Cytokine patterns after tourniquet-induced skeletal muscle ischaemia reperfusion in total knee replacement

Ischemic preconditioning upregulates Mitofusin2 and preserves muscle strength in tourniquet-induced ischemia/reperfusion

Background

Tourniquet-induced ischemia and reperfusion (I/R) has been related to postoperative muscle atrophy through mechanisms involving protein synthesis/breakdown, cellular metabolism, mitochondrial dysfunction, and apoptosis. Ischemic preconditioning (IPC) could protect skeletal muscle against I/R injury. This study aims to determine the underlying mechanisms of IPC and its effect on muscle strength after total knee arthroplasty (TKA).

Methods

Twenty-four TKA patients were randomized to receive either sham IPC or IPC (3 cycles of 5-min ischemia followed by 5-min reperfusion). Vastus medialis muscle biopsies were collected at 30 ​min after tourniquet (TQ) inflation and the onset of reperfusion. Western blot analysis was performed in muscle protein for 4-HNE, SOD2, TNF-ɑ, IL-6, p-Drp1^ser616, Drp1, Mfn1, Mfn2, Opa1, PGC-1ɑ, ETC complex I-V, cytochrome c, cleaved caspase-3, and caspase-3. Clinical outcomes including isokinetic muscle strength and quality of life were evaluated pre- and postoperatively.

Results

IPC significantly increased Mfn2 (2.0 ​± ​0.2 vs 1.2 ​± ​0.1, p ​= ​0.001) and Opa1 (2.9 ​± ​0.3 vs 1.9 ​± ​0.2, p ​= ​0.005) proteins expression at the onset of reperfusion, compared to the ischemic phase. There were no differences in 4-HNE, SOD2, TNF-ɑ, IL-6, p-Drp1^ser616/Drp1, Mfn1, PGC-1ɑ, ETC complex I-V, cytochrome c, and cleaved caspase-3/caspase-3 expression between the ischemic and reperfusion periods, or between the groups. Clinically, postoperative peak torque for knee extension significantly reduced in the sham IPC group (-16.6 [-29.5, -3.6] N.m, p ​= ​0.020), while that in the IPC group was preserved (-4.7 [-25.3, 16.0] N.m, p ​= ​0.617).

Conclusion

In TKA with TQ application, IPC preserved postoperative quadriceps strength and prevented TQ-induced I/R injury partly by enhancing mitochondrial fusion proteins in the skeletal muscle.

The translational potential of this article

Mitochondrial fusion is a potential underlying mechanism of IPC in preventing skeletal muscle I/R injury. IPC applied before TQ-induced I/R preserved postoperative quadriceps muscle strength after TKA.

Therapeutic effects of masitinib on abnormal mechanoreception in a mouse model of tourniquet-induced extremity ischemia-reperfusion

Tourniquets are widely used to stop extremity hemorrhage, but their use and subsequent release can result in nerve damage and degeneration, leading to neurological deficits. Increasing evidence has suggested a pivotal role of inflammation in nerve damage and abnormal mechanoreception. In this study, we investigated the therapeutic effects of masitinib (Mas), an anti-neuroinflammatory drug, on the mechanoreception of sensory neurons in a mouse model of tourniquet-induced hind paw ischemia-reperfusion (tourniquet/IR). C57BL/6 mice were subjected to 3 h of ischemia by placing a rubber band at the ankle joint and evaluated for subsequent reperfusion injury on day 1, 3, 7, 14, and 28 based on the experiments. Treatment with Mas (28 mg/kg/day, i.p.) began on the day of IR induction and lasted for 1, 3, 7, 14, or 28 days. Tourniquet/IR caused sensory nerve denervation in the skin of paw pads and abolished the hind paw mechanoreception to mechanical stimulation during the first 3 days of reperfusion. Sensory nerves gradually reinnervated in the skin of paw pads and allodynia began to appear on day 7. The maximum reaction occurred on day 14 and was maintained throughout the study period. Treatment with Mas mitigated nerve damage and improved hind paw mechanoreception to mechanical stimulation by decreasing the production of reactive oxygen species (ROS) during the early stages of tourniquet/IR. Mas also alleviated allodynia and decreased inflammatory cytokines (IL-1β and TNFα) in the skin of paw pads from days 7-28. Our data suggest that treatment with Mas significantly ameliorated paw numbness and allodynia in mouse hind paw tourniquet/IR.

