Femoral artery constriction by norepinephrine is enhanced by methylprednisolone in a rat model

Risk factors and pathogenesis of steroid-induced osteonecrosis of femoral head - A scoping review

Steroid induced osteonecrosis of the femoral head is commonly seen in clinical practice, but yet not fully understood. It is intriguing why only some cases develop and others escape from it. We did an extensive and up to date literature review on it, with the aim to identify its incidence, associated risk factor and pathogenesis. We found that the incidence ranged from 03 to 40%, and was more with associated risk factors. Several risk factors were identified, which included higher dose and prolonged duration of steroid consumption, and underlying disease for which the steroids were given. Pathogenesis of this disease is complex and not yet fully understood. Awareness about this condition and associated risk factors should help the clinicians in identifying the cases who are prone to develop osteonecrosis with the use of steroids.

Mechanisms of bone blood flow regulation in humans

Bone is a highly vascularized tissue. However, despite the importance of appropriate circulation for bone health, regulation of bone blood flow remains poorly understood. Invasive animal studies suggest that sympathetic activity plays an important role in bone flow control. However, it remains unknown if bone vasculature evidences robust vasoconstriction in response to sympathoexcitatory stimuli. Here, we characterized bone blood flow in young healthy individuals [n = 13, (four females)] in response to isometric handgrip exercise (IHE) and cold pressor test (CPT). These provide a strong stimulus for active vasoconstriction in the inactive muscle, and perhaps also in the bone. During sustained IHE to fatigue and CPT, we measured blood pressure, whole leg blood flow, and tibial perfusion using near-infrared spectroscopy. Tibia perfusion was determined as oxy- and deoxyhemoglobin. For both stimuli, tibial metabolism remained constant (i.e., no change in deoxyhemoglobin) and thus tibial arterial perfusion was represented by oxyhemoglobin. During IHE, oxyhemoglobin declined (beginning -0.20 ± 1.04 μM; end -1.13 ± 3.71 μM, both P < 0.01) slower than whole leg blood flow (beginning -0.85 ± 1.02 cm/s; end -2.72 ± 1.64 cm/s, both P < 0.01). However, during CPT, both oxyhemoglobin (beginning -0.46 ± 1.43 μM; end -0.60 ± 1.59 μM, both P < 0.01) and whole leg blood flow (beginning -1.52 ± 1.63 cm/s; end -0.69 ± 1.51 cm/s, both P < 0.01) declined with a similar timecourse, even though the magnitudes of decline were smaller than during IHE. These responses are likely due to the different timecourses of sympathetically mediated vasoconstriction in bone and muscle. These results indicate that sympathetic innervation of the bone vasculature serves a functional role in the control of flow in young healthy individuals.NEW & NOTEWORTHY The current study is the first one to noninvasively investigate control of bone blood perfusion in vivo in humans, on a moment-by-moment basis. Our results indicate that tibial bone vasculature demonstrates active vasoconstriction in response to sympathoexcitatory stimuli in young healthy individuals. Compared with whole leg vasculature, bone vasoconstrictor response seems to be smaller, delayed, and more variable.

Osthole stimulates bone formation, drives vascularization and retards adipogenesis to alleviate alcohol-induced osteonecrosis of the femoral head

Characteristic pathological changes in osteonecrosis of the femoral head (ONFH) include reduced osteogenic differentiation of bone mesenchymal stem cells (BMSCs), impaired osseous circulation and increased intramedullary adipocytes deposition. Osthole is a bioactive derivative from coumarin with a wide range of pharmacotherapeutic effects. The aim of this study was to unveil the potential protective role of osthole in alcohol‐induced ONFH. In vitro, ethanol (50 mmol/L) remarkably decreased the proliferation and osteogenic differentiation of BMSCs and impaired the proliferation and tube formation capacity of human umbilical vein endothelial cell (HUVECs), whereas it substantially promoted the adipogenic differentiation of BMSCs. However, osthole could reverse the effects of ethanol on osteogenesis via modulating Wnt/β‐catenin pathway, stimulate vasculogenesis and counteract adipogenesis. In vivo, the protective role of osthole was confirmed in the well‐constructed rat model of ethanol‐induced ONFH, demonstrated by a cascade of radiographical and pathological investigations including micro‐CT scanning, haematoxylin‐eosin staining, TdT‐mediated dUTP nick end labelling, immunohistochemical staining and fluorochrome labelling. Taken together, for the first time, osthole was demonstrated to rescue the ethanol‐induced ONFH via promoting bone formation, driving vascularization and retarding adipogenesis.

