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Nourmahnad A, Javad Shariyate M, Khak M, Grinstaff MW, Nazarian A, Rodriguez EK. Relaxin as a treatment for musculoskeletal fibrosis: What we know and future directions. Biochem Pharmacol 2024; 225:116273. [PMID: 38729446 PMCID: PMC11179965 DOI: 10.1016/j.bcp.2024.116273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 04/23/2024] [Accepted: 05/07/2024] [Indexed: 05/12/2024]
Abstract
Fibrotic changes in musculoskeletal diseases arise from the abnormal buildup of fibrotic tissue around the joints, leading to limited mobility, compromised joint function, and diminished quality of life. Relaxin (RLX) attenuates fibrosis by accelerating collagen degradation and inhibiting excessive extracellular matrix (ECM) production. Further, RLX disrupts myofibroblast activation by modulating the TGF-β/Smads signaling pathways, which reduces connective tissue fibrosis. However, the mechanisms and effects of RLX in musculoskeletal pathologies are emerging as increasing research focuses on relaxin's impact on skin, ligaments, tendons, cartilage, joint capsules, connective tissues, and muscles. This review delineates the actions of relaxin within the musculoskeletal system and the challenges to its clinical application. Relaxin shows significant potential in both in vivo and in vitro studies for broadly managing musculoskeletal fibrosis; however, challenges such as short biological half-life and sex-specific responses may pose hurdles for clinical use.
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Affiliation(s)
| | - Mohammad Javad Shariyate
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mohammad Khak
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Ara Nazarian
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, Armenia
| | - Edward K Rodriguez
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Faust TF, Castañeda PG. Arthrofibrosis of the knee in pediatric orthopedic surgery. ACTA ORTOPEDICA MEXICANA 2024; 38:179-187. [PMID: 38862148 DOI: 10.35366/115813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
Arthrofibrosis is a challenging complication associated with knee injuries in both children and adults. While much is known about managing arthrofibrosis in adults, it is necessary to understand its unique aspects and management strategies in the pediatric population. This paper provides an overview of arthrofibrosis in pediatric orthopedic surgery, focusing on its causes, implications, classifications, and management. This paper is a comprehensive review of the literature and existing research on arthrofibrosis in pediatric patients. Arthrofibrosis is characterized by excessive collagen production and adhesions, leading to restricted joint motion and pain. It is associated with an immune response and fibrosis within and around the joint. Arthrofibrosis can result from various knee injuries in pediatric patients, including tibial spine fractures, ACL and PCL injuries, and extra-articular procedures. Technical factors at the time of surgery play a role in the development of motion loss and should be addressed to minimize complications. Preventing arthrofibrosis through early physical therapy is recommended. Non-operative management, including dynamic splinting and serial casting, has shown some benefits. New pharmacologic approaches to lysis of adhesions have shown promise. Surgical interventions, consisting of arthroscopic lysis of adhesions (LOA) and manipulation under anesthesia (MUA), can significantly improve motion and functional outcomes. Arthrofibrosis poses unique challenges in pediatric patients, demanding a nuanced approach that includes prevention, early intervention with non-operative means, and improvements in surgical techniques. Modern pharmacological interventions offer promise for the future. Customized interventions and research focused on pediatric patients are critical for optimal outcomes.
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Affiliation(s)
- T F Faust
- Department of Research, Alabama College of Osteopathic Medicine. Alabama, USA
| | - P G Castañeda
- Baylor School of Medicine, Department of Pediatric Orthopedic Surgery, Texas Children's Hospital. USA
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Salmons HI, Carstens MF, Limberg AK, Bettencourt JW, Payne AN, Karczewski DC, Ryan ZT, Morrey ME, Sanchez-Sotelo J, Berry DJ, Dudakovic A, Abdel MP. Efficacy of ADIPOR1 and ADIPOR2 peptide-agonist AdipoRon in preventing contracture in a rabbit model of arthrofibrosis. J Orthop Res 2024. [PMID: 38605593 DOI: 10.1002/jor.25853] [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: 03/12/2024] [Revised: 03/19/2024] [Accepted: 04/01/2024] [Indexed: 04/13/2024]
Abstract
AdipoRon is an adiponectin receptor 1, 2 (ADIPOR1 and ADIPOR2) agonist with potential antifibrotic effects. Whether AdipoRon can mitigate joint stiffness in a rabbit model of arthrofibrosis is unknown. We examined the efficacy of intravenous (IV) AdipoRon at mitigating contracture in a rabbit model of knee arthrofibrosis. Fifty-six female New Zealand White rabbits were divided into three dosing groups: vehicle (dimethyl sulfoxide, DMSO), 2.5 mg/kg AdipoRon, and 5 mg/kg AdipoRon. AdipoRon, in DMSO, was administered IV preoperatively and for 5 days postoperatively (30 rabbits, Aim 1). AdipoRon was again dosed similarly after Kirschner wire (K-wire) removal at 8 weeks (26 rabbits; Aim 2). The primary outcome of joint passive extension angle (PEA,°) was measured at 8, 10, 12, 16, and 24 weeks following index surgery. At 24 weeks, rabbits were euthanized and limbs were harvested to measure posterior capsular stiffness (N cm/°). In Aim 1, the 5 mg/kg treated rabbits had a significant increase in PEA when compared to controls at 16-week (p < 0.05). In Aim 2, the 5 mg/kg treated rabbits had a significant increase in PEA when compared to controls at 10-week (p < 0.05). In both aims, no significant differences were observed at later time points. Capsular stiffness was no different in any group. We are the first to report the efficacy of IV AdipoRon in a rabbit model of arthrofibrosis. We identified a significant dose-dependent decrease in joint PEA at early time points; however, no differences were observed between groups at later time points. Clinical Significance: The present investigation provided the first assessment of AdipoRon's efficacy in mitigating knee stiffness in the current gold standard rabbit model of arthrofibrosis. Results of this investigation provided further evidence as to the potential role of AdipoRon as a preventative for arthrofibrosis in large mammals.
