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Brady RD, Shultz SR, McDonald SJ, O'Brien TJ. Neurological heterotopic ossification: Current understanding and future directions. Bone 2018; 109:35-42. [PMID: 28526267 DOI: 10.1016/j.bone.2017.05.015] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 05/15/2017] [Accepted: 05/15/2017] [Indexed: 12/30/2022]
Abstract
Neurological heterotopic ossification (NHO) involves the formation of bone in soft tissue following a neurological condition, of which the most common are brain and spinal cord injuries. NHO often forms around the hip, knee and shoulder joints, causing severe pain and joint deformation which is associated with significant morbidity and reduced quality of life. The cellular and molecular events that initiate NHO have been the focus of an increasing number of human and animal studies over the past decade, with this work largely driven by the need to unearth potential therapeutic interventions to prevent the formation of NHO. This review provides an overview of the present understanding of NHO pathogenesis and pathobiology, current treatments, novel therapeutic targets, potential biomarkers and future directions.
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Affiliation(s)
- Rhys D Brady
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, VIC, 3010, Australia.
| | - Sandy R Shultz
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, VIC, 3010, Australia
| | - Stuart J McDonald
- Department of Physiology, Anatomy and Microbiology, La Trobe University, VIC, 3086, Australia
| | - Terence J O'Brien
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, VIC, 3010, Australia
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Cholok D, Chung MT, Ranganathan K, Ucer S, Day D, Davis TA, Mishina Y, Levi B. Heterotopic ossification and the elucidation of pathologic differentiation. Bone 2018; 109:12-21. [PMID: 28987285 PMCID: PMC6585944 DOI: 10.1016/j.bone.2017.09.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/27/2017] [Accepted: 09/27/2017] [Indexed: 01/23/2023]
Abstract
Tissue regeneration following acute or persistent inflammation can manifest a spectrum of phenotypes ranging from the adaptive to the pathologic. Heterotopic Ossification (HO), the endochondral formation of bone within soft-tissue structures following severe injury serves as a prominent example of pathologic differentiation; and remains a persistent clinical issue incurring significant patient morbidity and expense to adequately diagnose and treat. The pathogenesis of HO provides an intriguing opportunity to better characterize the cellular and cell-signaling contributors to aberrant differentiation. Indeed, recent work has continued to resolve the unique cellular lineages, and causative pathways responsible for ectopic bone development yielding promising avenues for the development of novel therapeutic strategies shown to be successful in analogous animal models of HO development. This review details advances in the understanding of HO in the context of inciting inflammation, and explains how these advances inform the current standards of diagnosis and treatment.
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Affiliation(s)
- David Cholok
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Michael T Chung
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Kavitha Ranganathan
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Serra Ucer
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Devaveena Day
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, USA
| | - Thomas A Davis
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, USA; Department of Surgery, Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Yuji Mishina
- School of Dentistry, University of Michigan, Ann Arbor, MI, USA
| | - Benjamin Levi
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA.
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Abstract
In 16 years of conflict, primarily in Iraq and Afghanistan, wounded warriors have primarily been subjected to blast type of injuries. Evacuation strategies have led to unprecedented survival rates in blast-injured soldiers, resulting in large numbers of wounded warriors with complex limb trauma. Bone and soft tissue defects have resulted in increased use of complex reconstructive algorithms to restore limbs and function. In addition, in failed salvage attempts, advances in amputation options are being developed. In this review, we summarize state-of-the-art limb-salvage methods for both soft tissue and bone. In addition, we discuss advances in diagnostic methods with development of personalized clinical decision support tools designed to optimize outcomes after severe blast injuries. Finally, we present new advances in osteointegrated prostheses for above-knee amputations.
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Convente MR, Chakkalakal SA, Yang E, Caron RJ, Zhang D, Kambayashi T, Kaplan FS, Shore EM. Reply to: Macrophages Driving Heterotopic Ossification: Convergence of Genetically-Driven and Trauma-Driven Mechanisms. J Bone Miner Res 2018; 33:367-368. [PMID: 29194751 DOI: 10.1002/jbmr.3349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 11/20/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Michael R Convente
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Salin A Chakkalakal
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - EnJun Yang
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert J Caron
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Deyu Zhang
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Taku Kambayashi
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eileen M Shore
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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55
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Convente MR, Chakkalakal SA, Yang E, Caron RJ, Zhang D, Kambayashi T, Kaplan FS, Shore EM. Depletion of Mast Cells and Macrophages Impairs Heterotopic Ossification in an Acvr1 R206H Mouse Model of Fibrodysplasia Ossificans Progressiva. J Bone Miner Res 2018; 33:269-282. [PMID: 28986986 PMCID: PMC7737844 DOI: 10.1002/jbmr.3304] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 09/27/2017] [Accepted: 10/05/2017] [Indexed: 02/06/2023]
Abstract
Heterotopic ossification (HO) is a clinical condition that often reduces mobility and diminishes quality of life for affected individuals. The most severe form of progressive HO occurs in those with fibrodysplasia ossificans progressiva (FOP; OMIM #135100), a genetic disorder caused by a recurrent heterozygous gain-of-function mutation (R206H) in the bone morphogenetic protein (BMP) type I receptor ACVR1/ALK2. In individuals with FOP, episodes of HO frequently follow injury. The first sign of active disease is commonly an inflammatory "flare-up" that precedes connective tissue degradation, progenitor cell recruitment, and endochondral HO. We used a conditional-on global knock-in mouse model expressing Acvr1R206H (referred to as Acvr1cR206H/+ ) to investigate the cellular and molecular inflammatory response in FOP lesions following injury. We found that the Acvr1 R206H mutation caused increased BMP signaling in posttraumatic FOP lesions and early divergence from the normal skeletal muscle repair program with elevated and prolonged immune cell infiltration. The proinflammatory cytokine response of TNFα, IL-1β, and IL-6 was elevated and prolonged in Acvr1cR206H/+ lesions and in Acvr1cR206H/+ mast cells. Importantly, depletion of mast cells and macrophages significantly impaired injury-induced HO in Acvr1cR206H/+ mice, reducing injury-induced HO volume by ∼50% with depletion of each cell population independently, and ∼75% with combined depletion of both cell populations. Together, our data show that the immune system contributes to the initiation and development of HO in FOP. Further, the expression of Acvr1R206H in immune cells alters cytokine expression and cellular response to injury and unveils novel therapeutic targets for treatment of FOP and nongenetic forms of HO. © 2017 American Society for Bone and Mineral Research.
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Affiliation(s)
- Michael R Convente
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Salin A Chakkalakal
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - EnJun Yang
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert J Caron
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Deyu Zhang
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Taku Kambayashi
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Frederick S Kaplan
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eileen M Shore
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,The Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Clayman E, Abbassi B, Watt A, Payne W. Heterotopic Ossification: A Late Complication From a Chemical Burn. EPLASTY 2018; 18:ic3. [PMID: 29391922 PMCID: PMC5773936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Eric Clayman
- aUniversity of South Florida Morsani College of Medicine, Tampa
| | - Bahar Abbassi
- bDivision of Plastic Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa,Correspondence:
| | - Anthony W. Watt
- bDivision of Plastic Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa
| | - Wyatt G. Payne
- bDivision of Plastic Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa,cC. W. Bill Young Bay Pines VA Medical Center, Bay Pines, Fla
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Seavey JG, Wheatley BM, Pavey GJ, Tomasino AM, Hanson MA, Sanders EM, Dey D, Moss KL, Potter BK, Forsberg JA, Qureshi AT, Davis TA. Early local delivery of vancomycin suppresses ectopic bone formation in a rat model of trauma-induced heterotopic ossification. J Orthop Res 2017; 35:2397-2406. [PMID: 28390182 DOI: 10.1002/jor.23544] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 02/09/2017] [Indexed: 02/04/2023]
Abstract
Heterotopic ossification (HO) is a debilitating sequela of high-energy injuries. It frequently requires surgical excision once symptomatic and there is no practical prophylaxis for combat-injured patients. In this study, we examined the effect of local vancomycin powder on HO formation in a small animal model of blast-related, post-traumatic HO. Male Sprague-Dawley rats were subjected to a polytraumatic extremity injury and amputation with or without methicillin-resistant Staphylococcus aureus infection. Animals were randomized to receive a single local application of vancomycin (20 mg/kg) at the time of injury (POD-0, n = 34) or on postoperative day-3 (POD-3, n = 11). Quantitative volumetric measurement of ectopic bone was calculated at 12-weeks post-injury by micro-CT. Bone marrow and muscle tissues were also collected to determine the bacterial burden. Blood for serum cytokine analysis was collected at baseline and post-injury. Vancomycin treatment on POD-0 suppressed HO formation by 86% and prevented bone marrow and soft tissue infections. We concurrently observed a marked reduction histologically in nonviable tissue, chronic inflammatory cell infiltrates, bone infection, fibrous tissue, and areas of bone necrosis within this same cohort. Delayed treatment was significantly less efficacious. Neither treatment had a marked effect on the production of pro-inflammatory cytokines. Our study demonstrates that local vancomycin treatment at the time of injury significantly reduces HO formation in both the presence and absence of infection, with decreased efficacy if not given early. These findings further support the concept that the therapeutic window for prophylaxis is narrow, highlighting the need to develop early treatment strategies for clinical management. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2397-2406, 2017.
