NSAIDs and fracture healing

Trained innate immunity modulates osteoblast and osteoclast differentiation

Macrophages are key regulators in bone repair and regeneration. Recent studies have shown that long-term epigenetic changes and metabolic shifts occur during specific immune training of macrophages that affect their functional state, resulting in heightened (trained) or reduced (tolerant) responses upon exposure to a second stimulus. This is known as innate immune memory. Here, we study the impact of macrophages' memory trait on osteoblast differentiation of human mesenchymal stromal cells (hMSCs) and osteoclast differentiation. An in vitro trained immunity protocol of monocyte-derived macrophages was employed using inactivated Candida albicans and Bacillus Calmette-Guérin (BCG) to induce a 'trained' state and Pam3CSK4 (PAM) and Lipopolysaccharides (LPS) to induce a 'tolerance' state. Macrophages were subsequently cocultured with hMSCs undergoing osteogenic differentiation during either resting (unstimulated) or inflammatory conditions (restimulated with LPS). Alkaline phosphatase activity, mineralization, and cytokine levels (TNF, IL-6, oncostatin M and SDF-1α) were measured. In addition, macrophages underwent osteoclast differentiation. Our findings show that trained and tolerized macrophages induced opposing results. Under resting conditions, BCG-trained macrophages enhanced ALP levels (threefold), while under inflammatory conditions this was found in the LPS-tolerized macrophages (fourfold). Coculture of hMSCs with trained macrophages showed mineralization while tolerized macrophages inhibited the process under both resting and inflammatory conditions. While osteoclast differentiation was not affected in trained-macrophages, this ability was significantly loss in tolerized ones. This study further confirms the intricate cross talk between immune cells and bone cells, highlighting the need to consider this interaction in the development of personalized approaches for bone regenerative medicine.

Exploration of new models for primary dysmenorrhea treatment: low-power visible-light-activated photodynamic therapy and oral contraceptives

Background

Primary dysmenorrhea (PD) is one of the most common reasons that affect the life quality of women during childbearing age. This research aims to explore the efficacy and curative effect characteristics of oral contraceptives and low-power visible-light-activated photodynamic therapy (PDT). Besides investigating the possible mechanism of PDT, we expected to find a treatment model with better efficacy and fewer side effects.

Method

It was a multicenter, randomized, parallel-controlled study. Eligible participants were randomly assigned to three groups: placebo group, oral contraceptive (Marvelon) group, and the PDT group. They were treated continuously for three menstrual cycles and followed up for two cycles after treatment. The scores of the visual analog scale (VAS) and the concentration of pain-related small molecules in blood before and after treatment were recorded in each group, which can evaluate the therapeutic characteristics of different treatments.

Result

Both Marvelon and PDT were effective. The effect of Marvelon appears quickly which can significantly relieve symptoms at the beginning, while PDT shows a relatively slow role. There was no significant difference in the final efficacy two cycles after treatment. The therapeutic effect was achieved by reducing the concentrations of prostaglandin 2 (PGE2) and endothelin (ET) in the blood.

Conclusion

Marvelon and PDT are effective methods for the treatment of PD. The long-term efficacy of the two is similar, while the therapeutic characteristics and the side effects are different. Patients can choose the suitable way according to their individual needs.

The Effects of the Pericapsular Nerve Group Block on Postoperative Pain in Patients with Hip Fracture: A Multicenter Study

BACKGROUND

An adequate early mobilization followed by an effective and pain-free rehabilitation are critical for clinical and functional recovery after hip and proximal femur fracture. A multimodal approach is always recommended so as to reduce the administered dose of analgesics, drug interactions, and possible side effects. Peripheral nerve blocks should always be considered in addition to spinal or general anesthesia to prolong postoperative analgesia. The pericapsular nerve group (PENG) block appears to be a less invasive and more effective analgesia technique compared to other methods.

METHODS

We conducted multicenter retrospective clinical research, including 98 patients with proximal femur fracture undergoing osteosynthesis surgery within 48 h of occurrence of the fracture. Thirty minutes before performing spinal anesthesia, 49 patients underwent a femoral nerve (FN) block plus a lateral femoral cutaneous nerve (LCFN) block, and the other 49 patients received a PENG block. A non-parametric Wilcoxon-Mann-Whitney (α = 0.05) test was performed to evaluate the difference in resting and dynamic numerical rating scale (NRS) at 30 min, 6 h, 12 h, and 24 h.

RESULTS

the PENG block administration was more effective in reducing pain intensity compared to the FN block in association with the LFCN block, as seen in the resting and dynamic NRS at thirty minutes and 12 h follow-up.

CONCLUSION

the PENG block was more effective in reducing pain intensity than the femoral nerve block associated with the lateral femoral cutaneous nerve block in patients with proximal femur fracture undergoing to osteosynthesis.

Preventing Atrophic Long-Bone Nonunion: Retrospective Analysis at a Level I Trauma Center

Background: Among the risk factors for nonunion are unchangeable patient factors such as the type of injury and comorbidities, and factors that can be influenced by the surgeon such as fracture treatment and the postoperative course. While there are numerous studies analyzing unchangeable factors, there is poor evidence for factors that can be affected by the physician. This raises the need to fill the existing knowledge gaps and lay the foundations for future prevention and in-depth treatment strategies. Therefore, the goal of this study was to illuminate knowledge about nonunion in general and uncover the possible reasons for their development; Methods: This was a retrospective analysis of 327 patients from 2015 to 2020 from a level I trauma center in Germany. Information about patient characteristics, comorbidities, alcohol and nicotine abuse, fracture classification, type of osteosynthesis, etc., was collected. Matched pair analysis was performed, and statistical testing performed specifically for atrophic long-bone nonunion; Results: The type of osteosynthesis significantly affected the development of nonunion, with plate osteosynthesis being a predictor for nonunion. The use of wire cerclage did not affect the development of nonunion, nor did the use of NSAIDs, smoking, alcohol, osteoporosis and BMI; Conclusion: Knowledge about predictors for nonunion and strategies to avoid them can benefit the medical care of patients, possibly preventing the development of nonunion.

Black Phosphorus Accelerates Bone Regeneration Based on Immunoregulation

A fundamental understanding of inflammation and tissue healing suggests that the precise regulation of the inflammatory phase, both in terms of location and timing, is crucial for bone regeneration. However, achieving the activation of early inflammation without causing chronic inflammation while facilitating quick inflammation regression to promote bone regeneration continues to pose challenges. This study reveals that black phosphorus (BP) accelerates bone regeneration by building an osteogenic immunological microenvironment. BP amplifies the acute pro-inflammatory response and promotes the secretion of anti-inflammatory factors to accelerate inflammation regression and tissue regeneration. Mechanistically, BP creates an osteoimmune-friendly microenvironment by stimulating macrophages to express interleukin 33 (IL-33), amplifying the inflammatory response at an early stage, and promoting the regression of inflammation. In addition, BP-mediated IL-33 expression directly promotes osteogenic differentiation of bone marrow mesenchymal stem cells (BMSCs), which further facilitates bone repair. To the knowledge, this is the first study to reveal the immunomodulatory potential of BP in bone regeneration through the regulation of both early-stage inflammatory responses and later-stage inflammation resolution, along with the associated molecular mechanisms. This discovery serves as a foundation for the clinical use of BP and is an efficient approach for managing the immune microenvironment during bone regeneration.

Multi-Functional Small Molecule Alleviates Fracture Pain and Promotes Bone Healing

Bone injuries such as fractures are one major cause of morbidities worldwide. A considerable number of fractures suffer from delayed healing, and the unresolved acute pain may transition to chronic and maladaptive pain. Current management of pain involves treatment with NSAIDs and opioids with substantial adverse effects. Herein, we tested the hypothesis that the purine molecule, adenosine, can simultaneously alleviate pain and promote healing in a mouse model of tibial fracture by targeting distinctive adenosine receptor subtypes in different cell populations. To achieve this, a biomaterial-assisted delivery of adenosine is utilized to localize and prolong its therapeutic effect at the injury site. The results demonstrate that local delivery of adenosine inhibited the nociceptive activity of peripheral neurons through activation of adenosine A1 receptor (ADORA1) and mitigated pain as demonstrated by weight bearing and open field movement tests. Concurrently, local delivery of adenosine at the fracture site promoted osteogenic differentiation of mesenchymal stromal cells through adenosine A2B receptor (ADORA2B) resulting in improved bone healing as shown by histological analyses and microCT imaging. This study demonstrates the dual role of adenosine and its material-assisted local delivery as a feasible therapeutic approach to treat bone trauma and associated pain.

