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Dubin JA, Hameed D, Bains SS, Monárrez R, Swartz GN, DeRogatis M, Mont MA, Nace J, Delanois RE. A Comparison Between Polyethylene Exchange and Full Revision for Arthrofibrosis Following Total Knee Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00320-6. [PMID: 38604277 DOI: 10.1016/j.arth.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Arthrofibrosis is a debilitating postoperative complication and a major cause of patient dissatisfaction following total knee arthroplasty (TKA). There is no consensus regarding the optimal treatment for stiffness after TKA. For cases not amenable to manipulation under anesthesia (MUA), one component or full revision are both suitable options. In a value-based healthcare era, maximizing cost-effectiveness with optimized clinical outcomes for patients remains the ultimate goal. As such, we compared (1) Knee Injury and Osteoarthritis Outcome Scores for Joint Replacement (KOOS, JR), (2) range of motion (ROM), as well as (3) complication rates, including MUA and lysis of adhesions (LOA), between polyethylene exchange and full component revision for TKA arthrofibrosis. METHODS Patients were queried from an institutional database who underwent revision TKA for arthrofibrosis between January 1, 2015, and April 31, 2021. There were 33 patients who underwent full revision and 16 patients who underwent polyethylene exchange. Demographics and baseline characteristics between the cohorts were analyzed. Postoperative outcomes included MUA, LOA, and re-revision rates as well as KOOS, JR, and extension and flexion ROM at a mean follow-up of 3.8 years. Baseline comorbidities, including age, body mass index, alcohol use, tobacco use, and diabetes, were comparable between the full revision and polyethylene exchange revision cohorts (P > .05). The one and full component revisions had similar preoperative KOOS, JR (43 versus 42, P = .85), and flexion (81 versus 82 degrees, P = .80) versus extension (11 versus 11 degrees, P = .87) ROM. RESULTS The full component revision had higher KOOS, JR (65 versus 55, P = .04), and flexion (102 versus 92 degrees, P = .02), but similar extension (3 versus 3 degrees, P = .80) ROM at final follow-up compared to the polyethylene exchange revision, respectively. The MUA (18.2 versus 18.8%, P = .96) and LOA (2.0 versus 0.0%, P = .32) rates were similar between full component and polyethylene exchange revisions. There was one re-revision (3.0%) for the cohort of patients who initially underwent full revision. There were four full re-revisions (25.0%) and two polyethylene exchange re-revisions (12.5%) performed in the cohort of patients who initially underwent a polyethylene exchange revision. CONCLUSIONS The full component revision for stiffness after TKA showed favorable KOOS, JR, ROM, and outcomes in comparison to the polyethylene exchange revision. While the optimal treatment for stiffness after TKA is without consensus, this study supports the use of the full component revision when applied to the institutional population at hand. It is imperative that homogeneity exists in preoperative definitions, preoperative baseline patient demographics, ROM and function levels, outcome measures, and preoperative indications, as well as the inclusion of clinical data that assesses complete exchange, single exchange, and tibial insert exchange.
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Affiliation(s)
- Jeremy A Dubin
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Daniel Hameed
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sandeep S Bains
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Rubén Monárrez
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Gabrielle N Swartz
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Michael DeRogatis
- Department of Orthopaedics, St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - James Nace
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Laperche JM, Chang K, Albright JA, Ibrahim Z, Zhang H, Daniels AH, Barrett TJ. Shoulder Adhesive Capsulitis Prior to Total Knee Arthroplasty is Associated With Increased Rates of Postoperative Stiffness Requiring Manipulation Under Anesthesia and Arthroscopic Lysis of Adhesions. J Arthroplasty 2024; 39:960-965. [PMID: 37924990 DOI: 10.1016/j.arth.2023.10.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/23/2023] [Accepted: 10/26/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Arthrofibrosis following total knee arthroplasty (TKA) and adhesive capsulitis (AC) of the shoulder develop via a similar pathologic process. The purpose of this study was to examine the relationship between these two conditions. METHODS This was a retrospective cohort study using a large nationwide claims database. Patients who had a history of shoulder AC prior to TKA were compared to TKA patients who did not have AC history comparing rates of postoperative stiffness, manipulation under anesthesia (MUA), arthroscopic lysis of adhesions (LOAs), and revision arthroplasty at postoperative timepoints (3 months, 6 months, 1 year, and 2 years). RESULTS Within 3 months, 6 months, 1 year, and 2 years of their TKAs, patients who had a history of AC prior to TKA were significantly more likely to experience stiffness (OR [odds ratio] = 1.29, 1.28, 1.32, and 1.36, respectively) and LOAs (OR = 6.78, 3.65, 2.99, and 2.81, respectively). They also showed increased risk of MUA within 6 months, 1 year, and 2 years (OR = 1.15, 1.15, and 1.16, respectively) of their TKAs. Patients having a preoperative diagnosis of AC did not have an increased risk of undergoing revision surgery 1 year or 2 years after their TKAs (P > .05). CONCLUSIONS Patients diagnosed with AC prior to TKA experience higher rates of postoperative stiffness, resulting in additional interventions such as MUA and LOAs. These findings identify a particularly high-risk patient population that may benefit from additional interventions prior to and following TKA. LEVEL OF EVIDENCE This is a level III prognostic study.
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Affiliation(s)
- Jacob M Laperche
- Frank H. Netter School of Medicine, Quinnipiac University, North Haven, Connecticut; Department of Orthopedic Surgery, University Orthopedics, Providence, Rhode Island
| | - Kenny Chang
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - James A Albright
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Zainab Ibrahim
- Department of Orthopaedic Surgery, Brown University, Providence, Rhode Island
| | - Helen Zhang
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Alan H Daniels
- Department of Orthopedic Surgery, University Orthopedics, Providence, Rhode Island; Department of Orthopaedic Surgery, Brown University, Providence, Rhode Island
| | - Thomas J Barrett
- Department of Orthopedic Surgery, University Orthopedics, Providence, Rhode Island; Department of Orthopaedic Surgery, Brown University, Providence, Rhode Island
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Albright JA, Testa EJ, Ibrahim Z, Quinn MS, Chang K, Alsoof D, Diebo BG, Barrett TJ, Daniels AH. Postoperative Angiotensin Receptor Blocker Use is Associated With Decreased Rates of Manipulation Under Anesthesia, Arthroscopic Lysis of Adhesions, and Prosthesis-Related Complications in Patients Undergoing Total Knee Arthroplasty. J Arthroplasty 2024; 39:954-959.e1. [PMID: 37852448 DOI: 10.1016/j.arth.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 09/26/2023] [Accepted: 10/02/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND The cellular mechanisms underlying excess scar tissue formation in arthrofibrosis following total knee arthroplasty (TKA) are well-described. Angiotensin receptor blockers (ARB), particularly losartan, is a commonly prescribed antihypertensive with demonstrated antifibrotic properties. This retrospective study aimed to assess the rates of 1- and 2-year postoperative complications in patients who filled prescriptions for ARBs during the 90 days after TKA. METHODS Patients undergoing primary TKA were selected from a large national insurance database, and the impact of ARB use after TKA on complications was assessed. Of the 1,299,106 patients who underwent TKA, 82,065 had filled at least a 90-day prescription of losartan, valsartan, or olmesartan immediately following their TKA. The rates of manipulation under anesthesia (MUA), arthroscopic lysis of adhesions (LOA), aseptic loosening, periprosthetic fracture, and revision at 1 and 2 years following TKA were analyzed using multivariable logistic regressions to control for various comorbidities. RESULTS ARB use was associated with decreased rates of MUA (odds ratio [OR] = 0.94, 95% confidence interval (CI), 0.90 to 0.99), arthroscopy/LOA (OR = 0.86, 95% CI, 0.77 to 0.95), aseptic loosening (OR = 0.71, 95% CI, 0.61 to 0.83), periprosthetic fracture (OR = 0.58, 95% CI, 0.46 to 0.71), and revision (OR = 0.79, 95% CI, 0.74 to 0.85) 2 years after TKA. CONCLUSIONS ARB use throughout the 90 days after TKA is associated with a decreased risk of MUA, arthroscopy/LOA, aseptic loosening, periprosthetic fracture, and revision, demonstrating the potential protective abilities of ARBs. Prospective studies evaluating the use of ARBs in patients at risk for postoperative stiffness would be beneficial to further elucidate this association.
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Affiliation(s)
- J Alex Albright
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Edward J Testa
- Department of Orthopaedics, Brown University Warren Alpert Medical School, Providence, Rhode Island
| | - Zainab Ibrahim
- Department of Orthopaedics, Brown University Warren Alpert Medical School, Providence, Rhode Island
| | - Matthew S Quinn
- Department of Orthopaedics, Brown University Warren Alpert Medical School, Providence, Rhode Island
| | - Kenny Chang
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Daniel Alsoof
- Department of Orthopaedics, Brown University Warren Alpert Medical School, Providence, Rhode Island
| | - Bassel G Diebo
- Department of Orthopaedics, Brown University Warren Alpert Medical School, Providence, Rhode Island
| | - Thomas J Barrett
- Department of Orthopaedics, Brown University Warren Alpert Medical School, Providence, Rhode Island
| | - Alan H Daniels
- Department of Orthopaedics, Brown University Warren Alpert Medical School, Providence, Rhode Island
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Dudakovic A, Limberg AK, Bothun CE, Dilger OB, Bayram B, Bettencourt JW, Salmons HI, Thaler R, Karczewski DC, Owen AR, Iyer VG, Payne AN, Carstens MF, van Wijnen AJ, Berry DJ, Sanchez-Sotelo J, Morrey ME, Abdel MP. AdipoRon reduces TGFβ1-mediated collagen deposition in vitro and alleviates knee stiffness in vivo. J Cell Physiol 2024; 239:e31168. [PMID: 38149794 PMCID: PMC10922972 DOI: 10.1002/jcp.31168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/10/2023] [Accepted: 11/28/2023] [Indexed: 12/28/2023]
Abstract
Arthrofibrosis, which causes joint motion restrictions, is a common complication following total knee arthroplasty (TKA). Key features associated with arthrofibrosis include myofibroblast activation, knee stiffness, and excessive scar tissue formation. We previously demonstrated that adiponectin levels are suppressed within the knee tissues of patients affected by arthrofibrosis and showed that AdipoRon, an adiponectin receptor agonist, exhibited anti-fibrotic properties in human mesenchymal stem cells. In this study, the therapeutic potential of AdipoRon was evaluated on TGFβ1-mediated myofibroblast differentiation of primary human knee fibroblasts and in a mouse model of knee stiffness. Picrosirius red staining revealed that AdipoRon reduced TGFβ1-induced collagen deposition in primary knee fibroblasts derived from patients undergoing primary TKA and revision TKA for arthrofibrosis. AdipoRon also reduced mRNA and protein levels of ACTA2, a key myofibroblast marker. RNA-seq analysis corroborated the anti-myofibrogenic effects of AdipoRon. In our knee stiffness mouse model, 6 weeks of knee immobilization, to induce a knee contracture, in conjunction with daily vehicle (DMSO) or AdipoRon (1, 5, and 25 mg/kg) via intraperitoneal injections were well tolerated based on animal behavior and weight measurements. Biomechanical testing demonstrated that passive extension angles (PEAs) of experimental knees were similar between vehicle and AdipoRon treatment groups in mice evaluated immediately following immobilization. Interestingly, relative to vehicle-treated mice, 5 mg/kg AdipoRon therapy improved the PEA of the experimental knees in mice that underwent 4 weeks of knee remobilization following the immobilization and therapy. Together, these studies revealed that AdipoRon may be an effective therapeutic modality for arthrofibrosis.
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Affiliation(s)
- Amel Dudakovic
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Afton K. Limberg
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Cole E. Bothun
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Oliver B. Dilger
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Banu Bayram
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Roman Thaler
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | | | - Aaron R. Owen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Varun G. Iyer
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ashley N. Payne
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Andre J. van Wijnen
- Department of Biochemistry, University of Vermont College of Medicine, Burlington, VT, USA
| | - Daniel J. Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Mark E. Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Matthew P. Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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McCormick BP, Sequeira SB, Hasenauer MD, McKinstry RP, Boucher HR. Cushing's Syndrome Is Associated With Early Medical- and Surgical-Related Complications Following Total Joint Arthroplasty: A National Database Study. J Arthroplasty 2023; 38:2568-2572. [PMID: 37315630 DOI: 10.1016/j.arth.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Cushing's syndrome (CS) is a disorder characterized by exposure to supraphysiologic levels of glucocorticoids. The purpose of this study was to evaluate the association between CS and postoperative complication rates following total joint arthroplasty (TJA). METHODS Patients diagnosed with CS undergoing TJA for degenerative etiologies were identified from a large national database and matched 1:5 to a control cohort using propensity scoring. Propensity score matching resulted in 1,059 total hip arthroplasty (THA) patients with CS matched to 5,295 control THA patients and 1,561 total knee arthroplasty (TKA) patients with CS matched to 7,805 control TKA patients. Rates of medical complications occurring within 90 days of TJA and surgical-related complications occurring within 1 year of TJA were compared using odds ratios (ORs). RESULTS The THA patients with CS had higher incidences of pulmonary embolism (OR 2.21, P = .0026), urinary tract infection (UTI) (OR 1.29, P = .0417), pneumonia (OR 1.58, P = .0071), sepsis (OR 1.89, P = .0134), periprosthetic joint infection (OR 1.45, P = .0109), and all-cause revision surgery (OR 1.54, P = .0036). The TKA patients with CS had significantly higher incidences of UTI (OR 1.34, P = .0044), pneumonia (OR 1.62, P = .0042), and dislocation (OR 2.43, P = .0049) and a lower incidence of manipulation under anesthesia (MUA) (OR 0.63, P = .0027). CONCLUSION CS is associated with early medical- and surgical-related complications following TJA and a reduced incidence of MUA following TKA.
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Affiliation(s)
- Brian P McCormick
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Sean B Sequeira
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Mark D Hasenauer
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Robert P McKinstry
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Henry R Boucher
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland
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6
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Ramos MS, Pasqualini I, Surace PA, Molloy RM, Deren ME, Piuzzi NS. Arthrofibrosis After Total Knee Arthroplasty: A Critical Analysis Review. JBJS Rev 2023; 11:01874474-202312000-00001. [PMID: 38079496 DOI: 10.2106/jbjs.rvw.23.00140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
» Arthrofibrosis after total knee arthroplasty (TKA) is the new formation of excessive scar tissue that results in limited ROM, pain, and functional deficits.» The diagnosis of arthrofibrosis is based on the patient's history, clinical examination, absence of alternative diagnoses from diagnostic testing, and operative findings. Imaging is helpful in ruling out specific causes of stiffness after TKA. A biopsy is not indicated, and no biomarkers of arthrofibrosis exist.» Arthrofibrosis pathophysiology is multifactorial and related to aberrant activation and proliferation of myofibroblasts that primarily deposit type I collagen in response to a proinflammatory environment. Transforming growth factor-beta signaling is the best established pathway involved in arthrofibrosis after TKA.» Management includes both nonoperative and operative modalities. Physical therapy is most used while revision arthroplasty is typically reserved as a last resort. Additional investigation into specific pathophysiologic mechanisms can better inform targeted therapeutics.
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Affiliation(s)
- Michael S Ramos
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Levy KH, Fusco PJ, Salazar-Restrepo SA, Mathew DM, Pandey R, Ahmed S, Varghese KS, Rogando DO, Ahmed A, Ng MK. Unicompartmental knee arthroplasty revised to total knee arthroplasty versus primary total knee arthroplasty: A meta-analysis of matched studies. Knee 2023; 45:1-10. [PMID: 37708740 DOI: 10.1016/j.knee.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/13/2023] [Accepted: 09/03/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Unicompartmental knee arthroplasty (UKA) offers a less invasive alternative to total knee arthroplasty (TKA), but is accompanied by a high revision risk. The aim of our study was to perform a meta-analysis comparing outcomes of UKA revised to TKA versus primary TKA, to assess if UKA is an effective treatment option, despite its potential need for revision. METHODS Studies comparing matched cohorts of patients with UKA revised to TKA versus primary TKA were identified via the PubMed, Ovid EMBASE, and Scopus databases. The following outcome measures were compared between treatment modalities: postoperative reoperation or revision, total complications, range of motion, patient-reported outcome measures, and length of stay. RESULTS Ten studies were included with 1,070 patients: 410 UKA to TKA and 660 primary TKA. At an average follow-up of 5.6 years in the UKA to TKA cohort and 5.7 years in the primary TKA cohort, there were no significant difference in risk of revision (p = 0.81), total complications (p = 0.54), range of motion (p = 0.09), or length of stay (p = 0.31). Both objective and functional Knee Society Score were significantly higher in patients with primary TKA (p < 0.01). However, there was no difference in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) or pain scores (p = 0.13 and p = 0.21, respectively). CONCLUSION UKA revised to TKA produced comparable clinical and patient-reported outcomes to a primary TKA. UKA may be an effective treatment option in unicompartmental arthritis that would allow for improved functionality and satisfaction without the concern of outcomes deteriorating in patients where a revision becomes necessary.
