Effect of NSAIDs on Bone Healing Rates: A Meta-analysis

Multiple stress fractures: A case report and discussion

Stress fracture is the result of bone destruction with prolonged and repetitive loading. It usually occurs among various groups, including athletes, military recruits, and others. Early stress fractures often undergo undiagnosed or misdiagnosed because of atypical symptoms and effective medical examination. Here, we report a rare clinical case about the multiple stress fractures in one adolescent. Expect for the pathological biopsy, it hardly gets confirm diagnosis. With the increasing population of sports lover, healthcare institutions should be enhanced their understanding of stress fractures and enable effective management at an early stage.

Vagus nerve stimulation rescues persistent pain following orthopedic surgery in adult mice

ABSTRACT

Postoperative pain is a major clinical problem imposing a significant burden on patients and society. In a survey 2 years after orthopedic surgery, 57% of patients reported persisting postoperative pain. However, only limited progress has been made in the development of safe and effective therapies to prevent the onset and chronification of pain after orthopedic surgery. We established a tibial fracture mouse model that recapitulates clinically relevant orthopedic trauma surgery, which causes changes in neuropeptide levels in dorsal root ganglia and sustained neuroinflammation in the spinal cord. Here, we monitored extended pain behavior in this model, observing chronic bilateral hindpaw mechanical allodynia in both male and female C57BL/6J mice that persisted for >3 months after surgery. We also tested the analgesic effects of a novel, minimally invasive, bioelectronic approach to percutaneously stimulate the vagus nerve (termed percutaneous vagus nerve stimulation [pVNS]). Weekly pVNS treatment for 30 minutes at 10 Hz for 3 weeks after the surgery strongly reduced pain behaviors compared with untreated controls. Percutaneous vagus nerve stimulation also improved locomotor coordination and accelerated bone healing. In the dorsal root ganglia, vagal stimulation inhibited the activation of glial fibrillary acidic protein-positive satellite cells but without affecting microglial activation. Overall, these data provide novel evidence supportive of the use of pVNS to prevent postoperative pain and inform translational studies to test antinociceptive effects of bioelectronic medicine in the clinic.

[Non-unions of the upper extremities]

The diagnosis and treatment of non-unions still represents an interdisciplinary challenge. Therefore, prevention, early detection and specific treatment are of great importance. Non-unions of the upper extremities, although less common than that of the lower extremities, requires special attention for successful treatment due to the central role of the shoulder girdle and arm in day to day activities. Successful treatment of non-unions requires a comprehensive evaluation of the patient's medical history, a thorough clinical examination and in particular radiological imaging. In order to effectively treat the pseudarthrosis it is crucial to distinguish between pseudarthroses that are suspected to be due to infections and those that are not. This article presents a treatment algorithm for managing both pseudarthrosis due to infection and pseudarthrosis without infection in the upper extremities.

Biologic Impact of Anterior Cruciate Ligament Injury and Reconstruction

Surgical intervention after anterior cruciate ligament (ACL) tears is typically required because of the limited healing capacity of the ACL. However, mechanical factors and the inflammatory response triggered by the injury and surgery can impact patient outcomes. This review explores key aspects of ACL injury and reconstruction biology, including the inflammatory response, limited spontaneous healing, secondary inflammation after reconstruction, and graft healing processes. Understanding these biologic mechanisms is crucial for developing new treatment strategies and enhancing patient well-being. By shedding light on these aspects, clinicians and researchers can work toward improving quality of life for individuals affected by ACL tears.

LINE-1 RNA triggers matrix formation in bone cells via a PKR-mediated inflammatory response

Transposable elements (TEs) are mobile genetic modules of viral derivation that have been co-opted to become modulators of mammalian gene expression. TEs are a major source of endogenous dsRNAs, signaling molecules able to coordinate inflammatory responses in various physiological processes. Here, we provide evidence for a positive involvement of TEs in inflammation-driven bone repair and mineralization. In newly fractured mice bone, we observed an early transient upregulation of repeats occurring concurrently with the initiation of the inflammatory stage. In human bone biopsies, analysis revealed a significant correlation between repeats expression, mechanical stress and bone mineral density. We investigated a potential link between LINE-1 (L1) expression and bone mineralization by delivering a synthetic L1 RNA to osteoporotic patient-derived mesenchymal stem cells and observed a dsRNA-triggered protein kinase (PKR)-mediated stress response that led to strongly increased mineralization. This response was associated with a strong and transient inflammation, accompanied by a global translation attenuation induced by eIF2α phosphorylation. We demonstrated that L1 transfection reshaped the secretory profile of osteoblasts, triggering a paracrine activity that stimulated the mineralization of recipient cells.

The role of hematopoiesis in bone repair: an update

PURPOSE OF REVIEW

The repair of bone after injury requires the participation of many different immune cell populations, which are derived from the hematopoietic lineage. The field of osteoimmunology, or the study of the interactions between bone and the immune system, is a growing field with emerging impact on both the basic science and clinical aspects of fracture healing.

RECENT FINDINGS

Despite previous focus on the innate immune system in fracture healing, recent studies have revealed an important role for the adaptive immune system in bone repair. The composition of adaptive and innate immune cell populations present at the fracture site is significantly altered during aging and diet-induced obesity, which may contribute to delayed healing. Recent data also suggest a complicated relationship between fracture repair and systemic inflammation, raising the possibility that immune populations from distant sites such as the gut can impact the bone repair process.

SUMMARY

These findings have important implications for the treatment of fracture patients with antibiotics or anti-inflammatory drugs. Furthermore, the effects of systemic inflammation on fracture repair in the contexts of aging or obesity should be carefully interpreted, as they may not be uniformly detrimental.

Does double distal locking reduce non-union rates in intramedullary nailing for humeral shaft fracture?

INTRODUCTION

Intramedullary nailing is one of the surgical treatments for humeral shaft fracture. Non-union is a common complication, with rates of 10-20%. The objective of this study was to compare non-union in humeral shaft fractures treated by intramedullary nailing with double distal locking, single distal locking or no locking.

HYPOTHESIS

Nailing with double distal locking decreases non-union rates compared to single or no locking.

MATERIAL AND METHODS

This single-center retrospective comparative study included 87 patients with closed humeral shaft fracture without neurologic deficit treated by anterograde intramedullary nailing: group 1 (double locking): 15 fractures; group 2 (single locking): 63 fractures; group 3 (no locking): 9 fractures. Non-union was defined as absence of radiographic callus at 6 months without clinical pain. The primary endpoint was non-union rate per group. The secondary endpoints were Constant score at 6 months, and postoperative use of non-steroidal anti-inflammatory drugs (NSAIDs).

RESULTS

There were no significant differences in non-union rate: 20.0% in group 1, 20.3% in group 2, and 0% in group 3 (p=0.32). Constant score at 6 months was significantly different between the 3 groups (p=0.01). Group 2 used more NSAIDs than the other groups (39.1% vs. 20.0% in group 1 and 33.3% in group 3; p=0.37).

DISCUSSION

Non-union rates were similar regardless of distal locking for closed humeral shaft fractures without neurologic deficit treated by intramedullary nailing. Nevertheless, patients in the double locking group had higher Constant scores at 6 months, probably related to greater stability of fixation, allowing more efficient rehabilitation.

LEVEL OF EVIDENCE

III; retrospective comparative study.

Horizontal Alveolar Ridge Splitting and Expansion

When considering placing dental implants in atrophic edentulous sites, there may be inadequate site width and little or no vertical bone loss. Any of several surgical procedures can augment these sites. Extracortical augmentation is done by applying graft material against the cortical bone. This technique expects progenitor cells to migrate outside the bony ridge's confines and form new bone. Another method entails ridge splitting and expansion to create space for osteogenesis and, when possible, implant placement. This may be a better method for horizontal ridge augmentation. The ridge is split, separating the facial and lingual cortices for a complete bone fracture. The patient's osseous cells can then migrate into the created space from the exposed medullary bone to form bone. The technique can be preferably performed flapless so the intact periosteum maintains a blood supply to ensure appropriate healing.

