline
groups 6 months PO
Armstrong et al
(165)
Sheep
2 yearsold
U n i l a t e r a lt o t a m e d i a l m e n i s c e c t o m y . A t
groups 6 months PO
G h o s he t a l ( 1 9 9 5 1) 1 6 6 )
2 yearsold
U n i l a t e r a lt o t a l m e d i a l m e n i s c e c t o m y .A t
g i v e n l A f o r 5 w e e k s , t h e n s a c r i fi c e a l l
groups 6 months PO
A d a m ( 1 9 9 9 () 1 6 8 )
2 y e a r so l d
Total bilaterallateral meniscectomy,then
at 4 months PO aspirate SF and inject 2
mL of HA or saline lA for 5 weeks, then
s a c r i f i c ea l l g r o u p s 6 m o n t h s P O
G h o s he t a l ( 2 0 0 2 () 1 6 9 )
Female
7 years old
Total bilateral lateral meniscectomy,then
at 4 months PO aspirate SF and inject 2
mL of HA or saline IA for 5 weeks, then
s a c r i f i c ea l l g r o u p s 6 m o n t h s P O
T a b l e 1 : S u m m a r y o f S t u d i e sT h a t E v a l u a t eD i f f e r e n tH y a l u r o n a nP r e p a r a t i o n sU s i n g A n i m a l
Origin and MW of HA Used
A n i k a ,H A - M W1 . 5 x 1 0 6D a
S e i k a g a k uH, A 8 4 - M W 0 . 8 4
, i 1 0 6D a ; H A 2 3 0 . M W 2 . 3
, < 1 0 6D a
Findings
U n i l a t e r aAl C L Ti n c r e a s e dS F v o l u m e a n d d e c r e a s e dS F - H Ac o n c e n t r a t i o n
t ith lA
a n d M W a s a s s e s s e db y a g a r o s eg e l e l e c t r o p h o r e s iTs r. e a t m e n w
H A f a i l e dt o i m p r o v et h e s e p a r a m e t e r s .
Vacuolad
r egeneratioo
n f s y n o v i a lc e l l si n c r e a s e de x p r e s s i o no f h e a t s h o c k
p r o t e i n( H s p 7 2a) n d e l e v a t e dS F v o l u m ea n d p r o s t a g l a n d li e
n v e l si n
y e p r e s s e db y
s a l i n et r e a t e dj o i n t s .T h i s p a t h o l o g yw a s m o r e s i g n i f i c a n t l d
HA 84 treatment than HA 230. Evidenceof greater penetrationoh HA 84
into synovium.
A n i k a .H A - M W1 , 5 I 1 0 bD a
s n d f o c a le r o s i o n so n f e m o r a l
U n i l a t e r aAl C L Ti n c r e a s e do s t e o p h y t e a
r e g i o n s .H A
c o n d y l e sa n d c a u s e dc a r t i l a g eh y p e r t r o p h yi n a d l a c e n T
t r e a t m e n td i d n o t r e d u c ee r o s i o n so r o s t e o p h y t e sb u t c a r t i l a g e
h y p e r t r o p h yw a s d e c r e a s e d .
h i s t o l o g i c a lal yn d
B a y e r ,H A - M W0 . 5 r . 1 0 6 - 0 . 7 3 A C L Tc a u s e dc h o n d r o n r a l a cor fap a t e l l a e
asdetermined
'< '106 Da
. i g n i f i c a n t l lye s sp a t e l l a rA C
b y t r a n s m i s s i o ne l e c t r o nn r c r o s c o p y S
d a m a g ew i t h i . a .H A t r e a t m e n t sN. o i n d i c a t i o tnh a t t i m i n go f H A
t r e a t m e n t sw a s c n t r c a lt o o u t c o m e .
S e i k a g a k uH, A - M W 0 . 8 4
1 0 6D a ;S o d i u mP e n t o s a n
P o l y s u l f a tNe a P P S( 2 5 m g ) ,
o r N a P P S( 2 5m g ) - H A ( 2
Gait analysisshowed improverrent in NaPPS group; osteophytesworst in
N a P P S g r o u p , l e s s i n N a P P S g r o u p ; h i s t o l o g i cs c o r e s o f c a r t i l a g e
l o w e r f o r N a P P S a n d H A g r o u p s b L r tn o t f o r N a P P S - H A g r o u p .
HA
mLl
S e i k a g a k uH, A - M W 0 . 8 4 x
1 0 6D a
N i p p o nR o u s s e lH, A - M W 2 . 0
x 1 0 6D a
M e n i s c e c t o m i z e da n i m a l s g i v e n s a l i n e s h o w e d r e d u c e d l o a d i n g o f
operated limb. Both HA treatments increasedloading of operated joints.
R a d i o l o g i cs c o r e s w e r e r e d u c e d b y H A t r e a t m e n t s r e l a t i v et o s a l i n e b u t
h i s l o l o g i c s c o r e s f o r t h e m e d i a l t i b i a l p l a t e a u x c a r t i l a g e sw e r e r n c r e a s e d
when the higherMW HA was used.
S e i k a g a k uH, A = rvlw 0.84
Collagenand PG content of cartilagefrom operated joints not affected by
1 0 6D a
HA treatments conrpared with saline. PG synthesis in cartilageexplants
N i p p o nR o u s s e lH, A M W 2 . 0
from the tib al plateaux of the medial compartment of operated joints of
x 1 0 bD a
a n i m a l s t r e a t e d w i t h t h e h i g h N 4 WH A w e r e l o w e r t h a n t h e p l a c e b o
t r e a t e d g r o u p w h i l e t h e r e l e a s eo f P G s w a s h i g h e r .
