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Freedman BR, Kuttler A, Beckmann N, Nam S, Kent D, Schuleit M, Ramazani F, Accart N, Rock A, Li J, Kurz M, Fisch A, Ullrich T, Hast MW, Tinguely Y, Weber E, Mooney DJ. Enhanced tendon healing by a tough hydrogel with an adhesive side and high drug-loading capacity. Nat Biomed Eng 2022; 6:1167-1179. [PMID: 34980903 PMCID: PMC9250555 DOI: 10.1038/s41551-021-00810-0] [Citation(s) in RCA: 81] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 09/13/2021] [Indexed: 12/14/2022]
Abstract
Hydrogels that provide mechanical support and sustainably release therapeutics have been used to treat tendon injuries. However, most hydrogels are insufficiently tough, release drugs in bursts, and require cell infiltration or suturing to integrate with surrounding tissue. Here we report that a hydrogel serving as a high-capacity drug depot and combining a dissipative tough matrix on one side and a chitosan adhesive surface on the other side supports tendon gliding and strong adhesion (larger than 1,000 J m-2) to tendon on opposite surfaces of the hydrogel, as we show with porcine and human tendon preparations during cyclic-friction loadings. The hydrogel is biocompatible, strongly adheres to patellar, supraspinatus and Achilles tendons of live rats, boosted healing and reduced scar formation in a rat model of Achilles-tendon rupture, and sustainably released the corticosteroid triamcinolone acetonide in a rat model of patellar tendon injury, reducing inflammation, modulating chemokine secretion, recruiting tendon stem and progenitor cells, and promoting macrophage polarization to the M2 phenotype. Hydrogels with 'Janus' surfaces and sustained-drug-release functionality could be designed for a range of biomedical applications.
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Affiliation(s)
- Benjamin R Freedman
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA, USA
| | - Andreas Kuttler
- Novartis Institutes for Biomedical Research, Basel, Switzerland
| | | | - Sungmin Nam
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA, USA
| | - Daniel Kent
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA, USA
| | | | | | - Nathalie Accart
- Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - Anna Rock
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA, USA
| | - Jianyu Li
- Department of Mechanical Engineering, McGill University, Montreal, Quebec, Canada
| | - Markus Kurz
- Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - Andreas Fisch
- Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - Thomas Ullrich
- Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - Michael W Hast
- Biedermann Lab for Orthopaedic Research, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Yann Tinguely
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA, USA
| | - Eckhard Weber
- Novartis Institutes for Biomedical Research, Basel, Switzerland.
| | - David J Mooney
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA.
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA, USA.
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Abstract
Approved therapies for tendon diseases have not yet changed the clinical practice of symptomatic pain treatment and physiotherapy. This review article summarizes advances in the development of novel drugs, biologic products, and biomaterial therapies for tendon diseases with perspectives for translation of integrated therapies. Shifting from targeting symptom relief toward disease modification and prevention of disease progression may open new avenues for therapies. Deep evidence-based clinical, cellular, and molecular characterization of the underlying pathology of tendon diseases, as well as therapeutic delivery optimization and establishment of multidiscipline interorganizational collaboration platforms, may accelerate the discovery and translation of transformative therapies for tendon diseases.
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Affiliation(s)
- Benjamin R. Freedman
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138, USA
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA 02115, USA
| | - David J. Mooney
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138, USA
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA 02115, USA
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de Melo Viveiros ME, Viveiros MMH, da Silva MG, Rainho CA, Schellini SA. In vitro effect of triamcinolone and platelet-rich plasma on cytokine levels of elbow lateral epicondylitis-derived cells. J Orthop Surg Res 2022; 17:94. [PMID: 35168647 PMCID: PMC8848654 DOI: 10.1186/s13018-022-02990-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 02/03/2022] [Indexed: 12/04/2022] Open
Abstract
Background The pathogenesis and treatment of lateral elbow epicondylitis (LEE) are still controversial. The purpose of the current study was to evaluate the production of inflammatory cytokines by LEE-derived cells and to compare the anti-inflammatory effect of triamcinolone acetonide with platelet-rich plasma (PRP) on cytokines production in primary culture of these cells.
Methods Third passage cells from primary cultures of LEE were assessed for the production of the cytokines IL-1β, IL-6, IL-8, IL-10 and TNF-α by immune-enzymatic assay (ELISA), after the treatment with 1, 10 and 100 μM triamcinolone compared to no treated controls at the time points 6, 12, 18, 24, 48, 72 and 96 h, and to PRP at 48, 72 and 96 h. Results The cytokines IL-6 and IL-8 were produced in high concentrations by LEE cells. One, 10 and 100 μM triamcinolone induced significant decrease in the production of IL-6 and IL-8 at 48, 72 and 96 h, adding the time point 12 h for IL-8. Compared to controls, PRP caused a significant increase in the production of IL-6 and IL-8 and there was a significant increase in IL-10 production with the use of 100 μM triamcinolone at 48 h. The production of IL1-β and TNF-α was very low and did not change when the cultures were treated with triamcinolone or PRP. Conclusion LEE-derived cells produce IL-6 and IL-8, confirming the inflammatory nature of this condition. While triamcinolone inhibited the production of IL-6 and IL-8 by LEE cells, PRP induced an increase in these cytokines compared with controls. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-022-02990-0.
