Is there a relationship between the

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original Article

Is there a relationship between the

neutrophil/lymphocyte ratio and bilaterality in patients with coxarthrosis? ^夽

Gustavo Göhringer de Almeida Barbosa

, Fabricio Cardozo Vicente, Miguel Antonio Razia Fagundes, Lauro Manoel Etchepare Dornelles, Marcelo Reuwsaat Guimarães, Cristiano Valter Diesel

HospitaldaBeneficênciaPortuguesadePortoAlegre,PortoAlegre,RS,Brazil

a r t i c l e i n f o

Articlehistory:

Received31July2017 Accepted21September2017 Availableonline9October2018

Keywords:

Osteoarthrosis Inflammation Neutrophils Lymphocytes

a bs t r a c t

Objective:Theobjectiveofthisstudywastoevaluatetherelationshipbetweentheneu- trophil/lymphocyteratioandthepresenceofsignsofarthrosisinbothhipsinpatients followedatthismedicalcenter.

Methods:Thiswasacross-sectional,retrospectivestudythroughtheanalysisofmedical recordsanddatabasereviewofpatientsover18yearsofagewithhiparthrosis,followedat theoutpatientclinicofthishospital.

Results:Regarding the analysis of the Mann–Whitney test to correlate the neu- trophil/lymphocyteratioandlaterality,abi-lateraltestresultofp=0.036wasobtained,thus demonstratingasignificantdifferencebetweentheobservedgroups.Whenweanalyzedthe absolutevaluesofneutrophilsandlymphocytes,theauthorsobtainedresultsofp=0.14and p=0.24.Therefore,itwasnotpossibletoobservestatisticallysignificantdifferencesbetween theabsolutevaluesinthetwogroups.

Conclusion:Considering the interactions between the inflammatory mechanisms in osteoarthritisandthefactthattheinteractionbetweenneutrophilsandlymphocyteshas differencesinrelationtothelateralityofthecoxarthrosis,itishypothesizedthattheinflam- matoryetiologyofunilateral andbilateralosteoarthritis couldhavedifferentdynamics.

However,morein-depthstudieswithflow cytometryare neededtoassessthepossible impactofthesedifferencesintheinflammatorymechanismsobservedinthisstudy.

©2018SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

夽StudyconductedatHospitaldaBeneficênciaPortuguesadePortoAlegre,PortoAlegre,RS,Brazil.

∗ Correspondingauthor.

E-mail:gustavogab@hotmail.com(G.G.Barbosa).

https://doi.org/10.1016/j.rboe.2017.09.011

2255-4971/©2018SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Thisisanopenaccessarticle undertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Existerelac¸ãoentrearazãoneutrófilo/linfócitoeabilateralidadepara artrosedequadril?

Palavras-chave:

Osteoartrose Inflamac¸ão Neutrófilos Linfócitos

r e s u mo

Objetivo:Avaliararelac¸ãoentrearazãoneutrófilo/linfócitoeapresenc¸adesinaisdeartrose emambososquadrisempacientesacompanhadosnesteservic¸o.

Métodos: Estudotransversal,retrospectivo,queusouanálisedeprontuárioserevisãode bancodedadosdepacientesmaioresde18anoscomdiagnósticodeartrosedequadril acompanhadosnoambulatóriodestehospital.

Resultado: Comrelac¸ãoàanálisedotestedeMann-Whitneyparacorrelacionararazão neutrófilo/linfócitoealateralidade,observou-seumresultadodetestebilateralde0,036, evidencioudessemodoadiferenc¸aentreosgrupos.Quandoosvaloresabsolutosdeneutró- filoselinfócitosforamanalisados,observaram-sep=0,14ep=0,24,nãofoipossívelobservar diferenc¸asestatisticamentesignificativasentreosvaloresabsolutosnosdoisgrupos.

Conclusões: Considerando-se as interac¸ões entre os mecanismos inflamatórios na osteoartroseeofatodequeainterac¸ãoentreosneutrófiloseoslinfócitostemdiferenc¸as comrelac¸ãoàlateralidadedacoxartrose,épossívellevantarahipótesedequeaetiologia inflamatóriadaosteoartroseunilateraledabilateraltemdinâmicasdiferentes.Entretanto, sãonecessáriosestudosmaisaprofundados,comcitometriadefluxo,paraavaliaroimpacto comrelac¸ãoàsdiferenc¸asnosmecanismosinflamatóriosobservadosnesseestudo.

