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Jia W, Zhou Z, Zhan W. Musculoskeletal Biomaterials: Stimulated and Synergized with Low Intensity Pulsed Ultrasound. J Funct Biomater 2023; 14:504. [PMID: 37888169 PMCID: PMC10607075 DOI: 10.3390/jfb14100504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/10/2023] [Accepted: 09/21/2023] [Indexed: 10/28/2023] Open
Abstract
Clinical biophysical stimulating strategies, which have significant effects on improving the function of organs or treating diseases by causing the salutary response of body, have shown many advantages, such as non-invasiveness, few side effects, and controllable treatment process. As a critical technique for stimulation, the low intensity pulsed ultrasound (LIPUS) has been explored in regulating osteogenesis, which has presented great promise in bone repair by delivering a combined effect with biomaterials. This review summarizes the musculoskeletal biomaterials that can be synergized with LIPUS for enhanced biomedical application, including bone regeneration, spinal fusion, osteonecrosis/osteolysis, cartilage repair, and nerve regeneration. Different types of biomaterials are categorized for summary and evaluation. In each subtype, the verified biological mechanisms are listed in a table or graphs to prove how LIPUS was effective in improving musculoskeletal tissue regeneration. Meanwhile, the acoustic excitation parameters of LIPUS that were promising to be effective for further musculoskeletal tissue engineering are discussed, as well as their limitations and some perspectives for future research. Overall, coupled with biomimetic scaffolds and platforms, LIPUS may be a powerful therapeutic approach to accelerate musculoskeletal tissue repair and even in other regenerative medicine applications.
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Affiliation(s)
- Wanru Jia
- Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China;
| | - Zifei Zhou
- Department of Orthopedics, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Weiwei Zhan
- Department of Ultrasound, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China;
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Zeng LR, Zhu FB, Wang JY, Hou Q, Yue ZS, Yan SG, Quan RF, Zhang YL. Local influence of high molecular polyethylene particles on heterotopic ossification. Exp Ther Med 2017; 13:2934-2938. [PMID: 28587363 PMCID: PMC5450723 DOI: 10.3892/etm.2017.4327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 03/06/2017] [Indexed: 11/06/2022] Open
Abstract
We studied the effect of molecular polyethylene particles on local heterotopic ossification. A total of 36 healthy Sprague-Dawley rats were randomly divided into the control group (n=18) and the observation group (n=18). High molecular polyethylene particles were injected to rupture Achilles tendon position in the observation group, and normal saline was injected in the control group. X-ray examinations were conducted on Achilles tendon in the 4th, 8th and 12th week after operation. The incidence rate of heterotopic ossification was evaluated, and bone trabecula morphological structure was studied under optical microscope after hematoxylin and eosin staining. Bone morphogenetic protein 2 (BMP-2), transforming growth factor-β (TGF-β), interleukin-1 (IL-1), tumor necrosis factor-α (TNF-α), runt-related transcription factor 2 (Runx2) and matrix metalloproteinase-9 (MMP-9) expression levels were also measured. Our results showed that heterotopic ossification incidence in the observation group was significantly lower than that in the control group. Achilles tendon structure in the control group increased in volume, and its texture was harder and cartilage-like. In the observation group, trabecular bone volume, thickness and quantity were more than those observed in the control group. BMP-2, TGF-β, IL-1, TNF-α, Runx2 and MMP-9 levels in the observation group were significantly lower than those in the control group. We concluded that, high molecular polyethylene particles had a significant inhibiting effect on local heterotopic ossification.
