Molecular pathogenesis of fracture nonunion

The role of AKR1B10 in osteogenic differentiation of mesenchymal stem cells and atrophic nonunion

Atrophic nonunion is a chronic disease without effective medications. Here, high-throughput mRNA sequencing was used to explore the novel targets in atrophic nonunion. AKR1B10, a member of aldo-keto reductase family 1, is upregulated in atrophic nonunion tissues. There are currently no studies to reveal the role of AKR1B10 in atrophic nonunion. We used rat bone marrow-derived mesenchymal stem cells (BMSCs) to explore the effect of AKR1B10 on the osteogenic differentiation and autophagy. In vivo, we implanted collagen sponges loaded with LV-shAKR1B10-transduced BMSCs into rat fractured femurs to explore the role of AKR1B10 in fracture healing. The results showed that AKR1B10 reduced the activity of ALP, suppressed the expression of COL1A1, RUNX2 and OCN, and inhibited calcification deposition in osteogenically differentiated BMSCs. AKR1B10 reduced the expression of LC3II, decreased the number of autophagosomes, and promoted the expression of p62. In addition, the promoting effect of AKR1B10 knockdown on osteogenic differentiation of BMSCs was attenuated by 3-MA treatment. Implantation of collagen sponges found that knockdown of AKR1B10 promoted bone fracture healing. In conclusion, AKR1B10 inhibited the osteogenic differentiation and autophagy, and delayed the bone fracture healing. These results provide a new perspective on revealing the role of AKR1B10 in nonunion and may also provide a new therapeutic target for the treatment of nonunion.

An enhanced tri-layer bionic periosteum with gradient structure loaded by mineralized collagen for guided bone regeneration and in-situ repair

Severe fracture non-union often accompanied by damaged or even absent periosteum remains a significant challenge. This paper presents a novel tri-layer bionic periosteum with gradient structure and mineralized collagen (MC) mimics natural periosteum for in-situ repair and bone regeneration. The construct with ultrasonic polylactic acid as the loose outer fibrous layer (UPLA), poly(ε-caprolactone) as the intermediate barrier layer (PCL-M), and poly(ε-caprolactone)/MC as the inner osteoblastic layer (PM) was prepared. The physicochemical properties of layers were investigated. UPLA/PCL-M/PM exhibited a tensile strength (3.55 ± 0.23 MPa) close to that of natural periosteum and excellent adhesion between the layers. In vitro experiments demonstrated that all layers had no toxicity to cells. UPLA promoted inward growth of mouse fibroblasts. PCL-M with a uniform pore size (2.82 ± 0.05 μm) could achieve a barrier effect against fibroblasts according to the live/dead assay. Meanwhile, PM could effectively promote cell migration with high alkaline phosphatase expression and significant mineralization of the extracellular matrix. Besides, in vivo experiments showed that UPLA/PCL-M/PM significantly promoted the regeneration of bone and early angiogenesis. Therefore, this construct with gradient structure developed in this paper would have great application potential in the efficient and high-quality treatment of severe fractures with periosteal defects.

Fueling recovery: The importance of energy coupling between angiogenesis and osteogenesis during fracture healing

Approximately half of bone fractures that do not heal properly (non-union) can be accounted to insufficient angiogenesis. The processes of angiogenesis and osteogenesis are spatiotemporally regulated in the complex process of fracture healing that requires a substantial amount of energy. It is thought that a metabolic coupling between angiogenesis and osteogenesis is essential for successful healing. However, how this coupling is achieved remains to be largely elucidated. Here, we will discuss the most recent evidence from literature pointing towards a metabolic coupling between angiogenesis and osteogenesis. We will describe the metabolic profiles of the cell types involved during fracture healing as well as secreted products in the bone microenvironment (such as lactate and nitric oxide) as possible key players in this metabolic crosstalk.

Recent trends of stem cell therapies in The management of orthopedic surgical challenges

Emerged health-related problems especially with increasing population and with the wider occurrence of these issues have always put the utmost concern and led medicine to outgrow its usual mode of treatment, to achieve better outcomes. Orthopedic interventions are one of the most concerning hitches, requiring advancement in several issues, that show complications with conventional approaches. Advanced studies have been undertaken to address the issue, among which stem cell therapy emerged as a better area of growth. The capacity of the stem cells to renovate themselves and adapt into different cell types made it possible to implement its use as a regenerative slant. Harvesting the stem cells, particularly mesenchymal stem cells is easier and can be further grown in vitro. In this review, we have discussed orthopedic-related issues including bone defects and fractures, non-unions, ligament and tendon injuries, degenerative changes, and associated conditions, which require further approaches to execute better outcomes, and the advanced strategies that can be tagged along with various ways of application of mesenchymal stem cells. It aims to objectify the idea of stem cells, with a major focus on the application of Mesenchymal stem cells (MSCs) from different sources in various orthopedic interventions. It also discusses the limitations, and future scopes for further approaches in the field of regenerative medicine. The involvement of mesenchymal stem cells may transition the procedures in orthopedic interventions from predominantly surgical substitution and reconstruction to bio-regeneration and prevention. Nevertheless, additional improvements and evaluations are required to explore the effectiveness and safety of mesenchymal stem cell treatment in orthopedic regenerative medicine.

