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Zhang H, Fu J, Jie S, Wang X, Wang S, Wu H, Hu Y, Huang C. Induced membrane technique versus one-stage autografting in management of atrophic nonunion of long bone in the lower limb: clinical and health burden outcomes. J Orthop Surg Res 2023; 18:853. [PMID: 37946277 PMCID: PMC10636875 DOI: 10.1186/s13018-023-04296-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/17/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVE In this study, we aimed to compare the outcomes of the two-stage induced membrane technique (IMT) and one-stage autografting in the treatment of aseptic atrophic nonunion in lower limb long bones. METHODS From January 2014 to January 2022, we reviewed all surgically treated long bone nonunion patients, including patients aged 18 years or older with atrophic nonunion, who were either treated with the two-stage induced membrane technique (IMT) or one-stage autografting. Outcome parameters interns of clinical, quality of life and healthcare burden were recorded and retrospectively analysed between the two treatment populations. The follow-up time was at least 1 year. RESULTS In total, 103 patients who met the criteria for aseptic atrophic nonunion were enrolled. Among them, 41 (39.8%) patients were treated with two-stage IMT, and 62 (60.2%) patients were treated with one-stage autologous bone grafting. The follow-up time was 12 to 68 months, with an average of 28.4 months. The bone healing rate was comparable in both groups (IMT: 92.7% vs. one-stage grafting: 91.9%, P = 0.089) at 12 months post-operation, and the bone healing Lane-Sandhu score was superior in the IMT group (mean: 8.68 vs. 7.81, P = 0.002). Meanwhile, the SF-12 scores of subjective physical component score (PCS) (mean: 21.36 vs. 49.64, P < 0.01) and mental health component score (MCS) (mean: 24.85 vs. 46.14, P < 0.01) significantly increased in the IMT group, as well as in the one-stage grafting group, and no statistically significant difference was found within groups. However, the total hospital stays (median: 8 days vs. 14 days, P < 0.01) and direct medical healthcare costs (median: ¥30,432 vs. ¥56,327, P < 0.05) were greater in the IMT group, while the complications (nonunion 8, infection 3, material failure 2, and donor site pain 6) were not significantly different between the two groups (17.1% vs. 19.4, P = 0.770). CONCLUSION The data indicate that two-stage method of IMT serves as an alternative method in treating atrophic nonunion; however, it may not be a preferred option, in comprehensive considering patient clinical outcomes and healthcare burden. More evidence-based research is needed to further guide clinical decision-making.
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Affiliation(s)
- Hu Zhang
- Army Medical University (Third Military Medical University), Gaotanyan Street No.30, Shangpingba District, Chongqing, 400038, People's Republic of China
| | - Jingshu Fu
- Banan Hospital of Chongqing Medical University, Banan District, Longzhouwan Street No. 659, Chongqing City, 400038, People's Republic of China
| | - Shen Jie
- Department of Orthopaedics, Southwest Hospital, Army Medical University (Third Military Medical University), Gaotanyan Street No.30, Shangpingba District, Chongqing, 400038, People's Republic of China
| | - Xiaohua Wang
- Department of Orthopaedics, Southwest Hospital, Army Medical University (Third Military Medical University), Gaotanyan Street No.30, Shangpingba District, Chongqing, 400038, People's Republic of China
| | - Shulin Wang
- Department of Orthopaedics, Southwest Hospital, Army Medical University (Third Military Medical University), Gaotanyan Street No.30, Shangpingba District, Chongqing, 400038, People's Republic of China
| | - Hongri Wu
- Department of Orthopaedics, Southwest Hospital, Army Medical University (Third Military Medical University), Gaotanyan Street No.30, Shangpingba District, Chongqing, 400038, People's Republic of China.
- Department of Orthopedics, Navy 905th Hospital, Naval Medical University, Shanghai, People's Republic of China.
| | - Yongjun Hu
- Banan Hospital of Chongqing Medical University, Banan District, Longzhouwan Street No. 659, Chongqing City, 400038, People's Republic of China.
| | - Chunji Huang
- Army Medical University (Third Military Medical University), Gaotanyan Street No.30, Shangpingba District, Chongqing, 400038, People's Republic of China.
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Menger MM, Körbel C, Bauer D, Bleimehl M, Tobias AL, Braun BJ, Herath SC, Rollmann MF, Laschke MW, Menger MD, Histing T. Photoacoustic imaging for the study of oxygen saturation and total hemoglobin in bone healing and non-union formation. PHOTOACOUSTICS 2022; 28:100409. [PMID: 36213763 PMCID: PMC9535319 DOI: 10.1016/j.pacs.2022.100409] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 08/14/2022] [Accepted: 09/25/2022] [Indexed: 06/16/2023]
Abstract
Non-union formation represents a major complication in trauma surgery. Adequate vascularization has been recognized as vital for bone healing. However, the role of vascularization in the pathophysiology of non-union formation remains elusive. This is due to difficulties in studying bone microcirculation in vivo. Therefore, we herein studied in a murine osteotomy model whether photoacoustic imaging may be used to analyze vascularization in bone healing and non-union formation. We found that oxygen saturation within the callus tissue is significantly lower in non-unions compared to unions and further declines over time. Moreover, the amount of total hemoglobin (HbT) within the callus tissue was markedly reduced in non-unions. Correlation analyses showed a strong positive correlation between microvessel density and HbT, indicating that photoacoustically determined HbT is a valid parameter to assess vascularization during bone healing. In summary, photoacoustic imaging is a promising approach to study vascular function and tissue oxygenation in bone regeneration.
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Affiliation(s)
- Maximilian M. Menger
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tübingen, BG Trauma Center Tübingen, 72076 Tübingen, Germany
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg, Saar, Germany
| | - Christina Körbel
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg, Saar, Germany
| | - David Bauer
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg, Saar, Germany
| | - Michelle Bleimehl
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg, Saar, Germany
| | - Anne L. Tobias
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg, Saar, Germany
| | - Benedikt J. Braun
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tübingen, BG Trauma Center Tübingen, 72076 Tübingen, Germany
| | - Steven C. Herath
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tübingen, BG Trauma Center Tübingen, 72076 Tübingen, Germany
| | - Mika F. Rollmann
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tübingen, BG Trauma Center Tübingen, 72076 Tübingen, Germany
| | - Matthias W. Laschke
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg, Saar, Germany
| | - Michael D. Menger
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg, Saar, Germany
| | - Tina Histing
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tübingen, BG Trauma Center Tübingen, 72076 Tübingen, Germany
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Hixon KR, Katz DB, McKenzie JA, Miller AN, Guilak F, Silva MJ. Cryogel Scaffold-Mediated Delivery of Adipose-Derived Stem Cells Promotes Healing in Murine Model of Atrophic Non-Union. Front Bioeng Biotechnol 2022; 10:851904. [PMID: 35600896 PMCID: PMC9117654 DOI: 10.3389/fbioe.2022.851904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/23/2022] [Indexed: 01/08/2023] Open
Abstract
Non-union is defined as the permanent failure of a bone to heal and occurs clinically in 5% of fractures. Atrophic non-unions, characterized by absent/minimal callus formation, are poorly understood and difficult to treat. We recently demonstrated a novel murine model of atrophic non-union in the 3.6Col1A1-tk (Col1-tk) mouse, wherein dosing with the nucleoside analog ganciclovir (GCV) was used to deplete proliferating osteoprogenitor cells, leading to a radiographic and biomechanical non-union after the mid-shaft femur fracture. Using this Col1-tk atrophic non-union model, we hypothesized that the scaffold-mediated lentiviral delivery of doxycycline-inducible BMP-2 transgenes would induce osteogenesis at the fracture site. Cryogel scaffolds were used as a vehicle for GFP+ and BMP-2+ cell delivery to the site of non-union. Cryogel scaffolds were biofabricated through the cross-linking of a chitosan-gelatin polymer solution at subzero temperatures, which results in a macroporous, spongy structure that may be advantageous for a bone regeneration application. Murine adipose-derived stem cells were seeded onto the cryogel scaffolds, where they underwent lentiviral transduction. Following the establishment of atrophic non-unions in the femurs of Col1-tk mice (4 weeks post-fracture), transduced, seeded scaffolds were surgically placed around the site of non-union, and the animals were given doxycycline water to induce BMP-2 production. Controls included GFP+ cells on the cryogel scaffolds, acellular scaffolds, and sham (no scaffold). Weekly radiographs were taken, and endpoint analysis included micro-CT and histological staining. After 2 weeks of implantation, the BMP-2+ scaffolds were infiltrated with cartilage and woven bone at the non-union site, while GFP+ scaffolds had woven bone formation. Later, timepoints of 8 weeks had woven bone and vessel formation within the BMP-2+ and GFP + scaffolds with cortical bridging of the original fracture site in both groups. Overall, the cell-seeded cryogels promoted osseous healing. However, while the addition of BMP-2 promoted the endochondral ossification, it may provide a slower route to healing. This proof-of-concept study demonstrates the potential for cellularized cryogel scaffolds to enhance the healing of non-unions.
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Affiliation(s)
- Katherine R. Hixon
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, Washington University, St. Louis, MO, United States
- Thayer School of Engineering, Dartmouth College, Hanover, NH, United States
| | - Dakota B. Katz
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, Washington University, St. Louis, MO, United States
- Department of Biomedical Engineering, Washington University, St. Louis, MO, United States
- Center of Regenerative Medicine, Washington University, St. Louis, MO, United States
- Shriners Hospitals for Children—St. Louis, St. Louis, MO, United States
| | - Jennifer A. McKenzie
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, Washington University, St. Louis, MO, United States
| | - Anna N. Miller
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, Washington University, St. Louis, MO, United States
| | - Farshid Guilak
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, Washington University, St. Louis, MO, United States
- Department of Biomedical Engineering, Washington University, St. Louis, MO, United States
- Center of Regenerative Medicine, Washington University, St. Louis, MO, United States
- Shriners Hospitals for Children—St. Louis, St. Louis, MO, United States
| | - Matthew J. Silva
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, Washington University, St. Louis, MO, United States
- Department of Biomedical Engineering, Washington University, St. Louis, MO, United States
- Center of Regenerative Medicine, Washington University, St. Louis, MO, United States
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4
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Hughes LD, Khudr J, Gee E, Pillai A. Pitfalls preventing bone union with EXOGEN Low-Intensity Pulsed Ultrasound. SICOT J 2022; 8:15. [PMID: 35426791 PMCID: PMC9012134 DOI: 10.1051/sicotj/2022012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/23/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To evaluate the efficacy of EXOGEN in achieving union and common pitfalls in its use within the Manchester Foundation Trust (MFT) and Salford Royal Foundation Trust (SRFT). METHOD Patients receiving EXOGEN therapy between 01/01/2017 and 31/12/2019 at hospitals within MFT and SRFT were identified using EXOGEN logbooks and hospital IT systems. An equal number of patients were included from both sites. Data were retrospectively collected from clinical documents detailing clinical presentation comorbidities, and radiographic images, determining the radiological union post EXOGEN therapy. In addition, local practices were observed and compared to EXOGEN's standardized guidance for clinicians. RESULTS Fifty-eight patients were included in the primary review, with 9 subsequently excluded based on insufficient clinical data. 47% of patients achieved radiological union following completion of EXOGEN therapy. Outcomes of the 23 patients with persistent non-union were as follows - 18 were referred for revision surgery, 5 were prescribed further EXOGEN therapy, 2 refused or were unfit for further intervention, and 1 did not have a plan documented. No significant baseline differences were present in both outcome groups. However, at MFT and SRFT, rates of union with EXOGEN are below that previously published in the literature. CONCLUSION EXOGEN has proven successful in facilitating union in established cases of non-union without the risk and cost associated with revision surgery. Centre outcome differences may be explained by failure to educate clinicians and patients on the correct use of the EXOGEN device, failure to standardize follow-up or monitor compliance, and must be addressed to improve current services.
