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Dai J, Wu Z, Liu Z, Li C, Zhu L, Chen H, Chen X. Sources and control of impurity during one-pot enzymatic production of dehydroepiandrosterone. Appl Microbiol Biotechnol 2024; 108:399. [PMID: 38951177 PMCID: PMC11217079 DOI: 10.1007/s00253-024-13221-3] [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: 01/29/2024] [Revised: 05/21/2024] [Accepted: 06/03/2024] [Indexed: 07/03/2024]
Abstract
Dehydroepiandrosterone (DHEA) has a promising market due to its capacity to regulate human hormone levels as well as preventing and treating various diseases. We have established a chemical esterification coupled biocatalytic-based scheme by lipase-catalyzed 4-androstene-3,17-dione (4-AD) hydrolysis to obtain the intermediate product 5-androstene-3,17-dione (5-AD), which was then asymmetrically reduced by a ketoreductase from Sphingomonas wittichii (SwiKR). Co-enzyme required for KR is regenerated by a glucose dehydrogenase (GDH) from Bacillus subtilis. This scheme is more environmentally friendly and more efficient than the current DHEA synthesis pathway. However, a significant amount of 4-AD as by-product was detected during the catalytic process. Focused on the control of by-products, we investigated the source of 4-AD and identified that it is mainly derived from the isomerization activity of SwiKR and GDH. Increasing the proportion of glucose in the catalytic system as well as optimizing the catalytic conditions drastically reduced 4-AD from 24.7 to 6.5% of total substrate amount, and the final yield of DHEA achieved 40.1 g/L. Furthermore, this is the first time that both SwiKR and GDH have been proved to be promiscuous enzymes with dehydrogenase and ketosteroid isomerase (KSI) activities, expanding knowledge of the substrate diversity of the short-chain dehydrogenase family enzymes. KEY POINTS: • A strategy of coupling lipase, ketoreductase, and glucose dehydrogenase in producing DHEA from 4-AD • Both SwiKR and GDH are identified with ketosteroid isomerase activity. • Development of catalytic strategy to control by-product and achieve highly selective DHEA production.
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Affiliation(s)
- Jiawei Dai
- Institute of Fermentation Engineering, Zhejiang University of Technology, Hangzhou, 310014, China
- College of Biotechnology and Bioengineering, Zhejiang University of Technology, Hangzhou, 310014, China
| | - Zheyi Wu
- Institute of Fermentation Engineering, Zhejiang University of Technology, Hangzhou, 310014, China
- College of Biotechnology and Bioengineering, Zhejiang University of Technology, Hangzhou, 310014, China
| | - Zebin Liu
- Institute of Fermentation Engineering, Zhejiang University of Technology, Hangzhou, 310014, China
- College of Biotechnology and Bioengineering, Zhejiang University of Technology, Hangzhou, 310014, China
| | - Chen Li
- Institute of Fermentation Engineering, Zhejiang University of Technology, Hangzhou, 310014, China
- College of Biotechnology and Bioengineering, Zhejiang University of Technology, Hangzhou, 310014, China
| | - Linjiang Zhu
- Institute of Fermentation Engineering, Zhejiang University of Technology, Hangzhou, 310014, China
- College of Biotechnology and Bioengineering, Zhejiang University of Technology, Hangzhou, 310014, China
| | - Hanchi Chen
- Institute of Fermentation Engineering, Zhejiang University of Technology, Hangzhou, 310014, China
- College of Biotechnology and Bioengineering, Zhejiang University of Technology, Hangzhou, 310014, China
| | - Xiaolong Chen
- Institute of Fermentation Engineering, Zhejiang University of Technology, Hangzhou, 310014, China.
- College of Biotechnology and Bioengineering, Zhejiang University of Technology, Hangzhou, 310014, China.
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Franke M, Mancino C, Taraballi F. Reasons for the Sex Bias in Osteoarthritis Research: A Review of Preclinical Studies. Int J Mol Sci 2023; 24:10386. [PMID: 37373536 DOI: 10.3390/ijms241210386] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/06/2023] [Accepted: 06/17/2023] [Indexed: 06/29/2023] Open
Abstract
Osteoarthritis (OA) is one of the most common degenerative diseases of articular cartilage. During OA, all the elements that contribute to the joint undergo physiological and structural changes that impair the joint function and cause joint pain and stiffness. OA can arise naturally, with the aging population witnessing an increase in diagnoses of this pathology, but the root causes of OA have yet to be identified, and increasing interest is arising towards investigating biological sex as a risk factor. Clinical studies show increased prevalence and worse clinical outcomes for female patients, yet most clinical and preclinical studies have disproportionately focused on male subjects. This review provides a critical overview of preclinical practices in the context of OA, highlighting the underlying need for taking biological sex as both a risk factor and an important component affecting treatment outcome. A unique insight into the possible reasons for female underrepresentation in preclinical studies is offered, including factors such as lack of specific guidelines requiring the analysis of sex as a biological variable (SABV), research-associated costs and animal handling, and wrongful application of the reduction principle. Additionally, a thorough investigation of sex-related variables is provided, stressing how each of them could add valuable information for the understanding of OA pathophysiology, as well as sex-dependent treatment strategies.