S e i k a g a k uH, A - IVIW0.84 .<
1 0 6D a
M e n i s c e c t o m y a n d s a l i n e t r e a t m e n t i n c r e a s e ds u b c h o n d r a l b o n e o s t e o i d
v o l u m e & s u r f a c e s w i t h i n c r e a s e dt e t r a c y c l i n e l a b e l l i n g o f c a n c e l l o u s
bone accompanied by increasedcartilagedamage. These bone and
cartilageresponseswere reduced by lA HA treatment.
S e i k a g a k uH, A - I V I W0 . 8 4 . i
1 0 6D a
C a r t i l a g ea g g r e g a t e h i s t o l o g i c a l d a m a g e s c o r e s f o r H A t r e a t e d a n i m a l s
were lessthan for saline treated controls. KS-peptidelevels in SF
i n c r e a s ep r o g r e s s i v e l ya f t e r s a l i n e t r e a t m e n t b u t S F l e v e l s f o r a n i m a l s
given HA were not significantlydifferent from non-operated controls
values.
S e i k a g a k uH, A - - M W 0 . 8 4 x
M W o f e n d o g e n o u s H A i n S F o f j o i n t s d e t e r m i n e d b y m u l t i - a n g l el a s e r 1 0 6D a
light scattering photometry. Both HA preparationsincreasedSF-HA
S e i k a g a k uH, A - M W 2 . 3 ) < 1 0 6
molecular size when examine 5 weeks posttreatment but the smaller
Da
M W H A p r o d u c e d a l a r g e r m e a n i n c r e a s ei n e n d o g e n o u s H A t h a n d i d
t h e h i g h e r l V l WH A
F i c l i aH
, A M W 0 . 5 x 1 0 " - 0 . 7 3 R h e o l o g i c a lp r o p e r t i e s o f S F a s p i r a t e d f r o m j o i n t s o f g r o u p s b e f o r e a n d 5
x 1 0 6D a
weeks after treatments was determined by a micro Fourier rheometer.
P h a r m a c i a - U p j o hH
n ,A M W :
Both HA preparationsincreasedSF storage modulus and viscosity when
x ' t0 6 D a
3 x 106-6.9
examine 5 weeks after treatment compared with saline but the smaller
MW HA produced a larger mean improvement in these parametersthan
t h e h i g h e r M W p r e p a r a t i o n ,H A M W . . 3 - 6 . 9 x 1 0 6 D a .
30
8). leaclingthese authorsto concluclethat. in at
leastin the short-termr
of 6 months.HA treatment
was capableof colrectinga nuntberof structural
and cellularabnormalities
characteristic
of the osteoarthriticsynovialrnernbrane
towardil ntorenorrnal appearancc.
The extent of the reparatir,ecffect was more
er,identin prirralv OA thiin in seconclurv
OA. It
also 'uvassuggestecl
that the reductionin svnovial
inflamlnationmediatedby IA HA thertpv coulcl
e r p l a i nt h e m a i n t e n a n coel s y r n p t o n t a tri ec l i e fs e \ ' eral monthsaftcr the cessationctftl'eatrlcnt.N.{or.eover.this long termanti-inflantntaton
etlèct0l'H.\
w a sc o n s i s t e nwt i t h a n e a r l i e rc l i n i c l l r c 1 - x rsl th i c h
indicatedthat repeatedlA in.jections
oT H,\ rlere
capableof letardin-gthe rate of prorressionol'
c h o n d r o p a t hiyn O A p a t i e n t s( 1 8 0 ) .
In this latterstLrch.
it $ as shct$r.rtltatI t|catrtrent
c ) ' c l e so f ' 3 i n . j e c t i o n o
sf HA (NI\\' - 0..5 x
x
l 0 ' ' - 0 . 7 3 1 0 " D a ) o re l I r c n r s e l c c l i n i c a l l r
etlèctive in reclLrcin-c
the sr nt1'rtonts
ol OÀ [rLrt
a l s o s l o u , e c tl h e - l - l l o g r e s s i oor t1 ' c u r t i l t r s el o : : .
a s e v a l u a t c calr t h r o s c c r l t i c uflnl r u : i r r cl r t i l i t l u t c t l
a f t h r o s c o p i cs c o r i n g s \ s t e l n ( S o c i e t éI - r l i nuer r e
c l ' A l t h r o s c o p iIeS F A ] ) .l ' e l i r t i \ ct o l u \ i t r c r h c n i p \ .
Using the chan-resin the SFA scolc bt'lirle iutd
aftertreatments.
the perccnta-ge
of patientsconsidered a success(changesin the SFA scureof less
than:1points)was 557cin the HA groupcctntpared
with 377cof the lava_ue
group.
Anali'sis of the changesin the SFA caltilege
scoresfnrn'rbaselincto I vear showeclthat l67c of
t h e p a t i e n t so n H A t r e a t r n e nitn t p r < x e di l s c o n t paled to 0% itr the colttlol -u|or,rp.
Thr. sereritr 0l'
chondropathr'(r'isual analoguescalc) al\() \\ i.r\
evaluated
i n a l l k n e ec o m p i r r t l n c n tAs . h i s h l r s i s nifrcantdil'lèrencebetween-sroupsin taror ol'H,{
was fbund with respectto the lèntrtlalcondrles.
tibiiil plateaux. and fèntorotibial contpartlltents
overall. Additionally. the radiologice\antinarron
of ioint spacewidth in the mediul contpartntent
showeda minor joint spaceloss in the HA group
(0..11 | 0.16 mm) cclmparedwith the lavaget r e a t e dg r o u p( 0 . 6 - 5+ l . l 7 r n m ) .
