Detection of intra-articular pressure transmission between knees: a confirmation of the “internal hydraulic exoskeleton” system that protects articular cartilage from overloading

Authors:

Prof. Pitkin, M.R. Dr. Tech. Sci. Tufts University, Boston, MA 02111, USA. Phone 617-636-7000, e-mail: mpitkin@tuftsmedicalcenter.org

Annotation:

Introduction. Overloading of articular cartilages is generally accepted as one of the main causes of the pathogenesis of osteoarthritis and related pathological conditions. Understandably, osteoarthritis is diagnosed more often in people who systematically experience excessive stress on their joints, whether occupationally, such as military personnel, or as a result of a primary health disorder like a unilateral amputation of the lower limb. What is surprising is why the rates of osteoarthritis aren’t higher in the rest of the population since, according to mechanical estimates, the contact pressures applied to cartilage in the norm approach the maximum loading strength of the cartilage tissue. It is necessary to understand and describe how cartilage can withstand such high pressures throughout a person’s life in order to improve prevention and treatment strategies for osteoarthritis and related diseases.

Aim. The article describes experiments that substantiate the hypothesis that intra-articular pressures are transmitted via newly identified physiological system. The system, called “internal hydraulic exoskeleton”, includes the periosteum, which covers almost the entire skeleton, synovial capsules, and subperiosteal synovial fluid.
Disturbances in its normal functioning leads to the dangerous overloading of joints and their further pathology. The article further discusses a possible approach to improving the prevention and rehabilitation of articular pathology by preserving the health of the IHE system.

Materials and methods. In our study on rabbits [1], in each of ten animals, we simultaneously measured the pressure in both knee joints of the hind limbs, one of which was passively flexed and extended, while the other was fixed with a plaster cast. In four rabbits, upon completion of the first experiment, a circular dissection of the periosteum was performed along the perimeter of the femur, 3 cm above the right knee joint. The joint was articulated anew, as in the first experiment, and the pressure in the articulated and immobilized joints were simultaneously measured.

Results. In the first experiment, the pressure in the immobile joint changed each time the pressure in the articulated joint changed. After dissection of the periosteum in the second experiment, the pressure in the immobilized joint did not change when the pressure in the articulated joint changed. Simultaneous measurements of venous blood pressure did not show a correlation with changes in hydrostatic pressure in the joints, suggesting that intra-articular pressure was transmitted through the space between the periosteum and the bone surface.

Discussion. The experiments suggest that the subperiosteal hydrostatic junction of the synovial joints forms a morphological network designed to redistribute and reduce pressure along the entire periosteum, protecting articular surfaces from excessive stresses, as evidenced by the free transmission of hydrostatic pressures that was arrested by the transection of the periosteum.

Conclusion. Preserving the health of the identified “internal hydraulic exoskeleton” system, including the application of the proposed method of physical exercises (Sanomechanics®), should be considered as a necessary condition for the successful prevention and treatment of joint pathology. Further multidisciplinary research is needed to establish the features of the morphology and physiology of this system.

Funding. This study was funded in part by Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH (grant number: R44HD057492).

List of cited literature:

1. M. Pitkin, C. Cassidy, R. Muppavarapu, E. Pitkin, Subperiosteal Transmission of Intra-Articular Pressure Between Articulated and Stationary Joints, Nature.
Scientific Reports https://www.nature.com/articles/ srep08103 5 doi:10.1038/srep08103 (2015) 8103.

2. E.M. Zajtseva, L. Alekseeva, Prichiny boli pri osteoartroze i faktory progressirovanija zabolevanija (obzor literatury) [The Causes of pain in osteoarthritis and factors of disease progression (literature review)], Nauchno- prakticheskaja revmatologija [Scientific-practical rheumatology] (2011) 50-57 (In Russian).

3. M.A. Berglezov, T.M. Аndreeva Osteoartroz (`etiologija, patogenez) [Osteoarthritis (etiology, pathogenesis)] Vestnik travmatologii i ortopedii im. N.N. Priorova [Bulletin of traumatology and orthopedics named. N. N.
Priorova] (4) (2006) 79-86 (In Russian).