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Affiliation(s)
- Madeline Franke
- Center for Musculoskeletal Regeneration, Houston Methodist Academic Institute, Houston, TX 77030, USA
| | - Chiara Mancino
- Center for Musculoskeletal Regeneration, Houston Methodist Academic Institute, Houston, TX 77030, USA
| | - Francesca Taraballi
- Center for Musculoskeletal Regeneration, Houston Methodist Academic Institute, Houston, TX 77030, USA
- Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX 77030, USA
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Song X, Ma T, Hu H, Zhao M, Bai H, Wang X, Liu L, Li T, Sheng X, Xu X, Zhang X, Gao L. Chronic Circadian Rhythm Disturbance Accelerates Knee Cartilage Degeneration in Rats Accompanied by the Activation of the Canonical Wnt/β-Catenin Signaling Pathway. Front Pharmacol 2021; 12:760988. [PMID: 34858186 PMCID: PMC8632052 DOI: 10.3389/fphar.2021.760988] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/11/2021] [Indexed: 01/25/2023] Open
Abstract
With the gradual deepening of understanding of systemic health and quality of life, the factors affecting osteoarthritis (OA) are not limited to mechanical injury, metabolic abnormality, age and obesity, etc., but circadian rhythm, which plays a non-negligible role in human daily life. The purpose of this study was to explore the molecular mechanism of chronic circadian rhythm disturbance (CRD) inducing cartilage OA-like degeneration. Rats with the anterior cruciate ligament excision transection (ACLT) were used to establish the early-stage OA model (6-week). The light/dark (LD) cycle shifted 12 h per week for 22 weeks in order to establish a chronic CRD model. BMAL1 knockdown (KD) and Wnt/β-catenin pathway inhibition were performed in chondrocytes. The contents of proinflammatory factors and OA biomarkers in serum and chondrocyte secretions were detected by ELISA. Pathological and immunohistochemical staining of articular cartilage indicated the deterioration of cartilage. WB and qPCR were used to evaluate the relationship between matrix degradation and the activation of Wnt/β-catenin signaling pathway in chondrocytes. We found that chronic CRD could cause OA-like pathological changes in knee cartilage of rats, accelerating cartilage matrix degradation and synovial inflammation. The expression of MMP-3, MMP-13, ADAMTS-4, and β-catenin increased significantly; BMAL1, Aggrecan, and COL2A1 decreased significantly in either LD-shifted cartilage or BMAL1-KD chondrocytes. The expression of β-catenin and p-GSK-3β elevated, while p-β-catenin and GSK-3β diminished. The inhibitor XAV-939 was able to mitigated the increased inflammation produced by transfected siBMAL1. Our study demonstrates that chronic CRD disrupts the balance of matrix synthesis and catabolic metabolism in cartilage and chondrocytes, and it is related to the activation of the canonical Wnt/β-catenin signaling pathway.
