Effect of methotrexate on fracture healing

The effect of drugs on implant osseointegration- A narrative review

OBJECTIVE

This narrative review aims to investigate the effects of drugs on implant osseointegration, analyzing their potential positive or negative impact on the direct structural and functional connection between bone and load-carrying implants.

BACKGROUND

The review seeks to provide a comprehensive understanding of osseointegration, which refers to the successful integration of an implant with living bone, resulting in no progressive relative movement between them. Exploring the effects of drugs on implant osseointegration is crucial for optimizing outcomes and enhancing patient care in orthopedic implant procedures.

METHODS

Relevant studies on the effects of drugs on implant osseointegration were identified through a literature search. Electronic databases, including PubMed, Embase, and Google Scholar, were utilized, employing appropriate keywords and MeSH terms related to osseointegration, implants, and drug interventions. The search was limited to English studies.

DISCUSSION

This overview presents a detailed analysis of the effects of drugs on implant osseointegration. It explores drugs such as bisphosphonates, teriparatide, statins, angiotensin-converting enzyme inhibitors, beta-blockers, nitrites, and thiazide diuretics as promoters of osseointegration. Conversely, loop diuretics, non-steroidal anti-inflammatory drugs, corticosteroids, cyclosporine A, cisplatin, methotrexate, antibiotics, proton pump inhibitors (PPIs), antiepileptics, selective serotonin reuptake inhibitors (SSRIs), and anticoagulants are discussed as inhibitors of the process. The role of vitamin D3 remains uncertain. The complex relationship between drugs and the biology of implant osseointegration is emphasized, underscoring the need for further in vitro and in vivo studies to validate their effects CONCLUSION: This narrative review contributes to the literature by providing an overview of the effects of drugs on implant osseointegration. It highlights the complexity of the subject and emphasizes the necessity for more extensive and sophisticated studies in the future. Based on the synthesis of the reviewed literature, certain drugs, such as bisphosphonates and teriparatide, show potential for promoting implant osseointegration, while others, including loop diuretics and certain antibiotics, may impede the process. However, additional research is required to solidify these conclusions and effectively inform clinical practice.

General Considerations About Foot and Ankle Arthrodesis. Any Way to Improve Our Results?

Nonunion and adjacent joint osteoarthritis (OA) are known complications after a fusion procedure, and foot and ankle surgeons are commonly exposed to such disabling complications. Determining who is at risk of developing nonunion is essential to reducing nonunion rates and improving patient outcomes. Several evidenced-based modifiable risk factors related to adverse outcomes after foot and ankle arthrodesis have been identified. Patient-related risk factors that can be improved before surgery include smoking cessation, good diabetic control (HbAc1 <7%) and vitamin D supplementation. Intraoperatively, using less invasive techniques, avoiding joint preparation with power tools, using bone grafts or orthobiologics in more complex cases, high-risk patients, nonunion revision surgeries, and filling in bone voids at the arthrodesis site should be considered. Postoperatively, pain management with NSAIDs should be limited to a short period (<2 weeks) and avoided in high-risk patients. Furthermore, early postoperative weight-bearing has shown to be beneficial, and it does not seem to increase postoperative complications. The incidence of surrounding joint OA after foot and ankle fusion seems to increase progressively with time. Owing to its progression and high probability of being symptomatic, patients must be informed consequently, as they may require additional joint fusions, resulting in further loss of ankle/foot motion. In patients with symptomatic adjacent joint OA and unsatisfactory results after an ankle arthrodesis, conversion to total ankle arthroplasty (TAA) has become a potential option in managing these complex and challenging situations.

Mechanisms of Systemic Osteoporosis in Rheumatoid Arthritis

Rheumatoid arthritis (RA), an autoimmune disease, is characterized by the presence of symmetric polyarthritis predominantly of the small joints that leads to severe cartilage and bone destruction. Based on animal and human data, the pathophysiology of osteoporosis, a frequent comorbidity in conjunction with RA, was delineated. Autoimmune inflammatory processes, which lead to a systemic upregulation of inflammatory and osteoclastogenic cytokines, the production of autoantibodies, and Th cell senescence with a presumed disability to control the systemic immune system's and osteoclastogenic status, may play important roles in the pathophysiology of osteoporosis in RA. Consequently, osteoclast activity increases, osteoblast function decreases and bone metabolic and mechanical properties deteriorate. Although a number of disease-modifying drugs to treat joint inflammation are available, data on the ability of these drugs to prevent fragility fractures are limited. Thus, specific treatment of osteoporosis should be considered in patients with RA and an associated increased risk of fragility fractures.

Effect of Methotrexate Injection on Orthodontic Tooth Movement: An Experimental Study on Rats

INTRODUCTION

Knowledge about the effects of medications, vitamins, and various supplements on orthodontic tooth movement (OTM) is imperative for orthodontists. This study aimed to assess the effect of methotrexate (MTX) injection on OTM in rats.

