1
|
Skrinda-Melne M, Locs J, Grava A, Dubnika A. Calcium phosphates enhanced with liposomes - the future of bone regeneration and drug delivery. J Liposome Res 2024; 34:507-522. [PMID: 37988074 DOI: 10.1080/08982104.2023.2285973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 11/15/2023] [Indexed: 11/22/2023]
Abstract
Effective healing and regeneration of various bone defects is still a major challenge and concern in modern medicine. Calcium phosphates have emerged as extensively studied bone substitute materials due to their structural and chemical resemblance to the mineral phase of bone, along with their versatile properties. Calcium phosphates present promising biological characteristics that make them suitable for bone substitution, but a critical limitation lies in their low osteoinductivity. To supplement these materials with properties that promote bone regeneration, prevent infections, and cure bone diseases locally, calcium phosphates can be biologically and therapeutically modified. A promising approach involves combining calcium phosphates with drug-containing liposomes, renowned for their high biocompatibility and ability to provide controlled and sustained drug delivery. Surprisingly, there is a lack of research focused on liposome-calcium phosphate composites, where liposomes are dispersed within a calcium phosphate matrix. This raises the question of why such studies are limited. In order to provide a comprehensive overview of existing liposome and calcium phosphate composites as bioactive substance delivery systems, the authors review the literature exploring the interactions between calcium phosphates and liposomes. Additionally, it seeks to identify potential interactions between calcium ions and liposomes, which may impact the feasibility of developing liposome-containing calcium phosphate composite materials. Liposome capacity to protect bioactive compounds and facilitate localized treatment can be particularly valuable in scenarios involving bone regeneration, infection prevention, and the management of bone diseases. This review explores the implications of liposomes and calcium phosphate material containing liposomes on drug delivery, bioavailability, and stability, offering insights into their advantages.
Collapse
Affiliation(s)
- Marite Skrinda-Melne
- Rudolfs Cimdins Riga Biomaterials Innovations and Development Centre of RTU, Institute of General Chemical Engineering, Faculty of Materials Science and Applied Chemistry, Riga Technical University, Riga, Latvia
- Baltic Biomaterials Centre of Excellence, Headquarters at Riga Technical University, Riga, Latvia
| | - Janis Locs
- Rudolfs Cimdins Riga Biomaterials Innovations and Development Centre of RTU, Institute of General Chemical Engineering, Faculty of Materials Science and Applied Chemistry, Riga Technical University, Riga, Latvia
- Baltic Biomaterials Centre of Excellence, Headquarters at Riga Technical University, Riga, Latvia
| | - Andra Grava
- Rudolfs Cimdins Riga Biomaterials Innovations and Development Centre of RTU, Institute of General Chemical Engineering, Faculty of Materials Science and Applied Chemistry, Riga Technical University, Riga, Latvia
- Baltic Biomaterials Centre of Excellence, Headquarters at Riga Technical University, Riga, Latvia
| | - Arita Dubnika
- Rudolfs Cimdins Riga Biomaterials Innovations and Development Centre of RTU, Institute of General Chemical Engineering, Faculty of Materials Science and Applied Chemistry, Riga Technical University, Riga, Latvia
- Baltic Biomaterials Centre of Excellence, Headquarters at Riga Technical University, Riga, Latvia
| |
Collapse
|
2
|
Jahn D, Knapstein PR, Otto E, Köhli P, Sevecke J, Graef F, Graffmann C, Fuchs M, Jiang S, Rickert M, Erdmann C, Appelt J, Revend L, Küttner Q, Witte J, Rahmani A, Duda G, Xie W, Donat A, Schinke T, Ivanov A, Tchouto MN, Beule D, Frosch KH, Baranowsky A, Tsitsilonis S, Keller J. Increased β 2-adrenergic signaling promotes fracture healing through callus neovascularization in mice. Sci Transl Med 2024; 16:eadk9129. [PMID: 38630849 DOI: 10.1126/scitranslmed.adk9129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 03/27/2024] [Indexed: 04/19/2024]
Abstract
Traumatic brain injury (TBI) leads to skeletal changes, including bone loss in the unfractured skeleton, and paradoxically accelerates healing of bone fractures; however, the mechanisms remain unclear. TBI is associated with a hyperadrenergic state characterized by increased norepinephrine release. Here, we identified the β2-adrenergic receptor (ADRB2) as a mediator of skeletal changes in response to increased norepinephrine. In a murine model of femoral osteotomy combined with cortical impact brain injury, TBI was associated with ADRB2-dependent enhanced fracture healing compared with osteotomy alone. In the unfractured 12-week-old mouse skeleton, ADRB2 was required for TBI-induced decrease in bone formation and increased bone resorption. Adult 30-week-old mice had higher bone concentrations of norepinephrine, and ADRB2 expression was associated with decreased bone volume in the unfractured skeleton and better fracture healing in the injured skeleton. Norepinephrine stimulated expression of vascular endothelial growth factor A and calcitonin gene-related peptide-α (αCGRP) in periosteal cells through ADRB2, promoting formation of osteogenic type-H vessels in the fracture callus. Both ADRB2 and αCGRP were required for the beneficial effect of TBI on bone repair. Adult mice deficient in ADRB2 without TBI developed fracture nonunion despite high bone formation in uninjured bone. Blocking ADRB2 with propranolol impaired fracture healing in mice, whereas the ADRB2 agonist formoterol promoted fracture healing by regulating callus neovascularization. A retrospective cohort analysis of 72 patients with long bone fractures indicated improved callus formation in 36 patients treated with intravenous norepinephrine. These findings suggest that ADRB2 is a potential therapeutic target for promoting bone healing.
Collapse
Affiliation(s)
- Denise Jahn
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, 13353 Berlin, Germany
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Julius Wolff Institute, 13353 Berlin, Germany
| | - Paul Richard Knapstein
- University Medical Center Hamburg-Eppendorf, Department of Trauma and Orthopedic Surgery, 20251 Hamburg, Germany
| | - Ellen Otto
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, 13353 Berlin, Germany
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Julius Wolff Institute, 13353 Berlin, Germany
| | - Paul Köhli
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, 13353 Berlin, Germany
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Julius Wolff Institute, 13353 Berlin, Germany
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Clinician Scientist Program, 13353 Berlin, Germany
| | - Jan Sevecke
- University Medical Center Hamburg-Eppendorf, Department of Trauma and Orthopedic Surgery, 20251 Hamburg, Germany
| | - Frank Graef
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, 13353 Berlin, Germany
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Clinician Scientist Program, 13353 Berlin, Germany
| | - Christine Graffmann
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Julius Wolff Institute, 13353 Berlin, Germany
| | - Melanie Fuchs
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, 13353 Berlin, Germany
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Julius Wolff Institute, 13353 Berlin, Germany
| | - Shan Jiang
- University Medical Center Hamburg-Eppendorf, Department of Trauma and Orthopedic Surgery, 20251 Hamburg, Germany
| | - Mayla Rickert
- University Medical Center Hamburg-Eppendorf, Department of Trauma and Orthopedic Surgery, 20251 Hamburg, Germany
| | - Cordula Erdmann
- University Medical Center Hamburg-Eppendorf, Department of Trauma and Orthopedic Surgery, 20251 Hamburg, Germany
| | - Jessika Appelt
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, 13353 Berlin, Germany
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Julius Wolff Institute, 13353 Berlin, Germany
| | - Lawik Revend
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, 13353 Berlin, Germany
| | - Quin Küttner
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, 13353 Berlin, Germany
| | - Jason Witte
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Julius Wolff Institute, 13353 Berlin, Germany
| | - Adibeh Rahmani
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, 13353 Berlin, Germany
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Julius Wolff Institute, 13353 Berlin, Germany
| | - Georg Duda
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Julius Wolff Institute, 13353 Berlin, Germany
| | - Weixin Xie
- University Medical Center Hamburg-Eppendorf, Department of Trauma and Orthopedic Surgery, 20251 Hamburg, Germany
| | - Antonia Donat
- University Medical Center Hamburg-Eppendorf, Department of Trauma and Orthopedic Surgery, 20251 Hamburg, Germany
| | - Thorsten Schinke
- University Medical Center Hamburg-Eppendorf, Department of Osteology and Biomechanics, 20251 Hamburg, Germany
| | - Andranik Ivanov
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Core Unit Bioinformatics, 10117 Berlin, Germany
- Max-Delbrück-Center for Molecular Medicine, 13125 Berlin, Germany
| | - Mireille Ngokingha Tchouto
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Core Unit Bioinformatics, 10117 Berlin, Germany
| | - Dieter Beule
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Core Unit Bioinformatics, 10117 Berlin, Germany
- Max-Delbrück-Center for Molecular Medicine, 13125 Berlin, Germany
| | - Karl-Heinz Frosch
- University Medical Center Hamburg-Eppendorf, Department of Trauma and Orthopedic Surgery, 20251 Hamburg, Germany
| | - Anke Baranowsky
- University Medical Center Hamburg-Eppendorf, Department of Trauma and Orthopedic Surgery, 20251 Hamburg, Germany
| | - Serafeim Tsitsilonis
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, 13353 Berlin, Germany
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Julius Wolff Institute, 13353 Berlin, Germany
| | - Johannes Keller
- University Medical Center Hamburg-Eppendorf, Department of Trauma and Orthopedic Surgery, 20251 Hamburg, Germany
| |
Collapse
|
3
|
Quinaz T, Freire TF, Olmos A, Martins M, Ferreira FBN, de Moura MFSM, Zille A, Nguyễn Q, Xavier J, Dourado N. The Influence of Hydroxyapatite Crystals on the Viscoelastic Behavior of Poly(vinyl alcohol) Braid Systems. Biomimetics (Basel) 2024; 9:93. [PMID: 38392139 PMCID: PMC10886535 DOI: 10.3390/biomimetics9020093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/28/2024] [Accepted: 01/29/2024] [Indexed: 02/24/2024] Open
Abstract
Composites of poly(vinyl alcohol) (PVA) in the shape of braids, in combination with crystals of hydroxyapatite (HAp), were analyzed to perceive the influence of this bioceramic on both the quasi-static and viscoelastic behavior under tensile loading. Analyses involving energy-dispersive X-ray spectroscopy (EDS) and scanning electron microscopy (SEM) allowed us to conclude that the production of a homogeneous layer of HAp on the braiding surface and the calcium/phosphate atomic ratio were comparable to those of natural bone. The maximum degradation temperature established by thermogravimetric analysis (TGA) showed a modest decrease with the addition of HAp. By adding HAp to PVA braids, an increase in the glass transition temperature (Tg) is noticed, as demonstrated by dynamic mechanical analysis (DMA) and differential thermal analysis (DTA). The PVA/HAp composite braids' peaks were validated by Fourier transform infrared (FTIR) spectroscopy to be in good agreement with common PVA and HAp patterns. PVA/HAp braids, a solution often used in the textile industry, showed superior overall mechanical characteristics in monotonic tensile tests. Creep and relaxation testing showed that adding HAp to the eight and six-braided yarn architectures was beneficial. By exhibiting good mechanical performance and most likely increased biological qualities that accompany conventional care for bone applications in the fracture healing field, particularly multifragmentary ones, these arrangements can be applied as a fibrous fixation system.
