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Effect of NSAID Use on Bone Healing in Pediatric Fractures: A Preliminary, Prospective, Randomized, Blinded Study. J Pediatr Orthop 2020; 40:e683-e689. [PMID: 32555047 DOI: 10.1097/bpo.0000000000001603] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND This study aimed to investigate if nonsteroidal anti-inflammatory drugs (NSAIDs) used in the acute phase of bone healing in children with fractures result in delayed union or nonunion as compared with patients who do not take NSAIDs for pain control during this same time period. METHODS In this prospective, randomized, parallel, single-blinded study, skeletally immature patients with long bone fractures were randomized to 1 of 2 groups for their postfracture pain management. The NSAID group was prescribed weight-based ibuprofen, whereas the control group was not allowed any NSAID medication and instead prescribed weight-based acetaminophen. Both groups were allowed to use oxycodone for breakthrough pain. The primary outcome was fracture healing assessed at 2, 6, and 10 weeks. RESULTS One-hundred-two patients were enrolled between February 6, 2014 and September 23, 2016. Ninety-five patients (with 97 fractures) completed a 6-month follow-up (46 patients with 47 fractures in the control group and 49 patients 50 fractures in the NSAID group). None achieved healing at 1 to 2 weeks. By 6 weeks, 37 of 45 patients (82%) of control group and 46 out of 50 patients (92%) of ibuprofen group had healed fractures (P=0.22). At 10 to 12 week follow-up, 46 (98%) of the control group fractures were healed and 50 (100%) of the ibuprofen group fractures were healed. All were healed by 6 months. Healing was documented at a mean of 40 days in the control group and 31 days in the ibuprofen group (P=0.76). The mean number of days breakthrough oxycodone was used was 2.4 days in the control group and 1.9 days in the NSAID group (P=0.48). CONCLUSION Ibuprofen is an effective medication for fracture pain in children and its use does not impair clinical or radiographic long bone fracture healing in skeletally immature patients. LEVEL OF EVIDENCE Level I-therapeutic.
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2
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Effect of thiazolidinedione phenylacetate derivatives on wound-healing activity. Arch Pharm Res 2018; 42:790-814. [PMID: 29948772 DOI: 10.1007/s12272-018-1041-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 05/20/2018] [Indexed: 10/14/2022]
Abstract
The aim of this work was to evaluate the synthesis and structure-activity relationship of 4-((2,4-dioxothiazolidin-5-ylidene)methyl)phenyl 2-phenylacetate derivatives as potential wound-healing agents. The IC50 values of the lead compounds ranged from 0.01 to 0.05 µM. These compounds also increased the levels of extracellular prostaglandin E2 (PGE2) in A549 cells. Among the synthesized compounds, compounds 66, 67, 69, and 86 increased PGE2 levels 3- to 4-fold of those achieved with the negative control. Introduction of a halogen at the intermediate phenyl ring, compounds 66, 67, 69, and 86 resulted in higher IC50 values, which indicated lower cytotoxicity than that observed upon the introduction of other substituents at the same position. In particular, cells exposed to compound 69 showed significantly improved wound healing, and the wound closure rate achieved was approximately 3.2-fold higher than that of the control. Therefore, compound 69 can be used for tissue regeneration and treatment of diverse diseases caused by PGE2 deficiency. Overall, our findings suggested that compound 69 might be a novel candidate for skin wound therapy.
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Sheffer BW, Kelly DM, Rhodes LN, Sawyer JR. Perioperative Pain Management in Pediatric Spine Surgery. Orthop Clin North Am 2017; 48:481-486. [PMID: 28870307 DOI: 10.1016/j.ocl.2017.06.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pain management after spinal deformity correction surgery for scoliosis in the pediatric population can be difficult. Deformity correction with posterior spinal fusion causes significant tissue trauma. Historically, pain control has been achieved with intravenous opiates. Opiates provide excellent analgesic effect; however, they have serious consequences when used alone. In adult total joint arthroplasty, multimodal pain control has become an increasingly common method to achieve pain control without these sequelae. Recently, the same techniques have been studied in pediatric spinal deformity correction surgery. This article outlines the state of pain management in pediatric spine patients.
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Affiliation(s)
- Benjamin W Sheffer
- Department of Orthopaedic Surgery and Biomedical Engineering, Campbell Clinic, The University of Tennessee Health Science Center, Le Bonheur Children's Hospital, 51 North Dunlap Street, Memphis, TN 38105, USA.
| | - Derek M Kelly
- Department of Orthopaedic Surgery and Biomedical Engineering, Campbell Clinic, The University of Tennessee Health Science Center, Le Bonheur Children's Hospital, 51 North Dunlap Street, Memphis, TN 38105, USA
| | - Leslie N Rhodes
- Department of Orthopaedic Surgery and Biomedical Engineering, Campbell Clinic, The University of Tennessee Health Science Center, Le Bonheur Children's Hospital, 51 North Dunlap Street, Memphis, TN 38105, USA
| | - Jeffrey R Sawyer
- Department of Orthopaedic Surgery and Biomedical Engineering, Campbell Clinic, The University of Tennessee Health Science Center, Le Bonheur Children's Hospital, 51 North Dunlap Street, Memphis, TN 38105, USA
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Riggin CN, Qu F, Kim DH, Huegel J, Steinberg DR, Kuntz AF, Soslowsky LJ, Mauck RL, Bernstein J. Electrospun PLGA Nanofiber Scaffolds Release Ibuprofen Faster and Degrade Slower After In Vivo Implantation. Ann Biomed Eng 2017; 45:2348-2359. [PMID: 28653294 DOI: 10.1007/s10439-017-1876-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 06/15/2017] [Indexed: 01/04/2023]
Abstract
While delayed delivery of non-steroidal anti-inflammatory drugs (NSAIDs) has been associated with improved tendon healing, early delivery has been associated with impaired healing. Therefore, NSAID use is appropriate only if the dose, timing, and mode of delivery relieves pain but does not impede tissue repair. Because delivery parameters can be controlled using drug-eluting nanofibrous scaffolds, our objective was to develop a scaffold for local controlled release of ibuprofen (IBP), and characterize the release profile and degradation both in vitro and in vivo. We found that when incubated in vitro in saline, scaffolds containing IBP had a linear release profile. However, when implanted subcutaneously in vivo or when incubated in vitro in serum, scaffolds showed a rapid burst release. These data demonstrate that scaffold properties are dependent on the environment in which they are placed and the importance of using serum, rather than saline, for initial in vitro evaluation of biofactor release from biodegradable scaffolds.
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Affiliation(s)
- Corinne N Riggin
- Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz Philadelphia VA Medical Center, 3900 University & Woodland Avenue, Philadelphia, PA, 19104, USA.,McKay Orthopaedic Research Lab, University of Pennsylvania, 424 Stemmler Hall, 36th Street & Hamilton Walk, Philadelphia, PA, 19104, USA.,Department of Bioengineering, University of Pennsylvania, Suite 240 Skirkanich Hall, 210 South 33rd Street, Philadelphia, PA, 19104, USA
| | - Feini Qu
- Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz Philadelphia VA Medical Center, 3900 University & Woodland Avenue, Philadelphia, PA, 19104, USA.,McKay Orthopaedic Research Lab, University of Pennsylvania, 424 Stemmler Hall, 36th Street & Hamilton Walk, Philadelphia, PA, 19104, USA.,School of Veterinary Medicine, University of Pennsylvania, 3800 Spruce Street, Philadelphia, PA, 19104, USA
| | - Dong Hwa Kim
- Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz Philadelphia VA Medical Center, 3900 University & Woodland Avenue, Philadelphia, PA, 19104, USA.,McKay Orthopaedic Research Lab, University of Pennsylvania, 424 Stemmler Hall, 36th Street & Hamilton Walk, Philadelphia, PA, 19104, USA
| | - Julianne Huegel
- Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz Philadelphia VA Medical Center, 3900 University & Woodland Avenue, Philadelphia, PA, 19104, USA.,McKay Orthopaedic Research Lab, University of Pennsylvania, 424 Stemmler Hall, 36th Street & Hamilton Walk, Philadelphia, PA, 19104, USA
| | - David R Steinberg
- Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz Philadelphia VA Medical Center, 3900 University & Woodland Avenue, Philadelphia, PA, 19104, USA.,McKay Orthopaedic Research Lab, University of Pennsylvania, 424 Stemmler Hall, 36th Street & Hamilton Walk, Philadelphia, PA, 19104, USA
| | - Andrew F Kuntz
- Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz Philadelphia VA Medical Center, 3900 University & Woodland Avenue, Philadelphia, PA, 19104, USA.,McKay Orthopaedic Research Lab, University of Pennsylvania, 424 Stemmler Hall, 36th Street & Hamilton Walk, Philadelphia, PA, 19104, USA
| | - Louis J Soslowsky
- Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz Philadelphia VA Medical Center, 3900 University & Woodland Avenue, Philadelphia, PA, 19104, USA.,McKay Orthopaedic Research Lab, University of Pennsylvania, 424 Stemmler Hall, 36th Street & Hamilton Walk, Philadelphia, PA, 19104, USA.,Department of Bioengineering, University of Pennsylvania, Suite 240 Skirkanich Hall, 210 South 33rd Street, Philadelphia, PA, 19104, USA
| | - Robert L Mauck
- Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz Philadelphia VA Medical Center, 3900 University & Woodland Avenue, Philadelphia, PA, 19104, USA.,McKay Orthopaedic Research Lab, University of Pennsylvania, 424 Stemmler Hall, 36th Street & Hamilton Walk, Philadelphia, PA, 19104, USA.,Department of Bioengineering, University of Pennsylvania, Suite 240 Skirkanich Hall, 210 South 33rd Street, Philadelphia, PA, 19104, USA
| | - Joseph Bernstein
- Translational Musculoskeletal Research Center, Corporal Michael J. Crescenz Philadelphia VA Medical Center, 3900 University & Woodland Avenue, Philadelphia, PA, 19104, USA. .,McKay Orthopaedic Research Lab, University of Pennsylvania, 424 Stemmler Hall, 36th Street & Hamilton Walk, Philadelphia, PA, 19104, USA.
