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Wijaya JH, Tjahyanto T, Alexi R, Purnomo AE, Rianto L, Arjuna YYE, Tobing JFL, Yunus Y, Faried A. Application of rhBMP in spinal fusion surgery: any correlation of cancer incidence? A systematic review and meta-analysis. 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 2023; 32:2020-2028. [PMID: 37133762 DOI: 10.1007/s00586-023-07730-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/28/2023] [Accepted: 04/18/2023] [Indexed: 05/04/2023]
Abstract
PURPOSE Safety concerns regarding the application of bone morphogenetic proteins (BMPs) have been highlighted in recent years. It is noted that both BMP and their receptors being identified as a trigger for cancer growth. Here, we aimed to determine the safety and efficacy of BMP for spinal fusion surgery. METHODS We conducted this systematic review on topics of spinal fusion surgery with rhBMP application from three database (PubMed, EuropePMC, and Clinicaltrials.gov) with MeSH phrases such as "rh-BMP," "rhBMP," "spine surgery," "spinal arthrodesis," and "spinal fusion" were searched (using the Boolean operators "and" and "or"). Our research includes all articles, as long as published in English language. In the face of disagreement between the two reviewers, we discussed it together until all authors reached a consensus. The primary key outcome of our study is the incidence of cancer following rhBMP implantation. RESULTS Our study included a total of 8 unique studies (n = 37,682). The mean follow-up varies among all studies, with the longest follow-up is 66 months. Our meta-analysis showed that exposure to rhBMP in spinal surgery did increase the risk of cancers (RR 1.85, 95%CI [1.05, 3.24], p = 0.03). CONCLUSIONS Our study found that rhBMP was not associated with the increased risk of cancer incidence within the rhBMP cohort. Still, we did face several limitations, in which further studies are needed to confirm the result of our meta-analysis.
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Affiliation(s)
- Jeremiah Hilkiah Wijaya
- Department of Neurosurgery, Universitas Pelita Harapan, MH Thamrin Boulevard 1100, Karawaci, Tangerang, 15811, Banten, Indonesia.
| | - Teddy Tjahyanto
- Department of Medicine, Tarumanagara University, Jakarta, Indonesia
| | - Roberto Alexi
- Department of Medicine, Santo Vincentius Hospital, Singkawang, West Kalimantan, Indonesia
| | - Alexander Erick Purnomo
- Department of Neurosurgery, Universitas Pelita Harapan, MH Thamrin Boulevard 1100, Karawaci, Tangerang, 15811, Banten, Indonesia
| | - Louis Rianto
- Department of Orthopedics, Universitas Pelita Harapan, Karawaci, Tangerang, Banten, Indonesia
| | - Yang Yang Endro Arjuna
- Department of Neurosurgery, Universitas Pelita Harapan, MH Thamrin Boulevard 1100, Karawaci, Tangerang, 15811, Banten, Indonesia
| | | | - Yesaya Yunus
- Department of Neurosurgery, Universitas Pelita Harapan, MH Thamrin Boulevard 1100, Karawaci, Tangerang, 15811, Banten, Indonesia
| | - Ahmad Faried
- Department of Neurosurgery, Universitas Padjajaran, Bandung, West Java, Indonesia
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Agus Subagio E, Apriyansa Rahmadhan M, Faris M, Indarto Susilo R, Setiawan Suroto N, Utomo B, Wicaksono P, Hafid Bajamal A. Comparison of fusion outcomes of bone morphogenetics proteins-7 and bone autograft in posterolateral lumbar fusion : a systematic review. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2023.101765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
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Daffner SD, Bunch JT, Burton DC, Milam IV RA, Park DK, Strenge KB, Whang PG, An HS, Kopjar B. Better Functional Recovery After Single-Level Compared With Two-Level Posterolateral Lumbar Fusion. Cureus 2022; 14:e23010. [PMID: 35425678 PMCID: PMC9005157 DOI: 10.7759/cureus.23010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2022] [Indexed: 11/06/2022] Open
Abstract