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Affiliation(s)
- Xiaopeng Song
- Heilongjiang Key Laboratory for Laboratory Animals and Comparative Medicine, College of Veterinary Medicine, Northeast Agriculture University, Harbin, China.,College of Veterinary Medicine, Northeast Agricultural University, Harbin, China
| | - Tianwen Ma
- Heilongjiang Key Laboratory for Laboratory Animals and Comparative Medicine, College of Veterinary Medicine, Northeast Agriculture University, Harbin, China.,College of Veterinary Medicine, Northeast Agricultural University, Harbin, China
| | - Hailong Hu
- College of Veterinary Medicine, Northeast Agricultural University, Harbin, China
| | - Mingchao Zhao
- College of Veterinary Medicine, Northeast Agricultural University, Harbin, China
| | - Hui Bai
- College of Veterinary Medicine, Northeast Agricultural University, Harbin, China
| | - Xinyu Wang
- College of Veterinary Medicine, Northeast Agricultural University, Harbin, China
| | - Lin Liu
- College of Veterinary Medicine, Northeast Agricultural University, Harbin, China
| | - Ting Li
- College of Veterinary Medicine, Northeast Agricultural University, Harbin, China
| | - Xuanbo Sheng
- College of Veterinary Medicine, Northeast Agricultural University, Harbin, China
| | - Xinyu Xu
- College of Veterinary Medicine, Northeast Agricultural University, Harbin, China
| | - Xinmin Zhang
- College of Veterinary Medicine, Northeast Agricultural University, Harbin, China
| | - Li Gao
- Heilongjiang Key Laboratory for Laboratory Animals and Comparative Medicine, College of Veterinary Medicine, Northeast Agriculture University, Harbin, China.,College of Veterinary Medicine, Northeast Agricultural University, Harbin, China
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Li C, Zheng Z. Males and Females Have Distinct Molecular Events in the Articular Cartilage during Knee Osteoarthritis. Int J Mol Sci 2021; 22:ijms22157876. [PMID: 34360640 PMCID: PMC8346087 DOI: 10.3390/ijms22157876] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/15/2021] [Accepted: 07/21/2021] [Indexed: 12/25/2022] Open
Abstract
Osteoarthritis (OA) is a major public health challenge that imposes a remarkable burden on the affected individuals and the healthcare system. Based on the clinical observation, males and females have different prevalence rates and severity levels of OA. Thus, sex-based differences may play essential roles in OA’s prognosis and treatment outcomes. To date, the comprehensive understanding of the relationship between sex and OA is still largely lacking. In the current study, we analyzed a published transcriptome dataset of knee articular cartilage (GSE114007) from 18 healthy (five females, 13 males) and 20 OA (11 females, nine males) donors to provide a slight insight into this important but complex issue. First, comparing female healthy cartilage samples with those of males revealed 36 differential expression genes (DEGs), indicating the fundamental sex-related differences at the molecular level. Meanwhile, 923 DEGs were distinguished between OA and healthy female cartilage, which can be enriched to 15 Reactome pathways. On the other hand, when comparing OA and healthy male cartilage, there are only 419 DEGs were identified, and only six pathways were enriched against the Reactome database. The different signaling response to OA in the male and female cartilage was further enforced by recognizing 50 genes with significantly different OA-responsive expression fold changes in males and females. Particularly, 14 Reactome pathways, such as “Extracellular matrix organization”, “Collagen biosynthesis and modifying enzymes”, “Dissolution of fibrin clot”, and “Platelet Aggregation (Plug formation)”, can be noted from these 50 sex-dependent OA-responsive genes. Overall, the current study explores the Sex as a Biological Variable (SABV) at the transcriptomic level in the knee articular cartilage in both healthy status and OA event, which could help predict the differential OA prognosis and treatment outcome of males and female patients.
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Affiliation(s)
- Chenshuang Li
- Department of Orthodontics, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Zhong Zheng
- Division of Growth and Development, Section of Orthodontics, School of Dentistry, University of California, Los Angeles, CA 90095, USA
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
- Correspondence: ; Tel.: +1-(310)-206-5646
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Mukohara S, Mifune Y, Inui A, Nishimoto H, Kurosawa T, Yamaura K, Yoshikawa T, Kuroda R. In vitro and in vivo tenocyte-protective effectiveness of dehydroepiandrosterone against high glucose-induced oxidative stress. BMC Musculoskelet Disord 2021; 22:519. [PMID: 34090401 PMCID: PMC8180149 DOI: 10.1186/s12891-021-04398-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/17/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Dehydroepiandrosterone (DHEA), an adrenal steroid, has a protective role against diabetes. This study aimed to investigate the in vitro and in vivo protective effects of DHEA against high glucose-induced oxidative stress in tenocytes and tendons. METHODS Tenocytes from normal Sprague-Dawley rats were cultured in low-glucose (LG) or high-glucose (HG) medium with or without DHEA. The experimental groups were: control group (LG without DHEA), LG with DHEA, HG without DHEA, and HG with DHEA. Reactive oxygen species (ROS) production, apoptosis, and messenger RNA (mRNA) expression of NADPH oxidase (NOX) 1 and 4, and interleukin-6 (IL-6) were determined. Further, diabetic rats were divided into a control group and a DHEA-injected group (DHEA group). NOX1 and NOX4 protein expression and mRNA expression of NOX1, NOX4, IL-6, matrix metalloproteinase (MMP)-2, tissue inhibitors of matrix metalloproteinase (TIMP)-2, and type I and III collagens in the Achilles tendon were determined. RESULTS In rat tenocytes, DHEA decreased the expression of NOX1 and IL-6, ROS accumulation, and apoptotic cells. In the diabetic rat Achilles tendon, NOX1 protein expression and mRNA expression of NOX1, IL-6, MMP-2, TIMP-2, and type III collagen were significantly lower while type I collagen expression was significantly higher in the DHEA group than in the control group. CONCLUSIONS DHEA showed antioxidant and anti-inflammatory effects both in vitro and in vivo. Moreover, DHEA improved tendon matrix synthesis and turnover, which are affected by hyperglycemic conditions. DHEA is a potential preventive drug for diabetic tendinopathy.
