Marnie M. Saunders

Effect of COX-2-Specific Inhibition on Fracture-Healing in the Rat Femur

BACKGROUND Nonsteroidal anti-inflammatory medications have been shown to delay fracture-healing. COX-2-specific inhibitors such as celecoxib have recently been approved for human use. Our goal was to determine, mechanically, histologically, morphologically, and radiographically, whether COX-2-specific inhibition affects bone-healing. METHODS A nondisplaced unilateral fracture was created in the right femur of fifty-seven adult male rats. Rats were given no drug, indomethacin (1 mg/kg/day), or celecoxib (3 mg/kg/day) daily, starting on postoperative day 1. Fractures were analyzed at four, eight, and twelve weeks after creation of the fracture. Callus and bridging bone formation was assessed radiographically. The amounts of fibrous tissue, cartilage, woven bone, and mature bone formation were determined histologically. Morphological changes were assessed to determine fibrous healing, callus formation, and bone-remodeling. Callus strength and stiffness were assessed biomechanically with three-point bending tests. RESULTS At four weeks, only the indomethacin group showed biomechanical and radiographic evidence of delayed healing. Although femora from rats treated with celecoxib appeared to have more fibrous tissue than those from untreated rats at four and eight weeks, radiographic signs of callus formation, mechanical strength, and stiffness did not differ significantly between the groups. By twelve weeks, there were no significant differences among the three groups. CONCLUSIONS Postoperative administration of celecoxib, a COX-2-specific inhibitor, did not delay healing as seen at twelve weeks following fracture in adult rat femora. At four and eight weeks, fibrous healing predominated in the celecoxib group as compared with the findings in the untreated group; however, mechanical strength and radiographic signs of healing were not significantly inhibited. CLINICAL RELEVANCE Many orthopaedists rely on narcotic analgesia for postfracture and postoperative pain, despite deleterious side effects and morbidity. Traditional nonsteroidal anti-inflammatory medications have been shown to delay fracture union. This effect may be smaller with COX-2-specific inhibitors.

The Effects of Intratendinous and Retrocalcaneal Intrabursal Injections of Corticosteroid on the Biomechanical Properties of Rabbit Achilles Tendons

BACKGROUND The use of corticosteroid injections in the treatment of retrocalcaneal bursitis is controversial. We assessed the effects of corticosteroid injections, both within the tendon substance and into the retrocalcaneal bursa, on the biomechanical properties of rabbit Achilles tendons. The systemic effects of bilateral corticosteroid injections were also studied. METHODS The rabbits were divided into three treatment groups. The rabbits in Group I received injections of corticosteroid into the Achilles tendon on the left side and injections of normal saline solution into the Achilles tendon on the right, those in Group II received injections of corticosteroid into the retrocalcaneal bursa on the left side and injections of saline solution into the Achilles tendon on the right, and those in Group III received injections of corticosteroid into the Achilles tendon on the left side and injections of corticosteroid into the retrocalcaneal bursa on the right. These injections were given weekly for three weeks. At four weeks after the final injection, the tendons were harvested and were tested biomechanically to determine failure load, midsubstance strain and total strain, modulus of elasticity, failure stress, and total energy absorbed. The site of failure was also documented. The groups were compared according to the location of the injections, the type of injection (steroid or saline solution), and the total systemic load of steroid. RESULTS Specimens from limbs that had received intratendinous injections of corticosteroid showed significantly decreased failure stress compared with those from limbs that had received intratendinous injections of saline solution (p = 0.008). Specimens from limbs that had received intrabursal injections of corticosteroid demonstrated significantly decreased failure stress (p = 0.05), significantly decreased total energy absorbed (p = 0.017), and significantly increased total strain (p = 0.049) compared with specimens from limbs that had received intratendinous injections of saline solution. Specimens from limbs that had received intratendinous injections of corticosteroid were biomechanically equivalent to specimens from limbs that had received intrabursal injections of corticosteroid. Specimens from rabbits that had received bilateral injections of corticosteroid demonstrated significantly decreased failure load (p = 0.011), modulus of elasticity (p = 0.015), failure stress (p = 0.03), and total energy absorbed (p = 0.015) compared with those from rabbits that had received unilateral injections of steroid. CONCLUSIONS Local injections of corticosteroid, both within the tendon substance and into the retrocalcaneal bursa, adversely affected the biomechanical properties of rabbit Achilles tendons. Additionally, tendons from rabbits that had received bilateral injections of corticosteroid demonstrated an additive adverse effect, with significantly worse biomechanical properties compared with tendons from rabbits that had received unilateral injections of corticosteroid.

