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Khajuria DK, Karuppagounder V, Nowak I, Sepulveda DE, Lewis GS, Norbury CC, Raup-Konsavage WM, Vrana KE, Kamal F, Elbarbary RA. Cannabidiol and Cannabigerol, Nonpsychotropic Cannabinoids, as Analgesics that Effectively Manage Bone Fracture Pain and Promote Healing in Mice. J Bone Miner Res 2023; 38:1560-1576. [PMID: 37597163 PMCID: PMC10864058 DOI: 10.1002/jbmr.4902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 06/30/2023] [Accepted: 08/09/2023] [Indexed: 08/21/2023]
Abstract
Bone fractures are among the most prevalent musculoskeletal injuries, and pain management is an essential part of fracture treatment. Fractures heal through an early inflammatory phase, followed by repair and remodeling. Nonsteroidal anti-inflammatory drugs (NSAIDs) are not recommended for fracture pain control as they potently inhibit the inflammatory phase and, thus, impair the healing. Opioids do not provide a better alternative for several reasons, including abuse potential. Accordingly, there is an unmet clinical need for analgesics that effectively ameliorate postfracture pain without impeding the healing. Here, we investigated the analgesic efficacy of two nonpsychotropic cannabinoids, cannabidiol (CBD) and cannabigerol (CBG), in a mouse model for tibial fracture. Mice with fractured tibiae exhibited increased sensitivity to mechanical, cold, and hot stimuli. Both CBD and CBG normalized pain sensitivity to all tested stimuli, and their analgesic effects were comparable to those of the NSAIDs. Interestingly, CBD and CBG promoted bone healing via multiple mechanisms during the early and late phases. During the early inflammatory phase, both cannabinoids increased the abundance of periosteal bone progenitors in the healing hematoma and promoted the osteogenic commitment of these progenitors. During the later phases of healing, CBD and CBG accelerated the fibrocartilaginous callus mineralization and enhanced the viability and proliferation of bone and bone-marrow cells. These effects culminated in higher bone volume fraction, higher bone mineral density, and improved mechanical quality of the newly formed bone. Together, our data suggest CBD and CBG as therapeutic agents that can replace NSAIDs in managing postfracture pain as both cannabinoids exert potent analgesic effects and, at the same time, promote bone healing. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Deepak Kumar Khajuria
- Department of Orthopaedics and Rehabilitation, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033, USA
- Center for Orthopaedic Research and Translational Science (CORTS), The Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033, USA
| | - Vengadeshprabhu Karuppagounder
- Department of Orthopaedics and Rehabilitation, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033, USA
- Center for Orthopaedic Research and Translational Science (CORTS), The Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033, USA
| | - Irena Nowak
- Department of Orthopaedics and Rehabilitation, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033, USA
- Center for Orthopaedic Research and Translational Science (CORTS), The Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033, USA
| | - Diana E. Sepulveda
- Department of Pharmacology, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033, USA
- Department of Anesthesiology and Perioperative Medicine, The Pennsylvania State College of Medicine, Hershey, Pennsylvania 17033, USA
| | - Gregory S. Lewis
- Department of Orthopaedics and Rehabilitation, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033, USA
- Center for Orthopaedic Research and Translational Science (CORTS), The Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033, USA
| | - Christopher C Norbury
- Department of Microbiology and Immunology, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033, USA
| | - Wesley M. Raup-Konsavage
- Department of Pharmacology, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033, USA
| | - Kent E. Vrana
- Department of Pharmacology, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033, USA
| | - Fadia Kamal
- Department of Orthopaedics and Rehabilitation, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033, USA
- Center for Orthopaedic Research and Translational Science (CORTS), The Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033, USA
- Department of Pharmacology, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033, USA
| | - Reyad A. Elbarbary
- Department of Orthopaedics and Rehabilitation, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033, USA
- Center for Orthopaedic Research and Translational Science (CORTS), The Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033, USA
- Department of Biochemistry and Molecular Biology, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033, USA
- Center for RNA Molecular Biology, Pennsylvania State University, University Park, Pennsylvania 16802, USA
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Anastasilakis AD, Makras P, Paccou J, Bisbinas I, Polyzos SA, Papapoulos SE. Similarities and Differences in the Management of Patients with Osteoporotic Vertebral Fractures and Those with Rebound-Associated Vertebral Fractures Following Discontinuation of Denosumab. J Clin Med 2023; 12:5874. [PMID: 37762815 PMCID: PMC10532339 DOI: 10.3390/jcm12185874] [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: 07/21/2023] [Revised: 08/31/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Rebound-associated vertebral fractures (RVFx) following denosumab discontinuation are typically multiple, are commonly associated with acute sharp pain, increase the risk of imminent fractures, and are pathogenetically different from common osteoporotic vertebral fractures (VFx). A clinically relevant question is whether patients with RVFx should be managed differently from patients with osteoporotic VFx. To address this question, we performed a systematic search of the PubMed database, and we reviewed current evidence on the optimal management of patients with RVFx. For pain relief of patients with RVFx, potent analgesics, often opioids, are essential. Information on the effectiveness of braces in these patients is scarce. Vertebroplasty and kyphoplasty are strongly contraindicated as they confer a substantial risk for new VFx. Exercise may be helpful, but again evidence is lacking. In contrast to patients with osteoporotic VFx, in whom initial treatment with bone-forming agents is recommended, patients with RVFx should initiate treatment with potent antiresorptives. To summarize, patients who have sustained RVFx following denosumab discontinuation are at a very high risk for new fractures, especially VFx. The management of such patients requires a multidisciplinary approach that should not be restricted to pain relief and administration of antiosteoporotic medication, but should also include back protection, early mobilization, and appropriate exercise.
