Effects of Exercise or Mechanical Stimulation on Bone Development and Bone Repair

Synergistic interactions between physical exercise intervention, innovative materials, and neurovascular coupling in bone repair and injury recovery: a comprehensive review

Bone injury presents a prevalent challenge in clinical settings, with traditional treatment modalities exhibiting inherent limitations. Recent advancements have highlighted the potential of combining physical exercise intervention and innovative materials to enhance bone repair and recovery. This review explores the synergistic effects of physical exercise and novel materials in promoting bone regeneration, with a particular focus on the role of neurovascular coupling (NVC) mechanisms. Physical exercise not only stimulates bone cell function and blood circulation but also enhances the bioactivity of novel materials, such as nanofiber membranes and smart materials, which provide supportive scaffolds for bone cell attachment, proliferation, and differentiation. NVC, involving the interaction between neural activity and blood flow, is integral to the bone repair process, ensuring the supply of nutrients and oxygen to the injured site. Studies demonstrate that the combination of physical exercise and novel materials can accelerate bone tissue regeneration, with exercise potentially enhancing the bioactivity of materials and materials improving the effectiveness of exercise. However, challenges remain in clinical applications, including patient variability, material biocompatibility, and long-term stability. Optimizing the integration of physical exercise and novel materials for optimal therapeutic outcomes is a key focus for future research. This review examines the collaborative mechanisms between physical exercise, novel materials, and NVC, emphasizing their potential and the ongoing challenges in clinical settings. Further exploration is needed to refine their application and improve bone repair strategies.

A single-centre, retrospective study on the impact of omitting preoperative antibiotic prophylaxis on wound infections in minor orthopedic implant removals

BACKGROUND

The use of preoperative antibiotic prophylaxis (POAP) in elective implant removal (IR) is controversial due to a lack of evidence-based recommendations. First-generation cephalosporins, which are commonly used in orthopedic IR, are believed to reduce wound infection risks. However, the potential for serious side effects had raised concerns about their necessity. This study was intended to evaluate whether omitting POAP in small IR increases the risk of wound infections.

METHODS

This retrospective, single-centre cohort study was conducted at a level I trauma centre in Switzerland, including patients who underwent IR between January 1, 2016, and December 31, 2021. The IR procedures involved the upper extremities (UEs), such as the clavicle, olecranon, radius and ulna, as well as the lower extremities (LEs), such as the patella, tibia, fibula, (bi)malleolar and foot. Postoperative follow-up included clinical and radiological evaluations 6 weeks after surgery. The outcomes assessed were deep wound infections, wound healing complications, refractures, persistent pain, bleeding, neurovascular injuries and muscle hernias.

RESULTS

Of the 273 patients (mean age: 42.1 ± 14.5; 44% female), 117 (42.9%) received POAP. In the LE group (n = 141), 51.1% received POAP; in the UE group (n = 132), 34.1% received POAP. Eleven (4.0%) wound-healing disorders were documented, with five (4.3%) in the POAP group and six (3.8%) in the non-POAP group (p = 1). No deep wound infections were observed.

CONCLUSION

Withholding POAP in elective IR procedures does not significantly increase wound infection rates, suggesting it may be unnecessary in uncomplicated cases.

Biophysical stimuli for promoting bone repair and regeneration

Bone injuries and diseases are associated with profound changes in the biophysical properties of living bone tissues, particularly their electrical and mechanical properties. The biophysical properties of healthy bone are attributed to the complex network of interactions between its various cell types (i.e., osteocytes, osteoclast, immune cells and vascular endothelial cells) with the surrounding extracellular matrix (ECM) against the backdrop of a myriad of biomechanical and bioelectrical stimuli arising from daily physical activities. Understanding the pathophysiological changes in bone biophysical properties is critical to developing new therapeutic strategies and novel scaffold biomaterials for orthopedic surgery and tissue engineering, as well as provides a basis for the application of various biophysical stimuli as therapeutic agents to restore the physiological microenvironment of injured/diseased bone tissue, to facilitate its repair and regeneration. These include mechanical, electrical, magnetic, thermal and ultrasound stimuli, which will be critically examined in this review. A significant advantage of utilizing such biophysical stimuli to facilitate bone healing is that these may be applied non-invasively with minimal damage to surrounding tissues, unlike conventional orthopedic surgical procedures. Furthermore, the effects of such biophysical stimuli can be localized specifically at the bone defect site, unlike drugs or growth factors that tend to diffuse away after delivery, which may result in detrimental side effects at ectopic sites.

