The early effect of ibuprofen on the mechanical properties of healing medial collateral ligament

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and Their Effect on Musculoskeletal Soft-Tissue Healing: A Scoping Review

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are being increasingly employed as a part of multimodal non-opioid strategies to treat postoperative pain. In the present study, we sought to review the effects of short-term NSAID use on musculoskeletal soft-tissue healing.

METHODS

We performed a scoping review of all studies that included the use of NSAIDs and their effect on healing of soft tissues, which for the purpose of this review refers to non-osseous musculoskeletal tissue such as ligament, tendon, labrum, and meniscus. The inclusion criteria encompassed all studies (human, animal, and in vitro) that evaluated the effect of NSAIDs on soft-tissue healing. Subgroup analyses, wherever applicable, were conducted on the basis of the type of NSAID (cyclooxygenase [COX]-specific or nonspecific) and the type of study (human, animal, or in vitro). Relevant metadata from each study were abstracted, and descriptive statistics were used to summarize the results.

RESULTS

A total of 44 studies met the inclusion criteria, including 3 human studies, 33 animal studies, and 8 in vitro studies. These studies included 4 different NSAIDs in the human subgroup, 16 different NSAIDs in the animal subgroup, and 7 different NSAIDs in the in vitro subgroup. The majority of reported studies (including 1 of 2 human studies, 10 of 14 animal studies, and 3 of 3 in vitro studies) demonstrated that COX-2-selective inhibitors had negative impact on soft-tissue healing. In contrast, the majority of human and animal studies (2 of 2 and 19 of 30, respectively) demonstrated that nonselective COX inhibitors had no negative effect on the healing of labrum, tendons, and ligaments. The majority of in vitro studies demonstrated that NSAIDs have a harmful effect on biological processes involved in tendon-healing and regeneration (tenocyte proliferation, collagen and glycosaminoglycan synthesis).

CONCLUSIONS

Current limited evidence demonstrates that selective COX-2 inhibitors can negatively affect healing of musculoskeletal soft tissue after surgical repair. In contrast, the majority of studies demonstrate that nonselective COX inhibitors have no negative effect on musculoskeletal soft-tissue healing. Additional high-quality human clinical trials are necessary to provide more definitive conclusions.

Protective effect of early placement of nasogastric tube with solid dilator on tissue damage and stricture formation after caustic esophageal burns in rabbits

BACKGROUND

The ingestion of caustic substances remains an important public health issue worldwide. Children represent 80% of the ingestion injury population globally. Accidental alkaline material accounts for most caustic ingestions. There is no conclusive evidence of tissue damage and stricture protection of a nasogastric-tube with a solid dilator in the literature, therefore it was hypothesized that early intraesophageal tube placement does not cause additional histopathologic damage and prevents strictures.

METHODS

An exploratory study on experimental caustic esophageal burns in a rabbit model was designed. In the treated group a silicone tube was placed immediately after causing the burns, while the untreated group followed the natural course of the burn. On the twenty-secondday, an esophagectomy was performed on all animals for microscopic (Histopathologic Damage Score and Stenosis Index) and macroscopic analysis.

RESULTS

Forty animals were randomly divided into two groups. The Histopathologic Damage Score was 3.7±1.1 in the treated group versus 3.9±1.2 in the untreated group (p=.9690). The Stenosis Index was 0.6±0.1 in treated rabbits versus 2.3±0.2 in untreated (p<.0001).

CONCLUSION

The early placement of an intraesophageal tube with solid dilator prevents stenosis formation and does not produce greater tissue damage.

Management of acute isolated medial and posteromedial instability of the knee

Medial-sided knee injuries are very common, the medial collateral ligament being the most commonly injured ligament of the knee. Injuries to the medial side of the knee can occur in isolation or concomitant with other knee ligament injuries. Isolated grade I and II injuries have been typically treated nonoperatively with excellent results. Isolated grade III injuries, however, are less common and more controversial. Although some recent literature has shown acceptable results with nonoperative treatment of isolated grade III injuries, most authors recommend surgical treatment. A variety of operative techniques have been described, including repair, augmentation, and reconstruction, all with favorable outcomes. Choice of treatment method should be based on injury pattern with the goal of regaining valgus and anteromedial rotatory stability of the knee.