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Affiliation(s)
| | - Polyzois Makras
- Department of Endocrinology and Diabetes, 251 Hellenic Air Force & VA General Hospital, 115 25 Athens, Greece;
- Department of Medical Research, 251 Hellenic Air Force & VA General Hospital, 115 25 Athens, Greece;
| | - Julien Paccou
- Department of Rheumatology, University of Lille, 59000 Lille, France;
| | - Ilias Bisbinas
- First Department of Orthopaedics, 424 Military General Hospital, 564 29 Thessaloniki, Greece;
| | - Stergios A. Polyzos
- First Laboratory of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece;
| | - Socrates E. Papapoulos
- Department of Medical Research, 251 Hellenic Air Force & VA General Hospital, 115 25 Athens, Greece;
- Center for Bone Quality, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
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Čečrle M, Černý D, Sedláčková E, Míková B, Dudková V, Drncová E, Pokusová M, Skalský I, Tamášová J, Halačová M. Vitamin D for prevention of sternotomy healing complications: REINFORCE-D trial. Trials 2020; 21:1018. [PMID: 33308291 PMCID: PMC7731517 DOI: 10.1186/s13063-020-04920-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 11/19/2020] [Indexed: 11/29/2022] Open
Abstract
Background Most cardiac surgery patients undergo median sternotomy during open heart surgery. Sternotomy healing is an arduous, very complex, and multifactorial process dependent on many independent factors affecting the sternum and the surrounding soft tissues. Complication rates for median sternotomy range from 0.5 to 5%; however, mortality rates from complications are very variable at 7–80%. Low calcidiol concentration below 80 nmol/L results in calcium absorptive impairment and carries a risk of bone loss, which is considered as a risk factor in the sternotomy healing process. The primary objective of this clinical trial is to compare the incidence of all postoperative sternotomy healing complications in two parallel patient groups administered cholecalciferol or placebo. The secondary objectives are focused on general patient recovery process: sternal bone healing grade at the end of the trial, length of hospitalization, number of days spent in the ICU, number of days spent on mechanical lung ventilation, and number of hospital readmissions for sternotomy complications. Methods This clinical trial is conducted as monocentric, randomized, double-blind, placebo-controlled, with planned enrollment of 600 patients over 4 years, approximately 300 in the placebo arm and 300 in the treatment arm. Males and females from 18 to 95 years of age who fulfill the indication criteria for undergoing cardiac surgery with median sternotomy can be included in this clinical trial, if they meet the eligibility criteria. Discussion REINFORCE-D is the first monocentric trial dividing patients into groups based on serum calcidiol levels, and with dosing based on serum calcidiol levels. This trial may help to open up a wider range of postoperative healing issues. Trial registration EU Clinical Trials Register, EUDRA CT No: 2016-002606-39. Registered on September 8, 2016.
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Affiliation(s)
- Michal Čečrle
- Department of Clinical Pharmacy, Na Homolce Hospital, Prague, Czech Republic.,Institute of Pharmacology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Dalibor Černý
- Department of Clinical Pharmacy, Na Homolce Hospital, Prague, Czech Republic. .,Institute of Pharmacology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Eva Sedláčková
- Department of Cardiac Surgery, Na Homolce Hospital, Prague, Czech Republic
| | - Barbora Míková
- Department of Radiology, Na Homolce Hospital, Prague, Czech Republic
| | - Vlasta Dudková
- Department of Clinical Biochemistry, Hematology and Immunology, Na Homolce Hospital, Prague, Czech Republic
| | - Eva Drncová
- Department of Clinical Biochemistry, Hematology and Immunology, Na Homolce Hospital, Prague, Czech Republic
| | | | - Ivo Skalský
- Department of Cardiac Surgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jana Tamášová
- Department of Medical Physics, Na Homolce Hospital, Prague, Czech Republic
| | - Milada Halačová
- Department of Clinical Pharmacy, Na Homolce Hospital, Prague, Czech Republic.,Department of Pharmacology, 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
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Talukdar Y, Rashkow JT, Patel S, Lalwani G, Bastidas J, Khan S, Sitharaman B. Nanofilm generated non-pharmacological anabolic bone stimulus. J Biomed Mater Res A 2019; 108:178-186. [PMID: 31581364 DOI: 10.1002/jbm.a.36807] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 04/10/2019] [Accepted: 09/19/2019] [Indexed: 12/17/2022]
Abstract
Stimulus-responsive nanomaterials have mainly been employed to ablate or destroy tissues or to facilitate controlled release of drugs or biologics. Herein, we demonstrate the potential of stimulus-responsive nanomaterials to promote tissue regeneration via a non-pharmacological and noninvasive strategy. Thin nanofilms of an optically-absorbing organic dye or nanoparticle (single-walled graphene nanoribbons [SWOGNR]) were placed over (without touching the skin) a rodent femoral fracture site. A nanosecond pulsed near-infrared laser diode was employed to generate photoacoustic (PA) signals from the nanofilms. X-ray micro-computed tomography (microCT), histology, and mechanical testing results showed that daily PA stimulations of upto 45 min for 6 weeks (complete fracture healing) do not adversely affect bone regeneration and quality. Further, microCT and histological analysis showed 10 min daily stimulation for 2 weeks significantly increases bone quantity at the fracture sites of rats exposed to the nanoparticle-generated PA signals. In these rats, up to threefold increase in bone volume to callus volume ratio and twofold increase in bone mineral density within the callus were noted, compared to rats that were not exposed to the photoacoustic signals. The results taken together indicate that nanofilm-generated photoacoustic signals serve as an anabolic stimulus for bone regeneration. The results, in conjugation with the ability of these nanofilms to serve as PA contrast agents, present opportunities toward the development of integrated noninvasive imaging and noninvasive or invasive treatment strategies for bone loss due to disease or trauma.
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Affiliation(s)
- Yahfi Talukdar
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York
| | - Jason T Rashkow
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York
| | - Sunny Patel
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York
| | - Gaurav Lalwani
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York
| | - Juan Bastidas
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York
| | - Slah Khan
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York
| | - Balaji Sitharaman
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York
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Gallaher HM, Butler JR, Wills RW, Priddy LB, Elder SH, Heller SM, Brinkman E, Baumgartner W. Effects of short- and long-term administration of nonsteroidal anti-inflammatory drugs on osteotomy healing in dogs. Vet Surg 2019; 48:1318-1329. [PMID: 31291009 DOI: 10.1111/vsu.13282] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 04/17/2019] [Accepted: 06/18/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine the influence of short-term administration of carprofen on bone healing in dogs. STUDY DESIGN Randomized controlled experimental study. ANIMALS Eighteen purpose-bred sexually mature hound dogs. METHODS Tibial osteotomies were performed, and dogs were divided into three groups: no carprofen (n = 6), 2-week administration of carprofen at 2.2 mg/kg twice daily (n = 6), and 8-week administration of carprofen at 2.2 mg/kg twice daily (n = 5). Bone healing was evaluated radiographically at 4 and 8 weeks postoperatively. Postmortem, fracture healing was assessed via biomechanical testing (three-point bending), histological cartilage:callus ratio, and bone mineral density (BMD) with quantitative computed tomography. RESULTS No biomechanical difference was detected between dogs that received no carprofen and those that received 2 weeks of carprofen or between those that received 2 weeks vs 8 weeks of carprofen. Stiffness (P = .035) and maximum stress (P = .042) were higher in dogs that received no carprofen than in those that received 8 weeks of carprofen. Radiographic healing did not differ between dogs without carprofen and those with 2-week administration of carprofen (P = .9923). However, tibias of dogs without carprofen and those with 2-week administration of carprofen were more healed compared with those in the 8-week-carprofen group at 4 and 8 weeks after surgery (P = .0011). No treatment effect was detected by cartilage:callus ratio or BMD. CONCLUSION Long-term administration of carprofen had a negative effect on bone healing compared with short-term or no administration of carprofen. CLINICAL SIGNIFICANCE Nonsteroidal anti-inflammatory drugs should be used cautiously in dogs at risk for delayed bone healing, and administration should be discontinued beyond the perioperative period in dogs with fractures or osteotomies.