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Abstract
BACKGROUND AND PURPOSE NSAIDs are commonly used in the clinic, and there is a general perception that this does not influence healing in common types of human fractures. Still, NSAIDs impair fracture healing dramatically in animal models. These models mainly pertain to fractures of cortical bone in shafts, whereas patients more often have corticocancellous fractures in metaphyses. We therefore tested the hypothesis that the effect of an NSAID is different in shaft healing and metaphyseal healing. METHODS 26 mice were given an osteotomy of their left femur with an intramedullary nail. 13 received injections of indomethacin, 1 mg/kg twice daily. After 17 days of healing, the femurs were analyzed with 3-point bending and microCT. 24 other mice had holes drilled in both proximal tibias, to mimic a stable metaphyseal injury. A screw was inserted in the right tibial hole only. After 7 days of indomethacin injections or control injections, screw fixation was measured with mechanical pull-out testing and the side without a screw was analyzed with microCT. RESULTS In the shaft model, indomethacin led to a 35% decrease in force at failure (95% CI: 14-54). Callus size was reduced to a similar degree, as seen by microCT. Metaphyseal healing was less affected by indomethacin, as no effect on pull-out force could be seen (95% CI: -27 to 17) and there was only a small drop in new bone volume inside the drill hole. The difference in the relative effect of indomethacin between the 2 models was statistically significant (p = 0.006). INTERPRETATION Indomethacin had a minimal effect on stable metaphyseal fractures, but greatly impaired healing of unstable shaft fractures. This could explain some of the differences found between animal models and clinical experience.
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Affiliation(s)
- Olof Sandberg
- Orthopedics Section, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Per Aspenberg
- Orthopedics Section, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Macedo A, Goulart M, Alievi M, Mombach V, Dal-Bó Í, Mucillo M, Silva R, Minto B. Tibial osteosynthesis in a guinea pig (Cavia porcellus). ARQ BRAS MED VET ZOO 2015. [DOI: 10.1590/1678-7498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A guinea pig was presented with left pelvic limb lameness after unknown trauma. Radiographs revealed complete oblique diaphyseal fracture of the distal third of the left tibia and fibula. The guinea pig was treated surgically with an intramedullary pin. The day after surgery the guinea pig was using the limb comfortably (grade 1/5 lameness). Callus formation was obtained 21 days after surgery without complications.
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Affiliation(s)
| | | | | | | | | | | | - R.B. Silva
- Batalhão de Polícia do Exército de Brasília
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Phospholipases of mineralization competent cells and matrix vesicles: roles in physiological and pathological mineralizations. Int J Mol Sci 2013; 14:5036-129. [PMID: 23455471 PMCID: PMC3634480 DOI: 10.3390/ijms14035036] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Revised: 01/24/2013] [Accepted: 01/25/2013] [Indexed: 02/08/2023] Open
Abstract
The present review aims to systematically and critically analyze the current knowledge on phospholipases and their role in physiological and pathological mineralization undertaken by mineralization competent cells. Cellular lipid metabolism plays an important role in biological mineralization. The physiological mechanisms of mineralization are likely to take place in tissues other than in bones and teeth under specific pathological conditions. For instance, vascular calcification in arteries of patients with renal failure, diabetes mellitus or atherosclerosis recapitulates the mechanisms of bone formation. Osteoporosis—a bone resorbing disease—and rheumatoid arthritis originating from the inflammation in the synovium are also affected by cellular lipid metabolism. The focus is on the lipid metabolism due to the effects of dietary lipids on bone health. These and other phenomena indicate that phospholipases may participate in bone remodelling as evidenced by their expression in smooth muscle cells, in bone forming osteoblasts, chondrocytes and in bone resorbing osteoclasts. Among various enzymes involved, phospholipases A1 or A2, phospholipase C, phospholipase D, autotaxin and sphingomyelinase are engaged in membrane lipid remodelling during early stages of mineralization and cell maturation in mineralization-competent cells. Numerous experimental evidences suggested that phospholipases exert their action at various stages of mineralization by affecting intracellular signaling and cell differentiation. The lipid metabolites—such as arachidonic acid, lysophospholipids, and sphingosine-1-phosphate are involved in cell signaling and inflammation reactions. Phospholipases are also important members of the cellular machinery engaged in matrix vesicle (MV) biogenesis and exocytosis. They may favour mineral formation inside MVs, may catalyse MV membrane breakdown necessary for the release of mineral deposits into extracellular matrix (ECM), or participate in hydrolysis of ECM. The biological functions of phospholipases are discussed from the perspective of animal and cellular knockout models, as well as disease implications, development of potent inhibitors and therapeutic interventions.
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8
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The effect of nonsteroidal anti-inflammatory drugs on tissue healing. Knee Surg Sports Traumatol Arthrosc 2013; 21:540-9. [PMID: 22744434 DOI: 10.1007/s00167-012-2095-2] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 06/04/2012] [Indexed: 01/29/2023]
Abstract
PURPOSE Non-selective (NSAIDs) and selective (COX-2) nonsteroidal anti-inflammatory drugs are commonly used for their analgesic and anti-inflammatory effects. Their role after orthopaedic surgery has been infrequently described and remains controversial because of unclear effects on soft tissue and bone healing. This study critically reviews the available literature to describe the effects of NSAIDs and COX-2 inhibitors on soft tissue and bone healing. METHODS A Medline search was performed using NSAIDs or COX-2 inhibitors and tissue healing. The combined search yielded 637 articles. Following exclusion, 44 articles were deemed relevant with 9 articles on soft tissue healing and 35 articles on bone healing. The available evidence is based primarily on animal data (39 studies), with considerable variation in study methods. RESULTS In regard to soft tissue healing, there is insufficient evidence of a detrimental effect when using either NSAIDs or COX-2 inhibitors at standard doses for ≤2 weeks. For soft tissue to bone healing, a limited number of studies demonstrate impairment in healing. However, with respect to bone healing, indomethacin appears to have a clear detrimental effect, with less substantial evidence for other NSAIDs. CONCLUSIONS Short-term, low-dose use of NSAIDs and COX-2 inhibitors does not appear to have a detrimental effect following soft tissue injury, but is inhibitory in cases involving bony healing. However, additional well-controlled human studies are necessary to draw more definitive conclusions regarding their role. Clinically, the prudent use of anti-inflammatory medications following sports medicine injuries and surgeries appears to be a reasonable option in clinical practice unless bone healing is required. LEVEL OF EVIDENCE III.
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9
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Pountos I, Georgouli T, Calori GM, Giannoudis PV. Do nonsteroidal anti-inflammatory drugs affect bone healing? A critical analysis. ScientificWorldJournal 2012; 2012:606404. [PMID: 22272177 PMCID: PMC3259713 DOI: 10.1100/2012/606404] [Citation(s) in RCA: 171] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2011] [Accepted: 10/18/2011] [Indexed: 12/21/2022] Open
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) play an essential part in our approach to control pain in the posttraumatic setting. Over the last decades, several studies suggested that NSAIDs interfere with bone healing while others contradict these findings. Although their analgesic potency is well proven, clinicians remain puzzled over the potential safety issues. We have systematically reviewed the available literature, analyzing and presenting the available in vitro animal and clinical studies on this field. Our comprehensive review reveals the great diversity of the presented data in all groups of studies. Animal and in vitro studies present so conflicting data that even studies with identical parameters have opposing results. Basic science research defining the exact mechanism with which NSAIDs could interfere with bone cells and also the conduction of well-randomized prospective clinical trials are warranted. In the absence of robust clinical or scientific evidence, clinicians should treat NSAIDs as a risk factor for bone healing impairment, and their administration should be avoided in high-risk patients.
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Affiliation(s)
- Ippokratis Pountos
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds LS1 3EX, UK
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Zhu D, Mackenzie NCW, Farquharson C, MacRae VE. Mechanisms and clinical consequences of vascular calcification. Front Endocrinol (Lausanne) 2012; 3:95. [PMID: 22888324 PMCID: PMC3412412 DOI: 10.3389/fendo.2012.00095] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2012] [Accepted: 07/17/2012] [Indexed: 12/23/2022] Open
Abstract
Vascular calcification has severe clinical consequences and is considered an accurate predictor of future adverse cardiovascular events, including myocardial infarction and stroke. Previously vascular calcification was thought to be a passive process which involved the deposition of calcium and phosphate in arteries and cardiac valves. However, recent studies have shown that vascular calcification is a highly regulated, cell-mediated process similar to bone formation. In this article, we outline the current understanding of key mechanisms governing vascular calcification and highlight the clinical consequences. By understanding better the molecular pathways and genetic circuitry responsible for the pathological mineralization process novel drug targets may be identified and exploited to combat and reduce the detrimental effects of vascular calcification on human health.