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Affiliation(s)
- Luke D Hughes
- Stepping Hill Hospital, Poplar Grove, Hazel Grove, Stockport SK2 7JE, UK
| | - Jamal Khudr
- Royal Liverpool Hospital, Prescot St., Liverpool L7 8XP, UK
| | - Edward Gee
- Salford Royal Hospital, Stott Lane, Salford M6 8HD, UK
| | - Anand Pillai
- Wythenshawe Hospital, Southmoor Rd, Wythenshawe, Manchester M23 9LT, UK
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5
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Hixon KR, Miller AN. Animal models of impaired long bone healing and tissue engineering- and cell-based in vivo interventions. J Orthop Res 2022; 40:767-778. [PMID: 35072292 DOI: 10.1002/jor.25277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 12/05/2021] [Accepted: 01/16/2022] [Indexed: 02/04/2023]
Abstract
Bone healing after injury typically follows a systematic process and occurs spontaneously under appropriate physiological conditions. However, impaired long bone healing is still quite common and may require surgical intervention. Various complications can result in different forms of impaired bone healing including nonunion, critical-size defects, or stress fractures. While a nonunion may occur due to impaired biological signaling and/or mechanical instability, a critical-size defect exhibits extensive bone loss that will not spontaneously heal. Comparatively, a stress fracture occurs from repetitive forces and results in a non-healing crack or break in the bone. Clinical standards of treatment vary between these bone defects due to their pathological differences. The use of appropriate animal models for modeling healing defects is critical to improve current treatment methods and develop novel rescue therapies. This review provides an overview of these clinical bone healing impairments and current animal models available to study the defects in vivo. The techniques used to create these models are compared, along with the outcomes, to clarify limitations and future objectives. Finally, rescue techniques focused on tissue engineering and cell-based therapies currently applied in animal models are specifically discussed to analyze their ability to initiate healing at the defect site, providing information regarding potential future therapies. In summary, this review focuses on the current animal models of nonunion, critical-size defects, and stress fractures, as well as interventions that have been tested in vivo to provide an overview of the clinical potential and future directions for improving bone healing.
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Affiliation(s)
- Katherine R Hixon
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri, USA.,Thayer School of Engineering, Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire, USA
| | - Anna N Miller
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri, USA
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6
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Abstract
Despite major research efforts to elucidate mechanisms of non-union formation, failed fracture healing remains a common complication in orthopedic surgery. Adequate vascularization has been recognized as a crucial factor for successful bone regeneration, as newly formed microvessels guarantee the supply of the callus tissue with vital oxygen, nutrients, and growth factors. Accordingly, a vast number of preclinical studies have focused on the development of vascularization strategies to stimulate fracture repair. However, recent evidence suggests that stimulation of blood vessel formation is an oversimplified approach to support bone regeneration. This review discusses the role of vascularization during bone regeneration and delineates a phenomenon, for which we coin the term “the vascularization paradox of non-union-formation”. This view is based on the results of a variety of experimental studies that suggest that the callus tissue of non-unions is indeed densely vascularized and that pro-angiogenic mediators, such as vascular endothelial growth factor, are sufficiently expressed at the facture site. By gaining further insights into the molecular and cellular basis of non-union vascularization, it may be possible to develop more optimized treatment approaches or even prevent the non-union formation in the future.
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7
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McCabe FJ, McQuail PM, Turley L, Hurley R, Flavin RA. Anatomical reconstruction of first ray instability hallux valgus with a medial anatomical TMTJ1 plate. Foot Ankle Surg 2021; 27:869-873. [PMID: 33353832 DOI: 10.1016/j.fas.2020.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/22/2020] [Accepted: 11/25/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND First tarsometatarsal joint (TMTJ1) arthrodesis is a powerful tool for hallux valgus correction. Past criticism of the TMTJ1 arthrodesis has focused on high non-union rates, and consequent need for delayed weightbearing as prevention. In this study we present a selection and treatment protocol to minimise non-union while allowing early weightbearing. METHODS All TMTJ1 arthrodesis procedures for hallux valgus performed by the senior surgeon over the period June, 2016 to July, 2019 were included. An anatomically-designed, medial TMTJ1 plate and screw compression was utilised for TMTJ1 arthrodesis. The construct was augmented with synthetic intermetatarsal stabilisation. All patients were kept non-weightbearing for 2 weeks, followed by progressive weightbearing as tolerated for 4 weeks. Minimum follow-up was 1 year. RESULTS 300 modified Lapidus procedures were performed for hallux valgus with mean IMA 17° (Range: 14-29). Mean age was 58 years, with 93% female. 284 (94%) had an Akin osteotomy, while 222 cases (74%) were associated with another forefoot procedure. Patients began progressive weight bearing as tolerated from 2 weeks. All were fully weight bearing by 8 weeks post-operatively. There was a 100% union rate in this group. Mean AOFAS Hallux MTP-IP scores rose from 59 pre-operatively to 97 post-operatively. One plate was removed due to tibialis anterior impingement. There were no recurrences at final follow-up. CONCLUSIONS We describe a selection and treatment protocol for TMTJ1 arthrodesis for hallux valgus. This yields high union rates while allowing early weight bearing. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- F J McCabe
- Department of Trauma & Orthopaedics, St. Vincent's University Hospital, Elm Park, Dublin, D04 T6F4, Ireland.
| | - P M McQuail
- Department of Trauma & Orthopaedics, St. Vincent's University Hospital, Elm Park, Dublin, D04 T6F4, Ireland
| | - L Turley
- Department of Trauma & Orthopaedics, St. Vincent's University Hospital, Elm Park, Dublin, D04 T6F4, Ireland
| | - R Hurley
- Department of Trauma & Orthopaedics, St. Vincent's University Hospital, Elm Park, Dublin, D04 T6F4, Ireland
| | - R A Flavin
- Department of Trauma & Orthopaedics, St. Vincent's University Hospital, Elm Park, Dublin, D04 T6F4, Ireland
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8
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Hixon KR, McKenzie JA, Sykes DAW, Yoneda S, Hensley A, Buettmann EG, Zheng H, Skouteris D, McAlinden A, Miller AN, Silva MJ. Ablation of Proliferating Osteoblast Lineage Cells After Fracture Leads to Atrophic Nonunion in a Mouse Model. J Bone Miner Res 2021; 36:2243-2257. [PMID: 34405443 PMCID: PMC8719642 DOI: 10.1002/jbmr.4424] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 07/15/2021] [Accepted: 08/10/2021] [Indexed: 01/19/2023]
Abstract
Nonunion is defined as the permanent failure of a fractured bone to heal, often necessitating surgical intervention. Atrophic nonunions are a subtype that are particularly difficult to treat. Animal models of atrophic nonunion are available; however, these require surgical or radiation-induced trauma to disrupt periosteal healing. These methods are invasive and not representative of many clinical nonunions where osseous regeneration has been arrested by a "failure of biology". We hypothesized that arresting osteoblast cell proliferation after fracture would lead to atrophic nonunion in mice. Using mice that express a thymidine kinase (tk) "suicide gene" driven by the 3.6Col1a1 promoter (Col1-tk), proliferating osteoblast lineage cells can be ablated upon exposure to the nucleoside analog ganciclovir (GCV). Wild-type (WT; control) and Col1-tk littermates were subjected to a full femur fracture and intramedullary fixation at 12 weeks age. We confirmed abundant tk+ cells in fracture callus of Col-tk mice dosed with water or GCV, specifically many osteoblasts, osteocytes, and chondrocytes at the cartilage-bone interface. Histologically, we observed altered callus composition in Col1-tk mice at 2 and 3 weeks postfracture, with significantly less bone and more fibrous tissue. Col1-tk mice, monitored for 12 weeks with in vivo radiographs and micro-computed tomography (μCT) scans, had delayed bone bridging and reduced callus size. After euthanasia, ex vivo μCT and histology showed failed union with residual bone fragments and fibrous tissue in Col1-tk mice. Biomechanical testing showed a failure to recover torsional strength in Col1-tk mice, in contrast to WT. Our data indicates that suppression of proliferating osteoblast-lineage cells for at least 2 weeks after fracture blunts the formation and remodeling of a mineralized callus leading to a functional nonunion. We propose this as a new murine model of atrophic nonunion. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Katherine R Hixon
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Jennifer A McKenzie
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - David A W Sykes
- Department of Biology, Washington University in St. Louis, St. Louis, MO, USA
| | - Susumu Yoneda
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Austin Hensley
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA.,Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA
| | - Evan G Buettmann
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA.,Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA
| | - Hongjun Zheng
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Dimitrios Skouteris
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Audrey McAlinden
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA.,Department of Cell Biology & Physiology, Washington University in St. Louis, St. Louis, MO, USA.,St. Louis Shriners Hospital Research Center, Shriners Hospital for Children, St. Louis, MO, USA
| | - Anna N Miller
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Matthew J Silva
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA.,Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA
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Menger MM, Laschke MW, Scheuer C, Bauer D, Bleimehl M, Später T, Rollmann MF, Braun BJ, Herath SC, Raza A, Menger MD, Histing T. Establishment of a reliable model to study the failure of fracture healing in aged mice. J Gerontol A Biol Sci Med Sci 2021; 77:909-917. [PMID: 34626193 DOI: 10.1093/gerona/glab304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Indexed: 11/15/2022] Open
Abstract
The failure of fracture healing represents a substantial clinical problem. Moreover, aged patients demonstrate an elevated risk for failed bone healing. However, murine models to study the failure of fracture healing are established only in young adult animals. Therefore, the aim of this study was to develop a reliable model to study failed fracture healing in aged mice. After creation of a 1.8 mm segmental defect and periosteal resection, femora of aged mice (18-20 months) and young adult control mice (3-4 months) were stabilized by pin-clip fixation. Segmental defects were analyzed by means of biomechanics, X-ray and micro-computed tomography (µCT), as well as histomorphometric, immunohistochemical and Western blot analysis. After 10 weeks all animals showed a complete lack of osseous bridging, resulting in fracture healing failure. Segmental defects in aged mice revealed a reduced bone formation and vascularization when compared to young adult mice. This was associated with a decreased expression of bone formation markers. In addition, we detected a reduced number of tartrate-resistance acid phosphatase (TRAP)-positive osteoclasts and an elevated osteoprotegerin (OPG)/receptor activator of NF-ĸB ligand (RANKL)-ratio in aged animals, indicating a reduced osteoclast activity. Moreover, aged animals showed also an enhanced inflammatory response, characterized by an increased infiltration of macrophages within the callus tissue. Taken together, we herein report for the first time a reliable model to study fracture healing failure in aged mice. In the future, the use of this model enables to study novel therapeutic strategies and molecular mechanics of failed fracture healing during aging.
