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Tian X, Vater C, Raina DB, Findeisen L, Matuszewski LM, Tägil M, Lidgren L, Winkler A, Gottwald R, Modler N, Schaser KD, Disch AC, Zwingenberger S. Co-delivery of rhBMP-2 and zoledronic acid using calcium sulfate/hydroxyapatite carrier as a bioactive bone substitute to enhance and accelerate spinal fusion. Bioact Mater 2024; 36:256-271. [PMID: 38487704 PMCID: PMC10937206 DOI: 10.1016/j.bioactmat.2024.02.034] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/27/2024] [Accepted: 02/27/2024] [Indexed: 03/17/2024] Open
Abstract
Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been FDA-approved for lumbar fusion, but supraphysiologic initial burst release due to suboptimal carrier and late excess bone resorption caused by osteoclast activation have limited its clinical usage. One strategy to mitigate the pro-osteoclast side effect of rhBMP-2 is to give systemic bisphosphonates, but it presents challenges with systemic side effects and low local bioavailability. The aim of this in vivo study was to analyze if posterolateral spinal fusion (PLF) could be improved by utilizing a calcium sulfate/hydroxyapatite (CaS/HA) carrier co-delivering rhBMP-2 and zoledronic acid (ZA). Six groups were allocated (CaS/HA, CaS/HA + BMP-2, CaS/HA + systemic ZA, CaS/HA + local ZA, CaS/HA + BMP-2 + systemic ZA, and CaS/HA + BMP-2 + local ZA). 10-week-old male Wistar rats, were randomly assigned to undergo L4-L5 PLF with implantation of group-dependent scaffolds. At 3 and 6 weeks, the animals were euthanized for radiography, μCT, histological staining, or biomechanical testing to evaluate spinal fusion. The results demonstrated that the CaS/HA biomaterial alone or in combination with local or systemic ZA didn't support PLF. However, the delivery of rhBMP-2 significantly promoted PLF. Combining systemic ZA with BMP-2 didn't enhance spinal fusion. Notably, the co-delivery of rhBMP-2 and ZA using the CaS/HA carrier significantly enhanced and accelerated PLF, without inhibiting systemic bone turnover, and potentially reduced the dose of rhBMP-2. Together, the treatment regimen of CaS/HA biomaterial co-delivering rhBMP-2 and ZA could potentially be a safe and cost-effective off-the-shelf bioactive bone substitute to enhance spinal fusion.
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Affiliation(s)
- Xinggui Tian
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TUD Dresden University of Technology, 01307, Dresden, Germany
- Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus at TUD Dresden University of Technology, 01307, Dresden, Germany
| | - Corina Vater
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TUD Dresden University of Technology, 01307, Dresden, Germany
- Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus at TUD Dresden University of Technology, 01307, Dresden, Germany
| | - Deepak Bushan Raina
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lund, 22185, Sweden
| | - Lisa Findeisen
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TUD Dresden University of Technology, 01307, Dresden, Germany
- Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus at TUD Dresden University of Technology, 01307, Dresden, Germany
| | - Lucas-Maximilian Matuszewski
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TUD Dresden University of Technology, 01307, Dresden, Germany
- Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus at TUD Dresden University of Technology, 01307, Dresden, Germany
| | - Magnus Tägil
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lund, 22185, Sweden
| | - Lars Lidgren
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lund, 22185, Sweden
| | - Anja Winkler
- Institute of Lightweight Engineering and Polymer Technology at TUD Dresden University of Technology, 01062, Dresden, Germany
| | - Robert Gottwald
- Institute of Lightweight Engineering and Polymer Technology at TUD Dresden University of Technology, 01062, Dresden, Germany
| | - Niels Modler
- Institute of Lightweight Engineering and Polymer Technology at TUD Dresden University of Technology, 01062, Dresden, Germany
| | - Klaus-Dieter Schaser
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TUD Dresden University of Technology, 01307, Dresden, Germany
| | - Alexander C. Disch
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TUD Dresden University of Technology, 01307, Dresden, Germany
| | - Stefan Zwingenberger
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TUD Dresden University of Technology, 01307, Dresden, Germany
- Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus at TUD Dresden University of Technology, 01307, Dresden, Germany
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Markeviciute V, Puthia M, Arvidsson L, Liu Y, Törnquist E, Tengattini A, Huang J, Bai Y, Vater C, Petrolis R, Zwingenberger S, Krisciukaitis A, Smailys A, Lukosevicius S, Stravinskas M, Isaksson H, Tarasevicius S, Lidgren L, Tägil M, Raina DB. Systemically administered zoledronic acid activates locally implanted synthetic hydroxyapatite particles enhancing peri-implant bone formation: A regenerative medicine approach to improve fracture fixation. Acta Biomater 2024:S1742-7061(24)00124-7. [PMID: 38490481 DOI: 10.1016/j.actbio.2024.03.005] [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: 11/07/2023] [Revised: 02/11/2024] [Accepted: 03/07/2024] [Indexed: 03/17/2024]
Abstract
Fracture fixation in an ageing population is challenging and fixation failure increases mortality and societal costs. We report a novel fracture fixation treatment by applying a hydroxyapatite (HA) based biomaterial at the bone-implant interface and biologically activating the biomaterial by systemic administration of a bisphosphonate (zoledronic acid, ZA). We first used an animal model of implant integration and applied a calcium sulphate (CaS)/HA biomaterial around a metallic screw in the tibia of osteoporotic rats. Using systemic ZA administration at 2-weeks post-surgery, we demonstrated that the implant surrounded by HA particles showed significantly higher peri‑implant bone formation compared to the unaugmented implants at 6-weeks. We then evaluated the optimal timing (day 1, 3, 7 and 14) of ZA administration to achieve a robust effect on peri‑implant bone formation. Using fluorescent ZA, we demonstrated that the uptake of ZA in the CaS/HA material was the highest at 3- and 7-days post-implantation and the uptake kinetics had a profound effect on the eventual peri‑implant bone formation. We furthered our concept in a feasibility study on trochanteric fracture patients randomized to either CaS/HA augmentation or no augmentation followed by systemic ZA treatment. Radiographically, the CaS/HA group showed signs of increased peri‑implant bone formation compared with the controls. Finally, apart from HA, we demonstrated that the concept of biologically activating a ceramic material by ZA could also be applied to β-tricalcium phosphate. This novel approach for fracture treatment that enhances immediate and long-term fracture fixation in osteoporotic bone could potentially reduce reoperations, morbidity and mortality. STATEMENT OF SIGNIFICANCE: • Fracture fixation in an ageing population is challenging. Biomaterial-based augmentation of fracture fixation devices has been attempted but lack of satisfactory biological response limits their widespread use. • We report the biological activation of locally implanted microparticulate hydroxyapatite (HA) particles placed around an implant by systemic administration of the bisphosphonate zoledronic acid (ZA). The biological activation of HA by ZA enhances peri‑implant bone formation. •Timing of ZA administration after HA implantation is critical for optimal ZA uptake and consequently determines the extent of peri‑implant bone formation. • We translate the developed concept from small animal models of implant integration to a proof-of-concept clinical study on osteoporotic trochanteric fracture patients. • ZA based biological activation can also be applied to other calcium phosphate biomaterials.
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Affiliation(s)
- Vetra Markeviciute
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania; The Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
| | - Manoj Puthia
- The Faculty of Medicine, Division of Dermatology and Venerology, Lund University, 221 84 Lund, Sweden
| | - Linnea Arvidsson
- The Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
| | - Yang Liu
- The Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden; Department of Orthopedic Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine (SAHZU), Hangzhou, Zhejiang, China
| | - Elin Törnquist
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | | | - Jintian Huang
- The Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
| | - Yiguang Bai
- The Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden; Cell, Tissue & Organ engineering laboratory, Department of Clinical Sciences Lund, Stem Cell Centre, Lund University, Lund, Sweden; Department of Orthopaedics, Nanchong Central Hospital, The Second Clinical Institute of North Sichuan Medical College Nanchong, Sichuan, China
| | - Corina Vater
- University Hospital Carl Gustav Carus at Technische Universität Dresden, University Center of Orthopedics, Trauma and Plastic Surgery, 01307 Dresden, Germany
| | - Robertas Petrolis
- Department of Physics, Mathematics and Biophysics, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Stefan Zwingenberger
- University Hospital Carl Gustav Carus at Technische Universität Dresden, University Center of Orthopedics, Trauma and Plastic Surgery, 01307 Dresden, Germany
| | - Algimantas Krisciukaitis
- Department of Physics, Mathematics and Biophysics, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Alfredas Smailys
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Saulius Lukosevicius
- Department of Radiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Mindaugas Stravinskas
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Hanna Isaksson
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | - Sarunas Tarasevicius
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Lars Lidgren
- The Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
| | - Magnus Tägil
- The Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
| | - Deepak Bushan Raina
- The Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden.
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Sebastian S, Huang J, Liu Y, Collin M, Tägil M, Raina D, Lidgren L. Systemic rifampicin shows accretion to locally implanted hydroxyapatite particles in a rat abdominal muscle pouch model. J Bone Jt Infect 2023; 8:19-28. [PMID: 36687463 PMCID: PMC9850244 DOI: 10.5194/jbji-8-19-2023] [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] [Received: 10/05/2022] [Accepted: 12/06/2022] [Indexed: 01/11/2023] Open
Abstract
Introduction: biomaterials combined with antibiotics are routinely used for the management of bone infections. After eluting high concentrations of antibiotics during the first week, sub-inhibitory concentrations of antibiotics may lead to late repopulation of recalcitrant bacteria. Recent studies have shown that systemically given antibiotics like tetracycline and rifampicin (RIF) could seek and bind to locally implanted hydroxyapatite (HA). The aim of this in vivo study was to test if systemically administered rifampicin could replenish HA-based biomaterials with or without prior antibiotic loading to protect the material from late bacterial repopulation. Methods: in vivo accretion of systemically administered RIF to three different types of HA-based materials was tested. In group 1, nano (n)- and micro (m)-sized HA particles were used, while group 2 consisted of a calcium sulfate / hydroxyapatite (CaS / HA) biomaterial without preloaded antibiotics gentamycin (GEN) or vancomycin (VAN), and in group 3, the CaS / HA material contained GEN (CaS / HA + GEN) or VAN (CaS / HA + VAN). The above materials were implanted in an abdominal muscle pouch model in rats, and at 7 d post-surgery, the animals were assigned to a control group (i.e., no systemic antibiotic) and a test group (i.e., animals receiving one single intraperitoneal injection of RIF each day (4 mg per rat) for 3 consecutive days). Twenty-four hours after the third injection, the animals were sacrificed and the implanted pellets were retrieved and tested against Staphylococcus aureus ATCC 25923 in an agar diffusion assay. After overnight incubation, the zone of inhibition (ZOI) around the pellets were measured. Results: in the control group, 2 / 6 CaS / HA + GEN pellets had a ZOI, while all other harvested pellets had no ZOI. No pellets from animals in test group 1 had a ZOI. In test group 2, 10 / 10 CaS / HA pellets showed a ZOI. In test group 3, 5 / 6 CaS / HA + GEN and 4 / 6 CaS / HA + VAN pellets showed a ZOI. Conclusions: in this proof-of-concept study, we have shown that a locally implanted biphasic CaS / HA carrier after 1 week can be loaded by systemic RIF administration and exert an antibacterial effect. Further in vivo infection models are necessary to validate our findings.
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Affiliation(s)
- Sujeesh Sebastian
- Department of Clinical Sciences,
Orthopaedics, Faculty of Medicine, Lund University, Lund, Sweden
| | - Jintian Huang
- Department of Clinical Sciences,
Orthopaedics, Faculty of Medicine, Lund University, Lund, Sweden
| | - Yang Liu
- Department of Clinical Sciences,
Orthopaedics, Faculty of Medicine, Lund University, Lund, Sweden
| | - Mattias Collin
- Department of Clinical Sciences, Division of Infection Medicine, Lund
University, Lund, Sweden
| | - Magnus Tägil
- Department of Clinical Sciences,
Orthopaedics, Faculty of Medicine, Lund University, Lund, Sweden
| | - Deepak Bushan Raina
- Department of Clinical Sciences,
Orthopaedics, Faculty of Medicine, Lund University, Lund, Sweden
| | - Lars Lidgren
- Department of Clinical Sciences,
Orthopaedics, Faculty of Medicine, Lund University, Lund, Sweden
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Liu Y, Sebastian S, Huang J, Corbascio T, Engellau J, Lidgren L, Tägil M, Raina DB. Longitudinal in vivo biodistribution of nano and micro sized hydroxyapatite particles implanted in a bone defect. Front Bioeng Biotechnol 2022; 10:1076320. [PMID: 36601389 PMCID: PMC9806272 DOI: 10.3389/fbioe.2022.1076320] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
Hydroxyapatite (HA) has been widely used as a bone substitute and more recently as a carrier for local delivery of bone targeted drugs. Majority of the approved HA based biomaterials and drug carriers comprise of micrometer sized particulate HA (mHA) or granules and can therefore only be used for extracellular drug release. This shortcoming could be overcome with the use of cell penetrating HA nanoparticles (nHA) but a major concern with the clinical use of nHA is the lack of data on its in vivo biodistribution after implantation. In this study, we aimed to study the in vivo biodistribution of locally implanted nHA in a clinically relevant tibial void in rats and compare it with mHA or a combination of mHA and nHA. To enable in vivo tracking, HA particles were first labelled with 14C-zoledronic acid (14C-ZA), known to have a high binding affinity to HA. The labelled particles were then implanted in the animals and the radioactivity in the proximal tibia and vital organs was detected at various time points (Day 1, 7 and 28) post-implantation using scintillation counting. The local distribution of the particles in the bone was studied with micro-CT. We found that majority (>99.9%) of the implanted HA particles, irrespective of the size, stayed locally at the implantation site even after 28 days and the findings were confirmed using micro-CT. Less than 0.1% radioactivity was observed in the kidney and the spleen at later time points of day 7 and 28. No pathological changes in any of the vital organs could be observed histologically. This is the first longitudinal in vivo HA biodistribution study showing that the local implantation of nHA particles in bone is safe and that nHA could potentially be used for localized drug delivery.
