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INTRODUCTION. The current cell-based cartilage repair methods, such as autologous chondrocyte transplantation, are not sufficiently effective, and the surgery is painful and traumatic. Therefore, there is a need for a more effective cell therapy product with a minimally invasive surgical procedure for its implantation into the patient.AIM. This study aimed to develop a manufacturing technology for the production of an autologous cell-based medicinal product (CBMP) comprising three-dimensional structures (3D-spheroids) based on chondrocytes isolated from the patient’s cartilage tissue, as well as to evaluate its clinical efficacy.MATERIALS AND METHODS. Autologous chondrocytes isolated from the patient’s cartilage biopsy were propagated in monolayer culture to obtain the required number of cells. Subsequently, the chondrocytes were cultivated on plates with a non-adhesive coating to form 3D spheroids. All CBMP production steps were performed under aseptic conditions in cell culture isolators. The authors used phase-contrast microscopy and immunohistochemical staining with specific fluorescence-labelled antibodies to characterise chondrocyte phenotypes at different stages of cultivation. Genetic stability was controlled by karyotyping. The efficacy of Easytense® was evaluated in a clinical trial using specialised functional tests and the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. The primary efficacy endpoint was a change in the overall score on the Knee Injury and Osteoarthritis Outcome Score (KOOS).RESULTS. A manufacturing technology without using animal sera, growth factors, cytokines, or other additives was developed for the production of the autologous CBMP Easytense®. Karyological data confirmed that the chondrocytes retained genetic stability for 3 passages in monolayer culture. When cultured as 3D spheroids, the chondrocytes produced cartilage extracellular matrix proteins (type II collagen, aggrecan), thus acquiring the ability to repair damaged cartilage. The clinical trial demonstrated a statistically significant improvement in knee cartilage 12 months after the transplantation of 3D spheroids derived from autologous chondrocytes. The mean change in the overall KOOS score was 23.8±15.9.CONCLUSIONS. The clinical trial results indicate that Easytense® is highly effective for cartilage repair. Based on these results, the CBMP has been granted marketing authorisation and introduced into clinical practice in the Russian Federation. Easytense® has the potential to replace endoprosthetics and expensive surgeries abroad.

BackgroundThe self-assembling process of cartilage tissue engineering is a promising technique to heal cartilage defects, preventing osteoarthritic changes. Given that chondrocytes dedifferentiate when expanded, it is not known if cellular expansion affects the development of self-assembled neocartilage. The objective of this study was to use proteomic, mechanical, and biochemical analyses to quantitatively investigate the development of self-assembled neocartilage derived from passaged, rejuvenated costal chondrocytes.MethodsYucatan minipig costal chondrocytes were used to create self-assembled neocartilage constructs. After 1, 4, 7, 14, 28, 56, or 84 days of self-assembly, constructs were analyzed through a variety of histological, biomechanical, biochemical, and proteomic techniques.ResultsIt was found that temporal trends in neocartilage formation are similar to those seen in native hyaline articular cartilage development. For example, between days 7 and 84 of culture, tensile Young's modulus increased 4.4-times, total collagen increased 2.7-times, DNA content decreased 69.3%, collagen type II increased 1.5-times, and aggrecan dropped 55.3%, mirroring trends shown in native knee cartilage. Importantly, collagen type X, which is associated with cartilage calcification, remained at low levels (≤ 0.05%) at all neocartilage developmental time points, similar to knee cartilage (

PurposeTo validate the potential of quantifying R2 -R1ρ using one pair of signals with T1ρ preparation and T2 preparation incorporated to magnetization-prepared angle-modulated partitioned k-space spoiled gradient-echo snapshots (MAPSS) acquisition and to find an optimal preparation time (Tprep ) for in vivo knee MRI.MethodsBloch equation simulations were first performed to assess the accuracy of quantifying R2 -R1ρ using T1ρ - and T2 -prepared signals with an equivalent Tprep . For validation of this technique in comparison to the conventional approach that calculates R2 -R1ρ after estimating both T2 and T1ρ , phantom experiments and in vivo validation with five healthy subjects and five osteoarthritis patients were performed at a clinical 3T scanner.ResultsBloch equation simulations demonstrated that the accuracy of this efficient R2 -R1ρ quantification method and the optimal Tprep can be affected by image signal-to-noise ratio (SNR) and tissue relaxation times, but quantification can be closest to the reference with an around 25 ms Tprep for knee cartilage. Phantom experiments demonstrated that the proposed method can depict R2 -R1ρ changes with agarose gel concentration. With in vivo data, significant correlation was observed between cartilage R2 -R1ρ measured from the conventional and the proposed methods, and a Tprep of 25.6 ms provided the most agreement by Bland-Altman analysis. R2 -R1ρ was significantly lower in patients than in healthy subjects for most cartilage compartments.ConclusionAs a potential biomarker to indicate cartilage degeneration, R2 -R1ρ can be efficiently measured using one pair of T1ρ -prepared and T2 -prepared signals with an optimal Tprep considering cartilage relaxation times and image SNR.

Objective: Compositional-MRI parameters enable the assessment of cartilage ultrastructure. Correlation of these parameters with clinical outcomes is unclear. This systematic review investigated the correlation of various compositional- MRI parameters with clinical outcome measures following cartilage repair or regeneration interventions in the knee. Design: This study was registered with PROSPERO and reported in accordance with PRISMA. PubMed, Institute of Science Index, Scopus, Cochrane Central Register of Controlled Trials, and Embase databases were searched. All studies, regardless of type, that presented correlation of compositional- MRI parameters with clinical outcome measures were included. Two researchers independently performed data extraction and QUADAS-2 analysis. Compositional-MRI parameter change following intervention and correlation with clinical outcome measures were evaluated. Results: 19 studies were included. Risk of bias was generally low. 5 different compositional parameters were observed from the included studies. However, due to the significant variability in the reporting of compositional-MRI parameters across studies, meta-analyses were possible only for T2 values and T2 index values (T2 value of repair cartilage relative to normal cartilage). Correlation of T2 values of repair cartilage with clinical outcome score was r ​= ​0.33 [0.15, 0.52]. Correlation of T2 index with clinical outcome score was r ​= ​0.52 [0.32, 0.77]. Conclusions: Correlation between T2 values and clinical outcome scores following knee cartilage repair were found. The heterogeneity of the correlations extracted from the included studies limited the scope for the meta-analysis. Thus, standardised, high-quality studies are required for better assessment of correlation between compositional MRI parameters and clinical outcome measures after cartilage repair. Registration number: PROSPERO CRD42021287364.Study protocol available on PROSPERO website.

