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Schmid T, Wegener F, Hotfiel T, Hoppe MW. Moderate evidence exists for four microRNAs as potential biomarkers for tendinopathies and degenerative tendon ruptures at the upper extremity in elderly patients: conclusion of a systematic review with best-evidence synthesis. J Exp Orthop 2023; 10:81. [PMID: 37563331 PMCID: PMC10415244 DOI: 10.1186/s40634-023-00645-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/22/2023] [Indexed: 08/12/2023] Open
Abstract
PURPOSE The aim of this systematic review was to investigate tendon-specific microRNAs (miRNAs) as biomarkers for the detection of tendinopathies or degenerative tendon ruptures. Also, their regulatory mechanisms within the tendon pathophysiology were summarized. METHODS A systematic literature research was performed using the PRISMA guidelines. The search was conducted in the Pubmed database. The SIGN checklist was used to assess the study quality of the included original studies. To determine the evidence and direction of the miRNA expression rates, a best-evidence synthesis was carried out, whereby only studies with at least a borderline methodological quality were considered for validity purposes. RESULTS Three thousand three hundred seventy studies were reviewed from which 22 fulfilled the inclusion criteria. Moderate evidence was found for miR-140-3p and miR-425-5p as potential biomarkers for tendinopathies as well as for miR-25-3p, miR-29a-3p, miR-140-3p, and miR-425-5p for the detection of degenerative tendon ruptures. This evidence applies to tendons at the upper extremity in elderly patients. All miRNAs were associated with inflammatory cytokines as interleukin-6 or interleukin-1ß and tumor necrosis factor alpha. CONCLUSIONS Moderate evidence exists for four miRNAs as potential biomarkers for tendinopathies and degenerative tendon ruptures at the upper extremity in elderly patients. The identified miRNAs are associated with inflammatory processes.
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Affiliation(s)
- Tristan Schmid
- Movement and Training Science, Leipzig University, Jahnallee 59, 04109, Leipzig, Germany.
| | - Florian Wegener
- Movement and Training Science, Leipzig University, Jahnallee 59, 04109, Leipzig, Germany
| | - Thilo Hotfiel
- Center for Musculoskeletal Surgery Osnabrück (OZMC), Klinikum Osnabrück, Am Finkenhügel 1, 49076, Osnabrueck, Germany
| | - Matthias W Hoppe
- Movement and Training Science, Leipzig University, Jahnallee 59, 04109, Leipzig, Germany
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Papalia GF, Franceschetti E, Giurazza G, Parisi FR, Gregori P, Zampogna B, Longo UG, Papalia R. MicroRNA expression changes in the development of rotator cuff tendon injuries. JSES REVIEWS, REPORTS, AND TECHNIQUES 2023; 3:343-349. [PMID: 37588508 PMCID: PMC10426526 DOI: 10.1016/j.xrrt.2023.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Traumatic or degenerative rotator cuff (RC) tendon injuries are a leading cause of persistent shoulder pain and reduction of mobility with associated disability and dysfunction, which require each year more than 250,000 surgical repairs in the United States. MicroRNAs (miRNAs) are small noncoding RNAs, that in the posttranscriptional phase lead to the development and function of tissues. The aim of this review was to identify miRNA expression changes in patients with RC pathologies and to determine their relevance as a potential novel diagnostic and potentially therapeutic tool for RC disorders. Various miRNAs seemed to be key regulators in the muscle architecture, determining several modifications in muscle atrophy, skeletal muscle mechanical adaptation, lipid accumulation, and fibrosis in the presence of RC tears. The search was executed using PubMed, Medline, Scopus, and Cochrane Central. We included studies written in English that evaluated the role of miRNA in diagnosis, physiopathology, and potential therapeutic application of RC tendon injuries. We included 11 studies in this review. Many miRNAs emerged as key regulators in the pathogenesis of RC tears, inflammation, and muscle fatty degeneration. In fact, they are involved in the regulation of myogenesis, inflammatory cytokines, metalloproteases expression, muscle adaptation, adipogenesis, fibrogenic factors, and extracellular matrix synthesis. The gene expression may be altered in the pathological processes of tendon lesions. Therefore, the knowledge of all the gene mechanisms underlying RC tendinopathy should be achieved with future diagnostic and clinical studies.
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Affiliation(s)
- Giuseppe Francesco Papalia
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Edoardo Franceschetti
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Giancarlo Giurazza
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Francesco Rosario Parisi
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Pietro Gregori
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Biagio Zampogna
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Umile Giuseppe Longo
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Rocco Papalia
- Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy
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Ribbans WJ, September AV, Collins M. Tendon and Ligament Genetics: How Do They Contribute to Disease and Injury? A Narrative Review. Life (Basel) 2022; 12:life12050663. [PMID: 35629331 PMCID: PMC9147569 DOI: 10.3390/life12050663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 04/24/2022] [Accepted: 04/26/2022] [Indexed: 12/15/2022] Open
Abstract
A significant proportion of patients requiring musculoskeletal management present with tendon and ligament pathology. Our understanding of the intrinsic and extrinsic mechanisms that lead to such disabilities is increasing. However, the complexity underpinning these interactive multifactorial elements is still not fully characterised. Evidence highlighting the genetic components, either reducing or increasing susceptibility to injury, is increasing. This review examines the present understanding of the role genetic variations contribute to tendon and ligament injury risk. It examines the different elements of tendon and ligament structure and considers our knowledge of genetic influence on form, function, ability to withstand load, and undertake repair or regeneration. The role of epigenetic factors in modifying gene expression in these structures is also explored. It considers the challenges to interpreting present knowledge, the requirements, and likely pathways for future research, and whether such information has reached the point of clinical utility.
