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Abstract
STUDY DESIGN Review of literature. OBJECTIVES This review of literature investigates the application of mesenchymal stem cells (MSCs) in spinal fusion, highlights potential uses in the development of bone grafts, and discusses limitations based on both preclinical and clinical models. METHODS A review of literature was conducted looking at current studies using stem cells for augmentation of spinal fusion in both animal and human models. RESULTS Eleven preclinical studies were found that used various animal models. Average fusion rates across studies were 59.8% for autograft and 73.7% for stem cell-based grafts. Outcomes included manual palpation and stressing of the fusion, radiography, micro-computed tomography (μCT), and histological analysis. Fifteen clinical studies, 7 prospective and 8 retrospective, were found. Fusion rates ranged from 60% to 100%, averaging 87.1% in experimental groups and 87.2% in autograft control groups. CONCLUSIONS It appears that there is minimal clinical difference between commercially available stem cells and bone marrow aspirates indicating that MSCs may be a good choice in a patient with poor marrow quality. Overcoming morbidity and limitations of autograft for spinal fusion, remains a significant problem for spinal surgeons and further studies are needed to determine the efficacy of stem cells in augmenting spinal fusion.
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Affiliation(s)
- Michael A. Robbins
- University of California Davis Medical Center, Sacramento, CA, USA,Michael A. Robbins, Department of Orthopaedic Surgery, Mail Code MP240, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239, USA.
| | | | - Adam M. Wegner
- University of California Davis Medical Center, Sacramento, CA, USA
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Le Pape S, Gauthe R, Du Pouget L, Gille O, Vital JM, Ould-Slimane M. Endopelvic Approach for Iliac Crest Bone Harvesting. World Neurosurg 2017; 106:764-767. [PMID: 28739516 DOI: 10.1016/j.wneu.2017.07.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 07/14/2017] [Accepted: 07/15/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND The anterior approach to lumbar spine surgery has grown in popularity in the past few years; spinal fusion of the last 2 lumbar levels is often required. Although alternatives to bone grafting are available, including recombinant human bone morphogenetic protein 2 or bone substitutes, only cancellous autologous bone has all the required factors for bone growth. To avoid the use of bone substitutes, remote iliac crest bone harvesting remains the gold standard. However, this technique may lead to some unfavorable outcomes. CASE DESCRIPTION The patient was a 46-year-old man with severe back and left leg pain. Magnetic resonance imaging showed an inflammatory discopathy of L5-S1 associated with a left posterior lateral herniated disc. Conservative treatment failed, and surgical treatment of the lumbar disk disease and the herniated disc was scheduled. A novel iliac crest bone harvesting method was performed during the retroperitoneal approach to the anterior lumbar interbody fusion. The patient's postoperative course was uneventful. There were no adverse outcomes related to the bone donor site. CONCLUSIONS This is the first in vivo report of endopelvic iliac crest bone harvesting. This technique allows bone graft harvesting to be performed with the same retroperitoneal approach used for anterior lumbar interbody fusion. It avoids many common complications associated with the remote approach to the iliac crest.
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Affiliation(s)
- Sebastien Le Pape
- Regional Spine Institute, University Hospital of Rouen, Rouen, France.
| | - Remi Gauthe
- Regional Spine Institute, University Hospital of Rouen, Rouen, France
| | - Laure Du Pouget
- Department of Urology, University Hospital of Rouen, Rouen, France
| | - Olivier Gille
- Spine Unit 1, University Hospital Pellegrin, Bordeaux, France
| | - Jean-Marc Vital
- Spine Unit 1, University Hospital Pellegrin, Bordeaux, France
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Interobserver and Intraobserver Reliability in the Radiologic Assessment of Lumbar Interbody Fusion. Clin Spine Surg 2017; 30:E853-E856. [PMID: 27548041 DOI: 10.1097/bsd.0000000000000423] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective cohort study comparing intraobserver and interobserver reliability of 3 different radiologic fusion classifications following uninstrumented single-level anterior lumbar interbody fusion. OBJECTIVE OF THE STUDY The objective of the study was to compare the intraobserver and interobserver reliability of 3 different radiologic spinal fusion scoring systems. SUMMARY OF BACKGROUND DATA Knowledge regarding radiologic spinal fusion is crucial when studying patients that were treated with lumbar interbody fusion. The scoring system should be reliable and reproducible. Various radiologic classification systems coexist, but the reliability of these systems has thus far not been compared in a single consecutive group of patients. The aim of the present study was the identification of the most valid scoring system in the assessment of interbody fusion. METHODS We studied a retrospective consecutive cohort of 50 patients who underwent an anterior lumbar interbody fusion procedure by a single surgeon using a stand-alone cage performed between 1993 and 2002. Plain anterior-posterior, lateral radiographs, and flexion-extension radiographs were made during follow-up visits and were used for analysis. The interbody fusion was scored on these radiographic images using the 3 classification systems (Brantigan, Burkus, and the Radiographic Score) by 2 experienced musculoskeletal radiologists and 2 senior orthopedic spinal surgeons all of whom were blinded to clinical data and outcome. RESULTS Of the 3 classifications included in the current study, the Burkus classification had a moderate interobserver agreement and a substantial to perfect intraobserver agreement. The other classifications (Bratingan and the Radiographic Score) showed only fair interobserver agreement and moderate to substantial agreement among all observers. No significant differences in reliability between orthopedic surgeons and radiologists were found for all 3 classifications. CONCLUSIONS The Burkus classification system was classified as most reliable in this, but showed only moderate interobserver agreement. Therefore, the need for a more reliable classification system for the radiographic assessment of lumbar interbody fusion still exists to date.
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Use of Nanocrystalline Hydroxyapatite With Autologous BMA and Local Bone in the Lumbar Spine: A Retrospective CT Analysis of Posterolateral Fusion Results. Clin Spine Surg 2017; 30:E192-E197. [PMID: 28323699 PMCID: PMC5367494 DOI: 10.1097/bsd.0000000000000091] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
STUDY DESIGN A retrospective, multicenter, medical record review and independent analysis of computed tomographic scans was performed in 46 patients to determine radiographic arthrodesis rates after 1-segment, 2-segment, or 3-segment instrumented posterolateral fusions (PLF) using autograft, bone marrow aspirate (BMA), and a nanocrystalline hydroxyapatite bone void filler (nHA). OBJECTIVE To determine the radiographic arthrodesis rates after instrumented lumbar PLF using local autograft, BMA, and nHA. SUMMARY OF BACKGROUND DATA The use of iliac crest autograft in posterolateral spine fusion carries real and significant risks. Many forms of nanocrystalline hydroxyapatite have been studied in various preclinical models, but no human studies have reviewed its efficacy as a bone graft supplement in PLF. METHODS Posterolateral arthrodesis progression was documented approximately 12 months postoperatively using a computed tomographic scan and evaluated by an independent radiologist for the presence of bridging bone. One-year postoperative clinical outcomes were assessed using the PROLO score. RESULTS Radiographically, 91% patients treated exhibited bilateral or unilateral posterolateral bridging bone. Ninety-four percent of the segments treated exhibited bilateral or unilateral posterolateral bridging bone, whereas 6% segments exhibited no posterolateral bridging bone on either side. A total of 93% individual sites treated exhibited posterolateral bridging bone. In 1-segment, 2-segment, and 3-segment arthrodesis, 88%, 93%, and 100%, respectively, of individual sites exhibited radiographic bridging bone. One-year postoperative PROLO scores for 77% patients were excellent or good. There were no complications related to the posterolateral graft mass and no symptomatic nonunions. CONCLUSIONS The arthrodesis rates after instrumented lumbar fusion using local autograft mixed with BMA and the nHA is equivalent to the rates reported for iliac crest autograft in these indications, including stringent indications, such as 3-segment procedures. By approximately 12 months postoperatively, there was no significant difference in the rates of bridging bone between the 1-segment, 2-segment, and 3-segment procedures.
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Feasibility of Percutaneous Posterolateral Spinal Fusion With Recombinant Bone Morphogenetic Protein-2 (rhBMP-2): A Comparison With Standard Methods Using an Animal Model Study. Clin Spine Surg 2017; 30:E138-E147. [PMID: 28207623 DOI: 10.1097/bsd.0b013e3182aa6860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND CONTEXT The clinical application of recombinant bone morphogenetic protein in spinal surgery has been shown to be safe and effective. However, its use in minimally invasive spine surgery has been limited to anterior interbody fusion procedures. To date, no study has evaluated the feasibility of percutaneous posterolateral fusion in the spine utilizing recombinant bone morphogenetic protein-2 (rhBMP-2). PURPOSE To evaluate the feasibility of percutaneous posterolateral fusion in the spine utilizing rhBMP-2. STUDY DESIGN Animal study. METHODS This is an animal research model involving 32 New Zealand white rabbits stratified into 4 study groups: control, autogenous iliac crest bone graft (ICBG), demineralized bone matrix (DBM), and rhBMP-2 groups, with 8 study subjects per group. The rhBMP-2 group was subdivided into the open technique (right side) and the percutaneous technique groups (left side). Fusion was graded at 6 weeks and 3 months after plain radiography, computed tomography, and clinical assessment with the following grading system: grade A, no bone formation; grade B, non-bridging bone formation; grade C, fusion; and grade D, fusion with ectopic bone formation. RESULTS No fusion was noted in the placebo and the DBM groups. However, in the DBM group, bone formation occurred in 37.5% of the subjects. The rhBMP-2 group had a higher fusion rate compared with the ICBG group at 6 weeks and 3 months. The fusion rate for the ICBG, the rhBMP-2 (open), and the rhBMP-2 (percutaneous) groups were 37.5%, 87.5%, and 50.0% at 6 weeks and 50.0%, 100.0%, and 62.5% at 3 months, respectively. Ectopic bone formation occurred in 12.5% of the cases in the rhBMP-2 (percutaneous) group and in 25.0% of the cases in the rhBMP-2 (open) group. CONCLUSIONS Usage of rhBMP-2 is feasible for percutaneous posterolateral fusion of the lumbar spine in this animal model. However, a more precise delivery system might improve the fusion rate when the percutaneous technique is used. A significant rate of ectopic bone formation occurred when rhBMP-2 was used.
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Toth JM, Foley KT, Wang M, Seim HB, Simon Turner A. Is lumbar facet fusion biomechanically equivalent to lumbar posterolateral onlay fusion? J Neurosurg Spine 2017; 26:586-593. [PMID: 28156207 DOI: 10.3171/2016.10.spine16649] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study was designed with the following research objectives: 1) to determine the efficacy of facet fusion with recombinant human bone morphogenetic protein-2 (rhBMP-2) on an absorbable collagen sponge (ACS) in an ovine lumbar facet fusion model; 2) to radiographically and histologically compare the efficacy of lumbar facet fusion with rhBMP-2/ACS to facet fusion with an iliac crest bone graft (ICBG); and 3) to biomechanically compare lumbar facet fusion with rhBMP-2/ACS to lumbar posterolateral fusion (PLF) with ICBG. METHODS The efficacies of the 3 treatments to induce fusion were evaluated in an instrumented ovine lumbar fusion model. Eight sheep had 10 cm3/side ICBG placed as an onlay graft for PLF at L2-3. At the adjacent L3-4 level, 0.5 cm3/side ICBG was placed for facet fusion. Finally, 0.5 cm3/side rhBMP-2/ACS (0.43 mg/ml) was placed for facet fusion at L4-5. CT scans were obtained at 2, 4, and 6 months postoperatively with 2 reviewers conducting an evaluation of the 6-month results for all treated spinal levels. All 8 sheep were killed at 6 months, and all posterolateral instrumentation was removed at this time. The spines were then sectioned through L3-4 to allow for nondestructive unconstrained biomechanical testing of the L2-3 and L4-5 segments. All treated spinal levels were analyzed using undecalcified histology with corresponding microradiography. Statistical comparisons were made between the treatment groups. RESULTS The PLF with ICBG (ICBG PLF group) and the rhBMP-2 facet fusion (rhBMP-2 Facet group) treatment groups demonstrated similar levels of stiffness, with the rhBMP-2 Facet group having on average slightly higher stiffness in all 6 loading directions. All 8 levels in the autograft facet fusion treatment group demonstrated CT radiographic and histological fusion. All 8 levels in the rhBMP-2 Facet group showed bilateral CT radiographic and histological fusion. Six of 16 rhBMP-2/ACS-treated facet defects demonstrated small intraosseous hematomas or seromas. Four of the 8 levels (50%) in the ICBG PLF treatment group demonstrated bilateral histological fusion. Three of 8 levels in the ICBG PLF treatment group showed unilateral fusion. One of the 8 levels in the ICBG PLF treatment group demonstrated bilateral histological nonfusion. CONCLUSIONS Both rhBMP-2/ACS and autograft demonstrated 100% efficacy when used for facet fusion in the instrumented ovine model. However, the ICBG PLF treatment group only demonstrated a 50% bilateral fusion rate. Biomechanically, the ICBG PLF and rhBMP-2 Facet groups demonstrated similar stiffness in all 6 loading directions, with the rhBMP-2 Facet group having on average slightly higher stiffness in all directions.