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Affiliation(s)
- Maximilian M Menger
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg/Saar, Germany.,Department of Trauma and Reconstructive Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
| | - Matthias W Laschke
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg/Saar, Germany
| | - Claudia Scheuer
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg/Saar, Germany
| | - David Bauer
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg/Saar, Germany
| | - Michelle Bleimehl
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg/Saar, Germany
| | - Thomas Später
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg/Saar, Germany
| | - Mika F Rollmann
- Department of Trauma and Reconstructive Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
| | - Benedikt J Braun
- Department of Trauma and Reconstructive Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
| | - Steven C Herath
- Department of Trauma and Reconstructive Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
| | - Ahsan Raza
- Department of Experimental and Clinical Pharmacology and Toxicology, Saarland University, 66421 Homburg/Saar, Germany
| | - Michael D Menger
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg/Saar, Germany
| | - Tina Histing
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg/Saar, Germany.,Department of Trauma and Reconstructive Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
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10
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Houston J, Armitage L, Sedgwick PM, McGovern M, Smith RM, Trompeter AJ. Defining the Mean Angle of Diaphyseal Long Bone Nonunions-Does Shear Prevail? J Orthop Trauma 2021; 35:e322-e327. [PMID: 33395179 DOI: 10.1097/bot.0000000000002050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To define the mean angle of a series of diaphyseal nonunions based on radiographic analysis. DESIGN A retrospective cohort study. SETTING Two level-1 trauma centers. PATIENTS One hundred twenty patients presenting with nonunion. INTERVENTION A mean nonunion angle was calculated from a series of AP and lateral X-rays using a standardized technique. The nonunion angle was then estimated in a single plane by considering the greater of the 2 measured angles. Additional data collected included patient age, sex, nonunion site, initial fracture angle, and original fracture pattern. MAIN OUTCOME MEASUREMENT Single plane nonunion angle. RESULTS The mean angles of all nonunion in coronal plane was 42 degrees (SD 17 degrees) and 42 degrees in sagittal plane (SD 18 degrees) and 48 degrees (SD 15 degrees) in single plane. The single plane nonunion angle in fractures which were originally multiplanar was steeper to those occurring in originally single plane fractures (P 0.002) although both were close to 45 degrees. There was no significant difference in the nonunion angles on subgroup analysis of cohort location, sex, or anatomic location. CONCLUSIONS This study demonstrates the mean angle of diaphyseal nonunions from long bones of the lower limb approaches 45 degrees. This is noted in all types of fractures and is irrespective of anatomic location or sex. This confirms the hypothesis that shear is likely to play a role in the development of a nonunion. This study provides further evidence that nonunions occur primarily because of mechanical instability. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- James Houston
- Department of Trauma and Orthopaedics, St Georges University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Leanne Armitage
- Institute for Medical and Biomedical Education, St. George's, University of London, London, United Kingdom
| | - Philip M Sedgwick
- Institute for Medical and Biomedical Education, St. George's, University of London, London, United Kingdom
| | - Madeline McGovern
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; and
| | - Raymond M Smith
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Alex J Trompeter
- Department of Trauma and Orthopaedics, St Georges University Hospitals NHS Foundation Trust, London, United Kingdom
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11
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Wildemann B, Ignatius A, Leung F, Taitsman LA, Smith RM, Pesántez R, Stoddart MJ, Richards RG, Jupiter JB. Non-union bone fractures. Nat Rev Dis Primers 2021; 7:57. [PMID: 34354083 DOI: 10.1038/s41572-021-00289-8] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/24/2021] [Indexed: 11/09/2022]
Abstract
The human skeleton has remarkable regenerative properties, being one of the few structures in the body that can heal by recreating its normal cellular composition, orientation and mechanical strength. When the healing process of a fractured bone fails owing to inadequate immobilization, failed surgical intervention, insufficient biological response or infection, the outcome after a prolonged period of no healing is defined as non-union. Non-union represents a chronic medical condition not only affecting function but also potentially impacting the individual's psychosocial and economic well-being. This Primer provides the reader with an in-depth understanding of our contemporary knowledge regarding the important features to be considered when faced with non-union. The normal mechanisms involved in bone healing and the factors that disrupt the normal signalling mechanisms are addressed. Epidemiological considerations and advances in the diagnosis and surgical therapy of non-union are highlighted and the need for greater efforts in basic, translational and clinical research are identified.
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Affiliation(s)
- Britt Wildemann
- Experimental Trauma Surgery, Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany. .,Julius Wolff Institute and BIH Center for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Anita Ignatius
- Institute of Orthopedic Research and Biomechanics, Ulm University, Ulm, Baden Württemberg, Germany
| | - Frankie Leung
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, the University of Hong Kong, Hong Kong, Hong Kong
| | - Lisa A Taitsman
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA
| | - R Malcolm Smith
- Orthopedic trauma service, University of Massachusetts Medical School, Worcester, MA, USA
| | - Rodrigo Pesántez
- Departamento de Ortopedia Y Traumatología Fundación Santa Fé de Bogotá - Universidad de los Andes, Bogotá, Colombia
| | | | | | - Jesse B Jupiter
- Department of Orthopaedic surgery, Massachussets General Hospital, Boston, MA, USA.
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12
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Wu XQ, Wang D, Liu Y, Zhou JL. Development of a tibial experimental non-union model in rats. J Orthop Surg Res 2021; 16:261. [PMID: 33853660 PMCID: PMC8045330 DOI: 10.1186/s13018-021-02408-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Many non-union animal models have been developed to explore the problems surrounding fracture healing. However, the existing models are not perfect and cannot satisfy all non-union studies. This study aimed to make a non-union model of the tibia in rats by cauterization of the posterior of 2 mm on both sides of the fracture end after open osteotomy of the tibia and fixing the fractured tibia with a Kirschner wire 0.8 mm in diameter. METHODS For this study, 96 female adult Sprague-Dawley (SD) rats were used. The rats underwent surgery to produce a tibial open fracture and were fixed with a 0.8-mm diameter Kirschner wire. In 48 of the rats, the periosteum proximal and distal to the fracture end was cauterized. RESULTS At 2, 4, 6, and 8 weeks after surgery, radiological and histological analysis showed typical physiological healing in the control group, and the healing rate was 100% at 6 weeks. But the non-union group was characterized by resorption of the fracture ends with few callus formations and no bridging callus formation, and the healing rate was 0% at 8 weeks. CONCLUSIONS This method represents a reproducible model to create atrophic non-unions. This model provides a new option for studying the basic healing mechanisms and evaluating new therapies for bone regeneration and treatment of non-unions.
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Affiliation(s)
- Xue-Qiang Wu
- Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
- Department of Handsurgery, Tangshan Second Hospital, Tangshan, 063000, China
| | - Dong Wang
- Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Yang Liu
- Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
| | - Jun-Lin Zhou
- Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China.
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13
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Onishi T, Shimizu T, Akahane M, Okuda A, Kira T, Omokawa S, Tanaka Y. Robust method to create a standardized and reproducible atrophic non-union model in a rat femur. J Orthop 2020; 21:223-227. [PMID: 32273661 DOI: 10.1016/j.jor.2020.03.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 03/24/2020] [Indexed: 11/18/2022] Open
Abstract
Objective No evidence exists about which biological approach is more reliable for creating non-union model. We investigated how to create a reproducible atrophic non-union model in a rat femur. Methods We compared three groups: simple osteotomy (group A), partial periosteum cauterization (group B), and extensive periosteum and bone marrow resection (group C). Results All samples in group C demonstrated atrophic non-union in radiological, histological, and biomechanical analyses, however half of the samples in group B showed fracture healing at week 16. Conclusion Extensive resection of periosteum and bone marrow is important for a reproducible atrophic non-union model in a rat femur.
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Affiliation(s)
- Tadanobu Onishi
- Department of Orthopedic Surgery, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Takamasa Shimizu
- Department of Orthopedic Surgery, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Manabu Akahane
- Department of Public Health, Health Management and Policy, Nara Medical University School of Medicine, Kashihara, Nara, 634-8521, Japan
| | - Akinori Okuda
- Department of Orthopedic Surgery, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Tsutomu Kira
- Department of Orthopedic Surgery, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Shohei Omokawa
- Department of Hand Surgery, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Yasuhito Tanaka
- Department of Orthopedic Surgery, Nara Medical University, Kashihara, Nara, 634-8522, Japan
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14
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Wagner JM, Schmidt SV, Dadras M, Huber J, Wallner C, Dittfeld S, Becerikli M, Jaurich H, Reinkemeier F, Drysch M, Lehnhardt M, Behr B. Inflammatory processes and elevated osteoclast activity chaperon atrophic non-union establishment in a murine model. J Transl Med 2019; 17:416. [PMID: 31831031 PMCID: PMC6909450 DOI: 10.1186/s12967-019-02171-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 12/05/2019] [Indexed: 01/09/2023] Open
Abstract
Background Delayed bone healing, especially in long bones poses one of the biggest problems in orthopeadic and reconstructive surgery and causes tremendous costs every year. There is a need for exploring the causes in order to find an adequate therapy. Earlier investigations of human scaphoid non-union revealed an elevated osteoclast activity, accompanied by upregulated levels of TGF-beta and RANKL. Interestingly, scaphoid non-union seemed to be well vascularized. Methods In the current study, we used a murine femur-defect model to study atrophic non unions over a time-course of 10 weeks. Different time points were chosen, to gather insights into the dynamic processes of non-union establishment. Results Histological analyses as well as western blots and qRT-PCR indicated enhanced osteoclast activity throughout the observation period, paralleled by elevated levels of TGF-beta, TNF-alpha, MMP9, MMP13 and RANKL, especially during the early phases of non-union establishment. Interestingly, elevated levels of these mediators decreased markedly over a period of 10 weeks, as inflammatory reaction during non-union establishment seemed to wear out. To our surprise, osteoblastogenesis seemed to be unaffected during early stages of non-union establishment. Conclusion Taken together, we gained first insights into the establishment process of atrophic non unions, in which inflammatory processes accompanied by highly elevated osteoclast activity seem to play a leading role.
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Affiliation(s)
- Johannes M Wagner
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany.
| | - Sonja V Schmidt
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Mehran Dadras
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Julika Huber
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Christoph Wallner
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Stephanie Dittfeld
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Mustafa Becerikli
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Henriette Jaurich
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Felix Reinkemeier
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Marius Drysch
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Marcus Lehnhardt
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Björn Behr
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
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15
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Pan Z, Pan J, Wang H, Yu Z, Li Z, Yang W, Li J, Zhu Q, Luo Z. Healing physiology following delayed surgery for femoral midshaft fracture caused by high-energy injury: an in vivo study in dogs. J Int Med Res 2019; 47:5155-5173. [PMID: 31370721 PMCID: PMC6833404 DOI: 10.1177/0300060519860704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective An experimental model of severe soft tissue damage was designed to simulate high-energy fracture and observe the fracture healing process following early surgery and surgery delayed by 1 week. Methods Forty dogs were randomized to Group A (immediate surgery) and B (delayed surgery). The femur was broken, and the two ends were forcefully stabbed to damage the surrounding soft tissues. The fracture was repaired using a custom six-hole steel plate. Four dogs were killed on day 3 and weeks 1, 2, 4, and 8 following bone fracture. Soft tissue and bone were examined by light and electron microscopy. Results In Group A, no callus was present at 1, 2, 4, and 8 weeks following fracture, resulting in atrophic nonunion. In Group B, visible weak external callus was present 1 week following fracture, and good external callus growth was present at 2, 4, and 8 weeks, leading to callus healing. Conclusion These findings suggest that the first week is critical for fracture healing. Absence of callus in the early stage is indicative of absence of callus growth throughout the entire healing process, while the presence of callus in the early stage is indicative of vigorous callus growth thereafter.