Acetaminophen influences musculoskeletal signaling but not adaptations to endurance exercise training

Acetaminophen (ACE) is a widely used analgesic and antipyretic drug with various applications, from pain relief to fever reduction. Recent studies have reported equivocal effects of habitual ACE intake on exercise performance, muscle growth, and risks to bone health. Thus, this study aimed to assess the impact of a 6-week, low-dose ACE regimen on muscle and bone adaptations in exercising and non-exercising rats. Nine-week-old Wistar rats (n = 40) were randomized to an exercise or control (no exercise) condition with ACE or without (placebo). For the exercise condition, rats ran 5 days per week for 6 weeks at a 5% incline for 2 min at 15 cm/s, 2 min at 20 cm/s, and 26 min at 25 cm/s. A human equivalent dose of ACE was administered (379 mg/kg body weight) in drinking water and adjusted each week based on body weight. Food, water intake, and body weight were measured daily. At the beginning of week 6, animals in the exercise group completed a maximal treadmill test. At the end of week 6, rats were euthanized, and muscle cross-sectional area (CSA), fiber type, and signaling pathways were measured. Additionally, three-point bending and microcomputer tomography were measured in the femur. Follow-up experiments in human primary muscle cells were used to explore supra-physiological effects of ACE. Data were analyzed using a two-way ANOVA for treatment (ACE or placebo) and condition (exercise or non-exercise) for all animal outcomes. Data for cell culture experiments were analyzed via ANOVA. If omnibus significance was found in either ANOVA, a post hoc analysis was completed, and a Tukey's adjustment was used. ACE did not alter body weight, water intake, food intake, or treadmill performance (p > .05). There was a treatment-by-condition effect for Young's Modulus where placebo exercise was significantly lower than placebo control (p < .05). There was no treatment by condition effects for microCT measures, muscle CSA, fiber type, or mRNA expression. Phosphorylated-AMPK was significantly increased with exercise (p < .05) and this was attenuated with ACE treatment. Furthermore, phospho-4EBP1 was depressed in the exercise group compared to the control (p < .05) and increased in the ACE control and ACE exercise group compared to placebo exercise (p < .05). A low dose of ACE did not influence chronic musculoskeletal adaptations in exercising rodents but acutely attenuated AMPK phosphorylation and 4EBP1 dephosphorylation post-exercise.

NSAID use in orthopedic surgery: A review of current evidence and clinical practice guidelines

Nonsteroidal anti-inflammatory drugs (NSAIDs) are a valuable class of medications for orthopedic surgeons and often play a pivotal role in pain control. However, there are many common stipulations resulting in avoidance of its use in the treatment of musculoskeletal disease. This review summarizes the mechanism of action of NSAIDs as well as provides an overview of commonly used NSAIDs and the differences between them. It provides a concise summary on the osseous effects of NSAIDs with regard to bone healing and heterotopic ossification. Most of all, it serves as a guide or reference for orthopedic providers when counseling patients on the risks and benefits of NSAID use, as it addresses the common stipulations encountered: "It irritates my stomach," "I have a history of bariatric surgery," "I'm already on a blood thinner," "I've had a heart attack," and "I've got kidney problems" and synthesizes both current research and society recommendations regarding safe use and avoidance of NSAIDs.

Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement

ABSTRACT

Musculoskeletal injuries occur frequently in sport during practice, training, and competition. Injury assessment and management are common responsibilities for the team physician. Initial Assessment and Management of Musculoskeletal Injury-A Team Physician Consensus Statement is title 23 in a series of annual consensus documents written for the practicing team physician. This statement was developed by the Team Physician Consensus Conference, an annual project-based alliance of six major professional associations. The goal of this document is to help the team physician improve the care and treatment of the athlete by understanding the initial assessment and management of selected musculoskeletal injuries.

Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement

ABSTRACT

Musculoskeletal injuries occur frequently in sport during practice, training, and competition. Injury assessment and management are common responsibilities for the team physician. Initial Assessment and Management of Musculoskeletal Injury-A Team Physician Consensus Statement is title 23 in a series of annual consensus documents written for the practicing team physician. This statement was developed by the Team Physician Consensus Conference, an annual project-based alliance of six major professional associations. The goal of this document is to help the team physician improve the care and treatment of the athlete by understanding the initial assessment and management of selected musculoskeletal injuries.

Effect of postoperative fracture gap on bone union: A retrospective cohort analysis of simple femoral shaft fractures

BACKGROUND

Intramedullary nailing (IMN) is considered the gold-standard treatment for femoral shaft fractures. The post operative fracture gap is commonly recognized as a risk factor for nonunion. However, no evaluation standard for measuring the fracture gap size has yet been established. In addition, the clinical implications of the fracture gap size have also not been determined so far. This study aims to clarify how we should evaluate fracture gaps when assessing simple femoral shaft fractures with radiographs and to determine the acceptable cut-off value of the fracture gap size in simple femoral shaft fractures.

METHOD

A retrospective observational study with a consecutive cohort was conducted at the trauma center of a university hospital. We investigated the fracture gap using postoperative radiography and the postoperative bone union of transverse and short oblique femoral shaft fractures fixed by IMN. The receiver operating characteristic curve analysis was conducted to obtain the fracture gap's mean, minimum, and maximum cut-off values. Fisher's exact test was used at the cut-off value of the most accurate parameter.

RESULTS

In the four nonunions among the 30 cases, the analysis using ROC curves revealed that the maximum value had the highest accuracy among the maximum, minimum, and mean values of fracture-gap size. The cut-off value was determined to be 4.14 mm with high accuracy. Fisher's exact test showed that the incidence of nonunion was higher in the group with a maximum fracture gap of 4.14 mm or greater (risk ratio = not applicable, risk difference = 0.57, P = 0.001).

CONCLUSION

In simple transverse and short oblique femoral shaft fractures fixed with IMN, the fracture gap on radiographs should be evaluated by the maximum gap in the AP and lateral views. The remaining maximum fracture gap of ≥4.14 mm would be a risk factor for nonunion.

The Effect of Nonsteroidal Anti-inflammatory Drugs on Union Rates Following Joint Arthrodesis: A Meta-Analysis

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most widely used and prescribed medications because of their important role in reducing inflammation and pain, in addition to their non-addictive properties and safety profiles. However, some studies have documented an association between NSAIDs and delayed union or nonunion of joint arthrodesis procedures due to a potential inhibition of the bone's inflammatory healing response. As a result, some orthopedic surgeons hesitate to prescribe NSAIDs after an arthrodesis procedure. The purpose of this meta-analysis is to review all relevant literature regarding the effect of NSAIDs on union rates after arthrodesis and determine if NSAID therapy increases the risk of non-union in the setting of arthrodesis procedures. The study hypothesis was that NSAIDs would not have a significant effect on the risk of nonunion after arthrodesis. A thorough systematic review of Medline, Embase, the Cochrane Database of Systematic Reviews, and the Web of Science identified 3,050 articles to be screened. The variables of interest encompassed demographic factors, procedural details, type and administration of NSAIDs, the number of patients exposed to NSAIDs with and without successful union (case group), as well as the number of patients who did not receive NSAIDs with and without successful union (control group). All the data were analyzed using a maximum likelihood random-effects model. The number of non-union events versus routine healing from each study was used to calculate the odds ratio (OR) of successful healing after arthrodesis procedures with versus without NSAID therapy. Thirteen articles met the inclusion criteria for the meta-analysis. NSAID exposure showed an increased risk of nonunion, delayed union, or both following arthrodesis procedures; however, this did not meet statistical significance (OR, 1.48; confidence interval [CI], 0.96 to 2.30). A sub-analysis of pediatric and adult studies showed a significant increase in non-union risk in adults (OR, 1.717; CI, 1.012 to 2.914) when removing the pediatric cohort (p = 0.045). This meta-analysis provides evidence that NSAIDs can increase the risk of nonunion, delayed union, or both following arthrodesis procedures in adults. However, the study did not identify a risk of nonunion, delayed union, or both following arthrodesis procedures in the pediatric population.

Incidence of persistent opioid use following traumatic injury

INTRODUCTION

Major traumatic injuries are a known risk factor for persistent opioid use, but data describing the relationship between specific traumatic injuries and opioid use is lacking.

METHODS

We used insurance claims data from January 1, 2001 to December 31, 2020 to estimate the incidence of new persistent opioid use in three hospitalized trauma populations: individuals hospitalized after burn injury (3809, 1504 of whom required tissue grafting), individuals hospitalized after motor vehicle collision (MVC; 9041), and individuals hospitalized after orthopedic injury (47, 637). New persistent opioid use was defined as receipt of ≥1 opioid prescriptions 90-180 days following injury in an individual with no opioid prescriptions during the year prior to injury.

RESULTS

New persistent opioid use was observed in 12% (267/2305) of individuals hospitalized after burn injury with no grafting, and 12% (176/1504) of burn injury patients requiring tissue grafting. In addition, new persistent opioid use was observed in 16% (1454/9041) of individuals hospitalized after MVC, and 20% (9455/47, 637) of individuals hospitalized after orthopedic trauma. In comparison, rates of persistent opioid use in all trauma cohorts (19%, 11, 352/60, 487) were greater than the rates of persistent opioid use in both non-traumatic major surgery (13%) and non-traumatic minor surgery (9%).

