101
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Steplewski A, Fertala J, Tomlinson RE, Wang ML, Donahue A, Arnold WV, Rivlin M, Beredjiklian PK, Abboud JA, Namdari S, Fertala A. Mechanisms of reducing joint stiffness by blocking collagen fibrillogenesis in a rabbit model of posttraumatic arthrofibrosis. PLoS One 2021; 16:e0257147. [PMID: 34492074 PMCID: PMC8423260 DOI: 10.1371/journal.pone.0257147] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/24/2021] [Indexed: 02/06/2023] Open
Abstract
Posttraumatic fibrotic scarring is a significant medical problem that alters the proper functioning of injured tissues. Current methods to reduce posttraumatic fibrosis rely on anti-inflammatory and anti-proliferative agents with broad intracellular targets. As a result, their use is not fully effective and may cause unwanted side effects. Our group previously demonstrated that extracellular collagen fibrillogenesis is a valid and specific target to reduce collagen-rich scar buildup. Our previous studies showed that a rationally designed antibody that binds the C-terminal telopeptide of the α2(I) chain involved in the aggregation of collagen molecules limits fibril assembly in vitro and reduces scar formation in vivo. Here, we have utilized a clinically relevant arthrofibrosis model to study the broad mechanisms of the anti-scarring activity of this antibody. Moreover, we analyzed the effects of targeting collagen fibril formation on the quality of healed joint tissues, including the posterior capsule, patellar tendon, and subchondral bone. Our results show that blocking collagen fibrillogenesis not only reduces collagen content in the scar, but also accelerates the remodeling of healing tissues and changes the collagen fibrils’ cross-linking. In total, this study demonstrated that targeting collagen fibrillogenesis to limit arthrofibrosis affects neither the quality of healing of the joint tissues nor disturbs vital tissues and organs.
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Affiliation(s)
- Andrzej Steplewski
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Jolanta Fertala
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Ryan E. Tomlinson
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Mark L. Wang
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States of America
| | - Allison Donahue
- College of Medicine, Drexel University, Philadelphia, Pennsylvania, United States of America
| | - William V. Arnold
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States of America
| | - Michael Rivlin
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States of America
| | - Pedro K. Beredjiklian
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States of America
| | - Joseph A. Abboud
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States of America
| | - Surena Namdari
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States of America
| | - Andrzej Fertala
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- * E-mail:
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102
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Ibrahim IO, Nazarian A, Rodriguez EK. Clinical Management of Arthrofibrosis: State of the Art and Therapeutic Outlook. JBJS Rev 2021; 8:e1900223. [PMID: 32618740 DOI: 10.2106/jbjs.rvw.19.00223] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
* Arthrofibrosis is a pathologic condition that is characterized by excessive periarticular scar-tissue formation. Arthrofibrosis may occur secondary to injury, surgical trauma, hemarthrosis, or infection, or it may occur idiopathically.* The pathogenesis of arthrofibrosis is incompletely understood but involves the dysregulation of normal reparative pathways, with transforming growth factor-beta (TGF-[beta]) as a principal mediator.* Current treatment options for arthrofibrosis primarily involve physiotherapy, operative manipulation, and surgical debridement, all with imperfect results.* Currently, there are no pharmacologic treatment options for arthrofibrosis. This has prompted increased investigational interest in the development of antifibrotic intra-articular therapies.
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Affiliation(s)
- Ishaq O Ibrahim
- Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Ara Nazarian
- Harvard Medical School Orthopedic Trauma Initiative, Boston, Massachusetts.,Center for Advanced Orthopaedic Studies (A.N.), and Orthopaedic Trauma Service (E.K.R.), Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, Armenia
| | - Edward K Rodriguez
- Harvard Medical School Orthopedic Trauma Initiative, Boston, Massachusetts.,Center for Advanced Orthopaedic Studies (A.N.), and Orthopaedic Trauma Service (E.K.R.), Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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103
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Chen X, Wang Z, Huang Y, Deng W, Zhou Y, Chu M. Identification of novel biomarkers for arthrofibrosis after total knee arthroplasty in animal models and clinical patients. EBioMedicine 2021; 70:103486. [PMID: 34311327 PMCID: PMC8325099 DOI: 10.1016/j.ebiom.2021.103486] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 06/25/2021] [Accepted: 06/28/2021] [Indexed: 01/24/2023] Open
Abstract
Background Arthrofibrosis is a debilitating complication after total knee arthroplasty (TKA) which becomes a considerable burden for both patients and clinical practitioners. Our study aimed to identify novel biomarkers and therapeutic targets for drug discovery. Methods Potential biomarker genes were identified based on bioinformatic analysis. Twelve male New Zealand white rabbits underwent surgical fixation of unilateral knees to mimics the joint immobilization of the clinical scenario after TKA surgery. Macroscopic assessment, hydroxyproline content determination, and histological analysis of tissue were performed separately after 3-days, 1-week, 2-weeks, and 4-weeks of fixation. We also enrolled 46 arthrofibrosis patients and 92 controls to test the biomarkers. Clinical information such as sex, age, range of motion (ROM), and visual analogue scale (VAS) was collected by experienced surgeons Findings Base on bioinformatic analysis, transforming growth factor-beta receptor 1 (TGFBR1) was identified as the potential biomarkers. The level of TGFBR1 was significantly raised in the rabbit synovial tissue after 4-weeks of fixation (p<0.05). TGFBR1 also displayed a highly positive correlation with ROM loss and hydroxyproline contents in the animal model. TGFBR1 showed a significantly higher expression level in arthrofibrosis patients with a receiver operating characteristic (ROC) area under curve (AUC) of 0.838. TGFBR1 also performed positive correlations with VAS baseline (0.83) and VAS after 1 year (0.76) while negatively correlated with ROM baseline (-0.76) in clinical patients. Interpretation Our findings provided novel biomarkers for arthrofibrosis diagnosis and uncovered the role of TGFBR1. This may contribute to arthrofibrosis prevention and therapeutic drug discovery.
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Affiliation(s)
- Xi Chen
- Department of Adult Joint Reconstructive Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Jishuitan Orthopaedic College of Tsinghua University, 31 East Xinjiekou Street, Beijing 100035, China; Department of Immunology, School of Basic Medical Sciences, Peking University. NHC Key Laboratory of Medical Immunology (Peking University). Beijing, China
| | - Zhaolun Wang
- Department of Adult Joint Reconstructive Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Jishuitan Orthopaedic College of Tsinghua University, 31 East Xinjiekou Street, Beijing 100035, China
| | - Yong Huang
- Department of Adult Joint Reconstructive Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Jishuitan Orthopaedic College of Tsinghua University, 31 East Xinjiekou Street, Beijing 100035, China
| | - Wang Deng
- Department of Adult Joint Reconstructive Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Jishuitan Orthopaedic College of Tsinghua University, 31 East Xinjiekou Street, Beijing 100035, China
| | - Yixin Zhou
- Department of Adult Joint Reconstructive Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Jishuitan Orthopaedic College of Tsinghua University, 31 East Xinjiekou Street, Beijing 100035, China.
| | - Ming Chu
- Department of Immunology, School of Basic Medical Sciences, Peking University. NHC Key Laboratory of Medical Immunology (Peking University). Beijing, China.