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Affiliation(s)
- Jeffrey M Toth
- Department of Orthopaedic Surgery, The Medical College of Wisconsin Inc., Milwaukee, Wisconsin
| | - Kevin T Foley
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mei Wang
- Department of Orthopaedic Surgery, The Medical College of Wisconsin Inc., Milwaukee, Wisconsin
| | - Howard B Seim
- Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado
| | - A Simon Turner
- Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado
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AKT Pathway Affects Bone Regeneration in Nonunion Treated with Umbilical Cord-Derived Mesenchymal Stem Cells. Cell Biochem Biophys 2016; 71:1543-51. [PMID: 25413962 PMCID: PMC4449366 DOI: 10.1007/s12013-014-0378-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
Abstract
We have previously grafted human umbilical cord-derived mesenchymal stem cells (hUC-MSCs) with blood plasma to treat rat tibia nonunion. To further examine the biological characteristics of this process, we applied an established hUC-MSCs-treated rat nonunion model with the addition of an inhibitor of AKT. SD rats (80) were randomly divided into four groups: a fracture group (positive control); a nonunion group (negative control); a hUC-MSCs grafting with blood plasma group; and a hUC-MSCs grafting with blood plasma & AKT blocker group. The animals were sacrificed under deep anesthesia at 4 and 8 weeks post fracture for analysis. The fracture line became less defined at 4 weeks and disappeared at 8 weeks postoperatively in both the hUC-MSCs grafting with blood plasma and grafting with blood plasma & the AKT blocker, which is similar to the fracture group. Histological immunofluorescence studies showed that the numbers of hUC-MSCs in the calluses were significantly higher in the hUC-MSCs grafting with blood plasma than those in group with the AKT blocker. More bone morphogenetic protein 2 and bone sialoprotein expression and less osteoprotegerin and bone gla protein expression were observed in the AKT blocker group compared to the hUC-MSCs grafting with blood plasma. AKT gene expression in the AKT blocker group was decreased 50% compared to the hUC-MSCs with plasma group and decreased 70% compared to the fracture group, while the elastic modulus was decreased. In summary, our work demonstrates that AKT may play a role in modulating osteogenesis induced by hUC-MSCs.
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DeCarlo AA, Whitelock JM. The Role of Heparan Sulfate and Perlecan in Bone-regenerative Procedures. J Dent Res 2016; 85:122-32. [PMID: 16434729 DOI: 10.1177/154405910608500203] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Tissue engineering, grafting procedures, regeneration, and tissue remodeling are developing therapeutic modalities with great potential medical value, but these regenerative modalities are not as effective or predictable as clinicians and patients would like. Greater understanding of growth factors, cytokines, extracellular matrix molecules, and their roles in cell-mediated healing processes have made these regenerative therapies more clinically viable and will continue advancing the fields of tissue engineering and grafting. However, millions of oral and non-oral bone-grafting procedures are performed annually, and only a small percentage yield the most desirable results. Here we review the heparan-sulfate-decorated extracellular biomolecule named perlecan and the research relating to its potential as an adjunct in bone-regenerative procedures. The review includes an overview of bone graft substitutes and biological adjuncts to bone-regenerative procedures in medicine as they apply to periodontal disease, alveolar ridge augmentation, and barrier membrane therapy. Perlecan is discussed as a potential biological adjunct in terms of growth factor sequestration and delivery, and promoting cell adhesion, proliferation, differentiation, and angiogenesis. Further, we propose delivery and application schemes for perlecan and/or its domains in bone-regenerative procedures, with particular emphasis on its heparan-sulfate-decorated domain I. The perlecan molecule, with its heparan sulfate glycosylation, may provide a multi-faceted approach for the delivery of a more comprehensive stimulus than other single potential adjuncts currently available for bone-regenerative procedures.
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Affiliation(s)
- A A DeCarlo
- Agenta Biotechnologies, Inc., OADI Technology Center, Birmingham, AL 35211, USA.
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Duan R, Barbieri D, Luo X, Weng J, de Bruijn JD, Yuan H. Submicron-surface structured tricalcium phosphate ceramic enhances the bone regeneration in canine spine environment. J Orthop Res 2016; 34:1865-1873. [PMID: 26896645 DOI: 10.1002/jor.23201] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 02/15/2016] [Indexed: 02/04/2023]
Abstract
Calcium phosphate ceramics with submicron-scaled surface structure can trigger bone formation in non-osseous sites and are expected to enhance bone formation in spine environment. In this study, two tricalcium phosphate ceramics having either a submicron-scaled surface structure (TCP-S) or a micron-scaled one (TCP-B) were prepared and characterized regarding their physicochemical properties. Granules (size 1-2 mm) of both materials were implanted on either left or right side of spinous process, between the two lumbar vertebrae (L3-L4), and in paraspinal muscle of eight beagles. After 12 weeks of implantation, ectopic bone was observed in muscle in TCP-S explants (7.7 ± 3.7%), confirming their ability to inductively form bone in non-osseous sites. In contrast, TCP-B implants did not lead to bone formation in muscle. Abundant bone (34.1 ± 6.6%) was formed within TCP-S implants beside the two spinous processes, while limited bone (5.1 ± 4.5%) was seen in TCP-B. Furthermore, the material resorption of TCP-S was more pronounced than that of TCP-B in both the muscle and spine environments. The results herein indicate that the submicron-scaled surface structured tricalcium phosphate ceramic could enhance bone regeneration as compared to the micron-scaled one in spine environment. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1865-1873, 2016.
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Affiliation(s)
- Rongquan Duan
- Biomaterial Science and Technology, MIRA Institute, University of Twente, Enschede, The Netherlands.,Xpand Biotechnology BV, Bilthoven, The Netherlands.,Key Laboratory of Advanced Technologies of Materials, Ministry of Education, School of Materials Science and Engineering, Southwest Jiaotong University, Chengdu, China
| | | | - Xiaoman Luo
- Biomaterial Science and Technology, MIRA Institute, University of Twente, Enschede, The Netherlands.,Xpand Biotechnology BV, Bilthoven, The Netherlands
| | - Jie Weng
- Key Laboratory of Advanced Technologies of Materials, Ministry of Education, School of Materials Science and Engineering, Southwest Jiaotong University, Chengdu, China
| | - Joost D de Bruijn
- Biomaterial Science and Technology, MIRA Institute, University of Twente, Enschede, The Netherlands.,Xpand Biotechnology BV, Bilthoven, The Netherlands.,Department of Materials Science, Queen Marry University of London, London, United Kingdom
| | - Huipin Yuan
- Xpand Biotechnology BV, Bilthoven, The Netherlands.,College of Physical Science and Technology, Sichuan University, Chengdu, China.,Department of Complex Tissue Regeneration, MERLN Institute for Technology Inspired Regenerative Medicine, Maastricht University, Universiteitssingel 40, Maastricht, 6229 ER, The Netherlands
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Sing DC, Khanna R, Shaw JD, Metz LN, Burch S, Berven SH. Increasing Rates of Surgical Management of Multilevel Spinal Curvature in Elderly Patients. Spine Deform 2016; 4:365-372. [PMID: 27927494 DOI: 10.1016/j.jspd.2016.03.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 02/29/2016] [Accepted: 03/19/2016] [Indexed: 10/21/2022]
Abstract
STUDY DESIGN Retrospective analysis of Nationwide Inpatient Sample (NIS) database. OBJECTIVE To analyze trends in utilization and hospital charges for multilevel spinal curvature surgery in patients over 60 from 2004 to 2011. SUMMARY OF BACKGROUND DATA Multilevel spinal curvature has been increasingly recognized as a major source of morbidity in patients over sixty years of age. The economic burden of non-operative management for spinal curvature is elusive and likely underestimated. Though patient reported outcomes suggest that surgical treatment of spinal curvature may be superior to non-operative treatment in selected patients, surgical utilization trends remain unclear. METHODS Data were obtained from the NIS between 2004 and 2011. The NIS is the largest all-payer inpatient care database with approximately eight million annual patient discharges throughout the United States. Analysis included patients over age 60 with a spinal curvature diagnosis treated with a multi-level spinal fusion (≥3 levels fused) determined by ICD-9-CM diagnosis and procedure codes. Population-based utilization rates were calculated from US census data. RESULTS A total of 84,302 adult patients underwent multilevel spinal curvature surgery from 2004 to 2011. The annual number of ≥3 level spinal curvature fusions in patients over age 60 increased from 6,571 to 16,526, representing a 107.8% increase from 13.4 cases per 100,000 people in 2004 to 27.9 in 2011 (p < .001). Utilization rates in patients 65-69 years old experienced the greatest growth, increasing by 122% from 15.8 cases per 100,000 people to 35.1. Average hospital charges increased 108% from $90,557 in 2007 to $188,727 in 2011 (p < .001). CONCLUSIONS Rates of surgical management of multilevel spinal curvature increased from 2004 to 2011, exceeding growth of the 60+ age demographic during the same period. Growth was observed in all age demographics, and hospital charges consistently increased from 2004 to 2011 reflecting a per-user increase in expenditure. LEVEL OF EVIDENCE III.
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Affiliation(s)
- David C Sing
- Department of Orthopaedic Surgery, University of California-San Francisco, 1500 Owens St. Box 3004, San Francisco, CA 94158, USA
| | - Ryan Khanna
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, 303 E Chicago Ave, Chicago, IL 60611, USA
| | - Jeremy D Shaw
- Department of Orthopaedic Surgery, University of California-San Francisco, 1500 Owens St. Box 3004, San Francisco, CA 94158, USA
| | - Lionel N Metz
- Department of Orthopaedic Surgery, University of California-San Francisco, 1500 Owens St. Box 3004, San Francisco, CA 94158, USA
| | - Shane Burch
- Department of Orthopaedic Surgery, University of California-San Francisco, 1500 Owens St. Box 3004, San Francisco, CA 94158, USA
| | - Sigurd H Berven
- Department of Orthopaedic Surgery, University of California-San Francisco, 1500 Owens St. Box 3004, San Francisco, CA 94158, USA.
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Abstract
Pedicle screw fixation is the preferred method of posterior fusion in lumbar spinal surgery. The technique provides three-column support of the vertebrae, contributing to the biomechanical strength of the construct. However, open pedicle screw fixation often necessitates wide posterior exposure and dissection with soft-tissue disruption of the facet joint. Alternative posterior fixation techniques have been developed to reduce surgical time, soft-tissue dissection, disruption of the adjacent facet joint capsule, neurologic risk, and implant cost. Results of these techniques are comparable to those of standard pedicle screw fixation systems. Certain patients, especially those at a lower risk of nonunion or those who require posterior fixation only as an adjunct to anterior column support, may benefit from the shorter surgical time and limited posterior exposure of the alternative techniques. However, the decreased rigidity of these alternative constructs can result in excessive motion, which can lead to nonunion and early hardware failure.
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Stewart G, Gage GB, Neidert G, Adkisson HD. Within Patient Radiological Comparative Analysis of the Performance of Two Bone Graft Extenders Utilized in Posterolateral Lumbar Fusion: A Retrospective Case Series. Front Surg 2016; 2:69. [PMID: 26835455 PMCID: PMC4724723 DOI: 10.3389/fsurg.2015.00069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 12/18/2015] [Indexed: 01/17/2023] Open
Abstract
Two bone graft extenders differing in chemical composition were implanted contralaterally in 27 consecutive patients undergoing instrumented posterolateral lumbar fusion as standard-of-care. Bone marrow aspirate and autogenous bone graft were equally combined either with β-tricalcium phosphate (β-TCP) or a hybrid biomaterial [containing hyaluronic acid (HyA) but lacking a calcium salt] and implanted between the transverse processes. Fusion status on each side of the vertebrae was retrospectively graded (1–5 scale) on AP planar X-ray at multiple visits as available, through approximately 12 months. Additionally, consolidation or resorption since prior visit for each treatment was recorded. Sides receiving β-TCP extender showed marked resorption prior to bone consolidation during the first 6 months. By contrast, sides receiving the hybrid biomaterial containing integrated HyA showed rapid bone consolidation by week 6–8, with maintenance of initial bone volume through 12 months. Fusion grade was superior for the hybrid biomaterial, differing significantly from β-TCP at day 109 and beyond. Fusion success at >12 months was 92.9 vs. 67.9% for the hybrid biomaterial and β-TCP-treated sides, respectively. The hybrid biomaterial extender demonstrated a shortened time-to-fusion compared to the calcium-based graft. Mode of action has been demonstrated in the literature to differ between these compositions. Therefore, choice of synthetic biomaterial composition may significantly influence the mode of action of cellular events regulating appositional bone growth.