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Affiliation(s)
- Zhijun Pan
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Jingxin Pan
- Department of Orthopedics, The Fourth Hospital of Yulin, Yulin, Shaanxi, China
| | - Hanli Wang
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhou Yu
- Department of Burn, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhong Li
- Department of Orthopedics, Xi'an Honghui Hospital, Xi'an, Shaanxi, P.R. China
| | - Wenxue Yang
- Department of Orthopedics, The Fourth Hospital of Yulin, Yulin, Shaanxi, China
| | - Jing Li
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Qingsheng Zhu
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhuojing Luo
- Department of Orthopedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
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Abstract
Besides seminal functions in angiogenesis and blood pressure regulation, microvascular pericytes possess a latent tissue regenerative potential that can be revealed in culture following transition into mesenchymal stem cells. Endowed with robust osteogenic potential, pericytes and other related perivascular cells extracted from adipose tissue represent a potent and abundant cell source for refined bone tissue engineering and improved cell therapies of fractures and other bone defects. The use of diverse bone formation assays in vivo, which include mouse muscle pocket osteogenesis and calvaria replenishment, rat and dog spine fusion, and rat non-union fracture healing, has confirmed the superiority of purified perivascular cells for skeletal (re)generation. As a surprising observation though, despite strong endogenous bone-forming potential, perivascular cells drive bone regeneration essentially indirectly, via recruitment by secreted factors of local osteo-progenitors.
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17
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Meeson R, Moazen M, Sanghani-Kerai A, Osagie-Clouard L, Coathup M, Blunn G. The influence of gap size on the development of fracture union with a micro external fixator. J Mech Behav Biomed Mater 2019; 99:161-168. [PMID: 31357063 PMCID: PMC6715773 DOI: 10.1016/j.jmbbm.2019.07.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/31/2019] [Accepted: 07/18/2019] [Indexed: 02/02/2023]
Abstract
Increasingly, the rat femoral fracture model is being used for preclinical investigations of fracture healing, however, the effect of gap size and its influence on mechanobiology is not well understood. We aimed to evaluate the influence of osteotomy gap on osteotomy healing between the previously published extremes of guaranteed union (0.5 mm) and non-union (3 mm) using this model. A femoral osteotomy in 12–14 week old female Wistar rats was stabilised with a micro fixator (titanium blocks, carbon fiber bars) with an osteotomy gap of 1.0 mm (n = 5), 1.5 mm (n = 7), 2.0 mm (n = 6). After five weeks, the left femur was retrieved. The osteotomy gap was scanned using X-ray microtomography and then histologically evaluated. The radiographic union rate (complete mineralised bone bridging across the osteotomy) was three times higher for the 1.0 mm than the 2.0 mm gap. The 1.0 mm gap had the largest callus (0.069μm3) and bone volume (0.035μm3). Callus and bone volume were approximately 50% smaller within the 2.0 mm gap. Using cadaveric rat femurs stabilised with the external fixator, day 0 mechanical assessment of construct stiffness was calculated on materials testing machine displacement vs load output. The construct stiffness for the 1.0, 1.5 and 2.0 mm gaps was 32.6 ± 5.4, 32.5 ± 2.4, and 32.4 ± 8.3 N/mm (p = 0.779). Interfragmentary strain (IFS) was calculated using the change in osteotomy gap displacement as measured using microstrain miniature differential reluctance transducer spanning the osteotomy gap. Increasing the gap size significantly reduced the IFS (p = 0.013). The mean ‘day 0’ IFS for the 1.0, 1.5 and 2.0 mm gaps were 11.2 ± 1.3, 8.4 ± 1.5 and 6.1 ± 1.2% respectively. A 1.5 mm gap resulted in a delayed fracture healing by 5 weeks and may represent a useful test environment for fracture healing therapy. Increasing gap size did not affect construct stiffness, but did reduce the ‘day 0’ IFS, with a doubling of non-union and halving of bone volume measured between 1.0 and 2.0 mm gaps.
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Affiliation(s)
- Richard Meeson
- Division of Surgery, University College London, Stanmore, UK; Royal Veterinary College, Hertfordshire, UK.
| | - Mehran Moazen
- Division of Surgery, University College London, Stanmore, UK; Mechanical Engineering, University College London, UK
| | | | | | - Melanie Coathup
- Division of Surgery, University College London, Stanmore, UK; University of Central Florida, USA
| | - Gordon Blunn
- Division of Surgery, University College London, Stanmore, UK; University of Portsmouth, Portsmouth, UK
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18
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Peterson JR, Chen F, Nwankwo E, Dekker TJ, Adams SB. The Use of Bone Grafts, Bone Graft Substitutes, and Orthobiologics for Osseous Healing in Foot and Ankle Surgery. FOOT & ANKLE ORTHOPAEDICS 2019; 4:2473011419849019. [PMID: 35097327 PMCID: PMC8500392 DOI: 10.1177/2473011419849019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Achieving fusion in osseous procedures about the foot and ankle presents unique challenges to the surgeon. Many patients have comorbidities that reduce osseous healing rates, and the limited space and high weightbearing demand placed on fusion sites makes the choice of bone graft, bone graft substitute, or orthobiologic agent of utmost importance. In this review, we discuss the essential characteristics of grafts, including their osteoconductive, osteoinductive, osteogenic, and angiogenic properties. Autologous bone graft remains the gold standard and contains all these properties. However, the convenience and lack of donor site morbidity of synthetic bone grafts, allografts, and orthobiologics, including growth factors and allogenic stem cells, has led to these being used commonly as augments.
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Affiliation(s)
- Jonathan R. Peterson
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Fangyu Chen
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Eugene Nwankwo
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Travis J. Dekker
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Samuel B. Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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19
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Percutaneous screw fixation for painful non-union of lateral malleolus ankle fractures. Injury 2018; 49:1936-1941. [PMID: 30146366 DOI: 10.1016/j.injury.2018.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/09/2018] [Accepted: 08/14/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Lateral malleolus non-union can cause pain and loss of function. Standard treatment involves open approach with debridement, bone-grafting and plate stabilisation, with published surgical site infection rates to 17%. To minimise the risk of soft tissue complications and allow early mobilisation, we describe a technique for percutaneous cannulated screw stabilisation. MATERIALS AND METHODS Retrospective case review for all percutaneous lateral malleolus non-union stabilisation procedures undertaken in our hospital between 2011 and 2017 was performed. Fracture union was diagnosed by resolution of pain and swelling, with a return to full weight-bearing mobilisation and two-view radiographs consistent with union. RESULTS Twelve cases were reviewed. All fractures united. There was one superficial wound infection treated with oral antibiotics, and one early case with drill-piece fracture requiring conversion to open procedure with plate stabilisation. CONCLUSION We believe this to be the first report of percutaneous stabilisation for non-union of lateral malleolus fractures. We demonstrate this to be a safe and effective technique.
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20
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Schindeler A, Mills RJ, Bobyn JD, Little DG. Preclinical models for orthopedic research and bone tissue engineering. J Orthop Res 2018; 36:832-840. [PMID: 29205478 DOI: 10.1002/jor.23824] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 11/27/2017] [Indexed: 02/04/2023]
Abstract
In this review, we broadly define and discuss the preclinical rodent models that are used for orthopedics and bone tissue engineering. These range from implantation models typically used for biocompatibility testing and high-throughput drug screening, through to fracture and critical defect models used to model bone healing and severe orthopedic injuries. As well as highlighting the key methods papers describing these techniques, we provide additional commentary based on our substantive practical experience with animal surgery and in vivo experimental design. This review also briefly touches upon the descriptive and functional outcome measures and power calculations that are necessary for an informative study. Obtaining informative and relevant research outcomes can be very dependent on the model used, and we hope this evaluation of common models will serve as a primer for new researchers looking to undertake preclinical bone studies. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:832-840, 2018.
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Affiliation(s)
- Aaron Schindeler
- Orthopedic Research and Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, Sydney, New South Wales, 2145, Australia.,Discipline of Pediatrics and Child Health, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Rebecca J Mills
- Orthopedic Research and Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, Sydney, New South Wales, 2145, Australia
| | - Justin D Bobyn
- Orthopedic Research and Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, Sydney, New South Wales, 2145, Australia.,Discipline of Pediatrics and Child Health, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - David G Little
- Orthopedic Research and Biotechnology Unit, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, Sydney, New South Wales, 2145, Australia.,Discipline of Pediatrics and Child Health, Faculty of Medicine, University of Sydney, Sydney, Australia
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21
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Mills L, Tsang J, Hopper G, Keenan G, Simpson AHRW. The multifactorial aetiology of fracture nonunion and the importance of searching for latent infection. Bone Joint Res 2016; 5:512-519. [PMID: 27784669 PMCID: PMC5108351 DOI: 10.1302/2046-3758.510.bjr-2016-0138] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Objectives A successful outcome following treatment of nonunion requires the correct identification of all of the underlying cause(s) and addressing them appropriately. The aim of this study was to assess the distribution and frequency of causative factors in a consecutive cohort of nonunion patients in order to optimise the management strategy for individual patients presenting with nonunion. Methods Causes of the nonunion were divided into four categories: mechanical; infection; dead bone with a gap; and host. Prospective and retrospective data of 100 consecutive patients who had undergone surgery for long bone fracture nonunion were analysed. Results A total of 31% of patients had a single attributable cause, 55% had two causes, 14% had three causes and 1% had all four. Of those (31%) with only a single attributable cause, half were due to a mechanical factor and a quarter had dead bone with a gap. Mechanical causation was found in 59% of all patients, dead bone and a gap was present in 47%, host factors in 43% and infection was a causative factor in 38% of patients. In all, three of 58 patients (5%) thought to be aseptic and two of nine (22%) suspected of possible infection were found to be infected. A total of 100% of previously treated patients no longer considered to have ongoing infection, had multiple positive microbiology results. Conclusion Two thirds of patients had multiple contributing factors for their nonunion and 5% had entirely unexpected infection. This study highlights the importance of identifying all of the aetiological factors and routinely testing tissue for infection in treating nonunion. It raises key points regarding the inadequacy of a purely radiographic nonunion classification system and the variety of different definitions for atrophic nonunion in the current mainstream classifications used for nonunion. Cite this article: L. Mills, J. Tsang, G. Hopper, G. Keenan, A. H. R. W. Simpson. The multifactorial aetiology of fracture nonunion and the importance of searching for latent infection. Bone Joint Res 2016;5:512–519. DOI: 10.1302/2046-3758.510.BJR-2016-0138.