Collapse
Affiliation(s)
- Tiago Quinaz
- CMEMS-UMinho, Departamento de Engenharia Mecânica, Campus de Azurém, Universidade do Minho, 4804-533 Guimarães, Portugal
| | - Tânia F Freire
- CMEMS-UMinho, Departamento de Engenharia Mecânica, Campus de Azurém, Universidade do Minho, 4804-533 Guimarães, Portugal
| | - Andrea Olmos
- CMEMS-UMinho, Departamento de Engenharia Mecânica, Campus de Azurém, Universidade do Minho, 4804-533 Guimarães, Portugal
| | - Marcos Martins
- INESC TEC, R. Dr. Roberto Frias, 4200-465 Porto, Portugal
| | - Fernando B N Ferreira
- 2C2T-Centro de Ciência e Tecnologia Têxtil, Departamento de Engenharia Têxtil, Campus de Azurém, Universidade do Minho, 4804-533 Guimarães, Portugal
| | - Marcelo F S M de Moura
- Departamento de Engenharia Mecânica, Faculdade de Engenharia da Universidade do Porto, 4200-464 Porto, Portugal
| | - Andrea Zille
- 2C2T-Centro de Ciência e Tecnologia Têxtil, Departamento de Engenharia Têxtil, Campus de Azurém, Universidade do Minho, 4804-533 Guimarães, Portugal
| | - Quyền Nguyễn
- 2C2T-Centro de Ciência e Tecnologia Têxtil, Departamento de Engenharia Têxtil, Campus de Azurém, Universidade do Minho, 4804-533 Guimarães, Portugal
| | - José Xavier
- UNIDEMI, Department of Mechanical and Industrial Engineering, NOVA School of Science and Technology, Universidade NOVA de Lisboa, 2829-516 Caparica, Portugal
- LASI, Intelligent Systems Associate Laboratory, 4800-058 Guimarães, Portugal
| | - Nuno Dourado
- CMEMS-UMinho, Departamento de Engenharia Mecânica, Campus de Azurém, Universidade do Minho, 4804-533 Guimarães, Portugal
- LABBELS-Laboratório Associado, 4710-057 Braga, Portugal
| |
Collapse
|
4
|
Howard A, Myatt A, Hodgson H, Naeem H, Pepple S, Perumal A, Panteli M, Kanakaris N, Giannoudis PV. Retrograde intramedullary nailing or locked plating for stabilisation of distal femoral fractures? A comparative study of 193 patients. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:471-478. [PMID: 37612566 PMCID: PMC10771351 DOI: 10.1007/s00590-023-03650-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 07/15/2023] [Indexed: 08/25/2023]
Abstract
PURPOSE The aim of this study was to evaluate the results of distal femoral fracture fixation of two different methods, lateral locking plate (LP) or an Intra-medullary nail (IMN), in patients managed in our institution. More specifically, to assess: (a) if there was a difference in functional outcomes between the LP and IMN groups; (b) whether the rate of complications was different between the two groups. METHODS Between January 2009 and December 2018 adult patients with distal femoral fractures managed in our unit with either LP or IMN for extra and intra-articular fractures were eligible to participate. Demographic details, fracture type, procedures performed, time to union, complications and functional scores (Oxford Knee Score) were recorded and analysed. The mean follow up was 4 years (12-120 months). RESULTS Out of 193 patients who met the inclusion criteria, 93 received an IMN whereas 100 patients were treated with LP. Mean age was 64.2 (18-99) and 70.1 (18-100) for the IMN and LP groups respectively. Overall, the two groups had similar demographics and there was no significant difference in the type of fractures sustained (p > 0.05). The Oxford Knee Score was highest for patients fixed with LP, mean 37.3 (6-48, SD 7.3) versus 28.4 (3-48, SD 14.4), (p = < 0.02) compared to the IMN group. In terms of complications, the rate of non-union was higher in the LP group 8.6% versus 4% in those patients treated with an IMN, p value < 0.01. CONCLUSION While the rate of non-union was higher in the LP group and the functional results were superior in the plating group.
Collapse
Affiliation(s)
- Anthony Howard
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.
- Leeds General Infirmary University Hospital, Leeds, UK.
- NDORMS, Oxford University, Oxford, UK.
| | - A Myatt
- Leeds General Infirmary University Hospital, Leeds, UK
| | - H Hodgson
- Leeds General Infirmary University Hospital, Leeds, UK
| | - H Naeem
- Leeds General Infirmary University Hospital, Leeds, UK
| | - S Pepple
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - A Perumal
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - M Panteli
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Leeds General Infirmary University Hospital, Leeds, UK
| | - N Kanakaris
- Leeds General Infirmary University Hospital, Leeds, UK
| | - P V Giannoudis
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Leeds General Infirmary University Hospital, Leeds, UK
| |
Collapse
|
5
|
Cheng L, Wang G, Lu H, Li S, Xiong W, Wang J. Effect of Bushen Tiansui Decoction on Delayed Fracture Healing: A Systematic Review and Meta-analysis. JOURNAL OF MUSCULOSKELETAL & NEURONAL INTERACTIONS 2023; 23:471-488. [PMID: 38037365 PMCID: PMC10696372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Accepted: 10/20/2023] [Indexed: 12/02/2023]
Abstract
This review aimed to validate the therapeutic potential of Bushen Tiansui decoction (BSTSD), a traditional Chinese formulation, in treating delayed union of fractures. Comprehensive database searches identified randomized controlled trials up to September 13, 2022, assessing BSTSD's efficacy in delayed fracture healing. Outcomes were bone metabolism indexes and Harris hip scores. Quality and risk assessments were conducted using the Cochrane Collaboration's tools. Data were analyzed using RevMan software, with sensitivity analysis through Stata. BSTSD significantly improved bone GLA protein (SMD=1.76, P<0.00001) and alkaline phosphatase (SMD=1.31, P<0.00001). Additionally, Harris hip scores for pain, function, deformity, and motion showed marked improvement. BSTSD treatment also demonstrated enhanced clinical efficiency (RR=1.27, P<0.00001) with fewer complications. Sensitivity analyses indicated consistent results. BSTSD shows promise in treating delayed fracture unions, yet conclusions necessitate further high-quality research for validation.
Collapse
Affiliation(s)
- Ling Cheng
- Rehabilitation Medicine Department, Nanchang Hongdu Hospital of Traditional Chinese Medicine, China
| | - Gao Wang
- Orthopedics, Nanchang Hongdu Hospital of Traditional Chinese Medicine, China
| | - Hualong Lu
- Rehabilitation Medicine Department, Nanchang Hongdu Hospital of Traditional Chinese Medicine, China
| | - Song Li
- Rehabilitation Medicine Department, Nanchang Hongdu Hospital of Traditional Chinese Medicine, China
| | - Wei Xiong
- Rehabilitation Medicine Department, Nanchang Hongdu Hospital of Traditional Chinese Medicine, China
| | - Jun Wang
- General Surgery Department of Trauma Center, The First Hospital of Nanchang, China
| |
Collapse
|
6
|
Jahn D, Knapstein PR, Otto E, Köhli P, Sevecke J, Graef F, Graffmann C, Fuchs M, Jiang S, Rickert M, Erdmann C, Appelt J, Revend L, Küttner Q, Witte J, Rahmani A, Duda G, Xie W, Donat A, Schinke T, Ivanov A, Tchouto MN, Beule D, Frosch KH, Baranowsky A, Tsitsilonis S, Keller J. Increased beta2-adrenergic signaling is a targetable stimulus essential for bone healing by promoting callus neovascularization. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.07.14.548550. [PMID: 37502964 PMCID: PMC10369985 DOI: 10.1101/2023.07.14.548550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Traumatic brain injury (TBI) is associated with a hyperadrenergic state and paradoxically causes systemic bone loss while accelerating fracture healing. Here, we identify the beta2-adrenergic receptor (Adrb2) as a central mediator of these skeletal manifestations. While the negative effects of TBI on the unfractured skeleton can be explained by the established impact of Adrb2 signaling on bone formation, Adrb2 promotes neovascularization of the fracture callus under conditions of high sympathetic tone, including TBI and advanced age. Mechanistically, norepinephrine stimulates the expression of Vegfa and Cgrp primarily in periosteal cells via Adrb2, both of which synergistically promote the formation of osteogenic type-H vessels in the fracture callus. Accordingly, the beneficial effect of TBI on bone repair is abolished in mice lacking Adrb2 or Cgrp, and aged Adrb2-deficient mice without TBI develop fracture nonunions despite high bone formation in uninjured bone. Pharmacologically, the Adrb2 antagonist propranolol impairs, and the agonist formoterol promotes fracture healing in aged mice by regulating callus neovascularization. Clinically, intravenous beta-adrenergic sympathomimetics are associated with improved callus formation in trauma patients with long bone fractures. Thus, Adrb2 is a novel target for promoting bone healing, and widely used beta-blockers may cause fracture nonunion under conditions of increased sympathetic tone. Abstract Figure
Collapse
|
7
|
Gariffo G, Bottai V, Falcinelli F, Di Sacco F, Cifali R, Troiano E, Capanna R, Mondanelli N, Giannotti S. Use of Teriparatide in preventing delayed bone healing and nonunion: a multicentric study on a series of 20 patients. BMC Musculoskelet Disord 2023; 24:184. [PMID: 36906529 PMCID: PMC10007805 DOI: 10.1186/s12891-023-06278-0] [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] [Received: 12/01/2022] [Accepted: 02/28/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Delayed bone healing and nonunions represent a great challenge for the orthopedic surgeon. In addition to traditional surgical approaches, increasing attention is being given to the use of systemic anabolic therapy with Teriparatide, whose efficacy in preventing osteoporotic fractures is widely validated and whose application as a promoter of bone healing has been described but it is still debated. The aim of the study was to evaluate bone healing in a series of patients with delayed unions or nonunions treated with Teriparatide in conjunction with eventual appropriate surgical procedure. METHODS Twenty patients with an unconsolidated fracture that were treated at our Institutions from 2011 to 2020 with Teriparatide were retrospectively included into the study. The pharmacological anabolic support was used off-label with a planned duration of 6 months; radiographic healing was evaluated at 1-, 3- and 6-months follow-up outpatient visits over plain radiographs. Also, eventual side-effects were registered. RESULTS Radiographic signs indicative of favorable evolution of the bone callus were observed as early as at 1 month of therapy in 15% of cases; at 3 months, healing progression was appreciated in 80% of cases and complete healing in 10%; at 6 months, 85% of delayed and nonunions had healed. In all patients, the anabolic therapy was well tolerated. CONCLUSIONS In accordance to Literature, this study suggests that Teriparatide plays a potentially important role in the treatment of some forms of delayed unions or nou-nions, even in the presence of failure of hardware. The results suggest a greater effect of the drug when associated with a condition in which the bone is in an active phase of callogenesis, or with a "revitalizing" treatment which represents a local (mechanical and/or biological) stimulus to the healing process. Despite the small sample size and the variety of cases, the efficacy of Teriparatide in treating delayed unions or nonunions emerged, highlighting how this anabolic therapy can represent a useful pharmacological support in the treatment of such a pathology. Although the results obtained are encouraging, further studies, particularly prospective and randomized, are needed to confirm the efficacy of the drug, and define a specific treatment algorithm.