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Affiliation(s)
| | - Gary B Gage
- ISTO Technologies, Inc. , St. Louis, MO , USA
| | - Gary Neidert
- Innovative Analytics, Inc. , Kalamazoo, MI , USA
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Hu T, Abbah SA, Toh SY, Wang M, Lam RWM, Naidu M, Bhakta G, Cool SM, Bhakoo K, Li J, Goh JCH, Wong HK. Bone marrow-derived mesenchymal stem cells assembled with low-dose BMP-2 in a three-dimensional hybrid construct enhances posterolateral spinal fusion in syngeneic rats. Spine J 2015; 15:2552-63. [PMID: 26342750 DOI: 10.1016/j.spinee.2015.08.063] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 04/15/2015] [Accepted: 08/22/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The combination of potent osteoinductive growth factor, functional osteoblastic cells, and osteoconductive materials to induce bone formation is a well-established concept in bone tissue engineering. However, supraphysiological dose of growth factor, such as recombinant human bone morphogenetic protein 2 (rhBMP-2), which is necessary in contemporary clinical application, have been reported to result in severe side effects. PURPOSE We hypothesize that the synergistic osteoinductive capacity of low-dose bone morphogenetic protein 2 (BMP-2) combined with undifferentiated bone marrow-derived stromal cells (BMSCs) is comparable to that of osteogenically differentiated BMSCs when used in a rodent model of posterolateral spinal fusion. STUDY DESIGN/SETTING A prospective study using a rodent model of posterolateral spinal fusion was carried out. PATIENT SAMPLE Thirty-six syngeneic Fischer rats comprised the patient sample. METHODS Six groups of implants were evaluated as follows (n=6): (1) 10 µg BMP-2 with undifferentiated BMSCs; (2) 10 µg BMP-2 with osteogenic-differentiated BMSCs; (3) 2.5 µg BMP-2 with undifferentiated BMSCs; (4) 2.5 µg BMP-2 with osteogenic-differentiated BMSCs; (5) 0.5 µg BMP-2 with undifferentiated BMSCs; and (6) 0.5 µg BMP-2 with osteogenic-differentiated BMSCs. Optimal in vitro osteogenic differentiation of BMSCs was determined by quantitative real-time polymerase chain reaction (qRT-PCR) gene analysis whereas in vivo bone formation capacity was evaluated by manual palpation, micro-computed tomography, and histology. RESULTS Rat BMSCs cultured in fibrin matrix that was loaded into the pores of medical-grade poly epsilon caprolactone tricalcium phosphate scaffolds differentiated toward osteogenic lineage by expressing osterix, runt-related transcription factor 2, and osteocalcium mRNA when supplemented with dexamethasone, ascorbic acid, and β-glycerophosphate. Whereas qRT-PCR revealed optimal increase in osteogenic genes expression after 7 days of in vitro culture, in vivo transplantation study showed that pre-differentiation of BMSCs before transplantation failed to promote posterolateral spinal fusion when co-delivered with low-dose BMP-2 (1/6 or 17% fusion rate). In contrast, combined delivery of undifferentiated BMSCs with low-dose BMP-2 (2.5 µg) demonstrated significantly higher fusion rate (4/6 or 67%) as well as significantly increased volume of new bone formation (p<.05). CONCLUSION In summary, this study supports the combination of undifferentiated BMSCs and low-dose rhBMP-2 for bone tissue engineering construct.
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Affiliation(s)
- Tao Hu
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Level 11, NUHS Tower Block, 1E Kent Ridge Rd, 119228, Singapore
| | - Sunny Akogwu Abbah
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Level 11, NUHS Tower Block, 1E Kent Ridge Rd, 119228, Singapore
| | - Soo Yein Toh
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Level 11, NUHS Tower Block, 1E Kent Ridge Rd, 119228, Singapore
| | - Ming Wang
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Level 11, NUHS Tower Block, 1E Kent Ridge Rd, 119228, Singapore
| | - Raymond Wing Moon Lam
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Level 11, NUHS Tower Block, 1E Kent Ridge Rd, 119228, Singapore
| | - Mathanapriya Naidu
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Level 11, NUHS Tower Block, 1E Kent Ridge Rd, 119228, Singapore
| | - Gajadhar Bhakta
- Institute of Medical Biology, Agency for Science, Technology and Research (A*STAR), 8A Biomedical Grove, #06-06 Immunos, 138648, Singapore
| | - Simon M Cool
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Level 11, NUHS Tower Block, 1E Kent Ridge Rd, 119228, Singapore; Institute of Medical Biology, Agency for Science, Technology and Research (A*STAR), 8A Biomedical Grove, #06-06 Immunos, 138648, Singapore
| | - Kishore Bhakoo
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Level 11, NUHS Tower Block, 1E Kent Ridge Rd, 119228, Singapore; Singapore Bioimaging Consortium (SBIC), Agency for Science, Technology and Research (A*STAR), 11 Biopolis Way, #02-02 Helios Building, 138667, Singapore
| | - Jun Li
- Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Block EA, #03-12, 9 Engineering Drive 1, 117575, Singapore
| | - James Cho-Hong Goh
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Level 11, NUHS Tower Block, 1E Kent Ridge Rd, 119228, Singapore; Department of Biomedical Engineering, Faculty of Engineering, National University of Singapore, Block EA, #03-12, 9 Engineering Drive 1, 117575, Singapore
| | - Hee-Kit Wong
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Level 11, NUHS Tower Block, 1E Kent Ridge Rd, 119228, Singapore.
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Liu CC, Tian FM, Zhou Z, Wang P, Gou Y, Zhang H, Wang WY, Shen Y, Zhang YZ, Zhang L. Protective effect of calcitonin on lumbar fusion-induced adjacent-segment disc degeneration in ovariectomized rat. BMC Musculoskelet Disord 2015; 16:342. [PMID: 26552386 PMCID: PMC4640157 DOI: 10.1186/s12891-015-0788-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 10/23/2015] [Indexed: 02/06/2023] Open
Abstract
Background Intervertebral disc (IVD) degeneration and pathological changes in the spinal cord are major causes of back pain. In addition to its well-established anti-resorptive effect on bone, calcitonin (CT) potentially exerts protective effects on IVD degeneration in ovariectomized rats. However, possible therapeutic effects of CT on lumbar fusion-induced adjacent-segment disc degeneration (ASDD) have not been investigated yet. In this study, we examined the effects of CT on IVD degeneration adjacent to a lumbar fusion in ovariectomized rats. Methods Posterolateral lumbar fusion (PLF) at L4–5 was performed 4 weeks after ovariectomy (OVX) or sham surgery in female Sprague–Dawley rats. Following PLF + OVX, rats received either salmon CT (OVX + PLF + sCT, 16 IU/Kg/2d) or vehicle (OVX + PLF + V) treatment for 12 weeks; the remaining rats were divided into Sham + V, OVX + V, and PLF + V groups. Fusion status was analyzed by manual palpation and radiography. Adjacent segment disc was assessed by histological, histomorphometric, immunohistochemical analysis. L6 vertebrae microstructures were evaluated by micro-computed tomography. Results Histological analysis showed more severe ASDD occurred in OVX + PLF + V rats compared with the OVX + V or PLF + V groups. CT treatment suppressed the score for ASDD, increased disc height, and decreased the area of endplate calcification. Immunohistochemical staining demonstrated that CT decreased the expression of collagen type-I, matrix metalloproteinase-13, and a disintegrin and metalloproteinase with thrombospondin motifs-4, whereas it increased the expression of collagen type-II and aggrecan in the disc. Micro-computed tomography indicated that CT increased bone mass and improved the microstructure of the L6 vertebrae. Conclusions These results suggest that CT can prevent ASDD, induce beneficial changes in IVD metabolism, and inhibit deterioration of the trabecular microarchitecture of vertebrae in osteoporotic rats with lumbar fusion.
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Affiliation(s)
- Chang-Cheng Liu
- Orthopaedic Research Institution of Hebei, Third Hospital of Hebei Medical University, Shijiazhuang, 050017, P.R. China
| | - Fa-Ming Tian
- Medical Research Center, North China University of Science and Technology, Tangshan, 063000, P. R. China.
| | - Zhuang Zhou
- Department of Orthopedic Surgery, Affiliated Hospital of North China University of Science and Technology, No. 73 Jianshe South Rd., Tangshan, Hebei, 063000, P.R. China.
| | - Peng Wang
- Department of Orthopedic Surgery, Affiliated Hospital of North China University of Science and Technology, No. 73 Jianshe South Rd., Tangshan, Hebei, 063000, P.R. China.
| | - Yu Gou
- Department of Orthopedic Surgery, Affiliated Hospital of North China University of Science and Technology, No. 73 Jianshe South Rd., Tangshan, Hebei, 063000, P.R. China.
| | - Heng Zhang
- Department of Orthopedic Surgery, Affiliated Hospital of North China University of Science and Technology, No. 73 Jianshe South Rd., Tangshan, Hebei, 063000, P.R. China.
| | - Wen-Ya Wang
- Department of Pathology, School of Basic Medical Sciences, North China University of Science and Technology, Tangshan, 063000, P. R. China.
| | - Yong Shen
- Orthopaedic Research Institution of Hebei, Third Hospital of Hebei Medical University, Shijiazhuang, 050017, P.R. China.
| | - Ying-Ze Zhang
- Orthopaedic Research Institution of Hebei, Third Hospital of Hebei Medical University, Shijiazhuang, 050017, P.R. China.
| | - Liu Zhang
- Orthopaedic Research Institution of Hebei, Third Hospital of Hebei Medical University, Shijiazhuang, 050017, P.R. China. .,Department of Orthopedic Surgery, Affiliated Hospital of North China University of Science and Technology, No. 73 Jianshe South Rd., Tangshan, Hebei, 063000, P.R. China.
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Yasen M, Li X, Jiang L, Yuan W, Che W, Dong J. Effect of zoledronic acid on spinal fusion outcomes in an ovariectomized rat model of osteoporosis. J Orthop Res 2015; 33:1297-304. [PMID: 26011820 DOI: 10.1002/jor.22763] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Revised: 09/30/2014] [Accepted: 10/06/2014] [Indexed: 02/04/2023]
Abstract
To evaluate the effect of zoledronic acid (ZA) on spinal fusion in ovariectomized (OVX) rats. Female SD rats (n = 50) were OVX or sham-operated and randomized into five groups: Sham, OVX control, ZOL-20 (20 µg/kg), ZOL-100 (100 µg/kg), and ZOL-500 (500 µg/kg). Eight weeks after OVX, bilateral lumbar spinal fusion was performed using autologous iliac bone with ZA or saline according to the grouping. The lumbar spines were harvested at 8 weeks and subjected to radiographic, manual palpation, micro-computed tomographic (micro-CT), and histological analysis. The manual palpation result differed significantly only between the ZOL-500 (fused: partially fused: not fused, 9:0:0) and OVX control (4:2:3) (p < 0.05). The radiographic scales were also differed significantly only between these two groups. According to the micro-CT results, the bone volume fraction (BV/TV) were significantly higher in all ZA-treated groups (54.2%, 65.9%, and 73.6%) than OVX control (43.7%) (p < 0.01). At clinical dose or lower, ZA didn't alter the spinal fusion, but a higher dose increased the spinal fusion rate significantly. This study suggests ZA may have a positive effect on spinal fusion in the presence of osteoporosis, and spinal fusion surgery outcome is not likely to be altered by ZA at clinical dose.
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Affiliation(s)
- Miersalijiang Yasen
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Xiangqian Li
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Libo Jiang
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Wei Yuan
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Wu Che
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Jian Dong
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
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Polyelectrolyte Complex Carrier Enhances Therapeutic Efficiency and Safety Profile of Bone Morphogenetic Protein-2 in Porcine Lumbar Interbody Fusion Model. Spine (Phila Pa 1976) 2015; 40:964-73. [PMID: 25893351 DOI: 10.1097/brs.0000000000000935] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Porcine lumbar interbody fusion model. OBJECTIVE This study evaluates the effect of polyelectrolyte complex (PEC) carrier in enhancing the therapeutic efficiency and safety profile of bone morphogenetic protein-2 (BMP-2) in a large animal model. SUMMARY OF BACKGROUND DATA Extremely large amounts of BMP-2 are administered to achieve consistent spinal fusion, which has led to complications. Heparin-modified PEC carrying reduced BMP-2 doses of 0.5 μg was demonstrated to achieve consistent spinal fusion with reduction of complications in rodent model. The purpose of this study was to evaluate whether PEC could improve the therapeutic efficiency of BMP-2 in porcine model. METHODS Three-segment (L3-L6) anterior lumbar interbody fusions with instrumentation were performed on 6 pigs using 3 different doses of BMP-2, namely, (1) 50 μg, (2) 150 μg, and (3) 300 μg. The BMP-2 was delivered using heparin-modified alginate microbeads loaded into biodegradable cage. Fusion performance was evaluated after 3 months. RESULTS Manual palpation and micro-computed tomography showed consistent fusion in all experimental groups. Heterotopic bone formation beyond the cage implant area was more evident in group 2 and group 3 than in group 1. Similarly, superior bone microstructure was observed in the new bone with the lowered BMP-2 dose. Biomechanical evaluation revealed enhanced stiffness of the operated segments compared with nonoperated segments (P < 0.05). Mechanical stability was maintained despite dose reduction of BMP-2. Although the mineral apposition rate was higher in group 3, unsatisfactory bony microstructure with decreased trabecular number was observed in group 3 compared with group 1. CONCLUSION PEC carrying low doses of BMP-2 achieved consistent interbody fusion. We observed dose-related reduction in heterotopic ossification without compromising the stability of the fused segments. PEC carrier reduces the efficacious doses of BMP-2. This could enhance the safety profile of BMP-2 and reduce dose- and carrier-related complications. LEVEL OF EVIDENCE N/A.
