A myofibroblast-mast cell-neuropeptide axis of fibrosis in post-traumatic joint contractures: an in vitro analysis of mechanistic components

Ketotifen directly modifies the fibrotic response of human skin fibroblasts

Fibrosis is a destructive, end-stage disease process. In the skin, it is associated with systemic sclerosis and scarring with considerable health burden. Ketotifen is a clinical antihistamine and mast cell stabilizer. Studies have demonstrated mast cell-dependent anti-fibrotic effects of ketotifen but direct effects on fibroblasts have not been determined. Human dermal fibroblasts were treated with pro-fibrotic transforming growth factor-β1 (TGFβ) followed by ketotifen or control treatments to determine direct effects on fibrotic fibroblasts. Ketotifen impaired TGFβ-induced α-smooth muscle actin gene and protein responses and decreased cytoskeletal- and contractility-associated gene responses associated with fibrosis. Ketotifen reduced Yes-associated protein phosphorylation, transcriptional coactivator with PDZ binding motif transcript and protein levels, and phosphorylation of protein kinase B. In a fibroblast-populated collagen gel contraction assay, ketotifen reduced the contractile activity of TGFβ-activated fibroblasts. In a murine model of bleomycin-induced skin fibrosis, collagen density and dermal thickness were significantly decreased in ketotifen-treated mice supporting in vitro findings. These results support a novel, direct anti-fibrotic activity of ketotifen, reducing pro-fibrotic phenotypic changes in fibroblasts and reducing collagen fibres in fibrotic mouse skin. Together, these findings suggest novel therapeutic potential and a novel mechanism of action for ketotifen in the context of fibrosis.

An Updated Overview of Risk Factors for Shoulder Stiffness

A painful reduction in shoulder mobility, known as "shoulder stiffness", can occur both as a primary idiopathic condition and as a secondary condition, for example, following surgical procedures. Various factors can contribute to the development of primary shoulder stiffness. In this review we summarize the pathophysiological mechanisms, genetic influences, endocrine disorders, metabolic conditions, as well as other diseases and medical-therapeutic approaches that might have an impact on the development of primary shoulder stiffness.

Biomechanical study of the effect of traction on elbow joint capsule contracture

Dynamic orthoses have a significant effect on the treatment of elbow capsular contracture. Because of the lack of quantitative research on traction forces, determining the appropriate traction force to help stretch soft tissues and maintain the joint's range of motion is a challenge in the rehabilitation process. We developed a human elbow finite element (FE) model incorporating the activity behavior of the muscles and considering different capsular contracture locations, including total, anterior and posterior capsular contractures, to analyze the internal biomechanical responses of different capsular contracture models during flexion (30 to 80 degrees). Traction loads of 10, 20, 30 and 40 N were applied to the ulna and radius at the maximum flexion angle (80 degrees) to explore the appropriate traction loads at week 4 after a joint capsule injury. We observed a significant increase in posterior capsule stress with anterior capsular contracture (ACC), and the maximum peak stress was 1.3 times higher than that in the healthy model. During the fourth week after elbow capsule injury, the appropriate traction forces for total capsule contracture (TCC), ACC and posterior capsule contracture (PCC) were 20, 10 and 20 N, respectively; these forces maintained a stable biomechanical environment for the elbow joint and achieved a soft tissue pulling effect, thus increasing elbow mobility. The results can be used as a quantitative guide for the rehabilitation physicians to determine the traction load for a specific patient.

The treatment of a malunited posterior pilon fracture with talar dislocation: A staged surgical treatment protocol

BACKGROUND

Malunited posterior pilon fractures with talus dislocation (mPPFtd) are rare and there are no appropriate treatment strategies. The purpose of this study was to introduce a stepped strategy featuring preliminary soft tissue management according to the Ilizarov principle and delayed open reduction and internal fixation (ORIF) through a modified posteromedial approach to overcome rigid soft tissue contracture.

METHOD

From February 2015 to August 2021, 12 selected patients with mPPFtd who were treated with the staged protocol (Group A) were retrospectively analysed. The clinical and radiographic outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, the visual analogue scale (VAS) score, and the Burwell-Charnley score. Moreover, this case series was compared with some cases of fresh fracture (Group B) in patients that had the same baseline data from our previous study.

