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Hadro A, Huyke-Hernandez FA, Kleinsmith RM, Doxey SA, Schweitzer A, Ristow J, Cunningham BP, Braman J. Effect of post-operative NSAID use on rotator cuff repair outcomes. J Orthop 2024; 56:119-122. [PMID: 38828472 PMCID: PMC11141046 DOI: 10.1016/j.jor.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 05/12/2024] [Indexed: 06/05/2024] Open
Abstract
Background The impact of non-steroidal anti-inflammatory drugs (NSAIDs) on rotator cuff repair is an ongoing area of study within orthopedics, with conflicting results in current literature. Despite concerns over the deleterious effects of NSAIDs on rotator cuff healing, they are becoming an integral part of a multimodal post-operative pain control regiment. The purpose of this study was to compare post-operative patient-reported outcomes (PROs), complications rates, and retear rates of arthroscopic rotator cuff repairs in patients using ibuprofen post-operatively to those who abstained from NSAIDs for six weeks after surgery. It was hypothesized that a short course of ibuprofen post-operatively would not lead to inferior PRO scores, increased retear rates, nor increased complication rates after arthroscopic rotator cuff repair. Methods Patients of the primary surgeon who underwent arthroscopic rotator cuff repair between 2012 and 2022 were evaluated by retrospective chart review. In May 2017 the primary surgeon changed his protocol from avoiding NSAIDs for six weeks after surgery to routinely prescribing two weeks of Ibuprofen 800 mg TID post-operatively. Patients who avoided NSAIDs for six weeks were compared to patients who were prescribed NSAIDs post-operatively. Patient demographic data, pre-operative MRI results, pre-operative and post-operative PROs were collected from the EMR. Additionally, post-operative complications and repair failures requiring reoperation within one year were evaluated. Results 125 patients met inclusion criteria for this study with 36 patients in the NSAID group and 89 in the no NSAID group. When comparing improvement in PROs, the NSAID group reached MCID at one year in 83.8 % of patients and the no NSAID group reached MCID at one year in 73.9 % of patients. There was no significant difference between the groups in reaching MCID improvement at one year (p = 0.471). Five post-operative complications were reported in the no NSAID group and two in the NSAID group (5.7 % vs 5.4 %, respectively, p = 0.827). Finally, there was no significant difference in the percentage of post-operative rotator cuff repair failures requiring revision in the first year between the groups (2.3 % vs 2.7 %, p = 1.000). Conclusion There was no difference in percent of patients improving their PRO by the MCID between the groups that used ibuprofen and the group that did not. There was also no difference in post-operative complication rates and rates of symptomatic retear requiring reoperation between the groups. This supports that a short course of NSAIDs post-operatively, specifically ibuprofen, after rotator cuff repair does not increase reoperation rates nor lead to a clinically significant decrease in PROs at one year.
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Affiliation(s)
- Adam Hadro
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, MN, USA
| | - Fernando A. Huyke-Hernandez
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, MN, USA
| | - Rebekah M. Kleinsmith
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, MN, USA
| | - Stephen A. Doxey
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, MN, USA
| | - Adam Schweitzer
- College of Osteopathic Medicine, Des Moines University, Des Moines, IA, USA
| | - Jacob Ristow
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Brian P. Cunningham
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, USA
- Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, MN, USA
| | - Jonathan Braman
- Department of Orthopaedic Surgery, Henry Ford, Detroit, MI, USA
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Wu PY, Caceres AI, Chen J, Sokoloff J, Huang M, Baht GS, Nackley AG, Jordt SE, Terrando N. Vagus nerve stimulation rescues persistent pain following orthopedic surgery in adult mice. Pain 2024; 165:e80-e92. [PMID: 38422485 PMCID: PMC11247455 DOI: 10.1097/j.pain.0000000000003181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/21/2023] [Accepted: 12/13/2023] [Indexed: 03/02/2024]
Abstract
ABSTRACT Postoperative pain is a major clinical problem imposing a significant burden on patients and society. In a survey 2 years after orthopedic surgery, 57% of patients reported persisting postoperative pain. However, only limited progress has been made in the development of safe and effective therapies to prevent the onset and chronification of pain after orthopedic surgery. We established a tibial fracture mouse model that recapitulates clinically relevant orthopedic trauma surgery, which causes changes in neuropeptide levels in dorsal root ganglia and sustained neuroinflammation in the spinal cord. Here, we monitored extended pain behavior in this model, observing chronic bilateral hindpaw mechanical allodynia in both male and female C57BL/6J mice that persisted for >3 months after surgery. We also tested the analgesic effects of a novel, minimally invasive, bioelectronic approach to percutaneously stimulate the vagus nerve (termed percutaneous vagus nerve stimulation [pVNS]). Weekly pVNS treatment for 30 minutes at 10 Hz for 3 weeks after the surgery strongly reduced pain behaviors compared with untreated controls. Percutaneous vagus nerve stimulation also improved locomotor coordination and accelerated bone healing. In the dorsal root ganglia, vagal stimulation inhibited the activation of glial fibrillary acidic protein-positive satellite cells but without affecting microglial activation. Overall, these data provide novel evidence supportive of the use of pVNS to prevent postoperative pain and inform translational studies to test antinociceptive effects of bioelectronic medicine in the clinic.