Antiviral and Immunomodulatory Activities of Clinacanthus nutans (Burm. f.) Lindau

Clinacanthus nutans (Burm. f.) Lindau has been used as a traditional herbal medicine for treating snake bites, scalds, burns, and viral and bacterial infections. It has been attracting an increasing amount of attention because of its biological activities, including its antidiabetic, antioxidant, antibacterial, anticancer, anti-inflammatory, antiviral, and immunoregulatory activities. Here, we conducted a panoramic survey of the literature regarding the immunoregulatory, anti-inflammatory, and antiviral activities of C. nutans. We discovered that C. nutans extracts have virucidal activities against herpes simplex virus types 1 and 2, varicella-zoster virus, cyprinid herpesvirus 3, porcine reproductive and respiratory syndrome virus, mosquito-borne chikungunya virus, and potentially SARS-CoV-2; such activities likely result from C. nutans interfering with the entry, penetration, infection, and replication of viruses. We also reviewed the phytochemicals in C. nutans extracts that exhibit anti-inflammatory and immunoregulatory activities. This updated review of the antiviral, anti-inflammatory, and immunoregulatory activities of C. nutans may guide future agricultural practices and reveal clinical applications of C. nutans.

Molecular signatures distinguish senescent cells from inflammatory cells in aged mouse callus stromal cells

Cellular senescence plays important roles in age-related diseases, including musculoskeletal disorders. Senescent cells (SCs) exert a senescence-associated secretory phenotype (SASP) by producing SASP factors, some of which overlap with factors produced by inflammatory cells (Inf-Cs). However, the differences between SCs and Inf-Cs and how they interact with each other during fracture repair have not been well studied. Here, we analyzed single cell RNA sequencing data of aged mouse fracture callus stromal cells. We defined Inf-Cs as cells that express NF-κB Rela/Relb, SCs as cells that express the senescence genes, Cdkn1a, Cdkn2a or Cdkn2c, and inflammatory SCs (Inf-SCs) as cells that express both NF-κB and senescence genes. Differentially expressed genes and pathway analyses revealed that Inf-SCs and SCs had a similar gene expression profile and upregulated pathways that are related to DNA damage/oxidation-reduction and cellular senescence, while Inf-Cs expressed different gene signatures and pathways from SCs and Inf-SCs, mainly related to inflammation. Cellchat software analysis indicated that SCs and Inf-SCs are potential ligand-producing cells that affect Inf-Cs as target cells. Cell culture experiments demonstrated that SC conditioned medium promoted inflammatory gene expression by callus-derived mesenchymal progenitor cells, and Inf-Cs had reduced osteoblast differentiation capacity. In summary, we have identified three cell subclusters associated with inflammation and senescence in callus stromal cells, predicted potential effects of Inf-SCs and SCs on Inf-Cs by production of active ligands, and demonstrated that when mesenchymal progenitors acquire inflammatory phenotypes their osteogenic potential is reduced.

Melatonin promotes the restoration of bone defects via enhancement of miR-335-5p combined with inhibition of TNFα/NF-κB signaling

Accelerating the repair of a bone defect is crucial clinically due to the increased prevalence of trauma, tumor, and infections in bone. Studies have found that excess acute and chronic inflammation attenuate osteogenic differentiation of BMSCs (bone marrow mesenchymal stem cells). Moreover, TNF-α and NF-κB could inhibit osteoblasts differentiation of BMSCs and promote osteoclastogenesis via multiple mechanisms, such as increasing osteoclast precursor cells and acting synergistically with cell cytokines. However, melatonin could inhibit the expression of TNFα/NF-κB and promote bone formation by activating the Wnt/β-catenin signaling pathway. However, there has been no evidence regarding the effect of melatonin on TNFα/NF-κB-inhibited osteoblastogenesis and bone formation. This study aimed to investigate the role of melatonin on TNFα/NF-κB-inhibited osteoblastogenesis and bone formation. Micro-CT, high-throughput screening, overexpression, and other methods were used, and we found that the number of osteoblasts was elevated with melatonin treatment. Additionally, TNFα/NF-κB signaling was inhibited, while miR-335-5p expression increased markedly following treatment with melatonin. Furthermore, miR-335-5p negatively regulated TNFα/NF-κB signaling, while miR-335-5p inhibitor ameliorated the effects of melatonin on TNFα/NF-κB. In conclusion, melatonin facilitates osteogenesis in bone defect healing by enhancing miR-335-5p expression and inhibiting the TNFα/NF-κB pathway.

Current Clinical Concepts: Management of Common Lumbar Spine Posterior Column Disorders in Young, Active Individuals

Although posterior column disorders, such as spondylolysis and spondylolisthesis, are not commonly encountered in the general population, athletic trainers frequently see these conditions in athletic and active individuals due to the repetitive spinal extension and rotational loads placed on the pars interarticularis while participating in sport. Athletic trainers can successfully evaluate patients with posterior column disorders by performing a complete and comprehensive clinical examination to identify the location of pain, test spinal stability, and recognize compensatory movement patterns. Conservative management typically leads to a successful outcome in this population, with rest, bracing, and the use of therapeutic exercise having the best supporting evidence. In this Current Clinical Concepts review, we outlined the etiology and risk factors frequently associated with disorders of the posterior column. Additionally, we synthesized the literature for common evaluation techniques and interventions associated with the posterior column and provided a proposed rehabilitation progression to use in a younger, athletic population.

Rib Fractures in Professional Baseball Pitchers: Mechanics, Epidemiology, and Management

Pitching is a complex kinetic chain activity requiring the transfer of energy from the lower body, through the core and trunk, and finally through the arm to generate explosive acceleration of the baseball. As a result, large forces are generated in the trunk musculature and rib attachments from the late cocking phase of pitching through deceleration. The repetitive cumulative load and high pitch velocities put professional pitchers at risk of rib stress fracture. Given the potential for a prolonged recovery course and high rate of recurrence, early recognition of rib bone stress injury is critical to optimize care. Identifying torso strength imbalances, suboptimal pitching biomechanics (such as late or inadequate pelvic rotation), as well as metabolic deficiencies that may adversely affect bone health are essential to expedite safe return to play and prevent future injury. In this review, we discuss risk factors, mechanism of injury, typical clinical presentation, diagnostic imaging findings, and propose treatment and prevention strategies for rib stress fractures in overhand pitchers.

How Do Drugs Affect the Skeleton? Implications for Forensic Anthropology

Simple Summary

Forensic anthropologists analyze human remains to assist in the identification of the deceased, predominantly by assessing age-at-death, sex, stature, ancestry and any unique identifying features. Whilst methods have been established to create this biological profile of the skeleton, these may be influenced by a number of factors. This paper, for the first time, provides an overview from a reading of the clinical and pharmacological literature to explore whether the intake of drugs can affect the skeleton and whether these may have implications for forensic anthropology casework. In effect, drugs such as tobacco, heroin, and prescription medications can alter bone mineral density, can increase the risk of fractures, destroy bone and changes to the dentition. By considering how drugs can affect the skeleton, forensic anthropologists can be aware of this when attempting to identify the deceased.

Abstract

Forensic anthropologists rely on a number of parameters when analyzing human skeletal remains to assist in the identification of the deceased, predominantly age-at-death, sex, stature, ancestry or population affinity, and any unique identifying features. During the examination of human remains, it is important to be aware that the skeletal features considered when applying anthropological methods may be influenced and modified by a number of factors, and particular to this article, prescription drugs (including medical and non-medical use) and other commonly used drugs. In view of this, this paper aims to review the medical, clinical and pharmacological literature to enable an assessment of those drug groups that as side effects have the potential to have an adverse effect on the skeleton, and explore whether or not they can influence the estimation of age-at-death, sex and other indicators of the biological profile. Moreover, it may be that the observation of certain alterations or inconsistencies in the skeleton may relate to the use of drugs or medication, and this in turn may help narrow down the list of missing persons to which a set of human remains could belong. The information gathered from the clinical and medical literature has been extracted with a forensic anthropological perspective and provides an awareness on how several drugs, such as opioids, cocaine, corticosteroids, non-steroidal anti-inflammatory drugs, alcohol, tobacco and others have notable effects on bone. Through different mechanisms, drugs can alter bone mineral density, causing osteopenia, osteoporosis, increase the risk of fractures, osteonecrosis, and oral changes. Not much has been written on the influence of drugs on the skeleton from the forensic anthropological practitioner perspective; and this review, in spite of its limitations and the requirement of further research, aims to investigate the current knowledge of the possible effects of both prescription and recreational drugs on bones, contributing to providing a better awareness in forensic anthropological practice and assisting in the identification process of the deceased.

