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Wu X, Zhang W, Long L, Wang Y, Chen H, Wang K, Wang Z, Bai J, Xue D, Pan Z. KDELR2 promotes bone marrow mesenchymal stem cell osteogenic differentiation via GSK3β/β-catenin signaling pathway. Cell Tissue Res 2024; 396:269-281. [PMID: 38470494 DOI: 10.1007/s00441-024-03884-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 03/01/2024] [Indexed: 03/14/2024]
Abstract
Nonunion is a challenging complication of fractures for the surgeon. Recently the Lys-Asp-Glu-Leu (KDEL) endoplasmic reticulum protein retention receptor 2 (KDELR2) has been found that involved in osteogenesis imperfecta. However, the exact mechanism is still unclear. In this study, we used lentivirus infection and mouse fracture model to investigate the role of KDELR2 in osteogenesis. Our results showed that KDELR2 knockdown inhibited the osteogenic differentiation of mBMSCs, whereas KDELR2 overexpression had the opposite effect. Furthermore, the levels of active-β-catenin and phospho-GSK3β (Ser9) were upregulated by KDELR2 overexpression and downregulated by KDELR2 knockdown. In the fracture model, mBMSCs overexpressing KDELR2 promoted healing. In conclusion, KDELR2 promotes the osteogenesis of mBMSCs by regulating the GSK3β/β-catenin signaling pathway.
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Affiliation(s)
- Xiaoyong Wu
- Department of Orthopedic Surgery of the Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88, Jiefang Road, Hangzhou 310009, China
- Orthopedics Research Institute of Zhejiang University, No. 88, Jiefang Road, Hangzhou, 310009, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou City, PR China
| | - Weijun Zhang
- Department of Orthopedic Surgery of the Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88, Jiefang Road, Hangzhou 310009, China
- Orthopedics Research Institute of Zhejiang University, No. 88, Jiefang Road, Hangzhou, 310009, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou City, PR China
| | - Long Long
- Department of Orthopedic Surgery of the Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88, Jiefang Road, Hangzhou 310009, China
- Orthopedics Research Institute of Zhejiang University, No. 88, Jiefang Road, Hangzhou, 310009, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou City, PR China
- Linping Hospital of Integrated Chinese and Western Medicine, No.60,Baojian Road, Hangzhou, 310009, China
| | - Yibo Wang
- Guangdong Provincial Key Laboratory of Orthopedics and Traumatology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, China
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Hongyu Chen
- Department of Orthopedic Surgery of the Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88, Jiefang Road, Hangzhou 310009, China
- Orthopedics Research Institute of Zhejiang University, No. 88, Jiefang Road, Hangzhou, 310009, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou City, PR China
| | - Kanbin Wang
- Department of Orthopedic Surgery of the Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88, Jiefang Road, Hangzhou 310009, China
- Orthopedics Research Institute of Zhejiang University, No. 88, Jiefang Road, Hangzhou, 310009, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou City, PR China
| | - Zhongxiang Wang
- Department of Orthopedic Surgery of the Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88, Jiefang Road, Hangzhou 310009, China
- Orthopedics Research Institute of Zhejiang University, No. 88, Jiefang Road, Hangzhou, 310009, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou City, PR China
| | - Jinwu Bai
- Department of Orthopedic Surgery of the Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88, Jiefang Road, Hangzhou 310009, China
- Orthopedics Research Institute of Zhejiang University, No. 88, Jiefang Road, Hangzhou, 310009, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzou City, Zhejiang Province, PR China
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou City, PR China
| | - Deting Xue
- Department of Orthopedic Surgery of the Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88, Jiefang Road, Hangzhou 310009, China.
- Orthopedics Research Institute of Zhejiang University, No. 88, Jiefang Road, Hangzhou, 310009, China.
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzou City, Zhejiang Province, PR China.
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou City, PR China.
| | - Zhijun Pan
- Department of Orthopedic Surgery of the Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88, Jiefang Road, Hangzhou 310009, China.
- Orthopedics Research Institute of Zhejiang University, No. 88, Jiefang Road, Hangzhou, 310009, China.
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzou City, Zhejiang Province, PR China.
- Clinical Research Center of Motor System Disease of Zhejiang Province, Hangzhou City, PR China.
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El Sewify O, Abi-Rafeh J, Legler J, Karimi S, Baradaran A, Efanov JI. Clinical, Radiologic, and Functional Outcomes following Bone Grafting for Metacarpal Non-Unions: A Systematic Review. J Clin Med 2024; 13:1148. [PMID: 38398461 PMCID: PMC10889921 DOI: 10.3390/jcm13041148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
Objectives: Metacarpal non-unions are complex hand defects that can lead to severe hand impairment. Treatment may require the use of artificial or autologous bone grafts. This systematic review aims to describe the outcomes of bone grafting following metacarpal non-union in an attempt to establish an optimal therapeutic protocol for this complication. Methods: A systematic review was conducted in adherence with PRISMA guidelines. Data collection and analysis were performed in duplicate and confirmed by a third investigator. Our primary outcomes focused on radiological time to bone fusion and rates of non-union. Additionally, functional outcomes and complications were analyzed as means of central tendency. Results: Eighteen studies were included in the systematic review, accounting for a total of 47 patients. The average follow-up time was 12.4 months. Fourteen studies analyzed radiological outcomes, with atrophic non-union representing the most common type. The time to bone fusion, assessed radiologically, following bone graft was an average of 6.9 months (n = 14), with a 100% rate of union in 42 patients. Regarding patient-reported pain improvement, 76% of patients experienced pain relief. Moreover, all patients reported a complete subjective return to baseline hand function. Adverse events, limited to hematoma and seroma, were seen in three patients, representing a complication rate of 11.8% in the examined population. Conclusions: Metacarpal non-union can be treated successfully via vascularized and non-vascularized bone grafting. Based on the available evidence, bone grafts demonstrate favorable union rates, post-operative pain reduction, hand function recovery, earlier bone fusion times, and minimal complications in the context of metacarpal non-union management.
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Affiliation(s)
- Omar El Sewify
- Faculty of Medicine, Laval University, Quebec, QC G1V0A6, Canada
| | - Jad Abi-Rafeh
- Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, McGill University, Montreal, QC H3G2M1, Canada
| | - Jack Legler
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3G2M1, Canada
| | - Shayan Karimi
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3G2M1, Canada
| | - Aslan Baradaran
- Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, McGill University, Montreal, QC H3G2M1, Canada
| | - Johnny I. Efanov
- Plastic and Reconstructive Surgery, Department of Surgery, Centre hospitalier de l’Universite de Montreal (CHUM), Montreal, QC H2X3E4, Canada
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3
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Shariyate MJ, Kheir N, Caro D, Abbasian M, Rodriguez EK, Snyder BD, Nazarian A. Assessment of Bone Healing: Opportunities to Improve the Standard of Care. J Bone Joint Surg Am 2023; 105:1193-1202. [PMID: 37339171 DOI: 10.2106/jbjs.22.01224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
➤ Bone healing is commonly evaluated by clinical examination and serial radiographic evaluation. Physicians should be mindful that personal and cultural differences in pain perception may affect the clinical examination. Radiographic assessment, even with the Radiographic Union Score, is qualitative, with limited interobserver agreement.➤ Physicians may use serial clinical and radiographical examinations to assess bone healing in most patients, but in ambiguous and complicated cases, they may require other methods to provide assistance in decision-making.➤ In complicated instances, clinically available biomarkers, ultrasound, and magnetic resonance imaging may determine initial callus development. Quantitative computed tomography and finite element analysis can estimate bone strength in later callus consolidation phases.➤ As a future direction, quantitative rigidity assessments for bone healing may help patients to return to function earlier by increasing a clinician's confidence in successful progressive healing.
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Affiliation(s)
- Mohammad Javad Shariyate
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Nadim Kheir
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Daniela Caro
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mohammadreza Abbasian
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Edward K Rodriguez
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Brian D Snyder
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ara Nazarian
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Orthopaedic Surgery, Yerevan State Medical University Yerevan, Armenia
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4
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Halvachizadeh S, Martin DP, Pfeifer R, Jukema GN, Gueorguiev B, Pape HC, Berk T. Which non-infection related risk factors are associated with impaired proximal femur fracture healing in patients under the age of 70 years? BMC Musculoskelet Disord 2023; 24:405. [PMID: 37210475 DOI: 10.1186/s12891-023-06539-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 05/16/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND/PURPOSE Impaired healing is a feared complication with devastating outcomes for each patient. Most studies focus on geriatric fracture fixation and assess well known risk factors such as infections. However, risk factors, others than infections, and impaired healing of proximal femur fractures in non-geriatric adults are marginally assessed. Therefore, this study aimed to identify non-infection related risk factors for impaired fracture healing of proximal femur fractures in non-geriatric trauma patients. METHODS This study included non-geriatric patients (aged 69 years and younger) who were treated between 2013 and 2020 at one academic Level 1 trauma center due to a proximal femur fracture (PFF). Patients were stratified according to AO/OTA classification. Delayed union was defined as failed callus formation on 3 out of 4 cortices after 3 to 6 months. Nonunion was defined as lack of callus-formation after 6 months, material breakage, or requirement of revision surgery. Patient follow up was 12 months. RESULTS This study included 150 patients. Delayed union was observed in 32 (21.3%) patients and nonunion with subsequent revision surgery occurred in 14 (9.3%). With an increasing fracture classification (31 A1 up to 31 A3 type fractures), there was a significantly higher rate of delayed union. Additionally, open reduction and internal fixation (ORIF) (OR 6.17, (95% CI 1.54 to 24.70, p ≤ 0.01)) and diabetes mellitus type II (DM) (OR 5.74, (95% CI 1.39 to 23.72, p = 0.016)), were independent risk factors for delayed union. The rate of nonunion was independent of fracture morphology, patient's characteristics or comorbidities. CONCLUSION Increasing fracture complexity, ORIF and diabetes were found to be associated with delayed union of intertrochanteric femur fractures in non-geriatric patients. However, these factors were not associated with the development of nonunion.
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Affiliation(s)
- Sascha Halvachizadeh
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Harald-Tscherne Laboratory for Orthopedic and Trauma Research, University of Zurich, Sternwartstrasse 14, 8091, Zurich, Switzerland
| | - David Paul Martin
- Department of Orthopedics and Rehabilitation, University of Wisconsin, 1685 Highland Ave, Madison, WI, 53705, USA
| | - Roman Pfeifer
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Harald-Tscherne Laboratory for Orthopedic and Trauma Research, University of Zurich, Sternwartstrasse 14, 8091, Zurich, Switzerland
| | - Gerrolt Nico Jukema
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Harald-Tscherne Laboratory for Orthopedic and Trauma Research, University of Zurich, Sternwartstrasse 14, 8091, Zurich, Switzerland
| | - Boyko Gueorguiev
- AO Research Institute Davos, Clavadelerstrasse 8, 7270, Davos, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Harald-Tscherne Laboratory for Orthopedic and Trauma Research, University of Zurich, Sternwartstrasse 14, 8091, Zurich, Switzerland
| | - Till Berk
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
- Harald-Tscherne Laboratory for Orthopedic and Trauma Research, University of Zurich, Sternwartstrasse 14, 8091, Zurich, Switzerland.
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5
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Duda GN, Geissler S, Checa S, Tsitsilonis S, Petersen A, Schmidt-Bleek K. The decisive early phase of bone regeneration. Nat Rev Rheumatol 2023; 19:78-95. [PMID: 36624263 DOI: 10.1038/s41584-022-00887-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2022] [Indexed: 01/11/2023]
Abstract
Bone has a remarkable endogenous regenerative capacity that enables scarless healing and restoration of its prior mechanical function, even under challenging conditions such as advanced age and metabolic or immunological degenerative diseases. However - despite much progress - a high number of bone injuries still heal with unsatisfactory outcomes. The mechanisms leading to impaired healing are heterogeneous, and involve exuberant and non-resolving immune reactions or overstrained mechanical conditions that affect the delicate regulation of the early initiation of scar-free healing. Every healing process begins phylogenetically with an inflammatory reaction, but its spatial and temporal intensity must be tightly controlled. Dysregulation of this inflammatory cascade directly affects the subsequent healing phases and hinders the healing progression. This Review discusses the complex processes underlying bone regeneration, focusing on the early healing phase and its highly dynamic environment, where vibrant changes in cellular and tissue composition alter the mechanical environment and thus affect the signalling pathways that orchestrate the healing process. Essential to scar-free healing is the interplay of various dynamic cascades that control timely resolution of local inflammation and tissue self-organization, while also providing sufficient local stability to initiate endogenous restoration. Various immunotherapy and mechanobiology-based therapy options are under investigation for promoting bone regeneration.
