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Keum BR, Kim HJ, Kim GH, Chang DG. Osteobiologies for Spinal Fusion from Biological Mechanisms to Clinical Applications: A Narrative Review. Int J Mol Sci 2023; 24:17365. [PMID: 38139194 PMCID: PMC10743675 DOI: 10.3390/ijms242417365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/01/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023] Open
Abstract
Degenerative lumbar spinal disease (DLSD), including spondylolisthesis and spinal stenosis, is increasing due to the aging population. Along with the disease severity, lumbar interbody fusion (LIF) is a mainstay of surgical treatment through decompression, the restoration of intervertebral heights, and the stabilization of motion segments. Currently, pseudoarthrosis after LIF is an important and unsolved issue, which is closely related to osteobiologies. Of the many signaling pathways, the bone morphogenetic protein (BMP) signaling pathway contributes to osteoblast differentiation, which is generally regulated by SMAD proteins as common in the TGF-β superfamily. BMP-2 and -4 are also inter-connected with Wnt/β-catenin, Notch, and FGF signaling pathways. With the potent potential for osteoinduction in BMP-2 and -4, the combination of allogenous bone and recombinant human BMPs (rhBMPs) is currently an ideal fusion material, which has equalized or improved fusion rates compared to traditional materials. However, safety issues in the dosage of BMP remain, so overcoming current limitations will provide significant advancement in spine surgery. In the future, translational research and the application of clinical study will be important to overcome the current limitations of spinal surgery.
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Affiliation(s)
- Byeong-Rak Keum
- Research Center for Bioconvergence Analysis, Korea Basic Science Institute, Cheongju 28119, Republic of Korea;
| | - Hong Jin Kim
- Department of Orthopedic Surgery, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul 01757, Republic of Korea;
| | - Gun-Hwa Kim
- Research Center for Bioconvergence Analysis, Korea Basic Science Institute, Cheongju 28119, Republic of Korea;
| | - Dong-Gune Chang
- Department of Orthopedic Surgery, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul 01757, Republic of Korea;
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2
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Inoue G. The Essence of Clinical Practice Guidelines for Lumbar Spinal Stenosis, 2021: 4. Surgical Treatment. Spine Surg Relat Res 2023; 7:308-313. [PMID: 37636139 PMCID: PMC10447186 DOI: 10.22603/ssrr.2022-0209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/19/2022] [Indexed: 08/29/2023] Open
Affiliation(s)
- Gen Inoue
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
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3
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Choi SR, Kwon JW, Suk KS, Kim HS, Moon SH, Park SY, Lee BH. The Clinical Use of Osteobiologic and Metallic Biomaterials in Orthopedic Surgery: The Present and the Future. MATERIALS (BASEL, SWITZERLAND) 2023; 16:ma16103633. [PMID: 37241260 DOI: 10.3390/ma16103633] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/21/2023] [Accepted: 05/03/2023] [Indexed: 05/28/2023]
Abstract
As the area and range of surgical treatments in the orthopedic field have expanded, the development of biomaterials used for these treatments has also advanced. Biomaterials have osteobiologic properties, including osteogenicity, osteoconduction, and osteoinduction. Natural polymers, synthetic polymers, ceramics, and allograft-based substitutes can all be classified as biomaterials. Metallic implants are first-generation biomaterials that continue to be used and are constantly evolving. Metallic implants can be made from pure metals, such as cobalt, nickel, iron, or titanium, or from alloys, such as stainless steel, cobalt-based alloys, or titanium-based alloys. This review describes the fundamental characteristics of metals and biomaterials used in the orthopedic field and new developments in nanotechnology and 3D-printing technology. This overview discusses the biomaterials that clinicians commonly use. A complementary relationship between doctors and biomaterial scientists is likely to be necessary in the future.
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Affiliation(s)
- Sung-Ryul Choi
- Department of Orthopedic Surgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Republic of Korea
| | - Ji-Won Kwon
- Department of Orthopedic Surgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Republic of Korea
| | - Kyung-Soo Suk
- Department of Orthopedic Surgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Republic of Korea
| | - Hak-Sun Kim
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Seong-Hwan Moon
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Si-Young Park
- Department of Orthopedic Surgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Republic of Korea
| | - Byung Ho Lee
- Department of Orthopedic Surgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Republic of Korea
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Kawakami M, Takeshita K, Inoue G, Sekiguchi M, Fujiwara Y, Hoshino M, Kaito T, Kawaguchi Y, Minetama M, Orita S, Takahata M, Tsuchiya K, Tsuji T, Yamada H, Watanabe K. Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lumbar spinal stenosis, 2021 - Secondary publication. J Orthop Sci 2023; 28:46-91. [PMID: 35597732 DOI: 10.1016/j.jos.2022.03.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/17/2022] [Accepted: 03/29/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND The Japanese Orthopaedic Association (JOA) guideline for the management of lumbar spinal stenosis (LSS) was first published in 2011. Since then, the medical care system for LSS has changed and many new articles regarding the epidemiology and diagnostics of LSS, conservative treatments such as new pharmacotherapy and physical therapy, and surgical treatments including minimally invasive surgery have been published. In addition, various issues need to be examined, such as verification of patient-reported outcome measures, and the economic effect of revised medical management of patients with lumbar spinal disorders. Accordingly, in 2019 the JOA clinical guidelines committee decided to update the guideline and consequently established a formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline, incorporating the recent advances of evidence-based medicine. METHODS The JOA LSS guideline formulation committee revised the previous guideline based on the method for preparing clinical guidelines in Japan proposed by the Medical Information Network Distribution Service in 2017. Background and clinical questions were determined followed by a literature search related to each question. Appropriate articles based on keywords were selected from all the searched literature. Using prepared structured abstracts, systematic reviews and meta-analyses were performed. The strength of evidence and recommendations for each clinical question was decided by the committee members. RESULTS Eight background and 15 clinical questions were determined. Answers and explanations were described for the background questions. For each clinical question, the strength of evidence and the recommendation were both decided, and an explanation was provided. CONCLUSIONS The 2021 clinical practice guideline for the management of LSS was completed according to the latest evidence-based medicine. We expect that this guideline will be useful for all medical providers as an index in daily medical care, as well as for patients with LSS.
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Affiliation(s)
| | | | - Gen Inoue
- Department of Orthopaedic Surgery, Kitasato University, Japan
| | - Miho Sekiguchi
- Department of Orthopaedic Surgery, Fukushima Medical University, Japan
| | - Yasushi Fujiwara
- Department of Orthopaedic Surgery, Hiroshima City Asa Citizens Hospital, Japan
| | - Masatoshi Hoshino
- Department of Orthopaedic Surgery, Osaka City General Hospital, Japan
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Osaka University, Japan
| | | | - Masakazu Minetama
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Japan
| | - Sumihisa Orita
- Center for Frontier Medical Engineering (CFME), Department of Orthopaedic Surgery, Chiba University, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Japan
| | | | - Takashi Tsuji
- Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Japan
| | - Hiroshi Yamada
- Department of Orthopaedic Surgery, Wakayama Medical University, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University, Japan
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Kim YH, Ha KY, Kim YS, Kim KW, Rhyu KW, Park JB, Shin JH, Kim YY, Lee JS, Park HY, Ko J, Kim SI. Lumbar Interbody Fusion and Osteobiologics for Lumbar Fusion. Asian Spine J 2022; 16:1022-1033. [PMID: 36573302 PMCID: PMC9827209 DOI: 10.31616/asj.2022.0435] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/01/2022] [Indexed: 12/28/2022] Open
Abstract
Lumbar interbody fusion (LIF) is an excellent treatment option for a number of lumbar diseases. LIF can be performed through posterior, transforaminal, anterior, and lateral or oblique approaches. Each technique has its own pearls and pitfalls. Through LIF, segmental stabilization, neural decompression, and deformity correction can be achieved. Minimally invasive surgery has recently gained popularity and each LIF procedure can be performed using minimally invasive techniques to reduce surgery-related complications and improve early postoperative recovery. Despite advances in surgical technology, surgery-related complications after LIF, such as pseudoarthrosis, have not yet been overcome. Although autogenous iliac crest bone graft is the gold standard for spinal fusion, other bone substitutes are available to enhance fusion rate and reduce complications associated with bone harvest. This article reviews the surgical procedures and characteristics of each LIF and the osteobiologics utilized in LIF based on the available evidence.