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Affiliation(s)
- Pau Yen Wu
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
| | - Ana Isabel Caceres
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
| | - Jiegen Chen
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
| | - Jamie Sokoloff
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
| | - Mingjian Huang
- Department of Orthopaedic Surgery, Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, United States
| | - Gurpreet Singh Baht
- Department of Orthopaedic Surgery, Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, United States
| | - Andrea G. Nackley
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC, United States
| | - Sven-Eric Jordt
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC, United States
- Integrated Toxicology and Environmental Health Program, Duke University, Durham, United States
| | - Niccolò Terrando
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
- Department of Cell Biology, Duke University Medical Center, Durham, NC, United States
- Department of Integrative Immunobiology, Duke University Medical Center, Durham, NC, United States
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3
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Mdingi VS, Gens L, Mys K, Varga P, Zeiter S, Marais LC, Richards RG, Moriarty FT, Chittò M. Short-Term Celecoxib Promotes Bone Formation without Compromising Cefazolin Efficacy in an Early Orthopaedic Device-Related Infection: Evidence from a Rat Model. Antibiotics (Basel) 2024; 13:715. [PMID: 39200015 PMCID: PMC11350844 DOI: 10.3390/antibiotics13080715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 07/26/2024] [Accepted: 07/26/2024] [Indexed: 09/01/2024] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are crucial components of multimodal analgesia for musculoskeletal injuries, targeting cyclooxygenase (COX) enzymes (COX-1 and/or COX-2 isoenzymes). Concerns exist regarding their potential interference with bone healing and orthopaedic device-related infections (ODRI), where data are limited. This study aimed to investigate whether the COX-selectivity of NSAIDs interfered with antibiotic efficacy and bone changes in the setting of an ODRI. In vitro testing demonstrated that combining celecoxib (a COX-2 inhibitor) with cefazolin significantly enhanced antibacterial efficacy compared to cefazolin alone (p < 0.0001). In vivo experiments were performed using Staphylococcus epidermidis in the rat proximal tibia of an ODRI model. Long and short durations of celecoxib treatment in combination with antibiotics were compared to a control group receiving an antibiotic only. The long celecoxib treatment group showed impaired infection clearance, while the short celecoxib treatment showed increased bone formation (day 6, p < 0.0001), lower bone resorption (day 6, p < 0.0001), and lower osteolysis (day 6, BV/TV: p < 0.0001; BIC: p = 0.0005) compared to the control group, without impairing antibiotic efficacy (p > 0.9999). Given the use of NSAIDs as part of multimodal analgesia, and considering these findings, short-term use of COX-2 selective NSAIDs like celecoxib not only aids pain management but also promotes favorable bone changes during ODRI.
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Affiliation(s)
- Vuyisa Siphelele Mdingi
- AO Research Institute Davos, 7270 Davos, Switzerland; (V.S.M.)
- Department of Orthopaedic Surgery, School of Clinical Medicine, University of KwaZulu Natal, Durban 4041, South Africa
| | - Lena Gens
- AO Research Institute Davos, 7270 Davos, Switzerland; (V.S.M.)
| | - Karen Mys
- AO Research Institute Davos, 7270 Davos, Switzerland; (V.S.M.)
| | - Peter Varga
- AO Research Institute Davos, 7270 Davos, Switzerland; (V.S.M.)
| | - Stephan Zeiter
- AO Research Institute Davos, 7270 Davos, Switzerland; (V.S.M.)
| | - Leonard Charles Marais
- Department of Orthopaedic Surgery, School of Clinical Medicine, University of KwaZulu Natal, Durban 4041, South Africa
| | | | | | - Marco Chittò
- AO Research Institute Davos, 7270 Davos, Switzerland; (V.S.M.)