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Affiliation(s)
- Georg N Duda
- Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany. .,Berlin Institute of Health Centre for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Sven Geissler
- Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health Centre for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sara Checa
- Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Serafeim Tsitsilonis
- Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health Centre for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.,Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ansgar Petersen
- Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health Centre for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Katharina Schmidt-Bleek
- Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health Centre for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
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6
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Saul D, Menger MM, Ehnert S, Nüssler AK, Histing T, Laschke MW. Bone Healing Gone Wrong: Pathological Fracture Healing and Non-Unions-Overview of Basic and Clinical Aspects and Systematic Review of Risk Factors. Bioengineering (Basel) 2023; 10:bioengineering10010085. [PMID: 36671657 PMCID: PMC9855128 DOI: 10.3390/bioengineering10010085] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 12/31/2022] [Accepted: 01/05/2023] [Indexed: 01/11/2023]
Abstract
Bone healing is a multifarious process involving mesenchymal stem cells, osteoprogenitor cells, macrophages, osteoblasts and -clasts, and chondrocytes to restore the osseous tissue. Particularly in long bones including the tibia, clavicle, humerus and femur, this process fails in 2-10% of all fractures, with devastating effects for the patient and the healthcare system. Underlying reasons for this failure are manifold, from lack of biomechanical stability to impaired biological host conditions and wound-immanent intricacies. In this review, we describe the cellular components involved in impaired bone healing and how they interfere with the delicately orchestrated processes of bone repair and formation. We subsequently outline and weigh the risk factors for the development of non-unions that have been established in the literature. Therapeutic prospects are illustrated and put into clinical perspective, before the applicability of biomarkers is finally discussed.
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Affiliation(s)
- Dominik Saul
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tübingen, BG Trauma Center Tübingen, 72076 Tübingen, Germany
- Kogod Center on Aging and Division of Endocrinology, Mayo Clinic, Rochester, MN 55905, USA
- Institute for Clinical and Experimental Surgery, Saarland University, 66421 Homburg, Germany
- Correspondence:
| | - Maximilian M. Menger
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tübingen, BG Trauma Center Tübingen, 72076 Tübingen, Germany
- Institute for Clinical and Experimental Surgery, Saarland University, 66421 Homburg, Germany
| | - Sabrina Ehnert
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tübingen, BG Trauma Center Tübingen, 72076 Tübingen, Germany
| | - Andreas K. Nüssler
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tübingen, BG Trauma Center Tübingen, 72076 Tübingen, Germany
| | - Tina Histing
- Department of Trauma and Reconstructive Surgery, Eberhard Karls University Tübingen, BG Trauma Center Tübingen, 72076 Tübingen, Germany
| | - Matthias W. Laschke
- Institute for Clinical and Experimental Surgery, Saarland University, 66421 Homburg, Germany
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7
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Meesters DM, Wijnands KAP, van Eijk HMH, Hofman M, Hildebrand F, Verbruggen JPAM, Brink PRG, Poeze M. Arginine Availability in Reamed Intramedullary Aspirate as Predictor of Outcome in Nonunion Healing. Biomedicines 2022; 10:biomedicines10102474. [PMID: 36289736 PMCID: PMC9598747 DOI: 10.3390/biomedicines10102474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/18/2022] [Accepted: 10/01/2022] [Indexed: 11/16/2022] Open
Abstract
Fracture healing and nonunion development are influenced by a range of biological factors. Adequate amino acid concentrations, especially arginine, are known to be important during normal bone healing. We hypothesize that bone arginine availability in autologous bone marrow grafting, when using the reamer-irrigator-aspirator (RIA) procedure, is a marker of bone healing capacity in patients treated for nonunion. Seventeen patients treated for atrophic long bone nonunion by autologous bone grafting by the RIA procedure were included and divided into two groups, successful treatment of nonunion and unsuccessful, and were compared with control patients after normal fracture healing. Reamed bone marrow aspirate from a site distant to the nonunion was obtained and the amino acids and enzymes relevant to arginine metabolism were measured. Arginine and ornithine concentrations were higher in patients with successful bone healing after RIA in comparison with unsuccessful healing. Ornithine concentrations and arginase-1 expression were lower in all nonunion patients compared to control patients, while citrulline concentrations were increased. Nitric oxide synthase 2 (Nos2) expression was significantly increased in all RIA-treated patients, and higher in patients with a successful outcome when compared with an unsuccessful outcome. The results indicate an influence of the arginine-nitric oxide metabolism in collected bone marrow, on the outcome of nonunion treatment, with indications for a prolonged inflammatory response in patients with unsuccessful bone grafting therapy. The determination of arginine concentrations and Nos2 expression could be used as a predictor for the successful treatment of autologous bone grafting in nonunion treatment.
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Affiliation(s)
- Dennis M. Meesters
- Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center +, 6200 MD Maastricht, The Netherlands
- NUTRIM School for Nutrition and Translational Research in Metabolism, 6200 MD Maastricht, The Netherlands
- Correspondence: ; Tel.: +31-433-881-891
| | - Karolina A. P. Wijnands
- Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center +, 6200 MD Maastricht, The Netherlands
- NUTRIM School for Nutrition and Translational Research in Metabolism, 6200 MD Maastricht, The Netherlands
| | - Hans M. H. van Eijk
- Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center +, 6200 MD Maastricht, The Netherlands
- NUTRIM School for Nutrition and Translational Research in Metabolism, 6200 MD Maastricht, The Netherlands
| | - Martijn Hofman
- Department of Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Frank Hildebrand
- Department of Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Jan P. A. M. Verbruggen
- Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center +, 6200 MD Maastricht, The Netherlands
| | - Peter R. G. Brink
- Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center +, 6200 MD Maastricht, The Netherlands
| | - Martijn Poeze
- Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center +, 6200 MD Maastricht, The Netherlands
- NUTRIM School for Nutrition and Translational Research in Metabolism, 6200 MD Maastricht, The Netherlands
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8
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Tang Z, Yin M, Guo Y, Li W, Sun F, Guo Y, Chen Z, Zhou B. Taohong Siwu Decoction Promotes Osteo-Angiogenesis in Fractures by Regulating the HIF-1α Signaling Pathway. Evidence-Based Complementary and Alternative Medicine 2022; 2022:1-10. [PMID: 36193143 PMCID: PMC9526655 DOI: 10.1155/2022/6777447] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 08/02/2022] [Accepted: 08/13/2022] [Indexed: 11/17/2022]
Abstract
Background Vascular damage is a major consequence of bone fracture. Taohong Siwu decoction (TSD) can raise the expression of vascular endothelial growth factor (VEGF) in fracture healing. However, its molecular mechanism in promoting angiogenesis is still unknown. The aim of this study was to investigate the potential mechanisms of TSD in the regulation of osteo-angiogenesis in fracture healing. Methods A rat tibial fracture model was established. After low- (4.5 g·kg−1), medium- (9 g·kg−1), and high-dose TSD (18 g·kg−1) and panax notoginsenoside (25 mg kg−1) treatment, hematoxylin-eosin staining was employed to visualize pathological changes in bone tissues. The levels of cytokines (interleukin (IL)-2, tumor necrosis factor-α (TNF-α), IL-6, and IL-1β), thromboxane B2 (TXB2), and 6 ketone prostaglandin F1α (6-Keto-PGF1α) were quantified by enzyme-linked immunosorbent assay (ELISA). Immunofluorescence was used to identify the rat aortic endothelial cells (RAECs). Control serum, 10% TSD-containing serum, and 10% TSD-containing serum combined with hypoxia-inducible factor-1α (HIF-1α) inhibitor were used to treat the RAECs and rat osteoblasts. Transwell migration assay was utilized to examine the migration of the RAECs. The Matrigel tubulogenesis assay was used for the assessment of angiogenesis. The expression of angiogenesis- (von Hippel-Lindau tumor suppressor (VHL), HIF-1α, VEGF, angiopoietin-2 (Ang-2), and pVHL) and osteogenesis-related (alkaline phosphatase (ALP), runt-related transcription factor 2 (Runx2), and osteopontin-1 (OPN-1)) protein and gene was detected by western blot and quantitative real-time PCR (qRT-PCR). Results Compared with the model group, TSD increased the trabecular bone areas, numbers, and thicknesses in fractured rats. In the plasma, the levels of cytokines and TXB2 in the middle- and high-dose TSD group were significantly lower than those in the model group (P < 0.01). The 6-keto-PGF1α content was increased by middle- and high-dose TSD intervention (P < 0.01). Compared to the control serum group, the angiogenesis and migration of the RAECs were enhanced in the TSD group (P < 0.001). The expression of HIF-1α, VEGF, and Ang-2 in the TSD group upregulated significantly (P < 0.001). VHL and pVHL were inhibited under TSD-containing serum treatment (P < 0.001). ALP, Runx2, and OPN-1 were increased obviously in the TSD group (P < 0.001). Nevertheless, the HIF-1α inhibitor reversed these changes (P < 0.001). Conclusion TSD promotes angiogenesis and osteogenesis by regulating the HIF-1α signaling pathway. Meanwhile, it can effectively reduce the risk of inflammation and improve blood circulation.
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Gao G, Zhang Y, Li H, Nong L, Zhou X, Jiang W, Han L. Comparison of the Effectiveness of Simple Plate Fixation and Plate Combined with Local Fixation of Broken Ends in the Treatment of Oblique Fracture of Midshaft Clavicle. Orthop Surg 2022; 14:1331-1339. [PMID: 35603559 PMCID: PMC9251270 DOI: 10.1111/os.13310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/14/2022] [Accepted: 04/19/2022] [Indexed: 11/29/2022] Open
Abstract
Objective To compare the clinical efficacy of performing simple plate fixation with that using a plate combined with fracture end fixation to investigate the necessity of fracture end fixation outside the plate in cases of oblique fracture of the middle clavicle. Methods This was a retrospective follow‐up study of patients with middle clavicle oblique fractures (Robinson types 2A1 and 2A2) between 2015 and 2020. Patients were divided into two groups according to their treatment options: the simple plate fixation (SPF) group (n = 79; 43 men and 36 women; average age, 46.37 ± 14.54 years) and the plate combined with fracture local fixation (PLFP) group (n = 81; 36 men and 45 women; average age, 48.42 ± 12.55 years). Intraoperative blood loss, operation time, postoperative fracture healing time, postoperative shoulder function score (Constant–Murley and disabilities of the arm, shoulder, and hand [DASH] scores), clinical complications, and postoperative subjective satisfaction were compared between the two groups. Results One hundred sixty patients with a sufficient follow‐up period were included in the final analysis: 79 in the SPF group (follow‐up time: 16.24 ± 3.94 months) and 81 in the PLFP group (follow‐up time: 16.15 ± 3.43 months). Age, sex, body mass index, follow‐up duration, fracture classification, and cause of injury were not significantly different between the two groups. There was no significant difference in blood loss, Constant–Murley and DASH scores, follow‐up period, and postoperative subjective satisfaction between the two groups (P > 0.05). The fracture healing time was shorter in the PLFP group than in the SPF group (4.41 ± 0.99 vs. 4.87 ± 1.60 months, P < 0.05), but the operation duration was longer in the PLFP group than in the SPF group (65.48 ± 16.48 min, P < 0.05). There were seven (complication rate, 8.86%) and five (complication rate, 6.17%) cases that had complications in the SPF and PLFP groups, respectively. There was no significant difference in the complication rates between the two groups (P > 0.05). Conclusion Although the healing time was shorter in the PLFP group than in the SPF group, the clinical efficiency of the two methods in the treatment of oblique fracture of the middle clavicle was similar.
