Insights for possible association and impact of thyroidectomy to osteoarthritis

Abstract

Background and aim of study

Thyroidectomy and osteoarthritis have drawn more attention in last decades due to increase various local and systemic risk factors. This study is aimed to determine the association and impact between thyroidectomy and osteoarthritis by serological measurement of most specific related markers.

Results

Measurement of thyroid markers showed the level of thyroid-stimulating hormone (TSH) was significantly increased, while parathyroid hormone (PTH), triiodothyronine (T3), and thyroxine (T4) levels were decreased in osteoarthritis subjected to thyroidectomy group (OTG) when compared to hyperthyroidism subjected to thyroidectomy group (TG), osteoarthritis group (OG), and healthy control group (CG). Detection the activity of bone markers showed the level of R-factor was significantly elevated concomitant with significant reduction in Dickkopf related protein 1 (DKK1), human hyaluronan-binding protein 2 (HABP2), osteocalcin (OC) in OG and OTG groups, while osteopontin (OPN) and procollagen I C-terminal propeptide (PICP) were significantly increased and decreased in TG and OTG. Furthermore, the level of S100 Calcium binding protein (S100CBP) showed significant decreased in patient’s groups, while TG with OTG groups exhibited significant reduction in sclerostin (SOST) concentration. Regarding the inflammatory markers, the levels of interleukin-1 (IL-1) was increased in the OTG, while the level of interleukin-10 (IL-10) was increased in OG and TG groups, and reduced in OTG. While, the level of transforming growth factor-beta (TGF-β) was decreased in OG and TG associated with significant increases in tumor necrosis factor-alpha level (TNF-α) in OTG. Measurement of oxidant and antioxidant activity markers showed the levels of catalase (CAT), superoxide dismutase (SOD), and glutathione peroxidase (GPx) were significantly reduced in all patient’s groups compared to control, except the level of CAT in TG, whereas, malondialdehyde (MDA) level was increased in OG and OTG patients. Furthermore, the levels of Alkaline phosphatase (ALP), C-Reactive protein (CRP), and erythrocyte sedimentation rate (ESR) were increased in all patient groups compared to control, while fatty acid-binding protein (FABP) level was increased in OTG only.

Conclusion

This unique study in Iraq is identified the interaction effect and impact of thyroidectomy to osteoarthritis according to the results that showed various changes and degree of correlation of study biomarkers in all patient groups, however more depth of specific quantitative and qualitative studies are required to support this association and the impact claim at molecular level.

1 Background

Thyroid gland and its hormones have crucial roles in development of several organs associated with homeostatic controlling of fundamental physiological mechanisms related to energy expenditure and body growth [1]. In clinical practice, thyroid diseases are frequently observed as a result of functional abnormalities due to hyper and hypo production of thyroid hormones or through structural malformation development such as goiter, adenoma and carcinoma [2, 3]. Overactivity of thyroid gland (hyperthyroidism) can produce large quantities of thyroxine (T4) hormone which result in acceleration the rate of body metabolism, unintentional emaciation, and irregular tachycardia [4]. Hence, several therapies have been applied to manage the overproduction of thyroid hormones including beta-blockers, anti-thyroid medications, radioactive iodine, and surgery [5,6,7]. Thyroidectomy is a well-described surgical procedure used to excise the thyroid gland for treatment of hormonal and benign diseases that are not responsive to medical management as well as for malignancy [8]. Although, there is minimum occurrence of persistent complications post thyroidectomy, two possible complications might be raised as a result of close anatomic proximity of thyroid gland including recurrent laryngeal nerves and parathyroid glands. Furthermore, several multiple risk factors such as surgeon experience, surgical volume, thyroid pathology, procedure-related factors, and patient-related factors could involve in raising the occurrence of thyroidectomy possible complications [9,10,11]. However, careful operative technique and systemic strategy can prevent or decrease the incidence of complications [12, 13].

Osteoarthritis is a multifactorial most common joint disorder which defined clinically by presence of aching, pain and stiffness of the joint due to interaction of local and systemic risk factors [14]. Additional risk factors that relatively important might be varied based on the type of joints and stages of disease, as well as the development or progression of disease and the radiographic or systemic disease [14, 15]. Worldwide, no consistently effective methods are available to prevent development of osteoarthritis or control its progression, while the symptomatic therapies have provided few benefits for several patients [16].