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4
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Fisher A, Fisher L, Srikusalanukul W. Prediction of Osteoporotic Hip Fracture Outcome: Comparative Accuracy of 27 Immune-Inflammatory-Metabolic Markers and Related Conceptual Issues. J Clin Med 2024; 13:3969. [PMID: 38999533 PMCID: PMC11242639 DOI: 10.3390/jcm13133969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 06/26/2024] [Accepted: 07/03/2024] [Indexed: 07/14/2024] Open
Abstract
Objectives: This study, based on the concept of immuno-inflammatory-metabolic (IIM) dysregulation, investigated and compared the prognostic impact of 27 indices at admission for prediction of postoperative myocardial injury (PMI) and/or hospital death in hip fracture (HF) patients. Methods: In consecutive HF patient (n = 1273, mean age 82.9 ± 8.7 years, 73.5% females) demographics, medical history, laboratory parameters, and outcomes were recorded prospectively. Multiple logistic regression and receiver-operating characteristic analyses (the area under the curve, AUC) were used to establish the predictive role for each biomarker. Results: Among 27 IIM biomarkers, 10 indices were significantly associated with development of PMI and 16 were indicative of a fatal outcome; in the subset of patients aged >80 years with ischaemic heart disease (IHD, the highest risk group: 90.2% of all deaths), the corresponding figures were 26 and 20. In the latter group, the five strongest preoperative predictors for PMI were anaemia (AUC 0.7879), monocyte/eosinophil ratio > 13.0 (AUC 0.7814), neutrophil/lymphocyte ratio > 7.5 (AUC 0.7784), eosinophil count < 1.1 × 109/L (AUC 0.7780), and neutrophil/albumin × 10 > 2.4 (AUC 0.7732); additionally, sensitivity was 83.1-75.4% and specificity was 82.1-75.0%. The highest predictors of in-hospital death were platelet/lymphocyte ratio > 280.0 (AUC 0.8390), lymphocyte/monocyte ratio < 1.1 (AUC 0.8375), albumin < 33 g/L (AUC 0.7889), red cell distribution width > 14.5% (AUC 0.7739), and anaemia (AUC 0.7604), sensitivity 88.2% and above, and specificity 85.1-79.3%. Internal validation confirmed the predictive value of the models. Conclusions: Comparison of 27 IIM indices in HF patients identified several simple, widely available, and inexpensive parameters highly predictive for PMI and/or in-hospital death. The applicability of IIM biomarkers to diagnose and predict risks for chronic diseases, including OP/OF, in the preclinical stages is discussed.
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Affiliation(s)
- Alexander Fisher
- Department of Geriatric Medicine, The Canberra Hospital, ACT Health, Canberra 2605, Australia
- Department of Orthopaedic Surgery, The Canberra Hospital, ACT Health, Canberra 2605, Australia
- Medical School, Australian National University, Canberra 2601, Australia
| | - Leon Fisher
- Frankston Hospital, Peninsula Health, Melbourne 3199, Australia
| | - Wichat Srikusalanukul
- Department of Geriatric Medicine, The Canberra Hospital, ACT Health, Canberra 2605, Australia
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5
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Bowers KM, Anderson DE. Delayed Union and Nonunion: Current Concepts, Prevention, and Correction: A Review. Bioengineering (Basel) 2024; 11:525. [PMID: 38927761 PMCID: PMC11201148 DOI: 10.3390/bioengineering11060525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/12/2024] [Accepted: 05/17/2024] [Indexed: 06/28/2024] Open
Abstract
Surgical management of fractures has advanced with the incorporation of advanced technology, surgical techniques, and regenerative therapies, but delayed bone healing remains a clinical challenge and the prevalence of long bone nonunion ranges from 10 to 15% of surgically managed fractures. Delayed bone healing arises from a combination of mechanical, biological, and systemic factors acting on the site of tissue remodeling, and careful consideration of each case's injury-related, patient-dependent, surgical, and mechanical risk factors is key to successful bone union. In this review, we describe the biology and biomechanics of delayed bone healing, outline the known risk factors for nonunion development, and introduce modern preventative and corrective therapies targeting fracture nonunion.