CONCLUSIONS

These data demonstrate that new persistent opioid use frequently occurs in these common hospitalized trauma populations. Improved interventions to reduce persistent pain and opioid use in patients hospitalized after these and other traumas are needed.

Non-steroidal anti-inflammatory drugs in football - a "Keeping SCORE" approach to judicious use

Non-steroidal anti-inflammatory drug (NSAID) use in elite sport is high, with football being no exception. Increased awareness of significant adverse drug reactions from published research and retired players commentary in the media have made the topic mainstream. Despite this increased awareness, usage rates show no sign of significantly reducing. Footballers, like all elite athletes are focused on maximising their performance and potential - even at the expense of their long-term health. An educational intervention prior to the 2010 FIFA Men's World Cup aimed at reducing rates was ineffective, suggesting that education alone is not the answer. Our author group propose a 'safer use' rather than 'no use' of NSAIDs in football. A 'Keeping SCORE' approach is suggested, designed as a prescribing aid. The approach guides medical staff towards focusing on Safety checks, Clinical indication/judgement, Open dialogue, Recording, and Evaluation.

Ketorolac and bone healing: a review of the basic science and clinical literature

Although the efficacy of ketorolac in pain management and the short duration of use align well with current clinical practice guidelines, few studies have specifically evaluated the impact of ketorolac on bony union after fracture or surgery. The purpose of this study was to review the current basic science and clinical literature on the use of ketorolac for pain management after fracture and surgery and the subsequent risk of delayed union or nonunion. Animal studies demonstrate a dose-dependent risk of delayed union in rodents treated with high doses of ketorolac for 4 weeks or greater; however, with treatment for 7 days or low doses, there is no evidence of risk of delayed union or nonunion. Current clinical evidence has also shown a dose-dependent increased risk of pseudoarthrosis and nonunion after post-operative ketorolac administration in orthopedic spine surgery. However, other orthopedic subspecialities have not demonstrated increased risk of delayed union or nonunion with the use of peri-operative ketorolac administration. While evidence exists that long-term ketorolac use may represent risks with regard to fracture healing, insufficient evidence currently exists to recommend against short-term ketorolac use that is limited to the peri-operative period. LEVEL OF EVIDENCE V: Narrative Review.

Multimodal Pain Management After Outpatient Orthopedic Hand Surgery: A Prospective Randomized Trial

Purpose

Opioid stewardship ensures effective pain management while avoiding overprescribing of opioids after surgery. This prospective randomized study investigates the efficacy of a multimodal postoperative pain regimen compared to a traditional opioid-only pain regimen following elective outpatient orthopedic hand surgery. We hypothesized that patients receiving multimodal pain management would consume fewer opioids and report greater satisfaction than patients receiving only opioids.

Methods

Consecutive patients undergoing outpatient hand and upper extremity surgery performed by two board-certified fellowship-trained orthopedic hand surgeons at one institution were recruited and randomized into either a study or control group. The study group received a standing multimodal postoperative regimen consisting of scheduled oral acetaminophen and naproxen as well as oxycodone to be taken as needed. The control group received only oxycodone to be taken as needed. Postoperatively, daily pain levels, medication usage, refills, satisfaction, and adverse events were recorded. Descriptive statistics were performed.

Results

Of the 112 patients enrolled, 54 were randomized to the control group, and 58 were randomized to the study group. Study and control group patients did not differ significantly based on daily average pain scores or daily worst pain scores. However, study group patients reported fewer average daily oxycodone intake and total oxycodone pill count (7.0 vs 2.4 total pills, P <.005). In addition, the study group patients were more likely to report satisfaction with their postoperative pain control than control regimen patient's and were more likely to use the same pain regimen again if required.

Conclusion

A multimodal postoperative pain regimen reduces opioid usage and has higher patient satisfaction rates in comparison to traditional opioid-only regimens. Use of multimodal pain regimens that use nonopioids, such as acetaminophen and naproxen, over an opioid should be considered for postoperative pain after orthopedic hand surgery.

Level of Evidence

Therapeutic II.

Inpatient pain alleviation after orthopaedic trauma surgery-are we doing a good job?

PURPOSE

Poor pain alleviation (PPA) after orthopaedic surgery is known to increase recovery time, readmissions, patient dissatisfaction, and lead to chronic postsurgical pain. This study's goal was to identify the magnitude of PPA and its risk factors in the orthopaedic trauma patient population.

METHODS

A single-institution's electronic medical records from 2015 to 2018 were available for retrospective analysis. Inclusion criteria included orthopaedic fracture surgery patients admitted to the hospital for 24 h or more. Collected variables included surgery type, basic demographics, comorbidities, inpatient medications, pain scores, and length of stay. PPA was defined as a pain score of ≥ 8 on at least three occasions 4-12 h apart. Associations between collected variables and PPA were derived using a multivariable logistic regression model and expressed in adjusted odds ratios.

RESULTS

A total of 1663 patients underwent fracture surgeries from 2015 to 2018, and 25% of them reported PPA. Female sex, previous use of narcotics, increased ASA, increased baseline pain score, and younger age without comorbidities were identified as significant risk factors for PPA. Spine procedures were associated with increased risk of PPA, while procedures in the hip, shoulder, and knee had reduced risk. Patients experiencing PPA were less likely to receive NSAIDs compared to other pain medications.

CONCLUSIONS

This study found an unacceptably high rate of PPA after fracture surgery. While the identified risk factors for PPA were all non-modifiable, our results highlight the necessity to improve application of current multimodal approaches to pain alleviation including a more personalized approach to pain alleviation.

Endoscopic and morphological features of chronic gastritis in patients with lumbar spine osteochondrosis

OBJECTIVE

Aim: of the study is to determine the endoscopic and morphological features of chronic gastritis (CG) in patients with lumbar spinal OC.

PATIENTS AND METHODS

Materials and Methods: 102 patients with lumbar spine OC and CG were examined. The patients were diagnosed with Helicobacter pylori (HP) infection, according to which the patients were divided into two groups: the first group included 92 HP-positive patients, the second group consisted of 10 HP-negative patients.

RESULTS

Results: Among HP infected patients with lumbar spine OC, erosive gastropathy was most often diagnosed (in 40 (43.5%) of the examined), as well as erosive-papular and erosive-hemorrhagic gastropathy (in 14 (15.2%) and in 16 (17, 4 %) of patients, respectively), while erythematous gastropathy was more often diagnosed among HP-negative patients (in 7 (70.0 %) cases, respectively).

CONCLUSION

Conclusions: 1. 90.2% of patients with lumbar spine OC and CG have been diagnosed with HP infection. 2. Endoscopically, the lesion of the stomach MM in patients with lumbar spine OC corresponds mainly to erosive and erosive-hemorrhagic forms of gastropathy. 3. During histological examination of stomach MM, mainly 2nd and 3rd degrees of inflammation were established, especially in patients with erosive, erosive-papular and erosive-hemorrhagic forms of gastropathy.

DNA methylation-mediated Rbpjk suppression protects against fracture nonunion caused by systemic inflammation

Challenging skeletal repairs are frequently seen in patients experiencing systemic inflammation. To tackle the complexity and heterogeneity of the skeletal repair process, we performed single-cell RNA sequencing and revealed that progenitor cells were one of the major lineages responsive to elevated inflammation and this response adversely affected progenitor differentiation by upregulation of Rbpjk in fracture nonunion. We then validated the interplay between inflammation (via constitutive activation of Ikk2, Ikk2ca) and Rbpjk specifically in progenitors by using genetic animal models. Focusing on epigenetic regulation, we identified Rbpjk as a direct target of Dnmt3b. Mechanistically, inflammation decreased Dnmt3b expression in progenitor cells, consequently leading to Rbpjk upregulation via hypomethylation within its promoter region. We also showed that Dnmt3b loss-of-function mice phenotypically recapitulated the fracture repair defects observed in Ikk2ca-transgenic mice, whereas Dnmt3b-transgenic mice alleviated fracture repair defects induced by Ikk2ca. Moreover, Rbpjk ablation restored fracture repair in both Ikk2ca mice and Dnmt3b loss-of-function mice. Altogether, this work elucidates a common mechanism involving a NF-κB/Dnmt3b/Rbpjk axis within the context of inflamed bone regeneration. Building on this mechanistic insight, we applied local treatment with epigenetically modified progenitor cells in a previously established mouse model of inflammation-mediated fracture nonunion and showed a functional restoration of bone regeneration under inflammatory conditions through an increase in progenitor differentiation potential.

