Comparative evaluation of the osteoinductivity of two formulations of human demineralized bone matrix

Optimized bone grafting

Bone grafting is routinely performed in periodontology and oral surgery to fill bone voids. While autogenous bone is considered the gold standard because of its regenerative properties, allografts and xenografts have more commonly been utilized owing to their availability as well as their differential regenerative/biomechanical properties. In particular, xenografts are sintered at high temperatures, which allows for their slower degradation and resorption rates and/or nonresorbable features. As a result, clinicians have combined xenografts with other classes of bone grafts (most notably allografts and autografts in various ratios) for procedures requiring better long-term stability, such as contour grafting, sinus elevation procedures, and vertical bone augmentations. This review addresses the regenerative properties of each class of bone grafts and then highlights the importance of understanding each of their biomechanical and regenerative properties for clinical applications, including extraction site management, contour augmentation, sinus grafting, and horizontal and vertical augmentation procedures. Thereafter, an introduction toward the novel production of nonresorbable bone allografts (NRBAs) via high-temperature sintering is presented. These NRBAs not only pose the advantage of being more biocompatible than xenografts owing to their origin (human vs. animal bone) but also display nonresorbable properties similar to those of xenografts. Thus, while packaging allografts with xenografts in premixtures specific to various clinical indications has never been permitted owing to cross-species contamination and FDA/CE requirements, the discovery and production of NRBAs allows premixing with standard allografts in various ratios without regulatory restrictions. Therefore, premixtures of allografts with NRBAs can be produced in various ratios for specific indications (e.g., a 1:1 ratio similar to an allograft/xenograft mixture for sinus grafting) without the need for purchasing separate classes of bone grafts. This optimized form of bone grafting could theoretically provide clinicians more precise ratios without the need to purchase separate bone grafts. This review highlights the future potential for simplified and optimized bone grafting in periodontology and implant dentistry.

Enhanced osteogenicity of the demineralized bone-dermal matrix composite by the optimal partial demineralization for sustained release of bioactive molecules

Allogenic demineralized bone matrix (DBM), processed to expose bioactive proteins imbedded by calcium salts, is widely used for bone repair and regeneration as an alternative to the autologous bone graft. However, demineralized bone matrices from tissue banks vary significantly in residual calcium content and osteogenicity for clinical bone regeneration. The present study produced DBM with various residual calcium contents by partial demineralization using ethylenediaminetetraacetic acid disodium (EDTA) and hydrochloric acid. Compositional analysis reveals that, as the percent weight loss of bone materials increases from 0% to 74.9% during demineralization, the residual calcium content of DBM decreases from 24.8% to 0.2% and collagen content increases from 29.7% to 92.6%. Calorimetrical analysis and Fourier transform infrared (FTIR) analysis demonstrated that demineralization to the residual calcium content of <4% enables the complete exposure and/or release of bone collagen fibers and other bioactive molecules. In order to evaluate the relationship between the extent of demineralization and the osteogenicity of DBM, DBM particles were fabricated with the aid of acellular dermal matrix (ADM) microfibers to form flexible foam-like DBM/ADM composites. Proteomic analysis identified various type collagens and bone formation-related bioactive molecules in both ADM and DBM. Using the rat bilateral Φ = 5 mm calvarium defect repair model, the study had shown that the DBM/ADM composite with ~20% DBM residual calcium (e.g., ~40% calcium being removed) maximized the osteogenicity for bone defect repair after 4 and 8 weeks. DBM with ~40% calcium removal had the maximal osteogenicity presumably through the sustained release of bioactive molecules during the process of bone regeneration.

Allogenic Bone Graft in Dentistry: A Review of Current Trends and Developments

In an effort to prepare non-autologous bone graft or biomaterial that would possess characteristics comparable to autologous bone, many different allogenic bone derivatives have been created. Although different existing processing methods aim to achieve the very same results, the specific parameters applied during different stages material preparation can result in significant differences in the material's mechanical and biological properties The properties, including osteoconductive, osteoinductive, and even osteogenic potential, can differ vastly depending on particular preparation and storage techniques used. Osteogenic properties, which have long been thought to be characteristic to autogenic bone grafts only, now seem to also be achievable in allogenic materials due to the possibility to seed the host's stem cells on a graft before its implantation. In this article, we aim to review the available literature on allogenic bone and its derivatives as well as the influence of different preparation methods on its performance.

PEGylated Coating Affects DBM Osteoinductivity In Vivo by Changing Inflammatory Responses

PEGylation is a widely used modification in device coating or drug delivery by combing materials with poly(ethylene glycol) (PEG). In the present study, a well-established rat ectopic bone formation model was used to elucidate how PEGylated coating affects demineralized bone matrix (DBM) osteoinductivity in vivo by changing the inflammation events at the early phase of implantation. A range of cell-matrix interactions was characterized at the cellular and functional levels, including growth factor activity and kinetics, immune cell migration and activation, and bone formation in vivo. After 28 days, DBM's bone formation potential decreased in groups with increasing PEG concentration in the gelatin carrier. The increasing PEG concentration did not affect DBM's osteoinductive growth factor release or activity. However, increasing PEG cross-linking concentration resulted in decreased DBM-related early phase inflammatory reactions, reduced neutrophil infiltration, decreased coating material degradation, lowered the total number and active mast cells, and decreased CD80+ macrophage expression. Understanding and controlling cell-material responses may improve the design and development of functional medical devices.

The use of demineralised bone fibres (DBF) in conjunction with supercritical carbon dioxide (SCCO2) treated allograft in anterior lumbar interbody fusion (ALIF)

Spinal fusion is a common procedure for the treatment of various spinal pathologies. Since the early days, spinal fusion has been carried out with the use of bone grafts as interbody spacers. With the development of synthetic interbody implants, bone grafts were used to facilitate fusion. Although autograft provides the best outcomes for fusion, allografts have been sought after due to donor site morbidity and other shortcomings. Currently, a vast variety of demineralised bone matrix (DBM) products are available with their methods of processing and preparation impacting their properties and clinical outcomes. Demineralised bone fibres (DBF), a form a DBM can be easily packed into implants when mixed with other substances such as allograft bone and patient's blood providing a scaffold for the mixture. We report two cases of anterior lumbar interbody fusion (ALIF) utilising a titanium-polyetheretherketone (PEEK) interbody cage filled with DBF, allograft and patient's blood with a maximum of 12 months follow-up outcome.

Risk factors in bone augmentation procedures

Bone augmentation is an extremely common procedure in implant dentistry today because of significant advancements with reactive biomaterials, a better understanding of the mechanism of action that is found with growth factors contained in platelets, and improvements in surgical techniques. The expectation is for the surgeon to place the dental implant in the position that best serves the requirements of the prosthetic restorations. With the increasing demands that patients have for ideal prosthetic results, surgeons are expected to predictably augment both hard and soft tissues to provide the anticipated esthetic and functional outcomes. Bone grafting can be performed before, during, and after the implant placement; however, these augmentation procedures come with increased cost, the risk of complications such as infection or failure, and lengthening of the total treatment time. In addition, a plethora of grafting materials are available commercially, where they are often inadequately studied, or there is minimal information regarding their predictability or long-term success, or ability to support dental implants. It is clear that although the surgical field has seen major progress since early implant surgical techniques in the 1980s, major challenges still exist with hard tissue augmentation procedures. This review will discuss these challenges that are increased and often specific to bone graft healing, and which are becoming more common as implant site development often requires bone augmentation to improve volume or contour deficiencies. The risk factors that patients may present with that will affect outcomes with bone augmentation procedures are identified, and recommendations for the prevention of complications or managing complications once they have occurred are provided.

