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Pirri C, Sorbino A, Manocchio N, Pirri N, Devito A, Foti C, Migliore A. Chondrotoxicity of Intra-Articular Injection Treatment: A Scoping Review. Int J Mol Sci 2024; 25:7010. [PMID: 39000119 PMCID: PMC11241418 DOI: 10.3390/ijms25137010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 06/10/2024] [Accepted: 06/24/2024] [Indexed: 07/16/2024] Open
Abstract
The purpose of this scoping review was to identify possible chondrotoxic effects caused by drugs usually used for intra-articular injections. PubMed, Scopus, Web of Science and Cochrane were searched. Inclusion criteria required randomized controlled trials written in English that evaluate the toxic effect that damages the cartilage. The literature search resulted in 185 unique articles. 133 full-text articles were screened for inclusion, of which 65 were included. Corticosteroids, with the exception of triamcinolone, along with local anaesthetics, potentially excluding ropivacaine and liposomal bupivacaine, and nonsteroidal anti-inflammatory drugs, exhibited insufficient safety profiles to warrant casual use in clinical settings. Hyaluronic acid, on the other hand, appears to demonstrate safety while also mitigating risks associated with concurrent compounds, thereby facilitating therapeutic combinations. Additionally, there remains a paucity of data regarding platelet-rich plasma, necessitating further evaluation of its potential efficacy and safety. Overall, it seems that results are significantly influenced by the dosage and frequency of injections administered, observed in both human and animal studies.
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Affiliation(s)
- Carmelo Pirri
- Department of Neurosciences, Institute of Human Anatomy, University of Padova, 35121 Padova, Italy
| | - Andrea Sorbino
- Physical and Rehabilitation Medicine, Department of Clinical Sciences and Translational Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Nicola Manocchio
- Physical and Rehabilitation Medicine, Department of Clinical Sciences and Translational Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Nina Pirri
- Department of Medicine-DIMED, School of Radiology, Radiology Institute, University of Padova, 35121 Padova, Italy
| | - Antonio Devito
- Internal Medicine, S. Pietro Fatebenefratelli Hospital, 00189 Rome, Italy
| | - Calogero Foti
- Physical and Rehabilitation Medicine, Department of Clinical Sciences and Translational Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Alberto Migliore
- Rheumatology, S. Pietro Fatebenefratelli Hospital, 00189 Rome, Italy
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Bensa A, Salerno M, Boffa A, de Girolamo L, Laver L, Magalon J, Sánchez M, Tischer T, Filardo G. Corticosteroid injections for the treatment of osteoarthritis present a wide spectrum of effects ranging from detrimental to disease-modifying: A systematic review of preclinical evidence by the ESSKA Orthobiologic Initiative. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 38813889 DOI: 10.1002/ksa.12242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/26/2024] [Accepted: 04/28/2024] [Indexed: 05/31/2024]
Abstract
PURPOSE Aim of this systematic review of preclinical evidence was to determine the effects of intra-articular corticosteroid (CS) injections in joints affected by osteoarthritis (OA). METHODS A systematic review was performed on animal studies evaluating intra-articular CS injections for OA joints. The search was performed on PubMed, Cochrane, and Web of Science databases. A synthesis of the results was performed investigating CS effects by evaluating studies comparing CS with control groups. Morphological, histological, immunohistochemistry evaluations, clinical outcomes, biomarkers and imaging results were evaluated. The risk of bias was assessed according to the Systematic Review Centre for Laboratory Animal Experimentation's tool. RESULTS Thirty-two articles analysing CS effects in OA animal models were included (1079 joints), 18 studies on small and 14 on large animals. CS injections showed overall positive effects in at least one of the outcomes in 68% of the studies, while 16% reported a deleterious effect. CS improved cartilage and synovial outcomes in 68% and 60% of the studies, but detrimental effects were documented in 11% and 20% of the studies, respectively. Clinical parameters evaluated in terms of pain, lameness or joint swelling improved in 63% of the studies but deteriorated in 13%. Evidence is limited on imaging and biomarkers results, as well as on the best CS type, dose, formulation and injection protocol. The risk of bias assessment revealed a 28% low and an 18% high risk of bias. CONCLUSION Intra-articular CS injections induced a wide range of results on OA joints in experimental animal models, from disease-modifying and positive effects on pain and joint function at short-term evaluation to the lack of benefit or even negative effects. This underlines the need to identify more specific indications and treatment modalities to avoid possible detrimental effects while maximising the anti-inflammatory properties and the benefits of intra-articular CS in OA joints. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Alessandro Bensa
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
- Università della Svizzera Italiana, Faculty of Biomedical Sciences, Lugano, Switzerland
| | - Manuela Salerno
- Applied and Translational Research (ATR) Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Angelo Boffa
- Applied and Translational Research (ATR) Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Laura de Girolamo
- Orthopaedic Biotechnology Laboratory, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Lior Laver
- Department of Orthopaedics, Hillel Yaffe Medical Center (HYMC), Hadera, Israel
- Arthrosport Clinic, Tel-Aviv, Israel
- Rappaport Faculty of Medicine, Technion University Hospital (Israel Institute of Technology), Haifa, Israel
| | - Jérémy Magalon
- Cell Therapy Laboratory, Hôpital De La Conception, AP-HM, Marseille, France
- INSERM, NRA, C2VN, Aix Marseille Univ, Marseille, France
- Regenerative Medicine Department of Excellence, Marseille, France
| | - Mikel Sánchez
- Arthroscopic Surgery Unit, Hospital Vithas Vitoria, Vitoria-Gasteiz, Spain
- Advanced Biological Therapy Unit, Hospital Vithas Vitoria, Vitoria-Gasteiz, Spain
| | - Thomas Tischer
- Department of Orthopaedic Surgery, University of Rostock, Rostock, Germany
- Department of Orthopaedic and Trauma Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany
| | - Giuseppe Filardo
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
- Università della Svizzera Italiana, Faculty of Biomedical Sciences, Lugano, Switzerland
- Applied and Translational Research (ATR) Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Zimmerer A, Schulze F, Gebhardt S, Huesker K, Stobbe D, Grolimund D, Hesse B, Wassilew GI, Schoon J. Impact of gadolinium-based MRI contrast agent and local anesthetics co-administration on chondrogenic gadolinium uptake and cytotoxicity. Heliyon 2024; 10:e29719. [PMID: 38681575 PMCID: PMC11053198 DOI: 10.1016/j.heliyon.2024.e29719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/21/2024] [Accepted: 04/14/2024] [Indexed: 05/01/2024] Open
Abstract
The gadolinium-based contrast agent DOTA-Gd is clinically used in combination with local anesthetics for direct magnetic resonance arthrography. It remains unclear whether gadolinium uptake into cartilage is influenced by co-administration of bupivacaine or ropivacaine and whether DOTA-Gd alters their chondrotoxicity. Gadolinium quantification of chondrogenic spheroids revealed enhanced gadolinium uptake after simultaneous exposure to local anesthetics. Analyses of the spatial gadolinium distribution using synchrotron X-ray-fluorescence scanning indicates gadolinium exposed chondrocytes. In vitro exposure to DOTA-Gd does not alter viability and proliferation of human chondrocytes and the chondrotoxic potential of the anesthetics. Reduced viability induced by ropivacaine was found to be reversible, while exposure to bupivacaine leads to irreversible cell death. Our data suggest that ropivacaine is more tolerable than bupivacaine and that DOTA-Gd exposure does not alter the cytotoxicity of both anesthetics. Enhanced gadolinium uptake into cartilage due to co-administration of anesthetics should find attention.
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Affiliation(s)
- Alexander Zimmerer
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Germany
- Diakonieklinikum Stuttgart, Department of Orthopaedic and Trauma Surgery, Orthopädische Klinik Paulinenhilfe, Stuttgart, Germany
| | - Frank Schulze
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Germany
| | - Sebastian Gebhardt
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Germany
| | - Katrin Huesker
- Immunology Department, Institute for Medical Diagnostics (IMD), Berlin, Germany
| | - Dirk Stobbe
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Germany
| | - Daniel Grolimund
- Swiss Light Source, Paul Scherrer Institute, Villigen, Switzerland
| | - Bernhard Hesse
- Xploraytion GmbH, Berlin, Germany
- ESRF-The European Synchrotron, Grenoble, France
| | - Georgi I. Wassilew
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Germany
| | - Janosch Schoon
- Center for Orthopaedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Germany
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Kumlin M, Ungerstedt J, Cai H, Leonard E, Felländer-Tsai L, Qian H. The functional and molecular impact of triamcinolone acetonide on primary human bone marrow mesenchymal stem cells. Sci Rep 2023; 13:21787. [PMID: 38066109 PMCID: PMC10709330 DOI: 10.1038/s41598-023-48448-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 11/27/2023] [Indexed: 12/18/2023] Open
Abstract
Traumatic or degenerative joint pain is abundant in the population. Symptom relief by intra- and periarticular glucocorticoid administration is frequently used, however may have potentially devastating effects, changing the normal healing process of the joint. Mesenchymal stem cells (MSCs) are important for wound-healing processes due to their multipotency in regenerating osteoblasts, chondrocytes and adipocytes but also have immunomodulatory properties. The aim of this study was to investigate the impact of triamcinolone acetonide (TA) a common glucocorticoid administrated intra- and periarticularly, on human bone marrow derived MSC viability, functionality, multi-lineage differentiation and transcriptomic output. We found that TA treatment induced apoptosis and promoted adipogenesis while impairing chondrogenesis of MSCs. RNA sequencing indicated that TA modulated the inflammatory response of MSCs, which may have an impact on the immunologic environment where the inflammatory phase is a physiological part of the natural healing process. These data indicate that triamcinolone acetonide should be used with consideration bearing the patient's outcome in mind, with the intention to optimize joint recovery and homeostasis.
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Affiliation(s)
- Maritha Kumlin
- Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, K54, 141 86, Stockholm, Sweden.
| | - Johanna Ungerstedt
- Department of Medicine Huddinge, Center for Hematology and Regenerative Medicine (HERM), Karolinska Institute, Stockholm, Sweden
- ME Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Huan Cai
- Department of Medicine Huddinge, Center for Hematology and Regenerative Medicine (HERM), Karolinska Institute, Stockholm, Sweden
| | - Elory Leonard
- Department of Medicine Huddinge, Center for Hematology and Regenerative Medicine (HERM), Karolinska Institute, Stockholm, Sweden
| | - Li Felländer-Tsai
- Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, K54, 141 86, Stockholm, Sweden
| | - Hong Qian
- Department of Medicine Huddinge, Center for Hematology and Regenerative Medicine (HERM), Karolinska Institute, Stockholm, Sweden
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Parker EB, Hering KA, Chiodo CP, Smith JT, Bluman EM, Martin EA. Intraarticular Injections in the Foot and Ankle: Medication Selection Patterns and Perceived Risk Of Chondrotoxicity. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231216990. [PMID: 38145274 PMCID: PMC10748709 DOI: 10.1177/24730114231216990] [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] [Indexed: 12/26/2023] Open
Abstract
Background Intraarticular corticosteroid injections (ICIs) are widely used to treat foot and ankle conditions. Although laboratory studies indicate certain corticosteroids and local anesthetics used in ICIs are associated with chondrotoxic effects, and selected agents such as ropivacaine and triamcinolone may have less of these features, clinical evidence is lacking. We aimed to identify the patterns of drug selection, perceptions of injectate chondrotoxicity, and rationale for medication choice among surgeons in the American Orthopaedic Foot & Ankle Society (AOFAS). Methods An e-survey including demographics, practice patterns, and rationale was disseminated to 2011 AOFAS members. Frequencies and percentages were calculated for demographic data, anesthetic and steroid choice, rationale for injectate choice, and perception of chondrotoxicity. Bivariate analysis was used to identify practice patterns significantly associated with perceptions of injectate risk and rationale. Results In total, 387 surveys were completed. Lidocaine and triamcinolone were the most common anesthetic and corticosteroid used (51.2% and 39.3%, respectively). Less than half of respondents felt corticosteroids or local anesthetics bear risk of chondrotoxicity. Respondents agreeing that corticosteroids are chondrotoxic were more likely to use triamcinolone (P = .037). Respondents agreeing local anesthetics risk chondrotoxicity were less likely to use lidocaine (P = .023). Respondents choosing a local anesthetic based on literature were more likely to use ropivacaine (P < .001). Conclusion Corticosteroid and local anesthetic use in ICIs varied greatly. Rationale for ICI formulation was also variable, as the clinical implications are largely unknown. Those who recognized potential chondrotoxicity and who chose based on literature were more likely to choose ropivacaine and triamcinolone, as reflected in the basic science literature. Further clinical studies are needed to establish guidelines that shape foot and ankle ICI practices based on scientific evidence and reduce the variation identified by this study. Level of Evidence Level IV, cross-sectional survey study.
