{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,12]],"date-time":"2025-10-12T04:32:00Z","timestamp":1760243520187,"version":"build-2065373602"},"reference-count":40,"publisher":"MDPI AG","issue":"10","license":[{"start":{"date-parts":[[2022,10,3]],"date-time":"2022-10-03T00:00:00Z","timestamp":1664755200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Biomedicines"],"abstract":"<jats:p>Fracture healing and nonunion development are influenced by a range of biological factors. Adequate amino acid concentrations, especially arginine, are known to be important during normal bone healing. We hypothesize that bone arginine availability in autologous bone marrow grafting, when using the reamer-irrigator-aspirator (RIA) procedure, is a marker of bone healing capacity in patients treated for nonunion. Seventeen patients treated for atrophic long bone nonunion by autologous bone grafting by the RIA procedure were included and divided into two groups, successful treatment of nonunion and unsuccessful, and were compared with control patients after normal fracture healing. Reamed bone marrow aspirate from a site distant to the nonunion was obtained and the amino acids and enzymes relevant to arginine metabolism were measured. Arginine and ornithine concentrations were higher in patients with successful bone healing after RIA in comparison with unsuccessful healing. Ornithine concentrations and arginase-1 expression were lower in all nonunion patients compared to control patients, while citrulline concentrations were increased. Nitric oxide synthase 2 (Nos2) expression was significantly increased in all RIA-treated patients, and higher in patients with a successful outcome when compared with an unsuccessful outcome. The results indicate an influence of the arginine\u2013nitric oxide metabolism in collected bone marrow, on the outcome of nonunion treatment, with indications for a prolonged inflammatory response in patients with unsuccessful bone grafting therapy. The determination of arginine concentrations and Nos2 expression could be used as a predictor for the successful treatment of autologous bone grafting in nonunion treatment.<\/jats:p>","DOI":"10.3390\/biomedicines10102474","type":"journal-article","created":{"date-parts":[[2022,10,8]],"date-time":"2022-10-08T00:07:43Z","timestamp":1665187663000},"page":"2474","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Arginine Availability in Reamed Intramedullary Aspirate as Predictor of Outcome in Nonunion Healing"],"prefix":"10.3390","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1781-1363","authenticated-orcid":false,"given":"Dennis M.","family":"Meesters","sequence":"first","affiliation":[{"name":"Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center +, 6200 MD Maastricht, The Netherlands"},{"name":"NUTRIM School for Nutrition and Translational Research in Metabolism, 6200 MD Maastricht, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Karolina A. P.","family":"Wijnands","sequence":"additional","affiliation":[{"name":"Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center +, 6200 MD Maastricht, The Netherlands"},{"name":"NUTRIM School for Nutrition and Translational Research in Metabolism, 6200 MD Maastricht, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hans M. H.","family":"van Eijk","sequence":"additional","affiliation":[{"name":"Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center +, 6200 MD Maastricht, The Netherlands"},{"name":"NUTRIM School for Nutrition and Translational Research in Metabolism, 6200 MD Maastricht, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Martijn","family":"Hofman","sequence":"additional","affiliation":[{"name":"Department of Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, 52074 Aachen, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Frank","family":"Hildebrand","sequence":"additional","affiliation":[{"name":"Department of Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, 52074 Aachen, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jan P. A. M.","family":"Verbruggen","sequence":"additional","affiliation":[{"name":"Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center +, 6200 MD Maastricht, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Peter R. G.","family":"Brink","sequence":"additional","affiliation":[{"name":"Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center +, 6200 MD Maastricht, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5005-1285","authenticated-orcid":false,"given":"Martijn","family":"Poeze","sequence":"additional","affiliation":[{"name":"Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center +, 6200 MD Maastricht, The Netherlands"},{"name":"NUTRIM School for Nutrition and Translational Research in Metabolism, 6200 MD Maastricht, The Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2022,10,3]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"434","DOI":"10.1080\/17453674.2017.1321351","article-title":"The risk of non-union per fracture: Current myths and revised figures from a population of over 4 million adults","volume":"88","author":"Mills","year":"2017","journal-title":"Acta Orthop."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"273","DOI":"10.5435\/JAAOS-20-05-273","article-title":"Assessment of compromised fracture healing","volume":"20","author":"Bishop","year":"2012","journal-title":"J. Am. Acad. Orthop. Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"325","DOI":"10.1007\/s004020000252","article-title":"The influence of fracture etiology and type on fracture healing: A review of 104 consecutive tibial shaft fractures","volume":"121","author":"Karladani","year":"2001","journal-title":"Arch. Orthop. Trauma Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"S77","DOI":"10.1016\/S0020-1383(07)80012-X","article-title":"The health economics of the treatment of long-bone non-unions","volume":"38","author":"Kanakaris","year":"2007","journal-title":"Injury"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"S3","DOI":"10.1016\/S0020-1383(08)70003-2","article-title":"Fracture healing: The diamond concept","volume":"38","author":"Giannoudis","year":"2007","journal-title":"Injury"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1016\/j.ocl.2009.07.011","article-title":"The concept of induced membrane for reconstruction of long bone defects","volume":"41","author":"Masquelet","year":"2010","journal-title":"Orthop. Clin. N. Am."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"584","DOI":"10.1097\/BOT.0000000000000086","article-title":"The reamer-irrigator-aspirator as a device for harvesting bone graft compared with iliac crest bone graft: Union rates and complications","volume":"28","author":"Dawson","year":"2014","journal-title":"J. Orthop. Trauma"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"2973","DOI":"10.1007\/s11999-008-0538-3","article-title":"Bone graft harvest using a new intramedullary system","volume":"466","author":"Belthur","year":"2008","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"S72","DOI":"10.1016\/S0020-1383(10)70014-0","article-title":"Reamer-irrigator-aspirator bone graft and bi Masquelet technique for segmental bone defect nonunions: A review of 25 cases","volume":"41","author":"Stafford","year":"2010","journal-title":"Injury"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1270","DOI":"10.3945\/ajcn.110.009209","article-title":"Impaired fracture healing associated with amino acid disturbances","volume":"95","author":"Wijnands","year":"2012","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"897","DOI":"10.1111\/j.2042-7158.1997.tb06132.x","article-title":"Nitric oxide is a regulator of bone remodelling","volume":"49","author":"Chae","year":"1997","journal-title":"J. Pharm. Pharmacol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"247","DOI":"10.1097\/00003086-199908000-00030","article-title":"Nitric oxide mediated vasoreactivity during fracture repair","volume":"365","author":"Corbett","year":"1999","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"38","DOI":"10.1016\/0304-4165(86)90094-2","article-title":"A possible role for polyamines in cartilage in the mechanism of calcification","volume":"881","author":"Vittur","year":"1986","journal-title":"Biochim. Biophys. Acta"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"159","DOI":"10.1002\/jor.20060","article-title":"Nitric oxide enhances collagen synthesis in cultured human tendon cells","volume":"24","author":"Xia","year":"2006","journal-title":"J. Orthop. Res. Off. Publ. Orthop. Res. Soc."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1470","DOI":"10.1359\/jbmr.2002.17.8.1470","article-title":"Localization of nitric oxide synthases during fracture healing","volume":"17","author":"Zhu","year":"2002","journal-title":"J. Bone Miner. Res."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"535","DOI":"10.1359\/jbmr.2001.16.3.535","article-title":"Nitric oxide synthase isoforms during fracture healing","volume":"16","author":"Zhu","year":"2001","journal-title":"J. Bone Miner. Res."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1016\/j.bone.2015.11.006","article-title":"Deficiency of inducible and endothelial nitric oxide synthase results in diminished bone formation and delayed union and nonunion development","volume":"83","author":"Meesters","year":"2016","journal-title":"Bone"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"342","DOI":"10.1359\/jbmr.2000.15.2.342","article-title":"Nitric oxide modulates fracture healing","volume":"15","author":"Diwan","year":"2000","journal-title":"J. Bone Miner. Res."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1016\/0378-4347(93)80062-9","article-title":"Rapid routine determination of amino acids in plasma by high-performance liquid chromatography with a 2\u20133 microns Spherisorb ODS II column","volume":"620","author":"Rooyakkers","year":"1993","journal-title":"J. Chromatogr."