Analysis of mechanisms underlying BRMS1 suppression of metastasis

Introduction of normal, neomycin-tagged human chromosome 11 (neo11) reduces the metastatic capacity of MDA-MB-435 human breast carcinoma cells by 70–90% without affecting tumorigenicity. Differential display comparing MDA-MB-435 and neo11/435 led to the discovery of a human breast carcinoma metastasis suppressor gene, BRMS1, which maps to chromosome 11q13.1–q13.2. Stable transfectants of MDA-MB-435 and MDA-MB-231 breast carcinoma cells with BRMS1 cDNA still form progressively growing, locally invasive tumors when injected in mammary fat pads of athymic mice but exhibit significantly lower metastatic potential (50–90% inhibition) to lungs and regional lymph nodes. To begin elucidating the mechanism(s) of action, we measured the ability of BRMS1 to perturb individual steps of the metastatic cascade modeled in vitro. Consistent differences were not observed for adhesion to extracellular matrix components (laminin, fibronectin, type IV collagen, type I collagen, Matrigel); growth rates in vitro or in vivo; expression of matrix metalloproteinases, heparanase, or invasion. Likewise, BRMS1 expression did not up regulate expression of other metastasis suppressors, such as NM23, Kai1, KiSS1 or E-cadherin. Motility of BRMS1 transfectants was modestly inhibited (30–60%) compared to parental and vector-only transfectants. Ability to grow in soft agar was also decreased in MDA-MB-435 cells by 80–89%, but the decrease for MDA-MB-231 was less (13–15% reduction). Also, transfection and re-expression of BRMS1 restored the ability of human breast carcinoma cells to form functional homotypic gap junctions. Collectively, these data suggest that BRMS1 suppresses metastasis of human breast carcinoma by complex, atypical mechanisms.

Fluid flow-induced prostaglandin E2 response of osteoblastic ROS 17/2.8 cells is gap junction-mediated and independent of cytosolic calcium

It has been well demonstrated that bone adapts to mechanical loading. To accomplish this at the cellular level, bone cells must be responsive to mechanical loading (mechanoresponsive). This can occur via such mechanisms as direct cell deformation or signal transduction via complex pathways involving chemotransport, hormone response, and/or gene expression, to name a few. Mechanotransduction is the process by which a bone cell senses a biophysical signal and elicits a response. While it has been demonstrated that bone cells can respond to a wide variety of biophysical signals including fluid flow, stretch, and magnetic fields, the exact pathways and mechanisms involved are not clearly understood. We postulated that gap junctions may play an important role in bone cell responsiveness. Gap junctions (GJ) are membrane-spanning channels that physically link cells and support the transport of small molecules and ions in the process of gap junctional intercellular communication (GJIC). In this study we examined the role of GJ and GJIC in mechanically stimulated osteoblastic cells. Following fluid flow stimulation, we quantified prostaglandin E(2) (PGE(2)) (oscillatory flow) and cytosolic calcium (Ca(2+)) (oscillatory and steady flow) responses in ROS 17/2.8 cells and a derivative of these cells expressing antisense cDNA for the gap junction protein connexin 43 (RCx16) possessing significantly different levels of GJIC. We found that the ROS17/2.8 cells possessing increased GJIC also exhibited increased PGE(2) release to the supernatant following oscillatory fluid flow stimulation in comparison to coupling-decreased RCx16 cells. Interestingly, we found that neither osteoblastic cell line responded to oscillatory or steady fluid flow stimulation with an increase in Ca(2+). Thus, our results suggest that GJ and GJIC may be important in the mechanotransduction mechanisms by which PGE(2) is mechanically induced in osteoblastic cells independent of Ca(2+).