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Affiliation(s)
- Emily B. Parker
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Kalei A. Hering
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher P. Chiodo
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeremy T. Smith
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric M. Bluman
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Elizabeth A. Martin
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Charnwichai P, Tammachote R, Tammachote N, Chaichana T, Kitkumthorn N. Histological features of knee osteoarthritis treated with triamcinolone acetonide and hyaluronic acid. Biomed Rep 2023; 18:40. [PMID: 37228485 PMCID: PMC10203754 DOI: 10.3892/br.2023.1623] [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: 02/07/2023] [Accepted: 04/19/2023] [Indexed: 05/27/2023] Open
Abstract
Osteoarthritis (OA) is one of the most common degenerative joint diseases leading to disability in the end stage. Although intra-articular triamcinolone acetonide (TA) is one of the OA treatments that have been widely used, the side effects of such corticosteroids are still controversial. Intra-articular hyaluronic acid (HA) injection is another therapeutic option for patients with OA who do not want to use corticosteroids because of their side effects. However, the difference between the histological features associated with TA and HA in the treatment of OA remains unclear. Thus, the present study aimed to compare the histological effects of TA and HA on the cartilage of patients with knee OA. In the current study, 31 patients diagnosed with grade 3-4 knee OA on the Kellgren-Lawrence radiographic grading scale were separated into three groups: TA (n=12); HA (n=7) and untreated group (n=12). Histological examination of the whole articular cartilages of the patients was performed with hematoxylin and eosin and Alcian staining, as well as using a TUNEL assay. Clinical data such as cartilage thickness, structural and component deterioration, proteoglycan levels, apoptosis and empty lacunae were compared between the three groups. The results showed a high level of deterioration in both TA and HA groups but not in the untreated group, although the thickness of cartilage in the HA group was lower compared with that in the TA and untreated groups. The proteoglycan levels in the TA group were lower compared with those in the HA group. Moreover, the number of empty lacunae in the HA group was higher compared with that in the TA group, while no difference in apoptosis was found between TA and HA groups. A significant difference was not found in the histological staining between TA and HA groups. On the other hand, a significant difference was found in cartilage deterioration between the medial and lateral sides in these groups. TA and HA groups showed comparable histological results. TA injection is cheaper and easier but has more adverse effects for patients with knee OA than HA injection. Therefore, orthopaedists should select TA or HA based on the economic and specific needs of patients.
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Affiliation(s)
- Pattaranatcha Charnwichai
- Program in Biotechnology, Faculty of Science, Chulalongkorn University, Pathumwan 10330, Thailand
- Department of Botany, Faculty of Science, Chulalongkorn University, Pathumwan 10330, Thailand
| | - Rachaneekorn Tammachote
- Department of Botany, Faculty of Science, Chulalongkorn University, Pathumwan 10330, Thailand
| | - Nattapol Tammachote
- Department of Orthopedics, Faculty of Medicine, Thammasat University Hospital, Khlong Nueng, Pathumthani 10120, Thailand
| | - Thiamjit Chaichana
- Department of Pathology, Faculty of Medicine, Chulalongkorn University, Pathumwan, Bangkok 10330, Thailand
| | - Nakarin Kitkumthorn
- Department of Oral Biology, Faculty of Dentistry, Mahidol University, Bangkok 10400, Thailand
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Burnett RA, Khalid S, DeBenedetti A, Terhune EB, Angotti ML, Della Valle CJ. Intra-articular corticosteroid injections are associated with a dose-dependent risk of total knee arthroplasty at 5 years. Knee Surg Sports Traumatol Arthrosc 2023; 31:426-431. [PMID: 35773523 DOI: 10.1007/s00167-022-07017-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/15/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE Intra-articular corticosteroid injections (CSI) are used commonly for the non-operative management of patients with knee pain. Recent literature has raised concern for chondrotoxicity of CSI. The purpose of the present study is to evaluate for any dose-dependent association between CSI in non-osteoarthritic knees and subsequent total knee arthroplasty (TKA). METHODS The Pearl Diver database identified patients with a diagnosis of knee pain without concomitant osteoarthritis who were administered CSI over a 2-year period. Patients were compared to matched and unmatched cohorts. The primary endpoint was the incidence of TKA at 5 years. Multivariable regression analysis was used to assess CSI quantity as an independent risk factor. RESULTS 49,443 of 986,162 (5.0%) Patients diagnosed with knee pain without concomitant knee osteoarthritis who received at least one CSI were identified. At 5 years, there was a higher incidence of TKA in the matched injection cohort relative to the non-injection matched cohort (0.26 vs 0.13%; p < 0.001) and unmatched cohort (0.26 vs. 0.10%, p < 0.001). The quantity of CSI corresponded with an increased probability of TKA at 5 years; one injection: 0.22% (OR 1.23, 95% CI [0.87-1.74], p = 0.236); two injections: 0.39% (OR 1.98 CI [1.06-3.67], p = 0.03, three or more injections: 0.49% (OR 3.22 CI [1.60-6.48], p = 0.001). The average time to TKA after one CSI was 3.03 ± 2.29 years. This time was nearly halved with three CSI (1.78 ± 0.80 years, p < 0.001). CONCLUSIONS Intra-articular corticosteroid injections in patients without knee osteoarthritis at the time of injection are associated with a dose-dependent risk of TKA at 5 years. CSI may not be as benign of a treatment modality as previously thought.
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Affiliation(s)
- Robert A Burnett
- Midwest Orthopaedics at Rush LLC, 1611 W Harrison St, Suite 300, Chicago, IL, 60612, USA
| | - Syed Khalid
- Midwest Orthopaedics at Rush LLC, 1611 W Harrison St, Suite 300, Chicago, IL, 60612, USA
| | - Anne DeBenedetti
- Midwest Orthopaedics at Rush LLC, 1611 W Harrison St, Suite 300, Chicago, IL, 60612, USA
| | - E Bailey Terhune
- Midwest Orthopaedics at Rush LLC, 1611 W Harrison St, Suite 300, Chicago, IL, 60612, USA
| | - Morgan L Angotti
- Midwest Orthopaedics at Rush LLC, 1611 W Harrison St, Suite 300, Chicago, IL, 60612, USA
| | - Craig J Della Valle
- Midwest Orthopaedics at Rush LLC, 1611 W Harrison St, Suite 300, Chicago, IL, 60612, USA.
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Zhang A, Wang D, Diwan S, Lin CP, Calodney A, Rosenthal R, Chang Chien GC. Effects of local anesthetics and contrast agents on musculoskeletal regenerative medicine procedures. Regen Med 2022; 17:845-853. [PMID: 36069006 DOI: 10.2217/rme-2021-0176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
In regenerative medicine, cells, tissues and organs are often replaced, engineered or regrown in order to restore their function after they have been damaged or lost. Local anesthetics, corticosteroids and contrast agents are commonly employed for both diagnostic and therapeutic objectives in interventional pain and musculoskeletal treatments for regenerative medicine. There is growing evidence that routine injectables promote catabolism and disease processes. Thus, understanding the effects of these compounds on regenerative medicine injectates and target tissues such as tenocytes, chondrocytes, nucleus pulposus and ligamentous tissue is critical. This review includes the current research on the effects of local anesthetics and contrast agents, as well as their use and recommendations in regenerative medicine operations.
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Affiliation(s)
- Allan Zhang
- Department of Radiology, University of Connecticut Health Center, Farmington, CT, USA
| | - Daniel Wang
- Kansas City University, Kansas City, MO 64106, USA
| | | | - Chih-Peng Lin
- Department of Anesthesiology, National Taiwan University Hospital & National Taiwan University College of Medicine, Taipei, 10048, Taiwan
| | | | | | - George C Chang Chien
- Pain Management, Ventura County Medical Center, Ventura, CA 93003, USA.,GCC Institute Regenerative Medicine, Newport Beach, CA 92606, USA
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Wesdorp MA, Capar S, Bastiaansen-Jenniskens YM, Kops N, Creemers LB, Verhaar JA, Van Osch GJ, Wei W. Intra-articular Administration of Triamcinolone Acetonide in a Murine Cartilage Defect Model Reduces Inflammation but Inhibits Endogenous Cartilage Repair. Am J Sports Med 2022; 50:1668-1678. [PMID: 35315287 PMCID: PMC9069659 DOI: 10.1177/03635465221083693] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cartilage defects result in joint inflammation. The presence of proinflammatory factors has been described to negatively affect cartilage formation. PURPOSE To evaluate the effect and timing of administration of triamcinolone acetonide (TAA), an anti-inflammatory drug, on cartilage repair using a mouse model. STUDY DESIGN Controlled laboratory study. METHODS A full-thickness cartilage defect was created in the trochlear groove of 10-week-old male DBA/1 mice (N = 80). Mice received an intra-articular injection of TAA or saline on day 1 or 7 after induction of the defect. Mice were euthanized on days 10 and 28 for histological evaluation of cartilage defect repair, synovial inflammation, and synovial membrane thickness. RESULTS Mice injected with TAA had significantly less synovial inflammation at day 10 than saline-injected mice independent of the time of administration. At day 28, the levels of synovitis dropped toward healthy levels; nevertheless, the synovial membrane was thinner in TAA- than in saline-injected mice, reaching statistical significance in animals injected on day 1 (70.1 ± 31.9 µm vs 111.9 ± 30.9 µm, respectively; P = .01) but not in animals injected on day 7 (68.2 ± 21.86 µm vs 90.2 ± 21.29 µm, respectively; P = .26). A thinner synovial membrane was moderately associated with less filling of the defect after 10 and 28 days (r = 0.42, P = .02; r = 0.47, P = .01, respectively). Whereas 10 days after surgery there was no difference in the area of the defect filled and the cell density in the defect area between saline- and TAA-injected knees, filling of the defect at day 28 was lower in TAA- than in saline-injected knees for both injection time points (day 1 injection, P = .04; day 7 injection, P = .01). Moreover, there was less collagen type 2 staining in the filled defect area in TAA- than in saline-injected knees after 28 days, reaching statistical significance in day 1-injected knees (2.6% vs 18.5%, respectively; P = .01) but not in day 7-injected knees (7.4% vs 15.8%, respectively; P = .27). CONCLUSION Intra-articular injection of TAA reduced synovial inflammation but negatively affected cartilage repair. This implies that inhibition of inflammation may inhibit cartilage repair or that TAA has a direct negative effect on cartilage formation. CLINICAL RELEVANCE Our findings show that TAA can inhibit cartilage defect repair. Therefore, we suggest not using TAA to reduce inflammation in a cartilage repair setting.
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Affiliation(s)
- Marinus A. Wesdorp
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Serdar Capar
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | | | - Nicole Kops
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Laura B. Creemers
- Department of Orthopedic Surgery, UMC Utrecht, University Medical Center, Utrecht, the Netherlands
| | - Jan A.N. Verhaar
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Gerjo J.V.M. Van Osch
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands,Department of Otorhinolaryngology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands,Department of Biomechanical Engineering, Faculty of Mechanical, Maritime, and Materials Engineering, Delft University of Technology, Delft, the Netherlands,Gerjo J.V.M. Van Osch, PhD, Department of Orthopaedic Surgery and Sports Medicine and Department of Otorhinolaryngology, Erasmus MC, University Medical Center, Room Ee16.55c, Dr Molewaterplein 40, Rotterdam, 3015 GD, the Netherlands ()
| | - Wu Wei
- Department of Orthopaedic Surgery and Sports Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands,Department of Orthopedic Surgery, Elisabeth-Tweesteden Ziekenhuis, Tilburg, the Netherlands
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Zalecki CJ, Vishnubala D, Marino K, Nykjaer C, Sivan M. The use of single dose intra-articular local anaesthetics in the United Kingdom: A cross-sectional survey of sport and exercise medicine and musculoskeletal professionals. Musculoskeletal Care 2022; 20:681-685. [PMID: 35146889 PMCID: PMC9544231 DOI: 10.1002/msc.1618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/25/2022] [Accepted: 01/28/2022] [Indexed: 11/07/2022]
Affiliation(s)
| | | | - Katie Marino
- Nottingham University Hospital NHS TrustNottinghamUK
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Tarricone E, Elia R, Mattiuzzo E, Faggian A, Pozzuoli A, Ruggieri P, Brun P. The Viability and Anti-Inflammatory Effects of Hyaluronic Acid-Chitlac-Tracimolone Acetonide- β-Cyclodextrin Complex on Human Chondrocytes. Cartilage 2021; 13:920S-924S. [PMID: 32107923 PMCID: PMC8804853 DOI: 10.1177/1947603520908658] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To compare the effects of the complex triamcinolone acetonide-hydroxypropyl-β-cyclodextrin (TA-CD) on in vitro inflamed primary human articular chondrocytes in the presence or absence of the mixture hyaluronic acid-Chitlac, a lactose-modified chitosan (HA-CTL). DESIGN Changes in cell viability and pro-inflammatory cytokines gene expression were analyzed in human chondrocytes using an in vitro model of macrophage-mediated inflammation. Human monocytes U937 were differentiated to macrophages by phorbol 12-myristate 13-acetate (PMA) and lipopolysaccharides (LPS). The anti-inflammatory effects of the complex TA-CD and HA-CTL mixture were assessed on chondrocytes exposed for 24 hours to U937 conditioned medium (CM), by quantitative polymerase chain reaction analysis. RESULTS The TA-CD viability was enhanced by the presence of the HA-CTL mixture in chondrocyte cultures. The exposure of cells to CM significantly increased interleukin-1β and interleukin-6 gene expression, and when the complex TA-CD was added to the inflamed cells, gene transcription of cytokines was restored to near baseline values, both in the presence or in the absence of HA-CTL mixture. CONCLUSION The addition of HA-CTL mixture significantly attenuated cytotoxicity induced by TA and preserved the anti-inflammatory effects, thus confirming the chondroprotective role of the HA-CTL mixture.
