1
|
Laubach M, Kobbe P, Hutmacher DW. Biodegradable interbody cages for lumbar spine fusion: Current concepts and future directions. Biomaterials 2022; 288:121699. [PMID: 35995620 DOI: 10.1016/j.biomaterials.2022.121699] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/14/2022] [Accepted: 07/22/2022] [Indexed: 11/16/2022]
Abstract
Lumbar fusion often remains the last treatment option for various acute and chronic spinal conditions, including infectious and degenerative diseases. Placement of a cage in the intervertebral space has become a routine clinical treatment for spinal fusion surgery to provide sufficient biomechanical stability, which is required to achieve bony ingrowth of the implant. Routinely used cages for clinical application are made of titanium (Ti) or polyetheretherketone (PEEK). Ti has been used since the 1980s; however, its shortcomings, such as impaired radiographical opacity and higher elastic modulus compared to bone, have led to the development of PEEK cages, which are associated with reduced stress shielding as well as no radiographical artefacts. Since PEEK is bioinert, its osteointegration capacity is limited, which in turn enhances fibrotic tissue formation and peri-implant infections. To address shortcomings of both of these biomaterials, interdisciplinary teams have developed biodegradable cages. Rooted in promising preclinical large animal studies, a hollow cylindrical cage (Hydrosorb™) made of 70:30 poly-l-lactide-co-d, l-lactide acid (PLDLLA) was clinically studied. However, reduced bony integration and unfavourable long-term clinical outcomes prohibited its routine clinical application. More recently, scaffold-guided bone regeneration (SGBR) with application of highly porous biodegradable constructs is emerging. Advancements in additive manufacturing technology now allow the cage designs that match requirements, such as stiffness of surrounding tissues, while providing long-term biomechanical stability. A favourable clinical outcome has been observed in the treatment of various bone defects, particularly for 3D-printed composite scaffolds made of medical-grade polycaprolactone (mPCL) in combination with a ceramic filler material. Therefore, advanced cage design made of mPCL and ceramic may also carry initial high spinal forces up to the time of bony fusion and subsequently resorb without clinical side effects. Furthermore, surface modification of implants is an effective approach to simultaneously reduce microbial infection and improve tissue integration. We present a design concept for a scaffold surface which result in osteoconductive and antimicrobial properties that have the potential to achieve higher rates of fusion and less clinical complications. In this review, we explore the preclinical and clinical studies which used bioresorbable cages. Furthermore, we critically discuss the need for a cutting-edge research program that includes comprehensive preclinical in vitro and in vivo studies to enable successful translation from bench to bedside. We develop such a conceptual framework by examining the state-of-the-art literature and posing the questions that will guide this field in the coming years.
Collapse
Affiliation(s)
- Markus Laubach
- Australian Research Council (ARC) Training Centre for Cell and Tissue Engineering Technologies, Queensland University of Technology (QUT), Brisbane, QLD, 4000 Australia; Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD 4000, Australia; Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD 4059, Australia; Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany.
| | - Philipp Kobbe
- Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Dietmar W Hutmacher
- Australian Research Council (ARC) Training Centre for Cell and Tissue Engineering Technologies, Queensland University of Technology (QUT), Brisbane, QLD, 4000 Australia; Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD 4000, Australia; Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD 4059, Australia; Max Planck Queensland Center for the Materials Science of Extracellular Matrices, Queensland University of Technology, Brisbane, QLD 4000, Australia.