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Affiliation(s)
- William J. Ribbans
- School of Health, The University of Northampton, Northampton NN1 5PH, UK
- The County Clinic, Northampton NN1 5DB, UK
- Correspondence: ; Tel.: +44-1604-795414
| | - Alison V. September
- Division of Physiological Sciences, Department of Human Biology, Health Sciences Faculty, University of Cape Town, Cape Town 7700, South Africa; (A.V.S.); (M.C.)
- Health Through Physical Activity, Lifestyle and Sport Research Centre (HPALS), Department of Human Biology, Health Sciences Faculty, University of Cape Town, Cape Town 7700, South Africa
- International Federation of Sports Medicine (FIMS), Collaborative Centre of Sports Medicine, Department of Human Biology, University of Cape Town, Cape Town 7700, South Africa
| | - Malcolm Collins
- Division of Physiological Sciences, Department of Human Biology, Health Sciences Faculty, University of Cape Town, Cape Town 7700, South Africa; (A.V.S.); (M.C.)
- Health Through Physical Activity, Lifestyle and Sport Research Centre (HPALS), Department of Human Biology, Health Sciences Faculty, University of Cape Town, Cape Town 7700, South Africa
- International Federation of Sports Medicine (FIMS), Collaborative Centre of Sports Medicine, Department of Human Biology, University of Cape Town, Cape Town 7700, South Africa
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Pradeepa, Suresh V, Singh VK, Nayak KB, Senapati S, Chakraborty S. EVI1 promotes metastasis by downregulating TIMP2 in metastatic colon and breast cancer cells. Int J Biochem Cell Biol 2022; 142:106118. [PMID: 34800694 DOI: 10.1016/j.biocel.2021.106118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/30/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
Ecotropic viral integration site-1 (EVI1) is an oncogenic zinc finger transcription factor whose expression is frequently upregulated in a variety of cancers, including both myeloid malignancies and solid tumors. Previously, our group has shown that EVI1 knockdown minimizes the metastatic potential of colon cancer cells compared to that of control cells. In this study, to identify the potential targets that regulate cancer metastasis, control and EVI1 knockdown colon cancer cells were subjected to microarray. Differential gene expression analysis revealed significant downregulation of tissue inhibitor of matrix metalloproteinase-2 (TIMP2) in EVI1 expressing cells. EVI1 knockdown increased TIMP2 protein expression levels and reduced wound healing and migration capacity in metastatic cells. Mechanistically, the TIMP2 promoter harbors potential binding sites for EVI1; EVI1 binds to TIMP2 promoter and represses its expression, as observed using ChIP and luciferase assay, respectively. TIMP2 is an important metastasis suppressor gene; however, its function is suppressed in many cancers through hypermethylation. Thus, demethylation could prove to be a potential alternative to reactivate TIMP2 functional activity. Immunoprecipitation analysis showed that DNA-methyltransferase 1 (DNMT1), which plays a vital role in maintaining the genome methylation pattern during DNA replication and repair, interacts with EVI1 to promote TIMP2 silencing. Treating cancer cells in vitro with a known demethylation agent, 5-aza-2'-deoxycytidine (Aza-D), restored the optimal TIMP2 expression without altering EVI1 binding efficiency and reduced relative wound healing potential of cancer cells. Animal studies showed that Aza-D treated cells injected through the intravenous route exhibited reduced liver and skin metastasis when compared to non-treated cells. Furthermore, Aza-D treatment in mice delayed the metastasis progression compared to the vehicle treated group. Thus, the present study provides an insight into the therapeutic applications of demethylating agents to reduce cancer metastasis in models with EVI1 overexpressing tumors.
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Affiliation(s)
- Pradeepa
- Cancer Biology Group, Institute of Life Sciences, Nalco Square, Bhubaneswar, Odisha 751023, India
| | - Voddu Suresh
- Tumor Microenvironment and Animal Models Group, Institute of Life Sciences, Nalco Square, Bhubaneswar 751023, India
| | - Vivek Kumar Singh
- Cancer Biology Group, Institute of Life Sciences, Nalco Square, Bhubaneswar, Odisha 751023, India
| | - Kasturi Bala Nayak
- Cancer Biology Group, Institute of Life Sciences, Nalco Square, Bhubaneswar, Odisha 751023, India
| | - Shantibhusan Senapati
- Tumor Microenvironment and Animal Models Group, Institute of Life Sciences, Nalco Square, Bhubaneswar 751023, India
| | - Soumen Chakraborty
- Cancer Biology Group, Institute of Life Sciences, Nalco Square, Bhubaneswar, Odisha 751023, India.