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Affiliation(s)
- L Mills
- Royal Aberdeen Children's Hospital, Aberdeen, UK
| | - J Tsang
- Department of Orthopaedic Surgery, University of Edinburgh, Chancellor's building, 49 Little France Crescent, Edinburgh, EH16 4SB
| | - G Hopper
- West of Scotland, Glasgow Royal Infirmary, Glasgow, UK
| | - G Keenan
- Department of Orthopaedic Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK
| | - A H R W Simpson
- Department of Orthopaedic Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK
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22
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James AW, Hindle P, Murray IR, West CC, Tawonsawatruk T, Shen J, Asatrian G, Zhang X, Nguyen V, Simpson AH, Ting K, Péault B, Soo C. Pericytes for the treatment of orthopedic conditions. Pharmacol Ther 2016; 171:93-103. [PMID: 27510330 DOI: 10.1016/j.pharmthera.2016.08.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 08/01/2016] [Indexed: 01/15/2023]
Abstract
Pericytes and other perivascular stem cells are of growing interest in orthopedics and tissue engineering. Long regarded as simple regulators of angiogenesis and blood pressure, pericytes are now recognized to have MSC (mesenchymal stem cell) characteristics, including multipotentiality, self-renewal, immunoregulatory functions, and diverse roles in tissue repair. Pericytes are typified by characteristic cell surface marker expression (including αSMA, CD146, PDGFRβ, NG2, RGS5, among others). Although alone no marker is absolutely specific for pericytes, collectively these markers appear to selectively identify an MSC-like pericyte. The purification of pericytes is most well described as a CD146+CD34-CD45- cell population. Pericytes and other perivascular stem cell populations have been applied in diverse orthopedic applications, including both ectopic and orthotopic models. Application of purified cells has sped calvarial repair, induced spine fusion, and prevented fibrous non-union in rodent models. Pericytes induce these effects via both direct and indirect mechanisms. In terms of their paracrine effects, pericytes are known to produce and secrete high levels of a number of growth and differentiation factors both in vitro and after transplantation. The following review will cover existing studies to date regarding pericyte application for bone and cartilage engineering. In addition, further questions in the field will be pondered, including the phenotypic and functional overlap between pericytes and culture-derived MSC, and the concept of pericytes as efficient producers of differentiation factors to speed tissue repair.
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Affiliation(s)
- Aaron W James
- School of Dentistry, University of California, Los Angeles, United States; Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, United States; Orthopedic Hospital Research Center, University of California, Los Angeles, United States; Department of Pathology, Johns Hopkins University, Baltimore, MD, United States.
| | - Paul Hindle
- Department of Trauma and Orthopaedic Surgery, The University of Edinburgh, Edinburgh, United Kingdom
| | - Iain R Murray
- Department of Trauma and Orthopaedic Surgery, The University of Edinburgh, Edinburgh, United Kingdom; BHF Center for Vascular Regeneration & MRC Center for Regenerative Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Christopher C West
- BHF Center for Vascular Regeneration & MRC Center for Regenerative Medicine, University of Edinburgh, Edinburgh, United Kingdom; Department of Plastic and Reconstructive Surgery, St. Johns Hospital, Livingston, United Kingdom
| | - Tulyapruek Tawonsawatruk
- Department of Trauma and Orthopaedic Surgery, The University of Edinburgh, Edinburgh, United Kingdom; BHF Center for Vascular Regeneration & MRC Center for Regenerative Medicine, University of Edinburgh, Edinburgh, United Kingdom; Department of Orthopaedics, Ramathibodi Hospital, Madihol University, Thailand
| | - Jia Shen
- School of Dentistry, University of California, Los Angeles, United States
| | - Greg Asatrian
- School of Dentistry, University of California, Los Angeles, United States
| | - Xinli Zhang
- School of Dentistry, University of California, Los Angeles, United States
| | - Vi Nguyen
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, United States
| | - A Hamish Simpson
- Department of Trauma and Orthopaedic Surgery, The University of Edinburgh, Edinburgh, United Kingdom
| | - Kang Ting
- School of Dentistry, University of California, Los Angeles, United States
| | - Bruno Péault
- Orthopedic Hospital Research Center, University of California, Los Angeles, United States; BHF Center for Vascular Regeneration & MRC Center for Regenerative Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Chia Soo
- Orthopedic Hospital Research Center, University of California, Los Angeles, United States; Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States
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An intramembranous ossification model for the in silico analysis of bone tissue formation in tooth extraction sites. J Theor Biol 2016; 401:64-77. [PMID: 27113783 DOI: 10.1016/j.jtbi.2016.04.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 04/14/2016] [Accepted: 04/18/2016] [Indexed: 01/10/2023]
Abstract
The accurate modeling of biological processes allows us to predict the spatiotemporal behavior of living tissues by computer-aided (in silico) testing, a useful tool for the development of medical strategies, avoiding the expenses and potential ethical implications of in vivo experimentation. A model for bone healing in mouth would be useful for selecting proper surgical techniques in dental procedures. In this paper, the formulation and implementation of a model for Intramembranous Ossification is presented aiming to describe the complex process of bone tissue formation in tooth extraction sites. The model consists in a mathematical description of the mechanisms in which different types of cells interact, synthesize and degrade extracellular matrices under the influence of biochemical factors. Special attention is given to angiogenesis, oxygen-dependent effects and growth factor-induced apoptosis of fibroblasts. Furthermore, considering the depth-dependent vascularization of mandibular bone and its influence on bone healing, a functional description of the cell distribution on the severed periodontal ligament (PDL) is proposed. The developed model was implemented using the finite element method (FEM) and successfully validated by simulating an animal in vivo experiment on dogs reported in the literature. A good fit between model outcome and experimental data was obtained with a mean absolute error of 3.04%. The mathematical framework presented here may represent an important tool for the design of future in vitro and in vivo tests, as well as a precedent for future in silico studies on osseointegration and mechanobiology.
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Elliott DS, Newman KJH, Forward DP, Hahn DM, Ollivere B, Kojima K, Handley R, Rossiter ND, Wixted JJ, Smith RM, Moran CG. A unified theory of bone healing and nonunion. Bone Joint J 2016; 98-B:884-91. [DOI: 10.1302/0301-620x.98b7.36061] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 02/29/2016] [Indexed: 11/05/2022]
Abstract
This article presents a unified clinical theory that links established facts about the physiology of bone and homeostasis, with those involved in the healing of fractures and the development of nonunion. The key to this theory is the concept that the tissue that forms in and around a fracture should be considered a specific functional entity. This ‘bone-healing unit’ produces a physiological response to its biological and mechanical environment, which leads to the normal healing of bone. This tissue responds to mechanical forces and functions according to Wolff’s law, Perren’s strain theory and Frost’s concept of the “mechanostat”. In response to the local mechanical environment, the bone-healing unit normally changes with time, producing different tissues that can tolerate various levels of strain. The normal result is the formation of bone that bridges the fracture – healing by callus. Nonunion occurs when the bone-healing unit fails either due to mechanical or biological problems or a combination of both. In clinical practice, the majority of nonunions are due to mechanical problems with instability, resulting in too much strain at the fracture site. In most nonunions, there is an intact bone-healing unit. We suggest that this maintains its biological potential to heal, but fails to function due to the mechanical conditions. The theory predicts the healing pattern of multifragmentary fractures and the observed morphological characteristics of different nonunions. It suggests that the majority of nonunions will heal if the correct mechanical environment is produced by surgery, without the need for biological adjuncts such as autologous bone graft. Cite this article: Bone Joint J 2016;98-B:884–91.
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Affiliation(s)
- D. S. Elliott
- Ashford and St Peter’s Hospitals NHS Foundation
Trust, Guildford Road, Chertsey, Surrey
KT160PZ, UK
| | - K. J. H. Newman
- Ashford and St Peter’s Hospitals NHS Foundation
Trust, Guildford Road, Chertsey, Surrey
KT160PZ, UK
| | - D. P. Forward
- Nottingham University Hospitals NHS Trust, Nottingham
NG7 2UH, UK
| | - D. M. Hahn
- Nottingham University Hospitals NHS Trust, Nottingham
NG7 2UH, UK
| | - B. Ollivere
- Nottingham University Hospitals NHS Trust, Nottingham
NG7 2UH, UK
| | - K. Kojima
- University of Sao Paulo, Rua
Dr. Ovidio Pires de Campos, 333, Sao
Paulo, Brazil
| | - R. Handley
- John Radcliffe Hospital, Oxford, OX3
9DU, UK
| | | | - J. J. Wixted
- Beth Israel Hospital, Boston, Massachusetts, USA
| | - R. M. Smith
- Massachusetts
General Hospital, Boston, Massachusetts, USA
| | - C. G. Moran
- Nottingham University Hospitals NHS Trust, Nottingham
NG7 2UH, UK
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Adipose derived pericytes rescue fractures from a failure of healing--non-union. Sci Rep 2016; 6:22779. [PMID: 26997456 PMCID: PMC4800389 DOI: 10.1038/srep22779] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 02/16/2016] [Indexed: 12/21/2022] Open
Abstract
Atrophic non-union is attributed to biological failure of the fracture repair process. It occurs in up to 10% of fractures, results in significant morbidity to patients, and treatment often requires complex reconstructive procedures. We tested the ability of human bone derived marrow mesenchymal stem cells (MSC), and human adipose derived pericytes (the native ancestor of the MSC) delivered percutaneously to the fracture gap to prevent the formation of atrophic non-union in a rat model. At eight weeks, 80% of animals in the cell treatment groups showed evidence of bone healing compared to only 14% of those in the control group. Radiographic parameters showed significant improvement over the eight-week period in the cell treatment groups, and histology confirmed bone bridges at the fracture gap in the both treatment groups. The quality of bone produced and its biomechanical properties were significantly enhanced in both treatment groups. The results from this study demonstrate that MSC and pericytes have significant bone regeneration potential in an atrophic non-union model. These cells may have a role in the prevention of atrophic non-union and could enable a paradigm shift in the treatment of fractures at high risk of failing to heal and developing non-union.
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Wang C, Inzana JA, Mirando AJ, Ren Y, Liu Z, Shen J, O'Keefe RJ, Awad HA, Hilton MJ. NOTCH signaling in skeletal progenitors is critical for fracture repair. J Clin Invest 2016; 126:1471-81. [PMID: 26950423 DOI: 10.1172/jci80672] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 01/21/2016] [Indexed: 11/17/2022] Open
Abstract
Fracture nonunions develop in 10%-20% of patients with fractures, resulting in prolonged disability. Current data suggest that bone union during fracture repair is achieved via proliferation and differentiation of skeletal progenitors within periosteal and soft tissues surrounding bone, while bone marrow stromal/stem cells (BMSCs) and other skeletal progenitors may also contribute. The NOTCH signaling pathway is a critical maintenance factor for BMSCs during skeletal development, although the precise role for NOTCH and the requisite nature of BMSCs following fracture is unknown. Here, we evaluated whether NOTCH and/or BMSCs are required for fracture repair by performing nonstabilized and stabilized fractures on NOTCH-deficient mice with targeted deletion of RBPjk in skeletal progenitors, maturing osteoblasts, and committed chondrocytes. We determined that removal of NOTCH signaling in BMSCs and subsequent depletion of this population result in fracture nonunion, as the fracture repair process was normal in animals harboring either osteoblast- or chondrocyte-specific deletion of RBPjk. Together, this work provides a genetic model of a fracture nonunion and demonstrates the requirement for NOTCH and BMSCs in fracture repair, irrespective of fracture stability and vascularity.
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Ghodasra JH, Weatherford BM, Nickoli MS, Daley EL, Chen K, Zhang LQ, Hashmi SZ, Hsu EL, Hsu WK. The effect of rhBMP-2 in a novel, non-instrumented extremity nonunion model. J Orthop Sci 2016; 21:79-85. [PMID: 26740420 DOI: 10.1016/j.jos.2015.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 08/06/2015] [Accepted: 10/24/2015] [Indexed: 02/09/2023]
Abstract
BACKGROUND Pre-clinical models of bony nonunion typically employ critical-length defects. However, these models may not accurately reflect clinical practice since many nonunions are diagnosed without bone loss. We developed a non-displaced rat ulna fracture model in order to examine the efficacy of recombinant human bone morphogenetic protein-2 (rhBMP-2) with an absorbable collagen sponge (ACS) for nonunion treatment. METHODS Transverse diaphyseal ulna fractures were created in 24 Sprague-Dawley rats. Eight animals (Group 1: Nonunion) received no further intervention. The remaining 16 animals were treated with 5 μg rhBMP-2/ACS at 8 weeks after the original intervention (Group 2: Nonunion + BMP) or at the time of initial injury (Group 3: Fresh fracture + BMP). RESULTS In Group 1, 7 of 8 fractures demonstrated gross motion and a persistent radiographic gap (12.5% healing rate). In Groups 2 and 3, fractures healed at a rate of 75% (6 of 8 in each group) as determined by manual and radiographic evaluation. Biomechanical testing for torque load-to-failure and torsional stiffness demonstrated no significant difference between healed specimens treated with rhBMP-2. CONCLUSIONS To our knowledge, this is the first description of a physiologic, non-stabilized, non-defect fracture nonunion model in a rodent. Furthermore, unlike previous nonunion models, the healing rates after treatment with rhBMP-2 are comparable to that of clinical data, suggesting that this model may provide an environment more representative of nonunions in humans.
