- Email: [email protected]
5G Gene Polymorphism and Nontraumatic Lunatum Avascular Necrosis
SCIENTIFIC ARTICLE
Relationship of Plasminogen Activator Inhibitor 1 4G/5G Gene Polymorphism and Nontraumatic Lunatum Avascular Necrosis Metin Gönen, MD,* Ali Çag das¸ Yörükog lu, MD,‡ A. Nadir Aydemir, MD,‡ Gizem Akıncı Gönen, MD,† Emre Tepeli, MD,§ A. Fahir Demirkan, MD‡
Purpose Plasminogen activator inhibitor 1 (PAI-1) is a critical enzyme that regulates coagulation and fibrinolytic systems. The aim of this study was to determine the role of PAI-1 4G/ 5G polymorphism in nontraumatic avascular necrosis of the lunate. Methods The study included 45 patients with Kienböck disease and 45 healthy individuals as a control group. In both groups, genomic DNA was extracted from peripheral blood samples to determine the distributions of PAI-1 4G/5G polymorphism using allele-specific polymerase chain reaction and sequencing. Results No statistically significant difference was determined in the distribution of the gene polymorphism between the patient and control groups. We found the 5G/5G genotype to be 1.7 times higher in the control group compared with the patient group. A 1.6-fold increase in the 4G homozygote genotype was identified in the patient group. The patient and control groups were also evaluated for 4G/4G plus 4G/5G and 5G/5G in terms of genotype distribution. No statistically significant difference was found. Conclusions The findings suggest that the PAI-1 4G/4G polymorphism is not a genetic risk for Kienböck disease. Clinical relevance This study aimed to reveal the genetic etiology of Kienböck disease. (J Hand Surg Am. 2019;-(-):1.e1-e4. Copyright Ó 2019 by the American Society for Surgery of the Hand. All rights reserved.) Key words Avascular necrosis, gene polymorphism, Kienböck disease, lunate, PAI-1.
From the *Department of Orthopedics and Traumatology, Develi Hatice Muammer Kocaturk State Hospital; and †Department of Medical Genetics, Kayseri Education and Research Hospital, Kayseri; the ‡Faculty of Medicine, Department of Orthopedics and Traumatology, Pamukkale University, Denizli; and the §Next Genetic Center, _Istanbul, Turkey. Received for publication August 6, 2018; accepted in revised form September 25, 2019. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Ahmet Fahir Demirkan, MD, Faculty of Medicine, Department of Orthopedics and Traumatology, Pamukkale University, 20070 Denizli, Turkey; e-mail: [email protected]. 0363-5023/19/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2019.09.012
A
lunate (Kienböck disease), as defined by Robert Kienböck in 1910, is a condition characterized by subchondral ischemic damage and collapse of the lunate, resulting in degeneration of the wrist.1 The etiology and pathogenesis of the disease are still unclear, although it is generally accepted that the basis of the condition is at least temporary loss of interosseous blood flow.2 Plasminogen activator inhibitor 1 (PAI-1) is the enzyme that inhibits plasminogen, which is the precursor of plasmin, the main enzyme VASCULAR NECROSIS OF THE
Ó 2019 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1.e1
1.e2
GENE POLYMORPHISM AND LUNATE NECROSIS
involved in fibrinolysis.3 When there is a polymorphism at the PAI-1 gene, increased plasma concentrations of PAI-1 could increase the frequency of intravenous clotting.4,5 The PAI-1 gene has 3 genotypes: 4G/4G, 4G/5G, and 5G/5G. The genotype 4G allele appears to be associated with increased plasma PAI-1 levels, potentially increasing the chances of excessive intravascular clotting.6 Moreover, PAI-1 4G/5G gene polymorphism has been shown to be a risk factor for avascular necrosis of the femoral head. Individuals carrying 4G alleles have a higher risk for femoral head osteonecrosis compared with those who are 5G homozygous. Both 4G homozygotes and 4G/5G heterozygotes are associated with an increased risk for avascular necrosis of the femoral head compared with individuals who are 5G homozygous.4 To the best of our knowledge, no similar studies in literature have been conducted to evaluate the association between PAI-1 4G/5G polymorphism in association with avascular necrosis of the lunate. The aim of this study was to analyze PAI-1 4G/5G gene polymorphism in patients with nontraumatic avascular necrosis of the lunate.