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Lee JH, Kim YH, Rhee SM, Han J, Jeong HJ, Park JH, Oh JH, Jeon S. Rotator Cuff Tendon Healing Using Human Dermal Fibroblasts: Histological and Biomechanical Analyses in a Rabbit Model of Chronic Rotator Cuff Tears. Am J Sports Med 2021; 49:3669-3679. [PMID: 34554882 DOI: 10.1177/03635465211041102] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tenocytes derived from tendons have been reported to be effective in the treatment of rotator cuff tears through the expression of extracellular matrix proteins. Human dermal fibroblasts, known to express collagen types I and III as tenocytes do, may likely be substitutes for tenocytes to enhance healing rotator cuff tears. PURPOSE To demonstrate the capability of human dermal fibroblasts to enhance healing of rotator cuff tears. STUDY DESIGN Controlled laboratory study. METHODS The cellular properties and expression profiles of growth factors were compared between human dermal fibroblasts and tenocytes. In both cell types, a series of extracellular matrix proteins were analyzed along with matrix metalloproteinases and tissue inhibitors of metalloproteinases involved in the collagenolytic system. A total of 35 rabbits were divided into 5 groups: normal (n = 2), saline control (n = 9), fibrin control (n = 9), low dose of human fibroblasts (HF-LD; n = 9), and high dose of human fibroblasts (HF-HD; n = 6). Cells were injected into the sutured lesions at 6 weeks after creation of bilateral rotator cuff tears, followed by histological and biomechanical analyses at 12 weeks. RESULTS Human dermal fibroblasts exhibited a protein expression pattern similar to that of tenocytes. More specifically, the expression levels of collagen types I and III were comparable between fibroblasts and tenocytes. The histological analysis of 30 surviving rabbits showed that collagen fibers were more continuous and better oriented with a more mature interface between the tendon and bone in the sutured lesions in the HF-LD and HF-HD groups. Most importantly, biomechanical strength, measured using the load to failure at the injection site, was 58.8 ± 8.9 N/kg in the HF-HD group, increasing by approximately 2-fold (P = .0003) over the saline control group. CONCLUSION Human dermal fibroblasts, showing cellular properties comparable with tenocytes, effectively enhanced healing of chronic rotator cuff tears in rabbits. CLINICAL RELEVANCE Human dermal fibroblasts can be used in place of tenocytes to enhance healing of rotator cuff tears.
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Affiliation(s)
- Ji-Hye Lee
- Cutigen Research Institute, Tego Science, Seoul, Republic of Korea
| | - Yun Hee Kim
- Cutigen Research Institute, Tego Science, Seoul, Republic of Korea
| | - Sung-Min Rhee
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Jikhyon Han
- Cutigen Research Institute, Tego Science, Seoul, Republic of Korea
| | - Hyeon Jang Jeong
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Joo Hyun Park
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Joo Han Oh
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Saewha Jeon
- Cutigen Research Institute, Tego Science, Seoul, Republic of Korea
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Tendon and multiomics: advantages, advances, and opportunities. NPJ Regen Med 2021; 6:61. [PMID: 34599188 PMCID: PMC8486786 DOI: 10.1038/s41536-021-00168-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 09/01/2021] [Indexed: 02/08/2023] Open
Abstract
Tendons heal by fibrosis, which hinders function and increases re-injury risk. Yet the biology that leads to degeneration and regeneration of tendons is not completely understood. Improved understanding of the metabolic nuances that cause diverse outcomes in tendinopathies is required to solve these problems. 'Omics methods are increasingly used to characterize phenotypes in tissues. Multiomics integrates 'omic datasets to identify coherent relationships and provide insight into differences in molecular and metabolic pathways between anatomic locations, and disease stages. This work reviews the current literature pertaining to multiomics in tendon and the potential of these platforms to improve tendon regeneration. We assessed the literature and identified areas where 'omics platforms contribute to the field: (1) Tendon biology where their hierarchical complexity and demographic factors are studied. (2) Tendon degeneration and healing, where comparisons across tendon pathologies are analyzed. (3) The in vitro engineered tendon phenotype, where we compare the engineered phenotype to relevant native tissues. (4) Finally, we review regenerative and therapeutic approaches. We identified gaps in current knowledge and opportunities for future study: (1) The need to increase the diversity of human subjects and cell sources. (2) Opportunities to improve understanding of tendon heterogeneity. (3) The need to use these improvements to inform new engineered and regenerative therapeutic approaches. (4) The need to increase understanding of the development of tendon pathology. Together, the expanding use of various 'omics platforms and data analysis resulting from these platforms could substantially contribute to major advances in the tendon tissue engineering and regenerative medicine field.