Background Multiple studies describe the outcomes of patients undergoing single-level and multilevel posterolateral lumbar fusion (PLF). However, a comparison of outcomes between single-level and two-level PLF is lacking. The aim of this prospective cohort study was to compare outcomes between single-level and two-level instrumented PLF. Methods A total of 42 patients were enrolled at nine US centers between October 2015 and June 2017. Data included radiologic outcomes, visual analog scale (VAS) Back and Leg Pain, disability per the Oswestry Disability Index (ODI), and health-related quality of life (QoL) per 36-Item Short Form Survey version 2.0 (SF-36v2) at six weeks and three, six, 12, and 24 months. Results Twelve-month and 24-month follow-ups were completed by 38 (90.5%) and 32 (76.2%) subjects, respectively. The average age was 67 years, and 54.8% were female. Twenty-six received single-level PLF, and 16 received two-level PLF. In the single-level group, there was one reoperation, two postoperative infections, and one dural tear. In the two-level group, there was one postoperative infection. The surgeon computed tomography (CT)-based evaluation of fusion rate was 67.6% (25/37) at 12-month follow-up and 94.1% (32/34) at 24-month follow-up. The third-party evaluation of fusion rate was 52.8% (19/36) at six months, 81.1% (30/37) at 12 months, and 86.5% (32/37) at 24 months. There was a tendency toward a higher fusion rate in single-level compared with two-level PLF. The ODI, SF-36v2 Mental Component Score (MCS), and VAS Back Pain and Leg Pain outcomes improved by the first follow-up visit in both the single-level and two-level groups. Improvement in the ODI was 5.86 (95% confidence interval (CI): 0.03-11.69) points greater in the single-level group compared with the two-level group. Conclusions Compared with the two-level PLF subjects, single-level PLF subjects had better functional outcomes and reported higher satisfaction with the outcome of surgery but showed similar fusion, pain, and generic health-related quality of life outcomes. Both single-level and two-level PLF subjects demonstrated high fusion rates in association with improvements in pain, functional, and quality of life outcomes, as well as high satisfaction levels.
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Krticka M, Planka L, Vojtova L, Nekuda V, Stastny P, Sedlacek R, Brinek A, Kavkova M, Gopfert E, Hedvicakova V, Rampichova M, Kren L, Liskova K, Ira D, Dorazilová J, Suchy T, Zikmund T, Kaiser J, Stary D, Faldyna M, Trunec M. Lumbar Interbody Fusion Conducted on a Porcine Model with a Bioresorbable Ceramic/Biopolymer Hybrid Implant Enriched with Hyperstable Fibroblast Growth Factor 2. Biomedicines 2021; 9:733. [PMID: 34202232 PMCID: PMC8301420 DOI: 10.3390/biomedicines9070733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 06/18/2021] [Accepted: 06/22/2021] [Indexed: 11/17/2022] Open
Abstract
Many growth factors have been studied as additives accelerating lumbar fusion rates in different animal models. However, their low hydrolytic and thermal stability both in vitro and in vivo limits their workability and use. In the proposed work, a stabilized vasculogenic and prohealing fibroblast growth factor-2 (FGF2-STAB®) exhibiting a functional half-life in vitro at 37 °C more than 20 days was applied for lumbar fusion in combination with a bioresorbable scaffold on porcine models. An experimental animal study was designed to investigate the intervertebral fusion efficiency and safety of a bioresorbable ceramic/biopolymer hybrid implant enriched with FGF2-STAB® in comparison with a tricortical bone autograft used as a gold standard. Twenty-four experimental pigs underwent L2/3 discectomy with implantation of either the tricortical iliac crest bone autograft or the bioresorbable hybrid implant (BHI) followed by lateral intervertebral fixation. The quality of spinal fusion was assessed by micro-computed tomography (micro-CT), biomechanical testing, and histological examination at both 8 and 16 weeks after the surgery. While 8 weeks after implantation, micro-CT analysis demonstrated similar fusion quality in both groups, in contrast, spines with BHI involving inorganic hydroxyapatite and tricalcium phosphate along with organic collagen, oxidized cellulose, and FGF2- STAB® showed a significant increase in a fusion quality in comparison to the autograft group 16 weeks post-surgery (p = 0.023). Biomechanical testing revealed significantly higher stiffness of spines treated with the bioresorbable hybrid implant group compared to the autograft group (p < 0.05). Whilst histomorphological evaluation showed significant progression of new bone formation in the BHI group besides non-union and fibrocartilage tissue formed in the autograft group. Significant osteoinductive effects of BHI based on bioceramics, collagen, oxidized cellulose, and FGF2-STAB® could improve outcomes in spinal fusion surgery and bone tissue regeneration.