Collapse
Affiliation(s)
- Gabriele Gariffo
- Second Orthopedic and Traumatology Clinic, University of Pisa, Pisa, Italy
| | - Vanna Bottai
- Second Orthopedic and Traumatology Clinic, University of Pisa, Pisa, Italy
| | | | - Federico Di Sacco
- Second Orthopedic and Traumatology Clinic, University of Pisa, Pisa, Italy
| | - Roberta Cifali
- Second Orthopedic and Traumatology Clinic, University of Pisa, Pisa, Italy
| | - Elisa Troiano
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Viale Mario Bracci 16, 53100, Siena, Italy
| | - Rodolfo Capanna
- Second Orthopedic and Traumatology Clinic, University of Pisa, Pisa, Italy
| | - Nicola Mondanelli
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy. .,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Viale Mario Bracci 16, 53100, Siena, Italy.
| | - Stefano Giannotti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy.,Section of Orthopedics, Azienda Ospedaliero-Universitaria Senese, Viale Mario Bracci 16, 53100, Siena, Italy
| |
Collapse
|
8
|
Arlettaz Y. Augmented osteosynthesis in fragility fracture. Orthop Traumatol Surg Res 2023; 109:103461. [PMID: 36404483 DOI: 10.1016/j.otsr.2022.103461] [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] [Received: 12/01/2021] [Revised: 04/14/2022] [Accepted: 04/14/2022] [Indexed: 11/06/2022]
Abstract
Due to poor bone quality and complexity, some fractures are difficult to treat, with high risk of failure. Moreover, general health is often poor in elderly patients with multiple comorbidity and poor compliance, necessitating perfect first-line management to avoid re-operation. The armamentarium comprises specific internal fixation implants and also complementary methods such as autologous, homologous or heterologous bone graft or bone substitutes with varying mechanical and biological characteristics. Associating these options is what is mean by "augmented fixation". The present review of augmented osteosynthesis addresses the following questions: What are the characteristics of fragility fractures? Fragility fracture is caused by low-energy trauma on bone with poor structural quality and low mineral density. Treatment aims to enable early mobilization and weight-bearing while avoiding mechanical failure of fixation. Prolonged bedrest, loss of mobility and surgical revision are aggravating and sometimes fatal factors in these fragile patients. What are the biological techniques of fixation augmentation in fragility fracture? Autologous or homologous bone graft are the most widely used biological augmentation techniques. They fill spaces and promote osteoconduction and consolidation. Some bone-like phosphocalcic structures are opening up promising lines of research. What are the non-biological techniques of fixation augmentation in fragility fracture? Hydroxyapatite, phosphocalcic cement and acrylic cement are the most widely used synthetic materials. Biological and mechanical effects are variable according to composition, requiring specific implementation. What are the mechanical techniques of fixation augmentation in fragility fracture? There is at present no consensus as to the augmentation techniques to be applied in fragility fracture. Cerclage or complementary plating, or external fixation associated to internal fixation are possibilities. However, the literature consists only of small series reporting surgical techniques specific to a given surgeon or team. When and how should osteosynthesis for fragility fracture be augmented? The choice of augmentation depends on fracture location, comminution, available material and local experience. The more severe the fracture, the more complex the fixation. The approach needs to be adapted to the preoperative planning and the associated mechanical means (plate, complementary cerclage) and prosthetic replacement should be considered in certain joint fractures or fractures close to load-bearing surfaces. LEVEL OF EVIDENCE: V; expert opinion.
Collapse
Affiliation(s)
- Yvan Arlettaz
- SANTECHABLAIS, Chemin Du Verger 3, 1868 Collombey, Switzerland.
| |
Collapse
|
9
|
Liu Y, Guo D, Zhou X, Wang B, Li P, Li T. Effect of infrared irradiation combined with mannitol and kinesiology tape on postoperative swelling and pain in patients with a periarticular ankle fracture. Pak J Med Sci 2023; 39:257-261. [PMID: 36694737 PMCID: PMC9842990 DOI: 10.12669/pjms.39.1.5869] [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: 12/12/2021] [Revised: 11/02/2022] [Accepted: 11/15/2022] [Indexed: 11/17/2022] Open
Abstract
Objectives To explore the effect of infrared irradiation combined with mannitol and Kinesiology tape on postoperative swelling and pain in patients with a periarticular ankle fracture. Methods The research subjects of this study were 88 patients with periarticular ankle fracture treated by surgery in the Department of Orthopedics of Baoding No.1 Central Hospital from October, 2019 to May, 2021. They were randomly divided into the observation group and the control group based on the random number table method, with 44 cases in each group. All patients were treated after the operation. Patients in the control group were treated with conventional drugs; while those in the observation group were provided with infrared irradiation combined with mannitol and Kinesiology tape. Further comparison was conducted on the degree of swelling, pain and satisfaction after treatment at three, five and seven days after operation. Results At three, five and seven days after operation, the cross-section diameter of the injured limb was significantly smaller in the observation group than that in the control group, and the difference was statistically significant (p<0. 05). The degree of pain in both groups was significantly lower at three, five and seven days after operation than that before treatment; moreover, the degree of pain in the observation group was significantly lower than that in the control group, and the difference was statistically significant (p<0. 05). Besides, the comparison of posttreatment satisfaction in both groups after treatment revealed that the total satisfaction of patients in the observation group (97.73%) was higher than that in the control group (79.55%), with a statistically significant difference (p<0.05). Conclusion Infrared irradiation combined with mannitol and Kinesiology tape can effectively alleviate postoperative swelling and pain of patients with a periarticular ankle fracture.
Collapse
Affiliation(s)
- Yuanyuan Liu
- Yuanyuan Liu, Department of Orthopedics, Baoding NO.1 Central Hospital, Baoding, Hebei, 071000, China
| | - Deli Guo
- Deli Guo, Department of Orthopedics, Baoding NO.1 Central Hospital, Baoding, Hebei, 071000, China
| | - Xinghua Zhou
- Xinghua Zhou, Department of Orthopedics, Baoding NO.1 Central Hospital, Baoding, Hebei, 071000, China
| | - Bo Wang
- Bo Wang, Department of Orthopedics, Baoding NO.1 Central Hospital, Baoding, Hebei, 071000, China
| | - Panxiang Li
- Panxiang Li, Department of Orthopedics, Baoding NO.1 Central Hospital, Baoding, Hebei, 071000, China
| | - Tao Li
- Tao Li, Department of Orthopedics, Baoding NO.1 Central Hospital, Baoding, Hebei, 071000, China
| |
Collapse
|
10
|
Treatment of Femoral Shaft Pseudarthrosis, Case Series and Medico-Legal Implications. J Clin Med 2022; 11:jcm11247407. [PMID: 36556022 PMCID: PMC9787375 DOI: 10.3390/jcm11247407] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/14/2022] [Accepted: 12/13/2022] [Indexed: 12/15/2022] Open
Abstract
Pseudarthrosis (PSA) is a possible complication of femoral shaft fracture treatment. It is often associated with reduced bone quality and can, therefore, adversely affect quality of life. Its treatment poses a major challenge for orthopaedic surgeons. Several authors have set forth different surgical approaches for the treatment of pseudarthrosis, such as internal fixation with plate and screws, replacement of an intramedullary nail or prosthetic replacement. In cases associated with bone loss, osteopenia, or comminution of fracture fragments, autologous or homologous bone grafts may also be used. The chronic outcomes of the surgical treatment of femoral shaft pseudarthrosis, even when consolidation is achieved, are linked to disabling sequelae of clinical-functional relevance, deserving an adequate medico-legal evaluation. The purpose of this retrospective study is to analyse a clinical case series of patients treated for atrophic femoral shaft pseudarthrosis at the IRCCS Orthopaedic Institute Galeazzi, Milan, Italy, from 2014 to 2020 and their orthopaedic-traumatological and medico-legal implications.
