Addressing the gaps: sex differences in osteoarthritis of the knee

An introduction to the accompanying three papers.     

Hormonal modulation of connective tissue homeostasis and sex differences in risk for osteoarthritis of the knee

Young female athletes experience a higher incidence of ligament injuries than their male counterparts, females experience a higher incidence of joint hypermobility syndrome (a risk factor for osteoarthritis development), and post-menopausal females experience a higher prevalence of osteoarthritis than age-matched males. These observations indicate that fluctuating sex hormone levels in young females and loss of ovarian sex hormone production due to menopause likely contribute to observed sex differences in knee joint function and risk for loss of function. In studies of osteoarthritis, however, there is a general lack of appreciation for the heterogeneity of hormonal control in both women and men. Progress in this field is limited by the relatively few preclinical osteoarthritis models, and that most of the work with established models uses only male animals. To elucidate sex differences in osteoarthritis, it is important to examine sex hormone mechanisms in cells from knee tissues and the sexual dimorphism in the role of inflammation at the cell, tissue, and organ levels. There is a need to determine if the risk for loss of knee function and integrity in females is restricted to only the knee or if sex-specific changes in other tissues play a role. This paper discusses these gaps in knowledge and suggests remedies.     

Neural and psychosocial contributions to sex differences in knee osteoarthritic pain

People with osteoarthritis (OA) can have significant pain that interferes with function and quality of life. Women with knee OA have greater pain and greater reductions in function and quality of life than men. In many cases, OA pain is directly related to sensitization and activation of nociceptors in the injured joint and correlates with the degree of joint effusion and synovial thickening. In some patients, however, the pain does not match the degree of injury and continues after removal of the nociceptors with a total joint replacement. Growth of new nociceptors, activation of nociceptors in the subchondral bone exposed after cartilage degradation, and nociceptors innervating synovium sensitized by inflammatory mediators could all augment the peripheral input to the central nervous system and result in pain. Enhanced central excitability and reduced central inhibition could lead to prolonged and enhanced pain that does not directly match the degree of injury. Psychosocial variables can influence pain and contribute to pain variability. This review explores the neural and psychosocial factors that contribute to knee OA pain with an emphasis on differences between the sexes and gaps in knowledge.     

全膝关节置换术治疗骨关节炎

目的 探讨人工全膝关节置换术治疗骨关节病的临床疗效。方法 对31例人工全膝关节置换术进行临床分析和总结,并应用HSS膝关节评分系统进行分析。结果 手术优良率为93．6％,患者术后在疼痛、功能及关节活动度等方面都有明显改善。结论 全膝关节置换术是治疗骨关节病的有效方法。     

Morphometric alteration of femoral condyles due to knee osteoarthritis

Aim of this study was to estimate how knee osteoarthritis (OA) affects the shape of femoral condyles by comparing the radiuses of condylar curves between healthy and OA knees. Seventeen female and five male patients with established diagnosis of knee OA were included in the study. Radiuses of medial and lateral condylar curves were calculated from the side view knee X-ray by original mathematical equation and compared to referent values of healthy knees, after adjusting to body height. The average radiuses of condylar curves were between 52.6 +/- 6.2 and 17.6 +/- 3.5 mm medially, and between 43.3 +/- 8.4 and 15.4 +/- 3.7 mm laterally for 0 degrees and 90 degrees femoral flexion contact points, respectively The OA knees had longer curve radiuses medially and laterally at 0 degrees, 10 degrees, and 20 degrees femoral flexion contact points in comparison to the healthy sample (P < 0.001; t-test). Our results suggest that the shape of the femoral condyles in OA knees is changed. It should be aware not only in researching of OA etiology, but also in designing of knee endoprostheses, in a manner to achieve better individual sizing.     

Rat sex differences in anesthesia

Studies involving substantially lengthy rat surgeries require extended anesthesia periods and often involve use of sodium pentobarbital (PENT). Results of previous experiments from our laboratory and elsewhere suggest that the duration of anesthesia and the need for anesthetic supplementation may differ between male and female rats. In the study reported here, we induced anesthesia in male and female Sprague Dawley rats (n = 10 for each sex), using a three-step procedure: brief induction with 5% isoflurane inhalation, PENT (50 mg/kg of body weight, i.p.), combined with 50 mg of PENT/kg given intragastrically. Adequate anesthesia depth was confirmed by absence of a response to a toe pinch. Plasma PENT concentration was measured at sequential 20-min periods and was found, on average, to be lower (P = 0.03) in male (13.28 +/- 1.13 microg/ml) than in female (20.27 +/- 0.66 microg/ml) rats, and decreased more rapidly (P = 0.003) in male rats. Distribution to a fractionally greater lean body mass and more rapid metabolism in males may account for these differences and explain the need for anesthetic supplementation in male, but not female rats.     

