Yue-Hui Zhang

Modic changes: a systematic review of the literature

Modic changes (MC) are a common phenomenon on magnetic resonance imaging (MRI) in spinal degenerative diseases and strongly linked with low back pain (LBP). Histology, radiology, potential mechanisms, natural history and clinical studies of MC has formed the foundation on which our understanding of spinal degenerative diseases is built. The objective of this study was to provide a review of recent important advances in the study of MC and their clinical significance. This review article summarizes these studies, by delineating the possible mechanisms, and raising doubts and new questions. The related aspects such as discography and differential diagnosis with spinal infection and tumor on MRI are also discussed. Although most of researchers believe that MC are common findings in patients with spinal degenerative diseases and have an association with discogenic LBP, different results between studies may be produced from the differences in study design, inclusion criteria, and sample size. How the present knowledge of MC affects the management of spinal degenerative diseases remains unclear. Further studies of MC will explore therapeutic possibilities for future treatments of spinal degenerative diseases.

Both endoplasmic reticulum and mitochondria are involved in disc cell apoptosis and intervertebral disc degeneration in rats

Intervertebral disc cell apoptosis occurs through either death receptor or mitochondrial pathway, but whether disc cell apoptosis is also mediated by the endoplasmic reticulum (ER) pathway remains unclear. The objective of this study was to investigate whether ER and mitochondria are co-involved in disc cell apoptosis and intervertebral disc degeneration (IVDD) in rats. Forty-eight rats were used for in vivo experiments. IVDD was characterized by X-ray and histomorphology examination, disc cell apoptosis was detected by TUNEL staining, and the co-involvement of ER and mitochondria in apoptosis was determined by immunohistochemical staining for GRP78, GADD153, caspase-12, and cytochrome C. Additional eight rats were used for annular cell isolation and culture. After sodium nitroprusside treatment, annular cell apoptosis was observed morphologically and quantified by flow cytometry; the expression of biomarkers of ER stress and mitochondrial dysfunction were analyzed by reverse transcriptase PCR (RT-PCR), fluorescence double labeling, and Western blot; and mitochondrial membrane potential was detected by 5′,6,6′-tetrachloro-1,1′,3,3′-tetraethylbenzimidazolcarbo cyanine iodide (JC-1) staining. Finally, NS3694 and Z-ATAD-FMK were employed to inhibit the formation of apoptosome complex and the activation of caspase-12, respectively, and apoptotic incidence and caspase-9 activity were assayed. We found that IVDD, induced by unbalanced dynamic and static forces in the rats, was accompanied by increased disc cell apoptosis and enhanced expression of GRP78, GADD153, caspase-12, and cytochrome C. Annular cell apoptosis induced by sodium nitroprusside was confirmed by morphologic observation and flow cytometry. With increased apoptosis, the expression of GRP78, GADD153, and caspase-12 upregulated, mitochondrial membrane potential decreased, and accumulation of cytochrome C in the cytosol manifested. Furthermore, NS3694 and Z-ATAD-FMK dramatically suppress annular cell apoptosis and caspase-9 activity. In conclusion, disc cell apoptosis mediated simultaneously by ER and mitochondria plays a potent role in IVDD.

The influence of obesity on primary total hip arthroplasty outcomes: A meta-analysis of prospective cohort studies

BACKGROUND Whether or not, obesity negatively influencing the outcomes of primary total hip arthroplasty (THA) remains a controversial issue. Though observational studies focused on this topic, the reported conclusions remain inconsistent. Therefore, we performed a meta-analysis of prospective cohort studies to evaluate if obesity negatively affects: (1) the overall complication rate (incidence of dislocation, deep infection and osteolysis); (2) functional outcome; (3) operative time and stay duration in hospital for the primary THA. METHODS We searched the PubMed, Embase, Web of Science, and the Cochrane Library until July 2014 to identify the eligible prospective studies. The Newcastle Ottawa Scale (NOS) was used for quality assessment of the included studies. We extracted and pooled the data. As for continuous data, mean difference (MD) was calculated; for dichotomous variables, we calculated a weighted relative risk (RR) with its 95% confidence interval. Heterogeneity was evaluated using I(2) statistics. P ≤ 0.05 was thought to be significant. RESULTS Fifteen studies were eligible for data extraction, which involved 11,271 total hip arthroplasties. The pooled data of complication rate demonstrated that obese patients suffered higher rates of complication (RR: 1.68, 95% CI 1.23 to 2.30, P = 0.0004), dislocation (RR: 2.08, 95% CI 1.54 to 2.81, P < 0.0001) and deep infection (RR: 2.92, 95% CI 0.74 to 11.49, P = 0.13). For the functional result, obese patients acquired relatively lower Harris Hip Score than non-obese patients (MD: -2.75, 95% CI -4.77 to -0.6), no difference was found regarding Oxford Hip Score (MD: -0.46, 95% CI -2.18 to 1.26, P = 0.60). Obese patients compared to non-obese patients showed an increase duration of operation (MD: 10.67, 95% CI 3.00 to 18.35, P = 0.006). However, no significant difference was found in the length of stay in hospital between obese and non-obese patients (MD: -0.16, 95% CI -0.34 to 0.02, P = 0.08). CONCLUSIONS This meta-analysis of prospective cohort studies demonstrates that obesity negatively influences the overall complication rate, dislocation rate, functional outcome and operative time of primary total hip arthroplasty.