Collapse
|
11
|
Li L, Wang Y, Wang Z, Xue D, Dai C, Gao X, Ma J, Hang K, Pan Z. Knockdown of FOXA1 enhances the osteogenic differentiation of human bone marrow mesenchymal stem cells partly via activation of the ERK1/2 signalling pathway. Stem Cell Res Ther 2022; 13:456. [PMID: 36064451 PMCID: PMC9446550 DOI: 10.1186/s13287-022-03133-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/11/2022] [Indexed: 11/21/2022] Open
Abstract
Background The available therapeutic options for large bone defects remain extremely limited, requiring new strategies to accelerate bone healing. Genetically modified bone mesenchymal stem cells (BMSCs) with enhanced osteogenic capacity are recognised as one of the most promising treatments for bone defects. Methods We performed differential expression analysis of miRNAs between human BMSCs (hBMSCs) and human dental pulp stem cells (hDPSCs) to identify osteogenic differentiation-related microRNAs (miRNAs). Furthermore, we identified shared osteogenic differentiation-related miRNAs and constructed an miRNA-transcription network. The Forkhead box protein A1 (FOXA1) knockdown strategy with a lentiviral vector was used to explore the role of FOXA1 in the osteogenic differentiation of MSCs. Cell Counting Kit-8 was used to determine the effect of the knockdown of FOXA1 on hBMSC proliferation; real-time quantitative reverse transcription PCR (qRT-PCR) and western blotting were used to investigate target genes and proteins; and alkaline phosphatase (ALP) staining and Alizarin Red staining (ARS) were used to assess ALP activity and mineral deposition, respectively. Finally, a mouse model of femoral defects was established in vivo, and histological evaluation and radiographic analysis were performed to verify the therapeutic effects of FOXA1 knockdown on bone healing. Results We identified 22 shared and differentially expressed miRNAs between hDPSC and hBMSC, 19 of which were downregulated in osteogenically induced samples. The miRNA-transcription factor interaction network showed that FOXA1 is the most significant and novel osteogenic differentiation biomarker among more than 300 transcription factors that is directly targeted by 12 miRNAs. FOXA1 knockdown significantly promoted hBMSC osteo-specific genes and increased mineral deposits in vitro. In addition, p-ERK1/2 levels were upregulated by FOXA1 silencing. Moreover, the increased osteogenic differentiation of FOXA1 knockdown hBMSCs was partially rescued by the addition of ERK1/2 signalling inhibitors. In a mouse model of femoral defects, a sheet of FOXA1-silencing BMSCs improved bone healing, as detected by microcomputed tomography and histological evaluation. Conclusion These findings collectively demonstrate that FOXA1 silencing promotes the osteogenic differentiation of BMSCs via the ERK1/2 signalling pathway, and silencing FOXA1 in vivo effectively promotes bone healing, suggesting that FOXA1 may be a novel target for bone healing.
Collapse
Affiliation(s)
- Lijun Li
- Department of Orthopedics Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, People's Republic of China.,Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, People's Republic of China.,Clinical Research Center of Motor System Disease of Zhejiang Province, Zhejiang Province, Hangzhou City, People's Republic of China
| | - Yibo Wang
- Department of Orthopedics Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, People's Republic of China.,Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, People's Republic of China.,Clinical Research Center of Motor System Disease of Zhejiang Province, Zhejiang Province, Hangzhou City, People's Republic of China
| | - Zhongxiang Wang
- Department of Orthopedics Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, People's Republic of China.,Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, People's Republic of China.,Clinical Research Center of Motor System Disease of Zhejiang Province, Zhejiang Province, Hangzhou City, People's Republic of China
| | - Deting Xue
- Department of Orthopedics Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, People's Republic of China.,Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, People's Republic of China.,Clinical Research Center of Motor System Disease of Zhejiang Province, Zhejiang Province, Hangzhou City, People's Republic of China
| | - Chengxin Dai
- Department of Orthopedics Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, People's Republic of China.,Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, People's Republic of China.,Clinical Research Center of Motor System Disease of Zhejiang Province, Zhejiang Province, Hangzhou City, People's Republic of China
| | - Xiang Gao
- Department of Orthopedics Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, People's Republic of China.,Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China.,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, People's Republic of China.,Clinical Research Center of Motor System Disease of Zhejiang Province, Zhejiang Province, Hangzhou City, People's Republic of China
| | - Jianfei Ma
- Key Laboratory of Image Information Processing and Intelligent Control, School of Artificial Intelligence and Automation, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Kai Hang
- Department of Orthopedics Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, People's Republic of China. .,Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China. .,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, People's Republic of China. .,Clinical Research Center of Motor System Disease of Zhejiang Province, Zhejiang Province, Hangzhou City, People's Republic of China.
| | - Zhijun Pan
- Department of Orthopedics Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou City, Zhejiang Province, People's Republic of China. .,Orthopedics Research Institute of Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China. .,Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou City, Zhejiang Province, People's Republic of China. .,Clinical Research Center of Motor System Disease of Zhejiang Province, Zhejiang Province, Hangzhou City, People's Republic of China.
| |
Collapse
|
12
|
Preoperative contrast-enhanced ultrasound (CEUS) of long bone nonunions reliably predicts microbiology of tissue culture samples but not of implant-sonication. Orthop Traumatol Surg Res 2022; 108:102862. [PMID: 33610855 DOI: 10.1016/j.otsr.2021.102862] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 01/31/2021] [Accepted: 02/12/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Bacterial infection in the context of fracture repair remains a severe complication in trauma surgery and may result in long bone nonunion. Since treatment options for aseptic and infected nonunions vary greatly, diagnostic methods should ideally differentiate between these two entities as accurately as possible. Recently, contrast-enhanced ultrasound (CEUS) has been introduced as a preoperative imaging technique to evaluate hypervascularity at the fracture site as sign of bacterial infection. HYPOTHESIS Preoperative CEUS predicts results of microbiological evaluation obtained either by culture of tissue samples or by analyzing the sonication fluid following removal and sonication of the implant. PATIENTS AND METHODS Over the course of 6 months, 26 patients with long bone nonunions were included in this study. Patients' clinical data were evaluated. Tissue samples were collected intraoperatively and examined by standard microbiological techniques. The sonication method was applied to removed implants. Additionally, 1-3 days before surgery, CEUS was performed to determine hypervascularity at the nonunion site as a possible parameter for infection. RESULTS Culture of tissue samples indicated infection in 50% of cases and implant sonication in 57.7% of cases. However, there was merely a fair agreement (κ=0.231) between these two diagnostic methods. CEUS predicted results of tissue culture reliably (sensitivity 92.3% and specificity 100%), whereas implant sonication showed no significant correlations with results from CEUS. Hypertrophic and atrophic nonunions were evaluated separately to determine possible differences in vascularity. We found that contrast peak enhancement of CEUS was similar in atrophic and hypertrophic nonunions with positive culture of tissue samples. Both differed significantly from culture negative cases (p=0.0016 and 0.0062). Results of implant-sonication positive or negative cases in atrophic and hypertrophic nonunions, however, were less clear and could be misleading. DISCUSSION We were able to confirm CEUS as a valuable preoperative diagnostic tool that reliably predicts microbiology of tissue culture samples, but not of implant sonication. LEVEL OF EVIDENCE I; diagnostic study.
Collapse
|
13
|
Huang X, Chen Y, Chen B, Zheng K, Lin C, Lin F, Luo X. Reamed versus unreamed intramedullary nailing for the treatment of femoral shaft fractures among adults: A meta-analysis of randomized controlled trials. J Orthop Sci 2022; 27:850-858. [PMID: 34303590 DOI: 10.1016/j.jos.2021.03.022] [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] [Received: 10/23/2020] [Revised: 02/03/2021] [Accepted: 03/17/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this meta-analysis is to compare the merits and drawbacks between reamed intramedullary nailing (RIN) and unreamed intramedullary nailing (URIN) among adults. METHODS We comprehensively searched PubMed, MEDLINE database through the PubMed search engine, Google Scholar, Cochrane Library, Embase, VIPI (Database for Chinese Technical Periodicals), and CNKI (China National Knowledge Infrastructure) from inception to March 2020. Outcomes of interest included nonunion rates, implant failure rates, secondary procedure rates, blood loss, acute respiratory distress syndrome (ARDS) rates, and pulmonary complications rates. RESULTS Eight randomized controlled trials were included. The result of nonunion rates shows that the nonunion rate is significantly lower in the RIN group (RR = 0.20, 95% CI = 0.09-0.48, Z = 3.63, P = 0.0003). There were no significant differences for the risk of implant failure rates (RR = 0.55, 95% CI = 0.18-1.69, Z = 1.04, P = 0.30). The secondary procedure rates were significantly lower in the RIN group (RR = 0.28, 95% CI = 0.12-0.66, Z = 2.91, P = 0.004). The result shows that the blood loss of URIN group is significantly lower (RR = 145.52, 95% CI = 39.68-251.36, Z = 2.69, P = 0.007). The result shows that there was no significant difference in the ARDS rates (RR = 1.53, 95% CI = 0.37-6.29, Z = 0.59, P = 0.55) and the pulmonary complications rates between RIN group and URIN group (RR = 1.59, 95% CI = 0.61-4.17, Z = 0.94, P = 0.35). CONCLUSIONS Reamed intramedullary nailing would lead to lower nonunion rate, secondary procedure rate and more blood loss. Unreamed intramedullary nailing is related to a higher nonunion rate, secondary procedure rate and less blood loss. No significant difference is found in implant failure rate, ARDS rate and pulmonary complication rate between the two groups.