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Tashjian RZ, Kim SK, Roche MD, Jones KB, Teerlink CC. Genetic variants associated with rotator cuff tearing utilizing multiple population-based genetic resources. J Shoulder Elbow Surg 2021; 30:520-531. [PMID: 32663566 DOI: 10.1016/j.jse.2020.06.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/23/2020] [Accepted: 06/28/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The etiology of rotator cuff tearing is likely multifactorial, including a potential genetic predisposition. The purpose of the study was to identify genetic variants associated with rotator cuff tearing utilizing the UK Biobank (UKB) cohort, confirm variants using a separate genetic database, and evaluate tissue expression of genes with associated variants following rotator cuff tearing using RNA sequencing. METHODS Genome-wide association study (GWAS): A GWAS was performed using data from UKB with 5701 cases of rotator cuff injury. RNA sequencing analyses: rotator cuff biopsies were obtained from 24 patients with full-thickness rotator cuff tears who underwent arthroscopic rotator cuff repair (cases) and 9 patients who underwent open reduction internal fixation for a proximal humerus fracture (controls). Total RNA was extracted and differential gene expression was measured by RNAseq for genes with variants associated with rotator cuff tearing. RESULTS The results of the UKB GWAS identified 3 loci that reached genome-wide statistical significance: 2 loci on chromosome 7 in GLCCI1 (rs4725069; P = 5.0E-09) and THSD7A (rs575224171; P = 5.3E-09), and 1 locus on chromosome 2 in ZNF804A (rs775583810; P = 3.9E-09). The association with rotator cuff injury of the GLCCI1 single-nucleotide polymorphism (SNP; rs4725069) was confirmed in the Kaiser Permanente Research Bank cohort (P = .008). Twenty previously reported SNPs in 12 genes were evaluated using summary statistics from the UKB GWAS, which confirmed 3 SNPs in TNC with rotator cuff injury (rs1138545, rs72758637, and rs7021589; all P < .0024). Of 17 genes with variants associated with rotator cuff injury (14 previously from literature plus 3 new genes from current UKB GWAS), TIMP2, Col5A1, TGFBR1, and TNC were upregulated (P < .001 for all) and THSD7A was downregulated (P = .005) in tears vs. controls in the RNA sequencing data set. CONCLUSION The UKB GWAS has identified 3 novel loci associated with rotator cuff tearing (ZNF804A, GLCCI1, THSD7A). Expression of the THSD7A gene was significantly downregulated in rotator cuff tears vs. controls supporting a potential functional role. Three previously reported SNPs in the TNC gene were validated in the UKB GWAS, supporting a role for this gene in rotator cuff tearing. Finally, TIMP2, Col5A1, TGFBR1, and TNC genes were found to have significantly upregulated tissue expression in cases vs. controls supporting a biologic role in tearing for these genes.
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Affiliation(s)
- Robert Z Tashjian
- Department of Orthopaedics, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Stuart K Kim
- Department of Developmental Biology, Stanford University Medical School, Stanford, CA, USA
| | - Megan D Roche
- Department of Medicine, Stanford Prevention Research Center, Department of Epidemiology and Population Health, and Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA, USA; Department of Statistics, Stanford University School of Humanities and Sciences, Stanford, CA, USA
| | - Kevin B Jones
- Department of Orthopaedics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Craig C Teerlink
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Polymorphisms and alterations in gene expression associated with rotator cuff tear and healing following surgical repair: a systematic review. J Shoulder Elbow Surg 2021; 30:200-215. [PMID: 32827653 DOI: 10.1016/j.jse.2020.07.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/20/2020] [Accepted: 07/26/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Rotator cuff tears (RCTs) are a common cause of shoulder disability, yet both conservative and surgical treatment strategies can lead to poor results in some patient populations. Enhanced understanding of the genetic processes associated with RCTs can assist in the development of more effective management options and help predict individual responses to surgical treatment. This systematic review analyzes the current literature on the genetic footprint associated with RCTs and interprets these findings to enhance the current understanding of RCT pathogenesis, potential treatment regimens, and prognostic biomarkers of outcomes after surgical repair. METHODS A systematic search of the Embase, PubMed, and Web of Science electronic databases was performed. Medical Subject Headings (MeSH) and Emtree index terms were formulated from the concept terms "rotator cuff tear," "genetics," and "human," and synonyms of these concepts were applied to the Web of Science search. Articles were screened against predefined inclusion and exclusion criteria. Eligible studies compared gene expression patterns and genetic polymorphisms between cases (with RCTs) and controls (without RCTs). Quality assessment was performed with studies being rated as high, moderate, or poor quality. A modified best-evidence synthesis was applied, and studies were determined to be of strong, moderate, or limited evidence. RESULTS The search identified 259 articles. Of these studies, 26 were eligible for review. Two studies were considered poor quality; 15 studies, moderate quality; and 9 studies, high quality. Analysis of these articles found that RCTs were associated with alterations in genes that code for the extracellular matrix, cell apoptosis, immune and inflammatory responses, and growth factor pathways. In particular, there was strong evidence of a significant association between RCTs and the genes MMP3, TNC, and ESRRB. Strong evidence of an association between BMP5 upregulation and successful healing after surgical repair was also found. CONCLUSION This review provides strong evidence of an genetic association with RCTs. The genotype and gene expression patterns detailed within this review can assist in deciphering the biological mechanisms resulting in RCTs, as well as predicting an individual's response to surgical repair. Future research could investigate whether manipulating these genes-or their associated signaling pathways-could assist in RCT healing and whether genetic biomarkers could be used clinically to predict patient outcomes after surgical repair of RCTs.