Reduction of Opioid Consumption After Outpatient Orthopaedic Trauma Surgeries Using a Multimodal Pain Protocol

INTRODUCTION

Because of the dearth of literature in the orthopaedic trauma population, we aimed to analyze how a multimodal pain protocol after outpatient surgery affects opioid consumption, pain scores, and patient satisfaction.

METHODS

This was a cohort study with a historical control at an urban level 1 trauma center. Forty consecutive outpatients were given a peripheral nerve block and a multimodal pain protocol between September 2019 and March 2020 and compared with 70 consecutive preprotocol patients who received a peripheral nerve block and hydrocodone-acetaminophen. The primary outcome was morphine milligram equivalents (MMEs) consumed. Our secondary aims were pain scores and satisfaction.

RESULTS

Patients in the protocol were younger (36.45 versus 45.09 years, P = 0.007), butthere was no difference in sex, body mass index, American Society of Anesthesiologists, or surgical duration. There was a 59% reduction in opioids consumed in the first 4 days after surgery (3.83 MME versus 9.29 MME, P < 0.001). At the postoperative day-14 time point, protocol patients consumed a total of 5.59 MMEs, which is 40% less than just the first 4 days of the preprotocol (P = 0.02). Protocol patients assigned a higher rating of "least pain" on postoperative day 1 (1.24 versus 0.52, P = 0.04) but had higher satisfaction scores on day 1 (9.68 versus 8.54, P < 0.001) and day 2 (9.66 versus 8.61, P < 0.001).

CONCLUSION

Implementation of a multimodal pain management protocol after outpatient orthopaedic trauma surgeries reduced opioid consumption by >50% in the first 4 days postoperatively. Additional studies are needed to refine the multimodal pain protocol used in this study.

LEVEL OF EVIDENCE

II.

Enhanced Recovery After Surgery: Standardized Postoperative Instructions in Hand Surgery

Background: Enhanced Recovery After Surgery (ERAS) is a standardized approach to care of the surgical patient. Postoperative patient instructions, an aspect of ERAS protocols, are difficult to standardize in hand surgery because of the diversity of procedures. The aim of this study was to determine the effect of standardized hand surgery postoperative instructions on the number of unscheduled postoperative patient encounters. Methods: The study was an institutional review board-approved prospective cohort in which all hand surgery patients from 6 surgeons at a single, hospital-based academic institution were included. For a 6-month period, both before and after establishing a standardized postoperative instructional handout, data were collected on unscheduled postoperative encounters within 14 days of surgery. Results: There were 330 patients in the control group versus 282 who received standardized postoperative instructions. Trauma comprised 24.6% of cases in comparison to 75.4% elective. Individual surgeons did not significantly influence whether patients had an encounter. Overall, patients who received standardized instructions were just as likely as the control group to have unscheduled encounters (41.5% vs 43.9%, respectively). Notably, elective patients were significantly more likely to have encounters (46%) versus trauma patients (33.1%; P = .007); however, the standardized instructions did not influence the number of encounters for either group. Conclusions: This study did not demonstrate a difference in unscheduled postoperative encounters after initiation of standardized postoperative instructions for hand surgery patients. These findings may help providers save time and resources by tailoring the use of ERAS in this distinct patient population.

Curcumin attenuates prostatic hyperplasia caused by inflammation via up-regulation of bone morphogenetic protein and activin membrane-bound inhibitor

CONTEXT

Inflammation and epithelial-mesenchymal transition (EMT) play important roles in the occurrence and development of benign prostatic hyperplasia (BPH); curcumin exerts anti-proliferative, anti-inflammatory, and anti-EMT effects.

OBJECTIVE

To explore the anti-inflammatory and anti-EMT mechanisms of curcumin in BPH.

MATERIALS AND METHODS

Ten-week-old male C57BL/6 mice were administered lipopolysaccharide (LPS, 100 µg/kg) in the prostate lobules to establish an inflammatory BPH model (LPS group), and curcumin (120 mg/kg) was administered into the abdominal cavity for 2 weeks (three times a week, curcumin-treated group). A group of healthy mice served as the control group. The expression of Toll-like receptor 4 (TLR4), bone morphogenetic protein and activin membrane-bound inhibitor (BAMBI), EMT markers, inflammatory cytokines, and transforming growth factor β1 (TGF-β1) was detected by PCR and western blotting. TGF-β1 (0.1 ng/mL) and LPS (100 ng/mL) were used to induce EMT in benign prostatic hyperplasia epithelial cells (BPH-1).

RESULTS

In vivo, curcumin reduced the size of the prostate, suppressed the expression of vimentin and TLR4, and increased the expression of E-cadherin and BAMBI in the LPS-induced BPH mouse model. Moreover, curcumin decreased the levels of IL-6 and TNF-α by 44.52 and 46.17%, respectively. In vitro, curcumin attenuated cell proliferation, suppressed the expression of vimentin and TLR4, and increased the expression of E-cadherin and BAMBI in BPH-1 cells. Furthermore, BAMBI knockdown reversed the expression of vimentin and E-cadherin induced by curcumin.

DISCUSSION AND CONCLUSION

This study demonstrated that curcumin alleviated hyperplasia, EMT, and inflammation in vivo. Furthermore, curcumin suppressed EMT by targeting BAMBI via the TLR4/BAMBI/TGF-β1 signalling pathway in vitro, demonstrating its potential utility in BPH treatment.

Combination therapy with curcumin plus tamsulosin and finasteride in the treatment of men with benign prostatic hyperplasia: a single center, randomized control study

Background

To perform a prospective, randomized, single center study to investigate the efficacy of combined use of curcumin, an anti-inflammatory agent, with the best standard management (BSM, tamsulosin and finasteride) in benign prostatic hyperplasia (BPH) patients.

Methods

One hundred and twenty-two consecutive patients were randomized to receive tamsulosin 0.2 mg, finasteride 5 mg, and curcumin 2,250 mg once a day (curcumin + BSM group, n=61) versus tamsulosin 0.2 mg, finasteride 5 mg, and placebo (BSM group, n=61) for 6 months. The safety of treatments and their efficacy on improving waist circumference (WC), periprostatic fat thickness (PPFT), lower urinary tract symptoms (LUTS), and sexual function were assessed at baseline and month 6.

Results

One hundred and sixteen patients completed the whole procedure (116/122, 95.1%). There were significant improvements in prostate volume (PV), maximum flow rate (Qmax), the International Prostate Symptom Score (IPSS), IPSS-voiding subscore (IPSS-V), IPSS-storage subscore (IPSS-S), and quality of life (QoL) from baseline after treatment in both groups. Additionally, both WC and PPFT decreased significantly after treatments than those at baseline in the curcumin + BSM group. Also, WC and PPFT in the curcumin + BSM group were significantly lower than those in the BSM group. In addition, IPSS-S, QoL score, and the 5-item version of the International Index of Erectile Function (IIEF-5) in the curcumin + BSM group improved significantly compared with those in the BSM group.

Conclusions

We conclude that curcumin combined with tamsulosin and finasteride has more beneficial effects in reducing PPFT, protecting erectile function, improving urinary retention symptoms, and QoL scores in BPH patients compared to tamsulosin and finasteride alone.

Trial Registration

Chinese Clinical Trial Registry ChiCTR2100043800.

Role of prostaglandin E2 in tissue repair and regeneration

Tissue regeneration following injury from disease or medical treatment still represents a challenge in regeneration medicine. Prostaglandin E2 (PGE2), which involves diverse physiological processes via E-type prostanoid (EP) receptor family, favors the regeneration of various organ systems following injury for its capabilities such as activation of endogenous stem cells, immune regulation, and angiogenesis. Understanding how PGE2 modulates tissue regeneration and then exploring how to elevate the regenerative efficiency of PGE2 will provide key insights into the tissue repair and regeneration processes by PGE2. In this review, we summarized the application of PGE2 to guide the regeneration of different tissues, including skin, heart, liver, kidney, intestine, bone, skeletal muscle, and hematopoietic stem cell regeneration. Moreover, we introduced PGE2-based therapeutic strategies to accelerate the recovery of impaired tissue or organs, including 15-hydroxyprostaglandin dehydrogenase (15-PGDH) inhibitors boosting endogenous PGE2 levels and biomaterial scaffolds to control PGE2 release.