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Affiliation(s)
| | - David E. Anderson
- Large Animal Clinical Sciences, University of Tennessee College of Veterinary Medicine, 2407 River Dr., Knoxville, TN 37996-4550, USA;
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6
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Ryan PM, Scherry H, Pierson R, Wilson CD, Probe RA. NSAID use in orthopedic surgery: A review of current evidence and clinical practice guidelines. J Orthop Res 2024; 42:707-716. [PMID: 38273720 DOI: 10.1002/jor.25791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 01/01/2024] [Accepted: 01/10/2024] [Indexed: 01/27/2024]
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are a valuable class of medications for orthopedic surgeons and often play a pivotal role in pain control. However, there are many common stipulations resulting in avoidance of its use in the treatment of musculoskeletal disease. This review summarizes the mechanism of action of NSAIDs as well as provides an overview of commonly used NSAIDs and the differences between them. It provides a concise summary on the osseous effects of NSAIDs with regard to bone healing and heterotopic ossification. Most of all, it serves as a guide or reference for orthopedic providers when counseling patients on the risks and benefits of NSAID use, as it addresses the common stipulations encountered: "It irritates my stomach," "I have a history of bariatric surgery," "I'm already on a blood thinner," "I've had a heart attack," and "I've got kidney problems" and synthesizes both current research and society recommendations regarding safe use and avoidance of NSAIDs.
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Affiliation(s)
| | | | - Ryan Pierson
- Washington University Orthopaedics, Saint Louis, Missouri, USA
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7
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Torres HM, Arnold KM, Oviedo M, Westendorf JJ, Weaver SR. Inflammatory Processes Affecting Bone Health and Repair. Curr Osteoporos Rep 2023; 21:842-853. [PMID: 37759135 PMCID: PMC10842967 DOI: 10.1007/s11914-023-00824-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 09/29/2023]
Abstract
PURPOSE OF REVIEW The purpose of this article is to review the current understanding of inflammatory processes on bone, including direct impacts of inflammatory factors on bone cells, the effect of senescence on inflamed bone, and the critical role of inflammation in bone pain and healing. RECENT FINDINGS Advances in osteoimmunology have provided new perspectives on inflammatory bone loss in recent years. Characterization of so-called inflammatory osteoclasts has revealed insights into physiological and pathological bone loss. The identification of inflammation-associated senescent markers in bone cells indicates that therapies that reduce senescent cell burden may reverse bone loss caused by inflammatory processes. Finally, novel studies have refined the role of inflammation in bone healing, including cross talk between nerves and bone cells. Except for the initial stages of fracture healing, inflammation has predominately negative effects on bone and increases fracture risk. Eliminating senescent cells, priming the osteo-immune axis in bone cells, and alleviating pro-inflammatory cytokine burden may ameliorate the negative effects of inflammation on bone.
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Affiliation(s)
- Haydee M Torres
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Katherine M Arnold
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
- Biomedical Engineering and Physiology Track/Regenerative Sciences Program, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN, 55905, USA
| | - Manuela Oviedo
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Jennifer J Westendorf
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Samantha R Weaver
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
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8
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Ren Y, Zhang S, Weeks J, Rangel-Moreno J, He B, Xue T, Rainbolt J, Morita Y, Shu Y, Liu Y, Kates SL, Schwarz EM, Xie C. Reduced angiogenesis and delayed endochondral ossification in CD163 -/- mice highlights a role of M2 macrophages during bone fracture repair. J Orthop Res 2023; 41:2384-2393. [PMID: 36970754 PMCID: PMC10522791 DOI: 10.1002/jor.25564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 02/24/2023] [Accepted: 03/24/2023] [Indexed: 04/10/2023]
Abstract
While recent studies showed that macrophages are critical for bone fracture healing, and lack of M2 macrophages have been implicated in models of delayed union, functional roles for specific M2 receptors have yet to be defined. Moreover, the M2 scavenger receptor CD163 has been identified as a target to inhibit sepsis following implant-associated osteomyelitis, but potential adverse effects on bone healing during blockage therapy have yet to be explored. Thus, we investigated fracture healing in C57BL/6 versus CD163-/- mice using a well-established closed, stabilized, mid-diaphyseal femur fracture model. While gross fracture healing in CD163-/- mice was similar to that of C57BL/6, plain radiographs revealed persistent fracture gaps in the mutant mice on Day 14, which resolved by Day 21. Consistently, 3D vascular micro-CT demonstrated delayed union on Day 21, with reduced bone volume (74%, 61%, and 49%) and vasculature (40%, 40%, and 18%) compared to C57BL/6 on Days 10, 14, and 21 postfracture, respectively (p < 0.01). Histology confirmed large amounts of persistent cartilage in CD163-/- versus C57BL/6 fracture callus on Days 7 and 10 that resolves over time, and immunohistochemistry demonstrated deficiencies in CD206+ M2 macrophages. Torsion testing of the fractures confirmed the delayed early union in CD163-/- femurs, which display decreased yield torque on Day 21, and a decreased rigidity with a commensurate increase in rotation at yield on Day 28 (p < 0.01). Collectively, these results demonstrate that CD163 is required for normal angiogenesis, callus formation, and bone remodeling during fracture healing, and raise potential concerns about CD163 blockade therapy.