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Affiliation(s)
- Jonathan G Seavey
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland.,Orthopaedics, USU-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Benjamin M Wheatley
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland.,Orthopaedics, USU-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Gabriel J Pavey
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland.,Orthopaedics, USU-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Allison M Tomasino
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Margaret A Hanson
- Department of Pathology, Naval Medical Research Center, Silver Spring, Maryland
| | - Erin M Sanders
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Devaveena Dey
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Kaitlyn L Moss
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Benjamin K Potter
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland.,Orthopaedics, USU-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Jonathan A Forsberg
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland.,Orthopaedics, USU-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Ammar T Qureshi
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Thomas A Davis
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland.,Orthopaedics, USU-Walter Reed Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
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Makrantonaki E, Wlaschek M, Scharffetter-Kochanek K. Pathogenesis of wound healing disorders in the elderly. J Dtsch Dermatol Ges 2017; 15:255-275. [PMID: 28252848 DOI: 10.1111/ddg.13199] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 12/21/2016] [Indexed: 12/25/2022]
Abstract
The elderly constitute the age group most susceptible to wound healing disorders and chronic wounds, the most prevalent being venous leg ulcers, pressure ulcers, and diabetic foot ulcers. However, other age-associated diseases should also be taken into consideration in the diagnostic workup of chronic wounds, and not be underestimated. A better understanding of the pathomechanisms involved in the wound healing process is of key importance in combatting the difficulties associated with the treatment of chronic wounds. In recent decades, considerable progress has been made in the development of pioneering therapeutic strategies for chronic wounds. In this context, the use of growth factors and cytokines, tissue engineering, and cell therapy - including stem cells - have proven very promising. Nevertheless, prior to their introduction into routine clinical practice, large controlled clinical trials are required to assess the safety of these techniques.
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Affiliation(s)
| | - Meinhard Wlaschek
- Department of Dermatology and Allergic Diseases, University Medical Center Ulm
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Qureshi AT, Dey D, Sanders EM, Seavey JG, Tomasino AM, Moss K, Wheatley B, Cholok D, Loder S, Li J, Levi B, Davis TA. Inhibition of Mammalian Target of Rapamycin Signaling with Rapamycin Prevents Trauma-Induced Heterotopic Ossification. THE AMERICAN JOURNAL OF PATHOLOGY 2017; 187:2536-2545. [PMID: 29029772 DOI: 10.1016/j.ajpath.2017.07.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 07/18/2017] [Accepted: 07/26/2017] [Indexed: 12/27/2022]
Abstract
A pressing clinical need exists for 63% to 65% of combat-wounded service members and 11% to 20% of civilians who develop heterotopic ossification (HO) after blast-related extremity injury and traumatic injuries, respectively. The mammalian target of rapamycin pathway is a central cellular sensor of injury. We evaluated the prophylactic effects of rapamycin, a selective inhibitor of mammalian target of rapamycin signaling, on HO formation in a rat model of blast-related, polytraumatic extremity injury. Rapamycin was administered intraperitoneally daily for 14 days at 0.5 mg/kg or 2.5 mg/kg. Ectopic bone formation was monitored by micro-computed tomography and confirmed by histologic examination. Connective tissue progenitor cells, platelet-derived growth factor receptor-α-positive cells, and α-smooth muscle actin-positive blood vessels were assayed at postoperative day 7 by colony formation and immunofluorescence. Early gene expression changes were determined by low-density microarray. There was significant attenuation of 1) total new bone and soft tissue ectopic bone with 0.5 mg/kg (38.5% and 14.7%) and 2.5 mg/kg rapamycin (90.3% and 82.9%), respectively, 2) connective tissue progenitor cells, 3) platelet-derived growth factor receptor-α-positive cells, 4) α-smooth muscle actin-positive blood vessels, and 5) of key extracellular matrix remodeling (CD44, Col1a1, integrins), osteogenesis (Sp7, Runx2, Bmp2), inflammation (Cxcl5, 10, IL6, Ccl2), and angiogenesis (Angpt2) genes. No wound healing complications were noted. Our data demonstrate the efficacy of rapamycin in inhibiting blast trauma-induced HO by a multipronged mechanism.
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Affiliation(s)
- Ammar T Qureshi
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Devaveena Dey
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Erin M Sanders
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Jonathan G Seavey
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland; Department of Surgery, Uniformed Services University and the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Allison M Tomasino
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Kaitlyn Moss
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Benjamin Wheatley
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland; Department of Surgery, Uniformed Services University and the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - David Cholok
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
| | - Shawn Loder
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
| | - John Li
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
| | - Benjamin Levi
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
| | - Thomas A Davis
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, Maryland; Department of Surgery, Uniformed Services University and the Walter Reed National Military Medical Center, Bethesda, Maryland.
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The traumatic bone: trauma-induced heterotopic ossification. Transl Res 2017; 186:95-111. [PMID: 28668522 PMCID: PMC6715128 DOI: 10.1016/j.trsl.2017.06.004] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/22/2017] [Accepted: 06/08/2017] [Indexed: 01/08/2023]
Abstract
Heterotopic ossification (HO) is a common occurrence after multiple forms of extensive trauma. These include arthroplasties, traumatic brain and spinal cord injuries, extensive burns in the civilian setting, and combat-related extremity injuries in the battlefield. Irrespective of the form of trauma, heterotopic bone is typically endochondral in structure and is laid down via a cartilaginous matrix. Once formed, the heterotopic bone typically needs to be excised surgically, which may result in wound healing complications, in addition to a risk of recurrence. Refinements of existing diagnostic modalities, like micro- and nano-CT are being adapted toward early intervention. Trauma-induced HO is a consequence of aberrant wound healing, systemic and local immune system activation, infections, extensive vascularization, and innervation. This intricate molecular crosstalk culminates in activation of stem cells that initiate heterotopic endochondral ossification. Development of animal models recapitulating the unique traumatic injuries has greatly facilitated the mechanistic understanding of trauma-induced HO. These same models also serve as powerful tools to test the efficacy of small molecules which specifically target the molecular pathways underlying ectopic ossification. This review summarizes the recent advances in the molecular understanding, diagnostic and treatment modalities in the field of trauma-induced HO.
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Abstract
OBJECTIVE The objective of this study was to determine the contribution of lymphatic tissue to heterotopic ossification (HO). BACKGROUND HO is the pathologic development of ectopic bone within soft tissues often following severe trauma. Characterization of the tissue niche supporting HO is critical to identifying therapies directed against this condition. Lymphangiogenesis is upregulated during incidents of trauma, thereby coincident with the niche supportive of HO. We hypothesized that lymphatic tissues play a critical role in HO formation. METHODS Mice underwent hindlimb Achilles' tendon transection and dorsal burn injury (burn/tenotomy) to induce HO. The popliteal and inguinal lymph nodes were excised ipsilateral to the tenotomy site. Flow cytometry and immunostaining were used to quantify and localize lymphoendothelium. MicroCT was used to quantify HO. RESULTS Enrichment of mature lymphatic tissues was noted 2 weeks after injury at the tendon transection sites when compared with the contralateral, intact tendon based on LYVE1+ tubules (10.9% vs 0.8%, P < 0.05). Excision of the inguinal and popliteal nodes with draining popliteal lymphatic vessel significantly decreased the presence of mature lymphoendothelium 2 weeks after injury (10.9% vs 3.3%, P < 0.05). Bone-cartilage-stromal progenitor cells (CD105+/AlphaV+/Tie2-/CD45-/CD90-/BP1-) were also significantly decreased after lymph node excision (10.2% vs 0.5%, P < 0.05). A significant decrease was noted in the volume of de novo HO present within the soft tissues (0.12 mm vs 0.02 mm). CONCLUSION These findings suggest that lymphatic vessels are intimately linked with the de novo formation bone within soft tissues following trauma, and their presence may facilitate bone formation.