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Affiliation(s)
- Shintaro Mukohara
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Yutaka Mifune
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan.
| | - Atsuyuki Inui
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Hanako Nishimoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Takashi Kurosawa
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Kohei Yamaura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Tomoya Yoshikawa
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
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Huang K, Cai HL, Bao JP, Wu LD. Dehydroepiandrosterone and age-related musculoskeletal diseases: Connections and therapeutic implications. Ageing Res Rev 2020; 62:101132. [PMID: 32711158 DOI: 10.1016/j.arr.2020.101132] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/01/2020] [Accepted: 07/18/2020] [Indexed: 12/12/2022]
Abstract
Musculoskeletal disorders related to ageing are one of the most common causes of mortality and morbidity among elderly individuals worldwide. The typical constitutive components of the musculoskeletal system, including bone, muscle, and joints, gradually undergo a process of tissue loss and degeneration as a result of life-long mechanical and biological stress, ultimately leading to the onset of a series of age-related musculoskeletal diseases, including osteoporosis (OP), sarcopenia, and osteoarthritis (OA). Dehydroepiandrosterone (DHEA), a precursor of androgen secreted mainly by the adrenal gland, has attracted much attention as a marker for senescence due to its unique age-related changes. This pre-hormone has been publicly regarded as an "antidote for ageing" because of its favourable effect against a wide range of age-related diseases, such as Alzheimer disease, cardiovascular diseases, immunosenescence and skin senescence, though its effect on age-related musculoskeletal diseases has been explored to a lesser extent. In the present review, we summarized the action of DHEA against OP, sarcopenia and OA. Extensive detailed descriptions of the pathogenesis of each of these musculoskeletal disorders are beyond the scope of this review; instead, we aim to highlight the association of changes in DHEA with the processes of OP, sarcopenia and OA. A special focus will also be placed on the overlapping pathogeneses among these three diseases, and the molecular mechanisms underlying the action of DHEA against these diseases are discussed or postulated.
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Affiliation(s)
- Kai Huang
- Department of Orthopedic Surgery, Tongde Hospital of Zhejiang Province, Hangzhou, 310012, People's Republic of China.
| | - Hai-Li Cai
- Department of Ultrasound, The 903rd Hospital of PLA, Hangzhou, 310012, People's Republic of China
| | - Jia-Peng Bao
- Department of Orthopedic Surgery, The Second Hospital of Medical College, Zhejiang University, Hangzhou, 310009, People's Republic of China
| | - Li-Dong Wu
- Department of Orthopedic Surgery, The Second Hospital of Medical College, Zhejiang University, Hangzhou, 310009, People's Republic of China
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Huang K, Cai HL, Wu LD. Potential of dehydroepiandrosterone in modulating osteoarthritis-related pain. Steroids 2019; 150:108433. [PMID: 31229511 DOI: 10.1016/j.steroids.2019.108433] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 06/11/2019] [Accepted: 06/18/2019] [Indexed: 01/09/2023]
Abstract
Osteoarthritis (OA) is the most common form of degenerative arthropathy, and the primary symptom is chronic joint pain. Dehydroepiandrosterone (DHEA) exerts a chondroprotective effect against OA and has been reported to have potent structure-modifying effects on osteoarthritic cartilage, thereby attenuating disease progression. However, the ability of DHEA to modulate OA-related pain has not yet been verified. Recent evidence suggests that there may be a link between the pharmacological effects of DHEA and pain generation. For example, DHEA synthesized in the adrenal gland interferes directly with nerve growth factor (NGF) receptors, a major biochemical contributor to peripheral hypersensitivity. Similarly, endogenous DHEA produced in the spinal cord exerts a regulatory effect on nociception in neuropathic rats. In this short review, we discuss recent studies concerning crucial signalling cascades and molecular mechanisms involved in pain generation as well as the potential link between DHEA activity and nociception. Particular attention is given to the putative molecular mechanisms underlying the favourable efficacy of DHEA against pain generation. Elucidating the molecular mechanisms of DHEA against osteoarthritic pain may pave the way for the discovery and development of novel anti-OA drugs, as effective drugs for OA treatment are not currently available.