Multi-Functional Small Molecule Alleviates Fracture Pain and Promotes Bone Healing

Bone injuries such as fractures are one major cause of morbidities worldwide. A considerable number of fractures suffer from delayed healing, and the unresolved acute pain may transition to chronic and maladaptive pain. Current management of pain involves treatment with NSAIDs and opioids with substantial adverse effects. Herein, we tested the hypothesis that the purine molecule, adenosine, can simultaneously alleviate pain and promote healing in a mouse model of tibial fracture by targeting distinctive adenosine receptor subtypes in different cell populations. To achieve this, a biomaterial-assisted delivery of adenosine is utilized to localize and prolong its therapeutic effect at the injury site. The results demonstrate that local delivery of adenosine inhibited the nociceptive activity of peripheral neurons through activation of adenosine A1 receptor (ADORA1) and mitigated pain as demonstrated by weight bearing and open field movement tests. Concurrently, local delivery of adenosine at the fracture site promoted osteogenic differentiation of mesenchymal stromal cells through adenosine A2B receptor (ADORA2B) resulting in improved bone healing as shown by histological analyses and microCT imaging. This study demonstrates the dual role of adenosine and its material-assisted local delivery as a feasible therapeutic approach to treat bone trauma and associated pain.

Inflammatory Processes Affecting Bone Health and Repair

PURPOSE OF REVIEW

The purpose of this article is to review the current understanding of inflammatory processes on bone, including direct impacts of inflammatory factors on bone cells, the effect of senescence on inflamed bone, and the critical role of inflammation in bone pain and healing.

RECENT FINDINGS

Advances in osteoimmunology have provided new perspectives on inflammatory bone loss in recent years. Characterization of so-called inflammatory osteoclasts has revealed insights into physiological and pathological bone loss. The identification of inflammation-associated senescent markers in bone cells indicates that therapies that reduce senescent cell burden may reverse bone loss caused by inflammatory processes. Finally, novel studies have refined the role of inflammation in bone healing, including cross talk between nerves and bone cells. Except for the initial stages of fracture healing, inflammation has predominately negative effects on bone and increases fracture risk. Eliminating senescent cells, priming the osteo-immune axis in bone cells, and alleviating pro-inflammatory cytokine burden may ameliorate the negative effects of inflammation on bone.

The role of NSAID in mediating the effect of genetically predicted major depressive disorder on osteomyelitis: A Mendelian randomization study

BACKGROUND

Osteomyelitis and major depressive disorder (MDD) are significant health concerns with potential interconnections. However, the underlying mechanisms linking these conditions remain unknown. This study aimed to investigate the potential mediating role of non-steroidal anti-inflammatory drug (NSAID) medication in the association between MDD and the risk of osteomyelitis.

METHODS

We utilized summary data from large-scale genome-wide association studies (GWAS) to perform Mendelian randomization (MR) mediation analysis. Instrumental variables were selected based on genome-wide significance, and instrumental strength was assessed using F-statistics. Univariable and multivariable MR analyses were conducted to estimate causal effects and proportions mediated by NSAID medication.

RESULTS

The univariable MR analysis revealed significant associations between MDD and osteomyelitis (odds ratio [OR] = 1.44, 95 % confidence interval [CI]: 1.18-1.874) and between MDD and NSAID medication (OR = 1.36, 95 % CI 1.24-1.49). In the multivariable MR analysis, the direct effect of MDD on osteomyelitis was OR 1.35 (95 % CI: 1.09, 1.67) after adjusting for NSAID medication. The proportion of mediation by NSAID medication was 23 % (95 % CI: 0.05 %, 38.6 %).

CONCLUSION

This MR study provides evidence for a genetically predicted causal association between MDD, NSAID medication, and osteomyelitis. The findings emphasize the need for a comprehensive approach in managing individuals with comorbid depression and osteomyelitis, considering the potential risks and benefits of NSAID medication. Future research should address limitations and explore additional mediators and confounding factors to enhance understanding of this complex relationship.

Unbiased gene expression analysis of the delayed fracture healing observed in Zucker diabetic fatty rats

Aims

Impaired fracture repair in patients with type 2 diabetes mellitus (T2DM) is not fully understood. In this study, we aimed to characterize the local changes in gene expression (GE) associated with diabetic fracture. We used an unbiased approach to compare GE in the fracture callus of Zucker diabetic fatty (ZDF) rats relative to wild-type (WT) littermates at three weeks following femoral osteotomy.

Methods

Zucker rats, WT and homozygous for leptin receptor mutation (ZDF), were fed a moderately high-fat diet to induce T2DM only in the ZDF animals. At ten weeks of age, open femoral fractures were simulated using a unilateral osteotomy stabilized with an external fixator. At three weeks post-surgery, the fractured femur from each animal was retrieved for analysis. Callus formation and the extent of healing were assessed by radiograph and histology. Bone tissue was processed for total RNA extraction and messenger RNA (mRNA) sequencing (mRNA-Seq).

Results

Radiographs and histology demonstrated impaired fracture healing in ZDF rats with incomplete bony bridge formation and an influx of intramedullary inflammatory tissue. In comparison, near-complete bridging between cortices was observed in Sham WT animals. Of 13,160 genes, mRNA-Seq analysis identified 13 that were differentially expressed in ZDF rat callus, using a false discovery rate (FDR) threshold of 10%. Seven genes were upregulated with high confidence (FDR = 0.05) in ZDF fracture callus, most with known roles in inflammation.

Conclusion

These findings suggest that elevated or prolonged inflammation contributes to delayed fracture healing in T2DM. The identified genes may be used as biomarkers to monitor and treat delayed fracture healing in diabetic patients.

Evaluation and Treatment of Acute Trauma Pain in Older Adults

In the context of an ageing population, the demographic sands of trauma are shifting. Increasingly, trauma units are serving older adults who have sustained injuries in low-energy falls from a standing height. Older age is commonly associated with changes in physiology, as well as an increased prevalence of frailty and multimorbidity, including cardiac, renal and liver disease. These factors can complicate the safe and effective administration of analgesia in the older trauma patient. Trauma services therefore need to adapt to meet this demographic shift and ensure that trauma clinicians are sufficiently skilled in treating pain in complex older people. This article is dedicated to the management of acute trauma pain in older adults. It aims to highlight the notable clinical challenges of managing older trauma patients compared with their younger counterparts. It offers an overview of the evidence and practical opinion on the merits and drawbacks of commonly used analgesics, as well as more novel and emerging analgesic adjuncts. A search of Medline (Ovid, from inception to 7 November 2022) was conducted by a medical librarian to identify relevant articles using keyword and subject heading terms for trauma, pain, older adults and analgesics. Results were limited to articles published in the last 10 years and English language. Relevant articles' references were hand-screened to identify other relevant articles. There is paucity of dedicated high-quality evidence to guide management of trauma-related pain in older adults. Ageing-related changes in physiology, the accumulation of multimorbidity, frailty and the risk of inducing delirium secondary to analgesic medication present a suite of challenges in the older trauma patient. An important nuance of treating pain in older trauma patients is the challenge of balancing iatrogenic adverse effects of analgesia against the harms of undertreated pain, the complications and consequences of which include immobility, pneumonia, sarcopenia, pressure ulcers, long-term functional decline, increased long-term care needs and mortality. In this article, the role of non-opioid agents including short-course non-steroidal anti-inflammatory drugs (NSAIDs) is discussed. Opioid selection and dosing are reviewed for older adults suffering from acute trauma pain in the context of kidney and liver disease. The evidence base and limitations of other adjuncts such as topical and intravenous lidocaine, ketamine and regional anaesthesia in acute geriatric trauma are discussed.

Glycolytic reprogramming in macrophages and MSCs during inflammation

Background

Dysregulated inflammation is associated with many skeletal diseases and disorders, such as osteolysis, non-union of fractures, osteonecrosis, osteoarthritis and orthopaedic infections. We previously showed that continuous infusion of lipopolysaccharide (LPS) contaminated polyethylene particles (cPE) caused prolonged inflammation and impaired bone formation. However, the metabolic and bioenergetic processes associated with inflammation of bone are unknown. Mitochondria are highly dynamic organelles that modulate cell metabolism and orchestrate the inflammatory responses that involve both resident and recruited cells. Glycolytic reprogramming, the shift from oxidative phosphorylation (OXPHOS) to glycolysis causes inappropriate cell activation and function, resulting in dysfunctional cellular metabolism. We hypothesized that impaired immunoregulation and bone regeneration from inflammatory states are associated with glycolytic reprogramming and mitochondrial dysfunction in macrophages (Mφ) and mesenchymal stromal cells (MSCs).