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Affiliation(s)
- Yang Liu
- Department of Clinical Sciences Lund, Orthopedics, The Faculty of Medicine, Lund University, Lund, Sweden,*Correspondence: Yang Liu, ; Deepak Bushan Raina,
| | - Sujeesh Sebastian
- Department of Clinical Sciences Lund, Orthopedics, The Faculty of Medicine, Lund University, Lund, Sweden
| | - Jintian Huang
- Department of Clinical Sciences Lund, Orthopedics, The Faculty of Medicine, Lund University, Lund, Sweden
| | - Tova Corbascio
- Department of Clinical Sciences Lund, Orthopedics, The Faculty of Medicine, Lund University, Lund, Sweden
| | - Jacob Engellau
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Lars Lidgren
- Department of Clinical Sciences Lund, Orthopedics, The Faculty of Medicine, Lund University, Lund, Sweden
| | - Magnus Tägil
- Department of Clinical Sciences Lund, Orthopedics, The Faculty of Medicine, Lund University, Lund, Sweden
| | - Deepak Bushan Raina
- Department of Clinical Sciences Lund, Orthopedics, The Faculty of Medicine, Lund University, Lund, Sweden,*Correspondence: Yang Liu, ; Deepak Bushan Raina,
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Tian X, Raina DB, Vater C, Kilian D, Ahlfeld T, Platzek I, Nimtschke U, Tägil M, Lidgren L, Thomas A, Platz U, Schaser KD, Disch AC, Zwingenberger S. Evaluation of an Injectable Biphasic Calcium Sulfate/Hydroxyapatite Cement for the Augmentation of Fenestrated Pedicle Screws in Osteoporotic Vertebrae: A Biomechanical Cadaver Study. J Funct Biomater 2022; 13:jfb13040269. [PMID: 36547529 PMCID: PMC9786089 DOI: 10.3390/jfb13040269] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 11/17/2022] [Accepted: 11/23/2022] [Indexed: 12/05/2022] Open
Abstract
Cement augmentation of pedicle screws is one of the most promising approaches to enhance the anchoring of screws in the osteoporotic spine. To date, there is no ideal cement for pedicle screw augmentation. The purpose of this study was to investigate whether an injectable, bioactive, and degradable calcium sulfate/hydroxyapatite (CaS/HA) cement could increase the maximum pull-out force of pedicle screws in osteoporotic vertebrae. Herein, 17 osteoporotic thoracic and lumbar vertebrae were obtained from a single fresh-frozen human cadaver and instrumented with fenestrated pedicle screws. The right screw in each vertebra was augmented with CaS/HA cement and the un-augmented left side served as a paired control. The cement distribution, interdigitation ability, and cement leakage were evaluated using radiographs. Furthermore, pull-out testing was used to evaluate the immediate mechanical effect of CaS/HA augmentation on the pedicle screws. The CaS/HA cement presented good distribution and interdigitation ability without leakage into the spinal canal. Augmentation significantly enhanced the maximum pull-out force of the pedicle screw in which the augmented side was 39.0% higher than the pedicle-screw-alone side. Therefore, the novel biodegradable biphasic CaS/HA cement could be a promising material for pedicle screw augmentation in the osteoporotic spine.
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Affiliation(s)
- Xinggui Tian
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at Technische Universität Dresden, 01307 Dresden, Germany
- Center for Translational Bone, Joint and Soft Tissue Research, Faculty of Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, 01307 Dresden, Germany
| | - Deepak B. Raina
- Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, 22184 Lund, Sweden
| | - Corina Vater
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at Technische Universität Dresden, 01307 Dresden, Germany
- Center for Translational Bone, Joint and Soft Tissue Research, Faculty of Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, 01307 Dresden, Germany
| | - David Kilian
- Center for Translational Bone, Joint and Soft Tissue Research, Faculty of Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, 01307 Dresden, Germany
| | - Tilman Ahlfeld
- Center for Translational Bone, Joint and Soft Tissue Research, Faculty of Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, 01307 Dresden, Germany
| | - Ivan Platzek
- Department of Radiology, University Hospital Carl Gustav Carus at Technische Universität Dresden, 01307 Dresden, Germany
| | - Ute Nimtschke
- Institute of Anatomy, University Hospital Carl Gustav Carus at Technische Universität Dresden, 01307 Dresden, Germany
| | - Magnus Tägil
- Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, 22184 Lund, Sweden
| | - Lars Lidgren
- Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, 22184 Lund, Sweden
| | - Alexander Thomas
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at Technische Universität Dresden, 01307 Dresden, Germany
| | - Uwe Platz
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at Technische Universität Dresden, 01307 Dresden, Germany
| | - Klaus-Dieter Schaser
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at Technische Universität Dresden, 01307 Dresden, Germany
| | - Alexander C. Disch
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at Technische Universität Dresden, 01307 Dresden, Germany
| | - Stefan Zwingenberger
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at Technische Universität Dresden, 01307 Dresden, Germany
- Center for Translational Bone, Joint and Soft Tissue Research, Faculty of Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, 01307 Dresden, Germany
- Correspondence:
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Sebastian S, Tandberg F, Liu Y, Raina DB, Tägil M, Collin M, Lidgren L. Extended local release and improved bacterial eradication by adding rifampicin to a biphasic ceramic carrier containing gentamicin or vancomycin. Bone Joint Res 2022; 11:787-802. [DOI: 10.1302/2046-3758.1111.bjr-2022-0101.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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Aims There is a lack of biomaterial-based carriers for the local delivery of rifampicin (RIF), one of the cornerstone second defence antibiotics for bone infections. RIF is also known for causing rapid development of antibiotic resistance when given as monotherapy. This in vitro study evaluated a clinically used biphasic calcium sulphate/hydroxyapatite (CaS/HA) biomaterial as a carrier for dual delivery of RIF with vancomycin (VAN) or gentamicin (GEN). Methods The CaS/HA composites containing RIF/GEN/VAN, either alone or in combination, were first prepared and their injectability, setting time, and antibiotic elution profiles were assessed. Using a continuous disk diffusion assay, the antibacterial behaviour of the material was tested on both planktonic and biofilm-embedded forms of standard and clinical strains of Staphylococcus aureus for 28 days. Development of bacterial resistance to RIF was determined by exposing the biofilm-embedded bacteria continuously to released fractions of antibiotics from CaS/HA-antibiotic composites. Results Following the addition of RIF to CaS/HA-VAN/GEN, adequate injectability and setting of the CaS/HA composites were noted. Sustained release of RIF above the minimum inhibitory concentrations of S. aureus was observed until study endpoint (day 35). Only combinations of CaS/HA-VAN/GEN + RIF exhibited antibacterial and antibiofilm effects yielding no viable bacteria at study endpoint. The S. aureus strains developed resistance to RIF when biofilms were subjected to CaS/HA-RIF alone but not with CaS/HA-VAN/GEN + RIF. Conclusion Our in vitro results indicate that biphasic CaS/HA loaded with VAN or GEN could be used as a carrier for RIF for local delivery in clinically demanding bone infections. Cite this article: Bone Joint Res 2022;11(11):787–802.
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Affiliation(s)
- Sujeesh Sebastian
- Department of Clinical Sciences, Orthopedics, Lund University Faculty of Medicine, Lund, Sweden
| | - Felix Tandberg
- Department of Clinical Sciences, Orthopedics, Lund University Faculty of Medicine, Lund, Sweden
| | - Yang Liu
- Department of Clinical Sciences, Orthopedics, Lund University Faculty of Medicine, Lund, Sweden
| | - Deepak B. Raina
- Department of Clinical Sciences, Orthopedics, Lund University Faculty of Medicine, Lund, Sweden
| | - Magnus Tägil
- Department of Clinical Sciences, Orthopedics, Lund University Faculty of Medicine, Lund, Sweden
| | - Mattias Collin
- Division of Infection Medicine, Department of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
| | - Lars Lidgren
- Department of Clinical Sciences, Orthopedics, Lund University Faculty of Medicine, Lund, Sweden
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Xu H, Liu Y, Sezgin EA, Tarasevičius Š, Christensen R, Raina DB, Tägil M, Lidgren L. Comparative effectiveness research on proximal femoral nail versus dynamic hip screw in patients with trochanteric fractures: a systematic review and meta-analysis of randomized trials. J Orthop Surg Res 2022; 17:292. [PMID: 35658909 PMCID: PMC9164432 DOI: 10.1186/s13018-022-03189-z] [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] [Received: 04/17/2022] [Accepted: 05/18/2022] [Indexed: 11/28/2022] Open
Abstract
Background The treatments for trochanteric fractures try to regain early mobility and limit morbidity and risk of reoperations. The most currently used dynamic hip screw (DHS) and the proximal femoral nail (PFN) are both with pros and cons. We aimed to assess the comparative effectiveness of these interventions for trochanteric fractures by evaluating the surgical performance and postoperative outcomes.
Methods PubMed, Web of Science and Cochrane Central Register were searched for RCTs comparing DHS and PFN for trochanteric fractures. All selected studies and the risk of bias were assessed. Clinical data including operative time, intraoperative blood loss, intraoperative fluoroscopy time, successful closed reduction and complications like nonunion, implant failure and reoperation were recorded. Random-effects models were used in Review Manager software, and GRADE was applied for the interpretation of the evidence. Results From 286 identified trials, twelve RCTs including 1889 patients were eligible for inclusion; six RCTs directly comparing DHS with PFN, while other six compared DHS with proximal femoral nail antirotation (PFNA). Compared to DHS, PFN had shorter operative time and led to less intraoperative blood loss. However, DHS need less intraoperative fluoroscopy time than PFN. No difference was seen for the achievement of closed reduction. For risk of postoperative complications, no difference was seen between PFN and DHS for non-union, risk of implant failure and revision surgery. Conclusions PFN(A) resulted in a shorter operative time and less intraoperative blood loss compared to DHS. However, no difference was seen for postoperative complications. Trial registration PROSPERO: CRD42021239974. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-022-03189-z.
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Affiliation(s)
- Hong Xu
- Department of Orthopaedics, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang Province, China.
| | - Yang Liu
- Department of Clinical Sciences Lund, The Faculty of Medicine, Orthopedics, Lund University, Lund, Sweden
| | - Erdem Aras Sezgin
- Department of Orthopaedics&Traumatology, Faculty of Medicine, Aksaray University, Aksaray, Turkey
| | - Šarūnas Tarasevičius
- Department of Orthopedics, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.,Research Unit of Rheumatology, Department of Clinical Research, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Deepak Bushan Raina
- Department of Clinical Sciences Lund, The Faculty of Medicine, Orthopedics, Lund University, Lund, Sweden
| | - Magnus Tägil
- Department of Clinical Sciences Lund, The Faculty of Medicine, Orthopedics, Lund University, Lund, Sweden
| | - Lars Lidgren
- Department of Clinical Sciences Lund, The Faculty of Medicine, Orthopedics, Lund University, Lund, Sweden
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Raina DB, Markevičiūtė V, Stravinskas M, Kok J, Jacobson I, Liu Y, Sezgin EA, Isaksson H, Zwingenberger S, Tägil M, Tarasevičius Š, Lidgren L. A New Augmentation Method for Improved Screw Fixation in Fragile Bone. Front Bioeng Biotechnol 2022; 10:816250. [PMID: 35309986 PMCID: PMC8926351 DOI: 10.3389/fbioe.2022.816250] [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] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/31/2022] [Indexed: 11/21/2022] Open
Abstract
Pertrochanteric fractures (TF) due to osteoporosis constitute nearly half of all proximal femur fractures. TFs are treated with a surgical approach and fracture fixation is achieved using metallic fixation devices. Poor quality cancellous bone in osteoporotic patients makes anchorage of a fixation device challenging, which can lead to failure of the fracture fixation. Methods to reinforce the bone-implant interface using bone cement (PMMA) and other calcium phosphate cements in TFs have been described earlier but a clear evidence on the advantage of using such biomaterials for augmentation is weak. Furthermore, there is no standardized technique for delivering these biomaterials at the bone-implant interface. In this study, we firstly describe a method to deliver a calcium sulphate/hydroxyapatite (CaS/HA) based biomaterial for the augmentation of a lag-screw commonly used for TF fixation. We then used an osteoporotic Sawbones model to study the consequence of CaS/HA augmentation on the immediate mechanical anchorage of the lag-screw to osteoporotic bone. Finally, as a proof-of-concept, the method of delivering the CaS/HA biomaterial at the bone-implant interface as well as spreading of the CaS/HA material at this interface was tested in patients undergoing treatment for TF as well as in donated femoral heads. The mechanical testing results indicated that the CaS/HA based biomaterial increased the peak extraction force of the lag-screw by 4 times compared with un-augmented lag-screws and the results were at par with PMMA. The X-ray images from the patient series showed that it was possible to inject the CaS/HA material at the bone-implant interface without applying additional pressure and the CaS/HA material spreading was observed at the interface of the lag-screw threads and the bone. Finally, the spreading of the CaS/HA material was also verified on donated femoral heads and micro-CT imaging indicated that the entire length of the lag-screw threads was covered with the CaS/HA biomaterial. In conclusion, we present a novel method for augmenting a lag-screw in TFs, which could potentially reduce the risk of fracture fixation failure and reoperation in fragile osteoporotic patients.