Substrate stiffness regulates apoptosis and the mRNA expression of extracellular matrix regulatory genes in the rat annular cells.

Cells are subjected to static tension of different magnitudes when cultured on substrates with different stiffnesses. It has long been recognized that mechanical stress is an important modulator of the intervertebral disc degeneration. Here we studied the influence of substrate stiffness on cell morphology, apoptosis and extracellular matrix (ECM) metabolism of the rat annulus fibrosus (AF) cells which are known to be mechanosensitive cells. Polyacrylamide gel substrates with three different stiffnesses were prepared by varying the concentration of acrylamide and bisacrylamide, and the elastic modulus of the different gel substrates were measured with atomic force microscopy (AFM). First-passage rat annular cells were cultured on soft, intermediate, rigid substrates or plastics for 24 or 48 h. The percentages of apoptotic cells were detected by flow cytometry and caspase-3 activity, and morphologic changes were visualized by Hoechst 33258 staining and F-actin staining. In addition, the expression of ECM genes (Col1α1, Col2α1, aggrecan, MMP-3, MMP-13 and ADAMTS-5) were analyzed by RT-PCR. The three different substrates had elastic moduli varying between 1±0.23 kPa (soft, 5% gel with 0.06% bis), 32±2.89 kPa (intermediate, 10% gel with 0.13% bis) and 63±3.45 kPa (rigid, 10% gel with 0.26% bis) with a thickness about 60-70 μm. Most of the rat AF cells appeared small and rounded, and lost most of their stress fibers when cultured on soft substrate. There was a significant increase in the percentage of apoptotic cells in the rat AF cells cultured on soft and intermediate substrates relative to those on plastic surface, with a parallel decrease in the area of cell spreading and nucleus. The AF cells grown on intermediate or rigid substrate had reduced expression of Col1α1, Col2α1 and aggrecan and enhanced expression of MMP-3, MMP-13, and ADAMTS-5 at 24h or 48 h, respectively, relative to those cultured on plastic surface. Conversely, we observed an up-regulation of Col2α1 and aggrecan and no change in the gene expression of MMP-3, MMP-13, and ADAMTS-5 in AF cells on soft substrates. Rat AF cells are sensitive to substrate stiffness which can regulate the morphology, growth, apoptosis and ECM metabolism of rat AF cells, thus indicating the importance of substrate choice for cell transplantation and regeneration for the treatment of disc degeneration using tissue-engineering technique.

Antirotation proximal femoral nail versus dynamic hip screw for intertrochanteric fractures: A meta-analysis of randomized controlled studies