| |
Collapse
|
2
|
Abstract
STUDY DESIGN This study was a multi-endpoint analysis of bone graft substitutes implanted as a standalone graft in a clinically relevant Ovine model of instrumented posterolateral spinal fusion (PLF). OBJECTIVE The objective of this study was to obtain high-quality evidence on the efficacy of commercial bone graft substitutes compared with autograft in instrumented PLF using a state-of-the-art model with a complete range of assessment techniques. SUMMARY OF BACKGROUND DATA Preclinical and clinical data on the quality of spinal fusions obtained with bone graft substitutes are often limited. Calcium phosphates with submicron topography have shown promising results in PLF, as these are able to induce bone formation in tissues distant from the host bone, which facilitates bony union. METHODS Nine female, skeletally mature sheep (4-5 y) underwent posterior pedicle screw/rods instrumented PLF at L2-L3 and L4-L5 using the following bone graft materials as a standalone graft per spinal segment: (1) biphasic calcium phosphate with submicron topography (BCP<µm), (2) 45S5 Bioglass (BG), and (3) collagen-β-tricalcium phosphate with a 45S5 Bioglass adjunct (TCP/BG). Autograft bone (AB) was used as a positive control treatment. Twelve weeks after implantation, the spinal segments were evaluated by fusion assessment (manual palpation, x-ray, micro-computed tomography, and histology), fusion mass volume quantification (micro-computed tomography), range of motion (ROM) testing, histologic evaluation, and histomorphometry. RESULTS Fusion assessment revealed equivalence between AB and BCP<µm by all fusion assessment methods, whereas BG and TCP/BG led to significantly inferior results. Fusion mass volume was highest for BCP<µm, followed by AB, BG, and TCP/BG. ROM testing determined equivalence for spinal levels treated with AB and BCP<µm, while BG and TCP/BG exhibited higher ROM. Histologic evaluation revealed substantial bone formation in the intertransverse regions for AB and BCP<µm, whereas BG and TCP/BG grafts contained fibrous tissue and minimal bone formation. Histologic observations were supported by the histomorphometry data. CONCLUSIONS This study reveals clear differences in efficacy between commercially available bone graft substitutes, emphasizing the importance of clinically relevant animal models with multiendpoint analyses for the evaluation of bone graft materials. The results corroborate the efficacy of calcium phosphate with submicron topography, as this was the only material that showed equivalent performance to autograft in achieving spinal fusion.
Collapse
|
3
|
van Dijk LA, Duan R, Luo X, Barbieri D, Pelletier M, Christou C, Rosenberg AJWP, Yuan H, Barrèrre‐de Groot F, Walsh WR, de Bruijn JD. Biphasic calcium phosphate with submicron surface topography in an Ovine model of instrumented posterolateral spinal fusion. JOR Spine 2018; 1:e1039. [PMID: 31463454 PMCID: PMC6686792 DOI: 10.1002/jsp2.1039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/05/2018] [Accepted: 11/06/2018] [Indexed: 12/13/2022] Open
Abstract
As spinal fusions require large volumes of bone graft, different bone graft substitutes are being investigated as alternatives. A subclass of calcium phosphate materials with submicron surface topography has been shown to be a highly effective bone graft substitute. In this work, a commercially available biphasic calcium phosphate (BCP) with submicron surface topography (MagnetOs; Kuros Biosciences BV) was evaluated in an Ovine model of instrumented posterolateral fusion. The material was implanted stand-alone, either as granules (BCPgranules) or as granules embedded within a fast-resorbing polymeric carrier (BCPputty) and compared to autograft bone (AG). Twenty-five adult, female Merino sheep underwent posterolateral fusion at L2-3 and L4-5 levels with instrumentation. After 6, 12, and 26 weeks, outcomes were evaluated by manual palpation, range of motion (ROM) testing, micro-computed tomography, histology and histomorphometry. Fusion assessment by manual palpation 12 weeks after implantation revealed 100% fusion rates in all treatment groups. The three treatment groups showed a significant decrease in lateral bending at the fusion levels at 12 weeks (P < 0.05) and 26 weeks (P < 0.001) compared to the 6 week time-point. Flexion-extension and axial rotation were also reduced over time, but statistical significance was only reached in flexion-extension for AG and BCPputty between the 6 and 26 week time-points (P < 0.05). No significant differences in ROM were observed between the treatment groups at any of the time-points investigated. Histological assessment at 12 weeks showed fusion rates of 75%, 92%, and 83% for AG, BCPgranules and BCPputty, respectively. The fusion rates were further increased 26 weeks postimplantation. Similar trends of bone growth were observed by histomorphometry. The fusion mass consisted of at least 55% bone for all treatment groups 26 weeks after implantation. These results suggest that this BCP with submicron surface topography, in granules or putty form, is a promising alternative to autograft for spinal fusion.