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Affiliation(s)
- Deepak Bushan Raina
- Department of Clinical Sciences Lund, Orthopedics, The Faculty of Medicine, Lund University, Lund, Sweden
- *Correspondence: Deepak Bushan Raina,
| | - Vetra Markevičiūtė
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Mindaugas Stravinskas
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Joeri Kok
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | - Ida Jacobson
- Department of Clinical Sciences Lund, Orthopedics, The Faculty of Medicine, Lund University, Lund, Sweden
| | - Yang Liu
- Department of Clinical Sciences Lund, Orthopedics, The Faculty of Medicine, Lund University, Lund, Sweden
| | - Erdem Aras Sezgin
- Department of Orthopedics and Traumatology, Faculty of Medicine, Aksaray University, Aksaray, Turkey
| | - Hanna Isaksson
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | - Stefan Zwingenberger
- University Hospital Carl Gustav Carus at Technische Universität Dresden, University Center of Orthopedic, Trauma and Plastic Surgery, Dresden, Germany
| | - Magnus Tägil
- Department of Clinical Sciences Lund, Orthopedics, The Faculty of Medicine, Lund University, Lund, Sweden
| | - Šarūnas Tarasevičius
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Lars Lidgren
- Department of Clinical Sciences Lund, Orthopedics, The Faculty of Medicine, Lund University, Lund, Sweden
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Kok J, Törnquist E, Raina DB, Le Cann S, Novak V, Širka A, Lidgren L, Grassi L, Isaksson H. Fracture behavior of a composite of bone and calcium sulfate/hydroxyapatite. J Mech Behav Biomed Mater 2022; 130:105201. [DOI: 10.1016/j.jmbbm.2022.105201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 03/19/2022] [Accepted: 03/25/2022] [Indexed: 12/12/2022]
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10
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Liu Y, Nadeem A, Sebastian S, Olsson MA, Wai SN, Styring E, Engellau J, Isaksson H, Tägil M, Lidgren L, Raina DB. Bone mineral: A trojan horse for bone cancers efficient mitochondria targeted delivery and tumor eradication with nano hydroxyapatite containing doxorubicin. Mater Today Bio 2022; 14:100227. [PMID: 35265825 PMCID: PMC8898975 DOI: 10.1016/j.mtbio.2022.100227] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 11/04/2022] Open
Abstract
Efficient systemic pharmacological treatment of solid tumors is hampered by inadequate tumor concentration of cytostatics necessitating development of smart local drug delivery systems. To overcome this, we demonstrate that doxorubicin (DOX), a cornerstone drug used for osteosarcoma treatment, shows reversible accretion to hydroxyapatite (HA) of both nano (nHA) and micro (mHA) size. nHA particles functionalized with DOX get engulfed in the lysosome of osteosarcoma cells where the acidic microenvironment causes a disruption of the binding between DOX and HA. The released DOX then accumulates in the mitochondria causing cell starvation, reduced migration and apoptosis. The HA+DOX delivery system was also tested in-vivo on osteosarcoma bearing mice. Locally delivered DOX via the HA particles had a stronger tumor eradication effect compared to the controls as seen by PET-CT and immunohistochemical staining of proliferation and apoptosis markers. These results indicate that in addition to systemic chemotherapy, an adjuvant nHA could be used as a carrier for intracellular delivery of DOX for prevention of tumor recurrence after surgical resection in an osteosarcoma. Furthermore, we demonstrate that nHA particles are pivotal in this approach but a combination of nHA with mHA could increase the safety associated with particulate nanomaterials while maintaining similar therapeutic potential.
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Sezgin EA, Tor AT, Markevičiūtė V, Širka A, Tarasevičius Š, Raina DB, Liu Y, Isaksson H, Tägil M, Lidgren L. A combined fracture and mortality risk index useful for treatment stratification in hip fragility fractures. Jt Dis Relat Surg 2021; 32:583-589. [PMID: 34842088 PMCID: PMC8650669 DOI: 10.52312/jdrs.2021.382] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/20/2021] [Indexed: 02/06/2023] Open
Abstract
Objectives
In this study, we aimed to assess the stratification ability of the Fracture and Mortality Risk Evaluation (FAME) index for reoperation, new fragility fracture, and mortality during one-year follow-up. Patients and methods
Between November 2018 and July 2019, a total of 94 consecutive hip fragility fracture patients from two centers (20 males, 74 females; mean age: 79.3±8.9 years; range, 57 to 100 years) were retrospectively analyzed. The patients were classified into high, intermediate, and low fracture and mortality risk groups according to the Fracture Risk Assessment Tool (FRAX) score and Sernbo score, respectively, as well as nine combined categories according to the FAME index. Hospital records were reviewed to identify re-fractures (reoperations, implant failure, new fragility fractures on any site) and mortality at one year following the FAME index classification. Results
Overall re-fracture and mortality rates were 20.2% and 33%, respectively. High fracture risk category (FRAX-H) was significantly associated with higher re-fracture (odds ratio [OR]: 2.9, 95% confidence interval [CI]: 1-8.2, p=0.037) and mortality rates compared to others (OR: 3.7, 95% CI: 1.5-9.3, p=0.003). The patients classified within the FRAX-H category (n=35) had different mortality rates according to their Sernbo classification; i.e., patients classified as low mortality risk (Sernbo-L) (n=17) had lower mortality rates compared to others in this group (n=18) (35.3% and 66.7%, respectively), indicating a low statistical significance (OR: 0.3, 95% CI: 0.1-1.1, p=0.063). Similarly, within patients classified in Sernbo-L category (n=64), those classified as high fracture risk (FRAX-H) (n=17) had significantly higher re-fracture rates compared to others in this group (n=47) (35.3% and 8.5%, respectively), (OR: 5.9; 95% CI: 1.4-24.5), (p=0.017). Multivariate logistic regression analyses adjusting for covariates (age, sex, length of hospital stay and BMI) yielded similar results. Conclusion
The FAME index appears to be a useful stratification tool for allocating patients in a randomized-controlled trial for augmentation of hip fragility fractures.
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Affiliation(s)
- Erdem Aras Sezgin
- Aksaray Üniversitesi Tıp Fakültesi Ortopedi ve Travmatoloji Anabilim Dalı, 68200 Aksaray, Türkiye.
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Sebastian S, Sezgin EA, Stučinskas J, Tarasevičius Š, Liu Y, Raina DB, Tägil M, Lidgren L, W-Dahl A. Different microbial and resistance patterns in primary total knee arthroplasty infections - a report on 283 patients from Lithuania and Sweden. BMC Musculoskelet Disord 2021; 22:800. [PMID: 34535109 PMCID: PMC8449428 DOI: 10.1186/s12891-021-04689-5] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 09/06/2021] [Indexed: 01/06/2023] Open
Abstract
Background The microbiology and the susceptibility patterns of infected total knee arthroplasties (TKAs) vary depending on demographic, local antimicrobial stewardship, and surgical factors. We wanted to compare the recent microbial profile and antimicrobial resistance pattern in revisions due to infections after primary TKAs in Sweden and Lithuania. Our hypothesis was that there is a difference in bacteriology and resistance pattern based on patient related, societal and local hospital factors as almost similar praxis have been applied for TKA surgery, short term systemic prophylaxis and routine use of local gentamicin containing bone cement. Methods Primary TKAs revised for the first time due to verified or suspected infection were collected nationwide in Sweden during 2018, and in Lithuania between 2011 and 2020 from a single major TKA revision centre in Kaunas. We identified 202 TKAs in Sweden from the Swedish Knee Arthroplasty Register and 84 from Kaunas revised due to infection. We collected available culture reports and evaluated the type of microorganisms with antimicrobial resistance pattern at revision. Results The majority of the infected cases in Sweden were early-type prosthetic joint infection (PJI) (44%), whereas late-type PJI (52%) were more common in the Kaunas cases. Gram-positive bacteria prevailed in both Sweden (55%) and Lithuania (80%). Staphylococcus aureus was the most frequent organism identified in both countries (33% in Sweden and 34% in Lithuania). More polymicrobial infections were observed in Sweden than in Lithuania (16 and 6% respectively). Methicillin resistance in Staphylococcus aureus and coagulase-negative staphylococci were higher in Lithuania (4/28 and 19/29) than in Sweden (1/42 and 9/41). Conclusions The type of infections, microbial profile, and drug resistance pattern differed between Sweden and Lithuania. Societal and local hospitals factors with emerging resistance in Lithuania are the most plausible explanation for the difference. Lack of complete data on a national level in Lithuania underlines the importance of adding microbiology of PJIs in implant registers for national aggregation and allow cross country comparisons. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04689-5.
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Affiliation(s)
- Sujeesh Sebastian
- Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden.
| | - Erdem Aras Sezgin
- Department of Orthopaedics & Traumatology, Aksaray University Training and Research Hospital, Aksaray, Turkey
| | - Justinas Stučinskas
- Department of Orthopedics & Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Šarūnas Tarasevičius
- Department of Orthopedics & Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Yang Liu
- Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
| | - Deepak Bhushan Raina
- Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
| | - Magnus Tägil
- Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
| | - Lars Lidgren
- Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
| | - Annette W-Dahl
- Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden
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Liu Y, Raina DB, Sebastian S, Nagesh H, Isaksson H, Engellau J, Lidgren L, Tägil M. Sustained and controlled delivery of doxorubicin from an in-situ setting biphasic hydroxyapatite carrier for local treatment of a highly proliferative human osteosarcoma. Acta Biomater 2021; 131:555-571. [PMID: 34271171 DOI: 10.1016/j.actbio.2021.07.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 07/02/2021] [Accepted: 07/07/2021] [Indexed: 12/15/2022]
Abstract
Doxorubicin (DOX) is a cornerstone drug in the treatment of osteosarcoma. However, achieving sufficient concentration in the tumor tissue after systemic administration with few side effects has been a challenge. Even with the most advanced nanotechnology approaches, less than 5% of the total administered drug gets delivered to the target site. Alternatives to increase the local concentration of DOX within the tumor using improved drug delivery methods are needed. In this study, we evaluate a clinically approved calcium sulfate/hydroxyapatite (CaS/HA) carrier, both in-vitro and in-vivo, for local, sustained and controlled delivery of DOX to improve osteosarcoma treatment. In-vitro drug release studies indicated that nearly 28% and 36% of the loaded drug was released over a period of 4-weeks at physiological pH (7.4) and acidic pH (5), respectively. About 63% of the drug had been released after 4-weeks in-vivo. The efficacy of the released drug from the CaS/HA material was verified on two human osteosarcoma cell lines MG-63 and 143B. It was demonstrated that the released drug fractions functioned the same way as the free drug without impacting its efficacy. Finally, the carrier system with DOX was assessed using two clinically relevant human osteosarcoma xenograft models. Compared to no treatment or the clinical standard of care with systemic DOX administration, the delivery of DOX using a CaS/HA biomaterial could significantly hinder tumor progression by inhibiting angiogenesis and cell proliferation. Our results indicate that a clinically approved CaS/HA biomaterial containing cytostatics could potentially be used for the local treatment of osteosarcoma. STATEMENT OF SIGNIFICANCE: The triad of doxorubicin (DOX), methotrexate and cisplatin has routinely been used for the treatment of osteosarcoma. These drugs dramatically improved the prognosis, but 45-55% of the patients respond poorly to the treatment with low 5-year survival. In the present study, we repurpose the cornerstone drug DOX by embedding it in a calcium sulfate/hydroxyapatite (CaS/HA) biomaterial, ensuring a spatio-temporal drug release and a hypothetically higher and longer lasting intra-tumoral concentration of DOX. This delivery system could dramatically hinder the progression of a highly aggressive osteosarcoma compared to systemic administration, by inhibiting angiogenesis and cell proliferation. Our data show an efficient method for supplementary osteosarcoma treatment with possible rapid translational potential due to clinically approved constituents.
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Kok J, Širka A, Liu Y, Tarasevičius Š, Belickas J, Tägil M, Lidgren L, Isaksson H, Raina DB. Augmenting a dynamic hip screw with a calcium sulfate/hydroxyapatite biomaterial. Med Eng Phys 2021; 92:102-109. [PMID: 34167704 DOI: 10.1016/j.medengphy.2021.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 03/02/2021] [Revised: 04/30/2021] [Accepted: 05/09/2021] [Indexed: 11/28/2022]
Abstract
Internal fixation failure in hip fractures can lead to reoperation. Calcium sulfate/hydroxyapatite (CaS/HA) is a biomaterial that can be used for augmenting fracture fixation. We aimed to determine whether an injection of 2 ml CaS/HA increases the fixation of a dynamic hip screw inserted in synthetic and human trabecular bone. The study consists of two parts: 1) synthetic bone blocks (n = 74), with three subgroups: empty (cannulated screw, no injection), cannulated, and fenestrated; and 2) osteoporotic human femoral heads (n = 29), with the same subgroups. The heads were imaged using µCT. Bone volume fraction, insertion angle, and head diameter were measured. Pullout tests were performed and peak force, stiffness, and work were measured. The fenestrated group showed increases in pullout strength compared to no injection in the synthetic blocks. The cannulated group showed a higher pullout strength in low-density blocks. In the femoral heads, the variation was larger and there were no significant differences between groups. The bone volume fraction correlated with the peak force and work, and the insertion angle correlated with the stiffness. CaS/HA can improve the fixation of a dynamic hip screw. For clinical use, spreading of the material around the threads of the screw must be ensured.