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Abstract
BACKGROUND As the population grows older, the incidence and prevalence of conditions that lead to a predisposition for poor wound healing also increase. Ultimately, this increase in nonhealing wounds has led to significant morbidity and mortality with subsequent huge economic ramifications. Therefore, understanding specific molecular mechanisms underlying aberrant wound healing is of great importance. It has and will continue to be the leading pathway to the discovery of therapeutic targets, as well as diagnostic molecular biomarkers. Biomarkers may help identify and stratify subsets of nonhealing patients for whom biomarker-guided approaches may aid in healing. METHODS A series of literature searches were performed using Medline, PubMed, Cochrane Library, and Internet searches. RESULTS Currently, biomarkers are being identified using biomaterials sourced locally from human wounds and/or systemically using high-throughput "omics" modalities (genomic, proteomic, lipidomic, and metabolomic analysis). In this review, we highlight the current status of clinically applicable biomarkers and propose multiple steps in validation and implementation spectrum, including those measured in tissue specimens, for example, β-catenin and c-myc, wound fluid, matrix metalloproteinases and interleukins, swabs, wound microbiota, and serum, for example, procalcitonin and matrix metalloproteinases. CONCLUSIONS Identification of numerous potential biomarkers using different avenues of sample collection and molecular approaches is currently underway. A focus on simplicity and consistent implementation of these biomarkers, as well as an emphasis on efficacious follow-up therapeutics, is necessary for transition of this technology to clinically feasible point-of-care applications.
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Sung Hsieh HH, Chung MT, Allen RM, Ranganathan K, Habbouche J, Cholok D, Butts J, Kaura A, Tiruvannamalai-Annamalai R, Breuler C, Priest C, Loder SJ, Li J, Li S, Stegemann J, Kunkel SL, Levi B. Evaluation of Salivary Cytokines for Diagnosis of both Trauma-Induced and Genetic Heterotopic Ossification. Front Endocrinol (Lausanne) 2017; 8:74. [PMID: 28484423 PMCID: PMC5401868 DOI: 10.3389/fendo.2017.00074] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 03/27/2017] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Heterotopic ossification (HO) occurs in the setting of persistent systemic inflammation. The identification of reliable biomarkers can serve as an early diagnostic tool for HO, especially given the current lack of effective treatment strategies. Although serum biomarkers have great utility, they can be inappropriate or ineffective in traumatic acute injuries and in patients with fibrodysplasia ossificans progressiva (FOP). Therefore, the goal of this study is to profile the cytokines associated with HO using a different non-invasive source of biomarkers. METHODS Serum and saliva were collected from a model of trauma-induced HO (tHO) with hind limb Achilles' tenotomy and dorsal burn injury at indicated time points (pre-injury, 48 h, 1 week, and 3 weeks post-injury) and a genetic non-trauma HO model (Nfatc1-Cre/caAcvr1fl/wt ). Samples were analyzed for 27 cytokines using the Bio-Plex assay. Histologic evaluation was performed in Nfatc1-Cre/caAcvr1fl/wt mice and at 48 h and 1 week post-injury in burn tenotomy mice. The mRNA expression levels of these cytokines at the tenotomy site were also quantified with quantitative real-time PCR. Pearson correlation coefficient was assessed between saliva and serum. RESULTS Levels of TNF-α and IL-1β peaked at 48 h and 1 week post-injury in the burn/tenotomy cohort, and these values were significantly higher when compared with both uninjured (p < 0.01, p < 0.03) and burn-only mice (p < 0.01, p < 0.01). Immunofluorescence staining confirmed enhanced expression of IL-1β, TNF-α, and MCP-1 at the tenotomy site 48 h after injury. Monocyte chemoattractant protein-1 (MCP-1) and VEGF was detected in saliva showing elevated levels at 1 week post-injury in our tHO model when compared with both uninjured (p < 0.001, p < 0.01) and burn-only mice (p < 0.005, p < 0.01). The Pearson correlation between serum MCP-1 and salivary MCP-1 was statistically significant (r = 0.9686, p < 0.001) Similarly, the Pearson correlation between serum VEGF and salivary VEGF was statistically significant (r = 0.9709, p < 0.05). CONCLUSION In this preliminary study, we characterized the diagnostic potential of specific salivary cytokines that may serve as biomarkers for an early-stage diagnosis of HO. This study identified two candidate biomarkers for further study and suggests a novel method for diagnosis in the context of current difficult diagnosis and risks of current diagnostic methods in certain patients.
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Affiliation(s)
- Hsiao Hsin Sung Hsieh
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Experimental Rheumatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Michael T. Chung
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Ronald M. Allen
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Kavitha Ranganathan
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Joe Habbouche
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - David Cholok
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jonathan Butts
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Arminder Kaura
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Chris Breuler
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Caitlin Priest
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Shawn J. Loder
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - John Li
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Shuli Li
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jan Stegemann
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Steven L. Kunkel
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Benjamin Levi
- Burn/Wound and Regenerative Medicine Laboratory, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Davies OG, Grover LM, Lewis MP, Liu Y. PDGF is a potent initiator of bone formation in a tissue engineered model of pathological ossification. J Tissue Eng Regen Med 2017; 12:e355-e367. [PMID: 27696748 PMCID: PMC6084375 DOI: 10.1002/term.2320] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 07/27/2016] [Accepted: 09/26/2016] [Indexed: 02/06/2023]
Abstract
Heterotopic ossification (HO) is a debilitating condition defined by the rapid formation of bone in soft tissues. What makes HO fascinating is first the rate at which bone is deposited, and second the fact that this bone is structurally and compositionally similar to that of a healthy adult. If the mechanisms governing HO are understood, they have the potential to be exploited for the development of potent osteoinductive therapies. With this aim, a tissue‐engineered skeletal muscle was used model to better understand the role of inflammation on this debilitating phenomenon. It was shown that myoblasts could be divided into two distinct populations: myogenic cells and undifferentiated ‘reserve’ cells. Gene expression analysis of myogenic and osteoregulatory markers confirmed that ‘reserve’ cells were primed for osteogenic differentiation but had a reduced capacity for myogenesis. Osteogenic differentiation was significantly enhanced in the presence of platelet‐derived growth factor (PDGF)‐BB and bone morphogenetic protein 2 (BMP2), and correlated with conversion to a Sca‐1+/CD73+ phenotype. Alizarin red staining showed that PDGF‐BB promoted significantly more mineral deposition than BMP2. Finally, it was shown that PDGF‐induced mineralization was blocked in the presence of the pro‐inflammatory cytokines tumour necrosis factor‐α and interleukin 1. In conclusion, the present study identified that PDGF‐BB is a potent osteoinductive factor in a model of tissue‐engineered skeletal muscle, and that the osteogenic capacity of this protein was modulated in the presence of pro‐inflammatory cytokines. These findings reveal a possible mechanism by which HO develops following trauma. Importantly, these findings have implications for the induction and control of bone formation for regenerative medicine. © 2016 The Authors Journal of Tissue Engineering and Regenerative Medicine Published by John Wiley & Sons Ltd.
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Affiliation(s)
- Owen G Davies
- Centre for Biological Engineering, Wolfson School of Mechanical and Manufacturing Engineering, Loughborough University, Loughborough, UK.,School of Sport, Exercise and Health Sciences, National Centre for Sport and Exercise Medicine (NCSEM), Arthritis Research UK Centre for Sport, Exercise and Osteoarthritis, Loughborough University, Loughborough, UK
| | - Liam M Grover
- School of Chemical Engineering, University of Birmingham, Birmingham, UK
| | - Mark P Lewis
- School of Sport, Exercise and Health Sciences, National Centre for Sport and Exercise Medicine (NCSEM), Arthritis Research UK Centre for Sport, Exercise and Osteoarthritis, Loughborough University, Loughborough, UK
| | - Yang Liu
- Centre for Biological Engineering, Wolfson School of Mechanical and Manufacturing Engineering, Loughborough University, Loughborough, UK
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Makrantonaki E, Wlaschek M, Scharffetter-Kochanek K. Pathogenese von Wundheilungsstörungen bei älteren Patienten. J Dtsch Dermatol Ges 2017; 15:255-278. [DOI: 10.1111/ddg.13199_g] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 12/21/2016] [Indexed: 01/13/2023]
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Abstract
Better understanding of the biology of heterotopic ossification (HO) formation will lead to treatment and prevention modalities that can be directed specifically at the cellular level. Early identification of HO precursor cells and target genes may provide prognostic value that guides individualized prophylactic treatment. Better understanding of molecular signaling and proteomics variability will allow surgeons to individualize preemptive treatment to suppress inflammation and formation of HO. Careful surgical technique to avoid muscle damage is important. Damaged muscle should be debrided as a prophylactic measure. Hemostasis and avoidance of a postoperative hematoma may decrease the chance of formation of HO.
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Affiliation(s)
- William R Barfield
- Department of Orthopaedics, Medical University of South Carolina, 96 Jonathan Lucas Street-Suite 708, Charleston, SC 29425, USA
| | - Robert E Holmes
- Department of Orthopaedics, Medical University of South Carolina, 96 Jonathan Lucas Street-Suite 708, Charleston, SC 29425, USA
| | - Langdon A Hartsock
- Department of Orthopaedics, Medical University of South Carolina, 96 Jonathan Lucas Street-Suite 708, Charleston, SC 29425, USA.