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Affiliation(s)
| | | | | | | | - Roshan Pandey
- CUNY The City College of New York, New York, NY, USA
| | | | | | | | | | - Mitchell K Ng
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
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Wegner E, Mickan T, Truffel S, Slotina E, Müller L, Wunderlich F, Harper A, Ritz U, Rommens PM, Gercek E, Drees P, Baranowski A. The effect of losartan on the development of post-traumatic joint stiffness in a rat model. Biomed Pharmacother 2023; 166:115291. [PMID: 37557010 DOI: 10.1016/j.biopha.2023.115291] [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: 04/08/2023] [Revised: 07/27/2023] [Accepted: 08/04/2023] [Indexed: 08/11/2023] Open
Abstract
Post-traumatic joint stiffness (PTJS) is accompanied by a multidimensional disturbance of joint architecture. Pharmacological approaches represent promising alternatives as the traumatic nature of current therapeutic standards may lead to PTJS' progression. Losartan is an auspicious candidate, as it has demonstrated an antifibrotic effect in other organs. Forty-eight Sprague Dawley rats were randomized into equally sized losartan or control groups. After a standardized knee trauma, the joint was immobilized for either 2 weeks (n = 16), 4 weeks (n = 16) or 4 weeks with re-mobilization for an additional 4 weeks (n = 16). Pharmacotherapy with losartan or placebo (30 mg/kg/day) was initiated on the day of trauma and continued for the entire course. Joint contracture was measured alongside histological and molecular biological assessments. There were no significant biomechanical changes in joint contracture over time, comparing short-term (2 weeks) with long-term losartan therapy (4 weeks). However, comparing the formation of PTJS with that of the control, there was a trend toward improvement of joint mobility of 10.5° (p 0.09) under the influence of losartan. During the re-mobilization phase, no significant effect of losartan on range of motion (ROM) was demonstrated. At a cellular level, losartan significantly reduced myofibroblast counts by up to 72 % (4 weeks, p ≤ 0.001) without effecting the capsular configuration. Differences in expression levels of profibrotic factors (TGF-β, CTGF, Il-6) were most pronounced at week 4. The antifibrotic properties of losartan are not prominent enough to completely prevent the development of PTJS after severe joint injury.
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Affiliation(s)
- Erik Wegner
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Center of the Johannes Gutenberg University, Mainz 55131, Germany
| | - Tim Mickan
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Center of the Johannes Gutenberg University, Mainz 55131, Germany
| | - Sebastian Truffel
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Center of the Johannes Gutenberg University, Mainz 55131, Germany
| | - Ekaterina Slotina
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Center of the Johannes Gutenberg University, Mainz 55131, Germany
| | - Lukas Müller
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University, Mainz 55131, Germany; Mainz Research School of Translational Biomedicine, University Medical Center of the Johannes Gutenberg University, Mainz 55131, Germany
| | - Felix Wunderlich
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Center of the Johannes Gutenberg University, Mainz 55131, Germany
| | - Austin Harper
- St. George's University School of Medicine, True Blue, St. George, Grenada
| | - Ulrike Ritz
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Center of the Johannes Gutenberg University, Mainz 55131, Germany
| | - Pol M Rommens
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Center of the Johannes Gutenberg University, Mainz 55131, Germany
| | - Erol Gercek
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Center of the Johannes Gutenberg University, Mainz 55131, Germany
| | - Philipp Drees
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Center of the Johannes Gutenberg University, Mainz 55131, Germany
| | - Andreas Baranowski
- Department of Orthopaedics and Traumatology, Biomatics Group, University Medical Center of the Johannes Gutenberg University, Mainz 55131, Germany.
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Chen X, Gong L, Li C, Wang S, Wang Z, Chu M, Zhou Y. Single-cell and bulk tissue sequencing unravels the heterogeneity of synovial microenvironment in arthrofibrosis. iScience 2023; 26:107379. [PMID: 37705954 PMCID: PMC10495645 DOI: 10.1016/j.isci.2023.107379] [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: 01/20/2023] [Revised: 04/06/2023] [Accepted: 07/07/2023] [Indexed: 09/15/2023] Open
Abstract
Arthrofibrosis (AF) is a debilitating complication that occurs after trauma or surgery, leading to functional impairment and surgical failures worldwide. This study aimed to uncover the underlying mechanism of AF. A total of 141 patients were enrolled, and synovial samples were collected from both patients and animal models at different time points. Single-cell RNA-sequencing (scRNA-seq) and bulk tissue RNA sequencing (bulk-seq) were employed to profile the distinct synovial microenvironment. This study revealed changes in cell proportions during AF pathogenesis and identified Engrailed-1 (EN1) as a key transcription factor strongly associated with disease severity and clinical prognosis. Additionally, the researchers discovered a specific type of synovial fibroblast called DKK3-SLF, which played a critical role in driving AF development. These findings shed light on the composition and heterogeneity of the synovial microenvironment in AF, offering potential avenues for identifying therapeutic targets and developing clinical treatments for AF and other fibrotic diseases.
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Affiliation(s)
- Xi Chen
- Department of Adult Joint Reconstructive Surgery, Beijing Jishuitan Hospital, Capital Medical University, 31 East Xinjiekou Street, Beijing 100035, China
- Department of Immunology, School of Basic Medical Sciences, Peking University, NHC Key Laboratory of Medical Immunology (Peking University), Beijing, China
| | - Lihua Gong
- Department of Pathology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Cheng Li
- Department of Adult Joint Reconstructive Surgery, Beijing Jishuitan Hospital, Capital Medical University, 31 East Xinjiekou Street, Beijing 100035, China
| | - Siyuan Wang
- Department of Adult Joint Reconstructive Surgery, Beijing Jishuitan Hospital, Capital Medical University, 31 East Xinjiekou Street, Beijing 100035, China
| | - Ziyuan Wang
- Department of Adult Joint Reconstructive Surgery, Beijing Jishuitan Hospital, Capital Medical University, 31 East Xinjiekou Street, Beijing 100035, China
| | - Ming Chu
- Department of Immunology, School of Basic Medical Sciences, Peking University, NHC Key Laboratory of Medical Immunology (Peking University), Beijing, China
| | - Yixin Zhou
- Department of Adult Joint Reconstructive Surgery, Beijing Jishuitan Hospital, Capital Medical University, 31 East Xinjiekou Street, Beijing 100035, China
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Sarkovich S, Issa PP, Longanecker A, Martin D, Redondo K, McTernan P, Simkin J, Marrero L. Minoxidil weakens newly synthesized collagen in fibrotic synoviocytes from osteoarthritis patients. J Exp Orthop 2023; 10:84. [PMID: 37605092 PMCID: PMC10441905 DOI: 10.1186/s40634-023-00650-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 08/09/2023] [Indexed: 08/23/2023] Open
Abstract
PURPOSE Synovial fibrosis (SFb) formation and turnover attributable to knee osteoarthritis (KOA) can impart painful stiffness and persist following arthroplasty. To supplement joint conditioning aimed at maximizing peri-operative function, we evaluated the antifibrotic effect of Minoxidil (MXD) on formation of pyridinoline (Pyd) cross-links catalyzed by Plod2-encoded lysyl hydroxylase (LH)2b that strengthen newly synthesized type-I collagen (COL1) in fibroblastic synovial cells (FSCs) from KOA patients. MXD was predicted to decrease Pyd without significant alterations to Col1a1 transcription by FSCs stimulated with transforming growth factor (TGF)β1. METHODS Synovium from 10 KOA patients grouped by SFb severity was preserved for picrosirius and LH2b histology or culture. Protein and RNA were purified from fibrotic FSCs after 8 days with or without 0.5 µM MXD and/or 4 ng/mL of TGFβ1. COL1 and Pyd protein concentrations from ELISA and expression of Col1a1, Acta2, and Plod2 genes by qPCR were compared by parametric tests with α = 0.05. RESULTS Histological LH2b expression corresponded to SFb severity. MXD attenuated COL1 output in KOA FSCs but only in the absence of TGFβ1 and consistently decreased Pyd under all conditions with significant downregulation of Plod2 but minimal alterations to Col1a1 and Acta2 transcripts. CONCLUSIONS MXD is an attractive candidate for local antifibrotic pharmacotherapy for SFb by compromising the integrity of newly formed fibrous deposits by FSCs during KOA and following arthroplasty. Targeted antifibrotic supplementation could improve physical therapy and arthroscopic lysis strategies aimed at breaking down joint scarring. However, the effect of MXD on other joint-specific TGFβ1-mediated processes or non-fibrotic components requires further investigation.
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Affiliation(s)
- Stefan Sarkovich
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, 2021 Perdido St., Center for Advanced Learning and Simulation, 7th floor, New Orleans, LA, 70112, USA
| | - Peter P Issa
- School of Medicine, Louisiana State University Health Sciences Center, 2020 Gravier St., Lions Building, 5th floor, New Orleans, LA, 70112, USA
| | - Andrew Longanecker
- School of Medicine, Louisiana State University Health Sciences Center, 2020 Gravier St., Lions Building, 5th floor, New Orleans, LA, 70112, USA
| | - Davis Martin
- School of Medicine, Louisiana State University Health Sciences Center, 2020 Gravier St., Lions Building, 5th floor, New Orleans, LA, 70112, USA
| | - Kaitlyn Redondo
- Morphology and Imaging Core, Louisiana State University Health Sciences Center, 533 Bolivar St., Clinical Sciences Research Building, 5th floor, New Orleans, LA, 70112, USA
| | - Patrick McTernan
- Department of Physiology, Louisiana State University Health Sciences Center, 533 Bolivar St., Clinical Sciences Research Building, 4th floor, New Orleans, LA, 70112, USA
| | - Jennifer Simkin
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, 2021 Perdido St., Center for Advanced Learning and Simulation, 7th floor, New Orleans, LA, 70112, USA
| | - Luis Marrero
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, 2021 Perdido St., Center for Advanced Learning and Simulation, 7th floor, New Orleans, LA, 70112, USA.
- School of Medicine, Louisiana State University Health Sciences Center, 2020 Gravier St., Lions Building, 5th floor, New Orleans, LA, 70112, USA.
- Morphology and Imaging Core, Louisiana State University Health Sciences Center, 533 Bolivar St., Clinical Sciences Research Building, 5th floor, New Orleans, LA, 70112, USA.
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11
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Yocum D, Housholder E, Yergler J. Manipulation under Anesthesia Following TKA with Persona IQ: A Case Series. J Orthop Case Rep 2023; 13:127-131. [PMID: 37654748 PMCID: PMC10465745 DOI: 10.13107/jocr.2023.v13.i08.3844] [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: 05/08/2023] [Revised: 06/14/2023] [Indexed: 09/02/2023] Open
Abstract
Introduction Although surgical devices and techniques continue to improve, regular post-operative monitoring of patients is required to ensure the best outcomes. New technological advances have allowed physicians to monitor the daily recovery of total knee arthroplasty (TKA) patients. This report is the first to describe the utilization of an implantable gait monitoring device and its capacity to detect poor early post-operative outcomes. Case Report Two patients, a 78-year-old male and a 34-year-old female, were assessed post-TKA utilizing remote gait kinematics and clinical evaluations and determined to need manipulation under anesthesia due to severely limited range of motion. One patient, a 51-year-old female, with good clinical outcomes, was used for comparison. Conclusion Remote monitoring may provide an earlier indication than clinical evaluations in identification of TKA patients at risk of poor outcomes and may who need intervention. The use of remote kinematic gait data in earlier identification of patients at risk has the potential to help improve outcomes for the broader population of TKA patients.
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Affiliation(s)
- Derek Yocum
- Department of Research South Bend Orthopaedics, Mishawaka, IN, United States
| | - Emma Housholder
- Department of Research South Bend Orthopaedics, Mishawaka, IN, United States
| | - Jeffrey Yergler
- Department of Research South Bend Orthopaedics, Mishawaka, IN, United States
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12
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Jeffs AD, Boyd M, Larabee L, Shelton M, Bassil A, Taylor R, Berkoff D. The role of leukotriene inhibition using a 5-lipoxygenase (5-LO) inhibitor in a joint contracture model. J Exp Orthop 2023; 10:64. [PMID: 37341811 DOI: 10.1186/s40634-023-00616-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 05/05/2023] [Indexed: 06/22/2023] Open
Abstract
PURPOSE Arthrofibrosis is a common inflammatory complication of joint trauma and surgery. 5lipoxygenase (5-LO) is a key enzyme involved in inflammation. Inhibition of 5-LO has been shown to reduce inflammation in heart and lung models but has not been examined in a joint contracture model. METHODS Twenty-six rats underwent joint contracture. Six rats served as non-surgical controls. A 5-LO inhibitor, caffeic acid (CA), suspended in 10% ethanol was orally administered to 14 rats and ethanol without CA to the remaining 12 rats daily for 21 days. Leukotriene B4 (LTB4) levels were measured, both systemically and locally. 5-LO levels in the posterior capsule were quantified by measuring the ratio of the length of the posterior capsule demonstrating 5-LO immunostaining to the total length of the capsule. RESULTS Joint contracture was successfully achieved in all rats who underwent manipulation. Levels of 5- LO measured in the posterior capsule were significantly increased in the animals who underwent surgery (56%/44-64) compared to the non-surgical control animals (7%/4-9). LTB4 levels were found to be significantly lower in the non-surgical control animals (107.79 ± 34.08 pg/ml) compared to all surgical animals (157.6 ± 55.3 pg/ml). CONCLUSION Surgical intervention resulted in increased 5-LO activity of the synovial surface of the posterior capsule and increased LTB4 levels in the patellar tendon-fat pad. Oral administration of the 5LO inhibitor, CA, was ineffective at reducing systemic and local LTB4 levels and preventing knee joint contracture. Inhibiting 5-LO activity may still be effective in preventing arthrofibrosis and warrants further investigation.
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Affiliation(s)
- Alexander D Jeffs
- Department of Orthopaedics, The University of North Carolina, Chapel Hill, NC, USA.
| | - Michael Boyd
- Department of Orthopaedics, The University of North Carolina, Chapel Hill, NC, USA
- Department of Family Medicine, The University of North Carolina, Chapel Hill, NC, USA
| | - Landon Larabee
- The University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Matthew Shelton
- The University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Ross Taylor
- Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - David Berkoff
- Department of Orthopaedics, The University of North Carolina, Chapel Hill, NC, USA
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13
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Sacher SE, Neri JP, Gao MA, Argentieri EC, Potter HG, Koch KM, Koff MF. MAVRIC based T2 mapping assessment of infrapatellar fat pad scarring in patients with total knee arthroplasty. J Orthop Res 2023; 41:1299-1309. [PMID: 36262013 PMCID: PMC10113607 DOI: 10.1002/jor.25472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/06/2022] [Accepted: 10/18/2022] [Indexed: 02/04/2023]
Abstract
The infrapatellar fat pad (IPFP) has been implicated as a source of postoperative knee pain. Imaging the IPFP is challenging in patients with total knee arthroplasty (TKA) due to metallic susceptibility artifact. Multi-Acquisition Variable-Resonance Image Combination (MAVRIC)-based T2 Mapping has been developed to mitigate this artifact and can generate quantitative T2 data. Objectives of this study were to (1) measure T2 values of the IPFP in patients with TKAs using a MAVRIC based T2 mapping technique and (2) determine if IPFP T2 values are related to the degree of fat pad scarring or clinical magnetic resonance imaging (MRI) findings. Twenty-eight subjects (10 males, 18 females, Age: 66 + 7.2 years [Mean ± standard deviations]) undergoing clinical MRIs were sequentially recruited. Morphological imaging and quantitative T2 mapping sequences were performed on a clinical 1.5 T scanner. The morphologic images were graded for the presence and severity of fat pad scarring and clinical outcomes. T2 values were calculated in the total fat pad volume, a normal regions of interest (ROI), and an abnormal ROI. T2 values were shortened in the total IPFP volume (p = 0.001) and within abnormal regions (p = 0.003) in subjects with more severe IPFP scarring. The difference between T2 values in normal-abnormal regions was greater in subjects with severe versus no scarring (+1426.1%, p = 0.008). T2 values were elevated in patients with MRI findings of osteolysis (+32.3%, p = 0.02). These findings indicate that MAVRIC-based T2 Mapping may be used as a quantitative biomarker of postoperative IPFP scarring in individuals following TKA.