An In Vitro Orbital Flow Model to Study Mechanical Loading Effects on Osteoblasts

Flow induced by an orbital shaker is known to produce shear stress and oscillatory flow, but the utility of this model for studying mechanical loading effects in osteoblasts is not well defined. To test this, osteoblasts derived from the long bones of adult male C57BL/6J mice were plated on 6-well plates and subjected to orbital shaking at various frequencies (0.7, 1.4, and 3.3 Hz) for 30 and 60 min in serum-free differentiation media. The shear stress on cells produced by 0.7, 1.4, and 3.3 Hz shaking frequencies were 1.6, 4.5, and 11.8 dynes/cm2, respectively. ALP activity measured 72 h after shaking (orbital flow) showed a significant increase at 0.7 and 1.4 Hz, but not at 3.3 Hz, compared to static controls. Orbital flow-induced mechanical stress also significantly increased (25%) osteoblast proliferation at a 0.7 Hz flow compared to static controls. Additionally, expression levels of bone formation markers Osf2, Hif1a, Vegf, and Cox2 were significantly increased (1.5- to 3-fold, p < 0.05) in cells subjected to a 0.7 Hz flow compared to non-loaded control cells. We also evaluated the effect of orbital flow on key signaling pathways (mTOR, JNK, and WNT) known to mediate mechanical strain effects on osteoblasts. We found that blocking mTOR and WNT signaling with inhibitors significantly reduced (20-30%) orbital flow-induced ALP activity compared to cells treated using a vehicle. In contrast, inhibition of JNK signaling did not affect flow-induced osteoblast differentiation. In conclusion, our findings show that the flow produced by an orbital shaker at a lower frequency is an appropriate inexpensive model for studying the molecular pathways mediating mechanical strain effects on primary cultures of osteoblasts in vitro.

Assessing Patient Understanding and Satisfaction in Orthopedic Trauma and Elective Surgery Admissions

Background When seeking healthcare, patients often struggle to understand the information provided by healthcare professionals regarding their condition and treatment plan. Additionally, patient satisfaction with their experience can vary widely. Improved patient understanding and satisfaction are linked to better outcomes. This study aims to explore the factors influencing patient understanding to help healthcare professionals enhance these aspects. Objective This study evaluated the level of understanding and satisfaction among patients attending outpatient appointments. It also investigated factors influencing understanding by examining differences in results across various patient groups and analyzing these variations. Methods This study was conducted at Queens' Hospital Burton, a level III trauma unit, over a three-week period in September 2023. Patients attending their orthopedic outpatient appointments were given a questionnaire, which included both bipolar 1-5 scale questions and open-ended text response questions. Results Patients generally reported high levels of understanding and satisfaction, averaging 90.34% and 96.20%, respectively. Those seen in a nurse-led clinic demonstrated significantly greater understanding of their condition compared to those seen by a physician (p = 0.0377). Additionally, trauma patients had a significantly higher level of understanding (p = 0.0167) and satisfaction (p = 0.0115). Conclusions To achieve better patient outcomes, it is crucial to optimize both patient understanding and satisfaction. Nurse-led clinics demonstrate higher levels of understanding, so identifying and incorporating the factors that contribute to this success into physician-led clinics is essential. These factors may include differences in communication methods, the resources provided, or the consultation setting. Additionally, the educational methods used with trauma patients appear more effective than those used for elective cases and should be evaluated to determine if they can enhance understanding and outcomes in other settings. Implementing evidence-based strategies for effective patient communication, such as maintaining good eye contact, avoiding medical jargon, and establishing rapport, could improve understanding and satisfaction and ultimately lead to better patient outcomes.

