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Brown MG, Brady DJ, Healy KM, Henry KA, Ogunsola AS, Ma X. Stem Cells and Acellular Preparations in Bone Regeneration/Fracture Healing: Current Therapies and Future Directions. Cells 2024; 13:1045. [PMID: 38920674 PMCID: PMC11201612 DOI: 10.3390/cells13121045] [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: 03/30/2024] [Revised: 05/25/2024] [Accepted: 06/12/2024] [Indexed: 06/27/2024] Open
Abstract
Bone/fracture healing is a complex process with different steps and four basic tissue layers being affected: cortical bone, periosteum, fascial tissue surrounding the fracture, and bone marrow. Stem cells and their derivatives, including embryonic stem cells, induced pluripotent stem cells, mesenchymal stem cells, hematopoietic stem cells, skeletal stem cells, and multipotent stem cells, can function to artificially introduce highly regenerative cells into decrepit biological tissues and augment the healing process at the tissue level. Stem cells are molecularly and functionally indistinguishable from standard human tissues. The widespread appeal of stem cell therapy lies in its potential benefits as a therapeutic technology that, if harnessed, can be applied in clinical settings. This review aims to establish the molecular pathophysiology of bone healing and the current stem cell interventions that disrupt or augment the bone healing process and, finally, considers the future direction/therapeutic options related to stem cells and bone healing.
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Affiliation(s)
- Marcel G. Brown
- Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
| | - Davis J. Brady
- Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
| | - Kelsey M. Healy
- Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
| | - Kaitlin A. Henry
- Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
| | - Ayobami S. Ogunsola
- Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
| | - Xue Ma
- Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
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Perut F, Roncuzzi L, Gómez-Barrena E, Baldini N. Association between Bone Turnover Markers and Fracture Healing in Long Bone Non-Union: A Systematic Review. J Clin Med 2024; 13:2333. [PMID: 38673606 PMCID: PMC11051214 DOI: 10.3390/jcm13082333] [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: 03/14/2024] [Revised: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Fracture healing is a very complex and well-orchestrated regenerative process involving many cell types and molecular pathways. Despite the high efficiency of this process, unsatisfying healing outcomes, such as non-union, occur for approximately 5-10% of long bone fractures. Although there is an obvious need to identify markers to monitor the healing process and to predict a potential failure in callus formation to heal the fracture, circulating bone turnover markers' (BTMs) utility as biomarkers in association with radiographic and clinical examination still lacks evidence so far. Methods: A systematic review on the association between BTMs changes and fracture healing in long bone non-union was performed following PRISMA guidelines. The research papers were identified via the PubMed, Cochrane, Cinahl, Web of Science, Scopus, and Embase databases. Studies in which the failure of fracture healing was associated with osteoporosis or genetic disorders were not included. Results: A total of 172 studies were collected and, given the inclusion criteria, 14 manuscripts were included in this review. Changes in circulating BTMs levels were detected during the healing process and across groups (healed vs. non-union patients and healthy vs. patients with non-union). However, we found high heterogeneity in patients' characteristics (fracture site, gender, and age) and in sample scheduling, which made it impossible to perform a meta-analysis. Conclusions: Clinical findings and radiographic features remain the two important components of non-union diagnosis so far. We suggest improving blood sample standardization and clinical data collection in future research to lay the foundations for the effective use of BTMs as tools for diagnosing non-union.
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Affiliation(s)
- Francesca Perut
- Biomedical Science and Technologies and Nanobiotechnology Laboratory, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (L.R.); (N.B.)
| | - Laura Roncuzzi
- Biomedical Science and Technologies and Nanobiotechnology Laboratory, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (L.R.); (N.B.)
| | - Enrique Gómez-Barrena
- Department of Orthopedic Surgery and Traumatology, Hospital Universitario La Paz-IdiPAZ, 28046 Madrid, Spain;
- Facultad de Medicina, Universidad Autónoma de Madrid, 28029 Madrid, Spain
| | - Nicola Baldini
- Biomedical Science and Technologies and Nanobiotechnology Laboratory, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (L.R.); (N.B.)