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Affiliation(s)
- Sara E. Sacher
- Hospital for Special Surgery, 535 East 70th St, New York, NY 10021
| | - John P. Neri
- Hospital for Special Surgery, 535 East 70th St, New York, NY 10021
| | - Madeleine A. Gao
- Hospital for Special Surgery, 535 East 70th St, New York, NY 10021
| | | | - Hollis G. Potter
- Hospital for Special Surgery, 535 East 70th St, New York, NY 10021
| | | | - Matthew F. Koff
- Hospital for Special Surgery, 535 East 70th St, New York, NY 10021
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14
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Ly TD, Sambale M, Klösener L, Traut P, Fischer B, Hendig D, Kuhn J, Knabbe C, Faust-Hinse I. Understanding of arthrofibrosis: New explorative insights into extracellular matrix remodeling of synovial fibroblasts. PLoS One 2023; 18:e0286334. [PMID: 37235555 DOI: 10.1371/journal.pone.0286334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 05/14/2023] [Indexed: 05/28/2023] Open
Abstract
Arthrofibrosis following total knee arthroplasty is a fibroproliferative joint disorder marked by dysregulated biosynthesis of extracellular matrix proteins, such as collagens and proteoglycans. The underlying cellular events remain incompletely understood. Myofibroblasts are highly contractile matrix-producing cells characterized by increased alpha-smooth muscle actin expression and xylosyltransferase-I (XT-I) secretion. Human XT-I has been identified as a key mediator of arthrofibrotic remodeling. Primary fibroblasts from patients with arthrofibrosis provide a useful in vitro model to identify and characterize disease regulators and potential therapeutic targets. This study aims at characterizing primary synovial fibroblasts from arthrofibrotic tissues (AFib) regarding their molecular and cellular phenotype by utilizing myofibroblast cell culture models. Compared to synovial control fibroblasts (CF), AFib are marked by enhanced cell contractility and a higher XT secretion rate, demonstrating an increased fibroblast-to-myofibroblast transition rate during arthrofibrosis. Histochemical assays and quantitative gene expression analysis confirmed higher collagen and proteoglycan expression and accumulation in AFib compared to CF. Furthermore, fibrosis-based gene expression profiling identified novel modifier genes in the context of arthrofibrosis remodeling. In summary, this study revealed a unique profibrotic phenotype in AFib that resembles some traits of other fibroproliferative diseases and can be used for the future development of therapeutic interventions.
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Affiliation(s)
- Thanh-Diep Ly
- Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum NRW, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, North Rhine-Westphalia, Germany
| | - Meike Sambale
- Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum NRW, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, North Rhine-Westphalia, Germany
| | - Lara Klösener
- Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum NRW, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, North Rhine-Westphalia, Germany
| | - Philipp Traut
- Orthopädische Beratung und Begutachtung, Bad Oeynhausen, North Rhine-Westphalia, Germany
| | - Bastian Fischer
- Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum NRW, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, North Rhine-Westphalia, Germany
| | - Doris Hendig
- Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum NRW, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, North Rhine-Westphalia, Germany
| | - Joachim Kuhn
- Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum NRW, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, North Rhine-Westphalia, Germany
| | - Cornelius Knabbe
- Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum NRW, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, North Rhine-Westphalia, Germany
| | - Isabel Faust-Hinse
- Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum NRW, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, North Rhine-Westphalia, Germany
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15
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Li Y, Liao Q, Zeng J, Zhang Z, Li B, Luo Z, Xiao X, Liu G. Extracorporeal Shock Wave Therapy Improves Nontraumatic Knee Contracture in a Rat Model. Clin Orthop Relat Res 2023; 481:822-834. [PMID: 36724201 PMCID: PMC10013671 DOI: 10.1097/corr.0000000000002559] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 12/22/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Joint contractures occur frequently after trauma or immobilization, but few reliable treatments are available. Extracorporeal shock wave therapy (ESWT) is often used for various musculoskeletal conditions, but whether it is effective for treating joint contractures and the mechanisms through which it might work for that condition remain unclear. QUESTIONS/PURPOSES Using a rat model, we asked, does ESWT (1) inhibit the progression of knee contracture, (2) ameliorate histopathologic joint changes, and (3) improve serum and myofascial fibrosis-related factors? We also asked, (4) what is the possible mechanism by which ESWT inhibits knee contracture? METHODS Thirty-two male Sprague-Dawley rats (12 weeks old and weighing 300 to 400 g) were randomly separated into two groups: control group (eight rats) and noncontrol group (24) in the first week. Rats in the control group were kept free in cages for 4 weeks, and the right lower limbs of the rats in the noncontrol group were immobilized in plaster for 4 weeks. ROM was then measured for each rat with or without 4 weeks of immobilization. After ROM measurement, rats in the noncontrol group were randomly separated into three groups: immobilization group (eight rats), remobilization group (eight rats), and remobilization with ESWT group (eight rats) at Week 4. Knee contracture was induced in rats by fixing the right knee with a plaster cast as in a previous study. The plaster cast was removed after 4 weeks; knee contracture was established when passive ROM was decreased and dysfunction such as abnormal gait occurred. Subsequently, rats with a remobilized joint contracture were treated with or without ESWT for 15 days (on Days 5, 10, and 15). The therapeutic effect was examined using ROM, joint diameter (as an indication of swelling), histopathologic changes, and the levels of fibrosis-related extracellular matrix component factors (hyaluronic acid, serum procollagen peptide, and laminin). The effect of ESWT on fibrosis protein was also evaluated using immunohistochemistry, quantitative polymerase chain reaction (qPCR), and Western blot. The expressions of factors in the TGF-β/SMADs pathway were also determined using Western blot and qPCR. RESULTS ESWT mitigated immobilization-induced knee contracture in rats by improving ROM (immobilization versus remobilization with ESWT: 53° ± 8° versus 32° ± 8° [95% confidence interval 13° to 30°]; p < 0.001) and joint swelling (immobilization versus remobilization with ESWT: 8 ± 0.8 cm versus 6 ± 0.3 cm [95% CI 0.4 to 2.2 cm]; p = 0.01). Histopathologic features of remission were alleviated after ESWT (immobilization versus remobilization with ESWT: thickness of the knee space: 0.2 ± 0.03 mm versus 0.6 ± 0.01 mm [95% CI -0.49 to -0.33 mm]; p < 0.001. On Masson staining, the positive expression area, which indicates collagen fiber deposition, was 24% ± 5% versus 9% ± 2% ([95% CI 10% to 21%]; p < 0.001). ESWT improved the serum fibrosis factors of hyaluronic acid, procollagen peptide, and laminin (immobilization versus remobilization with ESWT: hyaluronic acid: 412 ± 32 versus 326 ±15 ng/mL [95% CI 29 to 144 ng/mL]; p = 0.003; serum procollagen peptide: 19 ± 1 versus 12 ±1 ng/mL [95% CI 3 to 11 ng/mL]; p < 0.001; laminin: 624 ± 78 versus 468 ±9 ng/mL [95% CI 81 to 231 ng/mL]; p = 0.006) and myofascial factors of α-SMA and Type I collagen associated with immobilization-induced contractures. CONCLUSION The findings suggest that ESWT improved joint contracture by inhibiting the TGF-β1/SMADs signaling pathway in rats. CLINICAL RELEVANCE This work suggests ESWT may be worth exploring in preliminary research in humans to determine whether it may be a treatment option for patients with nontraumatic knee contractures. If the mechanism of ESWT can be confirmed in humans, ESWT might be a therapy for diseases involved in the TGF-β1/SMADs signaling pathway, such as hypertroic scarring and scleroderma.
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Affiliation(s)
- Yang Li
- Shenzhen Luohu People’s Hospital, Luohu Hospital Group, Shenzhen, PR China
| | - Qing Liao
- Southern Medical University, Guangzhou, PR China
| | - Jing Zeng
- Southern Medical University, Guangzhou, PR China
| | | | - Baojian Li
- Southern Medical University, Guangzhou, PR China
| | - Ziyi Luo
- Southern Medical University, Guangzhou, PR China
| | - Xiang Xiao
- Shenzhen Luohu People’s Hospital, Luohu Hospital Group, Shenzhen, PR China
- Southern Medical University, Guangzhou, PR China
| | - Gang Liu
- Southern Medical University, Guangzhou, PR China
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16
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Mehta B, Goodman S, DiCarlo E, Jannat-Khah D, Gibbons JAB, Otero M, Donlin L, Pannellini T, Robinson WH, Sculco P, Figgie M, Rodriguez J, Kirschmann JM, Thompson J, Slater D, Frezza D, Xu Z, Wang F, Orange DE. Machine learning identification of thresholds to discriminate osteoarthritis and rheumatoid arthritis synovial inflammation. Arthritis Res Ther 2023; 25:31. [PMID: 36864474 PMCID: PMC9979511 DOI: 10.1186/s13075-023-03008-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 02/06/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND We sought to identify features that distinguish osteoarthritis (OA) and rheumatoid arthritis (RA) hematoxylin and eosin (H&E)-stained synovial tissue samples. METHODS We compared fourteen pathologist-scored histology features and computer vision-quantified cell density (147 OA and 60 RA patients) in H&E-stained synovial tissue samples from total knee replacement (TKR) explants. A random forest model was trained using disease state (OA vs RA) as a classifier and histology features and/or computer vision-quantified cell density as inputs. RESULTS Synovium from OA patients had increased mast cells and fibrosis (p < 0.001), while synovium from RA patients exhibited increased lymphocytic inflammation, lining hyperplasia, neutrophils, detritus, plasma cells, binucleate plasma cells, sub-lining giant cells, fibrin (all p < 0.001), Russell bodies (p = 0.019), and synovial lining giant cells (p = 0.003). Fourteen pathologist-scored features allowed for discrimination between OA and RA, producing a micro-averaged area under the receiver operating curve (micro-AUC) of 0.85±0.06. This discriminatory ability was comparable to that of computer vision cell density alone (micro-AUC = 0.87±0.04). Combining the pathologist scores with the cell density metric improved the discriminatory power of the model (micro-AUC = 0.92±0.06). The optimal cell density threshold to distinguish OA from RA synovium was 3400 cells/mm2, which yielded a sensitivity of 0.82 and specificity of 0.82. CONCLUSIONS H&E-stained images of TKR explant synovium can be correctly classified as OA or RA in 82% of samples. Cell density greater than 3400 cells/mm2 and the presence of mast cells and fibrosis are the most important features for making this distinction.
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Affiliation(s)
- Bella Mehta
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10009, USA.
- Weill Cornell Medicine, New York, NY, USA.
| | - Susan Goodman
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10009, USA
- Weill Cornell Medicine, New York, NY, USA
| | - Edward DiCarlo
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10009, USA
- Weill Cornell Medicine, New York, NY, USA
| | - Deanna Jannat-Khah
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10009, USA
- Weill Cornell Medicine, New York, NY, USA
| | - J Alex B Gibbons
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Miguel Otero
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10009, USA
- Weill Cornell Medicine, New York, NY, USA
| | - Laura Donlin
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10009, USA
- Weill Cornell Medicine, New York, NY, USA
| | | | | | - Peter Sculco
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10009, USA
- Weill Cornell Medicine, New York, NY, USA
| | - Mark Figgie
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10009, USA
- Weill Cornell Medicine, New York, NY, USA
| | - Jose Rodriguez
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10009, USA
- Weill Cornell Medicine, New York, NY, USA
| | | | | | | | | | | | - Fei Wang
- Weill Cornell Medicine, New York, NY, USA
| | - Dana E Orange
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10009, USA
- The Rockefeller University, New York, NY, USA
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17
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Parkulo TD, Likine EF, Ong KL, Watson HN, Smith LS, Malkani AL. Manipulation Following Primary Total Knee Arthroplasty is Associated With Increased Rates of Infection and Revision. J Arthroplasty 2023; 38:567-572.e1. [PMID: 36191695 DOI: 10.1016/j.arth.2022.09.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/16/2022] [Accepted: 09/26/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Stiffness following total knee arthroplasty (TKA) is a disabling complication and manipulation under anesthesia (MUA) is often performed as an early intervention. Few studies have focused on the revision risk, infection risk, demographics, and clinical outcomes in Medicare patients undergoing MUA following primary TKA. METHODS We reviewed 142,440 patients who had primary TKA from a national database and identified 3,652 patients (2.6%) who underwent MUA. Patient demographics and comorbid conditions were evaluated to identify risk factors. Incidence of revision and periprosthetic joint infection (PJI) at 1-, 2-, and 5-year time points in a cohort of MUA patients was compared to patients who did not undergo MUA. Multivariate Cox regressions were used for statistical analyses. RESULTS The incidence of MUA was higher in Black versus White individuals (4.1 versus 2.5%, P < .001). Revision risk was significantly greater in the MUA group at 1-, 2-, and 5-year time points with a hazard ratio (HR) of, 3.81, 3.90, and 3.22 respectively, P < .001. One- and 2-year revision risk was significantly greater when MUA occurred at 6 to 12 months post-TKA when compared to <3 months, P < .05. Risk of PJI was significantly greater in the MUA group with a HR of 2.2, 2.2, and 2.1 at 1, 2, and 5 years, respectively P < .001. CONCLUSION The incidence of MUA was 2.6%. There was an increased incidence of revision surgery and PJI in patients undergoing MUA. Patients at increased risk for stiffness following TKA should be closely monitored and treated with early intervention to minimize risk of poor outcomes.
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Affiliation(s)
- Travis D Parkulo
- University of Louisville, Department of Orthopaedic Surgery, Louisville, Kentucky
| | - Elive F Likine
- University of Louisville, Department of Orthopaedic Surgery, Louisville, Kentucky
| | | | | | | | - Arthur L Malkani
- University of Louisville, Department of Orthopedic Surgery, Adult Reconstruction Program, Louisville, Kentucky
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18
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Rockov ZA, Byrne CT, Rezzadeh KT, Durst CR, Spitzer AI, Paiement GD, Penenberg BL, Rajaee SS. Revision total knee arthroplasty for arthrofibrosis improves range of motion. Knee Surg Sports Traumatol Arthrosc 2023; 31:1859-1864. [PMID: 36809514 PMCID: PMC10090018 DOI: 10.1007/s00167-023-07353-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 02/10/2023] [Indexed: 02/23/2023]
Abstract
PURPOSE Arthrofibrosis after primary total knee arthroplasty (TKA) is a significant contributor to patient dissatisfaction. While treatment algorithms involve early physical therapy and manipulation under anaesthesia (MUA), some patients ultimately require revision TKA. It is unclear whether revision TKA can consistently improve these patient's range of motion (ROM). The purpose of this study was to evaluate ROM when revision TKA was performed for arthrofibrosis. METHODS A retrospective study of 42 TKA's diagnosed with arthrofibrosis from 2013 to 2019 at a single institution with a minimum 2-year follow-up was performed. The primary outcome was ROM (flexion, extension, and total arc of motion) before and after revision TKA, and secondary outcomes included patient reported outcomes information system (PROMIS) scores. Categorical data were compared using chi-squared analysis, and paired samples t tests were performed to compare ROM at three different times: pre-primary TKA, pre-revision TKA, and post-revision TKA. A multivariable linear regression analysis was performed to assess for effect modification on total ROM. RESULTS The patient's pre-revision mean flexion was 85.6 degrees, and mean extension was 10.1 degrees. At the time of the revision, the mean age of the cohort was 64.7 years, the average body mass index (BMI) was 29.8, and 62% were female. At a mean follow-up of 4.5 years, revision TKA significantly improved terminal flexion by 18.4 degrees (p < 0.001), terminal extension by 6.8 degrees (p = 0.007), and total arc of motion by 25.2 degrees (p < 0.001). The final ROM after revision TKA was not significantly different from the patient's pre-primary TKA ROM (p = 0.759). PROMIS physical function, depression, and pain interference scores were 39 (SD = 7.72), 49 (SD = 8.39), and 62 (SD = 7.25), respectively. CONCLUSION Revision TKA for arthrofibrosis significantly improved ROM at a mean follow-up of 4.5 years with over 25 degrees of improvement in the total arc of motion, resulting in final ROM similar to pre-primary TKA ROM. PROMIS physical function and pain scores showed moderate dysfunction, while depression scores were within normal limits. While physical therapy and MUA remain the gold standard for the early treatment of stiffness after TKA, revision TKA can improve ROM. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Zachary A Rockov
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 South San Vicente Boulevard, Suite 603, Los Angeles, CA, 90048, USA.
| | - Connor T Byrne
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 South San Vicente Boulevard, Suite 603, Los Angeles, CA, 90048, USA
| | - Kevin T Rezzadeh
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 South San Vicente Boulevard, Suite 603, Los Angeles, CA, 90048, USA
| | - Caleb R Durst
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 South San Vicente Boulevard, Suite 603, Los Angeles, CA, 90048, USA
| | - Andrew I Spitzer
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 South San Vicente Boulevard, Suite 603, Los Angeles, CA, 90048, USA
| | - Guy D Paiement
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 South San Vicente Boulevard, Suite 603, Los Angeles, CA, 90048, USA
| | - Brad L Penenberg
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 South San Vicente Boulevard, Suite 603, Los Angeles, CA, 90048, USA
| | - Sean S Rajaee
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 South San Vicente Boulevard, Suite 603, Los Angeles, CA, 90048, USA
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Jia D, Chen H, Dai J, He S, Liu Y, Liu Z, Zhang Y, Li X, Sun Y, Wang Q. Human Infrapatellar Fat Pad Mesenchymal Stem Cell-Derived Extracellular Vesicles Inhibit Fibroblast Proliferation by Regulating MT2A to Reduce Knee Arthrofibrosis. Stem Cells Int 2023; 2023:9067621. [PMID: 37091533 PMCID: PMC10115539 DOI: 10.1155/2023/9067621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 09/20/2022] [Accepted: 09/27/2022] [Indexed: 04/25/2023] Open
Abstract
Knee arthrofibrosis is one of the most serious complications of knee surgery; however, its pathogenesis is unclear, and current treatment methods have not achieved satisfactory results. Mesenchymal stem cells (MSCs) have good anti-inflammatory and antifibrotic properties, and studies have reported that human infrapatellar fat pad-derived MSCs (IPFSCs) have the advantages of strong proliferative and differentiating ability, ease of acquisition, and minimal harm to the donor. Increasing evidence has shown that MSCs function through their paracrine extracellular vesicles (EVs). Our study is aimed at exploring the effects of human IPFSC-derived EVs (IPFSC-EVs) on knee arthrofibrosis and the underlying mechanisms in vivo and in vitro. In the in vivo study, injecting IPFSC-EVs into the knee joint cavity effectively reduced surgery-induced knee arthrofibrosis in rats. In the in vitro study, IPFSC-EVs were found to inhibit the proliferation of fibroblasts in the inflammatory environment. Additionally, we screened a potential IPFSC-EV molecular target, metallothionein 2A (MT2A), using RNA sequencing. We found that silencing MT2A partially reversed the inhibitory effect of IPFSC-EVs on fibroblast proliferation in the inflammatory environment. In conclusion, IPFSC-EVs inhibit the progression of knee arthrofibrosis by regulating MT2A, which inhibits fibroblast proliferation in the inflammatory environment.