Resolution of inflammation in bone regeneration: From understandings to therapeutic applications

Impaired bone healing occurs in 5-10% of cases following injury, leading to a significant economic and clinical impact. While an inflammatory response upon injury is necessary to facilitate healing, its resolution is critical for bone tissue repair as elevated acute or chronic inflammation is associated with impaired healing in patients and animal models. This process is governed by important crosstalk between immune cells through mediators that contribute to resolution of inflammation in the local healing environment. Approaches modulating the initial inflammatory phase followed by its resolution leads to a pro-regenerative environment for bone regeneration. In this review, we discuss the role of inflammation in bone repair, the negative impact of dysregulated inflammation on bone tissue regeneration, and how timely resolution of inflammation is necessary to achieve normal healing. We will discuss applications of biomaterials to treat large bone defects with a specific focus on resolution of inflammation to modulate the immune environment following bone injury, and their observed functional benefits. We conclude the review by discussing future strategies that could lead to the realization of anti-inflammatory therapeutics for bone tissue repair.

An Innovative Pain Control Method Using Peripheral Nerve Block and Patient-Controlled Analgesia With Ketorolac After Bone Surgery in the Ankle Area: A Prospective Study

Although postoperative pain is inevitable after bone surgery, there is no general consensus regarding its ideal management. We hypothesized that the combination of ultrasound-guided peripheral nerve block (PNB) and patient-controlled analgesia (PCA) with ketorolac would be useful for pain control and reducing opioid usage. This prospective study aimed to evaluate the effectiveness of this method. This study included 95 patients aged >18 years who underwent bone surgery in the ankle area from June to December 2018. All operations were performed under anesthetic PNB, and additional PNB was given for pain control ∼11 hours after preoperative PNB. An additional PCA with ketorolac, started before rebound pain was experienced, was used for pain control in group A (49 patients) but not group B (46 patients). We used intramuscular injection with pethidine or ketorolac as rescue analgesics if pain persisted. A visual analogue scale (VAS) for pain was used to quantify pain at 6, 12, 18, 24, 36, 48, and 72 hours postoperatively. Patient satisfaction was assessed, along with side effects in both groups. VAS pain scores differed significantly between the groups at 24 hours after the operation (p = .013). All patients in group A were satisfied with the pain control method; however, 5 patients in group B were dissatisfied (p = .001), 3 owing to severe postoperative pain and 2 owing to postoperative nausea and vomiting. An average of 0.75 and 11.40 mg pethidine per patient was used in groups A and B, respectively, for 3 days. We concluded that the combined use of ultrasound-guided PNB and PCA with ketorolac can be an effective postoperative method of pain control that can reduce opioid usage.

Effects of NSAIDs on pre-osteoblast viability and osteogenic differentiation

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used in the treatment of a variety of musculoskeletal conditions, injuries and after surgery for postoperative pain management. Their use has been associated with impaired bone healing, possibly due to a multifactorial function, which may include inhibition of osteoblast recruitment and differentiation. However, up to date, there is no consensus regarding the impact of NSAIDs on bone-healing. The aim of the current study was to investigate the effects of five NSAIDs on the cellular functions of mouse MC3T3-E1 pre-osteoblasts. Cells were treated with the non-selective COX inhibitors lornoxicam and diclofenac, the COX-2 selective inhibitors parecoxib, meloxicam and paracetamol, as well as steroidal prednisolone at different doses and exposure times. The PrestoBlue™ technique was used to measure cell viability, an enzymatic assay was employed for alkaline phosphatase (ALP) activity and alizarin red S mineral staining was used to determine osteogenic differentiation. All drugs had a negative impact on pre-osteoblast cell growth, with the exception of paracetamol. Lornoxicam, diclofenac and meloxicam reduced ALP activity, while the other NSAIDs had no effect and prednisolone strongly increased ALP activity. In contrast, calcium deposits were either unaffected or increased by NSAID treatments but were significantly decreased by prednisolone. These results provide evidence that NSAIDs may adversely affect the viability of mouse pre-osteoblast cells but their actions on the osteogenic differentiation are drug-specific. The direct comparison of the effects of different NSAIDs and prednisolone on pre-osteoblasts may serve to place some NSAIDs in a preferential position for analgesic and anti-inflammatory therapy during bone repair.

Ibuprofen-based advanced therapeutics: breaking the inflammatory link in cancer, neurodegeneration, and diseases

Ibuprofen is a classical nonsteroidal anti-inflammatory drug (NSAID) highly prescribed to reduce acute pain and inflammation under an array of conditions, including rheumatoid arthritis, osteoarthritis, dysmenorrhea, and gout. Ibuprofen acts as a potential inhibitor for cyclooxygenase enzymes (COX-1 and COX-2). In the past few decades, research on this small molecule has led to identifying other possible therapeutic benefits. Anti-tumorigenic and neuroprotective functions of Ibuprofen are majorly recognized in recent literature and need further consideration. Additionally, several other roles of this anti-inflammatory molecule have been discovered and subjected to experimental assessment in various diseases. However, the major challenge faced by Ibuprofen and other drugs of similar classes is their side effects, and tendency to cause gastrointestinal injury, generate cardiovascular risks, modulate hepatic and acute kidney diseases. Future research should also be conducted to deduce new methods and approaches of suppressing the unwanted toxic changes mediated by these drugs and develop new therapeutic avenues so that these small molecules continue to serve the purposes. This article primarily aims to develop a comprehensive and better understanding of Ibuprofen, its pharmacological features, therapeutic benefits, and possible but less understood medicinal properties apart from major challenges in its future application.KEY POINTSIbuprofen, an NSAID, is a classical anti-inflammatory therapeutic agent.Pro-apoptotic roles of NSAIDs have been explored in detail in the past, holding the key in anti-cancer therapies.Excessive and continuous use of NSAIDs may have several side effects and multiple organ damage.Hyperactivated Inflammation initiates multifold detrimental changes in multiple pathological conditions.Targeting inflammatory pathways hold the key to several therapeutic strategies against many diseases, including cancer, microbial infections, multiple sclerosis, and many other brain diseases.

Emerging evidence that adaptive bone formation inhibition by non-steroidal anti-inflammatory drugs increases stress fracture risk

There is mounting evidence suggesting that the commonly used analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), may inhibit new bone formation with physical training and increase risk of stress fractures in physically active populations. Stress fractures are thought to occur when bones are subjected to repetitive mechanical loading, which can lead to a cycle of tissue microdamage, repair, and continued mechanical loading until fracture. Adaptive bone formation, particularly on the periosteal surface of long bones, is a concurrent adaptive response of bone to heightened mechanical loading that can improve the fatigue resistance of the skeletal structure, and therefore may play a critical role in offsetting the risk of stress fracture. Reports from animal studies suggest that NSAID administration may suppress this important adaptive response to mechanical loading. These observations have implications for populations such as endurance athletes and military recruits who are at risk of stress fracture and whose use of NSAIDs is widespread. However, results from human trials evaluating exercise and bone adaptation with NSAID consumption have been less conclusive. In this review, we identify knowledge gaps that must be addressed to further support NSAID-related guidelines intended for at-risk populations and individuals.

Different Chemical Structures and Physiological/Pathological Roles of Cyclooxygenases

This review describes cyclooxygenase (COX), which synthesizes prostanoids that play an important role in living things. The authors conducted a national and international literature review on the subject. The COX enzyme uses arachidonic acid to form prostanoids, which play a role in several physiological and pathological conditions. This enzyme has different isoforms, mainly COX-1 and COX-2. The constitutive isoform is COX-1, while COX-2 is the inducible isoform. Both are expressed in different tissues and at different levels, but they may also coexist within the same tissue. Both isoforms show essentially the same mode of action, but their substrates and inhibitors may differ. The COX-1 isoform, which plays a role in the continuation of physiological events, has an increased expression level in various carcinomas, and the COX-2 isoform, which is increased in inflammatory conditions, is typically expressed at low physiological levels in some tissues such as the brain, kidney, and uterus. In addition to investigating the efficacies of the COX-1 and COX-2 isoforms, the discovery of potential new COX enzymes and their effect continues. This review also looks at the roles of the COX enzyme in certain physiological and pathological conditions.