Vascular restoration through local delivery of angiogenic factors stimulates bone regeneration in critical size defects

Critical size bone defects represent a significant challenge worldwide, often leading to persistent pain and physical disability that profoundly impact patients' quality of life and mental well-being. To address the intricate and complex repair processes involved in these defects, we performed single-cell RNA sequencing and revealed notable shifts in cellular populations within regenerative tissue. Specifically, we observed a decrease in progenitor lineage cells and endothelial cells, coupled with an increase in fibrotic lineage cells and pro-inflammatory cells within regenerative tissue. Furthermore, our analysis of differentially expressed genes and associated signaling pathway at the single-cell level highlighted impaired angiogenesis as a central pathway in critical size bone defects, notably influenced by reduction of Spp1 and Cxcl12 expression. This deficiency was particularly pronounced in progenitor lineage cells and myeloid lineage cells, underscoring its significance in the regeneration process. In response to these findings, we developed an innovative approach to enhance bone regeneration in critical size bone defects. Our fabrication process involves the integration of electrospun PCL fibers with electrosprayed PLGA microspheres carrying Spp1 and Cxcl12. This design allows for the gradual release of Spp1 and Cxcl12 in vitro and in vivo. To evaluate the efficacy of our approach, we locally applied PCL scaffolds loaded with Spp1 and Cxcl12 in a murine model of critical size bone defects. Our results demonstrated restored angiogenesis, accelerated bone regeneration, alleviated pain responses and improved mobility in treated mice.

Zinc finger protein 36 like 2-histone deacetylase 1 axis is involved in the bone responses to mechanical stress

The molecular mechanism underlying the promotion of fracture healing by mechanical stimuli remains unclear. The present study aimed to investigate the role of zinc finger protein 36 like 2 (ZFP36L2)-histone deacetylase 1 (HDAC1) axis on the osteogenic responses to moderate mechanical stimulation. Appropriate stimulation of fluid shear stress (FSS) was performed on MC3T3-E1 cells transduced with ZFP36L2 and HDAC1 recombinant adenoviruses, aiming to validate the influence of mechanical stress on the expression of ZFP36L2-HDAC1 and the osteogenic differentiation and mineralization. The results showed that moderate FSS stimulation significantly upregulated the expression of ZFP36L2 in MC3T3-E1 cells (p < 0.01). The overexpression of ZFP36L1 markedly enhanced the levels of osteogenic differentiation markers, including bone morphogenetic protein 2 (BMP2), runt-related transcription factor 2 (RUNX2), alkaline phosphatase (ALP), Osterix, and collagen type I alpha 1 (COL1A1) (p < 0.01). ZFP36L2 accelerated the degradation of HDAC1 by specifically binding to its 3' UTR region, thereby fulfilling its function at the post-transcriptional regulatory gene level and promoting the osteogenic differentiation and mineralization fate of cells. Mechanical unloading notably diminished/elevated the expression of ZFP36L2/HDAC1, decreased bone mineral density and bone volume fraction, hindered the release of osteogenic-related factors and vascular endothelial growth factor in callus tissue (p < 0.01), and was detrimental to fracture healing. Collectively, proper stress stimulation plays a crucial role in facilitating osteogenesis through the promotion of ZFP36L2 and subsequent degradation of HDAC1. Targeting ZFP36L2-HDAC1 axis may provide promising insights to enhance bone defect healing.

Periodic static compression of micro-strain pattern regulates endochondral bone formation

Introduction: Developmental engineering based on endochondral ossification has been proposed as a potential strategy for repairing of critical bone defects. Bone development is driven by growth plate-mediated endochondral ossification. Under physiological conditions, growth plate chondrocytes undergo compressive forces characterized by micro-mechanics, but the regulatory effect of micro-mechanical loading on endochondral bone formation has not been investigated. Methods: In this study, a periodic static compression (PSC) model characterized by micro-strain (with 0.5% strain) was designed to clarify the effects of biochemical/mechanical cues on endochondral bone formation. Hydrogel scaffolds loaded with bone marrow mesenchymal stem cells (BMSCs) were incubated in proliferation medium or chondrogenic medium, and PSC was performed continuously for 14 or 28 days. Subsequently, the scaffold pretreated for 28 days was implanted into rat femoral muscle pouches and femoral condylar defect sites. The chondrogenesis and bone defect repair were evaluated 4 or 10 weeks post-operation. Results: The results showed that PSC stimulation for 14 days significantly increased the number of COL II positive cells in proliferation medium. However, the chondrogenic efficiency of BMSCs was significantly improved in chondrogenic medium, with or without PSC application. The induced chondrocytes (ichondrocytes) spontaneously underwent hypertrophy and maturation, but long-term mechanical stimulation (loading for 28 days) significantly inhibited hypertrophy and mineralization in ichondrocytes. In the heterotopic ossification model, no chondrocytes were found and no significant difference in terms of mineral deposition in each group; However, 4 weeks after implantation into the femoral defect site, all scaffolds that were subjected to biochemical/mechanical cues, either solely or synergistically, showed typical chondrocytes and endochondral bone formation. In addition, simultaneous biochemical induction/mechanical loading significantly accelerated the bone regeneration. Discussion: Our findings suggest that microstrain mechanics, biochemical cues, and in vivo microenvironment synergistically regulate the differentiation fate of BMSCs. Meanwhile, this study shows the potential of micro-strain mechanics in the treatment of critical bone defects.