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"e002276","DOI":"10.1136\/bmjopen-2012-002276","article-title":"The relative incidence of fracture non-union in the Scottish population (5.17 million): A 5-year epidemiological study","volume":"3","author":"Mills","year":"2013","journal-title":"BMJ Open"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"S48","DOI":"10.1016\/S0020-1383(15)30055-3","article-title":"Long bone non-unions treated with the diamond concept: A case series of 64 patients","volume":"46","author":"Giannoudis","year":"2015","journal-title":"Injury"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1725","DOI":"10.1016\/j.injury.2013.09.009","article-title":"Fracture non-union: Can biomarkers predict outcome?","volume":"44","author":"Pountos","year":"2013","journal-title":"Injury"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1038\/s41572-021-00289-8","article-title":"Non-union bone fractures","volume":"7","author":"Wildemann","year":"2021","journal-title":"Nat. Rev. Dis. Primers"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"S5","DOI":"10.1016\/S0020-1383(08)70010-X","article-title":"The diamond concept--open questions","volume":"39","author":"Giannoudis","year":"2008","journal-title":"Injury"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"627","DOI":"10.1302\/0301-620X.89B5.18183","article-title":"The factors affecting outcome after non-vascular bone grafting and internal fixation for nonunion of the scaphoid","volume":"89","author":"Ramamurthy","year":"2007","journal-title":"J. Bone Joint Surg. Br."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"S59","DOI":"10.1016\/S0020-1383(08)70016-0","article-title":"Classification of non-union: Need for a new scoring system?","volume":"39","author":"Calori","year":"2008","journal-title":"Injury"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"2036","DOI":"10.1016\/j.injury.2015.05.042","article-title":"Treatment of chronic (>1 year) fracture nonunion: Heal rate in a cohort of 767 patients treated with low-intensity pulsed ultrasound (LIPUS)","volume":"46","author":"Zura","year":"2015","journal-title":"Injury"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"3674045","DOI":"10.1155\/2017\/3674045","article-title":"Changes of Bone Turnover Markers in Long Bone Nonunions Treated with a Regenerative Approach","volume":"2017","author":"Granchi","year":"2017","journal-title":"Stem Cells Int."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"183","DOI":"10.22203\/eCM.v039a12","article-title":"Enhancement of fracture healing after citrulline supplementation in mice","volume":"39","author":"Meesters","year":"2020","journal-title":"Eur. Cell Mater."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"693","DOI":"10.1007\/s00508-005-0431-y","article-title":"The influence of oral L-arginine on fracture healing: An animal study","volume":"117","author":"Kdolsky","year":"2005","journal-title":"Wien. Klin. Wochenschr."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1016\/j.bone.2004.10.002","article-title":"Deletion of iNOS gene impairs mouse fracture healing","volume":"37","author":"Baldik","year":"2005","journal-title":"Bone"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1038\/nrrheum.2012.1","article-title":"Fracture healing under healthy and inflammatory conditions","volume":"8","author":"Claes","year":"2012","journal-title":"Nat. Rev. Rheumatol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"459","DOI":"10.1016\/j.semcdb.2008.07.004","article-title":"Bone remodeling during fracture repair: The cellular picture","volume":"19","author":"Schindeler","year":"2008","journal-title":"Semin. Cell Dev. Biol."},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Wijnands, K.A., Hoeksema, M.A., Meesters, D.M., van den Akker, N.M., Molin, D.G., Briede, J.J., Ghosh, M., Kohler, S.E., van Zandvoort, M.A., and de Winther, M.P. (2014). Arginase-1 deficiency regulates arginine concentrations and NOS2-mediated NO production during endotoxemia. PLoS ONE, 9.","DOI":"10.1371\/journal.pone.0086135"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1007\/s00068-017-0796-4","article-title":"The Non-Union Scoring System: An interobserver reliability study","volume":"45","author":"Houben","year":"2019","journal-title":"Eur. J. Trauma Emerg. Surg."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"S93","DOI":"10.1016\/j.injury.2014.10.030","article-title":"Validation of the Non-Union Scoring System in 300 long bone non-unions","volume":"45","author":"Calori","year":"2014","journal-title":"Injury"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"427","DOI":"10.1016\/S0753-3322(02)00273-1","article-title":"The metabolic basis of arginine nutrition and pharmacotherapy","volume":"56","author":"Flynn","year":"2002","journal-title":"Biomed. Pharmacother."},{"key":"ref_38","first-page":"E473","article-title":"Source and fate of circulating citrulline","volume":"241","author":"Windmueller","year":"1981","journal-title":"Am. J. Physiol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1042\/bj3360001","article-title":"Arginine metabolism: Nitric oxide and beyond","volume":"336","author":"Wu","year":"1998","journal-title":"Biochem. J."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1621S","DOI":"10.1093\/jn\/137.6.1621S","article-title":"Citrulline: A new player in the control of nitrogen homeostasis","volume":"137","author":"Moinard","year":"2007","journal-title":"J. Nutr."}],"container-title":["Biomedicines"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2227-9059\/10\/10\/2474\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T00:46:02Z","timestamp":1760143562000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2227-9059\/10\/10\/2474"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,10,3]]},"references-count":40,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2022,10]]}},"alternative-id":["biomedicines10102474"],"URL":"https:\/\/doi.org\/10.3390\/biomedicines10102474","relation":{},"ISSN":["2227-9059"],"issn-type":[{"type":"electronic","value":"2227-9059"}],"subject":[],"published":{"date-parts":[[2022,10,3]]}}}