Structuralmodificationin OA .jointsby IA inj e c t i o no f H A w i t h M W : 0 . , 5x 1 0 6 - 0 . 7 x3 1 0 6
Da was reportedin a randomized.placebocontrolled,doubleblind clinical studyrecentlyundert a k e n i n t h e U K ( 1 8 1 ) .I n t h i s s t u d y .t h o s eO A
patientswith less advanceddiseaseat the tirne of
entry. as determinedradiologically.when sub-
j e c t e dt o 3 c o u r s e so f 3 i n j e c t i o n so l ' H A o v e r l 2
months.sholr'eda si_unificantly
reduceclpro-sression of .jointspacenarro\\'ing(P : .021compaled
il'itl.ra mal.checl
placebo-treatedcohort. In the HA
treatedgroup. the rneanloss of .jclintspacewiclth
r.vas
0.22 + l.l mrn.whelclrsin the placebotreated
-group.the nrean loss u'as 0.60 + I .l rnm per
annunl.
DISCUSSION
There is a larsc bod1,of cviclcnccthat IA HA
t h e r a p lp' r o ri c l c ss r r r p t o n r a t ilcc l i e f i n t h e p a t i c n t s
u i t h k n e eO A . H o r i r ' r e r .i t s n r c c h a n i s norf a c t r o n
in this regarcl()r it\ IrotL'ntial
to rroclif-r'
the unclerl v i n g p a t h o l o s ro l ' O . \ i r r es t i l l c o n t e n t i o uiss s u e s .
T h c o r i s i n u lc r p l u n u t i i r n
b v B a l a z sa n d D e n l i n g e r '
t J . lt u n t lo t h c r st J - 1 . - 1t 5
t h l t t h e b e n e l i c i acl l i n i c a l
e l l r . e t so l L \ H . \ t h c r a p ri n C ) An a s r e l a t c ttlo t h e
r c s t o l u t i o ror 1 S F p h rr i c u l / r h c o l o c i c apll o p e r t i e s
1 1i 5 g l r s u I P i c n r c n t t i )t i \o\ l tl s l i . t tfe l o L r n ct lo b e i n c ( ) n \ i \ t ù nut i t h t h r 'r ' a l t i ccll e a r a n coe1 ' t h ca c l r r i n i s t e r c t lH . \ l l o n r t l r c s r n o v i a lc a v i t t a n c lt h e l o n g tcrnr clticricr ot the tltel'ap)'.
\ u r n c r o u si n r i t r o s t u d i e su n d c r t a k ew
n ith HAs
ol r llr rng \l\\'s .u'u,ere
subsecluently
undertaken
anclarldctlsupportto the view that this r-rbicluitous
GAG rnight be actin-t pharmacoluuicallvrather
thiin jr-rstas a unicluebiornatelial.Those in vitro
OA rrodels that compareclH,{s of cliftèrentMW
i n d i c a t e df.b r t h e l n o \ t p a r t . t h a t H A s u i t h h i g h
M W ( e g . > 1 . 0 X 1 0 " D r i t \ \ ù r c n r ( ) r eb i o l o g i c a l l l ,
rlctive
t h l n H , \ s o l l r ' s s csri z c{ e g . 0 . -X
i l 0 ( ' - I . 0X
1 0 " D a t . . \ t t h c ' u n r e t i n r e .o t h e r i n r i t l o s t u d r e s
t h i r tù \ l n l n e r l t h c i n t e n l c t i o nosl ' H A s r i i t h r e c e p t o r ' : a t t h c c e l l u l a rl e v e l s h o w e ctlh a t t h e s r n a l l e r
H A p o l v n r e r i cp o p u l a t i o nesl i c i t e ral s t r o n - e earn d
clLriteoftcn contraryresponsethan the lar-eerHA
populations.
In vivo studiesusinq anintalntoclelsof OA and
HA preparations
of varving NIW afTordecl
results
that contrasted
u ith tliose-senerated
by the in I'itro
OA models.Tl.rcscuninralstudiesand theil findin-gsare sunrnrarized
in Table l.
Although the stucliesidentifiedin Tiible I suggestthat HAs $ ith MWs between0.-5X l0ô-I .0 X
106Da couldbe the prefèrrecl
fbrrrs fbr IA therapv.
this interpretationis clouded by the nurnber of
protocolvariationsanclspeciesLlsedin thesestudies. In both small and large animal models.the
timing of HA treatmentsubsequent
to OA initiu-
tion and the interval before sacrificepost HA
treatmentalso variablemarkedll'.
Furthermore.resultsobtainedusin-grabbitntodels ofien conflicteclwith those generatedusinr
lar_9e
anirnalOA rnodels.This clifference
lrav al'lsc
becauseof speciesdit'terences.
but the extcnt ot
synovialinflarnmationand the rapicllate of caltila-r:edegenelationinduccclin the small anitnal
joints bv the sLrrgicalprclcedures
cornparedriith
that seeuin lar'-ce
animaljclintsmay be an intport a n tc o n s i d e l a t i o n .
N o t w i t h s t a n d i nt h
g e s es h o r tc o n t i n - utsh.c a n i r n a l
rnodelsstudiestogetherrvith the lirnitcdnuntberot
laboratorystudiesconducteclon tissue\tl'ont Ituman sr-rbjects
haveprovidecla ratronalhasrsfor the
pharmacologicactionsof HA antl ltot theseac
t i o n sr n a vb e i n l l L r c n c ebcrl i t s N l \ \ ' .