Bioinformatics Analysis and Experimental Validation of Differential Genes and Pathways in Bone Nonunions

Non-union fractures pose a significant clinical challenge, often leading to prolonged pain and disability. Understanding the molecular mechanisms underlying non-union fractures is crucial for developing effective therapeutic interventions. This study integrates bioinformatics analysis and experimental validation to unravel key genes and pathways associated with non-union fractures. We identified differentially expressed genes (DEGs) between non-union and fracture healing tissues using bioinformatics techniques. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses were employed to elucidate the biological processes and pathways involved. Common DEGs were identified, and a protein-protein interaction (PPI) network was constructed. Fibronectin-1 (FN1), Thrombospondin-1 (THBS1), and Biglycan (BGN) were pinpointed as critical target genes for non-union fracture treatment. Experimental validation involved alkaline phosphatase (ALP) and Alizarin Red staining to confirm osteogenic differentiation. Our analysis revealed significant alterations in pathways related to cell behavior, tissue regeneration, wound healing, infection, and immune responses in non-union fracture tissues. FN1, THBS1, and BGN were identified as key genes, with their upregulation indicating potential disruptions in the bone remodeling process. Experimental validation confirmed the induction of osteogenic differentiation. The study provides comprehensive insights into the molecular mechanisms of non-union fractures, emphasizing the pivotal roles of FN1, THBS1, and BGN in extracellular matrix dynamics and bone regeneration. The findings highlight potential therapeutic targets and pathways for further investigation. Future research should explore interactions between these genes, validate results using in vivo fracture models, and develop tailored treatment strategies for non-union fractures, promising significant advances in clinical management.

Suppression of DNMT2/3 by proinflammatory cytokines inhibits CtBP1/2-dependent genes to promote the occurrence of atrophic nonunion

Failure of bone healing after fracture often results in nonunion, but the underlying mechanism of nonunion pathogenesis is poorly understood. Herein, we provide evidence to clarify that the inflammatory microenvironment of atrophic nonunion (AN) mice suppresses the expression levels of DNA methyltransferases 2 (DNMT2) and 3A (DNMT3a), preventing the methylation of CpG islands on the promoters of C-terminal binding protein 1/2 (CtBP1/2) and resulting in their overexpression. Increased CtBP1/2 acts as transcriptional corepressors that, along with histone acetyltransferase p300 and Runt-related transcription factor 2 (Runx2), suppress the expression levels of six genes involved in bone healing: BGLAP (bone gamma-carboxyglutamate protein), ALPL (alkaline phosphatase), SPP1 (secreted phosphoprotein 1), COL1A1 (collagen 1a1), IBSP (integrin binding sialoprotein), and MMP13 (matrix metallopeptidase 13). We also observe a similar phenomenon in osteoblast cells treated with proinflammatory cytokines or treated with a DNMT inhibitor (5-azacytidine). Forced expression of DNMT2/3a or blockage of CtBP1/2 with their inhibitors can reverse the expression levels of BGLAP/ALPL/SPP1/COL1A1/IBSP/MMP13 in the presence of proinflammatory cytokines. Administration of CtBP1/2 inhibitors in fractured mice can prevent the incidence of AN. Thus, we demonstrate that the downregulation of bone healing genes dependent on proinflammatory cytokines/DNMT2/3a/CtBP1/2-p300-Runx2 axis signaling plays a critical role in the pathogenesis of AN. Disruption of this signaling may represent a new therapeutic strategy to prevent AN incidence after bone fracture.

Accumulation of advanced glycation end products promotes atrophic nonunion incidence in mice through a CtBP1/2-dependent mechanism

Atrophic nonunion (AN) is a complex and poorly understood pathological condition resulting from impaired fracture healing. Advanced glycation end products (AGEs) have been implicated in the pathogenesis of several bone disorders, including osteoporosis and osteoarthritis. However, the role of AGEs in the development of AN remains unclear. This study found that mice fed a high-AGE diet had a higher incidence of atrophic nonunion (AN) compared to mice fed a normal diet following tibial fractures. AGEs induced two C-terminal binding proteins (CtBPs), CtBP1 and CtBP2, which were necessary for the development of AN in response to AGE accumulation. Feeding a high-AGE diet after fracture surgery in CtBP1/2-/- and RAGE-/- (receptor of AGE) mice did not result in a significant occurrence of AN. Molecular investigation revealed that CtBP1 and CtBP2 formed a heterodimer that was recruited by histone deacetylase 1 (HDAC1) and runt-related transcription factor 2 (Runx2) to assemble a complex. The CtBP1/2-HDAC1-Runx2 complex was responsible for the downregulation of two classes of bone development and differentiation genes, including bone morphogenic proteins (BMPs) and matrix metalloproteinases (MMPs). These findings demonstrate that AGE accumulation promotes the incidence of AN in a CtBP1/2-dependent manner, possibly by modulating genes related to bone development and fracture healing. These results provide new insights into the pathogenesis of AN and suggest new therapeutic targets for its prevention and treatment.

The promotive role of USP1 inhibition in coordinating osteogenic differentiation and fracture healing during nonunion

BACKGROUND

Nonunion is a failure of fracture healing and a major complication after fractures. Ubiquitin-specific protease 1 (USP1) is a deubiquitinase that involved in cell differentiation and cell response to DNA damage. Herein we investigated the expression, function and mechanism of USP1 in nonunion.

METHODS AND RESULTS

Clinical samples were used to detect the USP1 expression in nonunion. ML323 was selected to inhibit USP1 expression throughout the study. Rat models and mouse embryonic osteoblasts cells (MC3T3-E1) were used to investigate the effects of USP1 inhibition on fracture healing and osteogenesis in vivo and in vitro, respectively. Histological changes were examined by micro-computerized tomography (Micro-CT), hematoxylin & eosin (H&E) staining and Masson staining. Alkaline phosphatase (ALP) activity detection and alizarin red staining were used for osteogenic differentiation observation. The expression of related factors was detected by quantitative real-time PCR, western blot or immunohistochemistry (IHC). It was shown that USP1 was highly expressed in nonunion patients and nonunion rats. USP1 inhibition by ML323 promoted fracture healing in nonunion rats and facilitated the expression of osteogenesis-related factors and the signaling of PI3K/Akt pathway. In addition, USP1 inhibition accelerated osteogenic differentiation and promoting PI3K/Akt signaling in MC3T3-E1 cells.

CONCLUSIONS

USP1 inhibition plays a promotive role in coordinating osteogenic differentiation and fracture healing during nonunion. PI3K/Akt may be the downstream pathway of USP1.

The role of macrophages in fracture healing: a narrative review of the recent updates and therapeutic perspectives

Objective

This review addresses the latest advances in research on the role of macrophages in fracture healing, exploring their relationship with failures in bone consolidation and the perspectives for the development of advanced and innovative therapies to promote bone regeneration.