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Affiliation(s)
- Joeri Kok
- Department of Biomedical Engineering, Lund University, Box 118, 22100 Lund, Sweden.
| | - Aurimas Širka
- Department of Orthopedics and Traumatology, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Eiveniu ave.2, Kaunas, Lithuania.
| | - Yang Liu
- Department of Clinical Sciences, Orthopedics, Faculty of Medicine, Lund University, BMC C12, 22184 Lund, Sweden.
| | - Šarūnas Tarasevičius
- Department of Orthopedics and Traumatology, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Eiveniu ave.2, Kaunas, Lithuania.
| | - Juozas Belickas
- Department of Orthopedics and Traumatology, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Eiveniu ave.2, Kaunas, Lithuania.
| | - Magnus Tägil
- Department of Clinical Sciences, Orthopedics, Faculty of Medicine, Lund University, BMC C12, 22184 Lund, Sweden.
| | - Lars Lidgren
- Department of Clinical Sciences, Orthopedics, Faculty of Medicine, Lund University, BMC C12, 22184 Lund, Sweden.
| | - Hanna Isaksson
- Department of Biomedical Engineering, Lund University, Box 118, 22100 Lund, Sweden; Department of Clinical Sciences, Orthopedics, Faculty of Medicine, Lund University, BMC C12, 22184 Lund, Sweden.
| | - Deepak Bushan Raina
- Department of Clinical Sciences, Orthopedics, Faculty of Medicine, Lund University, BMC C12, 22184 Lund, Sweden.
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Teotia AK, Qayoom I, Singh P, Mishra A, Jaiman D, Seppälä J, Lidgren L, Kumar A. Exosome-Functionalized Ceramic Bone Substitute Promotes Critical-Sized Bone Defect Repair in Rats. ACS Appl Bio Mater 2021; 4:3716-3726. [DOI: 10.1021/acsabm.1c00311] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Arun K. Teotia
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur 201806, India
| | - Irfan Qayoom
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur 201806, India
| | - Prerna Singh
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur 201806, India
- Center for Environmental Science and Engineering, Indian Institute of Technology Kanpur, Kanpur 201806, India
| | - Ankita Mishra
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur 201806, India
| | - Deepika Jaiman
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur 201806, India
| | - Jukka Seppälä
- Polymer Technology, School of Chemical Engineering, Aalto University, Espoo 02150, Finland
| | - Lars Lidgren
- Department of Orthopedics, Clinical Sciences Lund, Lund University, Lund 221 85, Sweden
| | - Ashok Kumar
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur 201806, India
- Center for Environmental Science and Engineering, Indian Institute of Technology Kanpur, Kanpur 201806, India
- Center for Nanoscience, Indian Institute of Technology Kanpur, Kanpur 201806, India
- The Mehta Family Centre for Engineering in Medicine, Indian Institute of Technology Kanpur, Kanpur 208016, India
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Raina DB, Matuszewski LM, Vater C, Bolte J, Isaksson H, Lidgren L, Tägil M, Zwingenberger S. A facile one-stage treatment of critical bone defects using a calcium sulfate/hydroxyapatite biomaterial providing spatiotemporal delivery of bone morphogenic protein-2 and zoledronic acid. Sci Adv 2020; 6:6/48/eabc1779. [PMID: 33246951 PMCID: PMC7695465 DOI: 10.1126/sciadv.abc1779] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 10/09/2020] [Indexed: 05/11/2023]
Abstract
Bone morphogenic proteins (BMPs) are the only true osteoinductive molecules. Despite being tremendously potent, their clinical use has been limited for reasons including supraphysiological doses, suboptimal delivery systems, and the pro-osteoclast effect of BMPs. Efforts to achieve spatially controlled bone formation using BMPs are being made. We demonstrate that a carrier consisting of a powder of calcium sulfate/hydroxyapatite (CaS/HA) mixed with bone active molecules provides an efficient drug delivery platform for critical femoral defect healing in rats. The bone-active molecules were composed of osteoinductive rhBMP-2 and the bisphosphonate, and zoledronic acid (ZA) was chosen to overcome BMP-2-induced bone resorption. It was demonstrated that delivery of rhBMP-2 was necessary for critical defect healing and restoration of mechanical properties, but codelivery of BMP-2 and ZA led to denser and stronger fracture calluses. Together, the CaS/HA biomaterial with rhBMP-2 and/or ZA can potentially be used as an off-the-shelf alternative to autograft bone.
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Affiliation(s)
- Deepak Bushan Raina
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lund 22185, Sweden.
| | - Lucas-Maximilian Matuszewski
- University Hospital Carl Gustav Carus at Technische Universität Dresden, University Center of Orthopedic, Trauma and Plastic Surgery, Dresden 01307, Germany
| | - Corina Vater
- University Hospital Carl Gustav Carus at Technische Universität Dresden, University Center of Orthopedic, Trauma and Plastic Surgery, Dresden 01307, Germany
| | - Julia Bolte
- University Hospital Carl Gustav Carus at Technische Universität Dresden, University Center of Orthopedic, Trauma and Plastic Surgery, Dresden 01307, Germany
| | - Hanna Isaksson
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lund 22185, Sweden
- Lund University, Department of Biomedical Engineering, Lund 22100, Sweden
| | - Lars Lidgren
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lund 22185, Sweden
| | - Magnus Tägil
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lund 22185, Sweden
| | - Stefan Zwingenberger
- University Hospital Carl Gustav Carus at Technische Universität Dresden, University Center of Orthopedic, Trauma and Plastic Surgery, Dresden 01307, Germany
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Raina DB, Širka A, Qayoom I, Teotia AK, Liu Y, Tarasevicius S, Tanner KE, Isaksson H, Kumar A, Tägil M, Lidgren L. Long-Term Response to a Bioactive Biphasic Biomaterial in the Femoral Neck of Osteoporotic Rats. Tissue Eng Part A 2020; 26:1042-1051. [PMID: 32242474 PMCID: PMC7580608 DOI: 10.1089/ten.tea.2020.0018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 03/27/2020] [Indexed: 11/13/2022] Open
Abstract
Osteoporosis often leads to fragility fractures of the hip, resulting in impaired quality of life and increased mortality. Augmenting the proximal femur could be an attractive option for prevention of fracture or fixation device failure. We describe a tissue engineering based strategy to enhance long-term bone formation in the femoral neck of osteoporotic rats by locally delivering bioactive molecules; recombinant human bone morphogenic protein-2 (rhBMP-2), and zoledronic acid (ZA) by using a calcium sulfate/hydroxyapatite (CaS/HA) biomaterial. A defect was created by reaming the femoral neck canal of osteoporotic (OVX) rats and they were treated as follows: G1. Empty, G2. CaS/HA, G3. CaS/HA+Systemic ZA, G4. CaS/HA+Local ZA, and G5. CaS/HA+Local ZA+rhBMP-2. Bone formation was evaluated 6 months after treatment. Further, radioactively labeled 14C-ZA was used to study the bioavailability of ZA at the defect location, which was determined by using scintillation counting. Micro-CT indicated significantly higher bone volume in groups G4 and G5 compared with the other treatment groups. This was confirmed qualitatively by histological assessment. Addition of rhBMP-2 gave no additional benefit in this model. Local delivery of ZA performed better than systemic administration of ZA. Mechanical testing showed no differences between the groups, likely reflecting that the addition of bioactive molecules had limited effect on cortical bone or the choice of mechanical testing setup was not optimal. Scintillation counting revealed higher amounts of 14C-ZA present in the treated leg of G4 compared with its contralateral control and compared with G3, indicating that local ZA delivery can be used to achieve high local concentrations without causing a systemic effect. This long-term study shows that local delivery of ZA using a CaS/HA carrier can regenerate cancellous bone in the femoral neck canal and has clear implications for enhancing implant integration and fixation in fragile bone.
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Affiliation(s)
- Deepak Bushan Raina
- Department of Clinical Sciences Lund, Orthopedics, Faculty of Medicine, Lund University, Lund, Sweden
| | - Aurimas Širka
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Irfan Qayoom
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, India
| | - Arun Kumar Teotia
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, India
| | - Yang Liu
- Department of Clinical Sciences Lund, Orthopedics, Faculty of Medicine, Lund University, Lund, Sweden
| | - Sarunas Tarasevicius
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Kathleen Elizabeth Tanner
- Queen Mary University of London, School of Engineering and Materials Science and Institute of Bioengineering, London, United Kingdom
| | - Hanna Isaksson
- Department of Clinical Sciences Lund, Orthopedics, Faculty of Medicine, Lund University, Lund, Sweden
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | - Ashok Kumar
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, India
| | - Magnus Tägil
- Department of Clinical Sciences Lund, Orthopedics, Faculty of Medicine, Lund University, Lund, Sweden
| | - Lars Lidgren
- Department of Clinical Sciences Lund, Orthopedics, Faculty of Medicine, Lund University, Lund, Sweden
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Abstract
Bone is a dynamic tissue with a quarter of the trabecular and a fifth of the cortical bone being replaced continuously each year in a complex process that continues throughout an individual's lifetime. Bone has an important role in homeostasis of minerals with non-stoichiometric hydroxyapatite bone mineral forming the inorganic phase of bone. Due to its crystal structure and chemistry, hydroxyapatite (HA) and related apatites have a remarkable ability to bind molecules. This review article describes the accretion of trace elements in bone mineral giving a historical perspective. Implanted HA particles of synthetic origin have proved to be an efficient recruiting moiety for systemically circulating drugs which can locally biomodulate the material and lead to a therapeutic effect. Bone mineral and apatite however also act as a waste dump for trace elements and drugs, which significantly affects the environment and human health. Cite this article: Bone Joint Res 2020;9(10):709-718.
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Affiliation(s)
| | | | | | - K Elizabeth Tanner
- School of Engineering and Materials Science and Institute of Bioengineering, Queen Mary University of London, London, UK
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Qayoom I, Verma R, Murugan PA, Raina DB, Teotia AK, Matheshwaran S, Nair NN, Tägil M, Lidgren L, Kumar A. A biphasic nanohydroxyapatite/calcium sulphate carrier containing Rifampicin and Isoniazid for local delivery gives sustained and effective antibiotic release and prevents biofilm formation. Sci Rep 2020; 10:14128. [PMID: 32839480 PMCID: PMC7445265 DOI: 10.1038/s41598-020-70726-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/22/2020] [Indexed: 12/23/2022] Open
Abstract
Long term multiple systemic antibiotics form the cornerstone in the treatment of bone and joint tuberculosis, often combined with local surgical eradication. Implanted carriers for local drug delivery have recently been introduced to overcome some of the limitations associated with conventional treatment strategies. In this study, we used a calcium sulphate hemihydrate (CSH)/nanohydroxyapatite (nHAP) based nanocement (NC) biomaterial as a void filler as well as a local delivery carrier of two standard of care tuberculosis drugs, Rifampicin (RFP) and Isoniazid (INH). We observed that the antibiotics showed different release patterns where INH showed a burst release of 67% and 100% release alone and in combination within one week, respectively whereas RFP showed sustained release of 42% and 49% release alone and in combination over a period of 12 weeks, respectively indicating different possible interactions of antibiotics with nHAP. The interactions were studied using computational methodology, which showed that the binding energy of nHAP with RFP was 148 kcal/mol and INH was 11 kcal/mol, thus varying substantially resulting in RFP being retained in the nHAP matrix. Our findings suggest that a biphasic ceramic based drug delivery system could be a promising treatment alternative to bone and joint TB.
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Affiliation(s)
- Irfan Qayoom
- Department of Biological Science and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, UP, 208016, India
| | - Rahul Verma
- Department of Chemistry, Indian Institute of Technology Kanpur, Kanpur, UP, 208016, India
| | - Prem Anand Murugan
- Department of Biological Science and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, UP, 208016, India
| | - Deepak Bushan Raina
- Department of Orthopaedics, The Medical Faculty, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Arun Kumar Teotia
- Department of Biological Science and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, UP, 208016, India
| | - Saravanan Matheshwaran
- Department of Biological Science and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, UP, 208016, India
- Centre for Environmental Sciences and Engineering, Indian Institute of Technology Kanpur, Kanpur, UP, 208016, India
| | - Nisanth N Nair
- Department of Chemistry, Indian Institute of Technology Kanpur, Kanpur, UP, 208016, India
| | - Magnus Tägil
- Department of Orthopaedics, The Medical Faculty, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Lars Lidgren
- Department of Orthopaedics, The Medical Faculty, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Ashok Kumar
- Department of Biological Science and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, UP, 208016, India.
- Centre for Environmental Sciences and Engineering, Indian Institute of Technology Kanpur, Kanpur, UP, 208016, India.
- Centre for Nanosciences, Indian Institute of Technology Kanpur, Kanpur, UP, 208016, India.