Collapse
Affiliation(s)
- Xu'an Huang
- School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Yifan Chen
- Department of Orthopedic Surgery, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Bin Chen
- Department of Orthopedic Surgery, Fuzhou Second Hospital Affiliated to Xiamen University, The Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, China; Department of Orthopedic Surgery, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Ke Zheng
- Department of Orthopedic Surgery, Fuzhou Second Hospital Affiliated to Xiamen University, The Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, China; Department of Orthopedic Surgery, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Chaohui Lin
- Department of Orthopedic Surgery, Fuzhou Second Hospital Affiliated to Xiamen University, The Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, China; Department of Orthopedic Surgery, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Fengfei Lin
- Department of Orthopedic Surgery, Fuzhou Second Hospital Affiliated to Xiamen University, The Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, China; Department of Orthopedic Surgery, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China.
| | | |
Collapse
|
14
|
Chen YH, Liao HJ, Lin SM, Chang CH, Rwei SP, Lan TY. Radiographic outcomes of the treatment of complex femoral shaft fractures (AO/OTA 32-C) with intramedullary nailing: a retrospective analysis of different techniques. J Int Med Res 2022; 50:3000605221103974. [PMID: 35676773 PMCID: PMC9189532 DOI: 10.1177/03000605221103974] [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: 11/17/2022] Open
Abstract
OBJECTIVES To assess the results of open versus closed reduction in intramedullary nailing (IMN) for complex femoral fractures (Arbeitsgemeinschaft für Osteosynthesefragen Foundation/Orthopaedic Trauma Association [AO/OTA]: 32-C) and to determine the factors involved in bone healing. METHODS This retrospective study involved 47 consecutive patients with complex femoral diaphyseal fractures who underwent reduction and fixation. RESULTS All open-reduction and 12 closed-reduction patients (52.17%) had an anatomical-to-small gap. The closed-small group had the highest bone union rate (100%), followed by the open-reduction (79.17%) and closed-large groups (72.73%); intergroup differences were significant. The closed-small group had the shortest mean union time (7.31 months), followed by the open-reduction group (7.58 months). The closed-large group had a significantly longer union time (9.75 months) than those in the closed-small and open-reduction groups. Femoral radiographic union scores in the closed-small and open-reduction groups were similar at three timepoints; scores were higher than those in the closed-large group, with a significant difference 6 and 9 months post-operatively. CONCLUSION IMN with closed reduction for complex femoral shaft fractures had better outcomes and fewer complications versus open reduction. For unsatisfactory closed reduction outcomes (i.e., residual gap >10 mm), minimally invasive techniques or open reduction with minimal stripping should be considered.
Collapse
Affiliation(s)
- Yu-Hung Chen
- Department of Orthopedic Surgery, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nanya S. Rd., New Taipei City
| | - Hsiu-Jung Liao
- Department of Orthopedic Surgery, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nanya S. Rd., New Taipei City
| | - Shang Ming Lin
- Department of Materials and Textiles, Asia Eastern University of Science and Technology, No. 58, Sec. 2, Sihchuan Rd., New Taipei City
| | - Chih-Hung Chang
- Department of Orthopedic Surgery, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nanya S. Rd., New Taipei City
| | - Syang-Peng Rwei
- Institute of Organic and Polymeric Materials, National Taipei University of Technology, 1, Sec. 3, Zhongxiao E. Rd., Taipei.,Research and Development Center for Smart Textile Technology, National Taipei University of Technology, 1, Sec. 3, Zhongxiao E. Rd., Taipei
| | - Tsung-Yu Lan
- Department of Orthopedic Surgery, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nanya S. Rd., New Taipei City.,Department of Materials and Textiles, Asia Eastern University of Science and Technology, No. 58, Sec. 2, Sihchuan Rd., New Taipei City.,Institute of Organic and Polymeric Materials, National Taipei University of Technology, 1, Sec. 3, Zhongxiao E. Rd., Taipei
| |
Collapse
|
15
|
Intramedullary Delivery of Autologous Bone Graft to Long Bone Defects Using Reamer Irrigator Aspirator 2 System: Technical Trick. Tech Orthop 2022. [DOI: 10.1097/bto.0000000000000584] [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: 11/26/2022]
|
16
|
Ahmad M, Krüger BT, Kroll T, Vettorazzi S, Dorn AK, Mengele F, Lee S, Nandi S, Yilmaz D, Stolz M, Tangudu NK, Vázquez DC, Pachmayr J, Cirstea IC, Spasic MV, Ploubidou A, Ignatius A, Tuckermann J. Inhibition of Cdk5 increases osteoblast differentiation and bone mass and improves fracture healing. Bone Res 2022; 10:33. [PMID: 35383146 PMCID: PMC8983726 DOI: 10.1038/s41413-022-00195-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 12/10/2021] [Accepted: 12/21/2021] [Indexed: 11/09/2022] Open
Abstract
Identification of regulators of osteoblastogenesis that can be pharmacologically targeted is a major goal in combating osteoporosis, a common disease of the elderly population. Here, unbiased kinome RNAi screening in primary murine osteoblasts identified cyclin-dependent kinase 5 (Cdk5) as a suppressor of osteoblast differentiation in both murine and human preosteoblastic cells. Cdk5 knockdown by siRNA, genetic deletion using the Cre-loxP system, or inhibition with the small molecule roscovitine enhanced osteoblastogenesis in vitro. Roscovitine treatment significantly enhanced bone mass by increasing osteoblastogenesis and improved fracture healing in mice. Mechanistically, downregulation of Cdk5 expression increased Erk phosphorylation, resulting in enhanced osteoblast-specific gene expression. Notably, simultaneous Cdk5 and Erk depletion abrogated the osteoblastogenesis conferred by Cdk5 depletion alone, suggesting that Cdk5 regulates osteoblast differentiation through MAPK pathway modulation. We conclude that Cdk5 is a potential therapeutic target to treat osteoporosis and improve fracture healing.
Collapse
Affiliation(s)
- Mubashir Ahmad
- Institute of Comparative Molecular Endocrinology (CME), Ulm University, Helmholtzstrasse 8/1, 89081, Ulm, Germany.,Institute of Orthopedic Research and Biomechanics, Ulm University, Helmholtzstrasse 14, 89081, Ulm, Germany
| | - Benjamin Thilo Krüger
- Institute of Orthopedic Research and Biomechanics, Ulm University, Helmholtzstrasse 14, 89081, Ulm, Germany
| | - Torsten Kroll
- Leibniz Institute on Aging - Fritz Lipmann Institute (FLI), Beutenbergstrasse 11, D-07745, Jena, Germany
| | - Sabine Vettorazzi
- Institute of Comparative Molecular Endocrinology (CME), Ulm University, Helmholtzstrasse 8/1, 89081, Ulm, Germany
| | - Ann-Kristin Dorn
- Institute of Comparative Molecular Endocrinology (CME), Ulm University, Helmholtzstrasse 8/1, 89081, Ulm, Germany
| | - Florian Mengele
- Praxisklinik für Orthopädie, Unfall- und Neurochirurgie Prof. Bischoff/Dr. Spies/Dr. Mengele, 89231, Neu-Ulm, Germany
| | - Sooyeon Lee
- Institute of Comparative Molecular Endocrinology (CME), Ulm University, Helmholtzstrasse 8/1, 89081, Ulm, Germany
| | - Sayantan Nandi
- Institute of Comparative Molecular Endocrinology (CME), Ulm University, Helmholtzstrasse 8/1, 89081, Ulm, Germany
| | - Dilay Yilmaz
- Institute of Comparative Molecular Endocrinology (CME), Ulm University, Helmholtzstrasse 8/1, 89081, Ulm, Germany
| | - Miriam Stolz
- Institute of Comparative Molecular Endocrinology (CME), Ulm University, Helmholtzstrasse 8/1, 89081, Ulm, Germany
| | - Naveen Kumar Tangudu
- Institute of Comparative Molecular Endocrinology (CME), Ulm University, Helmholtzstrasse 8/1, 89081, Ulm, Germany.,UPMC Hillman Cancer Center, Department of Pharmacology and Chemical Biology, University of Pittsburgh, 5115 Center Avenue, 15232, Pittsburgh, PA, USA
| | - David Carro Vázquez
- Institute of Comparative Molecular Endocrinology (CME), Ulm University, Helmholtzstrasse 8/1, 89081, Ulm, Germany.,TAmiRNA GmbH, Leberstrasse 20, 1110, Vienna, Austria
| | - Johanna Pachmayr
- Paracelsus Medizinische Privatuniverstät, Institute of Pharmacy, Strubergasse 21, 5020, Salzburg, Austria
| | - Ion Cristian Cirstea
- Institute of Comparative Molecular Endocrinology (CME), Ulm University, Helmholtzstrasse 8/1, 89081, Ulm, Germany
| | - Maja Vujic Spasic
- Institute of Comparative Molecular Endocrinology (CME), Ulm University, Helmholtzstrasse 8/1, 89081, Ulm, Germany
| | - Aspasia Ploubidou
- Leibniz Institute on Aging - Fritz Lipmann Institute (FLI), Beutenbergstrasse 11, D-07745, Jena, Germany
| | - Anita Ignatius
- Institute of Orthopedic Research and Biomechanics, Ulm University, Helmholtzstrasse 14, 89081, Ulm, Germany
| | - Jan Tuckermann
- Institute of Comparative Molecular Endocrinology (CME), Ulm University, Helmholtzstrasse 8/1, 89081, Ulm, Germany. .,Department of Endocrinology, Ludwig Maximilians University Munich, Munich, 80336, Germany.
| |
Collapse
|
17
|
Sun L, Ma J, Chen J, Pan Z, Li L. Bioinformatics-Guided Analysis Uncovers AOX1 as an Osteogenic Differentiation-Relevant Gene of Human Mesenchymal Stem Cells. Front Mol Biosci 2022; 9:800288. [PMID: 35295843 PMCID: PMC8920545 DOI: 10.3389/fmolb.2022.800288] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/04/2022] [Indexed: 01/05/2023] Open
Abstract
Background: The available therapeutic options of bone defects, fracture nonunion, and osteoporosis remain limited, which are closely related to the osteogenic differentiation of bone marrow–derived mesenchymal stem cells (BMSCs). Thus, there remains an urgent demand to develop a prediction method to infer osteogenic differentiation–related genes in BMSCs. Method: We performed differential expression analysis between hBMSCs and osteogenically induced samples. Association analysis, co-expression analysis, and PPI analysis are then carried out to identify potential osteogenesis-related regulators. GO enrichment analysis and GSEA are performed to identify significantly enriched pathways associated with AOX1. qRT-PCR and Western blotting were employed to investigate the expression of genes on osteogenic differentiation, and plasmid transfection was used to overexpress the gene AOX1 in hBMSCs. Result: We identified 25 upregulated genes and 17 downregulated genes. Association analysis and PPI network analysis among these differentially expressed genes show that AOX1 is a potential regulator of osteogenic differentiation. GO enrichment analysis and GSEA show that AOX1 is significantly associated with osteoblast-related pathways. The experiments revealed that AOX1 level was higher and increased gradually in differentiated BMSCs compared with undifferentiated BMSCs, and AOX1 overexpression significantly increased the expression of osteo-specific genes, thereby clearly indicating that AOX1 plays an important role in osteogenic differentiation. Moreover, our method has ability in discriminating genes with osteogenic differentiation properties and can facilitate the process of discovery of new osteogenic differentiation–related genes. Conclusion: These findings collectively demonstrate that AOX1 is an osteogenic differentiation-relevant gene and provide a novel method established with a good performance for osteogenic differentiation-relevant genes prediction.