Current Updates on Bone Grafting Biomaterials and Recombinant Human Growth Factors Implanted Biotherapy for Spinal Fusion: A Review of Human Clinical Studies

BACKGROUND

Owing to their great promise in the spinal surgeries, bone graft substitutes have been widely investigated for their safety and clinical potential. By the current advances in the spinal surgery, an understanding of the precise biological mechanism of each bone graft substitute is mandatory for upholding the induction of solid spinal fusion.

OBJECTIVE

The aim of the present review is to critically discuss various surgical implications and level of evidence of most commonly employed bone graft substitutes for spinal fusion.

METHOD

Data was collected via electronic search using "PubMed", "SciFinder", "ScienceDirect", "Google Scholar", "Web of Science" and a library search for articles published in peer-reviewed journals, conferences, and e-books.

RESULTS

Despite having exceptional inherent osteogenic, osteoinductive, and osteoconductive features, clinical acceptability of autografts (patient's own bone) is limited due to several perioperative and postoperative complications i.e., donor-site morbidities and limited graft supply. Alternatively, allografts (bone harvested from cadaver) have shown great promise in achieving acceptable bone fusion rate while alleviating the donor-site morbidities associated with implantation of autografts. As an adjuvant to allograft, demineralized bone matrix (DBM) has shown remarkable efficacy of bone fusion, when employed as graft extender or graft enhancer. Recent advances in recombinant technologies have made it possible to implant growth and differentiation factors (bone morphogenetic proteins) for spinal fusion.

CONCLUSION

Selection of a particular bone grafting biotherapy can be rationalized based on the level of spine fusion, clinical experience and preference of orthopaedic surgeon, and prevalence of donor-site morbidities.

Minor Review: An Overview of a Synthetic Nanophase Bone Substitute

Material is reviewed that consists of reconstituted collagen fibril gel mineralized in a manner that produces biomimetically sized nanoapatites intimately associated with the fibrils. This gel is formed into usable shapes with a modulus and strength that allow it to be surgically press fitted into bony defects. The design paradigm for the material is that the nanoapatites will dissolve into soluble Ca²⁺ as the collagen is degraded into RGD-containing peptide fragments due to osteoclastic action. This is intended to signal to the osteoclasts to continue removing the material in a biomimetic fashion similar to bony remodeling. Preliminary experiments in a subcutaneous rat model show that the material is biocompatible with respect to inflammatory and immunogenic responses, and that it supports cellular invasion. Preliminary experiments in a critical-sized mandibular defect in rats show that the material is resorbable and functions well as a bone morphogenetic 2 (BMP-2) carrier. We have produced a range of mechanical and biological responses by varying mechanical and chemical processing of the material.

The effects of Exendin-4 on bone marrow-derived mesenchymal cells

PURPOSE

GLP-1 receptor agonists are antidiabetic drugs currently used in the therapy of type 2 diabetes. Despite several in vitro and in vivo animal studies suggesting a beneficial effect of GLP-1 analogues on bone, in humans their skeletal effects are not clear and clinical studies report conflicting results.

METHODS

We differentiated human mesenchymal stromal cells (hMSC) toward the adipogenic and the osteoblastic lineages, analysing the effect of Exendin-4 (EXE) before, during and after specific differentiations.

RESULTS

We showed EXE ability to act selectively on a sub-population of hMSC characterised by a more stem potential, shifting them from G1 to S/M phase of cell cycle. We observed that EXE pre-treatment promotes both adipogenic and osteoblastic differentiations, possibly determined by an increased number of uncommitted progenitors. In fully differentiated cells, EXE affects mature adipocytes by increasing lipolysis, otherwise not altering osteoblasts metabolic activity. Moreover, the increased expression of osteoprotegerin, a modulator of the RANK/RANKL system, observed during osteogenic induction in presence of EXE, could negatively modulate osteoclastogenesis.

CONCLUSIONS

Our data suggest a complex action of EXE on bone, targeting the proliferation of mesenchymal progenitors, the metabolism of mature adipocytes and the modulation of osteoclastogenesis. Thus, an overall positive effect of this molecule on bone quality might be hypothesised.

Irradiation Sterilized Gelatin-Water-Glycerol Ternary Gel as an Injectable Carrier for Bone Tissue Engineering

Injectable gelatin gels offer an attractive option for filling bone defects. The challenge is to fabricate gelatin gels with optimal gelation properties, which can be irradiation sterilized. Here, a gelatin-water-glycerol (GWG) gel is reported for use as a broad-spectrum injectable carrier. This ternary gel is high in glycerol and low in water, and remains stable after gamma irradiation at doses (25 kGy). As an injectable gel, it remains a viscous solution at gelatin concentrations ≤2.0%, at room temperature. Its storage modulus increases dramatically and eventually exceeds the loss modulus around 46-50 °C, indicating a transition from a liquid-like state to an elastic gel-like state. This ternary gel ranges significantly in terms of storage modulus (12-1700 Pa) while demonstrating a narrow pH range (5.58-5.66), depending on the gelatin concentration. Therefore, it can be loaded with a variety of materials. It is highly cytocompatible compared with saline in vivo and culture media in vitro. When loaded with demineralized bone matrix, the composites show favorable injectability, and excellent osteogenesis performance, after irradiation. These features can be attributed to high hydrophilicity and fast degradability. These findings justify that this ternary gel is promising as an irradiation-sterilized and universal injectable delivery system.

Clinical, Radiographic, and Histologic Evaluation of Maxillary Sinus Lift Procedure Using a Highly Purified Xenogenic Graft (Laddec(®))

OBJECTIVES

The aim of this study was to evaluate the clinical, radiographic and histologic results when a highly purified xenogenic bone (Laddec(®)) was used as grafting material in maxillary sinuses.

MATERIAL AND METHODS

In fifteen patients requiring unilateral maxillary sinus augmentation, the grafting procedure was performed with Laddec(®). Forty-two implants were installed after a 6 month healing period. The height of the augmented sinus was measured radiographically immediately after augmentation and postoperatively up to 36 months. At the time of implant placement, a bone core was harvested in each patient for histological examination.

RESULTS

The cumulative implant survival rate was 97.6%. The original height was 3.65 (SD 0.7) mm and the augmented sinus height was 13.8 (SD 1.4) mm after the surgery. The reduced height of grafted xenogenic material (RDL) at the implant insertion was 0.83 (SD 0.38) mm, and at the final postoperative visit was 0.91 (SD 0.25) mm, showing no significant correlation with the follow-up periods by Spearman's test (P = 0.118). In addition, no significant difference in the RDL was observed according to the site of implantation (P = 0.682). The mean implant marginal bone loss was 0.38 (SD 0.24) mm. Histological analysis showed the bone cores were composed of 64.72 (SD 3.44)% newly formed bone, 17.41 (SD 2.02)% connective tissue, 16.93 (SD 2.83)% residual graft particles, and 0.94 (SD 0.11)% inflammatory cells.

