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Muscat SM, Butler MJ, Bettes MN, DeMarsh JW, Scaria EA, Deems NP, Barrientos RM. Post-operative cognitive dysfunction is exacerbated by high-fat diet via TLR4 and prevented by dietary DHA supplementation. Brain Behav Immun 2024; 116:385-401. [PMID: 38145855 PMCID: PMC10872288 DOI: 10.1016/j.bbi.2023.12.028] [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: 10/22/2023] [Revised: 12/04/2023] [Accepted: 12/20/2023] [Indexed: 12/27/2023] Open
Abstract
Post-operative cognitive dysfunction (POCD) is an abrupt decline in neurocognitive function arising shortly after surgery and persisting for weeks to months, increasing the risk of dementia diagnosis. Advanced age, obesity, and comorbidities linked to high-fat diet (HFD) consumption such as diabetes and hypertension have been identified as risk factors for POCD, although underlying mechanisms remain unclear. We have previously shown that surgery alone, or 3-days of HFD can each evoke sufficient neuroinflammation to cause memory deficits in aged, but not young rats. The aim of the present study was to determine if HFD consumption before surgery would potentiate and prolong the subsequent neuroinflammatory response and memory deficits, and if so, to determine the extent to which these effects depend on activation of the innate immune receptor TLR4, which both insults are known to stimulate. Young-adult (3mo) & aged (24mo) male F344xBN F1 rats were fed standard chow or HFD for 3-days immediately before sham surgery or laparotomy. In aged rats, the combination of HFD and surgery caused persistent deficits in contextual memory and cued-fear memory, though it was determined that HFD alone was sufficient to cause the long-lasting cued-fear memory deficits. In young adult rats, HFD + surgery caused only cued-fear memory deficits. Elevated proinflammatory gene expression in the hippocampus of both young and aged rats that received HFD + surgery persisted for at least 3-weeks after surgery. In a separate experiment, rats were administered the TLR4-specific antagonist, LPS-RS, immediately before HFD onset, which ameliorated the HFD + surgery-associated neuroinflammation and memory deficits. Similarly, dietary DHA supplementation for 4 weeks prior to HFD onset blunted the neuroinflammatory response to surgery and prevented development of persistent memory deficits. These results suggest that HFD 1) increases risk of persistent POCD-associated memory impairments following surgery in male rats in 2) a TLR4-dependent manner, which 3) can be targeted by DHA supplementation to mitigate development of persistent POCD.
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Affiliation(s)
- Stephanie M Muscat
- Institute for Behavioral Medicine Research, The Ohio State University, Columbus, OH, USA; Biomedical Sciences Graduate Program, The Ohio State University, Columbus, OH, USA; Department of Neuroscience, The Ohio State University, Columbus, OH, USA
| | - Michael J Butler
- Institute for Behavioral Medicine Research, The Ohio State University, Columbus, OH, USA
| | - Menaz N Bettes
- Institute for Behavioral Medicine Research, The Ohio State University, Columbus, OH, USA
| | - James W DeMarsh
- Institute for Behavioral Medicine Research, The Ohio State University, Columbus, OH, USA
| | - Emmanuel A Scaria
- Institute for Behavioral Medicine Research, The Ohio State University, Columbus, OH, USA
| | - Nicholas P Deems
- Institute for Behavioral Medicine Research, The Ohio State University, Columbus, OH, USA
| | - Ruth M Barrientos
- Institute for Behavioral Medicine Research, The Ohio State University, Columbus, OH, USA; Department of Neuroscience, The Ohio State University, Columbus, OH, USA; Department of Psychiatry & Behavioral Health, The Ohio State University, Columbus, OH, USA; Chronic Brain Injury Program, The Ohio State University, Columbus, OH, USA.
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Zhu M, Li M, Yang S, Li J, Gong C, Yu Q, Chen C, Zhang Y, Lin J, Tu F. Fish oil omega-3 Fatty Acids Alleviate Postoperative delirium-like Behavior in aged mice by Attenuating Neuroinflammation and Oxidative Stress. Neurochem Res 2024; 49:157-169. [PMID: 37640824 DOI: 10.1007/s11064-023-04020-9] [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] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/19/2023] [Accepted: 08/22/2023] [Indexed: 08/31/2023]
Abstract
Postoperative delirium (POD) is a common and serious neuropsychiatric syndrome among older patients, and lacks effective therapies. Omega-3 fatty acids, possessing anti-inflammatory and antioxidant properties, have shown potent neuroprotective effects in several diseases. The present study investigated whether omega-3 fatty acids could exert a neuroprotective role against POD in aged mice. A mouse model of POD was established to explore the role of omega-3 fatty acids in laparotomy-induced delirium-like behavior by evaluating systemic inflammatory changes, neuroinflammation, oxidative stress, and behavior at different time points in aged mice. Oral gavage with omega-3 fatty acids (300 mg/kg) for 3 weeks before surgery significantly attenuated anesthesia/surgery-induced POD-like behavior and the accumulation of proinflammatory cytokines from the peripheral blood in aged mice. Moreover, it also remarkably mitigated neuroinflammation and the oxidative stress response (malondialdehyde [MDA] and superoxide dismutase [SOD]) in the prefrontal cortex and hippocampus of surgical mice. Our findings provided evidence that pretreatment with omega-3 fatty acids may play a vital role in the treatment of POD through mechanisms involving its anti-inflammatory and antioxidant effects, which may be a promising prevention strategy for POD in aged patients.