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Abstract
While bone has a remarkable capacity for regeneration, serious bone trauma often results in damage that does not properly heal. In fact, one tenth of all limb bone fractures fail to heal completely due to the extent of the trauma, disease, or age of the patient. Our ability to improve bone regenerative strategies is critically dependent on the ability to mimic serious bone trauma in test animals, but the generation and stabilization of large bone lesions is technically challenging. In most cases, serious long bone trauma is mimicked experimentally by establishing a defect that will not naturally heal. This is achieved by complete removal of a bone segment that is larger than 1.5 times the diameter of the bone cross-section. The bone is then stabilized with a metal implant to maintain proper orientation of the fracture edges and allow for mobility. Due to their small size and the fragility of their long bones, establishment of such lesions in mice are beyond the capabilities of most research groups. As such, long bone defect models are confined to rats and larger animals. Nevertheless, mice afford significant research advantages in that they can be genetically modified and bred as immune-compromised strains that do not reject human cells and tissue. Herein, we demonstrate a technique that facilitates the generation of a segmental defect in mouse femora using standard laboratory and veterinary equipment. With practice, fabrication of the fixation device and surgical implantation is feasible for the majority of trained veterinarians and animal research personnel. Using example data, we also provide methodologies for the quantitative analysis of bone healing for the model.
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Affiliation(s)
- Bret H Clough
- Institute for Regenerative Medicine at Scott & White Hospital, Texas A&M Health Science Center
| | | | - Carl A Gregory
- Institute for Regenerative Medicine at Scott & White Hospital, Texas A&M Health Science Center; Molecular and Cellular Medicine, Texas A&M Health Science Center;
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Bigham-Sadegh A, Karimi I, Oryan A, Mahmoudi E, Shafiei-Sarvestani Z. Spinal fusion with demineralized calf fetal growth plate as novel biomaterial in rat model: a preliminary study. Int J Spine Surg 2015; 8:14444-1005. [PMID: 25694913 PMCID: PMC4325481 DOI: 10.14444/1005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Spinal fusions are being performed for various pathologies of the spine such as degenerative diseases, deformities, tumors and fractures. Recently, other bone substitutes such as demineralized bone matrix (DBM) have been developed for spinal fusion. Therefore, this study was conducted to evaluate the intertransverse posterolateral fusion with the Bovine fetal growth plate (DCFGP) and compare it with commercial DBM in rat model. Methods A total of 16 mature male rats (aged 4 months and weighing 200-300 g) were randomly divided in two groups. After a skin incision on posterolateral site, two separate fascial incisions were made 3 mm from the midline. A muscle-splitting approach was used to expose the transverse processes of L4 and L5. Group I (n = 8) underwent with implanted Bovine fetal growth plate among decorticated transverse processes. In group II (n = 8) commercial DBM was placed in the same manner. Fusion was evaluated by manual palpation, radiographical, gross and histopathological analysis. Results The manual palpation, radiological, gross and histopathological findings indicate high potential of the DCFGP in spinal fusion. At the 42nd postoperative day, new bone formation as evidenced by a bridge between L4 and L5 was visualized in all rats implanted with DCFGP and commercial DBM. The newly formed bone tissue was observed in all implanted areas on the 42nd day after operation in the two groups. Conclusions The spinal fusion of the animals of both groups demonstrated more advanced osteogenic potential and resulted in proper fusion of the transverse process of lumbar vertebra.
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Affiliation(s)
- Amin Bigham-Sadegh
- Department of Veterinary Surgery and Radiology, Faculty of Veterinary Medicine, Shahrekord University, Shahrekord, Iran
| | - Iraj Karimi
- Department of Veterinary Pathobiology, Faculty of Veterinary Medicine, Shahrekord University, Shahrekord, Iran
| | - Ahmad Oryan
- Department of Veterinary Pathobiology, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
| | - Elena Mahmoudi
- Department of Veterinary Surgery, School of Veterinary Medicine, Tehran University, Tehran, Iran
| | - Zahra Shafiei-Sarvestani
- Department of Veterinary Surgery and Radiology, Faculty of Veterinary Medicine, Shahrekord University, Shahrekord, Iran
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Scheufler KM, Diesing D. Einsatz von Knochenersatzmaterialien bei Fusionen der Wirbelsäule. DER ORTHOPADE 2015; 44:146-53. [DOI: 10.1007/s00132-014-3069-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Campana V, Milano G, Pagano E, Barba M, Cicione C, Salonna G, Lattanzi W, Logroscino G. Bone substitutes in orthopaedic surgery: from basic science to clinical practice. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2014; 25:2445-61. [PMID: 24865980 PMCID: PMC4169585 DOI: 10.1007/s10856-014-5240-2] [Citation(s) in RCA: 602] [Impact Index Per Article: 60.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 05/09/2014] [Indexed: 05/04/2023]
Abstract
Bone substitutes are being increasingly used in surgery as over two millions bone grafting procedures are performed worldwide per year. Autografts still represent the gold standard for bone substitution, though the morbidity and the inherent limited availability are the main limitations. Allografts, i.e. banked bone, are osteoconductive and weakly osteoinductive, though there are still concerns about the residual infective risks, costs and donor availability issues. As an alternative, xenograft substitutes are cheap, but their use provided contrasting results, so far. Ceramic-based synthetic bone substitutes are alternatively based on hydroxyapatite (HA) and tricalcium phosphates, and are widely used in the clinical practice. Indeed, despite being completely resorbable and weaker than cortical bone, they have exhaustively proved to be effective. Biomimetic HAs are the evolution of traditional HA and contains ions (carbonates, Si, Sr, Fl, Mg) that mimic natural HA (biomimetic HA). Injectable cements represent another evolution, enabling mininvasive techniques. Bone morphogenetic proteins (namely BMP2 and 7) are the only bone inducing growth factors approved for human use in spine surgery and for the treatment of tibial nonunion. Demineralized bone matrix and platelet rich plasma did not prove to be effective and their use as bone substitutes remains controversial. Experimental cell-based approaches are considered the best suitable emerging strategies in several regenerative medicine application, including bone regeneration. In some cases, cells have been used as bioactive vehicles delivering osteoinductive genes locally to achieve bone regeneration. In particular, mesenchymal stem cells have been widely exploited for this purpose, being multipotent cells capable of efficient osteogenic potential. Here we intend to review and update the alternative available techniques used for bone fusion, along with some hints on the advancements achieved through the experimental research in this field.
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Affiliation(s)
- V. Campana
- Department of Orthopaedics and Traumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy
| | - G. Milano
- Department of Orthopaedics and Traumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy
| | - E. Pagano
- Department of Orthopaedics and Traumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy
| | - M. Barba
- Institute of Anatomy and Cell Biology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - C. Cicione
- Institute of Anatomy and Cell Biology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - G. Salonna
- Department of Orthopaedics and Traumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy
| | - W. Lattanzi
- Institute of Anatomy and Cell Biology, Università Cattolica del Sacro Cuore, Rome, Italy
- Latium Musculoskeletal Tissue Bank, Rome, Italy
| | - G. Logroscino
- Department of Orthopaedics and Traumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy
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Klíma K, Vaněček V, Kohout A, Jiroušek O, Foltán R, Štulík J, Machoň V, Pavlíková G, Jendelová P, Syková E, Šedý J. Stem cells regenerative properties on new rat spinal fusion model. Physiol Res 2014; 64:119-28. [PMID: 25194134 DOI: 10.33549/physiolres.932728] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Stem cells biology is one of the most frequent topic of physiological research of today. Spinal fusion represents common bone biology challenge. It is the indicator of osteoinduction and new bone formation on ectopic model. The purpose of this study was to establish a simple model of spinal fusion based on a rat model including verification of the possible use of titanium microplates with hydroxyapatite scaffold combined with human bone marrow-derived mesenchymal stem cells (MSCs). Spinous processes of two adjacent vertebrae were fixed in 15 Wistar rats. The space between bony vertebral arches and spinous processes was either filled with augmentation material only and covered with a resorbable collagen membrane (Group 1), or filled with augmentation material loaded with 5 × 10⁶ MSCs and covered with a resorbable collagen membrane (Group 2). The rats were sacrificed 8 weeks after the surgery. Histology, histomorphometry and micro-CT were performed. The new model of interspinous fusion was safe, easy, inexpensive, with zero mortality. We did not detect any substantial pathological changes or tumor formation after graft implantation. We observed a nonsignificant effect on the formation of new bone tissue between Group 1 and Group 2. In the group with MSCs (Group 2) we described minor inflamatory response which indicates the imunomodulational and antiinflamatory role of MSCs. In conclusion, this new model proved to be easy to use in small animals like rats.
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Affiliation(s)
- K Klíma
- Department of Oral and Maxillofacial Surgery, General University Hospital, Prague, Czech Republic, Institute of Physiology, Academy of Sciences of the Czech Republic, Prague, Czech Republic.
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Nickoli MS, Hsu WK. Ceramic-based bone grafts as a bone grafts extender for lumbar spine arthrodesis: a systematic review. Global Spine J 2014; 4:211-6. [PMID: 25083364 PMCID: PMC4111951 DOI: 10.1055/s-0034-1378141] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 04/25/2014] [Indexed: 01/28/2023] Open
Abstract
Study Design Systematic review. Objective Ceramic-based bone grafts have been widely utilized to reduce the need for iliac crest bone grafting given the complications associated with the harvest of iliac crest autograft. As a family, ceramics vary widely based on differences in composition, manufacturing, porosity, and structure, which may ultimately affect their efficacy. This article reviews the current data of ceramics used in different environments in the lumbar spine to achieve arthrodesis. Methods Medline, EMBASE, and Cochrane Central Register of Controlled Trials were searched for publications from 1980 to 2013 involving ceramic-based bone grafts in the lumbar spine. Variables such as age of patients, volume of ceramic, procedure, time to evaluation, method of evaluation, specific composition of ceramic, adjuncts used with ceramic products, type of fusion, and fusion rate were compared using a multivariate logistic regression model. Results Thirty studies with 1,332 patients met the final inclusion criteria. The overall fusion rate for all ceramic products as a bone graft extender in the lumbar spine was 86.4%. Age, gender, method of evaluation (plain radiographs, computed tomography, or combination), or specific ceramic product did not significantly affect fusion rate. Ceramics used in combination with local autograft resulted in significantly higher fusion rates compared with all other adjuncts, and bone marrow aspirate and platelet concentrates resulted in significantly lower fusion rates. Conclusions Ceramic-based bone grafts represent a promising bone graft extender in lumbar spine fusion when an osteoinductive stimulus, such as local bone graft is available.
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Affiliation(s)
- Michael S. Nickoli
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States,Address for correspondence Michael Nickoli, MD 676 N. Saint ClairSuite 1350, Chicago, IL 60611United States
| | - Wellington K. Hsu
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
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Sun YX, Sun CL, Tian Y, Xu WX, Zhou CL, Xi CY, Yan JL, Wang XT. A comparison of osteocyte bioactivity in fine particulate bone powder grafts vs larger bone grafts in a rat bone repair model. Acta Histochem 2014; 116:1015-21. [PMID: 24835853 DOI: 10.1016/j.acthis.2014.04.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 04/02/2014] [Accepted: 04/03/2014] [Indexed: 11/30/2022]
Abstract
The osteogenic potential for bone grafts is based on numbers and activities of cells that survive transplantation. In this study, we compared the bioactivity of osteocytes in 300-500 μm fine particulate bone powder grafts to 2 mm larger bone grafts in a rat radial defect model. Expression levels of bone morphogenetic protein-2 (BMP-2), transforming growth factor-beta 1 (TGF-β1), alkaline phosphatase (ALP), and collagen I were semi-quantified by both immunohistochemistry and RT-PCR at days 1 and 4, as well as weeks 1, 2, 4, 6 and 10 post-transplantation. Within two weeks post-transplantation, more cells stained positively for BMP-2, TGF-β1, ALP, and collagen I within the bone grafts and in the surrounding tissues in the group transplanted with the fine particulate bone powder grafts than in those with larger bone grafts (P<0.05). The mRNA levels of all four markers in the group transplanted with fine particulate bone powder graft peaked earlier and were expressed more highly than in the larger bone graft group, suggesting that fine particulate bone powder grafts provide more viable and active osteocytes to accelerate bone defect healing than larger bone grafts.