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Lisboa FA, Bradley MJ, Hueman MT, Schobel SA, Gaucher BJ, Styrmisdottir EL, Potter BK, Forsberg JA, Elster EA. Nonsteroidal anti-inflammatory drugs may affect cytokine response and benefit healing of combat-related extremity wounds. Surgery 2016; 161:1164-1173. [PMID: 27919449 DOI: 10.1016/j.surg.2016.10.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 10/05/2016] [Accepted: 10/15/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND After adequate operative debridement and antimicrobial therapies, combat-related extremity wounds that either heal or fail are both associated with a distinct inflammatory response. Short-term use of nonsteroidal anti-inflammatory drugs in postoperative pain management may affect this response and, by consequence, the healing potential of these wounds. We investigated whether patients treated with nonsteroidal anti-inflammatory drugs had a distinct inflammatory response; different rates of critical colonization, defined as >105 colony forming units on quantitative bacteriology; and healing potential. METHODS We retrospectively reviewed the records of 73 patients with combat-related extremity wounds. Patients were separated into 2 groups: those who received nonsteroidal anti-inflammatory drugs during the debridement period (nonsteroidal anti-inflammatory drugs group, N = 17) and those who did not (control group; N = 56). Serum and wound tissue samples collected during each operative debridement were measured for 32 known cytokines and tested for quantitative bacteriology, respectively. We compared cytokine concentrations between groups and then designed a logistic regression model to identify variables associated with successful wound healing, while controlling for known confounders. RESULTS Despite similar demographics and wound characteristics, the nonsteroidal anti-inflammatory drugs group had significant lesser concentrations of inflammatory cytokines, interleukin-2, interleukin-6, interleukin-8, and monocyte chemoattractant protein-1. On multivariate analysis, nonsteroidal anti-inflammatory drug treatment emerged as a predictor of successful wound healing after controlling for known confounders such as wound size, tobacco use, Acute Physiology and Chronic Health Evaluation II score, and critical colonization. CONCLUSION Treatment with nonsteroidal anti-inflammatory drugs for postoperative pain management after major combat-related extremity trauma is associated with lesser concentrations of inflammatory cytokines and may contribute to a more favorable inflammatory response leading to successful wound healing.
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Affiliation(s)
- Felipe A Lisboa
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD; Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD; Surgical Critical Care Initiative (SC2i), Bethesda, MD
| | - Matthew J Bradley
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD; Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD; Surgical Critical Care Initiative (SC2i), Bethesda, MD
| | - Matthew T Hueman
- Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD; Surgical Critical Care Initiative (SC2i), Bethesda, MD
| | - Seth A Schobel
- Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD; Surgical Critical Care Initiative (SC2i), Bethesda, MD
| | - Beverly J Gaucher
- Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD; Surgical Critical Care Initiative (SC2i), Bethesda, MD
| | - Edda L Styrmisdottir
- Surgical Critical Care Initiative (SC2i), Bethesda, MD; DecisionQ, Arlington, VA
| | - Benjamin K Potter
- Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD; Surgical Critical Care Initiative (SC2i), Bethesda, MD
| | - Jonathan A Forsberg
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD; Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD; Surgical Critical Care Initiative (SC2i), Bethesda, MD
| | - Eric A Elster
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD; Department of Surgery, Uniformed Services University of Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD; Surgical Critical Care Initiative (SC2i), Bethesda, MD.
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Greising SM, Dearth CL, Corona BT. Regenerative and Rehabilitative Medicine: A Necessary Synergy for Functional Recovery from Volumetric Muscle Loss Injury. Cells Tissues Organs 2016; 202:237-249. [PMID: 27825146 DOI: 10.1159/000444673] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2016] [Indexed: 01/04/2023] Open
Abstract
Volumetric muscle loss (VML) is a complex and heterogeneous problem due to significant traumatic or surgical loss of skeletal muscle tissue. The consequences of VML are substantial functional deficits in joint range of motion and skeletal muscle strength, resulting in life-long dysfunction and disability. Traditional physical medicine and rehabilitation paradigms do not address the magnitude of force loss due to VML and related musculoskeletal comorbidities. Recent advancements in regenerative medicine have set forth encouraging and emerging therapeutic options for VML injuries. There is significant potential that combined rehabilitative and regenerative therapies can restore limb and muscle function following VML injury in a synergistic manner. This review presents the current state of the VML field, spanning clinical and preclinical literature, with particular focus on rehabilitation and regenerative medicine in addition to their synergy. Moving forward, multidisciplinary collaboration between clinical and research fields is encouraged in order to continue to improve the treatment of VML injuries and specifically address the encompassing physiology, pathology, and specific needs of this patient population. This is a work of the US Government and is not subject to copyright protection in the USA. Foreign copyrights may apply. Published by S. Karger AG, Basel.
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Abstract
Heterotopic ossification is the formation of bone at extraskeletal sites. The incidence of heterotopic ossification in military amputees from recent operations in Iraq and Afghanistan has been demonstrated to be as high as 65%. Heterotopic ossification poses problems to wound healing, rehabilitation, and prosthetic fitting. This article details the current evidence regarding its etiology, prevention, management, and research strategies.
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Pavey GJ, Qureshi AT, Tomasino AM, Honnold CL, Bishop DK, Agarwal S, Loder S, Levi B, Pacifici M, Iwamoto M, Potter BK, Davis TA, Forsberg JA. Targeted stimulation of retinoic acid receptor-γ mitigates the formation of heterotopic ossification in an established blast-related traumatic injury model. Bone 2016; 90:159-67. [PMID: 27368930 PMCID: PMC5546218 DOI: 10.1016/j.bone.2016.06.014] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 05/24/2016] [Accepted: 06/26/2016] [Indexed: 10/21/2022]
Abstract
Heterotopic ossification (HO) involves formation of endochondral bone at non-skeletal sites, is prevalent in severely wounded service members, and causes significant complications and delayed rehabilitation. As common prophylactic treatments such as anti-inflammatory drugs and irradiation cannot be used after multi-system combat trauma, there is an urgent need for new remedies. Previously, we showed that the retinoic acid receptor γ agonist Palovarotene inhibited subcutaneous and intramuscular HO in mice, but those models do not mimic complex combat injury. Thus, we tested Palovarotene in our validated rat trauma-induced HO model that involves blast-related limb injury, femoral fracture, quadriceps crush injury, amputation and infection with methicillin-resistant Staphylococcus aureus from combat wound infections. Palovarotene was given orally for 14days at 1mg/kg/day starting on post-operative day (POD) 1 or POD-5, and HO amount, wound dehiscence and related processes were monitored for up to 84days post injury. Compared to vehicle-control animals, Palovarotene significantly decreased HO by 50 to 60% regardless of when the treatment started and if infection was present. Histological analyses showed that Palovarotene reduced ectopic chondrogenesis, osteogenesis and angiogenesis forming at the injury site over time, while fibrotic tissue was often present in place of ectopic bone. Custom gene array data verified that while expression of key chondrogenic and osteogenic genes was decreased within soft tissues of residual limb in Palovarotene-treated rats, expression of cartilage catabolic genes was increased, including matrix metalloproteinase-9. Importantly, Palovarotene seemed to exert moderate inhibitory effects on wound healing, raising potential safety concerns related to dosing and timing. Our data show for the first time that Palovarotene significantly inhibits HO triggered by blast injury and associated complications, strongly indicating that it may prevent HO in patients at high risk such as those sustaining combat injuries and other forms of blast trauma.