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Affiliation(s)
- Youliang Ren
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Shiyang Zhang
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Jason Weeks
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Javier Rangel-Moreno
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Bin He
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Thomas Xue
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Joshua Rainbolt
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
| | - Yugo Morita
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Ye Shu
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Yuting Liu
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Stephen L. Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Edward M. Schwarz
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Chao Xie
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
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9
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Elder NM, Heavey SF, Tyler KR. Emergency Department Pain Management in the Older Adult. Clin Geriatr Med 2023; 39:619-634. [PMID: 37798068 DOI: 10.1016/j.cger.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Pain assessment and management in older adults is complex and requires evaluation and consideration of the type of pain, the acuity of the condition, comorbidities, and medications. Many older adults do not receive appropriate therapy for painful conditions in the emergency department (ED). This brief review article is focused on pharmacologic agents, drug-drug interactions, drug-disease interactions, and approaches in the management of painful conditions seen in older adults in the emergency department. Recommendations for specific painful conditions such as fragility fractures are discussed.
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Affiliation(s)
- Natalie M Elder
- University of Vermont, 111 Colchester Avenue, Burlington, VT 05401, USA
| | - Sean F Heavey
- University of California Davis, 4150 V Street, Sacramento, CA 95817, USA
| | - Katren R Tyler
- University of California Davis, 4150 V Street, Sacramento, CA 95817, USA.
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10
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Merrick M, Grange R, Rudd S, Shipway D. Evaluation and Treatment of Acute Trauma Pain in Older Adults. Drugs Aging 2023; 40:869-880. [PMID: 37563445 DOI: 10.1007/s40266-023-01052-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 08/12/2023]
Abstract
In the context of an ageing population, the demographic sands of trauma are shifting. Increasingly, trauma units are serving older adults who have sustained injuries in low-energy falls from a standing height. Older age is commonly associated with changes in physiology, as well as an increased prevalence of frailty and multimorbidity, including cardiac, renal and liver disease. These factors can complicate the safe and effective administration of analgesia in the older trauma patient. Trauma services therefore need to adapt to meet this demographic shift and ensure that trauma clinicians are sufficiently skilled in treating pain in complex older people. This article is dedicated to the management of acute trauma pain in older adults. It aims to highlight the notable clinical challenges of managing older trauma patients compared with their younger counterparts. It offers an overview of the evidence and practical opinion on the merits and drawbacks of commonly used analgesics, as well as more novel and emerging analgesic adjuncts. A search of Medline (Ovid, from inception to 7 November 2022) was conducted by a medical librarian to identify relevant articles using keyword and subject heading terms for trauma, pain, older adults and analgesics. Results were limited to articles published in the last 10 years and English language. Relevant articles' references were hand-screened to identify other relevant articles. There is paucity of dedicated high-quality evidence to guide management of trauma-related pain in older adults. Ageing-related changes in physiology, the accumulation of multimorbidity, frailty and the risk of inducing delirium secondary to analgesic medication present a suite of challenges in the older trauma patient. An important nuance of treating pain in older trauma patients is the challenge of balancing iatrogenic adverse effects of analgesia against the harms of undertreated pain, the complications and consequences of which include immobility, pneumonia, sarcopenia, pressure ulcers, long-term functional decline, increased long-term care needs and mortality. In this article, the role of non-opioid agents including short-course non-steroidal anti-inflammatory drugs (NSAIDs) is discussed. Opioid selection and dosing are reviewed for older adults suffering from acute trauma pain in the context of kidney and liver disease. The evidence base and limitations of other adjuncts such as topical and intravenous lidocaine, ketamine and regional anaesthesia in acute geriatric trauma are discussed.