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Affiliation(s)
- Harold I Salmons
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mason F Carstens
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Afton K Limberg
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ashley N Payne
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Zachary T Ryan
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark E Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Amel Dudakovic
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Laperche JM, Chang K, Albright JA, Ibrahim Z, Zhang H, Daniels AH, Barrett TJ. Shoulder Adhesive Capsulitis Prior to Total Knee Arthroplasty is Associated With Increased Rates of Postoperative Stiffness Requiring Manipulation Under Anesthesia and Arthroscopic Lysis of Adhesions. J Arthroplasty 2024; 39:960-965. [PMID: 37924990 DOI: 10.1016/j.arth.2023.10.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/23/2023] [Accepted: 10/26/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Arthrofibrosis following total knee arthroplasty (TKA) and adhesive capsulitis (AC) of the shoulder develop via a similar pathologic process. The purpose of this study was to examine the relationship between these two conditions. METHODS This was a retrospective cohort study using a large nationwide claims database. Patients who had a history of shoulder AC prior to TKA were compared to TKA patients who did not have AC history comparing rates of postoperative stiffness, manipulation under anesthesia (MUA), arthroscopic lysis of adhesions (LOAs), and revision arthroplasty at postoperative timepoints (3 months, 6 months, 1 year, and 2 years). RESULTS Within 3 months, 6 months, 1 year, and 2 years of their TKAs, patients who had a history of AC prior to TKA were significantly more likely to experience stiffness (OR [odds ratio] = 1.29, 1.28, 1.32, and 1.36, respectively) and LOAs (OR = 6.78, 3.65, 2.99, and 2.81, respectively). They also showed increased risk of MUA within 6 months, 1 year, and 2 years (OR = 1.15, 1.15, and 1.16, respectively) of their TKAs. Patients having a preoperative diagnosis of AC did not have an increased risk of undergoing revision surgery 1 year or 2 years after their TKAs (P > .05). CONCLUSIONS Patients diagnosed with AC prior to TKA experience higher rates of postoperative stiffness, resulting in additional interventions such as MUA and LOAs. These findings identify a particularly high-risk patient population that may benefit from additional interventions prior to and following TKA. LEVEL OF EVIDENCE This is a level III prognostic study.