CONCLUSIONS

According to our data, the highly purified xenogenic bone (Laddec(®)), used as graft material in the sinus lift procedure, may create adequate bone volume, and appropriate osseointegration of dental implants.

Benefits of biphasic calcium phosphate hybrid scaffold-driven osteogenic differentiation of mesenchymal stem cells through upregulated leptin receptor expression

Background

The use of mesenchymal stem cells (MSCs) and coralline hydroxyapatite (HA) or biphasic calcium phosphate (BCP) as a bone substitute for posterolateral spinal fusion has been reported. However, the genes and molecular signals by which MSCs interact with their surrounding environment require further elucidation.

Methods

MSCs were harvested from bone grafting patients and identified by flow cytometry. A composite scaffold was developed using poly(lactide-co-glycolide) (PLGA) copolymer, coralline HA, BCP, and collagen as a carrier matrix for MSCs. The gene expression profiles of MSCs cultured in the scaffolds were measured by microarrays. The alkaline phosphatase (ALP) activity of the MSCs was assessed, and the expression of osteogenic genes and proteins was determined by quantitative polymerase chain reaction (Q-PCR) and Western blotting. Furthermore, we cultured rabbit MSCs in BCP or coralline HA hybrid scaffolds and transplanted these mixtures into rabbits for spinal fusion. We investigated the differences between BCP and coralline HA hybrid scaffolds by dual-energy X-ray absorptiometry (DEXA) and computed tomography (CT).

Results

Tested in vitro, the cells were negative for hematopoietic cell markers and positive for MSC markers. There was higher expression of 80 genes and lower of 101 genes of MSCs cultured in BCP hybrid scaffolds. Some of these genes have been shown to play a role in osteogenesis of MSCs. In addition, MSCs cultured in BCP hybrid scaffolds produced more messenger RNA (mRNA) for osteopontin, osteocalcin, Runx2, and leptin receptor (leptin-R) than those cultured in coralline HA hybrid scaffolds. Western blotting showed more Runx2 and leptin-R protein expression in BCP hybrid scaffolds. For in vivo results, 3D reconstructed CT images showed continuous bone bridges and fusion mass incorporated with the transverse processes. Bone mineral content (BMC) values were higher in the BCP hybrid scaffold group than in the coralline HA hybrid scaffold group.

Conclusions

The BCP hybrid scaffold for osteogenesis of MSCs is better than the coralline HA hybrid scaffold by upregulating expression of leptin-R. This was consistent with in vivo data, which indicated that BCP hybrid scaffolds induced more bone formation in a spinal fusion model.

Evaluation of the effect of a gamma irradiated DBM-pluronic F127 composite on bone regeneration in Wistar rat

Demineralized bone matrix (DBM) is widely used for bone regeneration. Since DBM is prepared in powder form its handling properties are not optimal and limit the clinical use of this material. Various synthetic and biological carriers have been used to enhance the DBM handling. In this study we evaluated the effect of gamma irradiation on the physical-chemical properties of Pluronic and on bone morphogenetic proteins (BMPs) amount in DBM samples. In vivo studies were carried out to investigate the effect on bone regeneration of a gamma irradiated DBM-Pluronic F127 (DBM-PF127) composite implanted in the femur of rats. Gamma irradiation effects (25 kGy) on physical-chemical properties of Pluronic F127 were investigated by rheological and infrared analysis. The BMP-2/BMP-7 amount after DBM irradiation was evaluated by ELISA. Bone regeneration capacity of DBM-PF127 containing 40% (w/w) of DBM was investigated in transcortical holes created in the femoral diaphysis of Wistar rat. Bone porosity, repaired bone volume and tissue organization were evaluated at 15, 30 and 90 days by Micro-CT and histological analysis. The results showed that gamma irradiation did not induce significant modification on physical-chemical properties of Pluronic, while a decrease in BMP-2/BMP-7 amount was evidenced in sterilized DBM. Micro-CT and histological evaluation at day 15 post-implantation revealed an interconnected trabeculae network in medullar cavity and cellular infiltration and vascularization of DBM-PF127 residue. In contrast a large rate of not connected trabeculae was observed in Pluronic filled and unfilled defects. At 30 and 90 days the DBM-PF127 samples shown comparable results in term of density and thickness of the new formed tissue respect to unfilled defect. In conclusion a gamma irradiated DBM-PF127 composite, although it may have undergone a significant decrease in the concentration of BMPs, was able to maintains bone regeneration capability.

Use of demineralized bone matrix in the extremities

Autologous bone graft is considered as the gold standard for all indications for bone grafting procedures but the limited availability and complications in donor site resulted in seeking other options like allografts and bone graft substitutes. Demineralized bone matrix (DBM) is an allograft product with no quantity limitation. It is an osteoconductive material with osteoinductive capabilities, which vary among different products, depending on donor characteristics and differences in processing of the bone. The purpose of the present review is to provide a critical review of the existing literature concerning the use of DBM products in various procedures in the extremities. Clinical studies describing the use of DBM alone or in combination with other grafting material are available for only a few commercial products. The Level of Evidence of these studies and the resulting Grades of Recommendation are very low. In conclusion, further clinical studies of higher quality are required in order to improve the Recommendation Grades for or against the use of DBM products in bone grafting procedures.

Use of demineralized bone matrix in spinal fusion

Spinal fusion remains the gold-standard treatment for several pathological spine conditions. Although, autologous Iliac Crest Bone Grafting is considered the gold-standard graft choice to promote spinal fusion; however, it is associated with significant donor site morbidity and a limited graft quantity. Therefore, several bone graft alternatives have been developed, to augment arthrodesis. The purpose of this review is to present the results of clinical studies concerning the use of demineralized bone matrix (DBM), alone or as a composite graft, in the spinal fusion. A critical review of the English-language literature was conducted on Pubmed, using key word “demineralized bone matrix”, “DBM”, “spinal fusion”, and “scoliosis”. Results had been restricted to clinical studies. The majority of clinical trials demonstrate satisfactory fusion rates when DBM is employed as a graft extender or a graft enhancer. Limited number of prospective randomized controlled trials (4 studies), have been performed comparing DBM to autologous iliac crest bone graft in spine fusion. The majority of the clinical trials demonstrate comparable efficacy of DBM when it used as a graft extender in combination with autograft, but there is no clinical evidence to support its use as a standalone graft material. Additionally, high level of evidence studies are required, in order to optimize and clarify the indications of its use and the appropriate patient population that will benefit from DBM in spine arthrodesis.

Outcomes and complication rates of different bone grafting modalities in long bone fracture nonunions: a retrospective cohort study in 182 patients

BACKGROUND

Novel bone substitutes have challenged the notion of autologous bone grafting as the 'gold standard' for the surgical treatment of fracture nonunions. The present study was designed to test the hypothesis that autologous bone grafting is equivalent to other bone grafting modalities in the management of fracture nonunions of the long bones.