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Affiliation(s)
- Dazhou Jia
- Department of Orthopedics, Affiliated Hospital of Yangzhou University, Yangzhou, 225001 Jiangsu, China
| | - Hui Chen
- Department of Orthopedics, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, Jiangsu, China
| | - Jihang Dai
- Department of Orthopedics, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, Jiangsu, China
| | - Shiping He
- Department of Orthopedics, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, Jiangsu, China
| | - Yangyang Liu
- Department of Orthopedics, Affiliated Hospital of Yangzhou University, Yangzhou, 225001 Jiangsu, China
| | - Zhendong Liu
- Department of Orthopedics, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, Jiangsu, China
| | - Yaxin Zhang
- Department of Orthopedics, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, Jiangsu, China
| | - Xiaolei Li
- Department of Orthopedics, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, Jiangsu, China
| | - Yu Sun
- Department of Orthopedics, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, Jiangsu, China
| | - Qiang Wang
- Department of Orthopedics, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, Jiangsu, China
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20
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Rahardja R, Mehmood A, Coleman B, Munro JT, Young SW. Early manipulation under anaesthesia for stiffness following total knee arthroplasty is associated with a greater gain in knee flexion. Knee Surg Sports Traumatol Arthrosc 2023; 31:979-985. [PMID: 36042022 PMCID: PMC9957883 DOI: 10.1007/s00167-022-07128-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/12/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE This study aimed to identify the risk factors for manipulation under anaesthesia (MUA) following total knee arthroplasty (TKA) and whether performing an 'early' MUA within 3 months leads to a greater improvement in range of motion. METHODS Primary TKAs performed between 2013 and 2018 at three tertiary New Zealand hospitals were reviewed with a minimum follow-up of 1 year. Clinical details of patients who underwent MUA were reviewed to identify the knee flexion angle prior to and following MUA. Multivariate analysis identified the risk factors for undergoing MUA and compared flexion angles between 'early' (< 3 months) and 'late' MUA (> 3 months). RESULTS A total of 7386 primary TKAs were analysed in which 131 underwent an MUA (1.8%). Patients aged < 65 years were two times more likely to undergo MUA compared to patients aged ≥ 65 years (2.5 versus 1.3%, p < 0.001; adjusted HR = 2.1, p < 0.001). There was no difference in the final flexion angle post-MUA between early and late MUA (104.7° versus 104.1°, p = 0.819). However, patients who underwent early MUA had poorer pre-MUA flexion (72.3° versus 79.6°, p = 0.012), and subsequently had a greater overall gain in flexion compared to those who underwent late MUA (mean gain 33.1° versus 24.3°, p < 0.001). CONCLUSION Younger age was the only patient risk factor for MUA. Patients who underwent early MUA had similar post-MUA flexion, but had poorer pre-MUA flexion compared to those who underwent late MUA. Subsequently, a greater overall gain in flexion was achieved in those who underwent early MUA. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Richard Rahardja
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
| | - Aziz Mehmood
- grid.9654.e0000 0004 0372 3343Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Brendan Coleman
- grid.415534.20000 0004 0372 0644Department of Orthopaedic Surgery, Middlemore Hospital, Auckland, New Zealand
| | - Jacob T. Munro
- grid.414055.10000 0000 9027 2851Department of Orthopaedic Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Simon W. Young
- grid.9654.e0000 0004 0372 3343Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand ,grid.416471.10000 0004 0372 096XDepartment of Orthopaedic Surgery, North Shore Hospital, Auckland, New Zealand
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21
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Limberg AK, Salib CG, Tibbo ME, Vargas-Hernandez JS, Bettencourt JW, Bayram B, Berry CE, Dudakovic A, Bolon B, van Wijnen AJ, Morrey ME, Sanchez-Sotelo J, Berry DJ, Carter JM, Abdel MP. Immune cell populations differ in patients undergoing revision total knee arthroplasty for arthrofibrosis. Sci Rep 2022; 12:22627. [PMID: 36587032 PMCID: PMC9805429 DOI: 10.1038/s41598-022-22175-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 10/11/2022] [Indexed: 01/01/2023] Open
Abstract
Arthrofibrosis following total knee arthroplasty (TKA) is a debilitating condition typically diagnosed based on clinical findings. To gain insight into the histopathologic immune cell microenvironment of arthrofibrosis, we assessed the extent of tissue fibrosis and quantified immune cell populations in specific tissue regions of the posterior capsule. We investigated specimens from three prospectively-collected, matched cohorts, grouped as patients receiving a primary TKA for osteoarthritis, revision TKA for arthrofibrosis, and revision TKA for non-arthrofibrotic, non-infectious reasons. Specimens were evaluated using hematoxylin and eosin staining, picrosirius red staining, immunofluorescence, and immunohistochemistry with Aperio®-based digital image analysis. Increased collagen deposition and increased number of α-SMA/ACTA2 expressing myofibroblasts were present in the arthrofibrosis group compared to the two non-arthrofibrotic groups. CD163 + macrophages were the most abundant immune cell type in any capsular sample with specific enrichment in the synovial tissue. CD163 + macrophages were significantly decreased in the fibrotic tissue region of arthrofibrosis patients compared to the patients with primary TKA, and significantly increased in adipose tissue region of arthrofibrotic specimens compared to non-arthrofibrotic specimens. Synovial CD117 + mast cells were significantly decreased in arthrofibrotic adipose tissue. Together, these findings inform diagnostic and targeted therapeutic strategies by providing insight into the underlying pathogenetic mechanisms of arthrofibrosis.
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Affiliation(s)
- Afton K. Limberg
- grid.66875.3a0000 0004 0459 167XDepartment of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN 55905 USA
| | - Christopher G. Salib
- grid.66875.3a0000 0004 0459 167XDepartment of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN 55905 USA
| | - Meagan E. Tibbo
- grid.66875.3a0000 0004 0459 167XDepartment of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN 55905 USA
| | - Juan S. Vargas-Hernandez
- grid.66875.3a0000 0004 0459 167XDepartment of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN 55905 USA
| | - Jacob W. Bettencourt
- grid.66875.3a0000 0004 0459 167XDepartment of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN 55905 USA
| | - Banu Bayram
- grid.66875.3a0000 0004 0459 167XDepartment of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN 55905 USA
| | - Charlotte E. Berry
- grid.66875.3a0000 0004 0459 167XDepartment of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN 55905 USA
| | - Amel Dudakovic
- grid.66875.3a0000 0004 0459 167XDepartment of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN 55905 USA
| | - Brad Bolon
- GEMpath Inc, 1927 Lincoln Street, Longmount, CO 80501 USA
| | - Andre J. van Wijnen
- grid.59062.380000 0004 1936 7689Department of Biochemistry, University of Vermont, 89 Beaumont Avenue, Burlington, VT 05405 USA
| | - Mark E. Morrey
- grid.66875.3a0000 0004 0459 167XDepartment of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN 55905 USA
| | - Joaquin Sanchez-Sotelo
- grid.66875.3a0000 0004 0459 167XDepartment of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN 55905 USA
| | - Daniel J. Berry
- grid.66875.3a0000 0004 0459 167XDepartment of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN 55905 USA
| | - Jodi M. Carter
- grid.66875.3a0000 0004 0459 167XDepartment of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street S.W, Rochester, MN 55905 USA
| | - Matthew P. Abdel
- grid.66875.3a0000 0004 0459 167XDepartment of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN 55905 USA
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22
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Arraut J, Lygrisse KA, Singh V, Fiedler B, Schwarzkopf R, Rozell JC. The effect of losartan on range of motion and rates of manipulation in total knee arthroplasty: a retrospective matched cohort study. Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04696-8. [PMID: 36436067 DOI: 10.1007/s00402-022-04696-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 11/08/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Arthrofibrosis remains a common cause of patient dissatisfaction and reoperation after total knee arthroplasty (TKA). Losartan is an angiotensin receptor blocker (ARB) with inhibitory effects on transforming growth factor beta, previously implicated in tissue repair induced fibrosis, and has been studied to prevent stiffness following hip arthroscopy. This study aimed to evaluate pre- and postoperative range of motion (ROM) and the incidence of manipulation under anesthesia (MUA) following primary TKA in patients taking Losartan preoperatively for hypertension. MATERIALS AND METHODS A retrospective review of 170 patients from 2012 to 2020 who underwent a primary, elective TKA and were prescribed Losartan at least three months prior to surgery. All patients who were prescribed Losartan and had a preoperative and postoperative ROM in their chart were included and were matched to a control group of patients who underwent TKA and had no Losartan prescription. ROM, MUA, readmissions, reoperations, and revisions were assessed using chi-square and independent sample t tests. RESULTS Seventy-nine patients met the inclusion criteria. Preoperative ROM was similar between patients on Losartan and the control group (103.59° ± 16.14° vs. 104.59° ± 21.59°, respectively; p = 0.745). Postoperative ROM and ΔROM were greater for patients prescribed Losartan (114.29° ± 12.32° vs. 112.76° ± 11.65°; p = 0.429 and 10.57° ± 14.95° vs. 8.17° ± 21.68°; p = 0.422), though this difference did not reach statistical significance. There was no difference in readmission, rate of manipulation for stiffness, or all-cause revision rates. CONCLUSION In this study, we found that the use of Losartan did not significantly improve postoperative ROM, reduce MUA or decrease revision rates. Further prospective studies using Losartan are required to elucidate the potential effects on ROM and incidence of arthrofibrosis requiring MUA. LEVEL III EVIDENCE Retrospective cohort study.
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Affiliation(s)
- Jerry Arraut
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, New York, NY, 10003, USA
| | - Katherine A Lygrisse
- Department of Orthopaedic Surgery, Zucker School of Medicine at Hofstra/Northwell, Huntington Hospital, Huntington, NY, USA
| | - Vivek Singh
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, New York, NY, 10003, USA
| | - Benjamin Fiedler
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, New York, NY, 10003, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, New York, NY, 10003, USA
| | - Joshua C Rozell
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, New York, NY, 10003, USA.
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23
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Lyons M, Nunley RM, Ahmed Shokri A, Doneley T, Han HS, Harato K, Kuwasawa A, Lee DH, Qi X, Qian W, Ratanachai S, Wang W, Po-Han Chen B, Danker W. Goals, challenges and strategies for wound and bleeding management in total knee arthroplasty: A modified Delphi method. J Orthop Surg (Hong Kong) 2022; 30:10225536221138985. [PMID: 36374258 DOI: 10.1177/10225536221138985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Surgical techniques related to soft tissue management play critical roles in optimizing surgical outcomes and patient satisfaction in total knee arthroplasty (TKA). Despite the importance of wound closure and bleeding management approaches, no published guidelines/consensus are available. METHODS Twelve orthopedic surgeons participated in a modified Delphi panel consisting of 2 parts (each part comprising two rounds) from September-October 2018. Questionnaires were developed based on published evidence and guidelines on surgical techniques/materials. Questionnaires were administered via email (Round 1) or at a face-to-face meeting (subsequent rounds). Panelists ranked their agreement with each statement on a five-point Likert scale. Consensus was achieved if ≥70% of panelists selected 4/5, or 1/2. Statements not reaching consensus in Round 1 were discussed and repeated or modified in Round 2. Statements not reaching consensus in Round 2 were excluded from the final consensus framework. RESULTS Consensus was reached on 13 goals of wound management. Panelists agreed on 38 challenges and 71 strategies addressing surgical techniques or wound closure materials for each tissue layer, and management strategies for blood loss reduction or deep vein thrombosis prophylaxis in TKA. Statements on closure of capsular and skin layers, wound irrigation, dressings and drains required repeat voting or modification to reach consensus. CONCLUSION Consensus from Asia-Pacific TKA experts highlights the importance of wound management in optimizing TKA outcomes. The consensus framework provides a basis for future research, guidance to reduce variability in patient outcomes, and can help inform recommendations for wound management in TKA.
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Affiliation(s)
| | - Ryan M Nunley
- 12275Washington University of Medicine, St Louis, MO, USA
| | | | - Tyson Doneley
- 95053Brisbane Private Hospital, Spring Hill, QLD, Australia
| | - Hyuk-Soo Han
- 58927Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Korea, Republic of (South)
| | - Kengo Harato
- Keio University School of Medicine, Tokyo, Japan
| | | | - Dae-Hee Lee
- 36626Samsung Medical Center, Seoul, Korea, Republic of (South)
| | - Xin Qi
- The First Affiliated Hospital of Jilin University, Changchun City, China
| | - Wenwei Qian
- 34732Peking Union Medical College Hospital, Beijing, China
| | | | - Weijun Wang
- 66506Nanjing Drum Tower Hospital, Jiangsu Province, China
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Kaneguchi A, Ozawa J. Inflammation and Fibrosis Induced by Joint Remobilization, and Relevance to Progression of Arthrogenic Joint Contracture: A Narrative Review. Physiol Res 2022. [DOI: 10.33549/physiolres.934876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Joint immobilization is frequently administered after fractures and ligament injuries and can cause joint contracture as a side effect. The structures responsible for immobilization-induced joint contracture can be roughly divided into muscular and articular. During remobilization, although myogenic contracture recovers spontaneously, arthrogenic contracture is irreversible or deteriorates further. Immediately after remobilization, an inflammatory response is observed, characterized by joint swelling, deposit formation in the joint space, edema, inflammatory cell infiltration, and the upregulation of genes encoding proinflammatory cytokines in the joint capsule. Subsequently, fibrosis in the joint capsule develops, in parallel with progressing arthrogenic contracture. The triggers of remobilization-induced joint inflammation are not fully understood, but two potential mechanisms are proposed: 1) micro-damage induced by mechanical stress in the joint capsule, and 2) nitric oxide (NO) production via NO synthase 2. Some interventions can modulate remobilization-induced inflammatory and subsequent fibrotic reactions. Anti-inflammatory treatments, such as steroidal anti-inflammatory drugs and low-level laser therapy, can attenuate joint capsule fibrosis and the progression of arthrogenic contracture in remobilized joints. Antiproliferative treatment using the cell-proliferation inhibitor mitomycin C can also attenuate joint capsule fibrosis by inhibiting fibroblast proliferation without suppressing inflammation. Conversely, aggressive exercise during the early remobilization phases is counterproductive, because it facilitates inflammatory and then fibrotic reactions in the joint. However, the adverse effects of aggressive exercise on remobilization-induced inflammation and fibrosis are offset by anti-inflammatory treatment. To prevent the progression of arthrogenic contracture during remobilization, therefore, care should be taken to control inflammatory and fibrotic reactions in the joints.
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Affiliation(s)
- A Kaneguchi
- Department of Rehabilitation, Faculty of Rehabilitation, Hiroshima International University, Hiroshima, Japan
| | - J Ozawa
- Department of Rehabilitation, Faculty of Rehabilitation, Hiroshima International University, Hiroshima, Japan.