Collapse
Affiliation(s)
- Lukas A. van Dijk
- Kuros Biosciences BVBilthovenThe Netherlands
- Department of Oral and Maxillofacial SurgeryUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Rongquan Duan
- Kuros Biosciences BVBilthovenThe Netherlands
- Biomaterial Science and TechnologyUniversity of TwenteEnschedeThe Netherlands
| | - Xiaoman Luo
- Kuros Biosciences BVBilthovenThe Netherlands
| | | | - Matthew Pelletier
- Surgical and Orthopaedic Research Laboratories, Prince of Wales Clinical SchoolUniversity of New South WalesSydneyNew South WalesAustralia
| | - Chris Christou
- Surgical and Orthopaedic Research Laboratories, Prince of Wales Clinical SchoolUniversity of New South WalesSydneyNew South WalesAustralia
| | | | - Huipin Yuan
- Kuros Biosciences BVBilthovenThe Netherlands
- MERLN Institute for Technology‐inspired Regenerative MedicineMaastricht UniversityMaastrichtThe Netherlands
| | | | - William R. Walsh
- Surgical and Orthopaedic Research Laboratories, Prince of Wales Clinical SchoolUniversity of New South WalesSydneyNew South WalesAustralia
| | - Joost D. de Bruijn
- Kuros Biosciences BVBilthovenThe Netherlands
- School of Materials Science and EngineeringQueen Mary University of LondonLondonUK
| |
Collapse
|
4
|
Ishikawa K, Kawachi G, Tsuru K, Yoshimoto A. Fabrication of calcite blocks from gypsum blocks by compositional transformation based on dissolution-precipitation reactions in sodium carbonate solution. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2017; 72:389-393. [PMID: 28024601 DOI: 10.1016/j.msec.2016.11.093] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 10/26/2016] [Accepted: 11/23/2016] [Indexed: 11/18/2022]
Abstract
Calcium carbonate (CaCO3) has been used as a bone substitute, and is a precursor for carbonate apatite, which is also a promising bone substitute. However, limited studies have been reported on the fabrication of artificial calcite blocks. In the present study, cylindrical calcite blocks (ϕ6×3mm) were fabricated by compositional transformation based on dissolution-precipitation reactions using different calcium sulfate blocks as a precursor. In the dissolution-precipitation reactions, both CaSO4·2H2O and CaSO4 transformed into calcite, a polymorph of CaCO3, while maintaining their macroscopic structure when immersed in 1mol/L Na2CO3 solution at 80°C for 1week. The diametral tensile strengths of the calcite blocks formed using CaSO4·2H2O and CaSO4 were 1.0±0.3 and 2.3±0.7MPa, respectively. The fabrication of calcite blocks using CaSO4·2H2O and CaSO4 proposed in this investigation may be a useful method to produce calcite blocks because of the self-setting ability and high temperature stability of gypsum precursors.
Collapse
Affiliation(s)
- Kunio Ishikawa
- Department of Biomaterials, Faculty of Dental Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
| | - Giichiro Kawachi
- Department of Biomaterials, Faculty of Dental Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Kanji Tsuru
- Department of Biomaterials, Faculty of Dental Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Ayami Yoshimoto
- Department of Biomaterials, Faculty of Dental Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| |
Collapse
|
5
|
Elder BD, Holmes C, Goodwin CR, Lo SF, Puvanesarajah V, Kosztowski TA, Locke JE, Witham TF. A systematic assessment of the use of platelet-rich plasma in spinal fusion. Ann Biomed Eng 2015; 43:1057-70. [PMID: 25794962 DOI: 10.1007/s10439-015-1300-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 03/11/2015] [Indexed: 12/19/2022]
Abstract
Spinal fusion is one of the most commonly performed procedures for the treatment of spinal instability caused by a multitude of pathologies. However, despite significant advances in spinal instrumentation, failed fusion, or pseudoarthrosis, remains a significant challenge. Therefore, other additives such as bone graft extenders and growth factors have been explored as a method to augment fusion rates. Platelet-rich plasma (PRP) represents an additional approach, as it has shown some promise in bone regeneration. While the general use of PRP in orthopedic applications has been reviewed previously, its use in spinal fusion has not been systematically analyzed. The objective of this review is to systematically discuss the role of PRP in augmentation of bone regeneration for the purpose of spinal fusion. Background information on PRP, including a discussion of its preparation, activation, and growth factors, is included. Additionally, data from in vitro studies utilizing PRP in bone tissue engineering strategies is analyzed, and the available animal and clinical studies are systematically reviewed in order to provide guidance on future research pathways as well as the potential role of PRP in spinal fusion surgery.
