Selim SAFALI, M.D1., Bahattin Kerem AYDIN, M.D1., Alaaddin NAYMAN, M.D2.,
3Ceyhan UGURLUOGLU, M.D.
1Selçuk University Orthopedics and Taumatology Department, KONYA,
2Selçuk University Radiology Department, KONYA, 3Selçuk University Pathology Department, KONYA
used. After the rats were killed, their left femurs were disarticulated from their hip and knee joints. Soft tissues on the femoral bone were peeled off gently from the bone without any harm to the callus tissue. All of the left femurs were studied regarding clinical, radiological and histological aspects.
All the left femurs were removed and transferred immediately for radiologic analysis. The femurs obtained from group A, B, E and F used for histological analysis.
The femurs obtained from C, D, G and H used for biomechanical analysis.
Radiologic Analysis:
Sixty four femoras used for radiological analysis.
Computed Tomography (CT) images was performed with a 128×2-slice dual-source CT (Somatom Definition Flash, Siemens, Germany). The samples were placed in the CT for getting micro –CT images by scanning along the long axis of the femoral samples and the region of interest, 10 mm around the fracture site with o.6 mm collimation. The K wires were not removed as they did not cause any artifacts for radiological analysis.
Radiant Dicom Wiever 4.6.9 software used for radiological measurements. Total callus diameter, low radiodensity bone, high density bone, length of callus tissue and femoral diameter parameters measured. For measuring callus diameter, low radiodensity bone, high density bone and femoral diameter axial sections were used . For comparing of 2 weeks results; the ratio of total callus diameter/femoral diameter and for 4 weeks results the ratio of low density bone/ high density bone measurements used. [Figure 1]
Histological Analysis
A total 32 femurs from groups A, B, D and E were used for histological analysis. A buffered formalin solution was used for fixation for two days. After that, 10 % aceticacid
material testing machine (Elista, Istanbul, Turkey). The femurs were mounted with mini clamps on the testing device. These clamps gripped each specimen at the distal and proximal metaphyseal parts of the femurs for measuring resistance to longitudinal distraction forces in Newtons for all femurs. A distraction force was applied at 3 mm/min. The distraction forced applied increased until failure of healing region. Load to failure parameter were recorded for each specimen. 3 point bending test was planned but could not be used as two weeks specimens were not applicable because of only soft callus formation.
The recorded measurements in Newtons were used to compare the results for biomechanical evaluation.
Statistical Analysis
Mann Whitney U test was used for radiological, histological and biomechanical results analyses to evaluate the differences of two groups. All the analyses were performed by using IBM SPSS version 20.0 software (IBM Corp., Armonk, NY, USA. A p value <0.05 was considered to be statistically significant).
Results
Radiological results according to CT images are presented in Table 2.
It was observed that there was no significant difference between the results of the Mann Whitney U test in order to determine whether there was a significant difference between the curcumin 2nd week radiological evaluation and the control group .
It was observed that there was no significant difference between the results of the Mann Whitney U test in order to determine whether there was a significant difference between the curcumin 2nd week radiological evaluation and the control group (U=117,00, p>.05)
For radiological evaluation of 2 weeks results only total callus diameter/ femoral diameter measurement is used as hard callus formation was not proper. According to
statistical evaluation. Histological scores according to Huo classification are presented in Table 3.
It was observed that there was no significant difference between the histological examination results of the Mann Whitney U test in order to determine whether there was a significant difference between the 2.nd week curcumin and the 2.nd week control groups (U=30,00, p> .05).
It was observed that there was no significant difference between the histological examination results of the Mann Whitney U test in order to determine whether there was a significant difference between the 4.th week curcumin group and 4.th week control group (U=21,00, p> .05).
The mean scores were 4.8 in control and 4.2 in curcumin group at two weeks. The mean scores were 5.5 in control group and 5.9 in curcumin group at 4 weeks. The histological results were better in control group according to two weeks results, according to 4 weeks results curcumin group scores were better. But these results were not statistically significant.