BACKGROUND Previous studies comparing proximal femoral nail antirotation (PFNA) with dynamic hip screw (DHS) for peritrochanteric fractures reported conflicting findings. The objective of this meta-analysis was to compare the efficacy and safety of PFNA and DHS for pertrochanteric fractures. HYPOTHESIS PFNA achieves better efficacy for peritrochanteric fractures compared with DHS. MATERIALS AND METHODS Relevant randomized controlled trials comparing PFNA with DHS for pertrochanteric fractures were assessed for eligibility and included into this meta-analysis. Data were extracted independently and methodological quality was further assessed. The inclusion criteria of this meta-analysis were: randomized controlled trials comparing PFNA with DHS for pertrochanteric fractures and reporting at least one of these main outcomes, including operating time, blood loss, all causes mortality, and complications. RESULTS Five randomized controlled trials were finally included into this meta-analysis. Pooled results showed there were less blood loss (weighted mean difference Blood loss=-249.75ml, 95%CI -303.83 to -195.67, P<0.0001) and fewer complications (Odds ratio=0.40, 95%CI 0.23 to 0.70, P=0.001) in the PFNA group compared with the DHS group. However, there was no difference in term of mortality between those two groups (Odds ratio mortality=1.13, 95%CI 0.47 to 2.69, P=0.79). Sensitivity analysis by sequential omission of individual studies showed that the significance of pooled odds ratios was robust, which suggested this outcome was credible. DISCUSSION PFNA can benefit peritrochanteric fractures patients with less blood loss and fewer complications compared with DHS. The significant heterogeneity among the included trials for intraoperative blood loss, and operation time may be attributable to variation in the skills of the surgeons and the different types of perirochanteric fractures. In addition, more powered randomized studies are needed to identify the findings from this meta-analysis, and the effects of long-term follow-up also need further study, especially the impact on the mortality. LEVEL OF EVIDENCE Level II, meta-analysis of low powered randomized study.

ADAMTS-5 and Intervertebral Disc Degeneration: The Results of Tissue Immunohistochemistry and In Vitro Cell Culture

Matrix metalloproteinases (MMPs) are known to be involved in IVD degeneration by hydrolyzing the extracellular matrix (ECM), especially the collagens. The degradation of proteoglycans, which is another main ECM component in the IVD, however, has not been extensively investigated. This study aimed to determine the expression of ADAMTS‐5 in human herniated intervertebral disc (IVD) tissues and to investigate whether interleukin‐1β (IL‐1β)‐induced expression of ADAMTS‐5 is mediated by nitric oxide (NO). Forty‐five herniated IVDs were harvested and immunostained to determine the distribution and type of ADAMTS‐5 expressing cells. Rat NP cells maintained in alginate beads were treated with IL‐1β, accumulation of NO was detected by Griess reaction, the expression of ADAMTS‐5 and inducible nitric oxide synthase (iNOS) was analyzed by reverse transcriptase‐polymerase chain reaction (RT‐PCR), the content of proteoglycans in alginate beads was visualized by alcian blue staining, and the effect of aminoguanidine on the changes in alginate beads induced by IL‐1β treatment were also examined. Immunohistochemical results from 45 herniated discs showed that ADAMTS‐5‐positive cells are commonly seen in cell clusters, that the percentage of ADAMTS‐5‐positive cells was higher in uncontained herniated discs than in contained ones, and that the percentage of ADAMTS‐5‐positive cells correlated with the age of the patients. IL‐1β treatment resulted in increased accumulation of NO, increased expression of ADAMTS‐5 and iNOS, whereas the accumulation of proteoglycan in alginate beads decreased. Aminoguanidine significantly reversed the changes in alginate beads induced by IL‐1β treatment. We thus suggested that ADAMTS‐5 is probably involved in the process of IVD degeneration, and that IL‐1β‐induced expression of ADAMTS‐5 is mediated by NO.

Changes of substance P during fracture healing in ovariectomized mice.

Neuropeptides may play an important role in the healing process of osteoporotic fractures. The objective of this study was to determine the role of substance P during osteoporotic fracture healing. One hundred ninety-two mice were randomized into ovariectomy (OVX) and control (CON) group (n=96, respectively). Femoral shaft fracture was created 3 weeks after OVX. Bone mineral density (BMD), micro-CT (microCT) analysis of fracture callus formation and mineralization, microCT analysis of fracture site neovascularization and biomechanical property as well as substance P levels were evaluated 1, 2, 4, and 8 weeks after fracture and compared with CON group. Following OVX-induced bone loss, fracture healing in OVX mice was significantly poorer than that in CON mice, with a significant decrease of substance P at the fracture site at all time points and with the level at early stage (1 and 2 weeks) higher than later stage (4 and 8 weeks). Impaired angiogenesis was also noted in OVX mice. No significant change of substance P level in serum was found between different groups or time points. In conclusion, fracture healing is inferior in OVX-induced bone loss and associated with a significant decrease of substance P. Substance P may play an important role during osteoporotic fracture healing.

Blockade of substance P receptor attenuates osteoporotic pain, but not bone loss, in ovariectomized mice.