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25
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Premkumar A, Anatone A, Illescas A, Memtsoudis S, Cross MB, Sculco PK, Gonzalez Della Valle A. Perioperative Use of Antifibrotic Medications Associated With Lower Rate of Manipulation After Primary TKA: An Analysis of 101,366 Patients. J Arthroplasty 2022; 37:S1010-S1015.e1. [PMID: 35283229 DOI: 10.1016/j.arth.2022.03.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/28/2022] [Accepted: 03/06/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Several commonly prescribed medications have known antifibrotic properties and have been shown to reduce postoperative scar formation in other clinical areas, but it is unknown whether the use of such medications perioperatively in patients undergoing TKA may improve rates of postoperative stiffness. METHODS A large US employer-sponsored healthcare database (Truven Marketscan) was queried for patients who underwent elective primary TKA for primary osteoarthritis between 2015-2019. Demographic information and comorbidities were recorded, along with whether patients were prescribed one of several medications with known antifibrotic properties during the three months before or after surgery. RESULTS Complete data were available for 101,366 patients undergoing TKA, of which 4,536 underwent MUA (4.5%). Perioperative use of any antifibrotic medication was associated with a lower likelihood of undergoing MUA (P < .001). When controlling for age, sex, comorbidities, opioid use, length of stay, among other variables, perioperative use of specific ACE inhibitors (OR 0.91, CI 0.84-1, P = .042), COX-2 inhibitors (OR 0.88, CI 0.81-0.96, P = .002), and angiotensin II receptor blockers, specifically losartan (OR 0.80, CI 0.70-0.91, P = .007) all remained significantly associated with lower rates of MUA. CONCLUSION This study, spanning over a hundred thousand primary TKA procedures over a recent five-year period, demonstrates an association between perioperative use of specific medications with antifibrotic properties and a decreased rate of MUA. These data will help inform future studies aimed to prospectively evaluate the potential of antifibrotic medications in preventing postoperative stiffness in high-risk patients undergoing knee arthroplasty.
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Affiliation(s)
- Ajay Premkumar
- Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, NY
| | - Alex Anatone
- Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, NY
| | - Alex Illescas
- Hospital for Special Surgery, Biostatistics Core, New York, NY
| | - Stavros Memtsoudis
- Hospital for Special Surgery, Department of Anesthesiology, Critical Care, and Pain Management, New York, NY
| | - Michael B Cross
- Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, NY
| | - Peter K Sculco
- Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, NY
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Nabai L, Ghahary A, Jackson J. Localized Controlled Release of Kynurenic Acid Encapsulated in Synthetic Polymer Reduces Implant-Induced Dermal Fibrosis. Pharmaceutics 2022; 14:pharmaceutics14081546. [PMID: 35893802 PMCID: PMC9331703 DOI: 10.3390/pharmaceutics14081546] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/17/2022] [Accepted: 07/18/2022] [Indexed: 02/01/2023] Open
Abstract
Excessive fibrosis following surgical procedures is a challenging condition with serious consequences and no effective preventive or therapeutic option. Our group has previously shown the anti-fibrotic effect of kynurenic acid (KynA) in vitro and as topical cream formulations or nanofiber dressings in open wounds. Here, we hypothesized that the implantation of a controlled release drug delivery system loaded with KynA in a wound bed can prevent fibrosis in a closed wound. Poly (lactic-co-glycolic acid) (PLGA), and a diblock copolymer, methoxy polyethylene glycol-block-poly (D, L-lactide) (MePEG-b-PDLLA), were used for the fabrication of microspheres which were evaluated for their characteristics, encapsulation efficiency, in vitro release profile, and in vivo efficacy for reduction of fibrosis. The optimized formulation exhibited high encapsulation efficiency (>80%), low initial burst release (~10%), and a delayed, gradual release of KynA. In vivo evaluation of the fabricated microspheres in the PVA model of wound healing revealed that KynA microspheres effectively reduced collagen deposition inside and around PVA sponges and α-smooth muscle actin expression after 66 days. Our results showed that KynA can be efficiently encapsulated in PLGA microspheres and its controlled release in vivo reduces fibrotic tissue formation, suggesting a novel therapeutic option for the prevention or treatment of post-surgical fibrosis.
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Affiliation(s)
- Layla Nabai
- BC Professional Fire Fighters’ Burn & Wound Healing Research Lab, ICORD, The Blusson Spinal Cord Centre, 818 West 10th Ave, Vancouver, BC V5Z 1M9, Canada; (L.N.); (A.G.)
| | - Aziz Ghahary
- BC Professional Fire Fighters’ Burn & Wound Healing Research Lab, ICORD, The Blusson Spinal Cord Centre, 818 West 10th Ave, Vancouver, BC V5Z 1M9, Canada; (L.N.); (A.G.)
| | - John Jackson
- Faculty of Pharmaceutical Sciences, The University of British Columbia, 2045 Westbrook Mall, Vancouver, BC V6T 1Z3, Canada
- Correspondence:
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Scholp AJ, Jensen J, Chinnathambi S, Atluri K, Mendenhall A, Fowler T, Salem AK, Martin JA, Sander EA. Force-Bioreactor for Assessing Pharmacological Therapies for Mechanobiological Targets. Front Bioeng Biotechnol 2022; 10:907611. [PMID: 35928948 PMCID: PMC9343955 DOI: 10.3389/fbioe.2022.907611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/14/2022] [Indexed: 11/13/2022] Open
Abstract
Tissue fibrosis is a major health issue that impacts millions of people and is costly to treat. However, few effective anti-fibrotic treatments are available. Due to their central role in fibrotic tissue deposition, fibroblasts and myofibroblasts are the target of many therapeutic strategies centered primarily on either inducing apoptosis or blocking mechanical or biochemical stimulation that leads to excessive collagen production. Part of the development of these drugs for clinical use involves in vitro prescreening. 2D screens, however, are not ideal for discovering mechanobiologically significant compounds that impact functions like force generation and other cell activities related to tissue remodeling that are highly dependent on the conditions of the microenvironment. Thus, higher fidelity models are needed to better simulate in vivo conditions and relate drug activity to quantifiable functional outcomes. To provide guidance on effective drug dosing strategies for mechanoresponsive drugs, we describe a custom force-bioreactor that uses a fibroblast-seeded fibrin gels as a relatively simple mimic of the provisional matrix of a healing wound. As cells generate traction forces, the volume of the gel reduces, and a calibrated and embedded Nitinol wire deflects in proportion to the generated forces over the course of 6 days while overhead images of the gel are acquired hourly. This system is a useful in vitro tool for quantifying myofibroblast dose-dependent responses to candidate biomolecules, such as blebbistatin. Administration of 50 μM blebbistatin reliably reduced fibroblast force generation approximately 40% and lasted at least 40 h, which in turn resulted in qualitatively less collagen production as determined via fluorescent labeling of collagen.
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Affiliation(s)
- Austin J. Scholp
- Roy J. Carver Department of Biomedical Engineering, College of Engineering, University of Iowa, Iowa City, IA, United States
| | - Jordan Jensen
- Roy J. Carver Department of Biomedical Engineering, College of Engineering, University of Iowa, Iowa City, IA, United States
| | - Sathivel Chinnathambi
- Roy J. Carver Department of Biomedical Engineering, College of Engineering, University of Iowa, Iowa City, IA, United States
| | - Keerthi Atluri
- Division of Pharmaceutics and Translational Therapeutics, College of Pharmacy, University of Iowa, Iowa City, IA, United States
| | - Alyssa Mendenhall
- Roy J. Carver Department of Biomedical Engineering, College of Engineering, University of Iowa, Iowa City, IA, United States
| | - Timothy Fowler
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Aliasger K. Salem
- Division of Pharmaceutics and Translational Therapeutics, College of Pharmacy, University of Iowa, Iowa City, IA, United States
| | - James A. Martin
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Edward A. Sander
- Roy J. Carver Department of Biomedical Engineering, College of Engineering, University of Iowa, Iowa City, IA, United States
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- *Correspondence: Edward A. Sander,
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Butnaru M, Senioris A, Pagenstert G, Müller JH, Saffarini M, Dujardin F, Courage O. Arthroscopic management of unexplained pain following total knee arthroplasty. Arch Orthop Trauma Surg 2022; 142:1109-1115. [PMID: 33973087 DOI: 10.1007/s00402-021-03924-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 04/27/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Arthrofibrosis develops in 3-10% of knees after total knee arthroplasty (TKA), which may result in pain and restricted range-of-motion. Treatment options include manipulation under anaesthesia, arthroscopic debridement, and quadricepsplasty, but there is little consensus on their efficacy for treatment of unexplained pain after TKA. The purpose of this study was to report the prevalence and characteristics of unexplained pain after TKA as revealed by arthroscopic exploration, and assess the efficacy of arthroscopic procedures to relieve pain. MATERIALS AND METHODS From a consecutive series of 684 TKAs, 11 patients (1.6%) had unexplained pain at 7-48 months after TKA. Causes of pain remained unidentified after systematic and differential assessment, but arthroscopic exploration revealed fibrotic tissues, which were debrided during the same procedure. Patients were assessed first at 6-61 months and last at 90-148 months, with pain on a visual analog scale (pVAS) and range-of-motion recorded during both assessments, but Oxford Knee Score (OKS) and Forgotten Joint Score (FJS) only during the last assessment. Residual pain was classified as little or no pain (pVAS, 0-1), moderate pain (pVAS, 2-4), and severe pain (pVAS, 5-10). RESULTS At first follow-up (n = 11) pVAS improved by 4.1 ± 1.1 (p < 0.001), and range-of-motion improved by 5.0° ± 7.1° (p = 0.041). Seven patients (64%) had little or no residual pain, while four (36%) had moderate residual pain. At final follow-up (n = 9) pVAS improved by 3.2 ± 2.9 (p < 0.001), and range-of-motion improved by 4.4° ± 8.5° (p = 0.154). Six patients (67%) had little or no residual pain, while one (11%) had moderate and two (22%) had severe residual pain. CONCLUSION Arthroscopic exploration revealed that all 11 knees with unexplained pain had fibrotic tissues, the removal of which alleviated pain in only 67%, while moderate to severe pain persisted in 33% which merits further scrutiny.
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Affiliation(s)
- Michaël Butnaru
- Hôpital Privé de L'Estuaire, Ramsay Santé, Le Havre, France.,Hôpital Charles Nicolle, CHU de Rouen, Rouen, France
| | - Antoine Senioris
- Hôpital Privé de L'Estuaire, Ramsay Santé, Le Havre, France.,CH Dieppe, Dieppe, France
| | - Geert Pagenstert
- Department of Clinical Research, University of Basel, Basel, Switzerland.,Clarahof Clinic of Orthopaedic Surgery, Merian-Iselin-Hospital Swiss Olympic Medical Center, Basel, Switzerland.,Knee Institute Basel, Basel, Switzerland
| | | | - Mo Saffarini
- ReSurg SA, Rue Saint Jean 22, 1260, Nyon, Switzerland.
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Landy DC, Baral EC, Potter HG, Chiu YF, Sculco PK, Sculco TP, Wright TM, Koff MF. Magnetic Resonance Imaging Synovial Classification Is Associated With Revision Indication and Polyethylene Insert Damage. J Arthroplasty 2022; 37:S342-S349. [PMID: 35240284 DOI: 10.1016/j.arth.2022.02.086] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/14/2022] [Accepted: 02/21/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Patients with total knee arthroplasty (TKA) stiffness are commonly presumed to have arthrofibrosis though no specific test exists. In patients undergoing revision TKA, we asked the following question: (1) Do patients who are revised for stiffness display a synovial reaction on MRI that is different than patients revised for other reasons? (2) Do these patients have a different magnitude of polyethylene insert damage than patients revised for other reasons? and (3) Is the MRI synovial classification associated with polyethylene insert damage? METHODS Patients undergoing revision TKA for stiffness had a preoperative MRI performed, and the synovium was classified on MRI in a blinded fashion as arthrofibrosis, focal scarring, polymeric reaction, infection, or abnormal. At surgery, the polyethylene inserts were removed, and graded by 2 reviewers for total surface damage. RESULTS Revision indication and MRI synovial classification were associated (P < .0001), with a greater proportion of patients assigned an MRI classification of arthrofibrosis revised for arthrofibrosis and a greater proportion of patients assigned a polymeric classification revised for aseptic loosening. Patients assigned an MRI synovial classification of polymeric had the greatest damage to the tibial insert (P < .0001), and patients revised for the clinical indication of aseptic loosening had the greatest damage to the tibial insert (P < .0001). CONCLUSION Synovial grading on MRI is strongly associated with revision indication and polyethylene insert damage. In patients with stiffness in the absence of another complication, MRI can be a helpful diagnostic adjuvant in confirming the diagnosis of stiffness.
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Affiliation(s)
- David C Landy
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY
| | - Elexis C Baral
- Department of Biomechanics, Hospital for Special Surgery, New York, NY
| | - Hollis G Potter
- Department of Radiology and Imaging, MRI Research Laboratory, Hospital for Special Surgery, New York, NY
| | - Yu-Fen Chiu
- Biostatistics Core, Research Administration, Hospital for Special Surgery, New York, NY
| | - Peter K Sculco
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY
| | - Thomas P Sculco
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY
| | - Timothy M Wright
- Department of Biomechanics, Hospital for Special Surgery, New York, NY
| | - Matthew F Koff
- Department of Radiology and Imaging, MRI Research Laboratory, Hospital for Special Surgery, New York, NY
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Morris JL, McEwen P, Letson HL, Dobson GP. Anterior Cruciate Ligament Reconstruction Surgery: Creating a Permissive Healing Phenotype in Military Personnel and Civilians for Faster Recovery. Mil Med 2022; 187:1310-1317. [PMID: 35389483 PMCID: PMC9617292 DOI: 10.1093/milmed/usac093] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/28/2022] [Accepted: 05/20/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction Anterior cruciate ligament (ACL) rupture in military personnel and civilians can be a devastating injury. A service member is 10 times more likely to suffer an ACL injury than their civilian counterparts, and despite successful surgical stabilization, 4%-35% will develop arthrofibrosis, over 50% will not return to full active duty, and up to 50% will develop post-traumatic osteoarthritis (PTOA) within 15 years. Equally concerning, woman are 2 to 8 times more likely to experience ACL injuries than men, which represents a major knowledge gap. Materials and Methods A comprehensive literature search was performed in December 2021 using structured search terms related to prevalence, risk factors, disease progression, and treatment of ACL injury and reconstruction. The literature search was conducted independently by two researchers using PubMed, Cochrane, and Embase databases, with inclusion of articles with military, civilian, and sex relevance, and exclusion of most papers with a publication date greater than 10 years. The resources used for the review reflect the most current data, knowledge, and recommendations associated with research and clinical findings from reliable international sources. Results Currently, there is no effective system-based drug therapy that creates a “permissive environment” to reduce synovial and cartilage stress after ACL injury and reconstruction and prevent secondary complications. We argue that progress in this area has been hampered by researchers and clinicians failing to recognize that (1) an ACL injury is a system’s failure that affects the whole joint, (2) the early molecular events define and perpetuate different injury phenotypes, (3) male and female responses may be different and have a molecular basis, (4) the female phenotype continues to be under-represented in basic and clinical research, and (5) the variable outcomes may be perpetuated by the trauma of surgery itself. The early molecular events after ACL injury are characterized by an overexpression of joint inflammation, immune dysfunction, and trauma-induced synovial stress. We are developing an upstream adenosine, lidocaine, and magnesium therapy to blunt these early molecular events and expedite healing with less arthrofibrosis and early PTOA complications. Conclusions ACL injuries continue to be a major concern among military personnel and civilians and represent a significant loss in command readiness and quality of life. The lack of predictability in outcomes after ACL repair or reconstruction underscores the need for new joint protection therapies. The male–female disparity requires urgent investigation.
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Affiliation(s)
- Jodie L Morris
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville 4811, Australia
| | - Peter McEwen
- The Orthopaedic Research Institute of Queensland (ORIQL), Townsville, Queensland, QLD 4812, Australia
| | - Hayley L Letson
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville 4811, Australia
| | - Geoffrey P Dobson
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville 4811, Australia
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Afzali MF, Radakovich LB, Sykes MM, Campbell MA, Patton KM, Sanford JL, Vigon N, Ek R, Narez GE, Marolf AJ, Sikes KJ, Haut Donahue TL, Santangelo KS. Early removal of the infrapatellar fat pad/synovium complex beneficially alters the pathogenesis of moderate stage idiopathic knee osteoarthritis in male Dunkin Hartley guinea pigs. Arthritis Res Ther 2022; 24:282. [PMID: 36578046 PMCID: PMC9795160 DOI: 10.1186/s13075-022-02971-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/02/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The infrapatellar fat pad (IFP) is the largest adipose deposit in the knee; however, its contributions to the homeostasis of this organ remain undefined. To determine the influence of the IFP and its associated synovium (IFP/synovium complex or IFP/SC) on joint health, this study evaluated the progression of osteoarthritis (OA) following excision of this unit in a rodent model of naturally-occurring disease. METHODS Male Dunkin-Hartley guinea pigs (n=18) received surgical removal of the IFP in one knee at 3 months of age; contralateral knees received sham surgery as matched internal controls. Mobility and gait assessments were performed prior to IFP/SC removal and monthly thereafter. Animals were harvested at 7 months of age. Ten set of these knees were processed for microcomputed tomography (microCT), histopathology, transcript expression analyses, and immunohistochemistry (IHC); 8 sets of knees were dedicated to microCT and biomechanical testing (material properties of knee joints tissues and anterior drawer laxity). RESULTS Fibrous connective tissue (FCT) developed in place of the native adipose depot. Gait demonstrated no significant differences between IFP/SC removal and contralateral hindlimbs. MicroCT OA scores were improved in knees containing the FCT. Quantitatively, IFP/SC-containing knees had more osteophyte development and increased trabecular volume bone mineral density (vBMD) in femora and tibiae. Histopathology confirmed maintenance of articular cartilage structure, proteoglycan content, and chondrocyte cellularity in FCT-containing knees. Transcript analyses revealed decreased expression of adipose-related molecules and select inflammatory mediators in FCTs compared to IFP/SCs. This was verified via IHC for two key inflammatory agents. The medial articular cartilage in knees with native IFP/SCs showed an increase in equilibrium modulus, which correlated with increased amounts of magnesium and phosphorus. DISCUSSION/CONCLUSION Formation of the FCT resulted in reduced OA-associated changes in both bone and cartilage. This benefit may be associated with: a decrease in inflammatory mediators at transcript and protein levels; and/or improved biomechanical properties. Thus, the IFP/SC may play a role in the pathogenesis of knee OA in this strain, with removal prior to disease onset appearing to have short-term benefits.