TABLE 1.
Demographic Characteristics
Patient
Control
P
Mean SD
31.64 7.9
33.35 7.4
.293
Median (range)
31 (18e49)
34 (19e49)
Male (%)
27 (60)
22 (49)
Female (%)
18 (40)
23 (51)
Age
Gender .290
injuries, were excluded from the study. Control group subjects were similar in age and had no age-related wrist problems or evidence of Kienböck disease on plain wrist radiographs. We created plain radiographs of all patients; CT, magnetic resonance examination, or both were used to produce a diagnosis for earlystage patients. X-rays of the control group were normal, and neither CT nor MRI was performed in this group. The patient group was composed of 45 patients aged 18 to 49 years (27 men and 18 women); the control group was composed of 45 healthy subjects (22 men and 23 women) aged 19 to 49 years, with no wrist problems (Table 1). Peripheral blood samples of 2 mL were taken from both the patient and control groups. The blood samples were separately coded for the patient and control groups and stored at e20 C until DNA isolation. The concentrations and purity values of DNA samples isolated from peripheral blood from the patient and control groups were determined with the spectrophotometric method. The gene region containing the PAI-1 gene 4G/5G base pair (bp) was amplified by polymerase chain reaction (PCR) using the primers shown in Table 2. According to the PCR results, samples that gave 139-bp bands only with 4G primer were homozygous 4G genotypes, samples that gave 139-bp bands only with 5G primer were homozygous 5G genotypes, and samples that gave 139bp bands with both 5G and 4G primer were identified as heterozygous 4G5G genotypes (Fig. 1). Genotypes identified by allele-specific PCR in the 45 patients and 45 control subjects were confirmed by sequence analysis8 and PCR reaction.9
MATERIALS AND METHODS This study included patients aged 18 to 65 years who were given the diagnosis of avascular necrosis of the lunate in the hand surgery unit from January 2012 to June 2016, and a control group with a similar age distribution. The study protocol was approved by the ethics committee; written informed consent was obtained from all participants in the study. All patients had clinical symptoms of Kienböck disease, such as wrist pain, tenderness on palpation, and decreased motion or stiffness of the wrist. Plain radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) were used for diagnosis. In stage 1, MRI showed areas of decreased signal intensity on T1-weighted images and areas of decreased signal intensity on T2-weighted images. Stage 2 Kienböck disease is characterized by sclerosis evidenced by increased bone density of the lunate compared with the other carpal bones on radiographs and CT scans. Collapse of the entire lunate from distal to proximal in the coronal plane and elongation in the sagittal plane were used to diagnose stage 3 Kienböck disease in patients. Lunate collapse with associated radiocarpal or midcarpal degenerative arthritis was used as the diagnostic criterion of stage 4 patients.7 Patients with a history of wrist trauma, such as perilunate fracture-dislocations, carpal fractures, and ligament J Hand Surg Am.
Demographic Characteristics of Groups
Statistical analysis For 90 volunteers; we reached 92% power with 95% confidence for an odds ratio (OR) of 2.26. When parametric test assumptions were met, independent samples t test was used to compare independent group differences, and the Mann-Whitney U test to r
Vol. -, - 2019
1.e3
GENE POLYMORPHISM AND LUNATE NECROSIS
TABLE 2.