METHODS

A retrospective review of patients with fracture nonunions included in two prospective databases was performed at two US level 1 trauma centers from January 1, 1998 (center 1) or January 1, 2004 (center 2), respectively, until December 31, 2010 (n = 574). Of these, 182 patients required adjunctive bone grafting and were stratified into the following cohorts: autograft (n = 105), allograft (n = 38), allograft and autograft combined (n = 16), and recombinant human bone morphogenetic protein-2 (rhBMP-2) with or without adjunctive bone grafting (n = 23). The primary outcome parameter was time to union. Secondary outcome parameters consisted of complication rates and the rate of revision procedures and revision bone grafting.

RESULTS

The autograft cohort had a statistically significant shorter time to union (198 ± 172-225 days) compared to allograft (416 ± 290-543 days) and exhibited a trend towards earlier union when compared to allograft/autograft combined (389 ± 159-619 days) or rhBMP-2 (217 ± 158-277 days). Furthermore, the autograft cohort had the lowest rate of surgical revisions (17%) and revision bone grafting (9%), compared to allograft (47% and 32%), allograft/autograft combined (25% and 31%), or rhBMP-2 (27% and 17%). The overall new-onset postoperative infection rate was significantly lower in the autograft group (12.4%), compared to the allograft cohort (26.3%) (P < 0.05).

CONCLUSION

Autologous bone grafting appears to represent the bone grafting modality of choice with regard to safety and efficiency in the surgical management of long bone fracture nonunions.

Guided bone regeneration using demineralized allogenic bone matrix with calcium sulfate: case series

PURPOSE

The purpose of this case series was to evaluate the effect of guided bone regeneration using demineralized allogenic bone matrix with calcium sulfate.

MATERIALS AND METHODS

Guided bone regeneration using Demineralized Allogenic Bone Matrix with Calcium Sulfate (AlloMatrix™, Wright. USA) was performed at the time of implant placement from February 2010 to April 2010. At the time of the second surgery, clinical evaluation of bone healing and histologic evaluation were performed. The study included 10 patients, and 23 implants were placed. The extent of bony defects around implants was determined by measuring the horizontal and vertical bone defects using a periodontal probe from the mesial, distal, buccal, and lingual sides and calculating the mean and standard deviation of these measurements. Wedge-shaped tissue samples were obtained from 3 patients and histologic examination was performed.

RESULTS

In clinical evaluation, it was observed that horizontal bone defects were completely healed with new bones, and in the vertical bone defect area, 15.1% of the original defect area remained. In 3 patients, histological tests were performed, and 16.7-41.7% new bone formation was confirmed. Bone graft materials slowly underwent resorption over time.

CONCLUSION

AlloMatrix™ is an allograft material that can be readily manipulated. It does not require the use of barrier membranes, and good bone regeneration can be achieved with time.

Demineralized bone matrix in bone repair: history and use

Demineralized bone matrix (DBM) is an osteoconductive and osteoinductive commercial biomaterial and approved medical device used in bone defects with a long track record of clinical use in diverse forms. True to its name and as an acid-extracted organic matrix from human bone sources, DBM retains much of the proteinaceous components native to bone, with small amounts of calcium-based solids, inorganic phosphates and some trace cell debris. Many of DBM's proteinaceous components (e.g., growth factors) are known to be potent osteogenic agents. Commercially sourced as putty, paste, sheets and flexible pieces, DBM provides a degradable matrix facilitating endogenous release of these compounds to the bone wound sites where it is surgically placed to fill bone defects, inducing new bone formation and accelerating healing. Given DBM's long clinical track record and commercial accessibility in standard forms and sources, opportunities to further develop and validate DBM as a versatile bone biomaterial in orthopedic repair and regenerative medicine contexts are attractive.

Beta-tricalcium phosphate particles as a controlled release carrier of osteogenic proteins for bone tissue engineering

Beta-tricalcium phosphate (β-TCP) has been widely used as bone substitutes and delivery carriers of osteogenic proteins. However, low protein carrying capacity and agent burst release profiles of β-TCP limit their usage. This study investigates strategies to enhance protein carrying capacity of β-TCP particles with reduced initial burst by surface etching in citric acid solution or by creating apatite coatings with the simulate body fluid immersion approach. The release kinetics of protein from the modified β-TCP particles was investigated using Nel-like molecule-1 (Nell-1), a novel osteogenic protein, as a model protein. Although chemical etching treatments reduced the initial burst release of protein from the particles, a rapid burst release was observed with high protein dose. In contrast, the burst release of protein was significantly reduced by the apatite coating and a high protein dose was successfully delivered over a prolonged period from the apatite-coated particles. Protein release was further modulated by simultaneously delivering proteins from two different substrates: acid-etched and apatite-coated particles. The bioactivity of the protein was preserved during the loading procedure onto the particles. In addition, protein-loaded particles maintained biological activity in the lyophilized state over 4 weeks. These findings suggest that the protein carrying capacity of β-TCP can be modulated by surface modification, which has a potential for use as a protein carrier with controlled release.

Characterization of the inflammatory response to four commercial bone graft substitutes using a murine biocompatibility model

Bone grafting is utilized in nearly all orthopedic subspecialties and in most anatomic regions. Bone graft substitutes have the potential to offer similar efficacy as autogenous grafts without the morbidity of harvest. Several studies have noted the efficacy of new-generation bone substitute products, but few studies have evaluated their safety. This study characterizes and quantifies the inflammatory reaction to four different commercially available bone graft substitutes, which were examined using the in vivo murine air pouch biocompatibility model. One coralline hydroxyapatite product was chosen as an example of a purely osteoconductive material. Three demineralized bone matrix products were chosen to represent products that are both osteoconductive and osteoinductive. Samples were implanted in a murine air pouch and harvested after 14 days in situ. Pouch fluid was extracted, mRNA isolated, and reverse transcription polymerase chain reactions carried out to detect interleukin-1 gene expression as a marker for inflammation. In addition, multiple histological characteristics were examined to quantify cellular responses to the implanted materials. All bone graft substitutes induced a significant inflammatory response compared with negative controls. Histology and polymerase chain reaction data indicated that the level of inflammatory reaction was elevated in materials with a higher demineralized bone matrix to carrier proportion. The hydroxyapatite product generated a low inflammatory reaction. In conclusion, this study used an in vivo model of biocompatibility to demonstrate that a significant inflammatory reaction occurs when using implanted bone graft substitutes. When choosing a bone grafting method, surgeons should consider both the efficacy and safety of methods and materials used. Further studies are necessary to determine the ideal bone graft material to maximize efficacy while minimizing morbidity.