Hypermethylation of Frizzled1 is associated with Wnt/β-catenin signaling inactivation in mesenchymal stem cells of patients with steroid-associated osteonecrosis

The Wnt/β-catenin signaling pathway is associated with the pathogenesis of steroid-induced osteonecrosis. Our investigation studied whether aberrant CpG island hypermethylation of the FZD1 gene was present in patients with osteonecrosis of the femoral head (ONFH), which results in Wnt/β-catenin signaling inactivation and subsequent cell dysfunction. Bone marrow was collected from the proximal femurs of patients with steroid-associated ONFH (n = 21) and patients with new femoral neck fractures (n = 22), and then mesenchymal stem cells (MSCs) were isolated. We investigated cell viability, the transcription and translation levels of Wnt/β-catenin signaling-related genes, the extent of methylation at CpG islands of the FZD1 promoter, and the osteogenic and adipogenic differentiation abilities of MSCs from the control group and from the ONFH group treated with or without 5′-Aza-dC. According to the results, MSCs from the ONFH group showed a reduced proliferation ability, low transcription and translation levels of FZD1, inhibition of the Wnt/β-catenin signaling pathway, weakened osteogenesis and enhanced adipogenesis ability. Aberrant CpG island hypermethylation of FZD1 was observed in the ONFH group. Treatment with 5’-Aza-dC resulted in de novo FZD1 expression, reactivation of the Wnt/β-catenin signaling pathway and promotion of osteogenesis. Taken together, our study not only provides novel insights into the regulation of the Wnt/β-catenin signaling pathway in this disease but also reveals potential for the use of demethylating agents for the treatment of GC-associated ONFH.

Studies of genetic and molecular signaling processes in the bone disease osteonecrosis, when it is associated with steroid use, reveal insights into disease development and suggest new approaches for treatment. Steroid drugs increase the risk of osteonecrosis, in which bone tissue dies due to insufficient blood supply, but the mechanism of this effect is unclear. Researchers in China, led by Zhibo Sun at Wuhan University, investigated a link between the aberrant addition of methyl groups (CH₃) to the DNA of a specific gene and the onset of the disease. They identified an important molecular signaling pathway in cultured bone marrow cells from patients that is inhibited by the gene methylation. Treating these cells with a drug that inhibits methylation led to reactivation of the gene and the associated signalling pathway that promotes healthy bone formation.

Combined Treatment with an Anticoagulant and a Vasodilator Prevents Steroid-Associated Osteonecrosis of Rabbit Femoral Heads by Improving Hypercoagulability

Steroid-associated osteonecrosis of the femoral head remains a challenging problem in orthopedics worldwide. One pathomechanism is ischemia of the femoral head, as a result of thrombus formation and vasoconstriction. The present study investigates the effects of combination prevention with enoxaparin and EGb 761 on steroid-associated ONFH in rabbits. Rabbits were randomly divided into 5 groups (control group, model group, enoxaparin group, ginkgo group, and combination group). With the exception of the control group, the groups of rabbits were modeled with lipopolysaccharide and methylprednisolone acetate. Starting with modeling, the enoxaparin group and ginkgo group were injected with 1 μg/kg/day enoxaparin subcutaneously and orally given 40 mg/kg/day EGb 761 for 4 weeks, respectively; the combination group received both treatments. After modeling for 6 weeks, the hematology data indicated prolonged PT and APTT in the three prevention groups. The micro-CT examination revealed higher bone density and better structure; histomorphometry revealed significant pathological changes. Immunohistochemistry revealed higher expression of BMP-2 and VEGF, thus revealing better osteogenesis and angiogenesis activities. Among the three prevention groups, the combination group had the most efficient results. In conclusion, the combined prevention with an anticoagulant and a vasodilator has the potential to decrease the incidence of steroid-associated ONFH in rabbits.