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Affiliation(s)
- Márcio Eduardo de Melo Viveiros
- Department of Orthopedics and Traumatology, School of Medicine of Botucatu, São Paulo State University - UNESP, Botucatu, SP, Brazil
| | - Magda Massae Hata Viveiros
- Department of Ophthalmology, School of Medicine of Botucatu, São Paulo State University - UNESP, Botucatu, SP, 18618-970, Brazil
| | - Márcia Guimarães da Silva
- Department of Pathology, School of Medicine of Botucatu, São Paulo State University - UNESP, Botucatu, SP, Brazil
| | - Cláudia Aparecida Rainho
- Department of Chemical and Biological Sciences, Institute of Biosciences of Botucatu, São Paulo State University - UNESP, Botucatu, SP, Brazil
| | - Silvana Artioli Schellini
- Department of Ophthalmology, School of Medicine of Botucatu, São Paulo State University - UNESP, Botucatu, SP, 18618-970, Brazil.
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Mukohara S, Mifune Y, Inui A, Nishimoto H, Kurosawa T, Yamaura K, Yoshikawa T, Kuroda R. In vitro and in vivo tenocyte-protective effectiveness of dehydroepiandrosterone against high glucose-induced oxidative stress. BMC Musculoskelet Disord 2021; 22:519. [PMID: 34090401 PMCID: PMC8180149 DOI: 10.1186/s12891-021-04398-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/17/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Dehydroepiandrosterone (DHEA), an adrenal steroid, has a protective role against diabetes. This study aimed to investigate the in vitro and in vivo protective effects of DHEA against high glucose-induced oxidative stress in tenocytes and tendons. METHODS Tenocytes from normal Sprague-Dawley rats were cultured in low-glucose (LG) or high-glucose (HG) medium with or without DHEA. The experimental groups were: control group (LG without DHEA), LG with DHEA, HG without DHEA, and HG with DHEA. Reactive oxygen species (ROS) production, apoptosis, and messenger RNA (mRNA) expression of NADPH oxidase (NOX) 1 and 4, and interleukin-6 (IL-6) were determined. Further, diabetic rats were divided into a control group and a DHEA-injected group (DHEA group). NOX1 and NOX4 protein expression and mRNA expression of NOX1, NOX4, IL-6, matrix metalloproteinase (MMP)-2, tissue inhibitors of matrix metalloproteinase (TIMP)-2, and type I and III collagens in the Achilles tendon were determined. RESULTS In rat tenocytes, DHEA decreased the expression of NOX1 and IL-6, ROS accumulation, and apoptotic cells. In the diabetic rat Achilles tendon, NOX1 protein expression and mRNA expression of NOX1, IL-6, MMP-2, TIMP-2, and type III collagen were significantly lower while type I collagen expression was significantly higher in the DHEA group than in the control group. CONCLUSIONS DHEA showed antioxidant and anti-inflammatory effects both in vitro and in vivo. Moreover, DHEA improved tendon matrix synthesis and turnover, which are affected by hyperglycemic conditions. DHEA is a potential preventive drug for diabetic tendinopathy.
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Affiliation(s)
- Shintaro Mukohara
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Yutaka Mifune
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan.
| | - Atsuyuki Inui
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Hanako Nishimoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Takashi Kurosawa
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Kohei Yamaura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Tomoya Yoshikawa
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
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Qi J, Liu Q, Reisdorf RL, Boroumand S, Behfar A, Moran SL, Amadio PC, Gingery A, Zhao C. Characterization of a purified exosome product and its effects on canine flexor tenocyte biology. J Orthop Res 2020; 38:1845-1855. [PMID: 31930553 DOI: 10.1002/jor.24587] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 12/21/2019] [Indexed: 02/04/2023]
Abstract
Flexor tendon injuries and tendinopathy are very common but remain challenging in clinical treatment. Exosomes-based cell-free therapy appears to be a promising strategy for tendon healing, while limited studies have evaluated its impacts on tenocyte biology. The objective of this study was to characterize a novel purified exosome product (PEP) derived from plasma, as well as to explore its cellular effects on canine tenocyte biology. The transmission electron microscope revealed that exosomes of PEP present cup-shaped structures with the diameters ranged from 80 to 141 nm, and the NanoSight report presented that their size mainly concentrated around 100 nm. The enzyme-linked immunosorbent assay kits analysis showed that PEP was positive for CD63 and AChE expression, and the cellular uptake of exosomes internalized into tenocyte cytoplasm was observed. The cell growth assays displayed that tenocyte proliferation ability was enhanced by PEP solution in a dose-dependent manner. Tenogenic phenotype was preserved as is evident by that tendon-related genes expression (SCX, COL1A, COL3A1, TNMD, DCN, and MKX) were expressed insistently in a high level, while tenocytes were treated with 5% PEP solution. Furthermore, migration capability was maintained and total collagen deposition was increased. More interesting, dexamethasone-induced cellular apoptosis was attenuated during the incubation of tenocytes with a 5% PEP solution. These findings will provide the basic understandings about the PEP, and support the potential use of this biological strategy for tendon healing.
