title: Low-intensity pulsed ultrasound affects RUNX2 immunopositive osteogenic cells in delayed clinical fracture healing.
abstract: BACKGROUND
  Osteogenic cell proliferation and differentiation play an important role in adequate fracture healing, and is target for osteoinductive therapies in delayed fracture healing. The aim of this study was to investigate whether low-intensity pulsed ultrasound enhances fracture healing at the tissue level in patients with a delayed union of the osteotomized fibula through an effect on the presence of RUNX2 immunopositive osteogenic cells. The effect was studied in both atrophic and hypertrophic delayed unions.
  
  
  METHODS
  Biopsies were obtained from 6 female and 1 male patient (age 43-63) with a delayed union of the osteotomized fibula after a high tibial osteotomy treated for 2-4 months with or without low-intensity pulsed ultrasound in a randomized prospective double-blind placebo-controlled trial. Immunolocalization of RUNX2 protein was performed to identify osteogenic cells. Histomorphometrical analysis was performed to determine the number of cells expressing RUNX2 located within and around the newly formed woven bone at the fracture end (area of new bone formation), and up to 3 mm distant from the fracture end.
  
  
  RESULTS
  Cells expressing RUNX2 were present in all histological sections of control and low-intensity pulsed ultrasound-treated bone evaluated. Within the area of new bone formation, RUNX2 immunopositive cells were found in the undifferentiated soft connective tissue, at the bone surface (presumably osteoblasts), and within the newly formed woven bone. Low-intensity pulsed ultrasound treatment of fibula delayed unions significantly reduced the number of RUNX2 immunopositive cells within the soft connective tissue at the fracture ends, whereas the number of RUNX2 immunopositive cells at the bone surface was not affected. The number of RUNX2 immunopositive cells was similar for the atrophic and hypertrophic delayed unions.
  
  
  CONCLUSIONS
  Immunolocalization of RUNX2 positive cells in delayed unions of the fibula reveals that delayed clinical fracture healing does not result in impairment of osteogenic cell proliferation and/or differentiation at the tissue level, even if delayed unions are clinically regarded as atrophic. Reduced number of osteogenic RUNX2 immunopositive cells within the soft connective tissue, and unchanged number of RUNX2 immunopositive cells at the bone surface, implicate that low-intensity pulsed ultrasound does not increase osteogenic cell presence, but likely affects osteogenic cell differentiation.
authors.affiliation: Department of Oral Cell Biology, ACTA-University of Amsterdam and VU University Amsterdam, Research Institute MOVE, Amsterdam, The Netherlands.
authors.forename: Sjoerd
authors.initials: S
authors.lastname: Rutten
authors.forename: Peter A
authors.initials: PA
authors.lastname: Nolte
authors.forename: Clara M
authors.initials: CM
authors.lastname: Korstjens
authors.forename: Jenneke
authors.initials: J
authors.lastname: Klein-Nulend
mesh_terms: D000328:Adult; D002146:Bony Callus / Q000000981:diagnostic imaging / Q000378:metabolism / Q000473:pathology; D050659:Core Binding Factor Alpha 1 Subunit / Q000378:metabolism*; D005260:Female; D005360:Fibula / Q000000981:diagnostic imaging / Q000473:pathology; D017102:Fracture Healing; D005599:Fractures, Ununited / Q000000981:diagnostic imaging / Q000473:pathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D010011:Osteocytes / Q000378:metabolism* / Q000473:pathology*; D010012:Osteogenesis; D014465:Ultrasonics; D014463:Ultrasonography
chemical_list: D050659:Core Binding Factor Alpha 1 Subunit; C493709:RUNX2 protein, human