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40136 Bologna, Italy
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Yang J, Zhang X, Liang W, Chen G, Ma Y, Zhou Y, Fen R, Jiang K. Efficacy of adjuvant treatment for fracture nonunion/delayed union: a network meta-analysis of randomized controlled trials. BMC Musculoskelet Disord 2022; 23:481. [PMID: 35597937 PMCID: PMC9123731 DOI: 10.1186/s12891-022-05407-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/18/2022] [Indexed: 11/24/2022] Open
Abstract
Background Fracture nonunion/delayed union seriously affects physical and mental health and quality of life. The aim of this study was to evaluate the relative efficacy of different adjuvant treatments for nonunion/delayed union by network meta-analysis. Methods A comprehensive search was performed to identify randomized controlled trials (RCTs) evaluating adjuvant treatment in the management of nonunion/delayed union. A network meta-analysis reporting on healing rate, healing time, and adverse effect (AE) outcomes was conducted to assess and compare different interventions. Results Thirty studies were included in the analysis. For the healing rate outcome, bone marrow aspirate (BMA) + autologous cancellous bone (ACB) was found to be significantly better than ACB alone (odds ratio: 0.12; 95% confidence interval: 0.03, 0.59). In the ranking results, BMA+ platelet-rich plasma (PRP) (96%), BMA + ACB (90%), and BMA alone (82%) showed relative advantages in the healing rate. Low-intensity pulsed ultrasonography (LIUS) intervention significantly shortened the healing time compared with ACB (SMD: -9.26; 95% CI: − 14.64, − 3.87). LIUS (100%), BMA + PRP (74%), and bone morphogenetic proteins (BMPs) (69%) have relative advantages. Compared with the control, electromagnetic field (EMF) (OR: 13.21; 95% CI: 1.58, 110.40) and extracorporeal shock wave (ESWT) (OR: 4.90; 95% CI: 1.38, 17.43) had a higher AE risk. Conclusions Among the current intervention strategies, BMA in combination with PRP and ACB can improve the healing rate of nonunion/delayed union. LIUS can significantly shorten the healing time. EMF and ESWT may have a high risk of AE. However, large-scale, well-designed studies are still needed to confirm the results. Trial registration Retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05407-5.
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Affiliation(s)
- Jun Yang
- Department of Orthopedics and Traumatology, Yuxi Municipal Hospital of TCM, 53 Nie er Rd, Yuxi, Yunnan Province, 653100, People's Republic of China
| | - Xiangmin Zhang
- Department of Orthopedics and Traumatology, Yuxi Municipal Hospital of TCM, 53 Nie er Rd, Yuxi, Yunnan Province, 653100, People's Republic of China
| | - Wangbo Liang
- Department of Orthopedics and Traumatology, Yuxi Municipal Hospital of TCM, 53 Nie er Rd, Yuxi, Yunnan Province, 653100, People's Republic of China.
| | - Guo Chen
- Department of Orthopedics and Traumatology, Yuxi Municipal Hospital of TCM, 53 Nie er Rd, Yuxi, Yunnan Province, 653100, People's Republic of China.
| | - Yanbo Ma
- Department of Orthopedics and Traumatology, Yuxi Municipal Hospital of TCM, 53 Nie er Rd, Yuxi, Yunnan Province, 653100, People's Republic of China
| | - Yonghua Zhou
- Department of Orthopedics and Traumatology, Yuxi Municipal Hospital of TCM, 53 Nie er Rd, Yuxi, Yunnan Province, 653100, People's Republic of China
| | - Rong Fen
- Department of Orthopedics and Traumatology, Yuxi Municipal Hospital of TCM, 53 Nie er Rd, Yuxi, Yunnan Province, 653100, People's Republic of China
| | - Kaichang Jiang
- Department of Orthopedics and Traumatology, Yuxi Municipal Hospital of TCM, 53 Nie er Rd, Yuxi, Yunnan Province, 653100, People's Republic of China
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A pilot study of circulating levels of TGF-β1 and TGF-β2 as biomarkers of bone healing in patients with non-hypertrophic pseudoarthrosis of long bones. Bone Rep 2021; 16:101157. [PMID: 34950754 PMCID: PMC8671858 DOI: 10.1016/j.bonr.2021.101157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 11/20/2022] Open
Abstract