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Affiliation(s)
- Jacob M Laperche
- Frank H. Netter School of Medicine, Quinnipiac University, North Haven, Connecticut; Department of Orthopedic Surgery, University Orthopedics, Providence, Rhode Island
| | - Kenny Chang
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - James A Albright
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Zainab Ibrahim
- Department of Orthopaedic Surgery, Brown University, Providence, Rhode Island
| | - Helen Zhang
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Alan H Daniels
- Department of Orthopedic Surgery, University Orthopedics, Providence, Rhode Island; Department of Orthopaedic Surgery, Brown University, Providence, Rhode Island
| | - Thomas J Barrett
- Department of Orthopedic Surgery, University Orthopedics, Providence, Rhode Island; Department of Orthopaedic Surgery, Brown University, Providence, Rhode Island
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Dudakovic A, Limberg AK, Bothun CE, Dilger OB, Bayram B, Bettencourt JW, Salmons HI, Thaler R, Karczewski DC, Owen AR, Iyer VG, Payne AN, Carstens MF, van Wijnen AJ, Berry DJ, Sanchez-Sotelo J, Morrey ME, Abdel MP. AdipoRon reduces TGFβ1-mediated collagen deposition in vitro and alleviates knee stiffness in vivo. J Cell Physiol 2024; 239:e31168. [PMID: 38149794 PMCID: PMC10922972 DOI: 10.1002/jcp.31168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/10/2023] [Accepted: 11/28/2023] [Indexed: 12/28/2023]
Abstract
Arthrofibrosis, which causes joint motion restrictions, is a common complication following total knee arthroplasty (TKA). Key features associated with arthrofibrosis include myofibroblast activation, knee stiffness, and excessive scar tissue formation. We previously demonstrated that adiponectin levels are suppressed within the knee tissues of patients affected by arthrofibrosis and showed that AdipoRon, an adiponectin receptor agonist, exhibited anti-fibrotic properties in human mesenchymal stem cells. In this study, the therapeutic potential of AdipoRon was evaluated on TGFβ1-mediated myofibroblast differentiation of primary human knee fibroblasts and in a mouse model of knee stiffness. Picrosirius red staining revealed that AdipoRon reduced TGFβ1-induced collagen deposition in primary knee fibroblasts derived from patients undergoing primary TKA and revision TKA for arthrofibrosis. AdipoRon also reduced mRNA and protein levels of ACTA2, a key myofibroblast marker. RNA-seq analysis corroborated the anti-myofibrogenic effects of AdipoRon. In our knee stiffness mouse model, 6 weeks of knee immobilization, to induce a knee contracture, in conjunction with daily vehicle (DMSO) or AdipoRon (1, 5, and 25 mg/kg) via intraperitoneal injections were well tolerated based on animal behavior and weight measurements. Biomechanical testing demonstrated that passive extension angles (PEAs) of experimental knees were similar between vehicle and AdipoRon treatment groups in mice evaluated immediately following immobilization. Interestingly, relative to vehicle-treated mice, 5 mg/kg AdipoRon therapy improved the PEA of the experimental knees in mice that underwent 4 weeks of knee remobilization following the immobilization and therapy. Together, these studies revealed that AdipoRon may be an effective therapeutic modality for arthrofibrosis.
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Affiliation(s)
- Amel Dudakovic
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Afton K. Limberg
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Cole E. Bothun
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Oliver B. Dilger
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Banu Bayram
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Roman Thaler
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | | | - Aaron R. Owen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Varun G. Iyer
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ashley N. Payne
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Andre J. van Wijnen
- Department of Biochemistry, University of Vermont College of Medicine, Burlington, VT, USA
| | - Daniel J. Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Mark E. Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Matthew P. Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Cates WT, Denbeigh JM, Salvagno RT, Kakar S, van Wijnen AJ, Eaton C. Inflammatory Markers Involved in the Pathogenesis of Dupuytren's Contracture. Crit Rev Eukaryot Gene Expr 2024; 34:1-35. [PMID: 38912961 DOI: 10.1615/critreveukaryotgeneexpr.2024052889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
Dupuytren's disease is a common fibroproliferative disease that can result in debilitating hand deformities. Partial correction and return of deformity are common with surgical or clinical treatments at present. While current treatments are limited to local procedures for relatively late effects of the disease, the pathophysiology of this connective tissue disorder is associated with both local and systemic processes (e.g., fibrosis, inflammation). Hence, a better understanding of the systemic circulation of Dupuytren related cytokines and growth factors may provide important insights into disease progression. In addition, systemic biomarker analysis could yield new concepts for treatments of Dupuytren that attenuate circulatory factors (e.g., anti-inflammatory agents, neutralizing antibodies). Progress in the development of any disease modifying biologic treatment for Dupuytren has been hampered by the lack of clinically useful biomarkers. The characterization of nonsurgical Dupuytren biomarkers will permit disease staging from diagnostic and prognostic perspectives, as well as allows evaluation of biologic responses to treatment. Identification of such markers may transcend their use in Dupuytren treatment, because fibrotic biological processes fundamental to Dupuytren are relevant to fibrosis in many other connective tissues and organs with collagen-based tissue compartments. There is a wide range of potential Dupuytren biomarker categories that could be informative, including disease determinants linked to genetics, collagen metabolism, as well as immunity and inflammation (e.g., cytokines, chemokines). This narrative review provides a broad overview of previous studies and emphasizes the importance of inflammatory mediators as candidate circulating biomarkers for monitoring Dupuytren's disease.