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Affiliation(s)
- Yuan-Xin Sun
- Department of Orthopaedic Surgery, Daqing Oil Field General Hospital, Daqing 163001, China
| | - Cheng-Li Sun
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Ye Tian
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Wen-Xiao Xu
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Chang-Long Zhou
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Chun-Yang Xi
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Jing-Long Yan
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Xin-Tao Wang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin 150001, China.
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Gulsen S, Cokeliler D, Goktas H, Kucukturhan A, Ozcil B, Caner H. Improved Bone Formation in Osteoporotic Rabbits with the Bone Morphogenetic Protein-2 (rhBMP-2) Coated Titanium Screws Which Were Coated By Using Plasma Polymerization Technique. Open Access Maced J Med Sci 2014. [DOI: 10.3889/oamjms.2014.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Delaying of bone fusion in osteoporotic patients underwent spinal stabilization surgery leads to screw loosening, and this causes pseudoarticulation, mobility and fibrosis at vertebral segments. To prevent these complications, the screws coated with recombinant bone morphogenetic protein-2 (rhBMP-2) could be used. To verify this hypothesis, we coated 5 Titanium screws with rhBMP-2 using plasma polymerization method, and also used 10 uncoated screws for making comparison between coated and uncoated screws in different groups. And 15 skeletally mature white New Zealand female rabbits were assigned into three different groups: Group 1(N = 5): No osteoporosis induction and insertion of uncoated Titanium screw into right sacrum of each rabbit in group 1; group 2 (N = 5): Osteoporosis induction and insertion of uncoated Titanium screw into right sacrum of each rabbit in group 2; group 3 (N = 5) rhBMP-2 coated Titanium screw inserted into right sacrum of each rabbit in group 3. In summary, using of these coated screws provides new bone formation, but causes less fibrosis and less inflammation than uncoated screws at the interface between the coated screw and bone. Then the plasma polymerization technique provides controlled releasing of rhBMP-2 from the screw to the bone tissue in osteoporotic rabbits.
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Hydroxyapatite-Based Biomaterials Versus Autologous Bone Graft in Spinal Fusion: An In Vivo Animal Study. Spine (Phila Pa 1976) 2014; 39:E661-E668. [PMID: 24718060 DOI: 10.1097/brs.0000000000000311] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN An in vivo study was designed to compare the efficacy of biomimetic magnesium-hydroxyapatite (MgHA) and of human demineralized bone matrix (HDBM), both dispersed in a mixture of biomimetic MgHA nanoparticles, with that of an autologous bone graft. OBJECTIVE The objective of this study was to evaluate 2 new bone substitutes as alternatives to a bone autograft for spinal fusion, determining their osteoinductive and osteoconductive properties, and their capacity of remodeling, using a large animal model. SUMMARY OF BACKGROUND DATA Spinal fusion is a common surgical procedure and it is performed for different conditions. A successful fusion requires potentially osteogenic, osteoinductive, and osteoconductive biomaterials. METHODS A posterolateral spinal fusion model involved 18 sheep, bilaterally implanting test materials between the vertebral transverse processes. The animals were divided into 2 groups: 1 fusion level was treated with MgHA (group 1) or with HDBM-MgHA (group 2). The other fusion level received bone autografts in both groups. RESULTS Radiographical, histological, and microtomographic results indicated good osteointegration between the spinous process and the vertebral foramen for both materials. Histomorphometry revealed no significant differences between MgHA and autologous bone for all the parameters examined, whereas significantly lower values of bone volume were observed between HDBM-MgHA and autologous bone. Moreover, the normalization of the histomorphometric data with autologous bone revealed that MgHA showed a significantly higher value of bone volume and a lower value of trabecular number, more similar to autologous bone than HDBM-MgHA. CONCLUSION The study showed that the use of MgHA in an ovine model of spinal fusion led to the deposition of new bone tissue without qualitative and quantitative differences with respect to new bone formed with autologous bone, whereas the HDBM-MgHA led to a reduced deposition of newly formed bone tissue. LEVEL OF EVIDENCE N/A.
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Shin DA, Yang BM, Tae G, Kim YH, Kim HS, Kim HI. Enhanced spinal fusion using a biodegradable porous mesh container in a rat posterolateral spinal fusion model. Spine J 2014; 14:408-15. [PMID: 24268394 DOI: 10.1016/j.spinee.2013.08.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 07/05/2013] [Accepted: 08/23/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Posterolateral fusion (PLF) with an autogenous iliac bone graft is the most common procedure for treating various lumbar spinal diseases. However, the limited success and associated morbidity from an iliac crest graft demands new biologically competent graft enhancers or substitutes. PURPOSE To investigate the feasibility of tubular mesh container made of bioabsorbable sutures (poly-1,4-dioxane-2-one, PDO) for spinal fusion. STUDY DESIGN Experimental animal study. METHODS A biodegradable PDO tubular mesh container was used to contain small pieces of bone grafts. Twenty Sprague-Dawley male rats underwent PLF between L4 and L5 transverse processes with bilateral iliac grafts. Experimental animals were assigned into two different groups: autograft-only group (N=10) that underwent PLF with autograft-only or mesh container group (N=10) that underwent PLF with tubular mesh container filled with autogenous bone grafts. The rats were sacrificed at 8 weeks postoperatively, and the lumbar spines were removed. Spinal fusion was evaluated by manual palpation, microcomputed tomography, three-point bending test, and histological examination. RESULTS Solid fusion was achieved in all cases of the mesh container group, whereas the autograft-only group showed 60% of solid fusion. New bone mass was higher and more solidly fused in the mesh container group than the autograft-only group (p<.01). Volume of fusion mass and density of bone were significantly higher in the mesh container group (p<.05). In all cases, inflammatory response was minimal. CONCLUSIONS This study demonstrated that a tubular mesh container made of bioabsorbable suture is useful to hold small pieces of bone grafts and to enhance spinal fusion.
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Affiliation(s)
- Dong-Ah Shin
- Department of Neurosurgery, Yonsei University College of Medicine, 50 Yonsei-Ro, Seodaemun-Gu, Seoul, 120-752, Republic of Korea
| | - Bo Mi Yang
- School of Materials Science and Engineering, Gwangju Institute of Science and Technology, 123 Cheomdan-gwagiro, Buk-gu, Gwangju, 500-712, Republic of Korea
| | - Giyoong Tae
- School of Materials Science and Engineering, Gwangju Institute of Science and Technology, 123 Cheomdan-gwagiro, Buk-gu, Gwangju, 500-712, Republic of Korea
| | - Young Ha Kim
- Department of Chemistry, Chung-Ang University, 84 Heukseok-Ro, Dongjak-Gu, Seoul, Republic of Korea
| | - Hyung-Seok Kim
- Department of Forensic Medicine, Chonnam National University Medical School, 42 Jebong-Ro, Dong-Gu, Gwangju, 501-757, Republic of Korea
| | - Hyoung-Ihl Kim
- Department of Medical System Engineering, Gwangju Institute of Science and Technology, 123 Cheomdan-gwagiro, Buk-gu, Gwangju, 500-712, Republic of Korea; Department of Neurosurgery, Presbyterian Medical Center, 1-300 Junghwasan-dong, Wansangu, Jeonju, Jeonbuk, Republic of Korea.
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Spinal fusion in the next generation: gene and cell therapy approaches. ScientificWorldJournal 2014; 2014:406159. [PMID: 24672316 PMCID: PMC3927763 DOI: 10.1155/2014/406159] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 10/28/2013] [Indexed: 12/24/2022] Open
Abstract
Bone fusion represents a challenge in the orthopedics practice, being especially indicated for spine disorders. Spinal fusion can be defined as the bony union between two vertebral bodies obtained through the surgical introduction of an osteoconductive, osteoinductive, and osteogenic compound. Autogenous bone graft provides all these three qualities and is considered the gold standard. However, a high morbidity is associated with the harvest procedure. Intensive research efforts have been spent during the last decades to develop new approaches and technologies for successful spine fusion. In recent years, cell and gene therapies have attracted great interest from the scientific community. The improved knowledge of both mesenchymal stem cell biology and osteogenic molecules allowed their use in regenerative medicine, representing attractive approaches to achieve bone regeneration also in spinal surgery applications. In this review we aim to describe the developing gene- and cell-based bone regenerative approaches as promising future trends in spine fusion.
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Kodera R, Miyazaki M, Yoshiiwa T, Kawano M, Kaku N, Tsumura H. Manipulation of anabolic and catabolic responses with bone morphogenetic protein and zoledronic acid in a rat spinal fusion model. Bone 2014; 58:26-32. [PMID: 24103577 DOI: 10.1016/j.bone.2013.09.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Revised: 09/25/2013] [Accepted: 09/27/2013] [Indexed: 11/23/2022]
Abstract
Bone fusion involves a complex set of regulated signaling pathways that control the formation of new bone matrix and the resorption of damaged bone matrix at the surgical site. It has been reported that systemically administering a single dose of zoledronic acid (ZA) at the optimal time increases the strength of the bone morphogenetic protein (BMP)-mediated callus. In the present study, we aimed to investigate the effect of BMP-2 and ZA in a rat spinal model. Sixty-seven rats were divided into 6 groups: group I (n=11) animals were implanted with a carrier alone, group II (n=12) animals were implanted with a carrier and a subcutaneous injection of ZA was administered 2weeks after surgery, group III (n=12) animals were implanted with a carrier containing 1μg of rhBMP-2, group IV (n=12) animals were implanted with a carrier containing 1μg of rhBMP-2 and a subcutaneous injection of ZA was administered 2weeks after surgery, group V (n=10) animals were implanted with a carrier containing 3μg of rhBMP-2, and group VI (n=10) animals were implanted with a carrier containing 3μg of rhBMP-2 and a subcutaneous injection of ZA was administered 2weeks after surgery. The rats were euthanized after 6weeks, and their spines were explanted and assessed by manual palpation, radiography, high-resolution micro-computerized tomography (micro-CT), and histologic analysis. The fusion rates in group VI (60%) were considerably higher than those in the groups I (0%), II (0%), III (12.5%), IV (20.8%), and V (35%), (P<0.05). Additionally, the radiographic scores of group VI were higher than those in the other groups, (P<0.05). In micro-CT analysis, the tissue and bone volumes of the callus were significantly higher in group VI than those in the other groups, (P<0.05). The trabecular number was significantly higher and the trabecular spacing was significantly lower in group VI than those in the other groups, (P<0.05). The combination of rhBMP-2 and ZA administered systemically as a single dose at the optimal time was efficacious in our rat spinal fusion model. Our results suggest that this combination facilitates spinal fusion and has potential clinical application.
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Affiliation(s)
- Ryuzo Kodera
- Department of Orthopaedic Surgery, Oita University, Oita, Japan
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Roh JS, Yeung CA, Field JS, McClellan RT. Allogeneic morphogenetic protein vs. recombinant human bone morphogenetic protein-2 in lumbar interbody fusion procedures: a radiographic and economic analysis. J Orthop Surg Res 2013; 8:49. [PMID: 24373225 PMCID: PMC3916062 DOI: 10.1186/1749-799x-8-49] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 12/12/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Since the introduction of rhBMP-2 (Infuse) in 2002, surgeons have had an alternative substitute to autograft and its related donor site morbidity. Recently, the prevalence of reported adverse events and complications related to the use of rhBMP-2 has raised many ethical and legal concerns for surgeons. Additionally, the cost and decreasing reimbursement landscape of rhBMP-2 use have required identification of a viable alternative. Osteo allogeneic morphogenetic protein (OsteoAMP) is a commercially available allograft-derived growth factor rich in osteoinductive, angiogenic, and mitogenic proteins. This study compares the radiographic fusion outcomes between rhBMP-2 and OsteoAMP allogeneic morphogenetic protein in lumbar interbody fusion spine procedures. METHODS Three hundred twenty-one (321) patients from three centers underwent a transforaminal lumbar interbody fusion (TLIF) or lateral lumbar interbody fusion (LLIF) procedure and were assessed by an independent radiologist for fusion and radiographically evident complications. The independent radiologist was blinded to the intervention, product, and surgeon information. Two hundred and twenty-six (226) patients received OsteoAMP with autologous local bone, while ninety-five (95) patients received Infuse with autologous local bone. Patients underwent radiographs (x-ray and/or CT) at standard postoperative follow-up intervals of approximately 1, 3, 6, 12, and 18 months. Fusion was defined as radiographic evidence of bridging across endplates, or bridging from endplates to interspace disc plugs. Osteobiologic surgical supply costs were also analyzed to ascertain cost differences between OsteoAMP and rhBMP-2. RESULTS OsteoAMP produced higher rates of fusion at 6, 12, and 18 months (p ≤ 0.01). The time required for OsteoAMP to achieve fusion was approximately 40% less than rhBMP-2 with approximately 70% fewer complications. Osteobiologic supply costs were 80.5% lower for OsteoAMP patients (73.7% lower per level) than for rhBMP-2. CONCLUSIONS Results of this study indicate that OsteoAMP is a viable alternative to rhBMP-2 both clinically and economically when used in TLIF and LLIF spine procedures.