Feasibility of demineralized bone matrix for craniomaxillofacial contour restoration

Demineralized bone matrix (DBM) could be a good alternative for craniomaxillofacial contour restoration, especially in perialar, malar, temporal, and frontal regions. In this study, the histologic behavior of DBM was investigated in different tissue planes to determine its proper application plane for restoration of craniomaxillofacial contour deformities and defects.Forty Wistar rats were divided into 6 groups: (1) 0.3 mL of 0.9% saline was injected into the subperiosteal plane of the cranium, (2) 0.3 mL of DBM was implanted into the subperiosteal plane of the cranium, (3) 0.3 mL of 0.9% saline was injected into the subdermal plane on the left inguinal region, (4) 0.3 mL of DBM was implanted into the subdermal plane on the right inguinal region, (5) 0.3 mL of 0.9% saline was injected between the left external and internal oblique muscles, and (6) 0.3 mL of DBM was implanted between the right external and internal oblique muscles. At the 8th week half of the rats and at 16th week the remaining rats were killed in each group, and tissue samples were harvested. Histological and immunohistochemical evaluation revealed new bone tissue and bone marrow formation in all planes that DBM was given.Demineralized bone matrix can provide satisfactory results in craniomaxillofacial contour deformities including forehead, temporal, and malar augmentations, as well as mental and perialar augmentations and saddle nose corrections, with supraperiosteal or deep subcutaneous applications. However, superficial applications must be avoided because of the possibility of palpation, because it induces hard bone tissue formation in all tissue planes.

Grafting using injectable calcium sulfate in bone tumor surgery: comparison with demineralized bone matrix-based grafting

Background

Injectable calcium sulfate is a clinically proven osteoconductive biomaterial, and it is an injectable, resorbable and semi-structural bone graft material. The purpose of this study was to validate the clinical outcomes of injectable calcium sulfate (ICS) grafts as compared with those of a demineralized bone matrix (DBM)-based graft for filling in contained bony defects created by tumor surgery.

Methods

Fifty-six patients (41 males and 15 females) with various bone tumors and who were surgically treated between September 2003 and October 2007 were included for this study. The patients were randomly allocated into two groups, and either an ICS graft (28 patients) or a DBM-based graft (28 patients) was implanted into each contained defect that was developed by the surgery. The radiographic outcomes were compared between the two groups and various clinical factors were included for the statistical analysis.

Results

When one case with early postoperative pathologic fracture in the DBM group was excluded, the overall success rates of the ICS and DBM grafting were 85.7% (24/28) and 88.9% (24/27) (p > 0.05), respectively. The average time to complete healing was 17.3 weeks in the ICS group and 14.9 weeks in the DBM group (p > 0.05). Additionally, the ICS was completely resorbed within 3 months, except for one case.

Conclusions

Although the rate of resorption of ICS is a concern, the injectable calcium sulfate appears to be a comparable bone graft substitute for a DBM-based graft, with a lower cost, for the treatment of the bone defects created during surgery for various bone tumors.

Combined effects of porous hydroxyapatite and demineralized bone matrix on bone induction: in vitro and in vivo study using a nude rat model

Hydroxyapatite (HA) is an osteoconductive material used as a bone graft extender and demineralized bone matrix (DBM) has been used as a source of osteoinductive factors. A combination of DBM and HA is expected to create a composite with both osteoconductive and osteoinductive properties. This study examined the effect of a combination of DBM and HA on osteogenesis both in vitro and in vivo using an athymic nude rat abdominal muscle pouch model, and evaluated the possibility of HA as a carrier of DBM. Alkaline phosphatase (ALP) staining, ALP assay and measurements of the mRNA expression of ALP and Runx2 by RT-PCR were performed by transplanting human mesenchymal stem cells onto a plate. Five athymic nude rats each were assigned to one of two experimental groups (DBM/HA putty and only HA, i.e. 15 pouches per group). The muscle pouches were filled with DBM/HA putty or only HA. Radiographs were obtained at weeks 4 and 8, postoperatively. The animals were sacrificed at week 8 postoperatively and high resolution microCT was used to confirm the newly formed mineralized tissue. Each pouch was fixed, embedded, sectioned and processed for hematoxylin and eosin staining. The ALP value of the DBM/HA putty was higher than those of HA and control (p < 0.05, each). The expression of ALP mRNA appeared higher on the DBM/HA putty than on HA and control. MicroCT and histology examinations of the DBM/HA putty demonstrated the presence of newly generated mineralized tissues but there was no mineralized tissue in the HA cases. In conclusion, the DBM/HA putty indicated osteoblastic differentiation in vitro and showed ectopic mineralized tissue formation in the rat abdominal pouch model. These findings indicate that the DBM/HA putty can retain its oteoinductivity and HA can be used as a carrier of DBM.

Implant installation with bone augmentation and transmucosal healing with demineralized human cortical bone in the maxillary anterior region: report of 3 cases

It is well known that a decrease in vertical height and in horizontal width is seen after tooth extraction. Immediate implant placement, originally thought to prevent buccal wall resorption, showed little or no evident decrease of the resorption rate or pattern in animal experiments or clinical studies. Thus, the need for bone augmentation with immediate implantation has been suggested. However, until recently, simultaneous bone augmentation with immediate implant placement was thought to be possible only in a submerged environment. In this report, the harmony of soft and hard tissue was achieved in 3 patients by immediate implant placement and bone augmentation with transmucosal healing in esthetically challenging situations. Further evaluation is needed to monitor hard- and soft-tissue changes on a long-term basis. Implant placement and bone augmentation with transmucosal healing using demineralized bone matrix may be an option in the treatment of the loss of anterior teeth.

Complications and concerns with osteobiologics for spine fusion in clinical practice

STUDY DESIGN

Literature-based topic review.

OBJECTIVE

To review the complications and the concerns that may be associated with all of the commonly used osteobiologic options for spine fusion.

SUMMARY OF BACKGROUND DATA

Obtaining a solid arthrodesis is an important objective in many lumbar surgical procedures, and a wide array of bone graft materials may be used in an attempt to achieve this goal. Iliac crest bone graft, as well as all of the available osteobiologic alternatives, carries potential risks and concerns for both patient and surgeon.

METHODS

Review of literature and expert opinion.

CONCLUSION

Some of the potential complications associated with osteobiologic materials used in spinal fusion are well understood and clearly documented whereas others require further study and clarification. In any given clinical situation, the patient and surgeon need to balance the benefits and performance characteristics of the graft material with the risk profile to optimize clinical management.

A clinical study on bone formation using a demineralized bone matrix and resorbable membrane

OBJECTIVES

The purpose of this study was to evaluate new bone formation following guided bone regeneration (GBR) using a composite of demineralized cortical and nondemineralized cancellous bone admixed in a poloxamer reverse phase carrier (Orthoblast II) and resorbable collagen membrane (Ossix).

STUDY DESIGN

Fourteen patients (14 specimens) participated in this study from January 2006 to May 2006. In all these 14 patients, bone grafting for the regeneration of dehiscence defects around the implants was required. At the 4- and/or 6-month healing period, a biopsy specimen was obtained by one oral and maxillofacial surgeon. The specimens were fixed, demineralized, embedded, and sectioned by a pathologist, and histomorphometric evaluations were performed using a computer-assisted Visus Image Analysis System.