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Affiliation(s)
- Min Zhu
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Ming Li
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Simin Yang
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
- , Department of Anesthesiology, Suining Central Hospital, Suining, Sichuan, China
| | - Jiang Li
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Cansheng Gong
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Qingbo Yu
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Changlin Chen
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Yang Zhang
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Jingyan Lin
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China.
| | - Faping Tu
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China.
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Li X, Gao Y, Han X, Tang S, Li N, Liu X, Ni X. Maresin1 ameliorates postoperative cognitive dysfunction in aged rats by potentially regulating the NF-κB pathway to inhibit astrocyte activation. Exp Gerontol 2023; 176:112168. [PMID: 37055002 DOI: 10.1016/j.exger.2023.112168] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 04/09/2023] [Accepted: 04/10/2023] [Indexed: 04/15/2023]
Abstract
Postoperative cognitive dysfunction (POCD) is one of the most serious postoperative complications in the elderly population. Perioperative central neuroinflammation is considered to be an important pathological mechanism of POCD, with the activation of astrocytes playing a key role in central neuroinflammation. Maresin1 (MaR1) is a specific pro-resolving mediator synthesized by macrophages in the resolution stage of inflammation, and provides unique anti-inflammatory and pro-resolution effects by limiting excessive neuroinflammation and promoting postoperative recovery. However, the question remains whether MaR1 can have a positive effect on POCD. The objective of this study was to investigate the protective effect of MaR1 on POCD cognitive function in aged rats after splenectomy. Morris water maze test and IntelliCage test showed that splenectomy could cause transient cognitive dysfunction in aged rats; however, the cognitive impairment of rats was significantly mitigated when MaR1 pretreatment was administered. MaR1 significantly alleviated the fluorescence intensity and protein expression of glial fibrillary acidic protein and central nervous system specific protein in the cornu ammonis 1 region of the hippocampus. Simultaneously, the morphology of astrocytes was also severely altered. Further experiments showed that MaR1 inhibited the mRNA and protein expression of several key proinflammatory cytokines-interleukin-1β, interleukin-6, and tumor necrosis factor-α in the hippocampus of aged rats following splenectomy. The molecular mechanism underlying this process was explored by evaluating expression of components of the nuclear factor κB (NF-κB) signaling pathway. MaR1 substantially inhibited the mRNA and protein expression of NF-κB p65 and κB inhibitor kinase β. Collectively, these results suggest that MaR1 ameliorated splenectomy-induced transient cognitive impairment in elderly rats, and this neuroprotective mechanism may occur through regulating the NF-κB pathway to inhibit astrocyte activation.
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Affiliation(s)
- Xiuhua Li
- Department of Anaesthesia and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Yubo Gao
- Department of Anaesthesia and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Xu Han
- Department of Anaesthesia and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Shaling Tang
- Department of Anaesthesia and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Na Li
- Department of Anaesthesia and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Xing Liu
- Department of Anaesthesia and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Xinli Ni
- Department of Anaesthesia and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan 750004, China.