Objective The aim of this study was to investigate the effect of a substance P (SP) receptor (NK1 receptor [NK1-R]) antagonist on hyperalgesia and bone metabolism in ovariectomized mice. Methods Thirty-six 9-week-old mice were subjected to either bilateral ovariectomy or sham surgery. Three weeks after the operation, the mice were treated with either a single-dose injection or 2-week repeated daily administration of L-703606, an NK1-R antagonist. Behavioral tests were performed for pain assessment; tibiae and the third lumbar vertebrae were dissected and assessed for microarchitectural or biomechanical properties. The expressions of SP and NK1-R in the dorsal root ganglia and spinal cord were also evaluated. Results Both single-dose injection and 2-week repeated injections of L-703606 led to a significant increase in nociceptive threshold in ovariectomized mice. However, the antihyperalgesic effect faded at 2 hours and almost disappeared at 5 hours after a single-dose injection. With the 14-day repeated treatment of ovariectomized mice, the effect was not detectable at 24 hours after the first injection but was obvious at 24 hours after 1-week and 2-week administrations and still existed at 48 hours after the last injection. Ovariectomized mice at the hyperalgesic state had enhanced SP immunoreactivity in the dorsal root ganglia and up-regulated SP and NK1-R expressions in the spinal cord. However, no significant change in serum SP level was detected. Two-week treatment with L-703606 could down-regulate these expressions but failed to salvage the deteriorated trabecular microstructure and reduced compressive strength in ovariectomized mice. Conclusions Estrogen deficiency–induced hyperalgesia is achieved through up-regulation of SP and NK1-R expressions. Blockade of SP receptor can alleviate pain but cannot ameliorate bone loss. NK1-R antagonist is not recommended for the treatment of estrogen deficiency osteoporosis.

Study on Key Genes and Regulatory Networks Associated with Osteoporosis by Microarray Technology

OBJECTIVE DNA microarray data of patients with osteoporosis were compared with that of healthy people to identify key genes and thus disclose the underlying regulatory network. METHODS Microarray dataset GSE35958 was downloaded from the Gene Expression Omnibus database, including five gene chips from patients with primary osteoporosis and four from age-matching nonosteoporosis controls. Raw data were preprocessed and differentially expressed genes (DEGs) were identified by the t-test. Then, function and pathway annotations were given by gene ontology (GO) and KEGG. The regulatory network for the DEGs was established from the aspects of transcription factors and microRNAs (miRNAs). The regulators of the miRNAs were also predicted by the MATCH algorithm. RESULTS A total of 274 DEGs were obtained with 47 significantly over-represented GO terms and 2 KEGG pathways. Transcriptional and post-transcriptional regulatory networks were established for the DEGs. Moreover, upstream regulators of the miRNAs were also obtained. CONCLUSION A range of genes, which might be implicated in the development of osteoporosis were obtained in the present study. Our findings are of possible benefit for the understanding of the unsolved regulatory mechanisms, and future clinical diagnosis as well as treatment.

Nano-sized Al 2 O 3 particle-induced autophagy reduces osteolysis in aseptic loosening of total hip arthroplasty by negative feedback regulation of RANKL expression in fibroblasts

Aseptic loosening is mainly caused by wear debris generated by friction that can increase the expression of receptor activation of nuclear factor (NF)-κB (RANKL). RANKL has been shown to support the differentiation and maturation of osteoclasts. Although autophagy is a key metabolic pathway for maintaining the metabolic homeostasis of cells, no study has determined whether autophagy induced by Al2O3 particles is involved in the pathogenesis of aseptic loosening. The aim of this study was to evaluate RANKL levels in patients experiencing aseptic loosening after total hip arthroplasty (THA) and hip osteoarthritis (hOA) and to consequently clarify the relationship between RANKL and LC3II expression. We determined the levels of RANKL and autophagy in fibroblasts treated with Al2O3 particles in vitro while using shBECN-1 interference lentivirus vectors to block the autophagy pathway and BECN-1 overexpression lentivirus vectors to promote autophagy. We established a novel rat model of femoral head replacement and analyzed the effects of Al2O3 particles on autophagy levels and RANKL expression in synovial tissues in vivo. The RANKL levels in the revision total hip arthroplasty (rTHA) group were higher than those in the hOA group. In patients with rTHA with a ceramic interface, LC3II expression was high, whereas RANKL expression was low. The in vitro results showed that Al2O3 particles promoted fibroblast autophagy in a time- and dose-dependent manner and that RANKL expression was negatively correlated with autophagy. The in vivo results further confirmed these findings. Al2O3 particles induced fibroblast autophagy, which reduced RANKL expression. Decreasing the autophagy level promoted osteolysis and aseptic prosthetic loosening, whereas increasing the autophagy level reversed this trend.