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Affiliation(s)
- Lin-Ru Zeng
- Department of Orthopaedic Surgery, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang 311200, P.R. China
| | - Fang-Bing Zhu
- Department of Orthopaedic Surgery, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang 311200, P.R. China
| | - Jian-Yue Wang
- Department of Orthopaedic Surgery, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang 311200, P.R. China
| | - Qiao Hou
- Department of Orthopaedic Surgery, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang 311200, P.R. China
| | - Zhen-Shuang Yue
- Department of Orthopaedic Surgery, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang 311200, P.R. China
| | - Shi-Gui Yan
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, P.R. China
| | - Ren-Fu Quan
- Department of Orthopaedic Surgery, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang 311200, P.R. China
| | - Ying-Liang Zhang
- Department of Orthopaedic Surgery, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang 311200, P.R. China
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Zhao X, Zhao G, Shi Z, Zhou C, Chen Y, Hu B, Yan S. Low-intensity pulsed ultrasound (LIPUS) prevents periprosthetic inflammatory loosening through FBXL2-TRAF6 ubiquitination pathway. Sci Rep 2017; 7:45779. [PMID: 28378753 PMCID: PMC5381120 DOI: 10.1038/srep45779] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 03/02/2017] [Indexed: 01/01/2023] Open
Abstract
Previous studies have shown that Low intensity pulsed ultrasound(LIPUS) prevents polyethylene-debris-induced periprosthetic loosening in vivo, but the details of the mechanism by which it does so remain unclear. In this article, we used polyethylene debris induced RAW 264.7 cells as the in vitro model, and tested the effect of LIPUS on this model. Changes in the level of inflammatory cytokines, cell proliferation, and apoptosis were assessed. Gene overexpression and siRNA technique were applied, and the levels of expression of FBXL2, TRAF6, ERK, and related inflammatory cytokines were also measured. Results indicated that FBXL2-mediated TRAF6 ubiquitination and degradation also plays an important role in aseptic periprosthetic loosening process, and LIPUS prevents such loosening by strengthening this pathway.
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Affiliation(s)
- Xiang Zhao
- Department of orthopaedic surgery, the second affiliated hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of orthopaedic research, Zhejiang University, Hangzhou, China
| | - Gangsheng Zhao
- Department of Orthopaedic Surgery, Yiwu Central Hospital, the affiliated hospital of Wenzhou Medical College, Yiwu, China
| | - Zhongli Shi
- Department of orthopaedic surgery, the second affiliated hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of orthopaedic research, Zhejiang University, Hangzhou, China
| | - Chenhe Zhou
- Department of orthopaedic surgery, the second affiliated hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of orthopaedic research, Zhejiang University, Hangzhou, China
| | - Yunlin Chen
- Department of Orthopaedic Surgery, Ningbo sixth hospital, China
| | - Bin Hu
- Department of orthopaedic surgery, the second affiliated hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of orthopaedic research, Zhejiang University, Hangzhou, China
| | - Shigui Yan
- Department of orthopaedic surgery, the second affiliated hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Institute of orthopaedic research, Zhejiang University, Hangzhou, China
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Yan H, Liu X, Zhu M, Luo G, Sun T, Peng Q, Zeng Y, Chen T, Wang Y, Liu K, Feng B, Weng J, Wang J. Hybrid use of combined and sequential delivery of growth factors and ultrasound stimulation in porous multilayer composite scaffolds to promote both vascularization and bone formation in bone tissue engineering. J Biomed Mater Res A 2015; 104:195-208. [DOI: 10.1002/jbm.a.35556] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 07/30/2015] [Accepted: 08/11/2015] [Indexed: 01/12/2023]
Affiliation(s)
- Haoran Yan
- Key Laboratory of Advanced Technologies of Materials, Ministry of Education, School of Materials Science and Engineering, Southwest Jiaotong University; Chengdu 610031 People's Republic of China
| | - Xia Liu
- Key Laboratory of Advanced Technologies of Materials, Ministry of Education, School of Materials Science and Engineering, Southwest Jiaotong University; Chengdu 610031 People's Republic of China
| | - Minghua Zhu
- Sichuan Centre for Disease Control and Prevention; Chengdu 610041 People's Republic of China
| | - Guilin Luo
- Key Laboratory of Advanced Technologies of Materials, Ministry of Education, School of Materials Science and Engineering, Southwest Jiaotong University; Chengdu 610031 People's Republic of China
| | - Tao Sun
- Sichuan Centre for Disease Control and Prevention; Chengdu 610041 People's Republic of China
| | - Qiang Peng
- Sichuan Centre for Disease Control and Prevention; Chengdu 610041 People's Republic of China
| | - Yi Zeng