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Affiliation(s)
- Hayley M Gallaher
- Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi
| | - James R Butler
- Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi
| | - Robert W Wills
- Department of Pathobiology and Population Medicine, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi
| | - Lauren B Priddy
- Department of Agricultural and Biological Engineering, Bagley College of Engineering, Mississippi State University, Mississippi State, Mississippi
| | - Steven H Elder
- Department of Agricultural and Biological Engineering, Bagley College of Engineering, Mississippi State University, Mississippi State, Mississippi
| | - Sarah M Heller
- Department of Agricultural and Biological Engineering, Bagley College of Engineering, Mississippi State University, Mississippi State, Mississippi
| | - Erin Brinkman
- Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi
| | - Wes Baumgartner
- Department of Pathobiology and Population Medicine, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi
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Abstract
PURPOSE OF REVIEW This paper describes recent advances in understanding the mechanisms that drive fracture pain and how these findings are helping develop new therapies to treat fracture pain. RECENT FINDINGS Immediately following fracture, mechanosensitive nerve fibers that innervate bone are mechanically distorted. This results in these nerve fibers rapidly discharging and signaling the initial sharp fracture pain to the brain. Within minutes to hours, a host of neurotransmitters, cytokines, and nerve growth factor are released by cells at the fracture site. These factors stimulate, sensitize, and induce ectopic nerve sprouting of the sensory and sympathetic nerve fibers which drive the sharp pain upon movement and the dull aching pain at rest. If rapid and effective healing of the fracture occurs, these factors return to baseline and the pain subsides, but if not, these factors can drive chronic bone pain. New mechanism-based therapies have the potential to fundamentally change the way acute and chronic fracture pain is managed.
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Affiliation(s)
- Stefanie A T Mitchell
- Department of Pharmacology, University of Arizona, 1501 N. Campbell Ave., PO Box 245050, Tucson, AZ, 85724, USA
| | - Lisa A Majuta
- Department of Pharmacology, University of Arizona, 1501 N. Campbell Ave., PO Box 245050, Tucson, AZ, 85724, USA
| | - Patrick W Mantyh
- Department of Pharmacology, University of Arizona, 1501 N. Campbell Ave., PO Box 245050, Tucson, AZ, 85724, USA.
- Cancer Center, University of Arizona, Tucson, AZ, 85724, USA.
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Hegde V, Jo JE, Andreopoulou P, Lane JM. Effect of osteoporosis medications on fracture healing. Osteoporos Int 2016; 27:861-871. [PMID: 26419471 DOI: 10.1007/s00198-015-3331-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 09/17/2015] [Indexed: 01/19/2023]
Abstract
Antiosteoporotic medications are often used to concurrently treat a patient's fragility fractures and underlying osteoporosis. This review evaluates the existing literature from animal and clinical models to determine these drugs' effects on fracture healing. The data suggest that these medications may enhance bone healing, yet more thorough prospective studies are warranted. Pharmacologic agents that influence bone remodeling are an essential component of osteoporosis management. Because many patients are first diagnosed with osteoporosis when presenting with a fragility fracture, it is critical to understand how osteoporotic medications influence fracture healing. Vitamin D and its analogs are essential for the mineralization of the callus and may also play a role in callus formation and remodeling that enhances biomechanical strength. In animal models, antiresorptive medications, including bisphosphonates, denosumab, calcitonin, estrogen, and raloxifene, do not impede endochondral fracture healing but may delay repair due to impaired remodeling. Although bisphosphonates and denosumab delay callus remodeling, they increase callus volume and result in unaltered biomechanical properties. Calcitonin increases cartilage formation and callus maturation, resulting in improved biomechanical properties. Parathyroid hormone, an anabolic agent, has demonstrated promise in animal models, resulting in accelerated healing with increased callus volume and density, more rapid remodeling to mature bone, and improved biomechanical properties. Clinical data with parathyroid hormone have demonstrated enhanced healing in distal radius and pelvic fractures as well as postoperatively following spine surgery. Strontium ranelate, which may have both antiresorptive and anabolic properties, affects fracture healing differently in normal and osteoporotic bone. While there is no effect in normal bone, in osteoporotic bone, strontium ranelate increases callus bone formation, maturity, and mineralization; forms greater and denser trabeculae; and improves biomechanical properties. Further clinical studies with these medications are needed to fully understand their effects on fracture healing in order to simultaneously treat fragility fractures and underlying osteoporosis.
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Affiliation(s)
- V Hegde
- Department of Orthopaedic Surgery, University of California Los Angeles, 100 UCLA Medical Plaza, Suite 755, Los Angeles, CA, 90095, USA
| | - J E Jo
- Weill Cornell Medical College, 445 E 69th St, New York, NY, 10021, USA.
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 475 East 72nd Street, Ground Floor, New York, NY, 10021, USA.
- , 2900 Main St. Apt 332, Bridgeport, CT, 06606, USA.
| | - P Andreopoulou
- Department of Endocrinology, Hospital for Special Surgery, 519 East 72nd St, Suite 202, New York, NY, 10021, USA
| | - J M Lane
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 475 East 72nd Street, Ground Floor, New York, NY, 10021, USA
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Qazi SM, Sindby EJ, Nørgaard MA. Ibuprofen - a Safe Analgesic During Cardiac Surgery Recovery? A Randomized Controlled Trial. J Cardiovasc Thorac Res 2015; 7:141-8. [PMID: 26702342 PMCID: PMC4685279 DOI: 10.15171/jcvtr.2015.31] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 11/05/2015] [Indexed: 12/22/2022] Open
Abstract
Introduction: Postoperative pain-management with non-steroid anti-inflammatory drugs has been controversial, due to related side-effects. We investigated whether there was a significant difference between an oxycodone-based pain-management regimen versus a slow-release ibuprofen based regimen, in a short term post-cardiac surgery setting. Particular attention was given to the rate of myocardial infarction, sternal healing, gastro-intestinal complications, renal failure and all-cause mortality.