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Affiliation(s)
- Jeffrey S Roh
- Orthopedics International, 12333 NE 130th Lane #400, Kirkland, WA 98034, USA
| | | | - Justin S Field
- Desert Institute for Spine Care, 1635 E Myrtle Ave, Phoenix, AZ 85020, USA
| | - R Trigg McClellan
- Orthopaedic Trauma Institute, San Francisco General Hospital, UCSF, 2550 23rd Street, San Francisco, CA 94110, USA
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Fabrication and evaluation of porous beta-tricalcium phosphate/hydroxyapatite (60/40) composite as a bone graft extender using rat calvarial bone defect model. ScientificWorldJournal 2013; 2013:481789. [PMID: 24453864 PMCID: PMC3878745 DOI: 10.1155/2013/481789] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Accepted: 10/26/2013] [Indexed: 11/17/2022] Open
Abstract
Beta-tricalcium phosphate ( β -TCP) and hydroxyapatite (HA) are widely used as bone graft extenders due to their osteoconductivity and high bioactivity. This study aims to evaluate the possibility of using porous substrate with composite ceramics ( β -TCP: HA = 60% : 40%, 60TCP40HA) as a bone graft extender and comparing it with Bio-Oss. Interconnectivity and macroporosity of β -TCP porous substrate were 99.9% and 83%, respectively, and the macro-porosity of packed granule after crushing was 69%. Calvarial defect model with 8 mm diameter was generated with male Sprague-Dawley rats and 60TCP40HA was implanted. Bio-Oss was implanted for a control group and micro-CT and histology were performed at 4 and 8 weeks after implantation. The 60TCP40HA group showed better new bone formation than the Bio-Oss group and the bone formation at central area of bone defect was increased at 8 weeks in micro-CT and histology. The percent bone volume and trabecular number of the 60TCP40HA group were significantly higher than those of Bio-Oss group. This study confirms the usefulness of the porous 60TCP40HA composite as a bone graft extender by showing increased new bone formation in the calvarial defect model and improved bone formation both quantitatively and qualitatively when compared to Bio-Oss.
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81
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Mesenchymal stem cells: environmentally responsive therapeutics for regenerative medicine. Exp Mol Med 2013; 45:e54. [PMID: 24232253 PMCID: PMC3849579 DOI: 10.1038/emm.2013.94] [Citation(s) in RCA: 826] [Impact Index Per Article: 75.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 07/22/2013] [Indexed: 02/06/2023] Open
Abstract
Mesenchymal stem cells (MSCs) are partially defined by their ability to differentiate into tissues including bone, cartilage and adipose in vitro, but it is their trophic, paracrine and immunomodulatory functions that may have the greatest therapeutic impact in vivo. Unlike pharmaceutical treatments that deliver a single agent at a specific dose, MSCs are site regulated and secrete bioactive factors and signals at variable concentrations in response to local microenvironmental cues. Significant progress has been made in understanding the biochemical and metabolic mechanisms and feedback associated with MSC response. The anti-inflammatory and immunomodulatory capacity of MSC may be paramount in the restoration of localized or systemic conditions for normal healing and tissue regeneration. Allogeneic MSC treatments, categorized as a drug by regulatory agencies, have been widely pursued, but new studies demonstrate the efficacy of autologous MSC therapies, even for individuals affected by a disease state. Safety and regulatory concerns surrounding allogeneic cell preparations make autologous and minimally manipulated cell therapies an attractive option for many regenerative, anti-inflammatory and autoimmune applications.
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82
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Khashan M, Inoue S, Berven SH. Cell based therapies as compared to autologous bone grafts for spinal arthrodesis. Spine (Phila Pa 1976) 2013; 38:1885-91. [PMID: 23873235 DOI: 10.1097/brs.0b013e3182a3d7dc] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To compare the clinical outcome of cell based grafts combined with bone extenders to autologous bone grafts. SUMMARY OF BACKGROUND DATA Alternative graft options that combine mesenchymal stem cells (MSCs) and bone marrow aspirate (BMA) with synthetic or allograft scaffolds have been recently used in several animal and clinical studies. METHODS This systematic review of the literature addresses the following key questions (KQs): (1) Does the use of MSCs or BMA combined with synthetic or allograft extenders contribute to thoracolumbar fusion rates that are comparable with the rates achieved by the use of iliac crest graft? (2) Are these fusion rates comparable with those of local bone graft (LBG)? (3) Does the addition of MSCs or BMA to iliac crest bone graft or LBG contribute to better throracolumbar fusion rates? (4) Are the cervical spine fusion outcomes achieved by the use of SCM or BMA with synthetic or allograft scaffolds comparable with the iliac crest bone graft or LBG outcomes? (5) Was there any difference in terms of fusion rates, when MSCs were compared with BMA? RESULTS For KQ1, 4 level II, III studies used iliac crest bone graft as control. The results of these studies were inconsistent, and the overall body of evidence was found insufficient. Three, level II, III studies were identified for KQ2. Comparable fusion rates were demonstrated between LBG and BMA combined with calcium phosphate or collagen carrier. The overall body of evidence was found weak. For KQ3, one level III study was found. No significant difference was found in the fusion rates. No studies met the criteria for KQ4, 5. CONCLUSION The currently available evidence is insufficient to support the use of MSCs or BMA combined with synthetic or allograft materials as a substitute or supplementary graft to autologous bone graft. LEVEL OF EVIDENCE 2.
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Affiliation(s)
- Morsi Khashan
- *Orthopedic Surgery Department, University of California-San Francisco, San Francisco, CA †Department of Orthopedic Surgery, Hyogo College of Medicine, Nishinomiya, Japan
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BMP-2 induced early bone formation in spine fusion using rat ovariectomy osteoporosis model. Spine J 2013; 13:1273-80. [PMID: 23953506 DOI: 10.1016/j.spinee.2013.06.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 03/21/2013] [Accepted: 06/01/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Bone morphogenetic proteins (BMPs) enhance bone formation. Numerous animal studies have established that BMPs can augment spinal fusion. However, there is a lack of data on the effect of BMP-2 on spinal fusion in the osteoporotic spine. PURPOSE To investigate whether recombinant human BMP-2 (rhBMP-2) enhances spine fusion in an ovariectomized rat model. STUDY DESIGN In vivo animal study. METHODS Female Sprague-Dawley rats (n=60) were ovariectomized or sham operated and randomized into three groups: Sham (sham operated+fusion), ovariectomy (OVX) (OVX+fusion), and BMP (OVX+fusion+BMP-2). Six weeks after ovariectomy, unilateral lumbar spine fusion was performed using autologous iliac bone with/without rhBMP-2 delivered on a collagen matrix. For each group, gene expression and histology were evaluated at 3 and 6 weeks after fusion, and bone parameters were measured by microcomputed tomography at 3, 6, 9, and 12 weeks. RESULTS Real-time reverse-transcription polymerase chain reaction at 3 weeks showed markedly increased expression of osteoblast-related markers (namely alkaline phosphatase, osteocalcin, Runx2, Smad1, and Smad5) in the BMP group compared with the other groups (p=.0005, .0005, .003, .009 and .012, respectively). Although the Sham and OVX groups showed both sparse and compacted bones between transverse processes at 6 weeks, the BMP group had a significantly larger bone mass within the fusion bed at 3 weeks and later. All rats in the BMP group had bridging bone at 3 weeks; at 12 weeks, bridging bones in the Sham and OVX groups were about 50% and 25%, respectively, of that in the BMP group. CONCLUSIONS Recombinant human BMP-2 enhances spinal fusion in OVX rats and acts during early bone formation. Therapeutic BMP-2 may therefore improve the outcome of spinal fusion in the osteoporotic patient.
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Hustedt JW, Jegede KA, Badrinath R, Bohl DD, Blizzard DJ, Grauer JN. Optimal aspiration volume of vertebral bone marrow for use in spinal fusion. Spine J 2013; 13:1217-22. [PMID: 24075028 DOI: 10.1016/j.spinee.2013.07.435] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 11/20/2012] [Accepted: 07/03/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Bone marrow aspirate (BMA) has shown promise as a bone graft option in spinal fusion. The vertebral body is a convenient source for marrow aspirate as it is accessed in routine course of pedicle screw instrumentation. Studies have relied on data from the iliac crest to determine optimal aspiration volume from the vertebral body. PURPOSE This study is designed to determine the optimal aspiration volume for BMA taken from the vertebral body. STUDY DESIGN Prospective clinical study. PATIENT SAMPLE Data are drawn from 18 pedicles and 180 aspirations. The average age of the subjects was 50.3 years, and the subject pool comprised five men and seven women. OUTCOME MEASURES Nucleated cell count and alkaline phosphatase staining colony forming units. METHODS Ten 1 mL aliquots of BMA were incrementally aspirated through a cannulated pedicle tap for each instrumented vertebral body. The numbers of nucleated cells per mL of BMA were analyzed with a hemocytometer, and the percentage of osteoprogenitor cells per mL aspirate were estimated by an alk phos production assay. The study was funded through departmental funds, and none of the authors have any conflicts of interest to report related to the study. RESULTS Nucleated cell count decreased with increasing aspirate number (p<.001). The average cell count for the first mL was 45.8 million cells. Cell counts did not differ by age or sex (p=.943 and p=.685, respectively). Likewise, osteoprogenitor cell percentage decreased with increasing aspirate number (p<.001). CONCLUSIONS The 2 mL aspirate volume has been defined as ideal for the iliac crest, but there has been no analogous assessment of the effect of aspiration volume for other sources such as the vertebral body. This information is important for the clinical implementation of vertebral body aspirations if volume, cells, and presumably performance, of this potential bone graft option are to be optimized for spine cases. Our data show a direct relationship between increasing aspiration number and decreasing osteoprogenitor cellular concentration, with a drop to 50% of the original aspirate cell count by the 4th mL aspirate. The vertebral body is a potentially exciting source of osteoprogenitor cells that can be implemented for a variety of spinal uses.
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Affiliation(s)
- Joshua W Hustedt
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, PO Box 208071, New Haven, CT 06520-8071, USA
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Evans NR, Davies EM, Dare CJ, Oreffo RO. Tissue engineering strategies in spinal arthrodesis: the clinical imperative and challenges to clinical translation. Regen Med 2013; 8:49-64. [PMID: 23259805 DOI: 10.2217/rme.12.106] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Skeletal disorders requiring the regeneration or de novo production of bone present considerable reconstructive challenges and are one of the main driving forces for the development of skeletal tissue engineering strategies. The skeletal or mesenchymal stem cell is a fundamental requirement for osteogenesis and plays a pivotal role in the design and application of these strategies. Research activity has focused on incorporating the biological role of the mesenchymal stem cell with the developing fields of material science and gene therapy in order to create a construct that is not only capable of inducing host osteoblasts to produce bone, but is also osteogenic in its own right. This review explores the clinical need for reparative approaches in spinal arthrodesis, identifying recent tissue engineering strategies employed to promote spinal fusion, and considers the ongoing challenges to successful clinical translation.
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Affiliation(s)
- Nick R Evans
- Bone & Joint Research Group, Centre for Human Development, Stem Cells & Regeneration, Human Development & Health, Institute of Developmental Sciences, Southampton General Hospital, Southampton, UK.
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Osteoinductivity depends on the ratio of demineralized bone matrix to acellular dermal matrix in defects in rat skulls. Tissue Eng Regen Med 2013. [DOI: 10.1007/s13770-012-1083-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Lad SP, Bagley JH, Karikari IO, Babu R, Ugiliweneza B, Kong M, Isaacs RE, Bagley CA, Gottfried ON, Patil CG, Boakye M. Cancer After Spinal Fusion. Neurosurgery 2013; 73:440-9. [DOI: 10.1227/neu.0000000000000018] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Abstract
BACKGROUND:
Bone morphogenetic protein (BMP) is used in tens of thousands of spinal fusions each year. A trial evaluating a high-dose BMP formulation demonstrated that its use may be associated with an increased risk of cancer.