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Affiliation(s)
- Milan Krticka
- Trauma Surgery Department, Faculty of Medicine, Masaryk University and The University Hospital Brno, 625 00 Brno, Czech Republic; (M.K.); (V.N.); (D.I.)
| | - Ladislav Planka
- Department of Paediatric Surgery, Orthopedics and Traumatology, Faculty of Medicine, Masaryk University and The University Hospital Brno, 662 63 Brno, Czech Republic; (L.P.); (D.S.)
| | - Lucy Vojtova
- CEITEC-Central European Institute of Technology, Brno University of Technology, 612 00 Brno, Czech Republic; (P.S.); (A.B.); (M.K.); (J.D.); (T.Z.); (J.K.); (M.T.)
| | - Vladimir Nekuda
- Trauma Surgery Department, Faculty of Medicine, Masaryk University and The University Hospital Brno, 625 00 Brno, Czech Republic; (M.K.); (V.N.); (D.I.)
| | - Premysl Stastny
- CEITEC-Central European Institute of Technology, Brno University of Technology, 612 00 Brno, Czech Republic; (P.S.); (A.B.); (M.K.); (J.D.); (T.Z.); (J.K.); (M.T.)
| | - Radek Sedlacek
- Department of Mechanics, Biomechanics and Mechatronics, Faculty of Mechanical Engineering, Czech Technical University in Prague, 160 00 Prague, Czech Republic;
| | - Adam Brinek
- CEITEC-Central European Institute of Technology, Brno University of Technology, 612 00 Brno, Czech Republic; (P.S.); (A.B.); (M.K.); (J.D.); (T.Z.); (J.K.); (M.T.)
| | - Michaela Kavkova
- CEITEC-Central European Institute of Technology, Brno University of Technology, 612 00 Brno, Czech Republic; (P.S.); (A.B.); (M.K.); (J.D.); (T.Z.); (J.K.); (M.T.)
| | - Eduard Gopfert
- Veterinary Research Institute, 621 00 Brno, Czech Republic; (E.G.); (M.F.)
| | - Vera Hedvicakova
- University Center for Energy Efficient Buildings, Czech Technical University in Prague, 273 43 Bustehrad, Czech Republic; (V.H.); (M.R.)
- Department of Tissue Engineering, Institute of Experimental Medicine of the Czech Academy of Sciences, Videnska 1083, 142 20 Prague, Czech Republic
| | - Michala Rampichova
- University Center for Energy Efficient Buildings, Czech Technical University in Prague, 273 43 Bustehrad, Czech Republic; (V.H.); (M.R.)
- Department of Tissue Engineering, Institute of Experimental Medicine of the Czech Academy of Sciences, Videnska 1083, 142 20 Prague, Czech Republic
| | - Leos Kren
- Department of Pathology, Faculty of Medicine of Masaryk University and The University Hospital Brno, 625 00 Brno, Czech Republic; (L.K.); (K.L.)
| | - Kvetoslava Liskova
- Department of Pathology, Faculty of Medicine of Masaryk University and The University Hospital Brno, 625 00 Brno, Czech Republic; (L.K.); (K.L.)
| | - Daniel Ira
- Trauma Surgery Department, Faculty of Medicine, Masaryk University and The University Hospital Brno, 625 00 Brno, Czech Republic; (M.K.); (V.N.); (D.I.)
| | - Jana Dorazilová
- CEITEC-Central European Institute of Technology, Brno University of Technology, 612 00 Brno, Czech Republic; (P.S.); (A.B.); (M.K.); (J.D.); (T.Z.); (J.K.); (M.T.)
| | - Tomas Suchy
- Department of Composites and Carbon Materials, Institute of Rock Structure and Mechanics, The Czech Academy of Sciences, 182 09 Prague, Czech Republic;
| | - Tomas Zikmund
- CEITEC-Central European Institute of Technology, Brno University of Technology, 612 00 Brno, Czech Republic; (P.S.); (A.B.); (M.K.); (J.D.); (T.Z.); (J.K.); (M.T.)
| | - Jozef Kaiser
- CEITEC-Central European Institute of Technology, Brno University of Technology, 612 00 Brno, Czech Republic; (P.S.); (A.B.); (M.K.); (J.D.); (T.Z.); (J.K.); (M.T.)
| | - David Stary
- Department of Paediatric Surgery, Orthopedics and Traumatology, Faculty of Medicine, Masaryk University and The University Hospital Brno, 662 63 Brno, Czech Republic; (L.P.); (D.S.)
| | - Martin Faldyna
- Veterinary Research Institute, 621 00 Brno, Czech Republic; (E.G.); (M.F.)
| | - Martin Trunec
- CEITEC-Central European Institute of Technology, Brno University of Technology, 612 00 Brno, Czech Republic; (P.S.); (A.B.); (M.K.); (J.D.); (T.Z.); (J.K.); (M.T.)