Collapse
Affiliation(s)
- Benjamin D Elder
- Department of Neurosurgery, The Johns Hopkins Hospital, 1800 Orleans St., Room 6007, Baltimore, MD, 21287, USA,
| | | | | | | | | | | | | | | |
Collapse
|
6
|
Takeuchi M, Kamiya M, Wakao N, Hirasawa A, Kawanami K, Osuka K, Takayasu M. Large volume inside the cage leading incomplete interbody bone fusion and residual back pain after posterior lumbar interbody fusion. Neurosurg Rev 2015; 38:573-8; discussion 578. [PMID: 25666390 DOI: 10.1007/s10143-015-0610-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 05/20/2014] [Accepted: 11/16/2014] [Indexed: 11/28/2022]
Abstract
The purpose of this study is to compare intervertebral bone fusion and clinical outcomes in L4-5 posterior lumbar interbody fusion (PLIF) using the same posterior instrumentation with four combinations of one of three types of interbody cage with one of two bone grafts, iliac and local or only local. In 67 patients who underwent L4-5 PLIF, 19 patients had the Brantigan cage and iliac and local bone graft, 18 with the TELAMON C cage and iliac and local bone graft, 16 with the TELAMON C cage and local bone graft (TL), and 14 with the OIC PEEK cage and local bone graft. Clinical assessments were based on Japanese Orthopaedic Association (JOA) scores and on the visual analogue scale (VAS). The bone fusion assessments were based on radiography and CT scans according to the Brantigan, Steffee, and Fraser criteria. More than 2 years after surgery, these assessments were made. In the results, the fusion outcome for the group receiving TL was significantly less than those for the other three groups. In TL, multivariate logistic regression analysis showed that the inside volume of the cage of ≥2.0 mL was the only significant factor for incomplete fusion. Moreover, the VAS (low back pain) score was significantly higher for TL than for the other three groups. In conclusions, we believe that the large volume inside the cage (≥2.0 mL) with local bone graft may lead incomplete interbody bone fusion and residual postsurgical low back pain after PLIF.
Collapse
Affiliation(s)
- Mikinobu Takeuchi
- Department of Spine Center, Aichi Medical University Hospital, Karimata Yazako, Nagakute, Aichi, 480-1195, Japan,
| | | | | | | | | | | | | |
Collapse
|
7
|
Ishikawa K, Tram NXT, Tsuru K, Toita R. Fabrication of porous calcite using chopped nylon fiber and its evaluation using rats. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2015; 26:94. [PMID: 25649514 DOI: 10.1007/s10856-015-5432-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 12/14/2014] [Indexed: 06/04/2023]
Abstract
Although porous calcite has attracted attention as bone substitutes, limited studies have been made so far. In the present study, porous calcite block was fabricated by introducing chopped nylon fiber as porogen. Ca(OH)2 powder containing 10 wt% chopped nylon fiber was compacted at 150 MPa, and sintered to burn out the fiber and to carbonate the Ca(OH)2 under stream of 1:2 O2-CO2. Sintering of Ca(OH)2 at 750 °C or lower temperature resulted in incomplete burning out of the fiber whereas sintering at 800 °C or higher temperature resulted in the formation of CaO due to the thermal decomposition of Ca(OH)2. However, sintering at 770 °C resulted in complete burning out of the fiber and complete carbonation of Ca(OH)2 to calcite without forming CaO. Macro- and micro-porosities of the porous calcite were approximately 23 and 16%, respectively. Diameter of the macropores was approximately 100 μm which is suitable for bone tissue penetration. Porous calcite block fabricated by this method exhibited good tissue response when implanted in the bone defect in femur of 12-weeks-old rat. Four weeks after implantation, bone bonded on the surface of calcite. Furthermore, bone tissue penetrated interior to the macropore at 8 weeks. These results demonstrated the good potential value of porous calcite as artificial bone substitutes.