Primer Pairs Used in Propagation of Gene Region of Interest Primer
Gene Sequence
Primer used to insert 5G allele
GTC TGG ACA CGT GGG GG
Primer used to delete 4G allele
GTC TGG ACA CGT GGG GA
Upstream primer
AAG CTT TTA CCA TGG TAA CCC CTG GT
Downstream primer
TGC AGC CAG CCA CGT GAT TGT CTA G
DISCUSSION To the best of the author's knowledge, the PAI-1 4G/ 5G polymorphism has not been previously investigated in Kienböck disease. Many studies in the literature suggested that Kienböck disease is multifactorial and thought to be caused by recurrent microtrauma, perilunate dislocations, ulnar-negative variance, coagulation disorders, decreased arterial flow, and increased venous pressure, among other factors. Disruption of bone circulation owing to intravascular coagulation is another factor that has been suggested in the pathogenesis of avascular necrosis. The PAI-1 protein inhibits tissue-type plasminogen activator action by binding to it, reducing fibrin degradation.10 This protein is the human genome 675th bp, synthesized from the PAI-1 gene region in its locus. It affects the fibrinolytic system at different rates owing to 4G/5G polymorphism in this region.11 Increased plasma concentrations of PAI-1 are associated with deep venous thrombosis, coronary artery diseases, asthma, recurrent pregnancy loss, preeclampsia, and osteonecrosis of bones such as the femoral head.4,12,13 In a study by Glueck et al,6 59 patients with femoral head osteonecrosis were found to have a significantly higher PAI-1 4G homozygous genotype compared with a healthy control group. Similarly, Ferrari et al5 conducted a study of 26 renal transplant patients treated with corticosteroids, who developed osteonecrosis of the femoral head, and 326 healthy subjects. The control group had fewer 4G alleles compared with the patient group. There are also reports in the literature that there is no significant association between osteonecrosis and PAI-1 polymorphism.14 In the current study, no statistically significant relation was found between genotype distribution and lunate osteonecrosis, although in the control group, the genotype 5G/5G was 1.7 times higher than in the patient group, and the 4G homozygous genotype was 1.6 times higher in the patient group. Because this difference was not statistically significant, PAI-1 4G/4G polymorphism was not shown to be associated with Kienböck disease. In a meta-analysis composed of studies of the relation
FIGURE 1: Two-percent agarose gel images of PAI-1 4G/5G allele-specific PCR products.
compare independent group differences when parametric test assumptions were not met. We used chisquare analysis to compare categorical variables and applied univariate logistic regression analysis to examine the allele risk. In all analyses, P < .05 was considered statistically significant. RESULTS The 2 groups were similar in terms of demographic variables such as age and sex. There were no statistically significant differences between groups in genotype distribution (P ¼ .187). The genotype 5G/5G was 1.7 times higher in the control group than in the patient group, and the 4G homozygote genotype was 1.6 times higher in the patient group. The 4G/4G and 4G/5G genotype ratios were higher in the patient group compared with the control group; however, the difference was not statistically significant (Table 3). The distribution of genotypes was also studied according to alleles. The 4G allele (4G/4Ge4G/5G) was associated with an increased risk for Kienböck disease compared with those with 5G alleles (5G/ 5G), but this was not statistically significant (OR ¼ 2.259; 95% confidence interval, 0.917e5.562; P ¼ .076). The patient and control groups were also evaluated in terms of genotype distribution of 4G/4G plus 4G/5G and 5G/5G. The rate of 4G in the patient group was 76%, whereas this rate was 58% in the control group. There was no statistically significant association between these alleles and the diagnosis of Kienböck disease (P ¼ .074). J Hand Surg Am.
r
Vol. -, - 2019
1.e4
TABLE 3. Genotype
GENE POLYMORPHISM AND LUNATE NECROSIS
Genotype Distribution of Patient and Control Groups Patient
Control
Total
4G/4G
8 (18%)
5 (11%)
13 (14%)
4G/5G
26 (58%)
21 (47%)
47 (52%)
5G/5G
11 (24%)
Total
19 (42%)
45
45
.187
30 (33%) 90 (100%)
REFERENCES
between femoral head avascular necrosis and PAI-1 4G/5G polymorphism, 419 patients with femoral head osteonecrosis and 969 healthy subjects were evaluated. In the patient group, there was a significantly greater number of patients with 4G/4G (41%) plus 4G/5G (43%) genotypes than those with 5G/5G (15.7%) genotypes, and individuals carrying 4G alleles had a higher risk for femoral head osteonecrosis than did 5G homozygous individuals. However, allele-based 4G and 5G analysis showed no significant association. In the current study, 4G alleles (homozygous or heterozygous) had a higher risk for lunatum avascular necrosis compared with 5G homozygous individuals, but this association was not statistically significant (OR ¼ 2.259; 95% CI, 0.917e5.562; P ¼ .076). There was also no statistically significant difference in the 4G/4G plus 4G/ 5Ge5G/5G comparison analysis. There were some limitations to this study. The low overall incidence of Kienböck disease resulted in a small sample. In this study, the number of women was higher in the control group than in the patient group. Golay et al15 found no significant differences in age, sex, ethnicity, comorbidities, smoking status, excess alcohol use, or Lichtman stage between groups in which Kienböck disease was incidental or symptomatic. The results of this study showed no statistically significant relation between the PAI-1 4G/5G polymorphism and lunate avascular necrosis. The findings suggest that PAI-1 4G/4G polymorphism is not a genetic risk factor for Kienböck disease. To determine the distribution of these polymorphisms across the community, multicenter studies with different populations and larger groups of patients would be helpful.