Methods: This was a single-centre, open label parallel design randomised controlled study. Patients, who were undergoing cardiac surgery for the first time, were randomly allocated either to a regimen of slow-release oxycodone (10 mg twice daily) or slow-release ibuprofen (800 mg twice daily) combined with lansoprazole. Data relating to blood-tests, angiographies, surgical details and administered medicine were obtained from patient records. The follow-up period was 1 to 37 months (median 25 months).
Results: One hundred eighty-two patients were included in the trial and available for intention to treat analysis. There were no significant difference between the groups (P>0.05) in the rates of sternal healing, postoperative myocardial infarction or gastrointestinal bleeding. The preoperative levels of creatinine were found to increase by 100% in nine patients (9.6%) in the ibuprofen group, resulting in an acute renal injury (in accordance with the RIFLE-criteria). Eight of these patients returned to normal renal function within 14 days. The levels of creatinine in patients in the oxycodone group were not found to increase to the same magnitude.
Conclusion: The results of this study suggest that patients treated postoperatively, following cardiac surgery, are at no greater risk of harm if short term slow release ibuprofen combined with lansoprazole treatment is used when compared to an oxycodone based regimen. Renal function should, however, be closely monitored and in the event of any decrease in renal function ibuprofen must be discontinued.
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Affiliation(s)
- Saddiq Mohammad Qazi
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Hobrovej 18-22 9000 Aalborg, Denmark
| | - Eske Jesper Sindby
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Hobrovej 18-22 9000 Aalborg, Denmark
| | - Martin Agge Nørgaard
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Hobrovej 18-22 9000 Aalborg, Denmark
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Fu LJ, Tang TT, Hao YQ, Dai KR. Long-term effects of alendronate on fracture healing and bone remodeling of femoral shaft in ovariectomized rats. Acta Pharmacol Sin 2013; 34:387-92. [PMID: 23459092 DOI: 10.1038/aps.2012.170] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM To investigate the long-term effects of alendronate (Aln), a widely used oral bisphosphonate, on fracture healing and bone remodeling in ovariectomized rats. METHODS Adult female SD rats underwent ovariectomy, and then bilateral femoral osteotomy at 12 weeks post-ovariectomy. From d 2 post-ovariectomy, the animals were divided into 3 groups, and treated with Aln (3 mg·kg(-1)·d(-1), po) for 28 weeks (Aln/Aln), Aln for 12 weeks and saline for 16 weeks (Aln/Saline) or saline for 28 weeks (Saline/Saline). At 6 and 16 weeks post-fracture, the fracture calluses were examined with X-ray radiography, and biomechanical testing and histological analysis were performed. The calluses were labeled with tetracycline and calcein to evaluate the mineral apposition rate (MAR). RESULTS The fracture line was less distinct in the 2 Aln-treated groups at 6 weeks post-fracture, and disappeared in all the 3 groups at 16 weeks post-fracture. The size of the callus and radiographic density of the femora in the Aln/Aln group were the highest among the 3 groups at 6 and 16 weeks post-fracture. Similar results were observed in the ultimate load at failure and energy absorption. However, the treatment with Aln delayed endochondral ossification of the callus, and significantly increased the total sagittal-sectional area, percentage callus area and callus thickness, and decreased the MAR at 6 and 16 weeks post-fracture. CONCLUSION In the ovariectomized rat model, Aln is beneficial for the mechanical properties of the callus, but delays callus remodeling by suppressing the remodeling of woven bone into lamellar bone.
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10
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Vitamin D deficiency in an athlete sustaining refracture after intramedullary screw fixation of a Jones fracture. CURRENT ORTHOPAEDIC PRACTICE 2013. [DOI: 10.1097/bco.0b013e3182793029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kurmis AP, Kurmis TP, O'Brien JX, Dalén T. The effect of nonsteroidal anti-inflammatory drug administration on acute phase fracture-healing: a review. J Bone Joint Surg Am 2012; 94:815-23. [PMID: 22552671 DOI: 10.2106/jbjs.j.01743] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The analgesic efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) is well established, and these agents often form an integral part of posttraumatic pain management. However, potentially deleterious effects of resulting prostaglandin suppression on fracture-healing have been suggested. METHODS A systematic literature review involving searches of electronic databases and online sources was performed to identify articles exploring the influence of NSAIDs on fracture-healing. RESULTS A structured search approach identified 316 papers as potentially relevant to the topic, and these were manually reviewed. The majority described small-scale studies that were retrospective or observational in nature, with limited control of potentially confounding variables, or presented little key information that was not also present in other studies. CONCLUSIONS Although increasing evidence from animal studies suggests that cyclooxygenase-2 (COX-2) inhibition suppresses early fracture-healing, in vivo studies involving human subjects have not provided convincing evidence to substantiate this concern. We found no robust evidence to attest to a significant and appreciable patient detriment resulting from the short-term use of NSAIDs following a fracture. The balance of evidence in the available literature appears to suggest that a short-duration NSAID regimen is a safe and effective supplement to other modes of post-fracture pain control, without a significantly increased risk of sequelae related to disrupted healing.
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Affiliation(s)
- Andrew P Kurmis
- Department of Orthopaedics, Repatriation General Hospital, Daws Road, Daw Park 5041, South Australia, Australia.
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Abstract
In competitive athletes, stress fractures of the tibia, foot, and ankle are common and lead to considerable delay in return to play. Factors such as bone vascularity, training regimen, and equipment can increase the risk of stress fracture. Management is based on the fracture site. In some athletes, metabolic workup and medication are warranted. High-risk fractures, including those of the anterior tibial diaphysis, navicular, proximal fifth metatarsal, and medial malleolus, present management challenges and may require surgery, especially in high-level athletes who need to return to play quickly. Noninvasive treatment modalities such as pulsed ultrasound and extracorporeal shock wave therapy may have some benefit but require additional research.