©2018SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Osteoarthrosis (OA) is characterized by joint degeneration withsubchondralandperiosteallesions.Severalfactorsmay beinvolvedintheprogressionofjointdegeneration,suchas obesity, repetitivetaskinjuries,joint trauma, geneticalter- ations, metabolic and muscular diseases, infections, and coagulation disorders such as hemophilia.^1,2 OA is often described as a noninflammatory condition. However, new studieshaveshownthatthe progressofjointdegeneration iscorrelatedwiththeproductionofinflammationfactorsand withthereleaseofcartilage-degradingenzymes.³Thereisan increasinginterestinestablishingtheroleofinflammationin OAevolutionsinceitisoftenassociatedwithlow-gradesyn- ovitis.Atthecellularlevel,theinfiltrationofmacrophagesand perivascularTandBlymphocyteshasbeenobservedbothat earlyandinmoreadvancedOA.Inpatients withearly OA, thereisanincreaseintheexpressionofCD4+andCD68+cells inthesynoviumandanincreasedexpressionofinflammatory mediators.^4–6Neutrophilsandlymphocytesareprotagonists intheinflammatoryprocess.Theneutrophil/lymphocyteratio (NLR)iscalculatedbydividingtheabsoluteneutrophilcount bythelymphocytecountobtainedfromacompleteperipheral bloodcount.⁷NLRisaverycheapandeasytoobtainclinical markerandisusedasanindicatorofinflammatoryprocesses inseveralclinicalconditions,suchasankylosingspondylitis, sarcoidosis, andlung and colorectalcancer.^8–12 Theimpor- tanceofNLRinthediagnosisandfollow-upofOAprogression isnotpreciselyknown.Thisstudy wasaimedatevaluating therelationshipbetweenNLRandthepresenceofsignsofOA inbothhipsinpatientsfollowed-upatthismedicalfacility.

Material and methods

This isa cross-sectional, retrospectivestudy thatreviewed the medicalrecords anddatabaseofpatientsover18 years diagnosed withhip arthrosis who were followed-up at the outpatientclinicofthishospital.Atotalof132patientswere selected,and113wereeligibleforthisstudy.Thisstudywas approvedbytheResearchEthicsCommitteeunderCAAENo.

63313416.6.0000.5530.

ThepresenceofOAwasdefinedbyradiographicanalysis;

thestudyincludedpatientsolderthan18yearswithanyradi- ologicalalterationgreater thangrade2intheKelgreenand Lawrence¹³ score (Table 1) in either oftheir hips. Patients withrheumatologicorautoimmunediseases,coagulopathy, usingacorticoid,orwithchronicinfectionoraknownchronic inflammatorystatewereexcluded.

Patientsweredividedintotwogroups:theunilateralgroup, in whichonlyoneofthe hips presentedradiological alter- ationsgreaterthangradeI,andthebilateralgroup,inwhich both sides presented radiological alterations greater than gradeII.Regarding theblood cellcountvariables,themost recenthemogramwasevaluated,fromwhichthedatatomea- suretheNRLwasextracted.

Table1–KellgreenandLawrenceclassification.¹³

Grade Definition

I Jointspace(<3mm)

II Jointspaceobliteration

III Mildbonefriction(0–5mm)

IV Moderatebonefriction(5–10mm)

V Severebonefriction(>10mm)

Table2–Characteristicsofthesample.

Populationdistributionbyage,gender,andlaterality

Meanage 63.9(±9.6)

Gender

Male 58(51.3%)

Female 51(48.7%)

Laterality

Unilateral 16(14.2%)

Bilateral 97(85.8%)

Statisticalanalysis

Descriptivedata,suchasageandgender,weresummarizedas meanandsimplefrequencies.TheMann–Whitneytestwas usedtoassessthecorrelationbetweentheNLRandbilater- ality.Student’st-testwasusedtoanalyzetheexistenceofa relationshipbetweenabsoluteneutrophilandlymphocyteval- uesandbilaterality.AllanalyseswereperformedwithSPSS softwareversion22.0.p-Values<0.05wereconsideredstatis- ticallysignificant.

Duetothelackofpreviousdataintheliterature,thesample sizewascalculatedasaimingatobservingatwo-folddiffer- encebetweenthemeansofthegroups.Todetectadifference inNLRvalues,thestudy’spowerwassetat95%andthelevel ofsignificanceat0.05;atleast12patientswererequiredper group.

Results

Atotalof132patientswithhipOAwereconsidered.Ofthese, tenwereexcludedduetocomorbidities.Regardingthelosses, ninepatientswereexcludedduetoinsufficientdataforanal- ysis;113patientsmettheinclusioncriteriaandwereeligible forthestudy.

Themeanageofthestudyparticipantswas63.9years,with astandarddeviationof9.6years.Genderdistributionwasalso balanced:58men(51.3%)and51women(48.7%;Table2).Ofthe

Table3–Descriptivestatisticsofthe

neutrophil/lymphocyteratio,neutrophilcount,and lymphocytescountintheunilateralgroup.

Neutrophil/lymphocyteratio NLR

Median 5.22 Var=4.8

Minimum 1.32

Maximum 17.74

Neutrophils

Mean 7015.4(±2585)

Minimum 3010

Maximum 12,719

Lymphocytes

Mean 1709(±1.007)

Minimum 474

Maximum 3690

Kolmogorov-Smirnov’stestwasusedtoassessthenormalityofthe sample.