A n i m p o r t a n(t l e t e n r i n a n(t) 1t'l t e p h a f n t u c o l o g i c
a c t i v i t v o f u n t a c r o n t o l c c u l:eu c h a s H A i s i t s
a b i l i t y ' t o p c n e t r a t et h e c r t l l c e l l L r l a lr n u t r i r a n c l
i r t t c r a crti i t h r e c e p t o t o
' \ n t a r g ù tc e l l sr t r u c c l - l n t L l l a t ei n t h e p e r i c lel u l l r e n ri r o r t n t e not1 ' t h c : ce c l l : .
u h e r c i t c n n n r o c l L r l a tl L
h -c l n ( ) \c n t c n t ( ) 1 ( ) l h c f
b i o a c t i er n r o l e c u l e st o u n t l T l ' o r nt l t e r el l s . . . \ t
m e n t i o n e cpll e v i o u s l r .: n t a l l \ l \ \ H . \ o l r s o n r c r s .
r,vhichriould be c.rpcctecl
to clif'fLrse
freelt throLrglt
t h e i n t e l s t i t i arln a t i x c. a n c x h i b i tc o n t r a s t i ncse l l u lar responses
to analoguesof high MW. On thcsc
it
could
be predictedthat thc ntostphar-srlouncls.
m a c o l o g i c a l l ya c t i v e H A p r e p t l r a t i o l tr\i o t r l d b c
thosethat were srnallenolr-s:h
to guin lrcce\\t() thc
p e r i c c l l u l am
l a t r i x b u t s t i l l l a r s c L . n ( ) u stho c l r ei t
t h c r e q u i r e dc e l l L r l u r ' r ' e \ p o nu\ ct i t : r ' e t e | t o r s
ancl/orcontrol tl-rcntorcnrentof ilt)portantntcrliltors to and llrtrr the cells.
W e d o n o t v e t k n o w u ' h a tt h c i c l e r lM W o f ' H A
s h o u l cbl e t o f i r l l i l l t h e a b o l , er c q u i r e l l c n t \ M
. oleo\,er.it is probabli'not a firecl size ran-ue.
\'arving
w i t h t h e a n i r n asl p e c ise. t h ee x t e n to f i n l l a t n n t a t i o n
thtrtwould afÈct s1'nolialtissr-re
pel'nierbilitrancl
c e l l p o p u l a t i o nesn t e r i n -tsh e . j o i n tS. F I o l u n r e r. a t e
o f c l e a r a n c er.h e o l o - e yr .n d \ o o n . H o u c r c r ' .a s
alreadynoted.the animalntodelsand l'rurtran
studi e s d e s c r i b e dt o d a t e s u p p o f tt h c v i e w l h a t H A s
w ' i t hM W s w i t h i nt h er a n _ qoef 0 . 5 x l 0 ô -I . 0 x l 0 ô
Da lepresenta therapeutically
usel'ulcornprontise.
S U M M A R YA N D C O N C L U S I O N S
The HA is a uniqr-rentacromolecule
that pcrlbn.nsa nrultitudeof biophysical.biocheurical.
and
cell re_eulatolyroles in joint synovial tissues.
31
Within the past :10 years. preparationsof high
purity. pharmaceuticquality HA have become
commerciallyavailablein a variety of fbrrns and
MWs. Thesehave fbr.rncl
widespreadapplications
in orthopedicsand rheumatology.palticularlyfbr'
the treatmentof OA of peripheral.joints.However.
rrany cornpanics
havcl'cgistered
lA HA therapyas
a device fathef than a clrug and this has fueled
clebatcand resealchinto the rrechanismof actron
o l ' t h i s a g e n t .i t s a b i l i t l t o r n o c l i f yt h c u n d e r l y i r r g
.jointpatholo-lfin O,\. and r"hetherthe molecLrlar
sizeof the pleparationis inrportantfbr theseactir'l tl e s .
An earll' concept susgestecl
for the mode of
l u c t i o no f H A i u O A u a s b r r i s c o s r . r p p l e m e n t a t i t r n
o 1 ' c l v s f u n c t i o nSaFl : h o n e r e r .t h e r a p i ccl l e a r a n c e
o f H A f i ' o m s y n o r i i i l . j o i n t sa l t e r I A i n j c c t i r r n
with the long-tclrr s\ nrptonratjcbcnefits
to-gether
experiencedby patients\\ i-r\ n()t eonsistentri,ith
snch a proposal.Subsequent
laboratoryinvestigat i o n s s h o w e dt h a t H A e r h i b i t e d a n a l g e s i c / a n t i inflarnmatorv
anclir.nmunoregulatorl"
activities.
many
r r l s h i c h u e l e r n e d i a t e tchl r o u g hs p e c i f i cc e l l r e e ù p t ( ) l \s. r r c l ut s C D : 1 . 1A.l t h o u g ht h e s ep h a l r n a c o I o S i el c t r r i t i c ' so t ' H A p l o r i c l c r u
l n c r p l a n a t i o no f
I r o r rt h i : u g ù l rùt ( ) L l lpr lr o c l u cser n r 1 - r t o r n ur et ilci e lr n
O A . t h c i n r p o r t r i n eoc t ' \ l \ \ ' o n t l . r c s ca c t i v i t r e s
r e n ] l t i l t e t tl r n lc s 0 l r c t l .
I t t r i t l o \ t L l ( l i c \ t t . i t . t gc l . t o t . t i l t l )tcc\ o r c a l t i l a . u e
ù \ p 1 1 1 1e1r 1r l t u l c s h u r c r u g g c : t c t l l c h o n c l r o p r o t e c t i r r r t r l r ' l i r l H . \ . \ l o t - c o r c r ' i.n t h e s ee x p e r i m e n t s
H.\ prcpllltron' u itlr \l\\ s >2 X l0(' Da wcre
r n o r . cc l l e c t i r e t h u n H A o l ' M W < 1 X l 0 ô D a . I n
c o n t r a s t .s t l l d i e s L r s i n - as n i r n a l m o d c l s o f O A a n d
ditferent MW-HAs have conflicted u,ith the in
vitro findings. Paradoxically. in thcse anintal rnoclels of OA. HAs with MW >2 X l0('[)a rier-e
|eported to be less protectir e- tO cartila-ge and
svnorial cell rrctaholislr than HAs of less than
half thrssizc.