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Affiliation(s)
- Young-Hoon Kim
- Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kee-Yong Ha
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Youn-Soo Kim
- Department of Orthopaedic Surgery, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Ki-Won Kim
- Department of Orthopaedic Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kee-Won Rhyu
- Department of Orthopaedic Surgery, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jong-Beom Park
- Department of Orthopaedic Surgery, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Jae-Hyuk Shin
- Department of Orthopaedic Surgery, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Young-Yul Kim
- Department of Orthopaedic Surgery, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Jun-Seok Lee
- Department of Orthopaedic Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyung-Youl Park
- Department of Orthopaedic Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jaeryong Ko
- Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang-Il Kim
- Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea,Corresponding author: Sang-Il Kim Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seocho-gu, Seoul 06591, Korea Tel: +82-2-2258-6775, Fax: +82-2-535-9837, E-mail:
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6
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Golubovsky JL, Ejikeme T, Winkelman R, Steinmetz MP. Osteobiologics. Oper Neurosurg (Hagerstown) 2021; 21:S2-S9. [PMID: 34128067 DOI: 10.1093/ons/opaa383] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 09/06/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Osteobiologics are engineered materials that facilitate bone healing and have been increasingly used in spine surgery. Autologous iliac crest bone grafts have been used historically, but morbidity associated with graft harvesting has led surgeons to seek alternative solutions. Allograft bone, biomaterial scaffolds, growth factors, and stem cells have been explored as bone graft substitutes and supplements. OBJECTIVE To review current and emerging osteobiologic technologies. METHODS A literature review of English-language studies was performed in PubMed. Search terms included combinations of "spine," "fusion," "osteobiologics," "autologous," "allogen(e)ic," "graft," "scaffold," "bone morphogenic protein," and "stem cells." RESULTS Evidence supports allograft bone as an autologous bone supplement or replacement in scenarios where minimal autologous bone is available. There are promising data on ceramics and P-15; however, comparative human trials remain scarce. Growth factors, including recombinant human bone morphogenic proteins (rhBMPs) 2 and 7, have been explored in humans after successful animal trials. Evidence continues to support the use of rhBMP-2 in lumbar fusion in patient populations with poor bone quality or revision surgery, while there is limited evidence for rhBMP-7. Stem cells have been incredibly promising in promoting fusion in animal models, but human trials to this point have only involved products with questionable stem cell content, thereby limiting possible conclusions. CONCLUSION Engineered stem cells that overexpress osteoinductive factors are likely the future of spine fusion, but issues with applying viral vector-transduced stem cells in humans have limited progress.
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Affiliation(s)
- Joshua L Golubovsky
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Education Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tiffany Ejikeme
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Robert Winkelman
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael P Steinmetz
- Center for Spine Health, Department of Neurosurgery, Neurologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Abstract
BACKGROUND Back pain is a common chief complaint within the United States and is caused by a multitude of etiologies. There are many different treatment modalities for back pain, with a frequent option being spinal fusion procedures. The success of spinal fusion greatly depends on instrumentation, construct design, and bone grafts used in surgery. Bone allografts are important for both structural integrity and providing a scaffold for bone fusion to occur. METHOD Searches were performed using terms "allografts" and "bone" as well as product names in peer reviewed literature Pubmed, Google Scholar, FDA-510k approvals, and clinicaltrials.gov. RESULTS This study is a review of allografts and focuses on currently available products and their success in both animal and clinical studies. CONCLUSION Bone grafts used in surgery are generally categorized into 3 main types: autogenous (from patient's own body), allograft (from cadaveric or living donor), and synthetic. This paper focuses on allografts and provides an overview on the different subtypes with an emphasis on recent product development and uses in spinal fusion surgery.
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Affiliation(s)
- Justin D. Cohen
- Department of
Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Linda E. Kanim
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Andrew J. Tronits
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Hyun W. Bae
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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8
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Chang DG, Park JB, Han Y. Surgical outcomes of two kinds of demineralized bone matrix putties/local autograft composites in instrumented posterolateral lumbar fusion. BMC Musculoskelet Disord 2021; 22:200. [PMID: 33596888 PMCID: PMC7890888 DOI: 10.1186/s12891-021-04073-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/08/2021] [Indexed: 11/10/2022] Open
Abstract
Background This study aimed to assess the surgical outcomes of two kinds of demineralized bone matrix (DBM) putties/local autograft composites in instrumented posterolateral lumbar fusion (PLF). Methods Twenty-seven fusion segments of 19 patients, who underwent decompression and instrumented PLF for lumbar spinal stenosis or degenerative spondylolisthesis less than grade 1, were included in this study. The PLF mass consisted of different two kinds of DBMs (Grafton® and DBX®) and local autograft. Next, 7.5 cc of Grafton® DBM/local autograft composite was implanted on the left side, and the same amount of DBX® DBM/local autograft composite was implanted on the right side in the same patient. The PLF masses of 54 total sides (27 Grafton® sides and 27 DBX® sides) were assessed for fusion based on both flexion/extension lateral radiographs and computed tomography images at 12 and 24 months postoperatively. Clinical symptoms were also evaluated. Results At 12 months postoperatively, the fusion rates for the Grafton® and DBX® sides were 59.5 and 51.9%, respectively; the difference was not statistically significant (P = 0.425). At 24 months postoperatively, the fusion rates for the Grafton® and DBX® sides increased to 70.4 and 66.7%, respectively, but the difference was still not statistically significant (P = 0.574). Diabetes mellitus, smoking, and obesity (body mass index ≥25) negatively affected the fusion rate of both the Grafton® and DBX® sides. Visual analog scores for lower back pain and leg pain and Oswestry Disability Index were significantly improved after surgery (both, P < 0.01). No deep or superficial infections occurred postoperatively. No patients underwent revision surgery due to nonunion during follow-up. Conclusions Our results suggest that two kinds of DBMs/local autograft composites might be considered as useful bone graft substitute in instrumented posterolateral fusion for lumbar spinal stenosis or degenerative spondylolisthesis less than grade 1.
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Affiliation(s)
- Dong-Gune Chang
- Department of Orthopaedic Surgery, College of Medicine, Inje University Sanggye Paik Hospital, Inje University, Seoul, South Korea
| | - Jong-Beom Park
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, South Korea. .,Department of Orthopaedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Korea, 271 Cheonbo-ro, Uijeongbu-si, Gyeonggi-do, 11765, South Korea.
| | - Yangjun Han
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Han S, Park B, Lim JW, Youm JY, Choi SW, Kim DH, Ahn DK. Comparison of Fusion Rate between Demineralized Bone Matrix versus Autograft in Lumbar Fusion : Meta-Analysis. J Korean Neurosurg Soc 2020; 63:673-680. [PMID: 32455520 PMCID: PMC7671781 DOI: 10.3340/jkns.2019.0185] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/17/2020] [Indexed: 12/11/2022] Open
Abstract
The demineralized bone matrix (DBM) as the bone graft material to increase the fusion rate was widely used in spinal fusion. The current study aimed to compare the fusion rate of DBM to the fusion rate of autograft in lumbar spine fusion via meta-analysis of published literature. After systematic search, comparative studies were selected according to eligibility criteria. Checklist (risk of bias assessment tool for non-randomized study) was used to evaluate the risk of bias of the included nonrandomized controlled studies. The corresponding 95% confidence interval (95% CI) were calculated. We also used subgroup analysis to analyze the fusion rate of posterolateral lumbar fusion and lumbar interbody fusion. Eight studies were finally included in this meta-analysis. These eight studies included 581 patients. Among them, 337 patients underwent spinal fusion surgery using DBM (DBM group) and 204 patients underwent spinal fusion surgery with mainly autologous bone and without using DBM (control group). There was no significant differences of fusion rate between the two groups in posterolateral fusion analysis (risk ratio [RR], 1.03; 95% CI, 0.90–1.17; p=0.66) and interbody fusion analysis (RR, 1.13; 95% CI, 0.91–1.39; p=0.27). Based on the available evidence, the use of DBM with autograft in posterolateral lumbar spine fusion and lumbar interbody fusion showed a slightly higher fusion rate than that of autograft alone; however, there was no statistically different between two groups.