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Affiliation(s)
- William T Cates
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Janet M Denbeigh
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Sanjeev Kakar
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Andre J van Wijnen
- Department of Biochemistry, University of Vermont, Burlington, VT 05405, USA
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Sisto M, Lisi S. Targeting Interleukin-17 as a Novel Treatment Option for Fibrotic Diseases. J Clin Med 2023; 13:164. [PMID: 38202170 PMCID: PMC10780256 DOI: 10.3390/jcm13010164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/18/2023] [Accepted: 12/21/2023] [Indexed: 01/12/2024] Open
Abstract
Fibrosis is the end result of persistent inflammatory responses induced by a variety of stimuli, including chronic infections, autoimmune reactions, and tissue injury. Fibrotic diseases affect all vital organs and are characterized by a high rate of morbidity and mortality in the developed world. Until recently, there were no approved antifibrotic therapies. In recent years, high levels of interleukin-17 (IL-17) have been associated with chronic inflammatory diseases with fibrotic complications that culminate in organ failure. In this review, we provide an update on the role of IL-17 in fibrotic diseases, with particular attention to the most recent lines of research in the therapeutic field represented by the epigenetic mechanisms that control IL-17 levels in fibrosis. A better knowledge of the IL-17 signaling pathway implications in fibrosis could design new strategies for therapeutic benefits.
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Affiliation(s)
- Margherita Sisto
- Department of Translational Biomedicine and Neuroscience (DiBraiN), Section of Human Anatomy and Histology, University of Bari “Aldo Moro”, 70124 Bari, Italy;
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Jacobs CA, Stone AV, Johnson DL, Landy DC, Conley CE. Comparison of Physical Therapy Utilization and Motion-Related Re-operations Between Isolated Anterior Cruciate Ligament and Multi-Ligament Knee Injuries. Cureus 2023; 15:e40681. [PMID: 37485093 PMCID: PMC10357971 DOI: 10.7759/cureus.40681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2023] [Indexed: 07/25/2023] Open
Abstract
The increased prevalence of postoperative arthrofibrosis after multi-ligament knee injuries (MLKI) compared to isolated anterior cruciate ligament (ACL) injuries has been proposed to be due, in part, to patient factors limiting physical therapy utilization. The purpose of this study was to compare demographic factors, pre- and postoperative physical therapy utilization, and the need for motion-restoring surgery between MLKI and ACL-injured patients. Using the PearlDiver Mariner 151 database, two cohorts matched by age and sex were identified using current procedural terminology (CPT) codes and included those age 16 or greater that underwent isolated ACL (n=3801) vs. MLKI reconstruction (n=3801). The number of pre- and postoperative physical therapy visits was recorded, as was the need for motion-restoring surgery (arthroscopic lysis of adhesions or manipulation under anesthesia). Demographic factors, physical therapy utilization, and the prevalence of motion-restoring surgery were compared between the MLKI and ACL groups using t-tests or chi-square tests, as appropriate. A significantly greater proportion of those with MLKI underwent subsequent motion-restoring surgery (MLKI=412/3081 (13.4%) vs. ACL=84/3081 (2.7%), p<0.001; odds ratio = 5.5 (95% CI: 4.3, 7.0), p<0.0001). Following surgery, less than half of those with MLKI that underwent subsequent motion-restoring surgery attended physical therapy, which was significantly lower than those who did not require motion-restoring surgery (p<0.0001). The prevalence of motion-restoring surgery was significantly greater after MLKI when compared to an isolated ACL injury. While the etiology of arthrofibrosis after MLKI is likely complex, the current results suggest that demographic factors and physical therapy utilization are not solely responsible for the increased risk of arthrofibrosis after MLKI.
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Affiliation(s)
- Cale A Jacobs
- Orthopedic Surgery, Brigham and Women's Hospital, Boston, USA
| | - Austin V Stone
- Orthopedic Surgery and Sports Medicine, University of Kentucky, Lexington, USA
| | - Darren L Johnson
- Orthopedic Surgery and Sports Medicine, University of Kentucky, Lexington, USA
| | - David C Landy
- Orthopedic Surgery and Sports Medicine, University of Kentucky, Lexington, USA
| | - Caitlin E Conley
- Orthopedic Surgery and Sports Medicine, University of Kentucky, Lexington, USA
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Dudakovic A, Bayram B, Bettencourt JW, Limberg AK, Galvan ML, Carrasco ME, Stans B, Thaler R, Morrey ME, Sanchez-Sotelo J, Berry DJ, van Wijnen AJ, Abdel MP. The epigenetic regulator BRD4 is required for myofibroblast differentiation of knee fibroblasts. J Cell Biochem 2023; 124:320-334. [PMID: 36648754 PMCID: PMC9990907 DOI: 10.1002/jcb.30368] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 12/30/2022] [Indexed: 01/18/2023]
Abstract
Arthrofibrosis, which is characterized by excessive scar tissue and limited motion, can complicate the daily functioning of patients after total knee arthroplasty (TKA). Molecular hallmarks of arthrofibrosis include pathologic accumulation of myofibroblasts and disproportionate collagen deposition. Epigenetic mechanisms, including posttranslation modification of histones, control gene expression and may regulate fibrotic events. This study assessed the role of the bromodomain and extra-terminal (BET) proteins on myofibroblast differentiation. This group of epigenetic regulators recognize acetylated lysines and are targeted by a class of drugs known as BET inhibitors. RNA-seq analysis revealed robust mRNA expression of three BET members (BRD2, BRD3, and BRD4) while the fourth member (BRDT) is not expressed in primary TKA knee outgrowth fibroblasts. RT-qPCR and western blot analyses revealed that BET inhibition with the small molecule JQ1 impairs TGFβ1-induced expression of ACTA2, a key myofibroblast marker, in primary outgrowth knee fibroblasts. Similarly, JQ1 administration also reduced COL3A1 mRNA levels and collagen deposition as monitored by picrosirius red staining. Interestingly, the inhibitory effects of JQ1 on ACTA2 mRNA and protein expression, as well as COL3A1 expression and collagen deposition, were paralleled by siRNA-mediated depletion of BRD4. Together, these data reveal that BRD4-mediated epigenetic events support TGFβ1-mediated myofibroblast differentiation and collagen deposition as seen in arthrofibrosis. To our knowledge, these are the first studies that assess epigenetic regulators and their downstream events in the context of arthrofibrosis. Future studies may reveal clinical utility for drugs that target epigenetic pathways, specifically BET proteins, in the prevention and treatment of arthrofibrosis.