T h c n r e c h a n i s n r ( sf)ù s p o n s i b l et i r l t l i i s d i l ' f è r ' e n tial e-1'1cct
ol' HAs on cartilage and synor,ial ccll
metabolisnr al'e still the sub.ject of lcscarch but
coulcl be lclated to the enhancedpenett'ationol'the
smaller MW prcparations intct the tissr-rcs.
thereby
achievin-ghi-uherconccntration of the clrr-r-c
in the
pericellulal envilonrnent of the cell. The hi-ghcr
concentration clif'ferentialachieved by the lowcr
MW HA species relative to the lar-eerMW analogues could clicit a more potent pharmacologic
response by the cell. However. experintental evr-
G H O SAHN DG U I D O L I N
32
dence indicates that this explanation is far front
adequate and consideration also musl be -given to
recent studies in cell biology that have sl.rownthal
si_unaltransdLlction and gene expression arisin.n
lrom HA receptor bindin-calso can be MW-depcndent.
Despite the inadequacieso1'our present knou'ledge of HA interactions at the cellular ancl nrolecular levels. there is -good evidence ll'ont anilnal
models of OA and fl'orn str-rdies
on huntan s)'tlovial
biopsy specimens. that the structLlral rloclif'r'ing
efTèctsexhibited by HA in OA .joinrs ale largelv
r l e c l i a t e db 1 , i t s a n t i - i n f l u n m t r t ' r t ) .e r t o p l o t e u t i v e .
and immunoregulator1,prope.rtics.
T h e d a t a r e v i e r " , e cal l s o s L r g g c s t h a l c a f t i l a g e
protectlon ma\' occur. not tlonr a direct etfect o1'
H A o n c h o n d r o c v t c s . b u t s e c o n d a t ' yt o l h e d o w n
f e g u l a t i o no f c y t o k i n e .l l ' e e r a d i c a l .a n d p r o t e o l y t i c a c t i i ' i t i e si n t h e S F a n d s y n o v i L r n rw. h i c h
a c t o n c h o n d r o c y t e isi n d p r o m o t em a t f i x c a t a b o l i s r n . S y r n p t o r . n a tri e
c l i e f i n O A p a t i e n t sc o n f c r r e d b 1 ' I A H A t h e r a p ym
' av in the short-ternr
b e e x p l a i n e db 1 ,i n . r p r o v e m e ni ut j o i n t m e c h a n i c a l l ' u n c t i o n sH. o u e v e r .i t s l o n g e rI a s t i n gc l i n r c a l b e n e l i t sc a n o n l y b e r e c o n c i l e db y a c c e p t a n c e
t h a t t h i s a g e n t l s c a p a b l eo f p h a r i l ) a c o l o g i c a l l l ,
m o d i l ' ) , i n . cs c r t a i n p a t h o l o g i cp a t h u ' a ) , si n O A
t h a t g i V e r i s e t ( ) s Y r . n l l t o u rIsn. t h i s l e g a r d . t h e
p a r t i a l r e s t o r a t i o no t s l ' n o v i a l c e l l m e t a b o l i s n r
a n d n o r m a l i z a t i oonf H A b i o s y n t h e s (i s" r ' i s c o i n d u c t i o n " ) .w h i c h h a s b e e ns h o r in i n b o t h a n i n r a l
m o d e l s a n d h u n r a n s u b . j e ' c tuss r n s H A s u i t h i n
t h e M W r a n - s ce l 10 . . 5x 1 0 " - 1 . 0x 1 0 ( ' [ ) a .n t a r
b c o f c o n s i d e r a b li en r l l o r t a n e r .
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f l u i d sa n dt h c c f f e c to n g r h u e o ct irc c e l l s .O s t c o u r t hS l n r p S e n t r n
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contparcd
uith
c.lec
HR
YALURONAN
INTRA-ARTICULA
c h a i s n eC
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\ \\i t l r
N l i c f o h c - t c r o g c n e i(t)\l r c L r l ep i l l t s c p | o t c i r r r i n p i r l i c ' 1 r 1
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\ , I l i l k c r - H e r r r r l nE
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l l r c t o rk B i n h u n r a r ri n l l a m e csl v n o ri a l t i s s u c . . \ r t h r i l i sR h e u n r
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3 6 . B a l a z sE A . C i i b b sD A . T h c r h e o k r g i c i rPl r o p c r t i e sa n d
b i o l o r . r i c .tri lr n c t i o no f h v a l u r o n i ca c i c l .I n : ( - h e n l i \ t r vu n d N k r r a t r i r . L l u l u z s[ ; A . e d . N e n
l c c u l a l B i o l o g l -o f t h e I n t e r c e l l u l aM
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s v n o v i a lf l u i c lf r o n r p a t r e n t s$ ' i t h r l r e L l n r a t oiildl t h f i t i \ : l n ( lo t h e r
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l cl u k o c v t c sl.n U a r n r n l t i o nl 9 E ô :l 0 :
|5 30.
33
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, , n l r r u r r r l r l i o1r ti : : u ùt i r r r i i l i ( ) nC
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l t r t l r r , r r L , ( ) Hr.. L t l i i t r L r' :l .a I J | ( i ù |(1) nl t \ l r l L | | ( ) l l lttn( ) l r ' a L l ] r r
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a n d l o r r r r o l e c u l a r - u c i g h tv a l u l o n i ca c i d o r r r n i t o g e n - i n c l u c e c l
l t ' n r p h o c v t cp r o l i f è r ' a t i o rCr .u r r T h e r R e s 1 9 9 0 : - 1 7 : - i 3 7 - - { - 1 .