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Riasat K, Bardell D, Goljanek-Whysall K, Clegg PD, Peffers MJ. Epigenetic mechanisms in Tendon Ageing. Br Med Bull 2020; 135:90-107. [PMID: 32827252 PMCID: PMC7585832 DOI: 10.1093/bmb/ldaa023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/19/2020] [Accepted: 06/22/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Tendon is a composite material with a well-ordered hierarchical structure exhibiting viscoelastic properties designed to transfer force. It is recognized that the incidence of tendon injury increases with age, suggesting a deterioration in homeostatic mechanisms or reparative processes. This review summarizes epigenetic mechanisms identified in ageing healthy tendon. SOURCES OF DATA We searched multiple databases to produce a systematic review on the role of epigenetic mechanisms in tendon ageing. AREAS OF AGREEMENT Epigenetic mechanisms are important in predisposing ageing tendon to injury. AREAS OF CONTROVERSY The relative importance of epigenetic mechanisms are unknown in terms of promoting healthy ageing. It is also unknown whether these changes represent protective mechanisms to function or predispose to pathology. GROWING POINT Epigenetic markers in ageing tendon, which are under-researched including genome-wide chromatin accessibility, should be investigated. AREAS TIMELY FOR DEVELOPING RESEARCH Metanalysis through integration of multiple datasets and platforms will enable a holistic understanding of the epigenome in ageing and its relevance to disease.
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Affiliation(s)
- Kiran Riasat
- Department of Musculoskeletal Biology, Institute of Life Course and Medical Sciences, William Henry Duncan Building, 6 West Derby Street, Liverpool L7 8TX, UK
| | - David Bardell
- Department of Musculoskeletal Biology, Institute of Life Course and Medical Sciences, William Henry Duncan Building, 6 West Derby Street, Liverpool L7 8TX, UK.,Institute of Veterinary Science, University of Liverpool, Leahurst Campus, Neston, Wirral CH64 7TE, UK
| | - Katarzyna Goljanek-Whysall
- Department of Musculoskeletal Biology, Institute of Life Course and Medical Sciences, William Henry Duncan Building, 6 West Derby Street, Liverpool L7 8TX, UK
| | - Peter D Clegg
- Department of Musculoskeletal Biology, Institute of Life Course and Medical Sciences, William Henry Duncan Building, 6 West Derby Street, Liverpool L7 8TX, UK
| | - Mandy J Peffers
- Department of Musculoskeletal Biology, Institute of Life Course and Medical Sciences, William Henry Duncan Building, 6 West Derby Street, Liverpool L7 8TX, UK
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Cohen C, Figueiredo EA, Belangero PS, Andreoli CV, Leal MF, Ejnisman B. Genetic Aspects in Shoulder Disorders. Rev Bras Ortop 2020; 55:537-542. [PMID: 33093716 PMCID: PMC7575388 DOI: 10.1055/s-0040-1702955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 11/12/2019] [Indexed: 12/17/2022] Open
Abstract
The influence of genetic inheritance has been increasingly investigated in shoulder disorders, such as rotator cuff injury, instability and frozen shoulder. Although the initial findings are enlightening, it is necessary to progressively build a database of genetic markers to catalog genomic profiles that, later, may contribute for predicting the risk of the disease, as well as to the development of better diagnostic and treatment tools. The present article seeks to update what is evidence of genetic studies in the literature for these diseases, from polymorphism analyses, expression of candidate genes in tissues and broad genomic association studies (GWAS). However, it is necessary to point out that there is great difficulty in replicating and using the findings, mainly due to the lack of statistical power, the high rate of false-positive results and the large number of variables involved.