Management of medial-sided knee injuries, part 1: medial collateral ligament

The medial collateral ligament complex is a primary stabilizer that combines static and dynamic resistance to direct valgus stress while contributing significant restraints to rotatory motion and anterior-posterior translation. Varying opinions exist among investigators regarding injury classification and treatment algorithms. Whereas most agree that the majority of isolated medial collateral ligament complex injuries can be treated nonoperatively, isolated injuries with chronic instability and multiligament injuries may require operative intervention. Substantial confounding factors are present within published reports, making comparative analyses and systematic review challenging. This review focuses on the anatomy and biomechanics of the medial structures of the knee; it discusses the clinical evaluation of complex injuries; and it reviews nonoperative and operative treatment methods.

Non-steroidal anti-inflammatory drugs for athletes: an update

Sports medicine physicians often treat athletes in pain with non-steroidal anti-inflammatory drugs (NSAIDs). However, there is a lack of high-quality evidence to guide NSAID use. Their adverse effects have clinical relevance, and their possible negative consequences on the long-term healing process are slowly becoming more obvious. This article provides some practical management guidelines for the use of NSAIDs, developed to help sports medicine physicians deal with frequent sports-related injuries. We do not recommend their use for muscle injuries, bone fractures (also stress fractures) or chronic tendinopathy. In all cases, if chosen, NSAID treatments should always be kept as short as possible and should take into account the specific type of injury, the level of dysfunction and pain.

Negative effects of parecoxib and indomethacin on tendon healing: an experimental study in rats

Conventional non-steroidal anti-inflammatory drugs (NSAIDs) and newer specific cyclooxygenase-2 (cox-2) inhibitors are commonly used in muscular skeletal trauma and in relation to orthopedic surgery to reduce the inflammatory response and pain. Studies have indicated that these drugs can have a negative effect on tendon healing in the early proliferative phase, but might be beneficial in the remodeling phase when inflammation might impede healing. Our study was designed to investigate if short-term administration of cox inhibitors after injury or postoperatively might have negative effects on the tendon healing. The right Achilles tendon of 60 rats was cut transversely, a 3 mm long segment of the tendon was removed and left unrepaired. The animals were then given parecoxib, indomethacin or saline intraperitoneally twice daily for 7 days. After 14 days, the animals were euthanized. The transverse and sagittal diameters in the healing area were measured and mechanical testing of the tensile strength of the tendons was performed. We found a significantly lower tensile strength in rats given both parecoxib and indomethacin compared to the control group. Stiffness in the healing tendons was significantly lower in the parecoxib group compared to both the placebo and the indomethacin groups. The transverse and sagittal diameters of the tendons were reduced in both the parecoxib and indomethacin groups. Both parecoxib and indomethacin impaired tendon healing; the negative effect was most pronounced with parecoxib.

Vanadate ingestion enhances the organization and collagen fibril diameters of rat healing medical collateral ligaments

Although an injured medial collateral ligament (MCL) will naturally heal, the quality of healing tissue is inferior to the uninjured MCL tissue. Previous studies have shown promising results of sodium orthovanadate (vanadate) in enhancing the quality of rat skin wounds. This study therefore investigated whether vanadate enhances the quality of the rat healing MCL in terms of the collagen fibril organization and diameter. Six mature male Sprague-Dawley rats, with weight ranges of 475-505 g and ages of 25 weeks, were used in this study. Three rats in the experimental group received vanadate (0.2 mg/ml) in their saline drinking water (150 mM NaCl), whereas three rats in the control group were only given saline water. Three weeks after transection, the rat MCLs were harvested for hematoxylin and eosin (H&E) staining and transmission electron microscopy. It was found that vanadate promoted organization of collagen fibrils and significantly increased the diameters of collagen fibrils by 14% in healing MCL (P<0.001). These results indicate that application of vanadate may be a promising tissue engineering approach to enhance the quality of healing tissues such as injured MCLs.

The Non-surgical Management of Isolated Medial Collateral Ligament Injuries of the Knee

The medial collateral ligament is the most commonly injured ligament in the knee. All isolated grade I and II tears and most grade III tears can be treated nonoperatively with a supervised, functional, rehabilitation program. Good to excellent results can be expected with return to full preinjury activity level being the norm.