RESULTS

In Group A, the average length of time between the date of injury and the date of surgery was 4.8 ± 3.3 months. The average time to external fixator distraction, as the first-stage treatment, was 13.4 ± 1.0 days. In the second stage of ORIF, the posterosuperior dislocation of the talus was corrected with osteotomy and leverage manoeuvres. According to the Burwell-Charnley score system, the reduction quality was excellent in 9 cases and good in 3 cases. After a mean follow-up of 3.8 ± 2.1 years, there were no infections, wound healing problems, or nerve injuries in our cohort, and union was observed in all fractures without a loss of reduction. The baseline data of the two groups were not significantly different (p>0.05). The mean AOFAS score in Group A was 85.0 ± 10.5 and that in Group B was 95.4 ± 6.1 (p<0.05). The mean VAS score in Group A was 1.7 ± 1.4 and that in Group B was 0.7 ± 0.9 (p<0.05).

CONCLUSION

A staged surgical treatment strategy characterized by soft tissue management will improve the treatment of mPPFtd and produce satisfactory clinical outcomes.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Mast Cell Involvement in the Pathogenesis of Selected Musculoskeletal Diseases

In recent years, there has been a noteworthy revival of interest in the function of mast cells (MCs) in the human body. It is now acknowledged that MCs impact a wide array of processes beyond just allergies, leading to a shift in research direction. Unfortunately, some earlier conclusions were drawn from animal models with flawed designs, particularly centered around the receptor tyrosine kinase (Kit) pathway. Consequently, several subsequent findings may have been unreliable. Thus, what is now required is a re-examination of these earlier findings. Nevertheless, the remaining data are fascinating and hold promise for a better comprehension of numerous diseases and the development of more effective therapies. As the field continues to progress, many intriguing issues warrant further investigation and analysis. For instance, exploring the bidirectional action of MCs in rheumatoid arthritis, understanding the extent of MCs' impact on symptoms associated with Ehlers-Danlos syndrome, and unraveling the exact role of the myofibroblast-mast cell-neuropeptides axis in the joint capsule during post-traumatic contractures are all captivating areas for exploration. Hence, in this review, we summarize current knowledge regarding the influence of MCs on the pathogenesis of selected musculoskeletal diseases, including rheumatoid arthritis, spondyloarthritis, psoriatic arthritis, gout, muscle and joint injuries, tendinopathy, heterotopic ossification, and Ehlers-Danlos syndrome. We believe that this review will provide in-depth information that can guide and inspire further research in this area.

Optimizing repair of tendon ruptures and chronic tendinopathies: Integrating the use of biomarkers with biological interventions to improve patient outcomes and clinical trial design

Tendons are dense connective tissues of the musculoskeletal system that link bones with muscles to foster mobility. They have complex structures and exist in varying biomechanical, metabolic and biological environments. In addition, tendon composition and mechanical properties can change over the lifespan as an individual ages. Many tendons function in high stress conditions with a low vascular and neuronal supply, conditions often leading to development of chronic tendinopathies, and in some cases, overt rupture of the tissues. Given their essential nature for human mobility and navigation through the environment, the effective repair and regeneration of different tendons after injury or damage is critical for quality of life, and for elite athletes, the return to sport participation at a high level. However, for mainly unknown reasons, the outcomes following injury are not always successful and lead to functional compromise and risk for re-injury. Thus, there is a need to identify those patients who are at risk for developing tendon problems, as well those at risk for poor outcomes after injury and to design interventions to improve outcomes after injury or rupture to specific tendons. This review will discuss recent advances in the identification of biomarkers prognostic for successful and less successful outcomes after tendon injury, and the mechanistic implications of such biomarkers, as well as the potential for specific biologic interventions to enhance outcomes to improve both quality of life and a return to participation in sports. In addition, the implication of these biomarkers for clinical trial design is discussed, as is the issue of whether such biomarkers for successful healing of one tendon can be extended to all tendons or are valid only for tendons in specific biomechanical and biological environments. As maintaining an active lifestyle is critical for health, the successful implementation of these advances will benefit the large number of individuals at risk.