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Affiliation(s)
- Sanghyun Han
- Department of Neurosurgery, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Bumsoo Park
- Department of Neurosurgery, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jeong-Wook Lim
- Department of Neurosurgery, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jin-Young Youm
- Department of Neurosurgery, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Seoung-Won Choi
- Department of Neurosurgery, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Dae Hwan Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ki Ahn
- Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital, Seoul, Korea
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Russell N, Walsh WR, Lovric V, Kim P, Chen JH, Larson MJ, Vizesi F. In-vivo Performance of Seven Commercially Available Demineralized Bone Matrix Fiber and Putty Products in a Rat Posterolateral Fusion Model. Front Surg 2020; 7:10. [PMID: 32266283 PMCID: PMC7099880 DOI: 10.3389/fsurg.2020.00010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 02/28/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction: Demineralized bone matrix (DBM) is a widely used bone graft in spinal fusion. Most commercial DBMs are composed of demineralized bone particles (~125–800 microns) suspended in a carrier that provides improved handling but dilutes the osteoinductive component. DBM fibers (DBF) provide improved osteoconductivity and do not require a carrier. It has been suggested that 100% DBF may offer improved performance over particulate-based DBMs with carrier. Study Design: Seven commercially available DBM products were tested in an athymic rat posterolateral fusion model. There were four 100% DBFs, two DBFs containing a carrier, and one particulate-based DBM containing carrier. Objective: The study objectives were to evaluate the in vivo performance: (1) compare fusion rate and fusion maturity of six commercially available DBFs and one particulate-based DBM, and (2) assess the effect of carrier on fusion outcomes for DBFs in a posterolateral fusion model. Methods: The DBF/DBM products evaluated were: StrandTM Family, Propel® DBM Fibers, Vesuvius® Demineralized Fibers, Optium® DBM Putty, Grafton® DBF, Grafton Flex, and DBX® Putty. Single-level posterolateral fusion was performed in 69 athymic rats. Fusion was assessed bilaterally after 4 weeks by manual palpation, radiograph and CT for bridging bone. Fusion mass maturity was assessed with a CT maturity grading scale and by histology. Statistical analysis was performed using Fishers Exact Test for categorical data and Kruskal-Wallis Test for non-parametric data. Results: Strand Family achieved 100% fusion (18/18) by manual palpation, radiographic and CT evaluation, significantly higher than Propel Fibers, Vesuvius Fibers, Optium Putty, and DBX Putty, and not statistically higher than Grafton DBF and Grafton Flex. Strand Family provided the highest fusion maturity, with CT maturity grade of 2.3/3.0 and 89% mature fusion rate. Fusion results suggest a detrimental effect of carrier on fusion performance. Conclusions: There were large variations in fusion performance for seven commercially available DBM products in an established preclinical fusion model. There were even significant differences between different 100% DBF products, suggesting that composition alone does not guarantee in vivo performance. In the absence of definitive clinical evidence, surgeons should carefully consider available data in valid animal models when selecting demineralized allograft options.
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Affiliation(s)
| | - William R Walsh
- Surgical and Orthopaedic Research Laboratories, Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Vedran Lovric
- Surgical and Orthopaedic Research Laboratories, Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Peter Kim
- SeaSpine Inc., Carlsbad, CA, United States
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11
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Zhang H, Yang L, Yang XG, Wang F, Feng JT, Hua KC, Li Q, Hu YC. Demineralized Bone Matrix Carriers and their Clinical Applications: An Overview. Orthop Surg 2019; 11:725-737. [PMID: 31496049 PMCID: PMC6819172 DOI: 10.1111/os.12509] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/04/2019] [Accepted: 07/08/2019] [Indexed: 01/06/2023] Open
Abstract
Reconstruction of massive bone defects is challenging for orthopaedic clinicians, especially in cases of severe trauma and resection of tumors in various locales. Autologous iliac crest bone graft (ICBG) is the “gold standard” for bone grafting. However, the limited availability and complications at donor sites resulted in seeking other options like allografts and bone graft substitutes. Demineralized bone matrix (DBM) is a form of allograft using acidic solution to remove mineral components, while leaving much of the proteinaceous components native to bone, with small amounts of calcium‐based solids, inorganic phosphates, and some trace cell debris. It is an osteoconductive and osteoinductive biomaterial and is approved as a medical device for use in bone defects and spinal fusion. To pack consistently into the defect sites and stay firmly in the filling parts, DBM products have various forms combined with biocompatible viscous carriers, including sponges, strips, injectable putty, paste, and paste infused with chips. The present review aims to summarize the properties of various kind of viscous carriers and their clinical use combined with DBM in commercially available products. Given DBM'mercially available products. Given DBM;s long clinical track record and commercial accessibility in standard forms, opportunities to further develop and validate DBM as a versatile bone biomaterial in orthopaedic repair and regenerative medicine contexts are attractive.
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Affiliation(s)
- Hao Zhang
- Department of Bone Tumor, Tianjin Hospital, Tianjin, China.,Graduate School, Tianjin Medical University, Tianjin, China
| | - Li Yang
- Graduate School, Tianjin Medical University, Tianjin, China
| | | | - Feng Wang
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Jiang-Tao Feng
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Kun-Chi Hua
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Qi Li
- Beijing Wonderful Medical Biomaterial Co. Ltd., Beijing, China
| | - Yong-Cheng Hu
- Department of Bone Tumor, Tianjin Hospital, Tianjin, China
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12
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Li G, Li P, Chen Q, Thu HE, Hussain Z. Current Updates on Bone Grafting Biomaterials and Recombinant Human Growth Factors Implanted Biotherapy for Spinal Fusion: A Review of Human Clinical Studies. Curr Drug Deliv 2019; 16:94-110. [PMID: 30360738 DOI: 10.2174/1567201815666181024142354] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 08/01/2018] [Accepted: 10/18/2018] [Indexed: 01/16/2023]
Abstract
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.
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Affiliation(s)
- Guanbao Li
- Department of Minimally Invasive Spine Surgery, Yulin City Orthopaedic Hospital of Traditional Chinese Medicine and Western Medicine, NO.597, Jiaoyu Road, Yulin, Guangxi, 537000, China
| | - Pinquan Li
- Department of Minimally Invasive Spine Surgery, Yulin City Orthopaedic Hospital of Traditional Chinese Medicine and Western Medicine, NO.597, Jiaoyu Road, Yulin, Guangxi, 537000, China
| | - Qiuan Chen
- Department of Minimally Invasive Spine Surgery, Yulin City Orthopaedic Hospital of Traditional Chinese Medicine and Western Medicine, NO.597, Jiaoyu Road, Yulin, Guangxi, 537000, China
| | - Hnin Ei Thu
- Department of Pharmacology and Dental Therapeutics, Faculty of Dentistry, Lincoln University College, Jalan Stadium, SS 7/15, Kelana Jaya, 47301 Petaling Jaya, Selangor, Malaysia
| | - Zahid Hussain
- Department of Pharmaceutics, Faculty of Pharmacy, Universiti Teknologi MARA (UiTM), Puncak Alam Campus, Bandar Puncak Alam 42300, Selangor, Malaysia
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Radiographic and CT Evaluation of Recombinant Human Bone Morphogenetic Protein-2-assisted Cervical Spinal Interbody Fusion. Clin Spine Surg 2019; 32:71-79. [PMID: 30234566 DOI: 10.1097/bsd.0000000000000720] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
STUDY DESIGN This was a retrospective study. OBJECTIVE To radiographically demonstrate the distinct fusion pattern of recombinant human bone morphogenetic protein-2 (rhBMP-2) in the setting of anterior cervical discectomy and fusion. SUMMARY OF BACKGROUND DATA Studies investigating spinal fusion assisted with rhBMP-2 have yielded promising results, suggesting rhBMP-2 is an efficacious alternative to iliac crest autografts. rhBMP-2-assisted spinal fusion both hastens healing and eliminates patient morbidity from iliac crest autograft. Unique to rhBMP-assisted spinal fusion is its distinct radiographic fusion pattern as fusion is achieved. Despite promising results and increased clinical use of rhBMP-2, there remains a paucity of literature documenting this radiographic process. MATERIALS AND METHODS This study included 26 patients who underwent single-level anterior cervical discectomy and fusion using rhBMP-2. All data used for this study was collected from a prior FDA Investigational Device Exemption study. RESULTS A polyetheretherketone cage was used as an interbody disk spacer in all 26 patients. Patients were evaluated between 2 and 6 weeks after surgery and subsequently at 3, 6, 12, and 24 months postoperative. All patients underwent plain radiography at every follow-up visit, and computed tomograhy evaluation was performed at 3, 6, 12, and 24 months as part of the study protocol. Earliest fusion was observed at 3 months in 38% of patients. Likely fusion was observed in all patients by 12 months postoperative. CONCLUSIONS rhBMP-2 leads to both successful interbody fusion and an enhanced fusion rate with unique imaging characteristics. Additional characteristics of BMP observed in 100% of patients included prevertebral soft-tissue swelling and early endplate resorption. Other common features included polyetheretherketone cage migration, heterotopic bone formation and cage subsidence.