4. V. Zhirnov, V. Koko, p. Kolos, G. Smykova, E. Dmitrieva, I. Luneva Opyt primenenija artroskopii v uslovijah travmatologicheskogo otdeleija VKG 1602 MO RF pri patologii kolennogo sustava u voennosluzhaschih za poslednie 10 let [The use of arthroscopy in terms of the trauma of attaleia VCG 1602 of the defense ministry in the pathology of the knee joint from the Military over the past 10 years]. Glavnyj vrach Juga Rossii. Travmatologija – Ortopedija [The Chief physician of the South of Russia.
Orthopedics And Traumatology] (1 (71)) (2020) 56-60 (In Russian).

5. V. Shapovalov, O. Rikun, R. Gladkov, D. Averkiev, A. Kuzmin Sostojanie i perspektivy hirurgicheskogo lechenija voennosluzhaschih s patologiej kolennogo sustava v spetsializirovannyh ortopedo-travmatologicheskih 4 otdelenijah [Status and prospects of surgical treatment of military personnel with disorders of the knee joint in specialized orthopedic and trauma 4 offices]. Voenno- meditsinskij zhurnal [Military medical journal] 333(5) (2012) 4-12 (In Russian).

6. D. Flynn, L.H. Eaton, D.J. Langford, N. Ieronimakis, H. McQuinn, R.O. Burney, S.L. Holmes, A.Z. Doorenbos, A SMART design to determine the optimal treatment of chronic pain among military personnel, Contemp Clin Trials 73 (2018) 68-74.

7. K.L. Dominick, Y.M. Golightly, G.L. Jackson, Arthritis prevalence and symptoms among US non-veterans, veterans, and veterans receiving Department of Veterans Affairs Healthcare, The Journal of rheumatology 33(2) (2006) 348-354.

8. J.E. Showery, N.A. Kusnezov, J.C. Dunn, J.O. Bader, P.J. Belmont, Jr., B.R. Waterman, The Rising Incidence of Degenerative and Posttraumatic Osteoarthritis of the Knee in the United States Military, J Arthroplasty 31(10) (2016) 2108-14.

9. L. Smith, R. Westrick, S. Sauers, A. Cooper, D. Scofield, P. Claro, B. Warr, Underreporting of musculoskeletal injuries in the US Army: findings from an infantry brigade combat team survey study, Sports health 8(6) (2016) 507-513.

10. L.M. Smirnova, Biomekhanicheskie pokazateli peregruzki sohrannoj konechnosti u pacientov s amputaciej goleni, bedra ili vychleneniem v tazobedrennom sustave [Biomechanical indicators of overload of the preserved limb in patients with amputation of the lower leg, hip or separation in the hip joint], Genij Ortopedii [Genius of Orthopedics] 24(1) (2018) 50-56.

11. P.A. Struyf, C.M. van Heugten, M.W. Hitters, R.J. Smeets, The prevalence of osteoarthritis of the intact hip and knee among traumatic leg amputees, Archives of physical medicine and rehabilitation 90(3) (2009) 440-446.

12. C.H. Lloyd, S.J. Stanhope, I.S. Davis, T.D. Royer, Strength asymmetry and osteoarthritis risk factors in unilateral trans-tibial, amputee gait, Gait Posture 32(3) (2010) 296-300.

13. D.C. Norvell, J.M. Czerniecki, G.E. Reiber, C. Maynard, J.A. Pecoraro, N.S. Weiss, The prevalence of knee pain and symptomatic knee osteoarthritis among veteran traumatic amputees and nonamputees, Arch Phys Med Rehabil 86(3) (2005) 487-93.

14. A. Thambyah, J.C.H. Goh, S.D. De, Contact stresses in the knee joint in deep flexion, Medical engineering & physics 27(4) (2005) 329-335.

15. J.M. Fick, A. Thambyah, N.D. Broom, Articular Cartilage Compression: How Microstructural Response Influences Pore Pressure in Relation to Matrix Health, Connective Tissue Research 51(2) (2010) 132-149.

16. G.A. Ateshian, The role of interstitial fluid pressurization in articular cartilage lubrication, J Biomech 42(9) (2009) 1163-76.

17. M.R. Pitkin, Floating skeleton concept to explain causes of injuries in spine and success of any therapeutic procedure, Journal of Biomechanics 27(6) (1994) 813: http://www.jbiomech.com/ article/0021-9290(94)91368-4/abstract.

18. H. Gray, C.M. Goss, Anatomy of the human body, 28th ed., Lea & Febiger, Philadelphia,, 1966.

19. Q. McNemar, Note on the sampling error of the difference between correlated proportions or percentages, Psychometrika 12(2) (1947) 153-157.