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Wu Z, Zhou B, Chen L, Wang X, Abdelrahim MEA, Wei C. Bone morphogenetic protein-2 against iliac crest bone graft for the posterolateral fusion of the lumbar spine: A meta-analysis. Int J Clin Pract 2021; 75:e13911. [PMID: 33277737 DOI: 10.1111/ijcp.13911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 12/01/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The impact of bone morphogenetic protein-2 compared to autologous iliac crest bone graft to improve fusion rates for the posterolateral fusion of the lumbar spine remains inconclusive. This meta-analysis was performed to evaluate this relationship. METHODS A systematic literature search up to May 2020 was performed and 14 studies were detected with 1516 subjects with 789 of them were bone morphogenetic protein-2 and 727 of them were autologous iliac crest bone graft. They reported relationships between bone morphogenetic protein-2 and autologous iliac crest bone graft on fusion rates for the posterolateral fusion of the lumbar spine. Odds ratio (OR) with 95% confidence intervals (CIs) was calculated comparing the bone morphogenetic protein-2 or autologous iliac crest bone graft on the posterolateral fusion of the lumbar spine risks using the dichotomous and continuous method with a random- or fixed-effect model. RESULTS Bone morphogenetic protein-2 had significantly higher fusion rates (OR, 4.19; 95% CI, 2.82-6.20, P < .001); lower surgery time (OR, -26.64; 95% CI, -38.71 to -14.57, P < .001); lower blood loss (OR, -92.84; 95% CI, -131.71 to -53.97, P < .001); lower additional surgical procedures (OR, 0.46; 95% CI, 0.31-0.69, P < .001) and higher Oswestry Disability Index (OR, 1.49; 95% CI, 0.02-2.97, P = .05) compared to autologous iliac crest bone graft. However, no significant difference was found between bone morphogenetic protein-2 and autologous iliac crest bone graft in non-union rates (OR, 0.34; 95% CI, 0.08-1.53, P < .001); hospitalisation days (OR, -0.21; 95% CI, -0.48 to 0.07, P = .14) and adverse events (OR, 0.78; 95% CI, 0.52-1.16, P = .22). CONCLUSIONS Bone morphogenetic protein-2 significantly had a higher fusion rate, lower surgery time, lower blood loss, lower additional surgical procedures and higher Oswestry Disability Index compared to autologous iliac crest bone graft. This relationship forces us to recommend bone morphogenetic protein-2 for the posterolateral fusion of the lumbar spine to avoid any possible negative postoperative results.
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Affiliation(s)
- Zhenyu Wu
- Department one of Orthopedics, Affiliated Hospital of Beihua University, Jilin, Jilin, China
| | - Bo Zhou
- Department of Orthopedics, Yixing People's Hospital, Yixing, Jiangsu, China
| | - Liang Chen
- Department of Orthopedics, Yixing People's Hospital, Yixing, Jiangsu, China
| | - Xiaofeng Wang
- Department of Neurosurgery, Weinan Central Hospital, Weinan, Shaanxi, China
| | - Mohamed E A Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Cheng Wei
- Department of Orthopaedics, Nanjing Lishui People's Hospital, Nanjing, Jiangsu, China
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Reisener MJ, Pumberger M, Shue J, Girardi FP, Hughes AP. Trends in lumbar spinal fusion-a literature review. JOURNAL OF SPINE SURGERY 2020; 6:752-761. [PMID: 33447679 DOI: 10.21037/jss-20-492] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Over the past several decades, there has been an upward trend in the total number of spinal fusion procedures worldwide. Advanced spinal fusion techniques with or without internal fixation, additional innovations in surgical approaches, innovative implants including a wide variety of interbody devices, and new alternatives in bone grafting materials are some reasons for the increasing number of spine fusion procedures. Moreover, the indications for spinal fusion have broadened over time. Initially developed for the treatment of instability and deformity due to tuberculosis, scoliosis, and traumatic injury, spinal fusion surgery has now a wide range of indications like spondylolisthesis, congenital or degenerative deformity, spinal tumors, and pseudarthrosis, with degenerative disorders as the most common indication. This review emphasizes current lumbar fusion techniques and their development in the past decades.