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Affiliation(s)
- Amel Dudakovic
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Banu Bayram
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Afton K. Limberg
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - M. Lizeth Galvan
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Britta Stans
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Roman Thaler
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mark E. Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Daniel J. Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Andre J. van Wijnen
- Department of Biochemistry, University of Vermont College of Medicine, Burlington, VT, USA
| | - Matthew P. Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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10
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Dagneaux L, Limberg AK, Owen AR, Bettencourt JW, Dudakovic A, Bayram B, Gades NM, Sanchez-Sotelo J, Berry DJ, van Wijnen A, Morrey ME, Abdel MP. Knee immobilization reproduces key arthrofibrotic phenotypes in mice. Bone Joint Res 2023; 12:58-71. [PMID: 36647696 PMCID: PMC9872038 DOI: 10.1302/2046-3758.121.bjr-2022-0250.r2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
AIMS As has been shown in larger animal models, knee immobilization can lead to arthrofibrotic phenotypes. Our study included 168 C57BL/6J female mice, with 24 serving as controls, and 144 undergoing a knee procedure to induce a contracture without osteoarthritis (OA). METHODS Experimental knees were immobilized for either four weeks (72 mice) or eight weeks (72 mice), followed by a remobilization period of zero weeks (24 mice), two weeks (24 mice), or four weeks (24 mice) after suture removal. Half of the experimental knees also received an intra-articular injury. Biomechanical data were collected to measure passive extension angle (PEA). Histological data measuring area and thickness of posterior and anterior knee capsules were collected from knee sections. RESULTS Experimental knees immobilized for four weeks demonstrated mean PEAs of 141°, 72°, and 79° after zero, two, and four weeks of remobilization (n = 6 per group), respectively. Experimental knees demonstrated reduced PEAs after two weeks (p < 0.001) and four weeks (p < 0.0001) of remobilization compared to controls. Following eight weeks of immobilization, experimental knees exhibited mean PEAs of 82°, 73°, and 72° after zero, two, and four weeks of remobilization, respectively. Histological analysis demonstrated no cartilage degeneration. Similar trends in biomechanical and histological properties were observed when intra-articular violation was introduced. CONCLUSION This study established a novel mouse model of robust knee contracture without evidence of OA. This was appreciated consistently after eight weeks of immobilization and was irrespective of length of remobilization. As such, this arthrofibrotic model provides opportunities to investigate molecular pathways and therapeutic strategies.Cite this article: Bone Joint Res 2023;12(1):58-71.