In Iraq, several studies were carried solely in patients with thyroidectomy [17, 18] or osteoarthritis [19, 20]. However, there is no particular specific study identify the several serological markers changes and correlation between both diseases, therefore, this represents the unique Iraqi study which aimed to investigate the various serological markers alteration and the association and impact of thyroidectomy to osteoarthritis through measurement the concentration of various immunological, thyroid, bone, antioxidant and other serum markers using the serological assay, sandwich Enzyme Linked Immunosorbent Assay (ELISA).

2 Materials and methods

2.1 Ethical approval

This study was performed under a license of Scientific Committee in College of Medicine University of Wasit under license number (139 in 02/11/2021). All participant informed about this study, and verbal consent from all was obtained.

2.2 Exclusion criteria

The excluded criteria of this study were set which including the participant that suffer from malignancy, and other acute or chronic diseases including renal and liver condition. Furthermore, patients with immunodeficiency and other immune disorder were excluded from this study. Moreover, patients under certain medication like corticosteroid or hormonal therapy. Besides that, the females within the time of menstruation were further excluded from the study.

2.3 Study limitations

The considerable limitations of the current study are the limited number of participants in the study and the difficulties to obtained consent from some patients to involve in the study. Furthermore, due to very limited number of male patients, the study only involved female patients.

2.4 Study design and Samples

Totally, 120 women having an average age (40–65 years) and weight (60–90 kg) were categorized equally at four groups based on disease as the following:

• 1. TG: Hyperthyroidism patients subjected recently to thyroidectomy.

• 2. OG: Patients having a history of osteoarthritis.

• 3. OTG: Patients having a history of osteoarthritis and subjected recently to thyroidectomy.

• 4. CG: Healthy individuals having free acute or chronic diseases.

The thyroidectomy was conducted at The Red Crescent and Al-Karama Hospitals (Wasit, Iraq) from April (2019) to January (2022). After 12 h overnight fasting, the samples of blood were collected from the patients of TG and OTG in the hypothyroid phase as well as from the OG patients and CG individuals into free-anticoagulant and anticoagulant (sodium citrate) tubes. The serum samples were kept at 4ºC in the labeled Eppendorf tubes, and placed into darken boxes to avoid the phytochemical effects. Anticoagulant blood samples were applied directly for automated measurement of erythrocyte sedimentation rate (ESR).

2.5 Serology

Following the manufacturers’ instructions of ELISA kits (Sunlong Biotech, Zhejiang, China), thyroid (parathyroid hormone (PTH), thyroid stimulating hormone (TSH), triiodothyronine (T3) and thyroxine (T4)), bone (Dickkopf related protein 1 (DKK1), human hyaluronan-binding protein 2 (HABP2), osteocalcin (OC), osteopontin (OPN), procollagen I C-terminal propeptide (PICP), R-factor, S100 Calcium binding protein (S100CBP) and sclerostin (SOST)), immune (interleukin-1 (IL-1), interleukin-10 (IL-10), transforming growth factor-beta (TGF) and tumor necrosis factor-alpha (TNF-α)), antioxidant (catalase (CAT), glutathione peroxidase (GPx), superoxide dismutase (SOD) and malondialdehyde (MDA)) and other (Alkaline phosphatase (ALP), C-Reactive protein (CRP), erythrocyte sedimentation rate (ESR) and fatty acid-binding protein (FABP)) markers were measured and the concentration of markers were calculated by plotting the concentrations of the Standard of each marker and its OD on x-axis and y-axis, respectively, and plotting the samples’ ODs on Y-axis.

2.6 Statistical analysis

The t-test and One-Way ANOVA in GraphPad Prism Software (GraphPad Software Inc., California, USA) were applied to analysis of obtained data at a significance of P < 0.05 (*), P < 0.01 (**), P < 0.001 (***) and P < 0.0001 (****) to identify the changes between the study groups based on measurement of serological markers. Furthermore, the correlation between markers within the groups were performed using Pearson correlation analysis in SPSS software v29 (IBM SPSS, Chicago, USA). The data displayed as Mean ± Standard Deviation of Mean (M ± SD).