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n c u t r o p h iul d h e s i o nJ. C e l l S c i l 9 8 l : 5 0 : l l t l - 1 - 1 .
l l 9 . P l c h n r P . l l i o s r n t h e s i so f l l ' u l u l o n l t e . . \ 1 t c n t :A c t l o n s
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i L t l l L r l c er ln r l L r i n\t\' 1 t ( )i\o e\ t c \ . . - \ n t. l \ . ' t R c sl ( X ) 0 : 6l : - 1 9 9 - - 5 0 - 5 .
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i . H v a l u r o n i rcc i ( l i n h i b i t sr h ee x p r e s s i oonl ' u - P A .
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. i o c h i n t B i o p h t ' sA c t a l 9 l l l l : 9 6 7 l:l J l 9 . { .
t ) 5 . W e i n b e l g J B . P i p p e nA N { \ { . G r c c n b e r cC l S .E \ r f a \ a s c u l a r f i b n n l b r r n u t i o na n d d i s s o h l t i o ni n s v n o l i a l t i s s L r eo l
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h r a l u l o n i c a c i c lo n t i b r i n o l r , t i cf u c t o r si n t h c s t n o r i u l f l u i d ( i n
r i r o ) . P a t h o p h r s i o l o g vI 9 9 9 : 6 : -I1- 1 .
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r o s t c o l r t h l i t i cc l r o n d r o c r t elsn d s r n o v i o c r , t e sO
. s t c o a r t h r i t i(s a r t i l a g el ( X )l : 9 : l 6 l - f i .
9 8 . A k a t s u k r\ { . Y r r r u n r o t oY . T o t r e t t oK . Y a s L r i T . \ n r I r ' 1.
I n v i t r o e f t è c t so l h r a l t L r o n aonr . p
t r o s t a i : l l r n d i[n: . i n L l t r e t i o]n. r
i n t e r l e L r k i ln -i n r a b b i t a r t i c u l u lc h o n c l r o ct re s . . \ L c r l . . \ e t r l r r .
1993:lE:lll--5.
9 9 . F L r k u d aK . T r L k alrr n a l \ ' 1 .L l c r t r r\ 1 . O h \ 1 . \ : r r t l u S .
K u r r t i n oF . e t r l . H r l l L r r o n i ac c i di n h i h i t .i n t t r l c L r k i In r n L l L r c t ' t l
s u p c l o r i c liel n i ( ) ri'nr t r o r i n ec l r o n t l r o e \ l r 'I\n. l l i L n t l R
l a, I99- 1 6 : ll - 17 .
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l ( X ) . S h i r t t a z .u\ . J i k k o A . I u r n r o t i , \ 1 . K L r i k c \ l l \ \ .
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p r o t c o - g l \ c l nf | 0 n r t h e c e l l n l l t f i \ i n | r L h h iet h t r n r l r o c r tceL r l t u r c s
i n l h c p r c s c n c er r r d a b s c n c co l e r l 0 k i n e s .A r t h l i t i s R h e u n t
I t ) c ) 3 : 1 6 : l - +- 5
7i.
l 0 l . F L r k L r dKa. l ) a n H . T u k u u n r . t\ 1 . S l i t o h N l . T a n a k aS .
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b o l i n e a r t i c L r l a cl a r t i l a s e i n t h e p r e s e n c eo i i n t c . r l e i r k i n - 1 .
J P h a l r n a c oEl r p T h c r 1 9 9 6 : 1 7 7 : 1 6 75 1.
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. I c h i o Y . . - \ c l a c h\ r. \ l r r r s L L r r L k i
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s t t l l l t t cs v n t h e : i si t r c L t l l t t t c tcl l t o n d r o ctrc ' e n t h c r l t l c ti ln . r , l l . r
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e c l L r i nacr t i c u l â f c t f t i l r gpùl ( ) t e ( ) : r l \ e sl lrnr r l h c s ihr r I t r l r l L r r L n t r r
a n d C i a r p r o l è nR. e s V c t S c i 1 9 9 9 : 6 7 : l 8 i - 9 0
l0{r. Bleu K. Dinakarparrdiln
D . N r g r L s eH . T i s s u ei n h i b i l o f s o f r n c t a l l o p r o l e i n a s eEsr:o l u t i o n . s t n l c t u f ùi L n ( lf u n c t i ( ) n .
B i o c h i n rB i o p h l s A c t a Z ( X X ) : 1 . 1 7 7 : 1 6 7 - 1 1 . 3 .
1 0 7 . U i r k c c l a l - H r n s eH
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. \ M T S l l . . u t â g s r e c a n a sfcr o r n t h e A D . \ N { T S l a n t i l r . . l B i o l
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curtilaqeE
: v i d e n c et b r b o t h n t a t r i r n r c t a l l o p l o t e i n a sr ne r i r t g src-cûnilseacti\,itv in norntal. osteoûrthIitic.anci rheuntat0icl
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( T I \ l P I ) i n b o r , i n ea-r t i c u l â rc h o n c l r o c r , t eBsi.o n r e dR e s l 9 9 l :
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l u n dn i t r i c o r i c l ep r o r l u c t i o ni n e \ p e f i n r e n t a l l ti n d u c c do s t e o a r t h r i t i s J. R h c u n r a t ol 0l ( X ) : 2 7l 7
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t l c l r i r t l r r t i o rtri t h c a t a t r o l i cc v t o k i r r er n d s t r o r n e l r ' s i nl e l e r s c
l r o n r c . r l t i l u c cc L r l t u f e culi t h l l b r o n e c t i nl n g l t c n t s . A r - c hB i o
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I l - 1 . K l n - : .\r. F - - l c\r\ ' . K o c p p H . \ \ ' i l l i l n r : . 1 \ 1 .K u c t t n e rK h .