1. Wagner JP, Chung KC. A historical report on Robert Kienböck (1871-1953) and Kienböck’s disease. J Hand Surg Am. 2005;30(6): 1117e1121. 2. Lamas C, Carrera A, Proubasta I, Llusà M, Majó J, Mir X. The anatomy and vascularity of the lunate: considerations applied to Kienböck’s disease. Chir Main. 2007;26(1):13e20. 3. Asano T, Takahashi KA, Fujioka M, et al. Relationship between postrenal transplant osteonecrosis of the femoral head and gene polymorphisms related to the coagulation and fibrinolytic systems in Japanese subjects. Transplantation. 2004;77(2):220e225. 4. Liang X-N, Xie L, Cheng J-W, et al. Association between PAI-1 4G/ 5G polymorphisms and osteonecrosis of femoral head: a meta-analysis. Thromb Res. 2013;132(2):158e163. 5. Ferrari P, Schroeder V, Anderson S, et al. Association of plasminogen activator inhibitor-1 genotype with avascular osteonecrosis in steroid-treated renal allograft recipients. Transplantation. 2002;74(8): 1147e1152. 6. Glueck CJ, Fontaine RN, Gruppo R, et al. The plasminogen activator inhibitor-1 gene, hypofibrinolysis, and osteonecrosis. Clin Orthop Relat Res. 1999;366:133e146. 7. Arnaiz J, Piedra T, Cerezal L, et al. Imaging of Kienböck disease. AJR Am J Roentgenol. 2014;203(1):131e139. 8. Parpugga TK, Tatarunas V, Skipskis V, Kupstyte N, ZaliaduonytePeksiene D, Lesauskaite V. The effect of PAI-1 4G/5G polymorphism and clinical factors on coronary artery occlusion in myocardial infarction. Dis Markers. 2015;2015:260101. 9. Mohammed Suhail Akhter MS, Biswas A, Ranjan R, et al. Plasminogen activator inhibitor-1 (PAI-1) gene 4G/5G promoter polymorphism is seen in higher frequency in the Indian patients with deep vein thrombosis. Clin Appl Thromb Hemost. 2010;16(2): 184e188. 10. Cale JM, Lawrence DA. Structure-function relationships of plasminogen activator inhibitor-1 and its potential as a therapeutic agent. Curr Drug Targets. 2007;8(9):971e981. 11. Naran NH, Chetty N, Crowther NJ. The influence of metabolic syndrome components on plasma PAI-1 concentrations is modified by the PAI-1 4G/5G genotype and ethnicity. Atherosclerosis. 2008;196(1):155e163. 12. Kim H-O, Cho C-H, Cho Y-J, Cho S-H, Yoon K-S, Kim K. Significant associations of PAI-1 genetic polymorphisms with osteonecrosis of the femoral head. BMC Musculoskelet Disord. 2011;12(1):160. 13. Dawson S, Hamsten A, Wiman B, Henney A, Humphries S. Genetic variation at the plasminogen activator inhibitor-1 locus is associated with altered levels of plasma plasminogen activator inhibitor-1 activity. Arterioscler Thromb. 1991;11(1):183e190. 14. Li Y, Liu F-X, Yuan C, Meng L. Association between plasminogen activator inhibitor gene polymorphisms and osteonecrosis of the femoral head susceptibility. Medicine. 2017;96(42):e7047. 15. Golay SK, Rust P, Ring D. The radiological prevalence of incidental Kienböck disease. Arch Bone Joint Surg. 2016;4(3): 220e223.
ACKNOWLEDGMENTS This study was funded by Pamukkale University Scientific Research Project Committee (grant ID: 2016TIPF008).