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20
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Sebastian S, Liu Y, Christensen R, Raina DB, Tägil M, Lidgren L. Antibiotic containing bone cement in prevention of hip and knee prosthetic joint infections: A systematic review and meta-analysis. J Orthop Translat 2020; 23:53-60. [PMID: 32489860 PMCID: PMC7256060 DOI: 10.1016/j.jot.2020.04.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/07/2020] [Accepted: 04/10/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Prosthetic joint infection (PJI) is the most serious total joint arthroplasty (TJA) complication despite several aseptic and antiseptic preventive measures. There is no clear evidence or even consensus, whether antibiotic-loaded bone cement (ALBC) should be used, in addition to systemic short-term routine antibiotic prophylaxis, to reduce the risk of PJI in primary TJA. We aimed to analyze the efficacy of ALBC for prevention of PJI in patients undergoing primary TJA. METHODS We searched systematically for randomized controlled trials (RCTs) in PubMed, Scopus, Embase, Web of Science and Cochrane library. Two reviewers independently screened potentially eligible studies according to predefined selection criteria and assessed the risk of bias using a modified version of the Cochrane risk of bias tool. PJI was prespecified as the primary outcome of interest. The meta-analyses were based on risk ratios using random-effects model per default. For the purpose of sensitivity, the corresponding fixed effects model odds ratios were calculated with the use of the Peto method as well. To evaluate a potential difference in effect sizes using different types (subgroups) of antibiotics used in bone cement, and at different follow-up periods, we performed stratified meta-analyses. RESULTS Thirty-seven studies were eligible for the systematic review and qualitative synthesis, and 9 trials (6507 total joint arthroplasties) were included in this meta-analysis. Overall ALBC significantly reduced the risk of PJI following primary TJAs (RRs, 0.36; 95% CIs, 0.16 to 0.80; P = 0.01) with a moderate degree of inconsistency (I2 = 47%). Based on stratified meta-analyses the use of gentamicin appeared to have a better effect (P = 0.0005) in the total hip arthroplasty. Pooled data of different antibiotics used in knee arthroplasties showed a significant association of cefuroxime (RRs, 0.08; 95% CIs, 0.01 to 0.63; P = 0.02). Further, ALBCs significantly reduced the PJI at one and two years of follow-up (P = 0.03 and P = 0.005 respectively). CONCLUSIONS The evidence suggests that ALBCs are effective in reducing the PJI following primary TJA; i.e. between 20 and 84% reduced risk. However, the clear limitations of the available trial evidence highlight the need for joint-specific confirmatory trials, that will need to be designed as cluster-randomized trials of clinics in countries with well-functioning arthroplasty registries.The translational potential of this article: This meta-analysis highlights the prophylactic potential of ALBCs in lowering the risk of infection following primary hip or knee arthroplasties but emphasizes the need for more recent confirmatory trials.
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Affiliation(s)
- Sujeesh Sebastian
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden
| | - Yang Liu
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden
| | - Robin Christensen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen & Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Denmark
| | - Deepak Bushan Raina
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden
| | - Magnus Tägil
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden
| | - Lars Lidgren
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden
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Raina DB, Glencross A, Chaher N, Liu Y, Lidgren L, Isaksson H, Tägil M. Synthesis and Characterization of a Biocomposite Bone Bandage for Controlled Delivery of Bone-Active Drugs in Fracture Nonunions. ACS Biomater Sci Eng 2020; 6:2867-2878. [PMID: 33463281 DOI: 10.1021/acsbiomaterials.9b01574] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Fracture nonunions are common in orthopedics and their treatment often involves multiple surgical interventions. The aim of this study was to fabricate and characterize a gelatin-nano-hydroxyapatite membrane (GM)-based bone bandage for controlled delivery of bio-active molecules; recombinant human bone morphogenic protein-2 (rhBMP-2) and zoledronic acid (ZA) to promote osteoinduction and prevent callus resorption, respectively. In vitro cell-material interaction experiments using MC3T3 cells seeded on the GM indicated good biocompatibility. rhBMP-2-functionalized GM promoted osteogenic differentiation of MC3T3 cells and the rhBMP-2 bio-activity thus remained, as indicated by increased levels of alkaline phosphatase compared to only GM. The GM released a small amount (1.1%) of rhBMP-2 in vitro over a period of 5 weeks, demonstrating a strong interaction of rhBMP-2 with the GM. In the first animal study, the GM specimens loaded with rhBMP-2 or with the combination of rhBMP-2 + ZA were placed in the abdominal muscle pouch of rats. In the GM + rhBMP-2 + ZA group, significantly higher bone volume (21.5 ± 5.9 vs 2.7 ± 1.0 mm3) and area (3.3 ± 2.3 vs 1.0 ± 0.4 mm2) of bone were observed compared to GM + rhBMP-2 after 4 weeks, as indicated by micro-computed tomography and histomorphometry, respectively. Finally, a nonunion model in rats was used to evaluate the efficacy of the GM bandage and bio-active molecules in healing of fracture nonunions. The GM functionalized with rhBMP-2 + ZA led to higher bone formation around the fracture (63.9 ± 19.0 vs 31.8 ± 3.7 mm3) and stronger fracture callus (110.8 ± 46.8 vs 45.6 ± 17.8 N) compared to the empty controls. However, the overall union rate was only marginally improved. The GM alone or combined with ZA did not aid in bone healing in this model. Thus, this study shows that controlled delivery of rhBMP-2 + ZA via the developed GM is a promising approach that could aid in earlier full load bearing in patients with nonunion.
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Affiliation(s)
- Deepak Bushan Raina
- Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund 221 85, Sweden
| | - Alexandra Glencross
- Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund 221 85, Sweden.,Biomedical Engineering, Glasgow University, Glasgow G12 8QQ, U.K
| | - Nadia Chaher
- Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund 221 85, Sweden.,Biomedical Engineering, Glasgow University, Glasgow G12 8QQ, U.K
| | - Yang Liu
- Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund 221 85, Sweden
| | - Lars Lidgren
- Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund 221 85, Sweden
| | - Hanna Isaksson
- Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund 221 85, Sweden.,Department of Biomedical Engineering, Lund University, Lund 221 00, Sweden
| | - Magnus Tägil
- Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund 221 85, Sweden
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22
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Affiliation(s)
- Lars Lidgren
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden; ,Corresponding author:
| | - Deepak Bushan Raina
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden;
| | - Magnus Tägil
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden;
| | - K Elizabeth Tanner
- School of Engineering and Materials Science, Queen Mary University of London, UK
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Robertsson O, Sundberg M, Sezgin EA, Lidgren L, W-Dahl A. Higher Risk of Loosening for a Four-Pegged TKA Tibial Baseplate Than for a Stemmed One: A Register-based Study. Clin Orthop Relat Res 2020; 478:58-65. [PMID: 31135554 PMCID: PMC7000052 DOI: 10.1097/corr.0000000000000774] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Modern modular implants allow surgeons to mix different combinations of components within the same brand. From 1999 to 2012, the NexGen®-CR Option femoral component, together with a NexGen® Option Stemmed tibial plate (stemmed baseplate), which uses a short central stem, was the most-frequently used NexGen® combination in the Swedish Knee Arthroplasty Register. However, from 1999 to 2012, the same femoral component was also used along with the NexGen® Precoat four-pegged tibial baseplate (pegged baseplate). Considering the difference in the fixation concepts for these two tibial baseplates, we wanted to study whether their revision rates differed. QUESTIONS/PURPOSES To investigate the difference in (1) all-cause revision and (2) the risk of revision for aseptic loosening between the NexGen® pegged and stemmed baseplates when used with the NG-CR Option femoral component and the same two types of inserts. METHODS The Swedish Knee Arthroplasty Register provided data. The register, which was started in 1975, has since 1999 registered part numbers for individual implant components, allowing it to assess the combinations of components used in each patient. It has been shown to have high completeness (97%) and validity [12, 15]. The inclusion period was 1999 to 2012; during that time, 137,143 primary knee arthroplasties were registered, of which 125,094 were TKAs. Only TKAs performed for osteoarthritis and without patellar resurfacing were included, since not resurfacing the patella is the standard procedure in Sweden. This left 15,287 knees with the stemmed baseplate and 2479 with the pegged baseplate, or 12% and 2% of the total number of TKAs, respectively. Two general hospitals used the pegged baseplate exclusively during that period. Thus, specific patients were not selected for having the pegged plate. The mean age, mortality, and length of followup were similar for the two groups.We used the Kaplan-Meier statistics to calculate the cumulative revision rate (CRR) and Cox regression to compare risk ratios after adjusting for age and sex. The end point was a knee revision for respective all causes or aseptic loosening. The study ended on December 31, 2016. Due to the free healthcare system in Sweden it is highly unusual for patients to seek elective revision abroad, and by use of the extensive Swedish census register, we estimate the level of followup approximately 97%. RESULTS Knees with the pegged baseplate had a higher risk for all-cause revision than did those with the stemmed baseplate (5.8% [95% confidence interval {CI}, 4-8.3] and 3% [95% CI, 2.6-3.5] at 15 years; p = 0.003). After controlling for age and sex, the aseptic loosening risk in the pegged baseplate group was still higher than that in the stemmed group (relative risk, 5.40; 95% CI, 3.64-8.02; p < 0.001). CONCLUSIONS In this Swedish registry study, we observed a higher loosening risk with the pegged baseplate than the stemmed one, even after controlling for age and sex. Because this was only a comparison of implants from one vendor, and because there may have been other between-group differences for which we could not fully control, this concerning finding should be explored using data from other registries. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
| | - Lars Lidgren
- Departments of Infectious Diseases, Lund University, Lund, Sweden.,Departments of of Orthopedics, Lund University, Lund, Sweden
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25
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Sezgin EA, W-Dahl A, Lidgren L, Robertsson O. Weight and height separated provide better understanding than BMI on the risk of revision after total knee arthroplasty: report of 107,228 primary total knee arthroplasties from the Swedish Knee Arthroplasty Register 2009-2017. Acta Orthop 2019; 91:94-97. [PMID: 31698972 PMCID: PMC7006778 DOI: 10.1080/17453674.2019.1688006] [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] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background and purpose - Obesity defined as increased BMI is commonly associated with higher revision rates following total knee arthroplasty (TKA). We examined the effect of BMI on the rate of revision after TKA, for both infection and other reasons, and analyzed weight and height separately to provide better understanding of the risk profile.Patients and methods - The Swedish national knee arthroplasty register was used to identify 107,228 patients operated with primary TKA for osteoarthritis between 2009 and 2017. Cox proportional hazards regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) for BMI (categories: < 18.5, 18.5-24.9, 25-29.9, 30-34.9, 35-39.9, ≥ 40), weight (categories: < 65, 65-89, 90-114, ≥ 115 kg) and height (categories: < 160, 160-179, ≥ 180 cmResults - There were 2,503 revisions in the follow-up period; 1,036 for infection and 1,467 for other reasons. Higher BMI and weight categories were associated with a similar and statistically significantly increased risk of revision for all causes and for infection. The risk of revision for infection was almost twice in the highest BMI and highest weight group: HR = 3.4 (CI 2.3-4.7) and HR = 3.1 (CI 2.5-3.9) respectively. For BMI and weight categories there was no statistically significant association between revision for other reasons than infection, contrary to the tallest height category where it was statistically significant (HR = 1.3 [CI 1.1-1.5]).Interpretation - BMI, weight, and height may be associated with different types of risks for revision following TKA.
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Affiliation(s)
- Erdem A Sezgin
- Gazi University, Faculty of Medicine, Department of Orthopedics and Traumatology, Ankara, Turkey; ,Correspondence:
| | - Annette W-Dahl
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden; ,The Swedish Knee Arthroplasty Register, Lund, Sweden
| | - Lars Lidgren
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden; ,The Swedish Knee Arthroplasty Register, Lund, Sweden
| | - Otto Robertsson
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden; ,The Swedish Knee Arthroplasty Register, Lund, Sweden
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Abstract
Background and purpose - Targeted delivery of drugs is important to achieve efficient local concentrations and reduce systemic side effects. We hypothesized that locally implanted synthetic hydroxyapatite (HA) particles can act as a recruiting moiety for systemically administered drugs, leading to targeted drug accretion.Methods - Synthetic HA particles were implanted ectopically in a muscle pouch in rats, and the binding of systemically circulating drugs such as zoledronic acid (ZA), tetracycline and 18F-fluoride (18F) was studied. The local biological effect was verified in an implant integration model in rats, wherein a hollow implant was filled with synthetic HA particles and the animals were given systemic ZA, 2-weeks post-implantation. The effect of HA particle size on drug binding and the possibility of reloading HA particles were also evaluated in the muscle pouch.Results - The systemically administered biomolecules (ZA, tetracycline and 18F) all sought the HA moiety placed in the muscle pouch. Statistically significant higher peri-implant bone volume and peak force were observed in the implant containing HA particles compared with the empty implant. After a single injection of ZA at 2 weeks, micro HA particles showed a tendency to accumulate more 14C-zoledronic acid (14C-ZA) than nano-HA particles in the muscle pouch. HA particles could be reloaded when ZA was given again at 4 weeks, showing increased 14C-ZA accretion by 73% in microparticles and 77% in nanoparticles.Interpretation - We describe a novel method of systemic drug loading resulting in targeted accretion in locally implanted particulate HA, thereby biologically activating the material.