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Affiliation(s)
- Jason H Ghodasra
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Brian M Weatherford
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Michael S Nickoli
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Erika L Daley
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Kai Chen
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Li-Qun Zhang
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Sohaib Z Hashmi
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Erin L Hsu
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Wellington K Hsu
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA; Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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Carlier A, Lammens J, Van Oosterwyck H, Geris L. Computational modeling of bone fracture non-unions: four clinically relevant case studies. IN SILICO CELL AND TISSUE SCIENCE 2015; 2:1. [PMID: 26709368 PMCID: PMC4684906 DOI: 10.1186/s40482-015-0004-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 11/11/2015] [Indexed: 12/02/2022]
Abstract
The human skeleton has a remarkable regeneration capacity. Nevertheless, 5-10 % of the bone fractures fails to heal and develops into a non-union which is a challenging orthopedic complication requiring complex and expensive treatment. This review paper will discuss four different computational models, each capturing a particular clinical case of non-union: non-union induced by reaming of the marrow canal and periosteal stripping, non-union due to a large interfragmentary gap, non-union due to a genetic disorder [i.e. NF1 related congenital pseudoarthrosis of the tibia (CPT)] and non-union due to mechanical overload. Together, the four computational models are able to capture the etiology of a wide range of fracture non-union types and design novel treatment strategies thereof. Further research is required to corroborate the computational models in both animal and human settings and translate them from bench to bed side.
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Affiliation(s)
- Aurélie Carlier
- />Biomechanics Section, KU Leuven, Celestijnenlaan 300 C, PB 2419, 3000 Leuven, Belgium
- />Prometheus, Division of Skeletal Tissue Engineering, KU Leuven, O&N 1, Herestraat 49, PB 813, 3000 Leuven, Belgium
| | - Johan Lammens
- />Prometheus, Division of Skeletal Tissue Engineering, KU Leuven, O&N 1, Herestraat 49, PB 813, 3000 Leuven, Belgium
- />Department of Orthopaedics, University Hospitals of KU Leuven, KU Leuven, Weligerveld 1-blok 1, 3212 Pellenberg, Belgium
| | - Hans Van Oosterwyck
- />Biomechanics Section, KU Leuven, Celestijnenlaan 300 C, PB 2419, 3000 Leuven, Belgium
- />Prometheus, Division of Skeletal Tissue Engineering, KU Leuven, O&N 1, Herestraat 49, PB 813, 3000 Leuven, Belgium
| | - Liesbet Geris
- />Biomechanics Section, KU Leuven, Celestijnenlaan 300 C, PB 2419, 3000 Leuven, Belgium
- />Prometheus, Division of Skeletal Tissue Engineering, KU Leuven, O&N 1, Herestraat 49, PB 813, 3000 Leuven, Belgium
- />Biomechanics Research Unit, Department of Aerospace and Mechanical Engineering, University of Liege, Chemin des Chevreuils 1-BAT 52/3, 4000 Liege 1, Belgium
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30
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Schira J, Schulte M, Döbele C, Wallner C, Abraham S, Daigeler A, Kneser U, Lehnhardt M, Behr B. Human scaphoid non-unions exhibit increased osteoclast activity compared to adjacent cancellous bone. J Cell Mol Med 2015; 19:2842-50. [PMID: 26416438 PMCID: PMC4687713 DOI: 10.1111/jcmm.12677] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 08/03/2015] [Indexed: 01/08/2023] Open
Abstract
Scaphoid bones have a high prevalence for non-union. Even with adequate treatment, bone regeneration may not occur in certain instances. Although this condition is well described, the molecular pathology of scaphoid non-unions is still poorly defined. In this study, gene expression of osteogenic and angiogenic growth and transcription factors as well as inflammatory mediators were analysed in human scaphoid non-unions and intraindividually compared to adjacent autologous cancellous bone from the distal radius. In addition, histology and immunohistochemical stainings were performed to verify qRT-PCR data. Gene expression analysis revealed a significant up-regulation of RANKL, ALP, CYCLIN D1, MMP-13, OPG, NFATc1, TGF-β and WNT5A in scaphoid non-unions. Interestingly, RANKL and NFATc1, both markers for osteoclastogenesis, were significantly induced in non-unions. Moreover, WNT5A was highly up-regulated in all non-union samples. TRAP staining confirmed the observation of induced osteoclastogenesis in non-unions. With respect to genes related to osteogenesis, alkaline phosphatase was significantly up-regulated in scaphoid non-unions. No differences were detectable for other osteogenic genes such as RUNX-2 or BMP-2. Importantly, we did not detect differences in angiogenesis between scaphoid non-unions and controls in both gene expression and immunohistochemistry. Summarized, our data indicate increased osteoclast activity in scaphoid non-unions possibly as a result of the alterations in RANKL, TGF-β and WNT5A expression levels. These data increase our understanding for the reduced bone regeneration capacity present in scaphoid non-unions and may translate into the identification of new therapeutic targets to avoid secondary damages and prevent occurrence of non-unions to scaphoid bones.
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Affiliation(s)
- Jessica Schira
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Matthias Schulte
- Department of Plastic Surgery, BG Trauma Hospital Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Carmen Döbele
- Department of Plastic Surgery, BG Trauma Hospital Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Christoph Wallner
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Stephanie Abraham
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Adrien Daigeler
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Ulrich Kneser
- Department of Plastic Surgery, BG Trauma Hospital Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Marcus Lehnhardt
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Björn Behr
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
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Karnes JM, Daffner SD, Watkins CM. Multiple roles of tumor necrosis factor-alpha in fracture healing. Bone 2015; 78:87-93. [PMID: 25959413 DOI: 10.1016/j.bone.2015.05.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 04/29/2015] [Accepted: 05/01/2015] [Indexed: 01/08/2023]
Abstract
This review presents a summary of basic science evidence examining the influence of tumor necrosis factor-alpha (TNF-α) on secondary fracture healing. Multiple studies suggest that TNF-α, in combination with the host reservoir of peri-fracture mesenchymal stem cells, is a main determinant in the success of bone healing. Disease states associated with poor bone healing commonly have inappropriate TNF-α responses, which likely contributes to the higher incidence of delayed and nonunions in these patient populations. Appreciation of TNF-α in fracture healing may lead to new therapies to augment recovery and reduce the incidence of complications.
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Affiliation(s)
- Jonathan M Karnes
- Department of Orthopaedics, West Virginia University, Morgantown, WV, United States.
| | - Scott D Daffner
- Department of Orthopaedics, West Virginia University, Morgantown, WV, United States.
| | - Colleen M Watkins
- Department of Orthopaedics, West Virginia University, Morgantown, WV, United States.
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Longitudinal analysis of osteogenic and angiogenic signaling factors in healing models mimicking atrophic and hypertrophic non-unions in rats. PLoS One 2015; 10:e0124217. [PMID: 25910190 PMCID: PMC4409381 DOI: 10.1371/journal.pone.0124217] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 03/10/2015] [Indexed: 11/19/2022] Open
Abstract
Impaired bone healing can have devastating consequences for the patient. Clinically relevant animal models are necessary to understand the pathology of impaired bone healing. In this study, two impaired healing models, a hypertrophic and an atrophic non-union, were compared to physiological bone healing in rats. The aim was to provide detailed information about differences in gene expression, vascularization and histology during the healing process. The change from a closed fracture (healing control group) to an open osteotomy (hypertrophy group) led to prolonged healing with reduced mineralized bridging after 42 days. RT-PCR data revealed higher gene expression of most tested osteogenic and angiogenic factors in the hypertrophy group at day 14. After 42 days a significant reduction of gene expression was seen for Bmp4 and Bambi in this group. The inhibition of angiogenesis by Fumagillin (atrophy group) decreased the formation of new blood vessels and led to a non-healing situation with diminished chondrogenesis. RT-PCR results showed an attempt towards overcoming the early perturbance by significant up regulation of the angiogenic regulators Vegfa, Angiopoietin 2 and Fgf1 at day 7 and a further continuous increase of Fgf1, -2 and Angiopoietin 2 over time. However µCT angiograms showed incomplete recovery after 42 days. Furthermore, lower expression values were detected for the Bmps at day 14 and 21. The Bmp antagonists Dan and Twsg1 tended to be higher expressed in the atrophy group at day 42. In conclusion, the investigated animal models are suitable models to mimic human fracture healing complications and can be used for longitudinal studies. Analyzing osteogenic and angiogenic signaling patterns, clear changes in expression were identified between these three healing models, revealing the importance of a coordinated interplay of different factors to allow successful bone healing.
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Roberto-Rodrigues M, Fernandes RMP, Senos R, Scoralick ACD, Bastos AL, Santos TMP, Viana LP, Lima I, Guzman-Silva MA, Kfoury-Júnior JR. Novel rat model of nonunion fracture with vascular deficit. Injury 2015; 46:649-54. [PMID: 25661107 DOI: 10.1016/j.injury.2015.01.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 01/14/2015] [Accepted: 01/19/2015] [Indexed: 02/02/2023]
Abstract
Nonunion fractures occur frequently in humans, with profound implications (medical and non-medical). Although there are numerous animal models to study pathogenesis and treatment of nonunion fractures, there is apparently the lack of a definitive model for atrophic nonunion fracture. Therefore, the objective was to develop a low-cost rat model of nonunion fracture with a vascular deficit that enabled standardized quantitative analysis of bone growth and regeneration. The model was developed with two surgeries, performed apart. The first involved osteotomy of the femur diaphysis, removal of periosteum and endosteum, isolation of the fracture site using a latex artefact (Penrose drain tube), and reduction of the fracture using an intramedullary pin, whereas the second surgery was to remove the latex artefact. Based on radiographic imaging, micro-CT and histological analyses done 125 days after the fracture was induced, there was clear evidence of atrophic nonunion fracture, without pin migration or specimen loss. Perceived advantages of this model included low cost, ease of reproducibility, lack of specimen loss, and, finally, the potential to assess bone growth and regeneration under poor vascular conditions.