Pleiotropic Effects of Simvastatin and Losartan in Preclinical Models of Post-Traumatic Elbow Contracture

Elbow trauma can lead to post-traumatic joint contracture (PTJC), which is characterized by loss of motion associated with capsule/ligament fibrosis and cartilage damage. Unfortunately, current therapies are often unsuccessful or cause complications. This study aimed to determine the effects of prophylactically administered simvastatin (SV) and losartan (LS) in two preclinical models of elbow PTJC: an in vivo elbow-specific rat injury model and an in vitro collagen gel contraction assay. The in vivo elbow rat (n = 3-10/group) injury model evaluated the effects of orally administered SV and LS at two dosing strategies [i.e., low dose/high frequency/short duration (D1) vs. high dose/low frequency/long duration (D2)] on post-mortem elbow range of motion (via biomechanical testing) as well as capsule fibrosis and cartilage damage (via histopathology). The in vitro gel contraction assay coupled with live/dead staining (n = 3-19/group) evaluated the effects of SV and LS at various concentrations (i.e., 1, 10, 100 µM) and durations (i.e., continuous, short, or delayed) on the contractibility and viability of fibroblasts/myofibroblasts [i.e., NIH3T3 fibroblasts with endogenous transforming growth factor-beta 1 (TGFβ1)]. In vivo, no drug strategy prevented elbow contracture biomechanically. Histologically, only SV-D2 modestly reduced capsule fibrosis but maintained elevated cellularity and tissue hypertrophy, and both SV strategies lessened cartilage damage. SV modest benefits were localized to the anterior region, not the posterior, of the joint. Neither LS strategy had meaningful benefits in capsule nor cartilage. In vitro, irrespective of the presence of TGFβ1, SV (≥10 μM) prevented gel contraction partly by decreasing cell viability (100 μM). In contrast, LS did not prevent gel contraction or affect cell viability. This study demonstrates that SV, but not LS, might be suitable prophylactic drug therapy in two preclinical models of elbow PTJC. Results provide initial insight to guide future preclinical studies aimed at preventing or mitigating elbow PTJC.

A novel mice model of acute flares in osteoarthritis elicited by intra-articular injection of cultured mast cells

PURPOSE

Mast cells are multifunctional in osteoarthritis (OA), and infiltration of activated mast cells likely contributes to disease severity and progression. However, the detailed mechanisms of action are unclear. The purpose of this study was to elucidate the role of mast cell infiltration in OA at histological level using a new mice model and to investigate pharmacological inhibitory effects of existing mast cell stabilizers in this model.

METHODS

Mice were injected intra-articularly with monosodium iodoacetate (MIA 0.5 mg) or PBS on day 0, and PBS, with or without mast cells (MC: 1 × 10⁶ cells) on day 14. They were divided into four groups: OA flare (MIA + MC), OA (MIA + PBS), MC non-OA (PBS + MC), and PBS non-OA (PBS + PBS). In OA flare, the MC stabilizer drug (tranilast: 400 mg/kg/day) or PBS was administered intraperitoneally from days 15 to 21.

RESULTS

Histologically, modified Mankin score of the OA flare was significantly higher than that of OA (7.0 [1.8] vs. 3.3 [1.3], P < 0.05), and a larger number of mast cells was observed in OA flare than in OA (34.5 [6.3]/mm² vs. 27.2 [2.3]/mm², P < 0.05) on day 22. OA flare also showed acute exacerbation of pain and increased gene expression of pro-inflammatory cytokines and aggrecanase compared with OA. Administration of tranilast to OA flare-up provoked significant improvements in term of histological changes, pain, and gene expression at day 22.

CONCLUSION

Our novel model possibly mimics OA flare conditions, which may open a new strategy of disease-modifying treatment for OA, focused on controlling the multiple functions of mast cells.

Myofibroblasts: Function, Formation, and Scope of Molecular Therapies for Skin Fibrosis

Myofibroblasts are contractile, α-smooth muscle actin-positive cells with multiple roles in pathophysiological processes. Myofibroblasts mediate wound contractions, but their persistent presence in tissues is central to driving fibrosis, making them attractive cell targets for the development of therapeutic treatments. However, due to shared cellular markers with several other phenotypes, the specific targeting of myofibroblasts has long presented a scientific and clinical challenge. In recent years, myofibroblasts have drawn much attention among scientific research communities from multiple disciplines and specialisations. As further research uncovers the characterisations of myofibroblast formation, function, and regulation, the realisation of novel interventional routes for myofibroblasts within pathologies has emerged. The research community is approaching the means to finally target these cells, to prevent fibrosis, accelerate scarless wound healing, and attenuate associated disease-processes in clinical settings. This comprehensive review article describes the myofibroblast cell phenotype, their origins, and their diverse physiological and pathological functionality. Special attention has been given to mechanisms and molecular pathways governing myofibroblast differentiation, and updates in molecular interventions.

What Range of Motion and Functional Results Can Be Expected After Open Arthrolysis with Hinged External Fixation For Severe Posttraumatic Elbow Stiffness?