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Affiliation(s)
- Deepak Bushan Raina
- Faculty of Medicine, Department of Clinical Sciences, Orthopedics, Lund University, Lund; ,Correspondence:
| | - Yang Liu
- Faculty of Medicine, Department of Clinical Sciences, Orthopedics, Lund University, Lund;
| | - Hanna Isaksson
- Faculty of Medicine, Department of Clinical Sciences, Orthopedics, Lund University, Lund; ,Department of Biomedical Engineering, Lund University, Lund, Sweden
| | - Magnus Tägil
- Faculty of Medicine, Department of Clinical Sciences, Orthopedics, Lund University, Lund;
| | - Lars Lidgren
- Faculty of Medicine, Department of Clinical Sciences, Orthopedics, Lund University, Lund;
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Raina DB, Larsson D, Sezgin EA, Isaksson H, Tägil M, Lidgren L. Biomodulation of an implant for enhanced bone-implant anchorage. Acta Biomater 2019; 96:619-630. [PMID: 31301423 DOI: 10.1016/j.actbio.2019.07.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/14/2019] [Accepted: 07/04/2019] [Indexed: 12/23/2022]
Abstract
Aseptic loosening of implants is the major cause for revision surgery. By modulating the bone-implant interface, early bone-implant anchorage could be improved. Implant surface manipulation by the addition of osteopromotive molecules locally and systemically to promote implant integration has been described with limited success. This study describes a novel approach by making the implant capable of biologically modulating its surroundings. It was hypothesized that the early implant fixation would improve by filling the interior of the implant with a carrier providing spatio-temporal release of bone active drugs with known osteogenic effect. The implant consisted of a threaded polyether ether ketone (PEEK) hollow chamber with holes at the bottom. The implant was filled with a calcium sulphate (CaS)/hydroxyapatite (HA) carrier, delivering two bone active molecules; zoledronic acid (ZA) and bone morphogenic protein-2 (BMP-2). At first, a rat abdominal muscle pouch model indicated a sustained in-vivo release of both 125I-rhBMP-2 (57%) and 14C-ZA (22%) from the CaS/HA carrier over a period of 4-weeks. The biomodulated implant was then inserted in the proximal tibia in rats with the following experimental groups: G1) Empty implant, G2) Implant + CaS/HA, G3) Implant + CaS/HA + ZA and G4) Implant + CaS/HA + ZA + rhBMP-2. Significantly higher bone volume (BV) was seen around the implant in groups G3 (3.3 ± 0.7 mm3) and G4 (3.1 ± 0.7 mm3) compared to the control (1.3 ± 0.4 mm3) using micro-computed tomography and qualitative histology. Group G3, also exhibited significantly higher pull-out force and absorbed energy when compared to the control group G1. These findings indicate that a low dose of ZA alone, released in a controlled manner from within a fenestrated implant is enough to improve implant anchorage without the need of adding rhBMP-2. This simple method of using a fenestrated implant containing a ceramic carrier releasing bone active molecules improved bone anchorage and could clinically reduce prosthetic failure. STATEMENT OF SIGNIFICANCE: Aseptic loosening remains as a major cause for implant revisions and early reaction of surrounding bone to the prosthesis is important for longevity. A novel approach to enhance early bone-implant anchorage is presented. The implant is filled with a carrier providing controlled release of bone active molecules. In an animal model, a calcium sulphate (CaS)/hydroxyapatite (HA) carrier was used to provide a spatio-temporal release of bone morphogenic protein-2 (BMP-2) and zoledronic acid (ZA). Significantly better bone-implant integration was achieved using ZA alone, thereby eliminating the need for adding BMP-2. The developed method of implant biomodulation holds potential to prevent implant loosening and is an alternative to prosthetic coatings or systemic drug treatment. Importantly, all constituents are approved for clinical use.
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Abstract
Background and purpose - Patient-reported outcome (PRO) in total knee arthroplasty (TKA) patients with high body mass index (BMI) is controversial. We compared pain, function, quality of life, general health, and satisfaction among different BMI categories preoperatively and 1 year after primary TKA. Patients and methods - 4,318 patients were operated with a TKA for knee osteoarthritis in the Region of Skane in 2013-2015. In all, 3,327 patients (77%) had complete PRO data and information on BMI and were included. Preoperatively the patients filled in the Knee injury and Osteoarthritis Outcome Score (KOOS) and EQ-VAS (general health). 1 year postoperatively the same questionnaires were filled in together with a question asking whether they were satisfied with the surgery. Information on age, sex, BMI, and ASA grade were obtained from the Swedish Knee Arthroplasty Register. Each patient was classified as Outcome Measures in Rheumatology- Osteoarthritis Research Society International (OMERACT-OARSI) responder or not based on a combination of absolute and relative changes in scores. Welch's t-test and a chi-square test were used in the statistical analysis. Results - Both preoperatively and 1 year postoperatively the obese patients reported somewhat worse scores than the normal weight and overweight. The differences were small with 1 exception, the KOOS sport- and recreation function postoperatively, where normal-weight and overweight patients reported fewer problems than obese patients with a BMI over 35 (40 and 39 points vs. 31 points, p < 0.001). Similar proportions of patients were satisfied and categorized as OMERACT-OARSI responders in the different BMI categories. Interpretation - The degree of improvement in PROs 1 year after TKA surgery does not seem to be affected by BMI.
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Affiliation(s)
- Anders Overgaard
- The Parker Institute, Copenhagen University Hospital Fredriksberg, Copenhagen, Denmark; ,Correspondence:
| | - Lars Lidgren
- The Swedish Knee Arthroplasty Register, Lund, Sweden; ,Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lund, Sweden
| | - Martin Sundberg
- The Swedish Knee Arthroplasty Register, Lund, Sweden; ,Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lund, Sweden
| | - Otto Robertsson
- The Swedish Knee Arthroplasty Register, Lund, Sweden; ,Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lund, Sweden
| | - Annette W-Dahl
- The Swedish Knee Arthroplasty Register, Lund, Sweden; ,Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopaedics, Lund, Sweden
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Abstract
Objectives The aim of this study was to analyze drain fluid, blood, and urine simultaneously to follow the long-term release of vancomycin from a biphasic ceramic carrier in major hip surgery. Our hypothesis was that there would be high local vancomycin concentrations during the first week with safe low systemic trough levels and a complete antibiotic release during the first month. Methods Nine patients (six female, three male; mean age 75.3 years (sd 12.3; 44 to 84)) with trochanteric hip fractures had internal fixations. An injectable ceramic bone substitute, with hydroxyapatite in a calcium sulphate matrix, containing 66 mg of vancomycin per millilitre, was inserted to augment the fixation. The vancomycin elution was followed by simultaneously collecting drain fluid, blood, and urine. Results The antibiotic concentration in the drain reached a peak during the first six hours post-surgery (mean 966.1 mg/l), which decreased linearly to a mean value of 88.3 mg/l at 2.5 days. In the urine, the vancomycin concentration reached 99.8 mg/l during the first two days, followed by a logarithmic decrease over the next two weeks to reach 0 mg/l at 20 days. The systemic concentration of vancomycin measured in blood serum was low and decreased linearly from 2.17 mg/l at one hour post-surgery to 0 mg/l at four days postoperatively. Conclusion This is the first long-term pharmacokinetic study that reports vancomycin release from a biphasic injectable ceramic bone substitute. The study shows initial high targeted local vancomycin levels, sustained and complete release at three weeks, and systemic concentrations well below toxic levels. The plain ceramic bone substitute has been proven to regenerate bone but should also be useful in preventing bone infection. Cite this article: M. Stravinskas, M. Nilsson, A. Vitkauskiene, S. Tarasevicius, L. Lidgren. Vancomycin elution from a biphasic ceramic bone substitute. Bone Joint Res 2019;8:49–54. DOI: 10.1302/2046-3758.82.BJR-2018-0174.R2.
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Affiliation(s)
- M Stravinskas
- Orthopaedic Surgeon, Lithuanian University of Health, Kaunas, Lithuania
| | - M Nilsson
- Department of Orthopedics, Lund University Hospital, Lund, Sweden
| | - A Vitkauskiene
- Orthopaedic Surgeon, Lithuanian University of Health, Kaunas, Lithuania
| | - S Tarasevicius
- Orthopaedic Surgeon, Lithuanian University of Health, Kaunas, Lithuania
| | - L Lidgren
- Department of Orthopedics, Lund University Hospital, Lund, Sweden
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30
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Kok J, Širka A, Grassi L, Raina DB, Tarasevičius Š, Tägil M, Lidgren L, Isaksson H. Fracture strength of the proximal femur injected with a calcium sulfate/hydroxyapatite bone substitute. Clin Biomech (Bristol, Avon) 2019; 63:172-178. [PMID: 30903873 DOI: 10.1016/j.clinbiomech.2019.03.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/05/2019] [Accepted: 03/11/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Available interventions for preventing fragility hip fractures show limited efficacy. Injection of a biomaterial as bone substitute could increase the fracture strength of the hip. This study aimed to show the feasibility of injecting a calcium sulfate/hydroxyapatite based biomaterial in the femoral neck and to calculate the consequent change in strength using the finite element method. METHODS Five patients were injected with 10 ml calcium sulfate/hydroxyapatite in their femoral neck. Quantitative CT scans were taken before and after injection. Five additional patients with fragility hip fractures were also scanned and the images from the non-fractured contralateral sides were used. Finite element models were created for all proximal femora with and without injection and the models were tested under stance and sideways fall loading until fracture. The change in fracture strength caused by the injection was calculated. Additionally, perturbations in volume, location, and stiffness of the injected material were created to investigate their contribution to the fracture strength increase. FINDINGS The 10 ml injection succeeded in all patients. Baseline simulations showed theoretical fracture strength increases of 0-9%. Volume increase, change in location and increase in stiffness of the material led to increases in fracture strength of 1-27%, -8-26% and 0-17%, respectively. Altering the location of the injection to a more lateral position and increasing the stiffness of the material led to increases in fracture strength of up to 42%. INTERPRETATION This study shows that an injection of calcium sulfate/hydroxyapatite is feasible and can theoretically increase the hip's fracture strength.
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Affiliation(s)
- Joeri Kok
- Department of Biomedical Engineering, Lund University, Box 118, 221 00 Lund, Sweden.
| | - Aurimas Širka
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, A. Mickevičiaus g. 9, LT 44307 Kaunas, Lithuania
| | - Lorenzo Grassi
- Department of Biomedical Engineering, Lund University, Box 118, 221 00 Lund, Sweden.
| | - Deepak Bushan Raina
- Department of Orthopedics, Clinical Sciences, Lund University, Box 118, 221 00 Lund, Sweden.
| | - Šarūnas Tarasevičius
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, A. Mickevičiaus g. 9, LT 44307 Kaunas, Lithuania
| | - Magnus Tägil
- Department of Orthopedics, Clinical Sciences, Lund University, Box 118, 221 00 Lund, Sweden.
| | - Lars Lidgren
- Department of Orthopedics, Clinical Sciences, Lund University, Box 118, 221 00 Lund, Sweden
| | - Hanna Isaksson
- Department of Biomedical Engineering, Lund University, Box 118, 221 00 Lund, Sweden; Department of Orthopedics, Clinical Sciences, Lund University, Box 118, 221 00 Lund, Sweden.
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Bauer TW, Bedair H, Creech JD, Deirmengian C, Eriksson H, Fillingham Y, Grigoryan G, Hickok N, Krenn V, Krenn V, Lazarinis S, Lidgren L, Lonner J, Odum S, Shah J, Shahi A, Shohat N, Tarabichi M, W-Dahl A, Wongworawat MD. Hip and Knee Section, Diagnosis, Laboratory Tests: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S351-S359. [PMID: 30343973 DOI: 10.1016/j.arth.2018.09.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Sezgin EA, Robertsson O, W-Dahl A, Lidgren L. Nonagenarians qualify for total knee arthroplasty: a report on 329 patients from the Swedish Knee Arthroplasty Register 2000-2016. Acta Orthop 2019; 90:53-59. [PMID: 30334634 PMCID: PMC6366462 DOI: 10.1080/17453674.2018.1530173] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 02/08/2023] Open
Abstract
Background and purpose - The nonagenarian (those aged 90 years and older) population is expected to double in the next 20 years. This demographic age quake may have a significant impact on the incidence of total knee arthroplasty (TKA), although current literature provides limited data. We examined death and revision rates, patient-reported outcomes (PROs) and bias on patient selection of nonagenarian patients operated on with TKA for osteoarthritis (OA) between 2000 and 2016. Patients and methods - The Swedish national knee arthroplasty register was used to identify 329 nonagenarians (mean age, 92 years). Each patient was followed-up until death or the end of 2017. PRO data of 22 of these patients were compared with 65- to 74-year-old patients operated in 2015, from the same register. Results - 5 patients (1.5%) died within 90 days and 23 (7%) patients died within 365 days after TKA. 8 patients (2.4%) developed knee complications that needed revision. For patients followed for 5 and 10 years, more than 50% and 10%, respectively, lived without being revised. The patients had statistically significant improvements in PROs, not significantly different from the younger SKAR cohort. However, the material is small and this statistical finding does not preclude that there may be clinically relevant differences. TKA incidence was different amongst the 21 counties in the country (range, 0-5.1/10,000). Interpretation - Our study suggests that nonagenarians with knee OA qualify for TKA, having similar outcomes to younger patients. The data presented may help surgeons and patients assessing the risks and outcome associated with the procedure.
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Affiliation(s)
- Erdem A Sezgin
- Gazi University, Faculty of Medicine, Department of Orthopedics and Traumatology, Ankara, Turkey;;
| | - Otto Robertsson
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden;; ,The Swedish Knee Arthroplasty Register, Lund, Sweden
| | - Annette W-Dahl
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden;; ,The Swedish Knee Arthroplasty Register, Lund, Sweden
| | - Lars Lidgren
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden;; ,The Swedish Knee Arthroplasty Register, Lund, Sweden,Correspondence:
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Teotia AK, Raina DB, Isaksson H, Tägil M, Lidgren L, Seppälä J, Kumar A. Composite bilayered scaffolds with bio-functionalized ceramics for cranial bone defects: An in vivo evaluation. ACTA ACUST UNITED AC 2019. [DOI: 10.1088/2399-7532/aafc5b] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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34
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Stravinskas M, Tarasevicius S, Laukaitis S, Nilsson M, Raina DB, Lidgren L. A ceramic bone substitute containing gentamicin gives good outcome in trochanteric hip fractures treated with dynamic hip screw and in revision of total hip arthroplasty: a case series. BMC Musculoskelet Disord 2018; 19:438. [PMID: 30522476 PMCID: PMC6284312 DOI: 10.1186/s12891-018-2360-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 11/22/2018] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The primary objective was to investigate the clinical and radiological outcome in patients undergoing major hip surgery using a novel antibiotic containing bone substitute for local augmentation in trochanteric fracture fixation or revision of total hip arthroplasty (THA). METHODS We implanted a novel biphasic bone substitute CERAMENT™|G consisting of hydroxyapatite, calcium sulphate and gentamicin for bone regeneration and local antibiotic delivery in 20 patients treated surgically for trochanteric femoral fracture or uncemented hip revision. Preoperative, postoperative, 3 months and 1 year clinical and radiological assessment were performed including registration of any complications. In one trochanteric fracture patient, histological analyses were performed of bone biopsies taken at removal of hardware. RESULTS None of the trochanteric fractures or revision of THA showed any large migration. No local wound disturbances were seen and no infection was observed at one year follow-up. All trochanteric fractures healed at 3 months with a minimal sliding screw displacement on average 3 mm. Radiological analysis showed signs of bone remodeling and new bone formation in the substitute, illustrated also by histology in the biopsies taken from one trochanteric fracture at one year post-op. CONCLUSIONS Local CERAMENT™|G was shown to be safe in a limited prospective major hip surgery study. Remodeling of the bone graft substitute was observed in all patients. TRIAL REGISTRATION EU-CTR2018-004414-18 Retrospectively registered on November 20, 2018.