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Affiliation(s)
- Maryam F. Afzali
- grid.47894.360000 0004 1936 8083Department of Microbiology, Immunology and Pathology, Colorado State University, 200 West Lake Street, Fort Collins, CO 80523 USA
| | - Lauren B. Radakovich
- grid.47894.360000 0004 1936 8083Department of Microbiology, Immunology and Pathology, Colorado State University, 200 West Lake Street, Fort Collins, CO 80523 USA
| | - Madeline M. Sykes
- grid.47894.360000 0004 1936 8083Department of Microbiology, Immunology and Pathology, Colorado State University, 200 West Lake Street, Fort Collins, CO 80523 USA
| | - Margaret A. Campbell
- grid.47894.360000 0004 1936 8083Department of Microbiology, Immunology and Pathology, Colorado State University, 200 West Lake Street, Fort Collins, CO 80523 USA
| | - Kayley M. Patton
- grid.47894.360000 0004 1936 8083Department of Microbiology, Immunology and Pathology, Colorado State University, 200 West Lake Street, Fort Collins, CO 80523 USA
| | - Joseph L. Sanford
- grid.47894.360000 0004 1936 8083Department of Microbiology, Immunology and Pathology, Colorado State University, 200 West Lake Street, Fort Collins, CO 80523 USA
| | - Nicole Vigon
- grid.266683.f0000 0001 2166 5835Department of Biomedical Engineering, S631 Life Sciences Laboratory, University of Massachusetts, Amherst, 240 Thatcher Road, Amherst, MA 01003 USA
| | - Ryan Ek
- grid.266683.f0000 0001 2166 5835Department of Biomedical Engineering, S631 Life Sciences Laboratory, University of Massachusetts, Amherst, 240 Thatcher Road, Amherst, MA 01003 USA
| | - Gerardo E. Narez
- grid.266683.f0000 0001 2166 5835Department of Biomedical Engineering, S631 Life Sciences Laboratory, University of Massachusetts, Amherst, 240 Thatcher Road, Amherst, MA 01003 USA
| | - Angela J. Marolf
- grid.47894.360000 0004 1936 8083Department of Environmental and Radiological Health Sciences, Colorado State University, 123 Flint Cancer Center, Fort Collins, CO 80523 USA
| | - Katie J. Sikes
- grid.47894.360000 0004 1936 8083Department of Clinical Sciences, Colorado State University, 1678 Clinical Sciences, Fort Collins, CO 80523 USA
| | - Tammy L. Haut Donahue
- grid.56061.340000 0000 9560 654XBiomedical Engineering Department, The University of Memphis, 3806 Norriswood, Memphis, TN 38152 USA
| | - Kelly S. Santangelo
- grid.47894.360000 0004 1936 8083Department of Microbiology, Immunology and Pathology, Colorado State University, 200 West Lake Street, Fort Collins, CO 80523 USA
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No difference between mobile and fixed bearing in primary total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 2022; 30:3138-3154. [PMID: 35861866 PMCID: PMC9418337 DOI: 10.1007/s00167-022-07065-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 07/01/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE Both mobile (MB) and fixed (FB) bearing implants are routinely used for total knee arthroplasty (TKA). This meta-analysis compared MB versus FB for TKA in terms of implant positioning, joint function, patient reported outcome measures (PROMs), and complications. It was hypothesised that MB performs better than FB implants in primary TKA. METHODS This meta-analysis was conducted according to the 2020 PRISMA statement. In February 2022, the following databases were accessed: Pubmed, Web of Science, Google Scholar, Embase. All the randomized clinical trials (RCTs) comparing mobile versus fixed bearing for primary TKA were considered. RESULTS Data from 74 RCTs (11,116 procedures) were retrieved. The mean follow-up was 58.8 (7.5 to 315.6) months. The MB group demonstrated greater range of motion (ROM) (P = 0.02), Knee Society Score (KSS) score (P < 0.0001), and rate of deep infections (P = 0.02). No difference was found in implant positioning: tibial slope, delta angle, alpha femoral component angle, gamma femoral component angle, beta tibial component angle, tibiofemoral alignment angle, posterior condylar offset, radiolucent lines. No difference was found in duration of the surgical procedure. No difference was found in the following PROMs: Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analogue scale (VAS), function and pain subscales of the KSS score. No difference was found in the rate of anterior knee pain, revision, aseptic loosening, fractures, and deep vein thrombosis. CONCLUSION There is no evidence in support that MB implants promote greater outcomes compared to FB implants in primary TKA. LEVEL OF EVIDENCE Level I.
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Morris JL, Letson HL, McEwen P, Biros E, Dlaska C, Hazratwala K, Wilkinson M, Dobson GP. Comparison of intra-articular administration of adenosine, lidocaine and magnesium solution and tranexamic acid for alleviating postoperative inflammation and joint fibrosis in an experimental model of knee arthroplasty. J Orthop Surg Res 2021; 16:726. [PMID: 34930351 PMCID: PMC8686251 DOI: 10.1186/s13018-021-02871-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 12/05/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Dysregulated inflammatory responses are implicated in the pathogenesis of joint stiffness and arthrofibrosis following total knee arthroplasty (TKA). The purpose of this study was to compare the effects of intra-articular (IA) administration of tranexamic acid (TXA), an anti-fibrinolytic commonly used in TKA, and ALM chondroprotective solution on postoperative inflammation and joint tissue healing in a rat model of knee implant surgery. METHODS Male Sprague-Dawley rats (n = 24) were randomly divided into TXA or ALM treatment groups. The right knee of each rat was implanted with titanium (femur) and polyethylene (tibia) implants. An IA bolus (0.1 ml) of TXA or ALM was administered after implantation and capsule closure, and before skin closure. Postoperative coagulopathy, haematology and systemic inflammatory changes were assessed. Inflammatory and fibrotic markers were assessed in joint tissue, 28 days after surgery. RESULTS Haemostasis was comparable in animals treated with TXA or ALM after knee implant surgery. In contrast to ALM-treated animals, systemic inflammatory markers remained elevated at day 5 (IL-6, IL-12, IL-10, platelet count) and day 28 (IL-1β, IL-10) following surgery in TXA-treated animals. At day 28 following surgery, the extension range of motion of operated knees was 1.7-fold higher for ALM-treated animals compared to the TXA group. Key inflammatory mediators (NF-κB, IL-12, IL-2), immune cell infiltration (CD68+ cells) and markers of fibrosis (α-SMA, TGF-β) were also lower in capsular tissue of ALM-treated knees at day 28. CONCLUSION Data suggest that IA administration of ALM is superior to TXA for reducing postoperative systemic and joint inflammation and promoting restoration of healthy joint tissue architecture in a rat model of TKA. Further studies are warranted to assess the clinical translational potential of ALM IA solution to improve patient outcomes following arthroplasty.
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Affiliation(s)
- Jodie L Morris
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia.
- Heart and Trauma Research Laboratory, Division of Tropical Health and Medicine, College of Medicine and Dentistry,, James Cook University, Townsville, QLD, 4811, Australia.
| | - Hayley L Letson
- Heart and Trauma Research Laboratory, Division of Tropical Health and Medicine, College of Medicine and Dentistry,, James Cook University, Townsville, QLD, 4811, Australia
| | - Peter McEwen
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia
| | - Erik Biros
- Heart and Trauma Research Laboratory, Division of Tropical Health and Medicine, College of Medicine and Dentistry,, James Cook University, Townsville, QLD, 4811, Australia
| | - Constantin Dlaska
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia
| | - Kaushik Hazratwala
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia
| | - Matthew Wilkinson
- Orthopaedic Research Institute of Queensland, Townsville, QLD, Australia
| | - Geoffrey P Dobson
- Heart and Trauma Research Laboratory, Division of Tropical Health and Medicine, College of Medicine and Dentistry,, James Cook University, Townsville, QLD, 4811, Australia
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Gao Q, Li Z, Rhee C, Xiang S, Maruyama M, Huang EE, Yao Z, Bunnell BA, Tuan RS, Lin H, Gold MS, Goodman SB. Macrophages Modulate the Function of MSC- and iPSC-Derived Fibroblasts in the Presence of Polyethylene Particles. Int J Mol Sci 2021; 22:12837. [PMID: 34884641 PMCID: PMC8657553 DOI: 10.3390/ijms222312837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 11/21/2021] [Accepted: 11/24/2021] [Indexed: 01/15/2023] Open
Abstract
Fibroblasts in the synovial membrane secrete molecules essential to forming the extracellular matrix (ECM) and supporting joint homeostasis. While evidence suggests that fibroblasts contribute to the response to joint injury, the outcomes appear to be patient-specific and dependent on interactions between resident immune cells, particularly macrophages (Mφs). On the other hand, the response of Mφs to injury depends on their functional phenotype. The goal of these studies was to further explore these issues in an in vitro 3D microtissue model that simulates a pathophysiological disease-specific microenvironment. Two sources of fibroblasts were used to assess patient-specific influences: mesenchymal stem cell (MSC)- and induced pluripotent stem cell (iPSC)-derived fibroblasts. These were co-cultured with either M1 or M2 Mφs, and the cultures were challenged with polyethylene particles coated with lipopolysaccharide (cPE) to model wear debris generated from total joint arthroplasties. Our results indicated that the fibroblast response to cPE was dependent on the source of the fibroblasts and the presence of M1 or M2 Mφs: the fibroblast response as measured by gene expression changes was amplified by the presence of M2 Mφs. These results demonstrate that the immune system modulates the function of fibroblasts; furthermore, different sources of differentiated fibroblasts may lead to divergent results. Overall, our research suggests that M2 Mφs may be a critical target for the clinical treatment of cPE induced fibrosis.
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Affiliation(s)
- Qi Gao
- Orthopaedic Research Laboratories, Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA 94304, USA; (Q.G.); (C.R.); (M.M.); (E.E.H.); (Z.Y.)
| | - Zhong Li
- Center for Cellular and Molecular Engineering, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219, USA; (Z.L.); (S.X.); (R.S.T.); (H.L.)
| | - Claire Rhee
- Orthopaedic Research Laboratories, Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA 94304, USA; (Q.G.); (C.R.); (M.M.); (E.E.H.); (Z.Y.)
| | - Shiqi Xiang
- Center for Cellular and Molecular Engineering, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219, USA; (Z.L.); (S.X.); (R.S.T.); (H.L.)
| | - Masahiro Maruyama
- Orthopaedic Research Laboratories, Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA 94304, USA; (Q.G.); (C.R.); (M.M.); (E.E.H.); (Z.Y.)
| | - Elijah Ejun Huang
- Orthopaedic Research Laboratories, Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA 94304, USA; (Q.G.); (C.R.); (M.M.); (E.E.H.); (Z.Y.)
| | - Zhenyu Yao
- Orthopaedic Research Laboratories, Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA 94304, USA; (Q.G.); (C.R.); (M.M.); (E.E.H.); (Z.Y.)
| | - Bruce A. Bunnell
- Department of Microbiology, Immunology and Genetics, University of North Texas Health Science Center, Fort Worth, TX 76107, USA;
| | - Rocky S. Tuan
- Center for Cellular and Molecular Engineering, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219, USA; (Z.L.); (S.X.); (R.S.T.); (H.L.)
- Institute for Tissue Engineering and Regenerative Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Hang Lin
- Center for Cellular and Molecular Engineering, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219, USA; (Z.L.); (S.X.); (R.S.T.); (H.L.)
| | - Michael S. Gold
- Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219, USA;
| | - Stuart B. Goodman
- Orthopaedic Research Laboratories, Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA 94304, USA; (Q.G.); (C.R.); (M.M.); (E.E.H.); (Z.Y.)
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Steplewski A, Fertala J, Tomlinson RE, Wang ML, Donahue A, Arnold WV, Rivlin M, Beredjiklian PK, Abboud JA, Namdari S, Fertala A. Mechanisms of reducing joint stiffness by blocking collagen fibrillogenesis in a rabbit model of posttraumatic arthrofibrosis. PLoS One 2021; 16:e0257147. [PMID: 34492074 PMCID: PMC8423260 DOI: 10.1371/journal.pone.0257147] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/24/2021] [Indexed: 02/06/2023] Open
Abstract
Posttraumatic fibrotic scarring is a significant medical problem that alters the proper functioning of injured tissues. Current methods to reduce posttraumatic fibrosis rely on anti-inflammatory and anti-proliferative agents with broad intracellular targets. As a result, their use is not fully effective and may cause unwanted side effects. Our group previously demonstrated that extracellular collagen fibrillogenesis is a valid and specific target to reduce collagen-rich scar buildup. Our previous studies showed that a rationally designed antibody that binds the C-terminal telopeptide of the α2(I) chain involved in the aggregation of collagen molecules limits fibril assembly in vitro and reduces scar formation in vivo. Here, we have utilized a clinically relevant arthrofibrosis model to study the broad mechanisms of the anti-scarring activity of this antibody. Moreover, we analyzed the effects of targeting collagen fibril formation on the quality of healed joint tissues, including the posterior capsule, patellar tendon, and subchondral bone. Our results show that blocking collagen fibrillogenesis not only reduces collagen content in the scar, but also accelerates the remodeling of healing tissues and changes the collagen fibrils’ cross-linking. In total, this study demonstrated that targeting collagen fibrillogenesis to limit arthrofibrosis affects neither the quality of healing of the joint tissues nor disturbs vital tissues and organs.
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Affiliation(s)
- Andrzej Steplewski
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Jolanta Fertala
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Ryan E. Tomlinson
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Mark L. Wang
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States of America
| | - Allison Donahue
- College of Medicine, Drexel University, Philadelphia, Pennsylvania, United States of America
| | - William V. Arnold
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States of America
| | - Michael Rivlin
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States of America
| | - Pedro K. Beredjiklian
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States of America
| | - Joseph A. Abboud
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States of America
| | - Surena Namdari
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States of America
| | - Andrzej Fertala
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
- * E-mail:
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Chen X, Wang Z, Huang Y, Deng W, Zhou Y, Chu M. Identification of novel biomarkers for arthrofibrosis after total knee arthroplasty in animal models and clinical patients. EBioMedicine 2021; 70:103486. [PMID: 34311327 PMCID: PMC8325099 DOI: 10.1016/j.ebiom.2021.103486] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 06/25/2021] [Accepted: 06/28/2021] [Indexed: 01/24/2023] Open
Abstract
Background Arthrofibrosis is a debilitating complication after total knee arthroplasty (TKA) which becomes a considerable burden for both patients and clinical practitioners. Our study aimed to identify novel biomarkers and therapeutic targets for drug discovery. Methods Potential biomarker genes were identified based on bioinformatic analysis. Twelve male New Zealand white rabbits underwent surgical fixation of unilateral knees to mimics the joint immobilization of the clinical scenario after TKA surgery. Macroscopic assessment, hydroxyproline content determination, and histological analysis of tissue were performed separately after 3-days, 1-week, 2-weeks, and 4-weeks of fixation. We also enrolled 46 arthrofibrosis patients and 92 controls to test the biomarkers. Clinical information such as sex, age, range of motion (ROM), and visual analogue scale (VAS) was collected by experienced surgeons Findings Base on bioinformatic analysis, transforming growth factor-beta receptor 1 (TGFBR1) was identified as the potential biomarkers. The level of TGFBR1 was significantly raised in the rabbit synovial tissue after 4-weeks of fixation (p<0.05). TGFBR1 also displayed a highly positive correlation with ROM loss and hydroxyproline contents in the animal model. TGFBR1 showed a significantly higher expression level in arthrofibrosis patients with a receiver operating characteristic (ROC) area under curve (AUC) of 0.838. TGFBR1 also performed positive correlations with VAS baseline (0.83) and VAS after 1 year (0.76) while negatively correlated with ROM baseline (-0.76) in clinical patients. Interpretation Our findings provided novel biomarkers for arthrofibrosis diagnosis and uncovered the role of TGFBR1. This may contribute to arthrofibrosis prevention and therapeutic drug discovery.