RESULTS

A high proportion of new bone formation (12.3%-78.7%) was observed during the 4- and/or 6-month healing period. Although histopathologic findings indicated that the grafted materials did not completely resorb, new bone formation and bone remodeling were observed to increase with healing time.

CONCLUSION

It was concluded from this study that the use of GBR consisting of Orthoblast II and Ossix membranes caused favorable bone formation during the 6-month healing period. Additionally, the increase in the woven bone to lamellar bone (LB/WB) ratio and the new bone to residual graft material (NB/GM) ratio observed in this 6-month study also provided evidence of increasing bony remodeling and maturity as well as the continuous resorption of the grafting materials.

Variability across ten production lots of a single demineralized bone matrix product

BACKGROUND

Demineralized bone matrix is an osteoinductive allograft derived from processed bone that is commonly mixed with autogenous bone in fusion procedures to treat diseases of the spine. An increasing number of demineralized bone matrix-based products are commercially available for spinal fusion procedures, but osteoinductive variability has been found not only across different products but also among production lots from the same demineralized bone matrix formulation. The purpose of this study was to assess the lot-to-lot variability across a single demineralized bone matrix-based product in terms of both extracted bone morphogenetic protein (BMP) concentrations (in vitro) and fusion performance in rats (in vivo). The goal was also to determine whether the in vitro measures could sufficiently and accurately predict the in vivo fusion performance of different demineralized bone matrix-based product lots.

METHODS

BMP-2 and BMP-7 were extracted from ten production lots of InterGro DBM Putty and quantified with use of ELISA (enzyme-linked immunosorbent assay). A posterolateral lumbar spinal fusion was performed on forty athymic rats with implantation of a demineralized bone matrix-based product. Fusion success was determined at eight weeks with use of radiographs and manual palpation of the segments. Logistic regression was used to determine the predictive abilities of BMPs.

RESULTS

Significant lot-to-lot variability was found in terms of both BMP concentrations (22 to 110 pg of BMP-2 per milligram of product and 44 to 125 pg of BMP-7 per milligram of product) and in vivo rates of fusion (0% to 75%; p < 0.04 for all). BMP-2 and BMP-7 concentrations correlated positively with each other across lots (r = 0.77, p < 0.0001). Most notably, extracted amounts of BMP-2 and BMP-7 each predicted in a dose-dependent manner the in vivo fusion performance in rats (R(2) = 0.32, p < 0.01 for BMP-2, and R(2) = 0.22, p < 0.009 for BMP-7).

CONCLUSIONS

Assays for demineralized bone matrix-extracted BMP-2 and BMP-7 levels may be feasible and sufficient for predicting spinal fusion performance of individual production lots from the same demineralized bone matrix-based product.

Effects of e-beam radiation, storage, and hydration on osteoinductivity of DBM/AM composite

E-beam irradiation is often used to sterilize medical devices including demineralized bone matrix (DBM) products. In this study, the effect of e-beam on osteoinductivity of a DBM product in hydrous and anhydrous configurations has been evaluated at 0-, 6- and 12-month ambient storage using a nude rat muscle pouch model. The thermal and structural stabilities of DBM and acellular dermal matrix (AM) composites were analyzed using differential scanning calorimetry (DSC) and trypsin digestion assay. Both hydrous and anhydrous DBM/AM composites exhibited osteoinductivity after e-beam irradiation of 15 kGy. After 12-month ambient storage, the osteoinductivity of hydrous DBM/AM was diminished, whereas the anhydrous DBM/AM retained its osteoinductive potential. However, the DSC and trypsin analysis revealed that the DBM in anhydrous DBM/AM was more vulnerable to damage from e-beam irradiation than its hydrous counterpart. This study has found that although the anhydrous DBM has more structural damage than hydrous DBM from e-beam irradiation, it has retained its osteoinductivity better after 1-year ambient storage.

Effects of gamma-irradiation, storage and hydration on osteoinductivity of DBM and DBM/AM composite

This study investigated the effect of gamma-irradiation dose, irradiation temperature, hydration and storage condition on osteoinductivity of demineralized bone matrix (DBM) and demineralized bone matrix/acellular dermal matrix (DBM/AM) composite. DBM and DBM/AM in dry and hydrated form were treated with gamma-irradiation of 15-40 kGy at ambient or low temperature (-40 degrees C approximately -70 degrees C) and then stored at ambient condition for 6 months. The athymic rat muscle implant model was used to evaluate the osteoinductive potential of the DBM and DBM/AM composites. Histological and alkaline phosphatase (ALPase) activity assessments were carried out at 28 days after implantation to determine the new bone formation and ALPase activity. Both histological and ALPase activity analysis showed that the osteoinductivity of DBM decreased with the increase of gamma-irradiation dose at ambient temperature, whereas no decrease occurred when treated with gamma-irradiation at low temperature. However, the hydrated DBM showed diminishing osteoinductivity after 6-month storage at ambient condition, whereas the DBM in dry form retained their osteoinductivity after the 6-months storage. The findings in this study indicate that DBM and DBM/AM composites could retain their osteoinductivity when they are in dry configuration and are irradiated at low temperature (-40 degrees C approximately -70 degrees C) using the custom-made cold gamma-irradiation system.

In vitro and in vivo optimization of impaction allografting by demineralization and addition of rh-OP-1

Impaction allografting is a bone tissue engineering technique currently used in lower limb reconstruction orthopedic surgery. Our hypothesis was that biological optimization can be achieved by demineralization and addition of osteogenic protein-1 (OP-1) to the allograft. The objective of our in vitro study was to evaluate human mesenchymal stem cell (MSC) proliferation (Alamar Blue assay, titrated thymidine assay, total DNA Hoechst 33258, and scanning electron microscopy) and osteogenic differentiation (alkaline phosphatase assay) in two types of impacted carrier, namely, demineralized bone matrix (DBM) and insoluble collagenous bone matrix (ICBM), with or without OP-1. The objective in vivo was to compare the osteogenic potential of impacted DBM with or without OP-1, with that of impacted fresh frozen allograft (FFA), again with or without OP-1. DBM + OP-1 optimized osteoinduction and significantly improved (p < 0.05) proliferation and differentiation in comparison to the majority of all other graft preparation in vitro. In addition, DBM + OP-1 was significantly superior, with regard to osteogenesis, compared to the impacted FFA alone (p < 0.001), FFA + OP-1 (p = 0.01) and DBM alone (p = 0.02) in vivo. We propose that partial demineralization and addition of OP-1 provides a good method for improving the osteoinductive properties of fresh allograft currently used in the impaction grafting technique.

Safety and efficacy of commercially available demineralised bone matrix preparations: a critical review of clinical studies

Demineralised bone matrix (DBM), a form of allograft, possesses the properties of osteoinductivity and osteoconductivity. A large body of data obtained from extensive preclinical studies have clearly supported the utility of DBM in human clinical settings. However, it is now recognized that various DBM configurations may differ considerably with regard to their bone inductive activity. Several factors could account for such variability, including the biologic properties of the graft, the host environment, and the methods of allograft preparation. The differing efficacy of DBM products may also depend on differences in particle size and shape, donor selection criteria, protocols for collection and storage, as well as DBM carrier materials. Several comparative studies have confirmed the differences in the osteoinductive potential of various DBM preparations. The purpose of the present review is to provide a critical overview of the current applications of DBM in a clinical setting.