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13
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Yasui M, Shiraishi Y, Ozaki N, Hayashi K, Hori K, Ichiyanagi M, Sugiura Y. Nerve growth factor and associated nerve sprouting contribute to local mechanical hyperalgesia in a rat model of bone injury. Eur J Pain 2011; 16:953-65. [DOI: 10.1002/j.1532-2149.2011.00094.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2011] [Indexed: 01/23/2023]
Affiliation(s)
- M. Yasui
- Department of Functional Anatomy and Neuroscience; Nagoya University Graduate School of Medicine; Nagoya; Japan
| | - Y. Shiraishi
- Department of Judo Physical Therapy, Faculty of Health Care; Teikyo Heisei University; Tokyo; Japan
| | - N. Ozaki
- Department of Functional Anatomy; Kanazawa University Graduate School of Medical Science; Kanazawa; Japan
| | | | - K. Hori
- Department of Functional Anatomy; Kanazawa University Graduate School of Medical Science; Kanazawa; Japan
| | | | - Y. Sugiura
- Aichi Prefectural Colony; Kasugai; Japan
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14
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Treatment of lumbar pars interarticularis stress injuries in athletes with intravenous bisphosphonates: five case studies. Clin J Sport Med 2011; 21:141-3. [PMID: 21358506 DOI: 10.1097/jsm.0b013e31820f8f62] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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15
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Dodwell ER, Latorre JG, Parisini E, Zwettler E, Chandra D, Mulpuri K, Snyder B. NSAID exposure and risk of nonunion: a meta-analysis of case-control and cohort studies. Calcif Tissue Int 2010; 87:193-202. [PMID: 20552333 DOI: 10.1007/s00223-010-9379-7] [Citation(s) in RCA: 134] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Accepted: 03/28/2010] [Indexed: 02/01/2023]
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used for postoperative pain control. However, concerns regarding the potential deleterious effects of NSAIDs on bone healing have compelled many physicians to avoid NSAIDs in patients with healing fractures, osteotomies, and fusions. We systematically reviewed and analyzed the best clinical evidence regarding the effects of NSAID exposure on bone healing. Medline, Embase, and Cochrane electronic databases were searched for prospective and retrospective clinical studies of fracture, osteotomy, and fusion studies of patients with NSAID exposure and nonunion as an outcome. Study quality was assessed using the Newcastle-Ottawa Scale. Data on study design, patient characteristics, and risk estimates were extracted. Pooled effect estimates were calculated. Subanalyses were performed by bone type and by NSAID dose, duration, and route of administration. In the initial analysis of 11 cohort and case-control studies, the pooled odds ratio for nonunion with NSAID exposure was 3.0 (95% confidence interval 1.6-5.6). A significant association between lower-quality studies and higher reported odds ratios for nonunion was observed. When only higher-quality studies were considered, seven spine fusion studies were analyzed, and no statistically significant association between NSAID exposure and nonunion was identified (odds ratio = 2.2, 95% confidence interval 0.8-6.3). There was no increased risk of nonunion with NSAID exposure when only the highest-quality studies were assessed. Randomized controlled trials assessing NSAID exposure in fracture, fusion, and osteotomy populations are warranted to confirm or refute the findings of this meta-analysis of observational studies.
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Affiliation(s)
- Emily R Dodwell
- Harvard School of Public Health, Harvard University, Boston, MA, USA.
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16
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Abstract
Stress fracture represents an overuse injury of the bone resulting from excessive repetitive stress. Diagnosis in most cases is based on clinical evaluation. Plain radiographs may show characteristic changes 2 to 4 weeks from onset of symptoms. Increasingly, magnetic resonance imaging is recognized as the study of choice in the evaluation of stress injury of the bone. Most stress fractures at low-risk sites can be managed in the primary care setting with conservative measures. From a primary care perspective, orthopedic or sports medicine consultation is considered for stress fractures at high-risk sites. This article reviews general principles of diagnosis and management of stress fractures in adolescents.
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17
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Ziltener JL, Leal S, Fournier PE. Non-steroidal anti-inflammatory drugs for athletes: an update. Ann Phys Rehabil Med 2010; 53:278-82, 282-8. [PMID: 20363203 DOI: 10.1016/j.rehab.2010.03.001] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Accepted: 12/30/2009] [Indexed: 10/19/2022]
Abstract
Sports medicine physicians often treat athletes in pain with non-steroidal anti-inflammatory drugs (NSAIDs). However, there is a lack of high-quality evidence to guide NSAID use. Their adverse effects have clinical relevance, and their possible negative consequences on the long-term healing process are slowly becoming more obvious. This article provides some practical management guidelines for the use of NSAIDs, developed to help sports medicine physicians deal with frequent sports-related injuries. We do not recommend their use for muscle injuries, bone fractures (also stress fractures) or chronic tendinopathy. In all cases, if chosen, NSAID treatments should always be kept as short as possible and should take into account the specific type of injury, the level of dysfunction and pain.
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Affiliation(s)
- J-L Ziltener
- Unité orthopédie et traumatologie du sport, département de chirurgie, hôpitaux universitaires de Genève, 1211 Genève, Switzerland.
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18
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Urrutia J, Briceno J, Carmona M, Olavarria F, Hodgson F. Effect of a single dose of pamidronate administered at the time of surgery in a rabbit posterolateral spinal fusion model. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2010; 19:940-4. [PMID: 20127496 DOI: 10.1007/s00586-010-1288-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Revised: 01/11/2010] [Accepted: 01/15/2010] [Indexed: 11/27/2022]
Abstract
Spinal fusion is usually performed on patients who receive bisphosphonates (BP); however, limited data on their action on spinal fusion are available. Previous studies in animal models have shown that chronic administrations of BP reduced spinal fusion rates, and only one study has shown that a single dose administration of zolendronic acid increased fusion rate. The objective of the present study was to evaluate if pamidronate (PA), which was previously demonstrated to reduce spinal fusion rate when administered continuously for 8 weeks, would increase the spinal fusion rate if administered in a single dose at the time of surgery in a rabbit model. Thirty-two New Zealand rabbits underwent an L5-L6 posterolateral intertransverse fusion with iliac crest autograft. Animals were randomized to receive either PA 3 mg/kg in a single dose immediately after surgery, or normal saline. Animals were killed 8 weeks after surgery and fusion was determined by manual palpation and radiographic analysis. Fusion healing was obtained in eight rabbits (50%) in the PA group and in four animals (25%) in the control group, p = 0.137. In a rabbit model, a single dose of PA did not decrease lumbar spinal arthrodesis consolidation rates, but it obtained a nonsignificant higher spinal fusion rate.
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Affiliation(s)
- Julio Urrutia
- Department of Orthopaedic Surgery, Pontificia Universidad Catolica de Chile, Marcoleta 352, Santiago, Chile.