I l o r n r n i l h eSr ( i . \ . H r l r l L r l o n l n\ u p l ) r ' ù \ \ r 'i\i b r o t r r ' en1 iI l i l M t c n l n r c t l i . t l c rrll i r n t r r ! cl t r l t L t r t l r lc l t r ' l i l i L ger r' p l r n l c L r l l n r c :b r c - n ] r r n ù i n !P f ( ) r ù r ) -e!llLr rs r n l l r c ' i ' .. l O r t l r o pR . \ l 9 ( ) 91: 7 : 8 5 86 9 .
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i i r ( l ! l r r ( r l r l !r r l l l r n t n t . r t i r r .ù\ .L r ' n l ' . \ e t i o D : l t ) ( , ) - l : - l - l : - 1 - 1 - 7 .
I l h . H i r k r r n " o n[ - . l l r r l l g r c nR . \ e n g e I ) . R e - r u l r t i o no f
- r t r n t t l o etrc ' I i r r t c t i L rLnr l h r l r l L r r r r n il ct c i d i n \ i t r o l t r t l i n r i r o
c t l e c t \ o n p h r l t o c \t ( ) \ i \ . l o e o l r o t i o l t .a n t l m e t a b o l i s n rJ. C l i n
lnvest I980:66:19E--105.
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g e s i ce l t è c t o l s o c l i u r lh v a l u r o n a t et S P H t . N i p p o n Y a k u r i _ u a k u
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i t s a e t i o nm e c h a n i s r ' nosi c r p e - r i r r r . . n tjlot li n t p i r i n i n r ' . t t s..\ n r r
R l t eu n r D i s 1 9 9 3 : - 5 1l 7: E- l l .
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l l o . \ i r r r t . r n l t l (, i' . l l L r t tli' ] .I ) c l l l L r c\ 1 . G e i G . S a n r s oJnC .
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t l r r '[ \ ) n r i\ L r k i t r . l r r t i l t c l t r L l - n r L r(tj lte( )i \ t ù o i l r t h r i it ni sc l o g s l.:
I J i o e h c n r i cri r .l \ u l l \ .( ' l i n O r t h ( ) | 1 9 8 9 ' r J :l 1 7 8 - 1 3 5 .
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l \ l o r p h o l o - e i c al iln c l i n g sC. l i n O r t h o p 1 . 1 8 9 : 1 .:1l l1l 6 9 9 .
l l l . W e n z \ \ ' . B r e u s c hS J .G r a l J . S r l u r r n r n nL l . L ' l t r a r t r L r c
t u r a l t i n t l i n c su f l e l i n t r a a r t i c u l aarp p l i c a t i o no l h r u l u r o n u nr n a
c a n i n cr ) r o d erlr f r r t h r o p a t h tJ. O r t h o pR e sl ( X X ) : l l J : 6 0 1 - l l .
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o l i n t r a a r t i r r c l ahrr l l u r o n a t r i n - j c c t i o ni n e r p e r i r l e n t a lc a n i n e
o s t c o i l r t h f i t i \..\ r ' t h r i t i sI l . h e u n t1 9 9 3 : - 1: t1) 7 6 - 8 5 .
l l - { . S n r i t hG N . \ 4 i c k l e r E . { . \ l 1 e r s S l - . B r a n d tK D . E f l è c t
o f i n t r r u r t i c u l r lh r l l u r o n u n i nj e c t i o no n s v n u v i a lt l u i c lh _ " - a l u r 0 n a r i n t h c e l r l r s l t r s e0 f c n n i n cp o s t t r a u n t â t i cO s t c o a r t h r i t i s .
. l R h c u n r t t o l ( X )I : l l J :I - l l I 6 .
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S c i e n c ei n N l e d i c i n cT h c s i s .U n i v c r r i t yo i S l , t l n e y1 9 9 9 .
1 6 9 . ( l h o s h P . K i p i c B . S q , a i nN l . S m i t hN I N I .C a k e N { .R e a c l
R . I r r p r o v e r n e n itn r h e o l o - s i c apl a r i u l e t c r so f s v n o r i a l l l u i d s
r s p i r a t e dt i o m O A . j o i n t so l ' s h e c pa d m i n i s t e r e idn t n r - a r t i c u l a r
h v a l u r o n a n( N { W - 0 . 5 - 0 . 7 . 1X 1 0 6D l ) b u t r r o ta h i g h c r M W
p r e p a r a t i o n(.s u b n r i t t e cl i lr r p u b l i c a t i o n ) :
3l
1 7 0 . H i r o t a W . I n t r a a r t i c t r l a ri n j e c t i o no t h v a l u r o n i cr c r c l
l c c l u c e st o t a l a n r o u n t so l l e u k o t l i e n eC - , 1 .6 k e t o - p r o s t a g l a n d i n
F l - a l p h a . p r o s t a r l a n c l i nF 2 a l p h a r n c l i n t e r l e u k i n - l b e t a i l
s l n o r i a l l l u i d o l p a t i e n t sw i t h i n t e r n a .l l e r { n g e m e ni tn d i s o r d e r s
o f t h e t e n r p o l o n r a n c l i b r - r l a r . j o1i n3 trJ. O r a l N ' l a r i l l o l a cS u r c
l 9 9 t t : 1 6 : 3 85 .