OBJECTIVE:
To evaluate whether BMP, as commonly used today, is associated with an increased risk of cancer or benign tumors.
METHODS:
We performed a retrospective study using the Thomson Reuter MarketScan database. We retained all patients who had no previous diagnosis of cancer or benign tumor and had at least 2 years of uninterrupted enrollment in the database before and after their operations. A propensity score--matched cohort was created to ensure greater covariate balance between treatment groups.
RESULTS:
Within the propensity score--matched cohort (n = 4698), BMP-exposed patients had a nonsignificant increase in the rate of cancer diagnosis (9.37% vs 7.92%; P = .08). After adjustment for covariates, BMP exposure was associated with a 31% increased risk of benign tumor diagnosis (odds ratio, 1.31; 95% confidence interval, 1.02-1.68; P < .05). When the benign tumor diagnoses were stratified by organ type, BMP patients had significantly more diagnoses of benign nervous system tumors (0.81% vs 0.34%; P = .03), and within this group, benign tumors of the spinal meninges were much more common in the BMP-treated group (0.13% vs 0.02%; P = .002).
CONCLUSION:
The results of this large, independent, propensity-matched study suggest that the use of BMP in lumbar fusions is associated with a significantly higher rate of benign neoplasms but not malignancies.
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Affiliation(s)
- Shivanand P. Lad
- Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jacob H. Bagley
- Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Isaac O. Karikari
- Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ranjith Babu
- Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | | | | | - Robert E. Isaacs
- Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Carlos A. Bagley
- Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Oren N. Gottfried
- Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Chirag G. Patil
- Center for Neurosurgical Outcomes Research, Maxine Dunitz Neurosurgical Institute, Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Maxwell Boakye
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky
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Porosity of β-Tricalcium Phosphate Affects the Results of Lumbar Posterolateral Fusion. ACTA ACUST UNITED AC 2013; 26:E40-5. [DOI: 10.1097/bsd.0b013e31823db5e6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hirsch BP, Unnanuntana A, Cunningham ME, Lane JM. The effect of therapies for osteoporosis on spine fusion: a systematic review. Spine J 2013; 13:190-9. [PMID: 22658879 DOI: 10.1016/j.spinee.2012.03.035] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2011] [Revised: 12/06/2011] [Accepted: 03/28/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Fusion of the spine requires de novo bone formation and remodeling, processes that rely heavily on the action of the osteoblast and osteoclast. Bisphosphonate drugs and intermittent parathyroid hormone (PTH) therapy are widely prescribed to treat osteoporosis and act on the osteoblast/osteoclast complex. The impact of these medications on spine fusion is not known. PURPOSE To evaluate the available evidence on the potential impact of bisphosphonates and PTH on fusion rate and fusion quality in spinal arthrodesis. STUDY DESIGN A systematic review of the literature. PATIENT SAMPLE All available literature regarding the impact of bisphosphonates and PTH on spinal fusion. OUTCOME MEASURES Fusion rate and histologic, microstructural, or biomechanical measures of fusion quality. METHODS A systematic review of the literature published between 1980 and 2011 was conducted using major electronic databases. The results of studies meeting criteria for inclusion were then aggregated and examined for consensus on the effect of these medications on spine fusion. RESULTS The literature contained 18 animal studies and one clinical trial investigating the impact of these medications on spine fusion. Most animal studies evaluating the impact of bisphosphonates on fusion rate have not found statistically significant changes with treatment, although this fact may be attributable to low statistical power. The animal literature does suggest that bisphosphonate therapy results in a less histologically mature fusion mass; however, the impact of these changes on fusion mass biomechanics is unclear. The only available human study suggests that these bisphosphonates may increase the radiographically defined fusion rate but did not demonstrate an impact on clinical outcome. In animals, PTH improves the fusion rate and fusion mass microstructure, but data on its effect on fusion mass biomechanics are lacking. No studies have evaluated the impact of PTH on spine fusion in humans. CONCLUSIONS In animals, bisphosphonate therapy appears to impede maturation of the fusion mass, with an unclear effect on mechanical strength. This effect was not seen in the lone human study, which suggested that these medications improved the radiographically defined fusion rate. The available animal studies on intermittent PTH treatment suggest that it may improve fusion rate and fusion mass microstructure. Given the widespread use of these agents, further investigation into their impact on human spine fusion is necessary to inform the care of patients with osteoporosis who are undergoing spine surgery.
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Affiliation(s)
- Brandon P Hirsch
- Department of Orthopaedic Surgery, University of Miami/Jackson Health System, PO Box 016960 (D-27), Miami, FL 33101, USA.
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Consciência JADCG. Evolução psicossomática e clínica de pacientes com estenose do canal lombar operados com sistema interespinhoso. COLUNA/COLUMNA 2013. [DOI: 10.1590/s1808-18512013000300008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Procuramos avaliar a eficácia terapêutica de estabilizadores interespinosos na doença degenerativa lombar, e a evolução do índice de depressão e somatização de sintomas preexistentes nesses pacientes. MÉTODOS: Estudamos 20 pacientes com estenose de canal lombar. Considerados diversos critérios de inclusão, os pacientes concordaram em participar do estudo assinando o consentimento livre e esclarecido. Na avaliação clínica e psicossomática utilizamos: Escore Euroqol (EQ-5D); escala visual analógica (EVA) lombar e dos membros inferiores; Oswestry Disability Index versão 2.0 e Modified Somatic Perception Questionnaire (MSPQ) e Zung Self-Rating Depression Scale (ZDS). A análise estatística foi realizada com os testes de Friedman e Wilcoxon, sendo o nível de significância 0,05. RESULTADOS: Existiu uma melhoria em EQ-5D (p<0,001), EVA lombar e dos membros inferiores (p<0,001), ODI (p<0,001), sem alterações significativas no MSPQ (p=0,197). CONCLUSÃO: Em pacientes com doença degenerativa lombar (grau 2 e 3 de Benzel e 3 e 4 de Pfirmann), estáveis em termos psicossomáticos, o uso de estabilizadores interespinosos revelou-se eficaz considerando a evolução clínica e o índice de depressão preexistente relacionado com a patologia diagnosticada.
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Cho JH, Cho DC, Yu SH, Jeon YH, Sung JK, Kim KT. Effect of dietary calcium on spinal bone fusion in an ovariectomized rat model. J Korean Neurosurg Soc 2012; 52:281-7. [PMID: 23133713 PMCID: PMC3488633 DOI: 10.3340/jkns.2012.52.4.281] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 07/25/2012] [Accepted: 10/04/2012] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To evaluate the effect of calcium supplementation on spinal bone fusion in ovariectomized (OVX) rats. METHODS Sixteen female Sprague Dawley rats underwent bilateral ovariectomy at 12 weeks of age to induce osteoporosis and were randomly assigned to two groups : control group (n=8) and calcium-supplemented group (OVX-Ca, n=8). Autologous spinal bone fusion surgery was performed on both groups 8 weeks later. After fusion surgery, the OVX-Ca group was supplemented with calcium in drinking water for 8 weeks. Blood was obtained 4 and 8 weeks after fusion surgery. Eight weeks after fusion surgery, the rats were euthanized and the L4-5 spine removed. Bone fusion status and fusion volume were evaluated by manual palpation and three-dimensional computed tomography. RESULTS The mean fusion volume in the L4-5 spine was significantly greater in the OVX-Ca group (71.80±8.06 mm(3)) than in controls (35.34±8.24 mm(3)) (p<0.01). The level of osteocalcin, a bone formation marker, was higher in OVX-Ca rats than in controls 4 weeks (610.08±10.41 vs. 551.61±12.34 ng/mL) and 8 weeks (552.05±19.67 vs. 502.98±22.76 ng/mL) after fusion surgery (p<0.05). The level of C-terminal telopeptide fragment of type I collagen, a bone resorption marker, was significantly lower in OVX-Ca rats than in controls 4 weeks (77.07±12.57 vs. 101.75±7.20 ng/mL) and 8 weeks (69.58±2.45 vs. 77.15±4.10 ng/mL) after fusion surgery (p<0.05). A mechanical strength test showed that the L4-5 vertebrae in the OVX-Ca group withstood a 50% higher maximal load compared with the controls (p<0.01). CONCLUSION Dietary calcium given to OVX rats after lumbar fusion surgery improved fusion volume and mechanical strength in an ovariectomized rat model.
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Affiliation(s)
- Jae-Hoon Cho
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, Korea
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Aghdasi B, Montgomery SR, Daubs MD, Wang JC. A review of demineralized bone matrices for spinal fusion: the evidence for efficacy. Surgeon 2012; 11:39-48. [PMID: 23040457 DOI: 10.1016/j.surge.2012.08.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 06/11/2012] [Accepted: 08/24/2012] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Autologous Iliac Crest Bone Grafting (ICBG) is considered the gold-standard graft choice for spinal arthrodesis; however, it is associated with donor site morbidity and a limited graft supply. Bone graft alternatives to replace autograft and augment arthrodesis are a topic of ongoing research. This article will review properties of Demineralized Bone Matrix (DBM) and review the evidence for its use, including animal models and human clinical trials. METHODS A systematic and critical review of the English-language literature was conducted on Pubmed, Cochrane, CINAHL, and Google Scholar using search key terms such as 'Demineralized Bone Matrix', 'Spine' and 'Fusion'. Papers that were included were original research articles in peer-reviewed journals that investigated fusion outcomes. Scientific validity of articles was appraised using the PRISMA methodology. Articles were critically examined and compared according to study design, DBM type, outcomes, and results. Primary outcome of interest was fusion rate. Secondary outcomes included Oswestry Disability Index; Short Form-36 survey; Odom's criteria; Visual Analog Scale neurologic pain score; Japanese Orthopedic Association myelopathy score; Neck Disability and Ishihara Curvature Indices; and pseudarthrosis and surgical failure rates. RESULTS Demineralized Bone Matrix has been evaluated in animal models and human clinical trials of spine fusion. Results of animal studies indicate variation in performance within and among DBM products. The majority of human clinical trials report high fusion rates when DBM is employed as a graft extender or a graft enhancer. Few prospective randomized controlled trials have been performed comparing DBM to autologous iliac crest bone graft in spine fusion. CONCLUSIONS Although many animal and human studies demonstrate comparable efficacy of DBM when combined with autograft or compared to autograft alone, additional high level of evidence studies are required to clearly define the indications for its use in spine fusion surgeries and the appropriate patient population that will benefit from DBM.
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Affiliation(s)
- B Aghdasi
- Department of Orthopaedic Surgery, University of California at Los Angeles, Los Angeles, CA 90095, USA.
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Platelet-rich plasma combined with hydroxyapatite for lumbar interbody fusion promoted bone formation and decreased an inflammatory pain neuropeptide in rats. Spine (Phila Pa 1976) 2012; 37:1727-33. [PMID: 22433505 DOI: 10.1097/brs.0b013e31825567b7] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective interventional trial, using a rat model of lumbar interbody fusion. OBJECTIVE To examine the potential efficacy of platelet-rich plasma (PRP) for lumbar interbody fusion, using hydroxyapatite (HA). SUMMARY OF BACKGROUND DATA PRP is an autologous product containing a high concentration of platelets in a small volume of plasma and has osteoinductive effects. HA has osteoconductive ability and has been used in combination with autogenous bone for spine fusion. However, reports using PRP with HA for spine fusion are very few. The purpose of this study was to examine the efficacy of PRP with HA for spinal interbody fusion and at the same time to estimate the change in immunoreactivity of the inflammatory neuropeptide, calcitonin gene-related peptide (CGRP), in dorsal root ganglion (DRG) neurons innervating spinal discs. METHODS A total of 35 Sprague-Dawley rats were used in this study. Twenty-one rats were used for conducting interbody fusion experiments, 7 rats were used as immunostaining controls, and 7 other rats were used as blood donors for making PRP. L5-L6 interbody fusion was performed on 21 rats using HA + PRP (n = 7), HA + platelet-poor plasma (n = 7), or HA + saline (n = 7). Simultaneously, Fluoro-Gold neurotracer was applied to the intervertebral space to detect DRG neurons innervating the discs. L5-L6 lumbar radiographs were obtained and lumbar DRGs were immunostained for CGRP. The rate of bone union and the change in CGRP immunoreactive DRG neurons innervating the discs were evaluated and compared among groups. RESULTS All L5-L6 lumbar discs were fused in the PRP + HA group (fused 7/total 7), whereas only 1 case was fused in the platelet-poor plasma group (1 of 7) and no cases in the HA-only group (0 of 7), which was a significant difference. Upon immunohistochemical analysis, CGRP-positive neurons innervated L5-L6 intervertebral discs in nonunion cases, and these were significantly increased compared with those in union cases. CONCLUSION Our study suggests that using PRP with HA was beneficial for spine fusion. This combination may promote bone union and also decrease inflammatory neuropeptide in sensory neurons innervating the discs.