Background Pseudoarthrosis or non-union is a complication with an incidence of 5-10% of bone fractures, most frequently located in the diaphysis of long bones. The management of this complication is addressed by means of complex surgical procedures and is a concern for orthopaedic and trauma surgeons nowadays. The use of biomarkers for diagnosing patients at risk of non-union would help us to establish special measures for early corrective treatment. Methods Prospective exploratory pilot study with a cohort of 20 patients diagnosed of non-hypertrophic pseudoarthrosis of long bones who were treated surgically with either autologous bone graft or a Tissue Engineering Product composed of bone marrow-derived Mesenchymal Stromal Cells. Patients were followed for 12 months and plasma blood samples were obtained to determine circulating levels of Transforming Growth Factor Beta 1 and Beta 2 (TGF-β1 and TGF-β2, respectively) at inclusion, and at 1 week, 2 weeks, and months 1, 2, 3, 6 and 12 after surgery. Radiological bone healing was evaluated by the Tomographic Union Score (TUS). Results Basal levels of TGF-β1 and TGF-β2 were determined in the twenty patients (26,702 ± 14,537 pg/mL and 307.8 ± 83.1 pg/mL, respectively). Three of them withdrew from the study, so complete follow-up was conducted on 17 patients (9 successfully healed vs. 8 that did not heal). Statistically significant differences between the bone healing group and the non-union group were found at month 12 for both TGF-β1 (p = 0.005) and TGF-β2 (p = 0.02). Conclusions TGF-β1 and TGF-β2 are biomarkers that correlate with clinical evidence of bone regeneration and may be used to monitor patients, although early predictive value after intervention needs to be further studied in combination with other molecules.
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Liang W, Wu X, Dong Y, Chen X, Zhou P, Xu F. Mechanical stimuli-mediated modulation of bone cell function-implications for bone remodeling and angiogenesis. Cell Tissue Res 2021; 386:445-454. [PMID: 34665321 DOI: 10.1007/s00441-021-03532-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 09/21/2021] [Indexed: 12/20/2022]
Abstract
Bone remodeling, expressed as bone formation and turnover, is a complex and dynamic process closely related to its form and function. Different events, such as development, aging, and function, play a critical role in bone remodeling and metabolism. The ability of the bone to adapt to new loads and forces has been well known and has proven useful in orthopedics and insightful for research in bone and cell biology. Mechanical stimulation is one of the most important drivers of bone metabolism. Interestingly, different types of forces will have specific consequences in bone remodeling, and their beneficial effects can be traced using different biomarkers. In this narrative review, we summarize the major mediators and events in bone remodeling, focusing on the effects of mechanical stimulation on bone metabolism, cell populations, and ultimately, bone health.
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Affiliation(s)
- Wenqing Liang
- Department of Orthopaedics, Zhoushan Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University, 355 Xinqiao Road, Dinghai District, Zhoushan 316000, Zhejiang Province, People's Republic of China.
| | - Xudong Wu
- Department of Orthopaedics, Zhoushan Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University, 355 Xinqiao Road, Dinghai District, Zhoushan 316000, Zhejiang Province, People's Republic of China
| | - Yongqiang Dong
- Department of Orthopaedics, Xinchang People's Hospital, Shaoxing, 312500, Zhejiang Province, People's Republic of China
| | - Xuerong Chen
- Department of Orthopaedics, Shaoxing People's Hospital, Shaoxing Hospital, Zhejiang University School of Medicine, Shaoxing, 312000, Zhejiang Province, People's Republic of China
| | - Ping Zhou
- Department of Orthopaedics, Shaoxing People's Hospital, Shaoxing Hospital, Zhejiang University School of Medicine, Shaoxing, 312000, Zhejiang Province, People's Republic of China
| | - Fangming Xu
- Department of Orthopaedics, Zhoushan Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University, 355 Xinqiao Road, Dinghai District, Zhoushan 316000, Zhejiang Province, People's Republic of China.