Comparison of diclofenac with apigenin-glycosides rich Clinacanthus nutans extract for amending inflammation and catabolic protease regulations in osteoporotic-osteoarthritis rat model

BACKGROUND

Osteoporotic-osteoarthritis is an incapacitating musculoskeletal illness of the aged.

OBJECTIVES

The anti-inflammatory and anti-catabolic actions of Diclofenac were compared with apigenin-C-glycosides rich Clinacanthus nutans (CN) leaf extract in osteoporotic-osteoarthritis rats.

METHODS

Female Sprague Dawley rats were randomized into five groups (n = 6). Four groups were bilateral ovariectomised for osteoporosis development, and osteoarthritis were induced by intra-articular injection of monosodium iodoacetate (MIA) into the right knee joints. The Sham group was sham-operated, received saline injection and deionized drinking water. The treatment groups were orally given 200 or 400 mg extract/kg body weight or 5 mg diclofenac /kg body weight daily for 28 days. Articular cartilage and bone changes were monitored by gross and histological structures, micro-CT analysis, serum protein biomarkers, and mRNA expressions for inflammation and catabolic protease genes.

RESULTS

HPLC analysis confirmed that apigenin-C-glycosides (shaftoside, vitexin, and isovitexin) were the major compounds in the extract. The extract significantly and dose-dependently reduced cartilage erosion, bone loss, cartilage catabolic changes, serum osteoporotic-osteoarthritis biomarkers (procollagen-type-II-N-terminal-propeptide PIINP; procollagen-type-I-N-terminal-propeptide PINP; osteocalcin), inflammation (IL-1β) and mRNA expressions for nuclear-factor-kappa-beta NF-κβ, interleukin-1-beta IL-1β, cyclooxygenase-2; and matrix-metalloproteinase-13 MMP13 activities, in osteoporotic-osteoarthritis rats comparable to Diclofenac.

CONCLUSION

This study demonstrates that apigenin-C-glycosides at 400 mg CN extract/kg (about 0.2 mg apigenin-equivalent/kg) is comparable to diclofenac in suppressing inflammation and catabolic proteases for osteoporotic-osteoarthritis prevention. Graphical abstract.

Assessment, Quantification, and Management of Fracture Pain: from Animals to the Clinic

PURPOSE OF REVIEW

Fractures are painful and disabling injuries that can occur due to trauma, especially when compounded with pathologic conditions, such as osteoporosis in older adults. It is well documented that acute pain management plays an integral role in the treatment of orthopedic patients. There is no current therapy available to completely control post-fracture pain that does not interfere with bone healing or have major adverse effects. In this review, we focus on recent advances in the understanding of pain behaviors post-fracture.

RECENT FINDINGS

We review animal models of bone fracture and the assays that have been developed to assess and quantify spontaneous and evoked pain behaviors, including the two most commonly used assays: dynamic weight bearing and von Frey testing to assess withdrawal from a cutaneous (hindpaw) stimulus. Additionally, we discuss the assessment and quantification of fracture pain in the clinical setting, including the use of numeric pain rating scales, satisfaction with pain relief, and other biopsychosocial factor measurements. We review how pain behaviors in animal models and clinical cases can change with the use of current pain management therapies. We conclude by discussing the use of pain behavioral analyses in assessing potential therapeutic treatment options for addressing acute and chronic fracture pain without compromising fracture healing. There currently is a lack of effective treatment options for fracture pain that reliably relieve pain without potentially interfering with bone healing. Continued development and verification of reliable measurements of fracture pain in both pre-clinical and clinical settings is an essential aspect of continued research into novel analgesic treatments for fracture pain.

Overview of multimodal analgesia initiated in the perioperative setting

Despite progress in pain management in the perioperative setting, the literature is full of evidence that managing postoperative pain is suboptimal. Since the mechanism of pain is complex, the use of multimodal technique allows clinicians to use a combination of two or more drugs targeting different areas of pain transmission because of surgery. As part of enhanced recovery initiatives after surgery, healthcare and professional organisations incorporate the use of multimodal analgesia in surgical guidelines to improve patient satisfaction. This review aims to understand and summarise the current body of evidence involving the most common pharmacological therapies to manage postoperative pain in the preoperative setting.

The use of xenografts to prevent inferior border defects following bilateral sagittal split osteotomies: three-dimensional skeletal analysis using cone beam computed tomography

The aim of this retrospective study was to investigate grafting in the osteotomy gap during bilateral sagittal split osteotomy (BSSO), using a xenograft and fibrin glue. Hard tissue defects in the inferior mandibular border were assessed using cone beam computed tomography scans taken 1 week and 1year postoperatively. The study group of 20 patients underwent bone grafting during BSSO (mean age 26.1years; mean horizontal displacement 8.5mm) and the control group of 20 patients did not (mean age 30.2 years; mean horizontal displacement 7.6mm). The mean height of the mandibular defects was significantly lower in the study group, but there was no significant difference in volume measurements between the groups. Grafting had a negligible effect on large displacements (9.0-15.0mm), which might have been due to an inadequate amount and/or positioning of the graft, or to poor dimensional stability. This may be resolved by improved graft positioning or by using a different kind of (xeno)graft.

Prostaglandins and Bone

Prostaglandins (PGs) are highly bioactive fatty acids. PGs, especially prostaglandin E₂ (PGE₂), are abundantly produced by cells of both the bone-forming (osteoblast) lineage and the bone-resorbing (osteoclast) lineage. The inducible cyclooxygenase, COX-2, is largely responsible for most PGE₂ production in bone, and once released, PGE₂ is rapidly degraded in vivo. COX-2 is induced by multiple agonists - hormones, growth factors, and proinflammatory factors - and the resulting PGE₂ may mediate, amplify, or, as we have recently shown for parathyroid hormone (PTH), inhibit responses to these agonists. In vitro, PGE₂ can directly stimulate osteoblast differentiation and, indirectly via stimulation of RANKL in osteoblastic cells, stimulate the differentiation of osteoclasts. The net balance of these two effects of PGE₂ in vivo on bone formation and bone resorption has been hard to predict and, as expected for such a widespread local factor, hard to study. Some of the complexity of PGE₂ actions on bone can be explained by the fact that there are four receptors for PGE₂ (EP1-4). Some of the major actions of PGE₂ in vitro occur via EP2 and EP4, both of which can stimulate cAMP signaling, but there are other distinct signaling pathways, important in other tissues, which have not yet been fully elucidated in bone cells. Giving PGE₂ or agonists of EP2 and EP4 to accelerate bone repair has been examined with positive results. Further studies to clarify the pathways of PGE₂ action in bone may allow us to identify new and more effective ways to deliver the therapeutic benefits of PGE₂ in skeletal disorders.

Short-term perioperative parecoxib is not detrimental to shaft fracture healing in a rat model

Objectives

Experimental studies indicate that non-steroidal anti-inflammatory drugs (NSAIDs) may have negative effects on fracture healing. This study aimed to assess the effect of immediate and delayed short-term administration of clinically relevant parecoxib doses and timing on fracture healing using an established animal fracture model.

Methods

A standardized closed tibia shaft fracture was induced and stabilized by reamed intramedullary nailing in 66 Wistar rats. A ‘parecoxib immediate’ (Pi) group received parecoxib (3.2 mg/kg bodyweight twice per day) on days 0, 1, and 2. A ‘parecoxib delayed’ (Pd) group received the same dose of parecoxib on days 3, 4, and 5. A control group received saline only. Fracture healing was evaluated by biomechanical tests, histomorphometry, and dual-energy x-ray absorptiometry (DXA) at four weeks.

Results

For ultimate bending moment, the median ratio between fractured and non-fractured tibia was 0.61 (interquartile range (IQR) 0.45 to 0.82) in the Pi group, 0.44 (IQR 0.42 to 0.52) in the Pd group, and 0.50 (IQR 0.41 to 0.75) in the control group (n = 44; p = 0.068). There were no differences between the groups for stiffness, energy, deflection, callus diameter, DXA measurements (n = 64), histomorphometrically osteoid/bone ratio, or callus area (n = 20).

Conclusion

This study demonstrates no negative effect of immediate or delayed short-term administration of parecoxib on diaphyseal fracture healing in rats.