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104
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Lee AJ, Mahoney CM, Cai CC, Ichinose R, Stefani RM, Marra KG, Ateshian GA, Shah RP, Vunjak-Novakovic G, Hung CT. Sustained Delivery of SB-431542, a Type I Transforming Growth Factor Beta-1 Receptor Inhibitor, to Prevent Arthrofibrosis. Tissue Eng Part A 2021; 27:1411-1421. [PMID: 33752445 DOI: 10.1089/ten.tea.2021.0029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Fibrosis of the knee is a common disorder resulting from an aberrant wound healing response and is characterized by extracellular matrix deposition, joint contraction, and scar tissue formation. The principal regulator of the fibrotic cascade is transforming growth factor beta-1 (TGF-β1), a factor that induces rapid proliferation and differentiation of resident fibroblasts. In this study, we demonstrate successful inhibition of TGF-β1-driven myofibroblastic differentiation in human fibroblast-like synoviocytes using a small molecule TGF-β1 receptor inhibitor, SB-431542. We also demonstrate successful encapsulation of SB-431542 in poly(D,L-lactide-co-glycolide) (PLGA) as a potential prophylactic treatment for arthrofibrosis and characterize drug release and bioactivity in a three-dimensional collagen gel contraction assay. We assessed the effects of TGF-β1 and SB-431542 on cell proliferation and viability in monolayer cultures. Opposing dose-dependent trends were observed in cell proliferation, which increased in TGF-β1-treated cultures and decreased in SB-431542-treated cultures relative to control (p < 0.05). SB-431542 was not cytotoxic at the concentrations studied (0-50 μM) and inhibited TGF-β1-induced collagen gel contraction in a dose-dependent manner. Specifically, TGF-β1-treated gels contracted to 18% ± 1% of their initial surface area, while gels treated with TGF-β1 and ≥10 μM SB-431542 showed no evidence of contraction (p < 0.0001). Upon removal of the compound, all gels contracted to control levels after 44 h in culture, necessitating sustained delivery for prolonged inhibition. To this end, SB-431542 was encapsulated in PLGA microspheres (SBMS) that had an average diameter of 87.5 ± 24 μm and a loading capacity of 4.3 μg SB-431542 per milligram of SBMS. Functional assessment of SBMS revealed sustained inhibition of TGF-β1-induced gel contraction as well as hallmark features of myofibroblastic differentiation, including α-smooth muscle actin expression and connective tissue growth factor production. These results suggest that SB-431542 may be used to counter TGF-β1-driven events in the fibrotic cascade in the knee cartilage.
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Affiliation(s)
- Andy J Lee
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Christopher M Mahoney
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Charles C Cai
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Rika Ichinose
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Robert M Stefani
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Kacey G Marra
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gerard A Ateshian
- Department of Biomedical Engineering, Columbia University, New York, New York, USA.,Department of Mechanical Engineering, Columbia University, New York, New York, USA
| | - Roshan P Shah
- Department of Orthopaedic Surgery, and Columbia University, New York, New York, USA
| | - Gordana Vunjak-Novakovic
- Department of Biomedical Engineering, Columbia University, New York, New York, USA.,Department of Medicine, Columbia University, New York, New York, USA
| | - Clark T Hung
- Department of Biomedical Engineering, Columbia University, New York, New York, USA.,Department of Orthopaedic Surgery, and Columbia University, New York, New York, USA
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105
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Kaneguchi A, Ozawa J, Minamimoto K, Yamaoka K. Formation process of joint contracture after anterior cruciate ligament reconstruction in rats. J Orthop Res 2021; 39:1082-1092. [PMID: 32667709 DOI: 10.1002/jor.24800] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/04/2020] [Accepted: 06/30/2020] [Indexed: 02/04/2023]
Abstract
Knee joint contracture is often induced by anterior cruciate ligament reconstruction (ACLR). However, the temporal and spatial arthrofibrotic changes following inflammatory events, which occur in parallel with the formation of joint contractures after ACLR, are unknown. This study aimed to reveal: (a) time-dependent changes in myogenic and arthrogenic contractures; and (b) the process of arthrofibrosis development after ACLR. ACLR was performed on knees of rats unilaterally. Passive ranges of motions (ROMs) before and after myotomy, as well as inflammatory and fibrotic reactions, were examined before and after the surgery at various periods up to 56 days. Both ROMs before and after myotomy exhibited their lowest value on day 7 and increased thereafter in a time-dependent manner; nevertheless, significant restrictions remained by day 56. Myotomy partially increased ROMs at all time points, indicating contribution of the myogenic component to ACLR-induced contracture. Inflammatory and fibrotic reactions peaked on day 7. Arthrofibrosis, characterized by the thickening of the joint capsule and the shortening of the synovial length, was established by day 7 and was not completely resolved by day 56. Our results indicate that: (a) both myogenic and arthrogenic contractures generated through ACLR develop maximally by day 7 after surgery and subside thereafter, but persist at least until day 56; and (b) arthrofibrosis is established by day 7 after surgery and is not completely resolved by day 56. These findings suggest that treatment and intervention for preventing joint contracture after ACLR should be performed within the first 7 days after surgery.
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Affiliation(s)
- Akinori Kaneguchi
- Department of Rehabilitation, Faculty of Rehabilitation, Hiroshima International University, Higashi-Hiroshima, Hiroshima, Japan
| | - Junya Ozawa
- Department of Rehabilitation, Faculty of Rehabilitation, Hiroshima International University, Higashi-Hiroshima, Hiroshima, Japan
| | - Kengo Minamimoto
- Major in Medical Engineering and Technology, Graduate School of Medical Technology and Health Welfare Sciences, Hiroshima International University, Higashi-Hiroshima, Hiroshima, Japan
| | - Kaoru Yamaoka
- Department of Rehabilitation, Faculty of Rehabilitation, Hiroshima International University, Higashi-Hiroshima, Hiroshima, Japan
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106
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Blessing WA, Williamson AK, Kirsch JR, Grinstaff MW. The Prognosis of Arthrofibroses: Prevalence, Clinical Shortcomings, and Future Prospects. Trends Pharmacol Sci 2021; 42:398-415. [PMID: 33795150 DOI: 10.1016/j.tips.2021.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 02/18/2021] [Accepted: 02/28/2021] [Indexed: 02/06/2023]
Abstract
Fibrosis is the dysregulated biosynthesis of connective tissue that results from persistent infection, high serum cholesterol, surgery, trauma, or prolonged joint immobilization. As a disease that impacts connective tissue, it is prevalent across the body and disrupts normal extracellular and tissue organization. Ultimately, fibrosis impairs the tissue structural, mechanical, or biochemical function. This review describes the clinical landscape of joint fibrosis, that is, arthrofibrosis, including the risk factors and causes, as well as current clinical treatments and their shortcomings. Because treating arthrofibrosis remains an unmet clinical challenge, we present several animal models used for exploration of the physiopathology of arthrofibrosis and summarize their use for testing novel treatments. We then discuss therapeutics for the prevention or treatment of arthrofibrosis that are in preclinical development and in ongoing clinical trials. We conclude with recent findings from molecular biological studies of arthrofibroses that shed insight on future areas of research for improved treatments.