Osteoarthritis is the most common degenerative joint disorder. MicroRNAs are gene expression regulators that act post-transcriptionally to control tissue homeostasis. Microarray analysis was undertaken in osteoarthritic intact, lesioned and young intact cartilage. Principal component analysis showed that young intact cartilage samples were clustered together; osteoarthritic samples had a wider distribution; and osteoarthritic intact samples were separated into two subgroups, osteoarthritic-Intact-1 and osteoarthritic-Intact-2. We identified 318 differentially expressed microRNAs between young intact and osteoarthritic lesioned cartilage, 477 between young intact and osteoarthritic-Intact-1 cartilage and 332 between young intact and osteoarthritic-Intact-2 cartilage samples. For a selected list of differentially expressed microRNAs, results were verified in additional cartilage samples using qPCR. Of the validated DE microRNAs, four—miR-107, miR-143-3p, miR-361-5p and miR-379-5p—were selected for further experiments in human primary chondrocytes treated with IL-1β. Expression of these microRNAs decreased in human primary chondrocytes treated with IL-1β. For miR-107 and miR-143-3p, gain- and loss-of-function approaches were undertaken and associated target genes and molecular pathways were investigated using qPCR and mass spectrometry proteomics. Analyses showed that WNT4 and IHH, predicted targets of miR-107, had increased expression in osteoarthritic cartilage compared to young intact cartilage and in primary chondrocytes treated with miR-107 inhibitor, and decreased expression in primary chondrocytes treated with miR-107 mimic, suggesting a role of miR-107 in chondrocyte survival and proliferation. In addition, we identified an association between miR-143-3p and EIF2 signalling and cell survival. Our work supports the role of miR-107 and miR-143-3p in important chondrocyte mechanisms regulating proliferation, hypertrophy and protein translation. [ABSTRACT FROM AUTHOR]

BackgroundThe variation in articular cartilage thickness (ACT) in healthy knees is difficult to quantify and therefore poorly documented. Our aims are to (1) define how machine learning (ML) algorithms can automate the segmentation and measurement of ACT on magnetic resonance imaging (MRI) (2) use ML to provide reference data on ACT in healthy knees, and (3) identify whether demographic variables impact these results.MethodsPatients recruited into the Osteoarthritis Initiative with a radiographic Kellgren-Lawrence grade of 0 or 1 with 3D double-echo steady-state MRIs were included and their gender, age, and body mass index were collected. Using a validated ML algorithm, 2 orthogonal points on each femoral condyle were identified (distal and posterior) and ACT was measured on each MRI. Site-specific ACT was compared using paired t-tests, and multivariate regression was used to investigate the risk-adjusted effect of each demographic variable on ACT.ResultsA total of 3910 MRI were included. The average femoral ACT was 2.34 mm (standard deviation, 0.71; 95% confidence interval, 0.95-3.73). In multivariate analysis, distal-medial (-0.17 mm) and distal-lateral cartilage (-0.32 mm) were found to be thinner than posterior-lateral cartilage, while posterior-medial cartilage was found to be thicker (0.21 mm). In addition, female sex was found to negatively impact cartilage thickness (OR, -0.36; all values: P < .001).ConclusionML was effectively used to automate the segmentation and measurement of cartilage thickness on a large number of MRIs of healthy knees to provide normative data on the variation in ACT in this population. We further report patient variables that can influence ACT. Further validation will determine whether this technique represents a powerful new tool for tracking the impact of medical intervention on the progression of articular cartilage degeneration.

Abstract Background The self-assembling process of cartilage tissue engineering is a promising technique to heal cartilage defects, preventing osteoarthritic changes. Given that chondrocytes dedifferentiate when expanded, it is not known if cellular expansion affects the development of self-assembled neocartilage. The objective of this study was to use proteomic, mechanical, and biochemical analyses to quantitatively investigate the development of self-assembled neocartilage derived from passaged, rejuvenated costal chondrocytes. Methods Yucatan minipig costal chondrocytes were used to create self-assembled neocartilage constructs. After 1, 4, 7, 14, 28, 56, or 84 days of self-assembly, constructs were analyzed through a variety of histological, biomechanical, biochemical, and proteomic techniques. Results It was found that temporal trends in neocartilage formation are similar to those seen in native hyaline articular cartilage development. For example, between days 7 and 84 of culture, tensile Young’s modulus increased 4.4-times, total collagen increased 2.7-times, DNA content decreased 69.3%, collagen type II increased 1.5-times, and aggrecan dropped 55.3%, mirroring trends shown in native knee cartilage. Importantly, collagen type X, which is associated with cartilage calcification, remained at low levels (≤ 0.05%) at all neocartilage developmental time points, similar to knee cartilage (

PURPOSE:To assess changes in the patterns of T2 and T1rho values within grade 1 cartilage lesions of osteoarthritis (OA) patients compared to healthy controls. MATERIALS AND METHODS:Twenty healthy knees and 25 OA knees were examined on a 3 T scanner. Areas of signal heterogeneity within the cartilage of the distal femur were identified using fat suppressed proton density-weighted imagines. T2 and T1rho values in each OA patient with grade 1 lesions were compared to average T2 and T1rho values of the corresponding areas in healthy subjects. RESULTS:A total of 28 areas including grade 1 lesion were identified. Compared to normal cartilage, the majority of grade 1 cartilage lesions demonstrated either no significant change or a statistically significant increase in both T2 values (18/28, 64%) and T1rho values (23/28, 82%). Compared to T2, T1rho demonstrated a greater proportion of statistically significantly higher values in OA patients than those from the normal controls. However, T2 and T1rho values in grade 1 lesions can be decreased, or demonstrate mixed patterns compared to those in healthy cartilage. CONCLUSION:Our results suggest that early degenerative cartilage lesions can demonstrate various patterns of T2 and T1rho changes.