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Affiliation(s)
- Kai Huang
- Department of Orthopedic Surgery, Tongde Hospital of Zhejiang Province, Hangzhou 310012, PR China.
| | - Hai-Li Cai
- Department of Ultrasound, The 903rd Hospital of PLA, Hangzhou 310012, PR China
| | - Li-Dong Wu
- Department of Orthopedic Surgery, The Second Hospital of Medical College, Zhejiang University, Hangzhou 310009, PR China
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Que Q, Guo X, Zhan L, Chen S, Zhang Z, Ni X, Ye B, Wan S. The GLP-1 agonist, liraglutide, ameliorates inflammation through the activation of the PKA/CREB pathway in a rat model of knee osteoarthritis. JOURNAL OF INFLAMMATION-LONDON 2019; 16:13. [PMID: 31182934 PMCID: PMC6554939 DOI: 10.1186/s12950-019-0218-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 05/28/2019] [Indexed: 01/28/2023]
Abstract
Background Inflammation is a common pathological phenomenon of osteoarthritis (OA). Accumulated evidence indicates that ameliorating or suppressing inflammation might be a promising and effective therapeutic strategy for the treatment of OA. Notably, glucagon-like peptide-1 (GLP-1)-based drugs are being successfully used to control glucose levels in patients with diabetes mellitus. In addition, recent findings have indicated that GLP-1 agonists, such as liraglutide have therapeutic potential in preventing inflammation-related disorders through the regulation of protein kinase A (PKA)/ cyclic adenosine monophosphate (cAMP) response element-binding protein (CREB) signals. Intra-articular injection of monoiodoacetate (MIA) has been widely used to induce OA. Thus, the present study aimed to investigate whether liraglutide has anti-inflammatory effects on MIA-induced OA rats and uncover its underlying molecular mechanisms. Methods Intra-articular injection of MIA was used to induce knee OA in a rat model. Subcutaneous injection of liraglutide was used to upregulate the expression of GLP-1 receptor (GLP-1R). Western blot analysis was utilized to measure the expression of GLP-1R, PKA/CREB pathway components and inflammation-related proteins, such as tumor necrosis factor-alpha (TNF-α), interleukin-1 beta (IL-1β), and IL-6. Immunoprecipitation techniques were used to detect the interactions between GLP-1R and the PKA/CREB pathway. Results The levels of GLP-1R decreased significantly in the knees of OA rats, accompanied by the downregulation of PKA /CREB signals and upregulation of inflammation-related proteins. We also found that GLP-1R interacted with the PKA/CREB pathway and that liraglutide could activate PKA/CREB signals, thereby inhibiting the expression of inflammation-related proteins. Conclusions Together our results suggest that liraglutide exhibits anti-inflammatory activity through the activation of the PKA/CREB pathway in an OA rat model.
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Affiliation(s)
- Qihong Que
- Department of Orthopedic Surgery, Hospital of Traditional Chinese Medicine of Songyang, Zhejiang, 323400 People's Republic of China
| | - Xinghua Guo
- Department of Internal Medicine, Hospital of Traditional Chinese Medicine of Songyang, Zhejiang, 323400 People's Republic of China
| | - Longxin Zhan
- Department of Orthopedic Surgery, Hospital of Traditional Chinese Medicine of Songyang, Zhejiang, 323400 People's Republic of China
| | - Shaodong Chen
- 3Department of Orthopedic Surgery, Lishui City People's Hospital, Zhejiang, 323000 People's Republic of China
| | - Zengli Zhang
- Department of Orthopedic Surgery, Hospital of Traditional Chinese Medicine of Songyang, Zhejiang, 323400 People's Republic of China
| | - Xiaoming Ni
- Department of Orthopedic Surgery, Hospital of Traditional Chinese Medicine of Songyang, Zhejiang, 323400 People's Republic of China
| | - Bin Ye
- 4Department of Endocrinology, Lishui City People's Hospital, Zhejiang, 323000 People's Republic of China
| | - Shuanglin Wan
- Department of Orthopedic, Sir Run Run Shaw Hospital of Hangzhou, No.3, Qingchun east road, Jianggan district, Hangzhou Zhejiang, 310020 People's Republic of China
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