BACKGROUND

The elbow is more susceptible to loss of motion after trauma than any other joint. Open arthrolysis often is performed for posttraumatic elbow stiffness if the stiffness does not improve with nonsurgical treatment, but the midterm results of this procedure and factors that may limit recovery have not been widely studied.

QUESTIONS/PURPOSES

We reviewed patients who had undergone open arthrolysis with hinged external fixator for severe posttraumatic elbow stiffness (ROM ≤ 60°) with a minimum of 5 years followup to (1) analyze ROM gains; (2) assess functional improvement with the Mayo Elbow Performance Index (MEPI) and DASH, quality of life with the SF-36, pain with VAS, and ulnar nerve function with the Amadio rating scale and Dellon classification; and (3) identify complications and risk factors that might hinder mid-term elbow motion recovery after this procedure.

METHODS

Between March 2011 and December 2012, we generally offered patients with elbow stiffness an open arthrolysis procedure when function did not improve with 6 months of nonoperative therapy, and no contraindications such as immature heterotopic ossification or complete destruction of articular cartilage were present. During that time, 161 patients underwent open arthrolysis for posttraumatic elbow stiffness at our institution; 49 of them satisfied the study inclusion criteria (adults with elbow ROM ≤ 60° as a result of trauma) and exclusion criteria (stiffness caused by burns or central nervous system injuries, causative trauma associated with nonunion or malunion of the elbow, severe articular damage that would have necessitated joint arthroplasty, or prior elbow release). In general, a combined medial-lateral approach to the elbow was performed to address the soft tissue tethers and any blocks to elbow motion, and a hinged external fixator was applied for 6 weeks to maintain elbow stability and improve the efficacy of postoperative rehabilitation. These patients were evaluated retrospectively at a mean followup period of 69 months (range, 62-83 months), and demographics, disease characteristics, arthrolysis details, pre- and postoutcome measures as noted, and complications were recorded via an electronic database. Multivariate regression analysis was performed to identify factors associated with ROM recovery.

RESULTS

At final followup, total ROM increased from a preoperative mean of 27 ± 20° to a postoperative mean of 131 ± 11° (mean difference, 104°; 95% CI, 98°-111°; p < 0.001), and 98% (48 of 49) of patients achieved a functional ROM of 30° to 130°. Improvements were also found in functional scores (MEPI: 54 ± 12 to 95 ± 7, mean difference, 41 points; DASH: 48 ± 17 to 8 ± 8, mean difference, 40 points; both p < 0.001), life quality (physical SF-36: 46 ± 11 to 81 ± 12, mean difference, 35 points; mental SF-36: 43 ± 14 to 80 ± 9, mean difference, 37 points; both p < .001), pain (VAS: 2.5 ± 2.4 to 0.4 ± 0.8; mean difference, 2.0 points; p < 0.001), and ulnar nerve function (Amadio score: 7.8 ± 1.9 to 8.4 ± 0.8; mean difference, 0.6 points; p = 0.004). A total of 18% (nine of 49 patients) developed complications, including new-onset or exacerbated nerve symptoms (four patients), recurrent heterotopic ossification (two patients), and pin-related infections (three patients). No patients underwent subsequent surgery for any of the above complications. Lastly, the medium-term ROM was divided into ROM ≤ 120° (n = 9) and ROM > 120° (n = 40). After controlling for potential confounding variables such as duration of stiffness and tobacco use, we found that tobacco use was the only independent risk factor examined (odds ratio, 9; 95% CI, 2-47; p = 0.009) associated with recovery of ROM.

CONCLUSIONS

Satisfactory medium-term results were found for open arthrolysis with hinged external fixation with our protocol in patients who had severe posttraumatic elbow stiffness. Appropriate and sufficient releases of tethered soft tissues and correction of any blocks that affect elbow motion intraoperatively, a dedicated team approach, and an aggressive and systematic postoperative rehabilitation program are the core steps for this procedure. Additionally, the importance of preoperative discontinuation of tobacco use should be emphasized.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Tobacco use predicts poorer clinical outcomes and higher post-operative complication rates after open elbow arthrolysis

INTRODUCTION

Tobacco use is a worldwide public health problem, and has been found to be a predisposing factor for adverse functional outcomes and increased postoperative complication rates after various orthopedic operations. The purpose of this study was to determine the potential impact of tobacco use on open arthrolysis for post-traumatic elbow stiffness.

MATERIALS AND METHODS

A database search identified 145 patients with open arthrolysis performed for post-traumatic elbow stiffness; these were divided into three groups: current tobacco users (37), former users (28), and nonusers (80). All surgeries were performed using the same technique by the same doctor. General patient data, functional performance, and complications were documented and analyzed.