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Affiliation(s)
- Carina Cohen
- Disciplina de Medicina do Esporte e Atividade Física , Centro de Traumatologia do Esporte, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Eduardo A. Figueiredo
- Disciplina de Medicina do Esporte e Atividade Física , Centro de Traumatologia do Esporte, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Paulo S. Belangero
- Disciplina de Medicina do Esporte e Atividade Física , Centro de Traumatologia do Esporte, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Carlos Vicente Andreoli
- Disciplina de Medicina do Esporte e Atividade Física , Centro de Traumatologia do Esporte, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Mariana Ferreira Leal
- Departamento de Morfologia e Genética, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Benno Ejnisman
- Disciplina de Medicina do Esporte e Atividade Física , Centro de Traumatologia do Esporte, Universidade Federal de São Paulo, São Paulo, SP, Brasil
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Guan J, Geng WQ, Li Y, Liu GY, Ding LB, Liu YJ, Xue W, Wang H, Zheng XF. Decreased Synovial Fluid Biomarkers Levels Are Associated with Rehabilitation of Function and Pain in Rotator Cuff Tear Patients Following Electroacupuncture Therapy. Med Sci Monit 2020; 26:e923240. [PMID: 32915775 PMCID: PMC7507797 DOI: 10.12659/msm.923240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Background The aim of this study was to assess inflammatory cytokines levels in synovial fluid (SF) before and after electroacupuncture (EA) treatment and to explore whether these biomarkers are associated with function of rotator cuff tear (RCT) patients. Material/Methods We recruited 54 patients with RCT and separated them into an EA group and a control group. The SF biomarker levels were detected at baseline and at 6-week and 6-month follow-up. The symptomatic severity was evaluated by visual analog scale (VAS), Constant-Murley score, and American Shoulder and Elbow Surgeons score (ASES). We also investigated the correlation between symptomatic severity and biomarker levels in SF of the shoulder joint. Results The reductions in VAS and improved functional score (ASES and Constant-Murley score) were significantly different between the 2 groups, and SF biomarker concentrations were significantly lower in the EA group. IL-1β levels were significantly negatively correlated with Constant-Murley score (r=−0.73, P=0.04) and ASES score (r=−0.59, P<0.001) and positively correlated with VAS scores (r=0.81, P=0.004). IL-6 levels were significantly negatively correlated with Constant-Murley score (r=−0.67, P=0.03) and positively correlated with VAS score (r=0.7, P=0.01). MMP-1 levels were significantly negatively correlated with ASES score (r=−0.57, P<0.001). Conclusions The biomarkers in SF were directly associated with shoulder pain and shoulder function in rotator cuff tear. EA, as a safe and effective conservative therapy, obviously decreased the level of inflammatory cytokines in RCT patients, accompanied by a reduction in shoulder pain and improved function.
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Affiliation(s)
- Jian Guan
- Department of Orthopedic Surgery, Third Hospital of Shijiazhuang, Shijiazhuang, Hebei, China (mainland)
| | - Wei-Qiang Geng
- Department of Orthopedic Surgery, No. 980 Hospital, Joint Logistics Support Force People's Liberation Army (PLA), Handan Campus of Bethune International Hospital, Handan, Hebei, China (mainland)
| | - Yao Li
- Department of Orthopedic Surgery, Third Hospital of Shijiazhuang, Shijiazhuang, Hebei, China (mainland)
| | - Guang-Yuan Liu
- Department of Orthopedic Surgery, Third Hospital of Shijiazhuang, Shijiazhuang, Hebei, China (mainland)
| | - Luo-Bin Ding
- Department of Orthopedic Surgery, Third Hospital of Shijiazhuang, Shijiazhuang, Hebei, China (mainland)
| | - You-Jie Liu
- Department of Orthopedic Surgery and Sports Medicine Center, First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China (mainland)
| | - Wei Xue
- Department of Orthopedics, Handan Central Hospital, Handan, Hebei, China (mainland)
| | - Huajun Wang
- Department of Orthopedic Surgery and Sports Medicine Center, First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China (mainland)
| | - Xiao-Fei Zheng
- Department of Orthopedic Surgery and Sports Medicine Center, First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China (mainland)
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12
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Figueiredo EA, Loyola LC, Belangero PS, Campos Ribeiro-Dos-Santos ÂK, Emanuel Batista Santos S, Cohen C, Wajnsztejn A, Martins de Oliveira A, Smith MC, Pochini ADC, Andreoli CV, Ejnisman B, Cohen M, Leal MF. Rotator Cuff Tear Susceptibility Is Associated With Variants in Genes Involved in Tendon Extracellular Matrix Homeostasis. J Orthop Res 2020; 38:192-201. [PMID: 31444797 DOI: 10.1002/jor.24455] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/13/2019] [Indexed: 02/04/2023]
Abstract
Rotator cuff tears (RCT) is a multifactorial disease with genetic factors contributing for the disease etiology. We hypothesized that genetic variants in genes involved in extracellular matrix (ECM) homeostasis may alter susceptibility to RCT. We evaluated 20 polymorphisms of genes involved in ECM homeostasis in 211 cases of full-thickness tears of the supraspinatus (Nfemales = 130; Nmales = 81) and 567 age-matched controls (Nfemales = 317; Nmales = 250). Multivariate logistic regressions were carried out with age, gender, genetic ancestry (based on the analysis of 61 biallelic short insertion/deletion polymorphisms), and common co-morbidities (diabetes, dyslipidemia, and smoking habits) as covariates. We observed that carriers of the rare allele of both studied variants of TGFB1, as well as their G/A (rs1800470/rs1800469) haplotype, were less susceptible to RCT (p < 0.05). In contrast, carriers of the G allele of MMP9 rs17576 (p = 0.014) or G/G haplotype (rs17576/rs17577; p < 0.001) had an increased risk for tendon tears. The presence of the T allele of MMP2 rs2285053 (p = 0.033), the T allele of MMP3 rs679620 (p = 0.024), and the TT-genotype of TIMP2 rs2277698 (p = 0.01) was associated with susceptibility to tears, especially in females. In males, the A allele of COL5A1 rs3196378 (p = 0.032) and the G allele of TGFBR1 rs1590 (p = 0.039) were independent risk factors for RCT. The C/T COL5A1 (rs3196378/rs11103544) haplotype was associated with a reduced risk of tears in males (p = 0.03). In conclusion, we identified the genetic variants associated with RCT susceptibility, thereby reinforcing the role of genes involved in the structure and homeostasis of the ECM of tendons in disease development. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:192-201, 2020.