Background

The bone can fully restore its form and function after a fracture. However, the regenerative process of fracture healing is complex and is influenced by several factors, including macrophage activity. These cells have been found in the fracture site at all stages of bone regeneration, and their general depletion or the knockdown of receptors that mediate their differentiation, polarization, and/or function result in impaired fracture healing.

Methods

The literature search was carried out in the PubMed database, using combinations of the keywords "macrophage", "fracture healing, "bone regeneration", and "bone repair". Articles published within the last years (2017-2022) reporting evidence from in vivo long bone fracture healing experiments were included.

Conclusions

Studies published in the last five years on the role of macrophages in fracture healing strengthened the idea that what appears to be essential when it comes to a successful consolidation is the right balance between the M1/M2 populations, which have different but complementary roles in the process. These findings opened promising new avenues for the development of several macrophage-targeted therapies, including the administration of molecules and/or biomaterials intended to regulate macrophage differentiation and polarization, the local transplantation of macrophage precursors, and the use of exosomes to deliver signaling molecules that influence macrophage activities. However, more research is still warranted to better understand the diversity of macrophage phenotypes and their specific roles in each step of fracture healing and to decipher the key molecular mechanisms involved in the in vivo crosstalk between macrophages and other microenvironmental cell types, such as endothelial and skeletal stem/progenitor cells.

Three-Dimensional Computational Model Simulating the Initial Callus Growth during Fracture Healing in Long Bones: Application to Different Fracture Types

Bone fractures are among the most common and potentially serious injuries to the skeleton, femoral shaft fractures being especially severe. Thanks to recent advances in the area of in silico analysis, several approximations of the bone healing process have been achieved. In this context, the objective of this work was to simulate the initial phase of callus formation in long bones, without a pre-meshed domain in the 3D space. A finite element approach was computationally implemented to obtain the values of the cell concentrations along the whole domain and evaluate the areas where the biological quantities reached the thresholds necessary to trigger callus growth. A voxel model was used to obtain the 3D domain of the bone fragments and callus. A mesh growth algorithm controlled the addition of new elements to the domain at each step of the iterative procedure until complete callus formation. The implemented approach is able to reproduce the generation of the primary callus, which corresponds to the initial phase of fracture healing, independently of the fracture type and complexity, even in the case of several bone fragments. The proposed approach can be applied to the most complex bone fractures such as oblique, severely comminuted or spiral-type fractures, whose simulation remains hardly possible by means of the different existing approaches available to date.

Irisin promotes fracture healing by improving osteogenesis and angiogenesis

Background

Osteogenesis and angiogenesis are important for bone fracture healing. Irisin is a muscle-derived monokine that is associated with bone formation.

Methods

To demonstrate the effect of irisin on bone fracture healing, closed mid-diaphyseal femur fractures were produced in 8-week-old C57BL/6 mice. Irisin was administrated intraperitoneally every other day after surgery, fracture healing was assessed by using X-rays. Bone morphometry of the fracture callus were assessed by using micro-computed tomography. Femurs of mice from each group were assessed by the three-point bending testing. Effect of irisin on osteogenic differentiation in mesenchymal stem cells in vitro was evaluated by quantitative real-time polymerase chain reaction (qRT-PCR), alkaline phosphatase staining and alizarin red staining. Angiogenesis of human umbilical vein endothelial cells (HUVECs) were evaluated by qRT-PCR, migration tests, and tube formation assays.

Results

Increased callus formation, mineralization and tougher fracture healing were observed in the irisin-treated group than in the control group, indicating the better fracture callus healing due to Irisin treatment. The vessel surface and vessel volume fraction of the callus also increased in the irisin-treated group. The expression of BMP2, CD31, and VEGF in callus were enhanced in the irisin-treated group. In mouse bone mesenchymal stem cells, irisin promoted ALP expression and mineralization, and increased the expression of osteogenic genes, including OSX, Runx2, OPG, ALP, OCN and BMP2. Irisin also promoted HUVEC migration and tube formation. Expression of angiogenic genes, including ANGPT1, ANGPT2, VEGFb, CD31, FGF2, and PDGFRB in HUVECs were increased by irisin.

Conclusion

All the results indicate irisin can promote fracture healing through osteogenesis and angiogenesis. These findings help in the understanding of muscle–bone interactions during fracture healing.

The Translational Potential of this Article

Irisin was one of the most important monokine secreted by skeletal muscle. Studies have found that irisin have anabolic effect one bone remodeling through affecting osteocyte and osteoblast. Based on our study, irisin could promote bone fracture healing by increasing bone mass and vascularization, which provide a potential usage of irisin to promote fracture healing and improve clinical outcomes.

Aucubin promotes bone-fracture healing via the dual effects of anti-oxidative damage and enhancing osteoblastogenesis of hBM-MSCs

Background

Aucubin (AU), an iridoid glucoside isolated from many traditional herbal medicines, has anti-osteoporosis and anti-apoptosis bioactivities. However, the effect of AU on the treatment of bone-fracture remains unknown. In the present study, the aims were to investigate the roles and mechanisms of AU not only on osteoblastogenesis of human bone marrow-derived mesenchymal stromal cells (hBM-MSCs) and anti-oxidative stress injury in vitro, but also on bone-fracture regeneration by a rat tibial fracture model in vivo.

Methods

CCK-8 assay was used to assess the effect of AU on the viability and proliferation of hBM-MSCs. The expression of specific genes and proteins on osteogenesis, apoptosis and signaling pathways was measured by qRT-PCR, western blotting and immunofluorescence analysis. ALP staining and quantitative analysis were performed to evaluate ALP activity. ARS and quantitative analysis were performed to evaluate calcium deposition. DCFH-DA staining was used to assess the level of reactive oxygen species (ROS). A rat tibial fracture model was established to validate the therapeutic effect of AU in vivo. Micro-CT with quantitative analysis and histological evaluation were used to assess the therapeutic effect of AU locally injection at the fracture site.