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Buser Z, Brodke DS, Youssef JA, Rometsch E, Park JB, Yoon ST, Wang JC, Meisel HJ. Allograft Versus Demineralized Bone Matrix in Instrumented and Noninstrumented Lumbar Fusion: A Systematic Review. Global Spine J 2018; 8:396-412. [PMID: 29977726 PMCID: PMC6022962 DOI: 10.1177/2192568217735342] [Citation(s) in RCA: 18] [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] [Indexed: 12/31/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES The aim was to determine the fusion efficacy of allograft and demineralized bone matrix (DBM) in lumbar instrumented and noninstrumented fusion procedures for degenerative lumbar disorders. METHODS A literature search was conducted using the PubMed and Cochrane databases. To be considered, publications had to meet 4 criteria: patients were treated for a degenerative lumbar disorder, a minimum group size of 10 patients, use of allograft or DBM, and at least a 2-year follow-up. Data on the study population, follow-up time, surgery type, grafting material, fusion rates, and its definition were collected. RESULTS The search yielded 692 citations with 17 studies meeting the criteria including 4 retrospective and 13 prospective studies. Six studies used DBM and 11 employed allograft alone or in the combination with autograft. For the allograft, fusion rates ranged from 58% to 68% for noninstrumented and from 68% to 98% for instrumented procedures. For DBM, fusion rates were 83% for noninstrumented and between 60% and 100% for instrumented lumbar fusion procedures. CONCLUSIONS Both allograft and DBM appeared to provide similar fusion rates in instrumented fusions. On the other hand, in noninstrumented procedures DBM was superior. However, a large variation in the type of surgery, outcomes collection, lack of control groups, and follow-up time prevented any significant conclusions. Thus, studies comparing the performance of allograft and DBM to adequate controls in large, well-defined patient populations and with a sufficient follow-up time are needed to establish the efficacy of these materials as adjuncts to fusion.
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Affiliation(s)
- Zorica Buser
- University of Southern California, Los Angeles, CA, USA,Zorica Buser, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1450 Biggy Street, NRT-2509N, Los Angeles, CA 90033, USA.
| | | | | | | | - Jong-Beom Park
- Uijongbu St. Mary’s Hospital, The Catholic University of Korea, Uijongbu, Korea
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Fernandez de Grado G, Keller L, Idoux-Gillet Y, Wagner Q, Musset AM, Benkirane-Jessel N, Bornert F, Offner D. Bone substitutes: a review of their characteristics, clinical use, and perspectives for large bone defects management. J Tissue Eng 2018; 9:2041731418776819. [PMID: 29899969 PMCID: PMC5990883 DOI: 10.1177/2041731418776819] [Citation(s) in RCA: 364] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 04/24/2018] [Indexed: 12/13/2022] Open
Abstract
Bone replacement might have been practiced for centuries with various materials of natural origin, but had rarely met success until the late 19th century. Nowadays, many different bone substitutes can be used. They can be either derived from biological products such as demineralized bone matrix, platelet-rich plasma, hydroxyapatite, adjunction of growth factors (like bone morphogenetic protein) or synthetic such as calcium sulfate, tri-calcium phosphate ceramics, bioactive glasses, or polymer-based substitutes. All these substitutes are not suitable for every clinical use, and they have to be chosen selectively depending on their purpose. Thus, this review aims to highlight the principal characteristics of the most commonly used bone substitutes and to give some directions concerning their clinical use, as spine fusion, open-wedge tibial osteotomy, long bone fracture, oral and maxillofacial surgery, or periodontal treatments. However, the main limitations to bone substitutes use remain the management of large defects and the lack of vascularization in their central part, which is likely to appear following their utilization. In the field of bone tissue engineering, developing porous synthetic substitutes able to support a faster and a wider vascularization within their structure seems to be a promising way of research.
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Affiliation(s)
- Gabriel Fernandez de Grado
- INSERM (French National Institute of Health and Medical Research), “Regenerative Nanomedicine” laboratory, http://www.regmed.fr, UMR 1260, Faculté de Médecine, FMTS, F-67085 Strasbourg Cedex
- Université de Strasbourg, Faculté de Chirurgie Dentaire, 8 rue Ste Elisabeth, F-67000 Strasbourg
- Hôpitaux Universitaires de Strasbourg, 1 Place de l’Hôpital, F-67000 Strasbourg
| | - Laetitia Keller
- INSERM (French National Institute of Health and Medical Research), “Regenerative Nanomedicine” laboratory, http://www.regmed.fr, UMR 1260, Faculté de Médecine, FMTS, F-67085 Strasbourg Cedex
- Université de Strasbourg, Faculté de Chirurgie Dentaire, 8 rue Ste Elisabeth, F-67000 Strasbourg
| | - Ysia Idoux-Gillet
- INSERM (French National Institute of Health and Medical Research), “Regenerative Nanomedicine” laboratory, http://www.regmed.fr, UMR 1260, Faculté de Médecine, FMTS, F-67085 Strasbourg Cedex
- Université de Strasbourg, Faculté de Chirurgie Dentaire, 8 rue Ste Elisabeth, F-67000 Strasbourg
| | - Quentin Wagner
- INSERM (French National Institute of Health and Medical Research), “Regenerative Nanomedicine” laboratory, http://www.regmed.fr, UMR 1260, Faculté de Médecine, FMTS, F-67085 Strasbourg Cedex
- Université de Strasbourg, Faculté de Chirurgie Dentaire, 8 rue Ste Elisabeth, F-67000 Strasbourg
| | - Anne-Marie Musset
- INSERM (French National Institute of Health and Medical Research), “Regenerative Nanomedicine” laboratory, http://www.regmed.fr, UMR 1260, Faculté de Médecine, FMTS, F-67085 Strasbourg Cedex
- Université de Strasbourg, Faculté de Chirurgie Dentaire, 8 rue Ste Elisabeth, F-67000 Strasbourg
- Hôpitaux Universitaires de Strasbourg, 1 Place de l’Hôpital, F-67000 Strasbourg
| | - Nadia Benkirane-Jessel
- INSERM (French National Institute of Health and Medical Research), “Regenerative Nanomedicine” laboratory, http://www.regmed.fr, UMR 1260, Faculté de Médecine, FMTS, F-67085 Strasbourg Cedex
- Université de Strasbourg, Faculté de Chirurgie Dentaire, 8 rue Ste Elisabeth, F-67000 Strasbourg
| | - Fabien Bornert
- INSERM (French National Institute of Health and Medical Research), “Regenerative Nanomedicine” laboratory, http://www.regmed.fr, UMR 1260, Faculté de Médecine, FMTS, F-67085 Strasbourg Cedex
- Université de Strasbourg, Faculté de Chirurgie Dentaire, 8 rue Ste Elisabeth, F-67000 Strasbourg
- Hôpitaux Universitaires de Strasbourg, 1 Place de l’Hôpital, F-67000 Strasbourg
| | - Damien Offner
- INSERM (French National Institute of Health and Medical Research), “Regenerative Nanomedicine” laboratory, http://www.regmed.fr, UMR 1260, Faculté de Médecine, FMTS, F-67085 Strasbourg Cedex
- Université de Strasbourg, Faculté de Chirurgie Dentaire, 8 rue Ste Elisabeth, F-67000 Strasbourg
- Hôpitaux Universitaires de Strasbourg, 1 Place de l’Hôpital, F-67000 Strasbourg
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van der Stok J, Hartholt KA, Schoenmakers DAL, Arts JJC. The available evidence on demineralised bone matrix in trauma and orthopaedic surgery: A systematic review. Bone Joint Res 2017; 6:423-432. [PMID: 28733366 PMCID: PMC5539308 DOI: 10.1302/2046-3758.67.bjr-2017-0027.r1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 05/04/2017] [Indexed: 01/26/2023] Open
Abstract
Objectives The aim of this systematic literature review was to assess the clinical level of evidence of commercially available demineralised bone matrix (DBM) products for their use in trauma and orthopaedic related surgery. Methods A total of 17 DBM products were used as search terms in two available databases: Embase and PubMed according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses statement. All articles that reported the clinical use of a DBM-product in trauma and orthopaedic related surgery were included. Results The literature search resulted in 823 manuscripts of which 64 manuscripts met the final inclusion criteria. The included manuscripts consisted of four randomised controlled trials (level I), eight cohort studies (level III) and 49 case-series (level IV). No clinical studies were found for ten DBM products, and most DBM products were only used in combination with other grafting materials. DBM products were most extensively investigated in spinal surgery, showing limited level I evidence that supports the use Grafton DBM (Osteotech, Eatontown, New Jersey) as a bone graft extender in posterolateral lumbar fusion surgery. DBM products are not thoroughly investigated in trauma surgery, showing mainly level IV evidence that supports the use of Allomatrix (Wright Medical, London, United Kingdom), DBX (DePuy Synthes, Zuchwil, Switzerland), Grafton DBM, or OrthoBlast (Citagenix Laval, Canada) as bone graft extenders. Conclusions The clinical level of evidence that supports the use of DBM in trauma and orthopaedic surgery is limited and consists mainly of poor quality and retrospective case-series. More prospective, randomised controlled trials are needed to understand the clinical effect and impact of DBM in trauma and orthopaedic surgery. Cite this article: J. van der Stok, K. A. Hartholt, D. A. L. Schoenmakers, J. J. C. Arts. The available evidence on demineralised bone matrix in trauma and orthopaedic surgery: A systemati c review. Bone Joint Res 2017;6:423–432. DOI: 10.1302/2046-3758.67.BJR-2017-0027.R1.