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Fu J, Li J, Sun Y, Liu S, Song F, Liu Z. In-depth investigation of the mechanisms of Schisandra chinensis polysaccharide mitigating Alzheimer's disease rat via gut microbiota and feces metabolomics. Int J Biol Macromol 2023; 232:123488. [PMID: 36731694 DOI: 10.1016/j.ijbiomac.2023.123488] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 12/24/2022] [Accepted: 01/26/2023] [Indexed: 02/01/2023]
Abstract
Schisandra chinensis (S. chinensis) is an herbal medicine used for the treatment of Alzheimer's disease (AD). The purified polysaccharide fraction, namely SCP2, was previously isolated from S. chinensis crude polysaccharide (SCP) and its structure and in vitro activity were investigated. However, the in vivo activity of SCP2 and its potential mechanism for the treatment of AD have yet to be determined. This study used a combination of microbiomics and metabolomics to comprehensively explore the microbiota and metabolic changes in AD rats under SCP2 intervention, with the aim of elucidating the potential mechanisms of SCP2 in the treatment of AD. SCP2 showed significant therapeutic effects in AD rats, as evidenced by improved learning and memory capacity, reduced neuroinflammation, and restoration of the integrity of the intestinal barrier. Fecal metabolomic and microbiomic analyses revealed that SCP2 significantly modulated 19 endogenous metabolites and reversed gut microbiota disorders in AD rats. Moreover, SCP2 significantly increased the content of short-chain fatty acid (SCFAs) in the AD rats. Correlation analysis showed a significant correlation between gut microbes, metabolites and the content of SCFAs. Collectively, these findings will provide the basis for further development of SCP2.
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Affiliation(s)
- Jun Fu
- School of Pharmaceutical Sciences, Jilin University, Changchun 130021, China.; Jilin Provincial Key Laboratory of Chinese Medicine Chemistry and Mass Spectrometry, Changchun, Institute of Applied Chemistry, Chinese Academy of Sciences & National Center of Mass Spectrometry in Changchun, Changchun, 130022, China
| | - Jixun Li
- School of Pharmaceutical Sciences, Jilin University, Changchun 130021, China.; Jilin Provincial Key Laboratory of Chinese Medicine Chemistry and Mass Spectrometry, Changchun, Institute of Applied Chemistry, Chinese Academy of Sciences & National Center of Mass Spectrometry in Changchun, Changchun, 130022, China
| | - Yuzhen Sun
- School of Pharmaceutical Sciences, Jilin University, Changchun 130021, China.; Jilin Provincial Key Laboratory of Chinese Medicine Chemistry and Mass Spectrometry, Changchun, Institute of Applied Chemistry, Chinese Academy of Sciences & National Center of Mass Spectrometry in Changchun, Changchun, 130022, China
| | - Shu Liu
- Jilin Provincial Key Laboratory of Chinese Medicine Chemistry and Mass Spectrometry, Changchun, Institute of Applied Chemistry, Chinese Academy of Sciences & National Center of Mass Spectrometry in Changchun, Changchun, 130022, China
| | - Fengrui Song
- Jilin Provincial Key Laboratory of Chinese Medicine Chemistry and Mass Spectrometry, Changchun, Institute of Applied Chemistry, Chinese Academy of Sciences & National Center of Mass Spectrometry in Changchun, Changchun, 130022, China
| | - Zhongying Liu
- School of Pharmaceutical Sciences, Jilin University, Changchun 130021, China..
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Barreto Chang OL, Possin KL, Maze M. Age-Related Perioperative Neurocognitive Disorders: Experimental Models and Druggable Targets. Annu Rev Pharmacol Toxicol 2023; 63:321-340. [PMID: 36100220 DOI: 10.1146/annurev-pharmtox-051921-112525] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
With the worldwide increase in life span, surgical patients are becoming older and have a greater propensity for postoperative cognitive impairment, either new onset or through deterioration of an existing condition; in both conditions, knowledge of the patient's preoperative cognitive function and postoperative cognitive trajectory is imperative. We describe the clinical utility of a tablet-based technique for rapid assessment of the memory and attentiveness domains required for executive function. The pathogenic mechanisms for perioperative neurocognitive disorders have been investigated in animal models in which excessive and/or prolonged postoperative neuroinflammation has emerged as a likely contender. The cellular and molecular species involved in postoperative neuroinflammation are the putative targets for future therapeutic interventions that are efficacious and do not interfere with the surgical patient's healing process.