Breast cancer metastatic potential: correlation with increased heterotypic gap junctional intercellular communication between breast cancer cells and osteoblastic cells.

The breast cancer metastasis‐suppressor gene BRMS1 is downregulated in metastatic breast cancer cells. Previous reports have shown restoration of gap junctional intercellular communication (GJIC) in the metastatic human breast carcinoma cell line MDA‐MB‐435 (435) transfected with BRMS1 cDNA. Metastasis, to a large extent in most breast cancers, occurs to bone. However, the reason for this preferential metastasis is not known. We explored cell‐to‐cell communication between 435 carcinoma cells and a human osteoblastic cell line, hFOB1.19, to determine whether carcinoma cells can form gap junctions with bone cells and to explore the role of these heterotypic gap junctions and the BRMS1 gene in breast cancer metastasis to bone. 435 cells displayed greater cell‐to‐cell communication with hFOB 1.19 cells than with themselves. Transfection of BRMS1 into 435 cells increased homotypic gap junctional communication but did not significantly affect heterotypic communication with hFOBs. However, heterotypic communication of BRMS1 transfectants with hFOB cells was reduced relative to homotypic communication. In contrast, parental 435 cells displayed greater heterotypic communication with hFOBs relative to homotypic communication. Our results suggest that there are differences in the relative homotypic and heterotypic GJIC of metastasis‐capable and ‐suppressed cell lines.

Tibiotalocalcaneal Arthrodesis: A Biomechanical Assessment of Stability

Background: Combined ankle and subtalar (tibiotalocalcaneal) arthrodesis is a procedure that can be used to successfully treat disabling foot and ankle arthropathy and is a reasonable salvage alternative to amputation for the treatment of nonbraceable neuropathic, diabetic, degenerative, or rheumatoid joints. Although many methods of tibiotalocalcaneal (TTC) arthrodesis have been described in the literature, the most popular current methods involve the use of crossed cancellous bone screws, plates, or a locked retrograde intramedullary rod. Fusion in these patients can be difficult, with significant complications including infection, malunion, and nonunion. A persistent nonunion can lead to failure of the hardware and recurrent deformity. Methods: We biomechanically tested the stability and micromotion in four methods of TTC arthrodesis using liquid metal strain gauges and Instron (Norwood, MA) material testing systems. Anatomically identical synthetic bones with properties very similar to human bone were instrumented and tested. Four instrumentation techniques were tested: 1) three crossed 6.5-mm cancellous screws, 2) two crossed 6.5-mm cancellous screws, 3) locked retrograde intramedullary rod, and 4) locked retrograde intramedullary rod augmented with a single anteromedial bone staple. Six separate specimens for each technique were tested. Results: The three crossed cancellous screw technique provided the greatest stability with respect to micromotion (p < 0.05). The addition of a tibiotalar staple to the locked intramedullary rod conferred stability nearly equal to that of the three crossed cancellous screw fixation (p < 0.05). The locked intramedullary rod group and the two crossed cancellous screw group allowed significant micromotion at the arthrodesis sites, which was a full order of magnitude higher (p < 0.05) than in the three crossed cancellous screw group and the staple augmented intramedullary rod group. Conclusions: Biomechanically, a staple augmented locked intramedullary rod for TTC arthrodesis confers excellent stability nearly equal to the three crossed cancellous screw technique for TTC arthrodesis.