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Affiliation(s)
- Marie-Jacqueline Reisener
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA.,Department of Traumatology and Orthopedic Surgery, Charite-University Hospital Berlin, Berlin, Germany
| | - Matthias Pumberger
- Department of Traumatology and Orthopedic Surgery, Charite-University Hospital Berlin, Berlin, Germany
| | - Jennifer Shue
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Federico P Girardi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Alexander P Hughes
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Influence of the TGF-β Superfamily on Osteoclasts/Osteoblasts Balance in Physiological and Pathological Bone Conditions. Int J Mol Sci 2020; 21:ijms21207597. [PMID: 33066607 PMCID: PMC7589189 DOI: 10.3390/ijms21207597] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/09/2020] [Accepted: 10/10/2020] [Indexed: 12/19/2022] Open
Abstract
The balance between bone forming cells (osteoblasts/osteocytes) and bone resorbing cells (osteoclasts) plays a crucial role in tissue homeostasis and bone repair. Several hormones, cytokines, and growth factors-in particular the members of the TGF-β superfamily such as the bone morphogenetic proteins-not only regulate the proliferation, differentiation, and functioning of these cells, but also coordinate the communication between them to ensure an appropriate response. Therefore, this review focuses on TGF-β superfamily and its influence on bone formation and repair, through the regulation of osteoclastogenesis, osteogenic differentiation of stem cells, and osteoblasts/osteoclasts balance. After introducing the main types of bone cells, their differentiation and cooperation during bone remodeling and fracture healing processes are discussed. Then, the TGF-β superfamily, its signaling via canonical and non-canonical pathways, as well as its regulation by Wnt/Notch or microRNAs are described and discussed. Its important role in bone homeostasis, repair, or disease is also highlighted. Finally, the clinical therapeutic uses of members of the TGF-β superfamily and their associated complications are debated.
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Comparative Clinical Effectiveness and Safety of Bone Morphogenetic Protein Versus Autologous Iliac Crest Bone Graft in Lumbar Fusion: A Meta-analysis and Systematic Review. Spine (Phila Pa 1976) 2020; 45:E729-E741. [PMID: 31923133 PMCID: PMC7282484 DOI: 10.1097/brs.0000000000003372] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This is a systematic literature review and meta-analysis. OBJECTIVE We aimed to evaluate the efficacy and safety of recombinant human bone morphogenetic protein (RhBMP) and autologous iliac crest bone graft (ICBG) in lumbar fusion. SUMMARY OF BACKGROUND DATA RhBMP has been emphasized in lumbar fusion due to high fusion success rate. However, ICBG remains the criterion standard graft approach for lumbar fusion. The safety and effectiveness of rhBMP are controversial. METHODS Prospective randomized controlled trials were searched from PubMed, EMBASE, and Cochrane Central Register of Controlled Trails by using Medical Subject Headings terms "bone morphogenetic protein,' "bone transplantation,' and "spinal fusion.' Two independent investigators screened eligible studies, assessed the bias of original articles, extracted data including fusion success, Oswestry disability index improvement, improved short form 36 questionnaire scores, adverse events and re-operation, and a subgroup analysis. The GRADE approach was used to grade quality of evidence. RESULTS Twenty randomized controlled trials (2185 patients) met the inclusion criteria. There were higher fusion success rate (odds ratio [OR] 3.79, 95% confidence interval [CI] 1.88-7.63, P = 0.0002), better improvement of Oswestry Disability Index (mean difference 1.54, 95% CI 0.18-2.89, P = 0.03), and lower re-operation rate (OR 0.59, 95% CI 0.43-0.80, P = 0.0007) in rhBMP group. Heterogeneity was obvious in fusion success rate (I = 58%); hence, a subgroup analysis, based on protein type (rhBMP-2 or rhBMP-7), was performed, which suggested that only rhBMP-2 was better than ICBG for lumbar fusion. There was no difference in the incidence of adverse events between rhBMP and ICBG (OR 0.91, 95% CI 0.70-1.18, P = 0.47). CONCLUSION In lumbar fusion, rhBMP-2 exhibited a higher fusion success rate and reduced the risk of re-operation. No difference in complication rate is between rhBMP (rhBMP-2 and rhBMP-7) and ICBG. We suggest rhBMP especially rhBMP-2 as an effective substitute for ICBG for lumbar fusion. LEVEL OF EVIDENCE 1.