Gender differences in knee stability in response to whole-body vibration

The purpose of this study was to determine whether there are kinematic and electromyographic (EMG) differences between men and women in how the knee is controlled during a single-legged drop landing in response to whole-body vibration (WBV). Forty-five healthy volunteers, 30 men (age 22 ± 3 years; weight 76.8 ± 8.8 kg; height 179.0 ± 6.8 cm) and 15 women (age 22 ± 3 years; weight 61.0 ± 7.7 kg; height 161.9 ± 7.2 cm) were recruited for this study. Knee angles, vertical ground reaction forces, and the time to stabilize the knee were assessed after single-legged drop landings from a 30-cm platform. Surface EMG data in rectus femoris (RF) and hamstrings (H) and knee and ankle accelerometry signals were also acquired. The participants performed 3 pretest landings, followed by a 3-minute recovery and then completed 1 minute of WBV (30 Hz to 4 mm). Before vibration, the female subjects had a significantly higher peak vertical force value, knee flexion angles, and greater H preactivity (EMG(RMS) 50 milliseconds before activation) than did the male subjects. In addition, although not significant, the medial-lateral (ML) acceleration in both knee and ankle was also higher in women. After WBV, no significant differences were found for any of the other variables. However, there was a decrease in the RF to H activation ratio during the precontact phase and an increase in the ratio during the postcontact phase just in women, which leads to a decrement in ML acceleration. The gender differences reported in knee stability in response to WBV underline the necessity to perform specific neuromuscular training programs based on WBV together with instruction of the proper technique, which can assist the clinician in the knee injury prevention.     

Prevention of injury-related knee osteoarthritis: opportunities for the primary and secondary prevention of knee osteoarthritis

Where risk factors have been identified in knee and hip osteoarthritis (OA), with few exceptions, no prevention strategies have proven beneficial. The major risk factors for knee OA are advanced age, injury and obesity. However, there is limited or no evidence that they are modifiable or to what degree modifying them is effective in preventing development of knee OA or in preventing symptoms and progressive disease in persons with early OA. The notable exception is the growing epidemic of (sports) injury related knee OA. This review details the biological and clinical data indicating the efficacy of interventions targeting neuromuscular and biomechanical factors that make this subset of OA an attractive public health target, and highlights research opportunities for the future.     

Mate choice differences according to sex and age

We used 7,415 advertisements published in Spain to analyze traits sought/offered by men and women from different age groups. Findings regarding age, socioeconomic status, and physical attractiveness requirements support evolutionary predictions about mate preferences. However, changes in trait preferences among women under 40 appear to be contingent on Spain’s socioeconomic transformation. Women under 40 seek mainly physical attractiveness in men, whereas those over 40 seek mainly socioeconomic status. The trait most sought by men in all age groups is physical attractiveness. Traits sought and offered by advertisers may be conditioned by the personal situation of the advertiser. Mean age of advertisers (around their forties) and Spain’s social indicators suggest that the majority of advertisers have been unsuccessful in the mating arena at the conventional age.     

Neuromuscular efficiency during sit to stand movement in women with knee osteoarthritis

The purpose of this study was to investigate the neuromuscular efficiency of women with knee osteoarthritis (OA) when performing a sit-to-stand movement and during maximum strength efforts. Twelve women with unilateral knee OA (age 60.33 ± 6.66 years, height 1.61 ± 0.05 m, mass 77.08 ± 9.2 kg) and 11 controls (age 56.54 ± 5.46 years, height 1.64 ± 0.05 m, mass 77.36 ± 13.34 kg) participated in this study. Subjects performed a sit-to-stand movement from a chair while position of center of pressure and knee angular speed were recorded. Furthermore, maximal isokinetic knee extension and flexion strength at 60°/s, 120°/s and 150°/s was measured. Surface, electromyography (EMG) from the biceps femoris (BF), vastus lateralis (VL) and vastus medialis (VM) was recorded during all tests. Analysis of variance (ANOVA) showed that during the sit-to-stand OA group demonstrated significantly lower knee angular speed (44.49 ± 9.61°/s vs. 71.68 ± 19.86°/s), a more posterior position of the center of pressure (39.20 ± 7.02% vs. 41.95 ± 2.49%) and a higher antagonist BF activation (57.13 ± 20.55% vs. 32.01 ± 19.5%) compared with controls (p < 0.05). Further, women with knee OA demonstrated a lower Moment-to-EMG ratio than controls in extension and eccentric flexion at 60°/s and 150°/s, while the opposite was found for concentric flexion at 60°/s (p < 0.05). Among other factors, the slower performance of the sit-to-stand movement in women with OA is due to a less efficient use of the knee extensor muscles (less force per unit of EMG) and, perhaps, a higher BF antagonist co-activation. This may lead subjects with OA to adopt a different movement strategy compared with controls.     