The Comparison of Inflammatory Cytokines between Spinal and General Anesthesia following Changes in Ischemic Reperfusion due to Tourniquet during Lower Limb Surgery

Methods

In this randomized controlled clinical trial, 34 patients with lower limb surgery admitted at the orthopedic ward of Imam Reza Hospital, Birjand, Iran, were selected by the available sampling method. They were randomly divided into two groups as follows: general anesthesia (n = 17) and spinal anesthesia (n = 17). Venous blood samples were taken from the patients of both groups at baseline (before the use of tourniquet) and 12 and 24 hours after reperfusion. Interleukin-6 (IL-6), tumor necrotizing factor-α (TNF-α), high-sensitivity C-reactive protein (hs-CRP), and ferritin were measured and recorded. The data were analyzed using independent t-test, chi-square, and repeated measure at the significant level of 0.05.

Results

The results showed that hs-CRP and IL-6 significantly increased during the study (p < 0.001); however, the mean changes of TNF-α and ferritin were not significant during the study. Moreover, none of the inflammatory cytokines indicated significant differences between these two study groups (p < 0.05).

Conclusion

According to the results, the use of tourniquet can lead to inflammation, and the inflammation is similar in both groups.

Normal trajectory of Interleukin-6 and C-reactive protein in the perioperative period of total knee arthroplasty under an enhanced recovery after surgery scenario

Background

We designed the current study to understand the normal trajectories of interleukin-6 (IL-6) and C-reactive protein (CRP) in the immediate hours and days after primary total knee arthroplasty (TKA) under the management of an enhanced recovery after surgery (ERAS) protocol and examined whether one or the other returned to normal more quickly.

Methods

In this prospective cross-sectional study, we examined the plasma IL-6 and CRP levels in 100 patients undergoing primary TKA at the following time points: 12 h preoperatively as well as postoperatively 12 h, 48 h, 3 days and 2 weeks. Patients were followed up for 1 year to monitor the postoperative complications, especially the infection.

Results

IL-6 peaked at 48 h postoperatively. Then IL-6 started to decline at 3 days postoperatively and went back to baseline level at 2 weeks (p = 0.950). CRP peaked at 3 days postoperatively. At 2 weeks, CRP declined to a normal range, without being significantly different from the baseline level (p = 0.816).

Conclusion

We found that under the ERAS scenario, the postoperative peak of IL-6 and CRP was deferred compared with previous studies. Compared to IL-6, CRP showed a gradual rise after surgery. Both of these two biomarkers returned to normal under the ERAS scenario. Future multiple-center studies with larger sample size can help define the thresholds of IL-6 and CRP for periprosthetic joint infection (PJI) early diagnosis. With these reference data, a clinician can make a quicker decision to perform aspiration to diagnose early PJI and benefits more patients.

The Possible Pathophysiological Outcomes and Mechanisms of Tourniquet-Induced Ischemia-Reperfusion Injury during Total Knee Arthroplasty

Ischemia and reperfusion (I/R) injury induced by tourniquet (TQ) application leads to the release of both oxygen free radicals and inflammatory cytokines. The skeletal muscle I/R may contribute to local skeletal muscle and remote organ damage affecting outcomes after total knee arthroplasty (TKA). The aim of the study is to summarize the current findings associated with I/R injury following TKA using a thigh TQ, which include cellular alterations and protective therapeutic interventions. The PubMed database was searched using the keywords "ischemia reperfusion injury," "oxidative stress," "tourniquet," and "knee arthroplasty." The search was limited to research articles published in the English language. Twenty-eight clinical studies were included in this qualitative review. Skeletal muscle I/R reduces protein synthesis, increases protein degradation, and upregulates genes in cell stress pathways. The I/R of the lower extremity elevates local and systemic oxidative stress as well as inflammatory reactions and impairs renal function. Propofol reduces oxidative injury in this I/R model. Ischemic preconditioning (IPC) and vitamin C may prevent oxygen free radical production. However, a high dose of N-acetylcysteine possibly induces kidney injury. In summary, TQ-related I/R during TKA leads to muscle protein metabolism alteration, endothelial dysfunction, oxidative stress, inflammatory response, and renal function disturbance. Propofol, IPC, and vitamin C show protective effects on oxidative and inflammatory markers. However, a relationship between biochemical parameters and postoperative clinical outcomes has not been validated.