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Affiliation(s)
- Jun Qi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qian Liu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, China
| | | | - Soulmaz Boroumand
- Division of Cardiovascular Diseases and Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Atta Behfar
- Division of Cardiovascular Diseases and Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Steven L Moran
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Peter C Amadio
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Anne Gingery
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Chunfeng Zhao
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Abd El-Rahman GI, Behairy A, Elseddawy NM, Batiha GES, Hozzein WN, Khodeer DM, M. Abd-Elhakim Y. Saussurea lappa Ethanolic Extract Attenuates Triamcinolone Acetonide-Induced Pulmonary and Splenic Tissue Damage in Rats via Modulation of Oxidative Stress, Inflammation, and Apoptosis. Antioxidants (Basel) 2020; 9:antiox9050396. [PMID: 32397156 PMCID: PMC7278611 DOI: 10.3390/antiox9050396] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/26/2020] [Accepted: 04/27/2020] [Indexed: 12/12/2022] Open
Abstract
Background: In this era, worldwide interest has been directed towards using natural antioxidants to guard against drug side effects. Saussurea lappa is a famous medicinal plant with many biologically active compounds. Triamcinolone acetonide (TA) is an extensively used glucocorticoid. Hence, this study explored, for the first time, the possible beneficial effects of S. lappa ethanolic extract on TA-induced oxidative damage in the lung and spleen of rats. Methods: Five experimental groups were used: control group, S. lappa-treated group (600 mg/kg/day, orally), TA-treated group (40 mg/kg/twice/week I/P), S. lappa + TA co-treated group, and S. lappa/TA prophylactic group. Results: TA exposure significantly induced leukocytosis and neutrophilia. In addition, TA significantly reduced the levels of C-reactive protein, interleukin-12, tumor necrosis factor α, and immunoglobulins. Lung Caspase-3 overexpression and splenic CD8+ downregulation were also noted in the TA group. TA treatment significantly increased malondialdehyde concentration but reduced superoxide dismutase and glutathione peroxidase activities. S. lappa counteracted the TA oxidative and apoptotic effects. The best results were recorded in the prophylactic group. Conclusions:S. lappa has a remarkable protective effect via its anti-inflammatory, anti-apoptotic, and antioxidant capacity. Thus, it could be a candidate as a natural antioxidant to face glucocorticoid’s harmful side effects.
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Affiliation(s)
- Ghada I. Abd El-Rahman
- Department of Clinical Pathology, Faculty of Veterinary medicine, Zagazig University, Zagazig 44519, Egypt;
| | - Amany Behairy
- Department of Physiology, Faculty of Veterinary Medicine, Zagazig University, Zagazig 44519, Egypt;
| | - Nora M. Elseddawy
- Department of Pathology, Faculty of Veterinary medicine, Zagazig University, Zagazig 44519 Egypt;
| | - Gaber El-Saber Batiha
- Department of Pharmacology and Therapeutics, Faculty of Veterinary Medicine, Damanhour University, Damanhour 22511, AlBeheira, Egypt;
- National Research Center for Protozoan Diseases, Obihiro University of Agriculture and Veterinary Medicine, Nishi 2-13, Inada-cho, Obihiro, Hokkaido 080-8555, Japan
| | - Wael N. Hozzein
- Bioproducts Research Chair, Zoology Department, College of Science, King Saud University, Riyadh 11451, Saudi Arabia;
- Botany and Microbiology Department, Faculty of Science, Beni-Suef University, Beni-Suef 62511, Egypt
| | - Dina M. Khodeer
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Suez Canal University, Ismailia 41522, Egypt;
| | - Yasmina M. Abd-Elhakim
- Department of Forensic Medicine and Toxicology, Faculty of Veterinary Medicine, Zagazig University, Zagazig 44519, Egypt
- Correspondence:
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Puzzitiello RN, Patel BH, Nwachukwu BU, Allen AA, Forsythe B, Salzler MJ. Adverse Impact of Corticosteroid Injection on Rotator Cuff Tendon Health and Repair: A Systematic Review. Arthroscopy 2020; 36:1468-1475. [PMID: 31862292 DOI: 10.1016/j.arthro.2019.12.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 12/08/2019] [Accepted: 12/08/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess adverse effects of preoperative corticosteroid injections (CSIs) in patients with rotator cuff disease, especially before rotator cuff repair (RCR). METHODS A systematic review of the MEDLINE database was performed according to guidelines from the Preferred Reporting Item for Systematic Reviews and Meta-Analyses for all studies reporting on adverse clinical effects of CSIs on rotator cuff tendon. RESULTS A total of 8 articles were identified that report on adverse outcomes and risks associated with corticosteroid injections in the setting of rotator cuff tendinosis. Among these included articles, a single CSI for rotator cuff tendinosis was associated with increased risk of revision rotator cuff repair (odds ratio [OR]: range 1.3 [1.1-1.7] to 2.8 [2.2-3.4]) when administered up to a year before surgery and postoperative infections (OR: 2.1 [1.5-2.7]) when administered within a month before RCR. The risk of adverse outcomes after rotator cuff repair are greatest if a CSI is administered within 6 months of surgery (OR: 1.8 [1.3-2.6]) or if ≥2 injections are given within a year of surgery (OR: range 2.1 [1.8-2.5] to 3.3 [2.7-4.0]). CONCLUSION Several recent clinical trials have demonstrated that CSIs are correlated with increased risk of revision surgery after RCR in a temporal and dose dependent matter. Caution should be taken when deciding to inject a patient, and this treatment should be withheld if an RCR is to be performed within the following 6 months. LEVEL OF EVIDENCE IV, systematic review of Level III and IV studies.