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MESH Headings
- Aged
- Aged, 80 and over
- Anti-Bacterial Agents/administration & dosage
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/instrumentation
- Arthroplasty, Replacement, Hip/methods
- Bone Remodeling
- Bone Screws
- Bone Substitutes
- Calcium Sulfate
- Drug Combinations
- Durapatite
- Feasibility Studies
- Female
- Follow-Up Studies
- Fracture Fixation, Internal/adverse effects
- Fracture Fixation, Internal/instrumentation
- Fracture Fixation, Internal/methods
- Gentamicins/administration & dosage
- Hip/diagnostic imaging
- Hip/surgery
- Hip Fractures/diagnostic imaging
- Hip Fractures/surgery
- Humans
- Male
- Middle Aged
- Osteogenesis
- Postoperative Complications
- Prospective Studies
- Radiography
- Reoperation/adverse effects
- Reoperation/instrumentation
- Reoperation/methods
- Treatment Outcome
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Affiliation(s)
| | | | | | - Malin Nilsson
- Department of Orthopedics, Lund University Hospital, Lund, Sweden
| | | | - Lars Lidgren
- Department of Orthopedics, Lund University Hospital, Lund, Sweden
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Abstract
During the last decades, several research groups have used bisphosphonates for local application to counteract secondary bone resorption after bone grafting, to improve implant fixation or to control bone resorption caused by bone morphogenetic proteins (BMPs). We focused on zoledronate (a bisphosphonate) due to its greater antiresorptive potential over other bisphosphonates. Recently, it has become obvious that the carrier is of importance to modulate the concentration and elution profile of the zoledronic acid locally. Incorporating one fifth of the recommended systemic dose of zoledronate with different apatite matrices and types of bone defects has been shown to enhance bone regeneration significantly in vivo. We expect the local delivery of zoledronate to overcome the limitations and side effects associated with systemic usage; however, we need to know more about the bioavailability and the biological effects. The local use of BMP-2 and zoledronate as a combination has a proven additional effect on bone regeneration. This review focuses primarily on the local use of zoledronate alone, or in combination with bone anabolic factors, in various preclinical models mimicking different orthopaedic conditions. Cite this article: I. Qayoom, D. B. Raina, A. Širka, Š. Tarasevičius, M. Tägil, A. Kumar, L. Lidgren. Anabolic and antiresorptive actions of locally delivered bisphosphonates for bone repair: A review. Bone Joint Res 2018;7:548–560. DOI: 10.1302/2046-3758.710.BJR-2018-0015.R2.
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Affiliation(s)
- I Qayoom
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology, Kanpur, India
| | - D B Raina
- Department of Orthopedics, The Medical Faculty, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - A Širka
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Š Tarasevičius
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - M Tägil
- Department of Orthopedics, The Medical Faculty, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - A Kumar
- Department of Biological Sciences and Bioengineering; Centre for Environmental Sciences and Engineering; Centre for Nanosciences, Indian Institute of Technology Kanpur, Kanpur, India
| | - L Lidgren
- Department of Orthopedics, The Medical Faculty, Clinical Sciences Lund, Lund University, Lund, Sweden
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36
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Chen P, Wu Z, Leung A, Chen X, Landao-Bassonga E, Gao J, Chen L, Zheng M, Yao F, Yang H, Lidgren L, Allan B, Liu Y, Wang T, Zheng M. Fabrication of a silver nanoparticle-coated collagen membrane with anti-bacterial and anti-inflammatory activities for guided bone regeneration. Biomed Mater 2018; 13:065014. [DOI: 10.1088/1748-605x/aae15b] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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37
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Malchau H, Garellick G, Berry D, Harris WH, Robertson O, Kärrlholm J, Lewallen D, Bragdon CR, Lidgren L, Herberts P. Arthroplasty implant registries over the past five decades: Development, current, and future impact. J Orthop Res 2018; 36:2319-2330. [PMID: 29663575 DOI: 10.1002/jor.24014] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [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: 09/12/2017] [Accepted: 03/30/2018] [Indexed: 02/04/2023]
Abstract
Local, regional, and national registries have played an important role in the development of hip and knee arthroplasty and the treatment of patients with various maladies of these joints. Four arthroplasty registries stand out as leading forces behind the drive to popularize the use of registries and pursue the concept of evidence based medicine. The Mayo registry, started by Mark Coventry, is recognized as the oldest continuing registry for arthroplasty. The Harris Registry at Massachusetts General Hospital, along with the Mayo Registry, has greatly contributed to the advancement of arthroplasty surgery and have served an important role of identifying poorly performing implants and techniques in the United States. The Swedish Knee Arthroplasty Registry is the oldest national registry dedicated to joint arthroplasty and along with the Swedish Hip Arthroplasty Registry have established the infrastructure, analysis and reporting mechanisms, and leadership that has enabled other countries to subsequently develop national registries around the world. As more countries have adopted the concept of national registries, a new area of research is possible by pooling the resources of large registries as is now occurring with the Nordic countries. Several international organizations have been formed to promote future collaboration and develop international standards. The process of globalization of registries is a result of continued efforts over the past 50 years in improving and disseminating the knowledge gained from the early registries. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2319-2330, 2018.
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Affiliation(s)
- Henrik Malchau
- Sahlgrenska University Hospital, Molndal, Sweden.,Swedish Hip Arthroplasty Register Goteborg, Sweden.,Massachusetts General Hospital, Boston, Massachusetts
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38
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Širka A, Raina DB, Isaksson H, Tanner KE, Smailys A, Kumar A, Tarasevičius Š, Tägil M, Lidgren L. Calcium Sulphate/Hydroxyapatite Carrier for Bone Formation in the Femoral Neck of Osteoporotic Rats. Tissue Eng Part A 2018; 24:1753-1764. [PMID: 29855219 PMCID: PMC6302674 DOI: 10.1089/ten.tea.2018.0075] [Citation(s) in RCA: 12] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This study investigated bone regeneration in the femoral neck canal of osteoporotic rats using a novel animal model. A calcium sulphate (CS)/hydroxyapatite (HA) carrier was used to deliver a bisphosphonate, zoledronic acid (ZA), locally, with or without added recombinant human bone morphogenic protein-2 (rhBMP-2). Twenty-eight-week-old ovariectomized Sprague–Dawley rats were used. A 1 mm diameter and 8 mm long defect was created in the femoral neck by drilling from the lateral cortex in the axis of the femoral neck, leaving the surrounding cortex intact. Three treatment groups and one control group were used: (1) CS/HA alone, (2) CS/HA + ZA (10 μg) (3) CS/HA + ZA (10 μg) + rhBMP-2 (4 μg), and (4) empty defect (control). The bone formation was assessed at 4 weeks post surgery using in vivo micro computed tomography (micro-CT). At 8 weeks post surgery, the animals were sacrificed, and both defect and contralateral femurs were subjected to micro-CT, mechanical testing, and histology. Micro-CT results showed that the combination of CS/HA with ZA or ZA + rhBMP-2 increased the bone formation in the defect when compared to the other groups and to the contralateral hips. Evidence of new dense bone formation in CS/HA + ZA and CS/HA + ZA + rhBMP-2 groups was seen histologically. Mechanical testing results showed no differences in the load to fracture between the treatments in either of the treated or contralateral legs. The CS/HA biomaterial can be used as a carrier for ZA and rhBMP-2 to regenerate bone in the femoral neck canal of osteoporotic rats.
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Affiliation(s)
- Aurimas Širka
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania.,Department of Clinical Sciences Lund, Orthopedics, Faculty of Medicine; Lund University, Lund, Sweden
| | - Deepak Bushan Raina
- Department of Clinical Sciences Lund, Orthopedics, Faculty of Medicine; Lund University, Lund, Sweden
| | - Hanna Isaksson
- Department of Clinical Sciences Lund, Orthopedics, Faculty of Medicine; Lund University, Lund, Sweden.,Department of Biomedical Engineering; Lund University, Lund, Sweden
| | - K Elizabeth Tanner
- Department of Clinical Sciences Lund, Orthopedics, Faculty of Medicine; Lund University, Lund, Sweden.,School of Engineering, University of Glasgow, Glasgow, United Kingdom
| | - Alfredas Smailys
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ashok Kumar
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Uttar Pradesh, India
| | - Šarūnas Tarasevičius
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Magnus Tägil
- Department of Clinical Sciences Lund, Orthopedics, Faculty of Medicine; Lund University, Lund, Sweden
| | - Lars Lidgren
- Department of Clinical Sciences Lund, Orthopedics, Faculty of Medicine; Lund University, Lund, Sweden
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39
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Stravinskas M, Nilsson M, Horstmann P, Petersen MM, Tarasevicius S, Lidgren L. Antibiotic Containing Bone Substitute in Major Hip Surgery: A Long Term Gentamicin Elution Study. J Bone Jt Infect 2018; 3:68-72. [PMID: 29761068 PMCID: PMC5949569 DOI: 10.7150/jbji.23901] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 11/17/2017] [Accepted: 03/12/2018] [Indexed: 11/13/2022] Open
Abstract
Objectives: The objective is to present the antibiotic elution from a locally implanted gentamicin containing hydroxyapatite and calcium sulphate bone substitute with an extended follow up of 30 days. We also compare the pharmacokinetics of the ceramic bone substitute with a published study on gentamicin containing poly (methyl methacrylate) (PMMA) bone cement used in primary total hip arthroplasty. Methods: Gentamicin release was measured in the urine for a month and the serum for 4 days in 10 patients operated for trochanteric hip fractures and 10 patients in uncemented hip revisions. 17 patients were followed up at one year and 3 patients at 6 months. Results and Discussion: The gentamicin concentrations measured in serum were low and approximately 100 times less than in urine during the first days, indicating high local concentrations at the implant site. The elution from the biphasic bone substitute showed a stronger burst and higher gentamicin concentrations for the first week compared to that reported for PMMA used in hip arthroplasty. Also, for the bone substitute a complete gentamicin elution was obtained after 30 days, while for the PMMA cement sub-inhibitory MIC levels of gentamicin were still present in urine 60 days past surgery. No infections were detected. Conclusions: A new biphasic bone substitute containing antibiotics could potentially be used to prevent infection in patients treated for trochanteric hip fractures or uncemented hip revisions. The gentamicin elution from the bone substitute is efficient with high initial local gentamicin concentrations and complete release at 30 days.
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Affiliation(s)
| | - Malin Nilsson
- Dept of Orthopedics, Lund University Hospital, Lund, Sweden
| | - Peter Horstmann
- Dept of Orthopedics, Rigshospitalet, University of Copenhagen, Denmark
| | | | | | - Lars Lidgren
- Dept of Orthopedics, Lund University Hospital, Lund, Sweden
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40
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Raina DB, Larsson D, Mrkonjic F, Isaksson H, Kumar A, Lidgren L, Tägil M. Gelatin- hydroxyapatite- calcium sulphate based biomaterial for long term sustained delivery of bone morphogenic protein-2 and zoledronic acid for increased bone formation: In-vitro and in-vivo carrier properties. J Control Release 2018; 272:83-96. [DOI: 10.1016/j.jconrel.2018.01.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 12/30/2017] [Accepted: 01/08/2018] [Indexed: 12/11/2022]
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41
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Horstmann PF, Raina DB, Isaksson H, Hettwer W, Lidgren L, Petersen MM, Tägil M. Composite Biomaterial as a Carrier for Bone-Active Substances for Metaphyseal Tibial Bone Defect Reconstruction in Rats. Tissue Eng Part A 2017; 23:1403-1412. [DOI: 10.1089/ten.tea.2017.0040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Peter Frederik Horstmann
- Department of Orthopedics, Clinical Sciences, Lund University, Lund University Hospital, Lund, Sweden
- Department of Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Deepak Bushan Raina
- Department of Orthopedics, Clinical Sciences, Lund University, Lund University Hospital, Lund, Sweden
| | - Hanna Isaksson
- Department of Orthopedics, Clinical Sciences, Lund University, Lund University Hospital, Lund, Sweden
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | - Werner Hettwer
- Department of Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lars Lidgren
- Department of Orthopedics, Clinical Sciences, Lund University, Lund University Hospital, Lund, Sweden
| | - Michael Mørk Petersen
- Department of Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Magnus Tägil
- Department of Orthopedics, Clinical Sciences, Lund University, Lund University Hospital, Lund, Sweden
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Robertsson O, Thompson O, W-Dahl A, Sundberg M, Lidgren L, Stefánsdóttir A. Higher risk of revision for infection using systemic clindamycin prophylaxis than with cloxacillin. Acta Orthop 2017; 88:562-567. [PMID: 28492106 PMCID: PMC5560222 DOI: 10.1080/17453674.2017.1324677] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 04/10/2017] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Clindamycin has not been compared with other antibiotics for prophylaxis in arthroplasty. Since 2009, the Swedish Knee Arthroplasty Register (SKAR) has been collecting information on the prophylactic antibiotic regime used at every individual operation. In Sweden, when there is allergy to penicillin, clindamycin has been the recommended alternative. We examined whether there were differences in the rate of revision due to infection depending on which antibiotic was used as systemic prophylaxis. Patients and methods - Patients who had a total knee arthroplasty (TKA) performed due to osteoarthritis (OA) during the years 2009-2015 were included in the study. Information on which antibiotic was used was available for 80,018 operations (55,530 patients). Survival statistics were used to calculate the rate of revision due to infection until the end of 2015, comparing the group of patients who received cloxacillin with those who received clindamycin as systemic prophylaxis. Results - Cloxacillin was used in 90% of the cases, clindamycin in 7%, and cephalosporins in 2%. The risk of being revised due to infection was higher when clindamycin was used than when cloxacillin was used (RR =1.5, 95% CI: 1.2-2.0; p = 0.001). There was no significant difference in the revision rate for other causes (p = 0.2). Interpretation - We advise that patients reporting allergic reaction to penicillin should have their allergic history explored. In the absence of a clear history of type-I allergic reaction (e.g. urticaria, anaphylaxis, or bronchospasm), we suggest the use of a third-generation cephalosporin instead of clindamycin as perioperative prophylaxis when undergoing a TKR. No recommendation can be given regarding patients with type-1 allergy.