Dexamethasone Protects Against Tourniquet-Induced Acute Ischemia-Reperfusion Injury in Mouse Hindlimb

Extremity injuries with hemorrhage have been a significant cause of death in civilian medicine and on the battlefield. The use of a tourniquet as an intervention is necessary for treatment to an injured limb; however, the tourniquet and subsequent release results in serious acute ischemia-reperfusion (IR) injury in the skeletal muscle and neuromuscular junction (NMJ). Much evidence demonstrates that inflammation is an important factor to cause acute IR injury. To find effective therapeutic interventions for tourniquet-induced acute IR injuries, our current study investigated effect of dexamethasone, an anti-inflammatory drug, on tourniquet-induced acute IR injury in mouse hindlimb. In C57/BL6 mice, a tourniquet was placed on unilateral hindlimb (left hindlimb) at the hip joint for 3 h, and then released for 24 h to induce IR. Three hours of tourniquet and 24 h of release (24-h IR) caused gastrocnemius muscle injuries including rupture of the muscle sarcolemma and necrosis (42.8 ± 2.3% for infarct size of the gastrocnemius muscle). In the NMJ, motor nerve terminals disappeared, and endplate potentials were undetectable in 24-h IR mice. There was no gastrocnemius muscle contraction in 24-h IR mice. Western blot data showed that inflammatory cytokines (TNFα and IL-1β) were increased in the gastrocnemius muscle after 24-h IR. Treatment with dexamethasone at the beginning of reperfusion (1 mg/kg, i.p.) significantly inhibited expression of TNFα and IL-1β, reduced rupture of the muscle sarcolemma and infarct size (24.8 ± 2.0%), and improved direct muscle stimulation-induced gastrocnemius muscle contraction in 24-h IR mice. However, this anti-inflammatory drug did not improve NMJ morphology and function, and sciatic nerve-stimulated skeletal muscle contraction in 24-h IR mice. The data suggest that one-time treatment with dexamethasone at the beginning of reperfusion only reduced structural and functional impairments of the skeletal muscle but not the NMJ through inhibiting inflammatory cytokines.

Correlations between inflammatory cytokines, muscle damage markers and acute postoperative pain following primary total knee arthroplasty

BACKGROUND

Despite the success of total knee arthroplasty (TKA) in reducing knee pain and improving functional disability, the management of acute postoperative pain is still unsatisfactory. This study was aimed to quantitatively analyze the possible correlations between inflammatory cytokines, muscle damage markers and acute postoperative pain following primary TKA.

METHODS

Patients scheduled for unilateral primary TKA were consecutively included, the serial changes of the numerical rating scale (NRS) at rest (NRSR) and at walking (NRSW), serum inflammatory cytokines and muscle damage markers were assessed before surgery (T0) and at postoperative day 1, 2, 3 and 5 (T1-T4, respectively); while pain disability questionnaire (PDQ) and synovial fluid inflammatory cytokines were evaluated at T0. The correlations between inflammatory cytokines, muscle damage markers and pain scores were examined, and Bonferroni correction was applied for multiple comparisons.

RESULTS

Ninety six patients were included for serum markers and pain evaluations at T0-T4, while 54 (56.25%) for synovial fluid cytokines at T0. The NRSR at T1 and T2 were positively correlated with preoperative NRSW, while the NRSW at T1 to T4 were positively correlated with preoperative NRSR, NRSW and PDQ (all p < 0.05). The NRSR was positively correlated with serum PGE2, IL-6, and CK at T1; the NRSW was positively correlated with serum CRP at T1, with PGE2 and IL-6 at T1 to T3, with CK at T2 and T4, and with Mb and LDH at T1 to T4 (all p < 0.003). Meanwhile, positive correlations were observed between preoperative NRSW and synovial fluid PGE2, IL-6, IL-8, or TNF-α, as well as between PDQ and PGE2 (all p < 0.003), but no associations between postoperative pain scores and preoperative synovial fluid cytokines was found (all p ≥ 0.003). Additionally, the NRSR at T1 and T2, and NRSW at T1 to T4 were positively correlated with body mass index (all p < 0.05).