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Affiliation(s)
- Gong‐ming Gao
- Department of Orthopedics The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University Changzhou China
| | - Yi Zhang
- Department of Orthopedics The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University Changzhou China
| | - Hai‐bo Li
- Department of Orthopedics The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University Changzhou China
| | - Lu‐ming Nong
- Department of Orthopedics The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University Changzhou China
| | - Xin‐die Zhou
- Department of Orthopedics The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University Changzhou China
| | - Wei Jiang
- Department of Orthopedics The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University Changzhou China
| | - Long Han
- Department of Orthopedics The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University Changzhou China
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10
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Sadekar V, Watts AT, Moulder E, Souroullas P, Hadland Y, Barron E, Muir R, Sharma HK. Is a staged reloading protocol effective to time the removal of circular frames? Bone Jt Open 2022; 3:359-366. [PMID: 35491551 PMCID: PMC9134831 DOI: 10.1302/2633-1462.35.bjo-2021-0179.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aims The timing of when to remove a circular frame is crucial; early removal results in refracture or deformity, while late removal increases the patient morbidity and delay in return to work. This study was designed to assess the effectiveness of a staged reloading protocol. We report the incidence of mechanical failure following both single-stage and two stage reloading protocols and analyze the associated risk factors. Methods We identified consecutive patients from our departmental database. Both trauma and elective cases were included, of all ages, frame types, and pathologies who underwent circular frame treatment. Our protocol is either a single-stage or two-stage process implemented by defunctioning the frame, in order to progressively increase the weightbearing load through the bone, and promote full loading prior to frame removal. Before progression, through the process we monitor patients for any increase in pain and assess radiographs for deformity or refracture. Results There were 244 frames (230 patients) included in the analyses, of which 90 were Ilizarov type frames and 154 were hexapods. There were 149 frames which underwent single-stage reloading and 95 frames which underwent a two-stage reloading protocol. Mechanical failure occurred after frame removal in 13 frames (5%), which suffered refracture. There were no cases of change in alignment. There was no difference between refracture patients who underwent single-stage or two-stage reloading protocols (p = 0.772). In all, 14 patients had failure prevented through identification with the reloading protocol. Conclusion Our reloading protocol is a simple and effective way to confirm the timing of frame removal and minimize the rate of mechanical failure. Similar failure rates occurred between patients undergoing single-stage and two-stage reloading protocols. If the surgeon is confident with clinical and radiological assessment, it may be possible to progress directly to stage two and decrease frame time and patient morbidity. Cite this article: Bone Jt Open 2022;3(5):359–366.
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Affiliation(s)
- Vilas Sadekar
- Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Arun T. Watts
- Hull University Teaching Hospitals NHS Trust, Hull, UK
| | | | | | | | | | - Ross Muir
- Hull University Teaching Hospitals NHS Trust, Hull, UK
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11
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Iwatsu J, Watanuki M, Yoshida S, Hitachi S, Watanabe M, Aizawa T. Clinical outcome of porous hydroxyapatite/collagen graft on bone defects following curettage of bone tumors. J Biomed Mater Res B Appl Biomater 2022; 110:2211-2216. [PMID: 35441487 DOI: 10.1002/jbm.b.35070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/11/2022] [Accepted: 04/01/2022] [Indexed: 11/07/2022]
Abstract
Hydroxyapatite/collagen (HAp/col) has been reported to be a highly useful bone-like nanocomposite. This study included 33 human patients to investigate the details of the clinical outcomes, which are (1) onset of timing of bone regeneration, (2) replacement by regenerated bone of HAp/col and (3) complications, in human cases grafting HAp/col in large bone defects, following curettage of bone tumors. Porous HAp/col initiated bone regeneration approximately 59 days following the surgery. In 15 cases (45%), complete replacement by newly formed bone was observed 12 months after surgery. On the other hand, incomplete replacement of HAp/col at the final follow-up was observed in 13 cases (39%). In these cases, HAp/col could not be detected in the transparent area of postoperative plain radiographs owing to quick absorption; moreover, it was difficult to distinguish whether the transparent area in plain radiographs was remaining HAp/col, recurrence, or remaining tumor. In addition, larger HAp/col implantation volume (≧15 cm3 ) was associated with poorer result of complete replacement (log-rank, p = .005). Further studies are warranted for the construction of a new artificial bone graft substitute that is more quickly and surely regenerated by newly formed bone in large bone defects.
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Affiliation(s)
- Jun Iwatsu
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Munenori Watanuki
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Shinichirou Yoshida
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Shin Hitachi
- Department of Diagnostic Radiology, Tohoku University School of Medicine, Sendai, Japan
| | - Mika Watanabe
- Department of Pathology, Tohoku Kosai Hospital, Sendai, Japan
| | - Toshimi Aizawa
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
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12
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Stewart CC, O'Hara NN, Bzovsky S, Bahney CS, Sprague S, Slobogean GP. Bone turnover markers as surrogates of fracture healing after intramedullary fixation of tibia and femur fractures. Bone Joint Res 2022; 11:239-250. [PMID: 35442058 PMCID: PMC9057525 DOI: 10.1302/2046-3758.114.bjr-2021-0226.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Aims Bone turnover markers (BTMs) follow distinct trends after fractures and limited evidence suggests differential levels in BTMs in patients with delayed healing. The effect of vitamin D, and other factors that influence BTMs and fracture healing, is important to elucidate the use of BTMs as surrogates of fracture healing. We sought to determine whether BTMs can be used as early markers of delayed fracture healing, and the effect of vitamin D on BTM response after fracture. Methods A total of 102 participants aged 18 to 50 years (median 28 years (interquartile range 23 to 35)), receiving an intramedullary nail for a tibial or femoral shaft fracture, were enrolled in a randomized controlled trial comparing vitamin D3 supplementation to placebo. Serum C-terminal telopeptide of type I collagen (CTX; bone resorption marker) and N-terminal propeptide of type I procollagen (P1NP; bone formation marker) were measured at baseline, six weeks, and 12 weeks post-injury. Clinical and radiological fracture healing was assessed at three months. Results CTX and P1NP concentrations peaked at six weeks in all groups. Elevated six-week CTX and P1NP were associated with radiological healing at 12 weeks post-injury (odds ratio (OR) 10.5; 95% confidence interval 2.71 to 53.5, p = 0.002). We found no association between CTX or P1NP and functional healing. Baseline serum 25(OH)D showed a weak inverse relationship with P1NP (p = 0.036) and CTX (p = 0.221) at 12 weeks, but we observed no association between vitamin D supplementation and either BTM. Conclusion Given the association between six-week BTM concentrations and three-month radiological fracture healing, CTX and P1NP appear to be potential surrogate markers of fracture healing. Cite this article: Bone Joint Res 2022;11(4):239–250.
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Affiliation(s)
- Christopher C Stewart
- Department of Orthopaedic Surgery, University of California, San Francisco, California, USA
| | - Nathan N O'Hara
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sofia Bzovsky
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Chelsea S Bahney
- Steadman Philippon Research Institute, Center for Regenerative & Personalized Medicine, Vail, Colorado, USA.,Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco, California, USA
| | - Sheila Sprague
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Gerard P Slobogean
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
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13
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Abstract
Objectives: Methods: Results: Conclusions:
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14
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Rozental TD, Merchan N, Johannesdottir F, Lechtig A, Earp BE, Harper CM, Bouxsein ML. Longitudinal Changes in Serum Markers of Bone Metabolism and Bone Material Strength in Premenopausal Women with Distal Radial Fracture. J Bone Joint Surg Am 2022; 104:15-23. [PMID: 34648480 DOI: 10.2106/jbjs.21.00540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Markers of bone metabolism (MBM) play an important role in fracture evaluation, and changes have been associated with increased fracture risk. The purpose of the present study was to describe changes in MBM in premenopausal women with distal radial fractures. METHODS Premenopausal women with distal radial fractures (n = 34) and without fractures (controls) (n = 39) were recruited. Serum MBM in patients with distal radial fractures were obtained at the time of the initial presentation, 6 weeks, and 3, 6, and 12 months. MBM included 25(OH) vitamin D, PTH, osteocalcin, P1NP, BSAP, CTX, sclerostin, DKK1, periostin, and TRAP5b. Areal bone mineral density (aBMD) was assessed with dual x-ray absorptiometry, and the bone material strength index (BMSi) was assessed with microindentation. RESULTS Most MBM reached peak levels at 6 weeks after the injury, including osteocalcin (+17.7%), sclerostin (+23.5%), and DKK1 (12.6%). Sclerostin was lower (-27.4%) and DKK1 was higher (+22.2%) at 1 year after the fracture. CTX declined below baseline levels at 6 and 12 months, whereas TRAP5b, BSAP, and periostin did not significantly change. At 12 months, sclerostin was lower (p = 0.003) and DKK1 was higher (p = 0.03) in the distal radial fracture group than in the control group. Greater fracture severity was associated with greater increases in P1NP and BSAP. aBMD and BMSi were not associated with fracture. CONCLUSIONS Distal radial fractures caused increases in several MBM, which typically peaked at 6 weeks after injury and gradually decreased over 6 months. Sclerostin and DKK1 remained below and above baseline at 1 year, respectively. Increasing fracture severity resulted in larger changes in MBM. aBMD and BMSi did not discriminate between patients with distal radial fractures and controls. Continued efforts to identify markers of skeletal fragility in young women are warranted to mitigate future fracture risk. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Tamara D Rozental
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Nelson Merchan
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Fjola Johannesdottir
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Aron Lechtig
- Harvard Combined Orthopaedic Surgery Residency Program, Boston, Massachusetts
| | - Brandon E Earp
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Carl M Harper
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mary L Bouxsein
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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15
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Chaverri D, Vivas D, Gallardo-Villares S, Granell-Escobar F, Pinto JA, Vives J. A pilot study of circulating levels of TGF-β1 and TGF-β2 as biomarkers of bone healing in patients with non-hypertrophic pseudoarthrosis of long bones. Bone Rep 2022; 16:101157. [PMID: 34950754 DOI: 10.1016/j.bonr.2021.101157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 11/20/2022] Open
Abstract
Background Pseudoarthrosis or non-union is a complication with an incidence of 5-10% of bone fractures, most frequently located in the diaphysis of long bones. The management of this complication is addressed by means of complex surgical procedures and is a concern for orthopaedic and trauma surgeons nowadays. The use of biomarkers for diagnosing patients at risk of non-union would help us to establish special measures for early corrective treatment. Methods Prospective exploratory pilot study with a cohort of 20 patients diagnosed of non-hypertrophic pseudoarthrosis of long bones who were treated surgically with either autologous bone graft or a Tissue Engineering Product composed of bone marrow-derived Mesenchymal Stromal Cells. Patients were followed for 12 months and plasma blood samples were obtained to determine circulating levels of Transforming Growth Factor Beta 1 and Beta 2 (TGF-β1 and TGF-β2, respectively) at inclusion, and at 1 week, 2 weeks, and months 1, 2, 3, 6 and 12 after surgery. Radiological bone healing was evaluated by the Tomographic Union Score (TUS). Results Basal levels of TGF-β1 and TGF-β2 were determined in the twenty patients (26,702 ± 14,537 pg/mL and 307.8 ± 83.1 pg/mL, respectively). Three of them withdrew from the study, so complete follow-up was conducted on 17 patients (9 successfully healed vs. 8 that did not heal). Statistically significant differences between the bone healing group and the non-union group were found at month 12 for both TGF-β1 (p = 0.005) and TGF-β2 (p = 0.02). Conclusions TGF-β1 and TGF-β2 are biomarkers that correlate with clinical evidence of bone regeneration and may be used to monitor patients, although early predictive value after intervention needs to be further studied in combination with other molecules.
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16
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Knox AM, McGuire AC, Natoli RM, Kacena MA, Collier CD. Methodology, selection, and integration of fracture healing assessments in mice. J Orthop Res 2021; 39:2295-2309. [PMID: 34436797 PMCID: PMC8542592 DOI: 10.1002/jor.25172] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 08/02/2021] [Accepted: 08/13/2021] [Indexed: 02/04/2023]
Abstract
Long bone fractures are one of the most common and costly medical conditions encountered after trauma. Characterization of the biology of fracture healing and development of potential medical interventions generally involves animal models of fracture healing using varying genetic or treatment groups, then analyzing relative repair success via the synthesis of diverse assessment methodologies. Murine models are some of the most widely used given their low cost, wide variety of genetic variants, and rapid breeding and maturation. This review addresses key concerns regarding fracture repair investigations in mice and may serve as a guide in conducting and interpreting such studies. Specifically, this review details the procedures, highlights relevant parameters, and discusses special considerations for the selection and integration of the major modalities used for quantifying fracture repair in such studies, including X-ray, microcomputed tomography, histomorphometric, biomechanical, gene expression and biomarker analyses.