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Affiliation(s)
- Minnie Merrick
- Geriatric Perioperative Care, North Bristol NHS Trust, Bristol, UK
| | - Robert Grange
- Geriatric Perioperative Care, North Bristol NHS Trust, Bristol, UK
| | - Sarah Rudd
- Library and Knowledge Service, North Bristol NHS Trust, Bristol, UK
| | - David Shipway
- Geriatric Perioperative Care, North Bristol NHS Trust, Bristol, UK.
- University of Bristol, Bristol, UK.
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11
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Buitrago G, Harnett MM, Harnett W. Conquering rheumatic diseases: are parasitic worms the answer? Trends Parasitol 2023; 39:739-748. [PMID: 37487870 DOI: 10.1016/j.pt.2023.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/26/2023]
Abstract
Despite the introduction of novel treatment strategies, management of rheumatic disorders remains associated with substantial unmet clinical need. Of interest therefore, it has recently become apparent that there is a global inverse relationship between the incidence of such conditions and parasitic helminth infection, with striking examples involving rheumatoid arthritis (RA)/systemic lupus erythematosus (SLE) patients and filarial nematode worm infection in studies in India. Such findings reflect that helminths are master manipulators of the immune system, particularly in being able to modulate proinflammatory responses. The aim of this article is thus to consider findings to date on this exciting and intriguing research area to form an opinion on whether parasitic worms may be exploited to generate novel therapies for rheumatic diseases.
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Affiliation(s)
- Geraldine Buitrago
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow G4 0RE, UK
| | - Margaret M Harnett
- School of Infection and Immunity, University of Glasgow, Glasgow G12 8TA, UK
| | - William Harnett
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow G4 0RE, UK.
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Wu PY, Caceres AI, Chen J, Sokoloff J, Huang M, Baht GS, Nackley AG, Jordt SE, Terrando N. Vagus nerve stimulation rescues persistent pain following orthopedic surgery in adult mice. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.05.16.540949. [PMID: 37292744 PMCID: PMC10245641 DOI: 10.1101/2023.05.16.540949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Postoperative pain is a major clinical problem imposing a significant burden on our patients and society. Up to 57% of patients experience persistent postoperative pain 2 years after orthopedic surgery [49]. Although many studies have contributed to the neurobiological foundation of surgery-induced pain sensitization, we still lack safe and effective therapies to prevent the onset of persistent postoperative pain. We have established a clinically relevant orthopedic trauma model in mice that recapitulates common insults associated with surgery and ensuing complications. Using this model, we have started to characterize how induction of pain signaling contributes to neuropeptides changes in dorsal root ganglia (DRG) and sustained neuroinflammation in the spinal cord [62]. Here we have extended the characterization of pain behaviors for >3 months after surgery, describing a persistent deficit in mechanical allodynia in both male and female C57BL/6J mice after surgery. Notably, we have applied a novel minimally invasive bioelectronic approach to percutaneously stimulate the vagus nerve (termed pVNS) [24] and tested its anti-nociceptive effects in this model. Our results show that surgery induced a strong bilateral hind-paw allodynia with a slight decrease in motor coordination. However, treatment with pVNS for 30-minutes at10 Hz weekly for 3 weeks prevented pain behavior compared to naïve controls. pVNS also improved locomotor coordination and bone healing compared to surgery without treatment. In the DRGs, we observed that vagal stimulation fully rescued activation of GFAP positive satellite cells but did not affect microglial activation. Overall, these data provide novel evidence for the use of pVNS to prevent postoperative pain and may inform translational studies to test anti-nociceptive effects in the clinic.