3 Results

The obtaining data of thyroid markers were displayed a significant variation between and within the patient groups (OG, TG and OTG) when compared to CG (Fig. 1). The level of PTH is significantly decreased in OTG (37.48 ± 1.763 picograms per milliliter (pg/ml)) when compared to TG (46.9 ± 2.926 pg/ml), OG (64.62 ± 1.633 pg/ml) and CG (67.15 ± 1.734 pg/ml), whereas the TSH level is remarkably elevated in TG (2.461 ± 0.181 pg/ml) and OTG (3.087 ± 0.199 pg/ml) compare to OG (0.693 ± 0.0281 pg/ml) and CG (0.606 ± 0.0392 pg/ml). Furthermore, significant declined of T3 concentration was observed in OTG (35.139 ± 1.76 pg/ml) and TG (59.999 ± 0.68 pg/ml) when compared to CG (277.4 ± 27.47 pg/ml). Moreover, the level of T4 was significantly decreased in OG (37.7 ± 2.02 nanogram per milliliter (ng/ml)), TG (9.194 ± 0.498 ng/ml) and OTG (4.86 ± 0.515 ng/ml) when compared to CG (46.213 ± 2.12 ng/ml), whereas the relation between the markers and within the study groups showed statistical positive relationship between PTH and T3 in TG and between T3 and T4 in OTG. No further statistically significant positive or negative relations were seen (Table 1).

Fig. 1

Serum concentration of thyroid markers. The level of PTH was significantly reduction in TG and OTG groups compared to control. The OG, TG, and OTG groups exhibited significant elevation of TSH compared to control group. The level of T3 was significantly decreased in TG and OTG compared to CG and OG, while the level of T4 was significantly decreased in all patient groups compared to control group

Table 1 Correlations between thyroid markers in study groups

The obtaining levels of bone specific markers from OG, TG and OTG were varied significantly (P < 0.0001) when compared to CG. The estimated concentrations of these markers in CG were DKK1 (81.605 ± 2.63 pg/ml), HABP2 (37.45 ± 1.12 ng/ml), OC (28.13 ± 2.0068 ng/ml), OPN (1.63 ± 0.047 ng/ml), PICP (37 ± 1.98 ng/ml), R-factor (26.2 ± 3.336 unit per liter (U/L)), S100CBP (408.4 ± 15.259 pg/ml) and SOST (1.25 ± 0.105 ng/ml) (Fig. 2). Significant decreases in the levels of DKK1 (31.394 ± 1.81 pg/ml), HABP2 (3.868 ± 0.1 ng/ml), OC (13.73 ± 0.934 ng/ml) and S100CBP (206.2 ± 25.41 pg/ml) were seen in OC, associated with significant increases in the level of R-factor (190.7 ± 17.85 U/L) and SOST (1.78 ± 0.176 ng/ml) compare to CG. Furthermore, the TG exhibited significant increase in the levels of OPN (2.78 ± 0.204 ng/ml) and SOST (2.82 ± 0.183 ng/ml), concomitant with significant reduction in the levels of HABP2 (34.522 ± 1.241 ng/ml), PICP (22.15 ± 1.52 ng/ml) and S100CBP (167 ± 6.673 pg/ml) compared to CG. Moreover, the recorded significant elevation in the levels of R-factor (271.3 ± 23.98 U/L), OPN (3.17 ± 0.218 ng/ml) and SOST (3.63 ± 0.134 ng/ml) were seen in the OTG, while the levels of DKK1 (28.625 ± 1.388 pg/ml), HABP2 (3.016 ± 0.117 ng/ml), OC (12.81 ± 0.76 ng/ml), PICP (17.57 ± 1 ng/ml), and S100CBP (169.1 ± 3.796 pg/ml) were significantly declined compare to CG.

Fig. 2

Serum concentration of bone markers. The concentration of DKK1, HABP2, and OC were significantly decreased in OG and OTG compared to control group. The OG, TG, and OTG groups exhibited significant elevation of SOST level, while OPN level was increased only in the TG and OTG compared to control. However, the levels of S100CBP was reduced significantly in all diseased groups, while only TG and OTG displayed significant reduction in the level of PICP compared to control. Whereas, the level of R-factor was increased in both OG and OTG groups compared to control

Whereas, the correlation between bone markers and within the study groups showed statistical negative correlation between HABP2 and PICP in OG (Table 2). Further significant negative relationship between DKKI and SOST, and S100CBP with OPN in OTG were seen (Table 2). In CG there was positive relationship between OC and SOST marker at significant level (Table 2). All remaining bone markers within the study groups felt to show further significant positive or negative relationship.