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Adverse Impact of Corticosteroids on Rotator Cuff Tendon Health and Repair: A Systematic Review of Basic Science Studies. Arthrosc Sports Med Rehabil 2020; 2:e161-e169. [PMID: 32368753 PMCID: PMC7190543 DOI: 10.1016/j.asmr.2020.01.002] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 01/13/2020] [Indexed: 11/22/2022] Open
Abstract
Purpose To evaluate the in vitro effects of corticosteroid injections (CSIs) on rotator cuff tendon (RCT). Methods A systematic review of the MEDLINE database was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for all studies reporting on adverse biochemical and biomechanical effects of CSIs on RCT. Results Sixteen studies were identified that had been published in the last 15 years on the effects of corticosteroids on RCTs. Eight of these studies were on human RCTs, 6 were on rat tendons, 1 considered both human and rat tendons, and 1 was on dog tendon. Five studies analyzed the effects of corticosteroids on the biomechanical properties of RCT or rotator cuff repair, whereas the remaining observed the cellular and molecular effects of CSIs on RCT. Corticosteroids suppress an inflammatory response, induce apoptosis, and have negative effects on collagen and tendon cell viability in RCTs. The mechanical properties, including load to failure of RCTs and rotator cuff repair anchor pull-out strength, also are decreased by CSIs. These in vitro effects appear to be transient as well as frequency and dose dependent. Conclusions On a molecular level, CSIs decrease cellular proliferation, alter collagen and extracellular matrix composition, impede inflammatory pathways, decrease cellular viability, increase adipocyte differentiation, and increase apoptosis. These changes can be seen as early as 24 hours after corticosteroid exposure, last as long as 2 to 3 weeks, and are exacerbated by increased doses and decreased latency between doses. Biomechanical studies demonstrate that these changes result in decreased maximal load to failure, tendon stiffness, and suture anchor pull-out strength in rat shoulders up to 2 weeks but not at 3 and 4 weeks, post-CSI. Clinical Relevance Shoulder subacromial steroid injection is common, and practitioners should be aware of results both positive and deleterious.
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Tanaka T, Ogawa T, Yanai T, Okano E, Kohyama S, Ochiai N. Disruption of Flexor Tendon after Intrasheath Triamcinolone Acetonide Injection for Trigger Digits: Two Case Reports. J Hand Surg Asian Pac Vol 2019; 22:380-383. [PMID: 28774233 DOI: 10.1142/s0218810417720285] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We experienced two cases of flexor tendons rupture after triamcinolone acetate (TA) injection for trigger finger. A 45-year-old man underwent injection of 40 mg of TA and 1 mL of 1% lidocaine solution into his little finger. While playing golf 3 months after the injection, he heard a popping sound, and was unable to flex it. A 57-year-old female nurse had undergone injection of 40 mg of TA and 1 mL of 1% lidocaine solution into her thumb twice at a 2-month interval. Two months after the second injection, she was unable to flex it. Both cases had high concentrated TA injection at trigger digits. The present and previous cases illustrate that when TA is injected into trigger digits, the dose should be low, the safety interval should be long, and refuse injection into the tendon proper.