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Affiliation(s)
- Odmara L Barreto Chang
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA;
| | - Katherine L Possin
- Memory and Aging Center, Department of Neurology, and Global Brain Health Institute, University of California San Francisco, San Francisco, California, USA
| | - Mervyn Maze
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA; .,Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA
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Ferroptosis is involved in regulating perioperative neurocognitive disorders: emerging perspectives. J Neuroinflammation 2022; 19:219. [PMID: 36068571 PMCID: PMC9450301 DOI: 10.1186/s12974-022-02570-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/09/2022] [Indexed: 11/10/2022] Open
Abstract
Since the twenty-first century, the development of technological advances in anesthesia and surgery has brought benefits to human health. However, the adverse neurological effects of perioperative-related factors (e.g., surgical trauma, anesthesia, etc.) as stressors cannot be ignored as well. The nervous system appears to be more "fragile" and vulnerable to damage in developing and aging individuals. Ferroptosis is a novel form of programmed cell death proposed in 2012. In recent years, the regulation of ferroptosis to treat cancer, immune system disorders, and neurodegenerative diseases have seen an unprecedented surge of interest. The association of ferroptosis with perioperative neurocognitive disorders has also received much attention. Cognitive impairment can not only affect the individual's quality of life, but also impose a burden on the family and society. Therefore, the search for effective preventive and therapeutic methods to alleviate cognitive impairment caused by perioperative-related factors is a challenge that needs to be urgently addressed. In our review, we first briefly describe the connection between iron accumulation in neurons and impairment of brain function during development and aging. It is followed by a review of the pathways of ferroptosis, mainly including iron metabolism, amino acid metabolism, and lipid metabolism pathway. Furthermore, we analyze the connection between ferroptosis and perioperative-related factors. The surgery itself, general anesthetic drugs, and many other relevant factors in the perioperative period may affect neuronal iron homeostasis. Finally, we summarize the experimental evidence for ameliorating developmental and degenerative neurotoxicity by modulating ferroptosis. The suppression of ferroptosis seems to provide the possibility to prevent and improve perioperative neurocognitive impairment.
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Park S, Lee JJ, Lee J, Lee JK, Byun J, Kim I, Ha JH. Lowering n-6/ n-3 Ratio as an Important Dietary Intervention to Prevent LPS-Inducible Dyslipidemia and Hepatic Abnormalities in ob/ob Mice. Int J Mol Sci 2022; 23:ijms23126384. [PMID: 35742829 PMCID: PMC9224551 DOI: 10.3390/ijms23126384] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/03/2022] [Accepted: 06/06/2022] [Indexed: 12/12/2022] Open
Abstract
Obesity is closely associated with low-grade chronic and systemic inflammation and dyslipidemia, and the consumption of omega-3 polyunsaturated fatty acids (n-3 PUFAs) may modulate obesity-related disorders, such as inflammation and dyslipidemia. An emerging research question is to understand the dietary intervention strategy that is more important regarding n-3 PUFA consumption: (1) a lower ratio of n-6/n-3 PUFAs or (2) a higher amount of n-3 PUFAs consumption. To understand the desirable dietary intervention method of n-3 PUFAs consumption, we replaced lard from the experimental diets with either perilla oil (PO) or corn oil (CO) to have identical n-3 amounts in the experimental diets. PO had a lower n-6/n-3 ratio, whereas CO contained higher amounts of PUFAs; it inherently contained relatively lower n-3 but higher n-6 PUFAs than PO. After the 12-week dietary intervention in ob/ob mice, dyslipidemia was observed in the normal chow and CO-fed ob/ob mice; however, PO feeding increased the high density lipoprotein-cholesterol (HDL-C) level; further, not only did the HDL-C level increase, the low density lipoprotein-cholesterol (LDL-C) and triglyceride (TG) levels also decreased significantly after lipopolysaccharide (LPS) injection. Consequently, extra TG accumulated in the liver and white adipose tissue (WAT) of normal chow- or CO-fed ob/ob mice after LPS injection; however, PO consumption decreased serum TG accumulation in the liver and WAT. PUFAs replacement attenuated systemic inflammation induced by LPS injection by increasing anti-inflammatory cytokines but inhibiting pro-inflammatory cytokine production in the serum and WAT. PO further decreased hepatic inflammation and fibrosis in comparison with the ND and CO. Hepatic functional biomarkers (aspartate aminotransferase (AST) and alanine transaminase (ALT) levels) were also remarkably decreased in the PO group. In LPS-challenged ob/ob mice, PO and CO decreased adipocyte size and adipokine secretion, with a reduction in phosphorylation of MAPKs compared to the ND group. In addition, LPS-inducible endoplasmic reticulum (ER) and oxidative stress decreased with consumption of PUFAs. Taken together, PUFAs from PO and CO play a role in regulating obesity-related disorders. Moreover, PO, which possesses a lower ratio of n-6/n-3 PUFAs, remarkably alleviated metabolic dysfunction in LPS-induced ob/ob mice. Therefore, an interventional trial considering the ratio of n-6/n-3 PUFAs may be desirable for modulating metabolic complications, such as inflammatory responses and ER stress in the circulation, liver, and/or WAT.