Methods

We used the Seahorse XF96 analyzer and real-time qPCR to study the bioenergetics of Mφ and MSCs exposed to cPE. To understand the oxygen consumption rate (OCR), we used Seahorse XF Cell Mito Stress Test Kit with Seahorse XF96 analyzer. Similarly, Seahorse XF Glycolytic Rate Assay Kit was used to detect the extracellular acidification rate (ECAR) and Seahorse XF Real-Time ATP Rate Assay kit was used to detect the real-time ATP production rates from OXPHOS and glycolysis. Real-time qPCR was performed to analyze the gene expression of key enzymes in glycolysis and mitochondrial biogenesis. We further detected the gene expression of proinflammatory cytokines in Mφ and genes related to cell differentiation in MSC during the challenge of cPE.

Results

Our results demonstrated that the oxidative phosphorylation of Mφ exposed to cPE was significantly decreased when compared with the control group. We found reduced basal, maximal and ATP-production coupled respiration rates, and decreased proton leak in Mφ during challenge with cPE. Meanwhile, Mφ showed increased basal glycolysis and proton efflux rates (PER) when exposed to cPE. The percentage (%) of PER from glycolysis was higher in Mφ exposed to cPE, indicating that the contribution of the glycolytic pathway to total extracellular acidification was elevated during the challenge of cPE. In line with the results of OCR and ECAR, we found Mφ during cPE challenge showed higher glycolytic ATP (glycoATP) production rates and lower mitochondrial ATP (mitoATP) production rates which is mainly from OXPHOS. Interestingly, MSCs showed enhanced glycolysis during challenge with cPE, but no significant changes in oxygen consumption rates (OCR). In accordance, seahorse assay of real-time ATP revealed glycoATP rates were elevated while mitoATP rates showed no significant differences in MSC during challenge with cPE. Furthermore, Mφ and MSCs exposed to cPE showed upregulated gene expression levels of glycolytic regulators and Mφ exposed to cPE expressed higher levels of pro-inflammatory cytokines.

Conclusion

This study demonstrated the dysfunctional bioenergetic activity of bone marrow-derived Mφ and MSCs exposed to cPE, which could impair the immunoregulatory properties of cells in the bone niche. The underlying molecular defect related to disordered mitochondrial function could represent a potential therapeutic target during the resolution of inflammation.

Assessment and management of fractures

Fractures can have significant impact on function and quality of life, and an cause significant disruption to psychological and social wellbeing. A systematic approach is required for the assessment and management of fractures to ensure effective and timely recovery. Nurses play a key role in the care continuum to support the acute and rehabilitation phases of recovery. The use of Patient Reported Outcome Measures ensure a patient-centred approach to management, gauge progress and identify actions needed to optimise recovery. This article outlines the assessment and management of fractures, common concerns and potential complications.

Vagus nerve stimulation rescues persistent pain following orthopedic surgery in adult mice

Postoperative pain is a major clinical problem imposing a significant burden on our patients and society. Up to 57% of patients experience persistent postoperative pain 2 years after orthopedic surgery [49]. Although many studies have contributed to the neurobiological foundation of surgery-induced pain sensitization, we still lack safe and effective therapies to prevent the onset of persistent postoperative pain. We have established a clinically relevant orthopedic trauma model in mice that recapitulates common insults associated with surgery and ensuing complications. Using this model, we have started to characterize how induction of pain signaling contributes to neuropeptides changes in dorsal root ganglia (DRG) and sustained neuroinflammation in the spinal cord [62]. Here we have extended the characterization of pain behaviors for >3 months after surgery, describing a persistent deficit in mechanical allodynia in both male and female C57BL/6J mice after surgery. Notably, we have applied a novel minimally invasive bioelectronic approach to percutaneously stimulate the vagus nerve (termed pVNS) [24] and tested its anti-nociceptive effects in this model. Our results show that surgery induced a strong bilateral hind-paw allodynia with a slight decrease in motor coordination. However, treatment with pVNS for 30-minutes at10 Hz weekly for 3 weeks prevented pain behavior compared to naïve controls. pVNS also improved locomotor coordination and bone healing compared to surgery without treatment. In the DRGs, we observed that vagal stimulation fully rescued activation of GFAP positive satellite cells but did not affect microglial activation. Overall, these data provide novel evidence for the use of pVNS to prevent postoperative pain and may inform translational studies to test anti-nociceptive effects in the clinic.

Perioperative allogenic blood transfusions are associated with increased fracture related infection rates, but not nonunion in operatively treated distal femur fractures

INTRODUCTION

Distal femur fractures are common injuries that remain difficult for orthopedic surgeons to treat. High complication rates, including nonunion rates as high as 24% and infection rates of 8%, can lead to increased morbidity for these patients. Allogenic blood transfusions have previously been identified as risk factors for infection in total joint arthroplasty and spinal fusion surgeries. No studies have explored the relationship between blood transfusions and fracture related infection (FRI) or nonunion in distal femur fractures.

METHODS

418 patients with operatively treated distal femur fractures at two level I trauma centers were retrospectively reviewed. Patient demographics were collected including age, gender, BMI, medical comorbidities, and smoking. Injury and treatment information was also collected including open fracture, polytrauma status, implant, perioperative transfusions, FRI, and nonunion. Patients with less than three months of follow up were excluded.

RESULTS

366 patients were included in final analysis. One hundred thirty-nine (38%) patients received a perioperative blood transfusion. Forty-seven (13%) nonunions and 30 (8%) FRI were identified. Allogenic blood transfusion was not associated with nonunion (13% vs 12%, P = 0.87), but was associated with FRI (15% vs 4%, P<0.001). Binary logistic regression analysis identified a dose dependent relationship between number of perioperative blood transfusions and FRI: total transfusion ≥2 U PRBC RR= 3.47(1.29, 8.10, P = 0.02), ≥3 RR= 6.99 (3.01, 12.40, P<0.001), and ≥4 RR= 8.94 (4.03, 14.42, P<0.001).

DISCUSSION

In patients undergoing operative treatment of distal femur fractures, perioperative blood transfusions are associated with increased risk of fracture related infection, but not the development of a nonunion. This risk association increases in a dose-dependent relationship with increasing total blood transfusions received.

Exosomal Lnc NEAT1 from endothelial cells promote bone regeneration by regulating macrophage polarization via DDX3X/NLRP3 axis

BACKGROUND

Bone regeneration is a complex procedure that involves an interaction between osteogenesis and inflammation. Macrophages in the microenvironment are instrumental in bone metabolism. Amount evidence have revealed that exosomes transmitting lncRNA is crucial nanocarriers for cellular interactions in various biotic procedures, especially, osteogenesis. However, the underlying mechanisms of the regulatory relationship between the exosomes and macrophages are awaiting clarification. In the present time study, we aimed to explore the roles of human umbilical vein endothelial cells (HUVECs)-derived exosomes carrying nuclear enrichment enriched transcript 1 (NEAT1) in the osteogenesis mediated by M2 polarized macrophages and elucidate the underlying mechanisms.

RESULTS

We demonstrated HUVECs-derived exosomes expressing NEAT1 significantly enhanced M2 polarization and attenuated LPS-induced inflammation in vitro. Besides, the conditioned medium from macrophages induced by the exosomes indirectly facilitated the migration and osteogenic differentiation of bone marrow-derived mesenchymal stem cells (BMSCs). Mechanically, Exos carrying NEAT1 decreased remarkably both expression of dead-box helicase 3X-linked (DDX3X) and nod-like receptor protein 3 (NLRP3). The level of NLRP3 protein increased significantly after RAW264.7 cells transfected with DDX3X overexpression plasmid. Additionally, the knockdown of NEAT1 in exosomes partially counteracted the aforementioned effect of Exos. The results of air pouch rat model demonstrated that HUVECs-derived exosomes increased anti-inflammatory cytokines (IL-10) and decreased pro-inflammatory cytokines (IL-1β and IL-6) significantly in vivo, contributing to amelioration of LPS-induced inflammation. Afterwards, we further confirmed that the HUVECs-derived exosomes encapsulated in alginate/gelatin methacrylate (GelMA) interpenetrating polymer network (IPN) hydrogels could promote the bone regeneration, facilitate the angiogenesis, increase the infiltration of M2 polarized macrophages as well as decrease NLRP3 expression in the rat calvarial defect model.