RESULTS

Demographic data and disease characteristics were comparable at baseline. Postoperatively, significant differences were found among the three groups in terms of range of motion (P < 0.001), Mayo Elbow Performance Score (P = 0.006), visual analog scale score for pain (P = 0.015), Dellon classification for ulnar nerve symptoms (P = 0.013), and total complication rates (P < 0.001). The current tobacco users group had the poorest clinical outcomes and highest complication rates, while no significant differences were found between former users and nonusers.

CONCLUSIONS

Current tobacco users reported increased risk of poorer clinical outcomes and higher postoperative complication rates after open arthrolysis. Former users were found to have outcomes similar to those of nonusers. This study underlines the importance of discontinuing tobacco use for patients with post-traumatic elbow stiffness who are considering open arthrolysis.

LEVEL OF EVIDENCE

Level III; Retrospective Cohort Design; Therapeutic Study.

Development and validation of a new elbow-specific scoring system for patients with elbow stiffness: the Shanghai Elbow Dysfunction Score

BACKGROUND

Clinical scoring systems are increasingly important and popular for the evaluation of orthopedic patients. Elbow stiffness commonly causes functional impairment and upper-limb disability. The purpose of this study was to develop and validate a new elbow-specific assessment score to evaluate joint function in patients with elbow stiffness.

METHODS

The new system, the Shanghai Elbow Dysfunction Score (SHEDS), was developed in 3 portions: elbow motion capacities, elbow-related symptoms, and patient satisfaction level. A total of 73 patients with elbow stiffness were prospectively included. Intraclass correlation coefficients and Cronbach α values were calculated for test-retest reliability and internal consistency, respectively. Construct validity was assessed by correlating the SHEDS with previously validated scoring systems. Effect sizes (ES) and standardized response means (SRMs) were calculated for responsiveness.

RESULTS

Positive reliability with an intraclass correlation coefficient of 0.83 and adequate homogeneity with a Cronbach α value of 0.74 were found for the SHEDS. Good to excellent validity using Spearman correlation coefficients (SCCs) were determined for the total (0.51-0.82), motion (0.65-0.89), and symptom (0.35-0.53) scores. Responsiveness was large for the total ES, 3.48; SRM, 2.96), motion (ES, 2.54; SRM, 2.08), and symptom (ES, 1.26; SRM, 1.14) scores. There were no ceiling or floor effects. Significant positive correlations were found between patient satisfaction levels and the final scores (SCC, 0.62), as well as the score changes of the SHEDS (SCC, 0.42).

CONCLUSION

Our results suggest that the newly developed SHEDS is an excellent, comprehensive, valid scoring system to evaluate joint function in patients with elbow stiffness.

Prospective outcome assessment of arthroscopic arthrolysis for traumatic and degenerative elbow contracture

BACKGROUND

The purpose of this study was to evaluate the efficacy of arthroscopic elbow release for both traumatic and degenerative contractures from intraoperative recording through the recovery time until final follow-up.

METHODS

The study is based on 54 consecutive patients with extrinsic elbow contracture (traumatic in 31 and degenerative in 23) treated with arthroscopic arthrolysis by a single surgeon in 2011-2015. Range of motion (ROM) and the Mayo Elbow Performance Score (MEPS) were recorded preoperatively; intraoperatively; following release; and in the 1st, 3rd, 8th, 12th, and 26th weeks and at 2 years postoperatively.

RESULTS

Significant improvements were noted in extension, flexion, and range of motion, measured both intraoperatively and at all follow-up visits. The greatest improvement in the range of motion was achieved at the time of surgery (from 89° ± 28° to 131° ± 14°, P < .001); it then decreased at 1 week to 103° ± 22° (P < .001) and slowly recovered to reach 124° ± 22° after 2 years. This was better than the preoperative value (P < .001) but worse than the intraoperative value (P = .002). A similar pattern was observed in both traumatic and degenerative contractures. The MEPS improved from 73 ± 12 preoperatively to 93 ± 14 at the final evaluation (P < .001). The ROM and MEPS results at every follow-up were comparable for both traumatic and degenerative contractures. ROM improved regardless of the severity of contracture.

CONCLUSIONS

Arthroscopic elbow arthrolysis was similarly efficient in ROM restoration in both traumatic and degenerative contractures and regardless of the severity of contracture. After early deterioration, the achieved gain slowly recovers over a period of 6 months but may not recover to the ranges achieved during arthroscopy.