- Sichuan Centre for Disease Control and Prevention; Chengdu 610041 People's Republic of China
| | - Taijun Chen
- Key Laboratory of Advanced Technologies of Materials, Ministry of Education, School of Materials Science and Engineering, Southwest Jiaotong University; Chengdu 610031 People's Republic of China
| | - Yingying Wang
- Key Laboratory of Advanced Technologies of Materials, Ministry of Education, School of Materials Science and Engineering, Southwest Jiaotong University; Chengdu 610031 People's Republic of China
| | - Keliang Liu
- Sichuan Centre for Disease Control and Prevention; Chengdu 610041 People's Republic of China
| | - Bo Feng
- Key Laboratory of Advanced Technologies of Materials, Ministry of Education, School of Materials Science and Engineering, Southwest Jiaotong University; Chengdu 610031 People's Republic of China
| | - Jie Weng
- Key Laboratory of Advanced Technologies of Materials, Ministry of Education, School of Materials Science and Engineering, Southwest Jiaotong University; Chengdu 610031 People's Republic of China
| | - Jianxin Wang
- Key Laboratory of Advanced Technologies of Materials, Ministry of Education, School of Materials Science and Engineering, Southwest Jiaotong University; Chengdu 610031 People's Republic of China
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Zhu H, Cai X, Lin T, Shi Z, Yan S. Low-intensity pulsed ultrasound enhances bone repair in a rabbit model of steroid-associated osteonecrosis. Clin Orthop Relat Res 2015; 473:1830-9. [PMID: 25736917 PMCID: PMC4385349 DOI: 10.1007/s11999-015-4154-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 01/13/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Steroids are a leading cause of femoral head osteonecrosis. Currently there are no medications available to prevent and/or treat steroid-associated osteonecrosis. Low-intensity pulsed ultrasound (LIPUS) was approved by the FDA for treating delayed union of bone fractures. Some studies have reported that LIPUS can enhance bone formation and local blood flow in an animal model of fracture healing. However, whether the effect of osteogenesis and neovascularization by LIPUS can enhance the repair progress in steroid-associated osteonecrosis is unknown. QUESTIONS/PURPOSES We hypothesized that LIPUS may facilitate osteogenesis and neovascularization in the reparative processes of steroid-associated osteonecrosis. Using a rabbit animal model, we asked whether LIPUS affects (1) bone strength and trabecular architecture; (2) blood vessel number and diameter; and (3) BMP-2 and VEGF expression. METHODS Bilateral femoral head necrosis was induced by lipopolysaccharide and methylprednisolone in 24 rabbits. The left femoral heads of rabbits received LIPUS therapy (200 mW/cm(2)) for 20 minutes daily and were classified as the LIPUS group. The right femoral heads of the same rabbits did not receive therapy and were classified as the control group. All rabbits were euthanized 12 weeks after LIPUS therapy. Micro-CT, biomechanical testing, histologic evaluation, immunohistochemistry, quantitative real-time PCR, and Western blot were used for examination of the effects of LIPUS. RESULTS Twelve weeks after LIPUS treatment, the loading strength in the control group was 355 ± 38 N (95% CI, 315-394 N), which was lower (p = 0.028) than that in the LIPUS group (441 ± 78 N; 95% CI, 359-524 N). The bone tissue volume density (bone volume/total volume) in the LIPUS group (49.29% ± 12.37%; 95 % CI, 36.31%-62.27%) was higher (p = 0.022) than that in the control group (37.93% ± 8.37%; 95 % CI, 29.15%-46.72%). The percentage of empty osteocyte lacunae in the LIPUS group (17% ± 4%; 95% CI, 15%-20%) was lower (p = 0.002) than that in the control group (26% ± 9%; 95% CI, 21%-32%). The mineral apposition rate (μm/day) in the LIPUS group (2.3 ± 0.8 μm/day; 95% CI, 1.8 2.8 μm/day) was higher (p = 0.001) than that in the control group (1.6 ± 0.3 μm/day; 95% CL, 1.4-1.8 μm/day). The number of blood vessels in the LIPUS group (7.8 ± 3.6/mm(2); 95% CI, 5.5-10.1 mm(2)) was greater (p = 0.025) than the number in the control group (5.7 ± 2.6/mm(2); 95% CI, 4.0-7.3 mm(2)). Messenger RNA (mRNA) and protein expression of BMP-2 in the LIPUS group (75 ± 7, 95% CI, 70-79; and 30 ± 3, 95% CI, 28-31) were higher (both p < 0.001) than those in the control groups (46 ± 5, 95% CI, 43-49; and 15 ± 2, 95% CI, 14-16). However, there were no differences (p = 0.114 and 0.124) in mRNA and protein expression of vascular endothelial growth factor between the control (26 ± 3, 95% CI, 24-28; and 22 ± 6, 95% CI, 18-26) and LIPUS groups (28 ± 2, 95% CI, 26-29; and 23 ± 6, 95% CI, 19-27). CONCLUSIONS The results of this study indicate that LIPUS promotes osteogenesis and neovascularization, thus promoting bone repair in this steroid-associated osteonecrosis model. CLINICAL RELEVANCE LIPUS may be a promising modality for the treatment of early-stage steroid-associated osteonecrosis. Further research, including clinical trials to determine whether LIPUS has a therapeutic effect on patients with early-onset steroid-associated osteonecrosis may be warranted.