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Affiliation(s)
- Toshikazu Tanaka
- 1 Department of Orthopedic Surgery, Kikkoman General Hospital, Chiba, Japan
| | - Takeshi Ogawa
- 1 Department of Orthopedic Surgery, Kikkoman General Hospital, Chiba, Japan
| | - Takaji Yanai
- 1 Department of Orthopedic Surgery, Kikkoman General Hospital, Chiba, Japan
| | - Eriko Okano
- 1 Department of Orthopedic Surgery, Kikkoman General Hospital, Chiba, Japan
| | - Sho Kohyama
- 1 Department of Orthopedic Surgery, Kikkoman General Hospital, Chiba, Japan
| | - Naoyuki Ochiai
- 1 Department of Orthopedic Surgery, Kikkoman General Hospital, Chiba, Japan
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Ramírez JP, Bonati-Richardson F, García MP, Hidalgo C, Stoore C, Liendo R, Soza F, Landerer E, Paredes R. Intra-articular treatment with corticosteroids increases apoptosis in human rotator cuff tears. Connect Tissue Res 2019; 60:283-290. [PMID: 30091643 DOI: 10.1080/03008207.2018.1501040] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE The aim of this study is to evaluate in vivo the level of apoptosis in human rotator cuff tears and the relationship it might have with tendon degeneration. METHODS Rotator cuff biopsies from 19 male and female patients, ages between 38 and 68 years, with and without previous corticosteroid infiltrations were collected via arthroscopy. Biopsies from seven patients with healthy rotator cuffs were used as a control group. An in situ terminal deoxynucleotidyl transferase dUTP nick end labeling assay was performed to detect the level of apoptosis, which was expressed as a percentage of apoptotic cells (PAC). RESULTS PAC in patients with corticosteroid infiltrations was 76.97 ± 16.99 in all tendon rupture zones, in non-infiltrated patients was 35.89 ± 22.96, whereas in control patients was 14.48 ± 8.15. Likewise, the tendency of PAC reveals that apoptosis in control and non-infiltrated groups was different and dispersed in all tear zones; while in corticosteroid treated patients, the tendency was similar in all rupture sites. CONCLUSIONS This investigation leads us to conclude that the administration of corticosteroid is associated with a higher amount of apoptosis at the insertion site of the rotator cuff (rupture edge).
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Affiliation(s)
- Juan Pablo Ramírez
- a Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida , Universidad Andres Bello , Santiago , Chile
| | - Francesca Bonati-Richardson
- a Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida , Universidad Andres Bello , Santiago , Chile
| | - María Pía García
- a Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida , Universidad Andres Bello , Santiago , Chile
| | - Christian Hidalgo
- a Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida , Universidad Andres Bello , Santiago , Chile
| | - Caroll Stoore
- a Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida , Universidad Andres Bello , Santiago , Chile
| | - Rodrigo Liendo
- b Departamento Traumatología y Ortopedia, Facultad de Medicina , Pontificia Universidad Catolica de Chile , Santiago , Chile
| | - Francisco Soza
- b Departamento Traumatología y Ortopedia, Facultad de Medicina , Pontificia Universidad Catolica de Chile , Santiago , Chile
| | - Eduardo Landerer
- c Escuela de Medicina, Facultad de Medicina , Universidad Andres Bello , Santiago , Chile
| | - Rodolfo Paredes
- a Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida , Universidad Andres Bello , Santiago , Chile
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Busse P, Vater C, Stiehler M, Nowotny J, Kasten P, Bretschneider H, Goodman SB, Gelinsky M, Zwingenberger S. Cytotoxicity of drugs injected into joints in orthopaedics. Bone Joint Res 2019; 8:41-48. [PMID: 30915209 PMCID: PMC6397327 DOI: 10.1302/2046-3758.82.bjr-2018-0099.r1] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objectives Intra-articular injections of local anaesthetics (LA), glucocorticoids (GC), or hyaluronic acid (HA) are used to treat osteoarthritis (OA). Contrast agents (CA) are needed to prove successful intra-articular injection or aspiration, or to visualize articular structures dynamically during fluoroscopy. Tranexamic acid (TA) is used to control haemostasis and prevent excessive intra-articular bleeding. Despite their common usage, little is known about the cytotoxicity of common drugs injected into joints. Thus, the aim of our study was to investigate the effects of LA, GC, HA, CA, and TA on the viability of primary human chondrocytes and tenocytes in vitro. Methods Human chondrocytes and tenocytes were cultured in a medium with three different drug dilutions (1:2; 1:10; 1:100). The following drugs were used to investigate cytotoxicity: lidocaine hydrochloride 1%; bupivacaine 0.5%; triamcinolone acetonide; dexamethasone 21-palmitate; TA; iodine contrast media; HA; and distilled water. Normal saline served as a control. After an incubation period of 24 hours, cell numbers and morphology were assessed. Results Using LA or GC, especially triamcinolone acetonide, a dilution of 1:100 resulted in only a moderate reduction of viability, while a dilution of 1:10 showed significantly fewer cell counts. TA and CA reduced viability significantly at a dilution of 1:2. Higher dilutions did not affect viability. Notably, HA showed no effects of cytotoxicity in all drug dilutions. Conclusion The toxicity of common intra-articular injectable drugs, assessed by cell viability, is mainly dependent on the dilution of the drug being tested. LA are particularly toxic, whereas HA did not affect cell viability. Cite this article: P. Busse, C. Vater, M. Stiehler, J. Nowotny, P. Kasten, H. Bretschneider, S. B. Goodman, M. Gelinsky, S. Zwingenberger. Cytotoxicity of drugs injected into joints in orthopaedics. Bone Joint Res 2019;8:41–48. DOI: 10.1302/2046-3758.82.BJR-2018-0099.R1.