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Affiliation(s)
- Elena Tarricone
- Department of Molecular Medicine, Histology
Unit, University of Padova, Padova, Italy
| | - Rossella Elia
- Department of Molecular Medicine, Histology
Unit, University of Padova, Padova, Italy
| | - Elena Mattiuzzo
- Department of Molecular Medicine, Histology
Unit, University of Padova, Padova, Italy
| | - Alessia Faggian
- Department of Molecular Medicine, Histology
Unit, University of Padova, Padova, Italy
| | - Assunta Pozzuoli
- Musculoskeletal Pathology and Oncology
Laboratory, Department of Surgery, Oncology and Gastroenterology, University of Padova,
Padova, Italy,Orthopedic and Traumatologic Clinic,
Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova,
Italy
| | - Pietro Ruggieri
- Orthopedic and Traumatologic Clinic,
Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova,
Italy
| | - Paola Brun
- Department of Molecular Medicine, Histology
Unit, University of Padova, Padova, Italy,Paola Brun, Department of Molecular Medicine,
Histology Unit, University of Padua, Via Ugo Bassi 58B, Padova 35121, Italy.
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12
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Zheng H, Zhang D, Zhu Y, Wang Q. Effect of Tai Chi exercise on lower limb function and balance ability in patients with knee osteoarthritis: A protocol of a randomized controlled trial. Medicine (Baltimore) 2021; 100:e27647. [PMID: 34797287 PMCID: PMC8601362 DOI: 10.1097/md.0000000000027647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 10/14/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Knee osteoarthritis (KOA) is a chronic degenerative joint disease commonly occurring in middle-aged and elderly people. The main clinical manifestations are joint pain, limited activity, and decreased muscle strength resulting in decreased motor control ability. Exercise therapy is an effective method to enhance muscle strength of lower limbs, while China's traditional skill Tai Chi (TC) is a combination of activity and inertia, internal and external exercise therapy. In recent years, scholars at home and abroad have found that regular TC can effectively improve patients' lower limb function and balance ability. The purpose of this study is to explore the effects of TC on lower limb function and balance ability in patients with KOA. METHODS This is a prospective randomized controlled clinical trial. One hundred forty-six cases of KOA patients will be randomly divided into experimental group and control group according to 1:1 ratio, 73 cases in each group, the control group: sodium hyaluronate; experimental group: TC added on the basis of the control group. Both groups will receive standard treatment for 5 weeks and will be followed up for 3 months. Observation indicators include: the western Ontario and McMaster universities osteoarthritis index; hospital for special surgery knee score; balance stability index, liver and kidney function, adverse reaction rate, etc. SPSS 23.0 software will be used for data analysis. DISCUSSION This study will evaluate the effects of TC on lower limb function and balance ability of patients with KOA. The results of this trial will provide a clinical basis for the selection of exercise therapy for patients with KOA.
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Affiliation(s)
- Haoyun Zheng
- Beijing Hospital of Traditional Chinese Medicine, Beijing, China
| | - Dong Zhang
- Dongfang Hospital Beijing University of Chinese Medicine, Beijing, China
| | - Yonggang Zhu
- Beijing Hospital of Traditional Chinese Medicine, Beijing, China
| | - Qingfu Wang
- Beijing University of Chinese Medicine Third Affiliated Hospital, Beijing, China
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13
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Kelly BJ, Williams BR, Gravely AA, Schwanz K, Sechriest VF. Femoral head collapse after hip intra-articular corticosteroid injection: An institutional response to improve practice and increase patient safety. PLoS One 2021; 16:e0259242. [PMID: 34727125 PMCID: PMC8562809 DOI: 10.1371/journal.pone.0259242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 10/17/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Femoral head collapse (FHC) is a rarely reported complication of hip intra-articular corticosteroid injection (IACSI). Upon observing a high rate of FHC after hip IACSI, we sought to (1) describe how we addressed the problem through a systematic evaluation of clinical data and institutional care practices followed by process improvement efforts; and (2) report our results. METHODS Patients receiving hip IACSI during a 27-month period underwent retrospective review to determine the rate of FHC and to identify associated patient factors or practice shortfalls. Findings led to institution-wide interventions: (1) to improve patient/provider awareness of this association; and (2) to develop/implement practice guidelines. Rates of FHC after hip IACSI and practice patterns among providers before and after intervention were compared. RESULTS Initial FHC rate after hip IACSI was 20.4%. Patient-related factors included body mass index (p = 0.025), history of cancer therapy (p = 0.012), Vitamin D level (p = 0.030), and multiple injections (p = 0.004). Volume/dose of injectate and post-injection surveillance methods varied widely. Quality improvement (QI) intervention resulted in fewer treatment referrals (from 851 to 436), fewer repeat injections (mean = 1.61 to 1.37; p = 0.0006), and a 5% lower FHC rate (p = 0.1292). Variation in practice patterns persisted, so a systems-based Clinical Pathway was established. DISCUSSION When a high rate of FHC after hip IACSI was found to be associated with certain patient and practice factors, introduction of education materials and treatment guidelines decreased number of referrals, number of injections per patient, and FHC rate. In the absence of the systems-based Pathway, the type, dose, and volume of injectate and post-procedure follow-up remained variable.
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Affiliation(s)
- Brandon J. Kelly
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Benjamin R. Williams
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Amy A. Gravely
- Department of Research Service, Veterans Affairs Medical Center, Minneapolis, Minnesota, United States of America
| | - Kersten Schwanz
- Department of Physical Medicine/Rehabilitation, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - V. Franklin Sechriest
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, United States of America
- Department of Orthopaedic Surgery, Veterans Affairs Medical Center, Minneapolis, Minnesota, United States of America
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14
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Wu J, Li W, Ye B, Yao Y. The efficacy and safety of Xianling Gubao capsules in the treatment of knee osteoarthritis: A protocol for a randomized, double-blind, controlled trial. Medicine (Baltimore) 2021; 100:e27086. [PMID: 34516497 PMCID: PMC8428714 DOI: 10.1097/md.0000000000027086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/12/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Knee osteoarthritis (KOA) is a chronic degenerative joint disease, which is the most common type of osteoarthritis. The clinical manifestations are pain, swelling, and dysfunction of the knee joint, which seriously reduces the quality of life of patients and causes a huge social burden. At present, western medicine mainly focuses on symptomatic treatment, such as anti-inflammatory and pain relief, joint cavity injection, joint replacement, etc. The curative effect has certain limitations. Xianling Gubao capsule has some advantages in the treatment of KOA, but it lacks high-quality clinical research to verify it. Therefore, the purpose of this study is to evaluate the efficacy and safety of Xianling Gubao capsule in the treatment of KOA. METHODS A randomized, double-blind, double-simulation, parallel controlled trial design was used to study the efficacy and safety of Xianling Gubao capsules in the treatment of KOA. The patients were randomly divided into a treatment group and the control group according to 1:1. The treatment group: Xianling Gubao capsule + glucosamine hydrochloride capsule simulation agent treatment; the control group: glucosamine hydrochloride capsule + Xianling Gubao capsule simulation agent treatment. Both groups received standard treatment for 8 weeks and followed up for 30 days. And at the same time, pay attention to its efficacy and safety indicators. Observation indicators include: the western Ontario and McMaster universities osteoarthritis index, hospital for special surgery knee score, liver and kidney function, adverse reactions, etc. Data analysis was performed using SPSS 25.0 software. DISCUSSION This study will evaluate the efficacy and safety of Xianling Gubao capsule in the treatment of KOA. The results of this experiment will provide evidence support for Xianling Gubao capsule in the treatment of KOA. TRIAL REGISTRATION OSF Registration number: DOI 10.17605/OSF.IO/ERM9C.
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15
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Oyadomari S, Brown WE, Kwon H, Otarola G, Link JM, Athanasiou KA, Wang D. In Vitro Effects of Bupivacaine on the Viability and Mechanics of Native and Engineered Cartilage Grafts. Am J Sports Med 2021; 49:1305-1312. [PMID: 33667144 DOI: 10.1177/0363546521995184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although the toxic effects of bupivacaine on chondrocyte monolayer culture have been well described, its cellular and mechanical effects on native and engineered articular cartilage remain unclear. For the repair of articular cartilage defects, fresh autologous and allogenic cartilage grafts are commonly used, and engineered cell-based therapies are emerging. The outcome of grafting therapies aimed at repairing damaged cartilage relies largely on maintaining proper viability and mechanical suitability of the donor tissues. PURPOSE To investigate the in vitro effects of single bupivacaine exposure on the viability and mechanics of 2 cartilage graft types: native articular cartilage and engineered neocartilage. STUDY DESIGN Controlled laboratory study. METHODS Articular cartilage explants were harvested from the bovine stifle femoral condyles, and neocartilage constructs were engineered from bovine stifle chondrocytes using the self-assembling process, a scaffold-free approach to engineer cartilage tissue. Both explants and neocartilage were exposed to chondrogenic medium containing a clinically applicable bolus of 0.5%, 0.25%, or 0% (control) bupivacaine for 1 hour, followed by fresh medium wash and exchange. Cell viability and matrix content (collagen and glycosaminoglycan) were assessed at t = 24 hours after treatment, and compressive mechanical properties were assessed with creep indentation testing at t = 5 to 6 days after treatment. RESULTS Single bupivacaine exposure was chondrotoxic in both explants and neocartilage, with 0.5% bupivacaine causing a significant decrease in chondrocyte viability compared with the control condition (55.0% ± 13.4% vs 71.9% ± 13.5%; P < .001). Bupivacaine had no significant effect on matrix content for either tissue type. There was significant weakening of the mechanical properties in the neocartilage when treated with 0.5% bupivacaine compared with control, with decreased aggregate modulus (415.8 ± 155.1 vs 660.3 ± 145.8 kPa; P = .003), decreased shear modulus (143.2 ± 14.0 vs 266.5 ± 89.2 kPa; P = .002), and increased permeability (14.7 ± 8.1 vs 6.6 ± 1.7 × 10-15 m4/Ns; P = .009). Bupivacaine exposure did not have a significant effect on the mechanical properties of native cartilage explants. CONCLUSION Single bupivacaine exposure resulted in significant chondrotoxicity in native explants and neocartilage and significant weakening of mechanical properties of neocartilage. The presence of abundant extracellular matrix does not appear to confer any additional resistance to the toxic effects of bupivacaine. CLINICAL RELEVANCE Clinicians should be judicious regarding the use of intra-articular bupivacaine in the setting of articular cartilage repair.
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Affiliation(s)
- Sarah Oyadomari
- University of California Irvine School of Medicine, Irvine, California, USA
| | - Wendy E Brown
- Department of Biomedical Engineering, University of California Irvine, Irvine, California, USA
| | - Heenam Kwon
- Department of Biomedical Engineering, University of California Irvine, Irvine, California, USA
| | - Gaston Otarola
- Department of Biomedical Engineering, University of California Irvine, Irvine, California, USA
| | - Jarrett M Link
- Department of Biomedical Engineering, University of California Irvine, Irvine, California, USA
| | - Kyriacos A Athanasiou
- Department of Biomedical Engineering, University of California Irvine, Irvine, California, USA
| | - Dean Wang
- University of California Irvine School of Medicine, Irvine, California, USA.,Department of Orthopaedic Surgery, University of California Irvine Health, Orange, California, USA
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16
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Kearney CM, Korthagen NM, Plomp SGM, Labberté MC, de Grauw JC, van Weeren PR, Brama PAJ. Treatment effects of intra-articular triamcinolone acetonide in an equine model of recurrent joint inflammation. Equine Vet J 2020; 53:1277-1286. [PMID: 33280164 DOI: 10.1111/evj.13396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/17/2020] [Accepted: 11/19/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Intra-articular triamcinolone acetonide is a widely used treatment for joint inflammation despite limited scientific evidence of its efficacy. OBJECTIVES To investigate if intra-articular triamcinolone acetonide has sustained anti-inflammatory effects using an equine model of repeated joint inflammation. STUDY DESIGN Randomised controlled experimental study. METHOD For three consecutive cycles 2 weeks apart, inflammation was induced in both middle carpal joints of eight horses by injecting 0.25 ng lipopolysaccharide (LPS). After the first LPS injection only, treatment with 12 mg triamcinolone acetonide (TA) followed in one randomly assigned joint, while the contralateral joint was treated with sterile saline (control). Clinical parameters (composite welfare scores, joint effusion, joint circumference) were recorded and synovial fluid samples were analysed for various biomarkers (total protein, WBCC; PGE2 ; CCL2; TNFα; MMP; GAGs; C2C; CPII) at fixed timepoints (post injection hours 0, 8, 24, 72 and 168). The effects of time and treatment on clinical and synovial fluid parameters and the presence of time-treatment interactions were tested using a linear mixed model for repeated measures with horse as a random effect, and time and treatment as fixed effects. RESULTS The TA treated joints showed significantly higher peak synovial GAG concentrations (Difference in means 283.1875 µg/mL, 95% CI 179.8, 386.6, P < 0.000), and PGE2 levels (Difference in means 77.8025 pg/mL, 95% CI 21.2, 134.4, P < 0.007) after the first inflammation induction. Significantly lower TP levels were seen with TA treatment after the second induction (Difference in means -7.5 g/L, 95% CI -14.8, -0.20, P < 0.04) . Significantly lower WBCC levels were noted with TA treatment after the first (Difference in means -23.7125 × 109 cells/L, 95% CI -46.7, -0.7, P < 0.04) and second (Difference in means -35.95 × 109 cells/L, 95% CI -59.0, -12.9, P < 0.002) inflammation inductions. Significantly lower general MMP activity was also seen with TA treatment after the second inflammation inductions (Difference in means -51.65 RFU/s, 95% CI -92.4, -10.9, P < 0.01). MAIN LIMITATIONS This experimental study cannot fully reflect natural joint disease. CONCLUSIONS In this model, intra-articular TA seems to have some anti-inflammatory activity (demonstrated by reductions in TP, WBCC and general MMP activity) up to 2 weeks post treatment but not at 4 weeks. This anti-inflammatory effect appeared to outlast a shorter-lived, potentially detrimental effect illustrated by increased synovial GAG and PGE2 levels after the first induction.