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Affiliation(s)
- Hanxiao Zhu
- Department of Orthopaedic Surgery, Second Affiliated Hospital’s Campus in Binjiang District, School of Medicine, Zhejiang University, No. 88 Jiefang Road, Hangzhou, 310009 People’s Republic of China
| | - Xunzi Cai
- Department of Orthopaedic Surgery, Second Affiliated Hospital’s Campus in Binjiang District, School of Medicine, Zhejiang University, No. 88 Jiefang Road, Hangzhou, 310009 People’s Republic of China
| | - Tiao Lin
- Department of Orthopaedic Surgery, Second Affiliated Hospital’s Campus in Binjiang District, School of Medicine, Zhejiang University, No. 88 Jiefang Road, Hangzhou, 310009 People’s Republic of China
| | - Zhongli Shi
- Department of Orthopaedic Surgery, Second Affiliated Hospital’s Campus in Binjiang District, School of Medicine, Zhejiang University, No. 88 Jiefang Road, Hangzhou, 310009 People’s Republic of China
| | - Shigui Yan
- Department of Orthopaedic Surgery, Second Affiliated Hospital’s Campus in Binjiang District, School of Medicine, Zhejiang University, No. 88 Jiefang Road, Hangzhou, 310009 People’s Republic of China
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Hu B, Cai XZ, Shi ZL, Chen YL, Zhao X, Zhu HX, Yan SG. Microbubble injection enhances inhibition of low-intensity pulsed ultrasound on debris-induced periprosthetic osteolysis in rabbit model. ULTRASOUND IN MEDICINE & BIOLOGY 2015; 41:177-186. [PMID: 25438844 DOI: 10.1016/j.ultrasmedbio.2014.08.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 08/13/2014] [Accepted: 08/20/2014] [Indexed: 06/04/2023]
Abstract
We determined whether the addition of microbubbles enhances the effect of low-intensity pulsed ultrasound (LIPUS) on bone-implant integration in an early-stage osteolysis model. The bone canals were injected with titanium particles before implantation to establish the periprosthetic osteolysis model. Before ultrasonic therapy, the microbubble-enhanced LIPUS group (GTi-Us-Mb) received an intra-articular injection of microbubbles. Biomechanical testing revealed that GTi-Us-Mb had significantly greater fixation strength than the LIPUS group (GTi-Us). Distal periprosthetic bone mineral density was also higher in GTi-Us than in the Ti group (GTi), but no significant increase was detected after administration of microbubbles. Histomorphometric analyses revealed that bone formation around the implant in GTi-Us was enhanced by the addition of microbubbles in GTi-Us-Mb. Taken together, our data indicate that microbubble injection enhances the inhibitory effect of LIPUS on debris-induced osteolysis and further strengthens the mechanical fixation of implants in an early-stage osteolysis model in vivo.
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Affiliation(s)
- Bin Hu
- Department of Orthopedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xun-Zi Cai
- Department of Orthopedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Institute of Orthopedic Research, Zhejiang University, Hangzhou, Zhejiang, China
| | - Zhong-Li Shi
- Department of Orthopedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Institute of Orthopedic Research, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yun-Lin Chen
- Department of Orthopedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xiang Zhao
- Department of Orthopedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Han-Xiao Zhu
- Department of Orthopedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Shi-Gui Yan
- Department of Orthopedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China; Institute of Orthopedic Research, Zhejiang University, Hangzhou, Zhejiang, China.