CONCLUSIONS

Serum inflammatory cytokines and muscle damage markers are positively correlated with acute postoperative pain following primary TKA, and the key cytokines (CRP, PGE2, and IL-6) and markers (Mb, CK and LDH) may serve as the targets for developing novel analgesic strategies.

Dexamethasone promotes long-term functional recovery of neuromuscular junction in a murine model of tourniquet-induced ischaemia-reperfusion

AIM

Tourniquet-induced ischaemia and subsequent reperfusion cause serious ischaemia-reperfusion (IR) injury in the neuromuscular junction (NMJ) and skeletal muscle. Here, we investigated whether dexamethasone (Dex) promotes long-term functional recovery of the NMJ and skeletal muscle in tourniquet-induced hindlimb IR.

METHODS

Unilateral hindlimb of C57/BL6 mice was subjected to 3 h of ischaemia following 6 weeks of reperfusion (6-wk IR). Dex treatment began on the day of IR induction and lasted for different periods. Sciatic nerve-stimulated gastrocnemius muscle contraction was detected in situ. Function of the NMJ was measured in situ using electrophysiological recording of the miniature endplate potential (mEPP) and endplate potential (EPP). Western blot was used to detect protein expression of nicotinic acetylcholine receptors (nAChRs) in gastrocnemius muscles.

RESULTS

Gastrocnemius muscle contraction in mice with 6-wk IR was about 60% of normal skeletal muscle contraction recorded in age-matched sham mice. The amplitude of the mEPP and EPP was lower in mice with 6-wk IR, compared to sham mice. Dex treatment for 1 or 3 days did not restore the function of the NMJ and improve gastrocnemius muscle contraction in mice with 6-wk IR. Dex treatment for 1 week exerted a maximum effect on improving the function of the NMJ and skeletal muscle, with the effect of Dex gradually lessening with prolonged Dex treatment. There are no significant differences in protein expression of nAChR-α1 and nAChR-β1 subunits in the gastrocnemius muscle among all groups.

CONCLUSION

Dex promotes repair of the NMJ and subsequently restores skeletal muscle contractile function in tourniquet-induced 6-wk IR.

The Effect of Air Tourniquet on Interleukin-6 Levels in Total Knee Arthroplasty

Background:

Air tourniquet-induced skeletal muscle injury increases the concentrations of some cytokines such as interleukin-6 (IL-6) in plasma. However, the effect of an air tourniquet on the IL-6 concentrations after total knee arthroplasty (TKA) is unclear. We therefore investigated the impact of tourniquet-induced ischemia and reperfusion injury in TKA using the IL-6 level as an index.

Methods:

Ten patients with primary knee osteoarthrosis who underwent unilateral TKA without an air tourniquet were recruited (Non-tourniquet group). We also selected 10 age- and sex-matched control patients who underwent unilateral TKA with an air tourniquet (Tourniquet group). Venous blood samples were obtained at 3 points; before surgery, 24 h after surgery, and 7 days after surgery.

The following factors were compared between the two groups; IL-6, C-reactive protein (CRP), creatine phosphokinase (CPK), the mean white blood cell (WBC) counts, and the maximum daily body temperatures.

Results:

The IL-6 level at 24 h after surgery was significantly higher than that at any other point (p<0.01). No significant differences were observed in the WBC count, the body temperature, or the CRP, CPK, or IL-6 levels of the two groups at any of the time points.

Conclusion:

The effect of ischemia and reperfusion due to the use of an air tourniquet on increasing the IL-6 level was much smaller than that induced by surgical stress in TKA.

Tourniquet Use During Knee Replacement Surgery May Contribute to Muscle Atrophy in Older Adults

Muscle atrophy after total knee arthroplasty (TKA) occurs at a rate of 1% per day for the first 2 wk. Our hypothesis is that tourniquet-induced ischemia-reperfusion injury occurring during TKA influences metabolism and may contribute to atrophy. Identifying pathways that are upregulated during this critical "14-d window" after surgery may help us delineate therapeutic approaches to avoid muscle loss.