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Affiliation(s)
- Eduardo A Figueiredo
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, 04038-032, São Paulo, Brazil
| | - Leonor Casilla Loyola
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, 04038-032, São Paulo, Brazil.,Disciplina de Genética, Departamento de Morfologia e Genética, Universidade Federal de São Paulo, 04023-001, São Paulo, Brazil
| | - Paulo S Belangero
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, 04038-032, São Paulo, Brazil
| | | | - Sidney Emanuel Batista Santos
- Laboratório de Genética Humana e Médica, Instituto de Ciências Biológicas, Universidade Federal do Pará, Belém, Pará, Brazil
| | - Carina Cohen
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, 04038-032, São Paulo, Brazil
| | - Andre Wajnsztejn
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, 04038-032, São Paulo, Brazil
| | - Adrielle Martins de Oliveira
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, 04038-032, São Paulo, Brazil.,Disciplina de Genética, Departamento de Morfologia e Genética, Universidade Federal de São Paulo, 04023-001, São Paulo, Brazil
| | - Marília C Smith
- Disciplina de Genética, Departamento de Morfologia e Genética, Universidade Federal de São Paulo, 04023-001, São Paulo, Brazil
| | - Alberto de Castro Pochini
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, 04038-032, São Paulo, Brazil
| | - Carlos V Andreoli
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, 04038-032, São Paulo, Brazil
| | - Benno Ejnisman
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, 04038-032, São Paulo, Brazil
| | - Moises Cohen
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, 04038-032, São Paulo, Brazil
| | - Mariana F Leal
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, 04038-032, São Paulo, Brazil.,Disciplina de Genética, Departamento de Morfologia e Genética, Universidade Federal de São Paulo, 04023-001, São Paulo, Brazil
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13
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Cohen C, Leal MF, Loyola LC, Santos SEB, Ribeiro-Dos-Santos ÂKC, Belangero PS, Figueiredo EA, Wajnsztejn A, de Oliveira AM, Smith MC, Andreoli CV, de Castro Pochini A, Cohen M, Ejnisman B, Faloppa F. Genetic variants involved in extracellular matrix homeostasis play a role in the susceptibility to frozen shoulder: A case-control study. J Orthop Res 2019; 37:948-956. [PMID: 30667085 DOI: 10.1002/jor.24228] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 12/26/2018] [Indexed: 02/04/2023]
Abstract
Frozen shoulder is a condition of loss of active and passive motion as result of inflammatory contracture and fibrosis of the joint capsule. We hypothesize that genetic variants in genes involved in these processes such as genes that play a role in extracellular matrix homeostasis (collagens, glycoproteins, genes involved in TGFβ signaling, and metalloproteinases and its inhibitors) may contribute to the susceptibility to frozen shoulder. We evaluated eighteen SNPs of genes involved in extracellular matrix homeostasis in 186 cases (Nfemales = 114; Nmales = 72) of frozen shoulder and 600 age-matched controls (Nfemales = 308; Nmales = 292). Multivariate logistic regressions were carried out with age, gender, genetic ancestry, and common comorbidities as covariates. Carriers of the C allele of MMP13 rs2252070 and G/G MMP9 (rs17576 A>G/rs17577 G>A) haplotype may have an increased risk of frozen shoulder (p = 0.002, OR = 1.64, 95%CI = 1.20-2.26, and p = 0.046, OR = 1.40, 95%CI = 1.01-1.95, respectively), especially in females (p = 0.005, OR = 1.91, 95%CI = 1.22-2.99, and p = 0.046, OR = 1.59, 95%CI = 1.01-2.51, respectively). In females, the G allele of MMP9 rs17576 tended to contribute to the susceptibility to the studied disease (p = 0.05, OR = 1.51, 95%CI = 0.97-2.33). In contrast, the presence of the C allele of TGFB1 rs1800470 seems to be associated with a reduced risk (p = 0.04, OR = 0.47, 95%CI = 0.23-0.96) while the GG-genotype of TGFBR1 rs1590 was associated with increased risk (p = 0.027, OR = 4.11, 95%CI = 1.17-14.38) to frozen shoulder development in males. Thus, we identified genetic variants that were independent risk factors that can aid in the risk assessment of frozen shoulder reinforcing the involvement of MMP and TGFβ signaling in disease development. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.