Indomethacin and celecoxib impair rotator cuff tendon-to-bone healing

BACKGROUND

Nonsteroidal anti-inflammatory drugs are commonly prescribed after rotator cuff repair. These agents can impair bone formation, but no studies have evaluated their impact on tendon-to-bone healing.

HYPOTHESIS

Traditional nonselective nonsteroidal anti-inflammatory drugs and cyclooxygenase-2-specific nonsteroidal anti-inflammatory drugs interfere with tendon-to-bone healing.

STUDY DESIGN

Controlled laboratory study.

METHODS

One hundred eighty Sprague-Dawley rats underwent acute rotator cuff repairs. Postoperatively, 60 rats received 14 days of celecoxib, a cyclooxygenase-2-specific nonsteroidal anti-inflammatory drug; 60 received indomethacin, a traditional nonselective nonsteroidal anti-inflammatory drug; and 60 received standard rat chow. Animals were sacrificed at 2, 4, and 8 weeks and evaluated by gross inspection, biomechanical testing, histologic analysis, and polarized light microscopy to quantify collagen formation and maturation.

RESULTS

Five tendons completely failed to heal (4 celecoxib, 1 indomethacin). There were significantly lower failure loads in the celecoxib and indomethacin groups compared with the control groups at 2, 4, and 8 weeks (P < .001), with no significant difference between nonsteroidal anti-inflammatory drug groups. There were significant differences in collagen organization and maturation between the controls and both nonsteroidal anti-inflammatory drug groups at 4 and 8 weeks (P < .001). Controls demonstrated progressively increasing collagen organization during the course of the study (P < .001), whereas the nonsteroidal anti-inflammatory drug groups did not.

CONCLUSION

Traditional and cyclooxygenase-2-specific nonsteroidal anti-inflammatory drugs significantly inhibited tendon-to-bone healing. This inhibition appears linked to cyclooxygenase-2.

CLINICAL RELEVANCE

If the results of this study are verified in a larger animal model, the common practice of administering non-steroidal anti-inflammatory drugs after rotator cuff repair should be reconsidered.

Practical management: nonsteroidal antiinflammatory drug (NSAID) use in athletic injuries

Nonsteroidal antiinflammatory drugs (NSAIDs) are frequently used in the treatment of acute athletic injuries, often for analgesic purposes as the evidence to support enhanced healing is limited. However, the current evidence on NSAID use in athletic injury is slowly growing. On the basis of animal models and limited human studies, some practical management guidelines can be drawn to assist the sports physician. Specifically, NSAIDs are not recommended in the treatment of completed fractures, stress fractures at higher risk of nonunion, or in the setting of chronic muscle injury. The only exception may be very short-term use (eg, a few days) for analgesic purposes only. Judicious use of NSAIDs may be more appropriate in the management of acute ligament sprains, muscle strains, tendinitis, and eccentric muscle injury. However, length of treatment should always be kept as short as possible, with consideration of the specific type of injury, level of dysfunction, and pain.

The effect of analgesic agents on the healing rat medial collateral ligament

BACKGROUND

Studies have suggested that some nonselective nonsteroidal anti-inflammatory drugs, including piroxicam, may improve ligament healing, whereas other nonsteroidal anti-inflammatory drugs, including ibuprofen and the cyclooxygenase-2 inhibitor celecoxib, may have no effect on the mechanical properties or may even deter the healing process. These results might reflect variations in cyclooxygenase enzyme selectivity by different drugs or, alternatively, may be related to their analgesic properties because it is generally accepted that early activity improves ligament healing.

HYPOTHESIS

Nonselective nonsteroidal anti-inflammatory drugs improve ligament healing, whereas other analgesics provide lesser degrees of improvement, and cyclooxygenase-2 inhibitors are detrimental.

STUDY DESIGN

Controlled laboratory study.

METHODS

One hundred fifty-five Sprague-Dawley rats were divided into 7 treatment groups (piroxicam, naproxen, rofecoxib, butorphanol, 2 doses of acetaminophen, and control). The right medial collateral ligament of each rat was transected, and the drugs were administered postoperatively on days 1 to 6. On day 14, the rats were sacrificed, and mechanical testing was performed on the medial collateral ligament.

RESULTS

The piroxicam group demonstrated significantly greater load to failure (27%) compared with the control. No significant differences were observed between other groups.