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19
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Abstract
BACKGROUND Injections into or adjacent to soft tissue structures, including muscle, tendon, bursa, and fascia, for pain relief and an earlier return to play have become common in the field of sports medicine. STUDY DESIGN Clinical review. RESULTS Corticosteroids, local anesthetics, and ketorolac tromethamine (Toradol) are the most commonly used injectable agents in athletes. The use of these injectable agents have proven efficacy in some disorders, whereas the clinical benefit for others remain questionable. All soft tissue injections performed for pain control and/or an anti-inflammatory effect have potentially serious side effects, which must be considered, especially in the pregame setting. CONCLUSIONS The primary concern regarding corticosteroid and local anesthetic injections is an increased risk of tendon rupture associated with the direct injection into the tendon. Intramuscular Toradol injections provide significant analgesia, as well as an anti-inflammatory effect via its inhibitory effect on the cyclooxygenase pathway. The risk of bleeding associated with Toradol use is recognized but not accurately quantified.
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20
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Capsaicin-sensitive sensory nerve fibers contribute to the generation and maintenance of skeletal fracture pain. Neuroscience 2009; 162:1244-54. [PMID: 19486928 DOI: 10.1016/j.neuroscience.2009.05.065] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Revised: 05/21/2009] [Accepted: 05/25/2009] [Indexed: 11/22/2022]
Abstract
Although skeletal pain can have a marked impact on a patient's functional status and quality of life, relatively little is known about the specific populations of peripheral nerve fibers that drive non-malignant bone pain. In the present report, neonatal male Sprague-Dawley rats were treated with capsaicin or vehicle and femoral fracture was produced when the animals were young adults (15-16 weeks old). Capsaicin treatment, but not vehicle, resulted in a significant (>70%) depletion in the density of calcitonin-gene related peptide positive (CGRP(+)) sensory nerve fibers, but not 200 kDa neurofilament H positive (NF200(+)) sensory nerve fibers in the periosteum. The periosteum is a thin, cellular and fibrous tissue that tightly adheres to the outer surface of all but the articulated surface of bone and appears to play a pivotal role in driving fracture pain. In animals treated with capsaicin, but not vehicle, there was a 50% reduction in the severity, but no change in the time course, of fracture-induced skeletal pain-related behaviors as measured by spontaneous flinching, guarding and weight bearing. These results suggest that both capsaicin-sensitive (primarily CGRP(+) C-fibers) and capsaicin-insensitive (primarily NF200(+) A-delta fibers) sensory nerve fibers participate in driving skeletal fracture pain. Skeletal pain can be a significant impediment to functional recovery following trauma-induced fracture, osteoporosis-induced fracture and orthopedic surgery procedures such as knee and hip replacement. Understanding the specific populations of sensory nerve fibers that need to be targeted to inhibit the generation and maintenance of skeletal pain may allow the development of more specific mechanism-based therapies that can effectively attenuate acute and chronic skeletal pain.
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21
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Shima Y, Engebretsen L, Iwasa J, Kitaoka K, Tomita K. Use of bisphosphonates for the treatment of stress fractures in athletes. Knee Surg Sports Traumatol Arthrosc 2009; 17:542-50. [PMID: 19048230 DOI: 10.1007/s00167-008-0673-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Accepted: 11/05/2008] [Indexed: 12/14/2022]
Abstract
A literature review was performed to investigate the potential role of bisphosphonates for the treatment of stress fractures in athletes. Given the inhibitory action on osteoclast-mediated bone resorption, short-term suppression of bone remodeling using bisphosphonates could potentially treat stress fractures and prevent stress fractures from becoming regular fractures. To date, while there are some animal studies showing the scientific basis of bisphosphonates on stress fractures, there is still no conclusive evidence to prove any effect of bisphosphonates on stress fracture healing in humans. Further well-designed clinical trials should be carried out to establish their usefulness and safety. Until the results are available, it is prudent to limit the use of bisphosphonates for the treatment of stress fractures.
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Affiliation(s)
- Yosuke Shima
- Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway.
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22
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Fu L, Tang T, Miao Y, Hao Y, Dai K. Effect of 1,25-dihydroxy vitamin D3 on fracture healing and bone remodeling in ovariectomized rat femora. Bone 2009; 44:893-8. [PMID: 19442605 DOI: 10.1016/j.bone.2009.01.378] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2008] [Revised: 12/27/2008] [Accepted: 01/18/2009] [Indexed: 10/21/2022]
Abstract
Osteoporosis is a major health problem characterized by compromised bone strength that predisposes patients to an increased risk of fracture, more and more investigations are focusing on the treatment of osteoporotic fracture healing. However, there are few studies elucidating the efficacy of vitamin D, 1,25-dihydroxy vitamin D(3) (1,25(OH)(2)D(3)), on osteoporotic fracture healing. In the present study we have established an osteoporotic fracture rat model to evaluate the effects of 1,25(OH)(2)D(3) on fracture healing. Female SD rats of six-month-old (n=40) allocated randomly into two groups were given ovariectomy. Bilateral midshaft femoral osteotomy was performed 12 weeks post-ovariectomy. Then treatment was begun at the second day after osteotomy and continued until sacrifice at 6 and 16 weeks post-fracture with middle chain triglyceride (MCT) vehicle and 1,25(OH)(2)D(3) at 0.1 microg/kg/day by oral gavage. Fracture callus was evaluated by soft X-ray radiography, micro-computed tomography (micro-CT), biomechanical testing and histology. Soft X-ray radiography, at 6 weeks post-fracture, showed a less distinct fracture line in the 1,25(OH)(2)D(3) group compared with the MCT-vehicle group, however, the fracture line was invisible in both groups at 16 weeks post-fracture. Micro-CT based histomorphometric data, at 6 weeks post-fracture, showed that the total volume of callus (TV) was approximately 23% higher in the 1,25(OH)(2)D(3) group than that in the MCT-vehicle group (P<0.001), and the new bone volume (BV), BV/TV, the trabecular number (Tb.N), and density of TV also showed the same trend. At 16 weeks post-fracture, the increment still existed as shown by Tb.Th and density of TV (P<0.001, vs control). Biomechanical testing data, at 6 weeks post-fracture, showed that the ultimate load at failure and energy absorption of the 1,25(OH)(2)D(3) group were nearly one fold higher than that of the MCT-vehicle group (P<0.001). At 16 weeks post-fracture, the ultimate load and energy absorption were also higher with the treatment of 1,25(OH)(2)D(3) (P<0.01 vs control). Histology showed that the fracture callus in the 1,25(OH)(2)D(3) group was remodeled better compared to the control group. In conclusion, 1,25(OH)(2)D(3) could promote fracture healing by improving the histomorphometric parameters, mechanical strength and tendency to increase transformation of woven bone into lamellar bone in an ovariectomized rat model.
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Affiliation(s)
- Lingjie Fu
- Department of Orthopaedic Surgery, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, PR China.