Results

Our results revealed that AU did not affect the viability and proliferation of hBM-MSCs. Compared with control group, western blotting, PCR, ALP activity and calcium deposition proved that AU-treated groups promoted osteogenesis of hBM-MSCs. The ratio of phospho-Smad1/5/9 to total Smad also significantly increased after treatment of AU. AU-induced expression of BMP2 signaling target genes BMP2 and p-Smad1/5/9 as well as of osteogenic markers COL1A1 and RUNX2 was downregulated after treating with noggin and LDN193189. Furthermore, AU promoted the translocation of Nrf2 from cytoplasm to nucleus and the expression level of HO1 and NQO1 after oxidative damage. In a rat tibial fracture model, local injection of AU promoted bone regeneration.

Conclusions

Our study demonstrates the dual effects of AU in not only promoting bone-fracture healing by regulating osteogenesis of hBM-MSCs partly via canonical BMP2/Smads signaling pathway but also suppressing oxidative stress damage partly via Nrf2/HO1 signaling pathway.

Inflammation-dependent activation of NCOA2 associates with p300 and c-MYC/Max heterodimer to transactivate RUNX2-AS1 and mediate RUNX2 downstream bone differentiation genes in the pathology of septic nonunion

Septic nonunion (SN) is a common bone disorder caused by the failure of fracture healing. Local inflammation in fracture sites often causes SN; however, little is known about the molecular mechanisms of SN pathology. Herein, we identified a significant upregulation of the long non-coding RNA (lncRNA) RUNX2-AS1 (Runt-related Transcription Factor 2-Antisense 1) in the biopsies of SN patients. Overexpression or knockdown of RUNX2-AS1 in vitro could inhibit or induce, respectively, the expression of RUNX2 and RUNX2-downstream target genes, including ALPL (Alkaline Phosphatase), COL1A1 (Collagen Type I Alpha 1 Chain), IBSP (Integrin Binding Sialoprotein), MMP13 (Matrix Metallopeptidases), and SPP1 (Secreted Phosphoprotein 1), which are involved in bone differentiation. Mechanically, we demonstrated that a transcription factor c-MYC could assemble a transcriptional complex with its partner Max, a histone acetyltransferase p300, and nuclear receptor coactivator 2 (NCOA2), and this complex then bound to the promoter of RUNX2-AS1 to transactivate its expression. The mRNA and protein levels of NCOA2 were dose-dependently increased by treatment with lipopolysaccharide(LPS), a well-known inflammation trigger. LPS exposure increased the enrichment of the NCOA2-p300-c-MYC/Max complex on the RUNX2-AS1 promoter to activate its expression, thereby downregulating the expression of RUNX2 and RUNX2-downstream target genes. Depletion of NCOA2 reversed the expression of RUNX2-AS1, RUNX2, and RUNX2 target genes following LPS exposure. Taken together, our results demonstrate a new signaling pathway that contributes to the pathology of SN and may aid in preventing SN progression.

Modern genetic and immunological aspects of the pathogenesis of impaired consolidation of fractures (literature review)

The aim of this article is to analyze the genetic and immunological mechanisms of the development of fracture consolidation disorders at the present scientific stage.

Materials and methods. The search for literary sources was carried out in the open electronic databases of scientific literature PubMed and eLIBRARY. Search depth – 10 years.

Results. The review analyzes the literature data on the current state of the study of the molecular genetic mechanisms of reparative regeneration including the development of fracture consolidation disorders. The mechanisms of the most important links of pathogenesis which most often lead to various violations of the processes of bone tissue repair are considered.

Conclusion. The process of bone tissue repair is multifaceted, and many factors are involved in its implementation, however, we would like to note that the leading role in the course of reparative regeneration is played by a personalized genetically programmed response to this pathological condition. Nevertheless, despite the undeniable progress of modern medicine in studying the processes of bone recovery after a fracture, there are still many “white” spots in this issue, which dictates the need for further comprehensive study in order to effectively treat patients with impaired consolidation.

Polyostotic Fibrous Dysplasia Complicated by Pathological Fracture of Right Femoral Shaft with Nonunion: A Case Report

Introduction

Fibrous dysplasia is a benign fibrous bone tumor that accounts for 5% to 10% of benign bone tumors. It can manifest as simple fibrous dysplasia (70%–80%), polyostotic fibrous dysplasia (20%–30%), with approximately the same incidence in men and women. We report a patient with a rare case of multiple fibrous dysplasia combined with proximal femoral shepherd deformity with pathological fracture of the femoral shaft complicated by nonunion. It is necessary to understand the disease in more detail to avoid overtreatment of benign lesions or misdiagnosis of malignant tumors and other diseases.

Case presentation

A 58-year-old man with polyostotic fibrous dysplasia, bilateral proximal femur deformity, Shepherd’s angle deformity, right femoral shaft pathological fracture complicated by nonunion, we under fluoroscopy, in the obvious proximal fracture, take osteotomy, and process the shape of the cut bone fragment to adapt it to the corrected force line, and then restore it back to its original position, using intramedullary nailing technology complete the operation. Three months after the operation, he came to the hospital for re-examination, and an X-ray of the right femur was taken. It was found that the fractured end had a tendency to heal. The patient was instructed to gradually bear weight. After six months of re-examination, the patient could walk with a walker. One year after the operation, the patient could walk without a walker and take care of himself at home. However, there was still stretch-like pain in the right lower back, but it was tolerable.

Conclusions

For patients with polyostotic fibrous dysplasia combined with proximal femoral shepherd deformity and pathological fracture of the femoral shaft with nonunion, osteotomy combined with intramedullary nailing is a simple and convenient way to correct the deformity and obtain correct fracture alignment.