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Affiliation(s)
| | - R M P Fernandes
- Department of Morphology, Universidade Federal Fluminense, Niterói, Brazil
| | - R Senos
- Department of Morphology, Universidade Federal Fluminense, Niterói, Brazil; Department of Surgery of Veterinary Faculty, Universidade de São Paulo, São Paulo, Brazil.
| | - A C D Scoralick
- Department of Morphology, Universidade Federal Fluminense, Niterói, Brazil
| | - A L Bastos
- Department of Morphology, Universidade Federal Fluminense, Niterói, Brazil
| | - T M P Santos
- Department of Nuclear Engineering, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - L P Viana
- Department of Morphology, Universidade Federal Fluminense, Niterói, Brazil
| | - I Lima
- Department of Nuclear Engineering, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - M A Guzman-Silva
- Department of Pathology, Universidade Federal Fluminense, Niterói, Brazil
| | - J R Kfoury-Júnior
- Department of Surgery of Veterinary Faculty, Universidade de São Paulo, São Paulo, Brazil
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Hindfoot Valgus following Interlocking Nail Treatment for Tibial Diaphysis Fractures: Can the Fibula Be Neglected? Adv Orthop 2014; 2014:806363. [PMID: 25544899 PMCID: PMC4273594 DOI: 10.1155/2014/806363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 11/21/2014] [Accepted: 11/22/2014] [Indexed: 12/03/2022] Open
Abstract
Purpose. We evaluated whether intramedullary nail fixation for tibial diaphysis fractures with concomitant fibula fractures (except at the distal one-third level) managed conservatively with an associated fibula fracture resulted in ankle deformity and assessed the impact of the ankle deformity on lower extremity function. Methods. Sixty middle one-third tibial shaft fractures with associated fibular fractures, except the distal one-third level, were included in this study. All tibial shaft fractures were anatomically reduced and fixed with interlocking intramedullary nails. Fibular fractures were managed conservatively. Hindfoot alignment was assessed clinically. Tibia and fibular lengths were compared to contralateral measurements using radiographs. Functional results were evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Foot and Ankle Disability Index Score (FADI). Results. Anatomic union, defined as equal length in operative and contralateral tibias, was achieved in 60 fractures (100%). Fibular shortening was identified in 42 fractures (68%). Mean fibular shortening was 1.2 cm (range, 0.5–2 cm). Clinical exams showed increased hindfoot valgus in 42 fractures (68%). The mean KOOS was 88.4, and the mean FADI score was 90. Conclusion. Fibular fractures in the middle or proximal one-third may need to be stabilized at the time of tibial intramedullary nail fixation to prevent development of hindfoot valgus due to fibular shortening.
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Sato K, Watanabe Y, Harada N, Abe S, Matsushita T, Yamanaka K, Kaneko T, Sakai Y. Establishment of Reproducible, Critical-Sized, Femoral Segmental Bone Defects in Rats. Tissue Eng Part C Methods 2014; 20:1037-41. [DOI: 10.1089/ten.tec.2013.0612] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Kenji Sato
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yoshinobu Watanabe
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Noriko Harada
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Satoshi Abe
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Takashi Matsushita
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Katsuyuki Yamanaka
- Research and Development Department, GC Corporation, Itabashi, Tokyo, Japan
| | - Tadashi Kaneko
- Research and Development Department, GC Corporation, Itabashi, Tokyo, Japan
| | - Yuhiro Sakai
- Research and Development Department, GC Corporation, Itabashi, Tokyo, Japan
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Abstract
Management of tibia fractures by internal fixation, particularly intramedullary nails, has become the standard for diaphyseal fractures. However, for metaphyseal fractures or those at the metaphyseal-diaphyseal junction, choice of fixation device and technique is controversial. For distal tibia fractures, nailing and plating techniques may be used, the primary goal of each being to achieve acceptable alignment with minimal complications. Different techniques for reduction of these fractures are available and can be applied with either fixation device. Overall outcomes appear to be nearly equivalent, with minor differences in complications. Proximal tibia fractures can be fixed using nailing, which is associated with deformity of the proximal short segment. A newer technique-suprapatellar nailing-may minimize these problems, and use of this method has been increasing in trauma centers. However, most of the data are still largely based on case series.
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Abstract
Determining whether a bone fracture is healed is one of the most important and fundamental clinical determinations made in orthopaedics. However, there are currently no standardized methods of assessing fracture union, which in turn has created significant disagreement among orthopaedic surgeons in both clinical and research settings. An extensive amount of research has been dedicated to finding novel and reliable ways of determining healing with some promising results. Recent advancements in imaging techniques and introduction of new radiographic scores have helped decrease the amount of disagreement on this topic among physicians. The knowledge gained from biomechanical studies of bone healing has helped us refine our tools and create more efficient and practical research instruments. Additionally, a deeper understanding of the molecular pathways involved in the bone healing process has led to emergence of serologic markers as possible candidates in assessment of fracture union. In addition to our current physician centered methods, patient-centered approaches assessing quality of life and function are gaining popularity in assessment of fracture union. Despite these advances, assessment of union remains an imperfect practice in the clinical setting. Therefore, clinicians need to draw on multiple modalities that directly and indirectly measure or correlate with bone healing when counseling patients.
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Affiliation(s)
- Saam Morshed
- Department of Orthopaedic Surgery, University of San Francisco School of Medicine, San Francisco, CA 94143-0410, USA
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Guo J, Zhang Y, Hou Z, Li Z. A tip to reduce the malrotation of the spiral tibial fracture intraoperatively. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2014; 24:1617-23. [PMID: 24413848 DOI: 10.1007/s00590-014-1411-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Accepted: 01/03/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tibial spiral fractures treated by closed intramedullary (IM) nailing are at risk for malrotational deformities. The purpose of this study was to examine a method to minimize the risk of tibial malrotation during closed IM nailing of spiral tibial fractures. METHODS This trial is done through 24 patients of spiral tibial fractures with a mean age of 38.5 years (range 26-63 years). The patients were divided into two groups. One group the fractures were reduced by rotating the distal locked nail to obtain rotational alignment and another group by the standard assistant rotated technique. All the patients were evaluated with CT scans postoperatively. The parameters such as rotational values, operative and radiation exposure time were recorded and compared between two groups. Mann-Whitney test was used to test the significance of these parameters. RESULTS The group using the tip had a smaller mean rotational value, which was (6.8° ± 2.1° vs. 11.8° ± 5.2°; P < 0.01). The mean operative time was not statistically different (70.6 ± 4.4 vs. 63.0 ± 2.9 min; P > 0.05), so did the mean radiation exposure time (48.1 ± 4.2 vs. 42.6 ± 4.8 s; P > 0.05). CONCLUSION The described technique of rotating the nail after initial distal interlocking can correct rotational abnormalities in spiral tibial shaft fractures in the premise of not increasing the operative and radiation exposure times statistically.
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Affiliation(s)
- Jialiang Guo
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
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Tawonsawatruk T, Kelly M, Simpson H. Evaluation of native mesenchymal stem cells from bone marrow and local tissue in an atrophic nonunion model. Tissue Eng Part C Methods 2013; 20:524-32. [PMID: 24147916 DOI: 10.1089/ten.tec.2013.0465] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION It has been reported that cells or growth factors might improve bone regeneration in nonunion. However, the intrinsic potential of the nonunion tissue to regenerate bone is still unclear; in particular, it is not known whether there are progenitor cells within the nonunion. Thus, in this study, a clinically relevant model has been developed to investigate the nature of the cells in atrophic nonunion tissue and to assess their regenerative potential. MATERIALS AND METHODS Seventeen Wistar rats underwent the procedure to induce an atrophic nonunion at the tibial midshaft by stripping the periosteum and endosteum as well as creating a small (1.0 mm) noncritical gap. The fracture was stabilized with an external fixator. The proliferation ability of bone marrow-derived cells and nonunion tissue-derived cells was determined using colony forming assays. The differentiation potential of nonunion tissue-derived cells was also investigated. RESULTS Noncritical size defect nonunions were successfully induced in all of the animals. The typical characteristics of atrophic nonunions were demonstrated by radiography, micro-CT, and histology. An atrophic nonunion stimulated a systemic response in the bone marrow with an increase in bone marrow-derived mesenchymal stem cells. In contrast, cells derived from the nonunion gap were not able to form colonies. This indicated that the quiescent or inactive cells in the tissue at the atrophic nonunion gap could be induced to differentiate under osteogenic and chondrogenic conditions, but not under adipogenic conditions. Thus, these cells had the characteristics of osteochondral progenitor cells. DISCUSSION Although there was an increase in the systemic response in the atrophic nonunion model, the intrinsic potential of local tissue from the atrophic nonunion site was impaired. The cells derived from nonunion tissue could be stimulated to differentiate into bone under appropriate conditions. This suggested that there are progenitor cells in atrophic nonunion tissue, which have an intrinsic ability to regenerate bone, but the microenvironment in the atrophic nonunion site might be retarding their function. Consequently, physical or biological agents (such as growth factors or cells) are needed to reactivate the endogenous progenitor cells to make them regenerate bone in atrophic nonunions.
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Affiliation(s)
- Tulyapruek Tawonsawatruk
- 1 Orthopaedic Department, The Royal Infirmary of Edinburgh, The University of Edinburgh , Edinburgh, United Kingdom
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Bara JJ, McCarthy HE, Humphrey E, Johnson WEB, Roberts S. Bone marrow-derived mesenchymal stem cells become antiangiogenic when chondrogenically or osteogenically differentiated: implications for bone and cartilage tissue engineering. Tissue Eng Part A 2013; 20:147-59. [PMID: 23895198 DOI: 10.1089/ten.tea.2013.0196] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Osteochondral tissue repair requires formation of vascularized bone and avascular cartilage. Mesenchymal stem cells stimulate angiogenesis both in vitro and in vivo but it is not known if these proangiogenic properties change as a result of chondrogenic or osteogenic differentiation. We investigated the angiogenic/antiangiogenic properties of equine bone marrow-derived mesenchymal stem cells (eBMSCs) before and after differentiation in vitro. Conditioned media from chondrogenic and osteogenic cell pellets and undifferentiated cells was applied to endothelial tube formation assays using Matrigel™. Additionally, the cell secretome was analysed using LC-MS/MS mass spectrometry and screened for angiogenesis and neurogenesis-related factors using protein arrays. Endothelial tube-like formation was supported by conditioned media from undifferentiated eBMSCs. Conversely, chondrogenic and osteogenic conditioned media was antiangiogenic as shown by significantly decreased length of endothelial tube-like structures and degree of branching compared to controls. Undifferentiated cells produced higher levels of angiogenesis-related proteins compared to chondrogenic and osteogenic pellets. In summary, eBMSCs produce an array of angiogenesis-related proteins and support angiogenesis in vitro via a paracrine mechanism. However, when these cells are differentiated chondrogenically or osteogenically, they produce a soluble factor(s) that inhibits angiogenesis. With respect to osteochondral tissue engineering, this may be beneficial for avascular articular cartilage formation but unfavourable for bone formation where a vascularized tissue is desired.
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Affiliation(s)
- Jennifer J Bara
- 1 Musculoskeletal Regeneration Group, AO Research Institute , Platz, Switzerland
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41
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Lozada-Gallegos AR, Letechipia-Moreno J, Palma-Lara I, Montero AA, Rodríguez G, Castro-Muñozledo F, Cornejo-Cortés MA, Juárez-Mosqueda ML. Development of a bone nonunion in a noncritical segmental tibia defect model in sheep utilizing interlocking nail as an internal fixation system. J Surg Res 2013; 183:620-8. [DOI: 10.1016/j.jss.2013.02.060] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 02/20/2013] [Accepted: 02/28/2013] [Indexed: 11/25/2022]
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Macdonald W, Shefelbine SJ. Characterising neovascularisation in fracture healing with laser Doppler and micro-CT scanning. Med Biol Eng Comput 2013; 51:1157-65. [PMID: 23881721 PMCID: PMC3751219 DOI: 10.1007/s11517-013-1100-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 07/09/2013] [Indexed: 11/27/2022]
Abstract
Vascularity of the soft tissues around a bone fracture is critical for successful healing, particularly when the vessels in the medullary canal are ruptured. The objective of this work was to use laser Doppler and micro-computer tomography (micro-CT) scanning to characterise neovascularisation of the soft tissues surrounding the fracture during healing. Thirty-two Sprague–Dawley rats underwent mid-shaft osteotomy of the left femur, stabilised with a custom-designed external fixator. Five animals were killed at each of 2, 4 days, 1, 2, 4 and 6 weeks post-operatively. Femoral blood perfusion in the fractured and intact contralateral limbs was measured using laser Doppler scanning pre- and post-operatively and throughout the healing period. At sacrifice, the common iliac artery was cannulated and infused with silicone contrast agent. Micro-CT scans of the femur and adjacent soft tissues revealed vessel characteristics and distribution in relation to the fracture zone. Blood perfusion dropped immediately after surgery and then recovered to greater than the pre-operative level by proliferation of small vessels around the fracture zone. Multi-modal imaging allowed both longitudinal functional and detailed structural analysis of the neovascularisation process.