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23
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Abstract
Orthopedic trauma care and fracture management have advanced significantly over the last 50 years. New developments in the biology and biomechanics of the musculoskeletal system, fixation devices, and soft tissue management have greatly influenced our ability to care for musculoskeletal injuries. Many therapies and treatment modalities have the potential to transform future orthopedic treatment by decreasing invasive procedures and providing shorter healing times. Promising results in experimental models have led to an increase in clinical application of these therapies in human subjects. However, for many modalities, precise clinical indications, timing, dosage, and mode of action still need to be clearly defined. In order to further develop fracture management strategies, predict outcomes and improve clinical application of newer technologies, further research studies are needed. Together with evolving new therapies, the strategies to improve fracture care should focus on cost effectiveness. This is a great opportunity for the global orthopedic community, in association with other stakeholders, to address the many barriers to the delivery of safe, timely, and effective care for patients with musculoskeletal injuries in developing countries.
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Affiliation(s)
- George Mathew
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Ontario, Canada and AO Clinical Investigation, Zurich, Switzerland,Address for correspondence: Dr. George Mathew, Research Fellow, Division of Orthopaedic Surgery, McMaster University. E-mail:
| | - Beate P Hanson
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Ontario, Canada and AO Clinical Investigation, Zurich, Switzerland
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24
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Bove SE, Flatters SJL, Inglis JJ, Mantyh PW. New advances in musculoskeletal pain. ACTA ACUST UNITED AC 2008; 60:187-201. [PMID: 19166876 DOI: 10.1016/j.brainresrev.2008.12.012] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2008] [Indexed: 11/28/2022]
Abstract
Non-malignant musculoskeletal pain is the most common clinical symptom that causes patients to seek medical attention and is a major cause of disability in the world. Musculoskeletal pain can arise from a variety of common conditions including osteoarthritis, rheumatoid arthritis, osteoporosis, surgery, low back pain and bone fracture. A major problem in designing new therapies to treat musculoskeletal pain is that the underlying mechanisms driving musculoskeletal pain are not well understood. This lack of knowledge is largely due to the scarcity of animal models that closely mirror the human condition which would allow the development of a mechanistic understanding and novel therapies to treat this pain. To begin to develop a mechanism-based understanding of the factors involved in generating musculoskeletal pain, in this review we present recent advances in preclinical models of osteoarthritis, post-surgical pain and bone fracture pain. The models discussed appear to offer an attractive platform for understanding the factors that drive this pain and the preclinical screening of novel therapies to treat musculoskeletal pain. Developing both an understanding of the mechanisms that drive persistent musculoskeletal pain and novel mechanism-based therapies to treat these unique pain states would address a major unmet clinical need and have significant clinical, economic and societal benefits.
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Affiliation(s)
- Susan E Bove
- Department of Neurosciences Biology, Pfizer Global Research and Development, Groton Laboratories, Groton, CT, USA
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25
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26
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Novicoff WM, Manaswi A, Hogan MV, Brubaker SM, Mihalko WM, Saleh KJ. Critical analysis of the evidence for current technologies in bone-healing and repair. J Bone Joint Surg Am 2008; 90 Suppl 1:85-91. [PMID: 18292362 DOI: 10.2106/jbjs.g.01521] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Substances that enhance fracture-healing and bone regeneration have valuable clinical application and merit future research. Advances in these technologies will enhance our ability to heal fractures in a more effective and expedient manner. This review provides a brief description of the different techniques and technologies and their respective clinical utility. This paper also reviews the available literature on gene therapy, tissue engineering, growth factors, osteoconductive agents, and physical forces and assesses the evidence regarding the current status of these techniques of healing and regenerating bone. Only twenty-seven articles met our guidelines for studies containing Level-I evidence. We were able to determine that atrophic nonunions and pseudarthrosis led to poorer outcomes, and the results were uniformly poor irrespective of the technique used. Although the literature contains a large number of studies on the effects of different agents and modalities on bone repair and healing, it still is not clear how these agents work or in what circumstances they should be used. Many of the treatment modalities of interest are still at an experimental stage, so good evidence to support clinical practice is lacking. Additional multicenter, prospective randomized studies are needed to define the indications, specifications, dosage, limitations, and contraindications in the treatment of nonunions. Studies are also needed to address the full clinical feasibility of the role of each modality in fracture-healing and repair.
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27
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Koewler NJ, Freeman KT, Buus RJ, Herrera MB, Jimenez-Andrade JM, Ghilardi JR, Peters CM, Sullivan LJ, Kuskowski MA, Lewis JL, Mantyh PW. Effects of a monoclonal antibody raised against nerve growth factor on skeletal pain and bone healing after fracture of the C57BL/6J mouse femur. J Bone Miner Res 2007; 22:1732-42. [PMID: 17638576 DOI: 10.1359/jbmr.070711] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
UNLABELLED A closed femur fracture pain model was developed in the C57BL/6J mouse. One day after fracture, a monoclonal antibody raised against nerve growth factor (anti-NGF) was delivered intraperitoneally and resulted in a reduction in fracture pain-related behaviors of approximately 50%. Anti-NGF therapy did not interfere with bone healing as assessed by mechanical testing and histomorphometric analysis. INTRODUCTION Current therapies to treat skeletal fracture pain are limited. This is because of the side effect profile of available analgesics and the scarcity of animal models that can be used to understand the mechanisms that drive this pain. Whereas previous studies have shown that mineralized bone, marrow, and periosteum are innervated by sensory and sympathetic fibers, it is not understood how skeletal pain is generated and maintained even in common conditions such as osteoarthritis, low back pain, or fracture. MATERIALS AND METHODS In this study, we characterized the pain-related behaviors after a closed femur fracture in the C57BL/6J mouse. Additionally, we assessed the effect of a monoclonal antibody that binds to and sequesters nerve growth factor (anti-NGF) on pain-related behaviors and bone healing (mechanical properties and histomorphometric analysis) after fracture. RESULTS Administration of anti-NGF therapy (10 mg/kg, days 1, 6, and 11 after fracture) resulted in a reduction of fracture pain-related behaviors of approximately 50%. Attenuation of fracture pain was evident as early as 24 h after the initial dosing and remained efficacious throughout the course of fracture pain. Anti-NGF therapy did not modify biomechanical properties of the femur or histomorphometric indices of bone healing. CONCLUSIONS These findings suggest that therapies that target NGF or its cognate receptor(s) may be effective in attenuating nonmalignant fracture pain without interfering with bone healing.