CONCLUSIONS

HUVECs-derived exosomes enable transmitting NEAT1 to alleviate inflammation by inducing M2 polarization of macrophages through DDX3X/NLRP3 regulatory axis, which finally contributes to osteogenesis with the aid of alginate/GelMA IPN hydrogels in vivo. Thus, our study provides insights in bone healing with the aid of HUVECs-derived exosomes-encapsulated composite hydrogels, which exhibited potential towards the use of bone tissue engineering in the foreseeable future.

Molecular docking of 5-o-benzoylpinostrobin derivatives from boesenbergia pandurata roxb. as anti-inflammatory

Background: The use of NSAIDs, also known as non-steroidal anti-inflammatory drugs, has numerous adverse effects and consequences. For this reason, it is necessary to develop rational drugs as safer anti-inflammatory drugs with fewer side effects. Temu Kunci rhizome contains Pinostrobin (5-hydroxy-7- methoxyflavanone), which is believed to have anti-inflammatory properties. Objective: This study aims to determine the strongest anti-inflammatory activity at the cyclooxygenase-2 (COX-2) receptor through the 5-O-Benzoylpinostrobin derivative design. Methods: AutoDockTools on the COX-2 receptor (PDB code: 5IKR) were used in molecular docking in this study. The metrics employed were binding afinity (ΔG), inhibition constant (Ki), which serve as indicators of affinities, and amino acid residue similarity, which serves as a measure of the similarity of interactions. Predictive scores were confirmed by Molecular Docking Simulation. Results: The top five 5-O-Benzoylpinostrobin derivatives show a high affinity for the COX-2 receptor compared to Pinostrobin as a marker compound of Boesenbergia pandurata Roxb and furthermore give the lowest inhibition constant (Ki) and the highest negative binding free energy (ΔG), 35.40, 45.21, 54.75, 64.43, 76.97 nM and -10.16, -10.02, -9.91, -9.81, -9.7 kcal/mol. Interestingly, the five 5-O-Benzoylpinostrobin derivatives also have higher affinity than the native ligand Mefenamic acid, which is known to be a non-selective COX-2 inhibitor. The highest predicted affinity was shown by 4-Nitro-5-O-benzoylpinostrobin for the COX-2 receptor (PDP ID: 5IKR), with a higher predicted affinity for Mefenamic acid. Conclusion: The five selected 5-O-Benzoylpinostrobin derivatives were potent modifications of pinostrobin as an anti-inflammatory because they showed a higher affinity than Pinostrobin and Mefenamic acid. This study demonstrated that it is highly feasible to produce and test the novel 5-O-Benzoylpinostrobin derivative in vivo, specifically 4-Nitro-5-O-benzoylpinostrobin.

Efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of acute pain after orthopedic trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma and the Orthopedic Trauma Association

Objectives

Fracture is a common injury after a traumatic event. The efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs) to treat acute pain related to fractures is not well established.

Methods

Clinically relevant questions were determined regarding NSAID use in the setting of trauma-induced fractures with clearly defined patient populations, interventions, comparisons and appropriately selected outcomes (PICO). These questions centered around efficacy (pain control, reduction in opioid use) and safety (non-union, kidney injury). A systematic review including literature search and meta-analysis was performed, and the quality of evidence was graded per the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The working group reached consensus on the final evidence-based recommendations.

Results

A total of 19 studies were identified for analysis. Not all outcomes identified as critically important were reported in all studies, and the outcome of pain control was too heterogenous to perform a meta-analysis. Nine studies reported on non-union (three randomized control trials), six of which reported no association with NSAIDs. The overall incidence of non-union in patients receiving NSAIDs compared with patients not receiving NSAIDs was 2.99% and 2.19% (p=0.04), respectively. Of studies reporting on pain control and reduction of opioids, the use of NSAIDs reduced pain and the need for opioids after traumatic fracture. One study reported on the outcome of acute kidney injury and found no association with NSAID use.

Conclusions

In patients with traumatic fractures, NSAIDs appear to reduce post-trauma pain, reduce the need for opioids and have a small effect on non-union. We conditionally recommend the use of NSAIDs in patients suffering from traumatic fractures as the benefit appears to outweigh the small potential risks.

Molecular signatures distinguish senescent cells from inflammatory cells in aged mouse callus stromal cells

Cellular senescence plays important roles in age-related diseases, including musculoskeletal disorders. Senescent cells (SCs) exert a senescence-associated secretory phenotype (SASP) by producing SASP factors, some of which overlap with factors produced by inflammatory cells (Inf-Cs). However, the differences between SCs and Inf-Cs and how they interact with each other during fracture repair have not been well studied. Here, we analyzed single cell RNA sequencing data of aged mouse fracture callus stromal cells. We defined Inf-Cs as cells that express NF-κB Rela/Relb, SCs as cells that express the senescence genes, Cdkn1a, Cdkn2a or Cdkn2c, and inflammatory SCs (Inf-SCs) as cells that express both NF-κB and senescence genes. Differentially expressed genes and pathway analyses revealed that Inf-SCs and SCs had a similar gene expression profile and upregulated pathways that are related to DNA damage/oxidation-reduction and cellular senescence, while Inf-Cs expressed different gene signatures and pathways from SCs and Inf-SCs, mainly related to inflammation. Cellchat software analysis indicated that SCs and Inf-SCs are potential ligand-producing cells that affect Inf-Cs as target cells. Cell culture experiments demonstrated that SC conditioned medium promoted inflammatory gene expression by callus-derived mesenchymal progenitor cells, and Inf-Cs had reduced osteoblast differentiation capacity. In summary, we have identified three cell subclusters associated with inflammation and senescence in callus stromal cells, predicted potential effects of Inf-SCs and SCs on Inf-Cs by production of active ligands, and demonstrated that when mesenchymal progenitors acquire inflammatory phenotypes their osteogenic potential is reduced.

Integrating mechanistic-based and classification-based concepts into perioperative pain management: an educational guide for acute pain physicians

Chronic pain begins with acute pain. Physicians tend to classify pain by duration (acute vs chronic) and mechanism (nociceptive, neuropathic and nociplastic). Although this taxonomy may facilitate diagnosis and documentation, such categories are to some degree arbitrary constructs, with significant overlap in terms of mechanisms and treatments. In clinical practice, there are myriad different definitions for chronic pain and a substantial portion of chronic pain involves mixed phenotypes. Classification of pain based on acuity and mechanisms informs management at all levels and constitutes a critical part of guidelines and treatment for chronic pain care. Yet specialty care is often siloed, with advances in understanding lagging years behind in some areas in which these developments should be at the forefront of clinical practice. For example, in perioperative pain management, enhanced recovery protocols are not standardized and tend to drive treatment without consideration of mechanisms, which in many cases may be incongruent with personalized medicine and mechanism-based treatment. In this educational document, we discuss mechanisms and classification of pain as it pertains to commonly performed surgical procedures. Our goal is to provide a clinical reference for the acute pain physician to facilitate pain management decision-making (both diagnosis and therapy) in the perioperative period.

Paracetamol versus paracetamol/tramadol in postoperative intertrochanteric fracture: A noninferiority, randomized, controlled, double-blind study

BACKGROUND

One of the most common osteoporotic fractures among the elderly is hip fracture with tramadol frequently being prescribed for these patients. To decrease the risk of falling from tramadol, this study aimed to ascertain the effectiveness of paracetamol compared to paracetamol/tramadol for pain control following hip fixation surgery.

METHOD

This was a noninferiority, double-blind, randomized, controlled trial at a tertiary care hospital. All patients were recruited between February 2020 and March 2022. Patients were randomly assigned to paracetamol alone (Group A) or paracetamol/tramadol (Group B). All patients in both groups followed the same protocol for the first two days after surgery. To ascertain differences in pain control between the two groups, different regimens were followed from postoperative days 3-5. Pain scores were assessed by a visual analog scale (VAS). All patients were asked to complete a satisfaction questionnaire on day 5.

RESULT

A total of 30 patients were randomly allocated into Group A (paracetamol alone) and 30 into Group B (paracetamol + tramadol). The mean pain score for Group A was 5.85 ± 0.52 and 5.35 ± 0.74 for Group B. Mean cumulative doses in Group A were 4.50 ± 1.33 and 4.06 ± 1.18 in Group B. Although the mean satisfaction with pain management was higher in Group B, this was not statistically significant.

CONCLUSION

VAS scores from Group A were slightly higher than Group B. Based on a 2.0-point noninferiority margin of pain, paracetamol alone was not inferior to paracetamol/tramadol in postoperative intertrochanteric fracture.