CONCLUSIONS

Piroxicam improves ligament healing, but this effect cannot be attributed to all nonselective nonsteroidal anti-inflammatory drugs. Opiate analgesics, acetaminophen, and cyclooxygenase-2 inhibitors do not appear to categorically affect ligament healing.

CLINICAL RELEVANCE

In the treatment of ligament injury, piroxicam may be a drug of choice.

Decreasing inflammatory response of injured patellar tendons results in increased collagen fibril diameters

Tissue inflammation is essential in the healing process, but its effect on the quality of the healing tissue is not clear. This study determines the effect of decreasing early inflammation during wound healing in genetic deficient mice on collagen fibril diameter. Two strains of mice were used: three C3H/HeJ mice and three C3H/HeN mice for each of two time points (7 and 14 days postinjury). C3H/HeJ mice have a genetic deficiency in the production of tumor necrosis factor by macrophages and other cytokines in response to endotoxin, and C3H/HeN mice have no genetic deficiency. The right patellar tendon of both mouse strains was transversely transected, whereas the left patellar tendon was left intact for control. After 7 and 14 days, both right and left patellar tendons were harvested, and tendon samples were examined with transmission electron microscopy. We found that at 7 days, transected tendons of C3H/HeJ mice exhibited on average 1.6 times larger collagen fibril diameters than transected C3H/HeN tendons, whereas at 14 days, collagen fibril diameters of the C3H/HeJ mice were 1.3 times that of C3H/HeN mice. Also, at both 7 days and 14 days, collagen fibrils in C3H/HeJ mice appeared more organized than C3H/HeN mice. In addition, control tendons in both mouse strains showed no significant differences in collagen fibril diameter and organization. Therefore, these results suggest that decreasing the inflammatory response in the early stages of tendon wound healing enhances the quality of the healing tendon through increased collagen fiber diameter and better organization.

Effects of nonsteroidal anti-inflammatory drugs on bone formation and soft-tissue healing

Nonsteroidal anti-inflammatory drugs continue to be prescribed as analgesics for patients with healing fractures even though these drugs diminish bone formation, healing, and remodeling. Inhibition of bone formation can be clinically useful in preventing heterotopic ossification in selected clinical situations. In this regard, naproxen may be more efficacious than the traditional indomethacin, and short-term administration is as effective as long-term. When fracture healing or spine fusion is desired, nonsteroidal anti-inflammatory drugs should be avoided. Some nonsteroidal anti-inflammatory drugs have a positive effect on soft-tissue healing; they stimulate collagen synthesis and can increase strength in the early phases of repair during skin and ligament healing. Cyclooxygenase-2 inhibitors have an adverse effect on bone healing and may have an adverse effect on ligament healing. Therefore, further investigation is necessary to confirm that traditional nonsteroidal anti-inflammatory drugs may be preferable for the healing of collagenous tissues.

The influence of a cyclooxygenase-1 inhibitor on injured and uninjured ligaments in the rat

BACKGROUND

Results of previous studies have shown that piroxicam, a cyclooxygenase-1-2 inhibitor, improves the strength of healing ligaments, whereas celecoxib, a cyclooxygenase-2 inhibitor, impairs ligament healing.

HYPOTHESIS

The selective cyclooxygenase-1 inhibitor, SC-560, will improve the strength of ligament healing in an in vivo rat model.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eighty male Sprague-Dawley rats underwent surgical transection of their medial collateral ligament. Postoperatively, 20 rats were given SC-560 at a low dose and 20 at a high dose for the first 6 days of recovery; the other 40 received a normal diet. The animals were sacrificed 14 days later, and both the injured and uninjured ligaments were mechanically tested to failure in tension.

RESULTS

No significant differences in the strength of injured ligaments were found between drug and placebo treatment. However, the contralateral uninjured ligaments in the SC-560-treated groups failed at 27% higher energy and 22% higher load.

CONCLUSIONS

This cyclooxygenase-1 inhibitor did not improve the strength of ligament healing but did significantly improve the strength of the contralateral uninjured ligament.

CLINICAL RELEVANCE

A pure cyclooxygenase-1 inhibitor is probably not indicated as a positive influence on ligament healing but might provide benefits in ligament injury prevention.