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Affiliation(s)
- Dongxing Zhu
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, The University of EdinburghMidlothian, Scotland, UK
| | - Neil C. W. Mackenzie
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, The University of EdinburghMidlothian, Scotland, UK
| | - Colin Farquharson
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, The University of EdinburghMidlothian, Scotland, UK
| | - Vicky E. MacRae
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, The University of EdinburghMidlothian, Scotland, UK
- *Correspondence: Vicky E. MacRae, The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush, Roslin, Midlothian EH25 9RG, UK. e-mail:
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HO MEILING, CHANG JEKEN, TSAI HSIUTING, CHO MINGHSUANG, WANG GWOJAW. NONSTEROIDAL ANTI-INFLAMMATORY DRUGS ARREST CELL CYCLE IN G0/G1PHASE AND INDUCE CELL DEATH IN OSTEOBLAST-ENRICHED CULTURES. ACTA ACUST UNITED AC 2011. [DOI: 10.1142/s0218957701000623] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Nonsteroidal anti-inflammatory drugs have been widely prescribed for orthopaedic patients to relieve pain and chronic inflammation. However, it has been demonstrated that NSAIDs suppress bone repair and remodeling in vivo. We have reported that ketorolac inhibits bone repair in vivo and its critical effective timing is at the early stage of endochondral ossification. Our previous results showed that ketorolac and indomethacin inhibit osteoblast proliferation in vitro, suggesting that this effect may be one of the mechanisms contributing to the suppressive effect of NSAIDs on bone remodeling. Cell proliferation and death of osteoblasts should be well regulated through some relative apoptotic and mitotic factors during normal bone remodeling process. Accordingly, we proposed that the induction of osteoblastic cell death of NSAIDs might be one of the mechanisms involving their suppressive effect on bone remodeling in vivo. In this study, we investigated whether NSAIDs arrest osteoblastic cell cycle and/or induce cell death. Whether the mechanism was mediated through prostaglandin (PG) pathway. We tested the effects of ketorolac, indomethacin, diclofenac, piroxicam on cell cycle kinetics, cytotoxicity, and cell death pattern in osteoblast-enriched cultures derived from fetal rat calvaria. Our results showed that ketorolac and indomethacin arrested cell cycle at G0/G1phase. All the 4 NSAIDs had cytotoxic effects and these effects were concentration dependent. The sequence of the cytotoxic effects of these four NSAIDs at 10-4M were indomethacin > diclofenac > ketorolac > piroxicam. Both PGE1and PGE2(10-10-10-8M) also significantly elevated the LDH leakage of osteoblasts, while PGF2αhad no significant effect. These results revealed that the cytotoxic effects of NSAIDs on osteoblasts might not be through inhibiting prostaglandin synthesis. They may be through PG-independent pathways. The results from flow cytometry followed by AnnexinV-FITC and propidium iodide double staining showed that 24 hours treatment of all the 4 NSAIDs (10-6and 10-4M) significantly induced both apoptosis (p<0.01) and necrosis (p<0.01, or p<0.05) in osteoblast cultures. These effects of NSAIDs on cell cycle arrest and cell death induction in osteoblasts may be one of the important mechanisms contributing to their suppressive effect on bone repair and bone remodeling in vivo.
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Affiliation(s)
- MEI-LING HO
- Departments of Physiology, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, R.O.C
| | - JE-KEN CHANG
- Departments of Orthopaedics, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, R.O.C
| | - HSIU-TING TSAI
- Departments of Physiology, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, R.O.C
| | - MING-HSUANG CHO
- Departments of Physiology, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, R.O.C
| | - GWO-JAW WANG
- Departments of Orthopaedics, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, R.O.C
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Thomas MV, Puleo DA. Infection, inflammation, and bone regeneration: a paradoxical relationship. J Dent Res 2011; 90:1052-61. [PMID: 21248364 PMCID: PMC3169879 DOI: 10.1177/0022034510393967] [Citation(s) in RCA: 217] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Revised: 11/17/2010] [Accepted: 11/18/2010] [Indexed: 02/06/2023] Open
Abstract
Various strategies have been developed to promote bone regeneration in the craniofacial region. Most of these interventions utilize implantable materials or devices. Infections resulting from colonization of these implants may result in local tissue destruction in a manner analogous to periodontitis. This destruction is mediated via the expression of various inflammatory mediators and tissue-destructive enzymes. Given the well-documented association among microbial biofilms, inflammatory mediators, and tissue destruction, it seems reasonable to assume that inflammation may interfere with bone healing and regeneration. Paradoxically, recent evidence also suggests that the presence of certain pro-inflammatory mediators is actually required for bone healing. Bone injury (e.g., subsequent to a fracture or surgical intervention) is followed by a choreographed cascade of events, some of which are dependent upon the presence of pro-inflammatory mediators. If inflammation resolves promptly, then proper bone healing may occur. However, if inflammation persists (which might occur in the presence of an infected implant or graft material), then the continued inflammatory response may result in suboptimal bone formation. Thus, the effect of a given mediator is dependent upon the temporal context in which it is expressed. Better understanding of this temporal sequence may be used to optimize regenerative outcomes.
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Affiliation(s)
- M V Thomas
- Department of Oral Health Practice, University of Kentucky College of Dentistry, 800 Rose Street, Room D-124, Lexington, KY 40536-0297, USA.
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13
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Affiliation(s)
- Sigbjørn Dimmen
- Orthopaedic Department, Ullevaal Hospital, Oslo University Hospital, Kirkeveien 166, 0407 Oslo, Norway.
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Cottrell J, O’Connor JP. Effect of Non-Steroidal Anti-Inflammatory Drugs on Bone Healing. Pharmaceuticals (Basel) 2010; 3:1668-1693. [PMID: 27713323 PMCID: PMC4034003 DOI: 10.3390/ph3051668] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Revised: 05/05/2010] [Accepted: 05/24/2010] [Indexed: 01/11/2023] Open
Abstract
Nonspecific and COX-2 selective nonsteroidal anti-inflammatory drugs (NSAIDs) function by inhibiting the cyclooxygenase isoenzymes and effectively reduce pain and inflammation attributed to acute or chronic musculoskeletal pathologies. However, use of NSAIDs as an analgesic is thought to negatively contribute to bone healing. This review strived to provide a thorough unbiased analysis of the current research conducted on animals and humans regarding NSAIDs and their effect on bone healing. Specifically, this review discusses the role of animal models, dosing regiments, and outcome parameters when examining discrepancies about NSAIDS and their effects on bone regeneration. The role of COX-2 in bone regeneration needs to be better defined in order to further elucidate the impact of NSAIDs on bone healing.
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Affiliation(s)
| | - J. Patrick O’Connor
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +1-973-972-5011; Fax: +1-973-972-5594
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15
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Wu Y, Tai HH, Cho H. Synthesis and SAR of thiazolidinedione derivatives as 15-PGDH inhibitors. Bioorg Med Chem 2010; 18:1428-33. [DOI: 10.1016/j.bmc.2010.01.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2009] [Revised: 01/06/2010] [Accepted: 01/07/2010] [Indexed: 12/31/2022]
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Brochhausen C, Zehbe R, Watzer B, Halstenberg S, Gabler F, Schubert H, Kirkpatrick CJ. Immobilization and controlled release of prostaglandin E2from poly-L-lactide-co-glycolide microspheres. J Biomed Mater Res A 2009; 91:454-62. [DOI: 10.1002/jbm.a.32215] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Graham S, Leonidou A, Lester M, Heliotis M, Mantalaris A, Tsiridis E. Investigating the role of PDGF as a potential drug therapy in bone formation and fracture healing. Expert Opin Investig Drugs 2009; 18:1633-54. [DOI: 10.1517/13543780903241607] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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18
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Parecoxib and indomethacin delay early fracture healing: a study in rats. Clin Orthop Relat Res 2009; 467:1992-9. [PMID: 19319614 PMCID: PMC2706352 DOI: 10.1007/s11999-009-0783-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2008] [Accepted: 02/27/2009] [Indexed: 01/31/2023]
Abstract
Nonsteroidal antiinflammatory drugs (NSAIDs) are used to reduce inflammatory response and pain. These drugs have been reported to impair bone metabolism. Parecoxib, a specific COX-2 inhibitor, exerts an inhibitory effect on the mineralization of fracture callus after a tibial fracture in rats. Decreased bone mineral density (BMD) at a fracture site may indicate impairment of early healing, casting doubt on the safety of using COX-2 inhibitors during the early treatment of diaphyseal fractures. Forty-two female Wistar rats were randomly allocated to three groups. They were given parecoxib, indomethacin, or saline intraperitoneally for 7 days after being subjected to a closed tibial fracture stabilized with an intramedullary nail. Two and 3 weeks after surgery, the bone density at the fracture site was measured using dual energy xray absorptiometry (DEXA). Three weeks after the operation the rats were euthanized and the healing fractures were mechanically tested in three-point cantilever bending. Parecoxib decreased BMD at the fracture site for 3 weeks after fracture, indomethacin for 2 weeks. Both parecoxib and indomethacin reduced the ultimate bending moment and the bending stiffness of the healing fractures after 3 weeks. These results suggest COX inhibitors should be avoided in the early phase after fractures.
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Watzer B, Zehbe R, Halstenberg S, James Kirkpatrick C, Brochhausen C. Stability of prostaglandin E(2) (PGE (2)) embedded in poly-D,L: -lactide-co-glycolide microspheres: a pre-conditioning approach for tissue engineering applications. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2009; 20:1357-1365. [PMID: 19160024 DOI: 10.1007/s10856-008-3678-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2008] [Accepted: 12/16/2008] [Indexed: 05/27/2023]
Abstract
Prostaglandin E(2) (PGE(2)) is involved in angiogenesis, bone repair and cartilage metabolism. Thus, PGE(2) might represent a suitable signaling molecule in different tissue engineering applications. PGE(2) also has a short half-life time. Its incorporation into poly-D: ,L: -lactide-co-glycolide (PLGA) microspheres was demonstrated in a previous study. However, the stability of bioactive PGE(2) in these microspheres is unknown. With an adjusted mass spectrometry assay we investigated the amount of incorporated PGE(2) and the stability of PGE(2) in conventional cell culture medium and in PLGA microspheres. The stability of PGE(2) was closely pH dependent. Strong acidic or basic environments reduced the half-life from 300 h (pH 2.6-4.0) to below 50 h at pH 2.0 or pH 8.8. The half-life of PGE(2) incorporated into poly-D: ,L: -lactide-co-glycolide increased drastically to 70 days at 37 degrees C and to 300 days at 8 degrees C. Analysis with scanning electron microscopy (SEM) and atomic force microscopy (AFM) demonstrated a distinct nanostructure of the polymeric phase and both nano- and microporosity.