Table 2 Correlations between several bone markers in study groups

In relation to immune markers (Fig. 3), the concentration of IL-1 was increased significantly in the OTG (272.91 ± 16.33 pg/m) only compared to the CG. Furthermore, the level of IL-10 was also significantly elevated in the OG (63.86 ± 3.02 pg/ml) and the TG (60.55 ± 3.324 pg/ml), while significant decrease was recorded in the OTG (20.22 ± 2.157 pg/ml) compare to the CG. The TGF-β level was significantly declined in the OG (75.16 ± 2.854 pg/ml) and the TG (102.29 ± 3.918 pg/ml) when compared with CG. Moreover, the level of TNF-α was significant reduction in both OG (148.78 ± 6.263 pg/ml) and TG (152.23 ± 6.023 pg/ml), while increased in the OTG (289.52 ± 11.782 pg/ml) compare to CG. Whereas, the correlation between these markers and within the study groups showed neither significant positive relationship nor negative relationship as seen in (Table 3).

Fig. 3

Serum concentration of immune markers. The OTG group exhibited significant increase in level of IL-1 compared to control, while the level of IL-10 was decreased in OTG and increased in OG and TG groups compared to control. Both OG and TG groups showed significant reduction in the level of TGF-β and TNF-α compared to control, while OTG exhibited significant elevation in the level of TNF-α compared to control

Table 3 Correlations between immunological markers in study groups

Concerning the oxidant and antioxidant activity (Fig. 4), the levels of CAT were decreased significantly in the OG (20.02 ± 0.94 pg/ml) and the OTG (17.26 ± 1.346 pg/ml) compared to recorded level in the CG (36.61 ± 3.083 pg/ml). Similarly, the levels of both GPx and SOD were significant reduction in the OG (400.16 ± 20.056 pg/ml and 18.22 ± 1.605 U/ml, respectively), the TG (543.81 ± 22.925 pg/ml and 19.69 ± 1.07 U/ml, respectively) and OTG (491 ± 29.434 pg/ml and 13.57 ± 0.76 U/ml, respectively) in comparison with the obtained levels in the CG (646.77 ± 30.813 pg/ml and 24.56 ± 1.422 U/ml, respectively). Whereas, the result displayed significant elevation in the level of MDA in the OG (127.48 ± 9.253 ng/ml) and the OTG (182.77 ± 10.474 ng/ml) when compared to the estimation level in the CG (84.59 ± 2.283 ng/ml). On the other hand, the correlation between the markers within the study groups showed significant negative relationship between CAT and MDA in OG, and also between MDA and SOD in OTG (Table 4). The remaining markers in various study groups felt to appear significant relationship.

Fig. 4

Serum concentration of antioxidant markers. All diseased groups showed significant reduction in the level of GPx and SOD, while CAT level was decreased in OG and OTG compared to control group, while the level of MDA was increased significantly in OG and OTG groups compared to control

Table 4 Correlations between antioxidant markers in study groups

Regarding other study markers (Fig. 5), the concentrations of the ALP were elevated significantly in the OG (6.67 ± 0.556 ng/ml), the TG (7.13 ± 0.313 ng/ml) and the OTG (7.26 ± 0.363 ng/ml) compared to the CG (4.26 ± 0.093 ng/ml). Similarly, the levels of CRP were significantly elevated in the OG (23.93 ± 4.506 pg/ml), the TG (42.9 ± 5.661 pg/ml) and the OTG (112.41 ± 14.175 pg/ml) when compared to the CG (5.48 ± 1.023 pg/ml). Furthermore, significant increases in the levels of ESR were seen in the OG (35.9 ± 5.673 mm per hour (mm/h)), the TG (22.9 ± 3.114 mm/h) and the OTG (41.9 ± 4.523 mm/h) in comparison with the estimated level in the CG (14.4 ± 1.771 mm/h). Moreover, only OTG exhibited significant elevation of FABP concentration (16.57 ± 0.851 pg/ml) when compared to CG (13.7 ± 0.721 pg/ml). Whereas, the correlation between these markers and within the study groups showed neither significant positive relation nor significant negative relation (Table 5).