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Affiliation(s)
- Clodagh M Kearney
- UCD School of Veterinary Medicine, University College Dublin, Dublin, Ireland
| | - Nicoline M Korthagen
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Saskia G M Plomp
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Margot C Labberté
- UCD School of Veterinary Medicine, University College Dublin, Dublin, Ireland
| | - Janny C de Grauw
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - P R van Weeren
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Pieter A J Brama
- UCD School of Veterinary Medicine, University College Dublin, Dublin, Ireland
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Chondrotoxicity of Local Anesthetics: Liposomal Bupivacaine Is Less Chondrotoxic than Standard Bupivacaine. Adv Pharmacol Pharm Sci 2020; 2020:5794187. [PMID: 32399520 PMCID: PMC7199567 DOI: 10.1155/2020/5794187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/30/2019] [Accepted: 10/03/2019] [Indexed: 11/17/2022] Open
Abstract
Objective The purpose of this study is to determine whether (1) liposomal bupivacaine is chondrotoxic; (2) the chondrotoxicity of liposomal bupivacaine differs from standard bupivacaine; and (3) chondrotoxic effects are time dependent. Materials and Methods We obtained 72 10 mm articular cartilage plugs from 12 fresh bovine distal femoral knee joints and exposed them to either saline, 0.5% bupivacaine, or liposomal bupivacaine for either 30 or 90 minutes. Twenty-four hours after treatment, chondrocyte viability was measured with the use of a fluorescent live/dead assay. An ANOVA test of variance was performed followed by a Holm-Sidak test to make pairwise comparisons across conditions. Student's t-test was used to compare means. Results Percent viability of cells exposed to liposomal bupivacaine for 30 minutes was less versus saline control (53.9% ± 21.5% vs. 73.7 ± 18.4%, p=0.035), and this remained significant at 90 minutes (49.1% ± 20.3% vs. 67.2% ± 25.6%, p < 0.001). Liposomal bupivacaine had less chondrotoxic effects when compared with bupivacaine after 90 minutes, with greater viability (49.1% ± 20.3% vs. 21.4% ± 14.0%, p=0.003). Chondrotoxicity was found to be time dependent within the bupivacaine group (percent viability at 30 min: 45.5 ± 18.2%, 90 min: 21.4 ± 14.0%, p=0.001); however, liposomal bupivacaine did not demonstrate a significant time-dependent chondrotoxic relationship (p=0.583). Conclusions Bupivacaine and liposomal bupivacaine are both toxic to chondrocytes. Liposomal bupivacaine is less chondrotoxic than standard bupivacaine and does not demonstrate a time-dependent toxicity.
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18
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Effect of various factors on articular cartilage and their implications on arthroscopic procedures: A review of literature. J Clin Orthop Trauma 2020; 11:S396-S401. [PMID: 32523300 PMCID: PMC7275290 DOI: 10.1016/j.jcot.2019.06.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 06/16/2019] [Accepted: 06/18/2019] [Indexed: 11/23/2022] Open
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Angadi DS, Macdonald H, Atwal N. Autologous cell-free serum preparations in the management of knee osteoarthritis: what is the current clinical evidence? Knee Surg Relat Res 2020; 32:16. [PMID: 32660628 PMCID: PMC7219223 DOI: 10.1186/s43019-020-00036-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 02/27/2020] [Indexed: 12/14/2022] Open
Abstract
Background There is paucity in the current literature regarding clinical outcomes of autologous cell-free serum preparations. The objective of this paper is to collate the clinical evidence and review the results of intraarticular injections of autologous cell-free serum preparations in the management of knee osteoarthritis (OA). Methods A comprehensive English literature search was undertaken using the healthcare database website (https://hdas.nice.org.uk/). The PubMed, Medline, CINAHL, Embase and the Cochrane library databases were searched to identify all studies of autologous protein solution/autologous conditioned serum (ACS/APS) in the management of knee OA. We evaluated the reported clinical outcomes with respect to pain, function, morbidity, adverse effects and complications. Results Fifteen relevant articles were identified in the current literature. Outcomes following injection of ACS/APS have been reported in patients with age range (34–87 years) and unilateral or bilateral knee OA. Seven studies reported improvement in visual analog scale (VAS) whereas the Western Ontario and McMaster Universities osteoarthritis instrument (WOMAC) score improved in nine studies. Considerable variation was noted in the injection technique and duration of post-procedure assessment with only one study reporting long-term follow-up beyond 24 months. Joint swelling and injection-site pain were reported to be the most common complications; only one study reported a case of septic arthritis. However, no evidence is available to clearly identify factors that may predict the outcomes following this procedure. Conclusion Current data from the clinical studies would suggest that the intraarticular administration of autologous cell-free serum preparations, such as ACS/APS, in patients with knee OA may improve pain and function, with limited morbidity. High-quality clinical trials with stratified patient cohorts, longer follow-up duration and robust reporting of outcome measures are essential to improve the understanding of the indications and clinical effectiveness of these novel products.
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Affiliation(s)
- Darshan S Angadi
- Department of Trauma and Orthopaedics, Cheltenham General Hospital, Sandford Rd, Cheltenham, UK.
| | - Hamish Macdonald
- Department of Trauma and Orthopaedics, Cheltenham General Hospital, Sandford Rd, Cheltenham, UK
| | - Navraj Atwal
- Department of Trauma and Orthopaedics, Cheltenham General Hospital, Sandford Rd, Cheltenham, UK
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20
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Schumacher J, Boone L. Local anaesthetics for regional and intra‐articular analgesia in the horse. EQUINE VET EDUC 2019. [DOI: 10.1111/eve.13235] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- J. Schumacher
- Department of Clinical Sciences College of Veterinary Medicine Auburn University Auburn Alabama USA
| | - L. Boone
- Department of Clinical Sciences College of Veterinary Medicine Auburn University Auburn Alabama USA
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21
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Jayaram P, Kennedy DJ, Yeh P, Dragoo J. Chondrotoxic Effects of Local Anesthetics on Human Knee Articular Cartilage: A Systematic Review. PM R 2019; 11:379-400. [DOI: 10.1002/pmrj.12007] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 10/20/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Prathap Jayaram
- H. Ben Dept. Physical Medicine & Rehabilitation, Dept of Orthopedic SurgeryBaylor College of Medicine, 1 Baylor Plaza Houston TX
| | - David J. Kennedy
- Department of Physical Medicine and RehabilitationVanderbilt University Medical Center Nashville TN
| | - Peter Yeh
- H. Ben Dept. Physical Medicine & RehabilitationBaylor College of Medicine Houston TX
| | - Jason Dragoo
- Department of Orthopedic SurgeryStanford University Medical Center Stanford CA
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22
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Long-term pain relief in canine osteoarthritis by a single intra-articular injection of resiniferatoxin, a potent TRPV1 agonist. Pain 2019; 159:2105-2114. [PMID: 30015705 DOI: 10.1097/j.pain.0000000000001314] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The translational potential of analgesic approaches emerging from basic research can be augmented by client-owned dog trials. We report on a peripheral interventional approach that uses intra-articular injection of the ultrapotent TRPV1 agonist resiniferatoxin (RTX) to produce a selective long-term chemoinactivation of nociceptive primary afferent nerve endings for pain control in naturally occurring canine osteoarthritis. A single injection of 10 µg of RTX, produced suppression of pain, improvement in gait, weight bearing, and improvement in the dog's activities of daily living lasting 4 months or longer. Two to 3 years after the injection, there are no alterations to suggest that removal of inflammatory pain caused accelerated joint degeneration (Charcot joint) in any of the dogs. To amplify the effective use of canine subjects in translational analgesia research, we report a high-quality canine dorsal root ganglion transcriptome. Some targets for analgesia are highly conserved both in protein sequence and level of expression within a target tissue while others diverge substantially from the human. This knowledge is especially important for development of analgesics aimed at peripheral molecular targets and provides a template for informed translational research. The peripheral site of action, long duration of analgesia, apparent safety, and retention of coordination, all resulting from a single dose suggest that intra-articular RTX may be an effective intervention for osteoarthritis pain with few or no side effects and lead to an improved quality of life.
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23
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Martin SD, Conaway WK, Lei P. Use of Intra-Articular Corticosteroids in Orthopaedics. J Bone Joint Surg Am 2018; 100:885-891. [PMID: 29762289 DOI: 10.2106/jbjs.17.00289] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Scott D Martin
- Sports Medicine Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - William K Conaway
- Sports Medicine Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Pengfei Lei
- Sports Medicine Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts.,Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Orthopaedic Surgery, Xiangya Hospital, Central South University, Changsha, People's Republic of China
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24
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Nuelle CW, Cook CR, Stoker AM, Cook JL, Sherman SL. In Vivo Toxicity of Local Anesthetics and Corticosteroids on Supraspinatus Tenocyte Cell Viability and Metabolism. THE IOWA ORTHOPAEDIC JOURNAL 2018; 38:107-112. [PMID: 30104932 PMCID: PMC6047373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND This study was conducted to evaluate the effects of commonly used injection medication combinations on supraspinatus tenocyte cell viability and tissue metabolism. METHODS Twenty adult dogs underwent ultrasound guided injection of the canine equivalent of the subacromial space, based on random assignment to one of four treatment groups (n=5/group): normal saline, 1.0% lidocaine/methylprednisolone, 1.0% lidocaine/triamcinolone or 0.0625% bupivacaine/triamcinolone. Full-thickness sections of supraspinatus tendon were harvested under aseptic conditions and evaluated on days 1 and 7 post-harvest for cell viability and tissue metabolism. Data were analyzed for significant differences among groups. RESULTS Tendons exposed to 1% lidocaine/ methylprednisolone had significantly lower cell viability at day 1 as compared to all other groups and control. All local anesthetic/ corticosteroid combination groups had decreased cell viability at day 7 when compared to the control group. CONCLUSIONS This study demonstrated significant in vivo supraspinatus tenotoxicity following a single injection of combination local anesthetic/ corticosteroid when compared to saline controls. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Clayton W Nuelle
- Department of Orthopaedic Surgery, University of Missouri, Columbia
- The San Antonio Orthopaedic Group, San Antonio, TX
| | - Cristi R Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia
| | - Aaron M Stoker
- Department of Orthopaedic Surgery, University of Missouri, Columbia
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia
| | - Seth L Sherman
- Department of Orthopaedic Surgery, University of Missouri, Columbia
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Rubio-Martínez LM, Rioja E, Castro Martins M, Wipawee S, Clegg P, Peffers MJ. Local anaesthetics or their combination with morphine and/or magnesium sulphate are toxic for equine chondrocytes and synoviocytes in vitro. BMC Vet Res 2017; 13:318. [PMID: 29115971 PMCID: PMC5678813 DOI: 10.1186/s12917-017-1244-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 10/30/2017] [Indexed: 12/11/2022] Open
Abstract
Background Chondrotoxic effects of local anaesthetics are well reported in humans and some animal species but knowledge on their toxic effects on synoviocytes or equine chondrocytes or the effects on cellular production of inflammatory cytokines is limited. The purpose of this study was to evaluate the in vitro effects of local anaesthetics, morphine, magnesium sulphate (MgSO4) or their combinations on cell viability and pro-inflammatory cytokine gene expression of equine synoviocytes and chondrocytes. Equine synoviocytes and cartilage explants harvested from normal joints in a co-culture system were exposed to mepivacaine (4.4 mg/ml), bupivacaine (2.2 mg/ml), morphine (2.85 mg/ml) and MgSO4 (37 mg/ml) alone or each local anaesthetic plus morphine or MgSO4 or both together. Chondrocyte and synoviocyte cell viability was assessed by CellTiter-Glo Luminescent Cell Viability Assay. Synoviocyte gene expression of IL-1β, IL-6 or TNF-α was measured and compared using the ∆∆CT method. Results Morphine alone, MgSO4 alone or their combination did not alter cell viability or the expression of IL-1β, IL-6 or TNF-α. However, local anaesthetics alone or in combination with morphine and/or MgSO4 reduced cell viability and increased the gene expression of IL-1β, IL-6 or TNF-α. Single short exposure to local anaesthetics is toxic to both chondrocytes and synoviocytes and their combination with morphine and/or MgSO4 enhanced the cytotoxic effects. Conclusions This in vitro study gives further evidence of the absence of cytotoxic effects of morphine alone, MgSO4 alone or their combination on normal articular tissues. However, local anaesthetics alone or in combination with morphine and/or MgSO4 have cytotoxic effects on equine articular tissues. Electronic supplementary material The online version of this article (10.1186/s12917-017-1244-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- L M Rubio-Martínez
- Institute of Veterinary Science, University of Liverpool, Leahurst Campus, Chester High Road, CH647TE, Neston, UK.