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Affiliation(s)
- Gabriel J Pavey
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States; USU-Walter Reed Surgery, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Ammar T Qureshi
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States
| | - Allison M Tomasino
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States
| | - Cary L Honnold
- Department of Pathology, Naval Medical Research Center, Silver Spring, MD, United States
| | - Danett K Bishop
- Department of Wound Infections, Naval Medical Research Center, Silver Spring, MD, United States
| | - Shailesh Agarwal
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, United States
| | - Shawn Loder
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, United States
| | - Benjamin Levi
- Department of Surgery, University of Michigan Health System, Ann Arbor, MI, United States
| | - Maurizio Pacifici
- Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, PA, United States
| | - Masahiro Iwamoto
- Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, PA, United States
| | - Benjamin K Potter
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States; USU-Walter Reed Surgery, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Thomas A Davis
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States; USU-Walter Reed Surgery, Walter Reed National Military Medical Center, Bethesda, MD, United States.
| | - Jonathan A Forsberg
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD, United States; USU-Walter Reed Surgery, Walter Reed National Military Medical Center, Bethesda, MD, United States
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Ranganathan K, Agarwal S, Cholok D, Loder S, Li J, Sung Hsieh HH, Wang SC, Buchman SR, Levi B. The role of the adaptive immune system in burn-induced heterotopic ossification and mesenchymal cell osteogenic differentiation. J Surg Res 2016; 206:53-61. [PMID: 27916375 DOI: 10.1016/j.jss.2016.04.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 03/26/2016] [Accepted: 04/15/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Heterotopic ossification (HO) is the pathologic process of extraskeletal bone formation. Although the exact etiology remains unknown, inflammation appears to catalyze disease progression. The goal of this study is to determine the impact of the adaptive immune system on HO. METHODS HO was induced in 8-wk-old control C57BL/6 and immunocompromised Rag1tm1Mom (Rag1 KO) male mice deficient in B- and T-lymphocytes via combined Achilles tenotomy and burn injury. Microcomputed tomography quantified the extent of HO formation at the tenotomy site. Adipose-derived mesenchymal stem cells were harvested to evaluate osteogenic differentiation potential. RESULTS Areas of developing HO demonstrated substantial enrichment of CD45 + leukocytes at 3 wk after injury. HO from Rag1 KO mice was substantially less mature with foci of cartilage and disorganized trabecular bone present 12 wk after injury. Rag1 KO mice formed 60% less bone compared to immunocompetent controls (4.67 ± 1.5 mm versus 7.76 ± 0.65 mm; P = 0.001). Tartrate-resistant acid phosphatase staining and immunofluorescent analysis of osteoprotegerin and nuclear factor kappa-light-chain-enhancer of activated B cells demonstrated no appreciable difference in osteoclast number or activation. Alizarin red staining in vitro demonstrated a significant decrease in osteogenic potential in immunocompromised mice compared to controls (29.1 ± 0.54 mm versus 12.1 ± 0.14 mm; P < 0.001). CONCLUSIONS We demonstrate a prominent role for the adaptive immune system in the development of HO. In the absence of mature B- and T-lymphocytes, HO growth and development are attenuated. Furthermore, we demonstrate that mesenchymal populations from B- and T-cell deficient mice are inherently less osteogenic. This study identifies a potential therapeutic role for modulation of the adaptive immune system in the treatment of HO.
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Affiliation(s)
- Kavitha Ranganathan
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
| | - Shailesh Agarwal
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
| | - David Cholok
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
| | - Shawn Loder
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
| | - Jonathan Li
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
| | | | - Stewart C Wang
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
| | - Steven R Buchman
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
| | - Benjamin Levi
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan.
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Abstract
Heterotopic ossification--a complication of severe burns, head or blast injuries, and orthopaedic trauma--can result from altered adenosine metabolism in mesenchymal stem cells in response to elevated extracellular ATP (Peterson et al., this issue).
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Affiliation(s)
- Jonathan A Forsberg
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD 20910, USA
| | - Thomas A Davis
- Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD 20910, USA
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Jeffrey M Gimble
- LaCell, New Orleans, LA 70112, USA. Center for Stem Cell Research and Regenerative Medicine, School of Medicine, Tulane University, New Orleans, LA 70112, USA. Department of Medicine, School of Medicine, Tulane University, New Orleans, LA 70112, USA. Department of Surgery, School of Medicine, Tulane University, New Orleans, LA 70112, USA.
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Trauma-induced heterotopic bone formation and the role of the immune system: A review. J Trauma Acute Care Surg 2016; 80:156-65. [PMID: 26491794 DOI: 10.1097/ta.0000000000000883] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Extremity trauma, spinal cord injuries, head injuries, and burn injuries place patients at high risk of pathologic extraskeletal bone formation. This heterotopic bone causes severe pain, deformities, and joint contractures. The immune system has been increasingly implicated in this debilitating condition. This review summarizes the various roles immune cells and inflammation play in the formation of ectopic bone and highlights potential areas of future investigation and treatment. Cell types in both the innate and adaptive immune system such as neutrophils, macrophages, mast cells, B cells, and T cells have all been implicated as having a role in ectopic bone formation through various mechanisms. Many of these cell types are promising areas of therapeutic investigation for potential treatment. The immune system has also been known to also influence osteoclastogenesis, which is heavily involved in ectopic bone formation. Chronic inflammation is also known to have an inhibitory role in the formation of ectopic bone, whereas acute inflammation is necessary for ectopic bone formation.
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Eisenstein NM, Cox SC, Williams RL, Stapley SA, Grover LM. Bedside, Benchtop, and Bioengineering: Physicochemical Imaging Techniques in Biomineralization. Adv Healthc Mater 2016; 5:507-28. [PMID: 26789418 DOI: 10.1002/adhm.201500617] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 09/10/2015] [Indexed: 01/10/2023]
Abstract
The need to quantify physicochemical properties of mineralization spans many fields. Clinicians, mineralization researchers, and bone tissue bioengineers need to be able to measure the distribution, quantity, and the mechanical and chemical properties of mineralization within a wide variety of substrates from injured muscle to electrospun polymer scaffolds and everything in between. The techniques available to measure these properties are highly diverse in terms of their complexity and utility. Therefore it is of the utmost importance that those who intend to use them have a clear understanding of the advantages and disadvantages of each technique and its appropriateness to their specific application. This review provides all of this information for each technique and uses heterotopic ossification and engineered bone substitutes as examples to illustrate how these techniques have been applied. In addition, we provide novel data using advanced techniques to analyze human samples of combat related heterotopic ossification.
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Affiliation(s)
- Neil M. Eisenstein
- Chemical Engineering; University of Birmingham; Edgbaston B15 2TT UK
- Royal Centre for Defence Medicine; ICT Centre; Vincent Drive; Edgbaston B15 2SQ UK
| | - Sophie C. Cox
- Chemical Engineering; University of Birmingham; Edgbaston B15 2TT UK
| | | | - Sarah A. Stapley
- Royal Centre for Defence Medicine; ICT Centre; Vincent Drive; Edgbaston B15 2SQ UK
| | - Liam M. Grover
- Chemical Engineering; University of Birmingham; Edgbaston B15 2TT UK
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Aljurayyan A, Tanzer D, Tanzer M. Acute revision hip arthroplasty: a previously unrecognized risk factor for heterotopic ossification. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 26:183-8. [PMID: 26724809 DOI: 10.1007/s00590-015-1733-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 12/19/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND The aim of this retrospective review was to determine the incidence and severity of heterotrophic ossification (HO) following acute revision total hip arthroplasty (THA), and whether this represents a significant risk factor for HO that should be treated prophylactically. MATERIALS AND METHODS A total of seven patients (three men and four women) with a mean age of 55 years (39-70 years) who underwent a reoperation of their THA for any reason that required a hip arthrotomy within 3 weeks of their primary or revision THA were included, with a mean follow-up of 8.8 years (2-12 years). All patients were evaluated radiographically for any evidence of HO and clinically using the Harris Hip Score. RESULTS All seven hips (100 %) developed HO, with 71 % being severe (Brooker III and IV HO). One hip (14 %) developed Brooker IV HO, four hips (57 %) developed Brooker III HO, and two hips (29 %) developed Brooker II HO. The patient's range of motion varied, but was very limited in three patients. Three patients (42.8 %) were not satisfied with their surgery; one patient had Brooker IV HO, and two patients had Brooker III HO. CONCLUSION Acute reoperation after primary or revision THA is a significant risk factor for the development of extensive HO, which requires prophylactic treatment.
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Affiliation(s)
- Abdulaziz Aljurayyan
- Division of Orthopaedic Surgery, McGill University Health Centre, 1650 Cedar Avenue, B5.159, Montreal, QC, H3G 1A4, Canada.
| | - Dylan Tanzer
- Sackler Medical School, Tel Aviv University, Tel Aviv, Isreal
| | - Michael Tanzer
- Division of Orthopaedic Surgery, McGill University Health Centre, 1650 Cedar Avenue, B5.159, Montreal, QC, H3G 1A4, Canada.