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Affiliation(s)
- Xi Chen
- Department of Adult Joint Reconstructive Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Jishuitan Orthopaedic College of Tsinghua University, 31 East Xinjiekou Street, Beijing 100035, China; Department of Immunology, School of Basic Medical Sciences, Peking University. NHC Key Laboratory of Medical Immunology (Peking University). Beijing, China
| | - Zhaolun Wang
- Department of Adult Joint Reconstructive Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Jishuitan Orthopaedic College of Tsinghua University, 31 East Xinjiekou Street, Beijing 100035, China
| | - Yong Huang
- Department of Adult Joint Reconstructive Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Jishuitan Orthopaedic College of Tsinghua University, 31 East Xinjiekou Street, Beijing 100035, China
| | - Wang Deng
- Department of Adult Joint Reconstructive Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Jishuitan Orthopaedic College of Tsinghua University, 31 East Xinjiekou Street, Beijing 100035, China
| | - Yixin Zhou
- Department of Adult Joint Reconstructive Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Jishuitan Orthopaedic College of Tsinghua University, 31 East Xinjiekou Street, Beijing 100035, China.
| | - Ming Chu
- Department of Immunology, School of Basic Medical Sciences, Peking University. NHC Key Laboratory of Medical Immunology (Peking University). Beijing, China.
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Zhang L, Xing R, Huang Z, Ding L, Zhang L, Li M, Li X, Wang P, Mao J. Synovial Fibrosis Involvement in Osteoarthritis. Front Med (Lausanne) 2021; 8:684389. [PMID: 34124114 PMCID: PMC8187615 DOI: 10.3389/fmed.2021.684389] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/03/2021] [Indexed: 12/14/2022] Open
Abstract
Bone changes have always been the focus of research on osteoarthritis, but the number of studies on synovitis has increased only over the last 10 years. Our current understanding is that the mechanism of osteoarthritis involves all the tissues that make up the joints, including nerve sprouting, pannus formation, and extracellular matrix environmental changes in the synovium. These factors together determine synovial fibrosis and may be closely associated with the clinical symptoms of pain, hyperalgesia, and stiffness in osteoarthritis. In this review, we summarize the consensus of clinical work, the potential pathological mechanisms, the possible therapeutic targets, and the available therapeutic strategies for synovial fibrosis in osteoarthritis to gain insight and provide a foundation for further study.
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Affiliation(s)
- Li Zhang
- Departments of Orthopedics, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Runlin Xing
- Departments of Orthopedics, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Zhengquan Huang
- Departments of Orthopedics, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Liang Ding
- Departments of Orthopedics, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Li Zhang
- Departments of Orthopedics, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Mingchao Li
- Departments of Orthopedics, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Xiaochen Li
- Departments of Orthopedics, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Peimin Wang
- Departments of Orthopedics, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Jun Mao
- Departments of Orthopedics, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
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Lee AJ, Mahoney CM, Cai CC, Ichinose R, Stefani RM, Marra KG, Ateshian GA, Shah RP, Vunjak-Novakovic G, Hung CT. Sustained Delivery of SB-431542, a Type I Transforming Growth Factor Beta-1 Receptor Inhibitor, to Prevent Arthrofibrosis. Tissue Eng Part A 2021; 27:1411-1421. [PMID: 33752445 DOI: 10.1089/ten.tea.2021.0029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Fibrosis of the knee is a common disorder resulting from an aberrant wound healing response and is characterized by extracellular matrix deposition, joint contraction, and scar tissue formation. The principal regulator of the fibrotic cascade is transforming growth factor beta-1 (TGF-β1), a factor that induces rapid proliferation and differentiation of resident fibroblasts. In this study, we demonstrate successful inhibition of TGF-β1-driven myofibroblastic differentiation in human fibroblast-like synoviocytes using a small molecule TGF-β1 receptor inhibitor, SB-431542. We also demonstrate successful encapsulation of SB-431542 in poly(D,L-lactide-co-glycolide) (PLGA) as a potential prophylactic treatment for arthrofibrosis and characterize drug release and bioactivity in a three-dimensional collagen gel contraction assay. We assessed the effects of TGF-β1 and SB-431542 on cell proliferation and viability in monolayer cultures. Opposing dose-dependent trends were observed in cell proliferation, which increased in TGF-β1-treated cultures and decreased in SB-431542-treated cultures relative to control (p < 0.05). SB-431542 was not cytotoxic at the concentrations studied (0-50 μM) and inhibited TGF-β1-induced collagen gel contraction in a dose-dependent manner. Specifically, TGF-β1-treated gels contracted to 18% ± 1% of their initial surface area, while gels treated with TGF-β1 and ≥10 μM SB-431542 showed no evidence of contraction (p < 0.0001). Upon removal of the compound, all gels contracted to control levels after 44 h in culture, necessitating sustained delivery for prolonged inhibition. To this end, SB-431542 was encapsulated in PLGA microspheres (SBMS) that had an average diameter of 87.5 ± 24 μm and a loading capacity of 4.3 μg SB-431542 per milligram of SBMS. Functional assessment of SBMS revealed sustained inhibition of TGF-β1-induced gel contraction as well as hallmark features of myofibroblastic differentiation, including α-smooth muscle actin expression and connective tissue growth factor production. These results suggest that SB-431542 may be used to counter TGF-β1-driven events in the fibrotic cascade in the knee cartilage.
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Affiliation(s)
- Andy J Lee
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Christopher M Mahoney
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Charles C Cai
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Rika Ichinose
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Robert M Stefani
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Kacey G Marra
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gerard A Ateshian
- Department of Biomedical Engineering, Columbia University, New York, New York, USA.,Department of Mechanical Engineering, Columbia University, New York, New York, USA
| | - Roshan P Shah
- Department of Orthopaedic Surgery, and Columbia University, New York, New York, USA
| | - Gordana Vunjak-Novakovic
- Department of Biomedical Engineering, Columbia University, New York, New York, USA.,Department of Medicine, Columbia University, New York, New York, USA
| | - Clark T Hung
- Department of Biomedical Engineering, Columbia University, New York, New York, USA.,Department of Orthopaedic Surgery, and Columbia University, New York, New York, USA
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Salib CG, Reina N, van Wijnen AJ, Hanssen AD, Berry DJ, Abdel MP. Absence of signature inflammatory markers in synovial fluid for total knee arthroplasties revised for arthrofibrosis. Orthop Traumatol Surg Res 2021; 107:102870. [PMID: 33639288 PMCID: PMC8087631 DOI: 10.1016/j.otsr.2021.102870] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/17/2020] [Accepted: 11/26/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Current diagnostic criteria for arthrofibrosis are limited. Since many patients will be aspirated during their clinical course, synovial fluid analysis may supplement current diagnostic criteria for arthrofibrosis. The goal of this study was to determine a unique synovial fluid and inflammatory marker profile for diagnosing arthrofibrosis. HYPOTHESIS Patients with arthrofibrosis following total knee arthroplasty will have a unique synovial fluid aspirate profile compared to control patients to aid in diagnosis. MATERIALS AND METHODS Between 2013 and 2017, 32 patients (32 total knee arthroplasties [TKAs]) underwent revision TKAs for arthrofibrosis. Fourteen patients had pre-revision aspirations. They were 2:1 matched based on age, sex, body mass index (BMI), and year of revision to 28 patients who underwent aseptic revision TKAs for reasons other than arthrofibrosis (control group). Mean age at revision was 66years, with 64% males. RESULTS In TKAs revised for arthrofibrosis, mean total cell count was 828cells/uL. These aspirates contained a mean distribution of 46% macrophages (range: 4-76%), 31% lymphocytes (range: 11-68%), 21% neutrophils (range: 0-75%), 1% other cells (mainly synovial cells; range: 0-11%), and 1% eosinophils (range: 0-7%). There was no significant difference in mean total cell count (p=0.8) or mean distribution of macrophages (p=0.6), lymphocytes (p=0.1), neutrophils (p=0.2), eosinophils (p>0.9), or serum inflammatory markers (p>0.7) when compared to controls. All aspirations were culture negative for infection. DISCUSSION The profile of arthrofibrotic synovial fluid aspirates and serum inflammatory marker values were similar to patients revised for non-arthrofibrotic aseptic etiologies. This suggests synovial fluid and serum inflammatory markers in non-infected knees with arthrofibrosis should expect to have characteristics similar to synovial fluid and inflammatory marker profiles in other aseptic diagnoses. LEVEL OF EVIDENCE III; retrospective case-control study.
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40
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Bayram B, Owen AR, Dudakovic A, Bettencourt JW, Limberg AK, Morrey ME, Sanchez-Sotelo J, Berry DJ, Kocher JP, van Wijnen AJ, Abdel MP. Elevated Expression of Plasminogen Activator Inhibitor (PAI-1/SERPINE1) is Independent from rs1799889 Genotypes in Arthrofibrosis. Meta Gene 2021; 28. [PMID: 33816122 DOI: 10.1016/j.mgene.2021.100877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Arthrofibrosis is characterized by excessive extracellular matrix deposition in patients with total knee arthroplasties (TKAs) and causes undesirable joint stiffness. The pathogenesis of arthrofibrosis remains elusive and currently there are no diagnostic biomarkers for the pathological formation of this connective tissue. Fibrotic soft tissues are known to have elevated levels of plasminogen activator inhibitor-1 (PAI-1) (encoded by SERPINE1), a secreted serine protease inhibitor that moderates extracellular matrix remodeling and tissue homeostasis. The 4G/5G insertion/deletion (rs1799889) is a well-known SERPINE1 polymorphism that directly modulates PAI-1 levels. Homozygous 4G/4G allele carriers typically have higher PAI-1 levels and may predispose patients to soft tissue fibrosis (e.g., liver, lung, and kidney). Here, we examined the genetic contribution of the SERPINE1 rs1799889 polymorphism to musculoskeletal fibrosis in arthrofibrotic (n = 100) and non-arthrofibrotic (n = 100) patients using Sanger Sequencing. Statistical analyses revealed that the allele frequencies of the SERPINE1 rs1799889 polymorphism are similar in arthrofibrotic and non-arthrofibrotic patient cohorts. Because the fibrosis related SERPINE1 rs1799889 polymorphism is independent of arthrofibrosis susceptibility in TKA patients, the possibility arises that fibrosis of joint connective tissues may involve unique genetic determinants distinct from those linked to classical soft tissue fibrosis.
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Affiliation(s)
- Banu Bayram
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Aaron R Owen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Amel Dudakovic
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States.,Department of Biochemistry & Molecular Biology, Mayo Clinic, Rochester, MN, United States
| | | | - Afton K Limberg
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Mark E Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | | | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Jean-Pierre Kocher
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Andre J van Wijnen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States.,Department of Biochemistry & Molecular Biology, Mayo Clinic, Rochester, MN, United States
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
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Duensing I, Peters CL, Monteiro P, Anderson MB, Pelt CE. Higher incidence of manipulation under anesthesia following TKA associated with the periarticular infiltration of a liposomal bupivacaine cocktail compared to a modified Ranawat cocktail. J Orthop Surg (Hong Kong) 2020; 28:2309499020910816. [PMID: 32216578 DOI: 10.1177/2309499020910816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The purpose of this study was to compare the frequency of postoperative stiffness requiring manipulation under anesthesia (MUA) before and after switching from the intraoperative use of liposomal bupivacaine (LB). METHODS This was an institutional review board (IRB)-exempt retrospective cohort study (IRB#71733) on all patients who underwent primary total knee arthroplasty (TKA) by a single surgeon between April 2016 and December 2017. We compared 169 knees that received LB group to 167 knees that received a modified Ranawat cocktail (MR group). Perioperative care pathways remained consistent during the study period, as were requirements for MUA which included flexion range of motion below approximately 90 at 6-12 weeks. To compare the incidence of MUA between the groups, a population-averaged Poisson regression analysis was used. RESULTS The two groups were similar, with mean age of 63 (range 31-91) in the LB group and 64 (range 42-84) in the MR group, a preponderance of females in both groups (p = 0.866), similar preoperative knee flexion between groups (p = 0.162), and similar Patient-Reported Outcomes Measurement Information System scores. The frequency of MUA, however, was significantly lower in the MR group (LB: 7.7% [95% CI 3.7-12%] vs. MR: 2.4% [95% CI <1-4.7%] [IRR 3.2, 95% CI 1.08-9.76, p . 0.037]). CONCLUSIONS In summary, this is a novel report of a potentially previously unrecognized increased incidence of MUA associated with the use of LB compared with a MR cocktail. Given no other notable changes to the perioperative care or MUA thresholds following TKA, the reasons for these findings are unclear but deserve additional investigation.
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Affiliation(s)
- Ian Duensing
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | | | - Priscila Monteiro
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Mike B Anderson
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
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Attard V, Li CY, Self A, Mann DA, Borthwick LA, O’Connor P, Deehan DJ, Kalson NS. Quantification of intra-articular fibrosis in patients with stiff knee arthroplasties using metal-reduction MRI. Bone Joint J 2020; 102-B:1331-1340. [PMID: 32993344 PMCID: PMC7517723 DOI: 10.1302/0301-620x.102b10.bjj-2020-0841.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
AIMS Stiffness is a common complication after total knee arthroplasty (TKA). Pathogenesis is not understood, treatment options are limited, and diagnosis is challenging. The aim of this study was to investigate if MRI can be used to visualize intra-articular scarring in patients with stiff, painful knee arthroplasties. METHODS Well-functioning primary TKAs (n = 11), failed non-fibrotic TKAs (n = 5), and patients with a clinical diagnosis of fibrosis1 (n = 8) underwent an MRI scan with advanced metal suppression (Slice Encoding for Metal Artefact Correction, SEMAC) with gadolinium contrast. Fibrotic tissue (low intensity on T1 and T2, low-moderate post-contrast enhancement) was quantified (presence and tissue thickness) in six compartments: supra/infrapatella, medial/lateral gutters, and posterior medial/lateral. RESULTS Fibrotic tissue was identified in all patients studied. However, tissue was significantly thicker in fibrotic patients (4.4 mm ± 0.2 mm) versus non-fibrotic (2.5 mm ± 0.4 mm) and normal TKAs (1.9 mm ± 0.2 mm, p = < 0.05). Significant (> 4 mm thick) tissue was seen in 26/48 (54%) of compartments examined in the fibrotic group, compared with 17/30 (57%) non-fibrotic, and 10/66 (15%) normal TKAs. Although revision surgery did improve range of movement (ROM) in all fibrotic patients, clinically significant restriction remained post-surgery. CONCLUSION Stiff TKAs contain intra-articular fibrotic tissue that is identifiable by MRI. Studies should evaluate whether MRI is useful for surgical planning of debridement, and as a non-invasive measurement tool following interventions for stiffness caused by fibrosis. Revision for stiffness can improve ROM, but outcomes are sub-optimal and new treatments are required. Cite this article: Bone Joint J 2020;102-B(10):1331-1340.
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Affiliation(s)
- Veronica Attard
- Leeds NIHR Biomedical Research Centre, Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, Leeds, UK
| | - Cheuk Yin Li
- Department of Orthopaedics, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Alexander Self
- Department of Radiology, Royal Victoria Infirmary, Newcastle University Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Derek A. Mann
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Lee A. Borthwick
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Phil O’Connor
- Leeds NIHR Biomedical Research Centre, Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, Leeds, UK
| | - David J. Deehan
- Department of Orthopaedics, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Nicholas S. Kalson
- Department of Orthopaedics, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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Qadri M, Jay GD, Zhang LX, Richendrfer H, Schmidt TA, Elsaid KA. Proteoglycan-4 regulates fibroblast to myofibroblast transition and expression of fibrotic genes in the synovium. Arthritis Res Ther 2020; 22:113. [PMID: 32404156 PMCID: PMC7222325 DOI: 10.1186/s13075-020-02207-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/30/2020] [Indexed: 12/19/2022] Open
Abstract
Background Synovial tissue fibrosis is common in advanced OA with features including the presence of stress fiber-positive myofibroblasts and deposition of cross-linked collagen type-I. Proteoglycan-4 (PRG4) is a mucinous glycoprotein secreted by synovial fibroblasts and is a major component of synovial fluid. PRG4 is a ligand of the CD44 receptor. Our objective was to examine the role of PRG4-CD44 interaction in regulating synovial tissue fibrosis in vitro and in vivo. Methods OA synoviocytes were treated with TGF-β ± PRG4 for 24 h and α-SMA content was determined using immunofluorescence. Rhodamine-labeled rhPRG4 was incubated with OA synoviocytes ± anti-CD44 or isotype control antibodies and cellular uptake of rhPRG4 was determined following a 30-min incubation and α-SMA expression following a 24-h incubation. HEK-TGF-β cells were treated with TGF-β ± rhPRG4 and Smad3 phosphorylation was determined using immunofluorescence and TGF-β/Smad pathway activation was determined colorimetrically. We probed for stress fibers and focal adhesions (FAs) in TGF-β-treated murine fibroblasts and fibroblast migration was quantified ± rhPRG4. Synovial expression of fibrotic markers: α-SMA, collagen type-I, and PLOD2 in Prg4 gene-trap (Prg4GT) and recombined Prg4GTR animals were studied at 2 and 9 months of age. Synovial expression of α-SMA and PLOD2 was determined in 2-month-old Prg4GT/GT&Cd44−/− and Prg4GTR/GTR&Cd44−/− animals. Results PRG4 reduced α-SMA content in OA synoviocytes (p < 0.001). rhPRG4 was internalized by OA synoviocytes via CD44 and CD44 neutralization attenuated rhPRG4’s antifibrotic effect (p < 0.05). rhPRG4 reduced pSmad3 signal in HEK-TGF-β cells (p < 0.001) and TGF-β/Smad pathway activation (p < 0.001). rhPRG4 reduced the number of stress fiber-positive myofibroblasts, FAs mean size, and cell migration in TGF-β-treated NIH3T3 fibroblasts (p < 0.05). rhPRG4 inhibited fibroblast migration in a macrophage and fibroblast co-culture model without altering active or total TGF-β levels. Synovial tissues of 9-month-old Prg4GT/GT animals had higher α-SMA, collagen type-I, and PLOD2 (p < 0.001) content and Prg4 re-expression reduced these markers (p < 0.01). Prg4 re-expression also reduced α-SMA and PLOD2 staining in CD44-deficient mice. Conclusion PRG4 is an endogenous antifibrotic modulator in the joint and its effect on myofibroblast formation is partially mediated by CD44, but CD44 is not required to demonstrate an antifibrotic effect in vivo.