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Affiliation(s)
- William A Blessing
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
| | - Amanda K Williamson
- Departments of Biomedical Engineering, Chemistry, and Medicine, Boston University, Boston, MA 02215, USA
| | - Jack R Kirsch
- Departments of Biomedical Engineering, Chemistry, and Medicine, Boston University, Boston, MA 02215, USA
| | - Mark W Grinstaff
- Departments of Biomedical Engineering, Chemistry, and Medicine, Boston University, Boston, MA 02215, USA.
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107
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Bayram B, Owen AR, Dudakovic A, Bettencourt JW, Limberg AK, Morrey ME, Sanchez-Sotelo J, Berry DJ, Kocher JP, van Wijnen AJ, Abdel MP. Elevated Expression of Plasminogen Activator Inhibitor (PAI-1/SERPINE1) is Independent from rs1799889 Genotypes in Arthrofibrosis. Meta Gene 2021; 28. [PMID: 33816122 DOI: 10.1016/j.mgene.2021.100877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Arthrofibrosis is characterized by excessive extracellular matrix deposition in patients with total knee arthroplasties (TKAs) and causes undesirable joint stiffness. The pathogenesis of arthrofibrosis remains elusive and currently there are no diagnostic biomarkers for the pathological formation of this connective tissue. Fibrotic soft tissues are known to have elevated levels of plasminogen activator inhibitor-1 (PAI-1) (encoded by SERPINE1), a secreted serine protease inhibitor that moderates extracellular matrix remodeling and tissue homeostasis. The 4G/5G insertion/deletion (rs1799889) is a well-known SERPINE1 polymorphism that directly modulates PAI-1 levels. Homozygous 4G/4G allele carriers typically have higher PAI-1 levels and may predispose patients to soft tissue fibrosis (e.g., liver, lung, and kidney). Here, we examined the genetic contribution of the SERPINE1 rs1799889 polymorphism to musculoskeletal fibrosis in arthrofibrotic (n = 100) and non-arthrofibrotic (n = 100) patients using Sanger Sequencing. Statistical analyses revealed that the allele frequencies of the SERPINE1 rs1799889 polymorphism are similar in arthrofibrotic and non-arthrofibrotic patient cohorts. Because the fibrosis related SERPINE1 rs1799889 polymorphism is independent of arthrofibrosis susceptibility in TKA patients, the possibility arises that fibrosis of joint connective tissues may involve unique genetic determinants distinct from those linked to classical soft tissue fibrosis.
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Affiliation(s)
- Banu Bayram
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Aaron R Owen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Amel Dudakovic
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States.,Department of Biochemistry & Molecular Biology, Mayo Clinic, Rochester, MN, United States
| | | | - Afton K Limberg
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Mark E Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | | | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Jean-Pierre Kocher
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Andre J van Wijnen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States.,Department of Biochemistry & Molecular Biology, Mayo Clinic, Rochester, MN, United States
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
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108
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Mao D, Mi J, Pan X, Li F, Rui Y. Suppression of TGF-beta activity with remobilization attenuates immobilization-induced joint contracture in rats. Injury 2021; 52:434-442. [PMID: 33408055 DOI: 10.1016/j.injury.2020.12.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 12/22/2020] [Accepted: 12/24/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Joint contracture is a common complication of joint injury. This study aimed to assess the effect of inhibiting the transforming growth factor-β (TGF-β) signaling during joint immobilization and remobilization on immobilization-induced joint contracture in rats. METHODS The knees of rats were immobilized using Kirschner wires following trauma to the femoral condyles to generate joint contracture. After immobilization, levels of TGF-β and passive extension range of motion (ROM) were measured at different time points, joints were histologically analyzed by hematoxylin and eosin (H&E) and Masson trichrome staining, and the expression of inflammatory or fibrosis-related mediators, including interleukin-1β (IL-1β), phosphorylated Smad2/3 (p-Smad2/3), α-smooth muscle actin (α-SMA) and collagen types I (Col 1) and III (Col 3), were examined in joint capsules using immunohistochemistry and quantitative real-time polymerase chain reaction (qRT-PCR). Rats were also treated with LY2157299, a TGF-β receptor I kinase inhibitor, at different stages of immobilization and remobilization. RESULTS TGF-β1 levels in the serum and the number of p-Smad2/3+ cells in the joint capsule were significantly elevated after immobilization. ROM decreased during the 6 weeks of immobilization and partly recovered after remobilization. After treatment with LY2157299 during immobilization, the restricted ROM moderately increased, but this effect was stronger when combined with active motion. Mechanistically, the expression of IL-1β, TGF-β, fibrosis-related factors, and the density of collagen significantly decreased after treatment with LY2157299. CONCLUSIONS Inhibiting TGF-β signaling paired with active motion effectively attenuated the formation of immobilization-induced joint contracture in rats.
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Affiliation(s)
- Dong Mao
- Orthopaedic Institute, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, 214062, China
| | - Jingyi Mi
- Department of Sports Medicine, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, 214062, China
| | - Xiaoyun Pan
- Orthopaedic Institute, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, 214062, China
| | - Fengfeng Li
- Department of Orthopedics, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China.
| | - Yongjun Rui
- Department of Orthopedics, Wuxi 9th People's Hospital Affiliated to Soochow University, Wuxi, 214062, China
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109
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Aspinall SK, Bamber ZA, Hignett SM, Godsiff SP, Wheeler PC, Fong DT. Medical stretching devices are effective in the treatment of knee arthrofibrosis: A systematic review. J Orthop Translat 2021; 27:119-131. [PMID: 33659182 PMCID: PMC7878963 DOI: 10.1016/j.jot.2020.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 10/07/2020] [Accepted: 11/08/2020] [Indexed: 12/04/2022] Open
Abstract
AIMS This systematic review examines the available evidence on the use of medical stretching devices to treat knee arthrofibrosis, it suggests a focus for future studies addressing limitations in current research and identifies gaps in the published literature to facilitate future works. MATERIALS AND METHODS Articles were identified using the Cochrane Library, MEDLINE, PubMed and SCOPUS databases. Articles from peer reviewed journals investigating the effectiveness of medical stretching devices to increase range of movement when treating arthrofibrosis of the knee were included. RESULTS A total of 13 studies (558 participants) met the inclusion criteria with the devices falling into the following categories; CPM, load control or displacement control stretching devices. A statistically significant increase in range of movement was demonstrated in CPM, load-control and displacement-control studies (p < 0.001). The results show that the stretch doses applied using the CPM, load-control devices were performed over a considerably longer treatment time and involved significantly more additional physiotherapy compared to the displacement-control and patient actuated serial stretching devices. CONCLUSION The systematic review indicates that load-control and displacement-control devices are effective in increasing range of movement in the treatment of knee arthrofibrosis. Displacement-control devices involving patient actuated serial stretching techniques, may be more effective in increasing knee flexion than those utilising static progressive stretch.The paucity of research in this field indicates that more randomised controlled trials are required to investigate the superiority of the different types of displacement-control stretching devices and which of these would be most effective for use in clinical practice and to compare these with standard physiotherapy treatment.