Collapse
Affiliation(s)
- Lingtong Sun
- Affiliated Hangzhou Xixi Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianfei Ma
- Key Laboratory of Image Information Processing and Intelligent Control, School of Artificial Intelligence and Automation, Huazhong University of Science and Technology, Wuhan, China
| | - Juan Chen
- Affiliated Hangzhou Xixi Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhijun Pan
- Department of Orthopedics Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Orthopedics Research Institute of Zhejiang University, Hangzhou, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
- *Correspondence: Zhijun Pan, ; Lijun Li,
| | - Lijun Li
- Department of Orthopedics Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Orthopedics Research Institute of Zhejiang University, Hangzhou, China
- Key Laboratory of Motor System Disease Research and Precision Therapy of Zhejiang Province, Hangzhou, China
- *Correspondence: Zhijun Pan, ; Lijun Li,
| |
Collapse
|
18
|
Buso C, Zanini P, Titotto S. Bioinspired design proposal for a new external bone fixator device. Biomed Phys Eng Express 2022; 8. [PMID: 35100569 DOI: 10.1088/2057-1976/ac5092] [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: 10/15/2021] [Accepted: 01/31/2022] [Indexed: 11/11/2022]
Abstract
The article presents a new medical device through an authorial and interdisciplinary approach. It consists of a flexible external fixator, whose flexible property may bring advantages over rigid mechanisms. Its design was inspired by the DNA biological mechanism of condensation, while the modeling was based on the pseudo-rigid modeling technique. From the models obtained, this study conducted prototyping and computational tests to obtain a proof-of-concept of the bioinspired theory and dynamic functioning effectiveness. The prototyping relied on hot glue manufacturing and the computational simulations consisted of linear static analysis. The experimental analysis concluded that the prototype with fewer beams and thinner beams delivered better results in all three parameters: flexibility, height variation and rotation arc. In the computational analysis, among the design models with the variation of the number of beams, the model with 8 beams performed better. Concerning thickness variation, the one whose beams measured 8mm in thickness showed better results. Among the models with length variation, the design made with 100 mm long beams better equilibrated the parameters.
Collapse
Affiliation(s)
- Carla Buso
- 4D Printing and Biomimetics (4DB) Research Group, Universidade Federal do ABC, Av. dos Estados, 5001 - Bangú, Santo Andre, SP, 09210-170, BRAZIL
| | - Plinio Zanini
- 4D Printing and Biomimetics (4DB) Research Group, Universidade Federal do ABC, Av. dos Estados, 5001 - Bangú, Santo Andre, SP, 09210-170, BRAZIL
| | - Silvia Titotto
- 4D Printing and Biomimetics (4DB) Research Group, Universidade Federal do ABC, Av. dos Estados, 5001 - Bangú, Santo Andre, 09210-170, BRAZIL
| |
Collapse
|
19
|
Mondanelli N, Troiano E, Facchini A, Cesari M, Colasanti GB, Bottai V, Muratori F, Caffarelli C, Gonnelli S, Giannotti S. Combined Surgical and Medical Treatment for Vancouver B1 and C Periprosthetic Femoral Fractures: A Proposal of a Therapeutic Algorithm While Retaining the Original Stable Stem. Geriatr Orthop Surg Rehabil 2021; 12:21514593211067072. [PMID: 34992896 PMCID: PMC8725223 DOI: 10.1177/21514593211067072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 10/30/2021] [Accepted: 11/26/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION There is lack of consensus regarding best operative fixation strategy for periprosthetic femoral fractures (PFFs) around a stable stem. Evidence exists that some patterns of fracture around a stable stem are better treated with revision surgery than with standard fixation. Anyway, a more aggressive surgical procedure together with medical treatment could allow for stem retention, and reduced risk of nonunion/hardware failure, even in these cases. SIGNIFICANCE This paper is placed in a broader context of lack of studies on the matter, and its aim is to shed some light on the management of PFFs around a stable stem, when peculiar mechanical and biological aspects are present. RESULTS Based on our casuistry in the treatment of nonunions after PFF successfully treated with original stem retention, and on review of Literature about risk factors for fixation failure, an algorithm is proposed that can guide in choosing the ideal surgical technique even for first-time PFFs with a stable stem, without resorting to revision. Mechanical (major and minor) and biological (local and systemic) factors that may influence fracture healing, leading to nonunion and hardware failure, and subsequent need for re-operation, are considered. The proposed surgical technique consists of rigid fixation with absolute stability (using a plate and structural allograft) plus local biological support (structural allograft and autologous bone marrow concentrate over a platelet-rich plasma-based scaffold) at fracture site. Systemic anabolic treatment (Teriparatide) is also administered in the post-operative period. CONCLUSION Mechanical factors are not the only issues to be considered when choosing the surgical approach to PFFs over a stable stem. Systemic and local biological conditions should be taken into account, as well. A therapeutic algorithm is proposed, given the prosthetic stem to be stable, considering mechanical and biological criteria.
Collapse
Affiliation(s)
- Nicola Mondanelli
- Department of Medicine Surgery and
Neurosciences, University of Siena, Siena, Italy
- Section of Orthopedics, Azienda Ospedaliero-Universitaria
Senese, Policlinico Santa Maria alle Scotte, Siena, Italy
| | - Elisa Troiano
- Department of Medicine Surgery and
Neurosciences, University of Siena, Siena, Italy
- Section of Orthopedics, Azienda Ospedaliero-Universitaria
Senese, Policlinico Santa Maria alle Scotte, Siena, Italy
| | - Andrea Facchini
- Department of Medicine Surgery and
Neurosciences, University of Siena, Siena, Italy
- Section of Orthopedics, Azienda Ospedaliero-Universitaria
Senese, Policlinico Santa Maria alle Scotte, Siena, Italy
| | - Martina Cesari
- Department of Medicine Surgery and
Neurosciences, University of Siena, Siena, Italy
- Section of Orthopedics, Azienda Ospedaliero-Universitaria
Senese, Policlinico Santa Maria alle Scotte, Siena, Italy
| | | | - Vanna Bottai
- Second Clinic of Orthopedic and
Traumatology, University of Pisa, Pisa, Italy
| | - Francesco Muratori
- Section of Orthopedic Oncology and
Reconstructive Surgery, Azienda Ospedaliero-Universitaria
Careggi, Firenze, Italy
| | - Carla Caffarelli
- Department of Medicine Surgery and
Neurosciences, University of Siena, Siena, Italy
- Section of Internal Medicine, Azienda Ospedaliero-Universitaria
Senese, Policlinico Santa Maria alle Scotte, Siena, Italy
| | - Stefano Gonnelli
- Department of Medicine Surgery and
Neurosciences, University of Siena, Siena, Italy
- Section of Internal Medicine, Azienda Ospedaliero-Universitaria
Senese, Policlinico Santa Maria alle Scotte, Siena, Italy
| | - Stefano Giannotti
- Department of Medicine Surgery and
Neurosciences, University of Siena, Siena, Italy
- Section of Orthopedics, Azienda Ospedaliero-Universitaria
Senese, Policlinico Santa Maria alle Scotte, Siena, Italy
| |
Collapse
|
20
|
Identification of miRNA Regulatory Networks and Candidate Markers for Fracture Healing in Mice. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2021:2866475. [PMID: 34840596 PMCID: PMC8611357 DOI: 10.1155/2021/2866475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/13/2021] [Indexed: 12/22/2022]
Abstract
Background It is important to improve the understanding of the fracture healing process at the molecular levels, then to discover potential miRNA regulatory mechanisms and candidate markers. Methods Expression profiles of mRNA and miRNA were obtained from the Gene Expression Omnibus database. We performed differential analysis, enrichment analysis, protein-protein interaction (PPI) network analysis. The miRNA-mRNA network analysis was also performed. Results We identified 499 differentially expressed mRNAs (DEmRs) that were upregulated and 534 downregulated DEmRs during fracture healing. They were mainly enriched in collagen fibril organization and immune response. Using the PPI network, we screened 10 hub genes that were upregulated and 10 hub genes downregulated with the largest connectivity. We further constructed the miRNA regulatory network for hub genes and identified 13 differentially expressed miRNAs (DEmiRs) regulators. Cd19 and Col6a1 were identified as key candidate mRNAs with the largest fold change, and their DEmiR regulators were key candidate regulators. Conclusion Cd19 and Col6a1 might serve as candidate markers for fracture healing in subsequent studies. Their expression is regulated by miRNAs and is involved in collagen fibril organization and immune responses.
Collapse
|
21
|
Mice Lacking the Calcitonin Receptor Do Not Display Improved Bone Healing. Cells 2021; 10:cells10092304. [PMID: 34571953 PMCID: PMC8471896 DOI: 10.3390/cells10092304] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 11/17/2022] Open
Abstract
Despite significant advances in surgical techniques, treatment options for impaired bone healing are still limited. Inadequate bone regeneration is not only associated with pain, prolonged immobilization and often multiple revision surgeries, but also with high socioeconomic costs, underlining the importance of a detailed understanding of the bone healing process. In this regard, we previously showed that mice lacking the calcitonin receptor (CTR) display increased bone formation mediated through the increased osteoclastic secretion of sphingosine-1-phosphate (S1P), an osteoanabolic molecule promoting osteoblast function. Although strong evidence is now available for the crucial role of osteoclast-to-osteoblast coupling in normal bone hemostasis, the relevance of this paracrine crosstalk during bone regeneration is unknown. Therefore, our study was designed to test whether increased osteoclast-to-osteoblast coupling, as observed in CTR-deficient mice, may positively affect bone repair. In a standardized femoral osteotomy model, global CTR-deficient mice displayed no alteration in radiologic callus parameters. Likewise, static histomorphometry demonstrated moderate impairment of callus microstructure and normal osseous bridging of osteotomy ends. In conclusion, bone regeneration is not accelerated in CTR-deficient mice, and contrary to its osteoanabolic action in normal bone turnover, osteoclast-to-osteoblast coupling specifically involving the CTR-S1P axis, may only be of minor relevance during bone healing.