Oral Ketorolac as an Adjuvant Agent for Postoperative Pain Control After Arthroscopic Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Controlled Study

INTRODUCTION

Successful outpatient anterior cruciate ligament (ACL) reconstruction hinges on effective analgesia. Routinely, oral narcotic agents have been the preferred analgesic postoperatively in orthopaedic surgery. However, these agents have several known adverse effects and are associated with a potential for abuse. This study evaluates the efficacy of ketorolac, a nonsteroidal anti-inflammatory drug with analgesic properties, as an adjuvant agent for postoperative pain control after ACL reconstruction.

METHODS

Adult patients undergoing primary ACL reconstruction were prospectively enrolled. Exclusion criteria involved patients with a history of bleeding diathesis, renal dysfunction, chronic analgesia use, or alcohol abuse. Eligible patients were randomized into one of two groups. The control group received a standard-of-care pain protocol involving oxycodone-acetaminophen 5 to 325 on discharge. The ketorolac group additionally received intravenous ketorolac postoperatively and 3 days of oral ketorolac on discharge. Pain levels and total narcotic utilization were recorded three times per day for the first 5 days after surgery. Pain and functional outcomes were obtained at 2 and 6 weeks postoperatively.

RESULTS

The final analysis included 48 patients; the mean age of the cohort was 32 ± 11.6 years, and 60.4% of patients were female. No differences were observed in preoperative demographics, comorbidities, and preoperative functional scores between the two groups. Over the first 5 days after surgery, patients in the ketorolac group consumed a mean of 45.4% fewer narcotic pills than the control group (P < 0.001). In addition, mean postoperative pain scores were 22.36 points lower for patients in the ketorolac group (P < 0.001). There was no difference in functional outcome scores at up to 6 weeks postoperatively or adverse events between the two groups with no reported cases of gastrointestinal bleeding.

DISCUSSION

The use of adjunctive intravenous and short-term oral ketorolac substantially reduces narcotic utilization and pain levels after ACL reconstruction.

CLINICALTRIALGOV REGISTRATION NUMBER

NCT04246554.

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.

Fracture Healing in the Setting of Endocrine Diseases, Aging, and Cellular Senescence

More than 2.1 million age-related fractures occur in the United States annually, resulting in an immense socioeconomic burden. Importantly, the age-related deterioration of bone structure is associated with impaired bone healing. Fracture healing is a dynamic process which can be divided into four stages. While the initial hematoma generates an inflammatory environment in which mesenchymal stem cells and macrophages orchestrate the framework for repair, angiogenesis and cartilage formation mark the second healing period. In the central region, endochondral ossification favors soft callus development while next to the fractured bony ends, intramembranous ossification directly forms woven bone. The third stage is characterized by removal and calcification of the endochondral cartilage. Finally, the chronic remodeling phase concludes the healing process. Impaired fracture healing due to aging is related to detrimental changes at the cellular level. Macrophages, osteocytes, and chondrocytes express markers of senescence, leading to reduced self-renewal and proliferative capacity. A prolonged phase of "inflammaging" results in an extended remodeling phase, characterized by a senescent microenvironment and deteriorating healing capacity. Although there is evidence that in the setting of injury, at least in some tissues, senescent cells may play a beneficial role in facilitating tissue repair, recent data demonstrate that clearing senescent cells enhances fracture repair. In this review, we summarize the physiological as well as pathological processes during fracture healing in endocrine disease and aging in order to establish a broad understanding of the biomechanical as well as molecular mechanisms involved in bone repair.

Rib Fractures in Professional Baseball Pitchers: Mechanics, Epidemiology, and Management

Pitching is a complex kinetic chain activity requiring the transfer of energy from the lower body, through the core and trunk, and finally through the arm to generate explosive acceleration of the baseball. As a result, large forces are generated in the trunk musculature and rib attachments from the late cocking phase of pitching through deceleration. The repetitive cumulative load and high pitch velocities put professional pitchers at risk of rib stress fracture. Given the potential for a prolonged recovery course and high rate of recurrence, early recognition of rib bone stress injury is critical to optimize care. Identifying torso strength imbalances, suboptimal pitching biomechanics (such as late or inadequate pelvic rotation), as well as metabolic deficiencies that may adversely affect bone health are essential to expedite safe return to play and prevent future injury. In this review, we discuss risk factors, mechanism of injury, typical clinical presentation, diagnostic imaging findings, and propose treatment and prevention strategies for rib stress fractures in overhand pitchers.

FTY720 administration results in a M2 associated immunoregulatory effect that positively influences the outcome of alveolar bone repair outcome in mice

The alveolar bone repair process may be influenced by multiple local and systemic factors, which include immune system cells and mediators. Macrophages allegedly play important roles in the repair process, and the transition of an initial inflammatory M1 profile into a pro-reparative M2 profile theoretically contributes to a favorable repair outcome. In this context, considering immunoregulatory molecules as potential targets for improving bone repair, this study evaluated the role of the immunoregulatory molecule FTY720, previously described to favor the development of the M2 phenotype, in the process of alveolar bone healing in C57Bl/6 (WT) mice. Experimental groups submitted to tooth extraction and maintained under control conditions or treated with FTY720 were evaluated by microtomographic (μCT), histomorphometric, immunohistochemical and molecular analysis to characterize healing and host response features at 0, 1, 3, 7 and 14 days. Our results demonstrated that the FTY720 group presented higher bone tissue density, higher bone tissue volume, greater tissue volume fraction, greater number and thickness of trabeculae and a higher number of osteoblasts and osteoclasts than the control group. Accordingly, the bone markers BMP2, BMP7, ALPL, SOST and RANK mRNA expressions increased in the FTY720 treated group. Furthermore, the levels of FIZZ, ARG2 and IL-10 mRNA increased in the FTY720 group together with the presence of CD206⁺ cells, suggesting that the boost of bone formation mediated by FTY720 involves an increased polarization and activity of M2 macrophages in healing sites. Thus, our results demonstrate that FTY720 favored the process of alveolar bone repair, probably trough a strengthened M2 response, associated with an increased expression of markers osteogenic differentiation and activity markers. Immunoregulatory strategies based in the modulation of macrophage polarization profile can comprise effective tools to improve the bone repair process.

Low-Dose NSAIDs Efficacy in Orthopedic Applications

Non-steroidal anti-inflammatory drugs (NSAIDs) [cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) inhibitors] and COXIBs (the COX-2 selective inhibitors) may induce several potentially severe and life-threatening issues especially in elderly patients. The use of low-dose NSAIDs is associated with lower risk of side effects compared to the standard dosage. Low-dose NSAIDs could minimize the side effects of these drugs while maintaining their clinical efficacy and effectiveness. The present study evaluates the effectiveness and safety of low-dose NSAIDs in musculoskeletal applications.

Targeting chronic inflammation as a potential adjuvant therapy for osteoporosis

Systemic, chronic, low-grade inflammation (SCLGI) underlies the pathogenesis of various widespread diseases. It is often associated with bone loss, thus connecting chronic inflammation to the pathogenesis of osteoporosis. In postmenopausal women, osteoporosis is accompanied by SCLGI development, likely owing to estrogen deficiency. We propose that SCGLI persistence in osteoporosis results from failed inflammation resolution, which is mainly mediated by specialized, pro-resolving mediators (SPMs). In corroboration, SPMs demonstrate encouraging therapeutic effects in various preclinical models of inflammatory disorders, including bone pathology. Since numerous data implicate gut dysbiosis in osteoporosis-associated chronic inflammation, restoring balanced microbiota by supplementing probiotics and prebiotics could contribute to the efficient resolution of SCGLI. In the present review, we provide evidence for this hypothesis and argue that efficient SCGLI resolution may serve as a novel approach for treating osteoporosis, complementary to traditional anti-osteoporotic medications.

Contemporary perspectives on heterotopic ossification

Heterotopic ossification (HO) is the formation of ectopic bone that is primarily genetically driven (fibrodysplasia ossificans progressiva [FOP]) or acquired in the setting of trauma (tHO). HO has undergone intense investigation, especially over the last 50 years, as awareness has increased around improving clinical technologies and incidence, such as with ongoing wartime conflicts. Current treatments for tHO and FOP remain prophylactic and include NSAIDs and glucocorticoids, respectively, whereas other proposed therapeutic modalities exhibit prohibitive risk profiles. Contemporary studies have elucidated mechanisms behind tHO and FOP and have described new distinct niches independent of inflammation that regulate ectopic bone formation. These investigations have propagated a paradigm shift in the approach to treatment and management of a historically difficult surgical problem, with ongoing clinical trials and promising new targets.