Fundamental subchondral bone changes in spontaneous knee osteoarthritis

Osteoarthritis has an unknown aetiology, and tissue samples from early stage human osteoarthritis tissue cannot be reliably obtained. Therefore understanding the development of OA relies on using animal models: such as the spontaneous changes seen in the Dunkin-Hartley guinea pig strain, which are biochemically, histologically and radiologically similar to human OA. We investigated the role of bone change in early OA development using the non-OA developing Bristol strain-2 as control from 3 to 36 weeks by standard microfocal X-ray imaging and histological techniques. The patella, tibia and femur epiphyseal region and immediate subchondral area were analysed for bone density at all ages. We found that both radiological and histological osteoarthritis scores increased progressively for the Dunkin-Hartley, but not for the BS2 demonstrating its value as a control. The Dunkin-Hartley had a higher bone density and greater subchondral bone thickness from 24 weeks of age. We conclude that prior to any gross osteoarthritis pathology the Dunkin-Hartley are undergoing subchondral bone remodelling, thus demonstrating the fundamental role of early bone remodelling in the development of osteoarthritis.     

Stage-specific sex differences in Drosophila immunity to parasites and pathogens

Arguments from life-history theory predict that other things being equal females are likely to invest more in defence against parasites and pathogens than males. This is either because males and females differ in behaviour or, more importantly, because the variance in mating success is typically higher in males than in females. Such effects are likely to be most pronounced in those developmental stages where sex differences are greatest. In most organisms, but especially in holometabolous insects, this will be the adult stage. We explored sex-specific resistance to four natural enemies of Drosophila melanogaster that attack the insect at different developmental stages: the larval parasitoid Asobara tabida, the pupal parasitoid Pachycrepoideus vindemiae; and the adult pathogens Beauvaria bassiana (a fungus) and Tubulinosema kingi (a microsporidian). Measures of resistance were designed to reflect the four species’ natural history. Female larvae were able to defend themselves more strongly against A. tabida than males and there was weak evidence that adult females suffered less from microsporidian attack than males. No differences were found for the other two species. Our results provide some support for lower investment in defences in males, and we discuss why the strongest effect was found at the larval rather than the adult stage contrary to our prediction.     

On sex differences in sexual imprinting

Several studies have reported sex differences in the relation between early experience and later pair formation. These differences are usually ascribed to sex differences in ‘imprintability’. This interpretation has given rise to various functional explanations. In this article the evidence for both the existence of sex differences in imprintability (i.e. learning of plumage characteristics during juvenile life) and the functional explanations of these differences are critically examined. It is concluded that the existence of sex differences in imprintability has not been proved. Recent studies indicate that sex differences may be the result of a difference in the way both sexes weigh multiple criteria on which mate choice is based. It is suggested that more attention should be given to a causal and ontogenetic analysis of these criteria for an understanding of sex differences in mate choice. The function of sex differences found in imprinting studies seems not to be related to plumage differences between sexes but may be related to sex differences in optimal mate choice.     

On sex differences in optimal immunity

Sex biases in immunity have generated much interest because of their possible connection with sex differences in reproductive strategies. Researchers have often argued that males should invest less in immunity than should females. In a recent paper, Stoehr and Kokko challenge this reasonably substantiated view of 'susceptible males'. Their model, and another by Medley, helps highlight relevant tests that could explain other important sources of within-species variation in immunity and its importance to parasitism.     