In Sickness and in Health: The Oxygen Reactive Species and the Bone

Oxidative stress plays a central role in physiological and pathological bone conditions. Its role in signalment and control of bone cell population differentiation, activity, and fate is increasingly recognized. The possibilities of its use and manipulation with therapeutic goals are virtually unending. However, how redox balance interplays with the response to mechanical stimuli is yet to be fully understood. The present work summarizes current knowledge on these aspects, in an integrative and broad introductory perspective.

A new approach for initial callus growth during fracture healing in long bones

The incidence of bone fracture has become a major clinical problem on a worldwide scale. In the past two decades there has been an increase in the use of computational tools to analyse the bone fracture problem. In several works, various study cases have been analysed to compare human and animal bone fracture healing. Unfortunately, there are not many publications about computational advances in this field and the existing approaches to the problem are usually similar. In this context, the objective of this work is the application of a diffusion problem in the model of the bone fragments resulting from fracture, working together with a mesh-growing algorithm that allows free growth of the callus depending on the established conditions, without a pre-meshed domain. The diffusion problem concerns the different biological magnitudes controlling the callus growth, among which Mesenchymal Stem Cells and chondrocytes concentrations were chosen, together with Tumour Necrosis Factor α and Bone Morphogenetic Protein as the factors influencing the velocity in the callus formation. A Finite Element approach was used to solve the corresponding diffusion problems, obtaining the concentration values along the entire domain and allowing detecting the zones in which biological magnitudes reach the necessary thresholds for callus growth. The callus growth is guided by a geometrical algorithm which performs an additional mesh generation process (self-added mesh) at each step of the iterative procedure until complete callus formation. The proposed approach was applied to different types of diaphyseal femoral fractures treated by means of intramedullary nailing. Axisymmetric models based on triangular quadratic elements were used, obtaining results in good agreement with clinical evidence of these kinds of fractures. The algorithm proposed has the advantage of a natural callus growth, without the existence of a previous mesh that may affect the conditions and direction of growth. The approach is intended for the initial phase of callus growth. Future work will address the implementation of the corresponding formulations for tissue transformation and bone remodelling in order to achieve complete fracture healing.

The Role of Adenosine Receptor A2A in the Regulation of Macrophage Exosomes and Vascular Endothelial Cells During Bone Healing

Background

Macrophage exosomes and vascular endothelial cells (VECs) are critical to bone healing. However, few studies explore the molecular regulation of them in the bone fracture microenvironment.

Methods

In this study, we explored the effects of adenosine receptor A2A (ADA2AR) in macrophage exosomes and VECs during bone healing. CGS21680 (an ADA2AR agonist) and ZM241385 (an ADA2AR antagonist) were used. First, the effects of the ADA2AR on VECs during bone healing were studied in vivo in a rat tibial fracture model. Second, the effects of ADA2AR on VECs and in the regulation of VECs by macrophages were examined in the bone fracture microenvironment. Third, the effects of ADA2AR on the regulation of macrophage exosomes on VECs were analyzed. Finally, the genes and long non-coding RNAs (lncRNAs) associated with the regulation of VECs by the ADA2AR were examined by high-throughput sequencing and bioinformatics analysis.

Results

CGS21680 accelerated VEC proliferation in the early stage of bone healing and that ZM241385 suppressed VEC proliferation in vivo. ZM241385 inhibited cell viability and tube formation in vitro. However, CGS21680 did not promote tube formation, cell proliferation, or cell migration in vitro. The inhibition of macrophage exosomes could suppress tube formation and VEC migration. CGS21680 had no effects on tube formation in a macrophage-VEC co-culture. The macrophage exosomes were purified and CGS21680 promoted the macrophage secretion of exosomes. In contrast, ZM241385 inhibited the macrophage secretion exosomes. Finally, the lncRNA and mRNA involved in the activation of the ADA2AR in VECs were analyzed. CGS21680 upregulated 3274 mRNAs and downregulated 2236 mRNAs, and upregulated 1696 lncRNAs and downregulated 1882 lncRNAs. The hub genes involved in angiogenesis were Flt1, Fgf2, Mapk14, Fn1, and Jun.

Conclusion

The activation of ADA2AR was essential for angiogenesis and the secretion of exosomes by macrophages during bone healing; moreover, the inactivation of the ADA2AR led to poor angiogenesis and bone nonunion.

Targeting angiogenesis for fracture nonunion treatment in inflammatory disease

Atrophic fracture nonunion poses a significant clinical problem with limited therapeutic interventions. In this study, we developed a unique nonunion model with high clinical relevance using serum transfer-induced rheumatoid arthritis (RA). Arthritic mice displayed fracture nonunion with the absence of fracture callus, diminished angiogenesis and fibrotic scar tissue formation leading to the failure of biomechanical properties, representing the major manifestations of atrophic nonunion in the clinic. Mechanistically, we demonstrated that the angiogenesis defect observed in RA mice was due to the downregulation of SPP1 and CXCL12 in chondrocytes, as evidenced by the restoration of angiogenesis upon SPP1 and CXCL12 treatment in vitro. In this regard, we developed a biodegradable scaffold loaded with SPP1 and CXCL12, which displayed a beneficial effect on angiogenesis and fracture repair in mice despite the presence of inflammation. Hence, these findings strongly suggest that the sustained release of SPP1 and CXCL12 represents an effective therapeutic approach to treat impaired angiogenesis and fracture nonunion under inflammatory conditions.

Low-dose IL-34 has no effect on osteoclastogenesis but promotes osteogenesis of hBMSCs partly via activation of the PI3K/AKT and ERK signaling pathways

Background

Inflammatory microenvironment is significant to the differentiation and function of mesenchymal stem cells (MSCs). It evidentially influences the osteoblastogenesis of MSCs. IL-34, a newly discovered cytokine, playing a key role in metabolism. However, the research on its functional role in the osteogenesis of MSCs was rarely reported. Here, we described the regulatory effects of low-dose IL-34 on both osteoblastogenesis and osteoclastogenesis.