| | - E Rioja
- Institute of Veterinary Science, University of Liverpool, Leahurst Campus, Chester High Road, CH647TE, Neston, UK
| | - M Castro Martins
- Institute of Veterinary Science, University of Liverpool, Leahurst Campus, Chester High Road, CH647TE, Neston, UK
| | - S Wipawee
- Faculty of Veterinary Science, Rajamangala University of Technology Srivijaya (Thailand) and Institute of Aging and Chronic Disease, University of Liverpool, Liverpool, UK
| | - P Clegg
- Institute of Aging and Chronic Disease, University of Liverpool, Liverpool, UK
| | - M J Peffers
- Institute of Aging and Chronic Disease, University of Liverpool, Liverpool, UK
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Kleine SA, Budsberg SC. Synovial membrane receptors as therapeutic targets: A review of receptor localization, structure, and function. J Orthop Res 2017; 35:1589-1605. [PMID: 28374922 DOI: 10.1002/jor.23568] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/28/2017] [Indexed: 02/04/2023]
Abstract
Joint pathology and degeneration is a significant cause of pain. The synovial membrane plays an important role in maintenance of the joint, contributes to the pathology of many arthropathies and may be adversely affected in joint disease. Improving knowledge of the receptors present within the synovium will aid in a better understanding of joint pathology and the development of new treatments for diseases such as osteoarthritis and rheumatoid arthritis. Knowledge of the location and function of synovial membrane receptors (both in healthy and diseased synovium) may provide important targets in the treatment of various arthropathies. Classic pain receptors such as opioid receptors in the synovium are a mainstay in local and systemic management of chronic pain in many species. In addition to these, many other receptors such as bradykinin, neurokinin, transient receptor potential vanilloid, and inflammatory receptors, such as prostanoid and interleukin receptors have been discovered within the synovial membrane. These receptors are important in pain, inflammation, and in maintenance of normal joint function and may serve as targets for pharmacologic intervention in pathologic states. The goal of this review is to outline synovial membrane receptor localization and local therapeutic modulation of these receptors, in order to stimulate further research into pharmacological management of arthropathies at the local level. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1589-1605, 2017.
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Affiliation(s)
- Stephanie A Kleine
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, 2200 College Station Road, Athens 30602, Georgia
| | - Steven C Budsberg
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, 2200 College Station Road, Athens 30602, Georgia
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27
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Bernardoni ED, Frank RM, Gomoll AH. Looking Back: Safety of Current Treatments. OPER TECHN SPORT MED 2017. [DOI: 10.1053/j.otsm.2016.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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28
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Barrington JW, Emerson RH, Lovald ST, Lombardi AV, Berend KR. No Difference in Early Analgesia Between Liposomal Bupivacaine Injection and Intrathecal Morphine After TKA. Clin Orthop Relat Res 2017; 475:94-105. [PMID: 27339124 PMCID: PMC5174037 DOI: 10.1007/s11999-016-4931-z] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Opioid analgesics have been a standard modality for postoperative pain management after total knee arthroplasty (TKA) but are also associated with increased risk of nausea, pruritus, vomiting, respiratory depression, prolonged ileus, and cognitive dysfunction. There is still a need for a method of anesthesia that can deliver effective long-term postoperative pain relief without incurring the high cost and health burden of opioids and nerve blocks. QUESTIONS/PURPOSES (1) Is liposomal bupivacaine-based periarticular injection (PAI) more effective than morphine-based spinal anesthesia or ropivacaine-based PAI in controlling postoperative pain after TKA? (2) Do patients treated with liposomal bupivacaine-based PAI experience fewer opioid-related adverse events compared with patients treated with morphine-based spinal anesthesia or ropivacaine-based PAI in controlling postoperative pain after TKA? METHODS This multicenter, blind trial randomized 119 patients undergoing TKA with spinal anesthesia to receive spinal anesthesia plus periarticular injection with liposomal bupivacaine (40 patients), spinal anesthesia with bupivacaine plus intrathecal morphine (41 patients) but no liposomal bupivacaine injection, or spinal anesthesia with bupivacaine (38 patients) and no liposomal bupivacaine injection. The two groups that did not receive periarticular liposomal bupivacaine did receive periarticular injection with ropivacaine, and all three groups had ketorolac (30 mg) plus epinephrine (1:1000) in the periarticular injections. Patients in all three groups received identical perioperative multimodal analgesic and antiemetic drugs. All patients were analyzed in the group to which they were randomized and no patients were lost to followup. The primary study endpoints were visual analog score (VAS) for pain and narcotic use during postoperative day 1. Secondary endpoints included side effects associated with narcotic administration during the hospital stay. RESULTS Mean VAS pain in the liposomal bupivacaine PAI group was lower than that for the ropivacaine PAI group at 6 hours (1.8 ± 2.1 versus 3.3 ± 2.3, p = 0.005, mean difference: 1.5, 95% confidence interval [CI], 0.5-2.5) and 12 hours (1.5 ± 2.0 versus 3.3 ± 2.4, p < 0.001, mean difference: 1.8, 95% CI, 0.8-2.8) after surgery. The morphine spinal group had lower pain compared with the liposomal bupivacaine PAI group at 6 hours (0.9 ± 1.8 versus 1.8 ± 2.1, p = 0.035, mean difference: 1.0, 95% CI, 0.1-1.8), but there was no difference at 12 hours (0.8 ± 1.5 versus 1.5 ± 2.0, p = 0.086, mean difference: 0.7, 95% CI, -0.1 to 1.5). The magnitude of the differences at 6 and 12 hours are near the lower end of minimal clinically important differences reported in the literature, and thus the improvement shown in this study may only represent a small clinical improvement. Both the liposomal bupivacaine group (13% [five of 40]) and the ropivacaine group (5% [two of 38]) had fewer incidents of itching (pruritus) than the spinal morphine group (38% [15 of 41]) (p = 0.001). CONCLUSIONS This prospective multicenter three-arm blind randomized controlled trial showed potentially improved pain control at 6 and 12 hours in the liposomal bupivacaine and intrathecal morphine groups compared with the ropivacaine group at the cost of much higher incidences of pruritus (itching) in the intrathecal morphine group. Based on these results, we prefer the use of PAI with liposomal bupivacaine as an alternative to spinal anesthesia with intrathecal morphine as a result of similar postoperative pain control and the potential for reducing adverse events. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- John W. Barrington
- grid.418661.cPlano Orthopedic Sports Medicine and Spine Center, Plano, TX USA
| | | | - Scott T. Lovald
- grid.418983.f0000000096620001Exponent, Inc, 149 Commonwealth Drive, Menlo Park, CA 19104 USA
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Honcharuk E, Monica J. Complications Associated with Intra-Articular and Extra-Articular Corticosteroid Injections. JBJS Rev 2016; 4:01874474-201612000-00002. [DOI: 10.2106/jbjs.rvw.16.00004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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30
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Does chondrolysis occur after corticosteroid-analgesic injections? An analysis of patients treated for adhesive capsulitis of the shoulder. J Shoulder Elbow Surg 2016; 25:890-7. [PMID: 26803933 DOI: 10.1016/j.jse.2015.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 10/17/2015] [Accepted: 10/18/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Clinical studies using continuous infusions of local anesthetics and basic science studies that model injections of local anesthetics have shown chondrotoxicity. However, clinical studies do not exist that have assessed for the risk of chondrolysis in nonarthritic joints exposed to single or intermittent corticosteroid or analgesic injections. Currently, there are no data available to guide the clinician on the safety of using these injections in clinical practice. MATERIALS AND METHODS A retrospective review of patients treated for adhesive capsulitis of the shoulder with at least 1 intra-articular injection of a corticosteroid and anesthetic was performed. The inclusion criteria were a diagnosis of adhesive capsulitis and a minimum 2-year follow-up. Prospective follow-up was performed to obtain patient-determined outcome scores, range of motion, and radiographs to determine the presence of chondrolysis. RESULTS Fifty-six patients with a mean age of 52.5 ± 7.2 years were enrolled at a mean follow-up of 54 months. The mean number of injections performed was 1.5 ± 0.7 (range, 1-4). At final follow-up, the mean Western Ontario Osteoarthritis of the Shoulder score was 91.4% ± 14.2%; Disabilities of the Arm, Shoulder and Hand score, 6.7 ± 9.6; Shoulder Pain and Disability Index score, 7.4 ± 11.4; and Single Assessment Numeric Evaluation score, 92.7% ± 10.1%. The Shoulder Activity Score was 8.3 ± 4.7. Passive and active forward elevation, external rotation, internal rotation, and cross-body adduction showed no significant differences compared with the unaffected contralateral shoulder. There was no radiographic evidence of chondrolysis in any patient. CONCLUSIONS This study did not show chondrolysis in patients treated with an intra-articular corticosteroid and local anesthetic for adhesive capsulitis. The findings of this study do not support the cessation of using intra-articular analgesic-corticosteroid injections for the treatment of adhesive capsulitis. LEVEL OF EVIDENCE Level IV; Case Series; Treatment Study.
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Euppayo T, Siengdee P, Buddhachat K, Pradit W, Chomdej S, Ongchai S, Nganvongpanit K. In vitro effects of triamcinolone acetonide and in combination with hyaluronan on canine normal and spontaneous osteoarthritis articular cartilage. In Vitro Cell Dev Biol Anim 2016; 52:723-35. [PMID: 27130677 DOI: 10.1007/s11626-016-0022-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 03/25/2016] [Indexed: 01/01/2023]
Abstract
The purposes of this study were to examine the cartilage degradation effects of triamcinolone acetonide (TA) on normal and osteoarthritic (OA) primary canine chondrocytes and cartilage explants and to examine the cartilage degradation effects of TA in combination with low-molecular-weight hyaluronan (LMWHA). To assess the effects of these drugs on cell culture, 3,[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide (MTT) assay and real-time PCR were used to measure chondrotoxicity and determine gene expression, respectively. Uronic acid and hydroxyproline remaining in cartilage and histopathology were used to estimate the effects of these drugs on cartilage explants. In chondrocyte cultures, TA reduced chondrocyte viability in a concentration-dependent manner. LMWHA 2.5 mg/ml combined with TA at IC20 (0.09 mg/ml) could increase the viability of normal chondrocytes when compared with TA-treated alone. TA at IC20 induced down-regulation of ACAN and induced up-regulation of ADAMTS5 in canine normal chondrocytes. TA at IC20 (0.11 mg/ml) up-regulated ADAMTS5, MMP2, MMP3, MMP13, and ACAN expression in canine OA chondrocytes. In explant culture, TA at 1.25, 2.5, and 5 mg/ml increased the severity of structural damage, chondrocyte loss and cluster formation, and proteoglycan loss in OA cartilage. LMWHA could decrease the chondrotoxicity of TA at IC20 only in normal chondrocytes, as observed by chondrocyte viability. The combination of LMWHA and TA did not show clearly beneficial effects in all other normal and OA samples. Consequently, using TA alone or in combination with LMWHA in OA cartilage should be of concern because it may lead to cartilage destruction.