Objectives: To compare co-expression networks of normal and osteoarthritis knee cartilage to uncover molecules associated with the transcriptional misregulation compromising biological processes (BPs) critical for cartilage homeostasis. Design: Normal and osteoarthritis human knee cartilage RNA-seq GSE114007 dataset was obtained from the Gene Expression Omnibus database. Partial Correlation and Information Theory (PCIT) algorithm was used to build co-expression networks containing all nodes connecting to at least one differentially expressed gene (DEG) in normal and osteoarthritis networks. Hub and hub centrality genes were used to perform functional enrichment analysis. Enriched BPs known to be associated with both healthy and diseased cartilage were compared in depth. Results: Differential co-expression network analyses allowed the identification of DDX43 and USP42 as exclusively co-expressed with DEGs in normal and osteoarthritis networks, respectively. The top hub and hub centrality genes of these networks were HIST1H3A and SNHG12 (normal) and TAF9B and OTUD1 (osteoarthritis). Enrichment analysis revealed several shared BPs between the contrasting groups, which are well-known in osteoarthritis pathogenesis. Protein-protein interaction network analysis for these BPs showed a global down-regulation of transcription factors in osteoarthritis. Specific transcription factors were identified as pleiotropic mediators in articular cartilage maintenance since they take part in several BPs. In addition, chromatin organisation and modification proteins were found relevant for osteoarthritis development. Conclusion: Differential gene co-expression analysis allowed the identification of novel and high priority therapeutic candidate genes that may drive modifications in the transcriptional “status” of cartilage in osteoarthritis.

Purpose of Review: The role of the meniscus in preserving the biomechanical function of the knee joint has been clearly defined. The hypothesis that meniscus root integrity is a prerequisite for meniscus function is supported by the development of progressive knee osteoarthritis (OA) following meniscus root tears (MRTs) treated either non-operatively or with meniscectomy. Consequently, there has been a resurgence of interest in the diagnosis and treatment of MRTs. This review examines the contemporary literature surrounding the natural history, clinical presentation, evaluation, preferred surgical repair technique and outcomes. Recent Findings: Surgeons must have a high index of suspicion in order to diagnose a MRT because of the nonspecific clinical presentation and difficult visualization on imaging. Compared with medial MRTs that commonly occur in middle age/older patients, lateral meniscus root injuries tend to occur in younger males with lower BMIs, less cartilage degeneration, and with concomitant ligament injury. Subchondral insufficiency fractures of the knee have been found to be associated with both MRTs and following arthroscopic procedures. Meniscus root repair has demonstrated good outcomes, and acute injuries with intact cartilage should be repaired. Cartilage degeneration, BMI, and malalignment are important considerations when choosing surgical candidates. Meniscus centralization has emerged as a viable adjunct strategy aimed at correcting meniscus extrusion. Summary: Meniscus root repair results in a decreased rate of OA and arthroplasty and is economically advantageous when compared with nonoperative treatment and partial meniscectomy. The transtibial pull-through technique with the addition of centralization for the medial meniscus is associated with encouraging early results. [ABSTRACT FROM AUTHOR]

Magnetic resonance imaging (MRI) is a technique useful for the diagnosis of cartilage damage due to high sensitivity to identify subchondral bone abnormalities and full-thickness cartilage lesions. The lack of a study on knee cartilage changes over time in patients with osteoarthritis (OA) by MRI technique led us to investigate the accuracy of MRI in identifying knee cartilage changes over time in patients with OA in a systematic review. In the present systematic review, started from the beginning of 2020 in one of the University Hospitals in Iran, the databases of CINAHL, Ovid, Elsevier, Scopus, PubMed, Science Direct, and Web of Science were searched using the keywords MRI, OA, Cartilage Lesion, Imaging Techniques. A total of 169 articles were retrieved in the initial search, and after reviewing the titles, abstracts, and full-texts, finally, seven were enrolled in the systematic review. Review of the selected papers showed that a total of 1091 subjects were studied, of which 355 were males. The results of all the studies, except one, indicated the high accuracy of MRI to identify knee cartilage changes over time. MRI technique can show cartilage changes with high accuracy in patients with knee OA over time. We proved the potential of MRI to identify articular cartilage injuries in patients with OA and its importance to the evaluation of articular cartilage lesions along with other available techniques. [ABSTRACT FROM AUTHOR]

Articular cartilage defects in the knee and ankle are frequently seen in football (soccer) players and are often a result of trauma, but occasionally are the consequence of occult underlying conditions such as osteochondritis dissecans. Symptoms such as pain, swelling, and inability to ramp up may limit an athlete's performance and ability to compete. Initial evaluation includes a careful history and physical exam, including assessment of overall limb and joint alignment, ligamentous stability, meniscal damage, as well as associated degenerative change. Though nonoperative management serves as the mainstay for treatment in high-level athletes, surgical options are indicated in situations where symptoms persist. Osteochondral allograft (OCA) transplantation, in particular, allows for restoration of hyaline cartilage with predictable healing and accelerated return to activity. With appropriate indications and surgical technique, graft survival following OCA transplantation can exceed 90% at 10 years postoperatively, allow for predictable (70%-80%) return to sport, and produce clinically meaningful improvements in patient-reported outcomes. Full return to sports is often possible between 4 and 10 months postoperatively. Careful attention to postoperative rehabilitation and strength progression prior to return to sport is imperative to prevent graft overload, joint inflammation, or secondary injury to other knee structures such as meniscus or ligamentous structures. This article reviews the overall indications, technique, and outcomes of OCA transplantation in the athletic population.

Objective: Osteoarthritis (OA) is a multifactorial musculoskeletal disorder affecting mostly weight-bearing joints. Chondrocyte response to load is modulated by inflammatory mediators and factors involved in extracellular cartilage matrix (ECM) maintenance, but regulatory mechanisms are not fully clarified yet. By using a recently proposed experimental model combining biomechanical data with cartilage molecular information, basally and following ex-vivo load application, we aimed at improving the understanding of human cartilage response to cyclic mechanical compressive stimuli by including cartilage original anatomical position and OA degree as independent factors.Methods: 19 mono-compartmental Knee OA patients undergoing total knee replacement were recruited. Cartilage explants from four different femoral condyles zones and with different degeneration levels were collected. The response of cartilage samples, pooled according to OA score and anatomical position was tested ex-vivo in a bioreactor. Mechanical stimulation was obtained via a 3-MPa 1-Hz sinusoidal compressive load for 45-min to replicate average knee loading during normal walking. Samples were analysed for chondrocyte gene expression and ECM factor release.Results: Non parametric univariate and multivariate (generalized linear mixed model) analysis was performed to evaluate the effect of compression and IL-1β stimulation in relationship to the anatomical position, local disease severity and clinical parameters with a level of significance set at 0.05. We observed an anti-inflammatory effect of compression inducing a significant downmodulation of IL-6 and IL-8 levels correlated to the anatomical regions, but not to OA score. Moreover, ADAMTS5, PIICP, COMP and CS were upregulated by compression, whereas COL-2CAV was downmodulated, all in relationship to the anatomical position and to the OA degree.Conclusion: While unconfined compression testing may not be fully representative of the in-vivo biomechanical situation, this study demonstrates the importance to consider the original cartilage anatomical position for a reliable biomolecular analysis of knee OA metabolism following mechanical stimulation.