Methods

We performed the osteogenic effects of hBMSCs by exogenous and overexpressed IL-34 in vitro, so were the osteoclastogenesis effects of mBMMs by extracellular IL-34. CCK-8 was used to assess the effect of IL-34 on the viability of hBMSCs and mBMMs. ALP, ARS, and TRAP staining was used to evaluate ALP activity, mineral deposition, and osteoclastogenesis, respectively. qRT-PCR and Western blotting analysis were performed to detect the expression of target genes and proteins. ELISA was used to evaluate the concentrations of IL-34. In vivo, a rat tibial osteotomy model and an OVX model were established. Radiographic analysis and histological evaluation were performed to confirm the therapeutic effects of IL-34 in fracture healing and osteoporosis. Statistical differences were evaluated by two-tailed Student’s t test, one-way ANOVA with Bonferroni’s post hoc test, and two-way ANOVA with Bonferroni multiple comparisons post hoc test in the comparison of 2 groups, more than 2 groups, and different time points of treated groups, respectively.

Results

Promoted osteoblastogenesis of hBMSCs was observed after treated by exogenous or overexpressed IL-34 in vitro, confirmed by increased mineral deposits and ALP activity. Furthermore, exogenous or overexpressed IL-34 enhanced the expression of p-AKT and p-ERK. The specific AKT and ERK signaling pathway inhibitors suppressed the enhancement of osteoblastogenesis induced by IL-34. In a rat tibial osteotomy model, imaging and histological analyses testified the local injection of exogenous IL-34 improved bone healing. However, the additional IL-34 has no influence on both osteoclastogenesis of mBMMs in vitro and osteoporosis of OVX model of rat in vivo.

Conclusions

Collectively, our study demonstrate that low-dose IL-34 regulates osteogenesis of hBMSCs partly via the PIK/AKT and ERK signaling pathway and enhances fracture healing, with neither promoting nor preventing osteoclastogenesis in vitro and osteoporosis in vivo.

Nanomaterial Nitric Oxide Delivery in Traumatic Orthopedic Regenerative Medicine

Achieving bone fracture union after trauma represents a major challenge for the orthopedic surgeon. Fracture non-healing has a multifactorial etiology and there are many risk factors for non-fusion. Environmental factors such as wound contamination, infection, and open fractures can contribute to non-healing, as can patient specific factors such as poor vascular status and improper immunologic response to fracture. Nitric oxide (NO) is a small, neutral, hydrophobic, highly reactive free radical that can diffuse across local cell membranes and exert paracrine functions in the vascular wall. This molecule plays a role in many biologic pathways, and participates in wound healing through decontamination, mediating inflammation, angiogenesis, and tissue remodeling. Additionally, NO is thought to play a role in fighting wound infection by mitigating growth of both Gram negative and Gram positive pathogens. Herein, we discuss recent developments in NO delivery mechanisms and potential implications for patients with bone fractures. NO donors are functional groups that store and release NO, independent of the enzymatic actions of NOS. Donor molecules include organic nitrates/nitrites, metal-NO complexes, and low molecular weight NO donors such as NONOates. Numerous advancements have also been made in developing mechanisms for localized nanomaterial delivery of nitric oxide to bone. NO-releasing aerogels, sol- gel derived nanomaterials, dendrimers, NO-releasing micelles, and core cross linked star (CCS) polymers are all discussed as potential avenues of NO delivery to bone. As a further target for improved fracture healing, 3d bone scaffolds have been developed to include potential for nanoparticulated NO release. These advancements are discussed in detail, and their potential therapeutic advantages are explored. This review aims to provide valuable insight for translational researchers who wish to improve the armamentarium of the feature trauma surgeon through use of NO mediated augmentation of bone healing.

Conditioned media from endothelial progenitor cells cultured in simulated microgravity promote angiogenesis and bone fracture healing

Background

Paracrine signaling from endothelial progenitor cells (EPCs) is beneficial for angiogenesis and thus promotes tissue regeneration. Microgravity (MG) environment is found to facilitate the functional potentials of various stem or progenitor cells. The present study aimed to elucidate the effects of MG on pro-angiogenic properties and fracture repair capacities of conditioned media (CM) from EPCs.

Methods

Human peripheral blood-derived EPCs were cultured under MG or normal gravity (NG) followed by analysis for angiogenic gene expression. Furthermore, the serum-free CM under MG (MG-CM) or NG (NG-CM) were collected, and their pro-angiogenic properties were examined in human umbilical vein endothelial cells (HUVECs). In order to investigate the effects of MG-CM on fracture healing, they were injected into the fracture gaps of rat models, and radiography, histology, and mechanical test were performed to evaluate neovascularization and fracture healing outcomes.

Results

MG upregulated the expression of hypoxia-induced factor-1α (HIF-1α) and endothelial nitric oxide synthase (eNOS) and promoted NO release. Comparing to NG-CM, MG-CM significantly facilitated the proliferation, migration, and angiogenesis of HUVECs through NO-induced activation of FAK/Erk1/2-MAPK signaling pathway. In addition, MG-CM were verified to improve angiogenic activities in fracture area in a rat tibial fracture model, accelerate fracture healing, and well restore the biomechanical properties of fracture bone superior to NG-CM.

Conclusion

These findings provided insight into the use of MG bioreactor to enhance the angiogenic properties of EPCs’ paracrine signals via HIF-1α/eNOS/NO axis, and the administration of MG-CM favored bone fracture repair.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13287-020-02074-y.

Nanohydroxyapatite/polyamide 66 crosslinked with QK and BMP-2-derived peptide prevented femur nonunion in rats

A dual-peptide controlled released system based on nHA/PA66 scaffold for enhancing bone regeneration.

Pediatric aseptic lower leg fracture nonunion

PURPOSE

Lower leg nonunion in pediatric patients is a rarity. Therefore, eight European pediatric trauma units retrospectively analyzed all patients younger than 18 years suffering lower leg fractures resulting in aseptic nonunion.

METHODS

Thirteen children and adolescents less than 18 years old (2 girls and 11 boys) diagnosed with aseptic nonunion of the tibia and/or fibula were evaluated. In all patients, epidemiological data, mechanism of injury, fracture configuration, and the initial treatment concept were assessed, and the entire medical case documentation was observed. Furthermore, potential causes of nonunion development were evaluated.