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Affiliation(s)
- Sara K. Aspinall
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Zoe A. Bamber
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
- Division of Orthopaedics, Trauma and Sports Medicine, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Sue M. Hignett
- Loughborough Design School, Loughborough University, Loughborough, UK
| | - Steven P. Godsiff
- Department of Orthopaedic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Patrick C. Wheeler
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
- Department of Sport and Exercise Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Daniel T.P. Fong
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
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110
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Ipach B, Haasters F. [56/f-Unexpected shoulder stiffness after bicycle accident : Preparation for the medical specialist examination: part 60]. Unfallchirurg 2021; 124:164-170. [PMID: 33606051 DOI: 10.1007/s00113-021-00957-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Bastian Ipach
- Knie‑, Hüft- und Schulterchirurgie, Schön Klinik München Harlaching, Akademisches Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität (PMU) Salzburg, Österreich, Harlachinger Str. 51, 81547, München, Deutschland
| | - Florian Haasters
- Knie‑, Hüft- und Schulterchirurgie, Schön Klinik München Harlaching, Akademisches Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität (PMU) Salzburg, Österreich, Harlachinger Str. 51, 81547, München, Deutschland. .,Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Universitätsklinikum München, Ludwig-Maximilians-Universität (LMU), München, Deutschland.
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111
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Zhang Z, Zhu D, Zhang X, Liu Y, Wang J, Yan L. Tanshinone IIA regulates fibroblast proliferation and migration and post-surgery arthrofibrosis through the autophagy-mediated PI3K and AMPK-mTOR signaling pathway. Am J Transl Res 2021; 13:565-584. [PMID: 33594310 PMCID: PMC7868849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 11/29/2020] [Indexed: 06/12/2023]
Abstract
Post-surgery arthrofibrosis is one of the most restrictive factors in the development of intra-articular surgery and has presented tremendous obstacles for most orthopaedic surgeons. Tanshinone IIA (Tan IIA), a key active ingredient of Den-shen, has been used to treat fibrosis-related diseases, such as pulmonary, hepatic and myocardial fibrosis. In the present study, we aimed to investigate the effects of Tan IIA on post-surgery arthrofibrosis in vivo and in vitro. Histological analysis indicated that topical application of Tan IIA (10 mg/mL) could significantly alleviate postsurgery arthrofibrosis in rabbits. Immunohistochemistry results showed that proliferating cell nuclear antigen (PCNA) and tubulin protein expression was inhibited, whereas LC3 was activated in vivo. In vitro, EdU and flow cytometry assays demonstrated that Tan IIA could inhibit fibroblast proliferation by arresting cells in G2 phase. Scratch, Transwell and cytoskeleton protein immunofluorescence assays revealed that fibroblast migration was attenuated. Interestingly, LC3 immunofluorescence staining and transmission electron microscopy indicated that autophagy flux could be induced in fibroblasts by Tan IIA. However, the inhibitory effects of Tan IIA against fibroblast proliferation and migration were partially restored when fibroblast autophagy was suppressed after combined treatment with the autophagy inhibitor 3-methyladenine (3-MA). Finally, the expression of p-mTOR was suppressed in a dose-dependent manner after Tan IIA treatment but partially restored when Tan IIA treatment was combined with 3-MA intervention. The inhibitory effect of Tan IIA against fibroblast proliferation and migration may be related to autophagy induction mediated by the PI3K and AMPK-mTOR signaling pathway.
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Affiliation(s)
- Zhen Zhang
- Dalian Medicial UniversityDalian 116044, Liaoning, China
| | - Dongming Zhu
- Dalian Medicial UniversityDalian 116044, Liaoning, China
| | - Xiaobo Zhang
- Dalian Medicial UniversityDalian 116044, Liaoning, China
| | - Yun Liu
- Department of Orthopedics, Northern Jiangsu People’s Hospital, Clinical Medical College of Yangzhou UniversityYangzhou 225001, Jiangsu, China
| | - Jingcheng Wang
- Department of Orthopedics, Northern Jiangsu People’s Hospital, Clinical Medical College of Yangzhou UniversityYangzhou 225001, Jiangsu, China
| | - Lianqi Yan
- Central South UniversityChangsha 410012, Hunan, China
- Department of Orthopedics, Northern Jiangsu People’s Hospital, Clinical Medical College of Yangzhou UniversityYangzhou 225001, Jiangsu, China
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112
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Xiao D, Liang T, Zhuang Z, He R, Ren J, Jiang S, Zhu L, Wang K, Shi D. Lumican promotes joint fibrosis through TGF-β signaling. FEBS Open Bio 2020; 10:2478-2488. [PMID: 32910552 PMCID: PMC7609791 DOI: 10.1002/2211-5463.12974] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/26/2020] [Accepted: 09/03/2020] [Indexed: 01/06/2023] Open
Abstract
Joint contracture (also known as arthrofibrosis) is a fibrotic joint disorder characterized by excessive collagen production to form fibrotic scar tissue and adhesions within joint capsules. This can severely affect day‐to‐day activities and quality of life because of a restricted range of motion in affected joints. The precise pathogenic mechanism underlying joint contractures is not fully understood. Lumican belongs to the class II small leucine‐rich repeat proteoglycan superfamily, which makes up collagen fibrils in the extracellular matrix. Lumican is ubiquitously expressed in the skin, liver, heart, uterus and articular cartilage and has reported roles in cell migration, proliferation, angiogenesis and Toll‐like receptor 4 signaling. Previous research has suggested that lumican is involved in the pathogenesis of several fibrotic diseases. Because joint contracture resembles a fibrotic disease, we aimed to investigate the role of lumican in the development of joint contracture in vitro. Here, we showed that protein levels were up‐regulated in the fibrotic joint capsule versus control. We observed that lumican significantly enhanced the proliferation, migration and fibroblast–myofibroblast transition of synovial fibroblasts. Moreover, lumican led to increased transcription of alpha‐smooth muscle actin, matrix metallopeptidase 9, Collagen I, plasminogen activator inhibitor 1 and transforming growth factor‐β in vitro. Lumican treatment promoted collagen lattice contraction in a dose‐dependent manner as early as 24 h after treatment. Thus, our studies reveal that lumican could promote fibroblast–myofibroblast transition and joint contracture.
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Affiliation(s)
- Dahai Xiao
- Department of Joint and Trauma Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Tangzhao Liang
- Department of Joint and Trauma Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ze Zhuang
- Department of Joint and Trauma Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ronghan He
- Department of Joint and Trauma Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jianhua Ren
- Department of Joint and Trauma Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shihai Jiang
- Department of Joint and Trauma Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Lei Zhu
- Department of Plastic Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Kun Wang
- Department of Joint and Trauma Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Dehai Shi
- Department of Joint and Trauma Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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113
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Li CY, Ng Cheong Chung KJ, Ali OME, Chung NDH, Li CH. Literature review of the causes of pain following total knee replacement surgery: prosthesis, inflammation and arthrofibrosis. EFORT Open Rev 2020; 5:534-543. [PMID: 33072405 PMCID: PMC7528670 DOI: 10.1302/2058-5241.5.200031] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Adverse knee pain occurs in 10–34% of all total knee replacements (TKR), and 20% of TKR patients experience more pain post-operatively than pre-operatively. Knee pain is amongst the top five reasons for knee replacement revision in the United Kingdom. The number of TKRs is predicted to continue increasing due to the ageing population. A narrative literature review was performed on the different causes of pain following TKR. A database search on Scopus, PubMed, and Google Scholar was conducted to look for articles related to TKR, pain, and cause. Articles were selected based on relevance, publication date, quality of research and validation. Relevant sections were added to the review. One hundred and fourteen articles were identified and potential causes of TKR pain included: arthrofibrosis, aseptic loosening, avascular necrosis, central sensitization, component malpositioning, infection, instability, nerve damage, overstuffing, patellar maltracking, polyethylene wear, psychological factors and unresurfaced patella. It is important to tailor our approach to address the individual causes of pain. Certain controllable risk factors can be managed pre-operatively to minimize post-operative pain. Risk factors help to predict adverse pain outcomes and identify specific causes. There are multiple causes of pain following TKR. Some factors will require further extensive studies, and as pain is a commonly attributed reason for TKR revision, its underlying aetiologies should be explored. Understanding these factors helps to develop effective methods for diagnosis, prevention and management of TKR pain, which help to improve patient outcomes.