Safety and Efficacy of Postoperative Nonsteroidal Anti-inflammatory Drugs in Sports Medicine

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used for multimodal pain control after surgery. These medications work by selective or nonselective inhibition of cyclooxygenase, which has downstream effects on thromboxanes, prostaglandins, and prostacyclins. Clinical studies have shown beneficial effects for alleviating pain and reducing opioid consumption after surgery. Within hip arthroscopy, there is evidence that postoperative NSAIDs can also reduce the risk of symptomatic heterotopic bone formation. However, preclinical and animal studies have raised concern over the effect of NSAIDs on bone and soft-tissue healing. In addition, selective and nonselective cyclooxygenase 2 inhibitors may have different safety profiles regarding postoperative soft-tissue healing. The purpose of this review was to outline the mechanisms of action, efficacy, and effect on soft-tissue healing of postoperative NSAIDs and to provide evidence-based recommendations for appropriate use.

Intramedullary bone pedestal formation contributing to femoral shaft fracture nonunion: A case report and review of the literature

BACKGROUND

Femoral shaft fracture is a commonly encountered orthopedic injury that can be treated operatively with a low overall delayed/nonunion rate. In the case of delayed union after antegrade or retrograde intramedullary nail fixation, fracture dynamization is often attempted first. Nonunion after dynamization has been shown to occur due to infection and other aseptic etiologies. We present a unique case of diaphyseal femoral shaft fracture nonunion after dynamization due to intramedullary cortical bone pedestal formation at the distal tip of the nail.

CASE SUMMARY

A 37-year-old male experienced a high-energy trauma to his left thigh after coming down hard during a motocross jump. Evaluation was consistent with an isolated, closed, left mid-shaft femur fracture. He was initially managed with reamed antegrade intramedullary nail fixation but had continued thigh pain. Radiographs at four months demonstrated no evidence of fracture union and failure of the distal locking screw, and dynamization by distal locking screw removal was performed. The patient continued to have pain eight months after the initial procedure and 4 mo after dynamization with serial radiographs continuing to demonstrate no evidence of fracture healing. The decision was made to proceed with exchange nailing for aseptic fracture nonunion. During the exchange procedure, an obstruction was encountered at the distal tip of the failed nail and was confirmed on magnified fluoroscopy to be a pedestal of cortical bone in the canal. The obstruction required further distal reaming. A longer and larger diameter exchange nail was placed without difficulty and without a distal locking screw to allow for dynamization at the fracture site. Post-operative radiographs showed proper fracture and hardware alignment. There was subsequently radiographic evidence of callus formation at one year with subsequent fracture consolidation and resolution of thigh pain at eighteen months.

CONCLUSION

The risk of fracture nonunion caused by intramedullary bone pedestal formation can be mitigated with the use of maximum length and diameter nails and close follow up.

How Do Drugs Affect the Skeleton? Implications for Forensic Anthropology

Simple Summary

Forensic anthropologists analyze human remains to assist in the identification of the deceased, predominantly by assessing age-at-death, sex, stature, ancestry and any unique identifying features. Whilst methods have been established to create this biological profile of the skeleton, these may be influenced by a number of factors. This paper, for the first time, provides an overview from a reading of the clinical and pharmacological literature to explore whether the intake of drugs can affect the skeleton and whether these may have implications for forensic anthropology casework. In effect, drugs such as tobacco, heroin, and prescription medications can alter bone mineral density, can increase the risk of fractures, destroy bone and changes to the dentition. By considering how drugs can affect the skeleton, forensic anthropologists can be aware of this when attempting to identify the deceased.

Abstract

Forensic anthropologists rely on a number of parameters when analyzing human skeletal remains to assist in the identification of the deceased, predominantly age-at-death, sex, stature, ancestry or population affinity, and any unique identifying features. During the examination of human remains, it is important to be aware that the skeletal features considered when applying anthropological methods may be influenced and modified by a number of factors, and particular to this article, prescription drugs (including medical and non-medical use) and other commonly used drugs. In view of this, this paper aims to review the medical, clinical and pharmacological literature to enable an assessment of those drug groups that as side effects have the potential to have an adverse effect on the skeleton, and explore whether or not they can influence the estimation of age-at-death, sex and other indicators of the biological profile. Moreover, it may be that the observation of certain alterations or inconsistencies in the skeleton may relate to the use of drugs or medication, and this in turn may help narrow down the list of missing persons to which a set of human remains could belong. The information gathered from the clinical and medical literature has been extracted with a forensic anthropological perspective and provides an awareness on how several drugs, such as opioids, cocaine, corticosteroids, non-steroidal anti-inflammatory drugs, alcohol, tobacco and others have notable effects on bone. Through different mechanisms, drugs can alter bone mineral density, causing osteopenia, osteoporosis, increase the risk of fractures, osteonecrosis, and oral changes. Not much has been written on the influence of drugs on the skeleton from the forensic anthropological practitioner perspective; and this review, in spite of its limitations and the requirement of further research, aims to investigate the current knowledge of the possible effects of both prescription and recreational drugs on bones, contributing to providing a better awareness in forensic anthropological practice and assisting in the identification process of the deceased.

Orthognathic surgery in patients with systemic diseases

PURPOSE

To review the experience with orthognathic surgery in patients with systemic diseases, syndromic conditions or an oncological history at a tertiary center.

METHODS

All patients who had undergone orthognathic surgery and all patients who were considered for orthognathic surgery between January 2013 and August 2020 at a tertiary center were retrospectively reviewed. Patients with cleft lip/palate and orthognathic patients requiring craniofacial surgery or reconstructive surgery were excluded. Patients with an underlying disorder were identified and divided into 3 categories: systemic disease, syndromic condition, or oncological disease treated with chemotherapy and/or radiation therapy of the head and neck. Data on intraoperative and postoperative complications until 3 months after surgery were collected for the patients who had undergone surgery. If orthognathic surgery was contraindicated, the reason was extracted from the patient's medical record.

RESULTS

Eighty out of 1049 orthognathic patients had an underlying disorder (7.6%), including 50 patients with at least one systemic disease, 25 patients with a syndromic condition, and 5 patients with an oncological disease. A complication was encountered in respectively 5 (10%), 9 (36%), and 0 (0%) patients. Three out of 1134 patients who consulted the multidisciplinary orthognathic-orthodontic consultation had a contraindication for orthognathic surgery because of an underlying disease (0.3%).

CONCLUSION

Based on our findings, intraoperative and short-term postoperative complications in patients with an underlying disorder are not frequent. Contraindications for orthognathic surgery because of a medical condition are very rare.

Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review

Background

Long-term opioid use, which may have significant individual and societal impacts, has been documented in up to 20% of patients after trauma or orthopaedic surgery. The objectives of this scoping review were to systematically map the research on strategies aiming to prevent chronic opioid use in these populations and to identify knowledge gaps in this area.

Methods

This scoping review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. We searched seven databases and websites of relevant organizations. Selected studies and guidelines were published between January 2008 and September 2021. Preventive strategies were categorized as: system-based, pharmacological, educational, multimodal, and others. We summarized findings using measures of central tendency and frequency along with p-values. We also reported the level of evidence and the strength of recommendations presented in clinical guidelines.

Results

A total of 391 studies met the inclusion criteria after initial screening from which 66 studies and 20 guidelines were selected. Studies mainly focused on orthopaedic surgery (62,1%), trauma (30.3%) and spine surgery (7.6%). Among system-based strategies, hospital-based individualized opioid tapering protocols, and regulation initiatives limiting the prescription of opioids were associated with statistically significant decreases in morphine equivalent doses (MEDs) at 1 to 3 months following trauma and orthopaedic surgery. Among pharmacological strategies, only the use of non-steroidal anti-inflammatory drugs and beta blockers led to a significant reduction in MEDs up to 12 months after orthopaedic surgery. Most studies on educational strategies, multimodal strategies and psychological strategies were associated with significant reductions in MEDs beyond 1 month. The majority of recommendations from clinical practice guidelines were of low level of evidence.

Conclusions

This scoping review advances knowledge on existing strategies to prevent long-term opioid use in trauma and orthopaedic surgery patients. We observed that system-based, educational, multimodal and psychological strategies are the most promising. Future research should focus on determining which strategies should be implemented particularly in trauma patients at high risk for long-term use, testing those that can promote a judicious prescription of opioids while preventing an illicit use, and evaluating their effects on relevant patient-reported and social outcomes.