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

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.

Comparison of demineralized bone matrix with different cycling crushing times in posterolateral fusion model of athymic rats

Decalcified bone matrix (DBM) is a widely used alternative material for bone transplantation. In the DBM production process, an effective particle size and the highest utilization rate of raw materials can be achieved only through multiple high-speed circulating comminution. The rat posterolateral lumbar fusion model (PLF) is the most mature small animal model for the initial evaluation of the efficacy of graft materials for bone regeneration and spinal fusion. To evaluate the differences in the in vivo osteogenic effects of DBM pulverization through 1, 5, 9, and 14 high-speed cycles, sixty athymic rats were divided into six groups: single cycling crushing (CC1), 5 cycles of crushing (CC5), 9 cycles of crushing (CC9), 13 cycles of crushing (CC13), autogenous bone graft (ABG) and negative control (NC). Posterolateral lumbar fusion was performed. Six weeks after surgery, the bilateral lumbar fusion of athymic rats was evaluated through manual palpation, X-ray, micro-CT and histological sections. Rank data were tested by the rank-sum test, and nonparametric data were tested by the Kruskal‒Wallis H test. The manual palpation and X-ray results showed that the fusion rate did not significantly differ between the CC1, CC5, CC9, CC13 and ABG groups. However, cavities appeared in CC9 and CC13 on the micro-CT image. The bone mass (BV/TV) of CC1, CC5, CC9 and CC13 was better than that of the ABG group, while almost no osteogenesis was observed in the NC group. Histologically, there was no obvious difference between the four groups except that the CC9 group and CC13 group had more fibrous tissues in the new bone. In conclusion, DMB with different cycling crushing times has no obvious difference in fusion rate of PLF, but it is slightly better than the ABG group.

Murine models of posterolateral spinal fusion: A systematic review

BACKGROUND

Rodent models are commonly used experimentally to assess treatment effectiveness in spinal fusion. Certain factors are associated with better fusion rates. The objectives of the present study were to report the protocols most frequently used, to evaluate factors known to positively influence fusion rate, and to identify new factors.

METHOD

A systematic literature search of PubMed and Web of Science found 139 experimental studies of posterolateral lumbar spinal fusion in rodent models. Data for level and location of fusion, animal strain, sex, weight and age, graft, decortication, fusion assessment and fusion and mortality rates were collected and analyzed.

RESULTS

The standard murine model for spinal fusion was male Sprague Dawley rats of 295g weight and 13 weeks' age, using decortication, with L4-L5 as fusion level. The last two criteria were associated with significantly better fusion rates. On manual palpation, the overall mean fusion rate in rats was 58% and the autograft mean fusion rate was 61%. Most studies evaluated fusion as a binary on manual palpation, and only a few used CT and histology. Average mortality was 3.03% in rats and 1.56% in mice.

CONCLUSIONS

These results suggest using a rat model, younger than 10 weeks and weighing more than 300 grams on the day of surgery, to optimize fusion rates, with decortication before grafting and fusing the L4-L5 level.

Effects of Combined Magnetic Fields Treatment and Nano-Hydroxyapatite Coating on Porous Biphasic Calcium Phosphate Bone Graft in Rabbit Spinal Fusion Model

STUDY DESIGN

An animal experimental study was designed to investigate the efficacy of combined magnetic fields (CMF) treatment and nano-hydroxyapatite (HA) coating in the biphasic calcium phosphate (BCP) graft in posterolateral lumbar fusion.

OBJECTIVE

To evaluate the effects of CMF treatment and nano-HA/BCP and their combination effect in posterolateral lumbar fusion.

SUMMARY OF BACKGROUND DATA

Enhancement of artificial bone graft bioeffects could improve spinal fusion outcomes. The bone graft integration is vital in spinal fusion, nano-HA coating, and CMF treatment were reported as effective methods to improve bone graft integration.

METHODS

A bilateral transverse process fusion model was performed on 32 rabbits. The CMF treatment was performed for 30 minutes per day postoperation. The fusion rate, new bone formation, artificial bone graft-autologous bone fusion interface in x-ray and scanning electron microscopy, biomechanics property of fusion rate, histological fusion condition, artificial bone residual rate, and immunohistochemistry assessment of bone morphogenetic protein 2 (BMP-2) and Transforming growth factor beta 1 (TGF-β1) expression were observed at 9th week after surgery.