J Hand Surg Am.
P
r
Vol. -, - 2019
Relationship of Plasminogen Activator Inhibitor 1 4G/5G Gene Polymorphism and Nontraumatic Lunatum Avascular Necrosis Metin Gönen, MD,* Ali Çag das¸ Yörükog lu, MD,‡ A. Nadir Aydemir, MD,‡ Gizem Akıncı Gönen, MD,† Emre Tepeli, MD,§ A. Fahir Demirkan, MD‡
Purpose Plasminogen activator inhibitor 1 (PAI-1) is a critical enzyme that regulates coagulation and fibrinolytic systems. The aim of this study was to determine the role of PAI-1 4G/ 5G polymorphism in nontraumatic avascular necrosis of the lunate. Methods The study included 45 patients with Kienböck disease and 45 healthy individuals as a control group. In both groups, genomic DNA was extracted from peripheral blood samples to determine the distributions of PAI-1 4G/5G polymorphism using allele-specific polymerase chain reaction and sequencing. Results No statistically significant difference was determined in the distribution of the gene polymorphism between the patient and control groups. We found the 5G/5G genotype to be 1.7 times higher in the control group compared with the patient group. A 1.6-fold increase in the 4G homozygote genotype was identified in the patient group. The patient and control groups were also evaluated for 4G/4G plus 4G/5G and 5G/5G in terms of genotype distribution. No statistically significant difference was found. Conclusions The findings suggest that the PAI-1 4G/4G polymorphism is not a genetic risk for Kienböck disease. Clinical relevance This study aimed to reveal the genetic etiology of Kienböck disease. (J Hand Surg Am. 2019;-(-):1.e1-e4. Copyright Ó 2019 by the American Society for Surgery of the Hand. All rights reserved.) Key words Avascular necrosis, gene polymorphism, Kienböck disease, lunate, PAI-1.
From the *Department of Orthopedics and Traumatology, Develi Hatice Muammer Kocaturk State Hospital; and †Department of Medical Genetics, Kayseri Education and Research Hospital, Kayseri; the ‡Faculty of Medicine, Department of Orthopedics and Traumatology, Pamukkale University, Denizli; and the §Next Genetic Center, _Istanbul, Turkey. Received for publication August 6, 2018; accepted in revised form September 25, 2019. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Ahmet Fahir Demirkan, MD, Faculty of Medicine, Department of Orthopedics and Traumatology, Pamukkale University, 20070 Denizli, Turkey; e-mail: [email protected]. 0363-5023/19/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2019.09.012
A
lunate (Kienböck disease), as defined by Robert Kienböck in 1910, is a condition characterized by subchondral ischemic damage and collapse of the lunate, resulting in degeneration of the wrist.1 The etiology and pathogenesis of the disease are still unclear, although it is generally accepted that the basis of the condition is at least temporary loss of interosseous blood flow.2 Plasminogen activator inhibitor 1 (PAI-1) is the enzyme that inhibits plasminogen, which is the precursor of plasmin, the main enzyme VASCULAR NECROSIS OF THE
Ó 2019 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1.e1
1.e2
GENE POLYMORPHISM AND LUNATE NECROSIS
involved in fibrinolysis.3 When there is a polymorphism at the PAI-1 gene, increased plasma concentrations of PAI-1 could increase the frequency of intravenous clotting.4,5 The PAI-1 gene has 3 genotypes: 4G/4G, 4G/5G, and 5G/5G. The genotype 4G allele appears to be associated with increased plasma PAI-1 levels, potentially increasing the chances of excessive intravascular clotting.6 Moreover, PAI-1 4G/5G gene polymorphism has been shown to be a risk factor for avascular necrosis of the femoral head. Individuals carrying 4G alleles have a higher risk for femoral head osteonecrosis compared with those who are 5G homozygous. Both 4G homozygotes and 4G/5G heterozygotes are associated with an increased risk for avascular necrosis of the femoral head compared with individuals who are 5G homozygous.4 To the best of our knowledge, no similar studies in literature have been conducted to evaluate the association between PAI-1 4G/5G polymorphism in association with avascular necrosis of the lunate. The aim of this study was to analyze PAI-1 4G/5G gene polymorphism in patients with nontraumatic avascular necrosis of the lunate.