Icariin may benefit the mesenchymal stem cells of patients with steroid-associated osteonecrosis by ABCB1-promoter demethylation: a preliminary study

In this study, we found out a previously undefined function of icariin which restored the dynamic balance between osteogenic and adipogenic differentiation of mesenchymal stem cells (MSCs) in patients with osteonecrosis of femoral head (ONFH) via ABCB1-promoter demethylation. These findings provided important information regarding potential implication of icariin targeting epigenetic changes for the treatment of steroid -associated ONFH.

INTRODUCTION

Here, we investigated whether icariin can also exert a beneficial role in the reactivation of MSCs in the patients with steroid-associated ONFH via ABCB1-promoter demethylation.

METHODS

Bone marrow was collected from the proximal femur in patients with steroid-associated ONFH (n = 20) and patients with new femoral neck fractures (n = 22), and then MSCs were isolated. We investigated cell viability, intracellular reactive oxygen species (ROS) level, mitochondrial membrane potential (MMP), P-glycoprotein (P-gp) activity, the transcript levels of ABCB1 and oxidative stress-related genes, methylation extent at CpG islands of ABCB1 promoter, and osteogenic and adipogenic differentiation ability of MSCs from the femoral neck fractures group and from the steroid-associated ONFH group treated with or without icariin.

RESULTS

We observed that MSCs from the steroid-associated ONFH group showed reduced proliferation ability, elevated ROS level, depressed MMP, weakened osteogenesis, and enhanced adipogenesis while low P-gp activity, transcription level of ABCB1, and oxidative stress-related genes as well as aberrant CpG islands hypermethylation of ABCB1 were also noted in steroid-associated ONFH group. Treatment with icariin obviously induced de novo P-gp expression, decreased oxidative stress, and promoted osteogenesis.

CONCLUSION

Icariin may be a potential drug targeting epigenetic changes for the treatment of steroid-associated ONFH.

ABCB1 gene polymorphisms and glucocorticoid-induced avascular necrosis of the femoral head susceptibility: a meta-analysis

BACKGROUND

The results of studies on association between ABCB1 gene polymorphisms and glucocorticoid-induced avascular necrosis of the femoral head (GANFH) are controversial. This study aimed to assess the association of ABCB1 gene polymorphisms with the risk of GANFH by conducting a meta-analysis.

MATERIAL AND METHODS

The PubMed, Cochrane Library, and Embase databases were searched for papers that describe the association between ABCB1 polymorphisms and GANFH risk. Summary odds ratios and 95% confidence intervals (CI) were estimated based on a fixed-effects model or random-effects model, depending on the absence or presence of significant heterogeneity.

RESULTS

A total of 5 studies and 833 patients were included in the final analysis. Significant differences were found for rs1045642 polymorphism in the comparisons of CC vs. CT+TT (OR, 1.462; 95% CI, 1.066-2.007; P=0.019), and rs2032582 polymorphism in the comparisons of GG vs. G(TA)+(TA)(TA) (OR, 1.548; 95% CI,1.063-2.255; P=0.023).

CONCLUSIONS

The study demonstrated that the ABCB1 polymorphisms (rs1045642 and rs2032582) significantly reduced the risk of GANFH.

Steroid-associated hip joint collapse in bipedal emus

In this study we established a bipedal animal model of steroid-associated hip joint collapse in emus for testing potential treatment protocols to be developed for prevention of steroid-associated joint collapse in preclinical settings. Five adult male emus were treated with a steroid-associated osteonecrosis (SAON) induction protocol using combination of pulsed lipopolysaccharide (LPS) and methylprednisolone (MPS). Additional three emus were used as normal control. Post-induction, emu gait was observed, magnetic resonance imaging (MRI) was performed, and blood was collected for routine examination, including testing blood coagulation and lipid metabolism. Emus were sacrificed at week 24 post-induction, bilateral femora were collected for micro-computed tomography (micro-CT) and histological analysis. Asymmetric limping gait and abnormal MRI signals were found in steroid-treated emus. SAON was found in all emus with a joint collapse incidence of 70%. The percentage of neutrophils (Neut %) and parameters on lipid metabolism significantly increased after induction. Micro-CT revealed structure deterioration of subchondral trabecular bone. Histomorphometry showed larger fat cell fraction and size, thinning of subchondral plate and cartilage layer, smaller osteoblast perimeter percentage and less blood vessels distributed at collapsed region in SAON group as compared with the normal controls. Scanning electron microscope (SEM) showed poor mineral matrix and more osteo-lacunae outline in the collapsed region in SAON group. The combination of pulsed LPS and MPS developed in the current study was safe and effective to induce SAON and deterioration of subchondral bone in bipedal emus with subsequent femoral head collapse, a typical clinical feature observed in patients under pulsed steroid treatment. In conclusion, bipedal emus could be used as an effective preclinical experimental model to evaluate potential treatment protocols to be developed for prevention of ON-induced hip joint collapse in patients.