Cite this article: EFORT Open Rev 2020;5:534-543. DOI: 10.1302/2058-5241.5.200031
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Affiliation(s)
- Cheuk Yin Li
- School of Medical Education, Newcastle University, Framlington Place, Newcastle upon Tyne, UK
| | | | - Omar M E Ali
- School of Medical Education, Newcastle University, Framlington Place, Newcastle upon Tyne, UK
| | - Nicholas D H Chung
- School of Medical Education, Newcastle University, Framlington Place, Newcastle upon Tyne, UK
| | - Cheuk Heng Li
- School of Medical Education, Newcastle University, Framlington Place, Newcastle upon Tyne, UK
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114
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Velasco BT, Patel SS, Broughton KK, Frumberg DB, Kwon JY, Miller CP. Arthrofibrosis of the Ankle. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011420970463. [PMID: 35097416 PMCID: PMC8564948 DOI: 10.1177/2473011420970463] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Arthrofibrosis is a common, but often overlooked, condition that imparts significant morbidity following injuries and surgery to the foot and ankle. The most common etiologies are related to soft tissue trauma with subsequent fibrotic and contractile scar tissue formation within the ligaments and capsule of the ankle. This leads to pain, alterations in gait, and ankle dysfunction. Initial treatment often includes extensive physical therapy, however, if severe enough surgical options exist. Although the literature regarding ankle arthrofibrosis is scarce, this review article provides a greater understanding of the pathogenesis of arthrofibrosis and describes the current and future therapeutic options to treat fibrotic joints. Level of Evidence: Level V, expert opinion.
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Affiliation(s)
- Brian Timothy Velasco
- Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA
| | - Shalin S. Patel
- Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Boston, MA, USA
| | | | - David B. Frumberg
- Department of Orthopaedic Surgery, Yale School of Medicine, Yale-New Haven Hospital, New Haven, CT, USA
| | - John Y. Kwon
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Christopher P. Miller
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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115
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Prince N, Penatzer JA, Dietz MJ, Boyd JW. Localized cytokine responses to total knee arthroplasty and total knee revision complications. J Transl Med 2020; 18:330. [PMID: 32867801 PMCID: PMC7461261 DOI: 10.1186/s12967-020-02510-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 08/27/2020] [Indexed: 11/29/2022] Open
Abstract
Background The study of localized immune-related factors has proven beneficial for a variety of conditions, and one area of interest in the field of orthopaedics is the impact of implants and localized infections on immune response. Several cytokines have shown increased systemic concentrations (in serum/plasma) in response to implants and infection, but tissue-level cytokines have not been investigated as thoroughly. Methods This exploratory study investigated tissue-level cytokines in a cohort of patients (N = 17) in response to total knee arthroplasty and total knee revision to better understand the immune response to implants and localized infection (e.g., prosthetic joint infection). The overall goal of this study was to provide insight into the localized cytokine response of tissues and identify tissue-level markers specific to inflammation caused by implants vs. inflammation caused by infection. Tissues were collected across several anatomical locations and assayed with a panel of 20 human inflammatory cytokines to understand spatial differences in cytokine levels. Results In this study, six cytokines were elevated in implanted joints, as compared to native joints: IL-10, IL-12p70, IL-13, IL-17A, IL-4, and TNF-α (p < 0.05). Seven cytokines showed infection-dependent increases in localized tissues: IL-1α, IL-1β, IL-6, IL-8, MCP-1, MIP-1α, and MIP-1β (p < 0.05). Conclusions This study demonstrated that differences exist in tissue-level cytokines in response to presence of implant, and some cytokines were specifically elevated for infection; these responses may be informative of overall tissue health. These results highlight the utility of investigating localized cytokine concentrations to offer novel insights for total knee arthroplasty and total knee revision procedures, as well as their complications. Ultimately, this information could provide additional, quantitative measurements of tissue to aid clinical decision making and patient treatment options.
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Affiliation(s)
- Nicole Prince
- C. Eugene Bennett Department of Chemistry, West Virginia University, 64 Medical Center Drive, 3900 HSS, P.O. Box 9196, Morgantown, WV, 26506-9196, USA.,Department of Orthopaedics, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Julia A Penatzer
- C. Eugene Bennett Department of Chemistry, West Virginia University, 64 Medical Center Drive, 3900 HSS, P.O. Box 9196, Morgantown, WV, 26506-9196, USA.,Department of Orthopaedics, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Matthew J Dietz
- Department of Orthopaedics, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Jonathan W Boyd
- Department of Orthopaedics, West Virginia University School of Medicine, Morgantown, WV, USA. .,Department of Physiology and Pharmacology, West Virginia University, Morgantown, WV, USA.
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116
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Adhesive capsulitis of the hip joint in a young female. A case-report. Int J Surg Case Rep 2020; 75:526-529. [PMID: 33008793 PMCID: PMC7567048 DOI: 10.1016/j.ijscr.2020.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 08/05/2020] [Indexed: 11/29/2022] Open
Abstract
Adhesive capsulitis of hip joint is uncommon disease usually affecting young adults. Pain relief might be associated with arthrogram study. Hormonal changes during pregnancy might have some effect on adhesive capsulitis.
Introduction Adhesive capsulitis of the hip is a rare presenting pathology. History and physical examination are essential for diagnosis. Conservative management is the main line of treatment with surgical intervention preserved for resistant cases. Presentation of case The authors report a case of young female diagnosed with adhesive capsulitis of the hip with two pain free periods during pregnancy and after arthrogram. Discussion The relation between the pregnancy hormones and generalized laxity is well established. Animals studies proved the role of female hormones in treatment of adhesive capsulitis of the shoulder. Conclusion Hip pain relief during pregnancy can raise the suspicion of adhesive capsulitis of the hip. Further investigations are needed to prove this relation.
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117
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Siamwala JH, Zhao A, Barthel H, Pagano FS, Gilbert RJ, Rounds S. Adaptive and innate immune mechanisms in cardiac fibrosis complicating pulmonary arterial hypertension. Physiol Rep 2020; 8:e14532. [PMID: 32786064 PMCID: PMC7422804 DOI: 10.14814/phy2.14532] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/03/2020] [Accepted: 07/06/2020] [Indexed: 12/24/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a syndrome diagnosed by increased mean pulmonary artery (PA) pressure and resistance and normal pulmonary capillary wedge pressure. PAH is characterized pathologically by distal pulmonary artery remodeling, increased pulmonary vascular resistance, and plexiform lesions (PLs). Right ventricular fibrosis and hypertrophy, leading to right ventricular failure, are the main determinants of mortality in PAH. Recent work suggests that right ventricular fibrosis results from resident cardiac fibroblast activation and conversion to myofibroblasts, leading to replacement of contractile cardiomyocytes with nondistensible tissue incapable of conductivity or contractility. However, the origins, triggers, and consequences of myofibroblast expansion and its pathophysiological relationship with PAH are unclear. Recent advances indicate that signals generated by adaptive and innate immune cells may play a role in right ventricular fibrosis and remodeling. This review summarizes recent insights into the mechanisms by which adaptive and innate immune signals participate in the transition of cardiac fibroblasts to activated myofibroblasts and highlights the existing gaps of knowledge as relates to the development of right ventricular fibrosis.