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Affiliation(s)
- Bernhard Watzer
- Mother-Child Medical Center, Department of Pediatric Science, Philipps-University, Marburg, Germany
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Graham S, Gamie Z, Polyzois I, Narvani AA, Tzafetta K, Tsiridis E, Heliotis M, Mantalaris A, Tsiridis E. Prostaglandin EP2 and EP4 receptor agonists in bone formation and bone healing:In vivoandin vitroevidence. Expert Opin Investig Drugs 2009; 18:746-66. [DOI: 10.1517/13543780902893051] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Abstract
Cyclooxygenase (COX) catalyzes the conversion of arachidonic acid into prostaglandins (PGs), which play a significant role in health and disease in the gastrointestinal tract (GI) and in the renal, skeletal, and ocular systems. COX-1 is constitutively expressed and found in most normal tissues, whereas COX-2 can be expressed at low levels in normal tissues and is highly induced by pro-inflammatory mediators. Inhibitors of COX activity include: (1) conventional nonselective, nonsteroidal anti-inflammatory drugs (ns-NSAIDs) and (2) COX-2 selective nonsteroidal anti-inflammatory drugs (COX-2 s-NSAIDs). Inhibition of COX-1 often elicits GI toxicity in animals and humans. Therefore, COX-2 s-NSAIDs were developed to provide a selective COX-2 agent, while minimizing the attendant COX-1-mediated GI toxicities. Rats and dogs overpredict COX inhibition for renal effects such as renal handling of electrolytes in humans. COX inhibitors are shown to have both beneficial and detrimental effects, such as on healing of ligament or tendon tears, on the skeletal system in animal models. Certain ophthalmic conditions such as glaucoma and keratitis are associated with increased COX-2 expression, suggesting a potential role in their pathophysiology.
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Affiliation(s)
- Zaher A Radi
- Pfizer Global R&D, Drug Safety R&D, St. Louis, Missouri 63017, USA.
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Ketorolac and spinal fusion: does the perioperative use of ketorolac really inhibit spinal fusion? Spine (Phila Pa 1976) 2008; 33:2079-82. [PMID: 18698276 DOI: 10.1097/brs.0b013e31818396f4] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE To evaluate the effect of postoperative use of ketorolac (Toradol) on spinal fusion in humans. SUMMARY OF BACKGROUND DATA The value of parenteral ketorolac in postoperative analgesia has been well documented across surgical specialties. However, some studies have shown that ketorolac may adversely affect osteogenic activity and fracture healing. METHODS A total of 405 consecutive patients who underwent primary lumbar posterolateral intertransverse process fusion with pedicle screw instrumentation were included in this retrospective study. A subtotal of 228 patients received Toradol after surgery for adjunctive analgesia. Each patient received a mandatory dose of 30 mg intravenously every 6 hours for 48 hours. The same surgeon performed the fusion procedure on all of these patients. Historical controls included 177 patients who did not receive Toradol after surgery. The minimum follow-up period was 24 months. Nonunions were diagnosed by analyzing sequential radiographs, flexion-extension radiographs, and computed tomography with multiplanar reconstructions. The gold standard of surgical exploration was performed in symptomatic patients with diagnostic ambiguity or nonunions diagnosed by imaging. RESULTS There were no smokers in the study population. Pseudarthrosis was identified in 12 of 228 patients (5.3%) who received Toradol after surgery, and in 11 of 177 patients (6.2%) who did not. There was no significant difference detected in the nonunion rates between the two groups (P > 0.05, chi2 method). CONCLUSION Use of ketorolac after spinal fusion surgery in humans, limited to 48 hours after surgery for adjunctive analgesia, has no significant effect on ultimate fusion rates.
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Abstract
This article reinforces the clinical points of emphasis that have been stressed throughout this issue in a case scenario format. Common situations dealt with by physicians are examined to highlight the underlying physiology of the specific complaints and treatment interventions. The goal of this article is to present an evidenced-based review of pain management interventions in a format that allows for reader incorporation.
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Postoperative ketorolac does not predispose to pseudoarthrosis following posterior spinal fusion and instrumentation for adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 2008; 33:1119-24. [PMID: 18449047 DOI: 10.1097/brs.0b013e31816f6a2a] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective review comparing patients who had postoperative ketorolac and those who did not following posterior spinal fusion and instrumentation (PSFI) for adolescent idiopathic scoliosis (AIS). OBJECTIVE To analyze the effect of postoperative ketorolac on the incidence of pseudoarthrosis in postoperative AIS patients. SUMMARY OF BACKGROUND DATA Ketorolac (Toradol, Roche Laboratories, Nutley, NJ) is a nonsteroidal antiinflammatory drug that is an effective adjunct to manage postoperative pain. It has been previously demonstrated to inhibit spinal fusion in adult patients undergoing a L4 to sacral fusion. To our knowledge, there are no large studies analyzing this effect following PSFI for AIS. METHODS An IRB-approved retrospective medical record review was performed from 1994 to 2000 of patients undergoing a PSFI for AIS at a single institution. Segmental spinal instrumentation (Texas Scottish Rite Hospital) and iliac crest bone graft were used in both groups. Demographic and operative data were recorded. Patients were divided into those who had postoperative ketorolac (K group) and those who did not (NK group). Patients who had a surgically confirmed pseudoarthrosis were identified and the K group and NK group were statistically compared. RESULTS There were 161 patients in the NK group and 158 in the K group. There were no differences with respect to age (14.4 vs. 14.2 years), gender (83.9% vs. 84.8% females), levels fused (9.8 vs. 9.7), or preoperative curve magnitude (57.9 degrees vs. 58.9 degrees ). In the K group, the number of doses of ketorolac administered was 6.7 for an average of 26.7 mg for a duration of 46 hours after surgery. Patients in the K group were more likely to have Motrin (average 5.8 doses) compared with the NK group (average 0.7 doses) (P < 0.01). No patient in the K group had a history of cigarette smoking compared with 2 patients in the NK group, both of whom went on to solid arthrodesis. The overall incidence of pseudoarthrosis was 2.5% for all patients. There was no difference in the incidence of pseudoarthrosis comparing the K (1.9%) and the NK group (3.1%)(P = 0.7). When the single rod posterior implants were excluded, there was no difference between the K (0.7%) and NK groups (1.8%) (P = 0.58). CONCLUSION Ketorolac does not increase the incidence of developing a pseudoarthrosis when used as an adjunct for postoperative analgesia following a PSFI for AIS using segmental spinal instrumentation and iliac crest bone graft. The differences seen here compared with adults may be due to the greater healing potential in these young patients. We recommend utilization of ketorolac after surgery to supplement pain management when necessary.
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Pablos AB, Ramalho SA, König B, Furuse C, de Araújo VC, Cury PR. Effect of meloxicam and diclofenac sodium on peri-implant bone healing in rats. J Periodontol 2008; 79:300-6. [PMID: 18251644 DOI: 10.1902/jop.2008.070301] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND This study evaluated the effects of diclofenac sodium and meloxicam on peri-implant bone healing. METHODS Thirty male rats were divided into three groups: the control group (CG) received no drug; the diclofenac sodium group (DSG) received 1.07 mg/kg twice a day for 5 days; and the meloxicam group (MG) received 0.2 mg/kg daily for 5 days. A screw-shaped titanium implant was placed in the tibia. Fluorochromes, oxytetracycline (OxT), calcein (CA), and alizarin (AL), were injected at 7, 14, and 21 days, respectively, after implantation, and the animals were sacrificed 28 days after implant placement. The percentages of OxT-, CA-, and AL-labeled bone as well as the percentages of bone-to-implant contact (BIC), cortical bone area (CBA), and trabecular bone area (TBA) within the implant threads were evaluated. RESULTS Bone healing was delayed in the DSG during the first 14 days after implant placement (OxT-labeled bone: DSG: 5.3% +/- 7.3% versus CG: 13.2% +/- 9.8%, P = 0.002, and versus MG:14.4% +/- 13.1%, P = 0.05). The percentages of BIC (DSG: 49.6% +/- 21.9%; MG: 67.1% +/- 22.8%; and CG: 68.1% +/- 22.8%) and CBA (DSG: 63.7% +/- 21.2%; MG: 82.7% +/- 12.4%; CG: 84.9% +/- 10.6%) were lower in the DSG compared to the MG and CG (P <0.001). The percentage of TBA was significantly greater in the DSG compared to the MG and CG (DSG: 36.3% +/- 21.2% versus MG: 17.3% +/- 12.7% and versus CG: 15.1% +/- 10.6%; P <0.001). CONCLUSION Diclofenac sodium seemed to delay peri-implant bone healing and to decrease BIC, whereas meloxicam had no negative effect on peri-implant bone healing.
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Affiliation(s)
- Alethéia B Pablos
- Department of Implantology, São Leopoldo Mandic Dental Research Center, Campinas, SP, Brazil.
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Urrutia J, Mardones R, Quezada F. The effect of ketoprophen on lumbar spinal fusion healing in a rabbit model. Laboratory investigation. J Neurosurg Spine 2008; 7:631-6. [PMID: 18074688 DOI: 10.3171/spi-07/12/631] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Several reports have shown that nonsteroidal antiinflammatory drugs (NSAIDs) have an inhibitory effect in osteogenesis and reduce heterotopic ossification in humans. A deleterious effect of NSAIDs in posterolateral intertransverse process fusion has also been suggested. The authors used a validated rabbit model to try to determine the influence of the NSAID ketoprophen on the fusion rate in lumbar spinal arthrodesis. METHODS Thirty New Zealand male rabbits underwent posterolateral (intertransverse process) bilateral spinal fusions at a single level, using autologous bone graft obtained from both iliac crests. The animals were randomized after the operation, so that 15 rabbits received ketoprophen as a postoperative analgesic and the other 15 received the postoperative analgesic tramadol. The animals were killed 8 weeks after surgery, and fusion status was determined by inspection, palpation, anteroposterior radiographs, and histological analysis. RESULTS A solid fusion was obtained in eight rabbits (53%), and pseudarthrosis in seven rabbits (47%) in each group. CONCLUSIONS These findings suggest that the use of ketoprophen after intertransverse spinal fusion at a single level does not decrease the fusion rate, compared with tramadol.