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76
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Kolman S, Spiegel D, Namdari S, Hosalkar H, Keenan MA, Baldwin K. What's New in Orthopaedic Rehabilitation. J Bone Joint Surg Am 2015; 97:1892-8. [PMID: 26582622 DOI: 10.2106/jbjs.o.00827] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | - David Spiegel
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Surena Namdari
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Harish Hosalkar
- Center for Hip Preservation and Children's Orthopedics, Vista, California
| | - Mary Ann Keenan
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Keith Baldwin
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Papour A, Kwak JH, Taylor Z, Wu B, Stafsudd O, Grundfest W. Wide-field Raman imaging for bone detection in tissue. BIOMEDICAL OPTICS EXPRESS 2015; 6:3892-7. [PMID: 26504639 PMCID: PMC4605048 DOI: 10.1364/boe.6.003892] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 06/19/2015] [Accepted: 06/29/2015] [Indexed: 05/11/2023]
Abstract
Inappropriate bone growth in soft tissue can occur after trauma to a limb and can cause a disruption to the healing process. This is known as Heterotopic Ossification (HO) in which regions in the tissue start to mineralize and form microscopic bone-like structures. These structures continue to calcify and develop into large, non-functional bony masses that cause pain, limit limb movement, and expose the tissue to reoccurring infections; in the case of open wounds this can lead to amputation as a result of a failed wound. Both Magnetic Resonance Imaging (MRI) and X-ray imaging have poor sensitivity and specificity for the detection of HO, thus delaying therapy and leading to poor patient outcomes. We present a low-power, fast (1 frame per second) optical Raman imaging system with a large field of view (1 cm(2)) that can differentiate bone tissue from soft tissue without spectroscopy, this in contrast to conventional Raman microscopy systems. This capability may allow for the development of instrumentation which permits bedside diagnosis of HO.
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Affiliation(s)
- Asael Papour
- Quantum Electronics Laboratory, Department of Electrical Engineering, University of California Los Angeles, Los Angeles, California 90095, USA
| | - Jin Hee Kwak
- Section of Orthodontics, School of Dentistry, University of California Los Angeles, Los Angeles, California 90095, USA
| | - Zach Taylor
- Department of Bioengineering University of California Los Angeles, Los Angeles, California 90095, USA
| | - Benjamin Wu
- Department of Bioengineering University of California Los Angeles, Los Angeles, California 90095, USA
| | - Oscar Stafsudd
- Quantum Electronics Laboratory, Department of Electrical Engineering, University of California Los Angeles, Los Angeles, California 90095, USA
| | - Warren Grundfest
- Department of Bioengineering University of California Los Angeles, Los Angeles, California 90095, USA
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Noninvasive Multimodal Imaging to Predict Recovery of Locomotion after Extended Limb Ischemia. PLoS One 2015; 10:e0137430. [PMID: 26368024 PMCID: PMC4569513 DOI: 10.1371/journal.pone.0137430] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 08/17/2015] [Indexed: 01/19/2023] Open
Abstract
Acute limb ischemia is a common cause of morbidity and mortality following trauma both in civilian centers and in combat related injuries. Rapid determination of tissue viability and surgical restoration of blood flow are desirable, but not always possible. We sought to characterize the response to increasing periods of hind limb ischemia in a porcine model such that we could define a period of critical ischemia (the point after which irreversible neuromuscular injury occurs), evaluate non-invasive methods for characterizing that ischemia, and establish a model by which we could predict whether or not the animal’s locomotion would return to baselines levels post-operatively. Ischemia was induced by either application of a pneumatic tourniquet or vessel occlusion (performed by clamping the proximal iliac artery and vein at the level of the inguinal ligament). The limb was monitored for the duration of the procedure with both 3-charge coupled device (3CCD) and infrared (IR) imaging for tissue oxygenation and perfusion, respectively. The experimental arms of this model are effective at inducing histologically evident muscle injury with some evidence of expected secondary organ damage, particularly in animals with longer ischemia times. Noninvasive imaging data shows excellent correlation with post-operative functional outcomes, validating its use as a non-invasive means of viability assessment, and directly monitors post-occlusive reactive hyperemia. A classification model, based on partial-least squares discriminant analysis (PLSDA) of imaging variables only, successfully classified animals as “returned to normal locomotion” or “did not return to normal locomotion” with 87.5% sensitivity and 66.7% specificity after cross-validation. PLSDA models generated from non-imaging data were not as accurate (AUC of 0.53) compared the PLSDA model generated from only imaging data (AUC of 0.76). With some modification, this limb ischemia model could also serve as a means on which to test therapies designed to prolong the time before critical ischemia.
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Alfieri KA, Potter BK, Davis TA, Wagner MB, Elster EA, Forsberg JA. Preventing Heterotopic Ossification in Combat Casualties-Which Models Are Best Suited for Clinical Use? Clin Orthop Relat Res 2015; 473:2807-13. [PMID: 25917420 PMCID: PMC4523530 DOI: 10.1007/s11999-015-4302-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND To prevent symptomatic heterotopic ossification (HO) and guide primary prophylaxis in patients with combat wounds, physicians require risk stratification methods that can be used early in the postinjury period. There are no validated models to help guide clinicians in the treatment for this common and potentially disabling condition. QUESTIONS/PURPOSES We developed three prognostic models designed to estimate the likelihood of wound-specific HO formation and compared them using receiver operating characteristic (ROC) curve analysis and decision curve analysis (DCA) to determine (1) which model is most accurate; and (2) which technique is best suited for clinical use. METHODS We obtained muscle biopsies from 87 combat wounds during the first débridement in the United States, all of which were evaluated radiographically for development of HO at a minimum of 2 months postinjury. The criterion for determining the presence of HO was the ability to see radiographic evidence of ectopic bone formation within the zone of injury. We then quantified relative gene expression from 190 wound healing, osteogenic, and vascular genes. Using these data, we developed an Artificial Neural Network, Random Forest, and a Least Absolute Shrinkage and Selection Operator (LASSO) Logistic Regression model designed to estimate the likelihood of eventual wound-specific HO formation. HO was defined as any HO visible on the plain film within the zone of injury. We compared the models accuracy using area under the ROC curve (area under the curve [AUC]) as well as DCA to determine which model, if any, was better suited for clinical use. In general, the AUC compares models based solely on accuracy, whereas DCA compares their clinical utility after weighing the consequences of under- or overtreatment of a particular disorder. RESULTS Both the Artificial Neural Network and the LASSO logistic regression models were relatively accurate with AUCs of 0.78 (95% confidence interval [CI], 0.72-0.83) and 0.75 (95% CI, 0.71-0.78), respectively. The Random Forest model returned an AUC of only 0.53 (95% CI, 0.48-0.59), marginally better than chance alone. Using DCA, the Artificial Neural Network model demonstrated the highest net benefit over the broadest range of threshold probabilities, indicating that it is perhaps better suited for clinical use than the LASSO logistic regression model. Specifically, if only patients with greater than 25% risk of developing HO received prophylaxis, for every 100 patients, use of the Artificial Network Model would result in six fewer patients who unnecessarily receive prophylaxis compared with using the LASSO regression model while not missing any patients who might benefit from it. CONCLUSIONS Our findings suggest that it is possible to risk-stratify combat wounds with regard to eventual HO formation early in the débridement process. Using these data, the Artificial Neural Network model may lead to better patient selection when compared with the LASSO logistic regression approach. Future prospective studies are necessary to validate these findings while focusing on symptomatic HO as the endpoint of interest. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- Keith A. Alfieri
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD USA ,Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA ,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Benjamin K. Potter
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD USA ,Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA ,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA ,Surgical Critical Care Initiative, Bethesda, MD USA
| | - Thomas A. Davis
- Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA ,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Matthew B. Wagner
- Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA ,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA ,Surgical Critical Care Initiative, Bethesda, MD USA
| | - Eric A. Elster
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA ,Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD USA ,Surgical Critical Care Initiative, Bethesda, MD USA
| | - Jonathan A. Forsberg
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD USA ,Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA ,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA ,Section of Orthopaedics and Sports Medicine, Department of Molecular Medicine and Surgery, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden ,Surgical Critical Care Initiative, Bethesda, MD USA
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Pavey GJ, Qureshi AT, Hope DN, Pavlicek RL, Potter BK, Forsberg JA, Davis TA. Bioburden Increases Heterotopic Ossification Formation in an Established Rat Model. Clin Orthop Relat Res 2015; 473:2840-7. [PMID: 25822455 PMCID: PMC4523512 DOI: 10.1007/s11999-015-4272-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) develops in a majority of combat-related amputations wherein early bacterial colonization has been considered a potential early risk factor. Our group has recently developed a small animal model of trauma-induced HO that incorporates many of the multifaceted injury patterns of combat trauma in the absence of bacterial contamination and subsequent wound colonization. QUESTIONS/PURPOSES We sought to determine if (1) the presence of bioburden (Acinetobacter baumannii and methicillin-resistant Staphylococcus aureus [MRSA]) increases the magnitude of ectopic bone formation in traumatized muscle after amputation; and (2) what persistent effects bacterial contamination has on late microbial flora within the amputation site. METHODS Using a blast-related HO model, we exposed 48 rats to blast overpressure, femur fracture, crush injury, and subsequent immediate transfemoral amputation through the zone of injury. Control injured rats (n = 8) were inoculated beneath the myodesis with phosphate-buffered saline not containing bacteria (vehicle) and treatment rats were inoculated with 1 × 10(6) colony-forming units of A baumannii (n = 20) or MRSA (n = 20). All animals formed HO. Heterotopic ossification was determined by quantitative volumetric measurements of ectopic bone at 12-weeks postinjury using micro-CT and qualitative histomorphometry for assessment of new bone formation in the residual limb. Bone marrow and muscle tissue biopsies were collected from the residual limb at 12 weeks to quantitatively measure the bioburden load and to qualitatively determine the species-level identification of the bacterial flora. RESULTS At 12 weeks, we observed a greater volume of HO in rats infected with MRSA (68.9 ± 8.6 mm(3); 95% confidence interval [CI], 50.52-85.55) when compared with A baumannii (20.9 ± 3.7 mm(3); 95% CI, 13.61-28.14; p < 0.001) or vehicle (16.3 ± 3.2 mm(3); 95% CI, 10.06-22.47; p < 0.001). Soft tissue and marrow from the residual limb of rats inoculated with A baumannii tested negative for A baumannii infection but were positive for other strains of bacteria (1.33 × 10(2) ± 0.89 × 10(2); 95% CI, -0.42 × 10(2)-3.08 × 10(2) and 1.25 × 10(6) ± 0.69 × 10(6); 95% CI, -0.13 × 10(6)-2.60 × 10(6) colony-forming units in bone marrow and muscle tissue, respectively), whereas tissue from MRSA-infected rats contained MRSA only (4.84 × 10(1) ± 3.22 × 10(1); 95% CI, -1.47 × 10(1)-11.1 × 10(1) and 2.80 × 10(7) ± 1.73 × 10(7); 95% CI, -0.60 × 10(7)-6.20 × 10(7) in bone marrow and muscle tissue, respectively). CONCLUSIONS Our findings demonstrate that persistent infection with MRSA results in a greater volume of ectopic bone formation, which may be the result of chronic soft tissue inflammation, and that early wound colonization may be a key risk factor. CLINICAL RELEVANCE Interventions that mitigate wound contamination and inflammation (such as early débridement, systemic and local antibiotics) may also have a beneficial effect with regard to the mitigation of HO formation and should be evaluated with that potential in mind in future preclinical studies.