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Affiliation(s)
- Thippaporn Euppayo
- Animal Bone and Joint Research Laboratory, Department of Veterinary Biosciences and Public Health, Faculty of Veterinary Medicine, Chiang Mai University, Chiang Mai, 50100, Thailand
| | - Puntita Siengdee
- Animal Bone and Joint Research Laboratory, Department of Veterinary Biosciences and Public Health, Faculty of Veterinary Medicine, Chiang Mai University, Chiang Mai, 50100, Thailand
| | - Kittisak Buddhachat
- Animal Bone and Joint Research Laboratory, Department of Veterinary Biosciences and Public Health, Faculty of Veterinary Medicine, Chiang Mai University, Chiang Mai, 50100, Thailand
| | - Waranee Pradit
- Science and Technology Research Institute, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Siriwadee Chomdej
- Department of Biology, Faculty of Science, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Siriwan Ongchai
- Department of Biochemistry, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Korakot Nganvongpanit
- Animal Bone and Joint Research Laboratory, Department of Veterinary Biosciences and Public Health, Faculty of Veterinary Medicine, Chiang Mai University, Chiang Mai, 50100, Thailand.
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Does Reducing the Concentration of Bupivacaine When Performing Therapeutic Shoulder Joint Injections Impact the Clinical Outcome? AJR Am J Roentgenol 2016; 206:805-9. [DOI: 10.2214/ajr.15.15132] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Gulihar A, Robati S, Twaij H, Salih A, Taylor GJ. Articular cartilage and local anaesthetic: A systematic review of the current literature. J Orthop 2015; 12:S200-10. [PMID: 27047224 PMCID: PMC4796530 DOI: 10.1016/j.jor.2015.10.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 10/04/2015] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Chondrolysis involves the breakdown of cartilage following arthroscopic surgery, most commonly affecting the glenohumeral joint. METHODS This review summarises all clinical and laboratory studies regarding local anaesthetic (LA) and its association with chondrolysis. We identified 289 papers, 41 of which met our inclusion criteria and were included in the final review. RESULTS Bupivacaine, lidocaine, ropivacaine and levobupivacaine are all toxic to cartilage. Intra-articular infusions confer a greater toxicity to cartilage than single injections. CONCLUSIONS Intra-articular LA pain pumps carry a high risk of chondrolysis and should be avoided. Further studies are indicated to assess long-term single exposure LA implications.
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Key Words
- Arthroscopy
- Cartilage
- Chondrolysis
- GAG, glycosaminoglycan
- IL-6, interleukin-6
- LA, local anaesthetic
- LDH, lactate dehydrogenase
- Local anaesthetic
- MgSO4, magnesium sulphate
- PAGCL, post-arthroscopic glenohumeral chondrolysis
- PBS, phosphate buffered saline
- PG, proteoglycan
- PP, pain pump
- RCT, randomised controlled trial
- Review
- TKA, total knee athroplasty
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Affiliation(s)
- Abhinav Gulihar
- Trauma and Orthopaedics, Dartford and Gravesham NHS Trust, UK
| | | | | | - Alan Salih
- Trauma and Orthopaedics, East Sussex Hospitals, UK
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Barrington JW, Olugbode O, Lovald S, Ong K, Watson H, Emerson RH. Liposomal Bupivacaine: A Comparative Study of More Than 1000 Total Joint Arthroplasty Cases. Orthop Clin North Am 2015; 46:469-77. [PMID: 26410636 DOI: 10.1016/j.ocl.2015.06.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pain after total joint arthroplasty (TJA) can be severe and difficult to control. A single-dose local analgesic delivers bupivacaine in a liposomal time-release platform. In 2248 consecutive patients with hip and knee arthroplasty, half (Pre) were treated using a well-established multimodal analgesia, including periarticular injection (PAI), and half had the PAI substituted for a liposomal bupivacaine injection technique (Post). Pain scores were significantly lower for patients in the Post group for both hip and knee procedures. A large series of patients who had TJA experienced pain relief after the introduction of liposomal bupivacaine as part of an established multimodal protocol.
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Affiliation(s)
- John W Barrington
- Plano Orthopedic Sports Medicine & Spine Center, 5228 W Plano Pkwy, Plano, TX 75093, USA
| | - Oluseun Olugbode
- Texas Center for Joint Replacement, 6020 West Parker Road, Suite 470, Plano, TX 75093, USA
| | - Scott Lovald
- Exponent, Inc, 149 Commonwealth Drive, Menlo Park, CA 94025, USA.
| | - Kevin Ong
- Exponent, Inc, 3440 Market Street, Suite 600, Philadelphia, PA 19104, USA
| | - Heather Watson
- Exponent, Inc, 149 Commonwealth Drive, Menlo Park, CA 94025, USA
| | - Roger H Emerson
- Texas Center for Joint Replacement, 6020 West Parker Road, Suite 470, Plano, TX 75093, USA
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Sherman SL, Khazai RS, James CH, Stoker AM, Flood DL, Cook JL. In Vitro Toxicity of Local Anesthetics and Corticosteroids on Chondrocyte and Synoviocyte Viability and Metabolism. Cartilage 2015; 6:233-40. [PMID: 26425261 PMCID: PMC4568732 DOI: 10.1177/1947603515594453] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE There is growing concern that intra-articular injection of local anesthetic and/or corticosteroids may cause significant morbidity, including potential toxicity to chondrocytes and synoviocytes, after even a single exposure. We demonstrate that full thickness canine chondral and synovial samples exposed to various local anesthetics and corticosteroids exhibit decreased loss of cell viability compared with prior in vitro studies using monolayer culture, due to the protective effects of intact extracellular matrix and cell heterogeneity. METHODS Full-thickness cartilage and synovial explants were obtained from canine cadavers and exposed in culture media to the following for 24 hours: 1% lidocaine, 0.5% lidocaine, 0.25% bupivacaine, 0.125% bupvacaine, 0.0625% bupivacaine, betamethasone acetate, methylprednisolone acetate, triamcinolone acetonide, or culture media only (control). Cell viability was determined on days 1 and 7 of culture using a microscopic live-dead and alamar blue metabolic assays. RESULTS Complete loss of chondrocyte and synoviocyte viability was noted in the 1% and 0.5% lidocaine group, 0.25% and 0.125% bupivacaine group, betamethasone group, and methylprednisolone groups after 1 and 7 days of culture. Treatment with 0.0625% bupivacaine and triamcinolone demonstrated no decrease in cell viability or metabolism when compared to negative control. CONCLUSIONS In this canine explant model, 1% and 0.5% lidocaine, 0.25% and 0.125% bupivacaine, betamethasone acetate, and methylpresdnisolone acetate were severely chondrotoxic and synoviotoxic after a single exposure, despite intact extracellular matrix. In contrast, chondrocytes and synoviocytes exposed to 0.0625% bupivacaine and triamcinolone remained viable after treatment. Further in vivo study is needed before definitive recommendations can be made.
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Affiliation(s)
- Seth L. Sherman
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
| | - Ravand S. Khazai
- Department of Orthopaedic Surgery, University of Chicago, Chicago, IL, USA
| | | | - Aaron M. Stoker
- Comparative Orthopaedic Laboratory, University of Missouri, Columbia, MO, USA
| | - David L. Flood
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
| | - James L. Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA,Comparative Orthopaedic Laboratory, University of Missouri, Columbia, MO, USA
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Abstract
Ultrasonography (USG) is a safe, easily available, and cost-effective modality, which has the additional advantage of being real time for imaging and image-guided interventions of the musculoskeletal system. Musculoskeletal interventions are gaining popularity in sports and rehabilitation for rapid healing of muscle and tendon injuries in professional athletes, healing of chronic tendinopathies, aspiration of joint effusions, periarticular bursae and ganglia, and perineural injections in acute and chronic pain syndromes. This article aims to provide an overview of the spectrum of musculoskeletal interventions that can be done under USG guidance both for diagnostic and therapeutic purposes.
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Affiliation(s)
- Aditya Ravindra Daftary
- Department of InnoVision Imaging, Section of Musculoskeletal Imaging, Sportsmed Mumbai, Mumbai, Maharashtra, India
| | - Alpana Sudhir Karnik
- Department of InnoVision Imaging, Section of Musculoskeletal Imaging, Sportsmed Mumbai, Mumbai, Maharashtra, India
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Isyar M, Bilir B, Yilmaz I, Cakmak S, Sirin DY, Guzelant AY, Mahirogullari M. Are biological agents toxic to human chondrocytes and osteocytes? J Orthop Surg Res 2015. [PMID: 26223355 PMCID: PMC4520184 DOI: 10.1186/s13018-015-0264-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Purpose The aim of the present study is to investigate the effects of biological agents (BAs) on human chondrocytes and osteocytes in vitro. Methods Primary cell cultures obtained from gonarthrosis patients were divided into four groups, two of which were designated as control cultures of chondrocyte and osteocyte, and the other two groups were exposed to BAs administered via the culture medium. Cultured cells were characterized by immunophenotyping. Before and after administration of the agents, the cultures were observed by inverted and environmental scanning electron microscopy (ESEM). The number of live cells and the proliferation rate were monitored by MTT assay. Results Rituximab and adalimumab were the least toxic agents to chondrocytes, whereas adalimumab and etanercept were to osteocytes. Conclusion During periods of intense active inflammation, the concentration of the preferred BAs after inhibition of inflammation needs to be emphasized when their effects on cartilage and bone tissue are considered at the cellular level if the clinical practice is to continue.
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Affiliation(s)
- Mehmet Isyar
- Department of Orthopaedic and Traumatology, School of Medicine, Istanbul Medipol University, Bagcilar, 34214, Istanbul, Turkey.
| | - Bulent Bilir
- Department of Internal Medicine, School of Medicine, Namik Kemal University, 59100, Tekirdag, Turkey.
| | - Ibrahim Yilmaz
- Department of Pharmacovigilance and Rational Drug Use Team, Republic of Turkey, Ministry of Health, State Hospital, 59100, Tekirdag, Turkey.
| | - Selami Cakmak
- Department of Orthopaedic and Traumatology, Haydarpasa Training Hospital, Gulhane Military Medical Academy, 34668, Istanbul, Turkey.
| | - Duygu Yasar Sirin
- Faculty of Science, Department of Molecular Biology and Genetics, Namik Kemal University, 59100, Tekirdag, Turkey.
| | - Aliye Yildirim Guzelant
- Department of Physical Medicine and Rehabilitation, School of Medicine, Namik Kemal University, 59100, Tekirdag, Turkey.
| | - Mahir Mahirogullari
- Department of Orthopaedic and Traumatology, School of Medicine, Istanbul Medipol University, Bagcilar, 34214, Istanbul, Turkey.
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Sola M, Dahners L, Weinhold P, Svetkey van der Horst A, Kallianos S, Flood D. The viability of chondrocytes after an in vivo injection of local anaesthetic and/or corticosteroid. Bone Joint J 2015; 97-B:933-8. [DOI: 10.1302/0301-620x.97b7.35398] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
This in vivo controlled laboratory study was performed to evaluate various intra-articular clinical injection regimes that might be less toxic than some in vitro studies suggest. We hypothesised that low-concentration, preservative-free, pH-balanced agents would be less toxic than high-concentration non-pH-balanced agents with preservatives, and that injections of individual agents are less toxic than combined injections. The left knees of 12- to 13-week-old Sprague–Dawley rats were injected once with eight different single agents, including low and high concentrations of ropivacaine and triamcinolone, alone and in combination, as well as negative and positive controls. The rats were killed at one week or five months, and live–dead staining was performed to quantify the death of chondrocytes. All injections except pH-balanced 0.2% ropivacaine combined with preservative-free 1 mg/ml triamcinolone acetonide resulted in statistically significant decreases in chondrocyte viability, compared with control knees, after one week and five months (p < 0.001). After one week there was no significant difference in viability between 0.2% and 0.5% ropivacaine; however, 4 mg/ml triamcinolone resulted in a lower viability than 1 mg/ml triamcinolone. Although many agents commonly injected into joints are chondrotoxic, in this in vivo study diluting preservative-free 10 mg/ml triamcinolone 1:9 in 0.2% pH-balanced ropivacaine resulted in low toxicity. Cite this article: Bone Joint J 2015; 97-B:933–8.