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Affiliation(s)
- Julio Urrutia
- Department of Orthopaedic Surgery, Pontificia Universidad Catolica de Chile.
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Ince A, Sauer U, Wollmerstedt N, Hendrich C. No migration of acetabular cups after prophylaxis for heterotopic ossification. Clin Orthop Relat Res 2007; 461:125-9. [PMID: 17415004 DOI: 10.1097/blo.0b013e31805c0d82] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The possibility of migration of cementless cups in total joints after prophylaxis of heterotopic ossification with irradiation or nonsteroidal antiinflammatory drugs is a concern. Data investigating component stability with digital methods are lacking. This prospective study analyzed the migration of cementless cups after indomethacin and irradiation prophylaxis with the digital Einzel-Bild-Röntgen-Analyse tool. The irradiation group (106 hips) and the indomethacin group (98 hips) were compared with 82 hips that did not receive any prophylaxis. The same cementless acetabular implants were used in all cases, and patients were observed clinically and radiographically at 2 and 5 years. At the 5-year followup, the number of cups that showed migration greater than 1 mm in the irradiation group (five), the indomethacin group (three), and the control group (four) were not different. No cup was considered loose on the radiographs and no patient underwent revision surgery. The results of our study indicate irradiation or short-course use of indomethacin for prophylaxis of heterotopic ossification did not negatively affect the stability of cementless cups in primary total hip arthroplasties.
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Affiliation(s)
- Akif Ince
- Department of Orthopaedic Surgery, University Hospital Würz-burg, Würzburg, Germany.
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Li M, Thompson DD, Paralkar VM. Prostaglandin E(2) receptors in bone formation. INTERNATIONAL ORTHOPAEDICS 2007; 31:767-72. [PMID: 17593365 PMCID: PMC2266676 DOI: 10.1007/s00264-007-0406-x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/27/2007] [Revised: 05/18/2007] [Accepted: 05/22/2007] [Indexed: 10/23/2022]
Abstract
Prostaglandins, PGE(2) in particular, have diverse actions on various organs, including inflammation, bone healing, bone formation, embryo implantation, induction of labour and vasodilatation, among others. However, systemic side effects have limited their clinical utility. The pharmacological activities of PGE(2) are mediated through four G protein-coupled receptor subtypes, EP1-EP4. Recent studies have shown that EP2 and EP4 receptors play important roles in regulating bone formation and resorption. EP2 and EP4 receptor-selective agonists have been shown to stimulate local or systemic bone formation, augment bone mass and accelerate the healing of fractures or bone defects in animal models upon local or systemic administration, thus, potentially offering new therapeutic options for enhancing bone formation and bone repair in humans. This review will focus on the studies related to bone formation and bone healing in the EP receptor knockout (KO) mice and the EP2 or EP4 receptor-selective agonist treated animal models.
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Affiliation(s)
- M. Li
- Pfizer Global Research and Development, Groton Laboratories, Mail Stop 8118W-208, Groton, CT 06340 USA
| | - D. D. Thompson
- Pfizer Global Research and Development, Groton Laboratories, Mail Stop 6025-A4235, New London, CT 06320 USA
| | - V. M. Paralkar
- Pfizer Global Research and Development, Groton Laboratories, Mail Stop 8118W-208, Groton, CT 06340 USA
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Sen C, Erdem M, Gunes T, Koseoglu D, Filiz NO. Effects of diclofenac and tenoxicam on distraction osteogenesis. Arch Orthop Trauma Surg 2007; 127:153-9. [PMID: 17203285 DOI: 10.1007/s00402-006-0274-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2005] [Indexed: 11/29/2022]
Abstract
INTRODUCTION In the management of bone defects, pseudoarthrosis, deformities, chronic osteomyelitis and in extremity lengthening procedures, the technique of distraction osteogenesis (DO) has been frequently used. In this experimental animal study, the effects of two non-steroidal anti-inflammatory drugs, i.e., diclofenac and tenoxicam, on the outcomes of distraction osteogenesis are investigated. MATERIALS AND METHODS In this study, 30 mature New Zealand-type male rabbits (2.5-4.5 kg) were used. The rabbits were randomized into three groups, each consisting of ten animals. Under optimal operating conditions, a pre-reconstructed circular external fixator was applied on the right tibias of rabbits, and osteotomy was performed with a Gigli saw just below the tibial tuberosity. After seven postoperative days, distraction was initiated at a rhythm of 2 x 0.5 mm/day. During the 10 days of distraction, adjunctive therapy was not instituted for group I (control group). For 10 days, group II received i.m. diclofenac sodium (0.5 mg/kg per day) and group III was treated with tenoxicam (8 mg/kg per day i.m.). At the end of 3 weeks postoperatively, five rabbits from each group were killed for histologic examinations. The remaining rabbits were killed at the end of eight postoperative weeks for biomechanical and histological analysis. Besides, radiological examinations were performed at the end of 3, 6 and 8 weeks postoperatively for the radiologic evaluation of calluses. For statistical evaluations between groups, Kruskal-Wallis variance analysis, and for intergroup assessments, Mann-Whitney test were performed. RESULTS For radiological evaluations, the scoring system developed by Lane and Sandhu, and for histopathological assessments, the grading system of Huddlestone et al. were used. Biomechanical tests were realized using torsional loading. During the first 3 weeks, the groups did not differ much in the radiological parameters. However, in the diclofenac group and in especially the tenoxicam group, the histological scores were lower than in the control group. Radiological images obtained at the end of 6 weeks demonstrated inadequate consolidation in the diclofenac and tenoxicam groups when compared with the control group. At the end of 8 weeks postoperatively, in consideration of biomechanical, radiological and histological tests, significantly worse regenerates were obtained in the diclofenac and tenoxicam groups. CONCLUSIONS During the distraction osteogenesis period, diclofenac and tenoxicam affected the quality of regenerate unfavorably. This effect is sustained during all periods of bone healing. However, this finding should be supported by experimental and human studies.
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Affiliation(s)
- Cengiz Sen
- Department of Orthopedics and Traumatology, Medical School of Gaziosmanpasa University, Tip Fakultesi Dekanligi, 60100, Tokat, Turkey.
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Mullis BH, Copland ST, Weinhold PS, Miclau T, Lester GE, Bos GD. Effect of COX-2 inhibitors and non-steroidal anti-inflammatory drugs on a mouse fracture model. Injury 2006; 37:827-37. [PMID: 16497308 DOI: 10.1016/j.injury.2005.12.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2005] [Revised: 12/11/2005] [Accepted: 12/12/2005] [Indexed: 02/02/2023]
Abstract
A randomised, blinded, prospective animal study with 296 male C57BL/6N mice was performed to evaluate the biomechanical, biomolecular, biochemical, and histological impact of anti-inflammatory medications on fracture healing. A reproducible closed tibia fracture was created and stabilised with an intramedullary pin. Animals were randomised to placebo, ketorolac, ibuprofen, celecoxib, or rofecoxib treatment groups with biomechanical and biochemical testing at 4, 8, and 12 weeks. A second arm of the study was conducted in which animals were randomised to indomethacin or placebo treatment with biomechanical testing at 12 weeks. Histological and biomolecular studies were performed at 2 weeks on all groups in the first arm of the study. Biomechanical testing consisted of three-point bending evaluating maximum load, energy absorbed to maximum load, and stiffness. Safranin O-Fast Green stain was performed for histology. Biochemical quantifications of chondroitin and dermatan sulphate, hydroxyproline, total protein, and DNA content were performed. Osteocalcin and collagen types II and X were evaluated by in situ hybridisation. Some mechanical differences were seen between ketorolac and placebo at 4 weeks with respect to energy absorbed, but there were no differences in maximum load or stiffness seen between any treatment group and placebo at any time point. Indomethacin, celecoxib, rofecoxib, ibuprofen, and ketorolac did not significantly affect fracture healing in this young murine model.
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Chang JK, Wu SC, Wang GJ, Cho MH, Ho ML. Effects of non-steroidal anti-inflammatory drugs on cell proliferation and death in cultured epiphyseal-articular chondrocytes of fetal rats. Toxicology 2006; 228:111-23. [PMID: 17045721 DOI: 10.1016/j.tox.2006.08.028] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2006] [Revised: 08/14/2006] [Accepted: 08/14/2006] [Indexed: 12/21/2022]
Abstract
Previous reports indicated that non-steroidal anti-inflammatory drugs (NSAIDs) suppress bone repair. Our previous study further found that ketorolac delayed the endochondral bone formation, and the critical effective timing was at the early stage of repair. Furthermore, we found that NSAIDs suppressed proliferation and induced cell death of cultured osteoblasts. In this study, we hypothesized that chondrocytic proliferation and death, which plays an important role at the early stage of endochondral bone formation, might be affected by NSAIDs. Non-selective NSAIDs, indomethacin, ketorolac, diclofenac and piroxicam; cyclooxygenase-2 (COX-2) selective NSAIDs, celecoxib and DFU (an analog of rofecoxib); prostaglandins (PGs), PGE1, PGE2 and PGF2alpha; and each NSAID plus each PG were tested. The effects of NSAIDs on proliferation, cell cycle kinetics, cytotoxicity and cell death of epiphyseal-articular chondrocytes of fetal rats were examined. The results showed that all the tested NSAIDs, except DFU, inhibited thymidine incorporation of chondrocytes at a concentration range (10(-8) to 10(-4)M) covering the theoretic therapeutic concentrations. Cell cycle was arrested by NSAIDs at the G(0)/G(1) phase. Upon a 24h treatment, LDH leakage and cell death (both apoptosis and necrosis) were significantly induced by the four non-selective NSAIDs in chondrocyte cultures. However, COX-2 inhibitors revealed non-significant effects on cytotoxicity of chondrocytes except higher concentration of celecoxib (10(-4)M). Replenishments of PGE1, PGE2 or PGF2alpha could not reverse the effects of NSAIDs on chondrocytic proliferation and cytotoxicity. In this study, we found that therapeutic concentrations of non-selective NSAIDs caused proliferation suppression and cell death of chondrocytes, suggesting these adverse effects may be one of the reasons that NSAIDs delay the endochondral ossification during bone repair found in previous studies. Furthermore, these effects of NSAIDs may act via PG-independent mechanisms. COX-2 selective NSAIDs showed less deleterious effects on chondrocytic proliferation and death.