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Affiliation(s)
- Louis Dagneaux
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Afton K. Limberg
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron R. Owen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Amel Dudakovic
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Banu Bayram
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Naomi M. Gades
- Department of Comparative Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | | | - Daniel J. Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Andre van Wijnen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA,Department of Biochemistry, University of Vermont, Burlington, Vermont, USA
| | - Mark E. Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew P. Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA, Matthew P. Abdel. E-mail:
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van Wijnen AJ, Lewallen EA. Risk of Adhesive Capsulitis: Genetics Acting Shoulder to Shoulder?: Commentary on an article by Scott Kulm, PhD, et al.: "Genome-Wide Association Study of Adhesive Capsulitis Suggests Significant Genetic Risk Factors". J Bone Joint Surg Am 2022; 104:1959. [PMID: 36321970 DOI: 10.2106/jbjs.22.00920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Eric A Lewallen
- Department of Biological Sciences, Hampton University, Hampton, Virginia
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12
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van Wijnen AJ, Lewallen EA. Revision Surgery After TJR: A Family Affair?: Commentary on an article by Anders Brüggemann, MD, PhD, et al.: "Risk of Revision After Arthroplasty Associated with Specific Gene Loci. A Genomewide Association Study of Single-Nucleotide Polymorphisms in 1,130 Twins Treated with Arthroplasty". J Bone Joint Surg Am 2022; 104:e29. [PMID: 38011493 DOI: 10.2106/jbjs.21.01477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Affiliation(s)
| | - Eric A Lewallen
- Department of Biological Sciences, Hampton University, Hampton, Virginia
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Lee DR, Therrien E, Song BM, Camp CL, Krych AJ, Stuart MJ, Abdel MP, Levy BA. Arthrofibrosis Nightmares: Prevention and Management Strategies. Sports Med Arthrosc Rev 2022; 30:29-41. [PMID: 35113841 PMCID: PMC8830598 DOI: 10.1097/jsa.0000000000000324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Arthrofibrosis (AF) is an exaggerated immune response to a proinflammatory insult leading to pathologic periarticular fibrosis and symptomatic joint stiffness. The knee, elbow, and shoulder are particularly susceptible to AF, often in the setting of trauma, surgery, or adhesive capsulitis. Prevention through early physiotherapeutic interventions and anti-inflammatory medications remain fundamental to avoiding motion loss. Reliable nonoperative modalities exist and outcomes are improved when etiology, joint involved, and level of dysfunction are considered in the clinical decision making process. Surgical procedures should be reserved for cases recalcitrant to nonoperative measures. The purpose of this review is to provide an overview of the current understanding of AF pathophysiology, identify common risk factors, describe prevention strategies, and outline both nonoperative and surgical treatment options. This manuscript will focus specifically on sterile AF of the knee, elbow, and shoulder.
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Affiliation(s)
- Dustin R. Lee
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Erik Therrien
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Bryant M. Song
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Christopher L. Camp
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Aaron J. Krych
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Michael J. Stuart
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Mathew P. Abdel
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Bruce A. Levy
- Department of Orthopedic Surgery & Sports Medicine Mayo Clinic, Rochester, Minnesota, U.S.A
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Bayram B, Thaler R, Bettencourt JW, Limberg AK, Sheehan KP, Owen AR, Berry DJ, Morrey ME, Sanchez‐Sotelo J, Wijnen AJ, Dudakovic A, Abdel MP. Human outgrowth knee fibroblasts from patients undergoing total knee arthroplasty exhibit a unique gene expression profile and undergo myofibroblastogenesis upon TGFβ1 stimulation. J Cell Biochem 2022; 123:878-892. [PMID: 35224764 PMCID: PMC9133128 DOI: 10.1002/jcb.30230] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/24/2022] [Accepted: 02/15/2022] [Indexed: 11/11/2022]
Abstract
Arthrofibrosis is characterized by excessive extracellular matrix (ECM) deposition that results in restricted joint motion after total knee arthroplasties (TKAs). Currently, treatment options are limited. Therefore, an in vitro model of knee-related myofibroblastogenesis is valuable to facilitate investigation of the arthrofibrotic process, diagnostic and therapeutic options. In this study, we obtained intraoperative posterior capsule (PC), quadriceps tendon (QT), and suprapatellar pouch (SP) tissues from the knees of four patients undergoing primary TKAs for osteoarthritis. From these tissues, we isolated primary cells by the outgrowth method and subsequently characterized these cells in the absence and presence of the pro-myofibroblastic cytokine, transforming growth factor beta 1 (TGFβ1). Light microscopy of knee outgrowth cells revealed spindle-shaped cells, and immunofluorescence (IF) analysis demonstrated staining for the fibroblast-specific markers TE-7 and vimentin (VIM). These knee outgrowth fibroblasts differentiated readily into myofibroblasts as reflected by enhanced α-smooth muscle actin (ACTA2) mRNA and protein expression and increased mRNA expression of collagen type 1 (COL1A1) and type 3 (COL3A1) with collagenous matrix deposition in the presence of TGFβ1. Outgrowth knee fibroblasts were more sensitive to TGFβ1-mediated myofibroblastogenesis than adipose-derived mesenchymal stromal/stem cells (MSCs). While outgrowth knee fibroblasts isolated from three anatomical regions in four patients exhibited similar gene expression, these cells are distinct from other fibroblastic cell types (i.e., Dupuytren's fibroblasts) as revealed by RNA-sequencing. In conclusion, our study provides an in vitro myofibroblastic model of outgrowth knee fibroblasts derived from patients undergoing primary TKA that can be utilized to study myofibroblastogenesis and assess therapeutic strategies for arthrofibrosis.