RESULTS

The mean age of patients was 12.3 years with the youngest patient being seven and the oldest being 17 years old. Open fractures were found in six out of thirteen patients (46%). Nonunion was hypertrophic in ten and oligotrophic in three patients. Mean range of time to nonunion occurrence was 7.3 ± 4.6 months. Nonunion healing resulting in complete metal removal was found in 12 out of 13 patients (92%), only in one case of a misinterpreted CPT type II osseous consolidation could not be found during the observation period. Mean range of time between surgical nonunion revision and osseous healing was 7.3 months as well.

CONCLUSION

If treatment principles of the growing skeleton are followed consistently, aseptic nonunion of the lower leg remains a rare complication in children and adolescents. Factors influencing the risk of fracture nonunion development include patient's age, extended soft tissue damage, relevant bone loss, and inadequate initial treatment.

3D printing-assisted percutaneous fixation makes the surgery for scaphoid nonunion more accurate and less invasive

Purpose

The study was to explore whether the 3-dimensional printing guiding plate system could facilitate the modified procedure for arthroscopic treatment of nondisplaced scaphoid nonunion.

Methods

Patients, diagnosed with scaphoid nonunion without displacement, were randomly assigned into two groups. In Group A, the 3-dimensional printing guiding plate system was used for guiding fixation during the surgery. In Group B, fixation was performed with intra-operative fluoroscopy. The bone operation time was recorded during the surgery. The patients were evaluated before surgery and followed-up after six post-operative months, including motion ratio, strength ratio, Visual Analogue Scale, modified Mayo Scores, Patient Rated Wrist Evaluation scores, plain radiography and CT scan.

Results

Sixteen patients were recruited for the study. The average bone operation time in Group A was statistically shorter than that in Group B.

Conclusions

3-dimensional printing technique-assisted arthroscopic bone graft and fixation of scaphoid nonunion constitute an effective and accurate clinical treatment option.

The translational potential of this article

The concept and technique of 3D printing assisted percutaneous fixation introduced in this paper have the potential to be applied in a variety of operations requiring accurate percutaneous fixation, especially for the joint injuries.

Bone Microvasculature: Stimulus for Tissue Function and Regeneration

Bone is a highly vascularized organ, providing structural support to the body, and its development, regeneration, and remodeling depend on the microvascular homeostasis. Loss or impairment of vascular function can develop diseases, such as large bone defects, avascular necrosis, osteoporosis, osteoarthritis, and osteopetrosis. In this review, we summarize how vasculature controls bone development and homeostasis in normal and disease cases. A better understanding of this process will facilitate the development of novel disease treatments that promote bone regeneration and remodeling. Specifically, approaches based on tissue engineering components, such as stem cells and growth factors, have demonstrated the capacity to induce bone microvasculature regeneration and mineralization. This knowledge will have relevant clinical implications for the treatment of bone disorders by developing novel pharmaceutical approaches and bone grafts. Finally, the tissue engineering approaches incorporating vascular components may widely be applied to treat other organ diseases by enhancing their regeneration capacity. Impact statement Bone vasculature is imperative in the process of bone development, regeneration, and remodeling. Alterations or disruption of the bone vasculature leads to loss of bone homeostasis and the development of bone diseases. In this study, we review the role of vasculature on bone diseases and how vascular tissue engineering strategies, with a detailed emphasis on the role of stem cells and growth factors, will contribute to bone therapeutics.

NSM00158 Specifically Disrupts the CtBP2-p300 Interaction to Reverse CtBP2-Mediated Transrepression and Prevent the Occurrence of Nonunion

Carboxyl-terminal binding proteins (CtBPs) are transcription regulators that control gene expression in multiple cellular processes. Our recent findings indicated that overexpression of CtBP2 caused the repression of multiple bone development and differentiation genes, resulting in atrophic nonunion. Therefore, disrupting the CtBP2-associated transcriptional complex with small molecules may be an effective strategy to prevent nonunion. In the present study, we developed an in vitro screening system in yeast cells to identify small molecules capable of disrupting the CtBP2-p300 interaction. Herein, we focus our studies on revealing the in vitro and in vivo effects of a small molecule NSM00158, which showed the strongest inhibition of the CtBP2-p300 interaction in vitro. Our results indicated that NSM00158 could specifically disrupt CtBP2 function and cause the disassociation of the CtBP2-p300-Runx2 complex. The impairment of this complex led to failed binding of Runx2 to its downstream targets, causing their upregulation. Using a mouse fracture model, we evaluated the in vivo effect of NSM00158 on preventing nonunion. Consistent with the in vitro results, the NSM00158 treatment resulted in the upregulation of Runx2 downstream targets. Importantly, we found that the administration of NSM00158 could prevent the occurrence of nonunion. Our results suggest that NSM00158 represents a new potential compound to prevent the occurrence of nonunion by disrupting CtBP2 function and impairing the assembly of the CtBP2-p300-Runx2 transcriptional complex.

Epidemiology, Clinical Assessments, and Current Treatments of Nonunions

PURPOSE OF REVIEW

The failure of bony union following a fracture, termed a fracture nonunion, has severe patient morbidity and economic consequences. This review describes current consensuses and future directions of investigation for determining why, detecting when, and effective treatment if this complication occurs.

RECENT FINDINGS

Current nonunion investigation is emphasizing an expanded understanding of the biology of healing. This has led to assessments of the immune environment, multiple cytokines and morphogenetic factors, and the role of skeletogenic stem cells in the development of nonunion. Detecting biological markers and other objective diagnostic criteria is also a current objective of nonunion research. Treatment approaches in the near future will likely be dominated by the development of specific adjunct therapies to the nonunion surgical management, which will be informed by an expanded mechanistic understanding of nonunion biology. Current consensus among orthopedists is that improved diagnosis and treatment of nonunion hinges first on discoveries at the bench side with later translation to the clinic.