TABLE 1.
Demographic Characteristics
Patient
Control
P
Mean SD
31.64 7.9
33.35 7.4
.293
Median (range)
31 (18e49)
34 (19e49)
Male (%)
27 (60)
22 (49)
Female (%)
18 (40)
23 (51)
Age
Gender .290
injuries, were excluded from the study. Control group subjects were similar in age and had no age-related wrist problems or evidence of Kienböck disease on plain wrist radiographs. We created plain radiographs of all patients; CT, magnetic resonance examination, or both were used to produce a diagnosis for earlystage patients. X-rays of the control group were normal, and neither CT nor MRI was performed in this group. The patient group was composed of 45 patients aged 18 to 49 years (27 men and 18 women); the control group was composed of 45 healthy subjects (22 men and 23 women) aged 19 to 49 years, with no wrist problems (Table 1). Peripheral blood samples of 2 mL were taken from both the patient and control groups. The blood samples were separately coded for the patient and control groups and stored at e20 C until DNA isolation. The concentrations and purity values of DNA samples isolated from peripheral blood from the patient and control groups were determined with the spectrophotometric method. The gene region containing the PAI-1 gene 4G/5G base pair (bp) was amplified by polymerase chain reaction (PCR) using the primers shown in Table 2. According to the PCR results, samples that gave 139-bp bands only with 4G primer were homozygous 4G genotypes, samples that gave 139-bp bands only with 5G primer were homozygous 5G genotypes, and samples that gave 139bp bands with both 5G and 4G primer were identified as heterozygous 4G5G genotypes (Fig. 1). Genotypes identified by allele-specific PCR in the 45 patients and 45 control subjects were confirmed by sequence analysis8 and PCR reaction.9
MATERIALS AND METHODS This study included patients aged 18 to 65 years who were given the diagnosis of avascular necrosis of the lunate in the hand surgery unit from January 2012 to June 2016, and a control group with a similar age distribution. The study protocol was approved by the ethics committee; written informed consent was obtained from all participants in the study. All patients had clinical symptoms of Kienböck disease, such as wrist pain, tenderness on palpation, and decreased motion or stiffness of the wrist. Plain radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) were used for diagnosis. In stage 1, MRI showed areas of decreased signal intensity on T1-weighted images and areas of decreased signal intensity on T2-weighted images. Stage 2 Kienböck disease is characterized by sclerosis evidenced by increased bone density of the lunate compared with the other carpal bones on radiographs and CT scans. Collapse of the entire lunate from distal to proximal in the coronal plane and elongation in the sagittal plane were used to diagnose stage 3 Kienböck disease in patients. Lunate collapse with associated radiocarpal or midcarpal degenerative arthritis was used as the diagnostic criterion of stage 4 patients.7 Patients with a history of wrist trauma, such as perilunate fracture-dislocations, carpal fractures, and ligament J Hand Surg Am.
Demographic Characteristics of Groups
Statistical analysis For 90 volunteers; we reached 92% power with 95% confidence for an odds ratio (OR) of 2.26. When parametric test assumptions were met, independent samples t test was used to compare independent group differences, and the Mann-Whitney U test to r
Vol. -, - 2019
1.e3
GENE POLYMORPHISM AND LUNATE NECROSIS
TABLE 2.