Aberrant CpG islands' hypermethylation of ABCB1 in mesenchymal stem cells of patients with steroid-associated osteonecrosis

OBJECTIVE

Patients carrying an ABCB1 polymorphism have a higher risk of developing osteonecrosis of the femoral head (ONFH). We investigated whether aberrant dinucleotide CpG islands' hypermethylation of ABCB1 gene existed in mesenchymal stem cells (MSC) of patients with ONFH, which results in cell dysfunction.

METHODS

Bone marrow was collected from the proximal femur of patients with glucocorticoid (GC)-associated ONFH (n = 22) and patients with new femoral neck fractures (n = 25). MSC were isolated by density gradient centrifugation. We investigated cell viability, intracellular reactive oxygen species (ROS) level, mitochondrial membrane potential (MMP), the amount of P-glycoprotein (P-gp) and ABCB1 transcripts, and methylation at CpG islands of ABCB1 promoter from both the femoral neck fractures group and the GC-associated ONFH group treated with or without the DNA methyltransferase inhibitor, 5'-Aza-2-deoxycytidine (5'-Aza-dC).

RESULTS

We observed that MSC from GC-associated ONFH groups showed reduced proliferation ability, elevated ROS levels, and depressed MMP when compared with the other 2 groups. Low levels of P-gp and ABCB1 transcript, as well as ABCB1 gene hypermethylation, in patients with GC-associated ONFH were also noted. Treatment with 5'-Aza-dC rapidly restored ABCB1 expression. Analysis of general expression revealed that aberrant CpG islands' hypermethylation of ABCB1 caused sensitivity to GC and induced changes in the proliferation and oxidative stress of MSC under GC administration.

CONCLUSION

These data suggest that aberrant CpG islands' hypermethylation of ABCB1 gene may be responsible for individual differences in the development of GC-associated ONFH.

Glucocorticoids in osteonecrosis of the femoral head: a new understanding of the mechanisms of action

Glucocorticoid (GC) usage is the most common non-traumatic cause of osteonecrosis of the femoral head (ON). Despite the strong association of GC with ON, the underlying mechanisms have been unclear. Investigators have proposed both direct and indirect effects of GC on cells. Indirect and direct mechanisms remain intimately related and often result in positive feedback loops to potentiate the disease processes. However, the direct effects, in particular apoptosis, have recently been shown to be increasingly important. Suppression of osteoblast and osteoclast precursor production, increased apoptosis of osteoblasts and osteocytes, prolongation of the lifespan of osteoclasts and apoptosis of endothelial cells (EC) are all direct effects of GC usage. Elevated blood pressure through several pathways may raise the risk of clot formation. High-dose GC also decreases tissue plasminogen activator activity (t-PA) and increases plasma plasminogen activator inhibitor-1 (PAI-1) antigen levels increasing the procoagulant potential of GC. Inhibited angiogenesis, altered bone repair and nitric oxide metabolism can also result. Also, GC treatment modulates other vasoactive mediators such as endothelin-1, noradrenalin and bradykinin. Thus, GCs act as a regulator of local blood flow by modulating vascular responsiveness to vasoactive substances. Vasoconstriction induced in intraosseous femoral head arteries causes femoral head ischemia. GCs also cause ischemia through increased intraosseous pressure, which subsequently decreases the blood flow to the femoral head by apoptosis of ECs as well as elevating the level of adipogenesis and fat hypertrophy in the bone marrow. It is difficult to predict which patients receiving a specific dose of GC will develop ON, indicating individual differences in steroid sensitivity and the potential of additional mechanisms. The textbook model of ON is a multiple hit theory in which, with a greater number of risk factors, the risk of ON increases. While more effort is needed to better comprehend the role of GC in ON, newer data on GC action upon the endothelial cell and the regional endothelial bed dysfunction theory sheds new light on particular GC mechanisms. Better understanding of GC pathomechanisms can lead to better treatment options.