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Affiliation(s)
- J van der Stok
- Department of Orthopaedics, Reinier de Graaf Group, Delft, and Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - K A Hartholt
- Department of Surgery-Traumatology, Reinier de Graaf Group, Delft, The Netherlands
| | - D A L Schoenmakers
- Department of Orthopaedic Surgery, CAPHRI Research School, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - J J C Arts
- Department of Orthopaedic Surgery, CAPHRI Research School, Maastricht University Medical Centre, Maastricht, The Netherlands, and The Orthopaedic Biomechanics Group, Faculty of Biomedical Engineering, Eindhoven University of Technology, The Netherlands
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NaPier Z, Kanim LE, Thordarson S, Kropf MA, Cuéllar JM, Glaeser JD, Bae HW. Demineralized Bone Matrix Bone Biology and Clinical Use. ACTA ACUST UNITED AC 2016. [DOI: 10.1053/j.semss.2016.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Kadam A, Millhouse PW, Kepler CK, Radcliff KE, Fehlings MG, Janssen ME, Sasso RC, Benedict JJ, Vaccaro AR. Bone substitutes and expanders in Spine Surgery: A review of their fusion efficacies. Int J Spine Surg 2016; 10:33. [PMID: 27909654 DOI: 10.14444/3033] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
STUDY DESIGN A narrative review of literature. OBJECTIVE This manuscript intends to provide a review of clinically relevant bone substitutes and bone expanders for spinal surgery in terms of efficacy and associated clinical outcomes, as reported in contemporary spine literature. SUMMARY OF BACKGROUND DATA Ever since the introduction of allograft as a substitute for autologous bone in spinal surgery, a sea of literature has surfaced, evaluating both established and newly emerging fusion alternatives. An understanding of the available fusion options and an organized evidence-based approach to their use in spine surgery is essential for achieving optimal results. METHODS A Medline search of English language literature published through March 2016 discussing bone graft substitutes and fusion extenders was performed. All clinical studies reporting radiological and/or patient outcomes following the use of bone substitutes were reviewed under the broad categories of Allografts, Demineralized Bone Matrices (DBM), Ceramics, Bone Morphogenic proteins (BMPs), Autologous growth factors (AGFs), Stem cell products and Synthetic Peptides. These were further grouped depending on their application in lumbar and cervical spine surgeries, deformity correction or other miscellaneous procedures viz. trauma, infection or tumors; wherever data was forthcoming. Studies in animal populations and experimental in vitro studies were excluded. Primary endpoints were radiological fusion rates and successful clinical outcomes. RESULTS A total of 181 clinical studies were found suitable to be included in the review. More than a third of the published articles (62 studies, 34.25%) focused on BMP. Ceramics (40 studies) and Allografts (39 studies) were the other two highly published groups of bone substitutes. Highest radiographic fusion rates were observed with BMPs, followed by allograft and DBM. There were no significant differences in the reported clinical outcomes across all classes of bone substitutes. CONCLUSIONS There is a clear publication bias in the literature, mostly favoring BMP. Based on the available data, BMP is however associated with the highest radiographic fusion rate. Allograft is also very well corroborated in the literature. The use of DBM as a bone expander to augment autograft is supported, especially in the lumbar spine. Ceramics are also utilized as bone graft extenders and results are generally supportive, although limited. The use of autologous growth factors is not substantiated at this time. Cell matrix or stem cell-based products and the synthetic peptides have inadequate data. More comparative studies are needed to evaluate the efficacy of bone graft substitutes overall.
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Affiliation(s)
- Abhijeet Kadam
- Pennsylvania Hospital of the University of Pennsylvania Health System, Philadelphia, PA
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Efficacy of i-Factor Bone Graft versus Autograft in Anterior Cervical Discectomy and Fusion: Results of the Prospective, Randomized, Single-blinded Food and Drug Administration Investigational Device Exemption Study. Spine (Phila Pa 1976) 2016; 41:1075-1083. [PMID: 26825787 DOI: 10.1097/brs.0000000000001466] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective, randomized, controlled, parallel, single-blinded noninferiority multicenter pivotal FDA IDE trial. OBJECTIVE The objective of this study was to investigate efficacy and safety of i-Factor Bone Graft (i-Factor) compared with local autograft in single-level anterior cervical discectomy and fusion (ACDF) for cervical radiculopathy. SUMMARY OF BACKGROUND DATA i-Factor is a composite bone substitute material consisting of the P-15 synthetic collagen fragment adsorbed onto anorganic bone mineral and suspended in an inert biocompatible hydrogel carrier. P-15 has demonstrated bone healing efficacy in dental, orthopedic, and nonhuman applications. METHODS Patients randomly received either autograft (N = 154) or i-Factor (N = 165) in a cortical ring allograft. Study success was defined as noninferiority in fusion, Neck Disability Index (NDI), and Neurological Success endpoints, and similar adverse events profile at 12 months. RESULTS At 12 months (follow-up rate 87%), both i-Factor and autograft subjects demonstrated a high fusion rate (88.97% and 85.82%, respectively, noninferiority P = 0.0004), significant improvements in NDI (28.75 and 27.40, respectively, noninferiority P < 0.0001), and high Neurological Success rate (93.71% and 93.01%, respectively, noninferiority P < 0.0001). There was no difference in the rate of adverse events (83.64% and 82.47% in the i-Factor and autograft groups, respectively, P = 0.8814). Overall success rate consisting of fusion, NDI, Neurological Success and Safety Success was higher in i-Factor subjects than in autograft subjects (68.75% and 56.94%, respectively, P = 0.0382). Improvements in VAS pain and SF-36v2 scores were clinically relevant and similar between the groups. A high proportion of patients reported good or excellent Odom outcomes (81.4% in both groups). CONCLUSION i-Factor has met all four FDA mandated noninferiority success criteria and has demonstrated safety and efficacy in single-level ACDF for cervical radiculopathy. i-Factor and autograft groups demonstrated significant postsurgical improvement and high fusion rates. LEVEL OF EVIDENCE 1.
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Hinsenkamp M, Collard JF. Growth factors in orthopaedic surgery: demineralized bone matrix versus recombinant bone morphogenetic proteins. INTERNATIONAL ORTHOPAEDICS 2014; 39:137-47. [PMID: 25338109 DOI: 10.1007/s00264-014-2562-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 09/30/2014] [Indexed: 12/22/2022]
Abstract
During recent decades the utilisation of growth factors, especially BMPs, has received an increasing interest in orthopaedic surgery. For clinical implantation the two main options are demineralised bone matrix (DBM) and recombinant bone morphogenetic proteins (rhBMP). Many clinical studies agree on an equivalent osteoinductive effect between DBM, BMPs and autologous bone graft; however, the different origins and processing of DBM and rhBMP may introduce some fluctuations. Their respective characteristics are reviewed and possible interactions with their effectiveness are analysed. The main difference concerns the concentration of BMPs, which varies to an order of magnitude of 10(6) between DBM and rhBMPs. This may explain the variability in efficiency of some products and the adverse effects. Currently, considering osteoinductive properties, safety and availability, the DBM seems to offer several advantages. However, if DBM and rhBMPs are useful in some indications, their effectiveness and safety can be improved and more evidence-based studies are needed to better define the indications.
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Affiliation(s)
- Maurice Hinsenkamp
- Orthopaedic Research Laboratory (LROT) and Musculoskeletal Tissue Bank (BTE), Department of Orthopaedic Surgery, Hôpital Erasme, Université Libre de Bruxelles (ULB), 808, route de Lennik, Brussels, B-1070, Belgium,
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Kaiser MG, Groff MW, Watters WC, Ghogawala Z, Mummaneni PV, Dailey AT, Choudhri TF, Eck JC, Sharan A, Wang JC, Dhall SS, Resnick DK. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 16: bone graft extenders and substitutes as an adjunct for lumbar fusion. J Neurosurg Spine 2014; 21:106-32. [PMID: 24980593 DOI: 10.3171/2014.4.spine14325] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
In an attempt to enhance the potential to achieve a solid arthrodesis and avoid the morbidity of harvesting autologous iliac crest bone (AICB) for a lumbar fusion, numerous alternatives have been investigated. The use of these fusion adjuncts has become routine despite a lack of convincing evidence demonstrating a benefit to justify added costs or potential harm. Potential alternatives to AICB include locally harvested autograft, calcium-phosphate salts, demineralized bone matrix (DBM), and the family of bone morphogenetic proteins (BMPs). In particular, no option has created greater controversy than the BMPs. A significant increase in the number of publications, particularly with respect to the BMPs, has taken place since the release of the original guidelines. Both DBM and the calciumphosphate salts have demonstrated efficacy as a graft extender or as a substitute for AICB when combined with local autograft. The use of recombinant human BMP-2 (rhBMP-2) as a substitute for AICB, when performing an interbody lumbar fusion, is considered an option since similar outcomes have been observed; however, the potential for heterotopic bone formation is a concern. The use of rhBMP-2, when combined with calcium phosphates, as a substitute for AICB, or as an extender, when used with local autograft or AICB, is also considered an option as similar fusion rates and clinical outcomes have been observed. Surgeons electing to use BMPs should be aware of a growing body of literature demonstrating unique complications associated with the use of BMPs.