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Affiliation(s)
- P Busse
- University Center for Orthopaedics and Traumatology, and Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
| | - C Vater
- University Center for Orthopaedics and Traumatology, and Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
| | - M Stiehler
- University Center for Orthopaedics and Traumatology, and Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
| | - J Nowotny
- University Center for Orthopaedics and Traumatology, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
| | - P Kasten
- Orthopädisch-Chirurgisches Centrum Tübingen, Tübingen, Germany
| | - H Bretschneider
- University Center for Orthopaedics and Traumatology, and Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
| | - S B Goodman
- Departments of Orthopaedic Surgery and Bioengineering, Stanford University, Stanford, California, USA
| | - M Gelinsky
- Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
| | - S Zwingenberger
- University Center for Orthopaedics and Traumatology, and Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
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12
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Weber AE, Trasolini NA, Mayer EN, Essilfie A, Vangsness CT, Gamradt SC, Tibone JE, Kang HP. Injections Prior to Rotator Cuff Repair Are Associated With Increased Rotator Cuff Revision Rates. Arthroscopy 2019; 35:717-724. [PMID: 30733024 DOI: 10.1016/j.arthro.2018.10.116] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 10/21/2018] [Accepted: 10/24/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE To determine whether shoulder injections prior to rotator cuff repair (RCR) are associated with deleterious surgical outcomes. METHODS Two large national insurance databases were used to identify a total of 22,156 patients who received ipsilateral shoulder injections prior to RCR. They were age, sex, obesity, smoking status, and comorbidity matched to a control group of patients who underwent RCR without prior injections. The 2 groups were compared regarding RCR revision rates. RESULTS Patients who received injections prior to RCR were more likely to undergo RCR revision than matched controls (odds ratio [OR], 1.52; 95% confidence interval [CI], 1.38-1.68; P < .0001). Patients who received injections closer to the time of index RCR were more likely to undergo revision (P < .0001). Patients who received a single injection prior to RCR had a higher likelihood of revision (OR, 1.25; 95% CI, 1.10-1.43; P = .001). Patients who received 2 or more injections prior to RCR had a greater than 2-fold odds of revision (combined OR, 2.12; 95% CI, 1.82-2.47; P < .0001) versus the control group. CONCLUSIONS This study strongly suggests a correlation between preoperative shoulder injections and revision RCR. There is also a frequency dependence and time dependence to this finding, with more frequent injections and with administration of injections closer to the time of surgery both independently associated with higher revision RCR rates. Presently, on the basis of this retrospective database study, orthopaedic surgeons should exercise due caution regarding shoulder injections in patients whom they are considering to be surgical candidates for RCR. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Alexander E Weber
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A..
| | - Nicholas A Trasolini
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Erik N Mayer
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Anthony Essilfie
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - C Thomas Vangsness
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Seth C Gamradt
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - James E Tibone
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Hyunwoo Paco Kang
- Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, U.S.A
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13
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Traven SA, Brinton D, Simpson KN, Adkins Z, Althoff A, Palsis J, Slone HS. Preoperative Shoulder Injections Are Associated With Increased Risk of Revision Rotator Cuff Repair. Arthroscopy 2019; 35:706-713. [PMID: 30733035 DOI: 10.1016/j.arthro.2018.10.107] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 10/13/2018] [Accepted: 10/21/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The goal of this study was to determine whether the timing of preoperative shoulder injections is associated with an increased risk of revision rotator cuff repair following primary rotator cuff repair (RCR). METHODS A retrospective analysis of claims data of privately insured subjects from the MarketScan database for the years 2010 to 2014 was conducted. Multivariable logistic regression models were used to compare the odds of reoperation between groups. Laterality for the injection, index procedure, and subsequent surgery were verified for all subjects. RESULTS A total of 4,959 subjects with an arthroscopic RCR were identified, 392 of whom required revision RCR within the following 3 years. Patients who had an injection within 6 months preceding the index surgery were at a much higher risk of undergoing reoperation for revision RCR: 0 to 3 months prior, adjusted odds ratio (AOR) 1.375 (95% confidence interval [CI], 1.027-1.840); 3 to 6 months prior, AOR 1.822 (95% CI, 1.290-2.573); and 6 to 12 months prior, AOR 1.237 (95% CI, 0.787-1.943). CONCLUSIONS Patients who had received an injection within 6 months prior to RCR were much more likely to undergo a revision cuff repair within the following 3 years. The risk of reoperation significantly declines if there is more than 6 months between injection and RCR. Consideration should be given to minimizing preoperative injections in patients requiring RCR or delaying primary RCR for 6 months following injection. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Sophia A Traven
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina, U.S.A..