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Affiliation(s)
- Seohyun Park
- Department of Food Science and Nutrition, Dankook University, Cheonan 31116, Korea; (S.P.); (J.L.)
| | - Jae-Joon Lee
- Department of Food and Nutrition, Chosun University, Gwangju 61452, Korea;
| | - Jisu Lee
- Department of Food Science and Nutrition, Dankook University, Cheonan 31116, Korea; (S.P.); (J.L.)
| | - Jennifer K. Lee
- Food Science and Human Nutrition Department, University of Florida, Gainesville, FL 32611, USA;
| | - Jaemin Byun
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110, USA;
| | - Inyong Kim
- Food and Nutrition Department, Sunchon University, Suncheon 57922, Korea
- Correspondence: (I.K.); (J.-H.H.)
| | - Jung-Heun Ha
- Department of Food Science and Nutrition, Dankook University, Cheonan 31116, Korea; (S.P.); (J.L.)
- Research Center for Industrialization of Natural Neutralization, Dankook University, Yongin 16890, Korea
- Correspondence: (I.K.); (J.-H.H.)
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Bouabdellah M, Bensalah M, Kamoun C, Bellil M, Kooli M, Hadhri K. Advantages of three-dimensional printing in the management of acetabular fracture fixed by the Kocher-Langenbeck approach: randomised controlled trial. INTERNATIONAL ORTHOPAEDICS 2022; 46:1155-1163. [PMID: 35103815 DOI: 10.1007/s00264-022-05319-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 01/26/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE To compare the outcomes of the Kocher-Langenbeck reduction and fixation of the posterior structures of the acetabulum between 3D printing technique and conventional technique. METHODS Forty-three patients who sustained fractures of the posterior part of the acetabulum were randomly assigned to two groups: 3D printing (G1; n = 20) and conventional technique (G2; n = 23). The surgical time, intra-operative blood loss, differences between pre-and post-operative haemoglobin, universal functional and radiographic scores, and complications were compared between the groups. The minimum follow-up was 18 months. RESULTS The average operating time (120.75 min) and intra-operative blood loss (244 ml) were lower in G1 than in G2 (125.87 min and 268.7 ml, respectively; p = 0.42, p = 0.1, respectively). The difference between the pre- and post-operative haemoglobin was 1.71 g/dl in G1 and 1.93 g/dl in G2 (p = 0.113). Post-operative complications occurred more frequently in patients in G2 (34.7%) than in patients in G1 (15%), though these differences were also not significant (p = 0.6). The radiographic result was satisfactory in 16 patients (80%) in G1 and 18 patients (78.26%) in G2 (p = 0.5). The clinical result was satisfactory in 15 patients (75%) in G1 and in 17 patients (73.9%) in G2 (p = 0.6). CONCLUSIONS No significant differences were found in terms of surgical time, overall complications, and radiographic or functional outcomes between 3D printing and the conventional technique.
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Affiliation(s)
- Mohamed Bouabdellah
- Department of Orthopaedic and Traumatology of Charles Nicolle Hospital of Tunis- Tunisia, University of Tunis El Manar, Farhat Hached University Campus n ° 94, ROMMANA , 1068, Tunis, Tunisia.
- GHG-SOTCOT (Tunisian Group of Hip and Knee surgery-Tunisian Society of Orthopaedic Surgery and Traumatology, ROMMANA, Tunisia.
| | - Mohamed Bensalah
- Department of Orthopaedic and Traumatology of Charles Nicolle Hospital of Tunis- Tunisia, University of Tunis El Manar, Farhat Hached University Campus n ° 94, ROMMANA , 1068, Tunis, Tunisia
- GHG-SOTCOT (Tunisian Group of Hip and Knee surgery-Tunisian Society of Orthopaedic Surgery and Traumatology, ROMMANA, Tunisia
| | - Chrif Kamoun
- Department of Orthopaedic and Traumatology of Charles Nicolle Hospital of Tunis- Tunisia, University of Tunis El Manar, Farhat Hached University Campus n ° 94, ROMMANA , 1068, Tunis, Tunisia
| | - Mehdi Bellil
- Department of Orthopaedic and Traumatology of Charles Nicolle Hospital of Tunis- Tunisia, University of Tunis El Manar, Farhat Hached University Campus n ° 94, ROMMANA , 1068, Tunis, Tunisia
- GHG-SOTCOT (Tunisian Group of Hip and Knee surgery-Tunisian Society of Orthopaedic Surgery and Traumatology, ROMMANA, Tunisia
| | - Mondher Kooli
- Department of Orthopaedic and Traumatology of Charles Nicolle Hospital of Tunis- Tunisia, University of Tunis El Manar, Farhat Hached University Campus n ° 94, ROMMANA , 1068, Tunis, Tunisia
| | - Khaled Hadhri
- Department of Orthopaedic and Traumatology of Charles Nicolle Hospital of Tunis- Tunisia, University of Tunis El Manar, Farhat Hached University Campus n ° 94, ROMMANA , 1068, Tunis, Tunisia
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