Fig. 5

Serum concentration of other markers. The concentration of ALP, CRP, and ESR were significantly increased in all diseased groups compared to control, whereas only OTG group exhibited significant elevation in the level of FABP compared to control group

Table 5 Correlations between some factors in study population

4 Discussion

Thyroid hormones have demonstrated to play crucial several biological activities in the regulation of bone homeostasis, skeletal growth and metabolism [21]. The current study results manifested significant impact of thyroidectomy on thyroid hormones (PTH, T3 and T4) in osteoarthritic patients, and this might be attributed to the widely expression of thyroid hormones in bone, since the bone development and turnover are largely controlled by thyroid hormone. In pre-thyroidectomy patients, hyperthyroidism can accelerate the bone turnover, and bone mineral density losting; whereas, hypothyroidism in post thyroidectomy patients can reduce the processes of bone formation and increase the retardation of bone growth in childhood in addition to mild muscle weakness, generalized body ache and myalgia, adhesive capsulitis, carpal and tarsal tunnel syndrome, trigger finger, limited joint mobility, tendinitis, myopathy, muscle cramps, stiffness, and synovitis in the adults [22]. As obtained in this study, other researchers have been confirmed that alteration of TSH possesses strong impact to develop osteoarthritis with suggestion that increases of TSH levels might be attributed to the role of other variables such as homocysteine, insulin sensitivity indices and lipoprotein [18, 23]. In a recent experimental study, the authors have demonstrated that the role of analgesics in exhibiting various effects on thyroid functions, and these effects are depended on both the drug itself and its doses [24].

Importantly, the OTG patients in the current study are significantly exhibited high levels of R-factor, OPN and SOST associated with low levels of DKK1, HABPS, OC, PICP and S100CBP markers. The R-factor might increase due to impact of thyroidectomy on autoimmune features, immunoglobulin aggregation, or idiopathic antibody interaction [25]. The OPN is a multifunctional extracellular structural protein and therefore an organic component of bone. High levels of OPN in TG and OTG might a reflex to hyperthyroidism in pre-thyroidectomy patients, and the level of OPN could have negative effect on mineral density of bone and positive effect on bone turnover [26]. Furthermore, increasing the levels of SOST in the TG and OTG might be due to hyperthyroidism in pre-thyroidectomy patients which results in excess thyroid and parathyroid hormones, alterations in TSH concentrations, estrogen deficiency and mechanical unloading [27]. Nuclear DKK1 protein, an inhibitor of Wnt signaling which produced in excess in the inflamed rheumatoid joints by immune cells. It is expressed locally at high concentration in osteoblasts and osteocytes which prevent the reduction of bone formation and mass and regulate several related-genes involved in the detoxification of chemotherapeutic agents in addition to blocking the differentiation of sufficient osteoblasts to prevent bone loss [28]. The low level of DKK1 seen in OTG patients might coincidental with the results reported by Kim et al. [29]. The functional and pathogenic role of DKK1 signaling pathway was investigated by administration of DKK1 as a therapeutic agent that contributes in inhibition of thyroid cancer with consequent inhibition of cell migration and invasion [30]. Recent several studies confirmed that the HABPS is a human protein encoded by HABP2 gene which play critical role in development of thyroid cancer [31,32,33]. OC is a small non-collagenous protein hormone, which first identified as a calcium-binding protein and found in bone and dentin. Significant decreased of OC levels were seen in OG and OTG patients but not in TG, considering this change is not definitive or irrelevant. The high level of OC in hyperthyroid patients, and normal or subnormal concentration in hypothyroid patients suggesting that this change might control decreases in bone turnover [34]. In the other study, the clear reduction of OC as well as PICP in a patient due to therapeutic oral intake of bisphosphonates inhibits the bone turnover [35]. Thus, the study suggested that decreasing in a heterotrimeric glycoprotein PICP might correlate with the hypothyroidism as result of thyroidectomy. Obviously, S100CBP is new protein plays a role in angiogenesis, extracellular matrix remodeling, tumor microenvironment, and potentially aid in discrimination of follicular and papillary thyroid tumors as it over-expressed in metastatic papillary carcinomas [36]. Therefore, low level of S100CBP in the current study groups could be due to either benign hyperthyroidism which is the most form of disease, or to success of surgeon in removing of multifocal lesions during thyroidectomy. Although, several studies revealed S100CBP as a novel candidate biomarker, diagnostic and functional significance that requires further investigation.