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Affiliation(s)
- Otto Robertsson
- The Swedish Knee Arthroplasty Register, Lund University, Skåne University Hospital and Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden
| | - Olof Thompson
- Department of Infectious Diseases, Skåne University Hospital, Lund, Sweden
| | - Annette W-Dahl
- The Swedish Knee Arthroplasty Register, Lund University, Skåne University Hospital and Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden
| | - Martin Sundberg
- The Swedish Knee Arthroplasty Register, Lund University, Skåne University Hospital and Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden
| | - Lars Lidgren
- The Swedish Knee Arthroplasty Register, Lund University, Skåne University Hospital and Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden
| | - Anna Stefánsdóttir
- The Swedish Knee Arthroplasty Register, Lund University, Skåne University Hospital and Department of Clinical Sciences Lund, Orthopedics, Lund, Sweden
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Teotia AK, Raina DB, Singh C, Sinha N, Isaksson H, Tägil M, Lidgren L, Kumar A. Nano-Hydroxyapatite Bone Substitute Functionalized with Bone Active Molecules for Enhanced Cranial Bone Regeneration. ACS Appl Mater Interfaces 2017; 9:6816-6828. [PMID: 28171719 DOI: 10.1021/acsami.6b14782] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The aim of this study was to synthesize and characterize a nano-hydroxyapatite (nHAP) and calcium sulfate bone substitute (NC) for cranioplasty. The NC was functionalized with low concentrations of bone morphogenetic protein-2 (BMP-2) and zoledronic acid (ZA) and characterized both in vitro and in vivo. In vitro studies included MTT, ALP assays, and fluorescent staining of Saos-2 (human osteoblasts) and MC3T3-E1 (murine preosteoblasts) cells cultured on NC. An in vivo study divided 20 male Wistar rats into four groups: control (defect only), NC, NC + ZA, and NC + ZA + rhBMP-2. The materials were implanted in an 8.5 mm critical size defect in the calvarium for 12 weeks. Micro-CT quantitative analysis was carried out in vivo at 8 weeks and ex vivo after 12 weeks. Mineralization was highest in the NC + ZA + rhBMP-2 group (13.0 ± 2.8 mm3) compared to the NC + ZA group (9.0 ± 3.2 mm3), NC group (6.4 ± 1.9 mm3), and control group (3.4 ± 1.0 mm3) after 12 weeks. Histological and spectroscopic analysis of the defect site provided a qualitative confirmation of neo-bone, which was in agreement with the micro-CT results. In conclusion, NC can be used as a carrier for bioactive molecules, and functionalization with rhBMP-2 and ZA in low doses enhances bone regeneration.
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Affiliation(s)
- Arun Kumar Teotia
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur , Kanpur 208016, India
| | - Deepak Bushan Raina
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur , Kanpur 208016, India
- Department of Orthopedics, Clinical Sciences Lund, Lund University , Lund 221 85, Sweden
| | - Chandan Singh
- Center for Biomedical Research, SGPGIMS Campus , Lucknow 226014, India
| | - Neeraj Sinha
- Center for Biomedical Research, SGPGIMS Campus , Lucknow 226014, India
| | - Hanna Isaksson
- Department of Orthopedics, Clinical Sciences Lund, Lund University , Lund 221 85, Sweden
- Department of Biomedical Engineering, Lund University , Lund 221 00, Sweden
| | - Magnus Tägil
- Department of Orthopedics, Clinical Sciences Lund, Lund University , Lund 221 85, Sweden
| | - Lars Lidgren
- Department of Orthopedics, Clinical Sciences Lund, Lund University , Lund 221 85, Sweden
| | - Ashok Kumar
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur , Kanpur 208016, India
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Raina DB, Gupta A, Petersen MM, Hettwer W, McNally M, Tägil M, Zheng MH, Kumar A, Lidgren L. Muscle as an osteoinductive niche for local bone formation with the use of a biphasic calcium sulphate/hydroxyapatite biomaterial. Bone Joint Res 2016; 5:500-511. [PMID: 27784668 PMCID: PMC5108354 DOI: 10.1302/2046-3758.510.bjr-2016-0133.r1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [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: 05/12/2016] [Accepted: 07/29/2016] [Indexed: 12/21/2022] Open
Abstract
Objectives We have observed clinical cases where bone is formed in the overlaying muscle covering surgically created bone defects treated with a hydroxyapatite/calcium sulphate biomaterial. Our objective was to investigate the osteoinductive potential of the biomaterial and to determine if growth factors secreted from local bone cells induce osteoblastic differentiation of muscle cells. Materials and Methods We seeded mouse skeletal muscle cells C2C12 on the hydroxyapatite/calcium sulphate biomaterial and the phenotype of the cells was analysed. To mimic surgical conditions with leakage of extra cellular matrix (ECM) proteins and growth factors, we cultured rat bone cells ROS 17/2.8 in a bioreactor and harvested the secreted proteins. The secretome was added to rat muscle cells L6. The phenotype of the muscle cells after treatment with the media was assessed using immunostaining and light microscopy. Results C2C12 cells differentiated into osteoblast-like cells expressing prominent bone markers after seeding on the biomaterial. The conditioned media of the ROS 17/2.8 contained bone morphogenetic protein-2 (BMP-2 8.4 ng/mg, standard deviation (sd) 0.8) and BMP-7 (50.6 ng/mg, sd 2.2). In vitro, this secretome induced differentiation of skeletal muscle cells L6 towards an osteogenic lineage. Conclusion Extra cellular matrix proteins and growth factors leaking from a bone cavity, along with a ceramic biomaterial, can synergistically enhance the process of ectopic ossification. The overlaying muscle acts as an osteoinductive niche, and provides the required cells for bone formation. Cite this article: D. B. Raina, A. Gupta, M. M. Petersen, W. Hettwer, M. McNally, M. Tägil, M-H. Zheng, A. Kumar, L. Lidgren. Muscle as an osteoinductive niche for local bone formation with the use of a biphasic calcium sulphate/hydroxyapatite biomaterial. Bone Joint Res 2016;5:500–511. DOI: 10.1302/2046-3758.510.BJR-2016-0133.R1.
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Affiliation(s)
- D B Raina
- Department of Orthopaedics, Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, 208016, UP, India
| | - A Gupta
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, 208016, UP, India
| | - M M Petersen
- Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, 2100, Denmark
| | - W Hettwer
- Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, 2100, Denmark
| | - M McNally
- Oxford University Hospital, NHS Trust, Nuffield Orthopedic Centre, Headington, Oxford, OX3 7LD, UK
| | - M Tägil
- Department of Orthopedics, Clinical Sciences, University of Western Australia, Crawley, Australia
| | - M-H Zheng
- Centre for Orthopaedic Translational Research, School of Surgery, University of Western Australia, Crawley, Australia
| | - A Kumar
- Department of Biological Sciences and Bioengineering, Indian Institute of Technology Kanpur, Kanpur, 208016, UP, India
| | - L Lidgren
- Department of Orthopedics, Clinical Sciences, Lund University, Lund, 221 85, Sweden
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Stravinskas M, Horstmann P, Ferguson J, Hettwer W, Nilsson M, Tarasevicius S, Petersen MM, McNally MA, Lidgren L. Pharmacokinetics of gentamicin eluted from a regenerating bone graft substitute: In vitro and clinical release studies. Bone Joint Res 2016; 5:427-35. [PMID: 27678329 PMCID: PMC5047051 DOI: 10.1302/2046-3758.59.bjr-2016-0108.r1] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [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: 04/20/2016] [Accepted: 08/02/2016] [Indexed: 12/18/2022] Open
Abstract
Objectives Deep bone and joint infections (DBJI) are directly intertwined with health, demographic change towards an elderly population, and wellbeing. The elderly human population is more prone to acquire infections, and the consequences such as pain, reduced quality of life, morbidity, absence from work and premature retirement due to disability place significant burdens on already strained healthcare systems and societal budgets. DBJIs are less responsive to systemic antibiotics because of poor vascular perfusion in necrotic bone, large bone defects and persistent biofilm-based infection. Emerging bacterial resistance poses a major threat and new innovative treatment modalities are urgently needed to curb its current trajectory. Materials and Methods We present a new biphasic ceramic bone substitute consisting of hydroxyapatite and calcium sulphate for local antibiotic delivery in combination with bone regeneration. Gentamicin release was measured in four setups: 1) in vitro elution in Ringer’s solution; 2) local elution in patients treated for trochanteric hip fractures or uncemented hip revisions; 3) local elution in patients treated with a bone tumour resection; and 4) local elution in patients treated surgically for chronic corticomedullary osteomyelitis. Results The release pattern in vitro was comparable with the obtained release in the patient studies. No recurrence was detected in the osteomyelitis group at latest follow-up (minimum 1.5 years). Conclusions This new biphasic bone substitute containing antibiotics provides safe prevention of bone infections in a range of clinical situations. The in vitro test method predicts the in vivo performance and makes it a reliable tool in the development of future antibiotic-eluting bone-regenerating materials. Cite this article: M. Stravinskas, P. Horstmann, J. Ferguson, W. Hettwer, M. Nilsson, S. Tarasevicius, M. M. Petersen, M. A. McNally, L. Lidgren. Pharmacokinetics of gentamicin eluted from a regenerating bone graft substitute: In vitro and clinical release studies. Bone Joint Res 2016;5:427–435. DOI: 10.1302/2046-3758.59.BJR-2016-0108.R1.
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Affiliation(s)
- M Stravinskas
- Orthopaedic Surgeon, Lithuanian University of Health, Eivenių str. 2, LT-50009 Kaunas, Lithuania
| | - P Horstmann
- Musculoskeletal Tumor Section, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
| | - J Ferguson
- The Bone Infection Unit, Nuffield Orthopedic Centre, Oxford University Hospitals, Windmill Road, Headington, Oxford OX3 7HE, UK
| | - W Hettwer
- Musculoskeletal Tumor Section, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
| | - M Nilsson
- Department of Orthopedics, Lund University Hospital, SE-221 85 Lund, Sweden
| | - S Tarasevicius
- Orthopaedic Surgeon, Lithuanian University of Health, Eivenių str. 2, LT-50009 Kaunas, Lithuania
| | - M M Petersen
- Musculoskeletal Tumor Section, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
| | - M A McNally
- The Bone Infection Unit, Nuffield Orthopedic Centre, Oxford University Hospitals, Windmill Road, Headington, Oxford OX3 7HE, UK
| | - L Lidgren
- Department of Orthopedics, Lund University Hospital, SE-221 85 Lund, Sweden
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Abstract
Four hundred and thirty trochanteric fractures operated upon with McLaughlin, Ender or Richard's osteosynthesis were divided into 6 different types based on their radiographic appearance before and immediately after reposition with special reference to the medial cortical support. A significant correlation was found between the fracture type and subseq
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Abstract
In a clinical material of total hip prostheses, a study was performed of the range of femoral motion until impingement occurred between the neck of the femoral stem and the rim of the acetabular socket. The results were compared with the physiologic range of motion, and the clinically relevant motion restriction was measured. Restriction was most common in flexion. There was a correlation between the prosthetic design and the restriction due to impingement.
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Abstract
Computed tomography (CT) was employed to evaluate resurfacing metal cup arthroplasties, in shoulders affected by rheumatoid arthritis. Reconstruction of the information obtained, with the high frequency filter, resulted in an image of the cement and skeletal structures inside the cup. This new application of CT may prove valuable in assessing the complications and results of cup arthroplasties.
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Abstract
Eleven shoulders in 10 patients with rheumatoid arthritis were examined by conventional radiography and CT prior to cup hemiarthroplasty of the humeral head and the results were compared with the surgical findings. There was good agreement between preoperative CT and surgical findings. Humeral head cavities and erosions, with cortical boundaries, could be seen more accurately at CT than at conventional radiography. The HU of their contents corresponded to those of soft tissue, being granulomatous in nature at surgery. In 8 humeral heads CT disclosed large areas of fatty degeneration of bone marrow with HU between − 10 HU and − 76 HU that were not visible on the conventional radiographs. These “fatty cysts” had no cortical boundaries, unlike inflammatory granulomas, but both lesions may influence the surgical approach to hemiarthroplasty.
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Abstract
Impingement of the neck of the stem on to the rim of the socket may cause dislocation of the total hip prosthesis. The role of femoral anteversion in the occurrence of such impingement was analyzed in a clinical material of total hip prostheses with and without dislocation. A low femoral anteversion was linked to a clinically relevant reduction of the range of motion due to impingement and dominated in the group with dislocations. Impingement is minimized by inserting the femoral component in 10° to 20° of anteversion.
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