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Affiliation(s)
- Je-Ken Chang
- Department of Orthopaedics, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Carrillo JM, Sopena JJ, Rubio M, Redondo JI, Serra I, Soler C. Experimental use of polyamide bands in combination with intramedullary pinning for repair of oblique femoral fractures in rabbits. Vet Surg 2005; 34:387-92. [PMID: 16212595 DOI: 10.1111/j.1532-950x.2005.00059.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the use of polyamide bands, manufactured for securing electrical cables, for repair of oblique femoral fractures in rabbits. STUDY DESIGN Experimental study. ANIMALS Twelve nulliparous, 21-25-week-old, California female rabbits. METHODS Rabbits were divided into 3 groups (n=4) and studied for 14, 28, or 56 days. A Z-shaped mid-diaphyseal femoral osteotomy was repaired with a 2.5 mm intramedullary pin and a polyamide 6.6 cerclage band. Healing was evaluated at intervals by physical examination, limb use, femoral radiographs, and callus histology. RESULTS Rabbits had early limb use with good wound healing. From the 1st day, movement of the hip and stifle joints was satisfactory. Radiographically, fractures were healed at 28 days. Histologically, there was no foreign body reaction and bone healing was normal. CONCLUSION Nylon cerclage band application was accomplished easily, maintained reduction, and resulted in good healing and limb use. CLINICAL RELEVANCE Sterilized nylon bands, manufactured for electrical use, can be used for cerclage in rabbits.
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Affiliation(s)
- Jose M Carrillo
- Clinic Veterinary Hospital, Department of Animal Medicine and Surgery, Faculty of Health and Experimental Sciences, Cardenal Herrera-CEU University, Valencia, Spain.
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Persson PE, Sisask G, Nilsson O. Indomethacin inhibits bone formation in inductive allografts but not in autografts: studies in rat. Acta Orthop 2005; 76:465-9. [PMID: 16195059 DOI: 10.1080/17453670510041420] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are known to have inhibitory effects on new bone formation. We wanted to analyze some effects of the NSAID indomethacin on different inductive stimuli for bone formation. METHODS We experimentally induced heterotopic new bone with demineralized allogeneic bone matrix (DABM) and with bone autografts in rats, in order to study the effects of indomethacin on new bone formation at 3 and 6 weeks. RESULTS Indomethacin inhibited net bone formation in DABMs by 30% at 6 weeks. At 6 weeks, the mineral accretion rate was unaffected, indicating that it is at the early phase of the inductive process that mineral accretion is sensitive to inhibition by indomethacin, but not at the later stages. In traumatized skeletal bone, the (45)Ca-specific activity was higher than in non-traumatized bone, while indomethacin significantly reduced the (45)Ca uptake at 3 weeks, but not at 6 weeks. In the autografts, a net mineral loss occurred, but neither mineral content nor (45)Ca incorporation was affected by Indomethacin treatment. INTERPRETATION Indomethacin inhibited the early phase of new bone formation in heterotopic DABMs and the early bone healing process in traumatized skeletal bone, but did not affect resorption or bone formation in heterotopic autografts. blacksquare, square, filled.
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Dudkiewicz I, Brosh T, Perelman M, Salai M. Colchicine inhibits fracture union and reduces bone strength--in vivo study. J Orthop Res 2005; 23:877-81. [PMID: 16023003 DOI: 10.1016/j.orthres.2004.11.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2004] [Accepted: 11/19/2004] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Recent studies have demonstrated that Colchicine (CO) prevents heterotopic ossification (HO) after total hip replacement in patients suffering from familial Mediterranean fever (FMF). Other investigators have proved that CO is an in vitro inhibitor of proliferation of osteoblasts and osteosarcoma cells, and is a non-selective mitosis inhibitor and selective inhibitor of mineralization. METHODS A double blind prospective study comprised four groups of adult rats. The left posterior tibia in each rat was fractured except in one of the control groups. The study groups were treated with CO 1 mg/kg/day 1 week before, or on the fracture day. The control groups did not receive CO treatment. Six weeks after fracture induction the groups were compared radiographically mechanically and histologically. RESULTS Prolonged CO treatment had a significant negative influence on fracture healing according to radiological, clinical, mechanical (p<0.02), and pathological parameters (p<0.0001). CONCLUSIONS We were able to demonstrate that prolonged CO treatment reduced bone healing.
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Affiliation(s)
- Israel Dudkiewicz
- Department of Orthopedic Rehabilitation, The Chaim Sheba Medical Center, Tel Hashomer 52621, Israel.
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Chang JK, Wang GJ, Tsai ST, Ho ML. Nonsteroidal anti-inflammatory drug effects on osteoblastic cell cycle, cytotoxicity, and cell death. Connect Tissue Res 2005; 46:200-10. [PMID: 16546823 DOI: 10.1080/03008200500344025] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Previous studies indicated that nonsteroidal anti-inflammatory drugs (NSAIDs) suppress bone repair, growth, and remodeling in vivo. Our previous in vitro study demonstrated that indomethacin and ketorolac inhibited osteoblast proliferation. In this study, we further investigated the influences of 4 NSAIDs on cell cycle kinetics, cytotoxicity, and cell death pattern in osteoblast cultures from rat fetal calvaria. Our results showed that NSAIDs significantly arrested cell cycle at the G(0)/G(1) phase and induced cytotoxicity and cell death of osteoblasts. Apoptosis was more pronounced than necrosis caused by NSAIDs. Among these NSAIDs, piroxicam showed the least effect to produce osteoblastic dysfunction. Moreover, we found that the cytotoxic and apoptotic effects of NSAIDs on osteoblasts might not be prostaglandin related. These results suggest that the NSAID effects on cell cycle arrest and cell death induction in osteoblasts may be one of the important mechanisms contributing to their suppressive effect on bone formation.
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Affiliation(s)
- Je-Ken Chang
- Department of Orthopaedics, School of Medicine, Orthopaedic Research Center, Kaohsiung Medical University Chug-Ho Memorial Hospital, Kaohsiung, Taiwan
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Müller SS, Curcelli EC, Sardenberg T, Zuccon A, De Crudis Júnior JL, Padovani CR. Análise clínica e biomecânica do efeito do diclofenaco sódico na consolidação da fratura da tíbia no rato. ACTA ORTOPEDICA BRASILEIRA 2004. [DOI: 10.1590/s1413-78522004000400001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Os AINH (Antiinflamatórios não hormonais) são agentes utilizados na prática clínica que interferem no processo inflamatório pela inibição da síntese de prostaglandinas e tromboxanos. Alguns trabalhos experimentais investigaram sua ação no processo de consolidação de fraturas, por meio de estudos clínicos e histológicos, sendo escassas as análises biomecânicas. Nesse estudo foram utilizados 20 ratos da linhagem Wistar, divididos aleatoriamente em dois grupos iguais: grupo A (controle) e grupo B (tratado com diclofenaco sódico). Em ambos os grupos foram realizadas fraturas abertas, após perfuração, na tíbia direita. A administração da droga foi via intramuscular, dose única diária, por 28 dias. Os animais foram pesados semanalmente. Após o sacrifício as tíbias foram dissecadas, pesadas e submetidas a ensaio biomecânico de flexão analisando-se carga máxima, deformação e coeficiente de rigidez. Observou-se que no grupo tratado com AINH não houve aumento do peso corpóreo a partir da segunda semana e as tíbias fraturadas foram mais pesadas. Neste grupo o calo ósseo suportou menor carga máxima, apresentando maior deformação e menor coeficiente de rigidez. Nos animais tratados, o osso não fraturado também se mostrou menos rígido. Concluiu-se, nas condições estudadas, que o DS alterou o processo de consolidação e o metabolismo ósseo, levando a retardo na maturação do calo e menor rigidez do osso intacto, respectivamente.
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Kruyt MC, van Gaalen SM, Oner FC, Verbout AJ, de Bruijn JD, Dhert WJA. Bone tissue engineering and spinal fusion: the potential of hybrid constructs by combining osteoprogenitor cells and scaffolds. Biomaterials 2004; 25:1463-73. [PMID: 14697849 DOI: 10.1016/s0142-9612(03)00490-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
In this paper, we discuss the current knowledge and achievements on bone tissue engineering with regard to spinal fusion and highlight the technique that employs hybrid constructs of porous scaffolds with bone marrow stromal cells. These hybrid constructs potentially function in a way comparable to the present golden standard, the autologous bone graft, which comprises besides many other factors, a construct of an optimal biological scaffold with osteoprogenitor cells. However, little is known about the role of the cells in autologous grafts, and especially survival of these cells is questionable. Therefore, more research will be needed to establish a level of functioning of hybrid constructs to equal the autologous bone graft. Spinal fusion models are relevant because of the increasing demand for graft material related to this procedure. Furthermore, they offer a very challenging environment to further investigate the technique. Anterior and posterolateral animal models of spinal fusion are discussed together with recommendations on design and assessment of outcome parameters.
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Affiliation(s)
- M C Kruyt
- Department of Orthopaedics, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, Netherlands.