Cite this article: G. A. Hjorthaug, E. Søreide, L. Nordsletten, J. E. Madsen, F. P. Reinholt, S. Niratisairak, S. Dimmen. Short-term perioperative parecoxib is not detrimental to shaft fracture healing in a rat model. Bone Joint Res 2019;8:472–480. DOI: 10.1302/2046-3758.810.BJR-2018-0341.R1.

Differential fracture response to traumatic brain injury suggests dominance of neuroinflammatory response in polytrauma

Polytraumatic injuries, specifically long bone fracture and traumatic brain injury (TBI), frequently occur together. Clinical observation has long held that TBI can accelerate fracture healing, yet the complexity and heterogeneity of these injuries has produced conflicting data with limited information on underlying mechanisms. We developed a murine polytrauma model with TBI and fracture to evaluate healing in a controlled system. Fractures were created both contralateral and ipsilateral to the TBI to test whether differential responses of humoral and/or neuronal systems drove altered healing patterns. Our results show increased bone formation after TBI when injuries occur contralateral to each other, rather than ipsilateral, suggesting a role of the nervous system based on the crossed neuroanatomy of motor and sensory systems. Analysis of the humoral system shows that blood cell counts and inflammatory markers are differentially modulated by polytrauma. A data-driven multivariate analysis integrating all outcome measures showed a distinct pathological state of polytrauma and co-variations between fracture, TBI and systemic markers. Taken together, our results suggest that a contralateral bone fracture and TBI alter the local neuroinflammatory state to accelerate early fracture healing. We believe applying a similar data-driven approach to clinical polytrauma may help to better understand the complicated pathophysiological mechanisms of healing.

Enhanced migration and adhesion of peripheral blood neutrophils from SAPHO patients revealed by RNA-Seq

Background

SAPHO syndrome is a rare disease characterized by inflammatory lesions on skin and bones. Diversified manifestation and inadequate understanding of etiology has limited its diagnosis and treatment. The co-occurrence of other immune-mediated diseases strongly suggests an involvement of autoimmunity in SAPHO syndrome. However, the role of the largest population of circulating immune cells, neutrophils, is still not well explored. In this study, we performed RNA sequencing to profile the mRNA expression of neutrophils purified from peripheral blood of SAPHO patients to identify key genes associated with SAPHO syndrome, trying to find new functional molecules or biomarkers for this rare disease.

Results

A total of 442 differentially expressed genes were identified (p < 0.05, fold change > 2), in which 294 genes were upregulated and 148 genes were downregulated. Five differentially expressed genes of interest were verified by quantitative Real-Time Polymerase Chain Reaction (qRT-PCR), among which S100A12 was upregulated and positively related to high-sensitivity C-reactive protein (hsCRP), while the downregulated gene MYADM was positively related to osteocalcin. Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis showed that differentially expressed genes were enriched in “systemic lupus erythematosus” and “ECM-receptor interaction”. Gene ontology (GO) enrichment showed that differentially expressed genes may participate in biological processes such as “cell migration” and “cell adhesion”.

Conclusions

In conclusion, this study provides a first insight into transcriptome characteristics of SAPHO syndrome, indicating an over-active neutrophil recruitment in patients and possibly suggesting molecular candidates for further study on diagnosis and pathology of this disease.

Electronic supplementary material

The online version of this article (10.1186/s13023-019-1169-3) contains supplementary material, which is available to authorized users.

Exosomes in the Repair of Bone Defects: Next-Generation Therapeutic Tools for the Treatment of Nonunion

Nonunion with bone defects, a common complication after long bone fracture, is a major challenge for orthopaedic surgeons worldwide because of the high incidence rate and difficulties in achieving successful treatment. Bone defects are the main complications of nonunion. The conventional biological treatments for nonunion with bone defects involve the use of autologous bone grafts or bone graft substitutes and cell-based therapy. Traditional nonunion treatments have always been associated with safety issues and various other complications. Bone grafts have limited autologous cancellous bone and there is a risk of infection. Additionally, problems with bone graft substitutes, including rejection and stimulation of bone formation, have been noted, and the health of the stem cell niche is a major consideration in cell-based therapy. In recent years, researchers have found that exosomes can be used to deliver functional RNA and mediate cell-to-cell communication, suggesting that exosomes may repair bone defects by regulating cells and cytokines involved in bone metabolism. In this review, we highlight the possible relationships between risk factors for nonunion and exosomes. Additionally, we discuss the roles of exosomes in bone metabolism and bone regeneration.

Naproxen impairs load-induced bone formation, reduces bone toughness, and diminishes woven bone formation following stress fracture in mice

Debilitating stress fractures are surprisingly common in physically active individuals, including athletes, military recruits, and dancers. These individuals are overrepresented in the 30 million daily users of non-steroidal anti-inflammatory drugs (NSAIDs). We hypothesized that regular use of NSAIDs would predispose habitually loaded bones to stress fracture and delay the repair of these injuries. In this project, we used repetitive axial forelimb compression in mice as a model to test these hypotheses. First, adult mice were subjected to six bouts of forelimb compression over a period of two weeks, with aspirin, naproxen, or vehicle continuously administered through drinking water. Naproxen-treated mice had diminished load-induced bone formation as well as a significant loss in toughness in non-loaded bone, which were not observed in aspirin-treated mice. Furthermore, there were no differences in RANKL/OPG ratio or cortical bone parameters. Picrosirius red staining and second harmonic generation imaging revealed that alterations in bone collagen fibril size and organization were driving the loss of toughness in naproxen-treated mice. Separately, adult mice were subjected to an ulnar stress fracture generated by a single bout of fatigue loading, with NSAIDs provided 24 h before injury. Both aspirin-treated and naproxen-treated mice had normal forelimb use in the week after injury, whereas control mice favored the injured forelimb until day 7. However, woven bone volume was only significantly impaired by naproxen. Both NSAIDs were found to significantly inhibit Ptgs2 and Ngf expression following stress fracture, but only naproxen significantly affected serum PGE2 concentration. Overall, our results suggest that naproxen, but not aspirin, may increase the risk of stress fracture and extend the healing time of these injuries, warranting further clinical evaluation for patients at risk for fatigue injuries.

Medial iliac stress fractures in athletes: report of two rare cases: review of literature and clinical recommendations

Stress fractures are a common diagnosis in sports medicine and can result in significant loss of function, athlete playing time, and potentially lead to chronic symptoms. However, unusual locations of stress fractures may present with vague symptoms and a relatively benign physical exam, leading to difficulty in arriving at the correct diagnosis. Pelvic stress fractures are less common than lower-extremity stress fractures in athletes, occurring in only 1-5% of all stress fractures and typically occur in pubic rami. Furthermore, iliac bone stress fractures are even rarer, with only a few case reports in the literature. Their presentation can easily be missed on routine workup and imaging. We present two cases of the very rare superomedial iliac bone stress fracture in athletes, an unusual location for this uncommon stress fracture. We review the available literature on this condition and provide clinical commentary on workup and treatment recommendations.

Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury

PURPOSE

We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury.

METHODS

A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation. The guideline was submitted to the Orthopaedic Trauma Association (OTA) for review and was approved on October 16, 2018.

RESULTS

We present evidence-based best practice recommendations and pain medication recommendations with the hope that they can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. Recommendations are presented regarding pain management, cognitive strategies, physical strategies, strategies for patients on long term opioids at presentation, and system implementation strategies. We recommend the use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia. We also recommend connecting patients to psychosocial interventions as indicated and considering anxiety reduction strategies such as aromatherapy. Finally, we also recommend physical strategies including ice, elevation, and transcutaneous electrical stimulation. Prescribing for patients on long term opioids at presentation should be limited to one prescriber. Both pain and sedation should be assessed regularly for inpatients with short, validated tools. Finally, the group supports querying the relevant regional and state prescription drug monitoring program, development of clinical decision support, opioid education efforts for prescribers and patients, and implementing a department or organization pain medication prescribing strategy or policy.

CONCLUSIONS

Balancing comfort and patient safety following acute musculoskeletal injury is possible when utilizing a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this guideline, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.