Effects of Interference Fit Screw Length on Tibial Tunnel Fixation for Anterior Cruciate Ligament Reconstruction

Graft-tunnel mismatch during arthroscopically assisted anterior cruciate ligament reconstruction using the central-third patellar tendon results in less than 20 mm of bone plug remaining in the tibial tunnel. We decided to evaluate the strength of bone plug fixation using interference fit screws that were less than 20 mm in length. Biomechanical testing was performed on 48 porcine hindquarters using 9-mm diameter interference fit screws that measured 12.5, 15, and 20 mm in length. No significant difference was noted between the different-length screws for insertion torque, divergence, stiffness, displacement, or load to failure. We believe, therefore, that comparable graft fixation can be achieved in the tibial tunnel using 9-mm diameter interference fit screws that are less than 20 mm long, and that these shorter screws may be useful in cases of graft-tunnel mismatch.

Temporary anchorage device insertion variables: effects on retention

OBJECTIVE To quantify the influence of temporary anchorage device (TAD) insertion variables on implant retention. MATERIALS AND METHODS Three hundred thirty TADs from three companies were placed in synthetic bone replicas at variable depths and angulations and compared. Clinically relevant forces were applied to the TADs until failure of retention occurred. RESULTS In all three implants, increased insertion depth increased implant retention. As the distance from the abutment head to the cortical plate increased, the retention of all three implants decreased. A significantly greater force to fail was required for a 90 degrees insertion angle than for 45 degrees or 135 degrees insertion angles. No significant difference was found between the 45 degrees and 135 degrees insertion angles. A significant reduction in force to fail occurred when comparing 90 degrees and 45 degrees oblique insertion angles. CONCLUSIONS Increasing penetration depth of TADs results in greater retention. Increased abutment head distance from cortical plate leads to decreased retention. Placement of TADs at 90 degrees to the cortical plate is the most retentive insertion angle. Insertion at an oblique angle from the line of force reduces retention of TADs.

BioGlue and Dermabond save time, leak less, and are not mechanically inferior to two-layer and modified one-layer vasovasostomy

OBJECTIVE To compare operative time, patency, and integrity of glue-assisted versus suture-only vasovasostomies. DESIGN A Medline search revealed no vasovasostomy studies testing tissue adhesives other than fibrin. We compare glue-reinforced to suture-only vasovasostomies. SETTING An academic medical center. PATIENT(S) None. INTERVENTION(S) Using bull vas deferens, we performed: [1] two-layer anastomoses, [2] modified one-layer anatomoses, and [3] Bioglue, Dermabond, or CoSeal-reinforced anastomoses supported by three transmural sutures. MAIN OUTCOME MEASURE(S) Operative times were recorded, patency verified, and microscopic dissection performed to rule out luminal glue intravasation. Destructive mechanical testing was then completed with statistical comparison of load to failure, displacement to failure, and linear stiffness. RESULT(S) Operative time was greatest for two-layer anastomoses and significantly reduced for all three glue-reinforced three-suture anastomoses. All techniques were patent and free of glue intravasation. BioGlue and Dermabond demonstrated greater integrity than all other techniques. Mechanically, BioGlue and Dermabond were superior to both the unreinforced three stitch and CoSeal groups and were capable of resisting higher loads before failure. CONCLUSION(S) Glue-reinforced anastomoses are significantly less time consuming than traditional techniques. BioGlue and Dermabond have greater mechanical integrity and may be superior to both CoSeal and the sutured techniques.

Biomechanical analysis of in situ single versus double screw fixation in a nonreduced slipped capital femoral epiphysis model.

Abstract: Slipped capital femoral epiphyses (SCFE) were created in 24 pairs of immature bovine femurs. In 17 pairs of femurs, the slip was left nonreduced (one-third diameter of physis), and in 7 pairs, the slip was reduced. Stabilization of the slips was with either 1 or 2 threaded 6.5-mm screws in a compression mode. The specimens were subjected to shear or torsional loading forces to failure, with the goal of trying to reproduce clinical conditions of in situ screw fixation for acute or unstable SCFE. In the nonreduced model, double-screw fixation was 312% stiffer than single-screw fixation under torsional loading. In the reduced model, double-screw fixation was 137% stiffer than single-screw fixation under torsional loading. The increased rotational stability of double-screw fixation under torsional loading conditions may justify its use in in situ stabilization of acute or unstable SCFE.