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Affiliation(s)
- Banu Bayram
- Department of Orthopedic Surgery Mayo Clinic Rochester Minnesota USA
| | - Roman Thaler
- Department of Orthopedic Surgery Mayo Clinic Rochester Minnesota USA
| | | | - Afton K. Limberg
- Department of Orthopedic Surgery Mayo Clinic Rochester Minnesota USA
| | - Kevin P. Sheehan
- Department of Orthopedic Surgery Mayo Clinic Rochester Minnesota USA
| | - Aaron R. Owen
- Department of Orthopedic Surgery Mayo Clinic Rochester Minnesota USA
| | - Daniel J. Berry
- Department of Orthopedic Surgery Mayo Clinic Rochester Minnesota USA
| | - Mark E. Morrey
- Department of Orthopedic Surgery Mayo Clinic Rochester Minnesota USA
| | | | - Andre J. Wijnen
- Department of Biochemistry University of Vermont Burlington Vermont USA
- Department of Internal Medicine Erasmus University Medical Center Rotterdam the Netherlands
| | - Amel Dudakovic
- Department of Orthopedic Surgery Mayo Clinic Rochester Minnesota USA
- Department of Biochemistry & Molecular Biology Mayo Clinic Rochester Minnesota USA
| | - Matthew P. Abdel
- Department of Orthopedic Surgery Mayo Clinic Rochester Minnesota USA
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15
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Sanchez-Sotelo J. Arthroscopic management of elbow stiffness. J Exp Orthop 2021; 8:97. [PMID: 34709477 PMCID: PMC8552204 DOI: 10.1186/s40634-021-00420-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 10/19/2021] [Indexed: 11/17/2022] Open
Abstract
The elbow is particularly prone to stiffness. Loss of elbow motion is very limiting, and can be the result of trauma, primary osteoarthritis, heterotopic ossification and other conditions. Several exposures have been described for open elbow contracture release. Although a few decades ago elbow arthroscopy was considered only for diagnosis and removal of loose bodies, contemporary arthroscopic techniques allow successful management of the majority of conditions leading to elbow stiffness. Careful patient evaluation, use of advanced imaging studies, and acquisition of appropriate surgical skills are essential for the successful arthroscopic management of the stiff elbow. This expert opinion reviews some fundamentals of elbow stiffness as well as principles for the evaluation and arthroscopic management of the stiff elbow.
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Affiliation(s)
- Joaquin Sanchez-Sotelo
- Chair of the Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, Mayo Clinic, Gonda 14, 200 First Street SW, MN, 55905, Rochester, USA.
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16
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Corrigendum to 'Identification of novel biomarkers for arthrofibrosis after total knee arthroplasty in animal models and clinical patients'. EBioMedicine 2021; 71:103543. [PMID: 34419927 DOI: 10.1016/j.ebiom.2021.103543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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17
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van Wijnen AJ, Abdel MP. Toward a Genetic Crystal Ball for Patients with Rotator Cuff Disease: Commentary on an article by Elizabeth L. Yanik, PhD, ScM, et al.: "Identification of a Novel Genetic Marker for Risk of Degenerative Rotator Cuff Disease Surgery in the UK Biobank". J Bone Joint Surg Am 2021; 103:e55. [PMID: 34260443 DOI: 10.2106/jbjs.21.00434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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18
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Bayram B, Owen AR, Dudakovic A, Bettencourt JW, Limberg AK, Morrey ME, Sanchez-Sotelo J, Berry DJ, Kocher JP, van Wijnen AJ, Abdel MP. Elevated Expression of Plasminogen Activator Inhibitor (PAI-1/SERPINE1) is Independent from rs1799889 Genotypes in Arthrofibrosis. Meta Gene 2021; 28. [PMID: 33816122 DOI: 10.1016/j.mgene.2021.100877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Arthrofibrosis is characterized by excessive extracellular matrix deposition in patients with total knee arthroplasties (TKAs) and causes undesirable joint stiffness. The pathogenesis of arthrofibrosis remains elusive and currently there are no diagnostic biomarkers for the pathological formation of this connective tissue. Fibrotic soft tissues are known to have elevated levels of plasminogen activator inhibitor-1 (PAI-1) (encoded by SERPINE1), a secreted serine protease inhibitor that moderates extracellular matrix remodeling and tissue homeostasis. The 4G/5G insertion/deletion (rs1799889) is a well-known SERPINE1 polymorphism that directly modulates PAI-1 levels. Homozygous 4G/4G allele carriers typically have higher PAI-1 levels and may predispose patients to soft tissue fibrosis (e.g., liver, lung, and kidney). Here, we examined the genetic contribution of the SERPINE1 rs1799889 polymorphism to musculoskeletal fibrosis in arthrofibrotic (n = 100) and non-arthrofibrotic (n = 100) patients using Sanger Sequencing. Statistical analyses revealed that the allele frequencies of the SERPINE1 rs1799889 polymorphism are similar in arthrofibrotic and non-arthrofibrotic patient cohorts. Because the fibrosis related SERPINE1 rs1799889 polymorphism is independent of arthrofibrosis susceptibility in TKA patients, the possibility arises that fibrosis of joint connective tissues may involve unique genetic determinants distinct from those linked to classical soft tissue fibrosis.