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Elgaz S, Bonig H, Bader P. Mesenchymal stromal cells for osteonecrosis. J Transl Med 2020; 18:399. [PMID: 33081809 PMCID: PMC7576732 DOI: 10.1186/s12967-020-02565-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/10/2020] [Indexed: 12/24/2022] Open
Abstract
Osteonecrosis (ON) is an acquired debilitating skeletal disorder, which is caused by a multitude of traumatic and non-traumatic etiological factors. Vascular damage, mechanical stress and increased intraosseous pressure have been discussed as contributors to ON. The optimal treatment of ON remains to be determined, since the current gold standard, core decompression, is insufficiently effective. Specific properties of mesenchymal stromal cells (MSCs) provide the rationale for their assessment in advanced stages of ON: Osteoinductive potential has been demonstrated and MSC preparations of suitable quality for use as medicinal products have been developed. Here we review the scant information on the use of allogeneic or autologous MSCs in advanced ON as well as potentially supportive data from pre-clinical studies with autologous bone marrow mononuclear cells (auto BM-MNCs), which have been studied quite extensively and the presumed therapeutic effect of which was attributed to the rare MSCs contained in these cell products. Outcomes in clinical trials with MSCs and auto-BM-MNCs remain preliminary and non-definitive, at best promising, with respect to their pharmacological effect. Clearly, though, the application of any of these cell therapies was technically feasible and safe in that it was associated with low complication rates. The heterogeneity of cell type and source, study protocols, cell manufacturing, cell properties, cell doses and surgical techniques might contribute to inconsistent results.
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Affiliation(s)
- S Elgaz
- Department for Children and Adolescents, Division for Stem Cell Transplantation and Immunology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - H Bonig
- Institute of Transfusion Medicine and Immunohematology, and German Red Cross Blood Center Baden-Württemberg-Hessen, Goethe University, Frankfurt am Main, Germany
| | - P Bader
- Department for Children and Adolescents, Division for Stem Cell Transplantation and Immunology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
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Decreased Serum Pituitary Adenylate Cyclase Activating Polypeptide (PACAP) Levels May Reflect Disease Severity in Patients with Non-traumatic Osteonecrosis of Femoral Head. Int J Pept Res Ther 2020. [DOI: 10.1007/s10989-020-10098-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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RNA delivery by extracellular vesicles in mammalian cells and its applications. Nat Rev Mol Cell Biol 2020; 21:585-606. [PMID: 32457507 PMCID: PMC7249041 DOI: 10.1038/s41580-020-0251-y] [Citation(s) in RCA: 927] [Impact Index Per Article: 231.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2020] [Indexed: 02/06/2023]
Abstract
The term 'extracellular vesicles' refers to a heterogeneous population of vesicular bodies of cellular origin that derive either from the endosomal compartment (exosomes) or as a result of shedding from the plasma membrane (microvesicles, oncosomes and apoptotic bodies). Extracellular vesicles carry a variety of cargo, including RNAs, proteins, lipids and DNA, which can be taken up by other cells, both in the direct vicinity of the source cell and at distant sites in the body via biofluids, and elicit a variety of phenotypic responses. Owing to their unique biology and roles in cell-cell communication, extracellular vesicles have attracted strong interest, which is further enhanced by their potential clinical utility. Because extracellular vesicles derive their cargo from the contents of the cells that produce them, they are attractive sources of biomarkers for a variety of diseases. Furthermore, studies demonstrating phenotypic effects of specific extracellular vesicle-associated cargo on target cells have stoked interest in extracellular vesicles as therapeutic vehicles. There is particularly strong evidence that the RNA cargo of extracellular vesicles can alter recipient cell gene expression and function. During the past decade, extracellular vesicles and their RNA cargo have become better defined, but many aspects of extracellular vesicle biology remain to be elucidated. These include selective cargo loading resulting in substantial differences between the composition of extracellular vesicles and source cells; heterogeneity in extracellular vesicle size and composition; and undefined mechanisms for the uptake of extracellular vesicles into recipient cells and the fates of their cargo. Further progress in unravelling the basic mechanisms of extracellular vesicle biogenesis, transport, and cargo delivery and function is needed for successful clinical implementation. This Review focuses on the current state of knowledge pertaining to packaging, transport and function of RNAs in extracellular vesicles and outlines the progress made thus far towards their clinical applications.