Primer Pairs Used in Propagation of Gene Region of Interest Primer
Gene Sequence
Primer used to insert 5G allele
GTC TGG ACA CGT GGG GG
Primer used to delete 4G allele
GTC TGG ACA CGT GGG GA
Upstream primer
AAG CTT TTA CCA TGG TAA CCC CTG GT
Downstream primer
TGC AGC CAG CCA CGT GAT TGT CTA G
DISCUSSION To the best of the author's knowledge, the PAI-1 4G/ 5G polymorphism has not been previously investigated in Kienböck disease. Many studies in the literature suggested that Kienböck disease is multifactorial and thought to be caused by recurrent microtrauma, perilunate dislocations, ulnar-negative variance, coagulation disorders, decreased arterial flow, and increased venous pressure, among other factors. Disruption of bone circulation owing to intravascular coagulation is another factor that has been suggested in the pathogenesis of avascular necrosis. The PAI-1 protein inhibits tissue-type plasminogen activator action by binding to it, reducing fibrin degradation.10 This protein is the human genome 675th bp, synthesized from the PAI-1 gene region in its locus. It affects the fibrinolytic system at different rates owing to 4G/5G polymorphism in this region.11 Increased plasma concentrations of PAI-1 are associated with deep venous thrombosis, coronary artery diseases, asthma, recurrent pregnancy loss, preeclampsia, and osteonecrosis of bones such as the femoral head.4,12,13 In a study by Glueck et al,6 59 patients with femoral head osteonecrosis were found to have a significantly higher PAI-1 4G homozygous genotype compared with a healthy control group. Similarly, Ferrari et al5 conducted a study of 26 renal transplant patients treated with corticosteroids, who developed osteonecrosis of the femoral head, and 326 healthy subjects. The control group had fewer 4G alleles compared with the patient group. There are also reports in the literature that there is no significant association between osteonecrosis and PAI-1 polymorphism.14 In the current study, no statistically significant relation was found between genotype distribution and lunate osteonecrosis, although in the control group, the genotype 5G/5G was 1.7 times higher than in the patient group, and the 4G homozygous genotype was 1.6 times higher in the patient group. Because this difference was not statistically significant, PAI-1 4G/4G polymorphism was not shown to be associated with Kienböck disease. In a meta-analysis composed of studies of the relation
FIGURE 1: Two-percent agarose gel images of PAI-1 4G/5G allele-specific PCR products.
compare independent group differences when parametric test assumptions were not met. We used chisquare analysis to compare categorical variables and applied univariate logistic regression analysis to examine the allele risk. In all analyses, P < .05 was considered statistically significant. RESULTS The 2 groups were similar in terms of demographic variables such as age and sex. There were no statistically significant differences between groups in genotype distribution (P ¼ .187). The genotype 5G/5G was 1.7 times higher in the control group than in the patient group, and the 4G homozygote genotype was 1.6 times higher in the patient group. The 4G/4G and 4G/5G genotype ratios were higher in the patient group compared with the control group; however, the difference was not statistically significant (Table 3). The distribution of genotypes was also studied according to alleles. The 4G allele (4G/4Ge4G/5G) was associated with an increased risk for Kienböck disease compared with those with 5G alleles (5G/ 5G), but this was not statistically significant (OR ¼ 2.259; 95% confidence interval, 0.917e5.562; P ¼ .076). The patient and control groups were also evaluated in terms of genotype distribution of 4G/4G plus 4G/5G and 5G/5G. The rate of 4G in the patient group was 76%, whereas this rate was 58% in the control group. There was no statistically significant association between these alleles and the diagnosis of Kienböck disease (P ¼ .074). J Hand Surg Am.
r
Vol. -, - 2019
1.e4
TABLE 3. Genotype
GENE POLYMORPHISM AND LUNATE NECROSIS
Genotype Distribution of Patient and Control Groups Patient
Control
Total
4G/4G
8 (18%)
5 (11%)
13 (14%)
4G/5G
26 (58%)
21 (47%)
47 (52%)
5G/5G
11 (24%)
Total
19 (42%)
45
45
.187
30 (33%) 90 (100%)
REFERENCES
between femoral head avascular necrosis and PAI-1 4G/5G polymorphism, 419 patients with femoral head osteonecrosis and 969 healthy subjects were evaluated. In the patient group, there was a significantly greater number of patients with 4G/4G (41%) plus 4G/5G (43%) genotypes than those with 5G/5G (15.7%) genotypes, and individuals carrying 4G alleles had a higher risk for femoral head osteonecrosis than did 5G homozygous individuals. However, allele-based 4G and 5G analysis showed no significant association. In the current study, 4G alleles (homozygous or heterozygous) had a higher risk for lunatum avascular necrosis compared with 5G homozygous individuals, but this association was not statistically significant (OR ¼ 2.259; 95% CI, 0.917e5.562; P ¼ .076). There was also no statistically significant difference in the 4G/4G plus 4G/ 5Ge5G/5G comparison analysis. There were some limitations to this study. The low overall incidence of Kienböck disease resulted in a small sample. In this study, the number of women was higher in the control group than in the patient group. Golay et al15 found no significant differences in age, sex, ethnicity, comorbidities, smoking status, excess alcohol use, or Lichtman stage between groups in which Kienböck disease was incidental or symptomatic. The results of this study showed no statistically significant relation between the PAI-1 4G/5G polymorphism and lunate avascular necrosis. The findings suggest that PAI-1 4G/4G polymorphism is not a genetic risk factor for Kienböck disease. To determine the distribution of these polymorphisms across the community, multicenter studies with different populations and larger groups of patients would be helpful.