Lower limb ischaemia and reperfusion injury in healthy volunteers measured by oxidative and inflammatory biomarkers

Objective:

Ischaemia-reperfusion (IR) injury is partly caused by the release of reactive oxygen species and cytokines and may result in remote organ injury. Surgical patients are exposed to surgical stress and anaesthesia, both of which can influence the IR response. An IR model without these interfering factors of surgery is, therefore, useful to test the potential of antioxidant and cytokine-modulatory treatments. The aim of this study was to characterize a human ischaemia-reperfusion model with respect to oxidative and inflammatory biomarkers.

Materials and methods:

Ten male volunteers were exposed to 20 minutes of lower limb ischaemia. Muscle biopsies and blood samples were taken at baseline and 5, 15, 30, 60 and 90 minutes after tourniquet release and analysed for malondialdehyde (MDA), ascorbic acid, dehydroascorbic acid, tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-1 receptor antagonist (IL-1Ra), IL-6, IL-10, TNF-receptor (TNF-R)I, TNF-RII and YKL-40.

Results:

We found no significant increase in MDA in the muscle biopsies after reperfusion. Plasma levels of oxidative and pro- and anti-inflammatory parameters showed no significant differences between baseline and after reperfusion at any sampling time.

Conclusion:

Twenty minutes of lower limb ischaemia does not result in an ischaemia-reperfusion injury in healthy volunteers, measurable by oxidative and pro- and anti-inflammatory biomarkers in muscle biopsies and in the systemic circulation.

Comparison of three different tourniquet application strategies for minimally invasive total knee arthroplasty: a prospective non-randomized clinical trial

INTRODUCTION

It is still controversial on the optimal timing of tourniquet used in total knee arthroplasty (TKA). Most previous studies focused on the comparison of different tourniquet application in controversial TKA, while the aim of our work was to compare three strategies of tourniquet application in minimally invasive TKA.

MATERIALS AND METHODS

90 patients were enrolled in this study. Based on the different tourniquet application strategies, they were divided into three groups. Group A: using tourniquet during the whole surgery; Group B: tourniquet inflated before incision and deflated after the hardening of the cement; Group C: using tourniquet during the cementation. Blood loss and serum levels of C-reactive protein, IL-6, creatine kinase and myoglobin were checked preoperatively. The HSS knee score, VAS pain score, range of motion (ROM), limb swelling and hospital stays were also recorded.

RESULTS

The mean levels of Hb and Hct were lower in Group C (104.2 ± 10.4 g/L, 31.8 ± 3.2 %) than those in Groups A (111.4 ± 14.4 g/L, p = 0.035; 34.1 ± 4.1 %, p = 0.032) and B (112.8 ± 14.3 g/L, p = 0.013; 34.5 ± 3.7 %, p = 0.011) immediately after the surgery. Compared with Groups A and B, both serum inflammation and muscle damage markers were lower in Group C. There were no significant differences between the groups in terms of HSS knee score, ROM, estimated blood loss, swelling ratio, VAS pain score and hospital stays.

CONCLUSIONS

Using a tourniquet full time in minimally invasive TKA causes less intraoperative blood loss and more excessive inflammation and muscle damage. However, the advantage of part-time using tourniquet did not show in early functional outcomes.

Epidural anesthesia followed by epidural analgesia produces less inflammatory response than spinal anesthesia followed by intravenous morphine analgesia in patients with total knee arthroplasty

Background

Anesthesia and inflammatory response have been studied in major abdominal and thoracic surgical procedures, but not in major orthopaedic reconstructive procedures such as total knee arthroplasty. Most studies have compared general anesthesia with epidural anesthesia, but none has compared epidural with spinal.

Material/Methods

In a prospective randomized study, 2 groups of patients scheduled for total knee arthroplasty for osteoarthritis were evaluated regarding the inflammatory response to 2 types of regional anesthesia. In 30 patients (Group A) with spinal anesthesia followed by intravenous morphine analgesia, and in 26 patients (Group B) with epidural anesthesia followed by epidural analgesia, the inflammatory response was assessed through the calculation of leucocyte concentration (WBC), C-reactive protein (CRP), monocyte chemotactic protein 1 (MCP-1), interleukins (IL-1, IL-6, IL-10, IL-18), TNF-a, and leucocyte activation molecules CD11b and CD62l, in 3 blood samples (immediately before induction to anesthesia, immediately after closure of the operative wound, and at 24 hours post-operatively).