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Affiliation(s)
- Michael G Kaiser
- Department of Neurosurgery, Columbia University, New York, New York
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22
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Kiely PD, Brecevich AT, Taher F, Nguyen JT, Cammisa FP, Abjornson C. Evaluation of a new formulation of demineralized bone matrix putty in a rabbit posterolateral spinal fusion model. Spine J 2014; 14:2155-63. [PMID: 24512696 DOI: 10.1016/j.spinee.2014.01.053] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 11/12/2013] [Accepted: 01/22/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Alternatives to autologous bone graft (ABG) with osteoconductive, osteoinductive, and osteogenic potential continue to prove elusive. Demineralized bone matrix (DBM) however, with its osteoconductive and osteoinductive potential remains a viable option to ABG in posterolateral spine fusion. PURPOSE To compare the efficacy of a new formulation of DBM putty with that of ABG in a rabbit posterolateral spinal fusion model. STUDY DESIGN Efficacy of a new formulation of DBM was studied in an experimental animal posterolateral spinal fusion model. METHODS Twenty-four male New Zealand White rabbits underwent bilateral posterolateral spine arthrodesis of the L5-L6 intertransverse processes, using either ABG (control group, n=12) or DBM (DBM made from rabbit bone) putty (test group, n=12). The animals were killed 12 weeks after surgery and the lumbar spines were excised. Fusion success was evaluated by manual palpation, high resolution X-rays, microcomputed tomography imaging, biomechanical four-point bending tests, and histology. RESULTS Two animals were lost because of anesthetic related issues. Manual palpation to assess fusion success in the explanted lumbar spines showed no statistical significant difference in successful fusion in 81.8% (9/11) of DBM group and 72.7% (8/11) of ABG group (p=.99). Reliability of these assessments was measured between three independent observers and found near perfect agreement (intraclass correlation cofficient: 0.92 and 0.94, respectively). Fusion using high resolution X-rays was solid in 10 of the DBM group and 9 of the ABG group (p=.59). Biomechanical testing showed no significant difference in stiffness between the control and test groups on flexion, extension, and left lateral and right lateral bends, with p values accounting for .79, .42, .75, and .52, respectively. The bone volume/total volume was greater than 85% in the DBM treated fusion masses. Histologic evaluation revealed endochondral ossification in both groups, but the fusion masses were more mature in the DBM group. CONCLUSIONS The DBM putty achieved comparable fusion rates to ABG in the rabbit posterolateral spinal fusion model.
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Affiliation(s)
- Paul D Kiely
- Integrated Spine Research Department, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
| | - Antonio T Brecevich
- Integrated Spine Research Department, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Fadi Taher
- Integrated Spine Research Department, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Joseph T Nguyen
- Integrated Spine Research Department, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Frank P Cammisa
- Integrated Spine Research Department, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Celeste Abjornson
- Integrated Spine Research Department, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
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Abstract
The choice among the many options of approach and adjunct techniques in planning a posterior lumbar fusion can be problematic. Debates remain as to whether solid fusion has an advantage over pseudarthrosis regarding long-term symptom deterioration and whether an instrumented or a noninstrumented approach will best serve clinically and/or cost effectively, particularly in elderly patients. Increased motion resulting in higher rates of nonunion and the use of nonsteroidal anti-inflammatory drugs have been studied in animal models and are presumed risk factors, despite the lack of clinical investigation. Smoking is a proven risk factor for pseudarthrosis in both animal models and level III clinical studies. Recent long-term studies and image/clinical assessment of lumbar fusions and pseudarthrosis show that, although imaging remains a key area of difficulty in assessment, including an instrumented approach and a well-selected biologic adjunct, as well as achieving a solid fusion, all carry important long-term clinical advantages in avoiding revision surgery for nonunion.
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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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Tilkeridis K, Touzopoulos P, Ververidis A, Christodoulou S, Kazakos K, Drosos GI. Use of demineralized bone matrix in spinal fusion. World J Orthop 2014; 5:30-37. [PMID: 24649412 PMCID: PMC3952692 DOI: 10.5312/wjo.v5.i1.30] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 09/17/2013] [Accepted: 11/03/2013] [Indexed: 02/06/2023] Open
Abstract
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.
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Kurien T, Pearson RG, Scammell BE. Bone graft substitutes currently available in orthopaedic practice: the evidence for their use. Bone Joint J 2013; 95-B:583-97. [PMID: 23632666 DOI: 10.1302/0301-620x.95b5.30286] [Citation(s) in RCA: 126] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
We reviewed 59 bone graft substitutes marketed by 17 companies currently available for implantation in the United Kingdom, with the aim of assessing the peer-reviewed literature to facilitate informed decision-making regarding their use in clinical practice. After critical analysis of the literature, only 22 products (37%) had any clinical data. Norian SRS (Synthes), Vitoss (Orthovita), Cortoss (Orthovita) and Alpha-BSM (Etex) had Level I evidence. We question the need for so many different products, especially with limited published clinical evidence for their efficacy, and conclude that there is a considerable need for further prospective randomised trials to facilitate informed decision-making with regard to the use of current and future bone graft substitutes in clinical practice.
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Affiliation(s)
- T Kurien
- Queen’s Medical Centre, University of Nottingham, Nottingham, United Kingdom
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A systematic review of comparative studies on bone graft alternatives for common spine fusion procedures. 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 2013; 22:1423-35. [PMID: 23440339 DOI: 10.1007/s00586-013-2718-4] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Revised: 01/01/2013] [Accepted: 02/10/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND The increased prevalence of spinal fusion surgery has created an industry focus on bone graft alternatives. While autologous bone graft remains the gold standard, the complications and morbidity from harvesting autologous bone drives the search for reliable and safe bone graft substitutes. With the recent information about the adverse events related to bone morhogenetic protein use, it is appropriate to review the literature about the numerous products that are not solely bone morphogenetic protein. PURPOSE The purpose of this literature review is to determine the recommendations for use of non-bone morphogenetic protein bone graft alternatives in the most common spine procedures based on a quantifiable grading system. STUDY DESIGN Systematic literature review. METHODS A literature search of MEDLINE (1946-2012), CINAHL (1937-2012), and the Cochrane Central Register of Controlled Trials (1940-April 2012) was performed, and this was supplemented by a hand search. The studies were then evaluated based on the Guyatt criteria for quality of the research to determine the strength of the recommendation. RESULTS In this review, more than one hundred various studies on the ability of bone graft substitutes to create solid fusions and good patient outcomes are detailed. CONCLUSION The recommendations for use of bone graft substitutes and bone graft extenders are based on the strength of the studies and given a grade.
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Hsu WK, Nickoli MS, Wang JC, Lieberman JR, An HS, Yoon ST, Youssef JA, Brodke DS, McCullough CM. Improving the clinical evidence of bone graft substitute technology in lumbar spine surgery. Global Spine J 2012; 2:239-48. [PMID: 24353975 PMCID: PMC3864464 DOI: 10.1055/s-0032-1315454] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Accepted: 03/02/2012] [Indexed: 11/20/2022] Open
Abstract
Bone graft substitutes have been used routinely for spine fusion for decades, yet clinical evidence establishing comparative data remains sparse. With recent scrutiny paid to the outcomes, complications, and costs associated with osteobiologics, a need to improve available data guiding efficacious use exists. We review the currently available clinical literature, studying the outcomes of various biologics in posterolateral lumbar spine fusion, and establish the need for a multicenter, independent osteobiologics registry.