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Affiliation(s)
- Adam M. Knox
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA
| | - Anthony C. McGuire
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA
| | - Roman M. Natoli
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA
| | - Melissa A. Kacena
- Department of Orthopaedic Surgery, Indiana University School of Medicine, IN, USA
- Richard L. Roudebush VA Medical Center, IN, USA
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17
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Chitwood JR, Chakraborty N, Hammamieh R, Moe SM, Chen NX, Kacena MA, Natoli RM. Predicting fracture healing with blood biomarkers: the potential to assess patient risk of fracture nonunion. Biomarkers 2021; 26:703-717. [PMID: 34555995 DOI: 10.1080/1354750x.2021.1985171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Fracture non-union is a significant orthopaedic problem affecting a substantial number of patients yearly. Treatment of nonunions is devastating to patients and costly to the healthcare system. Unfortunately, the diagnosis of non-union is typically made in a reactionary fashion by an orthopaedic surgeon based on clinical assessment and radiographic features several months into treatment. For this reason, investigators have been trying to develop prediction algorithms; however, these have relied on population-based approaches and lack the predictive capability necessary to make individual treatment decisions. There is also a growing body of literature focussed on identifying blood biomarkers that are associated with non-union. This review describes the research that has been done in this area. Further studies of patient-centered, precision medicine approaches will likely improve fracture non-union diagnostic/prognostic capabilities.
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Affiliation(s)
- Joseph R Chitwood
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nabarun Chakraborty
- Medical Readiness Systems Biology, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Rasha Hammamieh
- Medical Readiness Systems Biology, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Sharon M Moe
- Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Neal X Chen
- Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Melissa A Kacena
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Roman M Natoli
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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18
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Nicholson JA, Yapp LZ, Keating JF, Simpson AHRW. Monitoring of fracture healing. Update on current and future imaging modalities to predict union. Injury 2021; 52 Suppl 2:S29-S34. [PMID: 32826052 DOI: 10.1016/j.injury.2020.08.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/22/2020] [Accepted: 08/07/2020] [Indexed: 02/02/2023]
Abstract
Fracture nonunion causes considerable patient morbidity and an associated burden to society. Traditional reliance on radiographs to monitor union has limitations as bridging callus of long bone fractures can take three or more months to occur. Computed Tomographic (CT) scanning is becoming increasingly popular and can evaluate bridging callus in the late stages of healing to confirm union. The use of dynamic contrast enhanced Magnetic Resonance Imaging (MRI) and advances in nuclear imaging may yield benefits in the assessment of the infected nonunion. Emerging evidence supports the use of ultrasound to detect bridging callus prior to radiographic confirmation and it may be of use to predict patients at high risk of nonunion. This paper is part of a Supplement supported by The Osteosynthesis and Trauma Care Foundation (OTCF).
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Affiliation(s)
- J A Nicholson
- Department of Orthopaedic and Trauma Surgery, Edinburgh Royal Infirmary, Little France, Edinburgh EH16 4SU, United Kingdom.
| | - L Z Yapp
- Department of Orthopaedic and Trauma Surgery, Edinburgh Royal Infirmary, Little France, Edinburgh EH16 4SU, United Kingdom
| | - J F Keating
- Department of Orthopaedic and Trauma Surgery, Edinburgh Royal Infirmary, Little France, Edinburgh EH16 4SU, United Kingdom
| | - A H R W Simpson
- Department of Orthopaedic and Trauma Surgery, Edinburgh Royal Infirmary, Little France, Edinburgh EH16 4SU, United Kingdom
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19
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Nauta SP, Poeze M, Heeren RMA, Porta Siegel T. Clinical use of mass spectrometry (imaging) for hard tissue analysis in abnormal fracture healing. Clin Chem Lab Med 2021; 58:897-913. [PMID: 32049645 DOI: 10.1515/cclm-2019-0857] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 12/16/2019] [Indexed: 12/23/2022]
Abstract
Common traumas to the skeletal system are bone fractures and injury-related articular cartilage damage. The healing process can be impaired resulting in non-unions in 5-10% of the bone fractures and in post-traumatic osteoarthritis (PTOA) in up to 75% of the cases of cartilage damage. Despite the amount of research performed in the areas of fracture healing and cartilage repair as well as non-unions and PTOA, still, the outcome of a bone fracture or articular cartilage damage cannot be predicted. Here, we discuss known risk factors and key molecules involved in the repair process, together with the main challenges associated with the prediction of outcome of these injuries. Furthermore, we review and discuss the opportunities for mass spectrometry (MS) - an analytical tool capable of detecting a wide variety of molecules in tissues - to contribute to extending molecular understanding of impaired healing and the discovery of predictive biomarkers. Therefore, the current knowledge and challenges concerning MS imaging of bone and cartilage tissue as well as in vivo MS are discussed. Finally, we explore the possibilities of in situ, real-time MS for the prediction of outcome during surgery of bone fractures and injury-related articular cartilage damage.
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Affiliation(s)
- Sylvia P Nauta
- The Maastricht MultiModal Molecular Imaging Institute (M4I), Division of Imaging Mass Spectrometry, Maastricht University, Maastricht, The Netherlands.,Department of Orthopedic Surgery and Traumasurgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Martijn Poeze
- Department of Surgery, Division of Traumasurgery, Maastricht University Medical Center, Maastricht, The Netherlands.,NUTRIM, School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Ron M A Heeren
- The Maastricht MultiModal Molecular Imaging Institute (M4I), Division of Imaging Mass Spectrometry, Maastricht University, Universiteitssingel 50, 6229ER Maastricht, The Netherlands
| | - Tiffany Porta Siegel
- The Maastricht MultiModal Molecular Imaging Institute (M4I), Division of Imaging Mass Spectrometry, Maastricht University, Maastricht, The Netherlands
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20
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Ernst M, Baumgartner H, Döbele S, Höntzsch D, Pohlemann T, Windolf M. Clinical feasibility of fracture healing assessment through continuous monitoring of implant load. J Biomech 2020; 116:110188. [PMID: 33444926 DOI: 10.1016/j.jbiomech.2020.110188] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/16/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
Current fracture fixation follow-up is based on subjective radiological and clinical examination. Efforts to objectify the procedure have been undertaken since decades. Assessment of implant load as an indirect predictor of callus maturity has so far failed to enter clinical routine due to limited practicability, technical obstacles and its snap-shot nature. We recently introduced the concept of continuous implant load monitoring to aid in diagnosing fracture healing progression. This study aimed at investigating the feasibility of the system in a clinical context. Ten patients treated with Taylor-Spatial-Frame external fixators following pathological tibia fractures were equipped with a Fracture Monitor device attached to a fixator-strut and were monitored until hardware removal. Two patients were excluded due to technical issues. Implant load and fracture activity was continuously and autonomously measured for 139 ± 89 days (mean ± SD). Data was wirelessly collected with consumer smartphones. Relative implant load initially rose for 34.1 ± 22.2 days and finally declined to a level of 45.0 ± 33.8% of the maximum implant load. In five patients the load dropped below 50% of the maximum load. These patients underwent hardware removal according to the clinical assessment. In three patients, whose external fixators were exchanged to internal fixation at the end of the study, implant load did not drop below the 50% margin. The continuous measurement principle allows resolving implant load progression and appears indicative for the bone healing status. Data can be acquired in a homecare setting and is believed to provide valuable information to support timely healing assessment and enable patient specific after-care.
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Affiliation(s)
| | - Heiko Baumgartner
- BG Trauma Center Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Stefan Döbele
- BG Trauma Center Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Dankward Höntzsch
- BG Trauma Center Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Tim Pohlemann
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany
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21
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Olçar HA, Halıcı M, Kafadar İH, Karaman İ, Lekesizcan A, Gönen ZB. Can injection of adipose stem cells to non-union zone increase bone union? Experimental rat study. Jt Dis Relat Surg 2020; 31:20-7. [PMID: 32160489 DOI: 10.5606/ehc.2020.71270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objectives
This study aims to evaluate the effects of local adipose stem cell injection on non-union and diabetic non-union of rat femurs. Materials and methods
Forty-eight female Wistar albino rats (weighing mean 200 g and aged 8 weeks) were used in this study. The rats were divided into six groups. Group 1 was chosen as a reference for receptor activator of nuclear factor-kappa (k) B (RANK), receptor activator of nuclear factor-k B ligand (RANKL) and osteoprotegerin (OPG) genes and no femur osteotomy was performed in this group. Group 2 underwent femur osteotomy, the osteotomy was fixed with a 1.5 mm K-wire as retrograde from the knee joint, and no gap was left in the osteotomy line. In order to induce non-union, femurs underwent osteotomy fixed with K-wires in groups 3, 4, 5 and 6. In addition, the osteotomy line was measured as 1.8 mm gap with electronic calipers and the gap was fixed with U staple. Before osteotomy, streptozocin was injected intraperitoneally at a dose of 60 mg/kg in 0.1 mol/L citrate buffer solution (Ph 4.4) in groups 4 and 6, in order to induce diabetes mellitus. Left femur anteroposterior and lateral X-rays were taken 10 weeks after the operation and the union in group 2 and non-union in groups 3, 4, 5, and 6 were confirmed. To see if injection of adipose stem cells into the non-union site increases bone union, 2 mL 0.9% sodium chloride (NaCl) in groups 3 and 4 and 2×106 adipose stem cell in groups 5 and 6 were locally injected into the non-union area with fluoroscopy. Femur X-rays were taken eight weeks after the injection and all rats were sacrificed. Femurs of rats were removed for histopathological and gene expression evaluation. Results
There were significant differences between the groups injected 0.9% NaCI and adipose stem cells in terms of bone healing according to radiological and histopathological evaluations (p<0.05). No statistically significant difference was observed between the groups in terms of gene expression levels. Conclusion According to the results of our study, local adipose stem cell injection has positive radiological and histopathological effects in diabetic and non-diabetic femoral non-unions, independently of RANK, RANKL, or OPG gene expression pathways.
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Abstract
New knowledge about the molecular biology of fracture-healing provides opportunities for intervention and reduction of risk for specific phases that are affected by disease and medications. Modifiable and nonmodifiable risk factors can prolong healing, and the informed clinician should optimize each patient to provide the best chance for union. Techniques to monitor progression of fracture-healing have not changed substantially over time; new objective modalities are needed.
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Affiliation(s)
- Justin E Hellwinkel
- Department of Orthopedic Surgery, New York Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
- Center for Regenerative Sports Medicine, The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado
| | - Theodore Miclau
- Orthopaedic Trauma Institute, University of California, San Francisco (UCSF) and Zuckerberg San Francisco General Hospital (ZSFG), San Francisco, California
| | - Matthew T Provencher
- Center for Regenerative Sports Medicine, The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado
| | - Chelsea S Bahney
- Center for Regenerative Sports Medicine, The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado
- Orthopaedic Trauma Institute, University of California, San Francisco (UCSF) and Zuckerberg San Francisco General Hospital (ZSFG), San Francisco, California
| | - Zachary M Working
- Orthopaedic Trauma Institute, University of California, San Francisco (UCSF) and Zuckerberg San Francisco General Hospital (ZSFG), San Francisco, California
- Oregon Health & Science University, Portland, Oregon
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Wu J, Liu L, Hu H, Gao Z, Lu S. Bioinformatic analysis and experimental identification of blood biomarkers for chronic nonunion. J Orthop Surg Res 2020; 15:208. [PMID: 32503597 PMCID: PMC7275361 DOI: 10.1186/s13018-020-01735-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 05/27/2020] [Indexed: 12/13/2022] Open
Abstract
Background Incomplete fracture healing may lead to chronic nonunion; thus, determining fracture healing is the primary issue in the clinical treatment. However, there are no validated early diagnostic biomarkers for assessing chronic nonunion. In this study, bioinformatics analysis combined with an experimental verification strategy was used to identify blood biomarkers for chronic nonunion. Methods First, differentially expressed genes in chronic nonunion were identified by microarray data analysis. Second, Dipsaci Radix (DR), a traditional Chinese medicine for fracture treatment, was used to screen the drug target genes. Third, the drug-disease network was determined, and biomarker genes were obtained. Finally, the potential blood biomarkers were verified by ELISA and qPCR methods. Results Fifty-five patients with open long bone fractures (39 healed and 16 nonunion) were enrolled in this study, and urgent surgical debridement and the severity of soft tissue injury had a significant effect on the prognosis of fracture. After the systems pharmacology analysis, six genes, including QPCT, CA1, LDHB, MMP9, UGCG, and HCAR2, were chosen for experimental validation. We found that all six genes in peripheral blood mononuclear cells (PBMCs) and serum were differentially expressed after injury, and five genes (QPCT, CA1, MMP9, UGCG, and HCAR2) were significantly lower in nonunion patients. Further, CA1, MMP9, and QPCT were markedly increased after DR treatment. Conclusion CA1, MMP9, and QPCT are biomarkers of nonunion patients and DR treatment targets. However, HCAR2 and UGCG are biomarkers of nonunion patients but not DR treatment targets. Therefore, our findings may provide valuable information for nonunion diagnosis and DR treatment. Trial registration ISRCTN, ISRCTN13271153. Registered 05 April 2020—Retrospectively registered.