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Affiliation(s)
- Pau Yen Wu
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
| | - Ana Isabel Caceres
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
| | - Jiegen Chen
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
| | - Jamie Sokoloff
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
| | - Mingjian Huang
- Department of Orthopaedic Surgery, Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, United States
| | - Gurpreet Singh Baht
- Department of Orthopaedic Surgery, Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, United States
| | - Andrea G Nackley
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC, United States
| | - Sven-Eric Jordt
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC, United States
- Integrated Toxicology & Environmental Health Program, Duke University, Durham, United States
| | - Niccolò Terrando
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
- Department of Cell Biology, Duke University Medical Center, Durham, NC, United States
- Department of Integrative Immunobiology, Duke University Medical Center, Durham, NC, United States
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Murphy PB, Kasotakis G, Haut ER, Miller A, Harvey E, Hasenboehler E, Higgins T, Hoegler J, Mir H, Cantrell S, Obremskey WT, Wally M, Attum B, Seymour R, Patel N, Ricci W, Freeman JJ, Haines KL, Yorkgitis BK, Padilla-Jones BB. Efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of acute pain after orthopedic trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma and the Orthopedic Trauma Association. Trauma Surg Acute Care Open 2023; 8:e001056. [PMID: 36844371 PMCID: PMC9945020 DOI: 10.1136/tsaco-2022-001056] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/09/2023] [Indexed: 02/25/2023] Open
Abstract
Objectives Fracture is a common injury after a traumatic event. The efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) to treat acute pain related to fractures is not well established. Methods Clinically relevant questions were determined regarding NSAID use in the setting of trauma-induced fractures with clearly defined patient populations, interventions, comparisons and appropriately selected outcomes (PICO). These questions centered around efficacy (pain control, reduction in opioid use) and safety (non-union, kidney injury). A systematic review including literature search and meta-analysis was performed, and the quality of evidence was graded per the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The working group reached consensus on the final evidence-based recommendations. Results A total of 19 studies were identified for analysis. Not all outcomes identified as critically important were reported in all studies, and the outcome of pain control was too heterogenous to perform a meta-analysis. Nine studies reported on non-union (three randomized control trials), six of which reported no association with NSAIDs. The overall incidence of non-union in patients receiving NSAIDs compared with patients not receiving NSAIDs was 2.99% and 2.19% (p=0.04), respectively. Of studies reporting on pain control and reduction of opioids, the use of NSAIDs reduced pain and the need for opioids after traumatic fracture. One study reported on the outcome of acute kidney injury and found no association with NSAID use. Conclusions In patients with traumatic fractures, NSAIDs appear to reduce post-trauma pain, reduce the need for opioids and have a small effect on non-union. We conditionally recommend the use of NSAIDs in patients suffering from traumatic fractures as the benefit appears to outweigh the small potential risks.
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Affiliation(s)
- Patrick B Murphy
- Department of Surgery, Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - George Kasotakis
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Elliott R Haut
- Department of Surgery, Johns Hopkins Univ, Baltimore, Maryland, USA
| | - Anna Miller
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, Missouri, USA
| | - Edward Harvey
- Department of Surgery, McGill University, Montreal, Québec, Canada
| | - Eric Hasenboehler
- Holy Spirit Hospital Penn State Health, Camp Hill, Pennsylvania, USA
| | - Thomas Higgins
- Department of Orthopaedics, University of Utah Health, Salt Lake City, Utah, USA
| | - Joseph Hoegler
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Hassan Mir
- Department of Orthopaedic Surgery, University of South Florida, Tampa, Florida, USA
| | - Sarah Cantrell
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - William T Obremskey
- The Vanderbilt Orthopaedic Institute Center for Health Policy, Nashville, Tennessee, USA
| | - Meghan Wally
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Basem Attum
- Institute Center for Health Policy, Nashville, Tennessee, USA
| | - Rachel Seymour
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nimitt Patel
- Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - William Ricci
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Jennifer J Freeman
- Department of Surgery, TCU and UNTHSC School of Medicine, Fort Worth, Texas, USA
| | - Krista L Haines
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Brian K Yorkgitis
- Department of Surgery, University of Florida College of Medicine – Jacksonville, Jacksonville, Florida, USA
| | - Brandy B Padilla-Jones
- Department of General Surgery, Sunrise Hospital and Medical Center, Las Vegas, Nevada, USA
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14
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Liu J, Lin X, McDavid A, Yang Y, Zhang H, Boyce BF, Xing L. Molecular signatures distinguish senescent cells from inflammatory cells in aged mouse callus stromal cells. Front Endocrinol (Lausanne) 2023; 14:1090049. [PMID: 36875448 PMCID: PMC9981154 DOI: 10.3389/fendo.2023.1090049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/02/2023] [Indexed: 02/18/2023] Open
Abstract
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.