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Affiliation(s)
- Wellington K. Hsu
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois,Address for correspondence and reprint requests Wellington K. Hsu, M.D. Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine676 N. St. Clair Street, #1350Chicago, IL 60611
| | - M. S. Nickoli
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - J. C. Wang
- Department of Orthopaedic Surgery, UCLA Comprehensive Spine Center, Santa Monica, California
| | - J. R. Lieberman
- University of Connecticut Medical Center, Farmington, Connecticut
| | - H. S. An
- Rush University Medical Center, Chicago, Illinois
| | | | | | | | - C. M. McCullough
- Resources for Medical Education and Collaboration, Durango, Colorado
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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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Hoffmann MF, Jones CB, Sietsema DL. Adjuncts in posterior lumbar spine fusion: comparison of complications and efficacy. Arch Orthop Trauma Surg 2012; 132:1105-10. [PMID: 22562366 DOI: 10.1007/s00402-012-1529-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Indexed: 12/01/2022]
Abstract
PURPOSE The purpose of this study was to define the efficacy of recombinant human Bone Morphogenetic Protein-2 (rhBMP-2) and Demineralized Bone Matrix (DBM) compared to autograft in posterior lumbar spine fusion by comparing complication rates. METHODS During a 7-year period (2003-2009), all patients undergoing posterior lumbar fusion were retrospectively evaluated within a large orthopedic surgery private practice. Patient demographics, comorbidities, number of levels, type of surgery, and types of bone void filler and osteobiologics were analyzed. Complications were defined as reoperation secondary to failed symptomatic fusion, hyper-reaction with fluid collections, bone overgrowth, and infections. RESULTS 1,398 patients were evaluated with 41.1 % males and 58.9 % females. Mean age was 60 years and BMI 30.6 kg/m². Patients were subdivided in treatment groups: rhBMP-2, 947 (67.7 %), DBM 306 (21.9 %), and autograft 145 (10.4 %). The overall infection rate was 2.1 %. No significant differences were found between the three groups. The incidence of seroma formation was higher in the BMP group (3.2 %) than in the DBM or autograft group (2.0 and 1.4 %, respectively) but this was not significant (p = 0.286 and p = 0.245, respectively). 103 patients (7.4 %) underwent redo surgery for clinically significant nonunion. We found significantly fewer nonunions (4.3 %) in the rhBMP-2 group (p < 0.001) compared to the DBM or autograft group (13.1 and 15.2 %, respectively). CONCLUSION ICBG is the gold standard. DBM leads to comparable fusion rates and does not increase infection or seroma formation. rhBMP-2 supplementation instead of ICBG or bone marrow aspirate results in higher fusion rates compared to autograft alone or autograft plus DBM.
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Affiliation(s)
- Martin F Hoffmann
- Grand Rapids Medical Education Partners, 1000 Monroe Ave NW, Grand Rapids, MI 49503, USA.
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Pietrzak WS, Dow M, Gomez J, Soulvie M, Tsiagalis G. The in vitro elution of BMP-7 from demineralized bone matrix. Cell Tissue Bank 2011; 13:653-61. [PMID: 22200971 DOI: 10.1007/s10561-011-9286-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Accepted: 12/13/2011] [Indexed: 01/25/2023]
Abstract
Demineralized bone matrix (DBM) grafts induce new bone formation by locally releasing matrix-associated growth factors, such as bone morphogenetic proteins (BMPs), to the surrounding tissue after implantation. However, the release kinetics of BMPs from DBM lack characterization. Such information can potentially help to improve processing techniques to maximize graft osteoinductive potential, as well as increase understanding of the osteoinductive process itself. We produced DBM with three particle size ranges from bovine cortical bone, i.e., <106, 106-300, and 300-710 μm and extracted 1.5 g of each size range in 40 ml of Sorensen's buffer at room temperature for up to 168 h. The BMP-7 concentration of the DBM and the buffer were measured at each time point using enzyme-linked immunosorbant assay. Based on measurement of the concentration of BMP-7 in the buffer, the 0-8 h elution rate was high, i.e., 3.3, 2.9, and 2.2 ng BMP-7/g DBM h, and for the 8-168 h interval was much lower, at 0.039, 0.15, and 0.11 ng BMP-7/g DBM h for the three size ranges, respectively. By 168 h, there was no indication that elution was nearing completion. Measurement of the residual BMP-7 remaining in the DBM as a function of time yielded unexpected results, i.e., after the BMP-7 content of the DBM declined for the first 4-6 h, it paradoxically increased for the remaining interval. We propose a two-compartment model to help explain these results in terms of the possible distribution of BMP-7 in bone matrix.
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Rocha FS, Ramos LMA, Batista JD, Zanetta-Barbosa D, Ferro EAV, Dechichi P. Bovine Anorganic Bone Graft Associated with Platelet-Rich Plasma: Histologic Analysis in Rabbit Calvaria. J ORAL IMPLANTOL 2011; 37:511-8. [DOI: 10.1563/aaid-joi-d-09-00091.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Autogenous bone tissue has regeneration potential; however, this capacity may not be sufficient in larger bone defects. The aim of this study is to histologically evaluate anorganic bovine bone grafts (GenOx Inorg) with or without platelet-rich plasma (PRP). Two bone lesions were created in calvaria of 12 rabbits. The 24 surgical lesions were separated into 3 groups: coagulous, anorganic, and anorganic with PRP. At the 4-week time point, the animals were euthanized and the grafted area removed, fixed in formalin 10% with phosphate buffered saline, 0.1 M, and embedded in paraffin. The histologic parameters analyzed were new bone filling the defect area, presence of giant cells and particles of the graft, and new bone formation associated with the particles. In the coagulous group, defects were filled with fibrous tissue that attached the periosteum and little bone neoformation in the periphery. In anorganic groups with or without PRP, little new bone formation in the periphery of the defect was observed; however, in the center of some defects there was new bone. Moderate presence of giant cells and little new bone formation was associated with the innumerous graft particles. Histologic results revealed no statistically significant differences among the defects new bone fill between the studied groups (P = .64). There was no significant difference in the number of giant cells (P = .60), graft particles (P = .46), and new bone formation around graft particles (P = .26), whether PRP was added or not. Anorganic bone, isolated or mixed with PRP, was biocompatible and osteoconductive, while maintaining bone volume.
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Affiliation(s)
| | | | - Jonas Dantas Batista
- School of Dentistry - Oral & Maxillofacial Surgery and Implantology Department, University of Uberlândia, Minas Gerais, Brazil
| | - Darceny Zanetta-Barbosa
- School of Dentistry - Oral & Maxillofacial Surgery and Implantology Department, University of Uberlândia, Minas Gerais, Brazil
| | | | - Paula Dechichi
- Biomedical Science Institute, University of Uberlândia, Minas Gerais, Brazil
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Abstract
STUDY DESIGN Review of literature. OBJECTIVE To evaluate the available literature supporting the use of lumbar fusion extenders in clinical practice. SUMMARY OF BACKGROUND DATA Because of the morbidity associated with the harvest of autologous iliac crest bone grafts, the search for lumber fusion extenders and replacements has accelerated. Many formulations of lumbar fusion extenders have been developed, and it is essential to evaluate clinical literature and available outcome metrics of these extenders. METHODS A review of English-language literature was performed between 1990 and January of 2010 for all literature presenting clinical outcomes of lumbar fusion extenders. After controlling for inclusion and exclusion criteria and assigning levels of evidence, 19 clinical studies were fully reviewed including those for demineralized bone matrix, recombinant human bone morphogenetic protein 2 (rhBMP-2), β-tricalcium phosphate, and calcium sulfate. RESULTS The most extensively studied of the lumbar fusion extenders is β-tricalcium phosphate, especially with regard to its use in adolescent scoliosis correction. The use of rhBMP-2 and demineralized bone matrix is supported only by two and three clinical studies, respectively. Calcium sulfate and other miscellaneous extenders are not conclusively or consistently supported by available clinical studies. CONCLUSION Calcium phosphate is the most supported of the lumbar fusion extenders. rhBMP-2 and demineralized bone matrix are supported by smaller bodies of evidence. These formulations are supported by these initial studies but in some cases need to be better examined with regard to side effect profiles.
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Schuckert KH, Jopp S, Osadnik M. The use of platelet rich plasma, bone morphogenetic protein-2 and different scaffolds in oral and maxillofacial surgery - literature review in comparison with own clinical experience. EJOURNAL OF ORAL MAXILLOFACIAL RESEARCH 2011; 2:e2. [PMID: 24421984 PMCID: PMC3886066 DOI: 10.5037/jomr.2011.2102] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Accepted: 01/18/2011] [Indexed: 12/16/2022]
Abstract
Objectives The purpose of this article was to review and critically assess the use of
platelet rich plasma, recombinant human bone morphogenetic protein-2 and
different scaffolds (i.e. tricalciumphosphate, polycaprolactone,
demineralized bone matrix and anorganic bovine bone mineral) in oral and
maxillofacial surgery comparing the relevant literature and own clinical
experience. Material and Methods A literature review was conducted using MEDLINE, MEDPILOT and COCHRANE
DATABASE OF SYSTEMATIC REVIEWS. It concentrated on manuscripts and overviews
published in the last five years (2006-2010). The key terms employed were
platelet rich plasma, bone morphogenetic proteins and their combinations
with the above mentioned scaffolds. The results of clinical studies and
animal trials were especially emphasized. The statements from the literature
were compared with authors’ own clinical data. Results New publications and overviews demonstrate the advantages of platelet rich
plasma in bone regeneration. The results from the literature review were
discussed and compared with the publications detailing authors' own
experiences. Conclusions A favourable outcome concerning newly grown bone was achieved combining
platelet rich plasma in addition to optimal matrices with or without
recombinant human bone morphogenetic protein-2, depending on the clinical
case. As a consequence, the paradigm shift from transplantation of
autogenous bone to bone tissue engineering appears promising.