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Affiliation(s)
- Jingwei Wu
- Department of Orthopedics, Xuanwu Hospital, Capital Medical University, Beijing, 100053, People's Republic of China
| | - Limin Liu
- Department of Orthopedics, Xuanwu Hospital, Capital Medical University, Beijing, 100053, People's Republic of China.
| | - Huaijian Hu
- Department of Orthopedics, Xuanwu Hospital, Capital Medical University, Beijing, 100053, People's Republic of China
| | - Zhihua Gao
- Department of Orthopedics, Xuanwu Hospital, Capital Medical University, Beijing, 100053, People's Republic of China
| | - Shibao Lu
- Department of Orthopedics, Xuanwu Hospital, Capital Medical University, Beijing, 100053, People's Republic of China.
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24
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Abstract
PURPOSE OF REVIEW The failure of bony union following a fracture, termed a fracture nonunion, has severe patient morbidity and economic consequences. This review describes current consensuses and future directions of investigation for determining why, detecting when, and effective treatment if this complication occurs. RECENT FINDINGS Current nonunion investigation is emphasizing an expanded understanding of the biology of healing. This has led to assessments of the immune environment, multiple cytokines and morphogenetic factors, and the role of skeletogenic stem cells in the development of nonunion. Detecting biological markers and other objective diagnostic criteria is also a current objective of nonunion research. Treatment approaches in the near future will likely be dominated by the development of specific adjunct therapies to the nonunion surgical management, which will be informed by an expanded mechanistic understanding of nonunion biology. Current consensus among orthopedists is that improved diagnosis and treatment of nonunion hinges first on discoveries at the bench side with later translation to the clinic.
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Affiliation(s)
- G Bradley Reahl
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, MA, 02118, USA.
| | - Louis Gerstenfeld
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, MA, 02118, USA
| | - Michael Kain
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, MA, 02118, USA.
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Pountos I, Walters G, Panteli M, Einhorn TA, Giannoudis PV. Inflammatory Profile and Osteogenic Potential of Fracture Haematoma in Humans. J Clin Med 2019; 9:jcm9010047. [PMID: 31878248 PMCID: PMC7019316 DOI: 10.3390/jcm9010047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 12/15/2022] Open
Abstract
Fracture haematoma forms immediately after fracture and is considered essential for the bone healing process. Its molecular composition has been briefly investigated with our current understanding being based on animal studies. This study aims to analyse the inflammatory cytokine content of fracture haematoma in humans and determine its effect on osteoprogenitor cells. Twenty-three patients were recruited following informed consent. Peripheral blood, fracture haematoma and bone were collected. A Luminex assay on the levels of 34 cytokines was performed and autologous peripheral blood samples served as control. Mesenchymal Stem Cells (MSCs) were isolated following collagenase digestion and functional assays were performed. Gene expression analysis of 84 key osteogenic molecules was performed. Thirty-three inflammatory cytokines were found to be significantly raised in fracture haematoma when compared to peripheral serum (p < 0.05). Amongst the most raised molecules were IL-8, IL-11 and MMP1, -2 and -3. Fracture haematoma did not significantly affect MSC proliferation, but ALP activity and calcium deposition were significantly increased in the MSCs undergoing osteogenic differentiation. Medium supplementations with fracture haematoma resulted in a statistically significant upregulation of osteogenic genes including the EGF, FGF2 and VEGFA. This seems to be the pathway involved in the osteogenic effect of fracture haematoma on bone cells. In conclusion, fracture haematoma is found to be a medium rich in inflammatory and immunomodulatory mediators. At the same time, it contains high levels of anti-inflammatory molecules, regulates osteoclastogenesis, induces angiogenesis and the production of the extracellular matrix. It appears that fracture haematoma does not affect osteoprogenitor cells proliferation as previously thought, but induces an osteogenic phenotype.
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Affiliation(s)
- Ippokratis Pountos
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds LS 2 9JT, UK; (G.W.); (M.P.); (P.V.G.)
- Correspondence: ; Tel.: +44-113-3922750
| | - Gavin Walters
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds LS 2 9JT, UK; (G.W.); (M.P.); (P.V.G.)
| | - Michalis Panteli
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds LS 2 9JT, UK; (G.W.); (M.P.); (P.V.G.)
| | - Thomas A. Einhorn
- Department of Orthopaedic Surgery, NYU Langone Health, New York, NY 10016, USA;
| | - Peter V. Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds LS 2 9JT, UK; (G.W.); (M.P.); (P.V.G.)
- NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, Leeds LS7 4SA, UK
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26
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Yuasa M, Saito M, Blum DM, Hysong AA, Egawa S, Uppuganti S, Yoshii T, Okawa A, Schwartz HS, Moore-Lotridge SN, Nyman JS, Schoenecker JG. The Size of Intramedullary Fixation Affects Endochondral-Mediated Angiogenesis During Fracture Repair. J Orthop Trauma 2019; 33:e385-93. [PMID: 31259800 DOI: 10.1097/BOT.0000000000001555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To explore the effect of intramedullary pin size on the biology of a healing fracture, specifically endochondral angiogenesis. We hypothesized that fracture fixation with a smaller pin would permit greater interfragmentary strain resulting in increased total amount of vascular endothelial growth factor within the callus and greater angiogenesis compared to fixation with a larger pin. METHODS Transverse mid-shaft femur fractures in 8-week-old mice were fixed with either a 23-gauge (G) or 30-G pin. Differences in interfragmentary strain at the fracture site were estimated between cohorts. A combination of histology, gene expression, serial radiography, and microcomputed tomography with and without vascular contrast agent were used to assess fracture healing and vascularity for each cohort. RESULTS Larger soft-tissue callus formation increased vascular endothelial growth factor-A expression, and a corresponding increase in vascular volume was observed in the higher strain, 30-G cohort. Radiographic analysis demonstrated earlier hard callus formation with greater initial interfragmentary strain, similar rates of union between pin size cohorts, yet delayed callus remodeling in mice with the larger pin size. CONCLUSIONS These findings suggest that the stability conferred by an intramedullary nail influences endochondral angiogenesis at the fracture.
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27
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Santolini E, West RM, Giannoudis PV. Leeds-Genoa Non-Union Index: a clinical tool for asessing the need for early intervention after long bone fracture fixation. Int Orthop 2019; 44:161-172. [PMID: 31440889 PMCID: PMC6938791 DOI: 10.1007/s00264-019-04376-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 07/08/2019] [Indexed: 01/29/2023]
Abstract
AIM OF THE STUDY The aim of this case-control study was to develop a clinical decision rule to support assessment of the risk of long-bone non-union and plan for appropriate early intervention. METHODS Two hundred patients (100 cases and 100 controls) were recruited. Risk factors identified to contribute to the development of non-union were recorded and analysed with a multivariable logistic regression model. Tabulation of the outcome (non-union/union) against each risk factor in turn (univariable analysis) was carried out. Odds ratios and confidence intervals were derived using Wald's method. A receiver-operator curve was calculated and the area under the curve was computed. Having established the eight most important risk factors, a non-union risk index was developed as the count of the risk factors present in each patient. RESULTS The five risk factors for non-union with greater effect size were post-surgical fracture gap > 4 mm (odds ratio (OR) = 11.97 95% CI (4.27, 33.53)), infection superficial/deep (OR 10.16 (2.44, 42.36)), not optimum mechanical stability (OR 10.06 (3.75, 26.97)), displacement > 75% of shaft width (OR 6.81 (2.21, 20.95)), and site of fracture-tibia (OR 4.33 (1.32, 14.14)). The ROC curve for the non-union index was 0.924, sensitivity 91%, specificity 77%. CONCLUSIONS The non-union index derived from counting risk factors predicts union for 0-4 risk factors and non-union for 5-8 risk factors. It can be readily applied and can guide clinicians about the risk of development of long-bone non-union. It can become a powerful aid for assessing fracture fixation outcome and to support early intervention.
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Affiliation(s)
- Emmanuele Santolini
- Academic Unit of Trauma and Orthopaedics, University of Genoa, Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy.,Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon wing, Level D, LS13EX, Leeds, West Yorkshire, UK
| | - Robert M West
- Leeds Institute of Health Sciences, University of Leeds, 101 Clarendon Road, Leeds, UK
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon wing, Level D, LS13EX, Leeds, West Yorkshire, UK. .,NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK.
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28
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Granchi D, Ciapetti G, Gómez-Barrena E, Rojewski M, Rosset P, Layrolle P, Spazzoli B, Donati DM, Baldini N. Biomarkers of bone healing induced by a regenerative approach based on expanded bone marrow-derived mesenchymal stromal cells. Cytotherapy 2019; 21:870-885. [PMID: 31272868 DOI: 10.1016/j.jcyt.2019.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/29/2019] [Accepted: 06/09/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Safety and feasibility of a regenerative strategy based on the use of culture-expanded mesenchymal stromal cells (MSCs) have been investigated in phase 2 trials for the treatment of nonunion and osteonecrosis of the femoral head (ONFH). As part of the clinical study, we aimed to evaluate if bone turnover markers (BTMs) could be useful for predicting the regenerative ability of the cell therapy product. MATERIALS AND METHODS The bone defects of 39 patients (nonunion: n = 26; ONFH: n = 13) were treated with bone marrow-derived MSCs, expanded using a clinical-grade protocol and combined with biphasic calcium phosphate before implantation. Bone formation markers, bone-resorption markers and osteoclast regulatory proteins were measured before treatment (baseline) and after 12 and 24 weeks from surgery. At the same time-points, clinical and radiological controls were performed to evaluate the bone-healing progression. RESULTS We found that C-Propeptide of Type I Procollagen (CICP) and C-terminal telopeptide of type-I collagen (CTX) varied significantly, not only over time, but also according to clinical results. In patients with a good outcome, CICP increased and CTX decreased, and this trend was observed in both nonunion and ONFH. Moreover, collagen biomarkers were able to discriminate healed patients from non-responsive patients with a good diagnostic accuracy. DISCUSSION CICP and CTX could be valuable biomarkers for monitoring and predicting the regenerative ability of cell products used to stimulate the repair of refractory bone diseases. To be translated in a clinical setting, these results are under validation in a currently ongoing phase 3 clinical trial.
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Affiliation(s)
- Donatella Granchi
- SSD Fisiopatologia Ortopedica e Medicina Rigenerativa, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.
| | - Gabriela Ciapetti
- SSD Fisiopatologia Ortopedica e Medicina Rigenerativa, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | | | - Markus Rojewski
- Institute for Clinical Transfusion Medicine and Immunogenetic Ulm (IKT Ulm), Ulm, Germany
| | - Philippe Rosset
- Service of Orthopaedic Surgery and Traumatology, CHRU, Tours, France
| | - Pierre Layrolle
- Inserm, UMR 1238, PHY-OS, Bone sarcomas and remodeling of calcified tissues, Faculty of Medicine, University of Nantes, Nantes, France
| | - Benedetta Spazzoli
- Clinica Ortopedica III, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Davide Maria Donati
- Clinica Ortopedica III, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy; Dipartimento di Scienze Biomediche e Neuromotorie, Università degli Studi di Bologna, Bologna, Italy
| | - Nicola Baldini
- SSD Fisiopatologia Ortopedica e Medicina Rigenerativa, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy; Dipartimento di Scienze Biomediche e Neuromotorie, Università degli Studi di Bologna, Bologna, Italy
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29
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Armiento AR, Alini M, Stoddart MJ. Articular fibrocartilage - Why does hyaline cartilage fail to repair? Adv Drug Deliv Rev 2019; 146:289-305. [PMID: 30605736 DOI: 10.1016/j.addr.2018.12.015] [Citation(s) in RCA: 172] [Impact Index Per Article: 34.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/07/2018] [Accepted: 12/27/2018] [Indexed: 12/12/2022]
Abstract
Once damaged, articular cartilage has a limited potential to repair. Clinically, a repair tissue is formed, yet, it is often mechanically inferior fibrocartilage. The use of monolayer expanded versus naïve cells may explain one of the biggest discrepancies in mesenchymal stromal/stem cell (MSC) based cartilage regeneration. Namely, studies utilizing monolayer expanded MSCs, as indicated by numerous in vitro studies, report as a main limitation the induction of type X collagen and hypertrophy, a phenotype associated with endochondral bone formation. However, marrow stimulation and transfer studies report a mechanically inferior collagen I/II fibrocartilage as the main outcome. Therefore, this review will highlight the collagen species produced during the different therapeutic approaches. New developments in scaffold design and delivery of therapeutic molecules will be described. Potential future directions towards clinical translation will be discussed. New delivery mechanisms are being developed and they offer new hope in targeted therapeutic delivery.