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Li M, Ke HZ, Qi H, Healy DR, Li Y, Crawford DT, Paralkar VM, Owen TA, Cameron KO, Lefker BA, Brown TA, Thompson DD. A novel, non-prostanoid EP2 receptor-selective prostaglandin E2 agonist stimulates local bone formation and enhances fracture healing. J Bone Miner Res 2003; 18:2033-42. [PMID: 14606517 DOI: 10.1359/jbmr.2003.18.11.2033] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
UNLABELLED CP-533,536, a newly discovered, non-prostanoid EP2 receptor-selective PGE2 agonist, stimulates local bone formation and enhances fracture healing in rat models. INTRODUCTION There is a significant medical need for agents that can stimulate local bone formation and enhance fracture healing. We tested the effects of CP-533,536, a newly discovered, non-prostanoid EP2 receptor-selective prostaglandin E2 (PGE2) agonist, in stimulating local bone formation and enhancing fracture healing in rat models. MATERIALS AND METHODS In the first model, a single injection of CP-533,536 at doses of 0.3, 1, or 3 mg/kg to the proximal tibial metaphysis of 6-week-old male rats was given on day 1, and the local bone anabolic effect was determined on day 7. We then tested the effects of this compound in inducing bone formation on rat periosteum of the femur. A single dose of 0.3 mg of CP-533,536 incorporated in a poly-(D,L-lactide-co-glycolide) (PLGH) matrix was injected onto the periosteum of the femur in 3-week-old male rats, and local bone formation was determined on day 14. Finally, the ability of CP-533,536 in PLGH matrix in enhancing fracture healing was tested using the rat femoral fracture model. CP-533,536 in PLGH matrix at doses of 0.05, 0.5, or 5 mg was delivered to the local fracture site on the same day of fracture, and its efficacy was evaluated on day 21. RESULTS AND CONCLUSIONS A single injection of CP-533,536 at doses of 0.3, 1, or 3 mg/kg to the proximal tibial metaphysis dose-dependently stimulated local lamellar bone formation on trabecular, endocortical, and periosteal surfaces, and thus increased bone mineral content and bone strength at the injected site. Similarly, a single injection of 0.3 mg of CP-533,536 incorporated in PLGH matrix onto the periosteum of the femur induced significantly local bone formation. In the rat femoral fracture model, CP-533,536 in PLGH matrix at doses of 0.05, 0.5, and 5 mg dose-dependently increased callus size, density, and strength compared with PLGH matrix alone. These results show that CP-533,536 stimulates new bone formation on trabecular, endocortical, and periosteal surfaces and enhances fracture healing. These data reveal that EP2 receptor-selective agonists provide therapeutic potential for local bone augmentation, bone repair, and bone healing in humans.
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Affiliation(s)
- Mei Li
- Department of Cardiovascular and Metabolic Diseases, Pfizer Global Research and Development, Groton Laboratories, Groton, Connecticut 06340, USA
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Harder AT, An YH. The mechanisms of the inhibitory effects of nonsteroidal anti-inflammatory drugs on bone healing: a concise review. J Clin Pharmacol 2003; 43:807-15. [PMID: 12953337 DOI: 10.1177/0091270003256061] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Nonsteroidal anti-inflammatory drug (NSAID) use continues to expand at a remarkable rate due both to the broad spectrum of clinical applications for these medications and to the relatively recent introduction of the popular COX-2-selective inhibitors. The use of NSAIDs is particularly prevalent in patients with a variety of musculoskeletal conditions and injuries. Reports of impaired bone healing associated with NSAID use, therefore, are a particular cause for concern. Animal and in vitro studies have demonstrated impaired bone healing in the presence of traditional NSAIDs, as measured by a variety of different parameters. More recently, initial studies investigating the effects of COX-2-selective inhibitors on bone healing have yielded similar results. With mounting evidence that NSAIDs do in fact interfere with proper bone healing in various animal models, questions have arisen regarding the potential mechanism through which NSAIDs produce this outcome and whether these results can be translated to clinical settings. A likely pathway for these observed effects results from an understanding of the steps involved in bone healing itself. These steps include an inflammatory response, bone resorption, and new bone formation. Investigations over the past several decades have elucidated a role for prostaglandins (PGs) in each of these areas. Specifically, PGs have been shown to elicit and participate in inflammatory responses, increase osteoclast activity and subsequent bone resorption, and increase osteoblast activity and new bone formation. This apparent integral role for PGs in the process of bone healing, coupled with the knowledge that NSAIDs act by inhibiting the production of PGs, results in an understanding of the likely mechanism through which NSAIDs impart their deleterious effects on bone healing. By inhibiting the COX enzymes and the subsequent production of PGs, NSAIDs not only achieve their desired anti-inflammatory effects but also inhibit the increased production of PGs that is necessary for bone healing to occur. Despite this understanding of the potential mechanism through which NSAIDs inhibit bone healing in a laboratory setting, few studies exist that show whether these inhibitory effects are also evident clinically. Thus, further studies will need to decipher whether similar inhibitory effects occur in a clinical setting.
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Affiliation(s)
- Adam T Harder
- Orthopaedic Research Laboratories, Medical University of South Carolina, 96 Jonathan Lucas Street, CSB708, Charleston, SC 29425, USA
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Kraus VB. Cyclooxygenase-2 inhibitors and nonsteroidal anti-inflammatory drugs in the management of arthritis. Foot Ankle Clin 2003; 8:187-200, vii. [PMID: 12911235 DOI: 10.1016/s1083-7515(03)00035-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The management of arthritis pain should be individualized to the needs and characteristics of the patient. The decision to use nonsteroidal anti-inflammatory drugs (NSAIDs), and in particular the cyclooxygenase-2 (COX-2) inhibitors, is multidimensional. The challenge is to achieve optimal pain relief at the minimum dose to minimize adverse effects. Whenever possible, NSAIDs should be given as monotherapies or in combinations at the lowest effective doses. The COX-2 inhibitors are a safe choice for most patients who are at low risk for a cardiovascular event. Individuals who are at risk for thromboses should not receive unopposed COX-2 inhibitors; COX-2 should be given in combination with low-dose aspirin which is expected to be cardioprotective in high-risk patients.
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Affiliation(s)
- Virginia Byers Kraus
- Division of Rheumatology, Department of Medicine, Box 3416, Duke University Medical Center, Durham, NC 27710, USA.
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Abstract
BACKGROUND Spine surgeons discourage the use of nonsteroidal anti-inflammatory drugs following spine arthrodesis because of their inhibitory effect on bone-healing. To our knowledge, there are no data on the effects of the new cyclooxygenase-2 inhibitors on bone-healing. We undertook this study to determine the effects of these more selective nonsteroidal anti-inflammatory drugs on spinal fusion in a rabbit model. METHODS Seventy-two New Zealand White rabbits underwent a posterolateral intertransverse process arthrodesis with use of autologous iliac crest bone. Sixty-six rabbits survived the surgical procedure and the perioperative period and had an uneventful postoperative course. These rabbits were randomly divided into three groups. One group received 10 mg/kg of celecoxib orally, the second group received 10 mg/kg of indomethacin orally, and the third group (the control group) received 1 cm (3) of saline solution orally. The rabbits received the treatment daily for eight weeks, after which they were killed and the lumbar spine was harvested. The specimens were palpated for motion, radiographed, and prepared for histological analysis. The quality of the fusion was graded at each level by assigning a histological score of 0 to 7. RESULTS Gross inspection and palpation revealed that 64% (fourteen) of the twenty-two control spines and 45% (ten) of the twenty-two spines in the rabbits treated with celecoxib were fused. With the numbers available, this difference was not significant (p = 0.224). Of the twenty-two spines in the indomethacin-treated rabbits, 18% (four) were fused, and this percentage was significantly different from the control value (p = 0.002). On radiographic assessment, the spine segment was deemed to be fused in 82% (eighteen) of the twenty-two controls, 86% (nineteen) of the twenty-two rabbits treated with celecoxib, and 41% (nine) of the twenty-two indomethacin-treated animals. Only the difference between the indomethacin-treated and control groups was significant (p = 0.004). The histological scores averaged 5.2, 4.8, and 3.5 for the control, celecoxib, and indomethacin groups, respectively. There was a significant difference between the control and indomethacin groups (p = 0.002) but not between the celecoxib and control groups (p = 0.161). CONCLUSIONS These results suggest that celecoxib does not significantly inhibit the rate of spinal fusion in rabbits. They also suggest that the inhibitory effects of nonsteroidal anti-inflammatory drugs on bone-healing are likely mediated by inhibition of cyclooxygenase-1 and that celecoxib is the better choice if treatment with nonsteroidal anti-inflammatory drugs is deemed necessary following spinal arthrodesis.
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Affiliation(s)
- John Long
- Department of Othopaedic Surgery, Barnes-Jewish Hospital at Washington University St Louis, Missouri 63110, USA
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Abstract
STUDY DESIGN Reviews were conducted. OBJECTIVES To review the biology of spine fusion healing, and to outline several fundamental principles required for the selection of a bone graft substitute. SUMMARY OF BACKGROUND DATA More than 200,000 spine fusions are performed each year in the United States. The success of this procedure is limited by morbidity from iliac crest bone graft harvest and a nonunion rate that ranges from 10% to 40%. In recent years, there has been an increased understanding of the biology of spine fusion healing. In addition, there has been a focus on finding suitable substitutes for autogenous iliac crest bone graft to promote spine fusion. The selection of a specific bone graft substitute can be a daunting task for the surgeon. METHODS The available literature was reviewed and combined with the author's personal experience. RESULTS A basic understanding of the biology of healing in different types of spine fusions and the differences between different categories of bone graft substitutes can help surgeons organize the graft selection process. CONCLUSIONS In general, purely osteoconductive substitutes are less effective in adult posterolateral spine fusions, but may be suitable in the anterior spine when it is rigidly immobilized. Osteoinductive substitutes are more likely to be successful as extenders, enhancers, or substitutes for posterolateral spine fusion.