Collapse
Affiliation(s)
- Kunio Ishikawa
- Department of Biomaterials, Faculty of Dental Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan,
| | | | | | | |
Collapse
|
8
|
Malhotra A, Pelletier M, Oliver R, Christou C, Walsh WR. Platelet-Rich Plasma and Bone Defect Healing. Tissue Eng Part A 2014; 20:2614-33. [DOI: 10.1089/ten.tea.2013.0737] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Angad Malhotra
- Surgical and Orthopedic Research Laboratories, Prince of Wales Clinical School, The University of New South Wales, Prince of Wales Hospital, Randwick, Australia
| | - Matthew Pelletier
- Surgical and Orthopedic Research Laboratories, Prince of Wales Clinical School, The University of New South Wales, Prince of Wales Hospital, Randwick, Australia
| | - Rema Oliver
- Surgical and Orthopedic Research Laboratories, Prince of Wales Clinical School, The University of New South Wales, Prince of Wales Hospital, Randwick, Australia
| | - Chris Christou
- Surgical and Orthopedic Research Laboratories, Prince of Wales Clinical School, The University of New South Wales, Prince of Wales Hospital, Randwick, Australia
| | - William R. Walsh
- Surgical and Orthopedic Research Laboratories, Prince of Wales Clinical School, The University of New South Wales, Prince of Wales Hospital, Randwick, Australia
| |
Collapse
|
9
|
Pelletier MH, Oliver RA, Christou C, Yu Y, Bertollo N, Irie H, Walsh WR. Lumbar spinal fusion with β-TCP granules and variable Escherichia coli-derived rhBMP-2 dose. Spine J 2014; 14:1758-68. [PMID: 24486479 DOI: 10.1016/j.spinee.2014.01.043] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 11/28/2013] [Accepted: 01/20/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The ideal tissue-engineered solution for any bone graft substitute is to assist in the rapid formation of bone and facilitate fusion. PURPOSE The present study aims to evaluate this E-BMP-2 (Escherichia coli-derived human bone morphogenetic protein-2) in ovine posterolateral lumbar fusion (PLF) to examine the influence of dose and overall performance in a model with similar graft size and diffusive challenges to the human. STUDY DESIGN/SETTING In vivo large animal model study. METHODS An adult ovine PLF was performed in 30 animals with groups of E-BMP-2 with a beta-tricalcium phosphate (β-TCP) carrier at three different dosages, β-TCP alone, and autograft from the iliac crest. The fusions were assessed by radiography (X-ray and microcomputed tomography), mechanical testing, and hard-tissue histology with bone labels at 6, 8, and 10 weeks along with routine paraffin histology at 12 weeks. RESULTS Results showed increasing new bone and fusion rate with E-BMP-2 dose, whereas β-TCP alone was largely resorbed and did not achieve fusion in this model at 12 weeks. Autograft showed similar grading for the amount of bone between the transverse processes but a lower fusion rate than β-TCP/E-BMP-2 groups. Bone labels revealed new bone formation at all time points for the E-BMP2 groups, whereas the autograft group showed active bone formation at 10 weeks. Beta-tricalcium phosphate displayed reliable incorporation into the decorticated host bone, whereas limited new bone was found between the transverse processes. At the center of the fusion mass, increased E-BMP-2 dose led to increased incorporation of β-TCP by new bone. CONCLUSIONS These results suggest that E-BMP-2 was capable of producing posterolateral fusion in the ovine model that is equal to or superior to autologous graft in terms of fusion rate and mechanical strength. E-BMP-2 dose had considerable influence on β-TCP granule resorption.