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Affiliation(s)
- W Macdonald
- Department of Bioengineering, Imperial College, South Kensington, London, SW7 2AZ, UK.
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Mathieu M, Rigutto S, Ingels A, Spruyt D, Stricwant N, Kharroubi I, Albarani V, Jayankura M, Rasschaert J, Bastianelli E, Gangji V. Decreased pool of mesenchymal stem cells is associated with altered chemokines serum levels in atrophic nonunion fractures. Bone 2013; 53:391-8. [PMID: 23318974 DOI: 10.1016/j.bone.2013.01.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 01/02/2013] [Accepted: 01/03/2013] [Indexed: 01/21/2023]
Abstract
Nonunion fractures can cause severe dysfunction and are often difficult to treat mainly due to a poor understanding of their physiopathology. Although many aspects of impaired fracture healing have been extensively studied, little is known about the cellular and molecular mechanisms leading to atrophic nonunion. Therefore, the aim of the present study was to assess the pools and biological functions of bone marrow-derived mesenchymal stem cells (hMSCs) and circulating endothelial progenitor cells (EPCs) in atrophic nonunion patients compared to healthy subjects, and the systemic levels of growth factors involved in the recruitment, proliferation and differentiation of these cells. In nonunions, the pool of hMSCs was decreased and their proliferation delayed. However, once committed, hMSCs from nonunions were able to proliferate, differentiate into osteoblastic cells and mineralize in vitro as efficiently as hMSCs from healthy subjects. In parallel, we found altered serum levels of chemokines and growth factors involved in the chemotaxis and proliferation of hMSCs such as leptin, interleukin-6 (IL-6) and its soluble receptor, platelet-derived growth factor-BB (PDGF-BB), stem cell factor (SCF) and insulin-like growth factor-1 (IGF-1). Moreover, we showed that the number of EPCs and their regulating growth factors were not affected in nonunion patients. If nonunion is generally attributed to a vascular defect, our results also support a role for a systemic mesenchymal and osteogenic cell pool defect that might be related to alterations in systemic levels of factors implicated in their chemotaxis and proliferation.
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Affiliation(s)
- Myrielle Mathieu
- Laboratory of Bone and Metabolic Biochemistry, Université Libre de Bruxelles, 808 Route de Lennik, 1070 Brussels, Belgium.
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44
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Abstract
This review is aimed at clinicians appraising preclinical trauma studies and researchers investigating compromised bone healing or novel treatments for fractures. It categorises the clinical scenarios of poor healing of fractures and attempts to match them with the appropriate animal models in the literature. We performed an extensive literature search of animal models of long bone fracture repair/nonunion and grouped the resulting studies according to the clinical scenario they were attempting to reflect; we then scrutinised them for their reliability and accuracy in reproducing that clinical scenario. Models for normal fracture repair (primary and secondary), delayed union, nonunion (atrophic and hypertrophic), segmental defects and fractures at risk of impaired healing were identified. Their accuracy in reflecting the clinical scenario ranged greatly and the reliability of reproducing the scenario ranged from 100% to 40%. It is vital to know the limitations and success of each model when considering its application.
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Affiliation(s)
- L. A. Mills
- Royal National Orthopaedic Hospital, Stanmore, Brockley
Hill, Middlesex HA7 4LP, UK
| | - A. H. R. W. Simpson
- Edinburgh University, Department
of Orthopaedics and Trauma, Chancellors Building, Little
France, Edinburgh EH16 4SB, UK
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45
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Regeneration of the proximal tibial epiphysis during callus distraction for atrophic nonunion after infantile osteomyelitis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2011. [DOI: 10.1007/s00590-011-0850-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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46
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Coulibaly MO, Sietsema DL, Burgers TA, Mason J, Williams BO, Jones CB. Recent advances in the use of serological bone formation markers to monitor callus development and fracture healing. Crit Rev Eukaryot Gene Expr 2011; 20:105-27. [PMID: 21133841 DOI: 10.1615/critreveukargeneexpr.v20.i2.20] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The failure of an osseous fracture to heal, or the development of a nonunion, is common; however, current diagnostic measures lack the capability of early and reliable detection of such events. Analyses of radiographic imaging and clinical examination, in combination, remain the gold standard for diagnosis; however, these methods are not reliable for early detection. Delayed diagnosis of a nonunion is costly from both the patient and treatment standpoints. In response, repeated efforts have been made to identify bone metabolic markers as diagnostic or prognostic tools for monitoring bone healing. Thus far, the evidence regarding a correlation between the kinetics of most bone metabolic markers and nonunion is very limited. With the aim of classifying the role of biological pathways of bone metabolism and of understanding bone conditions in the development of osteoporosis, advances have been made in our knowledge of the molecular basis of bone remodeling, fracture healing, and its failure. Procollagen type I amino-terminal propeptide has been shown to be a reliable bone formation marker in osteoporosis therapy and its kinetics during fracture healing has been recently described. In this article, we suggest that procollagen type I amino-terminal propeptide presents a good opportunity for early detection of nonunion. We also review the role and potential of serum PINP, as well as other markers, as indications of fracture healing.
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47
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Abstract
Although the unquestionable value of autologous bone grafting and the analogous value of the reaming by-products in nonunion treatment have been mentioned extensively in the literature, there is ongoing vivid discussion for the treatment of those case scenarios where the fracture nonunion is complicated by other local environment adverse circumstances. The graft expansion with growth factors as the bone morphogenetic proteins (BMPs) offers the possibility to reduce the number of operative procedures, complications, length of hospital stay, and time to union. In this article, we consider the potential clinical scenarios for graft expansion with BMPs.
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Affiliation(s)
- Peter V Giannoudis
- Department of Trauma & Orthopedic Surgery, University of Leeds, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK.
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48
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Geris L, Gerisch A, Schugart RC. Mathematical modeling in wound healing, bone regeneration and tissue engineering. Acta Biotheor 2010; 58:355-67. [PMID: 20676732 DOI: 10.1007/s10441-010-9112-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 07/05/2010] [Indexed: 01/11/2023]
Abstract
The processes of wound healing and bone regeneration and problems in tissue engineering have been an active area for mathematical modeling in the last decade. Here we review a selection of recent models which aim at deriving strategies for improved healing. In wound healing, the models have particularly focused on the inflammatory response in order to improve the healing of chronic wound. For bone regeneration, the mathematical models have been applied to design optimal and new treatment strategies for normal and specific cases of impaired fracture healing. For the field of tissue engineering, we focus on mathematical models that analyze the interplay between cells and their biochemical cues within the scaffold to ensure optimal nutrient transport and maximal tissue production. Finally, we briefly comment on numerical issues arising from simulations of these mathematical models.
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49
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Geris L, Reed AAC, Vander Sloten J, Simpson AHRW, Van Oosterwyck H. Occurrence and treatment of bone atrophic non-unions investigated by an integrative approach. PLoS Comput Biol 2010; 6:e1000915. [PMID: 20824125 PMCID: PMC2932678 DOI: 10.1371/journal.pcbi.1000915] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Accepted: 08/03/2010] [Indexed: 12/15/2022] Open
Abstract
Recently developed atrophic non-union models are a good representation of the clinical situation in which many non-unions develop. Based on previous experimental studies with these atrophic non-union models, it was hypothesized that in order to obtain successful fracture healing, blood vessels, growth factors, and (proliferative) precursor cells all need to be present in the callus at the same time. This study uses a combined in vivo-in silico approach to investigate these different aspects (vasculature, growth factors, cell proliferation). The mathematical model, initially developed for the study of normal fracture healing, is able to capture essential aspects of the in vivo atrophic non-union model despite a number of deviations that are mainly due to simplifications in the in silico model. The mathematical model is subsequently used to test possible treatment strategies for atrophic non-unions (i.e. cell transplant at post-osteotomy, week 3). Preliminary in vivo experiments corroborate the numerical predictions. Finally, the mathematical model is applied to explain experimental observations and identify potentially crucial steps in the treatments and can thereby be used to optimize experimental and clinical studies in this area. This study demonstrates the potential of the combined in silico-in vivo approach and its clinical implications for the early treatment of patients with problematic fractures. In light of the ageing population, the occurrence of bone fractures is expected to rise substantially in the near future. In 5 to 10% of these cases, the healing process does not succeed in repairing the bone, leading to the formation of delayed unions or even non-unions. In this study we used a combination of an animal model mimicking a clinical non-union situation and a mathematical model developed for normal fracture healing to investigate both the causes of non-union formation and potential therapeutic strategies that can be applied to restart the healing process. After showing that the mathematical model is able to simulate key aspects of the non-union formation, we have used it to investigate several treatment strategies. One of these strategies, the treatment of a non-union involving a transplantation of cells from the bone marrow to the fracture site, was also tested in a pilot animal experiment. Both the simulations and the experiments showed the formation of a bony union between the fractured bone ends. In addition, we used the mathematical model to explain some unexpected experimental observations. This study demonstrates the added value of using a combination of mathematical modelling and experimental research as well the potential of using cell transplantation for the treatment of non-unions.
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Affiliation(s)
- Liesbet Geris
- Division of Biomechanics and Engineering Design, Department of Mechanical Engineering, Katholieke Universiteit Leuven, Leuven, Belgium.
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50
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Geris L, Schugart R, Van Oosterwyck H. In silico design of treatment strategies in wound healing and bone fracture healing. PHILOSOPHICAL TRANSACTIONS. SERIES A, MATHEMATICAL, PHYSICAL, AND ENGINEERING SCIENCES 2010; 368:2683-2706. [PMID: 20439269 DOI: 10.1098/rsta.2010.0056] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Wound and bone fracture healing are natural repair processes initiated by trauma. Over the last decade, many mathematical models have been established to investigate the healing processes in silico, in addition to ongoing experimental work. In recent days, the focus of the mathematical models has shifted from simulation of the healing process towards simulation of the impaired healing process and the in silico design of treatment strategies. This review describes the most important causes of failure of the wound and bone fracture healing processes and the experimental models and methods used to investigate and treat these impaired healing cases. Furthermore, the mathematical models that are described address these impaired healing cases and investigate various therapeutic scenarios in silico. Examples are provided to illustrate the potential of these in silico experiments. Finally, limitations of the models and the need for and ability of these models to capture patient specificity and variability are discussed.
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Affiliation(s)
- L Geris
- Division of Biomechanics and Engineering Design, Department of Mechanical Engineering, Katholieke Universiteit Leuven, , Celestijnenlaan 300C (2419), 3001 Leuven, Belgium.
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