Fixators dynamization for delayed union and non-union of femur and tibial fractures: a review of techniques, timing and influence factors

The optimal balance between mechanical environment and biological factors is crucial for successful bone healing, as they synergistically affect bone development. Any imbalance between these factors can lead to impaired bone healing, resulting in delayed union or non-union. To address this bone healing disorder, clinicians have adopted a technique known as "dynamization" which involves modifying the stiffness properties of the fixator. This technique facilitates the establishment of a favorable mechanical and biological environment by changing a rigid fixator to a more flexible one that promotes bone healing. However, the dynamization of fixators is selective for certain types of non-union and can result in complications or failure to heal if applied to inappropriate non-unions. This review aims to summarize the indications for dynamization, as well as introduce a novel dynamic locking plate and various techniques for dynamization of fixators (intramedullary nails, steel plates, external fixators) in femur and tibial fractures. Additionally, Factors associated with the effectiveness of dynamization are explored in response to the variation in dynamization success rates seen in clinical studies.

Biomaterial scaffolds regulate macrophage activity to accelerate bone regeneration

Bones are important for maintaining motor function and providing support for internal organs. Bone diseases can impose a heavy burden on individuals and society. Although bone has a certain ability to repair itself, it is often difficult to repair itself alone when faced with critical-sized defects, such as severe trauma, surgery, or tumors. There is still a heavy reliance on metal implants and autologous or allogeneic bone grafts for bone defects that are difficult to self-heal. However, these grafts still have problems that are difficult to circumvent, such as metal implants that may require secondary surgical removal, lack of bone graft donors, and immune rejection. The rapid advance in tissue engineering and a better comprehension of the physiological mechanisms of bone regeneration have led to a new focus on promoting endogenous bone self-regeneration through the use of biomaterials as the medium. Although bone regeneration involves a variety of cells and signaling factors, and these complex signaling pathways and mechanisms of interaction have not been fully understood, macrophages undoubtedly play an essential role in bone regeneration. This review summarizes the design strategies that need to be considered for biomaterials to regulate macrophage function in bone regeneration. Subsequently, this review provides an overview of therapeutic strategies for biomaterials to intervene in all stages of bone regeneration by regulating macrophages.

Significance of mechanical loading in bone fracture healing, bone regeneration, and vascularization

In 1892, J.L. Wolff proposed that bone could respond to mechanical and biophysical stimuli as a dynamic organ. This theory presents a unique opportunity for investigations on bone and its potential to aid in tissue repair. Routine activities such as exercise or machinery application can exert mechanical loads on bone. Previous research has demonstrated that mechanical loading can affect the differentiation and development of mesenchymal tissue. However, the extent to which mechanical stimulation can help repair or generate bone tissue and the related mechanisms remain unclear. Four key cell types in bone tissue, including osteoblasts, osteoclasts, bone lining cells, and osteocytes, play critical roles in responding to mechanical stimuli, while other cell lineages such as myocytes, platelets, fibroblasts, endothelial cells, and chondrocytes also exhibit mechanosensitivity. Mechanical loading can regulate the biological functions of bone tissue through the mechanosensor of bone cells intraosseously, making it a potential target for fracture healing and bone regeneration. This review aims to clarify these issues and explain bone remodeling, structure dynamics, and mechano-transduction processes in response to mechanical loading. Loading of different magnitudes, frequencies, and types, such as dynamic versus static loads, are analyzed to determine the effects of mechanical stimulation on bone tissue structure and cellular function. Finally, the importance of vascularization in nutrient supply for bone healing and regeneration was further discussed.