Assessment of paraoxonase activities in patients with knee osteoarthritis

The objective of this study was to investigate serum paraoxonase and arylesterase activities, and lipid hydroperoxide (LOOH) and total thiol (total free sulfhydryl groups, -SH) levels along with lipid parameters in patients with knee osteoarthritis. Thirty-six patients with knee osteoarthritis and 30 healthy individuals were enrolled in the study. Serum paraoxonase and arylesterase activities were measured spectrophotometrically. LOOH levels were measured by ferrous oxidation with xylenol orange assay (FOX-2). Serum high-density lipoprotein-cholesterol (HDL-C), -SH levels, paraoxonase and arylesterase activities were significantly lower in the patient group than those in the controls (P < 0.05, for all), while LOOH and low-density lipoprotein (LDL) levels were significantly higher. In conclusion, paraoxonase and arylesterase activities were decreased significantly in patients with knee osteoarthritis. Lower serum paraoxonase-1 activity and lower level of HDL-C seem to be related to increased oxidative stress and inflammatory condition in these patients. It is known that paraoxonases reduce oxidative stress in serum and tissues thereby protecting against cardiovascular disease, particularly atherosclerosis. Thus, decreased paraoxonase and arylesterase activities play a role in the pathogenesis of atherosclerosis through increased susceptibility to lipid peroxidation in patients with osteoarthritis.     

Understanding the biology of sex and gender differences: using subgroup analysis and statistical design to detect sex differences in clinical trials

In May 2000, a General Accounting Office (GAO) report revealed that although women are now participating in clinical trials in numbers proportionate to their numbers in the general population, data collected in these trials are not routinely analyzed by sex.[1] Without such sex analysis, clinically relevant information about potentially lifesaving treatments could be lost. In July 2001, the Society for Women's Health Research convened a workshop to address strategies for conducting subgroup analyses to detect sex differences. Workshop participants concluded that understanding sex differences will enable medical researchers to design healthcare interventions for both men and women more effectively and that one can plan for and conduct sex analysis without compromising the quality of the study or making the study prohibitively expensive.     

A new approach to study the sex differences in adipose tissue

Obesity is one of the most invaliding and preventable diseases in the United States. Growing evidence suggests that there are sex differences in obesity in human and experimental animals. However, the specific mechanisms of this disease are unknown. Consequently, there is any particular treatment according to the sex/gender at this time. During the last decade, we observe a rise in the study of adipocyte and the possible mechanisms involved in the different roles of the fat. Furthermore, the effect of sex steroids on the adipocyte is one of the fields that need elucidation. Supporting evidence suggests that sex steroids play an essential role not only in the fat distribution, but also, in its metabolism, proliferation, and function. Thus, using in vitro and in vivo studies will contribute to our fight against this critical health public problem encompassing both sexes. In the present review, we discuss some of the recent advances in the adipocytes and the effect of the sex steroids on the adipose tissue. Also, we propose a new alternative to study the role of sex steroids on adipocyte biology through human adipose-derived stem cells.     

Using lod scores to detect sex differences in male-female recombination fractions

Human recombination fraction (RF) can differ between males and females, but investigators do not always know which disease genes are located in genomic areas of large RF sex differences. Knowledge of RF sex differences contributes to our understanding of basic biology and can increase the power of a linkage study, improve gene localization, and provide clues to possible imprinting. One way to detect these differences is to use lod scores. In this study we focused on detecting RF sex differences and answered the following questions, in both phase-known and phase-unknown matings: (1) How large a sample size is needed to detect a RF sex difference? (2) What are "optimal" proportions of paternally vs. maternally informative matings? (3) Does ascertaining nonoptimal proportions of paternally or maternally informative matings lead to ascertainment bias? Our results were as follows: (1) We calculated expected lod scores (ELODs) under two different conditions: "unconstrained," allowing sex-specific RF parameters (theta(female), theta(male)); and "constrained," requiring theta(female) = theta(male). We then examined the DeltaELOD (identical with difference between maximized constrained and unconstrained ELODs) and calculated minimum sample sizes required to achieve statistically significant DeltaELODs. For large RF sex differences, samples as small as 10 to 20 fully informative matings can achieve statistical significance. We give general sample size guidelines for detecting RF differences in informative phase-known and phase-unknown matings. (2) We defined p as the proportion of paternally informative matings in the dataset; and the optimal proportion p(circ) as that value of p that maximizes DeltaELOD. We determined that, surprisingly, p(circ) does not necessarily equal (1/2), although it does fall between approximately 0.4 and 0.6 in most situations. (3) We showed that if p in a sample deviates from its optimal value, no bias is introduced (asymptotically) to the maximum likelihood estimates of theta(female) and theta(male), even though ELOD is reduced (see point 2). This fact is important because often investigators cannot control the proportions of paternally and maternally informative families. In conclusion, it is possible to reliably detect sex differences in recombination fraction.