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Affiliation(s)
- Karl-Heinz Schuckert
- Institute Indente - Institute of Innovative Oral Surgery and Medicine, Centre for Tissue Engineering Hannover Germany
| | - Stefan Jopp
- Institute Indente - Institute of Innovative Oral Surgery and Medicine, Centre for Tissue Engineering Hannover Germany
| | - Magdalena Osadnik
- Institute Indente - Institute of Innovative Oral Surgery and Medicine, Centre for Tissue Engineering Hannover Germany
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Vaz K, Verma K, Protopsaltis T, Schwab F, Lonner B, Errico T. Bone grafting options for lumbar spine surgery: a review examining clinical efficacy and complications. SAS JOURNAL 2010; 4:75-86. [PMID: 25802654 PMCID: PMC4365636 DOI: 10.1016/j.esas.2010.01.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Iliac crest harvest has been considered the “gold standard” at producing successful arthrodesis of the lumbar spine but is also associated with many donor-site morbidities. Many alternatives have been used to avoid iliac crest harvest, including autologous bone from other donor sites, allogeneic bone, ceramics, and recombinant human bone morphogenetic proteins (rhBMPs). This review will highlight the properties and preparations of these graft types and their potential complications and reported clinical efficacy. Methods A Medline search was conducted via PubMed by use of the following terms in various combinations: lumbar fusion, freeze-dried allograft, fresh-frozen allograft, autograft, iliac crest, demineralized bone matrix, rhBMP-2, rhBMP-7, scoliosis, bone marrow aspirate, HEALOS, coralline hydroxyapatite, beta tricalcium phosphate, synthetic, ceramics, spinal fusion, PLF, PLIF, ALIF, and TLIF. Only articles written in English were assessed for appropriate material. Related articles were also assessed depending on the content of articles found in the original literature search. Conclusions Although iliac crest remains the gold standard, reported success with alternative approaches, especially in combination, has shown promise. Stronger evidence with limited sources of potential bias is necessary to provide a clear picture of their clinical efficacy.
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Affiliation(s)
- Kenneth Vaz
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases-Langone Medical Center, New York, NY
| | - Kushagra Verma
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases-Langone Medical Center, New York, NY
| | - Themistocles Protopsaltis
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases-Langone Medical Center, New York, NY
| | - Frank Schwab
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases-Langone Medical Center, New York, NY
| | - Baron Lonner
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases-Langone Medical Center, New York, NY
| | - Thomas Errico
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases-Langone Medical Center, New York, NY
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Feng Y, Wang S, Jin D, Sheng J, Chen S, Cheng X, Zhang C. Free vascularised fibular grafting with OsteoSet®2 demineralised bone matrix versus autograft for large osteonecrotic lesions of the femoral head. INTERNATIONAL ORTHOPAEDICS 2009; 35:475-81. [PMID: 20012040 DOI: 10.1007/s00264-009-0915-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Revised: 11/06/2009] [Accepted: 11/06/2009] [Indexed: 12/13/2022]
Abstract
The aim of this study was to compare the safety and efficacy of OsteoSet®2 DBM with autologous cancellous bone in free vascularised fibular grafting for the treatment of large osteonecrotic lesions of the femoral head. Twenty-four patients (30 hips) with large osteonecrotic lesions of the femoral head (stage IIC in six hips, stage IIIC in 14, and stage IVC in ten, according to the classification system of Steinberg et al.) underwent free vascularised fibular grafting with OsteoSet®2 DBM. This group was retrospectively matched to a group of 24 patients (30 hips) who underwent free vascularised fibular grafting with autologous cancellous bone during the same time period according to the aetiology, stage, and size of the lesion and the mean preoperative Harris hip score. A prospective case-controlled study was then performed with a mean follow-up duration of 26 months. The results show no statistically significant differences between the two groups in overall clinical outcome or the radiographic assessment. Furthermore, no adverse events related to the use of the OsteoSet®2 DBM were observed. The results demonstrate that OsteoSet®2 DBM combined with autograft bone performs equally as well as that of autologous bone alone. Therefore, OsteoSet®2 DBM can be used as a safe and effective graft extender in free vascularised fibular grafting for large osteonecrotic lesions of the femoral head.
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Affiliation(s)
- Yong Feng
- Department of Orthopaedics, Shanghai Sixth People's Hospital, Jiao Tong University, Shanghai, China
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Joaquim AF, Sansur CA, Hamilton DK, Shaffrey CI. Degenerative lumbar stenosis: update. ARQUIVOS DE NEURO-PSIQUIATRIA 2009; 67:553-8. [DOI: 10.1590/s0004-282x2009000300039] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Accepted: 04/30/2009] [Indexed: 11/22/2022]
Abstract
We present a literature review of the diagnosis and treatment of acquired lumbar spinal stenosis (LS), with a brief description of new surgical techniques. LS is the most common cause of spinal surgery in individuals older than 65 years of age. Neurogenic claudication and radiculopathy result from compression of the cauda equina and lumbosacral nerve roots by degenerated spinal elements. Surgical decompression is a well established treatment for patients with refractory, or moderate to severe clinical symptoms. However, the variety of surgical options is vast. New techniques have been developed with the goal of increasing long term functional outcomes. In this article we review lumbar decompression and fusion as treatment options for LS but also present other recent developments. Prospective long term studies are necessary to know which procedures would result in optimal patient outcome.
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Aslan H, Sheyn D, Gazit D. Genetically engineered mesenchymal stem cells: applications in spine therapy. Regen Med 2009; 4:99-108. [PMID: 19105619 DOI: 10.2217/17460751.4.1.99] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Spine disorders and intervertebral disc degeneration are considered the main causes for the clinical condition commonly known as back pain. Spinal fusion by implanting autologous bone to produce bony bridging between the two vertebrae flanking the degenerated-intervertebral disc is currently the most efficient treatment for relieving the symptoms of back pain. However, donor-site morbidity, complications and the long healing time limit the success of this approach. Novel developments undertaken by regenerative medicine might bring more efficient and available treatments. Here we discuss the pros and cons of utilizing genetically engineered mesenchymal stem cells for inducing spinal fusion. The combination of the stem cells, gene and carrier are crucial elements for achieving optimal spinal fusion in both small and large animal models, which hopefully will lead to the development of clinical applications.
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Affiliation(s)
- Hadi Aslan
- Skeletal Biotech Lab, Hebrew University, The Hebrew University of Jerusalem- Hadassah Medical Center, Jerusalem, Israel
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How to store autologous bone graft perioperatively: an in vitro study. Arch Orthop Trauma Surg 2008; 128:1007-11. [PMID: 18389265 DOI: 10.1007/s00402-008-0616-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2007] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Autologous bone graft is the golden standard for bone grafting, but little is known about the influence of various preservation techniques used during surgery immediately following harvest on the osseous structures and graft vitality. Several studies focussed on the optimal treatment of the bone during harvest and implantation, but only few examined the intraoperative storage conditions on the back table. The aim of our study was to examine the influence of various intraoperative preservation techniques on human cancellous bone at different points to optimize the storage during surgery. MATERIALS AND METHODS Cancellous bone was harvested during hip arthroplasty and stored for 2 and 4 h under dry conditions, inside a swab moistened with saline solution or in saline solution, 5% glucose solution or culture medium. After the storage period, the bone was cultured and examined 7 days after the first cells grew out in one of these groups. Following the identification of the cells as osteoblast-like cells, the cultures were analysed by fluorescence staining, cell count and the XTT-test. RESULTS Fluorescence staining revealed no avital cells in all groups. Dry storage of the bone led to significantly lower cell metabolism after 2 h compared to saline solution and 5% glucose solution. The same was true after 4 h dry storage compared to the moistened swab, and glucose and culture medium. Cell count was significantly lower after 2 h of dry storage compared to saline solution and culture medium. CONCLUSIONS Perioperative storage of cancellous bone under dry conditions should be avoided. The bone graft should be stored in saline or 5% glucose solution or a moistened swab.
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