Osteoarthritis is the most common degenerative joint disorder. MicroRNAs are gene expression regulators that act post-transcriptionally to control tissue homeostasis. Microarray analysis was undertaken in osteoarthritic intact, lesioned and young intact cartilage. Principal component analysis showed that young intact cartilage samples were clustered together; osteoarthritic samples had a wider distribution; and osteoarthritic intact samples were separated into two subgroups, osteoarthritic-Intact-1 and osteoarthritic-Intact-2. We identified 318 differentially expressed microRNAs between young intact and osteoarthritic lesioned cartilage, 477 between young intact and osteoarthritic-Intact-1 cartilage and 332 between young intact and osteoarthritic-Intact-2 cartilage samples. For a selected list of differentially expressed microRNAs, results were verified in additional cartilage samples using qPCR. Of the validated DE microRNAs, four—miR-107, miR-143-3p, miR-361-5p and miR-379-5p—were selected for further experiments in human primary chondrocytes treated with IL-1β. Expression of these microRNAs decreased in human primary chondrocytes treated with IL-1β. For miR-107 and miR-143-3p, gain- and loss-of-function approaches were undertaken and associated target genes and molecular pathways were investigated using qPCR and mass spectrometry proteomics. Analyses showed that WNT4 and IHH, predicted targets of miR-107, had increased expression in osteoarthritic cartilage compared to young intact cartilage and in primary chondrocytes treated with miR-107 inhibitor, and decreased expression in primary chondrocytes treated with miR-107 mimic, suggesting a role of miR-107 in chondrocyte survival and proliferation. In addition, we identified an association between miR-143-3p and EIF2 signalling and cell survival. Our work supports the role of miR-107 and miR-143-3p in important chondrocyte mechanisms regulating proliferation, hypertrophy and protein translation.

Background: While an excellent option for osteochondral defects in the adult knee, fresh osteochondral allograft (FOCA) in the skeletally immature adolescent knee has been infrequently studied. Purpose: To compare radiographic and patient-reported outcomes (PROs) in skeletally mature and immature adolescents after FOCA in the knee for treatment of unsalvageable osteochondritis dissecans (OCD). Study Design: Cohort study; Level of evidence, 3. Methods: Included were 34 patients (37 knees) who underwent size-matched FOCA of the knee for unsalvageable OCD lesions. All patients were aged ≤19 years and had a minimum of 12 months of follow-up. Patient characteristics, lesion characteristics, reoperations, and PROs were evaluated and compared between patients with open physes (skeletally immature; n = 20) and those with closed physes (skeletally mature; n = 17). Graft failure was defined as the need for revision osteochondral grafting. Postoperative radiographs were analyzed at 1 year and the final follow-up for graft incorporation and classified as A (complete), B (≥50% healed), or C (<50% healed). Results: The mean patient age was 15.4 years (range, 9.6-17.6 years), and the mean follow-up was 2.1 years (range, 1-5.3 years). The mean graft size was 5.0 cm2 and did not differ significantly between the study groups. Patients with open physes were younger (14.7 vs 16.2 years; P =.002) and more commonly male (80% vs 35%; P =.008). At the 1-year follow-up, 85% of immature patients and 82% of mature patients had radiographic healing grades of A or B. Patients with open physes were more likely to achieve complete radiographic union at 1 year (65% vs 15%; P =.007) and demonstrated better Knee injury and Osteoarthritis Outcome Score (KOOS) Daily Living (96.8 vs 88.5; P =.04) and KOOS Quality of Life (87.0 vs 56.8; P =.01) at the final follow-up. Complications were no different in either group, and graft failure occurred in only 1 skeletally mature patient with a trochlear lesion. Conclusion: FOCA treatment for unsalvageable OCD in the young knee may be expected to yield excellent early results. Despite the presence of open physes and immature epiphyseal osteochondral anatomy, equivalent or improved healing and PRO scores compared with those of skeletally mature patients may be expected. [ABSTRACT FROM AUTHOR]

ObjectivesTo investigate the change in cartilage T2 values and structural degeneration in knee joints over 72 months in women of African American (AA) vs Caucasian American (CA) ethnicity.MethodsKnee 3T magnetic resonance imaging (MRIs) from baseline, 24, 48 and 72 months visits of 100 AA and 100 CA women from the Osteoarthritis Initiative (OAI) were assessed for cartilage T2 values and whole-organ magnetic resonance imaging (WORMS) score. Subjects were pair-matched by age, body mass index (BMI), Kellgren-Lawrence (KL) score, clinical site and subcohort within the OAI. We compared the rate of change in whole knee cartilage T2 values and WORMS cartilage, bone marrow edema pattern (BMEP) and meniscus scores between the two ethnic groups using mixed random effects models.ResultsAt 24 and 48 months 60 subjects and at 72 months 45 subjects per group were available for analysis resulting in 38 complete pairs with data of all time points. Compared to CA, cartilage T2 values in AA increased at a significantly faster rate at baseline (AA: 0.45 ms/y, CA: 0.35 ms/y, P = 0.029) and averaged over 6 years (AA: 0.36 ms/y, CA: 0.27 ms/y, P = 0.039) with changes in both groups reaching a plateau by 48 months. Cartilage, meniscus and BMEP scores tended to increase in both groups during follow up, but rates of change did not differ by ethnicity.ConclusionCartilage T2 values increased faster over 72 months in AA than CA, however changes in WORMS cartilage, meniscus and BMEP scores did not differ. T2 values may be able to distinguish ethnicity-related differences of cartilage degeneration at an early stage before differences in structural joint degeneration appear.