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MESH Headings
- Acinetobacter baumannii/pathogenicity
- Amputation, Surgical
- Animals
- Bacterial Load
- Biopsy
- Blast Injuries/complications
- Colony Count, Microbial
- Disease Models, Animal
- Femoral Fractures/complications
- Male
- Methicillin-Resistant Staphylococcus aureus/pathogenicity
- Muscle, Skeletal/diagnostic imaging
- Muscle, Skeletal/injuries
- Muscle, Skeletal/microbiology
- Muscle, Skeletal/pathology
- Ossification, Heterotopic/diagnosis
- Ossification, Heterotopic/microbiology
- Osteogenesis
- Rats, Sprague-Dawley
- Risk Factors
- Staphylococcal Infections/diagnosis
- Staphylococcal Infections/microbiology
- Time Factors
- Wound Infection/diagnosis
- Wound Infection/microbiology
- X-Ray Microtomography
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Affiliation(s)
- Gabriel J. Pavey
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
- />Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Ammar T. Qureshi
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
| | - Donald N. Hope
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
- />Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Rebecca L. Pavlicek
- />Department of Wound Infections, Naval Medical Research Center, Silver Spring, MD USA
| | - Benjamin K. Potter
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
- />Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD USA
- />Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Jonathan A. Forsberg
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
- />Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD USA
- />Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Thomas A. Davis
- />Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910 USA
- />Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD USA
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Abstract
BACKGROUND Heterotopic ossification (HO) affects the majority of combat-related lower extremity wounds involving severe fracture and amputation. Defining the timing of early osteogenic-related genes may help identify candidate prophylactic agents and guide the timing of prophylactic therapy after blast and other combat-related extremity injuries. QUESTIONS/PURPOSES Using a recently developed animal model of combat-related HO, we sought to determine (1) the timing of early chondrogenesis, cartilage formation, and radiographic ectopic bone development; and (2) the early cartilage and bone-related gene and protein patterns in traumatized soft tissue. METHODS We used an established rat HO model consisting of blast exposure, controlled femur fracture, crush injury, and transfemoral amputation through the zone of injury. Postoperatively, rats were euthanized on Days 3 to 28. We assessed evidence of early ectopic bone formation by micro-CT and histology and performed proteomic and gene expression analysis. RESULTS All rats showed radiographic evidence of HO within 28 days. Key chondrogenic (collagen type I alpha 1 [COL1α1], p = 0.016) and osteogenic-related genes (Runt-related transcription factor 2 [RUNX-2], p = 0.029; osteoclacin [OCN], p = 0.032; phosphate-regulating neutral endopeptidase, X-linked [PHEX], p = 0.0290, and POU domain class 5 transcription factor [POU5F], p = 0.016) and proteins (Noggin [NOG], p = 0.04, OCN, p = 0.02, RUNX- 2, p = 0.04, and substance P-1 [SP-1], p = 0.01) in the injured soft tissue, normalized to the contralateral limb and/or sham-treated naïve rats, increased on Days 3 to 14 postinjury. By 14 days, foci of hypertrophic chondrocytes, hyaline cartilage, and woven bone were present in the soft tissue surrounding the amputation site. CONCLUSIONS We found that genes that regulate early chondrogenic and osteogenic signaling and bone development (COL1α1, RUNX-2, OCN, PHEX, and POU5F1) are induced early during the tissue reparative/healing phase in a rat model simulating a combat-related extremity injury. CLINICAL RELEVANCE The ability to correlate molecular events with histologic and morphologic changes will assist researchers and clinicians to understand HO and hence formulate therapeutic interventions.
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Analysis of the Pro- and Anti-Inflammatory Cytokines Secreted by Adult Stem Cells during Differentiation. Stem Cells Int 2015; 2015:412467. [PMID: 26300921 PMCID: PMC4537750 DOI: 10.1155/2015/412467] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 12/12/2014] [Accepted: 12/15/2014] [Indexed: 01/06/2023] Open
Abstract
Adipose-derived stromal/stem cells (ASCs) are adult stem cells that have the potential to differentiate into mesenchymal lineage cells. The abundance of ASCs in adipose tissue and easy accessibility with relatively little donor site morbidity make them attractive candidate cells for tissue engineering and regenerative medicine. However, the underlying inflammatory process that occurs during ASC differentiation into adipocytes and osteoblast has not been extensively investigated. ASCs cultured in osteogenic and adipogenic differentiation medium were characterized by oil red o staining and alizarin red staining, respectively. ASCs undergoing osteogenic and adipogenic differentiation were isolated on days 7, 14, and 21 and assessed by qRT-PCR for the expression of pro- and anti-inflammatory cytokines. ASCs undergoing osteogenic differentiation expressed a distinct panel of cytokines that differed from the cytokine profile of ASCs undergoing adipogenic differentiation at each of the time points analyzed. Mapping the cytokine expression profile during ASC differentiation will provide insight into the role of inflammation in this process and identify potential targets that may aid in enhancing osteogenic or adipogenic differentiation for the purposes of tissue engineering and regenerative medicine.
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83
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Abstract
An 18-year-old man presented with mid left thigh pain after sequential lacrosse injuries 1 month and 2 weeks prior. Physical examination was significant for a tender mass in the mid left thigh.
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84
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Forsberg JA, Potter BK, Wagner MB, Vickers A, Dente CJ, Kirk AD, Elster EA. Lessons of War: Turning Data Into Decisions. EBioMedicine 2015; 2:1235-42. [PMID: 26501123 PMCID: PMC4588374 DOI: 10.1016/j.ebiom.2015.07.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 07/14/2015] [Accepted: 07/14/2015] [Indexed: 02/03/2023] Open
Abstract
Background Recent conflicts in Afghanistan and Iraq produced a substantial number of critically wounded service-members. We collected biomarker and clinical information from 73 patients who sustained 116 life-threatening combat wounds, and sought to determine if the data could be used to predict the likelihood of wound failure. Methods From each patient, we collected clinical information, serum, wound effluent, and tissue prior to and at each surgical débridement. Inflammatory cytokines were quantified in both the serum and effluent, as were gene expression targets. The primary outcome was successful wound healing. Computer intensive methods were used to derive prognostic models that were internally validated using target shuffling and cross-validation methods. A second cohort of eighteen critically injured civilian patients was evaluated to determine if similar inflammatory responses were observed. Findings The best-performing models enhanced clinical observation with biomarker data from the serum and wound effluent, an indicator that systemic inflammatory conditions contribute to local wound failure. A Random Forest model containing ten variables demonstrated the highest accuracy (AUC 0.79). Decision Curve Analysis indicated that the use of this model would improve clinical outcomes and reduce unnecessary surgical procedures. Civilian trauma patients demonstrated similar inflammatory responses and an equivalent wound failure rate, indicating that the model may be generalizable to civilian settings. Interpretation Using advanced analytics, we successfully codified clinical and biomarker data from combat patients into a potentially generalizable decision support tool. Analysis of inflammatory data from critically ill patients with acute injury may inform decision-making to improve clinical outcomes and reduce healthcare costs. Funding United States Department of Defense Health Programs. We analyzed biomarker and clinical data to predict the likelihood of wound failure. We found that systematic inflammatory conditions contribute to local wound failure. This response is comparable between combat wounded and civilian patients. This response can be measured and translated into clinical decision support tools. These predictive models will benefit both military and civilian health systems.