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Affiliation(s)
| | - Mauro Alini
- AO Research Institute Davos, 7270 Davos Platz, Switzerland.
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30
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Stewart CC, O’Hara NN, Orwig D, Hochberg MC, Sprague S, Magaziner J, Slobogean GP. Serum 25(OH)D is associated with an altered bone turnover marker response after a hip fracture. J Orthop Res 2019; 37:535-540. [PMID: 30578572 PMCID: PMC6484430 DOI: 10.1002/jor.24200] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 11/21/2018] [Indexed: 02/04/2023]
Abstract
C-terminal telopeptide of type I collagen (CTX) and procollagen type 1 N-terminal propeptide (P1NP) are bone turnover markers (BTMs) that are promising surrogate measures of fracture healing; however, it is unknown if their response is affected by other bone healing metabolites. Since 70% of fracture patients are reported to have insufficient serum vitamin D, we sought to determine if serum 25(OH)D levels are associated with differential changes in CTX and P1NP concentrations after hip fracture. This prospective cohort included hip fracture patients 65 years of age or older admitted to one of eight Baltimore-area hospitals. Serum samples were collected at baseline, 2-, 6-, and 12-month post-fracture. A mixed-effects repeated-measures analysis was used to determine the longitudinal association between vitamin D deficiency (25(OH)D < 20 ng/ml) and CTX and P1NP. Baseline lab values were obtained for 296 participants (mean age, 80.8 years; 51% male; 55% 25(OH)D < 20 ng/ml). During the acute fracture healing period P1NP concentrations increased by 14% (95%CI: 7-21%, p < 0.01) while CTX levels did not change (p = 0.07). Both CTX and P1NP decreased below baseline at 6 and 12 months. CTX levels were higher in participants with baseline 25(OH)D < 20 ng/ml (p = 0.01). There was no association between 25(OH)D < 20 ng/ml and P1NP levels over the study duration (p = 0.33). Data from this large, longitudinal cohort support claims that CTX and P1NP concentrations change during fracture healing; however, the differential response of CTX among vitamin D deficient patients highlights important questions for its utility as a reliable surrogate marker of fracture healing. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.
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Affiliation(s)
- Christopher C. Stewart
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 6th Floor, Suite 300, 110 S. Paca St., Baltimore 21201, Maryland,University of California, San Francisco School of Medicine, San Francisco, California
| | - Nathan N. O’Hara
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 6th Floor, Suite 300, 110 S. Paca St., Baltimore 21201, Maryland
| | - Denise Orwig
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Marc C. Hochberg
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sheila Sprague
- Department of Surgery, McMaster University, Hamilton, Ontario
| | - Jay Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Gerard P. Slobogean
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 6th Floor, Suite 300, 110 S. Paca St., Baltimore 21201, Maryland
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31
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McCoy TH, Fragomen AT, Hart KL, Pellegrini AM, Raskin KA, Perlis RH. Genomewide Association Study of Fracture Nonunion Using Electronic Health Records. JBMR Plus 2019; 3:23-28. [PMID: 30680360 DOI: 10.1002/jbm4.10063] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 05/14/2018] [Accepted: 05/23/2018] [Indexed: 01/13/2023] Open
Abstract
Nonunion is a clinically significant complication of fracture associated with worse outcomes, including increased pain, disability, and higher healthcare costs. The risk for nonunion is likely to be complex and multifactorial, and as such, the biology underlying such risk remains poorly understood. Genetic studies represent one approach to identify implicated biology for further investigation, but to date the lack of large cohorts for study has limited such efforts. We utilized the electronic health records of two large academic medical centers in Boston to identify individuals with fracture nonunion and control individuals with fracture but no evidence of nonunion. We conducted a genomewide association study among 1760 individuals of Northern European ancestry with upper or lower extremity fracture, including 131 with nonunion, to examine whether common variants were associated with nonunion in this cohort. In all, one locus in the Calcyon (CALY) gene exceeded a genomewide threshold for statistical significance (p = 1.95e-8), with eight additional loci associated with p < 5e-7. Previously reported candidate genes were not supported by this analysis. Electronic health records should facilitate identification of common genetic variations associated with adverse orthopedic outcomes. The loci we identified in this small cohort require replication and further study to characterize mechanism of action, but represent a starting point for the investigation of genetic liability for this costly outcome.
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Affiliation(s)
- Thomas H McCoy
- Center for Quantitative Health Massachusetts General Hospital and Harvard Medical School Boston MA USA
| | - Austin T Fragomen
- Limb Lengthening and Complex Reconstruction Service Hospital for Special Surgery and Weill Cornell Medical College New York NY USA
| | - Kamber L Hart
- Center for Quantitative Health Massachusetts General Hospital and Harvard Medical School Boston MA USA
| | - Amelia M Pellegrini
- Center for Quantitative Health Massachusetts General Hospital and Harvard Medical School Boston MA USA
| | - Kevin A Raskin
- Department of Orthopaedic Surgery Massachusetts General Hospital and Harvard Medical School Boston MA USA
| | - Roy H Perlis
- Center for Quantitative Health Massachusetts General Hospital and Harvard Medical School Boston MA USA
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32
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Abstract
This article examines new imaging, diagnostic, and assessment techniques that may affect the care of patients with orthopedic trauma and/or infection. Three-dimensional imaging has assisted in fracture assessment preoperatively, whereas improvement in C-arm technology has allowed real-time evaluation of implant placement and periarticular reduction before leaving the operating room. Advances in imaging techniques have allowed earlier and more accurate diagnosis of nonunion and infection. Innovations in bacteriologic testing have improved the sensitivity and specificity of perioperative and peri-implant infections. It is critical that surgeons remain up to date on the options available for optimal patient care.
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33
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Abstract
BACKGROUND In contrast to other tissues, bone has the remarkable ability to heal without scarring. After union of the fracture, the remodeled bone ideally does not differ from the original bone, especially in terms of biomechanical properties. The healing of a fracture resembles the embryonic development of bone. Depending on the biomechanical properties of the fracture, bone heals directly or indirectly, which refers to the formation of cartilage as a step before new bone appears. Currently, treatment of the patient is often limited to anatomical reduction and optimization of the fracture environment with respect to biomechanics. PROSPECTS Future treatment strategies, however, could include systemic medication that could be especially beneficial for patients at risk of complications in fracture healing. The aim of this review is to provide an overview on the process of fracture healing and to depict possibilities for current and future treatment strategies.
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Affiliation(s)
- Valentin Rausch
- Chirurgische Universitätsklinik und Poliklinik, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Deutschland
| | - Dominik Seybold
- Chirurgische Universitätsklinik und Poliklinik, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Deutschland.
| | - Matthias Königshausen
- Chirurgische Universitätsklinik und Poliklinik, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Deutschland
| | - Manfred Köller
- Chirurgische Universitätsklinik und Poliklinik, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Deutschland
| | - Thomas A Schildhauer
- Chirurgische Universitätsklinik und Poliklinik, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Deutschland
| | - Jan Geßmann
- Chirurgische Universitätsklinik und Poliklinik, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Deutschland
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Abstract
OBJECTIVES To develop and validate an unbiased, accurate, convenient, and inexpensive means of determining when an osseous defect has healed and recovered sufficient strength to allow weight bearing. METHODS A novel image processing software algorithm was created to analyze the radiographic images and produce a metric designed to reflect the bone strength. We used a rat femoral segmental defect model that provides a range of healing responses from complete union to nonunion. Femora were examined by x-ray, micro-computed tomography and mechanical testing. Accurate simulated radiographic images at different incident x-ray beam angles were produced from the micro-computed tomography data files. RESULTS The software-generated metric (SC) showed high levels of correlation with both the mechanical strength (τMech) and the polar moment of inertia (pMOI), with the mechanical testing data having the highest association. The optimization analysis yielded optimal oblique angles θB of 125 degrees for τMech and 50 degrees for pMOI. The Pearson R values for the optimized model were 0.71 and 0.64 for τMech and pMOI, respectively. Further validation using true radiographs also demonstrated that the metric was accurate and that the simulations were realistic. CONCLUSIONS The preliminary findings suggest a very promising methodology to assess bone fracture healing using conventional radiography. With radiographs acquired at appropriate incident angles, it proved possible to accurately calculate the degree of healing and the mechanical strength of the bone. Further research is necessary to refine this approach and determine whether it translates to the human clinical setting.
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Hasan A, Byambaa B, Morshed M, Cheikh MI, Shakoor RA, Mustafy T, Marei HE. Advances in osteobiologic materials for bone substitutes. J Tissue Eng Regen Med 2018; 12:1448-1468. [DOI: 10.1002/term.2677] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 02/04/2018] [Accepted: 04/12/2018] [Indexed: 01/03/2023]
Affiliation(s)
- Anwarul Hasan
- Department of Mechanical and Industrial Engineering, College of Engineering; Qatar University; Doha Qatar
| | - Batzaya Byambaa
- Center for Biomedical Engineering, Department of Medicine; Brigham and Women's Hospital, Harvard Medical School; Cambridge MA USA
- Harvard-MIT Division of Health Sciences and Technology; Massachusetts Institute of Technology; Cambridge MA USA
| | - Mahboob Morshed
- School of Life Sciences; Independent University, Bangladesh (IUB); Dhaka Bangladesh
| | - Mohammad Ibrahim Cheikh
- Department of Mechanical Engineering, Faculty of Engineering and Architecture; American University of Beirut; Beirut Lebanon
| | | | - Tanvir Mustafy
- Department of Mechanical Engineering; Ecole Polytechnique de Montreal; Quebec Canada
| | - Hany E. Marei
- Biomedical Research Center; Qatar University; Doha Qatar
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Hussein AI, Mancini C, Lybrand KE, Cooke ME, Matheny HE, Hogue BL, Tornetta P, Gerstenfeld LC. Serum proteomic assessment of the progression of fracture healing. J Orthop Res 2018; 36:1153-1163. [PMID: 28971515 PMCID: PMC5880751 DOI: 10.1002/jor.23754] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 09/27/2017] [Indexed: 02/04/2023]
Abstract
A targeted proteomic analysis of murine serum over a 35-day course of fracture healing was carried out to determine if serum proteomic changes could be used to monitor the biological progression of fracture healing. Transverse, closed femoral fractures where generated and stabilized with intramedullary fixation. A single stranded DNA aptamer-based multiplexed proteomic approach was used to assay 1,310 proteins. The transcriptomic profiles for genes matching the 1,310 proteins were obtained by microarray analysis of callus mRNA. Of the 1,310 proteins analyzed, 850 proteins showed significant differences among the time points (p-value <0.05). Ontology assessment associated these proteins with osteoblasts, monocyte/macrophage lineages, mesenchymal stem cell lines, hepatic tissues, and lymphocytes. Temporal clustering of these data identified proteins associated with inflammation, cartilage formation and bone remodeling stages of healing. VEGF, Wnt, and TGF-βsignaling pathways were restricted to the period of cartilage formation. Comparison of the proteomic and transcriptomic profiles showed that 87.5% of proteins in serum had concordant expression to their mRNA expression in the callus, while 12.5% of the protein and mRNA expression patterns were discordant. The discordant proteins that were elevated in the serum but down regulated in callus mRNA expression were related to clotting functions, allograft rejection, and complement function. While proteins down regulated in the serum and elevated in callus mRNA were associated with osteoblast function, NF-ĸb, and activin signaling. These data show the serum proteome may be used to monitor the different biological stages of fracture healing and have translational potential in assessing human fracture healing. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1153-1163, 2018.