Biomechanical results are presented in Table 4.
It was observed that there was no significant difference between the biomechanical examination results of the Mann Whitney U test in order to determine whether there was a significant difference between the 2.nd week curcumin group and the 2.nd week control group (U=29,00, p> .05).
It was observed that there was no significant difference between the biomechanical examination results of the Mann Whitney-U test in order to determine whether there was a significant difference between the 4th week curcumin group and the 4.th week control group (U=27,50, p> .05).
The mean load to failure was 8.3 N in control and 8.6 N in curcumin group after two weeks; 8.9 in control and 8.2 in curcumin group after four weeks.
Curcumin is a well-known antioxidant, anti-inflammatory, antimicrobial, chemopreventive and anti-carcinogenic agent [24-26]. Although its clinical application is hindered by low water solubility, poor absorption, bioavailability [27], the number of scientific publications about curcumin is still increasing. On the date of November 2018, there are more than 12000 papers about curcumin. For the last 3 years the total number of studies concerning curcumin is more than 3900. It has been published that curcumin has the potential for increasing the synthesis of collogen, promoting angiogenesis, decreasing reactive oxygen radicals and promoting wound healing process [9,13, 28, 29].
Curcumin has positive effects on bone metabolism stimulating osteoblasts and inhibiting osteoclasts [30]. It has important effects on cell modulator agents such as activating protein-1, β-catenin,peroxisome, proliferator-activated receptor-γ and nuclearfactor-Κβ (NF-κΒ) [31]. Curcumin inactivates NF-κΒ, which is important on preventing carcinogenesis. In some animal model studies it has been showed that curcumin can increase bone strength, prevent osteopenia and can be benefical in management of osteopenia [32,33].
In vivo studies about curcumin confirm its benefical effects on preventing and treating of bone metastases regardless of the primary tumour. [34].
The use of curcumin in osteoarthritis is still being investigated in experimental and clinical studies. Its inhibitory effect on inflammatory markers such as IL-6, IL-8, 5-lipooxygenase and COX-2 has been published.
Selective COX-2 inhibition is an important point as this is a advantage for gastrointestinal tolerance for patient use. Curcumin also have anti-catabolic property as suppressing gene expression of metalloproteinase enzymes which responsible from degredation of joint matrix [35-37]. Also, it has been demonstrated that curcumin can reduce the formation of agents which are
animal model study investigating its effect on fracture healing by radiological, histological and biomechanical tests in the same study.
In this study we created a femur fracture injury model and searched for the effects of oral curcumin. The histological results were better in curcumin groups in 2 and 4 weeks results. But histological results were not statistically significant. This may be secondary to curcumin’s anti-inflammatory effect. The first phase of bone healing process is inflammation phase and curcumin may inhibitory effect on inflammation phase. Same situation is also valid for 4 weeks results which represent healing or callus phase of fracture healing. This results as quite different from previous publication [18]. The histological evaluation system of our study is different from Li ‘s paper.
In our study we used to evaluate the healing by Huo’s classification which has 10 parameters using only light microscopy with hematoxylin and eosin staining. The other study published their histological examination results by using osteoblast cell count and immunohistochemical tissue staining, immunofluorescence Western blots. But there is not any objective classification system about this histologic examination in literature. Of course, the number of osteoblasts and other immunohistochemical parameters are important for fracture healing process, but we could not find any publication comparing Huo’s histologic classification and osteoblast count. So the difference of histological results between these similar studies may be secondary to the usage of different histological evaluation methods.