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Affiliation(s)
- Jamila H. Siamwala
- Department of Molecular PharmacologyPhysiology and BiotechnologyBrown UniversityProvidenceRIUSA
- Warren Alpert Medical School of Brown UniversityProvidence VA Medical CenterProvidenceRIUSA
| | - Alexander Zhao
- Department of Molecular PharmacologyPhysiology and BiotechnologyBrown UniversityProvidenceRIUSA
| | - Haley Barthel
- Department of Molecular PharmacologyPhysiology and BiotechnologyBrown UniversityProvidenceRIUSA
| | - Francesco S. Pagano
- Department of Molecular PharmacologyPhysiology and BiotechnologyBrown UniversityProvidenceRIUSA
| | - Richard J. Gilbert
- Ocean State Research InstituteProvidence VA Medical CenterProvidenceRIUSA
| | - Sharon Rounds
- Warren Alpert Medical School of Brown UniversityProvidence VA Medical CenterProvidenceRIUSA
- Department of MedicineDivision of PulmonaryCritical Care and SleepWarren Alpert Medical School of Brown UniversityProvidenceRIUSA
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BMP9 is a potential therapeutic agent for use in oral and maxillofacial bone tissue engineering. Biochem Soc Trans 2020; 48:1269-1285. [PMID: 32510140 DOI: 10.1042/bst20200376] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/08/2020] [Accepted: 05/15/2020] [Indexed: 02/07/2023]
Abstract
Oral and maxillofacial surgery is often challenging due to defective bone healing owing to the microbial environment of the oral cavity, the additional involvement of teeth and esthetic concerns. Insufficient bone volume as a consequence of aging and some oral and maxillofacial surgical procedures, such as tumor resection of the jaw, may further impact facial esthetics and cause the failure of certain procedures, such as oral and maxillofacial implantation. Bone morphogenetic protein (BMP) 9 (BMP9) is one of the most effective BMPs to induce the osteogenic differentiation of different stem cells. A large cross-talk network that includes the BMP9, Wnt/β, Hedgehog, EGF, TGF-β and Notch signaling pathways finely regulates osteogenesis induced by BMP9. Epigenetic control during BMP9-induced osteogenesis is mainly dependent on histone deacetylases (HDACs), microRNAs (miRNAs) and long noncoding RNAs (lncRNAs), which adds another layer of complexity. As a result, all these factors work together to orchestrate the molecular and cellular events underlying BMP9-related tissue engineering. In this review, we summarize our current understanding of the SMAD-dependent and SMAD-independent BMP9 pathways, with a particular focus on cross-talk and cross-regulation between BMP9 and other major signaling pathways in BMP9-induced osteogenesis. Furthermore, recently discovered epigenetic regulation of BMP9 pathways and the molecular and cellular basis of the application of BMP9 in tissue engineering in current oral and maxillofacial surgery and other orthopedic-related clinical settings are also discussed.
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Postoperative Serum Cytokine Levels Are Associated With Early Stiffness After Total Knee Arthroplasty: A Prospective Cohort Study. J Arthroplasty 2020; 35:S336-S347. [PMID: 32269006 PMCID: PMC8279012 DOI: 10.1016/j.arth.2020.02.046] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/03/2020] [Accepted: 02/21/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Inflammatory cytokines have been implicated in organ fibrosis; however, their role in the development of arthrofibrosis after total knee arthroplasty (TKA) has not been well explored. The purpose of this study is to assess whether perioperative synovial fluid or blood plasma cytokine levels are associated with reduced early post-TKA range of motion. METHODS A total of 179 patients with end-stage idiopathic osteoarthritis undergoing TKA were enrolled in this prospective cohort study. Synovial fluid and blood plasma were collected prearthrotomy and plasma was collected longitudinally in the postacute care unit and on postoperative days (PODs) 1 and 2. Stiffness was defined as ≤95° range of motion measured with a goniometer at 6 weeks (±2 weeks). RESULTS Thirty-two of 162 (19.8%) patients analyzed were stiff at 6 weeks postoperatively. Postoperative plasma levels of 9 cytokines (Eotaxin3, IL-5, IL12_23p40, IP10, VEGF, IL-7, IL-12p70, IL-16, IL-17a) were significantly different between stiff and nonstiff patients on POD1 and/or POD2. An association between preoperative plasma and synovial fluid cytokine levels and the development of postoperative stiffness was not detected. CONCLUSION The results of this study suggest that there is a distinct acute postoperative cytokine response profile in patients who develop stiffness 6 weeks after TKA. This profile was characterized by significant differences in levels of 9 cytokines over the first 2 postoperative days. These results identify cytokines that are potential biomarkers for risk of early stiffness after TKA and may play a role in the pathophysiology of this outcome.