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Mariscal G, Nuñez JH, Barrios C, Domenech-Fernández P. A meta-analysis of bone morphogenetic protein-2 versus iliac crest bone graft for the posterolateral fusion of the lumbar spine. J Bone Miner Metab 2020; 38:54-62. [PMID: 31292724 DOI: 10.1007/s00774-019-01025-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 06/30/2019] [Indexed: 10/26/2022]
Abstract
The impact of autologous iliac crest bone graft versus BMP-2 to improve fusion rates for posterolateral fusion (PLF) of the lumbar spine remains unanswered. Single-institution-centered data dominate the literature, providing results that may be contradictory or inconclusive. The aim of this paper is to analyze data pooled from multiple well-controlled studies that examined both ICBG and BMP-2 for use in PLF. This meta-analysis also provides details of success in different subsets of patients with variable risk factors for delayed and non-unions. Six high-quality randomized clinical trials were selected. Efficacy, morbidity, quality of life, and safety were compared between the BMP-2 group and the ICBG group. A total of 908 patients were included in the study. At 24 months, 94% of patients achieved fusion in the BMP-2 group and 83% in the ICBG group. At 6 and 12 months, the fusion was also greater in the BMP-2 group (86% vs. 60% and 88% vs. 80%, respectively). Surgical time, intraoperative blood loss, and hospitalization days also showed significant differences in favor of the experimental group (p < 0.01). There were no differences between two groups in the Oswestry Disability Index, 36-Item Short Form Health Survey and Back Pain Score, whereas a greater number of additional surgical procedures were performed in the ICBG group (p = 0.001). In conclusion, the use of BMP-2 in PLF reduced the surgical morbidity and had more beneficial effects on the fusion rate. The quality of life based on clinical scores was the same in both groups.
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Affiliation(s)
- Gonzalo Mariscal
- Musculoskeletal Diseases Research Institute, Catholic University of Valencia, Carrer de Quevedo, 2, 46001, Valencia, Spain
| | - Jorge H Nuñez
- Spine Unit, Department of Traumatology and Orthopedic Surgery, Hospital Sant Joan de Deu, Passeig de Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain.
- Spine Unit, Department of Traumatology and Orthopedic Surgery, University Hospital of Mutua Terrassa, Plaça del Doctor Robert, 5, 08221, Terrassa, Barcelona, Spain.
| | - Carlos Barrios
- Musculoskeletal Diseases Research Institute, Catholic University of Valencia, Carrer de Quevedo, 2, 46001, Valencia, Spain
| | - Pedro Domenech-Fernández
- Spine Unit, Department of Traumatology and Orthopedic Surgery, Hospital Sant Joan de Deu, Passeig de Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
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Efficacy and safety of bone substitutes in lumbar spinal fusion: a systematic review and network meta-analysis of randomized controlled trials. 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 2019; 29:1261-1276. [PMID: 31872300 DOI: 10.1007/s00586-019-06257-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 09/21/2019] [Accepted: 12/16/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE A variety of alternative grafts to autologous iliac crest bone (ICBG) have been developed for lumbar spondylodesis, due to frequent complications following ICBG harvest. The optimal alternative graft to ICBG, however, remains elusive till now. The purpose of this study was to compare the efficacy and safety of fusion materials in lumbar degeneration diseases and to provide a ranking spectrum of the grafts. METHODS Randomized controlled trials (RCTs) comparing different bone grafts in lumbar arthrodesis were eligible for inclusion. A network meta-analysis was performed for endpoints including fusion rate and incidence of adverse events. RESULTS Twenty-seven RCTs involving 2488 patients and 13 available interventions were included. rhBMP-2 provided the highest fusion rate, being significantly superior to that of ICBG (OR = 0.21, p < 0.001), autograft local bone (ALB) (OR = 0.18, p = 0.022), rhBMP-7 (OR = 0.15, p < 0.001), allograft (OR = 0.13, p = 0.009), and DBM + ALB (OR = 0.07, p = 0.048). The treatment efficacy of allograft could be significantly enhanced by bone marrow concentrate (BMC) supplying (OR = 0.16, p = 0.010). ICBG ranks second on the frequency of complications, which is significantly higher than that of allograft (OR = 0.14, p = 0.041) and ALB (OR = 0.14, p = 0.030). All of the other comparisons showed similar efficacy and safety profiles between groups. CONCLUSION Ranking spectrums of the efficacy and safety for various bone grafts were provided graphically. Though rhBMP-2 was of the highest success rate, the application should be taken with proper caution because of the widely proposed life-threatening adverse events. ALB, ALB plus synthetic ceramic materials and allograft mixed with BMC were also proved to be potentially effective alternative graft to ICBG. These slides can be retrieved under Electronic Supplementary Material.