113patientincludedinthestudy,16(14.2%)presenteduni- lateral OAand 97(85.8%)were includedinthebilateral OA group.

ThemedianNLRintheunilateralgroupwas5.22.Inthe bilateral group, the median was 2.64. The absolute mean values ofneutrophils and lymphocytes and their standard deviations were 7015.4(±2585) and1709 (±1007) inthe unilateralgroup,respectively,and5925.6(±3146)and2054.2 (±928)inthebilateralgroup(Tables3and4).

IntheMann–WhitneytesttocorrelateNLRandlaterality,a bilateraltestresultof0.036wasobserved,demonstratingasta- tisticallysignificantdifferencebetweentheobservedgroups (Table5).

When analyzing the absolutevalues ofneutrophils and lymphocytes,thetestspresentedp=0.14andp=0.24;itwas not possible to observe statistically significant differences betweentheabsolutevaluesinthetwogroups(Table5).

Table4–Descriptivestatisticsoftheneutrophil/lymphocyteratio,neutrophilcount,andlymphocytescountinthe bilateralgroup.

Neutrophil/lymphocyteratio NLR

Median 2.64 Var=2.8

Minimum 0.83

Maximum 17.2

Neutrophils

Mean 5925.6(±3.146)

Minimum 2040

Maximum 24,212

Lymphocytes

Mean 2054.2(±928)

Minimum 465

Maximum 5923

Kolmogorov-Smirnov’stestwasusedtoassessthenormalityofthesample.

Table5–NLR,neutrophilcountandlymphocytecount, andlaterality.

Comparisonbetweengroups

NLRandlaterality U=521 Bilateraltesting:0.036 Neutrophilsandlaterality x=1089±721Bilateraltesting:0.14 Lymphocytesandlaterality x=345±721Bilateraltesting:0.24

Discussion

To date, the inflammatory mechanisms associated with hip OA are still not well established. In contrast to other rheumatologicdiseases,suchasgout,psoriasis,andrheuma- toid arthritis, the crucial role played by inflammation in osteoarthritishasonlyrecentlybeenobserved.Thepresence of an inflammatory component is noteworthy, in light of symptomssuchasjointpain,edema,andstiffness.¹⁴

Thediseaseonsetischaracterizedbycartilagedamageand chondrocytedeath.Progressively,OAevolvestoasubchondral lesion,causinganimbalanceintheosteoclastboneresorption dynamicsandinboneremodelingbyosteoblasts.¹⁵

Chondrocytesmaintainthe componentsofthecartilagi- nousmatrixunderlowturnoverconditions.InOA,exposureto alterationsinthejointmicroenvironment,suchasmechanical stress, inflammatory cytokines, and oxidative stress, pro- motestheactivationofchondrocytesandothersynovialcells andjointtissues.¹⁶

In arecent study that analyzed the occurrence ofcells ofinflammatoryorigininthesynovialfluidofpatientswith OA,apreponderanceoflymphocytesoftheNKlineagewas observed.¹⁷

IncontrasttoperipheralNKcells,theNKcellsfromsyn- ovialfluidexpresseddifferentphenotypes,withconsiderable potentialtoproducepro-inflammatorymolecules,especially granzymeA,aproinflammatorymoleculerecentlyidentified inanimalstudies.¹⁸

Thesedatasuggest that, inpatients withOA,thepecu- liardynamicsbetweeninflammatorycellsare ofetiological importance.However,theliteraturedoesnotpresentdataon thedynamicsofinflammatorycellsinpatientswithunilateral andbilateralOA.

ThepresentstudyobserveddifferencesintheNLRinthe peripheralbloodofpatientswithunilateralandbilateralOA.

Intheunilateralgroup,themedianwas5.22,whileinthebilat- eralgroupthemedianwas2.64;thedifferencebetweenthem wasconsideredstatisticallysignificant(p=0.03).Inthegroup withunilateralinvolvement,themedianwasalmosttwicethe valueofthebilateralgroup.

Conclusion

Considering the interactions between the inflammatory mechanismsinOAandthefactthattheinteractionbetween neutrophilsandlymphocytesshowsdifferencesregardingthe laterality of coxarthrosis, it can be hypothesized that the inflammatoryresponsesofunilateralandbilateralOA have differentdynamics.Moreover,thefactthatthesampleswere collectedinonlyonemomentoftimedoesnotallowtodraw conclusionsaboutwhethertheobserveddifferenceisacause

or consequence of OA laterality. Therefore, more in-depth studiesarerequired,withseveralsamplescollectedovertime, associatedwithmeasurementsofotherinflammatorymark- ers and the use of flow cytometric analysis techniques to evaluatetheimpact ofthe differencesintheinflammatory mechanismsobservedinthisstudy.

Conflicts of interest

Theauthorsdeclarenoconflictsofinterest.

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