Quantification of various growth factors in different demineralized bone matrix preparations

Besides autografts, allografts, and synthetic materials, demineralized bone matrix (DBM) is used for bone defect filling and treatment of non-unions. Different DBM formulations are introduced in clinic since years. However, little is known about the presents and quantities of growth factors in DBM. Aim of the present study was the quantification of eight growth factors important for bone healing in three different "off the shelf" DBM formulations, which are already in human use: DBX putty, Grafton DBM putty, and AlloMatrix putty. All three DBM formulations are produced from human donor tissue but they differ in the substitutes added. From each of the three products 10 different lots were analyzed. Protein was extracted from the samples with Guanidine HCL/EDTA method and human ELISA kits were used for growth factor quantification. Differences between the three different products were seen in total protein contend and the absolute growth factor values but also a large variability between the different lots was found. The order of the growth factors, however, is almost comparable between the materials. In the three investigated materials FGF basic and BMP-4 were not detectable in any analyzed sample. BMP-2 revealed the highest concentration extractable from the samples with approximately 3.6 microg/g tissue without a significant difference between the three DBM formulations. In DBX putty significantly more TGF-beta1 and FGFa were measurable compared to the two other DBMs. IGF-I revealed the significantly highest value in the AlloMatrix and PDGF in Grafton. No differences were accessed for VEGF. Due to the differences in the growth factor concentration between the individual samples, independently from the product formulation, further analyzes are required to optimize the clinical outcome of the used demineralized bone matrix.

Evaluation of DBM/AM composite as a graft substitute for posterolateral lumbar fusion

Demineralized bone matrix (DBM) has been investigated as a bone graft substitute for spinal fusion with less morbidity. Various carriers have been added to DBM to enhance its handling characteristics. This study investigates the spinal fusion induced by a composite of DBM and acellular dermal matrix (AM) in comparison with autologous bone in an athymic rat spinal fusion model. Single-level intertransverse process fusions were performed in 60 athymic nude rats grafted with 2 mL/kg of DBM/AM composite, AM alone, or autologous bone. Fusion was assessed at 6 weeks by radiography, manual palpation, and histology. At 6 weeks, 70% of the animals from the DBM/AM composite group exhibited complete spine fusion, whereas 35% from the autologous bone group and 20% from AM group showed bridging with some gaps. The DBM/AM composite induced a significantly higher fusion rate than both the autologous bone and AM groups (p < 0.001) in all measured parameters. The current study demonstrated that using DBM/AM composite can have more robust fusion than autologous bone at 6 weeks in an athymic rat spinal fusion model.

An overview of the histology of skeletal substitute materials

CONTEXT

Orthopedic and spine surgeons are in frequent need of bone for skeletal reconstruction. The amount of autograft is limited, and conventional allograft has some disadvantages, so surgeons are now using increasing amounts of demineralized allograft and a variety of synthetic materials to replace or "extend" autograft.

OBJECTIVE

To provide an overview of the composition and histology of the materials most likely to be seen by pathologists today.

DATA SOURCES

The review is based on published literature and the author's experience with preclinical studies and human biopsies.

CONCLUSIONS

Pathologists are likely to find these skeletal substitute materials in biopsy and resection specimens from patients who have undergone prior treatment, and recognizing a synthetic bone substitute can help explain an otherwise confusing specimen. Pathologists also play an important role in helping define the safety and efficacy of new bioactive materials.

A comparison of commercially available demineralized bone matrix for spinal fusion

In an effort to augment the available grafting material as well as to increase spinal fusion rates, the utilization of a demineralized bone matrix (DBM) as a graft extender or replacement is common. There are several commercially available DBM substances available for use in spinal surgery, each with different amounts of DBM containing osteoinductive proteins. Each product may have different osteoinductivity potential due to different methods of preparation, storage, and donor specifications. The purpose of this study is to prospectively compare the osteoinductive potential of three different commercially available DBM substances in an athymic rodent spinal fusion model and to discuss the reasons of the variability in osteoinductivity. A posterolateral fusion was performed in 72 mature athymic nude female rats. Three groups of 18 rats were implanted with 1 of 3 DBMs (Osteofil, Grafton, and Dynagraft). A fourth group was implanted with rodent autogenous iliac crest bone graft. The rats were sacrificed at 2, 4, 6, and 8 weeks. A dose of 0.3 cm(3) per side (0.6 cm(3)per animal) was used for each substance. Radiographs were taken at 2 weeks intervals until sacrifice. Fusion was determined by radiographs, manual palpation, and histological analysis. The Osteofil substance had the highest overall fusion rate (14/18), and the highest early 4 weeks fusion rate of (4/5). Grafton produced slightly lower fusion rates of (11/17) overall, and lower early 4 weeks fusion rate of (2/5). There was no statistically significant difference between the rate of fusion after implantation of Osteofil and Grafton. None of the sites implanted with Dynagraft fused at any time point (0/17), and there was a significantly lower fusion rate between the Dynagraft and the other two substances at the six-week-time point and for final fusion rate (P = 0.0001, Fischer's exact test). None of the autogenous iliac crest animals fused at any time point. Non-decalcified histology confirmed the presence of a pseudarthrosis or the presence of a solid fusion, and the results were highly correlated with the manual testing. Although all products claim to have significant osteoinductive capabilities, this study demonstrates that there are significant differences between some of the tested products.

Evaluation of bone regeneration at critical-sized calvarial defect by DBM/AM composite

This study investigated the bone-regenerative potential of a demineralized bone and acellular matrix (DBM/AM) composite (AlloCraft DBM) in comparison with autologous bone using an in vivo model. Critical-sized calvarial defects (5 mm) were created in athymic rats. The defects were grafted with either the DBM/AM composite or the acellular human dermal matrix (AM), and compared with the defects filled with autologous bone (positive control) and the empty defect (negative control). Histological and radiographic assessments were carried out at 4 and 8 weeks after surgery to determine the biological healing, the amount and type of new bone formation and the percentage of new bone filled in the critical defects. At 4 weeks, DBM/AM composite group had the highest percentage of the defect filled with new bone (84%), which was significantly greater than autologous bone (62%), AM (41%), and untreated control (32%) groups. At 8 weeks, the DBM/AM continued to have the highest percentage of the defect filled with new bone (91%). The autologous bone group increased the percentage of bone fill to 83%. The defects either filled with AM or left untreated still had less of the defect filled with new bone, 57% and 33%, respectively. The total healing of defects grafted with DBM/AM was comparable with autologous bone group at 8 weeks. The results demonstrated that the DBM/AM composite promoted new bone formation more rapidly than autologous bone at calvarial defect in athymic rats. The study supports that DBM/AM is a potential substitute of autologous bone for bone repair.