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Cai C, Wang J, Huo N, Wen L, Xue P, Huang Y. Msx2 plays an important role in BMP6-induced osteogenic differentiation of two mesenchymal cell lines: C3H10T1/2 and C2C12. Regen Ther 2020; 14:245-251. [PMID: 32455154 PMCID: PMC7232041 DOI: 10.1016/j.reth.2020.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 02/27/2020] [Accepted: 03/11/2020] [Indexed: 12/21/2022] Open
Abstract
Bone morphogenetic proteins (BMPs), have been shown to enhance the osteogenic differentiation of mesenchymal cells (MCs) and to promote bone formation. BMP6 is known to play an important role in the process of MCs towards osteogenic differentiation by virtue of their osteoinductive and cell type specific proliferative activity. However, the molecular mechanism relate to BMP6 osteoinductive activity is still unclear and continues to warrant further investigation. Msx2 is a member of the homeobox gene family of transcription factors and promotes calcification. Hence, we wondered if it might also play a role in BMP6-induced osteogenesis. In this study, two mouse mesenchymal cell lines were treated with BMP6, adenovirus-Msx2 (Ad-Msx2) or adenovirus-siMsx2 (Ad-siMsx2). Based on the results of mRNA and protein expression, it was indicated that BMP6 could enhance the expression of Msx2 and activate the phosphorylation of Smad 1/5/8, p38 and ERK1/2. Being transfected by Ad-Msx2, the BMP6-induced activation of phosphorylation was significantly promoted. On the contrary, two cell lines transfected by Ad-siMsx2 presented an inhibited expression of three phosphorylated proteins even after being induced by BMP6. The evaluation of ALP, OPN, OC and calcium deposits revealed the osteogenic results those were corresponding to the results of mRNA and protein. Taken together, these findings can be a novel viewpoint for the understanding of the mechanisms of BMP6-induced osteogenesis and provide therapeutic targets of bone defect.
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Affiliation(s)
- Chuan Cai
- Department of Stomatology, The First Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Jing Wang
- Department of Stomatology, The First Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Na Huo
- Department of Stomatology, The First Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Li Wen
- Department of Stomatology, The First Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Peng Xue
- Department of Stomatology, The First Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Ye Huang
- Department of Dermatology, Air Force General Hospital of Chinese PLA, Beijing, 100412, China
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Xu K, Ma J, Liu Z, Wang X, Yan S, Liu Z, Sun F, Wang K. Effect of Sleeve Gastrectomy on Bone Metabolism and Serum 5-Hydroxytryptamine in Obese Rats. Med Sci Monit 2020; 26:e924097. [PMID: 32324718 PMCID: PMC7193245 DOI: 10.12659/msm.924097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Studies have shown that bariatric surgery, such as sleeve gastrectomy (SG), has an adverse effect on bone, including decreased bone mineral density (BMD) and bone metabolism. Peripheral 5-hydroxytryptamine (5-HT) has an adverse regulatory effect on bone formation. Here, we assessed changes in bone metabolism and whether 5-HT is involved in the effect of SG on bone metabolism. MATERIAL AND METHODS A rat model of obesity was established using Wistar rats. After successful modeling, rats were randomly assigned to 2 groups - the SG group and the Sham group - with 10 rats in each group. We then performed sleeve gastrectomy or sham operation. Bone metabolic markers and BMD of rats were measured at 2 and 16 weeks after the operation and the level of 5-HT in serum was determined. Rats were killed at 16 weeks after the operation, and bones of the hind limbs were harvested to measure 5-HT by immunofluorescence. RESULTS BMD was decreased and bone metabolism demonstrated a trend of bone destruction in the rats after SG. A significantly increasing trend in the level of serum 5-HT was found, and bone immunofluorescence showed increased expression of 5-HT. CONCLUSIONS BMD was decrease and bone metabolism demonstrated a trend of bone destruction after SG. SG can affect the level of 5-HT in serum or bone tissue and the 5-HT may be involved in the process through which SG affects bone metabolism.
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Affiliation(s)
- Kai Xu
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China (mainland).,Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China (mainland)
| | - Junxing Ma
- Gastrointestinal Surgery, Feicheng Hospital Affiliated to Shandong First Medical University, Feicheng People's Hospital, Feicheng, Shandong, China (mainland)
| | - Zhi Liu
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China (mainland)
| | - Xiaoyang Wang
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China (mainland)
| | - Shaohua Yan
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China (mainland).,Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China (mainland)
| | - Zitian Liu
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China (mainland).,Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China (mainland)
| | - Fuyun Sun
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China (mainland).,Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China (mainland)
| | - Kexin Wang
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China (mainland)
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