| | - Daniel Brinton
- Department of Healthcare Leadership and Management College of Health Professions, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Kit N Simpson
- Department of Healthcare Leadership and Management College of Health Professions, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Zachary Adkins
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Alyssa Althoff
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - John Palsis
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Harris S Slone
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina, U.S.A
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14
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Ueda Y, Inui A, Mifune Y, Sakata R, Muto T, Harada Y, Takase F, Kataoka T, Kokubu T, Kuroda R. The effects of high glucose condition on rat tenocytes in vitro and rat Achilles tendon in vivo. Bone Joint Res 2018; 7:362-372. [PMID: 29922457 PMCID: PMC5987694 DOI: 10.1302/2046-3758.75.bjr-2017-0126.r2] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Objectives The aim of this study was to investigate the effect of hyperglycaemia on oxidative stress markers and inflammatory and matrix gene expression within tendons of normal and diabetic rats and to give insights into the processes involved in tendinopathy. Methods Using tenocytes from normal Sprague-Dawley rats, cultured both in control and high glucose conditions, reactive oxygen species (ROS) production, cell proliferation, messenger RNA (mRNA) expression of NADPH oxidase (NOX) 1 and 4, interleukin-6 (IL-6), matrix metalloproteinase (MMP)-2, tissue inhibitors of matrix metalloproteinase (TIMP)-1 and -2 and type I and III collagens were determined after 48 and 72 hours in vitro. In an in vivo study, using diabetic rats and controls, NOX1 and 4 expressions in Achilles tendon were also determined. Results In tenocyte cultures grown under high glucose conditions, gene expressions of NOX1, MMP-2, TIMP-1 and -2 after 48 and 72 hours, NOX4 after 48 hours and IL-6, type III collagen and TIMP-2 after 72 hours were significantly higher than those in control cultures grown under control glucose conditions. Type I collagen expression was significantly lower after 72 hours. ROS accumulation was significantly higher after 48 hours, and cell proliferation after 48 and 72 hours was significantly lower in high glucose than in control glucose conditions. In the diabetic rat model, NOX1 expression within the Achilles tendon was also significantly increased. Conclusion This study suggests that high glucose conditions upregulate the expression of mRNA for NOX1 and IL-6 and the production of ROS. Moreover, high glucose conditions induce an abnormal tendon matrix expression pattern of type I collagen and a decrease in the proliferation of rat tenocytes. Cite this article: Y. Ueda, A. Inui, Y. Mifune, R. Sakata, T. Muto, Y. Harada, F. Takase, T. Kataoka, T. Kokubu, R. Kuroda. The effects of high glucose condition on rat tenocytes in vitro and rat Achilles tendon in vivo. Bone Joint Res 2018;7:362–372. DOI: 10.1302/2046-3758.75.BJR-2017-0126.R2
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Affiliation(s)
- Y Ueda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - A Inui
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Y Mifune
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - R Sakata
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - T Muto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Y Harada
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - F Takase
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - T Kataoka
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - T Kokubu
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - R Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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15
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Osti L, Buda M, Del Buono A, Osti R, Massari L, Maffulli N. Apoptosis and rotator cuff tears: scientific evidence from basic science to clinical findings. Br Med Bull 2017; 122:123-133. [PMID: 28369181 DOI: 10.1093/bmb/ldx008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 03/08/2017] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Excessive apoptosis has been hypothesized as possible cause of tendinopathy and tear in the tendons of the rotator cuff (RC). Different mechanisms and molecules play a key role in cell regulation. Biological interventions can affect the process of apoptosis to control the tendinopathy process, and may be useful to design new treatments. SOURCE OF DATA We identified basic science, in vitro and in vivo preclinical and clinical studies listed in the Pubmed Google Scholar, CINAHL, Cochrane Central and Embase Biomedical databases in English, Spanish, Italian and French concerning the effects of apoptosis on RC tendons. AREAS OF AGREEMENT The homeostasis between the apoptotic and inflammatory processes is dynamic and controlled by pro- and anti-apoptotic mechanisms and signals, with variable balance in different areas of the RC tendons in human specimens. AREAS OF CONTROVERSY Apoptosis can be identified along the whole tendon, not only in the area of the lesion. Therefore, it is not necessary to undertake wide debridement of the torn edges of the tendon when undertaking a repair. GROWING POINTS The identification of the various factors that control apoptosis and its mechanisms can help to design new treatments and exert positive effects in the recovery from tendon tears. AREAS TIMELY FOR DEVELOPING RESEARCH Further studies are needed to produce clear guidelines to determine how to balance the apoptosis process to reduce the failed healing response found in non-traumatic RC tears.