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Affiliation(s)
- Amira I. Hussein
- Department of Orthopaedic Surgery; Boston University; 715 Albany Street, E 243 Boston 02118 Massachusetts
| | - Christian Mancini
- Department of Orthopaedic Surgery; Boston University; 715 Albany Street, E 243 Boston 02118 Massachusetts
| | - Kyle E. Lybrand
- Department of Orthopaedic Surgery; Boston University; 715 Albany Street, E 243 Boston 02118 Massachusetts
| | - Margaret E. Cooke
- Department of Orthopaedic Surgery; Boston University; 715 Albany Street, E 243 Boston 02118 Massachusetts
| | - Heather E. Matheny
- Department of Orthopaedic Surgery; Boston University; 715 Albany Street, E 243 Boston 02118 Massachusetts
| | - Brenna L. Hogue
- Department of Orthopaedic Surgery; Boston University; 715 Albany Street, E 243 Boston 02118 Massachusetts
| | - Paul Tornetta
- Department of Orthopaedic Surgery; Boston University; 715 Albany Street, E 243 Boston 02118 Massachusetts
| | - Louis C. Gerstenfeld
- Department of Orthopaedic Surgery; Boston University; 715 Albany Street, E 243 Boston 02118 Massachusetts
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Wang Y, Newman MR, Benoit DSW. Development of controlled drug delivery systems for bone fracture-targeted therapeutic delivery: A review. Eur J Pharm Biopharm 2018; 127:223-236. [PMID: 29471078 DOI: 10.1016/j.ejpb.2018.02.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 02/17/2018] [Accepted: 02/17/2018] [Indexed: 01/09/2023]
Abstract
Impaired fracture healing is a major clinical problem that can lead to patient disability, prolonged hospitalization, and significant financial burden. Although the majority of fractures heal using standard clinical practices, approximately 10% suffer from delayed unions or non-unions. A wide range of factors contribute to the risk for nonunions including internal factors, such as patient age, gender, and comorbidities, and external factors, such as the location and extent of injury. Current clinical approaches to treat nonunions include bone grafts and low-intensity pulsed ultrasound (LIPUS), which realizes clinical success only to select patients due to limitations including donor morbidities (grafts) and necessity of fracture reduction (LIPUS), respectively. To date, therapeutic approaches for bone regeneration rely heavily on protein-based growth factors such as INFUSE, an FDA-approved scaffold for delivery of bone morphogenetic protein 2 (BMP-2). Small molecule modulators and RNAi therapeutics are under development to circumvent challenges associated with traditional growth factors. While preclinical studies has shown promise, drug delivery has become a major hurdle stalling clinical translation. Therefore, this review overviews current therapies employed to stimulate fracture healing pre-clinically and clinically, including a focus on drug delivery systems for growth factors, parathyroid hormone (PTH), small molecules, and RNAi therapeutics, as well as recent advances and future promise of fracture-targeted drug delivery.
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Affiliation(s)
- Yuchen Wang
- Department of Biomedical Engineering, 308 Robert B. Goergen Hall, University of Rochester, Rochester, NY 14627, USA; Center for Musculoskeletal Research, 601 Elmwood Ave, University of Rochester Medical Center, Rochester, NY 14642, USA.
| | - Maureen R Newman
- Department of Biomedical Engineering, 308 Robert B. Goergen Hall, University of Rochester, Rochester, NY 14627, USA; Center for Musculoskeletal Research, 601 Elmwood Ave, University of Rochester Medical Center, Rochester, NY 14642, USA.
| | - Danielle S W Benoit
- Department of Biomedical Engineering, 308 Robert B. Goergen Hall, University of Rochester, Rochester, NY 14627, USA; Center for Musculoskeletal Research, 601 Elmwood Ave, University of Rochester Medical Center, Rochester, NY 14642, USA; Department of Chemical Engineering, 4517 Wegmans Hall, University of Rochester, Rochester, NY 14627, USA; Department of Orthopaedics, 601 Elmwood Ave, University of Rochester, Rochester, NY 14642, USA; Department of Biomedical Genetics, 601 Elmwood Ave, University of Rochester, Rochester, NY 14642, USA; Center for Oral Biology, 601 Elmwood Ave, University of Rochester Medical Center, Rochester, NY 14642, USA.
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Abstract
Current methods for diagnosis of bone healing after treatment of trauma injuries rely on clinical findings and the use of imaging methodologies that provide conclusive results but only at mid/long-term post-intervention. In this Perspective we present and discuss incipient evidence on biomarkers that may serve for monitoring the progression of bone healing as well as predicting eventual nonunion outcomes.
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Affiliation(s)
- Daniel Chaverri
- Hospital ASEPEYO Sant Cugat, Avinguda Alcalde Barnils, 54-60, Sant Cugat del Vallès, 08174 Barcelona, Spain
| | - Joaquim Vives
- Servei de Teràpia Cel·lular, Banc de Sang i Teixits, Edifici Dr. Frederic Duran i Jordà, Passeig Taulat, 116, 08005 Barcelona, Spain.,Departament de Medicina, Universitat Autònoma de Barcelona, Passeig de la Vall d'Hebron 129-139, 08035 Barcelona, Spain.,Musculoskeletal Tissue Engineering Group, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Passeig de la Vall d'Hebron 129-139, 08035 Barcelona, Spain
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Walters G, Pountos I, Giannoudis PV. The cytokines and micro-environment of fracture haematoma: Current evidence. J Tissue Eng Regen Med 2017; 12:e1662-e1677. [PMID: 29047220 DOI: 10.1002/term.2593] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 08/31/2017] [Accepted: 10/09/2017] [Indexed: 12/18/2022]
Abstract
Fracture haematoma formation is the first and foremost important stage of fracture healing. It orchestrates the inflammatory and cellular processes leading to the formation of callus and the restoration of the continuity of the bone. Evidence suggests that blocking this initial stage could lead to an impairment of the overall bone healing process. This review aims to analyse the existing evidence of molecular contributions to bone healing within fracture haematoma and to determine the potential to modify the molecular response to fracture in the haematoma with the aim of improving union times. A comprehensive search of literature documenting fracture haematoma cytokine content was performed. Suitable papers according to prespecified criteria were identified and analysed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A total of 89 manuscripts formed the basis of this analysis. Low oxygen tension, high acidity, and high calcium characterised initially the fracture haematoma micro-environment. In addition, a number of cytokines have been measured with concentrations significantly higher than those found in peripheral circulation. Growth factors have also been isolated, with an observed increase in bone morphogenetic proteins, platelet-derived growth factor, and transforming growth factor. Although molecular modification of fracture haematoma has been attempted, more research is required to determine a suitable biological response modifier leading to therapeutic effects. The cytokine content of fracture haematoma gives insight into processes occurring in the initial stages of fracture healing. Manipulation of signalling molecules represents a promising pathway to target future therapies aiming to upregulate the osteogenesis.
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Affiliation(s)
- Gavin Walters
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK
| | - Ippokratis Pountos
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK
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40
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Marcucio RS, Qin L, Alsberg E, Boerckel JD. Reverse engineering development: Crosstalk opportunities between developmental biology and tissue engineering. J Orthop Res 2017; 35:2356-2368. [PMID: 28660712 DOI: 10.1002/jor.23636] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 05/12/2017] [Indexed: 02/04/2023]
Abstract
The fields of developmental biology and tissue engineering have been revolutionized in recent years by technological advancements, expanded understanding, and biomaterials design, leading to the emerging paradigm of "developmental" or "biomimetic" tissue engineering. While developmental biology and tissue engineering have long overlapping histories, the fields have largely diverged in recent years at the same time that crosstalk opportunities for mutual benefit are more salient than ever. In this perspective article, we will use musculoskeletal development and tissue engineering as a platform on which to discuss these emerging crosstalk opportunities and will present our opinions on the bright future of these overlapping spheres of influence. The multicellular programs that control musculoskeletal development are rapidly becoming clarified, represented by shifting paradigms in our understanding of cellular function, identity, and lineage specification during development. Simultaneously, advancements in bioartificial matrices that replicate the biochemical, microstructural, and mechanical properties of developing tissues present new tools and approaches for recapitulating development in tissue engineering. Here, we introduce concepts and experimental approaches in musculoskeletal developmental biology and biomaterials design and discuss applications in tissue engineering as well as opportunities for tissue engineering approaches to inform our understanding of fundamental biology. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2356-2368, 2017.
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Affiliation(s)
- Ralph S Marcucio
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | - Ling Qin
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, 36th Street and Hamilton Walk, Philadelphia 19104-6081, Pennsylvania
| | - Eben Alsberg
- Departments of Biomedical Engineering and Orthopaedic Surgery, Case Western Reserve University, Cleveland, Ohio
| | - Joel D Boerckel
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, 36th Street and Hamilton Walk, Philadelphia 19104-6081, Pennsylvania.,Department of Bioengineering, University of Pennslyvania, Philadelphia, Pennsylvania.,Department of Aerospace and Mechanical Engineering, University of Notre Dame, Notre Dame, Indiana
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41
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Granchi D, Gómez-Barrena E, Rojewski M, Rosset P, Layrolle P, Spazzoli B, Donati DM, Ciapetti G. Changes of Bone Turnover Markers in Long Bone Nonunions Treated with a Regenerative Approach. Stem Cells Int 2017; 2017:3674045. [PMID: 28744314 DOI: 10.1155/2017/3674045] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 04/06/2017] [Accepted: 05/14/2017] [Indexed: 02/07/2023] Open
Abstract
In this clinical trial, we investigated if biochemical bone turnover markers (BTM) changed according to the progression of bone healing induced by autologous expanded MSC combined with a biphasic calcium phosphate in patients with delayed union or nonunion of long bone fractures. Bone formation markers, bone resorption markers, and osteoclast regulatory proteins were measured by enzymatic immunoassay before surgery and after 6, 12, and 24 weeks. A satisfactory bone healing was obtained in 23 out of 24 patients. Nine subjects reached a good consolidation already at 12 weeks, and they were considered as the “early consolidation” group. We found that bone-specific alkaline phosphatase (BAP), C-terminal propeptide of type I procollagen (PICP), and beta crosslaps collagen (CTX) changed after the regenerative treatment, BAP and CTX correlated to the imaging results collected at 12 and 24 weeks, and BAP variation along the healing course differed in patients who had an “early consolidation.” A remarkable decrease in BAP and PICP was observed at all time points in a single patient who experienced a treatment failure, but the predictive value of BTM changes cannot be determined. Our findings suggest that BTM are promising tools for monitoring cell therapy efficacy in bone nonunions, but studies with larger patient numbers are required to confirm these preliminary results.
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42
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Abstract
A fundamental issue in clinical orthopaedics is the determination of when a fracture is united. However, there are no established "gold standards," nor standardized methods for assessing union, which has resulted in significant disagreement among orthopaedic surgeons in both clinical practice and research. A great deal of investigative work has been directed to addressing this problem, with a number of exciting new techniques described. This review provides a brief summary of the burden of nonunion fractures and addresses some of the challenges related to the assessment of fracture healing. The tools currently available to determine union are discussed, including various imaging modalities, biomechanical testing methods, and laboratory and clinical assessments. The evaluation of fracture healing in the setting of both patient care and clinical research is integral to the orthopaedic practice. Weighted integration of several available metrics must be considered to create a composite outcome measure of patient prognosis.