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Affiliation(s)
- Banu Bayram
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Aaron R Owen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Amel Dudakovic
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States.,Department of Biochemistry & Molecular Biology, Mayo Clinic, Rochester, MN, United States
| | | | - Afton K Limberg
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Mark E Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | | | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Jean-Pierre Kocher
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Andre J van Wijnen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States.,Department of Biochemistry & Molecular Biology, Mayo Clinic, Rochester, MN, United States
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
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Wang CX, Flick TR, Patel AH, Sanchez F, Sherman WF. Patients with Dupuytren's Contracture, Ledderhose Disease, and Peyronie's Disease are at higher risk of arthrofibrosis following total knee arthroplasty. Knee 2021; 29:190-200. [PMID: 33640618 DOI: 10.1016/j.knee.2021.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 11/05/2020] [Accepted: 02/05/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Total knee arthroplasty (TKA) is a successful treatment for patients with late stage osteoarthritis, yet arthrofibrosis remains a consistent cause of TKA failure. Dupuytren's, Ledderhose and Peyronie's Diseases are related conditions of increased fibroblast proliferation. The aim of this study was to identify whether an association exists between these conditions and arthrofibrosis following TKA. METHODS Patient records were queried from 2010 to 2016 using an administrative claims database to compare the rates of arthrofibrosis, manipulation under anesthesia (MUA), lysis of adhesions (LOA), and revision TKA in patients with independent chart diagnoses of Dupuytren's Contracture, Ledderhose, or Peyronie's Diseases versus those without. Complications were queried and compared using multivariate logistic regression. RESULTS Patients with Dupuytren's (n = 5,232) and Ledderhose (n = 50,716) had a significantly higher rate of ankylosis following TKA: 30-days (OR, 1.54; OR, 1.23), 90-days (OR, 1.20; OR, 1.24), 6-months (OR, 1.23; OR, 1.23), and 1-year (OR, 1.28; OR, 1.23), while patients with Peyronie's (n = 1,186) had a higher rate of diagnosis at 6-months (OR, 1.37) and 1-year (OR, 1.35). Patients with diagnoses of any of the fibroproliferative diseases had a statistically higher risk of MUA at 90-days, 6-month, and 1-year following primary TKA. These cohorts did not have a significantly higher rate of revision TKA. CONCLUSION There is an increased odds risk of arthrofibrosis and MUA in patients who have undergone TKA and have a diagnosis of Dupuytren's Contracture, Ledderhose, or Peyronie's Diseases. Improvements to frequency and application of post-operative treatment should be considered in these cohorts to improve outcomes.
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Affiliation(s)
- Cindy X Wang
- Department of Orthopedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, USA.
| | - Travis R Flick
- Department of Orthopedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, USA.
| | - Akshar H Patel
- Department of Orthopedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, USA.
| | - Fernando Sanchez
- Department of Orthopedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, USA.
| | - William F Sherman
- Department of Orthopedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, USA.
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Velasco BT, Patel SS, Broughton KK, Frumberg DB, Kwon JY, Miller CP. Arthrofibrosis of the Ankle. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011420970463. [PMID: 35097416 PMCID: PMC8564948 DOI: 10.1177/2473011420970463] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Arthrofibrosis is a common, but often overlooked, condition that imparts significant morbidity following injuries and surgery to the foot and ankle. The most common etiologies are related to soft tissue trauma with subsequent fibrotic and contractile scar tissue formation within the ligaments and capsule of the ankle. This leads to pain, alterations in gait, and ankle dysfunction. Initial treatment often includes extensive physical therapy, however, if severe enough surgical options exist. Although the literature regarding ankle arthrofibrosis is scarce, this review article provides a greater understanding of the pathogenesis of arthrofibrosis and describes the current and future therapeutic options to treat fibrotic joints. Level of Evidence: Level V, expert opinion.
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Affiliation(s)
- Brian Timothy Velasco
- Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA
| | - Shalin S. Patel
- Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Boston, MA, USA
| | | | - David B. Frumberg
- Department of Orthopaedic Surgery, Yale School of Medicine, Yale-New Haven Hospital, New Haven, CT, USA
| | - John Y. Kwon
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Christopher P. Miller
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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