PurposeTo develop and compare with the classical region of interest (ROI)-based approach a fully automatic, local, and unbiased way of studying the knee T1ρ relaxation time by creating an atlas and using voxel-based relaxometry (VBR) in osteoarthritis (OA) and anterior cruciate ligament (ACL) subjects.Materials and methodsIn this study 110 subjects from two cohorts: 1) Mild OA 40 patients with mild-OA Kellgren-Lawrence (KL) ≤ 2 and 15 controls KL ≤ 1; 2) ACL cohort (a model for early OA): 40 ACL-injured patients imaged prior to ACL reconstruction and 1-year postsurgery and 15 controls are analyzed. All the subjects were acquired at 3T with a protocol that includes: 3D-FSE (CUBE) and 3D-T1ρ . A nonrigid registration technique was applied to align all the images on a single template. This allows for performing VBR to assess local statistical differences of T1ρ values using z-score analysis. VBR results were compared with those obtained with classical ROI-based technique.ResultsROI-based results from atlas-based segmentation were consistent with classical ROI-based method (coefficient of variation [CV] = 3.83%). Voxel-based group analysis revealed local patterns that were overlooked by the ROI-based approach; eg, VBR showed posterior lateral femur and posterior lateral tibia significant T1ρ elevations in ACL-injured patients (sample mean z-score=9.7 and 10.3). Those elevations were overlooked by the classical ROI-based approach (sample mean z-score=1.87 and -1.73) CONCLUSION: VBR is a feasible and accurate tool for the local evaluation of the biochemical composition of knee articular cartilage. VBR is capable of detecting specific local patterns on T1ρ maps in OA and ACL subjects.

Osteoarthritis (OA) is one of the most prevalent disorders in today’s society, resulting in significant socio-economic costs and morbidity. MRI is widely used as a non-invasive imaging tool for OA of the knee. However, conventional knee MRI has limitations to detect subtle early cartilage degeneration before morphological changes are visually apparent. Novel MRI pulse sequences for cartilage assessment have recently received increased attention due to newly developed compositional MRI techniques, including: T2 mapping, T1rho mapping, delayed gadolinium-enhanced MRI of cartilage (dGEMRIC), sodium MRI, diffusion-weighted imaging (DWI)/ diffusion tensor imaging (DTI), ultrashort TE (uTE), and glycosaminoglycan specific chemical exchange saturation transfer (gagCEST) imaging. In this article, we will first review these quantitative assessments. Then, we will discuss the variations of quantitative values of knee articular cartilage with cartilage layer (depth)- and angle (regional)-dependent approaches. Multiple MRI sequence techniques can discern qualitative differences in knee cartilage. Normal articular hyaline cartilage has a zonal variation in T2 relaxation times with increasing T2 values from the subchondral bone to the articular surface. T1rho values were also higher in the superficial layer than in the deep layer in most locations in the medial and lateral femoral condyles, including the weight-bearing portion. Magic angle effect on T2 mapping is clearly observed in the both medial and lateral femoral condyles, especially within the deep layers. One of the limitations for clinical use of these compositional assessments is a long scan time. Recent new approaches with compressed sensing (CS) and MR fingerprinting (MRF) have potential to provide accurate and fast quantitative cartilage assessments. [ABSTRACT FROM AUTHOR]

The recent significant increase in accuracy of medical image processing is attributed to the use of deep neural networks as manual segmentation generates errors in interpretation besides, is very arduous and inefficient. Generative adversarial networks (GANs) is a particular interest to medical researchers, as it implements adversarial loss without explicit modeling of the probability density function. Medical image segmentation methods face challenges of generalization and over-fitting, as medical data suffers from various shapes and diversity of organs. Furthermore, generating a sufficiently large annotated dataset at a clinical site is costly. To generalize learning with a small amount of training data, we propose guided GANs (GGANs) that can decimate samples from an input image and guide networks to generate images and corresponding segmentation mask. The decimated sampling is the key element of the proposed method employed to reduce network size using only a few parameters. Moreover, this method yields promising results by generating several outputs, such as bagging approach. Furthermore, errors of loss function increase, during the generation of original images and corresponding segmentation mask, in comparison to generating only the segmentation mask. Minimization of increased error leads (GGANs) to enhance the performance of segmentation using smaller datasets and less testing time. This method can be applied to a wide range of segmentation problems for different modalities and various organs (such as aortic root, left atrium, knee cartilage, and brain tumors) during a real-time crisis in hospitals. The proposed network also yields high accuracy compared to state-of-the-art networks.

Microfracture surgery is a bone marrow stimulation technique for treating cartilage defects and injuriesin the knee. Current methods rely on surgical skill and instrumentation. This study investigates the potential useof laser technology as an alternate means to create the microfracture holes. Lasers investigated in this study include an erbium:YAG laser (λ = 2.94 μm), titanium:sapphire femtosecond laser system (λ = 1700 nm), and Nd:glass femtosecond laser (λ = 1053 nm). Bovine samples were ablated at fluences of 8 to 18 J∕cm2 with the erbium:YAG laser, at a power of 300 ± 15 mW with the titanium:sapphire femtosecond system, and at an energy of 3 μJ∕pulse with the Nd:glass laser. Samples were digitally photographed and histological sections were taken for analysis. The erbium:YAG laser is capable of fast and efficient ablation; specimen treated with fluences of 12 and 18 J∕cm2 experienced significant amounts of bone removal and minimal carbonization with saline hydration. The femtosecond laser systems successfully removed cartilage but not clinically significant amounts of bone. Precise tissue removal was possible but not to substantial depths due to limitations of the systems. With additional studies and development, the use of femtosecond laser systems to ablate bone may be achieved at clinically valuable ablation rates.

PurposeTo determine reproducibility of the femoral condyle cartilage volume (CV) in cross-sectional and longitudinal studies using various 3D imaging techniques at 1.5 T and 3 T.Materials and methodsIn 21 subjects with osteoarthritis, magnetic resonance imaging (MRI) including four different sequences (sagittal 3D fat suppressed spoiled gradient-echo [SPGR] at 1.5 T, fat suppressed fast low angle shot [FLASH] at 3 T, water-excitation dual echo steady state [DESS] at 3 T, and water-excitation multiecho data image combination [MEDIC] at 3 T) were acquired at baseline and ∼1 year later. The CV measured using semiautomated segmentation software by three readers was analyzed.ResultsThe mean of the interclass correlation coefficient between each reader from SPGR, FLASH, DESS, and MEDIC was 0.899, 0.948, 0.943, and 0.954, respectively. The mean CV (×10(4) mm(3) ) measured by each reader from SPGR/FLASH/DESS/MEDIC sequences was the following in this order: 1.34/1.52/1.50/1.35, 1.21/1.43/1.40/1.27, 1.22/1.37/1.36/1.22, and 1.17/1.36/1.35/1.21 by readers 1, 2, 3 (first analysis), and 3 (second analysis), respectively. There was no statistically significant difference in CV between any readers in any sequences. The CV measured on FLASH and DESS tended to be greater than that on SPGR or MEDIC.ConclusionInter- and intraobserver reproducibility of cartilage segmentation using semiautomated software was validated. Although there was no statistical significance, there was a tendency of under- or overestimating CV by each sequence.