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Affiliation(s)
| | | | - Saam Morshed
- Orthopaedic Trauma Institute San Francisco, CA, USA
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Krishnan L, Priddy LB, Esancy C, Klosterhoff BS, Stevens HY, Tran L, Guldberg RE. Delivery vehicle effects on bone regeneration and heterotopic ossification induced by high dose BMP-2. Acta Biomater 2017; 49:101-112. [PMID: 27940197 DOI: 10.1016/j.actbio.2016.12.012] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 11/10/2016] [Accepted: 12/06/2016] [Indexed: 11/15/2022]
Abstract
Bone morphogenetic protein-2 (BMP-2), delivered on absorbable collagen sponge, is frequently used to treat bone defects. However, supraphysiological BMP-2 doses are common and often associated with complications such as heterotopic ossification and inflammation, causing pain and impaired mobility. This has prompted investigations into strategies to spatially control bone regeneration, for example growth factor delivery in appropriate scaffolds. Our objective was to investigate the spatiotemporal effects of high dose BMP-2 on bone regeneration as a function of the delivery vehicle. We hypothesized that an alginate delivery system would spatially restrict bone formation compared to a collagen sponge delivery system. In vitro, BMP-2 release was accelerated from collagen sponge compared to alginate constructs. In vivo, bone regeneration was evaluated over 12weeks in critically sized rat femoral segmental defects treated with 30μg rhBMP-2 in alginate hydrogel or collagen sponge, surrounded by perforated nanofiber meshes. Total bone volume, calculated from micro-CT reconstructions, was higher in the alginate group at 12weeks. Though bone volume within the central defect region was greater in the alginate group at 8 and 12weeks, heterotopic bone volume was similar between groups. Likewise, mechanical properties from ex vivo torsional testing were comparable between groups. Histology corroborated these findings and revealed heterotopic mineralization at 2weeks post-surgery in both groups. Overall, this study recapitulated the heterotopic ossification associated with high dose BMP-2 delivery, and demonstrated that the amount and spatial pattern of bone formation was dependent on the delivery matrix. STATEMENT OF SIGNIFICANCE Alginate hydrogel-based BMP-2 delivery has induced better spatiotemporal bone regeneration in animals, compared to clinically used collagen sponge, at lower BMP-2 doses. Lack of clear dose-response relationships for BMP-2 vis-à-vis bone regeneration has contributed to the use of higher doses clinically. We investigated the potential of the alginate system, with comparatively favorable BMP-2 release-kinetics, to reduce heterotopic ossification and promote bone regeneration, when used with a high BMP-2 dose. While defect mineralization improved with alginate hydrogel, the initial high-release phase and likely early tissue exposure to BMP-2 appeared sufficient to induce heterotopic ossification. The characterization presented here should provide the framework for future evaluations of strategies to optimize bone formation and minimize adverse effects of high dose BMP-2 therapy.
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Affiliation(s)
- Laxminarayanan Krishnan
- Parker H. Petit Institute for Bioengineering & Bioscience, Georgia Institute of Technology, 315 Ferst Drive NW, Atlanta, GA 30332, USA
| | - Lauren B Priddy
- Parker H. Petit Institute for Bioengineering & Bioscience, Georgia Institute of Technology, 315 Ferst Drive NW, Atlanta, GA 30332, USA; Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, 313 Ferst Drive NW, Atlanta, GA 30332, USA
| | - Camden Esancy
- Parker H. Petit Institute for Bioengineering & Bioscience, Georgia Institute of Technology, 315 Ferst Drive NW, Atlanta, GA 30332, USA
| | - Brett S Klosterhoff
- Parker H. Petit Institute for Bioengineering & Bioscience, Georgia Institute of Technology, 315 Ferst Drive NW, Atlanta, GA 30332, USA; George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, 801 Ferst Drive NW, Atlanta, GA 30332, USA
| | - Hazel Y Stevens
- George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, 801 Ferst Drive NW, Atlanta, GA 30332, USA
| | - Lisa Tran
- Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Robert E Guldberg
- Parker H. Petit Institute for Bioengineering & Bioscience, Georgia Institute of Technology, 315 Ferst Drive NW, Atlanta, GA 30332, USA; George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, 801 Ferst Drive NW, Atlanta, GA 30332, USA.
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Abstract
Delayed healing and nonunion of fractures represent enormous burdens to patients and healthcare systems. There are currently no approved pharmacological agents for the treatment of established nonunions, or for the acceleration of fracture healing, and no pharmacological agents are approved for promoting the healing of closed fractures. Yet several pharmacologic agents have the potential to enhance some aspects of fracture healing. In preclinical studies, various agents working across a broad spectrum of molecular pathways can produce larger, denser and stronger fracture calluses. However, untreated control animals in most of these studies also demonstrate robust structural and biomechanical healing, leaving unclear how these interventions might alter the healing of recalcitrant fractures in humans. This review describes the physiology of fracture healing, with a focus on aspects of natural repair that may be pharmacologically augmented to prevent or treat delayed or nonunion fractures (collectively referred to as DNFs). The agents covered in this review include recombinant BMPs, PTH/PTHrP receptor agonists, activators of Wnt/β-catenin signaling, and recombinant FGF-2. Agents from these therapeutic classes have undergone extensive preclinical testing and progressed to clinical fracture healing trials. Each can promote bone formation, which is important for the stability of bridged calluses, and some but not all can also promote cartilage formation, which may be critical for the initial bridging and subsequent stabilization of fractures. Appropriately timed stimulation of chondrogenesis and osteogenesis in the fracture callus may be a more effective approach for preventing or treating DNFs compared with stimulation of osteogenesis alone. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:213-223, 2017.
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Affiliation(s)
- Paul Kostenuik
- School of DentistryUniversity of MichiganPhylon Pharma ServicesNewbury ParkCalifornia
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Kasnavieh SMH, Sadeghi SMH, Khameneh SMH, Khodadoost M, Bazrafshan A, Kamalinejad M, Jaladat AM, Jafari S, Yasinzadeh MR, Gachkar L. Dietary Recommendations in Fracture Healing in Traditional Persian Medicine: A Historical Review of Literature. J Evid Based Complementary Altern Med 2017; 22:513-517. [PMID: 30208734 PMCID: PMC5871169 DOI: 10.1177/2156587216685509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Fracture repair is a complex process. An inappropriate diet is a contributing risk factor for fracture nonunion. The aim of this study was to extract dietary recommendations for fracture healing according to traditional Persian medicine (TPM) literature. METHOD The contents relevant to diets in fracture healing were selected from main textbooks in TPM like Al Qanon fi Al-teb ( The Canon). Other reference textbooks in traditional medicine were also used for a comprehensive study in this respect. Finally content analysis was used for summarizing and describing the results. FINDINGS Food stuffs are classified in TPM according to their nutritive value, their assimilability, and the quality of achieved chyme. Some light meals like chicken soup are recommended for the early days of fracture and high-nutrient and dense foods such as goat's or sheep's head and nuts are advised in following days for fracture healing acceleration and callus formation. Several recommendations are also provided for pacing the healing process. CONCLUSION A comparison of Avicenna and other Persian sage's recommended regimens with the recent evidence revealed the potential positive effects of their regimen for bone healing acceleration. It can shed light on a part of history of orthopedics and add to current knowledge about bone fracture and its management.
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Affiliation(s)
| | | | | | | | | | | | | | - Shirin Jafari
- 2 Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Latif Gachkar
- 2 Shahid Beheshti University of Medical Sciences, Tehran, Iran
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46
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Abstract
OBJECTIVES The purpose was to evaluate economic benefit of calcium and vitamin D supplementation in orthopaedic trauma patients. We hypothesized that reduced nonunion rates could justify the cost of supplementing every orthopaedic trauma patient. DESIGN Retrospective, economic model. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Adult patients over 3 consecutive years presenting with acute fracture. INTERVENTION Operative or nonoperative fracture management. MAIN OUTCOME MEASUREMENTS Electronic medical records were queried for ICD-9 code for diagnosis of nonunion and for treatment records of nonunion for fractures initially treated within our institution. RESULTS In our hospital, a mean of 92 (3.9%) fractures develop nonunion annually. A 5% reduction in nonunion risk from 8 weeks of vitamin D supplementation would result in 4.6 fewer nonunions per year. The mean estimate of cost for nonunion care is $16,941. Thus, the projected reduction in nonunions after supplementation with vitamin D and calcium would save $78,030 in treatment costs per year. The resulting savings outweigh the $12,164 cost of supplementing all fracture patients during the first 8 weeks of fracture healing resulting in a net savings of $65,866 per year. CONCLUSIONS Vitamin D and calcium supplementation of orthopaedic trauma patients for 8 weeks after fracture seems to be cost effective. Supplementation may also reduce the number of subsequent fractures, enhance muscular strength, improve balance in the elderly, elevate mood leading to higher functional outcome scores, and diminish hospital tort liability by reducing the number of nonunions. LEVEL OF EVIDENCE Economic Level V. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Benjamin R Childs
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, OH, affiliated with Case Western Reserve University
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47
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Abstract
Osteoimmunology research is a new emerging research field that investigates the links between the bone and immune responses. Results from osteoimmunology studies suggest that bone is not only an essential component of the musculoskeletal system, but is also actively involved in immune regulation. Many important factors involved in immune regulation also participate in bone homeostasis. Bone homeostasis is achieved by a coordinated action between bone-synthesizing osteoblasts and bone-degrading osteoclasts. An imbalanced action between osteoblasts and osteoclasts often results in pathological bone diseases: osteoporosis is caused by an excessive osteoclast activity, whereas osteopetrosis results from an increased osteoblast activity. This review focuses on dendritic cell-specific transmembrane protein (DC-STAMP), an important protein currently considered as a master regulator of osteoclastogenesis. Of clinical relevance, the frequency of circulating DC-STAMP+ cells is elevated during the pathogenesis of psoriatic diseases. Intriguingly, recent results suggest that DC-STAMP also plays an imperative role in bone homeostasis by regulating the differentiation of both osteoclasts and osteoblasts. This article summarizes our current knowledge on DC-STAMP by focusing on its interacting proteins, its regulation on osteoclastogenesis-related genes, its possible involvement in immunoreceptor tyrosine-based inhibitory motif (ITIM)-mediated signaling cascade, and its potential of developing therapeutics for clinical applications. J. Cell. Physiol. 231: 2402-2407, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ya-Hui Chiu
- Division of Allergy, Immunology and Rheumatology, School of Medicine, University of Rochester, Rochester, New York
| | - Christopher T Ritchlin
- Division of Allergy, Immunology and Rheumatology, School of Medicine, University of Rochester, Rochester, New York
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48
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49
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Abstract
Large bone defects caused by fracture, non-union and bone tumor excision has been a major clinical problem. Autogenous bone grafting and Ilizarov method are commonly performed to treat them. However, bone grafting has limitation in volume of available bone, and Ilizarov method requires long periods of time to treat. Accordingly, there is need for stem cell therapy for bone repair and/or regeneration. Mesenchymal stem cells (MSCs) hold the ability to differentiate into osteoblasts and are available from a wide variety of sources. The route of "intramembranous ossification (direct bone formation)" by transplantation of undifferentiated MSCs has been tested but it did not demonstrate the success initially envisaged. Recently another approach has been examined being the transplantation of "MSCs pre-differentiated in vitro into cartilage-forming chondrocytes" into bone defect, in brief, representing the route of "endochondral ossification (indirect bone formation)". It's a paradigm shift of Stem Cell Therapy for bone regeneration. We have already reported on the healing of large femur defects in rats by transplantation of "MSCs pre-differentiated in vitro into cartilage-forming chondrocytes". We named the cells as Mesenchymal Stem Cell-Derived Chondrocytes (MSC-DCs). The success of reconstruction of a massive 15-mm femur defect (approximately 50% of the rat femur shaft length) provides a sound foundation for potential clinical application of this technique. We believe our results may offer a new avenue of reconstruction of large bone defect, especially in view of the their high reproducibility and the excellent biomechanical strength of repaired femora.
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50
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Abstract
Non-union continues to be the most devastating complication after fracture fixation. Its treatment can be prolonged and often unpredictable. The burden to the patient, surgeon and health care system can be immense. Strategies to prevent it and or identify early its development are desirable in order to improve the clinical course of the affected patients and their outcomes. We undertook a systematic review of the literature in order to identify the most common and important risk factors based on the hierarchy of level of evidence. Accordingly, a stratification scale was formed which highlighted 10 risk factors including; an open method of fracture reduction, open fracture, presence of post-surgical fracture gap, smoking, infection, wedge or comminuted types of fracture, high degree of initial fracture displacement, lack of adequate mechanical stability provided by the implant used, fracture location in the poor zone of vascularity of the affected bone, and the presence of the fracture in the tibia. Clinicians should take in to account these findings when managing patients with long bone fractures, particularly the femur and tibia in order to minimise the risk of non-union.
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Affiliation(s)
- Emmanuele Santolini
- Academic Department of Trauma and Orthopaedics, Floor A, Clarendon Wing, LGI, University of Leeds, Leeds, UK; Clinica Orthopedica, University of Genoa, IRCCS A.O.U. San Martino - IST, Largo R. Benzi 10 - 16132, Genova, Italy
| | - Robert West
- Academic Department of Statistics, University of Leeds, Leeds, UK
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, Floor A, Clarendon Wing, LGI, University of Leeds, Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK.
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