1. Wagner JP, Chung KC. A historical report on Robert Kienböck (1871-1953) and Kienböck’s disease. J Hand Surg Am. 2005;30(6): 1117e1121. 2. Lamas C, Carrera A, Proubasta I, Llusà M, Majó J, Mir X. The anatomy and vascularity of the lunate: considerations applied to Kienböck’s disease. Chir Main. 2007;26(1):13e20. 3. Asano T, Takahashi KA, Fujioka M, et al. Relationship between postrenal transplant osteonecrosis of the femoral head and gene polymorphisms related to the coagulation and fibrinolytic systems in Japanese subjects. Transplantation. 2004;77(2):220e225. 4. Liang X-N, Xie L, Cheng J-W, et al. Association between PAI-1 4G/ 5G polymorphisms and osteonecrosis of femoral head: a meta-analysis. Thromb Res. 2013;132(2):158e163. 5. Ferrari P, Schroeder V, Anderson S, et al. Association of plasminogen activator inhibitor-1 genotype with avascular osteonecrosis in steroid-treated renal allograft recipients. Transplantation. 2002;74(8): 1147e1152. 6. Glueck CJ, Fontaine RN, Gruppo R, et al. The plasminogen activator inhibitor-1 gene, hypofibrinolysis, and osteonecrosis. Clin Orthop Relat Res. 1999;366:133e146. 7. Arnaiz J, Piedra T, Cerezal L, et al. Imaging of Kienböck disease. AJR Am J Roentgenol. 2014;203(1):131e139. 8. Parpugga TK, Tatarunas V, Skipskis V, Kupstyte N, ZaliaduonytePeksiene D, Lesauskaite V. The effect of PAI-1 4G/5G polymorphism and clinical factors on coronary artery occlusion in myocardial infarction. Dis Markers. 2015;2015:260101. 9. Mohammed Suhail Akhter MS, Biswas A, Ranjan R, et al. Plasminogen activator inhibitor-1 (PAI-1) gene 4G/5G promoter polymorphism is seen in higher frequency in the Indian patients with deep vein thrombosis. Clin Appl Thromb Hemost. 2010;16(2): 184e188. 10. Cale JM, Lawrence DA. Structure-function relationships of plasminogen activator inhibitor-1 and its potential as a therapeutic agent. Curr Drug Targets. 2007;8(9):971e981. 11. Naran NH, Chetty N, Crowther NJ. The influence of metabolic syndrome components on plasma PAI-1 concentrations is modified by the PAI-1 4G/5G genotype and ethnicity. Atherosclerosis. 2008;196(1):155e163. 12. Kim H-O, Cho C-H, Cho Y-J, Cho S-H, Yoon K-S, Kim K. Significant associations of PAI-1 genetic polymorphisms with osteonecrosis of the femoral head. BMC Musculoskelet Disord. 2011;12(1):160. 13. Dawson S, Hamsten A, Wiman B, Henney A, Humphries S. Genetic variation at the plasminogen activator inhibitor-1 locus is associated with altered levels of plasma plasminogen activator inhibitor-1 activity. Arterioscler Thromb. 1991;11(1):183e190. 14. Li Y, Liu F-X, Yuan C, Meng L. Association between plasminogen activator inhibitor gene polymorphisms and osteonecrosis of the femoral head susceptibility. Medicine. 2017;96(42):e7047. 15. Golay SK, Rust P, Ring D. The radiological prevalence of incidental Kienböck disease. Arch Bone Joint Surg. 2016;4(3): 220e223.
ACKNOWLEDGMENTS This study was funded by Pamukkale University Scientific Research Project Committee (grant ID: 2016TIPF008).
J Hand Surg Am.
P
r
Vol. -, - 2019