Prefabrication of Vascularized Bone Flap by Demineralized Bone Matrix

Demineralized bone matrix (DBM) has been reported to have osteoconductive and osteoinductive properties and has been clinically used as a bone graft alternative. In the present study we attempted to generate a vascularized bone flap by subcutaneous implantation of DBM with a vascular loop to provide blood supply in a rat model. Thirty male Sprague-Dawley rats were divided into two groups according to the presence or absence of blood supply. In the experimental group, the bone flap was created by application of 0.4 mL of DBM onto two pieces of gelatin sponge sheets between which a vascular loop was sandwiched. A prefabricated flap without a vascular loop served as the control. The flaps were biopsied at three different time intervals postoperatively (2, 4, and 6 weeks). The results showed that DBM induced subcutaneous bone formation in both of the groups. However, in the nonvascularized group, the amount of bony tissue had decreased at four postoperative weeks and continued to do so afterwards. In contrast, bone formation was active at four weeks in the vascularized group. Our study indicated that implantation of DBM can prefabricate a bone flap. Blood supply to the flap is considered a key factor of the success of this prefabrication.

The osteoinductive properties of Nell-1 in a rat spinal fusion model

BACKGROUND CONTEXT

Recombinant growth factors bone morphogenetic protein-2 (BMP-2) and BMP-7 are currently approved for human use but are associated with various adverse effects including ectopic bone formation and local inflammatory reaction. The development of alternative growth factors may help minimize the adverse effects of current osteoinductive therapeutics. Nell-1 (Nel-like molecule-1; Nel [a protein strongly expressed in neural tissue encoding epidermal growth factor like domain]) is a novel secretory molecule that appears to act more specifically on osteoblasts than the BMPs, which can act on multiple cell types. From a molecular point of view, Nell-1 is directly regulated by runt-related transcription factor 2 (Runx2/Cbfa1), a master regulatory gene controlling bone formation. Previous studies showed that Nell-1 accelerates osteogenic differentiation in vitro and calvarial bone formation in vivo. We hypothesize that Nell-1 may also effectively form bone in spinal fusion.

PURPOSE

Our primary aim was to assess if direct adenoviral gene delivery with Nell-1 in a demineralized bone matrix (DBM) carrier can improve spinal fusion in a rat model. Because adenoviral vectors allow for sustained growth factor delivery, they were used for initial feasibility testing before protein studies.

STUDY DESIGN/SETTING

Two groups of 20 athymic rats underwent posterolateral intertransverse process spinal fusion at L4-L5 with implanted DBM carrier containing either adenovirus coding for Nell-1 (AdNell-1) or control, Lac Z (AdLacZ). No cells were implanted. The 20 rats were sacrificed at 6 weeks for evaluation of spinal fusion.

METHODS

All animals underwent Faxitron radiographs at 2, 4, and 6 weeks, manual spine palpation at 6 weeks, and high-resolution micro computerized tomography (microCT) at 6 weeks. Spinal fusion rate was assessed by: 1) 6-week Faxitron images; 2) manual palpation by three independent observers; 3) microCT; and 4) histology. New bone formation was assessed by hematoxylin-eosin and Masson trichrome staining on decalcified, coronally sectioned spine segments.

RESULTS

All differences achieved statistical significance. After 6 weeks, direct application of adenoviral Nell-1 in a DBM carrier achieved significantly higher rates of spinal fusion over Lac Z controls: 60% Nell-1 versus 20% Lac Z by manual palpation and 70% Nell-1 versus 20% Lac Z by microCT and histology. Histological assessment of bone quality and maturity revealed more mature, higher quality bone in all the Nell-1 treated specimens relative to Lac Z at 6 weeks.

CONCLUSIONS

Spinal fusion is more accurately assessed by microCT and histology than manual palpation. Direct application of adenoviral Nell-1 in a DBM carrier achieved significantly higher rates of spinal fusion over Lac Z controls at 6 weeks. Direct application of adenoviral Nell-1 in a DBM carrier also achieved significantly higher rates of spinal fusion over other reports in the literature using direct adenoviral BMP application. Direct application of adenoviral BMP in an allograft carrier achieved 8% fusion for BMP-2 and 16% fusion for BMP-7 at 8 weeks. These results indicate that Nell-1 may be a potent osteoinductive molecule. In addition, the regulation of Nell-1 by the master bone regulatory gene, Runx2 suggests that Nell-1 may exert its effects more specifically in osteoblastic cells than BMPs which affect multiple cell types. Overall, Nell-1 may fulfil a current need for an osteoinductive factor.

Augmentation of demineralized bone matrix (DBM) mineralization by a synthetic growth factor mimetic

These studies evaluated whether F2A4-K-NS, a peptide mimetic of FGF-2, could augment ectopic bone production following the subcutaneous implant of human demineralized bone matrix (DBM). DBM was formulated into a gel with and without F2A4-K-NS, and injected subcutaneously into athymic rats. After 28 days the resultant tissue was excised and fixed. The tissue was examined with soft X-rays and microcomputerized tomography (micro-CT), and by histological methods. Inclusion of F2A4-K-NS with DBM resulted in an increased mineral deposition as determined by soft X-ray and micro-CT analysis and von Kossa staining. DBM-containing tissues showed extensive mineralization compared to the carrier alone, which was poorly mineralized. The mineralization was qualitatively and quantitatively the most extensive in the samples containing F2A4-K-NS plus DBM. Additionally, the highest amount of von Kossa staining for calcium was observed in tissues from animals that had received DBM plus F2A4-K-NS. In these studies, 100 ng of peptide per 0.2 mL of injectable DBM gel generated the most optimal results. The synthetic peptide F2A4-K-NS augmented DBM-induced ectopic mineralization in athymic animals.

Commercially Available Demineralized Bone Matrix Compositions to Regenerate Calvarial Critical-Sized Bone Defects

BACKGROUND

Demineralized bone matrix products are often used by surgeons to regenerate bone. Several different types of carriers have been combined with demineralized bone matrix to improve clinical handling and surgical outcome. The aim of the study was to quantitate bone regeneration in standard-sized calvarial defects (a critical-sized defect) in response to commercially available demineralized bone matrix formulations.

METHODS

The commercial demineralized bone matrix formulations were tested as received in 8-mm-diameter calvarial critical-sized defects in an athymic rat model. The demineralized bone matrix treatment groups included the following: (1) Allomatrix; (2) demineralized bone matrix plus sodium hyaluronate (DBX); (3) DBX with poly(DL-lactide) mesh; 4) Dynagraft; (5) Grafton; (6) Regenafil; and (7) human demineralized bone matrix without a carrier. An eighth treatment was a poly(DL-lactide) mesh. At designated times of 2, 4, and 8 weeks, the critical-sized defects were recovered and processed for undecalcified histology and histomorphometry. Histomorphometric data were subjected to an analysis of variance and Fisher's protected least significant difference multiple comparison test. Significance was established at p <or= 0.05.

RESULTS

Allomatrix, Dynagraft, Regenafil, and poly(DL-lactide) mesh alone had less bone formation than DBX, Grafton, DBX plus mesh, and demineralized bone matrix.

CONCLUSIONS

DBX, DBX plus mesh, demineralized bone matrix, and Grafton produced more bone formation than Allomatrix, Dynagraft, mesh alone, and Regenafil.