Collapse
Affiliation(s)
- Matthew H Pelletier
- Surgical and Orthopaedic Research Laboratories, University of New South Wales, Prince of Wales Clinical School, Level 1 Clinical Sciences Building, Prince of Wales Hospital, Avoca St Randwick, New South Wales 2031, Australia
| | - Rema A Oliver
- Surgical and Orthopaedic Research Laboratories, University of New South Wales, Prince of Wales Clinical School, Level 1 Clinical Sciences Building, Prince of Wales Hospital, Avoca St Randwick, New South Wales 2031, Australia
| | - Chris Christou
- Surgical and Orthopaedic Research Laboratories, University of New South Wales, Prince of Wales Clinical School, Level 1 Clinical Sciences Building, Prince of Wales Hospital, Avoca St Randwick, New South Wales 2031, Australia
| | - Yan Yu
- Surgical and Orthopaedic Research Laboratories, University of New South Wales, Prince of Wales Clinical School, Level 1 Clinical Sciences Building, Prince of Wales Hospital, Avoca St Randwick, New South Wales 2031, Australia
| | - Nicky Bertollo
- Surgical and Orthopaedic Research Laboratories, University of New South Wales, Prince of Wales Clinical School, Level 1 Clinical Sciences Building, Prince of Wales Hospital, Avoca St Randwick, New South Wales 2031, Australia
| | - Hiroyuki Irie
- Osteopharma, Inc., Osteopharma YSK Building 2F, 1-2-5 Uchihommachi Cho-ku Osaka 540-0026, Japan
| | - William R Walsh
- Surgical and Orthopaedic Research Laboratories, University of New South Wales, Prince of Wales Clinical School, Level 1 Clinical Sciences Building, Prince of Wales Hospital, Avoca St Randwick, New South Wales 2031, Australia.
| |
Collapse
|
10
|
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.
Collapse
|
11
|
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.
Collapse
|
12
|
Malhotra A, Pelletier MH, Yu Y, Walsh WR. Can platelet-rich plasma (PRP) improve bone healing? A comparison between the theory and experimental outcomes. Arch Orthop Trauma Surg 2013. [PMID: 23197184 DOI: 10.1007/s00402-012-1641-1] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The increased concentration of platelets within platelet-rich plasma (PRP) provides a vehicle to deliver supra-physiologic concentrations of growth factors to an injury site, possibly accelerating or otherwise improving connective tissue regeneration. This potential benefit has led to the application of PRP in several applications; however, inconsistent results have limited widespread adoption in bone healing. This review provides a core understanding of the bone healing mechanisms, and corresponds this to the factors present in PRP. In addition, the current state of the art of PRP preparation, the key aspects that may influence its effectiveness, and treatment outcomes as they relate specifically to bone defect healing are presented. Although PRP does have a sound scientific basis, its use for bone healing appears only beneficial when used in combination with osteoconductive scaffolds; however, neither allograft nor autograft appear to be appropriate carriers. Aggressive processing techniques and very high concentrations of PRP may not improve healing outcomes. Moreover, many other variables exist in PRP preparation and use that influence its efficacy; the effect of these variables should be understood when considering PRP use. This review includes the essentials of what has been established, what is currently missing in the literature, and recommendations for future directions.
Collapse
Affiliation(s)
- Angad Malhotra
- Surgical and Orthopaedic Research Laboratories, Prince of Wales Clinical School, The University of New South Wales, Sydney, Australia.
| | | | | | | |
Collapse
|
13
|
Chatterjea A, Yuan H, Chatterjea S, Garritsen H, Renard A, van Blitterswijk CA, de Boer J. Engineering New Bone via a Minimally Invasive Route Using Human Bone Marrow-Derived Stromal Cell Aggregates, Microceramic Particles, and Human Platelet-Rich Plasma Gel. Tissue Eng Part A 2013; 19:340-9. [DOI: 10.1089/ten.tea.2012.0104] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Anindita Chatterjea
- Department of Tissue Regeneration, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Huipin Yuan
- Department of Tissue Regeneration, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | | | - Henk Garritsen
- Institut für Klinische Transfusionsmedizin, Städtisches Klinikum Braunschweig gGmbH, Braunschweig, Germany
| | - Auke Renard
- Department of Orthopaedics, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Clemens A. van Blitterswijk
- Department of Tissue Regeneration, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Jan de Boer
- Department of Tissue Regeneration, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| |
Collapse
|
14
|
Abstract