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120
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Is EDTA Irrigation Effective in Reducing Bacterial Infection in a Rat Model of Contaminated Intra-articular Knee Implants? Clin Orthop Relat Res 2020; 478:1111-1121. [PMID: 32012144 PMCID: PMC7170675 DOI: 10.1097/corr.0000000000001119] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND To mitigate the possibility of infection after arthroplasty, intraoperative irrigation is essential to remove contaminating bacteria. Previous studies have demonstrated that irrigation with an EDTA solution before wound closure is superior to irrigation with normal saline in removing contaminating bacteria in a rat model of open fractures. However, the effectiveness of an EDTA solution in a model with a contaminated intra-articular implant remains unclear. QUESTIONS/PURPOSES (1) Does irrigation with an EDTA solution decrease the proportion of culture-positive joints compared with normal saline, benzalkonium chloride, and povidone iodine? (2) Is an EDTA solution toxic to cells resident in joints including chondrocytes, osteoblasts, and synovial fibroblasts? (3) Does irrigation with an EDTA solution have adverse effects including arthrofibrosis and hypocalcemia? METHODS We first established a model of contaminated intra-articular implants. Female Sprague-Dawley rats (n = 30 for each treatment group) underwent knee arthrotomy and implantation of a femoral intramedullary wire with 1 mm of intra-articular communication. To simulate bacterial contamination, the inserted wire was inoculated with either Staphylococcus aureus or Escherichia coli. After 1 hour, the wound and implant were irrigated with normal saline, benzalkonium chloride, povidone iodine, or an EDTA solution (1 mM). The animals were euthanized 1 week later, and the distal femur, knee capsule, and implanted wire were harvested for bacterial culture using standard techniques. In this study, we used a well-established animal model of an intra-articular implant and inoculated the implant to simulate the clinical setting of intraoperative contamination. The proportion of culture-positive joints in normal saline, benzalkonium chloride, povidone-iodine, and EDTA groups were compared. The viable cell numbers (chondrocytes, osteoblasts, and synovial fibroblasts) were counted and compared after treatment with either solution. Measurement of blood calcium level and histological examination of the joint were performed to rule out hypocalcemia and arthrofibrosis after EDTA irrigation. RESULTS With S. aureus inoculation, EDTA irrigation resulted in fewer culture-positive joints than normal saline (37% [11 of 30] versus 70% [21 of 30]; p = 0.019), benzalkonium chloride (83% [25 of 30]; p < 0.001), and povidone iodine (83% [25 of 30]; p < 0.001) irrigation. Likewise, infection rates for implant inoculation with E. coli were also lower in the EDTA irrigation group (13% [four of 30]) than in the normal saline (60% [18 of 30]; p < 0.001), benzalkonium chloride (77% [23 of 30]; p < 0.001), and povidone iodine (80% [24 of 30]; p < 0.001) groups. Between normal saline control and EDTA, there were no differences in cell viability in chondrocytes (normal saline: 98% ± 18%; EDTA: 105% ± 18%; p = 0.127), osteoblasts (normal saline: 102 ± 19%, EDTA: 103 ± 14%; p = 0.835), and synovial fibroblasts (normal saline: 101% ± 21%, EDTA: 110% ± 13%; p = 0.073). EDTA irrigation did not result in hypocalcemia (before irrigation: 2.21 ± 0.32 mmol/L, after irrigation: 2.23 ± 0.34 mmol/L; p = 0.822); and we observed no arthrofibrosis in 30 histologic samples. CONCLUSIONS In a rat model of a bacteria-contaminated intra-articular implants, intraoperative irrigation with 1 mmol/L of an EDTA solution was superior to normal saline, 0.03% benzalkonium chloride, and 0.3% povidone iodine in preventing surgical-site infection and caused no adverse effects including death of resident cells, arthrofibrosis, and hypocalcemia. Future studies should seek to replicate our findings in other animal models, perhaps such as dog and goat. CLINICAL RELEVANCE If other animal models substantiate the efficacy and safety of the EDTA solution, clinical trials would be warranted to determine whether the use of an EDTA irrigation solution might reduce the risk of periprosthetic joint infections in patients compared with traditional irrigation solutions.
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121
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Atluri K, Brouillette MJ, Seol D, Khorsand B, Sander E, Salem AK, Fredericks D, Petersen E, Smith S, Fowler TP, Martin JA. Sulfasalazine Resolves Joint Stiffness in a Rabbit Model of Arthrofibrosis. J Orthop Res 2020; 38:629-638. [PMID: 31692083 DOI: 10.1002/jor.24499] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 10/06/2019] [Indexed: 02/04/2023]
Abstract
Joint stiffness due to fibrosis/capsule contracture is a seriously disabling complication of articular injury that surgical interventions often fail to completely resolve. Fibrosis/contracture is associated with the abnormal persistence of myofibroblasts, which over-produce and contract collagen matrices. We hypothesized that intra-articular therapy with drugs targeting myofibroblast survival (sulfasalazine), or collagen production (β-aminopropionitrile and cis-hydroxyproline), would reduce joint stiffness in a rabbit model of fibrosis/contracture. Drugs were encapsulated in poly[lactic-co-glycolic] acid pellets and implanted in joints after fibrosis/contracture induction. Capsule α-smooth muscle actin (α-SMA) expression and intimal thickness were evaluated by immunohistochemistry and histomorphometry, respectively. Joint stiffness was quantified by flexion-extension testing. Drawer tests were employed to determine if the drugs induced cruciate ligament laxity. Joint capsule fibroblasts were tested in vitro for contractile activity and α-SMA expression. Stiffness in immobilized joints treated with blank pellets (control) was significantly higher than in non-immobilized, untreated joints (normal) (p = 0.0008), and higher than in immobilized joints treated with sulfasalazine (p = 0.0065). None of the drugs caused significant cruciate ligament laxity. Intimal thickness was significantly lower than control in the normal and sulfasalazine-treated groups (p = 0.010 and 0.025, respectively). Contractile activity in the cells from controls was significantly increased versus normal (p = 0.001). Sulfasalazine and β-aminopropionitrile significantly inhibited this effect (p = 0.005 and 0.0006, respectively). α-SMA expression was significantly higher in control versus normal (p = 0.0021) and versus sulfasalazine (p = 0.0007). These findings support the conclusion that sulfasalazine reduced stiffness by clearing myofibroblasts from fibrotic joints. Statement of clinical significance: The results provide proof-of-concept that established joint stiffness can be resolved non-surgically. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:629-638, 2020.
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Affiliation(s)
- Keerthi Atluri
- Department of Pharmaceutical Sciences and Experimental Therapeutics, University of Iowa, Iowa City, Iowa, 52242
| | - Marc J Brouillette
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, 52242
| | - Dongrim Seol
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, 52242
| | - Behnoush Khorsand
- Department of Pharmaceutical Sciences and Experimental Therapeutics, University of Iowa, Iowa City, Iowa, 52242
| | - Edward Sander
- Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa, 52242
| | - Aliasger K Salem
- Department of Pharmaceutical Sciences and Experimental Therapeutics, University of Iowa, Iowa City, Iowa, 52242
| | - Douglas Fredericks
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, 52242
| | - Emily Petersen
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, 52242
| | - Sonja Smith
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, 52242
| | - Timothy P Fowler
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, 52242
| | - James A Martin
- Department of Pharmaceutical Sciences and Experimental Therapeutics, University of Iowa, Iowa City, Iowa, 52242.,Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, 52242.,Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa, 52242
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Kaneguchi A, Ozawa J, Yamaoka K. Intra-articular injection of mitomycin C prevents progression of immobilization-induced arthrogenic contracture in the remobilized rat knee. Physiol Res 2020; 69:145-156. [PMID: 31852201 DOI: 10.33549/physiolres.934149] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This study tested whether cell cycle inhibitor mitomycin C (MMC) prevents arthrogenic contracture progression during remobilization by inhibiting fibroblast proliferation and fibrosis in the joint capsule. Rat knees were immobilized in a flexed position to generate flexion contracture. After three weeks, the fixation device was removed and rat knees were allowed to freely move for one week. Immediately after and three days after fixator removal, rats received intra-articular injections of MMC or saline. The passive extension range of motion (ROM) was measured before and after myotomy of the knee flexors to distinguish myogenic and arthrogenic contractures. In addition, both cellularity and fibrosis in the posterior joint capsule were assessed histologically. Joint immobilization significantly decreased ROMs both before and after myotomy compared with untreated controls. In saline-injected knees, remobilization increased ROM before myotomy, but further decreased that after myotomy compared with that of knees immediately after three weeks of immobilization. Histological analysis revealed that hypercellularity, mainly due to fibroblast proliferation, and fibrosis characterized by increases in collagen density and joint capsule thickness occurred after remobilization in saline-injected knees. Conversely, MMC injections were able to prevent the remobilization-enhanced reduction of ROM after myotomy by inhibiting both hypercellularity and joint capsule fibrosis. Our results suggest that joint capsule fibrosis accompanied by fibroblast proliferation is a potential cause of arthrogenic contracture progression during remobilization, and that inhibiting fibroblast proliferation may constitute an effective remedy.