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Affiliation(s)
- Jonathan A Forsberg
- Department of Surgery at the Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, MD USA ; Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD USA ; Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
| | - Benjamin K Potter
- Department of Surgery at the Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, MD USA ; Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
| | - Matthew B Wagner
- Department of Surgery at the Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, MD USA ; Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD USA ; Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics Memorial Sloan-Kettering Cancer Center, New York, NY USA
| | - Christopher J Dente
- Department of Surgery, Emory University, Atlanta, GA USA ; Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
| | - Allan D Kirk
- Department of Surgery, Duke University Medical Center, Durham, NC USA ; Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
| | - Eric A Elster
- Department of Surgery at the Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, MD USA ; Regenerative Medicine Department, Naval Medical Research Center, Silver Spring, MD USA ; Surgical Critical Care Initiative (SC2i), Bethesda, MD, USA
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85
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Rowan MP, Cancio LC, Elster EA, Burmeister DM, Rose LF, Natesan S, Chan RK, Christy RJ, Chung KK. Burn wound healing and treatment: review and advancements. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:243. [PMID: 26067660 PMCID: PMC4464872 DOI: 10.1186/s13054-015-0961-2] [Citation(s) in RCA: 468] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Burns are a prevalent and burdensome critical care problem. The priorities of specialized facilities focus on stabilizing the patient, preventing infection, and optimizing functional recovery. Research on burns has generated sustained interest over the past few decades, and several important advancements have resulted in more effective patient stabilization and decreased mortality, especially among young patients and those with burns of intermediate extent. However, for the intensivist, challenges often exist that complicate patient support and stabilization. Furthermore, burn wounds are complex and can present unique difficulties that require late intervention or life-long rehabilitation. In addition to improvements in patient stabilization and care, research in burn wound care has yielded advancements that will continue to improve functional recovery. This article reviews recent advancements in the care of burn patients with a focus on the pathophysiology and treatment of burn wounds.
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Affiliation(s)
- Matthew P Rowan
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA.
| | - Leopoldo C Cancio
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA
| | - Eric A Elster
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA
| | - David M Burmeister
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA
| | - Lloyd F Rose
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA
| | - Shanmugasundaram Natesan
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA
| | - Rodney K Chan
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA.,Brooke Army Medical Center, 3551 Roger Brook Dr, Fort Sam Houston, TX, 78234, USA
| | - Robert J Christy
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA
| | - Kevin K Chung
- United States Army Institute for Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX, 78234, USA.,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA
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Convente MR, Wang H, Pignolo RJ, Kaplan FS, Shore EM. The immunological contribution to heterotopic ossification disorders. Curr Osteoporos Rep 2015; 13:116-24. [PMID: 25687936 PMCID: PMC4417939 DOI: 10.1007/s11914-015-0258-z] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The formation of bone outside the endogenous skeleton is a significant clinical event, rendering affected individuals with immobility and a diminished quality of life. This bone, termed heterotopic ossification (HO), can appear in patients following invasive surgeries and traumatic injuries, as well as progressively manifest in several congenital disorders. A unifying feature of both genetic and nongenetic episodes of HO is immune system involvement at the early stages of disease. Activation of the immune system sets the stage for the downstream anabolic events that eventually result in ectopic bone formation, rendering the immune system a particularly appealing site of early therapeutic intervention for optimal management of disease. In this review, we will discuss the immunological contributions to HO disorders, with specific focus on contributing cell types, signaling pathways, relevant in vivo animal models, and potential therapeutic targets.
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Affiliation(s)
- Michael R Convente
- Center for Research in FOP and Related Disorders, Perelman School of Medicine, University of Pennsylvania, 424 Stemmler Hall, 36th Street and Hamilton Walk, Philadelphia, PA, 19104, USA,
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87
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Harris M, Cilwa K, Elster EA, Potter BK, Forsberg JA, Crane NJ. Pilot study for detection of early changes in tissue associated with heterotopic ossification: moving toward clinical use of Raman spectroscopy. Connect Tissue Res 2015; 56:144-52. [PMID: 25738521 DOI: 10.3109/03008207.2015.1013190] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Over 60% of combat-wounded patients develop heterotopic ossification (HO). Nearly 33% of them require surgical excision for symptomatic lesions, a procedure that is both fraught with complications and can delay or regress functional rehabilitation. Relative medical contraindications limit widespread use of conventional means of primary prophylaxis, such as nonspecific nonsteroidal anti-inflammatory medications and radiotherapy. Better methods for risk stratification are needed to both mitigate the risk of current means of primary prophylaxis as well as to evaluate novel preventive strategies currently in development. We asked whether Raman spectral changes, measured ex vivo, could be associated with histologic evidence of the earliest signs of HO formation and substance P (SP) expression in tissue biopsies from the wounds of combat casualties. In this pilot study, we compared normal muscle tissue, injured muscle tissue, very early HO lesions (< 16 d post-injury), early HO lesions (> 16 d post-injury) and mature HO lesions. The Raman spectra of these tissues demonstrate clear differences in the Amide I and III spectral regions of HO lesions compared to normal tissue, denoted by changes in the Amide I band center (p < 0.01) and the 1340/1270 cm(-1) (p < 0.05) band area and band height ratios. SP expression in the HO lesions appears to peak between 16 and 30 d post-injury, as determined by SP immunohistochemistry of corresponding tissue sections, potentially indicating optimal timing for administration of therapeutics. Raman spectroscopy may therefore prove a useful, non-invasive and early diagnostic modality to detect HO formation before it becomes evident either clinically or radiographically.
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Affiliation(s)
- Mitchell Harris
- Department of Surgery, Uniformed Services University of Health Science , Bethesda, MD , USA
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88
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Polfer EM, Hope DN, Elster EA, Qureshi AT, Davis TA, Golden D, Potter BK, Forsberg JA. The development of a rat model to investigate the formation of blast-related post-traumatic heterotopic ossification. Bone Joint J 2015; 97-B:572-6. [DOI: 10.1302/0301-620x.97b4.34866] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Currently, there is no animal model in which to evaluate the underlying physiological processes leading to the heterotopic ossification (HO) which forms in most combat-related and blast wounds. We sought to reproduce the ossification that forms under these circumstances in a rat by emulating patterns of injury seen in patients with severe injuries resulting from blasts. We investigated whether exposure to blast overpressure increased the prevalence of HO after transfemoral amputation performed within the zone of injury. We exposed rats to a blast overpressure alone (BOP-CTL), crush injury and femoral fracture followed by amputation through the zone of injury (AMP-CTL) or a combination of these (BOP-AMP). The presence of HO was evaluated using radiographs, micro-CT and histology. HO developed in none of nine BOP-CTL, six of nine AMP-CTL, and in all 20 BOP-AMP rats. Exposure to blast overpressure increased the prevalence of HO. This model may thus be used to elucidate cellular and molecular pathways of HO, the effect of varying intensities of blast overpressure, and to evaluate new means of prophylaxis and treatment of heterotopic ossification. Cite this article: Bone Joint J 2015;97-B:572–6
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Affiliation(s)
- E. M. Polfer
- Regenerative Medicine, Naval Medical Research
Center, 503 Robert Grant Ave, Silver
Spring, Maryland 20910, USA
| | - D. N. Hope
- Regenerative Medicine, Naval Medical Research
Center, 503 Robert Grant Ave, Silver
Spring, Maryland 20910, USA
| | - E. A. Elster
- Uniformed Services University of the Health
Sciences, 4301 Jones Bridge Rd, Bethesda, Maryland
20814, USA
| | - A. T. Qureshi
- Regenerative Medicine, Naval Medical Research
Center, 503 Robert Grant Ave, Silver
Spring, Maryland 20910, USA
| | - T. A. Davis
- Regenerative Medicine, Naval Medical Research
Center, 503 Robert Grant Ave, Silver
Spring, Maryland 20910, USA
| | - D. Golden
- Regenerative Medicine, Naval Medical Research
Center, 503 Robert Grant Ave, Silver
Spring, Maryland 20910, USA
| | - B. K. Potter
- Walter Reed National Military Medical
Center, 8901 Wisconsin Ave, Bethesda, Maryland
20889, USA
| | - J. A. Forsberg
- Regenerative Medicine, Naval Medical Research
Center, 503 Robert Grant Ave, Silver
Spring, Maryland 20910, USA
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