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ORIGINAL RESEARCH

Dual-gene therapy of SIRT3 and SIRT4 enhances bone repair in diabetes through mitochondrial network remodeling

Zhaojin Li1,2# ,  Jiarui Liu1# ,  Huihui Zhang3# ,  Zhanchao Wang4 ,  Ziyu Zhang2 ,  Zi Yan5 ,  Wanying Chen2 ,  Wenqiang Zhou6,7 ,  Chun Pan1 ,  Chengxu Geng2 ,  Hanxiao Sun2 ,  Jian Hou8* ,  Xing Hua9* ,  Huajun Wang6* ,  Shiyu Li1,2*
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1 Department of Immunology, School of Medicine, Jinan University, Guangzhou, Guangdong, China
2 Institute of Genomic Medicine, College of Pharmacy, Jinan University, Guangzhou, Guangdong, China
3 Department of Burns, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
4 Department of Orthopaedics, Chongming Hospital Affiliated to Shanghai University of Medicine and Health Sciences, Shanghai, China
5 Department of Urology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
6 Department of Sports Medicine, The First Affiliated Hospital, Guangdong Provincial Key Laboratory of Speed Capability, The Guangzhou Key Laboratory of Precision Orthopedics and Regenerative Medicine, School of Medicine, Jinan University, Guangzhou, Guangdong, China
7 Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
8 Department of Cardiology, The Affiliated Panyu Central Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
9 Department of Pathology, First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
BMT, 246 https://doi.org/10.12336/bmt.25.00246
Submitted: 4 December 2025 | Revised: 30 December 2025 | Accepted: 7 January 2026 | Published: 16 June 2026
© 2026 by the Author(s). Licensee Biomaterials Translational, USA. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 (CC BY-NC-SA 4.0) (https://creativecommons.org/licenses/by-nc-sa/4.0/deed.en)
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Abstract

Difficult fracture healing in diabetic patients poses a significant clinical challenge, with chronic inflammation driven by mitochondrial dysfunction-induced classically activated macrophages (pro-inflammatory)/alternatively activated macrophages (anti-inflammatory) (M1/M2) polarization imbalance in macrophages considered a core cause. At present, there is a clinical need for effective strategies to regulate M2 polarization and for simple, efficient mitochondrial liquid biopsy approaches. In this study, we discovered that dual-gene expression of Sirtuin 3 (SIRT3) and Sirtuin 4 (SIRT4) (pSIRT3/4) effectively restores mitochondrial network homeostasis. Following pSIRT3/4 treatment, M2 polarization was significantly enhanced, accelerating fracture healing in diabetic patients. This finding suggests that mitochondrial network homeostasis plays a crucial role in regulating M2 polarization. By screening mitochondrial network marker proteins, we developed a simple and efficient system to assess mitochondrial network homeostasis. In addition, we validated this new evaluation system across various models of mitochondrial dysfunction. The findings demonstrate that pSIRT3/4 successfully reconstructed the mitochondrial network by activating the peroxisome proliferator-activated receptor gamma coactivator-1α/mitochondrial transcription factor A signaling axis, thereby inducing macrophages to polarize from pro-inflammatory M1 to reparative M2. This transformation significantly improved the inflammatory microenvironment and bolstered osteoblast differentiation capacity. Animal studies confirmed that this treatment effectively accelerated fracture healing. We report a novel mechanism by which SIRT3/4 facilitates bone regeneration by regulating the “mitochondrial network homeostasis–metabolic reprogramming–stable M2 polarization” axis. This study offers a new strategy for early intervention in diabetic fractures and presents a simple, efficient tool for clinical evaluation related to mitochondrial network homeostasis.

Keywords
Mitochondrial network
Mitochondrial metabolism
Sirtuin
Polarization
Diabetes fracture
Funding
This work was supported by the National Natural Science Foundation of China (82300018), the Guangdong Basic and Applied Basic Research Foundation (2025A1515012604), the Shenzhen Medical Research Fund (A2502023), the Basic Research Project of Guangzhou High-Level University (2023A03J0606), the Funding by Science and Technology Projects in Guangzhou (2025A03J4334), the Talents’ Plan Foundation of Guangdong Second Provincial General Hospital (2025B008), and the Youth S&T Talent Support Programme of Guangdong Provincial Association for Science and Technology (to SL).
Conflict of interest
The authors declare no conflict of interest.
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