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Chen CM, Chen CF, Wang JY, Madda R, Tsai SW, Wu PK, Chen WM. Bone morphogenetic protein activity preservation with extracorporeal irradiation- and liquid nitrogen freezing-treated recycled autografts for biological reconstruction in malignant bone tumor. Cryobiology 2019; 89:82-89. [DOI: 10.1016/j.cryobiol.2019.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 04/30/2019] [Accepted: 05/01/2019] [Indexed: 02/06/2023]
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Haws BE, Khechen B, Patel DV, Yoo JS, Guntin JA, Cardinal KL, Ahn J, Singh K. Impact of Iliac Crest Bone Grafting on Postoperative Outcomes and Complication Rates Following Minimally Invasive Transforaminal Lumbar Interbody Fusion. Neurospine 2019; 16:772-779. [PMID: 31284335 PMCID: PMC6944998 DOI: 10.14245/ns.1938006.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 05/07/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The relationship between bone graft technique and postoperative outcomes for minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) has not been well-defined. This study aims to determine the effect of iliac crest bone grafting (ICBG) on patient-reported outcomes (PROs) and complication rates following MIS TLIF. METHODS Primary, single-level MIS TLIF patients were consecutively analyzed. Patients that prospectively received a percutaneous technique of ICBG were compared to patients that retrospectively received bone morphogenetic protein-2 (BMP-2). Complication rates were assessed perioperatively and up to 1 year postoperatively. Changes in Oswestry Disability Index (ODI), visual analogue scale (VAS) back, and VAS leg pain were compared. Rates of minimum clinically important difference (MCID) achievement at final follow-up for ODI, VAS back, and VAS leg scores were compared. RESULTS One hundred forty-nine patients were included: 101 in the BMP-2 cohort and 48 in the ICBG cohort. The ICBG cohort demonstrated increases in intraoperative blood loss and shorter lengths of stay. ICBG patients also experienced longer operative times, though this did not reach statistical significance. No significant differences in complication or reoperation rates were identified. The ICBG cohort demonstrated greater improvements in VAS leg pain at 6-week and 12-week follow-up. No other significant differences in PROs or MCID achievement rates were identified. CONCLUSION Patients undergoing MIS TLIF with ICBG experienced clinically insignificant increases in intraoperative blood loss and did not experience increases in postoperative pain or disability. Complication and reoperation rates were similar between groups. These results suggest that ICBG is a safe option for MIS TLIF.
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Affiliation(s)
- Brittany E Haws
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Benjamin Khechen
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Dil V Patel
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Joon S Yoo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Jordan A Guntin
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kaitlyn L Cardinal
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Junyoung Ahn
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Cottrill E, Ahmed AK, Lessing N, Pennington Z, Ishida W, Perdomo-Pantoja A, Lo SF, Howell E, Holmes C, Goodwin CR, Theodore N, Sciubba DM, Witham TF. Investigational growth factors utilized in animal models of spinal fusion: Systematic review. World J Orthop 2019; 10:176-191. [PMID: 31041160 PMCID: PMC6475812 DOI: 10.5312/wjo.v10.i4.176] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 01/03/2019] [Accepted: 01/26/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Over 400000 Americans annually undergo spinal fusion surgeries, yet up to 40% of these procedures result in pseudoarthrosis even with iliac crest autograft, the current “gold standard” treatment. Tissue engineering has the potential to solve this problem via the creation of bone grafts involving bone-promoting growth factors (e.g., bone morphogenetic protein 2). A broad assessment of experimental growth factors is important to inform future work and clinical potential in this area. To date, however, no study has systematically reviewed the investigational growth factors utilized in preclinical animal models of spinal fusion.
AIM To review all published studies assessing investigational growth factors for spinal fusion in animal models and identify promising agents for translation.
METHODS We conducted a systematic review of the literature using PubMed, Embase, Cochrane Library, and Web of Science databases with searches run on May 29th, 2018. The search query was designed to include all non-human, preclinical animal models of spinal fusion reported in the literature without a timespan limit. Extracted data for each model included surgical approach, level of fusion, animal species and breed, animal age and sex, and any other relevant characteristics. The dosages/sizes of all implant materials, spinal fusion rates, and follow-up time points were recorded. The data were analyzed and the results reported in tables and text. PRISMA guidelines were followed for this systematic review.