Effects of NSAIDs and environmental oxygen pressure on bone regeneration

Objective: To evaluate the effects of administering diclofenac and ketoprofen, as well as the effects of environmental oxygen pressure variation on mandibular bone regeneration. Methods: Thirty-six guinea pigs were distributed into two equal groups. Mandibular bone defects were performed on both groups. Group A was monitored under oxygen pressure at altitude (3320msl, 107mm Hg). Group B was monitored at sea level oxygen pressure (150msl, 157mm Hg). Each group was subdivided into 3 equal groups (A1, A2, A3 and B1, B2, B3). Subgroups A1 and B1 were given diclofenac; subgroups A2 and B2 ketoprofen; subgroups A3 and B3 NaCl. Bone regeneration was evaluated histologically on days 15 and 30. Results: After 15 days in the group controlled at sea level, the level of osteoblasts presented by the control subgroup was significantly higher (28.00±2.65) compared to the diclofenac subgroup (16.00±6.25) and to the ketoprofen subgroup (18.00±4.36); (p=0.041). After 15 days in the group controlled at altitude, the level of osteoblasts was significantly higher in the control subgroup (38.00±5.29) compared to the diclofenac subgroup (21.67±6.35) and to the ketoprofen subgroup (19.33±2.52); p=0.007. After 30 days in the group at sea level there was no difference found in the cell counting; p>0.05. After 30 days in the group controlled at altitude, the level of osteoblast was significantly higher in the control subgroup (58.00±4.58) compared to the diclofenac subgroup (34.33±4.73) and the ketoprofen subgroup (34.00±11.14); (p=0.003). Conclusion: The administration of diclofenac and ketoprofen produced lower mandibular bone regeneration, the effect being significantly more negative at sea level.

Effects of Perioperative Nonsteroidal Anti-inflammatory Drug Administration on Soft Tissue Healing: A Systematic Review of Clinical Outcomes After Sports Medicine Orthopaedic Surgery Procedures

Background:

The effects of perioperative nonsteroidal anti-inflammatory drugs (NSAIDs) on soft tissue healing in humans have yet to be established.

Purpose:

To systematically review the literature addressing the effects of perioperative NSAID administration on soft tissue healing and clinical patient outcomes.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

This review study was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. A review of the literature regarding the existing evidence for clinical effects of NSAID use on soft tissue healing was performed through use of the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980 to present), and MEDLINE. Inclusion criteria for articles were as follows: outcome studies after soft tissue (ligament, meniscus, tendon, muscle) healing after surgical procedure with perioperative NSAID administration, at least 1 year of follow-up, English language, and human participants.

Results:

A total of 466 studies were initially retrieved, with 4 studies satisfying all inclusion criteria. Among the surgical procedures reported, 93% of the patients (4144/4451) underwent anterior cruciate ligament (ACL) reconstruction, 3% (120/4451) underwent rotator cuff repair, 3% (155/4451) underwent Bankart shoulder repair, and 1% (32/4451) underwent meniscal repair. The reported surgical failure rate among patients administered NSAIDs was 3.6% (157/4360). The reported surgical failure rate among control participants not given NSAIDs was 3.7% (147/3996). NSAID use showed no statistically significant effect on need for reoperation in meniscal repair (P = .99), ACL reconstruction (P = .8), and Bankart repair (P = .8) compared with no NSAID administration. Celecoxib administration had a significantly higher rate of retear (37%) after rotator cuff repair compared with ibuprofen (7%) (P = .009).

Conclusion:

Insufficient data are available to definitively state the effects of perioperative NSAIDs on soft tissue healing. Use of NSAIDs should be considered on a case-by-case basis and may not affect healing rates following either meniscal, ACL, rotator cuff, or Bankart repair. However, celecoxib (a selective COX-2 inhibitor) may inhibit tendon-to-bone healing in rotator cuff repair. Further research through clinical trials is required to fully determine whether NSAIDs have an adverse effect on soft tissue healing.

Self-Complementary Adeno-Associated Virus-Mediated Interleukin-1 Receptor Antagonist Gene Delivery for the Treatment of Osteoarthritis: Test of Efficacy in an Equine Model

The authors are investigating self-complementary adeno-associated virus (scAAV) as a vector for intra-articular gene-delivery of interleukin-1 receptor antagonist (IL-1Ra), and its therapeutic capacity in the treatment of osteoarthritis (OA). To model gene transfer on a scale proportional to the human knee, a frequent site of OA incidence, studies were focused on the joints of the equine forelimb. Using AAV2.5 capsid and equine IL-1Ra as a homologous transgene, a functional ceiling dose of ∼5 × 10¹² viral genomes was previously identified, which elevated the steady state levels of eqIL-1Ra in synovial fluids by >40-fold over endogenous production for at least 6 months. Here, using an osteochondral fragmentation model of early OA, the functional capacity of scAAV.IL-1Ra gene-delivery was examined in equine joints over a period of 12 weeks. In the disease model, transgenic eqIL-1Ra expression was several fold higher than seen previously in healthy joints, and correlated directly with the severity of joint pathology at the time of treatment. Despite wide variation in expression, the steady-state eqIL-1Ra in synovial fluids exceeded that of IL-1 by >400-fold in all animals, and a consistent treatment effect was observed. This included a 30-40% reduction in lameness and ∼25% improvement in total joint pathology by both magnetic resonance imaging and arthroscopic assessments, which included reduced joint effusion and synovitis, and improved repair of the osteochondral lesion. No vector-related increase in eqIL-1Ra levels in blood or urine was noted. Cumulatively, these studies in the equine model indicate scAAV.IL-1Ra administration is reasonably safe and capable of sustained therapeutic IL-1Ra production intra-articularly in joints of human scale. This profile supports consideration for human testing in OA.

Tibia fractures and NSAIDs. Does it make a difference? A multicenter retrospective study

PURPOSE

The purpose of this study was to compare healing time for diaphyseal tibia fractures (OTA/AO 42 A, B, C) treated with intramedullary nailing (IMN) in one geographic cohort using nonsteroidal anti-inflammatory drugs (NSAIDs) for post-operative pain control to that of another geographic cohort using opioid medications. The groups represent differing cultural approaches to post-operative pain control. We hypothesized there would be no difference in healing time.

METHODS

Tibia fractures presenting at two level I trauma centers located in different countries between January 1, 2010 and December 31, 2017 were retrospectively screened for enrollment. Fractures classified as OTA/AO 42 A, B, or C that were treated with IMN and had radiographic follow up to union were included. At hospital discharge, one cohort (n = 190) was prescribed NSAIDs and the other (n = 182) was prescribed opioids for pain control. Each analgesic method represented the standard of care for that location. Fracture union was defined as cortical bridging in at least 3 out of 4 cortices on AP and lateral radiographs. The primary outcome was healing time on radiographic evaluation.

RESULTS

There was no statistically significant difference in healing time between the opioid and NSAID groups: 185 vs 180.5 days respectively (p = 0.64). Both groups had similar mean age. Student t-tests were run to compare rates of tobacco use, diabetes mellitus (DM), open fractures, and polytrauma between the two groups. The opioid cohort had statistically significant higher rates of tobacco use, DM, and polytrauma. The NSAID cohort, however, had a larger number of open fractures.

CONCLUSION

The difference in healing time between the NSAID and opioid groups was not statistically significant. The deleterious effect of NSAID use on fracture healing has been debated for decades. Numerous animal studies have supported this theory; however, high quality clinical studies in humans have not provided convincing evidence to substantiate this negative effect. Our study suggests that NSAIDs may be used safely and effectively in the acute phase of fracture healing without significantly increasing the risk of delayed union or nonunion. Prospective randomized studies are necessary to rule out the negative effect of NSAIDS on bone healing.

The effect of non-steroidal anti-inflammatory drugs on the osteogenic activity in osseointegration: a systematic review

Non-steroidal anti-inflammatory drugs are commonly used in implant dentistry for management of post-operative pain. The objective of this systematic review was to analyse the effect of non-steroidal anti-inflammatory drugs on the osteogenic activity of osteoblasts with an emphasis on its effect on osseointegration. A systematic literature search for in vitro, animal models, and clinical trials was conducted using Ovid, PubMed, Scopus, and Web of Science databases. Articles published since the introduction of selective COX-2 inhibitors, between January 1999 and July 2018, were selected. The integrated search followed the PRISMA statement with the following key terms: non-steroidal anti-inflammatory drug/s, titanium, osseointegration, and osteoblast. The review is registered at PROSPERO database: CRD42016051448. The titles and abstracts of each research article in the initial search (n = 875) were independently screened by two reviewers. A third independent reviewer reviewed the articles that were included by one but excluded by the other reviewer. This resulted in the cataloguing of 79 full-text manuscripts where the articles were assessed for the following criteria: the study investigates the effects of NSAIDs on osteoblasts, explores the COX pathway and its effect on osteogenic activity, and compares the effects of NSAIDs on osteoblasts with a control group. A total of 13 articles have been included for qualitative synthesis. There is a lack of consensus in the literature to explicitly conclude that there is a relationship between the use of post-operative NSAIDs and failed osseointegration; however, osseointegration does not appear to be negatively affected by NSAIDs in the human clinical studies.