Davidson’s plum is a native Australian fruit used traditionally as food and medicine. The fruit contains anthocyanins as glucosides and sambubiosides of cyanidin and peonidin (691 mg/100 g of dried pulp) with rutin and quercetin glycosides (193 mg/100 g). Dietary supplementation of Davidson’s plum at approximately 8 mg anthocyanins/kg/day in rats attenuated the signs of metabolic syndrome induced by high-carbohydrate, high-fat diet. Davidson’s plum reduced visceral fat accumulation, total abdominal fat weight, size of retroperitoneal adipocytes, and plasma triglycerides and non-esterified fatty acids, normalised blood pressure, reduced left ventricular stiffness, decreased infiltration of inflammatory cells in both left ventricle and liver, decreased collagen deposition in heart, and reduced both fat vacuoles in liver and obesity-induced degeneration of knee cartilage. There were no changes in glucose tolerance with treatment. Davidson’s plum reduced colonic Clostridiaceae spp, and increased Turicibacter spp. and Akkermansia muciniphila. Our findings indicate that Davidson’s plum is a potential complementary treatment for metabolic syndrome.

Objective: Marrow stimulation is used to address knee cartilage defects. In this study, we used the fragility index (FI), reverse fragility index (rFI), and fragility quotient (FQ) to evaluate statistical fragility of outcomes reported in randomized controlled trials (RCTs) evaluating marrow stimulation., Design: PubMed, Embase, and MEDLINE were queried for recent RCTs (January 1, 2010-September 5, 2023) assessing marrow stimulation for cartilage defects of the knee. The FI and rFI were calculated as the number of outcome event reversals required to alter statistical significance for significant and nonsignificant outcomes, respectively. The FQ was determined by dividing the FI by the study sample size., Results: Across 155 total outcomes from 21 RCTs, the median FI was 3 (interquartile range [IQR], 2-5), with an associated median FQ of 0.067 (IQR, 0.033-0.010). Thirty-two outcomes were statistically significant, with a median FI of 2 (IQR, 1-3.25) and FQ of 0.050 (IQR, 0.025-0.069). Ten of the 32 (31.3%) outcomes reported as statistically significant had an FI of 1. In total, 123 outcomes were nonsignificant, with a median rFI of 3 (IQR, 2-5). Studies assessing stem cell augments were the most fragile, with a median FI of 2. In 55.5% of outcomes, the number of patients lost to follow-up was greater than or equal to the FI., Conclusion: Statistical findings in RCTs evaluating marrow stimulation for cartilage defects of the knee are statistically fragile. We recommend combined reporting of P -values with FI and FQ metrics to aid in the interpretation of clinical findings in comparative trials assessing cartilage restoration., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

BackgroundUnderstanding the acute response of healthy knee cartilage to running may provide valuable insight into functional properties. In recent years, quantitative magnetic resonance (MR) imaging techniques (T1(ρ) and T2 relaxation measurement) have shown tremendous potential and unique ability to noninvasively and quantitatively determine cartilage response to physiologic levels of loading occurring with physiologic levels of exercise.PurposeTo measure the short-term changes in MR T1(ρ) and T2 relaxation times of knee articular cartilage and meniscus in healthy individuals immediately after 30 minutes of running.Study designDescriptive laboratory study.MethodsTwenty young healthy volunteers, aged 22 to 35 years, underwent 3T MR imaging of the knee before and immediately after 30 minutes of running. Quantitative assessment of the cartilage and menisci was performed using MR images with a T1(ρ) and T2 mapping technique. After adjusting for age, sex, and body mass index, repeated-measures analysis of variance was used to determine the effects of running on MR relaxation times.ResultsThe post-run T1(ρ) and T2 measurement showed significant reduction in all regions of cartilage except the lateral tibia when compared with the pre-run condition. The medial tibiofemoral (T1(ρ): 9.4%, P < .0001; T2: 5.4%, P = .0049) and patellofemoral (T1(ρ): 12.5%, P < .0001; T2: 5.7%, P = .0007) compartments experienced the greatest reduction after running. The superficial layer of the articular cartilage showed significantly higher change in relaxation times than the deep layer (T1(ρ): 9.6% vs 8.2%, P = .050; T2: 6.0% vs 3.5%, P = .069). The anterior and posterior horns of the medial meniscus (9.7%, P = .016 and 11.4%, P = .001) were the only meniscal subregions with significant changes in T1(ρ) after running.ConclusionShorter T1(ρ) and T2 values after running suggest alteration in the water content and collagen fiber orientation of the articular cartilage. Greater changes in relaxation times of the medial compartment and patellofemoral joint cartilage indicate greater load sharing by these areas during running.

Background: Anterior cruciate ligament (ACL) tear represents a common orthopedic traumatic issue that often leads to an early development of osteoarthritis. To improve the diagnostic and prognostic techniques involved in the assessment of the joint after the trauma and during the healing process, the present work proposes a multi-parametric approach that aims to investigate the relationship between joint function and soft tissue status before and after ACL reconstruction. Methods: Thirteen consecutive patients who underwent ACL reconstruction were preliminarily enrolled in this study. Joint laxity assessment as well as magnetic resonance imaging with T2 mapping were performed in the pre-operative stage, at four and 18 months after surgery to acquire objective information to correlate knee function and soft tissue condition. Results: Correlations were found between graft and cartilage T2 signal, suggesting an interplay between these tissues within the knee joint. Moreover, graft maturation resulted in being connected to joint laxity, as underlined by the correlation between the graft T2 signal and the temporal evolution of knee function. Conclusions: This preliminary study represents a step forward in assessing the effects of ACL graft maturation on knee biomechanics, and vice versa. The presented integrated framework underlines the possibility to quantitatively assess the impact of ACL reconstruction on trauma recovery and cartilage homeostasis. Moreover, the reported findings—despite the preliminary nature of the clinical impacts—evidence the possibility of monitoring the surgery outcomes using a multi-parametric prognostic investigation tool.