STUDY DESIGN Review article, review of literature. OBJECTIVE To review the bone graft options that exist for posterolateral and posterior interbody lumbar fusion. SUMMARY OF BACKGROUND DATA As the number of lumbar fusion surgeries has increased over the last decade, alternative methods of grafting have been developed. Iliac crest autograft bone has traditionally been used for lumbar fusion. The downside to this graft option, however, is donor site morbidity. METHODS The current literature on alternatives to iliac crest autograft bone for obtaining lumbar fusion was reviewed. RESULTS Platelet gels, demineralized bone matrix, synthetic bone graft, and bone morphogenetic protein are potential options for bone graft supplementation or substitution. In preclinical studies, platelet gels have been beneficial to bone growth when combined with autograft, but clinical studies do not support the use of platelet gel in posterolateral lumbar fusion. Preclinical studies of demineralized bone matrix have shown significant variability in the osteoinductive properties of the available products, and clinical data showing efficacy is limited. The use of synthetic bone graft material (ceramics) in lumbar fusion surgery is increasing. Calcium phosphate compounds (i.e., beta-tricalcium phosphate and hydroxyapetite) are most commonly used and are often combined with type I collagen to form a matrix. These materials provide an osteoconductive scaffold for bony ingrowth and can be combined with bone marrow aspirate or used as a carrier for osteogenic factors. Bone morphogenetic protein (rhBMP-2) has been shown to provide similar or even increased fusion rates over autograft iliac crest bone. There are, however, potential safety concerns associated with the use of bone morphogenetic protein that are not fully understood. CONCLUSION Several alternatives to iliac crest autograft bone provide promising early clinical results in achieving posterolateral and posterior interbody lumbar fusion.
Collapse
|
15
|
Stammers AH, Trowbridge CC, Marko M, Woods EL, Brindisi N, Pezzuto J, Klayman M, Fleming S, Petzold J. Autologous platelet gel: fad or savoir? Do we really know? THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2009; 41:P25-P30. [PMID: 20092084 PMCID: PMC4813532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Autologous platelet-gel (APG) is the process of harvesting ones own cells (platelets), concentrating them most often through centrifugation, exposing them to an agonist which induces activation which releases intrinsic substances, and applying them to a target area to accelerate wound healing. APG is attractive because it concentrates a large number of biologically active substances, which are primarily proteins that participate in complex series of mechanisms involved in inflammation and wound healing. It has been used in numerous applications including sports medicine, dermatology, and surgery. However, there are few prospective randomized trials that have compared it in a rigorous manner to other techniques or to placebo. The following report is a review of APG, which includes a description of its perceived benefit, identification of the various modalities where it has been used, and criticisms concerning its use.
Collapse
Affiliation(s)
- Alfred H Stammers
- Department of Perfusion Services, Geisinger Health Systems, Danville and Wilkes Barre, Pennsylvania, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Kuo SM, Lin LC, Kang PL, Tsai JC, Chang SJ. Evaluation of Bone Growth Using Artificial Bone Substitute (Osteoset®) and Platelet Gel Mixtures: A Preliminarily Study in Dogs. ACTA ACUST UNITED AC 2009; 37:78-84. [DOI: 10.1080/10731190902742497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
|
17
|
Feiz-Erfan I, Harrigan M, Sonntag VKH, Harrington TR. Effect of autologous platelet gel on early and late graft fusion in anterior cervical spine surgery. J Neurosurg Spine 2007; 7:496-502. [DOI: 10.3171/spi-07/11/496] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Object
In a double-blind randomized study, platelet concentrate was used to treat 50 patients who underwent anterior cervical fusion with allograft bone and internal fixation, predominantly for degenerative disc disease or soft herniated cervical disc. The goal in this study was to compare the outcomes in patients treated with and without the platelet gel.
Methods
Patients were assessed radiographically at 6, 12, and 52 weeks and at 2 years if needed. Clinically, patients were evaluated with the visual analog scale, Neck Disability Index, Short Form–36, and a modified Prolo Scale.
Results
Follow-up included 90% of the patients at 1 year and 84% at 2 years. The overall fusion rate was 84%.
Conclusions
Whereas patients with degenerative discs treated with platelet gel demonstrated early fusion at the 12-week follow-up interval, no consistent early fusion was obtained with the use of the platelet gel preparation in patients with a soft disc herniation.