RESULTS

CMF treatment and nano-HA coating increased the fusion rate, adjusted optical density index, intensity of binding of artificial and autologous bone, bone growth rate, and bending stiffness. CMF treatment also significantly increased BMP-2 and TGF-β1 expression in fusion region while nano-HA coating significantly decreased artificial bone residual rate.

CONCLUSION

Our findings suggest that porous nano-HA/BCP graft could significantly improve spine fusion outcome with excellent bioactivity, biocompatibility and degradability and CMF treatment could significantly improve spine fusion outcome by improving bioactivity and biocompatibility of artificial bone graft in rabbit. Combination of CMF treatment with nano-HA/BCP graft could significantly increase posterolateral lumbar fusion rate in rabbit, which would be a potential strategy for spine fusion preclinical study.

LEVEL OF EVIDENCE

N/A.

Spinal fusion with demineralized calf fetal growth plate as novel biomaterial in rat model: a preliminary study

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.

The effect of poloxamer 407-based hydrogel on the osteoinductivity of demineralized bone matrix

Background

Demineralized bone matrix (DBM) is used for bone healing due to its osteoinductivity, but it requires a carrier for clinical application. Here, we report the effects on the osteoinductivity of DBM by use of a poloxamer 407-based hydrogel as the carrier, compared to sterile water.

Methods

DBM-W and DBM-H represent 27 wt% of DBM with sterile water and DBM with a poloxamer 407-based hydrogel, respectively. Both of the compositions were applied to human mesenchymal stem cell (MSC) cultures, and monitored for alkaline phosphatase (ALP) staining and ALP activity. Six 10-week-old athymic nude rats were used for abdominal muscle grafting with either DBM-W or DBM-H, and were tested by plane radiography, microfocus X-ray computed tomography (CT), and decalcified histology to evaluate ectopic bone formation.

Results

The DBM-W group showed stronger ALP staining at 7, 14, and 21 days of treatment, and significantly higher ALP activity at 7 and 14 days of treatment, compared to the DBM-H group. Plane radiography could not confirm the radio-opaque lesions in the rat ectopic bone formulation model. However, ectopic bone formation was observed in both groups by micro-CT. Compared to the DBM-H group, the DBM-W group showed higher bone volume, percent bone volume and trabecular number, and the difference in percent bone volume was statistically significant. Decalcified histology found bony tissue with lamellation in both groups.

Conclusions

Our results suggest that poloxamer 407-based hydrogel has efficacy as a DBM carrier since it shows ectopic bone formation, but its effects on the quality and quantity of osteoblastic differentiation in rat abdominal ectopic bone and MSC are considered negative.

Demineralized bone matrix, as a graft enhancer of auto-local bone in posterior lumbar interbody fusion

Study Design

A case controlled study with prospective data collection.

Purpose

To evaluate the early influence and the final consequence of demineralized bone matrix (DBM) on auto-local bone as a graft enhancer in posterior lumbar interbody fusion (PLIF).

Overview of Literature

DBM is known as an osteoinductive material; however, it has not been clearly recognized to enhance auto-local bone with a small amount.

Methods

Patients who had a PLIF were allocated into two groups. Group I (70 cases) used auto-local bone chips and group II (44 cases) used DBM as an additive to auto-local bone, 1 mL per a segment. Group selection was alternated. Early assessment was performed by computed tomography at 6 months and final assessment was done by simple radiography after 24 months at least. The degree of bone formation was assessed by 4 grade scale.

Results

The subjects of both groups were homogenous and had similar Oswestry Disability Index at final assessment. The ratio of auto-local bone chips and DBM was 6:1. The degree of bone formation at 6 months after surgery was superior in group II. However, there was no significant difference between the two groups at the final assessment.

Conclusions

DBM was not recognized to enhance auto-local bone with small amount.

A review of demineralized bone matrices for spinal fusion: the evidence for efficacy

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.

Novel oxysterols activate the Hedgehog pathway and induce osteogenesis

Localized induction of bone formation is essential during orthopedic procedures that involve skeletal repair, such as surgical treatment of non-union bone fractures and degenerative disk disease. Herein we disclose the synthesis and biological evaluation of novel oxysterol derivatives designed as anabolic bone growth agents. Structure-activity relationship studies of oxysterol 4 have identified analogues such as 18, 21 and 30. These new analogues are characterized by higher potency in an osteoblast differentiation assay and/or by increased metabolic stability in human liver microsomes. Oxysterols 4, 18 and 21 were evaluated in vivo in a rat spinal fusion model.

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.