Segmentation is one of important methods in medical images processing, particularly as it allows images to be analysed. The method used for segmentation depends on the image problem to be resolved. In this research, knee cartilage needs to be segmented to determine the level of the Osteoarthritis (OA) and for further treatment. Knee cartilage is a soft hyline sponge that is located at the end of the femur, tibia and patella bone to release friction during movement. OA is a knee cartilage problem wherein there is a thinning of the cartilage that results in a shift especially happening between femur and tibia bone causing discomfort and pain. Thinning of the knee cartilage is due to many factors such as age, body weight, genetic, accident, sport injury and extreme use such as physical work. OA can occur to a male or female, child or adult. The effects experienced by patients with OA are such as difficulty to walk, limited movement, and pain in the thin cartilage areas. Monitoring of patients' condition needs to be done to help reduce the problem and thereby enable specialists to perform the appropriate treatment. Imaging is a method used today to monitor the condition of patients with OA. Previous studies showed that MRI is a suitable method for monitoring the condition of patients with OA because of its advantages in visualising knee cartilage more clearly than other imaging methods. Thus, for segmenting the knee cartilage which as mentioned before is an important process in medical images processing, the MR images were selected based on many factors. Segmentation in this study was aimed to obtain the cartilage region to diagnose patient OA level. Various segmentation techniques have been developed by researchers in segmenting the knee cartilage region but they have been unable to segment precisely due to the thin structure of the knee cartilage, especially for patients with intermediate and severe OA. COMSeg technique was developed to segment knee cartilage, especially for those experiencing a normal and intermediate OA and try to implement it to severe OA. The development of this new technique takes into account the imaging method used, the images feature obtained so it can be suitable to process knee image and then selection of an appropriate technique to be applied to the selected images as input. [ABSTRACT FROM AUTHOR]

Assessment of human joint cartilage is a crucial tool to detect and diagnose pathological conditions. This exploratory study develop a workflow for 3D modeling of cartilage, muscle and bone based on multimodal imaging. We present a novel methodology to evaluate knee condition using features extracted from magnetic resonance imaging (MRI) and computed tomography (CT) data. New evaluation metrics were created and a unique set of data was gathered from healthy control subjects and patients with clinically evaluated degeneration or trauma. We developed patient specific 3D models of the tibial, femoral, and patellar bones and cartilages. We compare the sensitivity of different metrics to classify the cartilage condition and evaluate degeneration based on bones and muscle densitometry. The present work demonstrates the potential for improving sensitivity in cartilage assessment. [ABSTRACT FROM AUTHOR]

Objective: This study aims to determine how magnetic resonance imaging (MRI) acquisition techniques and calculation methods affect T2 values of knee cartilage at 1.5 tesla and to identify sequences that can be used for high-resolution T2 mapping in short scanning times.Materials and Methods: This study was performed on phantom and 29 patients who underwent MRI of the knee joint at 1.5 tesla. The protocol includes T2 mapping sequences based on Single-Echo Spin Echo (SESE), Multi-Echo Spin Echo (MESE), Fast Spin Echo (FSE) and Turbo Gradient Spin Echo (TGSE). The T2 relaxation times were quantified and evaluated using three calculation methods (MapIt, Syngo Offline and mono-exponential fit). signal-to-noise ratios (SNR) were measured in all sequences. All statistical analyses were performed using the t-test.Results: The average T2 values in phantom were 41.7 ± 13.8 ms for SESE, 43.2 ± 14.4 ms for MESE, 42.4 ± 14.1 ms for FSE and 44 ± 14.5 ms for TGSE. In the patient study, the mean differences were 6.5 ± 8.2 ms, 7.8 ± 7.6 ms and 8.4 ± 14.2 ms for MESE, FSE and TGSE compared to SESE, respectively; these statistical results were not significantly different (p > 0.05). The comparison between the three calculation methods showed no significant difference (p > 0.05). The t-test showed no significant difference between SNR values for all sequences.Conclusion: T2 values depend not only on the sequence type but also on the calculation method. None of the sequences revealed significant differences compared to the SESE reference sequence. TGSE with its short scanning time can be used for high-resolution T2 mapping. [ABSTRACT FROM AUTHOR]

It has been observed that injuries, which involve only a part of the joint cartilage thickness, show a partial healing ability, but some healing potential is present in the case of injuries that affect the subchondral osseous tissue. The methods of treatment for chondral defects are nonsurgical: pharmacological chondroprotection (nutraceuticals containing chondroitin sulphate and glucosamine sulphate), viscosupplementation, PRP and cytokine modulation. The surgical options include palliative approaches, marrow stimulation, and cell-based regeneration techniques. The microfracturing technique has started to be used in the ’80s using equine models. The basic principle of microfracturing is to stimulate cartilage repair, not regeneration. It represents the first line of therapy for cartilage defects that affect its full thickness. The advantages of microfracturing are: it is a minimally invasive procedure, technical simplicity, decreased surgical morbidity, and low costs, thus making it a common procedure. However, microfracturing is not a bulletproof technique. There is a high rate of treatment failure after 5 years. Constant decline of the outcome during the 5-year follow-up after surgery is also described. Lesion size represents a better predictor regarding outcome, compared to age. The best results are obtained in young patients, small lesions and low-demand patients. Microfractures can be augmented using BMAC (bone marrow aspirate concentrate) containing 0-0.1% progenitor cells. The matrix aids in the improvement of microfractures, and it also increases the stability of the blood clot, acting as a barrier that avoids the fibroblast invasion of the graft. There is still a place for microfractures in chondral defects. Better results can be achieved with an improved technique, an optimized rehabilitation, and adding several augmentation techniques.