Ficus deltoidea Prevented Bone Loss in Preclinical Osteoporosis/Osteoarthritis Model by Suppressing Inflammation

Osteoporosis (OP) and osteoarthritis (OA) are debilitating musculoskeletal diseases of the elderly. Ficus deltoidea (FD) or mistletoe fig, a medicinal plant, was pre-clinically evaluated against OP- and OA-related bone alterations, in postmenopausal OA rat model. Thirty twelfth-week-old female rats were divided into groups (n = 6). Four groups were bilateral ovariectomized (OVX) and OA-induced by intra-articular monosodium iodoacetate (MIA) injection into the right knee joints. The Sham control and OVX-OA non-treated groups were given deionized water. The three other OVX-OA groups were orally administered daily with FD extract (200, 400 mg/kg) or diclofenac (5 mg/kg) for 4 weeks. The rats' bones and blood were evaluated for protein and mRNA expressions of osteoporosis and inflammatory indicators, and micro-CT computed tomography for bone microstructure. The non-treated OVX-OA rats developed severe OP bone loss and bone microstructural damage in the subchondral and metaphyseal regions, supported by reduced serum bone formation markers (osteocalcin, osteoprotegerin) and increased bone resorption markers (RANKL and CTX-I). The FD extract significantly (p < 0.05) mitigated these bone microstructural and biomarker changes by dose-dependently down-regulating pro-inflammatory NF-κβ, TNF-α, and IL-6 mRNA expressions. The FD extract demonstrated good anti-osteoporotic properties in this OP/OA preclinical model by stimulating bone formation and suppressing bone resorption via anti-inflammatory pathways. This is among the few reports relating the subchondral bone plate and trabecular thickening with the metaphyseal trabecular osteopenic bone loss under osteoporotic-osteoarthritis conditions, providing some insights on the debated inverse relationship between osteoporosis and osteoarthritis.

Association of Insulin-like Growth Factor-1, Bone Mass and Inflammation to Low-energy Distal Radius Fractures and Fracture Healing in Elderly Women Attending Emergency Care

OBJECTIVE

Elderly patients suffer fractures through low-energy mechanisms. The distal radius is the most frequent fracture localization. Insulin-like growth factor-1 (IGF1) plays an important role in the maintenance of bone mass and its levels decline with advancing age and in states of malnutrition. Our aim was to investigate the association of IGF1 levels, bone mass, nutritional status, and inflammation to low-energy distal radius fractures and also study if fracture healing is influenced by IGF1, nutritional status, and inflammation.

METHODS

Postmenopausal women, 55 years or older, with low-energy distal radius fractures occurring due to falling on slippery ground, indoors or outdoors, were recruited in the emergency department (ED) and followed 1 and 5 weeks after the initial trauma with biomarkers for nutritional status and inflammation. Fractures were diagnosed according to standard procedure by physical examination and X-ray. All patients were conservatively treated with plaster casts in the ED. Patients who needed interventions were excluded from our study. Fracture healing was evaluated from radiographs. Fracture healing assessment was made with a five-point scale where the radiological assessment included callus formation, fracture line, and stage of union. Blood samples were taken within 24 h after fracture and analyzed in the routine laboratory. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry (DXA).

RESULTS

Thirty-eight Caucasian women, aged 70.5 ± 8.9 years (mean ± SD) old, were recruited. Nutritional status, as evaluated by albumin (40.3 ± 3.1 g/L), IGF1 (125.3 ± 39.9 μg/L), body mass index (26.9 ± 3.6 kg/m² ), arm diameter (28.9 ± 8.9 cm), and arm skinfold (2.5 ± 0.7 cm), was normal. A positive correlation was found between IGF1 at visit 1 and the lowest BMD for hip, spine, or radius (r = 0.39, P = 0.04). High sensitive C-reactive protein (hsCRP) and leukocytes were higher at the fracture event compared to 5 weeks later (P = 0.07 and P < 0.001, respectively). Fracture healing parameters (i.e. callus formation, fracture line, and stage of union) were positively correlated with the initial leukocyte count and to difference in thrombocyte count between visit 1 and 3.

CONCLUSIONS

In elderly women with low-energy distal radius fractures, an association between IGF1 and lowest measures of BMD was found, indicating that low IGF1 could be an indirect risk factor for fractures. Fracture healing was associated with initial leukocytosis and a lower thrombocyte count, suggesting that inflammation and thrombocytes are important components in fracture healing.

The effect of nonsteroidal anti-inflammatory drugs on bone healing in humans: A qualitative, systematic review

STUDY OBJECTIVE

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used in postoperative pain management. While an increasing number of in vitro and animal studies point toward an inhibitory effect of NSAIDs on bone healing process, the few existing retro- and prospective clinical studies present conflicting data.

DESIGN

The aim of this qualitative, systematic review was to investigate the impact of perioperative use of NSAIDs in humans on postoperative fracture/spinal fusion healing compared to other used analgesics measured as fracture nonunion with radiological control.

PATIENTS/INTERVENTIONS

We performed a systematic literature search of the last 38 years using PubMed Embase and the Cochrane Controlled Trials Register including retro- and prospective clinical, human trials assessing the effect of NSAIDs on postoperative fracture/spinal fusion healing when used for perioperative pain management with a radiological follow up to assess eventual nonunion. Due to different study designs, drugs, dosages/exposition times and different methods to assess fracture nonunion, these studies were not pooled for a meta-analysis. A descriptive summary of all studies, level of evidence, study quality and study bias assessment using different scores were used.

MAIN RESULTS

Three prospective randomized controlled studies and thirteen retrospective cohort human studies were identified for a total of 12'895 patients. The overall study quality was low according to Jadad and Oxford Levels of Evidence scores.

CONCLUSIONS

Published results of human trials did not show strong evidence that NDAIDs for pain therapy after fracture osteosynthesis or spinal fusion lead to an increased nonunion rate. Reviewed studies present such conflicting data, that no clinical recommendation can be made regarding the appropriate use of NSAIDs in this context. Considering laboratory data of animal, human tissue research and recommendation of clinical reviews, a short perioperative exposition to NSAIDs is most likely not deleterious. However, randomized, controlled studies are warranted to support or refute this hypothesis.

Pain Management After Bone Reconstruction Surgery Using an Analgesic Bone Cement: A Functional Noninvasive In Vivo Study Using Gait Analysis

Postoperative pain after bone reconstruction is a serious complication that could jeopardize the global success of a surgery. This pain must be controlled and minimized during the first 3 to 4 postoperative days to prevent it from becoming chronic. In this study, a critical-size bone defect was created at the femoral distal end of rats and filled by an injectable calcium phosphate cement (CPC) loaded or not with local anesthetics (bupivacaine or ropivacaine). A functional evaluation of the gait was performed using the CatWalk system to compare the postoperative pain relief enhanced by the different CPCs after such a bone filling surgery. The results demonstrated significant pain relief during the short-term postoperative period, as shown by the print area and intensity parameters of the operated paw. At 24hours, the print area decreased by 65%, 42%, and 24%, and the intensity decreased by 25%, 9%, and 1% for unloaded, ropivacaine-loaded, and bupivacaine-loaded CPCs, respectively, compared with the preoperative values. Bupivacaine-loaded CPC provided an earlier return to full functional recovery than ropivacaine-loaded CPC. Moreover, the CPCs retained their biologic and mechanical properties. For all these reasons, anesthetic-loaded CPCs could be part of the global pain management protocol after bone reconstruction surgery such as iliac crest bone grafting procedures.

PERSPECTIVE

Bupivacaine-loaded CPC provided an earlier return to full gait function than ropivacaine-loaded CPC, with preserved bone filling properties. Such analgesic CPCs deserve further in vivo investigation and may be part of the global pain management protocol after bone reconstruction or bone augmentation surgery such as iliac crest bone grafting.