RESULTS Twenty-six articles were included in this study, comprising 14 experimental growth factors: AB204 (n = 1); angiopoietin 1 (n = 1); calcitonin (n = 3); erythropoietin (n = 1); basic fibroblast growth factor (n = 1); growth differentiation factor 5 (n = 4), combined insulin-like growth factor 1 + transforming growth factor beta (n = 4); insulin (n = 1); NELL-1 (n = 5); noggin (n = 1); P-15 (n = 1); peptide B2A (n = 2); and secreted phosphoprotein 24 (n = 1). The fusion rates of the current gold standard treatment (autologous iliac crest bone graft, ICBG) and the leading clinically used growth factor (BMP-2) ranged widely in the included studies, from 0-100% for ICBG and from 13%-100% for BMP-2. Among the identified growth factors, calcitonin, GDF-5, NELL-1, and P-15 resulted in fusion rates of 100% in some cases. In addition, six growth factors - AB204, angiopoietin 1, GDF-5, insulin, NELL-1, and peptide B2A - resulted in significantly enhanced fusion rates compared to ICBG, BMP-2, or other internal control in some studies. Large heterogeneity in animal species, fusion method, and experimental groups and time points was observed across the included studies, limiting the direct comparison of the growth factors identified herein.
CONCLUSION Several promising investigational growth factors for spinal fusion have been identified herein; directly comparing the fusion efficacy and safety of these agents may inform clinical translation.
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Affiliation(s)
- Ethan Cottrill
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, MD 21287, United States
| | - A Karim Ahmed
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, MD 21287, United States
| | - Noah Lessing
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, MD 21287, United States
| | - Zachary Pennington
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, MD 21287, United States
| | - Wataru Ishida
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, MD 21287, United States
| | | | - Sheng-fu Lo
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, MD 21287, United States
| | - Elizabeth Howell
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, United States
| | - Christina Holmes
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, MD 21287, United States
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, United States
| | - Nicholas Theodore
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, MD 21287, United States
| | - Daniel M Sciubba
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, MD 21287, United States
| | - Timothy F Witham
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, MD 21287, United States
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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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Dorati R, DeTrizio A, Modena T, Conti B, Benazzo F, Gastaldi G, Genta I. Biodegradable Scaffolds for Bone Regeneration Combined with Drug-Delivery Systems in Osteomyelitis Therapy. Pharmaceuticals (Basel) 2017; 10:E96. [PMID: 29231857 PMCID: PMC5748651 DOI: 10.3390/ph10040096] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 11/27/2017] [Accepted: 11/29/2017] [Indexed: 12/31/2022] Open
Abstract
A great deal of research is ongoing in the area of tissue engineering (TE) for bone regeneration. A possible improvement in restoring damaged tissues involves the loading of drugs such as proteins, genes, growth factors, antibiotics, and anti-inflammatory drugs into scaffolds for tissue regeneration. This mini-review is focused on the combination of the local delivery of antibiotic agents with bone regenerative therapy for the treatment of a severe bone infection such as osteomyelitis. The review includes a brief explanation of scaffolds for bone regeneration including scaffolds characteristics and types, a focus on severe bone infections (especially osteomyelitis and its treatment), and a literature review of local antibiotic delivery by the combination of scaffolds and drug-delivery systems. Some examples related to published studies on gentamicin sulfate-loaded drug-delivery systems combined with scaffolds are discussed, and future perspectives are highlighted.
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Affiliation(s)
- Rossella Dorati
- Department of Drug Sciences, University of Pavia, Viale Taramelli 12, 27100 Pavia, Italy.
- Center of Health Technology, University of Pavia, Via Ferrata 1, 27100 Pavia, Italy.
| | - Antonella DeTrizio
- Department of Drug Sciences, University of Pavia, Viale Taramelli 12, 27100 Pavia, Italy.
| | - Tiziana Modena
- Department of Drug Sciences, University of Pavia, Viale Taramelli 12, 27100 Pavia, Italy.
- Center of Health Technology, University of Pavia, Via Ferrata 1, 27100 Pavia, Italy.
| | - Bice Conti
- Department of Drug Sciences, University of Pavia, Viale Taramelli 12, 27100 Pavia, Italy.
- Center of Health Technology, University of Pavia, Via Ferrata 1, 27100 Pavia, Italy.
| | - Francesco Benazzo
- Center of Health Technology, University of Pavia, Via Ferrata 1, 27100 Pavia, Italy.
- Centre oh Health Technology (CHT), Via Ferrata 1, University of Pavia, 27100 Pavia, Italy.
| | - Giulia Gastaldi
- Centre oh Health Technology (CHT), Via Ferrata 1, University of Pavia, 27100 Pavia, Italy.
- Department of Molecular Medicine, University of Pavia, Viale Taramelli 2, 27100 Pavia, Italy.
| | - Ida Genta
- Department of Drug Sciences, University of Pavia, Viale Taramelli 12, 27100 Pavia, Italy.
- Center of Health Technology, University of Pavia, Via Ferrata 1, 27100 Pavia, Italy.
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