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Affiliation(s)
- A Kaneguchi
- Department of Rehabilitation, Faculty of Rehabilitation, Hiroshima International University, Hiroshima, Japan.
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Effects of Immobilization and Re-Mobilization on Knee Joint Arthrokinematic Motion Quality. J Clin Med 2020; 9:jcm9020451. [PMID: 32041248 PMCID: PMC7074294 DOI: 10.3390/jcm9020451] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/18/2020] [Accepted: 02/05/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Knee immobilization is a common intervention for patients with traumatic injuries. However, it usually leads to biomechanical/morphological disturbances of articular tissues. These changes may contribute to declining kinetic friction-related quality of arthrokinematics; however, this phenomenon has not been analyzed in vivo and remains unrecognized. Thus, the aim of the present study is to investigate the effect of immobilization and subsequent re-mobilization on the quality of arthrokinematics within the patellofemoral joint, analyzed by vibroarthrography (VAG). METHODS Thirty-four patients after 6-weeks of knee immobilization and 37 controls were analyzed. The (VAG) signals were collected during knee flexion/extension using an accelerometer. Patients were tested on the first and last day of the 2-week rehabilitation program. RESULTS Immobilized knees were characterized by significantly higher values of all VAG parameters when compared to controls (p < 0.001) on the first day. After 2 weeks, the participants in the rehabilitation program that had immobilized knees showed significant improvement in all measurements compared to the baseline condition, p < 0.05. However, patients did not return to normal VAG parameters compared to controls. CONCLUSION Immobilization-related changes within the knee cause impairments of arthrokinematic function reflected in VAG signal patterns. The alterations in joint motion after 6 weeks of immobilization may be partially reversible; however, the 2-week physiotherapy program is not sufficient for full recovery.
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Bernstein A, Reichert SNA, Südkamp NP, Hernandez SL, Nerlich AG, Kühle J, Mayr HO. Expression of xylosyltransferases I and II and their role in the pathogenesis of arthrofibrosis. J Orthop Surg Res 2020; 15:27. [PMID: 31973761 PMCID: PMC6979351 DOI: 10.1186/s13018-020-1544-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 01/02/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Arthrofibrosis is a painful and restraining complication that occurs after about 10% of total knee arthroplasty and cruciate ligament surgery. The pathogenesis of arthrofibrosis has not yet been fully understood. Stress signals stimulate immune cells, and fibroblast differentiates into myofibroblast, which produce a large amount of collagen. Xylosyltransferases also appear to be involved in these pathways. They catalyze proteoglycan biosynthesis, which is involved in tissue remodeling and myofibroblast differentiation. The aim of this study was to investigate the relationship between the disease arthrofibrosis and the expression of the two isoforms of xylosyltransferases I and II. METHODS Tissue samples from 14 patients with arthrofibrosis were compared with tissue samples from seven healthy controls. The xylosyltransferases were detected by immunohistochemistry. The tissues were divided into four different areas of interest: vessels, synovialis, cell-poor and cell-rich fibrosis, or cell-poor and cell-rich areas in the control group. A quantification of the results was performed by modification of the immunoreactive score according to Remmele and Stegner. RESULTS Xylosyltransferase I was expressed in the various tissue types at varying rates. Xylosyltransferase I expression was considerably and significantly stronger than that of xylosyltransferase II. The following sequences of xylosyltransferase I and xylosyltransferase II expression were determined as follows: vessels >> cell-rich fibrosis > cell-poor fibrosis > synovialis. A positive correlation between the number of positive fibroblasts and the immunoreactive scoring system (IRS) was documented. CONCLUSIONS The significant positive correlation of xylosyltransferase -I expression with increasing number of fibroblasts demonstrates a high myofibroblast differentiation rate, which implies a gradual event as the pathogenesis of arthrofibrosis.
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Affiliation(s)
- Anke Bernstein
- G.E.R.N. Tissue Replacement, Regeneration & Neogenesis, Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Sven N. A. Reichert
- G.E.R.N. Tissue Replacement, Regeneration & Neogenesis, Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Norbert P. Südkamp
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Sergio Latorre Hernandez
- G.E.R.N. Tissue Replacement, Regeneration & Neogenesis, Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Andreas G. Nerlich
- Institute of Pathology, Academic Clinics München-Bogenhausen and München-Schwabing, 81925 Munich, Germany
| | - Jan Kühle
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Hermann O. Mayr
- Department of Orthopedics and Trauma Surgery, Medical Center - Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Germany, Hugstetter Straße 55, 79106 Freiburg, Germany
- Department of Knee, Hip and Shoulder Surgery, Schoen Clinic Munich Harlaching, Harlachinger Strasse 51, 81547 Munich, Germany
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Baranowski A, Schlemmer L, Förster K, Slotina E, Mickan T, Truffel S, Klein A, Mattyasovszky SG, Hofmann A, Ritz U, Rommens PM. Effects of losartan and atorvastatin on the development of early posttraumatic joint stiffness in a rat model. Drug Des Devel Ther 2019; 13:2603-2618. [PMID: 31440039 PMCID: PMC6679684 DOI: 10.2147/dddt.s204135] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 06/27/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND After a trauma, exuberant tissue healing with fibrosis of the joint capsule can lead to posttraumatic joint stiffness (PTJS). Losartan and atorvastatin have both shown their antifibrotic effects in different organ systems. OBJECTIVE The purpose of this study was the evaluation of the influence of losartan and atorvastatin on the early development of joint contracture. In addition to joint angles, the change in myofibroblast numbers and the distribution of bone sialoprotein (BSP) were assessed. STUDY DESIGN AND METHODS In this randomized and blinded experimental study with 24 rats, losartan and atorvastatin were compared to a placebo. After an initial joint injury, rat knees were immobilized with a Kirschner wire. Rats received either losartan, atorvastatin or a placebo orally daily. After 14 days, joint angle measurements and histological assessments were performed. RESULTS Losartan increased the length of the inferior joint capsule. Joint angle and other capsule length measurements did not reveal significant differences between both drugs and the placebo. At cellular level both losartan and atorvastatin reduced the total number of myofibroblasts (losartan: 191±77, atorvastatin: 98±58, placebo: 319±113 per counting field, p<0.01) and the percentage area of myofibroblasts (losartan: 2.8±1.8% [p<0.05], atorvastatin: 2.5±1.7% [p<0.01], vs control [6.4±4%], respectively). BSP was detectable in equivalent amounts in the joint capsules of all groups with only a trend toward a reduction of the BSP-stained area by atorvastatin. CONCLUSION Both atorvastatin and losartan reduced the number of myofibroblasts in the posterior knee joint capsule of rat knees 2 weeks after trauma and losartan increased the length of the inferior joint capsule. However, these changes at the cellular level did not translate an increase in range of motion of the rats´ knee joints during early contracture development.
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Affiliation(s)
- Andreas Baranowski
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Ludwig Schlemmer
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Katharina Förster
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Ekaterina Slotina
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Tim Mickan
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Sebastian Truffel
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Anja Klein
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Stefan G Mattyasovszky
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Alexander Hofmann
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
- Department of Traumatology and Orthopaedics 1, Westpfalz-Medical Centre Kaiserslautern, Kaiserslautern, Germany
| | - Ulrike Ritz
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Pol M Rommens
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
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