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Affiliation(s)
- Jiatong Liu
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Xi Lin
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Andrew McDavid
- Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, United States
| | - Yutiancheng Yang
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Hengwei Zhang
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Brendan F. Boyce
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, United States
- Orthopaedics and Rehabilitation, Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, United States
| | - Lianping Xing
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, United States
- Orthopaedics and Rehabilitation, Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, United States
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Iafrate L, Benedetti MC, Donsante S, Rosa A, Corsi A, Oreffo ROC, Riminucci M, Ruocco G, Scognamiglio C, Cidonio G. Modelling skeletal pain harnessing tissue engineering. IN VITRO MODELS 2022; 1:289-307. [PMID: 36567849 PMCID: PMC9766883 DOI: 10.1007/s44164-022-00028-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/01/2022] [Accepted: 07/04/2022] [Indexed: 12/27/2022]
Abstract
Bone pain typically occurs immediately following skeletal damage with mechanical distortion or rupture of nociceptive fibres. The pain mechanism is also associated with chronic pain conditions where the healing process is impaired. Any load impacting on the area of the fractured bone will stimulate the nociceptive response, necessitating rapid clinical intervention to relieve pain associated with the bone damage and appropriate mitigation of any processes involved with the loss of bone mass, muscle, and mobility and to prevent death. The following review has examined the mechanisms of pain associated with trauma or cancer-related skeletal damage focusing on new approaches for the development of innovative therapeutic interventions. In particular, the review highlights tissue engineering approaches that offer considerable promise in the application of functional biomimetic fabrication of bone and nerve tissues. The strategic combination of bone and nerve tissue engineered models provides significant potential to develop a new class of in vitro platforms, capable of replacing in vivo models and testing the safety and efficacy of novel drug treatments aimed at the resolution of bone-associated pain. To date, the field of bone pain research has centred on animal models, with a paucity of data correlating to the human physiological response. This review explores the evident gap in pain drug development research and suggests a step change in approach to harness tissue engineering technologies to recapitulate the complex pathophysiological environment of the damaged bone tissue enabling evaluation of the associated pain-mimicking mechanism with significant therapeutic potential therein for improved patient quality of life. Graphical abstract Rationale underlying novel drug testing platform development. Pain detected by the central nervous system and following bone fracture cannot be treated or exclusively alleviated using standardised methods. The pain mechanism and specificity/efficacy of pain reduction drugs remain poorly understood. In vivo and ex vivo models are not yet able to recapitulate the various pain events associated with skeletal damage. In vitro models are currently limited by their inability to fully mimic the complex physiological mechanisms at play between nervous and skeletal tissue and any disruption in pathological states. Robust innovative tissue engineering models are needed to better understand pain events and to investigate therapeutic regimes.
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Affiliation(s)
- Lucia Iafrate
- Center for Life Nano- & Neuro-Science (CLN2S), Istituto Italiano di Tecnologia, Rome, Italy
| | - Maria Cristina Benedetti
- Center for Life Nano- & Neuro-Science (CLN2S), Istituto Italiano di Tecnologia, Rome, Italy
- Department of Biology and Biotechnologies “Charles Darwin”, Sapienza University of Rome, Rome, Italy
| | - Samantha Donsante
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Alessandro Rosa
- Center for Life Nano- & Neuro-Science (CLN2S), Istituto Italiano di Tecnologia, Rome, Italy
- Department of Biology and Biotechnologies “Charles Darwin”, Sapienza University of Rome, Rome, Italy
| | - Alessandro Corsi
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Richard O. C. Oreffo
- Bone and Joint Research Group, Stem Cells and Regeneration, Institute of Developmental Sciences, Centre for Human Development, University of Southampton, Southampton, UK
| | - Mara Riminucci
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Giancarlo Ruocco
- Center for Life Nano- & Neuro-Science (CLN2S), Istituto Italiano di Tecnologia, Rome, Italy
| | - Chiara Scognamiglio
- Center for Life Nano- & Neuro-Science (CLN2S), Istituto Italiano di Tecnologia, Rome, Italy
| | - Gianluca Cidonio
- Center for Life Nano- & Neuro-Science (CLN2S), Istituto Italiano di Tecnologia, Rome, Italy
- Bone and Joint Research Group, Stem Cells and Regeneration, Institute of Developmental Sciences, Centre for Human Development, University of Southampton, Southampton, UK
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