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Koo KH, Lee JH, Chang BS, Lee CK. Effects of alendronate on lumbar posterolateral fusion using hydroxyapatite in rabbits. Artif Organs 2012; 36:1047-55. [PMID: 22963016 DOI: 10.1111/j.1525-1594.2012.01509.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
There are controversies regarding the effect of alendronate on spine fusion. In order to study the effects of alendronate on fusion with porous hydroxyapatite, a total of 47 rabbits underwent posterolateral lumbar fusion. The rabbits received saline (control group), alendronate 0.5 mg/kg/week (low-dose group), or alendronate 1 mg/kg/week (high-dose group) per oral beginning 2 weeks before surgery. All animals were euthanized 12 weeks after surgery, and the extent of fusion was assessed by radiographs, manual palpation, computed tomography (CT) scan, mechanical testing, and histologic examination. The fusion rates by manual palpation, radiography, and CT scan were similar in all groups. There was no significant difference in pixel optic density from the CT scan. Biomechanical testing showed the tensile strength of the control group was higher than that of the treatment group including the low- and high-dose group. In histologic examination, the fusion masses of control animals were characterized by a higher predominance of well-incorporated, trabeculated bone with a prominent marrow element. The treatment group showed a higher proportion of woven bone structures and thicker bony trabeculae. There was no significant difference in the fusion rate, but the tensile strength of treatment group was significantly lower. Histologic examination showed that alendronate inhibited bone resorption and remodeling.
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Affiliation(s)
- Ki Hyoung Koo
- Department of Orthopaedic Surgery, Dongguk University Ilsan Hospital, Goyang, Korea
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Should symptomatic iliac screws be electively removed in adult spinal deformity patients fused to the sacrum? Spine (Phila Pa 1976) 2012; 37:1175-81. [PMID: 22146291 DOI: 10.1097/brs.0b013e3182426970] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective, single-institution review of adult deformity patients who underwent iliac screw (IS) removal placed during fusion to the sacrum. OBJECTIVE To demonstrate whether IS removal offered benefit in terms of hip/buttock pain overlying the IS and whether IS could be removed without significant complications. SUMMARY OF BACKGROUND DATA ISs are effective at countering cantilever forces imparted on sacral pedicle screws. Despite the efficacy of IS fixation, pain or implant prominence can lead to elective IS removal. There has been no study about IS removal in adult spinal deformity patients. METHODS A total of 395 consecutive walking adult spinal deformity patients fused to the sacrum with IS fixation and minimum 2-year follow-up met study inclusion criteria. Clinical/radiographical data were analyzed. Because there is no validated pain outcomes instrument specific to this situation, an 8-question IS removal questionnaire was designed and used for the sole purpose of this inquiry, within which a universally accepted numeric rating scale for pain was included. RESULTS.: Twenty-four of 395 (6.1%) patients (2 men and 22 women) with mean age of 50.5 ± 10.8 years underwent elective IS removal at mean 2.6 ± 1.3 years from index surgery. Mean follow-up from initial surgery was 6.3 ± 4.0 years. Symptoms included hip/buttock pain in all 24 patients and IS prominence in 5 patients (20.8%). Screw removal was bilateral in 18 (75%) patients and unilateral in 6 (25%) patients. Using a numeric rating pain scale (0-10), hip/buttock pain improved after IS removal: preoperative 6.9 ± 1.8, postoperative 2.0 ± 2.7 (P < 0.05). Patients reported hip/buttock symptoms post-IS removal as "much improved" (78.3%), "somewhat improved" (8.7%), and "unchanged" (13.0%). Two of 24 (8.3%) patients sustained complications from IS removal (wound infection, n = 1; coronal/sagittal imbalance, n = 1). Presented with the same set of circumstances, 22 of 24 (91.7%) patients would have their IS removed again, including one of the patients who had a complication. CONCLUSION Of 395 consecutive walking patients who had ISs placed during fusion to the sacrum for adult spinal deformity, 24 (6.1%) underwent elective removal. Patients had a statistically significant improvement in hip/buttock pain after IS removal, and a low prevalence of complications after the procedure was observed.
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Odri GA, Hami A, Pomero V, Seite M, Heymann D, Bertrand-Vasseur A, Skalli W, Delecrin J. Development of a per-operative procedure for concentrated bone marrow adjunction in postero-lateral lumbar fusion: radiological, biological and clinical assessment. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2012; 21:2665-72. [PMID: 22639299 DOI: 10.1007/s00586-012-2375-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Revised: 04/07/2012] [Accepted: 05/10/2012] [Indexed: 12/13/2022]
Abstract
PURPOSE Addition of bone marrow to the bone graft in the postero-lateral lumbar arthrodesis is a widely used technique. Bone marrow brings stem cells and growth factors contained in the platelets, favorable for bone growth. Adjunction of concentrated bone marrow should create better conditions and may increase bone growth. METHODS Simple blind randomized clinical, prospective, monocentric trial was conducted. Fifteen patients underwent lumbar arthrodesis. During surgery, a fraction of the bone marrow harvested was centrifuged. One side received this concentrate with autologous bone and ceramics; the other side received the same graft with unconcentrated bone marrow. A quantitative study, realised with a volume calculating software on CT-scan images, determined the cortical bone volume in the graft post-operatively and at 3 months. The osteoprogenitor cells, nucleated cells and platelet concentrations were determined. RESULTS The biological study found an average concentration of six times for the nucleated cells, 3.5 times for the platelets and 2.2 times for the osteoprogenitor cells. The comparison of the mean cortical bone volumes post-operatively and at 3 months was not significantly different. CONCLUSIONS Despite the concentration obtained, there was no increase of bone growth by adding concentrated bone marrow. However, the number of stem cells in bone marrow was low and maybe a stronger concentration is needed to obtain a difference. The 3D reconstruction of the graft and the analysis of the graft's volume using a novel software was efficient according to the similarity of the graft's volume post-operatively in all patients.
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Affiliation(s)
- G A Odri
- Clinique Chirurgicale Orthopédique et Traumatologique, CHU Hôtel Dieu, 1 Place Alexis Ricordeau, 44093, Nantes Cedex 1, France.
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Abstract
STUDY DESIGN Randomized, controlled study in a laboratory setting. Blinded observations/assessment of study outcomes. OBJECTIVE The purpose of this study was to determine the performance characteristics of MASTERGRAFT PUTTY as a bone graft extender in a rabbit posterolateral spine fusion model. SUMMARY OF BACKGROUND DATA The rabbit posterolateral fusion model is an established environment for testing of fusion concepts. It offers the opportunity to obtain radiographical, histological, and biomechanical data on novel fusion materials. METHODS Thirty-six rabbits were entered into the study with 30 used for analysis. Bilateral posterolateral lumbar intertransverse fusions were performed at L5-L6. The lateral two-thirds of the transverse processes were decorticated and covered with graft material: autograft only (2.5-3.0 cc per side), 25% MASTERGRAFT PUTTY/75% autograft (3.0 cc total per side), or 50% MASTERGRAFT PUTTY and 50% autograft (3.0 cc total per side). Animals were humanely killed at 8 weeks postsurgery. RESULTS The autograft group had a 63% radiographical fusion rate (5 of 8) and correlated with manual palpation results (63%). The 25% MASTERGRAFT PUTTY group had a 73% radiographical fusion rate (8 of 11) and a manual palpation fusion rate of 64%. The 50% MASTERGRAFT PUTTY group demonstrated a 91% (10 of 11) radiographical fusion rate and 73% manual palpation fusion rate. Histologically, no inflammatory reactions were evident regardless of implant. The 2 MASTERGRAFT PUTTY groups had new bone in direct apposition to the MASTERGRAFT ceramic granules. CONCLUSION In this commonly used rabbit posterolateral fusion model, MASTERGRAFT PUTTY in an autograft extender mode produces clinically and radiographically similar results to autograft fusion alone.
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Zeitouni S, Krause U, Clough BH, Halderman H, Falster A, Blalock DT, Chaput CD, Sampson HW, Gregory CA. Human mesenchymal stem cell-derived matrices for enhanced osteoregeneration. Sci Transl Med 2012; 4:132ra55. [PMID: 22553253 PMCID: PMC11034748 DOI: 10.1126/scitranslmed.3003396] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/24/2024]
Abstract
The methodology for the repair of critical-sized or non-union bone lesions has unpredictable efficacy due in part to our incomplete knowledge of bone repair and the biocompatibility of bone substitutes. Although human mesenchymal stem cells (hMSCs) differentiate into osteoblasts, which promote bone growth, their ability to repair bone in vivo has been variable. We hypothesized that given the multistage process of osteogenesis, hMSC-mediated repair might be maximal at a specific time point of healing. Using a mouse model of calvarial healing, we demonstrate that the osteo-repair capacity of hMSCs can be substantially augmented by treatment with an inhibitor of peroxisome proliferator-activated receptor γ, but efficacy is confined to the rapid osteogenic phase. Upon entry into the bone-remodeling phase, hMSC retention signals are lost, resulting in truncation of healing. To solve this limitation, we prepared a scaffold consisting of hMSC-derived extracellular matrix (ECM) containing the necessary biomolecules for extended site-specific hMSC retention. When inhibitor-treated hMSCs were coadministered with ECM, they remained at the injury, well into the remodeling phase of healing, which resulted in reproducible and complete repair of critical-sized bone defects in mice in 3 weeks. These data suggest that hMSC-derived ECM and inhibitor-treated hMSCs could be used at optimal times to substantially and reproducibly improve bone repair.
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Affiliation(s)
- Suzanne Zeitouni
- Institute for Regenerative Medicine at Scott and White Hospital, Texas A&M Health Science Center, Module C, 5701 Airport Road, Temple, TX 76502
- Systems Biology and Translational Medicine, Texas A&M Health Science Center, 701 Southwest H.K. Dodgen Loop, Temple, TX 76504
| | - Ulf Krause
- Institute for Regenerative Medicine at Scott and White Hospital, Texas A&M Health Science Center, Module C, 5701 Airport Road, Temple, TX 76502
| | - Bret H. Clough
- Institute for Regenerative Medicine at Scott and White Hospital, Texas A&M Health Science Center, Module C, 5701 Airport Road, Temple, TX 76502
| | - Hillary Halderman
- Systems Biology and Translational Medicine, Texas A&M Health Science Center, 701 Southwest H.K. Dodgen Loop, Temple, TX 76504
| | - Alexander Falster
- Department of Earth and Environmental Sciences, University of New Orleans, New Orleans, LA 70148
| | - Darryl T. Blalock
- Institute for Regenerative Medicine at Scott and White Hospital, Texas A&M Health Science Center, Module C, 5701 Airport Road, Temple, TX 76502
| | - Christopher D. Chaput
- Department of Orthopedic Surgery, Scott and White Hospital, Texas A&M Health Science Center, 2401 S. 31st Street, Temple, TX 76508
| | - H. Wayne Sampson
- Systems Biology and Translational Medicine, Texas A&M Health Science Center, 701 Southwest H.K. Dodgen Loop, Temple, TX 76504
| | - Carl A. Gregory
- Institute for Regenerative Medicine at Scott and White Hospital, Texas A&M Health Science Center, Module C, 5701 Airport Road, Temple, TX 76502
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Heterotopic ossification associated with recombinant human bone morphogenetic protein-2 (infuse) in posterolateral lumbar spine fusion: a case report. Spine (Phila Pa 1976) 2012; 37:E502-6. [PMID: 22020605 DOI: 10.1097/brs.0b013e318238870b] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A case of heterotopic ossification in the lumbar spine associated with the off-label use of recombinant human bone morphogenetic protein-2 (rhBMP-2) is reported. OBJECTIVE To highlight a previously unreported complication of rhBMP-2 use and to review the literature pertinent to the topic. SUMMARY OF BACKGROUND DATA There is no report in the literature regarding a large mass of rhBMP-2-associated heterotopic ossification surrounding the paraspinal musculature. METHODS The clinical and radiographical features of this complication and treatment course are presented. RESULTS The surgical excision of heterotopic ossification and removal of symptomatic instrumentation have resulted in the patient remaining asymptomatic at 1 year of follow-up examination. CONCLUSION The reported case adds to the literature of off-label use of rhBMP-2 and the potential for the formation of heterotopic ossification with its use.
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Koo KH, Yeo DH, Ahn JM, Kim BS, Kim CS, Im GI. Lumbar Posterolateral Fusion Using Heparin-Conjugated Fibrin for Sustained Delivery of Bone Morphogenic Protein-2 in a Rabbit Model. Artif Organs 2012; 36:629-34. [DOI: 10.1111/j.1525-1594.2012.01444.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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