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Affiliation(s)
- Carina Cohen
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Mariana F Leal
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil.,Disciplina de Genética, Departamento de Morfologia e Genética, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Leonor C Loyola
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil.,Disciplina de Genética, Departamento de Morfologia e Genética, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Sidney E B Santos
- Laboratório de Genética Humana e Médica, Instituto de Ciências Biológicas, Universidade Federal do Pará, Belém, PA, Brazil
| | - Ândrea K C Ribeiro-Dos-Santos
- Laboratório de Genética Humana e Médica, Instituto de Ciências Biológicas, Universidade Federal do Pará, Belém, PA, Brazil
| | - Paulo S Belangero
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Eduardo A Figueiredo
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Andre Wajnsztejn
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Adrielle M de Oliveira
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil.,Disciplina de Genética, Departamento de Morfologia e Genética, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Marília C Smith
- Disciplina de Genética, Departamento de Morfologia e Genética, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Carlos V Andreoli
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | - Moises Cohen
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Benno Ejnisman
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Flávio Faloppa
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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14
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Santoro Belangero P, Antônio Figueiredo E, Cohen C, de Seixas Alves F, Hiromi Yanaguizawa W, Cardoso Smith M, Vicente Andreoli C, de Castro Pochini A, Teresa de Seixas Alves M, Ejnisman B, Cohen M, Ferreira Leal M. Changes in the expression of matrix extracellular genes and TGFB family members in rotator cuff tears. J Orthop Res 2018; 36:2542-2553. [PMID: 29614203 DOI: 10.1002/jor.23907] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 03/18/2018] [Indexed: 02/04/2023]
Abstract
Lack of synthesis of extracellular matrix compounds may contribute to degeneration of the tendons. Thus, we aimed to evaluate the expression of extracellular matrix and TGFB family members in ruptured and non-ruptured tendons of the rotator cuff, as well as the effect of clinical factors on gene expression in tendon samples, and the relationship between histological findings and altered gene expression. Injured and non-injured supraspinatus tendon samples and subscapular non-injured tendon samples were collected from 38 patients with rotator cuff tears. Non-injured supraspinatus tendons were obtained from eight controls. Specimens were used for histological evaluation, quantification of collagen fibers, and mRNA and protein expression analyses. Increased COL1A1, COL1A2, COL3A1, COL5A1, FN1, TNC, and TGFBR1 mRNA expression was observed in the tear samples (p < 0.05). Duration of symptoms was correlated with the levels of collagen type I/III fibers (p = 0.032; ρ = 0.0447) and FN1 immunostaining (p = 0.031; ρ = 0.417). Smoking was associated with increased frequency of microcysts, myxoid degeneration, and COL5A1, FN1, TNC, and TGFB1 mRNA expression (p < 0.05). FN1 immunostaining was correlated with the number of years of smoking (p = 0.048; ρ = 0.384). Lower levels of collagen type I/III fibers were detected in samples with fissures (0 = 0.046). High frequency of microcysts was associated with increased COL5A1, FN1, and TNC expression (p < 0.05, for all comparisons). Neovascularization was associated with reduced FN1 (p = 0.035) and TGFBR1 expression (p = 0.034). Our findings show differential expression of matrix extracellular genes and TGFB family members in the degeneration process involved in rotator cuff tears. These molecular alterations are influenced by clinical factors. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2542-2553, 2018.
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Affiliation(s)
- Paulo Santoro Belangero
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, Rua Borges Lagoa, 783, São Paulo, São Paulo, 04038-032, Brazil
| | - Eduardo Antônio Figueiredo
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, Rua Borges Lagoa, 783, São Paulo, São Paulo, 04038-032, Brazil
| | - Carina Cohen
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, Rua Borges Lagoa, 783, São Paulo, São Paulo, 04038-032, Brazil
| | - Felipe de Seixas Alves
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, Rua Borges Lagoa, 783, São Paulo, São Paulo, 04038-032, Brazil.,Departamento de Patologia, Universidade Federal de São Paulo, São Paulo, São Paulo, 04038-032, Brazil
| | - Wânia Hiromi Yanaguizawa
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, Rua Borges Lagoa, 783, São Paulo, São Paulo, 04038-032, Brazil.,Departamento de Patologia, Universidade Federal de São Paulo, São Paulo, São Paulo, 04038-032, Brazil
| | - Marília Cardoso Smith
- Disciplina de Genética, Departamento de Morfologia e Genética, Universidade Federal de São Paulo, São Paulo, São Paulo, 04023-001, Brazil
| | - Carlos Vicente Andreoli
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, Rua Borges Lagoa, 783, São Paulo, São Paulo, 04038-032, Brazil
| | - Alberto de Castro Pochini
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, Rua Borges Lagoa, 783, São Paulo, São Paulo, 04038-032, Brazil
| | | | - Benno Ejnisman
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, Rua Borges Lagoa, 783, São Paulo, São Paulo, 04038-032, Brazil
| | - Moises Cohen
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, Rua Borges Lagoa, 783, São Paulo, São Paulo, 04038-032, Brazil
| | - Mariana Ferreira Leal
- Departamento de Ortopedia e Traumatologia, Universidade Federal de São Paulo, Rua Borges Lagoa, 783, São Paulo, São Paulo, 04038-032, Brazil.,Disciplina de Genética, Departamento de Morfologia e Genética, Universidade Federal de São Paulo, São Paulo, São Paulo, 04023-001, Brazil
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