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Affiliation(s)
- M. Sola
- University of North Carolina, Orthopaedic
Research Labs, 134B Glaxo Building. CB# 7546, 101A
Mason Farm Rd. Chapel Hill, North Carolina
27599, USA
| | - L. Dahners
- University of North Carolina, CB
#7055, Bioinformatics Building, Chapel
Hill, North Carolina 27599-7055, USA
| | - P. Weinhold
- University of North Carolina, Orthopaedic
Research Labs, 134B Glaxo Building. CB# 7546, 101A
Mason Farm Rd. Chapel Hill, North Carolina
27599, USA
| | - A. Svetkey van der Horst
- University of North Carolina, Orthopaedic
Research Labs, 134B Glaxo Building. CB# 7546, 101A
Mason Farm Rd. Chapel Hill, North Carolina
27599, USA
| | - S. Kallianos
- University of North Carolina, Orthopaedic
Research Labs, 134B Glaxo Building. CB# 7546, 101A
Mason Farm Rd. Chapel Hill, North Carolina
27599, USA
| | - D. Flood
- University of Missouri Missouri Orthopaedic
Institute, 1100 Virginia Avenue, DC953.00, Columbia, Missouri
65212, USA
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Von Keudell A, Syed HM, Canseco JA, Gomoll AH. Efficacy of common surgical compounds in preventing articular chondrocyte death from desiccation. Knee Surg Sports Traumatol Arthrosc 2015; 23:1346-1350. [PMID: 24061713 DOI: 10.1007/s00167-013-2631-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 08/18/2013] [Indexed: 11/25/2022]
Abstract
PURPOSE Purpose of this study was to identify potential substances that prevent desiccation of chondrocytes. METHODS Macroscopically normal bovine cartilage explants (n = 80) were exposed to room air, or covered with surgical lubricant, Lactated ringer (LR) or Seprafilm (Genzyme Biosurgery, Cambridge, MA) for 0, 30, 60 or 120 min. The viability of superficial chondrocytes was measured after 48 h of incubation in tissue culture media at 37 °C by Live/Dead staining. Chondrotoxicity was measured as the extent of cell death below the articular surface. Statistical analysis was performed with a two-way analysis of variance on the data set and a subsequent Tukey's post hoc test. RESULTS Chondrocyte death correlated positively with the length of exposure, regardless of the treatment (p < 0.0001). The extent of superficial chondrocyte death was minimally lower in the LR (89.1 ± 2.6 %, 80.8 ± 1.2 %) and surgical lube (84.3 ± 1.8 %, 75.9 ± 2.7 %) groups than the control (82 ± 5.7 %, 65.6 ± 13.3 %) and Seprafilm group (77.6 ± 3.9 %, 63.3 ± 6.9 %) (p < 0.001) at the first two time points, with no significant difference between the latter groups. After 60 and 120 min, surgical lube resulted in less chondrocyte death than all other groups (70.4 ± 6.8 % and 60.9 ± 5.9 %, all p < 0.0001). CONCLUSION The data suggest that depending on the expected length of exposure of the articular cartilage surface, different compounds appear to be protective. For exposures exceeding 60 min, surgical lubricant demonstrated the highest protective potential. Results from this study indicate that protecting exposed articular surfaces with surgical lubricant for orthopaedic procedures lasting more than 1 h lead to decreased chondrocyte death and suggest improved cartilage functional outcomes postoperatively.
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Affiliation(s)
- A Von Keudell
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - H M Syed
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - J A Canseco
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Harvard-MIT Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
- Laboratory for Tissue Engineering and Regenerative Medicine, Department of Anesthesia, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - A H Gomoll
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Wernecke C, Braun HJ, Dragoo JL. The Effect of Intra-articular Corticosteroids on Articular Cartilage: A Systematic Review. Orthop J Sports Med 2015; 3:2325967115581163. [PMID: 26674652 PMCID: PMC4622344 DOI: 10.1177/2325967115581163] [Citation(s) in RCA: 192] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background: Intra-articular (IA) corticosteroid therapy has been used for the treatment of inflammation and pain in the knee since the 1950s. Purpose: To review the current literature on the effects of IA corticosteroids on articular cartilage. Study Design: Systematic review. Methods: A MEDLINE and SCOPUS database search was performed, and studies were selected for basic science and clinical trial research on corticosteroids with direct outcome measures of cartilage health. Preliminary searches yielded 1929 articles, and final analysis includes 40 studies. Results: Methylprednisolone, dexamethasone, hydrocortisone, betamethasone, prednisolone, and triamcinolone were reported to display dose-dependent deleterious effects on cartilage morphology, histology, and viability in both in vitro and in vivo models. The beneficial animal in vivo effects of methylprednisolone, hydrocortisone, and triamcinolone occurred at low doses (usually <2-3 mg/dose or 8-12 mg/cumulative total dose in vivo), at which increased cell growth and recovery from damage was observed; the single human clinical trial indicated a beneficial effect of triamcinolone. However, at higher doses (>3 mg/dose or 18-24 mg/cumulative total dose in vivo), corticosteroids were associated with significant gross cartilage damage and chondrocyte toxicity. Dose and time dependency of corticosteroid chondrotoxicity was supported in the in vitro results, however, without clear dose thresholds. Conclusion: Corticosteroids have a time- and dose-dependent effect on articular cartilage, with beneficial effects occurring at low doses and durations and detrimental effects at high doses and durations. Clinically, beneficial effects are supported for IA administration, but the lowest efficacious dose should be used.
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Sherman SL, James C, Stoker AM, Cook CR, Khazai RS, Flood DL, Cook JL. In Vivo Toxicity of Local Anesthetics and Corticosteroids on Chondrocyte and Synoviocyte Viability and Metabolism. Cartilage 2015; 6:106-12. [PMID: 26069713 PMCID: PMC4462250 DOI: 10.1177/1947603515571001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Intra-articular injection of local anesthetic and/or corticosteroid is an adjunct treatment for arthritic and inflammatory orthopedic conditions. Despite potential benefits, there is growing concern that these medications may cause significant morbidity, including potential toxicity to intra-articular chondrocytes and synoviocytes. DESIGN Twenty dogs underwent intra-articular injection of the shoulder joint using ultrasound guidance, with the following injectates (n = 5 each): negative control (saline), methylprednisolone/1.0% lidocaine, triamcinolone/1.0% lidocaine, and triamcinolone/0.0625% bupivacaine. The dogs were euthanized 24 hours postinjection for reasons unrelated to this study. Synovium/cartilage explants were harvested under sterile conditions and assessed immediately or cultured for 7 days. Synoviocyte and chondrocyte viability was determined on day 1 and day 7 using Calcien AM and Sytox Blue live/dead fluorescent stains, and cell metabolism determined on day 2 using the alamar blue additive test. Results were compared statistically. RESULTS On day 1 synovium exposed to 1%L/M demonstrated a significant decrease in cell metabolism (P = 0.0107) and subjective synoviocyte viability scores (P = 0.013) compared with the negative control. Cartilage exposed to 1%L/M demonstrated decreased chondrocyte viability and cell metabolism versus all other groups, although not significantly. After 7 days of culture, cartilage viable cell density in the 1%L/M group was significantly (P ≤ 0.001) lower than the negative control. Subjective synoviocyte viability scores was significantly lower in the 1%L/M (P = 0.013), 1%L/T (P ≤ 0.001), and 0.0625%B/T groups (P = 0.006) compared with the negative control. CONCLUSIONS This study suggests potential negative effects of combination local anesthetic/corticosteroid on intra-articular cell viability and cell metabolism. Further study is needed before determining definitive clinical recommendations.
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Affiliation(s)
- Seth L. Sherman
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
| | - Christopher James
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
| | - Aaron M. Stoker
- Comparative Orthopaedic Laboratory, University of Missouri, Columbia, MO, USA
| | - Cristi R. Cook
- Comparative Orthopaedic Laboratory, University of Missouri, Columbia, MO, USA
| | - Ravand S. Khazai
- Department of Orthopaedic Surgery, University of Chicago, Chicago, IL, USA
| | - David L. Flood
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
| | - James L. Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA,Comparative Orthopaedic Laboratory, University of Missouri, Columbia, MO, USA
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Differential cytotoxicity of corticosteroids on human mesenchymal stem cells. Clin Orthop Relat Res 2015; 473:1155-64. [PMID: 25187334 PMCID: PMC4317436 DOI: 10.1007/s11999-014-3925-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 08/27/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Corticosteroids are a common, short-term, local antiinflammatory and analgesic for treating patients with musculoskeletal disorders. Studies have shown the deleterious effects of corticosteroids on chondrocytes, suggesting a potentiation of degenerative joint disease. Mesenchymal stem cells (MSCs) are the direct progenitors of chondrocytes and other musculoskeletal tissue. Additionally, they serve an important antiinflammatory role, which can combat the chronic inflammatory state that mediates degenerative joint disease. Little is known about how corticosteroids interact with this regenerative and reparative cell population. QUESTIONS/PURPOSES We asked: (1) Are corticosteroids cytotoxic to MSCs in a dose-response fashion? (2) Is there a differential effect in the level of cytotoxicity to MSCs between commercially available corticosteroid preparations? METHODS Human MSCs were isolated and cultured from periarticular adipose tissue obtained from 20 patients undergoing primary THA. MSCs were exposed for 60 minutes to one of four commonly used corticosteroid preparations: betamethasone sodium phosphate-betamethasone acetate (6 mg/mL), dexamethasone sodium phosphate (4 mg/mL), methylprednisolone (40 mg/mL), or triamcinolone acetonide (40 mg/mL). Among the four preparations (treatment groups), cells were exposed to increasing concentrations of drugs according to the following titrations of the commercially available preparation: 0.0 (control solution of 1X phosphate buffered saline), 3.125, 6.25, 12.5, 25, 50, 75, and 100 % (undiluted commercial product). Cells were allowed to recover in standard culture media for 24 hours. After the recovery period, cell viability was measured using -(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium (MTS) tetrazolium dye-based cellular viability assay and live-dead cell fluorescent staining. For the MTS assay, measurements were quantified in units of optical density (OD). ANOVA was performed at every experimental steroid concentration. When this global test was statistically significant, all pairwise comparisons were performed at that concentration with p values adjusted by the Tukey method to guard against Type I error. RESULTS Exposure to corticosteroids decreased MSC viability in a curvilinear dose-response pattern. For betamethasone, the mean MTS OD at 0% steroid concentration was 1.03 (SD, 0.12) and decreased to 0.00 (SD, 0.00) at 25% steroid concentration. For dexamethasone, the mean MTS OD at 0% steroid concentration was 1.00 (SD, 0.07) and decreased to 0.00 (SD, 0.01) at 100% steroid concentration. For methylprednisolone, the mean MTS OD at 0% steroid concentration was 1.03 (SD, 0.09) and decreased to 0.00 (SD, 0.00) at 100% steroid concentration. For triamcinolone, the mean MTS OD at 0% steroid concentration was 1.02 (SD, 0.09) and decreased to 0.00 (SD, 0.00) at 75% steroid concentration. There were large differences among commercially available preparations, and these differences were present at every concentration. In general, dexamethasone was most gentle on MSCs (average OD by steroid concentration: 0% = 1.00; 3.125% = 0.86; 6.25% = 0.74; 12.5% = 0.53; 25% = 0.30; 50% = 0.20; 75% = 0.09; 100% = 0.00, triamcinolone and methylprednisolone were intermediate (triamcinolone average OD by steroid concentration: 0% = 1.02; 3.125% = 0.82; 6.25% = 0.64; 12.5% = 0.45; 25% = 0.18; 50% = 0.03; 75% = 0.00; 100% = 0.00; methylprednisolone average OD by steroid concentration: 0% = 1.03; 3.125% = 0.74; 6.25% = 0.54; 12.5% = 0.31; 25% = 0.12; 50% = 0.01; 75% = 0.00; 100% = 0.00), and betamethasone was most toxic (average OD by steroid concentration: 0% = 1.03; 3.125% = 0.74; 6.25% = 0.27; 12.5% = 0.02; 25% = 0.00; 50% = 0.00; 75% = 0.00; 100% = 0.00). ANOVA testing showed p values less than 0.0001 at every tested concentration (with the exception of the 0% control solution; p = 0.204) with subsequent pairwise comparisons supporting the relationships described above. The outcomes were maintained after stratifying by age, sex, or indication for THA (osteoarthritis versus avascular necrosis). CONCLUSIONS Commonly used intraarticular corticosteroids had a dose-dependent, profound, and differential effect on MSCs in this in vitro model, with betamethasone being the most toxic. Further studies are needed to assess if the in vitro effects of these agents translate into similar in vivo outcomes. CLINICAL RELEVANCE Corticosteroids frequently are used by physicians to reduce inflammation in patients with musculoskeletal disorders, but these agents may hinder MSCs' innate regenerative capacity in exchange for temporary analgesia. Our study suggests that choosing dexamethasone may result in less harmful effects when compared with other injectable steroids.
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Yang SL, Zhang YB, Jiang ZT, Li ZZ, Jiang DP. Lidocaine potentiates the deleterious effects of triamcinolone acetonide on tenocytes. Med Sci Monit 2014; 20:2478-83. [PMID: 25433272 PMCID: PMC4259563 DOI: 10.12659/msm.891116] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Local anesthetics are commonly used for the treatment of a variety of tendinopathies in combination with corticosteroids injection. The goal of this study was to evaluate the effects of lidocaine and triamcinolone acetonide (TA) on cultured rat tenocytes and to determine whether there is a synergistic effect. Material/Methods Rat patellar tendon-derived tenocytes were cultured with or without TA and lidocaine, and the culture without any additive served as the control. Cell morphology and cell viability were evaluated. Expressions of tenocyte-related genes were measured by qRT-PCR. Results TA, when exposed to tenocytes in vitro, significantly decreased cell viability. The cells cultured with TA had a flattened shape. Moreover, the expressions of tenocyte-related genes in tenocytes were markedly decreased in the TA-treated group. We found that 1% lidocaine synergistically increased the deleterious effects of TA. Conclusions Our data provide evidence of the detrimental effects of these drugs on tendon tissues. Injection of TA in combination with 1% lidocaine should be used with caution.