Objective: Assessment of human joint cartilage is a crucial tool to detect and diagnose pathological conditions. This exploratory study developed a workflow for 3D modeling of cartilage and bone based on multimodal imaging. New evaluation metrics were created and, a unique set of data was gathered from healthy controls and patients with clinically evaluated degeneration or trauma., Design: We present a novel methodology to evaluate knee bone and cartilage based on features extracted from magnetic resonance imaging (MRI) and computed tomography (CT) data. We developed patient specific 3D models of the tibial, femoral, and patellar bones and cartilages. Forty-seven subjects with a history of degenerative disease, traumatic events, or no symptoms or trauma (control group) were recruited in this study. Ninety-six different measurements were extracted from each knee, 78 2D and 18 3D measurements. We compare the sensitivity of different metrics to classify the cartilage condition and evaluate degeneration., Results: Selected features extracted show significant difference between the 3 groups. We created a cumulative index of bone properties that demonstrated the importance of bone condition to assess cartilage quality, obtaining the greatest sensitivity on femur within medial and femoropatellar compartments. We were able to classify degeneration with a maximum recall value of 95.9 where feature importance analysis showed a significant contribution of the 3D parameters., Conclusion: The present work demonstrates the potential for improving sensitivity in cartilage assessment. Indeed, current trends in cartilage research point toward improving treatments and therefore our contribution is a first step toward sensitive and personalized evaluation of cartilage condition.

Objective: The objective of the study was to evaluate the mechanical properties of living human knee cartilage using our ultrasonic device, and to compare the measurements with respect to cartilage degeneration and aging., Design: A total of 95 knees which had undergone arthroscopic knee surgery, from 88 patients, were included in the study, with informed consent. All procedures were reviewed and approved by the ethical committee of our hospital. In the study group, there were 41 men, 47 women, 39 right knees, and 56 left knees. The conditions primarily included knee osteoarthritis and anterior cruciate ligament rupture. The mean operative age was 44.1 years old (range = 10-83). We compared mechanical properties of the knee cartilage with respect to aging and gender, in comparison with normal cartilage. A P value of <0.05 represented statistical significance., Results: In the context of the International Cartilage Repair Society (ICRS) classification of cartilage degeneration (grade 0-3), the signal intensity in grade 0 was significantly larger than that in grade 1, 2, or 3. The thickness in grade 0 was significantly higher than that in grade 1, 2, or 3. Normal cartilage in older women had the lowest signal intensity and the least cartilage thickness among all the groups., Conclusion: The ultrasonic system we developed was able to detect early degenerative changes in living cartilage in knees. The lowest signal intensity and least cartilage thickness in normal cartilage among older women were correlated to a large prevalence of knee osteoarthritis in women., Level of Evidence: Level IV, case series.

Objective: Although being overweight or obese is an important risk factor for the development of knee osteoarthritis (OA), the interplay between weight and genetic factors remains unclear. This study aimed to examine the associations between weight and knee cartilage volume/defects over 10 years in offspring having at least one parent with a total knee replacement (TKR) for primary knee OA and in controls without a knee OA family history.Method: 367 participants (183 offspring and 184 controls) aged from 26 to 61 years were recruited at baseline, and followed at 2 and 10 years later. T1-weighted magnetic resonance imaging (MRI) of the right knee was used to measure cartilage volume/defects at each time-point. Mixed-effects models were used with adjustment for potential confounders.Results: Study participants were middle-age adults (mean age 45 years, mean weight 77.5 kg at baseline). In multivariable analysis, increasing body weight was deleteriously associated with medial tibiofemoral cartilage volume (β = -0.28 ml, per 1 SD increase, 95% CI -0.49 to -0.07) and presence of medial tibiofemoral cartilage defects (RR = 1.27, per 1 SD increase, 95% CI 1.07 to 1.51) in offspring over 10 years. Similar associations were observed for lateral tibiofemoral cartilage volume (β = -0.19 ml, P = 0.059), and defects (RR = 1.24, P = 0.049). However, there were no statistically significant associations between weight and cartilage volume or defects in controls.Conclusion: The adverse effects of increasing weight are stronger in the offspring of people with knee replacement for knee OA suggesting genetics-environment interaction with regard to overweight/obesity in the pathogenesis of knee OA particularly in the early stages. [ABSTRACT FROM AUTHOR]

Objective: Compositional-MRI parameters enable the assessment of cartilage ultrastructure. Correlation of these parameters with clinical outcomes is unclear. This systematic review investigated the correlation of various compositional- MRI parameters with clinical outcome measures following cartilage repair or regeneration interventions in the knee., Design: This study was registered with PROSPERO and reported in accordance with PRISMA. PubMed, Institute of Science Index, Scopus, Cochrane Central Register of Controlled Trials, and Embase databases were searched. All studies, regardless of type, that presented correlation of compositional- MRI parameters with clinical outcome measures were included. Two researchers independently performed data extraction and QUADAS-2 analysis. Compositional-MRI parameter change following intervention and correlation with clinical outcome measures were evaluated., Results: 19 studies were included. Risk of bias was generally low. 5 different compositional parameters were observed from the included studies. However, due to the significant variability in the reporting of compositional-MRI parameters across studies, meta-analyses were possible only for T2 values and T2 index values (T2 value of repair cartilage relative to normal cartilage). Correlation of T2 values of repair cartilage with clinical outcome score was r ​= ​0.33 [0.15, 0.52]. Correlation of T2 index with clinical outcome score was r ​= ​0.52 [0.32, 0.77]., Conclusions: Correlation between T2 values and clinical outcome scores following knee cartilage repair were found. The heterogeneity of the correlations extracted from the included studies limited the scope for the meta-analysis. Thus, standardised, high-quality studies are required for better assessment of correlation between compositional MRI parameters and clinical outcome measures after cartilage repair., Registration Number: PROSPERO CRD42021287364.Study protocol available on PROSPERO website., Competing Interests: Beth Lineham: There are no financial or personal interests that could have potentially and inappropriately influenced the integrity of the work in this manuscript to disclose by the author. Harin Wijayathunga: There are no financial or personal interests that could have potentially and inappropriately influenced the integrity of the work in this manuscript to disclose by the author. Emma Moran: There are no financial or personal interests that could have potentially and inappropriately influenced the integrity of the work in this manuscript to disclose by the author. Farag Shuweihdi: There are no financial or personal interests that could have potentially and inappropriately influenced the integrity of the work in this manuscript to disclose by the author. Harun Gupta: There are no financial or personal interests that could have potentially and inappropriately influenced the integrity of the work in this manuscript to disclose by the author. Hemant Pandit: There are no financial or personal interests that could have potentially and inappropriately influenced the integrity of the work in this manuscript to disclose by the author. Nagitha Wijayathunga: There are no financial or personal interests that could have potentially and inappropriately influenced the integrity of the work in this manuscript to disclose by the author., (© 2023 The Authors.)