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Akman S, Gögüs A, Sener N, Bilgiç B, Aksoy B, Seckin F. Effect of diclofenac sodium on union of tibial fractures in rats. Adv Ther 2002; 19:119-25. [PMID: 12201352 DOI: 10.1007/bf02850267] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Nonsteroidal anti-inflammatory drugs are often used for 7 to 10 days after fracture because of their effects on bone metabolism. This study evaluated the effect of diclofenac sodium, administered at clinical dosage and duration, on bone union. Fifty-four male Wistar rats were randomly and equally divided into three groups: control, diclofenac 1 mg, and diclofenac 2 mg. Closed diaphyseal fractures were induced in the right tibias of all rats; the two diclofenac groups received intramuscular injections in the contralateral hips for 10 days. All animals were immobilized in circular casts on the upper thighs. Six rats in each group were sacrificed at weeks 2, 4, and 6, and bony union was evaluated clinically, radiologically, and histologically. At the end of 2 weeks, clinical examinations showed subjective differences between the two treated groups and control animals, with more stable callus formation in controls. Radiologic evaluation of the callus showed numeric, but not significant, differences between control and treated animals. At 4 and 6 weeks, clinical and radiologic findings were comparable among groups. Histologically, no significant differences in callus formation were evident at any evaluation.
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Affiliation(s)
- Senol Akman
- Second Orthopedic and Trauma Clinic, Sisli Etfal Hastanesi
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Boden SD. Biology of lumbar spine fusion and use of bone graft substitutes: present, future, and next generation. TISSUE ENGINEERING 2000; 6:383-99. [PMID: 10992434 DOI: 10.1089/107632700418092] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Posterolateral lumbar spine arthrodesis is a commonly performed procedure, yet the biology of healing is poorly understood. Nonunion, or failure to achieve a solid bony fusion, occurs in up to 40% of patients. We first developed and validated a rabbit model to characterize the healing process by measuring macroscopic parameters, microscopic parameters, and gene expression. We found that presently available osteoconductive and weakly osteoinductive materials were insufficient to replace autografts, but could in some cases serve as bone graft extenders. In contrast, two osteoinductive growth factors currently in development could replace autograft in non-human primates and in humans, but may be limited by the high dose required, carrier variability, and high cost. We identified, cloned, and sequenced a novel complementary DNA (cDNA) encoding for an intracellular protein LMP-1, which is expressed during the first few hours of osteoblast differentiation. LMP-1 expression is able to induce many BMPs, their receptors, and other bone growth factors. Local implantation of bone marrow cells transfected with LMP-1 cDNA induced spine fusion in 100% of sites tested; no bone formed at the control sites without LMP-1. This strategy of local gene therapy may provide a basis for the next generation of bone graft substitutes.
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Affiliation(s)
- S D Boden
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia 30033, USA.
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Rohde C, Anderson DE, Bertone AL, Weisbrode SE. Effects of phenylbutazone on bone activity and formation in horses. Am J Vet Res 2000; 61:537-43. [PMID: 10803649 DOI: 10.2460/ajvr.2000.61.537] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine the effects of phenylbutazone (PBZ) on bone activity and bone formation in horses. ANIMALS 12 healthy 1- to 2-year-old horses. PROCEDURES Biopsy was performed to obtain unicortical bone specimens from 1 tibia on day 0 and from the contralateral tibia on day 14. Fluorochromic markers were administered IV 2 days prior to and on days 0, 10, 15, and 25 after biopsy was performed. Six horses received PBZ (4.4 mg/kg of body weight, PO, q 12 h) and 6 horses were used as controls. All horses were euthanatized on day 30 and tissues from biopsy sites, with adjacent cortical bone, were collected. Osteonal density and activity, mineral apposition rate (MAR), and percentage of mineralized tissue filling the biopsy-induced defects in cortical bone were assessed. Serum samples from all horses were analyzed for bone-specific alkaline phosphatase activity and concentration of PBZ. RESULTS MAR was significantly decreased in horses treated with PBZ. Regional acceleratory phenomenon was observed in cortical bone in both groups but was significantly decreased in horses treated with PBZ. Osteonal activity was similar at all time points in all horses. In control horses, percentage of mineralized tissue filling the cortical defects was significantly greater in defects present for 30 days, compared with defects present for 14 days. Differences in percentage of mineralized tissue were not detected in horses treated with PBZ. CONCLUSIONS AND CLINICAL RELEVANCE PBZ decreased MAR in cortical bone and appeared to decrease healing rate of cortical defects in horses.
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Affiliation(s)
- C Rohde
- Department of Veterinary Clinical Sciences, The Ohio State University, Columbus 43210, USA
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Martin GJ, Boden SD, Titus L. Recombinant human bone morphogenetic protein-2 overcomes the inhibitory effect of ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), on posterolateral lumbar intertransverse process spine fusion. Spine (Phila Pa 1976) 1999; 24:2188-93; discussion 2193-4. [PMID: 10562982 DOI: 10.1097/00007632-199911010-00003] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN An animal model of posterolateral intertransverse process spine fusion healing. OBJECTIVE To evaluate the effect of systemic ketorolac, alone and in combination with locally applied recombinant human bone morphogenetic protein-2, on spine fusion healing. SUMMARY OF BACKGROUND DATA The effect of nonsteroidal anti-inflammatory drugs on bone graft healing in animals remains controversial. However, most studies point to the inhibition of fracture repair, especially during the early healing period. METHODS Forty-nine adult New Zealand white rabbits underwent single-level lumbar fusion with autologous iliac bone graft. Two mini-osmotic pumps were implanted subcutaneously and filled with saline as a control or ketorolac. Rabbits were divided into three groups: 1) control (saline in pump); 2) nonsteroidal anti-inflammatory drug (ketorolac in pump); 3) nonsteroidal anti-inflammatory drug (ketorolac in pump) and bone morphogenetic protein (bone graft soaked in a 3.0 mg solution of recombinant human bone morphogenetic protein-2. All rabbits were killed after 6 weeks. RESULTS In the control group, 75% (12 in 16) of the surviving rabbits were judged to have solidly fused lumbar spines as compared with only 35% (6 in 17) of the animals that received ketorolacachieved fusion (P = 0.037). Of the animals that received ketorolac and recombinant bone morphogenetic protein-2, 100% (9 in 9) fused. CONCLUSIONS The results of this study confirm the detrimental effect of a commonly used nonsteroidal anti-inflammatory drug on spinal fusion during the immediate postoperation period in a established rabbit model of posterolateral lumbar spine fusion. The addition of recombinant bone morphogenetic protein-2 to the autograft bone was able to compensate for the inhibitory effect of ketorolac on bone formation. On the basis of these data, caution is urged in the routine use of nonsteroidal anti-inflammatory drugs for postoperation analgesia in patients undergoing spine arthrodesis.
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Affiliation(s)
- G J Martin
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Wurnig C, Schwameis E, Bitzan P, Kainberger F. Six-year results of a cementless stem with prophylaxis against heterotopic bone. Clin Orthop Relat Res 1999:150-8. [PMID: 10212608 DOI: 10.1097/00003086-199904000-00020] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The hypothesis of a possibly diminished bony ingrowth revealed by the development of radiolucency or a radiodense line with time around a cementless femoral stem subsequent to indomethacin administration for prevention of heterotopic ossification was investigated. Eighty prospective patients with indomethacin prophylaxis were compared with 82 patients without indomethacin prophylaxis chosen retrospectively. The same cementless implant was used in all cases, and patients were observed clinically and radiologically for a minimum of 6 years. The mean postoperative Harris hip score at 6 years was 91 versus 88 points, respectively, and there were significantly more excellent results (Harris hip score > 90) in the indomethacin group. None of the patients underwent revision surgery. Radiologic signs such as loss of bone density and radiodense lines were observed around the shoulder of the prosthesis in a similar percentage in both groups. Significant subsidence of the stem was observed in one instance in the indomethacin group and in three instances in the control group. The results of this study are a strong indication that indomethacin does not influence the development of radiolucency or other radiologic changes around a cementless stem after 6 years.
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Affiliation(s)
- C Wurnig
- Department of Orthopaedics, University of Vienna, Austria
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Glassman SD, Rose SM, Dimar JR, Puno RM, Campbell MJ, Johnson JR. The effect of postoperative nonsteroidal anti-inflammatory drug administration on spinal fusion. Spine (Phila Pa 1976) 1998; 23:834-8. [PMID: 9563116 DOI: 10.1097/00007632-199804010-00020] [Citation(s) in RCA: 222] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN The influence of ketorolac on spinal fusion was studied in a retrospective review of 288 patients who underwent an instrumented spinal fusion. OBJECTIVE To assess the effect of postoperative ketorolac administration on subsequent fusion rates. SUMMARY OF BACKGROUND DATA Nonsteroidal anti-inflammatory drugs are widely used compounds, which are known to inhibit osteogenic activity and have been shown to decrease spinal fusion in an animal model. No previous studies have examined the influence of nonsteroidal anti-inflammatory drugs on spinal fusion in clinical practice. METHODS The medical records of 288 patients who underwent instrumented spinal fusion from L4 to the sacrum between 1991 and 1993 were reviewed retrospectively. The 121 patients who received no nonsteroidal anti-inflammatory drugs were compared with the 167 patients who received ketorolac after surgery. The groups were demographically equivalent. RESULTS Ketorolac had a significant adverse effect on fusion, with five nonunions in the nondrug group and 29 nonunions in the ketorolac group (P > 0.001). Ketorolac administration also significantly decreased the fusion rate for subgroups including men, women, smokers, and nonsmokers. The odds ratio demonstrated that nonunion was approximately five times more likely after ketorolac administration. Cigarette smoking also decreased the fusion rate (P > 0.01); smokers were 2.8 times more likely to develop nonunion. CONCLUSION These data suggest that nonsteroidal anti-inflammatory drugs significantly inhibit spinal fusion at doses typically used for postoperative pain control. The authors recommend that these drugs be avoided in the early postoperative period.
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Affiliation(s)
- S D Glassman
- Department of Orthopaedic Surgery, University of Louisville School of Medicine, Kentucky, USA
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