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Affiliation(s)
- Nathan J Koewler
- Neurosystems Center and Department of Diagnostic and Biological Sciences, University of Minnesota, Minneapolis, Minnesota, USA
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28
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Abstract
OBJECTIVES To determine whether patients with unexplained nonunions, patients with a history of multiple low-energy fractures with at least one progressing to a nonunion, and patients with a nonunion of a nondisplaced pubic rami or sacral ala fracture would have an underlying metabolic or endocrine abnormality that had not been previously diagnosed. DESIGN Case series. SETTING Tertiary referral center. PATIENTS AND INTERVENTION From a larger series of 683 consecutive patients with nonunion seen by us between January 1998 and December 2005, 37 patients were referred to 1 of 2 clinically practicing endocrinologists to undergo an evaluation for metabolic and endocrine abnormalities. The screening criteria were: 1) an unexplained nonunion that occurred despite adequate reduction and stabilization (and debridement in initially infected cases) without obvious technical error and without any other obvious etiology; 2) a history of multiple low-energy fractures with at least one progressing to a nonunion; or 3) a nonunion of a nondisplaced pubic rami or sacral ala fracture. RESULTS In all, 31 of the 37 patients (83.8%, 95% CI: 71.3% to 93.8%) who met our screening criteria had one or more new diagnoses of metabolic or endocrine abnormalities. The most common newly diagnosed abnormality was vitamin D deficiency (25 of 37 patients; 68%). Other newly diagnosed abnormalities included calcium imbalances, central hypogonadism, thyroid disorders, and parathyroid hormone disorders. All newly diagnosed abnormalities were treated medically. Eight patients who underwent no operative intervention following the diagnosis and treatment of a new metabolic or endocrine abnormality achieved bony union in an average of 7.6 months (range, 3 to 12 months) following their first visit to the endocrinologist. CONCLUSIONS Although our study does not prove a causal link between metabolic and endocrine abnormalities and either the development or healing of nonunions, 84% of the patients who met our screening criteria were found to have metabolic or endocrine abnormalities, and eight of our patients achieved bony union following medical treatment alone. All patients with nonunion who meet our screening criteria should be referred to an endocrinologist for evaluation because they are likely to have undiagnosed metabolic or endocrine abnormalities that may be interfering with bone healing.
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Affiliation(s)
- Mark R Brinker
- The Center for Problem Fractures and Limb Restoration, Fondren Orthopedic Group, Texas Orthopedic Hospital, TX, USA.
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29
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Jimenez-Andrade JM, Martin CD, Koewler NJ, Freeman KT, Sullivan LJ, Halvorson KG, Barthold CM, Peters CM, Buus RJ, Ghilardi JR, Lewis JL, Kuskowski MA, Mantyh PW. Nerve growth factor sequestering therapy attenuates non-malignant skeletal pain following fracture. Pain 2007; 133:183-96. [PMID: 17693023 DOI: 10.1016/j.pain.2007.06.016] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2007] [Revised: 05/08/2007] [Accepted: 06/15/2007] [Indexed: 11/21/2022]
Abstract
Current therapies to treat skeletal fracture pain are extremely limited. Some non-steroidal anti-inflammatory drugs have been shown to inhibit bone healing and opiates induce cognitive dysfunction and respiratory depression which are especially problematic in the elderly suffering from osteoporotic fractures. In the present report, we developed a closed femur fracture pain model in the mouse where skeletal pain behaviors such as flinching and guarding of the fractured limb are reversed by 10mg/kg morphine. Using this model we showed that the administration of a monoclonal antibody against nerve growth factor (anti-NGF) reduced fracture-induced pain-related behaviors by over 50%. Treatment with anti-NGF reduced c-Fos and dynorphin up-regulation in the spinal cord at day 2 post-fracture. However, anti-NGF treatment did not reduce p-ERK and c-Fos expression at 20 and 90 min, respectively, following fracture. This suggests NGF is involved in maintenance but not the acute generation of fracture pain. Anti-NGF therapy did not inhibit bone healing as measured by callus formation, bridging of the fracture site or mechanical strength of the bone. As the anti-NGF antibody does not appreciably cross the blood-brain barrier, the present data suggest that the anti-hyperalgesic action of anti-NGF therapy results from blockade of activation and/or sensitization of the CGRP/trkA positive fibers that normally constitute the majority of sensory fibers that innervate the bone. These results demonstrate that NGF plays a significant role in driving fracture pain and that NGF sequestering therapies may be efficacious in attenuating this pain.
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Affiliation(s)
- Juan M Jimenez-Andrade
- Neurosystems Center and Department of Diagnostic and Biological Sciences, University of Minnesota, Minneapolis, MN 55455, USA
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30
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Labovitz JM, Revill K. Osteoporosis: pathogenesis, new therapies and surgical implications. Clin Podiatr Med Surg 2007; 24:311-32. [PMID: 17430772 DOI: 10.1016/j.cpm.2006.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Many developments occurred in the realm of bone healing in recent years. Genetic discoveries, new proteins affecting bone health, and new treatments have steered our treatment of traumatic and iatrogenic fractures in new directions. Osteoporosis strikes many subsets of the world population, including: women, the elderly, and those suffering from arthritis, autoimmune diseases, HIV, and the immunocompromised. This disease predisposes people to an increased risk of low trauma and fragility fractures. The baby boomer generation and an increasing lifespan may burden the economy by creating such a large group susceptible to such a potentially devastating disease. The novel treatments and coping with the potentially challenging surgical implications will aide the podiatric physician in both medical and surgical management of osteoporosis.
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Affiliation(s)
- Jonathan M Labovitz
- West Los Angeles-Veterans Administration Medical Center, Los Angeles, and Samuel Meritt College of Podiatric Medicine, Oakland, CA 94609, USA.
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31
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LaBella CR. Common Acute Sports-Related Lower Extremity Injuries in Children and Adolescents. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2007. [DOI: 10.1016/j.cpem.2007.02.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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32
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Abstract
Stress fractures are a common occurrence in athletes, and the incidence of stress fractures in female Division 1 collegiate athletes is double that of men. Hormonal influences on bone and bone morphology may influence the risk for fracture. A high level of suspicion and special imaging procedures allow for accurate diagnosis of these fractures. In stress fractures that are associated with the female athlete triad, addressing the three aspects of the triad--eating disorders, amenorrhea, and osteoporosis--are critical for successful treatment. Preparticipation screening for the presence of signs of the female athlete triad by monitoring weight, energy level, menstrual cycles, and bone mineral density may help to prevent the occurrence of stress fractures in this population.
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Affiliation(s)
- David Feingold
- Division of Sports Medicine, Department of Orthopaedic Surgery, The David Geffen University of California Los Angeles School of Medicine, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
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