Collapse
|
22
|
Mazzotta A, Stagni C, Rocchi M, Rani N, Del Piccolo N, Filardo G, Dallari D. Bone marrow aspirate concentrate/platelet-rich fibrin augmentation accelerates healing of aseptic upper limb nonunions. J Orthop Traumatol 2021; 22:21. [PMID: 34089398 PMCID: PMC8179859 DOI: 10.1186/s10195-021-00582-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 05/04/2021] [Indexed: 12/30/2022] Open
Abstract
Introduction Nonunions remain a significant burden in orthopedics, often afflicting young males of working age. Positive findings have been published using bone marrow aspirate concentrate (BMAC) and platelet-rich fibrin (PRF) for the treatment augmentation of lower limb nonunions. The aim of this study was to investigate if the treatment augmentation with BMAC and PRF can also accelerate the healing of nonunions of the upper limb. Materials and methods Sixty-eight patients (45 men, 23 women) affected by 75 nonunions of long bones of the upper limb were treated and divided into two groups. The first series was treated with standard surgery alone (group A); afterwards, the second series benefited from standard surgery with the addition of BMAC and PRF applied on lyophilized bone chips. Nonunions were classified radiographically according to the Weber–Cech method and prognostically using the Calori and Moghaddam scores. All patients were radiographically assessed at 1.5, 3, 6, 12, and 24 months of follow-up. Results Baseline demographic characteristics did not present differences between groups. No differences were documented in terms of complications (two in group A and three in group B). Significant differences were instead documented in terms of healing time. The first healing signs were observed 1.5 months after surgery in 90.7% of patients in group B and 34.4% of group A (p < 0.0005). At 1.5, 3, 6, and 12 months, a higher radiographic score was found for group B (all p < 0.0005), while no difference was found at final follow-up of 24 months (90.6% of group A and 97.7% of group B achieved radiological healing). Faster healing with BMAC/PRF augmentation was confirmed for all bones, as well as for the subgroup of patients affected by atrophic nonunions (p = 0.001). Conclusion This study showed the benefits of restoring both mechanical and biological aspects when addressing nonunions of the long bones of the upper limb. In particular, the association of BMAC and PRF to lyophilized bone chips was safe and able to accelerate healing time. These good results were confirmed for humerus, radius, and ulna sites, as well as for challenging atrophic nonunions of the upper limb.
Collapse
Affiliation(s)
- Alessandro Mazzotta
- Reconstructive Orthopaedic Surgery Innovative Techniques, Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Cesare Stagni
- Reconstructive Orthopaedic Surgery Innovative Techniques, Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Martina Rocchi
- Reconstructive Orthopaedic Surgery Innovative Techniques, Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli, 1, 40136, Bologna, Italy. .,, Via di Casaglia 28, 40135, Bologna, Italy.
| | - Nicola Rani
- Reconstructive Orthopaedic Surgery Innovative Techniques, Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Nicolandrea Del Piccolo
- Reconstructive Orthopaedic Surgery Innovative Techniques, Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Giuseppe Filardo
- Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, via di Barbiano, 1/10, 40136, Bologna, Italy
| | - Dante Dallari
- Reconstructive Orthopaedic Surgery Innovative Techniques, Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli, 1, 40136, Bologna, Italy
| |
Collapse
|
23
|
Low-dose IL-34 has no effect on osteoclastogenesis but promotes osteogenesis of hBMSCs partly via activation of the PI3K/AKT and ERK signaling pathways. Stem Cell Res Ther 2021; 12:268. [PMID: 33947456 PMCID: PMC8097863 DOI: 10.1186/s13287-021-02263-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 03/02/2021] [Indexed: 12/29/2022] Open
Abstract
Background Inflammatory microenvironment is significant to the differentiation and function of mesenchymal stem cells (MSCs). It evidentially influences the osteoblastogenesis of MSCs. IL-34, a newly discovered cytokine, playing a key role in metabolism. However, the research on its functional role in the osteogenesis of MSCs was rarely reported. Here, we described the regulatory effects of low-dose IL-34 on both osteoblastogenesis and osteoclastogenesis. Methods We performed the osteogenic effects of hBMSCs by exogenous and overexpressed IL-34 in vitro, so were the osteoclastogenesis effects of mBMMs by extracellular IL-34. CCK-8 was used to assess the effect of IL-34 on the viability of hBMSCs and mBMMs. ALP, ARS, and TRAP staining was used to evaluate ALP activity, mineral deposition, and osteoclastogenesis, respectively. qRT-PCR and Western blotting analysis were performed to detect the expression of target genes and proteins. ELISA was used to evaluate the concentrations of IL-34. In vivo, a rat tibial osteotomy model and an OVX model were established. Radiographic analysis and histological evaluation were performed to confirm the therapeutic effects of IL-34 in fracture healing and osteoporosis. Statistical differences were evaluated by two-tailed Student’s t test, one-way ANOVA with Bonferroni’s post hoc test, and two-way ANOVA with Bonferroni multiple comparisons post hoc test in the comparison of 2 groups, more than 2 groups, and different time points of treated groups, respectively. Results Promoted osteoblastogenesis of hBMSCs was observed after treated by exogenous or overexpressed IL-34 in vitro, confirmed by increased mineral deposits and ALP activity. Furthermore, exogenous or overexpressed IL-34 enhanced the expression of p-AKT and p-ERK. The specific AKT and ERK signaling pathway inhibitors suppressed the enhancement of osteoblastogenesis induced by IL-34. In a rat tibial osteotomy model, imaging and histological analyses testified the local injection of exogenous IL-34 improved bone healing. However, the additional IL-34 has no influence on both osteoclastogenesis of mBMMs in vitro and osteoporosis of OVX model of rat in vivo. Conclusions Collectively, our study demonstrate that low-dose IL-34 regulates osteogenesis of hBMSCs partly via the PIK/AKT and ERK signaling pathway and enhances fracture healing, with neither promoting nor preventing osteoclastogenesis in vitro and osteoporosis in vivo.
Collapse
|
24
|
Ismailidis P, Suhm N, Clauss M, Mündermann A, Cadosch D. Scope and Limits of Teriparatide Use in Delayed and Nonunions: A Case Series. Clin Pract 2021; 11:47-57. [PMID: 33573004 PMCID: PMC7931020 DOI: 10.3390/clinpract11010009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/08/2021] [Accepted: 01/21/2021] [Indexed: 11/22/2022] Open
Abstract
Nonunion is known to occur in up to 10% of all bone fractures. Until recently, the treatment options considered in cases of delayed union and nonunion focused on revision surgery and improvement of local healing. Lately, teriparatide has been introduced as an osteoanabolic factor that induces fracture healing in cases with delayed or nonunions. We report on a series of five cases of delayed and nonunions treated with teriparatide: delayed unions of an atypical femoral fracture, of a multifragmentary clavicle fracture, and of a periprosthetic humeral fracture; nonunion of a tibial and fibular fracture; and infected nonunion of a tibial and fibular fracture. Based on this series, the indications and limits of application of teriparatide in cases of impaired fracture healing are discussed. Due to the “off-label” character of this application, informed consent, and cost coverage from the healthcare insurance must be obtained prior to treatment. In our experience and according to the limited existing literature, teriparatide is a safe feasible treatment in cases of delayed and nonunions with a reasonable need of resources. While adequate biomechanical stability remains the cornerstone of fracture healing, as well as healing of nonunions, teriparatide could help avoid repetitive surgeries, especially in atrophic delayed and nonunions, as well as in patients with impaired fracture healing undergoing bisphosphonate therapy. There is an urgent need for widely accepted definitions, standardized protocols, as well as further clinical trials in the field of impaired fracture healing.
Collapse
Affiliation(s)
- Petros Ismailidis
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; (N.S.); (M.C.); (A.M.); (D.C.)
- Department of Biomedical Engineering, University of Basel, Gewerbestrasse 14, 4123 Allschwil, Switzerland
- Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4056 Basel, Switzerland
- Correspondence: ; Tel.: +41-789490281; Fax: +41-61-265-73-21
| | - Norbert Suhm
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; (N.S.); (M.C.); (A.M.); (D.C.)
| | - Martin Clauss
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; (N.S.); (M.C.); (A.M.); (D.C.)
- Center for Musculosceletal Infections, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland
| | - Annegret Mündermann
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; (N.S.); (M.C.); (A.M.); (D.C.)
- Department of Biomedical Engineering, University of Basel, Gewerbestrasse 14, 4123 Allschwil, Switzerland
- Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4056 Basel, Switzerland
| | - Dieter Cadosch
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland; (N.S.); (M.C.); (A.M.); (D.C.)
| |
Collapse
|
25
|
Ogay V, Mun EA, Kudaibergen G, Baidarbekov M, Kassymbek K, Zharkinbekov Z, Saparov A. Progress and Prospects of Polymer-Based Drug Delivery Systems for Bone Tissue Regeneration. Polymers (Basel) 2020; 12:E2881. [PMID: 33271770 PMCID: PMC7760650 DOI: 10.3390/polym12122881] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 12/12/2022] Open
Abstract
Despite the high regenerative capacity of bone tissue, there are some cases where bone repair is insufficient for a complete functional and structural recovery after damage. Current surgical techniques utilize natural and synthetic bone grafts for bone healing, as well as collagen sponges loaded with drugs. However, there are certain disadvantages associated with these techniques in clinical usage. To improve the therapeutic efficacy of bone tissue regeneration, a number of drug delivery systems based on biodegradable natural and synthetic polymers were developed and examined in in vitro and in vivo studies. Recent studies have demonstrated that biodegradable polymers play a key role in the development of innovative drug delivery systems and tissue engineered constructs, which improve the treatment and regeneration of damaged bone tissue. In this review, we discuss the most recent advances in the field of polymer-based drug delivery systems for the promotion of bone tissue regeneration and the physical-chemical modifications of polymers for controlled and sustained release of one or more drugs. In addition, special attention is given to recent developments on polymer nano- and microparticle-based drug delivery systems for bone regeneration.