Collapse
|
18
|
Bae H, Kanim L, Spayde E, Wong P, Zhao L, Pradhan B, Delamarter R. Does Autologous Bone Marrow Aspirate Enhance Graft Effectiveness for Spinal Fusion? ACTA ACUST UNITED AC 2006. [DOI: 10.1053/j.semss.2006.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
|
19
|
Jenis LG, Banco RJ, Kwon B. A prospective study of Autologous Growth Factors (AGF) in lumbar interbody fusion. Spine J 2006; 6:14-20. [PMID: 16413442 DOI: 10.1016/j.spinee.2005.08.014] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2005] [Revised: 08/20/2005] [Accepted: 08/25/2005] [Indexed: 02/03/2023]
Abstract
BACKGROUND Numerous preclinical and clinical studies have reported on the use of platelet concentrates to promote tissue healing. The results in spinal fusion applications are limited and controversial. PURPOSE The purpose of the current prospective clinical cohort study is to assess the effect of Autologous Growth Factors (AGF) on lumbar interbody fusion with specific attention paid to determination of clinical and radiographic outcomes. STUDY DESIGN/SETTING Prospective clinical study PATIENT SAMPLE Candidates for anterior-posterior lumbar fusion with diagnosis of degenerative disc disease and/or up to grade I spondylolytic spondylolisthesis based on positive provocative discography. OUTCOME MEASURES Clinical (visual analogue pain scale/functional outcome assessment) and radiographic outcomes (fusion on computed tomography at 6 months and plain radiographs at 12 and 24 months). METHODS Thirty-seven patients were assigned to standard anterior-posterior interbody fusion L2-S1 (single or two-level) using iliac crest bone graft (autograft group: 22 patients with 32 levels operated) or allograft combined with autogenous growth factors (AGF group: 15 patients with 25 levels operated). Radiographic outcomes were collected at 6 months postsurgery with computed tomography and at 12 and 24 months with plain radiographs. Pre- and postoperative clinical outcome measures included visual analog scores (VAS) for back and leg pain (0-10), SF-36 scores, and Oswestry disability determination. Average clinical and radiographic follow-up for the autograft group was 24.3+/-5.6 months (12-36 months) and AGF was 25.7+/-7.5 (6-40 months). RESULTS Fusion incorporation at each end plate was determined at 56% in both autograft and AGF (p=NS) patients based on computed tomography at 6 months with minimal subsidence noted and no direct correlation between the incidence or degree of cage subsidence and bone graft technique. The 12- and 24-month radiographic results confirmed an 85% arthrodesis rate for the autograft patients, whereas the AGF patients had an 89% fusion rate (p=NS). Clinical outcomes were similar for both groups and no significant differences were noted for pain or functional outcome improvements. CONCLUSIONS AGF combined with an allograft carrier is equivalent in radiographic and clinical outcomes to autograft in one- or two-level lumbar interbody fusion with supplemental posterior fixation and, thus, eliminates any morbidity from iliac crest bone graft harvesting. AGF combined with an appropriate carrier is a reasonable alternative to autograft and expensive bone induction technologies. Further research is still required to examine the optimum carriers, preparation and formulation, and platelet concentrations for this technology.
Collapse
Affiliation(s)
- Louis G Jenis
- Boston Spine Group, New England Baptist Hospital, 125 Parker Hill Ave., Boston, MA 02120, USA.
| | | | | |
Collapse
|
20
|
Bose B, Balzarini MA. Bone graft gel: autologous growth factors used with autograft bone for lumbar spine fusions. Adv Ther 2002; 19:170-5. [PMID: 12431042 DOI: 10.1007/bf02848692] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
A method to combine autologous growth factors (AGF) with autologous bone graft in a bone graft gel for spine fusions is described. The bone graft gel can be inserted into cages for interbody fusions or used directly for posterolateral intertransverse fusions. Sixty patients have undergone spinal fusion surgery under this technique. No equipment problems have been encountered and no adverse effects observed that could be attributed to AGF. Early clinical outcomes indicated solid or maturing fusions in 58 of 60 patients. AGFs to enhance bone healing represent an economical and readily available autologous source of growth factors.
Collapse
Affiliation(s)
- Bikash Bose
- Department of Neurosurgery, Christiana Care Health System, Newark, Delaware, USA
| | | |
Collapse
|