The study identified that there were significant variations in levels of immune markers (IL-1, IL-10, INF-α and TGF-β) of patient’s study groups when compared to healthy CG. Various authors recorded the plausible relation of immunity with the prognosis of thyroidectomy; however, the results are inconsistent due to the influence of other factors such as the phase of inflammation, type of thyroid dysfunction or tumor, type of surgery (laparoscopic or conventional) and patient’s age that has a great prognostic value of individual immunological markers [37]. Patients undergoing surgery or trauma are often suffered from acquired immunologic deficits that may predispose them to sepsis, in addition to excessive production of cytokines such as IL and TNF [38]. Miccoli et al. [39] concluded that TGF-β serum levels seem to be correlated with pain evaluation, demonstrating that decreased postoperative distress is an objective outcome.

Antioxidants are molecules that fight oxidation, a chemical reaction that can produce high free radicals and chain reactions causing damage to the cells. The study findings showed a significant reduction in the levels of CAT, GPx and SOD, concomitant with elevation of MDA. In patients suffer from arthritis, Sarban et al. [40] reported an increasing of lipid peroxidation and decreasing of plasma total antioxidant capacity due to inflammatory reaction. Grover and Samson [41] showed that the antioxidant supplementation is benefit for pain relief and function of knee arthritis. On other hand, many authors detected imbalance between antioxidative system and free radicals production in individuals of thyroid dysfunction confirming that the oxidative stress was elevated due to thyroidectomy and thyroarathyroectomy in spite of using the replacement drugs [42]. Pasko [43] determined that there was deep imbalance in oxide modification of proteins-antioxidant defense system in patients having the signs of hypothyroidism, which indicate the great effect of oxidative stress in pathogenesis of post-operative hypoparathyroidism suggesting that the using of antioxidant-antihypoxant drugs in early postoperative period provide an area of complex therapy for patients with signs of post-operative hypoparathyroidism.

Significant elevation of ALP, CRP and ESR in patients of all study groups, and increasing of FABP in patients of OTG were observed in the current study. The increasing level of serum ALP agrees with the findings of Bin-Hong et al. [44], and conflicted with Al-Janabi et al. [18]. This finding might be explained by increasing bone turnover and decreasing the bone quality in patients of OG and OTG, and/or thyroidectomy induced hepatic toxicity in TG and OTG. Jin et al. [45] showed that the higher level of serum CRP in osteoarthritis was significantly associated with the grade of systemic inflammation as well as with the pain score and physical function. Post thyroidectomy, Jian et al. [46] revealed a positive association to increasing levels of serum CRP and draining volume on first postoperative day, draining tube removal time, dysphagia, pain and cosmetic satisfaction. Although, the study detected strong significant changes of CRP and ESR levels among patients of study groups with no significant positive or negative correlation. Other studies were concluded a modest correlation between each other, and a weakly correlation with disease activity [47, 48]. As obtained in this study, the poor action of FABP as promising biomarkers of burden of disease in osteoarthritis was showed by other [49]; however, higher levels in patients with overt hypothyroidism was seen in OTG similar to that seen in other study [50]. The increased FABP levels may refer to a pre-diabetic phase, subclinical atherosclerosis, and disruption in fatty acid metabolism [50].

5 Conclusion

Routine determination of the various serobiochemical markers levels prior and post-thyroidectomy makes it possible to assess the severity of illness in osteoarthritic patients. Rapid increasing in incidence of osteoarthritis suggests that the crucial impact of thyroidectomy on health care and public health systems in future, with providing compelling evidence for the markers that significantly altered between thyroidectomy and osteoarthritis. Long-term and precise specific studies with involvement of a large number of patients including male and female appeared necessary in providing more reliable and valuable data.