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Smith RL, Schwarz EM. Are biologic treatments a potential approach to wear- and corrosion-related problems? Clin Orthop Relat Res 2014; 472:3740-6. [PMID: 24993143 PMCID: PMC4397762 DOI: 10.1007/s11999-014-3765-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
WHERE ARE WE NOW?: Biological treatments, defined as any nonsurgical intervention whose primary mechanism of action is reducing the host response to wear and/or corrosion products, have long been postulated as solutions for osteolysis and aseptic loosening of total joint arthroplasties. Despite extensive research on drugs that target the inflammatory, osteoclastic, and osteogenic responses to wear debris, no biological treatment has emerged as an approved therapy. We review the extensive preclinical research and modest clinical research to date, which has led to the central conclusion that the osteoclast is the primary target. We also allude to the significant changes in health care, unabated safety concerns about chronic immunosuppressive/antiinflammatory therapies, industry's complete lack of interest in developing an intervention for this condition, and the practical issues that have narrowly focused the possibilities for a biologic treatment for wear debris-induced osteolysis. WHERE DO WE NEED TO GO?: Based on the conclusions from research, and the economic, regulatory, and practical issues that limit the future directions toward the development of a biologic treatment, there are a few rational approaches that warrant investigation. These largely focus on FDA-approved osteoporosis therapies that target the osteoclast (bisphosphonates and anti-RANK ligand) and recombinant parathyroid hormone (teriparatide) prophylactic treatment to increase osseous integration of the prosthesis to overcome high-risk susceptibility to aseptic loosening. The other roadblock that must be overcome if there is to be an approved biologic therapy to prevent the progression of periprosthetic osteolysis and aseptic loosening is the development of radiological measures that can quantify a significant drug effect in a randomized, placebo-controlled clinical trial. We review the progress of volumetric quantification of osteolysis in animal studies and clinical pilots. HOW DO WE GET THERE?: Accepting the aforementioned rigid boundaries, we describe the emergence of repurposing FDA-approved drugs for new indications and public (National Institutes of Health, FDA, Centers for Disease Control and Prevention) and private (universities and drug and device manufactures) partnerships as the future roadmap for clinical translation. In the case of biologic treatments for wear debris-induced osteolysis, this will involve combined federal and industry funding of multicenter clinical trials that will be run by thought leaders at large medical centers.
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Affiliation(s)
- R. Lane Smith
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA USA
| | - Edward M. Schwarz
- Department of Orthopaedics, University of Rochester, Rochester, NY USA ,The Center for Musculoskeletal Research, University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14642 USA
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Abstract
Despite advances in systemic osteoporosis therapeutic outcomes, management of fragility fractures and implant fixation in osteoporotic bone remain difficult clinical challenges. Low initial bone density and a prolonged healing response can lead to fracture nonunion and aseptic implant loosening. Local treatment strategies could be used to prevent fracture, accelerate healing, and increase implant fixation by locally stimulating anabolic pathways or inhibiting catabolic pathways. Local strategies under investigation include direct drug release from injectable materials or implant surface coatings. Common locally delivered drugs include bisphosphonates, parathyroid hormone, and bone morphogenetic proteins, yet additional compounds targeting novel pathways in bone biology are also being actively explored. Mechanical stimulation via low intensity pulsed ultrasound, alone or in combination with drug therapy, may also prove effective to promote local bone healing and implant fixation within osteoporotic bone.
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Affiliation(s)
- F Brennan Torstrick
- The George W. Woodruff School of Mechanical Engineering, Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, 315 Ferst Dr. NW, Atlanta, GA, 30332-0363, USA
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Namazi H. Low-intensity pulsed ultrasound (LIPUS) may prevent polyethylene induced periprosthetic osteolysis in vivo: a novel molecular mechanism. ULTRASOUND IN MEDICINE & BIOLOGY 2012; 38:1845-1847. [PMID: 22633268 DOI: 10.1016/j.ultrasmedbio.2012.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Revised: 02/02/2012] [Accepted: 02/03/2012] [Indexed: 06/01/2023]
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