Collapse
Affiliation(s)
- Vyacheslav Ogay
- Stem Cell Laboratory, National Center for Biotechnology, Nur-Sultan 010000, Kazakhstan; (V.O.); (G.K.)
| | - Ellina A. Mun
- School of Sciences and Humanities, Nazarbayev University, Nur-Sultan 010000, Kazakhstan;
| | - Gulshakhar Kudaibergen
- Stem Cell Laboratory, National Center for Biotechnology, Nur-Sultan 010000, Kazakhstan; (V.O.); (G.K.)
| | - Murat Baidarbekov
- Research Institute of Traumatology and Orthopedics, Nur-Sultan 010000, Kazakhstan;
| | - Kuat Kassymbek
- Department of Medicine, School of Medicine, Nazarbayev University, Nur-Sultan 010000, Kazakhstan; (K.K.); (Z.Z.)
| | - Zharylkasyn Zharkinbekov
- Department of Medicine, School of Medicine, Nazarbayev University, Nur-Sultan 010000, Kazakhstan; (K.K.); (Z.Z.)
| | - Arman Saparov
- Department of Medicine, School of Medicine, Nazarbayev University, Nur-Sultan 010000, Kazakhstan; (K.K.); (Z.Z.)
| |
Collapse
|
26
|
Yu K, Wang G, Cai W, Wu D, Wei X, Zhang K, Liu R, Sun Q, Wang Z. Identification of antemortem, perimortem and postmortem fractures by FTIR spectroscopy based on a rabbit tibial fracture model. SPECTROCHIMICA ACTA. PART A, MOLECULAR AND BIOMOLECULAR SPECTROSCOPY 2020; 239:118535. [PMID: 32502812 DOI: 10.1016/j.saa.2020.118535] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/22/2020] [Accepted: 05/23/2020] [Indexed: 06/11/2023]
Abstract
The identification of antemortem, perimortem and postmortem fractures is very important for forensic pathologists and anthropologists. However, traditional methods are subjective, time-consuming, and have low accuracy, which do not fundamentally solve the problem. In this study, we utilized Fourier transform infrared (FTIR) spectroscopy and chemometrics to identify antemortem, perimortem and postmortem fractures in a rabbit tibial fracture model. Based on the results of the principal component analysis (PCA), changes in the ante-perimortem fracture repair process are mainly associated with protein variations, while postmortem fractures are more likely to result in lipid changes during degradation. Then, a partial least squares discriminant analysis (PLS-DA) was performed to assess the classification ability of the training and predictive datasets, with classification accuracies of 88.9% and 86.7%, respectively. According to the latent variable 1 (LV1) loading plot, amide I and amide II (proteins) are mostly classified as ante-perimortem and postmortem fractures. In conclusion, FTIR spectroscopy is a reliable tool to identify antemortem, perimortem and postmortem fractures. FTIR has the advantages of rapid, objective and strong discrimination. and shows great potential for analyzing forensic cases under actual natural conditions.
Collapse
Affiliation(s)
- Kai Yu
- Department of Forensic Pathology, College of Forensic Medicine, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Gongji Wang
- Department of Forensic Pathology, College of Forensic Medicine, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Wumin Cai
- Department of Forensic Pathology, College of Forensic Medicine, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Di Wu
- Department of Forensic Pathology, College of Forensic Medicine, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Xin Wei
- Department of Forensic Pathology, College of Forensic Medicine, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Kai Zhang
- Department of Forensic Pathology, College of Forensic Medicine, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Ruina Liu
- Department of Forensic Pathology, College of Forensic Medicine, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Qinru Sun
- Department of Forensic Pathology, College of Forensic Medicine, Xi'an Jiaotong University, Xi'an, Shaanxi, China.
| | - Zhenyuan Wang
- Department of Forensic Pathology, College of Forensic Medicine, Xi'an Jiaotong University, Xi'an, Shaanxi, China.
| |
Collapse
|
27
|
Goodman SB, Lin T. Modifying MSC Phenotype to Facilitate Bone Healing: Biological Approaches. Front Bioeng Biotechnol 2020; 8:641. [PMID: 32671040 PMCID: PMC7328340 DOI: 10.3389/fbioe.2020.00641] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/26/2020] [Indexed: 12/11/2022] Open
Abstract
Healing of fractures and bone defects normally follows an orderly series of events including formation of a hematoma and an initial stage of inflammation, development of soft callus, formation of hard callus, and finally the stage of bone remodeling. In cases of severe musculoskeletal injury due to trauma, infection, irradiation and other adverse stimuli, deficient healing may lead to delayed or non-union; this results in a residual bone defect with instability, pain and loss of function. Modern methods of mechanical stabilization and autologous bone grafting are often successful in achieving fracture union and healing of bone defects; however, in some cases, this treatment is unsuccessful because of inadequate biological factors. Specifically, the systemic and local microenvironment may not be conducive to bone healing because of a loss of the progenitor cell population for bone and vascular lineage cells. Autologous bone grafting can provide the necessary scaffold, progenitor and differentiated lineage cells, and biological cues for bone reconstruction, however, autologous bone graft may be limited in quantity or quality. These unfavorable circumstances are magnified in systemic conditions with chronic inflammation, including obesity, diabetes, chronic renal disease, aging and others. Recently, strategies have been devised to both mitigate the necessity for, and complications from, open procedures for harvesting of autologous bone by using minimally invasive aspiration techniques and concentration of iliac crest bone cells, followed by local injection into the defect site. More elaborate strategies (not yet approved by the U.S. Food and Drug Administration-FDA) include isolation and expansion of subpopulations of the harvested cells, preconditioning of these cells or inserting specific genes to modulate or facilitate bone healing. We review the literature pertinent to the subject of modifying autologous harvested cells including MSCs to facilitate bone healing. Although many of these techniques and technologies are still in the preclinical stage and not yet approved for use in humans by the FDA, novel approaches to accelerate bone healing by modifying cells has great potential to mitigate the physical, economic and social burden of non-healing fractures and bone defects.
Collapse
Affiliation(s)
- Stuart B Goodman
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA, United States.,Department of Bioengineering, Stanford University, Stanford, CA, United States
| | - Tzuhua Lin
- Orthopaedic Research Laboratories, Stanford University, Stanford, CA, United States
| |
Collapse
|
28
|
Synthetic Bone Substitutes and Mechanical Devices for the Augmentation of Osteoporotic Proximal Humeral Fractures: A Systematic Review of Clinical Studies. J Funct Biomater 2020; 11:jfb11020029. [PMID: 32380687 PMCID: PMC7353588 DOI: 10.3390/jfb11020029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 04/25/2020] [Accepted: 04/29/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Different augmentation techniques have been described in the literature in addition to the surgical treatment of proximal humeral fractures. The aim of this systematic review was to analyze the use of cements, bone substitutes, and other devices for the augmentation of proximal humeral fractures. METHODS A systematic review was conducted by using PubMed/MEDLINE, ISI Web of Knowledge, Cochrane Library, Scopus/EMBASE, and Google Scholar databases according the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines over the years 1966 to 2019. The search term "humeral fracture proximal" was combined with "augmentation"; "polymethylmethacrylate, PMMA"; "cement"; "bone substitutes"; "hydroxyapatite"; "calcium phosphates"; "calcium sulfate"; "cell therapies", and "tissue engineering" to find the literature relevant to the topic under review. RESULTS A total of 10 clinical studies considered eligible for the review, with a total of 308 patients, were included. Mean age at the time of injury was 68.8 years (range of 58-92). The most commonly described techniques were reinforcing the screw-bone interface with bone PMMA cement (three studies), filling the metaphyseal void with synthetic bone substitutes (five studies), and enhancing structural support with metallic devices (two studies). CONCLUSION PMMA cementation could improve screw-tip fixation. Calcium phosphate and calcium sulfate injectable composites provided good biocompatibility, osteoconductivity, and lower mechanical failure rate when compared to non-augmented fractures. Mechanical devices currently have a limited role. However, the available evidence is provided mainly by level III to IV studies, and none of the proposed techniques have been sufficiently studied.
Collapse
|
29
|
Marongiu G, Contini A, Cozzi Lepri A, Donadu M, Verona M, Capone A. The Treatment of Acute Diaphyseal Long-bones Fractures with Orthobiologics and Pharmacological Interventions for Bone Healing Enhancement: A Systematic Review of Clinical Evidence. Bioengineering (Basel) 2020; 7:bioengineering7010022. [PMID: 32102398 PMCID: PMC7148449 DOI: 10.3390/bioengineering7010022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 02/17/2020] [Accepted: 02/20/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The healing of long bones diaphyseal fractures can be often impaired and eventually end into delayed union and non-union. A number of therapeutic strategies have been proposed in combination with surgical treatment in order to enhance the healing process, such as scaffolds, growth factors, cell therapies and systemic pharmacological treatments. Our aim was to investigate the current evidence of bone healing enhancement of acute long bone diaphyseal fractures. METHODS A systematic review was conducted by using Pubmed/MEDLINE; Embase and Ovid databases. The combination of the search terms "long-bones; diaphyseal fracture; bone healing; growth factors; cell therapies; scaffolds; graft; bone substitutes; orthobiologics; teriparatide". RESULTS The initial search resulted in 4156 articles of which 37 papers fulfilled the inclusion criteria and were the subject of this review. The studies included 1350 patients (837 males and 513 females) with a mean age of 65.3 years old. CONCLUSIONS General lack of high-quality studies exists on the use of adjuvant strategies for bone healing enhancement in acute shaft fractures. Strong evidence supports the use of bone grafts, while only moderate evidence demineralized bone matrix and synthetic ceramics. Conflicting results partially supported the use of growth factors and cell therapies in acute fractures. Teriparatide showed promising results, particularly for atypical femoral fractures and periprosthetic femoral fractures.
Collapse
Affiliation(s)
- Giuseppe Marongiu
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (A.C.); (M.V.); (A.C.)
- Correspondence: or ; Tel.: +39-070-6094368
| | - Andrea Contini
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (A.C.); (M.V.); (A.C.)
| | - Andrea Cozzi Lepri
- Orthopaedic Traumatologic Center, University of Florence, 50121 Florence, Italy;
| | - Matthew Donadu
- Dipartimento di Chimica e Farmacia, University of Sassari, 07100 Sassari, Italy;
| | - Marco Verona
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (A.C.); (M.V.); (A.C.)
| | - Antonio Capone
- Orthopaedic and Trauma Clinic, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (A.C.); (M.V.); (A.C.)
| |
Collapse
|