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Affiliation(s)
- Leonardo Osti
- Unit of Arthroscopy and Sports Medicine, Hesperia Hospital, Via Arqua', Modena, Italy
| | - Matteo Buda
- Department of Trauma and Orthopaedic Surgery, University of Ferrara, S.Anna Hospital, Via Aldo Moro, Ferrara, Italy
| | - Angelo Del Buono
- Department of Orthopedic and Trauma Surgery, Fidenza Hospital, Via Tincati, Fidenza, Italy
| | - Raffaella Osti
- Department of Trauma and Orthopaedic Surgery, University of Ferrara, S.Anna Hospital, Via Aldo Moro, Ferrara, Italy
| | - Leo Massari
- Department of Trauma and Orthopaedic Surgery, University of Ferrara, S.Anna Hospital, Via Aldo Moro, Ferrara, Italy
| | - Nicola Maffulli
- Department of Trauma and Orthopaedic Surgery, University of Salerno, Italy.,Centre for Sports and Exercise Medicine Queen Mary University of London Barts and The London School of Medicine and Dentistry, Mile End Hospital London, UK
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16
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Muto T, Kokubu T, Mifune Y, Inui A, Sakata R, Harada Y, Takase F, Kurosaka M. Effects of platelet-rich plasma and triamcinolone acetonide on interleukin-1ß-stimulated human rotator cuff-derived cells. Bone Joint Res 2016; 5:602-609. [PMID: 27965219 PMCID: PMC5227058 DOI: 10.1302/2046-3758.512.2000582] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 09/13/2016] [Indexed: 12/13/2022] Open
Abstract
Objectives Triamcinolone acetonide (TA) is widely used for the treatment of rotator cuff injury because of its anti-inflammatory properties. However, TA can also produce deleterious effects such as tendon degeneration or rupture. These harmful effects could be prevented by the addition of platelet-rich plasma (PRP), however, the anti-inflammatory and anti-degenerative effects of the combined use of TA and PRP have not yet been made clear. The objective of this study was to determine how the combination of TA and PRP might influence the inflammation and degeneration of the rotator cuff by examining rotator cuff-derived cells induced by interleukin (IL)-1ß. Methods Rotator cuff-derived cells were seeded under inflammatory stimulation conditions (with serum-free medium with 1 ng/ml IL-1ß for three hours), and then cultured in different media: serum-free (control group), serum-free + TA (0.1mg/ml) (TA group), serum-free + 10% PRP (PRP group), and serum-free + TA (0.1mg/ml) + 10% PRP (TA+PRP group). Cell morphology, cell viability, and expression of inflammatory and degenerative mediators were assessed. Results Exposure to TA significantly decreased cell viability and changed the cell morphology; these effects were prevented by the simultaneous administration of PRP. Compared with the control group, expression levels of inflammatory genes and reactive oxygen species production were reduced in the TA, PRP, and TA+PRP groups. PRP significantly decreased the expression levels of degenerative marker genes. Conclusions The combination of TA plus PRP exerts anti-inflammatory and anti-degenerative effects on rotator cuff-derived cells stimulated by IL-1ß. This combination has the potential to relieve the symptoms of rotator cuff injury. Cite this article: T. Muto, T. Kokubu, Y. Mifune, A. Inui, R. Sakata, Y. Harada, F. Takase, M. Kurosaka. Effects of platelet-rich plasma and triamcinolone acetonide on interleukin-1ß-stimulated human rotator cuff-derived cells. Bone Joint Res 2016;5:602–609. DOI: 10.1302/2046-3758.512.2000582.
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Affiliation(s)
- T Muto
- Department of Orthopedic Surgery, Kobe University Graduate School of Medicine, Kobe City, Japan
| | - T Kokubu
- Department of Orthopedic Surgery, Kobe University Graduate School of Medicine, Kobe City, Japan
| | - Y Mifune
- Department of Orthopedic Surgery, Kobe University Graduate School of Medicine, Kobe City, Japan
| | - A Inui
- Department of Orthopedic Surgery, Kobe University Graduate School of Medicine, Kobe City, Japan
| | - R Sakata
- Department of Orthopedic Surgery, Kobe University Graduate School of Medicine, Kobe City, Japan
| | - Y Harada
- Department of Orthopedic Surgery, Kobe University Graduate School of Medicine, Kobe City, Japan
| | - F Takase
- Department of Orthopedic Surgery, Kobe University Graduate School of Medicine, Kobe City, Japan
| | - M Kurosaka
- Department of Orthopedic Surgery, Kobe University Graduate School of Medicine, Kobe City, Japan
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17
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Affiliation(s)
- I R Murray
- Department of Orthopaedics, The University of Edinburgh, Chancellors Building, Little France Crescent, Edinburgh, EH16 4SB, UK
| | - R F LaPrade
- Steadman Philippon Research Institute, Vail, Colorado, USA
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