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Affiliation(s)
- Shu-long Yang
- Department of Pediatric Surgery, Second Affiliated Hospital, Harbin Medical University, Harbin, China (mainland)
| | - Yu-bo Zhang
- Department of Pediatric Surgery, Second Affiliated Hospital, Harbin Medical University, Harbin, China (mainland)
| | - Zhi-tao Jiang
- Department of Pediatric Surgery, Second Affiliated Hospital, Harbin Medical University, Harbin, China (mainland)
| | - Zhao-zhu Li
- Department of Pediatric Surgery, Second Affiliated Hospital, Harbin Medical University, Harbin, China (mainland)
| | - Da-peng Jiang
- Department of Pediatric Surgery, Second Affiliated Hospital, Harbin Medical University, Harbin, China (mainland)
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Wu DQ, Zhong HM, Ding QH, Ba L. Protective effects of biochanin A on articular cartilage: in vitro and in vivo studies. Altern Ther Health Med 2014; 14:444. [PMID: 25398247 PMCID: PMC4251671 DOI: 10.1186/1472-6882-14-444] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 10/29/2014] [Indexed: 01/28/2023]
Abstract
Background Increased production of matrix metalloproteinases (MMPs) is closely related to the progression of osteoarthritis (OA). The present study was performed to investigate the potential value of biochanin A in inhibition of MMP expression in both rabbit chondrocytes and an animal model of OA. Methods MTT assay was performed to assess chondrocyte survival in monolayers. The mRNA and protein expression of MMPs (including MMP-1, MMP-3, and MMP-13) and tissue inhibitor of metalloproteinase-1 (TIMP-1) in interleukin-1 < beta > (IL-1β)-induced rabbit chondrocytes were determined by quantitative real-time PCR and enzyme-linked immunosorbent assay (ELISA), respectively. The involvement of the NF-kappaB (NF-κB) pathway activated by IL-1β was determined by western blotting. The in vivo effects of biochanin A were evaluated by intra-articular injection in an experimental OA rabbit model induced by anterior cruciate ligament transection (ACLT). Results Biochanin A downregulated the expression of MMPs and upregulated TIMP-1 at both the mRNA and protein levels in IL-1β-induced chondrocytes in a dose-dependent manner. In addition, IL-1β-induced activation of NF-κB was attenuated by biochanin A, as determined by western blotting. Moreover, biochanin A decreased cartilage degradation as determined by both morphological and histological analyses in vivo. Conclusions Taken together, these findings suggest that biochanin A may be a useful agent in the treatment and prevention of OA.
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Stueber T, Karsten J, Stoetzer C, Leffler A. Differential cytotoxic properties of drugs used for intra-articular injection on human chondrocytes. Eur J Anaesthesiol 2014; 31:640-5. [DOI: 10.1097/eja.0000000000000121] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Limited therapeutic benefits of intra-articular cortisone injection for patients with femoro-acetabular impingement and labral tear. Knee Surg Sports Traumatol Arthrosc 2014; 22:750-5. [PMID: 24488223 DOI: 10.1007/s00167-014-2862-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 01/20/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Intra-articular (IA) hip cortisone injection is commonly performed as a therapeutic modality in patients with femoral acetabular impingement (FAI). To our knowledge, there is no published data evaluating the clinical benefit of these injections. The purpose of this study was to assess the efficacy of therapeutic IA cortisone injection in these patients. METHODS At our institution, patients with FAI and labral tear prospectively recorded their numerical rating scale (NRS) pain scores pre-injection, during post-injection anaesthetic phase, and at 14 days post-injection. From this cohort, all patients treated with guided IA cortisone injection, no radiographic evidence of arthritis (Tönnis grade 0 or 1) and pain relief during the anaesthetic phase of the IA injection were included. An absolute change of two points on the NRS score was considered the minimal amount of clinically significant pain relief. Pain scores were compared between the different types of steroid injected. RESULTS Fifty-four patients (35 females, 19 males) with a mean age of 32 ± 12 years were included. Average median pre-injection NRS score was 7.0 (range 2.5-10.0), post-injection anaesthetic phase was 1.0 (range 0.0-5.0), and 14 day post-injection was 5.0 (range 0.0-10.0). As a group, NRS scores significantly diminished from post-injection anaesthetic phase to 14 days post-injection (p < 0.001). At 14 days post-injection, only 20 patients (37 %) and at 6 weeks, only 3 patients (6 %) reported a clinically significant decrease in pain. Average duration of pain relief was 9.8 days. There was no difference in pain reduction between steroid preparations. CONCLUSION In patients with symptomatic FAI and labral tear, intra-articular cortisone injection has limited clinical benefit as a therapeutic modality. However, anaesthetic-only IA injections for patients who may be candidates for hip arthroscopy can be a useful diagnostic tool.
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Chee AV, Ren J, Lenart BA, Chen EY, Zhang Y, An HS. Cytotoxicity of local anesthetics and nonionic contrast agents on bovine intervertebral disc cells cultured in a three-dimensional culture system. Spine J 2014; 14:491-8. [PMID: 24246749 PMCID: PMC3945015 DOI: 10.1016/j.spinee.2013.06.095] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 05/28/2013] [Accepted: 06/24/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Carragee et al. reported an accelerated progression of lumbar intervertebral disc (IVD) degeneration after discography in a human trial. Local anesthetics and contrast agents have exhibited toxicity to cardiac, renal, and neuronal cells. We hypothesize that local anesthetics or contrast agents commonly injected into the disc space during discography may result in cytotoxicity in vitro. In this study, we compared the cytotoxicity of these agents, alone or in combination, using nucleus pulposus (NP) and annulus fibrosus (AF) cells in a three-dimensional (3D) culture system. PURPOSE The purpose of this study was to examine the effects of local anesthetics and contrast agents on IVD cells to help guide their usage in future clinical practices. STUDY DESIGN Ours was an in vitro study to assess the cytotoxicity of local anesthetics and contrast agents commonly used in discography, using bovine NP and AF cells cultured in a 3D system. METHODS Bovine NP and AF cells were isolated and encapsulated in alginate beads and cultured in media completed with serum and ascorbic acid. Beads were transferred to a 24-well plate and treated with local anesthetics, nonionic contrast agents, or with saline as a control for 2, 6, and 16 hours. Three different concentrations of local anesthetics, lidocaine and bupivacaine, were tested: 0.25%, 0.125%, and 0.0625%. Two different dilutions (1:2 or 1:4) of nonionic contras agents, iohexol and iopamidol, were tested. In a parallel study, beads were incubated with a combination of local anesthetics at equipotent concentrations and contrast agents for 6 hours. Cells were then examined with the LIVE/DEAD cell assay. Live cells (fluorescing green) and dead cells (fluorescing red) were visualized using fluorescent microscopy. The percentage of live cells after treatment was determined. RESULTS More cell death was observed when NP and AF cells were incubated with anesthetics than contrast agents at the concentrations tested. When tested at equipotent concentrations, 0.125% bupivacaine (N=8) resulted in significantly more cell death than 0.5% lidocaine (N=6) in NP cells (p<.05). In these studies, cell death caused by bupivacaine was both dose and time dependent. When tested at the same dilutions, iopamidol diluted 1:2 caused slightly more cell death than iohexol. When incubating the cells with a combination of contrast and anesthetic agent, the cytotoxic effects of the anesthetics and contrast agent were not synergistic. In this culture system, AF cells were more sensitive to some of the agents than NP cells. CONCLUSIONS Cell death was observed when AF and NP cells were incubated in a dose- and time-dependent manner with local anesthetics and contrast agents commonly used for discography. Relative toxicity of these compounds was noted in the order of bupivacaine, lidocaine, iopamidol, and iohexol. Future studies of the effects of these agents in organ culture or animal models are indicated to predict what happens in vivo.
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Affiliation(s)
- Ana V Chee
- Department of Orthopedic Surgery, Rush University, 1611 W Harrison St, Suite 300, Chicago, IL 60612, USA
| | - Jing Ren
- Department of Orthopedic Surgery, Rush University, 1611 W Harrison St, Suite 300, Chicago, IL 60612, USA
| | - Brett A Lenart
- Department of Orthopedic Surgery, Rush University, 1611 W Harrison St, Suite 300, Chicago, IL 60612, USA
| | - Er-Yun Chen
- Rush Alzheimer's Disease Center, Rush University, 1735 W. Harrison St, Chicago, IL 60612, USA
| | - Yejia Zhang
- Department of Physical Medicine & Rehabilitation, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA
| | - Howard S An
- Department of Orthopedic Surgery, Rush University, 1611 W Harrison St, Suite 300, Chicago, IL 60612, USA.
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Dregalla RC, Lyons NF, Reischling PD, Centeno CJ. Amide-type local anesthetics and human mesenchymal stem cells: clinical implications for stem cell therapy. Stem Cells Transl Med 2014; 3:365-74. [PMID: 24436443 DOI: 10.5966/sctm.2013-0058] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In the realm of regenerative medicine, human mesenchymal stem cells (hMSCs) are gaining attention as a cell source for the repair and regeneration of tissues spanning an array of medical disciplines. In orthopedics, hMSCs are often delivered in a site-specific manner at the area of interest and may require the concurrent application of local anesthetics (LAs). To address the implications of using hMSCs in combination with anesthetics for intra-articular applications, we investigated the effect that clinically relevant doses of amide-type LAs have on the viability of bone marrow-derived hMSCs and began to characterize the mechanism of LA-induced hMSC death. In our study, culture-expanded hMSCs from three donors were exposed to the amide-type LAs ropivacaine, lidocaine, bupivacaine, and mepivacaine. To replicate the physiological dilution of LAs once injected into the synovial capsule, each anesthetic was reduced to 12.5%, 25%, and 50% of the stock solution and incubated with each hMSC line for 40 minutes, 120 minutes, 360 minutes, and 24 hours. At each time point, cell viability assays were performed. We found that extended treatment with LAs for 24 hours had a significant impact on both hMSC viability and adhesion. In addition, hMSC treatment with three of the four anesthetics resulted in cell death via apoptosis following brief exposures. Ultimately, we concluded that amide-type LAs induce hMSC apoptosis in a time- and dose-dependent manner that may threaten clinical outcomes, following a similar trend that has been established between these particular anesthetics and articular chondrocytes both in vitro and in vivo.
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Affiliation(s)
- Ryan C Dregalla
- Regenerative Sciences, LLC, Broomfield, Colorado, USA; Centeno-Schultz Clinic, Broomfield, Colorado, USA
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Pek YS, Pitukmanorom P, Ying JY. Sustained release of bupivacaine for post-surgical pain relief using core–shell microspheres. J Mater Chem B 2014; 2:8194-8200. [DOI: 10.1039/c4tb00948g] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Core–shell PLGA/PLLA polymer microspheres sustained 2 weeks in vivo bupivacaine release, providing extended postoperative analgesia without infection or joint damage.
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Affiliation(s)
- Y. Shona Pek
- Institute of Bioengineering and Nanotechnology
- , Singapore 138669
| | | | - Jackie Y. Ying
- Institute of Bioengineering and Nanotechnology
- , Singapore 138669
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Breu A, Eckl S, Zink W, Kujat R, Angele P. Cytotoxicity of local anesthetics on human mesenchymal stem cells in vitro. Arthroscopy 2013; 29:1676-84. [PMID: 23993145 DOI: 10.1016/j.arthro.2013.06.018] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Revised: 05/08/2013] [Accepted: 06/26/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to investigate the cytotoxic potency of local anesthetics on human mesenchymal stem cells (MSCs) before and after chondrogenic differentiation. METHODS MSCs were exposed to equal and equipotent concentrations of bupivacaine, ropivacaine, and mepivacaine for 1 hour. Cell viability, apoptosis, and necrosis were determined using flow cytometry and live/dead staining. After chondrogenic differentiation, MSC viability was determined in aggregates exposed to equipotent concentrations of the named agents, applying fluorescence microscopy. RESULTS All local anesthetics showed detrimental cytotoxic effects on MSC monolayer cultures in a concentration- and time-specific manner. Minimum viability rates were found 96 hours after a 1-hour exposure. Bupivacaine 0.5% caused a reduction of vital MSCs to 5% ± 1%. Sixteen percent ± 2% viable cells were detected after treatment with 0.75% ropivacaine. Exposure to 2% mepivacaine decreased vitality rates to 1% ± 0%. Ropivacaine was significantly less cytotoxic than were bupivacaine and mepivacaine. Immediate cell death was mainly caused by necrosis followed by apoptosis afterward. Viability rates of MSCs embedded in cartilaginous tissue after chondrogenic differentiation were not reduced by local anesthetic treatment. CONCLUSIONS Local anesthetics are cytotoxic to MSCs in a concentration-, time-, and agent-dependent manner in monolayer cultures but not in whole-tissue probes. CLINICAL RELEVANCE MSCs are applied for treatment of cartilage defects. Intra-articular application of local anesthesia is a common procedure in pain management and has shown chondrotoxic effects. Therefore, it is crucial to evaluate the impact of local anesthetics on human MSCs and regenerative cartilage tissue engineering.
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Affiliation(s)
- Anita Breu
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany.
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