MATERIALS AND METHODS

Twenty-eight male Wistar rats were randomized into four groups (n = 7). The first molar and central incisor were connected using a nickel-titanium (NiTi) coil spring with a 50 g load in each rat. The two experimental groups received 0.75 mg/kg and 1.5 mg/kg MTX, respectively, intraperitoneally for 21 days. The negative control group did not receive any injection and did not undergo orthodontic treatment. The positive control group underwent orthodontic treatment and received 0.9% saline (NaCl) injections for 21 days. All rats were sacrificed with chloroform inhalation after 21 days; their maxilla was resected, and the mean number of Howship's lacunae, blood vessels, osteoclasts, and resorption lacunae was counted. The reduction in bone volume (bone volume to total volume ratio (BV/TV)) at the site of the maxillary molar was quantified by microcomputed tomography (micro-CT).

RESULTS

OTM, the number of osteoclasts, and the number of blood vessels significantly increased in rats treated with MTX (P < 0.05). However, the increase in the number of Howship's lacunae and resorption lacunae was not significant (P > 0.05). Lower BV/TV in the MTX groups was in agreement with the increased number of osteoclasts.

CONCLUSION

Injection of MTX can significantly increase OTM and decrease root resorption in rats.

Osteoimmunology in Bone Fracture Healing

PURPOSE OF REVIEW

In the process of bone fracture healing, inflammation is thought to be an essential process that precedes bone formation and remodeling. We review recent studies on bone fracture healing from an osteoimmunological point of view.

RECENT FINDINGS

Based on previous observations that many types of immune cells infiltrate into the bone injury site and release a variety of molecules, recent studies have addressed the roles of specific immune cell subsets. Macrophages and interleukin (IL)-17-producing γδ T cells enhance bone healing, whereas CD8⁺ T cells impair bone repair. Additionally, IL-10-producing B cells may contribute to bone healing by suppressing excessive and/or prolonged inflammation. Although the involvement of other cells and molecules has been suggested, the precise underlying mechanisms remain elusive. Accumulating evidence has begun to reveal the deeper picture of bone fracture healing. Further studies are required for the development of novel therapeutic strategies for bone fracture.

Effect of methotrexate on bone and wound healing

INTRODUCTION

Methotrexate (MTX) is one of the most commonly used disease modifying drugs administered for wide spectrum of conditions. Through the expansion of the indications of MTX use, an increasing number of patients nowadays attend orthopaedic departments receiving this pharmacological agent. The aim of this manuscript is to present our current understanding on the effect of MTX on bone and wound healing. Areas covered: The authors offer a comprehensive review of the existing literature on the experimental and clinical studies analysing the effect of MTX on bone and wound healing. The authors also analyse the available literature and describe the incidence of complications after elective orthopaedic surgery in patients receiving MTX. Expert opinion: The available experimental data and clinical evidence are rather inadequate to allow any safe scientific conclusions on the effect of MTX on bone healing. Regarding wound healing, in vitro and experimental animal studies suggest that MTX can adversely affect wound healing, whilst the clinical studies show that lose-dose MTX is safe and does not affect the incidence of postoperative wound complications.

Serum of patients with active rheumatoid arthritis inhibits differentiation of osteochondrogenic precursor cells

Delayed fracture healing is frequently experienced in patients with systemic inflammation such as during rheumatoid arthritis (RA). The reasons for this are diverse, but could also be caused by inflammatory cytokines and/or growth factors in serum from patients with active disease. We hypothesized that serum from patients with active RA contains circulating inflammatory factors that inhibit differentiation of osteochondrogenic precursors. Serum was obtained from 15 patients with active RA (active RA-sera) and from the same patients in clinical remission 1 year later (remission RA-sera; controls). The effect of active RA-sera on osteochondrogenic differentiation of chondrogenic ATDC5 cells and primary human periosteum-derived progenitor cells (HPDC) was determined in micromass culture. In ATDC5 cells, active RA-sera reduced Ki67 transcription levels by 40% and cartilage matrix accumulation by 14% at day 14, and Alp transcription levels by 16%, and matrix mineralization by 17% at day 21 compared with remission RA-sera. In HPDCs, active RA-sera inhibited metabolic activity by 8%, SOX9 transcription levels by 14%, and cartilage matrix accumulation by 7% at day 7 compared with remission RA-sera. In conclusion, sera from patients with active RA negatively affect differentiation of osteochondrogenic precursors, and as a consequence may contribute to delayed fracture healing in these patients.

Failure of a carbon fiber-reinforced polymer implant used for transforaminal lumbar interbody fusion

Lumbar interbody fusion is a common procedure owing to the high prevalence of degenerative spinal disorders. During such procedures, carbon fiber-reinforced polymer (CFRP) cages are frequently utilized to fill the void created between adjacent vertebral bodies, to provide mechanical stability, and to carry graft material. Failure of such implants can lead to significant morbidity. We discuss the possible causes leading to the failure of a CFRP cage in a patient with rheumatoid arthritis. Review of a 49-year-old woman who underwent revision anterior lumbar interbody fusion 2 years after posterior instrumentation and transforaminal lumbar interbody fusion at L4-L5 and L5-S1. The patient developed pseudarthrosis at the two previously fused levels with failure of the posterior instrumentation. Revision surgery reveled failure with fragmentation of the CFRP cage at the L5-S1 level. CFRP implants can break if mechanical instability or nonunion occurs in the spinal segments, thus emphasizing the need for optimizing medical management and meticulous surgical technique in achieving stability.