Validation of the Liverpool Elbow Score for evaluation of elbow stiffness

Background

The Liverpool Elbow Score (LES) has been widely used to assess the outcomes of total elbow replacement in various conditions. However, there have been no published validation studies on LES for patients with stiff elbows undergoing arthrolysis. The purpose of this study was to find out whether LES could be equally applied to evaluate joint function in patients with elbow stiffness.

Methods

A total of 63 patients with elbow stiffness were included in this retrospective validation study. The LES combines a nine-item patient-answered questionnaire (PAQ) and a six-item clinical assessment score (CAS), and can also be divided to evaluate two different parameters: elbow motion capacity (EMC) and elbow-related symptoms (ERS). Construct validity was assessed by correlating LES with previously validated scoring systems, and Spearman correlation coefficients (SCCs) were calculated. Effect size (ES) and standardized response mean (SRM) were calculated to determine responsiveness.

Results

There were no ceiling or floor effects in the target population. Good-to-excellent validity was determined based on total score (0.45–0.89), PAQ (0.42–0.88), CAS (0.35–0.60), EMC (0.46–0.86), and ERS (0.36–0.59). High responsiveness (ES/SRM) was observed in total score (2.80/2.24), PAQ (2.34/1.78), CAS (2.90/2.34), EMC (2.92/2.35), and ERS (0.55/0.52).

Conclusion

Our results suggest that the LES is a valid elbow-specific scoring system that can be used to evaluate joint function in patients with elbow stiffness, though some items included had some weakness either.

Post-traumatic stiff elbow

Post-traumatic and post-operative stiffness of the elbow joint is relatively common and may in pronounced cases markedly interfere with normal upper extremity function.Soft-tissue contractures and heterotopic bone formation are two major causes of limited movement.Extensive recent research has elucidated many of the pathways contributing to these conditions, but the exact mechanisms are still unknown.In the early phase of soft-tissue contractures conservative treatment may be valuable, but in longstanding cases operative treatment is often necessary.Several different options are available depending on the severity of the condition and the underlying offending structures. Surgical treatment may allow significant gains in movement but rarely complete restoration, and complications are not uncommon.The following presentation reviews the recent literature on pathomechanisms and treatment alternatives. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170062.

Risk Factors for Shoulder Stiffness: Current Concepts

Shoulder stiffness is a condition of painful restriction of the glenohumeral range of motion. Numerous risk factors for primary and postoperative shoulder stiffness have been described. This article summarizes the known aspects of the pathophysiology of shoulder stiffness, with special attention to elements of molecular biology and genetics, which could influence the risk of developing shoulder stiffness. Furthermore, the role of hormonal and metabolic factors, medical disorders, drugs, and of other published risk factors for primary and postoperative shoulder stiffness is reviewed and discussed. Finally, aspects related to shoulder surgery and postoperative rehabilitation protocols, which could influence the development of postoperative stiffness are presented.

Management of Adult Elbow Fracture Dislocations

Elbow fracture dislocations are complicated injuries that are difficult to manage and fraught with complications. A complete series of radiographs is typically complemented with CT scan to evaluate the elbow and assist preoperative planning. Typically, operative intervention is necessary and a systematic approach to the elbow injuries should be chosen. This article addresses the coronoid and proceeds to the radial head, lateral soft tissues, and finally the medial ligaments if elbow instability persists. With a focused, systematic surgical approach, improved outcomes have been demonstrated and patients may recover full function and range of motion in the affected elbow.

Curbing Inflammation in Multiple Sclerosis and Endometriosis: Should Mast Cells Be Targeted?

Inflammatory diseases and conditions can arise due to responses to a variety of external and internal stimuli. They can occur acutely in response to some stimuli and then become chronic leading to tissue damage and loss of function. While a number of cell types can be involved, mast cells are often present and can be involved in the acute and chronic processes. Recent studies in porcine and rabbit models have supported the concept of a central role for mast cells in a “nerve-mast cell-myofibroblast axis” in some inflammatory processes leading to fibrogenic outcomes. The current review is focused on the potential of extending aspects of this paradigm into treatments for multiple sclerosis and endometriosis, diseases not usually thought of as having common features, but both are reported to have activation of mast cells involved in their respective disease processes. Based on the discussion, it is proposed that targeting mast cells in these diseases, particularly the early phases, may be a fruitful avenue to control the recurring inflammatory exacerbations of the conditions.