Bone restoration after revision hip arthroplasty with femoral bone defects using extensively porous-coated stems with cortical strut allografts

Background

Stress shielding and bone loss of the femur are of great concern after revision total hip arthroplasty (THA) with extensively porous-coated stems, especially in a femur with already bone loss. The femoral bone remodeling patterns after revision THA with femoral bone defects using extensively porous-coated stems with cortical strut allografts remain unclear.

Methods

We retrospectively reviewed 47 patients who underwent revision THA using extensively porous-coated stems combined with cortical strut allografts and 75 patients without allografts. The minimum follow-up was 2 years. Femoral bone remodeling signs, including stress shielding, bone restoration in bone defect area, distal cortical hypertrophy, and femoral width, were compared between patients with and without cortical strut allografts. Clinical outcomes were also compared between two groups.

Results

Patients with cortical strut allografts showed less severe stress shielding (P = 0.01) than patients without allografts. Patients with allografts had more osseous restoration in bone defect area than patients without allografts (63.8% vs 30.7%, P < 0.001). Femoral width was significantly higher in femur with allografts than in femur without allografts at the immediate postoperative stage and latest follow-up (both P < 0.001). The hip function score, re-revision rate, and complications were comparable between two groups.

Conclusion

The application of cortical strut allografts can decrease the severity of stress shielding, augment osseous restoration in bone defect area and improve femoral bone stock after revision THA using extensively porous-coated stems.

Minimum 8-year follow-up of revision THA with severe femoral bone defects using extensively porous-coated stems and cortical strut allografts

Background

Revision total hip arthroplasty (THA) with severe femoral bone defects remains a major challenge. The purpose of this study is to report the minimum 8-year clinical and radiographic results of revision THA with severe femoral bone defects treated with extensively porous-coated stems and cortical strut allografts.

Methods

We retrospectively identified 44 patients diagnosed with Paprosky type III and IV femoral bone defects between January 2006 and July 2011. The exclusion criteria were patients not eligible for surgery, revised with extensively porous-coated stems alone, lost to follow-up and deceased. A total of 31 patients treated with extensively porous-coated stems and cortical strut allografts were finally included in this study. The degree of femoral bone defects was categorized as Paprosky type IIIA in 19 patients, type IIIB in 9 patients and type IV in 3 patients. The mean duration of follow-up was 11.0 ± 1.5 (range, 8.1–13.5) years.

Results

The mean Harris Hip Score improved significantly from 43.4 ± 10.5 points to 85.2 ± 6.6 points (P < 0.001). Similarly, WOMAC and SF-12 scores also significantly improved. Twenty-eight stems achieved stable bone ingrowth, two stems showed stable fibrous ingrowth, and one stem was radiologically unstable. Complete union and bridging between cortical strut allografts and host bone was achieved in all 31 patients. The femoral width was augmented with cortical strut allografts after revision surgery (an increase of 10.5 ± 0.5 mm) and showed a slight decrease of 2.5 ± 4.8 mm after the 10-year follow-up. Using re-revision for any reason as an endpoint, the Kaplan-Meier cumulative survival rate of the stem was 96.2% (95% confidence interval, 75.7–99.5%) at 10 years.

Conclusion

Our data demonstrate that the use of extensively porous-coated stems combined with cortical strut allografts in revision THA with Paprosky type III and IV femoral bone defects can provide satisfactory clinical and radiographic outcomes with a minimum follow-up of 8 years.

MiR-539-5p negatively regulates migration of rMSCs induced by Bushen Huoxue decoction through targeting Wnt5a

Bone fractures are very common, and above 5% of the fractures are impaired, leading to nonunions and severe disablilities. The traditional Chinese medicine Bushen Huoxue decoction (BHD) has been used to treat fracture in China. Our previous report has found that BHD promotes migration of rat mesenchymal stem cells (rMSCs) by activating Wnt5a signaling pathway. However, whether and how miRNAs are involved in modulating rMSCs migration induced by BHD has not been explored. In the present study, miRNA microarray analysis and further validation by real-time quantitative RT-PCR revealed that miR-539-5p was down-regulated in BHD-induced rMSCs. Transfection of miR-539-5p mimics suppressed rMSCs migration while the miR-539-5p inhibitor promoted rMSCs migration. Our results suggested that miR-539-5p was a negative regulator of migration of rMSCs induced by BHD. Target prediction analysis tools and Dual-luciferase reporter gene assay identified Wnt5a as a direct target of miR-539-5p. MiR-539-5p inhibited the expression of the Wnt5a and its downstream signaling molecules including JNK, PKC and CaMKII, which played a critical role in regulating migration of rMSCs. Taken together, our results demonstrate that miR-539-5p negatively regulates migration of rMSCs induced by BHD through targeting Wnt5a. These findings provide evidence that miR-539-5p should be considered as an important candidate target for the development of preventive or therapeutic approaches against bone nonunions.

Bioengineering application using co-cultured mesenchymal stem cells and preosteoclasts may effectively accelerate fracture healing

Fracture non-union is the most challenging complication following fracture injuries. Despite ongoing improvements in the surgical technique and implant design, the treatment efficacy of fracture non-union is still far from satisfactory and currently there is no optimal solution. Of all of the methods used for the treatment of non-union, bone tissue bioengineering using scaffolds and mesenchymal stem cells (MSCs) is the most widely studied and has emerged as a promising approach to address these challenges. However, there are several critical limitations, such as the low survival rate of MSCs under an inflammatory, ischemic environment. Accumulating studies have demonstrated that preosteoclasts not only play a role in the remodeling of the callus, but also participate in the entire process of fracture repair. The close crosstalk between preosteoclasts and MSCs stimulates the recruitment, proliferation, and differentiation of osteoblasts and improves the osteogenic differentiation of MSCs. With no in vivo study reported thus far, we hypothesize that the administration of preosteoclasts together with MSCs at a certain ratio may effectively accelerate fracture healing and provide a new and promising therapeutic strategy for the clinical management of fracture non-union.