20. J.R. Levick, Microvascular architecture and exchange in synovial joints, Microcirculation 2(3) (1995) 217-233.

21. K. Gaffney, R.B. Williams, V.A. Jolliffe, D.R. Blake, Intra- articular pressure changes in rheumatoid and normal peripheral joints, Ann Rheum Dis 54(8) (1995) 670-3.

22. S.W. O’Driscoll, A. Kumar, R.B. Salter, The effect of the volume of effusion, joint position and continuous passive motion on intraarticular pressure in the rabbit knee, J Rheumatol 10(3) (1983) 360-3.

23. J.R. Levick, An investigation into the validity of subatmospheric pressure recordings from synovial fluid and their dependence on joint angle, J Physiol 289 (1979) 55-67.

24. A.D. Knight, J.R. Levick, Effect of fluid pressure on the hydraulic conductance of interstitium and fenestrated endothelium in the rabbit knee, J. Physiol. 360 (1985) 311-332.

25. M.I. Jayson, A.S. Dixon, Intra-articular pressure in rheumatoid arthritis of the knee. 3. Pressure changes during joint use, Annals of the rheumatic diseases 29(4) (1970) 401-408.

26. M.J. Wilcox, J.P. Barad, C.C. Wilcox, E.L. Peebles, D.S. Minckler, Performance of a new, low-volume, high- surface area aqueous shunt in normal rabbit eyes, J Glaucoma 9(1) (2000) 74-82.

27. E. Fischer-Friedrich, A.A. Hyman, F. Julicher, D.J. Muller, J. Helenius, Quantification of surface tension and internal pressure generated by single mitotic cells, Sci. Rep. 4(29 August) (2014).

28. S. Jawed, K. Gaffney, D.R. Blake, Intra-articular pressure profile of the knee joint in a spectrum of inflammatory arthropathies, Ann Rheum Dis 56(11) (1997) 686-9.

29. W.B. Greene, F.H. Netter, Netter’s orthopaedics, 1st ed., Saunders Elsevier, Philadelphia, PA, 2006.

30. J.R. Dwek, The periosteum: what is it, where is it, and what mimics it in its absence?, Skeletal radiology 39(4) (2010) 319-323.

31. H. Wingstrand, A. Wingstrand, P. Krantz, Intracapsular and atmospheric pressure in the dynamics and stability of the hip: a biomechanical study, Acta Orthopaedica 61(3) (1990) 231-235.

32. C.A. Squier, S. Ghoneim, C.R. Kremenak, Ultrastructure of the periosteum from membrane bone, J Anat 171 (1990) 233-9.

33. T.E. Popowics, Z. Zhu, S.W. Herring, Mechanical properties of the periosteum in the pig, Sus scrofa, Archives of oral biology 47(10) (2002) 733-741.

34. A.D. Knight, J.R. Levick, The density and distribution of capillaries around a synovial cavity, Experimental Physiology 68(4) (1983) 629.

35. R.E. Shadwick, Mechanical design in arteries, Journal of Experimental Biology 202(23) (1999) 3305-3313.

36. N.M. Kumar, N.B. Gilula, The gap junction communication channel, Cell 84(3) (1996) 381-8.

37. L. Rosendal, H. Langberg, A. Skov-Jensen, M. Kjaer, Incidence of injury and physical performance adaptations during military training, Clin J Sport Med 13(3) (2003) 157-63.

38. K. Steinbruck, [Epidemiology of sports injuries–25-year- analysis of sports orthopedic-traumatologic ambulatory care], Sportverletz Sportschaden 13(2) (1999) 38-52.

39. A.I. Marchenkova, A.L. Marchenkov, Problemy travmatizma v processe obucheniya horeograficheskomu iskusstvu [Problems of injuries in the process of teaching choreographic art] Pedagogika: tradicii i innovacii [Pedagogy: traditions and innovations], 2012, pp. 172- 174 (In Russian).

40. M. Benjamin, T. Kumai, S. Milz, B.M. Boszczyk, A.A. Boszczyk, J.R. Ralphs, The skeletal attachment of tendons–tendon “entheses”, Comp Biochem Physiol A Mol Integr Physiol 133(4) (2002) 931-45.