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Affiliation(s)
- Marwa Qadri
- Department of Biomedical and Pharmaceutical Sciences, Chapman University School of Pharmacy, Rinker Health Sciences Campus, 9401 Jeronimo Road, Irvine, CA, 92618, USA.,Department of Pharmacology, College of Pharmacy, Jazan University, Jazan, 82826, Saudi Arabia
| | - Gregory D Jay
- Department of Emergency Medicine, Rhode Island Hospital, Providence, RI, USA
| | - Ling X Zhang
- Department of Emergency Medicine, Rhode Island Hospital, Providence, RI, USA
| | - Holly Richendrfer
- Department of Emergency Medicine, Rhode Island Hospital, Providence, RI, USA
| | - Tannin A Schmidt
- Biomedical Engineering Department, School of Dental Medicine, University of Connecticut, Farmington, CT, USA
| | - Khaled A Elsaid
- Department of Biomedical and Pharmaceutical Sciences, Chapman University School of Pharmacy, Rinker Health Sciences Campus, 9401 Jeronimo Road, Irvine, CA, 92618, USA.
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Wang MM, Feng YS, Xing Y, Dong F, Zhang F. Mechanisms involved in the arthrofibrosis formation and treatments following bone fracture. J Back Musculoskelet Rehabil 2020; 32:947-954. [PMID: 31403938 DOI: 10.3233/bmr-191499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Arthrofibrosis is a common complication for patients with bone fracture following external and internal fixation. In this review, we summarize the related factors and significant pathways for joint adhesion following fracture surgery. Moreover, the different types of treatments and related preventive measures are also discussed. Many factors related to the development and treatment of arthrofibrosis are discussed in this review in order to provide possible clues for the prospective targets to develop new medication or treatments for preventing or reducing the joint adhesion following orthopedic surgery.
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Affiliation(s)
- Man-Man Wang
- Department of Rehabilitation Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Ya-Shuo Feng
- Department of Rehabilitation Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Ying Xing
- Department of Rehabilitation Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Fang Dong
- Department of Clinical Laboratory Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Feng Zhang
- Department of Rehabilitation Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China.,Hebei Provincial Orthopedic Biomechanics key laboratory, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
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45
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Atluri K, Brouillette MJ, Seol D, Khorsand B, Sander E, Salem AK, Fredericks D, Petersen E, Smith S, Fowler TP, Martin JA. Sulfasalazine Resolves Joint Stiffness in a Rabbit Model of Arthrofibrosis. J Orthop Res 2020; 38:629-638. [PMID: 31692083 DOI: 10.1002/jor.24499] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 10/06/2019] [Indexed: 02/04/2023]
Abstract
Joint stiffness due to fibrosis/capsule contracture is a seriously disabling complication of articular injury that surgical interventions often fail to completely resolve. Fibrosis/contracture is associated with the abnormal persistence of myofibroblasts, which over-produce and contract collagen matrices. We hypothesized that intra-articular therapy with drugs targeting myofibroblast survival (sulfasalazine), or collagen production (β-aminopropionitrile and cis-hydroxyproline), would reduce joint stiffness in a rabbit model of fibrosis/contracture. Drugs were encapsulated in poly[lactic-co-glycolic] acid pellets and implanted in joints after fibrosis/contracture induction. Capsule α-smooth muscle actin (α-SMA) expression and intimal thickness were evaluated by immunohistochemistry and histomorphometry, respectively. Joint stiffness was quantified by flexion-extension testing. Drawer tests were employed to determine if the drugs induced cruciate ligament laxity. Joint capsule fibroblasts were tested in vitro for contractile activity and α-SMA expression. Stiffness in immobilized joints treated with blank pellets (control) was significantly higher than in non-immobilized, untreated joints (normal) (p = 0.0008), and higher than in immobilized joints treated with sulfasalazine (p = 0.0065). None of the drugs caused significant cruciate ligament laxity. Intimal thickness was significantly lower than control in the normal and sulfasalazine-treated groups (p = 0.010 and 0.025, respectively). Contractile activity in the cells from controls was significantly increased versus normal (p = 0.001). Sulfasalazine and β-aminopropionitrile significantly inhibited this effect (p = 0.005 and 0.0006, respectively). α-SMA expression was significantly higher in control versus normal (p = 0.0021) and versus sulfasalazine (p = 0.0007). These findings support the conclusion that sulfasalazine reduced stiffness by clearing myofibroblasts from fibrotic joints. Statement of clinical significance: The results provide proof-of-concept that established joint stiffness can be resolved non-surgically. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:629-638, 2020.
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Affiliation(s)
- Keerthi Atluri
- Department of Pharmaceutical Sciences and Experimental Therapeutics, University of Iowa, Iowa City, Iowa, 52242
| | - Marc J Brouillette
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, 52242
| | - Dongrim Seol
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, 52242
| | - Behnoush Khorsand
- Department of Pharmaceutical Sciences and Experimental Therapeutics, University of Iowa, Iowa City, Iowa, 52242
| | - Edward Sander
- Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa, 52242
| | - Aliasger K Salem
- Department of Pharmaceutical Sciences and Experimental Therapeutics, University of Iowa, Iowa City, Iowa, 52242
| | - Douglas Fredericks
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, 52242
| | - Emily Petersen
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, 52242
| | - Sonja Smith
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, 52242
| | - Timothy P Fowler
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, 52242
| | - James A Martin
- Department of Pharmaceutical Sciences and Experimental Therapeutics, University of Iowa, Iowa City, Iowa, 52242.,Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, 52242.,Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa, 52242
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46
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Kaneguchi A, Ozawa J, Yamaoka K. Intra-articular injection of mitomycin C prevents progression of immobilization-induced arthrogenic contracture in the remobilized rat knee. Physiol Res 2020; 69:145-156. [PMID: 31852201 DOI: 10.33549/physiolres.934149] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This study tested whether cell cycle inhibitor mitomycin C (MMC) prevents arthrogenic contracture progression during remobilization by inhibiting fibroblast proliferation and fibrosis in the joint capsule. Rat knees were immobilized in a flexed position to generate flexion contracture. After three weeks, the fixation device was removed and rat knees were allowed to freely move for one week. Immediately after and three days after fixator removal, rats received intra-articular injections of MMC or saline. The passive extension range of motion (ROM) was measured before and after myotomy of the knee flexors to distinguish myogenic and arthrogenic contractures. In addition, both cellularity and fibrosis in the posterior joint capsule were assessed histologically. Joint immobilization significantly decreased ROMs both before and after myotomy compared with untreated controls. In saline-injected knees, remobilization increased ROM before myotomy, but further decreased that after myotomy compared with that of knees immediately after three weeks of immobilization. Histological analysis revealed that hypercellularity, mainly due to fibroblast proliferation, and fibrosis characterized by increases in collagen density and joint capsule thickness occurred after remobilization in saline-injected knees. Conversely, MMC injections were able to prevent the remobilization-enhanced reduction of ROM after myotomy by inhibiting both hypercellularity and joint capsule fibrosis. Our results suggest that joint capsule fibrosis accompanied by fibroblast proliferation is a potential cause of arthrogenic contracture progression during remobilization, and that inhibiting fibroblast proliferation may constitute an effective remedy.
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Affiliation(s)
- A Kaneguchi
- Department of Rehabilitation, Faculty of Rehabilitation, Hiroshima International University, Hiroshima, Japan.
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47
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Salib CG, Reina N, Trousdale WH, Limberg AK, Tibbo ME, Jay AG, Robin JX, Turner TW, Jones CR, Paradise CR, Lewallen EA, Bolon B, Carter JM, Berry DJ, Morrey ME, Sanchez-Sotelo J, van Wijnen AJ, Abdel MP. Inhibition of COX-2 Pathway as a Potential Prophylaxis Against Arthrofibrogenesis in a Rabbit Model of Joint Contracture. J Orthop Res 2019; 37:2609-2620. [PMID: 31410880 PMCID: PMC6848758 DOI: 10.1002/jor.24441] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 07/25/2019] [Indexed: 02/04/2023]
Abstract
Arthrofibrosis is a common complication following total knee arthroplasty caused by pathologic fibroblast activation and excessive collagen deposition around a synovial joint leading to debilitating loss of motion. Treatment options are limited because the pathologic mechanisms remain to be characterized. Dysregulation of the inflammatory cascade may lead to communication between myofibroblasts and immune cells triggering tissue metaplasia, and excessive collagen deposition described clinically as arthrofibrosis. We explored the novel use of celecoxib (selective cyclooxygenase-2 [COX-2] inhibitor) to disrupt the downstream effects of the post-traumatic inflammatory cascade and inhibit scar tissue formation in a validated rabbit model of arthrofibrosis combined with new parameters for quantifying the stiffness of the posterior capsule. Biomechanical and molecular analyses, of contracted rabbit knee posterior capsule tissue after COX-2 inhibition revealed increased maximal passive extension and down-regulation of collagen messenger RNA compared with controls. Histopathologic examination suggested a trend of decreased quantities of dense fibrous connective tissue with COX-2 inhibition. These data may suggest that inhibiting the inflammatory cascade could potentially reduce pathologic myofibroblast activation, thereby reducing scar tissue formation and increasing the range of motion in arthrofibrotic joints. Implementing a multi-modal pharmacologic approach may simultaneously target numerous cellular components contributing to the complex process of arthrofibrogenesis. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2609-2620, 2019.
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Affiliation(s)
- Christopher G. Salib
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Nicolas Reina
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - William H. Trousdale
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Afton K. Limberg
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Megan E. Tibbo
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Anthony G. Jay
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Joseph X. Robin
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Travis W. Turner
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Carter R. Jones
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | | | - Eric A. Lewallen
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Brad Bolon
- GEMpath, Inc., 1610 Pace Street, Unit 900-343, Longmont, CO 80504
| | - Jodi M. Carter
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Daniel J. Berry
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Mark E. Morrey
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | | | - Andre J. van Wijnen
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905,Department of Biochemistry & Molecular Biology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Matthew P. Abdel
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
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48
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Bhave A, Sodhi N, Anis HK, Ehiorobo JO, Mont MA. Static progressive stretch orthosis-consensus modality to treat knee stiffness-rationale and literature review. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S256. [PMID: 31728380 DOI: 10.21037/atm.2019.06.55] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The current literature supports static progressive stretch (SPS) orthoses as the consensus modality to treat joint stiffness as an adjunct to manual therapy. Over 50 published studies prove the efficacy and safety of this modality as an adjunct to therapy to improve range of motion (ROM) as well as decrease stiffness and pain. Data from a large prospective study on SPS effectiveness identified a 90% improvement in ROM, 84% reduction in stiffness and swelling, 70% reduction in pain, and no reports of complications or injury. Another 13 studies evaluating patients with knee stiffness have shown excellent results with SPS, and a reduced need for manipulation under anesthesia or additional surgeries. The bidirectional SPS device allows for ROM therapy in both flexion and extension, uses short, 5-minute incremental stretches for up to a 30-minute session applied 1 to 3 times per day for 8 weeks, though treatment might be needed for longer durations (8 to 12 weeks) in cases with chronic stiffness/contracture, to improve motion and significantly reduces need for manipulation or surgery for treatment of knee fibrosis. Earlier application of SPS therapy, even immediately postoperative following corrective surgery for motion loss, can greatly improve the results for patients who have limitations in knee motion.
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Affiliation(s)
- Anil Bhave
- Department of Physical Therapy, Rubin Institute for Advanced Orthopaedics, Sinai Hospital, Baltimore, MD, USA
| | - Nipun Sodhi
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, Northwell Health, New York, NY, USA
| | - Hiba K Anis
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Joseph O Ehiorobo
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
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Paish HL, Baldock TE, Gillespie CS, del Carpio Pons A, Mann DA, Deehan DJ, Borthwick LA, Kalson NS. Chronic, Active Inflammation in Patients With Failed Total Knee Replacements Undergoing Revision Surgery. J Orthop Res 2019; 37:2316-2324. [PMID: 31231835 PMCID: PMC6851711 DOI: 10.1002/jor.24398] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 06/06/2019] [Indexed: 02/04/2023]
Abstract
Chronic pain and restricted knee motion is a significant problem following the total knee arthroplasty (TKA). The molecular pathogenesis of pain post-TKA is not known and no targeted therapeutic intervention is available. The aim of this study was to investigate whether pro-inflammatory mediators are elevated in revision knee patients, indicating an active, ongoing inflammatory process that may contribute to pain. Twelve key markers (pro-inflammatory cytokines granulocyte-macrophage colony-stimulating factor [GM-CSF], interleukin 5 [IL-5], IL-8 and IL-10, chemokines CCL2, CCL3, CCL4, and CCL13, mediators of angiogenesis Flt-1, vascular endothelial growth factor, and cell migration vascular cell adhesion molecule 1 and intercellular adhesion molecule 1) were measured in knee tissue and synovial fluid (SF) from primary TKA (n = 29) and revision patients (n = 32). Indications for surgery were osteoarthritis (OA) for primary TKA, and component loosening (n = 11), stiffness (n = 11), laxity pattern (n = 8), or progression of OA in patella resurfacing (n = 3) for revision surgery. Pain levels (WOMAC score) were higher in revision than primary patients (p ≤ 0.05). Time from primary to revision ranged from 8 months to 30 years (median 10 years). All markers were elevated in revision TKA; there was no trend toward decreasing levels with greater time from primary surgery for any marker studied in SF. Similar results were seen in knee tissue. We found no differences comparing indications for revision surgery (p ≥ 0.05). The elevation of inflammatory mediators in painful post-TKA knees requiring revision suggests active, chronic inflammation. Characterization of upregulated markers provides rationale for targeted therapy, even many years from the primary surgery. © 2019 The Authors. Journal of Orthopaedic Research® published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society. J Orthop Res 37:2316-2324, 2019.
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Affiliation(s)
- Hannah L. Paish
- Fibrosis Research Group, Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneNE2 4HHUnited Kingdom
| | - Thomas Edward Baldock
- Musculoskeletal Unit, Department of Orthopaedics, Freeman Hospital, Newcastle HospitalsNHS TrustNewcastle upon TyneNE7 7DNUnited Kingdom
| | - Colin S. Gillespie
- School of Mathematics & StatisticsNewcastle UniversityNewcastle upon TyneNE2 4HHUnited Kingdom
| | - Alicia del Carpio Pons
- Fibrosis Research Group, Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneNE2 4HHUnited Kingdom
| | - Derek A. Mann
- Fibrosis Research Group, Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneNE2 4HHUnited Kingdom
| | - David J. Deehan
- Fibrosis Research Group, Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneNE2 4HHUnited Kingdom,Musculoskeletal Unit, Department of Orthopaedics, Freeman Hospital, Newcastle HospitalsNHS TrustNewcastle upon TyneNE7 7DNUnited Kingdom
| | - Lee A. Borthwick
- Fibrosis Research Group, Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneNE2 4HHUnited Kingdom
| | - Nicholas S. Kalson
- Fibrosis Research Group, Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneNE2 4HHUnited Kingdom,Musculoskeletal Unit, Department of Orthopaedics, Freeman Hospital, Newcastle HospitalsNHS TrustNewcastle upon TyneNE7 7DNUnited Kingdom
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50
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Rodrigues MM, Fontoura CP, Garcia CSC, Martins ST, Henriques JAP, Figueroa CA, Roesch-Ely M, Aguzzoli C. Investigation of plasma treatment on UHMWPE surfaces: Impact on physicochemical properties, sterilization and fibroblastic adhesion. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2019; 102:264-275. [DOI: 10.1016/j.msec.2019.04.048] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/20/2019] [Accepted: 04/14/2019] [Indexed: 01/21/2023]
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