The radiological evaluation results were better in curcumin group, which also did not revealed statistically difference. The CT evaluation used for investigating the bony union in rat femurs. The diameter of callus formation and its ratio to intact bone diameter used for radiologic examinations. The results radiologic results of similar publication showed statistically better results with curcumin use. In that study the authors also used
The two weeks results were better in curcumin group and 4 weeks results were better in control group. But when we compare the results there was no statistically difference between the control and curcumin groups. There is only one paper about the biomechanical effects of curcumin on bone tissue [39]. In that study the authors searched the effect of curcumin on intact bone tissue by using ovariectomized rat model. They concluded that curcumin has no statistically positive effect on bone tissue by evaluation of biomechanical tests. Our results are similar with this study although we used femur fracture model.
There are also some limitations of our study. First there is a lack of immunoflorecence and immunohistochemical evaluation which can be an important examination for evaluating the histological results. Also the lack of Western blot analysis can be mentioned about the limitations of histologic evaluation. Secondly we could not apply three point bending test for biomechanical evaluation. Although the fracture healing tissue were not applicable this test, longer follow up results can be investgated for this analysis. And lastly, the number of the rats used could be higher for more adequate results.
Curcumin has been used especially in Asian countries to treat different kinds of diseases due to its antioxidant, anti-inflammatory, immunomodulatory and antimicrobial effects for many years [3-10]. In our experimental study we detect that curcumin did not improve the fracture healing process according to biomechanical, radiological and histological evaluation. We think that curcumin’s anti-inflammatory property may be responsible for this ineffectiveness on fracture healing process.
Conclusion
According to our results, curcumin has no positive effect on fracture healing not only histologically but also radiologically and biomechanically. Curcumin’s effect may be more noticeable with long term follow up investigation as it may have a positive effect in
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1.Introduction
Pilon fractures are relatively rare and it constitutes %1-10 of all lower extremity fractures[1]. It generally results from high energy trauma with axial compression. Management of tibia pilon fractures are difficult due to intraarticular communion and soft tissue problems[2]. Purposes of tibia pilon fracture treatment are anatomic reduction of articular surface, restore the alignment and length of the extremity and to allow early range of motion to ankle and protect soft tissue integrity[3 4].
Historically, pilon fractures treated by open reduction and rigid internal fixation[5]. After unacceptable high soft-tissue complication rates of ORIF, Schatzker et al. introduced staged treatment for pilon fractures and they report a decrease of soft tissue complications dramatically[6]. Also, Bone et al. published combined treatment with internal fixation and external fixation to decrease soft tissue complications [7].
Different approaches described including, anteromedial, anterolateral, extensile approach and combined approaches [8]. After modern low profile anatomic plate designs, minimally invasive locking plates getting more popular for pilon fractures. MIPO treatment provides stable articular fixation with less soft tissue complications than classic ORIF[9]. Definitive external fixation(ExFix) is also useful method for pilon fractures. ExFix has many advantages over ORIF. The use of the external fixator in
There is no gold standard treatment for pilon fracture in the literature. Surgeon’s experience, soft tissue status of the patient and availability of implants are important factors to choose treatment option for pilon fractures.
The purpose of present study is to compare short term results of surgically treated pilon fractures in our clinic with Ilizarov external fixator and minimally invasive plate osteosynthesis(MIPO).
2.Methods
After institutional review board approval, records of patients who underwent ORIF or CREF between 2013 and 2018 evaluated.
Inclusion criteria were (1) displaced pilon fracture(Ruedi- Allgöwer type 2-3) and (2) patients treated with Ilizarov external fixator or MIPO with a minimum of 12 months follow up period. Patients with ipsilateral neurovascular deficit, Gustillo-Andersen type 3B and 3C open fractures, history of previous ankle surgery were excluded from the study. After exclusions, 25 patients treated with Ilizarov external fixator and 25 patient treated with minimally invasive plate osteosynthesis were included in the study.
The mean age of patients was 45,5 years (16-77, SD:14.7) including 35 male and 15 female. Patients were divided into two groups according to fixation methods.
First group consisted of patients treated with closed or limited open reduction and external fixation. In the second group, patients received MIPO with single or staged surgery.