41. J. Dorfl, Migration of tendinous insertions. I. Cause and mechanism, J Anat 131(Pt 1) (1980) 179-95.

42. J.D. Fogle, A.C. Jannings, M.T. Gross, R.A. Scheuring, J. Crist, Concerns About Ankle Injury Prophylaxis and Acceptance of the Parachute Ankle Brace Among Jumpmaster Students, Mil Med 183(5-6) (2018) e135-e139.

43. H. Reid, S. Wood, Achilles Tendinopathy: Advice and Management. https://www.ouh.nhs.uk/patient-guide/ leaflets/files/11924Ptendinopathy.pdf Oxford University Hospitals NHS Foundation Trust (2015).

44. U. Bilkay, C. Tokat, E. Helvaci, C. Ozek, O. Zekioglu, T. Onat, E. Songur, Osteogenic capacities of tibial and cranial periosteum: a biochemical and histologic study, J Craniofac Surg 19(2) (2008) 453-8.

45. M. Benjamin, B. Moriggl, E. Brenner, P. Emery, D. McGonagle, S. Redman, The “enthesis organ” concept: why enthesopathies may not present as focal insertional disorders, Arthritis & Rheumatism 50(10) (2004) 3306-3313.

46. M. Benjamin, D. McGonagle, Basic concepts of enthesis biology and immunology, J Rheumatol Suppl 83 (2009) 12-3.

47. M. Nordin, N. Kahanovitz, R. Verderame, M. Parnianpour, S. Yabut, K. Viola, N. Greenidge, M. Mulvihill, Normal trunk muscle strength and endurance in women and the effect of exercises and electrical stimulation. Part 1: Normal endurance and trunk muscle strength in 101 women, Spine 12(2) (1987) 105-11.

48. G. Li, L. Wan, M. Kozanek, Determination of real-time in-vivo cartilage contact deformation in the ankle joint, J Biomech 41(1) (2008) 128-36.

49. M. Pitkin, Floating Skeleton Concept. In:, Biomechanics for Life. Introduction to Sanomechanics Springer, Heidelberg, Dordrecht, London, New York, 2011, pp. pp.1-24.

50. K.C. Morrell, W.A. Hodge, D.E. Krebs, R.W. Mann, Corroboration of in vivo cartilage pressures with implications for synovial joint tribology and osteoarthritis causation, Proc Natl Acad Sci U S A 102(41) (2005) 14819-24.

51. N.V. Jaumard, J.A. Bauman, W.C. Welch, B.A. Winkelstein, Pressure measurement in the cervical spinal facet joint: considerations for maintaining joint anatomy and an intact capsule, Spine 36(15) (2011) 1197-1203.

52. M. Pitkin, Biomechanics for Life. Introduction to Sanomechanics: http://www.springer.com/medicine/ orthopedics/book/978-3-642-17176-5, Springer Heidelberg, Dondrecht, London, New York: , 2011.

53. O. Galibin, Sanomechanics and Floating Skeleton Concept for Learning and Teaching Yoga Therapy, J Altern Complement Integr Med 2(1) (2016) http://heraldopenaccess.us/fulltext/Alternative- Co m p l e m e n t a r y – & – I n t e g r a t i v e – M e d i c i n e / Sanomechanics-and-Floating-Skeleton-Concept-for- Learning-and-Teaching-Yoga-Therapy.pdf.

54. M. Pitkin, New Training System – Sanomechanics – Based on the Discovery of Subperiosteal Transmission of Pressures Between Joint Capsules, Military Health System Research Symposium MHSRS-19-00181, Kissime, FL, 2019, p. 182.

55. G. Popov, G. Country, N. Paramonova Fizicheskaya podgotovlennost’ lic, perenesshih amputaciyu nizhnih konechnostej [Physical fitness of persons with amputation of the lower extremities], (2013) (In Russian).

56. V.G. Suslyaev, K.K. Shcherbina, L.M. Smirnova, A.V. Sokurov, T.V. Ermolenko, Novaya medicinskaya tekhnologiya protezirovaniya i fizicheskoj reabilitacii posle amputacii nizhnej konechnosti.[New medical technology, prosthetics and physical rehabilitation after the amputation of the lower limb] Vestnik medicinskogo instituta «Reaviz»: reabilitaciya, vrach i zdorov’e [Bulletin of medical Institute “Reaviz”: rehabilitation, doctor and health] (2 (38)) (2019) (In Russian).

57. J.J. Knapik, S.C. Craig, K.G. Hauret, B.H. Jones, Risk factors for injuries during military parachuting, Aviat Space Environ Med 74(7) (2003) 768-74.