Results

The MCP-1 values showed a statistically significant increase (p<0.02) in the group of patients with spinal anesthesia. Of the leucocyte activation molecules, a high statistically significant increase was noticed in the expression of CD11b on monocytes in the sample taken 24 hours post-operatively in the patients of group A. Similarly, CD62l expression on neutrophils showed a high statistically significant reduction in the sample taken 24 hours post-operatively in the group of patients with spinal anesthesia compared to the group of patients with epidural anesthesia.

Conclusions

Our results show that epidural anesthesia followed by epidural analgesia produced less inflammatory response compared with spinal anesthesia followed by intravenous morphine analgesia in patients operated on with total knee arthroplasty, and that the most sensitive markers of those investigated were the CD11b and CD62l leucocyte activation molecules.

Assessment of endothelium and inflammatory response at the onset of reperfusion injury in hand surgery

Background

Activation of the endothelium, complement activation and generation of cytokines are known events during ischemia-reperfusion (I/R) that mediate tissue injury. Our aim was to elucidate their respective participation at the onset of the reperfusion phase. Tourniquet application in hand surgery causes short-term ischemia, followed by reperfusion and was therefore used as the model in this study.

Methods

Ten patients were included in the study after obtaining informed consent. A tourniquet was placed on the upper arm and inflated to 250 mmHg for 116 ± 16 min, during which the surgery was performed. Venous blood and tissue samples from the surgical area were taken at baseline as well as 0, 2, and 10 min after reperfusion and analyzed for the following parameters: Endothelial integrity and/or activation were analyzed by measuring heparan sulfate and syndecan-1 in serum, and vWF, heparan sulfate proteoglycan as well as CD31on tissue. Complement activation was determined by C3a and C4d levels in plasma, levels of C1-inhibitor in serum, and IgG, IgM, C3b/c, and C4b/c deposition on tissue. Cytokines and growth factors IL-5, IL-6, IL-7, IL-8, IL-10, IL-17, G-CSF, GM-CSF, MCP-1, TNFα, VEGF, and PDGF bb were measured in the serum. Finally, CK-MM levels were determined in plasma as a measure for muscle necrosis.

Results

Markers for endothelial activation and/or integrity as well as complement activation showed no significant changes until 10 min reperfusion. Among the measured cytokines, IL-6, IL-7, IL-17, TNFα, GM-CSF, VEGF, and PDGF bb were significantly increased at 10 min reperfusion with respect to baseline. CK-MM showed a rise from baseline at the onset of reperfusion (p < 0.001) and dropped again at 2 min (p < 0.01) reperfusion, suggesting ischemic muscle damage.

Conclusions

In this clinical model of I/R injury no damage to the endothelium, antibody deposition or complement activation were observed during early reperfusion. However, an increase of pro-inflammatory cytokines and growth factors was shown, suggesting a contribution of these molecules in the early stages of I/R injury.

Silicone ring versus pneumatic cuff tourniquet: a comparative quantitative study in healthy individuals

INTRODUCTION

The aim of the present study was to compare a new silicone ring tourniquet (SRT) with a classic pneumatic cuff tourniquet (PT) in terms of tolerance and recovery time following their use in healthy volunteers.

METHODS

Both tourniquets were applied in the arm and thigh of 15 healthy unmedicated volunteers. PT pressure was kept at 100 mmHg above the systolic blood pressure. The appropriate model of the SRT was used according to the systolic blood pressure. Pain was assessed by visual analogue scale and arterial blood pressure, pulse rate and oxygen saturation were monitored in all volunteers.

RESULTS

There was no statistically significant difference in tolerance time between SRT and PT in the arm (19.13 vs. 18.25 min) and thigh (21.52 vs. 21.39 min) nor in recovery time between the two devices.

CONCLUSION

The SRT performed similarly to the classic PT in terms of tolerance and recovery time when applied in the arm and thigh of unmedicated healthy volunteers.