l 7 l . P u r r z Ii - . S c h i a ro n F . R a r r o n d aR . N 4 a l a t c sVt. G a n r b ; L
i r
P . T u t l e s c oS . I n t r l a r t i c u l a rh t , a l r - r r o nai c j d i n t h e t r e u t n r e nttl 1
i n f l a n r r n l t o r ta' n c ln o n i n l l a m r n a t o rkvn c c c l l u s i o n s .C u r r T h c r
Resl9E3:-11:6-!l-7.
l 7 l . P r r n zIi - . S c h i a r o nF . C l a r a s i F
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l . \ \ l P o l : r r t o r i l l f l u i d .( l l i n E x p R h e L r m a t o l
I 9 S 9 : l : l1 r - 5 0 .
l l . l . I ) t r L r r l r r l o\ 1. . \ r t n c n \ 1 . I . r s t r - a\ ,t. A l n r o r -B . H i g h
n r o l c e L r l rur e
l i c h t. L r t l i L r n
h \ r l u r ( ) n l r t lùL I i r l e c t i n) i n o s t e o l r t h r i
t i s o f t h c k n c c : . r o n c r c r r rp l r r c c b icr ( ) n t r ( ) l l ct(rli l l . O s t e o a r t h r j
t i s C a r t i l r g cI 9 9 l : I : ( ) r -l 0 . l
l 7 - 1 . C o r l l i k r E l \ 1 . P c l L r s o( i F . C i i c l i o t t iS . D e D u r l n t e C .
Palmicri D. Savoit \1. ct al. Thc etIèctsol intra-irrliculrr
a i l n r i n i s t r a t i o n1 ' t h eh r u l u r - o n iacc i d o n o s t c o a r t h r i toi sf t h c
k n e e : a c l i n i c l l s t u d l ' * i t h i n r r r u n o l o g i c a ul n c l b i o c h e n r i c a l
e v a l u u t i o n sE. L r r. l R h e u n r l t o lI n l l a n r m l 9 t ) 5 :I 5 : - 1 7 - - 5 6 .
1 7 5 . l \ { c n s i t i c r iN I . ; \ n r b r o s i o 1 . . l n n a c c S . P e r b e l l i n i A .
N i c o l a i sl - . V i s c o e l a s t i ce r a l L r a t i o n
o l ' d i l ' l è r e n tk n e e o s l e o a r t h l i t i s t h c r a p i c s..l N , l a tS c i N , l a tl \ l e - t l1 9 9 - 5 : 6
l i :0 7 .
I 7 ( r . I - r ' i z z i c nLr . C o r o n i H . B l c e h i n i P . I n t n t a r t i c u l ahl y a l u r o n i e r r c i d i n t h c t r c r l r l e n t o l o : l c o a r l h r i t i so f t h c k n c c :
( ' l i n i i r r ll L n t nl ( r r n h o l ( ) r i u l' rt tl r t l r .( l i n E \ p R h e u n l r t o l 9 9 l l :
l6:1il()
l - - . ( l L r r l , , L Ii r) . I i r r rl : . ( i r r c r r iIr) . I ' i t s t l r r iR
t loi n c h c t tI i.
\ l 0 r l L r l . r l r r tr r lt r , \ 1 . ( , i r r l l l r i thi \r r o d i u l ] t h r r l r r r o n l r t ct:D 0 r .. \tL-oafil)riR
t i \e
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' t r r r e l rS r i ei c t r \ \ L r r k s h r ropn \ O a n c iC O X . I ; l o r e n c eO
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1 7 3 . C i L r i d o l iD
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[ ] r ' i z z i c l oL . N { o l p h o k r g i c nal n a l y s i so l a r t i c u l n rc a r l i l a g cb i o p s i e sf r o n r u n t n d o n r i z e cd l i r r i c a ls t u d vc o m p a r i n gt h c e l l c c t so l '
r v a l u r o n a t c( H y a l g a n lu n t l n r e t h r l p r e c l 5 ( X ) - 7 3 0k D a s o c l i u n h
n i s o l r n eû c e t i l t eo n p r i n r a r vo s t e o i r r t h r i t oi sf t h c k n e e .O s l e o l t r t h l i t i sC a r - t i l r glc0 0 l : 9 : 3 7 18 L
1 7 9 . P r s q L r a lRi o n c h e t t Ii . G u e l l a D . T a p a r c l l iF . t s o r a l c lFi .
B e r s a m i r l iG . N l o r i G . e t a l . \ ' l o r p l r o l o g i c aul n a l r : i s o l k n e c
s v n o r i a l m c r n b r a n cb i o p s i c s l i o n r a n t n d o n r i z e dc o n t r o l l e t l
c l i n i c a l s t u c l l 'c o r n p a r i n - tl th c c t ' f f c t s o f s o d i u l n h r a l u r o n a t e
( H y a l g a n ) a n d r r e t h v l p r e d n i s o k r nlec ù t a l c ( I ) c p o n t c c l - o l i)n
o s t e o a r t h r i t i sR. h e L r n r r t o l o gl (r X ) l : - 1 0l :- : t - 6 9 .
1 8 0 . L i s t r a tV . A r l u l X . f ' a t t l n e l l oF . B o n v u l c t . l P . S i r n o n
n c t J . A n r o l B . e t i i l . . \ r t h r o s c o p i ce l a l u a t i o n o f p o t c n t i a l
s t r ù c t L l rner o t l i l rr n g a c t i \i t ) ' o f h v a l u r o n a n( H V a l g a n )i n o s t e o a f i h r i t i so f t h e k n e e .O s t e o a r t h r i t iC
s a r t i l a g c1 9 9 7 : 5 : 1 5 3
fi1.
l 8 l . . l L r bR
b W . P i r a S . B e i n a tL . D a r c r e . lG
. i s h e nP . S t r u c ture ntoclillcation
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D i s 2 ( X |) : 6 0 : . 1 6 .

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